The lecture notes on psychiatry are intended for students of medical colleges and universities. This publication discusses the issues of the modern classification of mental disorders, the main syndromes of mental illness, affective disorders, as well as modern aspects of narcology. The book will be an indispensable tool for those who want to quickly prepare for the exam and successfully pass it.
LECTURE No. 1. General psychopathology
Organization of psychiatric care. The main provisions of the law of the Russian Federation on psychiatric care. Major psychopathological syndromes. The concept of nosology. Etiology of mental illness. Principles of modern classification of mental disorders. General psychopathology.
1. The subject and tasks of psychiatry. History of development
Psychiatry is a medical discipline that studies the diagnosis and treatment, etiology, pathogenesis and prevalence of mental illness, as well as the organization of psychiatric care for the population.
Psychiatry, literally translated from Greek, means the healing of the soul. This terminology does not correspond to our modern understanding of mental illness. In order to comprehend the origin of this definition, it is necessary to recall the history of the formation of the human worldview. In ancient times, people saw the surrounding phenomena and objects, endowing them with a soul. Phenomena such as death and sleep seemed obscure and incomprehensible to primitive man. According to ancient beliefs, the soul, flying out of the body in a dream, sees various events, wanders somewhere, participating in them, and this is exactly what a person observes in a dream. In ancient Greece, it was believed that if you wake up a sleeping person, then the soul may not have time to return back to the body, and in those cases when the soul left and did not return, the person died. In the same Ancient Greece, a little later, an attempt is made to combine mental experiences and mental illness with one or another organ of the human body, for example, the liver was considered the organ of love, and only in later images does the heart pierced by the arrow of Cupid become the organ of love.
Psychiatry is a specialty of medicine that is part of clinical medicine. In addition to the main research methods used in clinical medicine, such as examination, palpation and auscultation, a number of techniques are used to study mental illness to identify and assess the patient's mental state - observation and conversation with him. In the case of mental disorders, as a result of monitoring the patient, one can detect the originality of his actions and behavior. In the event that the patient is disturbed by auditory or olfactory hallucinations, he may plug his ears or nose. During observation, it can be noted that patients seal windows and ventilation openings so that the gas allegedly let in by neighbors does not penetrate into the apartment. This behavior may indicate the presence of olfactory hallucinations. In the case of obsessive fears, patients can make movements that are incomprehensible to others, which are rituals. An example is the endless washing of hands in fear of contamination, stepping over cracks in the asphalt, "so that trouble does not happen."
When talking with a psychiatrist, the patient himself can tell him about his experiences, fears, fears, bad mood, explaining the wrong behavior, and also express inadequate judgment situations and delusional experiences.
For a correct assessment of the patient's condition, it is of great importance to collect information about his past life, attitude to current events, and relationships with people around him.
As a rule, when collecting such information, painful interpretations of certain events and phenomena are revealed. In this case, it is not so much about the anamnesis as about the mental state of the patient.
An important point in assessing the mental state of the patient is the data of an objective history, as well as information that is obtained from close relatives of the patient and those around him.
Sometimes doctors encounter the phenomenon of anosognosia - the denial of the disease by the patient himself and his close relatives, which is typical for such mental illnesses as epilepsy, oligophrenia, schizophrenia. In medical practice, there are cases when the parents of the patient do not seem to see obvious signs of the disease, being quite educated people and even doctors. Sometimes, despite the denial of the fact that a relative has an illness, some of them agree to carry out the necessary diagnostics and treatment. In such situations, the psychiatrist must show maximum professionalism, flexibility and tact. It is necessary to carry out treatment without specifying the diagnosis, without insisting on it and without convincing relatives of anything, based on the interests of the patient. Sometimes relatives, denying the disease, refuse to conduct a course of necessary therapy. Such behavior can lead to worsening of the symptoms of the disease and its transition to a chronic course.
Mental illnesses, in contrast to somatic illnesses, which are an episode in a patient's life, last for years, and sometimes for a lifetime. Such a long course of mental illness provokes the emergence of a number of social problems: relationships with the outside world, people, etc.
The personal qualities of the patient, the level of maturity of the individual, as well as the formed character traits, play an important role in the process of assessing a mental illness and its consequences, which is most clearly revealed in the study of clinical variants of neuroses.
Gradually (with the development and study of psychiatry), several independent areas emerged: child and adolescent psychiatry, geriatric, forensic, military psychiatry, narcology, and psychotherapy. These areas are based on general psychiatric knowledge and are developed in the practice of a doctor.
It has been established that there is a close relationship between somatic and mental diseases, since absolutely any somatic disorder has a pronounced effect on the personality of the patient and his mental activity. The severity of mental disorders in different diseases is different. For example, in diseases of the cardiovascular system, such as hypertension, atherosclerosis, the decisive role belongs to the somatogenic factor. Personality reactions are more pronounced in those diseases that result in facial defects and disfiguring scars.
The reaction of the individual, the disease is influenced by many factors:
1) the nature of the disease, its severity and rate of development;
2) the idea of this disease in the patient himself;
3) the nature of the treatment and the psychotherapeutic environment in the hospital;
4) personal qualities of the patient;
5) attitude towards the disease of the patient, as well as his relatives and colleagues.
According to L. L. Rokhlin, there are five options for the reaction of the individual to the disease:
1) asthenodepressive;
2) psychasthenic;
3) hypochondria;
4) hysterical;
5) euphoric-anosognosic.
The term “somatically conditioned psychosis”, which is now widespread, was proposed by K. Schneider. In order to make such a diagnosis, the following conditions are necessary:
1) distinct symptoms of a somatic disease;
2) an obvious relationship in time between somatic and mental disorders;
3) parallel course of mental and somatic disorders;
4) exogenous or organic symptoms.
Somatogenically caused mental illnesses and mental disorders can be psychotic, neurotic and psychopathic in nature, thus, it would be correct to speak not about the nature of mental disorders, but about the level of mental disorders. The psychotic level of mental disorders is a condition in which the patient is not able to adequately assess himself, the environment, the relationship of external events to himself and his situation. This level of mental disorders is accompanied by a violation of mental reactions, behavior, as well as disorganization of the patient's psyche. Psychosis- a painful mental disorder, which is manifested entirely or mainly by an inadequate reflection of the real world with a violation of behavior, a change in various aspects of mental activity. As a rule, psychosis is accompanied by the appearance of phenomena that are not characteristic of the normal psyche: hallucinations, delusions, psychomotor and affective disorders.
The neurotic level of mental disorders is characterized by the fact that the correct assessment of one's own state as painful, correct behavior, as well as disorders in the field of autonomic, sensorimotor and affective manifestations are preserved. This level of disturbance of mental activity, disorders of mental activity is not accompanied by a change in attitude to ongoing events. According to the definition of A. A. Portnov, these disorders are a violation of involuntary adaptation.
The psychopathic level of mental disorders is manifested by persistent disharmony of the patient's personality, which is expressed in a violation of adaptation to the environment, which is associated with excessive affectivity and affective assessment of the environment. The above level of mental disorders can be observed in a patient all his life or occur in connection with past somatic diseases, as well as with anomalies in the development of personality.
Expressed psychotic disorders in the form of psychoses are much less common than other disorders. Often, patients first of all turn to general practitioners, which is associated with the onset of the disease in the form of the appearance of vegetative and somatic symptoms.
The course of somatic diseases is adversely affected by mental trauma. As a result of unpleasant experiences of the patient, sleep is disturbed, appetite decreases, the activity and resistance of the body to diseases decrease.
The initial stages of the development of mental illness differ in that somatic disorders are more pronounced than mental disorders.
1. A young catering worker complained of heart palpitations and high blood pressure. At the appointment with the therapist, no pathology was noted, the doctor regarded these disorders as age-related functional. Later, her menstrual function disappeared. At the appointment with the gynecologist, pathology was also not revealed. The girl began to rapidly gain weight, the endocrinologist also did not note any deviations. None of the specialists paid attention to low mood, motor retardation and decreased performance. The decrease in working capacity was explained by the girl's concern, the presence of somatic pathology. After attempting to commit suicide, at the insistence of close relatives, the girl was consulted by a psychiatrist, who diagnosed her as a depressive state.
2. A 56-year-old man, after a vacation at sea, began to complain of pain behind the sternum and feeling unwell, in connection with which he was taken to the therapeutic department of the city clinical hospital. After the examination, the presence of cardiac pathology was not confirmed. Close relatives visited him, assuring him that everything was in order, although the man felt much worse every day. Then he had the idea that those around him consider him a simulator and think that he specifically complains of pain in his heart so as not to work. In the patient's condition every day, especially in the morning, there was a deterioration in the state of health.
Suddenly, in the morning, the patient went into the operating room and, taking a scalpel, tried to commit suicide. An ambulance was called to the patient by the hospital staff together with a psychiatric team, which later found out that the patient had depression. This disease in the patient was accompanied by all the signs of a depressive state, such as melancholy, motor retardation, decreased intellectual activity, slowing down of mental activity, and weight loss.
