In the third issue of the journal World Psychiatry for 2013 (currently available only in English, a Russian translation is in preparation), the working group for the preparation of ICD-11 diagnostic criteria for stress disorders presented its draft of a new section of the international classification.
PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. However, approaches to diagnosing these conditions have remained the subject of serious controversy for a long time due to the nonspecificity of many clinical manifestations, difficulties in distinguishing painful conditions from normal reactions to stressful events, the presence of significant cultural characteristics in responding to stress, etc.
Much criticism has been leveled at the criteria for these disorders in the DSM-IV and DSM-5. For example, according to the working group members, adjustment disorder is one of the most poorly defined mental disorders, which is why it is often described as a “garbage bin” diagnosis in the psychiatric classification scheme. D The diagnosis of PTSD has been criticized for its wide combination of different symptom clusters, low diagnostic threshold, high level of comorbidity, and, in relation to DSM-IV criteria, for the fact that more than 10 thousand different combinations of 17 symptoms can lead to this diagnosis.
All this served as the reason for a fairly serious revision of the criteria for this group of disorders in the ICD-11 project.
The first innovation concerns a name for a group of stress-related disorders. In ICD-10 there is a heading F43 “Reaction to severe stress and adjustment disorders”, which belongs to the section F40 - F48 “Neurotic, stress-related and somatoform disorders”. The Working Group recommends avoiding the commonly used but confusing term " stress-related disorders", due to the fact that numerous disorders can be associated with stress (for example, depression, disorders associated with the use of alcohol and other psychoactive substances, etc.), but most of them can also occur in the absence of stressful or traumatic life events events. In this case, we are talking only about disorders for which stress is an obligatory and specific cause of their development. An attempt to emphasize this point in the ICD-11 draft was the introduction of the term “disorders specifically associated with stress,” which can probably most accurately be translated into Russian as “ disorders, directly stress related" This is the name planned to be given to the section where the disorders discussed below will be placed.
The working group's proposals for specific disorders include:
- more narrow concept of PTSD, which does not allow a diagnosis to be made based only on nonspecific symptoms;
- new category " complex PTSD"("complex PTSD"), which, in addition to the core symptoms of PTSD, additionally includes three groups of symptoms;
- new diagnosis prolonged grief reaction”, used to characterize patients who experience an intense, painful, disabling, and abnormally persistent reaction to bereavement;
- significant revision of diagnostics " adjustment disorders", including specification of symptoms;
- revision concepts« acute reaction to stress"in line with the idea of this condition as a normal phenomenon, which, however, may require clinical intervention.
In general, the proposals of the working group can be presented as follows:
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Previous ICD-10 codes |
Main diagnostic signs in the new edition |
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Post-traumatic stress disorder (PTSD) |
A disorder that develops following exposure to an extreme threatening or terrifying event or series of events and is characterized by three “core” features:
Symptoms must last for at least several weeks and cause significant deterioration in functioning. The introduction of a criterion for impaired functioning is necessary to increase the diagnostic threshold. In addition, the authors of the project are also trying to increase the ease of diagnosis and reduce comorbidity by identifying core elements PTSD, and not lists of equivalent “typical signs” of the disorder, which, apparently, is a certain deviation from the usual operational approach in diagnosis for the ICD to ideas closer to those of Russian psychiatry about the syndrome. |
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Complex post-traumatic stress disorder |
A disorder that occurs after exposure to an extreme or long-term stressor that is difficult or impossible to recover from. The disorder is characterized main (core) symptoms of PTSD(see above), as well as (in addition to them) the development of persistent, end-to-end disturbances in the affective sphere, attitude towards oneself and social functioning, including:
Complex PTSD is a new diagnostic category, it replaces its overlapping ICD-10 category F62.0 “Persistent personality changes after disaster experience,” which failed to attract scientific interest and did not include disorders resulting from prolonged stress in early childhood. These symptoms may occur following exposure to a single traumatic stressor, but more often occur following severe prolonged stress or multiple or repeated adverse events that cannot be avoided (eg, exposure to genocide, child sexual abuse, exposure to children in war, severe domestic violence , torture or slavery). |
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Prolonged grief reaction |
A disorder in which, after the death of a loved one, persistent and all-encompassing sadness and longing for the deceased or constant immersion in thoughts about the deceased persist. Experience Data:
These experiences can also be characterized as difficulty accepting death, a sense of losing part of oneself, anger at the loss, feelings of guilt, or difficulty engaging in social and other activities. Several sources of evidence indicate the need to introduce a prolonged grief reaction:
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Adjustment disorder |
A maladjustment response to a stressful event, ongoing psychosocial difficulties, or a combination of stressful life events that typically occurs within a month of exposure to the stressor and tends to resolve within 6 months unless the stressor persists for a longer period. The stressor response is characterized by symptoms of preoccupation with the problem, such as excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its consequences. There is an inability to adapt, i.e. symptoms interfere with daily functioning, difficulty concentrating or sleep disturbances occur, leading to impaired performance. Symptoms may also be associated with loss of interest in work, social life, caring for others, or leisure activities, leading to impairment in social or professional functioning (limited social circle, conflicts in the family, absenteeism from work, etc.). If diagnostic criteria are met for another disorder, then that disorder should be diagnosed instead of adjustment disorder. According to the authors of the project, there is no evidence of the validity of the subtypes of adjustment disorder described in ICD-10, and therefore they will be removed from ICD-11. Such subtypes may be misleading by focusing on the dominant content of distress, thereby obscuring the underlying commonality of these disorders. Subtypes are not relevant to treatment choice and are not associated with a specific prognosis |
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Reactive attachment disorder |
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Disinhibited attachment disorder |
See Rutter M, Uher R. Classification issues and challenges in childhood and adolescent psychopathology. Int Rev Psychiatry 2012; 24:514-29 |
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Conditions that are not disorders and are included in the section “Factors influencing the state of public health and visits to health care institutions” (Chapter Z in ICD-10) |
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Acute reaction to stress |
Refers to the development of transient emotional, cognitive, and behavioral symptoms in response to exceptional stress, such as an extreme traumatic experience, that entails serious harm or threat to the safety or physical integrity of the person or those close to the person (eg, natural disasters, accidents, military assaults, assaults, rape), or unexpected and dangerous changes in an individual's social status and/or environment, such as the loss of one's family due to a natural disaster. Symptoms are considered as a normal spectrum of reactions caused by extreme severity of the stressor. Symptoms are usually found over a period of several hours to several days from exposure to stressful stimuli or events, and usually begin to subside within a week after the event or after the threatening situation has resolved. According to the authors of the project, the proposed ICD-11 description of the acute reaction to stress " does not meet the requirements of the definition of mental disorder" and the duration of symptoms will help distinguish acute stress reactions from pathological reactions associated with more severe disorders. However, if we recall, for example, the classical descriptions of these states by E. Kretschmer (whom the authors of the project, apparently, did not read and the last edition of his “Hysteria” in English dates back to 1926), then nevertheless their removal beyond the boundaries of pathological states causes some doubt. Probably, following this analogy, hypertensive crisis or hypoglycemic conditions should be removed from the