3. During the movie show, the child vomited. With this complaint, his parents went to the doctor. In the hospital, a study of the stomach and liver was carried out, the child was examined by a neuropathologist. After these procedures, no pathology was found. When collecting an anamnesis from the child's parents, it was possible to find out that for the first time vomiting occurred after the child ate a bar of chocolate, ice cream, an apple and sweets in the cinema. While watching a movie, the child vomited, which later took on the character of a conditioned reflex.
In whatever field of medicine he works, whatever specialty the doctor prefers, he must necessarily proceed from the fact that he is dealing primarily with a living person, a personality, with all its individual subtleties. Every doctor needs knowledge of psychiatric science, since most of the patients with mental disorders first of all turn not to psychiatrists, but to representatives of another medical specialty. Before the patient comes under the supervision of a psychiatrist, it often takes a very long period of time. As a rule, a general practitioner deals with patients who suffer from minor forms of mental disorders - neuroses and psychopathy. This pathology deals with small, or borderline, psychiatry.
The Soviet psychiatrist O. V. Kerbikov argued that borderline psychiatry is the area of medicine in which the contact of a psychiatrist with general practitioners is most necessary. The latter, in this case, are at the forefront of protecting the mental health of the population.
To avoid mistreatment of the patient, the doctor needs a knowledge of psychiatric science in general and borderline science in particular. If you treat the mentally ill incorrectly, you can provoke the occurrence of iatrogenia - a disease unwittingly caused by a doctor. The emergence of this pathology can be facilitated not only by words frightening the patient, but also by facial expressions and gestures. A doctor, a person who is directly responsible for the health of his patient, must not only behave correctly himself, but also control the behavior of the nurse and teach her the subtleties of communication with the patient, while observing all the rules of deontology. In order to avoid additional trauma to the patient's psyche, the doctor must understand the internal picture of the disease, that is, how his patient relates to his disease, what is his reaction to it.
General practitioners are often the first to meet with psychoses in their very initial stage, when the painful manifestations are not yet very pronounced, not too noticeable. Quite often, a doctor of any profile may encounter initial manifestations, especially if the initial form of a mental illness outwardly resembles some kind of somatic illness. Often a pronounced mental illness initiates a somatic pathology, and the patient himself is firmly “convinced” that he has some (actually non-existent) disease (cancer, syphilis, some kind of disfiguring physical defect) and insistently requires special or surgical treatment. Quite often, diseases such as blindness, deafness, paralysis are a manifestation of hysterical disorders, latent depression, occurring under the guise of a somatic disease.
Almost any doctor can find himself in a situation where emergency psychiatric care is required, for example, to stop the state of acute psychomotor agitation in a patient with delirium tremens, to do everything possible when status epilepticus occurs, or attempts to commit suicide.
Nosological direction in modern psychiatry (from the Greek. nosos- "disease") is common both in our country and in some European countries. Based on the structure of this area, all mental disorders are presented in the form of separate mental illnesses, such as schizophrenia, manic-depressive, alcoholic and other psychoses. It is believed that each disease has a variety of provoking and predisposing factors, a characteristic clinical picture and course, its own etiopathogenesis, although different types and variants are distinguished, as well as the most likely prognosis. As a rule, all modern psychotropic drugs are effective for certain symptoms and syndromes, regardless of the disease in which they occur. Another rather serious drawback of this direction is the unclear position of those mental disorders that do not fit into the clinical picture and the course of certain diseases. For example, according to some authors, disorders that occupy an intermediate position between schizophrenia and manic-depressive psychosis are special schizoaffective psychoses. According to others, these disorders should be included in schizophrenia, others interpret them as atypical forms of manic-depressive psychosis.
The famous German psychiatrist E. Kraepelin is considered the founder of the nosological direction. He was the first to present most mental disorders in the form of individual diseases. Although even before the systematics of E. Kraepelin, some mental illnesses were identified as independent: circular insanity, described by the French psychiatrist J. - P. Falre, later called manic-depressive psychosis, alcoholic polyneuritic psychosis, studied and described by S. S. Korsakov, progressive paralysis, which is one of the forms of syphilitic brain damage, described by the French psychiatrist A. Bayle.
The fundamental method of the nosological direction is a detailed description of the clinical picture and the course of mental disorders, for which representatives of other directions call this direction E. Kraepelin's descriptive psychiatry. The main sections of modern psychiatry include: geriatric, adolescent and child psychiatry. They are areas of clinical psychiatry devoted to the characteristics of the manifestations, course, treatment and prevention of mental disorders at the appropriate age.
The branch of psychiatry called narcology studies the diagnosis, prevention and treatment of drug addiction, substance abuse and alcoholism. In Western countries, doctors specializing in the field of narcology are called addictionists (from the English word addiction - “addiction, dependence”).
Forensic psychiatry develops the foundations of forensic psychiatric examination, and also works to prevent socially dangerous actions of mentally ill people.
Social psychiatry deals with the study of the role of social factors in the occurrence, course, prevention and treatment of mental illness and the organization of psychiatric care.
Transcultural psychiatry is a section of clinical psychiatry devoted to a comparative study of the characteristics of mental disorders and the level of mental health among different nations and cultures.
A section such as orthopsychiatry unites the approaches of psychiatry, psychology and other medical sciences to the diagnosis and treatment of behavioral disorders. Particular attention is paid to preventive measures aimed at preventing the development of these disorders in children. Sections of psychiatry are also sexopathology and suicidology (dealing with the study of the causes and development of measures to prevent suicide at the level of preventing suicidal behavior preceding them).
Borderline with psychiatry and at the same time separate scientific disciplines are psychotherapy, medical psychology, and psychopharmacology.
2. Organization of mental health care
The organization of psychiatric care in any country is based on the rights of citizens to whom this assistance is provided. It cannot be carried out without resolving the issues of the legal status of the mentally ill. According to the legislation of our state, which contains provisions concerning both the mentally ill person himself and the doctor and the psychiatric service, it is necessary to protect the interests of the mentally ill as much as possible and at the same time protect society from the dangerous actions of the mentally ill. Psychiatric assistance to the population can be provided both in inpatient and outpatient settings.
Inpatient psychiatric care
To provide inpatient care to the population, there are psychiatric hospitals and psychiatric departments that can be specialized for the treatment of patients with borderline non-psychotic conditions, neuroses and neurosis-like conditions, cerebroasthenic disorders, psychosomatic diseases, as well as patients suffering from psychosis and at the same time somatic diseases that require active therapy or surgical intervention.
Patients from a certain area or section of a psychoneurological dispensary are admitted to the same department of a psychiatric hospital (territorial principle of distribution of patients).
In addition, each hospital has departments for the treatment of elderly patients, children, adolescents, as well as persons with borderline conditions. More recently, special departments of psycho-reanimation began to appear in large psychiatric hospitals.
According to WHO experts, 1.0-1.5 beds per 1000 population is considered sufficient, in Russia there are 1.2 per 1000 population or 10% of the total number of beds. In children's and adolescent departments, patients not only receive treatment, but also study according to the mass school program.
For certain groups of patients, mainly those with borderline neuropsychiatric illness, in order to reduce the adverse effects of isolation of the mentally ill from society, some departments of psychiatric hospitals use the system of "open doors". In connection with the increase in life expectancy of the population, there is an urgent need for the development of psychiatric care for the elderly.
Outpatient care for the mentally ill
Psychoneurological dispensaries operating on a territorial basis were established in 1923. Currently, psychiatric care outside the walls of the hospital is developing in three directions: assistance to patients in the psychoneurological dispensary is being improved; a new type of advisory psychiatric care is being formed without registering the patient in this institution; psychiatric care is being improved outside the dispensary, in the system of general medical care - in the psychotherapeutic rooms of polyclinics - to provide it to patients with borderline disorders and early detection of patients with other mental illnesses.
In addition, treatment in day hospitals has recently begun to be practiced, where patients come in the morning, receive appropriate treatment, participate in work processes, entertainment, and return home in the evening. There are also night hospitals where patients stay after work in the evening and at night. During this time, they undergo therapeutic measures, for example, a course of intravenous infusions, acupuncture, therapeutic massage, and in the morning the patients return to work.
For children with various neurotic conditions, there are sanatorium, so-called forest schools, in which weakened children receive appropriate therapy and study for one quarter.
In the prevention and treatment of mental illness, the creation of a regimen of work and rest, a long stay in the fresh air, and physical education are of great importance. Patients suffering from chronic mental illness are in neuropsychiatric boarding schools, where they receive the necessary treatment.
Children with mental retardation study in special auxiliary schools. They can come there from home or live permanently in boarding schools at schools, where constant special supervision and systematic treatment are carried out. Children with organic lesions of the central nervous system, as well as with stuttering, receive the necessary medical care in specialized nursery-kindergartens, where psychiatrists, psychologists and speech therapists work together with educators.
The psycho-neurological dispensary, in addition to the rooms in which the necessary medical care is provided, includes medical and labor workshops where mentally disabled people work. Being in medical and labor workshops makes it possible to carry out systematic treatment, provide patients with food, and also earn a small amount of money for the patients themselves.
In recent years, in connection with the increased incidence of suicides, a special service has been developed to combat suicides, mainly represented by the "Hotline", which any person who is in a serious mental state due to life's failures can contact at any time of the day. Qualified psychological assistance by telephone is provided by psychiatrists and psychologists who have undergone special training.
There are special rooms in general somatic polyclinics for providing psychotherapeutic and psychological assistance to adults and adolescents. In most large cities, there are special crisis departments, the work of which is aimed at preventing suicidal behavior.
In rural areas, there are psychiatric departments in the central district hospitals, as well as a network of psychiatric offices in rural hospitals and district clinics.
Narcological service
In 1976, a special narcological dispensary was introduced into the health care institutions, which is the basis of the narcological service.
The Narcological Service has stationary, semi-stationary and out-of-hospital units and is a network of specialized institutions that provide medical, legal, medical and social, as well as medical and preventive care to patients with drug addiction, alcoholism and substance abuse.
Rights of mentally ill people
For the first time, the "Regulations on the conditions and procedure for the provision of psychiatric care aimed at protecting the rights of the mentally ill" were adopted by the Decree of the Presidium of the Supreme Soviet of the USSR of January 5, 1988. Later (1993), a special law "On psychiatric care and guarantees of the rights of citizens" was adopted in its provision”, according to which qualified psychiatric care is provided free of charge, taking into account all the achievements of science and practice. This law is based on regulations according to which the dignity of the patient should not be infringed upon in the provision of psychiatric care. This law also regulates the procedure for conducting a psychiatric examination. This law states that psychiatric examination and preventive examinations are carried out only at the request or with the consent of the subject, and examination and examination of a minor under 15 years of age - at the request or with the consent of his parents or legal representative.
When conducting a psychiatric examination, the doctor is obliged to introduce himself to the patient, as well as his legal representative as a psychiatrist. The exception is those cases when the examination can be carried out without the consent of the subject or his legal representative: in the presence of a severe mental disorder with an immediate danger to himself and others, if the subject is under dispensary observation. Outpatient psychiatric care for persons with mental illness is provided depending on medical indications and is carried out in the form of consultative and therapeutic assistance and dispensary observation.
Persons with mental disorders are placed under dispensary observation, regardless of their consent or the consent of their legal representative (in cases where they are recognized as incapacitated). At the same time, the attending physician constantly monitors the state of their mental health through regular examinations and the provision of necessary medical and social assistance.
In cases of inpatient treatment of a patient with mental disorders, consent to this treatment in writing is required, with the exception of patients who are in compulsory treatment by a court decision, as well as patients involuntarily hospitalized by law enforcement agencies. Without the consent of the patient, i.e. involuntarily, persons with such mental disorders are placed in a psychiatric hospital that make them dangerous to themselves and others, as well as patients in those states when they are unable to satisfy basic life needs (for example, with catatonic stupor, severe dementia) and can cause significant harm to their health due to the deterioration of their mental state if they are left without psychiatric help.
A patient admitted to a hospital as a result of involuntary hospitalization must be examined by a commission of doctors within 48 hours, which determines the validity of hospitalization. In cases where hospitalization is recognized as justified, the conclusion of the commission is submitted to the court to decide on the further stay of the patient in the hospital, at the location of the hospital.
The involuntary stay of a patient in a psychiatric hospital lasts as long as the grounds for involuntary hospitalization persist (aggressive actions in connection with delusions and hallucinations, active suicidal tendencies).
To prolong involuntary hospitalization, a re-examination by the commission is carried out once a month for the first six months, and then once every 6 months.
An important achievement in observance of the rights of mentally ill citizens is the release of them from liability for socially dangerous actions (crimes) committed by them during their illness.
3. Major psychopathological syndromes. The concept of nosology
Translated from Greek, “syndrome” means “accumulation”, “confluence”. At the moment, the medical term "syndrome" means a set of symptoms united by a single pathogenesis, a natural combination of productive and negative symptoms. The German psychiatrist K. Kalbaum in 1863, when describing catatonia, proposed the term "symptom complex". At that time, catatonia was considered a separate disease, but later it became clear that this is a typical variant of the symptom complex.
The syndrome as a stage of the disease can be the same in various mental disorders, which is due to the body's adaptation to changed living conditions (illness) and is achieved using the same type of response methods. This manifestation is observed in the form of symptoms and syndromes, which become more complicated with the development of the disease, transforming from simple to complex or from small to large. With various mental illnesses, the clinical picture changes in a certain sequence, that is, there is a stereotype of development characteristic of each disease. Allocate a general pathological stereotype of development, characteristic of all diseases, and a nosological stereotype, which is typical for individual diseases.
The general pathological stereotype of the development of diseases suggests the presence of general patterns in their course. At the initial stages of progressive mental illness, neurotic disorders are more often detected, and only then affective, delusional and psycho-organic disorders appear, that is, with the progression of mental illness, the clinical picture steadily becomes more complicated and deepens.
For example, the formation of clinical manifestations in patients with schizophrenia is as follows: at the initial stages, disorders of the neurotic level, asthenic, phobic are detected, then affective disorders appear, delusional symptoms, complicated by hallucinations and pseudohallucinations, the Kandinsky-Clerambault syndrome joins, accompanied by paraphrenic delirium and leading to apathetic dementia.
Nosological diagnosis reflects the integrity of productive and negative disorders.
It should be noted that neither productive nor negative disorders have absolute nosological specificity and only apply to the type of diseases or groups of diseases - psychogenic, endogenous and exogenous-organic. In each of these groups of diseases, all the isolated productive symptoms take place. For example: asthenic and neurotic syndromes are characteristic of neuroses and neurotic personality developments; affective, delusional, hallucinatory, motor - for reactive psychoses such as depression, paranoids, stuporous states, transient intellectual disorders - for hysterical psychoses.
Both with exogenous organic and endogenous diseases, all of the above syndromes are present. There is also a certain preference, which consists in the highest frequency and severity of them for a particular group of diseases. Despite the general pathological patterns of the formation of a personality defect, negative mental disorders due to illness have ambiguous trends in groups of diseases.
As a rule, negative disorders are represented by the following syndromes: asthenic or cerebroasthenic personality changes, including psychopathic disorders, manifested in the form of pathocharacterological disorders in psychogenic diseases. Negative disorders in exogenous organic diseases are characterized by psychopathic personality changes, manifested by excessive saturation of experiences, inadequacy in strength and severity of emotional reactions and aggressive behavior.
In schizophrenia, personality changes are characterized by emotional impoverishment and dissociation of emotional manifestations, their dysfunction and inadequacy.
As a rule, patients with schizophrenia do not suffer from memory, however, there are well-known cases when patients, being in the department for a long time, do not know the name of the attending physician, roommates, find it difficult to give dates. These memory disorders are not true, but caused by affective disorders.
4. Principles of the modern classification of mental disorders
General provisions
Throughout the world, there are officially two types of classifications of mental disorders: national classifications and International, developed within the framework of the World Health Organization (WHO) and regularly updated.
To date, the International Classification of Mental Disorders and Conduct Disorders of the 10th revision (ICD-10) is in force, which differs significantly from previous versions of the International Classification of Mental Disorders and is quite progressive, reflecting recent achievements in world psychiatry. However, according to most of the various psychiatric schools and directions, there are significant shortcomings in the ICD-10 classification.
These include: atheoretical, inconsistent and excessive complexity of the classification of mental disorders in general.
In addition to the imperfections of the ICD-10 described above, one can add an unreasonable, albeit partial, departure from clinical and nosological positions, the separation of mental disorders, psychopathological syndromes and even symptoms as independent diseases, a skeptical attitude towards the fundamental concepts and provisions of psychiatry, proven by the world clinical practice.
Due to these features, the use of the ICD-10 as the basis for the presentation of educational material on psychiatry is very difficult for students to master this medical discipline. In this regard, the third part of the textbook ("Private Psychiatry"), which describes mental illness and more or less independent forms of mental disorders, is built on the basis of the domestic classification of mental disorders. This classification is more consistent, logical, mainly based on clinical and nosological principles and is widely used in Russian psychiatry.
For example: the chapters of "Private Psychiatry" reflect the ratio of clinical and nosological forms of mental disorders in the domestic sense with those in the ICD-10.
Domestic classification of mental disorders
In the domestic classification of mental disorders, clinical and nosological forms are divided on the basis of a close relationship between established etiological factors and pathogenetic mechanisms, as well as the similarity of clinical manifestations, dynamics and outcomes of mental diseases.
1. Endogenous mental illnesses:
1) schizophrenia;
2) manic-depressive psychosis;
3) cyclothymia;
4) functional mental disorders of late age.
As a rule, these diseases are caused by internal pathogenic factors, including hereditary predisposition, with a certain participation in their occurrence of various external negative factors.
2. Endogenous-organic mental illness:
1) epilepsy (epileptic disease);
2) atrophic diseases of the brain, dementia of the Alzheimer's type;
3) Alzheimer's disease;
4) senile dementia;
5) Pick's disease;
6) Huntington's chorea;
7) Parkinson's disease;
8) mental disorders caused by vascular diseases of the brain.
In the development of these diseases, the root cause can be both internal factors leading to organic damage to the brain and cerebro-organic pathology, and external factors due to external influence of a biological nature: traumatic brain injury, neuroinfection, intoxication.
3. Somatogenic, exogenous and exogenous-organic mental disorders:
1) mental disorders in somatic diseases;
2) exogenous mental disorders;
3) mental disorders in infectious diseases of extracerebral localization;
4) alcoholism;
5) drug addiction and substance abuse;
6) mental disorders due to medicinal, industrial and other intoxications;
7) exogenous organic mental disorders;
8) mental disorders in traumatic brain injuries;
9) mental disorders in neuroinfections;
10) mental disorders in brain tumors.
This rather large group includes: mental disorders caused by somatic diseases and various exogenous factors of extracerebral localization, often leading to cerebro-organic damage. As a rule, endogenous factors play a certain but not dominant role in the formation of mental disorders in this group. It is worth emphasizing that mental illnesses that have developed in connection with brain tumors, with a high degree of conditionality, can be attributed to disorders of an exogenous nature.
4. Psychogenic disorders:
1) reactive psychoses;
2) neuroses;
3) psychosomatic (somatoform) disorders.
This group of disorders develops as a result of the impact of stressful situations on the personality and the bodily sphere.
5. Pathology of personality development:
1) psychopathy (personality disorders);
2) oligophrenia (a state of mental underdevelopment);
3) other delays and distortions of mental development.
This group includes mental states caused by abnormal personality formation.
5. Sections of the International Classification of Mental Disorders, 10th revision (ICD-10)
This classification includes 11 sections.
F0 - organic, including symptomatic, mental disorders.
F1 - mental and behavioral disorders due to the use of psychoactive substances.
F2 - schizophrenia, schizotypal and delusional disorders.
F3 - mood disorders (affective disorders).
F4 - neurotic, stress-related and somatoform disorders.
F5 - behavioral syndromes associated with physiological disorders and physical factors.
F6 - Disorders of mature personality and behavior in adults.
F7 - mental retardation.
F8 - violations of psychological development.
F9 - behavioral and emotional disorders, usually beginning in childhood and adolescence.
F99 - unspecified mental disorder.
6. General psychopathology
6.1. Perceptual disorders
Perception is the initial stage of higher nervous activity. Thanks to perception, external and internal stimuli become facts of consciousness, reflecting individual properties of objects and events.
Irritant → sensation → perception → representation.
Sensation is the simplest mental process, consisting in the reflection of individual properties of objects and phenomena, arising in the process of their impact on the senses.
Perception is the mental process of reflecting objects and phenomena as a whole, in the aggregate of their properties. Does not depend on the will of the individual.
Representation - an image of an object or phenomenon, reproduced in the mind on the basis of past impressions. Depends on the will of the individual.
Symptoms of Perceptual Disorders
Hyperesthesia- Hypersensitivity to normal stimuli. Often occurs with exogenous organic lesions of the central nervous system (intoxication, trauma, infection), manic states.
hypoesthesia(hypoeesthesia) - decreased sensitivity to stimuli. Often observed in disorders of consciousness, organic disorders of the central nervous system, depressive states. Anesthesia is the extreme degree of hypoesthesia. Painful mental anesthesia is a subjectively seemingly very painful weakening of some kind of sensitivity, due to a decrease in emotional tone ( anesthesia psychica dolorosa). Seen in depression.
agnosia- non-recognition of the stimulus, occurs with organic lesions of the central nervous system, hysterical sensitivity disorders.
Paresthesia- subjective sensations that occur without an irritant (tingling, crawling, numbness, etc.). Disorders have localization, clearly limited by zones of innervation. They are a symptom of a neurological disorder.
Senestopathy(illusions of a general feeling) - vague, difficult to localize, unpleasant, painful bodily sensations. They have peculiar descriptions by patients (pulling, pouring, stratification, turning over, drilling, etc.). Sensations do not have a real basis, "non-objective", do not correspond to the zones of innervation. Often found in the structure of the senesto-hypochondriac syndrome (senestopathy + ideas of "imaginary" illness + affective disorders), with schizophrenia, depression.
Illusions- an erroneous perception of real-life objects and events.
Affectogenic illusions occur with fear, anxiety, depression, ecstasy. Their occurrence is facilitated by the fuzzy perception of the environment (poor lighting, slurred speech, noise, remoteness of the object). The content of illusions is associated with affective experiences. For example, with a pronounced fear for one's life, a person hears threats in the conversation of far-standing people.
Physical- associated with the peculiarities of physical phenomena (a spoon in a glass of water seems crooked).
Pareidolic illusions- visual illusions, in which patterns, cracks, tree branches, clouds are replaced by images of fantastic content. Observed with delirium, intoxication with psychomimetics.
With illusions, there is always a real object (as opposed to hallucinations) or a phenomenon of the surrounding world, which is reflected incorrectly in the mind of the patient. Illusions in some cases are difficult to differentiate from the patient's delusional interpretation of the environment, in which objects and phenomena are correctly perceived, but absurdly interpreted.
Edeitism- a sensually vivid representation of the immediately preceding sensation (especially a vivid memory).
Phantasm- sensually vivid, distinctly fantastic daydreams.
hallucinations- a disorder of perception in the form of images and ideas that arise without a real object.
Simple hallucinatory images arise in one analyzer (for example, only visual ones).
Complex(complex) - two or more analyzers are involved in the formation of images. The content of hallucinations is connected by a common plot. For example, in alcoholic delirium, the patient "sees" the trait, "feels" his touch, and "hears" the speech addressed to him.
According to the analyzers (by modalities), the following types of hallucinations are distinguished.
visual hallucinations. Elementary (photopsies) are devoid of a clear form - smoke, sparks, spots, stripes. Completed - in the form of individual people, objects and phenomena.
Depending on the subjective assessment of the size, there are:
1) normoptic - a hallucinatory image corresponds to the real size of objects;
2) microoptical hallucinations - reduced sizes (cocainism, alcoholic delirium);
3) macrooptical hallucinations - gigantic.
Types of visual hallucinations:
1) extracampal hallucinations - visual images appear outside the field of view (from the side, from behind);
2) autoscopic hallucinations - vision of the patient's own double.
Visual hallucinations usually occur against the background of clouded consciousness.
Hallucinatory images can be painted in one color (with epilepsy they are often monochrome, red), they can be mobile and motionless, scene-like (with oneiroid), persistent and fragmentary.
Auditory (verbal) hallucinations. Elementary (acoasms) - noise, crackling, calls by name. Phonemes are individual words or phrases. Hallucinatory experiences are most often presented in the form of voices. It can be one particular voice or several (chorus of voices).
1) imperative, or commanding, hallucinations (are indications for hospitalization in a psychiatric hospital);
2) commenting (an imaginary interlocutor comments on the actions and thoughts of the patient); threatening, insulting;
3) antagonistic (the content is opposite in meaning - either accusing or defending).
Tactile (tactile) hallucinations unlike senestopathies, they are objective in nature, the patient clearly describes his feelings: “cobwebs on his face”, “insect crawling”. A characteristic symptom for some intoxications, in particular cyclodol, is the “symptom of a disappearing cigarette”, in which the patient clearly feels the presence of a cigarette sandwiched between his fingers, but when he brings his hand to his face, the cigarette disappears. For non-smokers, this may be an imaginary glass of water.
Thermal- sensation of warmth or cold.
Hygric- sensation of moisture on the surface of the body.
Haptic- sudden sensation of touching, grasping.
Kinesthetic hallucinations- sensation of imaginary movement.
speech motor hallucinations- the feeling that the speech apparatus makes movements and pronounces words against the will of the patient. In fact, it is a variant of ideational and motor automatisms.
hallucinations of general feeling(visceral, bodily, interoceptive, enteroceptive) are manifested by sensations of the presence of foreign objects or living beings inside the body.
For the patient, sensations have precise localization and “objectivity”. Patients clearly describe their sensations (“snakes in the head”, “nails in the stomach”, “worms in the pleural cavity”).
Taste hallucinations- a feeling in the oral cavity of unusual taste sensations, usually unpleasant, not associated with eating. Often they are the reason for the patient's refusal to eat.
Olfactory hallucinations- an imaginary perception of odors emanating from objects or from one's own body, often of an unpleasant nature. Often coexist with taste.
They can be observed in the form of a monosymptom (Bonner's hallucinosis - an unpleasant smell from one's own body).
The division into true and false hallucinations is clinically important.
true hallucinations- the patient perceives hallucinatory images as part of the real world, the content of hallucinations is reflected in the patient's behavior. Patients “shake off” imaginary insects, flee from monsters, talk with imaginary interlocutors, plug their ears, which may be an objective sign of their presence. Extra projection is characteristic, i.e., images are projected outward or into real space within reach. The course is usually acute. Characteristic of exogenous psychoses (poisoning, trauma, infection, psychogeny). Criticism of the patient to experiences is absent.
False hallucinations (pseudo hallucinations) Patients lack a sense of objective reality. The patient perceives images of the inner "I". It clearly distinguishes between reality and hallucinatory image. Interoprojection is characteristic, voices sound "inside the head", images appear before the inner eye, or the source is inaccessible to the senses (voices from space, telepathic communication, astral, etc.). There is almost always a sense of accomplishment, of violence. The patient "understands" that the images are transmitted only to him. The course is usually chronic. There may be a critical attitude to experiences, but at the height of psychosis there is no criticism. Observed in endogenous psychoses.
Hypnagogic hallucinations Most often visual hallucinations. They appear when the eyes are closed at rest, often precede falling asleep, and are projected onto a dark background.
Hypnapompic hallucinations- the same, but when waking up. These two types of hallucinations are often referred to as varieties of pseudohallucinations. Among this variety of hallucinations, the following types of pathological representations are observed: visual (most often), verbal, tactile and combined. These disorders are not yet a symptom of psychosis; they often indicate a prepsychotic state or occur during an exacerbation of severe somatic diseases. In some cases, they require correction if they are the cause of sleep disturbance.
Additionally, according to the features of occurrence, the following types of hallucinations are distinguished.
functional hallucinations always auditory, appear only with a real sound stimulus. But unlike illusions, a real stimulus does not merge (is not replaced) with a pathological image, but coexists with it.
reflex hallucinations lie in the fact that correctly perceived real images are immediately accompanied by the appearance of a hallucinatory image similar to them. For example, the patient hears a real phrase - and immediately a similar phrase begins to sound in his head.
Apperceptive hallucinations appear after the volitional effort of the patient. For example, patients with schizophrenia often "cause" their voices.
Hallucinations of Charles Bonnet are observed when the peripheral part of the analyzer is damaged (blindness, deafness), as well as in conditions of sensory deprivation. Hallucinations always occur in the field of the affected or informatively limited analyzer.
Psychogenic hallucinations arise under the influence of psychic trauma or suggestion. Their content reflects the psycho-traumatic situation or the essence of suggestion.
Psychosensory disorders- violation of the perception of the size, shape, relative position of objects in space and (or) the size, weight of one's own body (disorders of the body scheme).
micropsia- reduction in the size of visible objects.
macropsia- an increase in the size of visible objects.
Metamorphopsia- violation of the perception of space, shape and size of objects.
Poropsia- violation of the perception of space in perspective (elongated or compressed).
Polyopsia- with the formal preservation of the organ of vision, instead of one object, several are seen.
Optical allesthesia- It seems to the patient that the objects are allegedly in the wrong place.
Dysmegalopsia- changes in the perception of objects, in which the latter seem to be twisted around their axis.
Autometamorphopsia- a distorted perception of the shape and size of one's own body. Disorders occur in the absence of visual control.
Violation of the perception of the passage of time(tachychronia - subjective sensation of time acceleration, bradychronia - slowdown). It is often observed in depression and manic states.
Violation of the perception of the sequence of temporal events.
This includes the phenomena of "already seen" - deja vu, "already heard" - deja entendu, "already tested" - deja vecu and "never seen" - jamais vu, "not heard" - jamais entendu, "previously untested" - jamais vecu. In the first case, patients in a new, unfamiliar environment have the feeling that this environment is already familiar to them. In the second, a well-known setting seems to be seen for the first time.
Psychosensory disorders rarely occur individually. Usually, individual symptoms of psychosensory disorders are considered within the framework of two main syndromes: derealization syndrome and depersonalization syndrome.
These disorders are most often found in exogenous organic psychoses, withdrawal states, epilepsy, and neurorheumatism.
Perceptual Disorder Syndromes
Hallucinosis- a psychopathological syndrome, the leading disorder of which are hallucinations. Hallucinations, as a rule, occur in one analyzer, less often in several. Emerging affective disorders, delusions, psychomotor agitation are secondary and reflect the content of hallucinatory experiences. Hallucinosis occurs against the background of clear consciousness.
Disorders can proceed acutely, while bright hallucinatory symptoms are characteristic, hallucinatory arousal, an affective component of psychosis is expressed, delirium is possible, psychotically narrowed consciousness can be noted.
In the chronic course of hallucinosis, the affective component fades away, hallucinations become a monosymptom habitual for the patient, and a critical attitude towards disorders often appears.
Acute auditory (verbal) hallucinosis. The leading symptom is auditory (verbal) hallucinations. The prodromal period is characterized by elementary auditory hallucinations (acoasma, phonemes), hyperacusis. At the height of psychosis, true hallucinations are characteristic (sounds come from outside - from behind the wall, from another room, from behind). Patients talk about what they hear in great detail, and it seems as if they are seeing it (scene-like hallucinosis).
There is always an affective component - fear, anxiety, anger, depression. Often there is a hallucinatory variant of psychomotor agitation, in which the patient's behavior reflects the content of hallucinations (patients talk with imaginary interlocutors, plug their ears, make suicidal attempts, refuse to eat). Perhaps the formation of secondary delusions (hallucinatory delusions), delusional ideas reflect the content of hallucinations and affective experiences.
There is no criticism of what is happening. Consciousness is formally clear, psychotically narrowed, patients are focused on their experiences.
Chronic verbal hallucinosis- the manifestation is usually limited to hallucinatory symptoms.
It can be observed as an unfavorable outcome of acute verbal hallucinosis. At the same time, the intensity of the affect first decreases, then the behavior is ordered, delirium disappears. There is a critique of experiences. Hallucinations lose their brightness, their content becomes monotonous, indifferent to the patient (encapsulation).
Chronic verbal hallucinosis without an acute psychotic stage begins with rare hallucinatory episodes that become more frequent and intensify. Sometimes it is possible to form an irrelevant interpretive delusion.
It occurs in infectious, intoxication, traumatic and vascular lesions of the brain. It may be the initial sign of schizophrenia, while it becomes more complicated and transforms into the Kandinsky-Clerambault syndrome.
Peduncular visual hallucinosis (Lermitte hallucinosis)
occurs when the legs of the brain are damaged (tumors, injuries, toxoplasmosis, vascular disorders). The leading symptom is visual hallucinations with extra projection at a small distance from the eyes, often on the side. As a rule, hallucinations are mobile, silent, emotionally neutral. Attitude to experiences is critical.
Visual hallucinosis of Charles Bonnet occurs with complete or partial blindness. Initially, there are separate incomplete visual hallucinations. Further, their number grows, they become voluminous, scene-like. At the height of experiences, criticism of hallucinations may disappear.
Van Bogart hallucinosis characterized by constant true visual hallucinations. More often these are zoooptic hallucinations in the form of beautiful butterflies, small animals, flowers. At first, hallucinations occur against an emotionally neutral background, but over time, the following appear in the structure of the syndrome: affective tension, psychomotor agitation, delirium. Hallucinosis is replaced by delirium. It is characteristic that this hallucinosis is preceded by a stage of somnolence and narcoleptic seizures.
Kandinsky-Clerambault Syndrome is a kind of syndrome of the first rank in the diagnosis of schizophrenia. The structure of the syndrome includes auditory pseudohallucinations, mental automatisms.
At hallucinatory form syndrome is dominated by auditory pseudohallucinations.
At delusional version the clinical picture is dominated by delusions of influence (telepathic, hypnotic, physical). Usually there are all kinds of automatisms.
Mental automatism- alienation to the patient of their own mental processes and motor acts - their own thoughts, feelings, movements are felt inspired, violent, subject to extraneous influences.
There are several types of mental automatism.
1. Ideatory (associative) is manifested by the presence of a feeling of embedding other people's thoughts, the phenomena of openness of thoughts are noted (the feeling that one's own thoughts become known to others, sound, a feeling of theft of thoughts).
2. Sensory (sensory) mental automatism consists in the emergence of sensations, feelings, as if under the influence of external ones. Alienation of one's own emotions is characteristic, the patient has a feeling that emotions arise under the influence of an outside force.
3. Motor (kinesthetic, motor) mental automatism is characterized by the patient's feeling that any movements are carried out under the influence of external influences.
The presence of this syndrome in the clinical picture of the disease indicates the severity of the psychotic process and requires massive complex therapy.
The syndrome is characteristic of schizophrenia, however, some authors rarely describe intoxication, trauma, vascular disorders.
It is also possible to develop the so-called inverted variant of the Kandinsky-Clerambault syndrome, in which the patient himself supposedly has the ability to influence others. These phenomena are usually combined with delusional ideas of greatness, special power.
Derealization syndrome. The leading symptom is an alienated and distorted perception of the surrounding world as a whole. At the same time, there may be violations of the perception of the pace of time (time flows faster or slower), colors (everything is in gray tones or vice versa bright), distorted perception of the surrounding space. Deja vu symptoms may also be observed.
When depressed, the world may seem gray, time drags on slowly. The predominance of bright colors in the surrounding world is noted by patients with the use of certain psychoactive drugs.
The perception of the environment in red and yellow tones is typical for twilight epileptic conditions.
A change in the perception of the shape and size of the surrounding space is characteristic of intoxication with psychoactive substances and organic brain lesions.
Depersonalization Syndrome It is expressed in a violation of self-consciousness, a distorted perception of one's own personality and the alienation of individual physiological or mental manifestations. In contrast to mental automatism, in these disorders there are no sensations of external influence. There are several options for depersonalization.
Allopsychic depersonalization. Feeling of a change in one's own "I", duality, the appearance of an alien personality, reacting differently to the environment.
Anesthetic depersonalization. Loss of higher emotions, the ability to feel, experience. Complaints of excruciating insensitivity are characteristic. Patients lose the ability to feel pleasure or displeasure, joy, love, hate or sadness.
neurotic depersonalization. Typically, patients complain of inhibition of all mental processes, changes in emotional response. Patients are focused on their experiences, an abundance of complaints about difficulty in mental activity, difficulty in concentrating attention is revealed. Characterized by obsessive "self-digging", introspection.
Somato-physical depersonalization. Changes in the perception of internal organs, alienation of the perception of individual processes with the loss of their sensual brightness are characteristic. Lack of satisfaction from urination, defecation, eating, sexual intercourse.
Violation of the scheme and dimensions of the body and its individual parts. Feelings of disproportion of the body and limbs, "wrong position" of the arms or legs. Under visual control, phenomena disappear. For example, the patient constantly has a feeling of the immensity of the fingers, but when looking at the hands, these sensations disappear.
Dysmorphophobia. The belief in the existence of a non-existent shortcoming in oneself proceeds without severe disorders of mental activity. It manifests itself mainly in adolescents as a transient age-related phenomenon.
Senesto-hypochondriac syndrome. The basis of the syndrome is senestopathies, which occur first. Subsequently, overvalued ideas of hypochondriacal content are added. Patients turn to doctors, the mental nature of the disease is rejected, so they constantly insist on a more in-depth examination and treatment. Subsequently, hypochondriacal delirium may develop, which is accompanied by its own interpretation of disorders, often of anti-scientific content, there is no trust in health workers at this stage (reaches the level of open confrontation).
6.2. Thinking disorders
Thinking- this is a function of cognition, with the help of which a person analyzes, connects, generalizes, classifies. Thinking is based on two processes: analysis(decomposition of the whole into its constituent parts in order to highlight the main and secondary) and synthesis(creation of a holistic image from separate parts). Thinking is judged by a person's speech and sometimes by actions and deeds.
Disorders of the form of the associative process
Accelerated pace (tachyphrenia)- thinking is superficial, thoughts flow quickly, easily replace each other. Increased distractibility is characteristic, patients constantly jump to other topics. Speech is fast, loud. Patients do not correlate the strength of the voice with the situation. Statements are interspersed with poetic phrases, singing. The associations between thoughts are superficial, but nevertheless they are understandable.
The most pronounced degree of accelerated thinking is leap of ideas(fuga idiorum). There are so many thoughts that the patient does not have time to utter them, unfinished phrases are characteristic, speech is excited. It is necessary to differentiate with broken thinking, in which associations are completely absent, the pace of speech remains normal, there is no characteristic emotional richness. An accelerated pace of thinking is characteristic of mania and stimulant intoxication.
mentism- a subjective feeling when there are a lot of unrelated thoughts in the head. This is a short term state. In contrast to accelerated thinking, this is an extremely painful condition for the patient. The symptom is characteristic of the Kandinsky-Clerambault syndrome.
Slow pace (bradyphrenia). Thoughts arise with difficulty and stay in the mind for a long time. Slowly replace one another. Speech is quiet, poor in words, answers are delayed, phrases are short. Subjectively, patients describe that thoughts, appearing, overcome resistance, "toss and turn like stones." Patients consider themselves intellectually untenable, stupid. The most severe form of slow thinking is monoideism, when one thought persists in the patient's mind for a long time. This type of disorder is characteristic of depressive syndrome, organic brain lesions.
Sperung- breaks in thoughts, "blockage of thinking", the patient suddenly loses his thought. Most often, experiences are subjective and may not be noticeable in speech. In severe cases, sudden cessation of speech. Often combined with mental influxes, reasoning, observed with a clear mind.
Slipping thinking- deviation, slipping of reasoning to side thoughts, the thread of reasoning is lost.
Disruption of thought. With this disorder, there is a loss of logical connections between individual thoughts. Speech becomes incomprehensible, the grammatical structure of speech is preserved. The disorder is characteristic of the remote stage of schizophrenia.
For incoherent (incoherent) thinking characterized by a complete loss of logical connections between individual short statements and individual words (verbal okroshka), speech loses grammatical correctness. The disorder occurs when there is a disturbed consciousness. Incoherent thinking is part of the structure of the amental syndrome (often in a state of agony, with sepsis, severe intoxication, cachexia).
reasoning- empty, fruitless, vague reasoning, not filled with concrete meaning. Empty talk. Seen in schizophrenia.
autistic thinking- reasoning is based on the subjective attitudes of the patient, his desires, fantasies, delusions.
Often there are neologisms - words invented by the patient himself.
Symbolic thinking- Patients give a special meaning to random objects, turning them into special symbols. Their content is not clear to others.
paralogical thinking- reasoning with "crooked logic", based on a comparison of random facts and events. characteristic of the paranoid syndrome.
Duality (ambivalence)- the patient affirms and denies the same fact at the same time, often occurs in schizophrenia.
Perseverative thinking- stuck in the mind of one thought or idea. The repetition of one answer to different subsequent questions is typical.
Verbigeration- a characteristic violation of speech in the form of repetition of words or endings with their rhyming.
Pathological thoroughness of thinking. There is excessive detail in statements and reasoning. The patient "gets stuck" on circumstances, unnecessary details, the topic of reasoning is not lost. Characteristic for epilepsy, paranoid syndrome, psychoorganic syndromes, for paranoid delusions (especially noticeable when substantiating a delusional system).
Disorders of the semantic content of the associative process
Overvalued ideas- thoughts that are closely fused with the personality of the patient, determining his behavior, having a basis in a real situation, arising from it. Criticism towards them is flawed, incomplete. According to the content, overvalued ideas of jealousy, invention, reformism, personal superiority, litigious, hypochondriacal content are distinguished.
The interests of patients are narrowed down to overvalued ideas that occupy a dominant position in the mind. Most often, overvalued ideas arise in psychopathic personalities (too self-confident, anxious, suspicious, with low self-esteem) and in the structure of reactive states.
crazy ideas- false conclusions that arise on a painful basis, the patient is not critical of them, cannot be dissuaded. The content of delusional ideas determines the behavior of the patient. The presence of delusions is a symptom of psychosis.
The main features of delusional ideas: absurdity, incorrectness of the content, complete lack of criticism, impossibility of dissuasion, the determining influence on the patient's behavior.
According to the mechanism of occurrence, the following types of delirium are distinguished.
Primary delusion- delusional ideas arise first. Sometimes it is present as a monosymptom (for example, with paranoia), as a rule, systematized, monothematic. The presence of successive stages of formation is characteristic: delusional mood, delusional perception, delusional interpretation, crystallization of delirium.
Secondary delusion- sensual, arises on the basis of other mental disorders.
Effective nonsense. Closely associated with severe emotional pathology. It is subdivided into holotimic and catathymic.
Golotimny delirium occurs with polar affective syndromes. With euphoria - ideas with increased self-esteem, and with melancholy - with a low one.
Catatim delirium occurs in certain life situations, accompanied by emotional stress. The content of the delusion is related to the situation and personality traits.
Induced (suggested) delirium. It is observed when a patient (inductor) convinces others of the reality of his conclusions, as a rule, it occurs in families.
Depending on the content of delusional ideas, several characteristic varieties of delusions are distinguished.
Persecurative forms of delusions (delusions of influence) At delusions of persecution the patient is convinced that a group of persons or one person is pursuing him. Patients are socially dangerous, because they themselves begin to pursue suspected persons, whose circle is constantly growing. They need hospital treatment and long-term observation.
delusions of relationship- patients are convinced that others have changed their attitude towards them, become hostile, suspicious, constantly hinting at something.
Delusions of special significance- Patients believe that TV shows are selected especially for them, everything that happens around has a certain meaning.
Delusion of poisoning- the name itself reflects the essence of delusional experiences. The patient refuses to eat, often there are olfactory and gustatory hallucinations.
Delusion impact- the patient is convinced that imaginary pursuers in some special way (evil eye, damage, special electric currents, radiation, hypnosis, etc.) affect his physical and mental state (Kandinsky-Clerambault syndrome). The delusion of influence can be inverted when the patient is convinced that he himself influences and controls others (inverted Kandinsky-Clerambault syndrome). Often the delirium of love influence is singled out separately.
Crazy ideas of material damage(robbing, stealing) are characteristic of involutional psychoses.
Delusional ideas of greatness. Delusions of grandeur include a group of different delusions that can be combined in the same patient: delirium of power(the patient claims to be endowed with special abilities, power); reformism(ideas about the reorganization of the world); inventions(belief in the accomplishment of a great discovery); special origin(the conviction of patients that they are descendants of great people).
Manichaean delirium- the patient is convinced that he is at the center of the struggle between the forces of good and evil.
Mixed forms of delusions
Brad staging. Patients are convinced that those around them are putting on a performance especially for them. Fit with delirium of intermetamorphosis, which is characterized by delusional forms of false recognitions.
Symptom of a negative and positive twin (Karpg's syndrome). With a symptom of a negative twin, the patient takes loved ones for strangers. False recognition is typical.
With the symptom of a positive twin, strangers and strangers are perceived as acquaintances and relatives.
Symptom Fregoli - it seems to the patient that the same person appears to him in various reincarnations.
Delusion of self-accusation(they are convinced that they are sinners).
Delusions of megalomaniac content- the patient believes that because of him all mankind suffers. The patient is dangerous for himself, extended suicides are possible (the patient kills his family and himself).
End of introductory segment.
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Mental illness, like any other chronic illness, can cause a family crisis. A severe mental disorder imposes restrictions on the organization of family life, requires a change in the habitual way of life of all its members, compliance with a special regime, forces them to give up pleasant habits, change plans for the future, redistribute responsibilities, not to mention feelings of uncertainty, helplessness, fear, and the patient and his relatives. The burden of care and responsibility for the future of a loved one falls on the relatives of a sick person.
Mentally ill people and their relatives are often in social isolation. And this leads to a reduction in ties with a wider social environment, which is one of the most important factors that reduce the quality of family life.
Diagnosis of a mental disorder often leads the patient's relatives to "feelings of guilt and shame", many of them hide the very fact that there is a mentally ill person in the family, they are afraid that someone will find out about the relative's illness.
To make it easier for relatives of the mentally ill to cope with emerging problems, they need information about the illness of a loved one, methods of treatment, the system for organizing psychiatric and social assistance, and forms of assistance directly in the community. They can get this information in psychiatric literacy courses.
Psychiatric education as a form of informational and socio-psychological support for relatives of patients and the patients themselves began to be actively introduced in our country. As a rule, psychiatric education programs combine two components - informational and socio-psychological support.
Psychiatric education serves as the basis for:
understanding the illness of a loved one and helping him cope with it
prevention of exacerbations and repeated hospitalizations;
early access to help in case of exacerbation of the disease;
In our organization, the program of psychiatric education for relatives of the mentally ill has been conducted since 1996. The tasks that we solve by conducting classes with relatives are as follows:
1. instilling a scientifically based understanding of mental illness, their nature, possible manifestations, course, prognosis, system of care and monitoring of patients, alternatives to drug treatment, tactics of modern social rehabilitation measures;
2. prevention of recurrence of the disease;
3. improving patient compliance and understanding the importance of psychosocial programs;
4. development and maintenance of realistic expectations regarding the mental state and social functioning of the patient;
5. search for peace of mind through knowledge and mutual emotional support;
6. reducing social exclusion and isolation, creating a natural network of social support
7. overcoming feelings of guilt, impotence, shame, despair associated with the disease;
8. creating an atmosphere of empathy and informed optimism for each participant.
Working with relatives of the mentally ill involves a less benign discussion than with patients about prognosis, long-term supportive care, stigma, and disability. In the classroom, other tasks are also solved: we pay attention to the development of skills for solving problems, communicating with medical staff and in the family.
When conducting an educational program for relatives of the mentally ill, an interactive learning model is used (exchange of opinions, experiences, encouragement to be active in the process of conducting classes, expression of feelings, support). The classes are supported by a friendly atmosphere, respectful attitude, the expectations and individual needs of the program participants are always taken into account.
The classes have a clear structure - each lesson begins with a greeting, identifying the participants' requests on the topic of the lesson (15 minutes). Then follows the main part in the form of lectures, reports (1 - 1.5 hours). This part of the lesson is accompanied by an exchange of experience of the listeners, in the course of the presentation they can ask a question, exchange opinions. At the end of the lesson, its results are summed up, a repetition of the past is carried out, a short discussion (15 minutes).
Leading classes (doctors, psychologists, social workers) present the material in a simple and understandable language for the audience. The group consists of 12 - 15 listeners. Classes are held once a week, in the evening. The course of study is usually three months.
The basic training course for relatives of patients suffering from chronic mental illness, as well as the content of the classes (in the form of lectures) are presented below.
1st lesson. Acquaintance. Goals and objectives of the program of psychiatric education. Determination of information requests of relatives of patients. Determination of the rules for conducting classes. A conversation about the family, its functions, problems that arise when one of its members falls ill with a mental disorder, about helping the family during this period.
“The family meets with the disease earlier than the doctor, at the stage of pre-symptoms and the first, so-called hidden, obscure symptoms. The reaction to the occurrence of the disease depends on the severity and speed of its development, ideas about it and prejudices. With an acute - sudden onset, the period of uncertainty in terms of establishing a diagnosis is small. With its slow development, this period, which is very disturbing for loved ones, can stretch for months and even years.»
From the lecture “The Family and Mental Illness: What Can Help the Family to Overcome the Illness”:
“There is no need to rush. The recovery process can be lengthy. It is very important to get more rest. Everything will fall into place in time. Keep calm. The manifestation of excessive enthusiasm is a normal reaction. Try to moderate it. Disagreement is also normal. Try to be calm about it."
2nd lesson. Psychiatry as a medical discipline. Classification of mental disorders, their prevalence, causes, course, prognosis.
From the lecture "Psychiatry, its boundaries, problems and tasks": All attempts to draw a clear line between the concepts of mental norm and pathology have so far been unsuccessful. Therefore, psychiatrists make a conclusion about the absence or presence of such a pathology in a particular person, based on the experience of their work, studying the characteristics of the manifestations of the disease, the patterns of its development and course in many patients, as well as the results of additional studies, and when pathology is detected, they characterize it as a mental disorder, mental illness, symptom or syndrome.
3rd lesson. Symptoms and syndromes of mental illness.
You will learn about the manifestations of mental disorders in the lecture "The main symptoms and syndromes of mental disorders".
From the lecture: Speaking of depression, we, first of all, have in mind the following manifestations of it.
1. Decreased mood, a feeling of depression, depression, melancholy, in severe cases, felt physically as heaviness, or pain in the chest. This is an extremely painful condition for a person.
2. Decrease in mental activity (thoughts become poorer, short, vague). A person in this state does not answer questions immediately - after a pause, he gives short, monosyllabic answers, speaks slowly, in a quiet voice. Quite often, patients with depression note that they find it difficult to understand the meaning of the question asked to them, the essence of what they have read, and complain of memory loss. Such patients have difficulty making decisions and cannot switch to new activities.
3. Motor inhibition - patients experience weakness, lethargy, muscle relaxation, they talk about fatigue, their movements are slow, constrained.
4th lesson. Schizophrenia: clinic, course, prognosis.
From a lecture "Some of the most common mental disorders: schizophrenia, mood disorders, neurotic disorders, disorders associated with exposure to external factors": Schizophrenia is the most important clinical and social problem of psychiatry worldwide: it affects about 1% of the world's population, and is recorded annually in the world 2 million new cases. In terms of prevalence, schizophrenia occupies one of the first places among mental illnesses and is the most common cause of disability.
5th lesson. Identification of signs of recurrence of the disease. The concept of "handwriting of relapse" (a purely personal combination of precursors of relapse), the necessary actions at an early, middle or late stage of relapse.
For information on how to communicate with a family member suffering from a mental disorder, you can learn in the lecture "How loved ones cope with everyday problems that arise when living together with a mentally ill person."
From the lecture: An important point that stabilizes the condition of a sick person is the preservation of the usual, simple life routine in the house, for example, a stable time to get up in the morning, sleep time, and meal hours. It is necessary to create a calm, consistent, predictable life as much as possible. This will enable the sick person to cope with anxiety, confusion, to understand what and at what time you expect from him and what to expect from you in turn.
6th lesson Treatment of schizophrenia.
From a lecture «Modern therapy of schizophrenia: The main pharmacological action of neuroleptics is the blocking of dopamine receptors, resulting in the normalization of the activity of the dopamine system of brain cells, namely, the decrease in this activity to the optimal level. Clinically, i.e. at the level of symptoms of the disease, this corresponds to a noticeable decrease or complete disappearance of the productive symptoms of the disease (delusions, hallucinations, catatonic symptoms, agitation, attacks of aggression). The ability of neuroleptics to completely or partially suppress such manifestations of psychosis as delusions, hallucinations, catatonic symptoms is called antipsychotic action.
7th lessons. Treatment of affective disorders.
» . Psychotherapy for schizophrenia and affective disorders ”: Treatment of a depressive state involves the appointment of antidepressants - drugs that improve mood. Their effect is due to the influence on various neurotransmitter systems, and primarily on the noradrenal and serotonin systems.
From the lecture "Treatment of affective disorders » . Psychotherapy for Schizophrenia and Mood Disorders: …Psychotherapy for people with schizophrenia or affective disorders can be directed at different levels of functioning. Firstly, with the help of special psychotherapeutic and training techniques, it is possible to influence the basic mental - cognitive (cognitive) functions: attention, memory, thinking.
8th lesson. Psychological problems in families, ways to solve them.
From the topic lecture: Feeling imaginary guilt, relatives seek to atone for it and behave in such a way as if they harmed the patient. Many are afraid of being exposed for what they think they have done wrong, and fearfully await public blame. They painfully decide whether they are guilty and how much. This leads to an endless search for who else is to blame for the illness of a relative, this, as it were, removes part of the blame from them. The search for the guilty does not allow you to experience grief, loss. They remain and do not allow to accept the situation as it is, to live peacefully and constructively resolve. .
9th lesson. Modern system of psychiatric and social assistance.
You can read about how psychiatric care works, its capabilities, and current development trends in the lecture. "Psychiatric care: history and current state".
10th and 11th lessons. General overview of legislation relating to the provision of psychiatric care. Rights and benefits of the mentally ill.
We recommend reading the following thematic lectures: and "Involuntary (forced) hospitalization of citizens in a psychiatric hospital"
From the lecture: “General review of the legislation on psychiatric care. Compulsory measures of a medical nature" “Everyone has the right to health care and medical care” - this is what Article 41 of the Constitution of the Russian Federation says. This right of every citizen of Russia and a person on its territory requires proper legislative regulation. The main normative act regulating this range of legal relations on the territory of the Russian Federation is the Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens.
From the lecture:"Involuntary (forced) hospitalization of citizens in a psychiatric hospital" Article 29The Law of the Russian Federation "On psychiatric care and guarantees of the rights of citizens in its provision" defines the grounds for placing a citizen in a psychiatric hospital. The structure of this article includes three criteria required for involuntary (forced) hospitalization in a psychiatric hospital.
Lesson 12 (final). Psychosocial rehabilitation: basic concepts, forms and methods of work. Help the family in the rehabilitation of the patient. Community organizations, support groups, other community resources. Parting. Obtaining books, brochures, designed for user assistance. Tea drinking.
You can get acquainted with the basic principles, methods and types of psychosocial rehabilitation in the thematic lecture "Psychosocial rehabilitation: a modern approach".
From the lecture: Rehabilitation in patients with mental disorders, as in somatic diseases, is recommended to begin when the condition stabilizes and the pathological manifestations weaken. For example, rehabilitation of a patient with schizophrenia should begin when symptoms such as delusions, hallucinations, thought disorders, etc. decrease. But even if the symptoms of the disease remain, rehabilitation can be carried out within the limits of the patients' ability to succumb to learning, respond to psychosocial interventions.
In our experience, after the relatives of patients undergo a psychoeducation course, their knowledge in the field of psychiatry increases, skills for effective communication with the patient are formed, the social network expands, and, which is very important, a general idea of their own psychological problems appears and a request for help in solving them . Therefore, after completing a psychoeducation course, depending on the nature of the problems and the degree of readiness (motivation) to solve them, we offer relatives short-term forms of psychological assistance (psychological counseling, training) or long-term psychotherapy.
Here are some reviews of parents - participants in the program of family psychiatric education.
“I have been a participant in a psychiatric education program for several months now and I realized that the feelings I experienced were a normal reaction to my daughter's illness: I was very afraid that I myself was sick. Now I have someone to talk to, they understand me, I don't feel as lonely as before. And most importantly, every time I come to class, I learn something important and new for myself.”
(I.G., 62 years old).
“Neighbors do not understand me and are afraid of my son. Now I sometimes tell them about psychiatry, about how people like my sick son are treated in England. They are surprised and even once, when my son fell ill again, they asked how to help me.”
(T.S., aged 52).
“I take advice. Before, it seemed to me that nothing changes in my wife's illness. And now, looking back, as I was taught, I compare what was before and what is now, and I see improvements - small, but they are. ”(P.G., 48 years old).
M. M. Rakitin
Selected Lectures on Psychiatry
Foreword
The presented work aims to familiarize psychiatrists, narcologists and psychotherapists with the main topical issues that arise in the diagnosis and treatment of the most common diseases in the 21st century. Lectures are devoted to the problems of general psychopathology (clinical syndromology), psychopathy (in modern terminology - personality disorders), drug addiction psychopathology and, finally, topical issues of the clinic and treatment of meth-alcohol psychoses.
It should be noted that many questions are based on non-traditional approaches, which forces a new approach to the diagnosis of mental illness. This is especially true for clinical syndromology. In these lectures, we tried to treat terms and definitions as carefully as possible.
The lecture on the psychopathology of drug addiction presents non-traditional views on the qualifications of intoxication, withdrawal and post-abstinence states. It seems to us that the underestimation of the possibility of the appearance of equivalents of epileptiform paroxysms in post-withdrawal states and remissions often leads to a breakdown in both inpatient and outpatient remission.
The lecture on meth-alcohol psychoses traces the continuum: abstinence - delirium tremens - encephalopathy, which is considered as a single process of only varying degrees of severity, and the proposed treatment of these conditions is based on a single biochemical process. The principles of the treatment process used, which are not based on such an approach, often lead to disastrous results for patients. The adequacy of classifying alcoholic hallucinoses and paranoids as meth-alcohol psychoses is called into question.
No less controversial are the issues of diagnosing psychopathy. The well-known criteria - stability, totality and severity to the degree of maladaptation, as shown by follow-up studies, were not specific enough, and the very concept of psychopathy is still in the zone of diagnostic uncertainty. This becomes especially clear in connection with the advent of the tenth revision of mental illness. The concept of “Personality Disorder” includes both constitutional psychopathy and psychopathization of the personality and the neurotic development of the personality and even sociopathy.
Candidate of Medical Sciences, Associate Professor V. Ya. Evtushenko
Clinical syndromology
Introduction to General Psychopathology
The study of any discipline begins with an acquaintance with the terminological apparatus, various concepts, their content. The most common concept in medicine is the concept of DISEASE. Virchow gave the following definition of it: illness is life in cramped conditions. The definition is very concise, incomplete and may include various states of being, that is, it is not specific, because limited means are also life in cramped conditions. There are more common definitions, but they, like the first, suffer from either vagueness and verbosity, or extreme vagueness. Thus, it is extremely difficult to define the most general concepts, but on the other hand, they still have to be done so that specialists can understand each other.
Psychiatry deals mainly with diseases of two types:
Psychosis - by this term we mean a violation of the arbitrary adaptation of a person's mental activity.
Neurosis - Violation of the vital adaptation of the personality.
The division is very conditional, it is enough to recall that many psychoses manifest neurosis-like symptoms, in which vital maladjustment comes to the fore. And on the other hand, in actually neurotic disorders, there are separate signs of arbitrary maladaptation. With this example, we wanted to demonstrate the impossibility of giving a definitive definition of the most general terms.
The structural elements of mental illness are studied by general psychopathology, without which psychiatry would be extremely poor. The doctrine of psychopathological syndromes, first developed by the German psychiatric school, helped to understand the chaos of mental illness.
General psychopathology studies the cross section of the disease, i.e., syndromes, its structural elements, their genetic connection, developmental dynamics. At first, it was believed that the syndrome and status are synonyms, the syndrome is simply the quintessence of status. Now this situation no longer suits us, because the status gives only a cross section of the disease, and we need the dynamics of the disease - syndromokinesis (a series of statuses). At the moment, the syndrome is understood not only as a status, but as its dynamics and severity. That is, the concept of syndrome and syndromokinesis gradually merge.
Earlier, a lot was said about the various variants and types of the syndrome, simple, complex, small, large syndromes, etc. were described. A complex syndrome was considered as a combination of simple ones, large - small ones. Apparently, such ideas are too mechanistic and insufficient, because the addition of quantitative indicators entails qualitative changes. The doctrine of syndromes has not been fully developed so far, there is a lot of confusion in it. We give a slightly different didactic scheme.
The syndrome as a complex formation consists of elementary structural units. Probably, the elementary unit can be considered a symptom. Actually, the classification of the manifestations of the disease begins with it. Symptoms can be subjective and objective. For example: headache - self-report, the patient's complaints with it should be regarded as a subjective symptom; and the appearance and behavior of the patient, as objective. Hallucinations: - the patient's story about sensations is a subjective symptom, and the patient's behavior during them (looks around, listens, shakes something off) is an objective syndrome. Of course, it can be difficult to distinguish between them, but it is still necessary to strive for this, since we naturally prefer the objective signs of the disease. On the other hand, the doctor does not have the right to ignore subjective symptoms because of the presumption of trust in the patient. It seems to us that the desire of medicine only to objectify the disease, saturate it with technology and blind faith in its testimony offends a sick person and impoverishes the clinic. It is known that the sensory apparatus of the body reacts extremely subtly to almost any changes in internal homeostasis and, long before the appearance of objective signs, it signals about malfunctions in one or another organ, organ system.
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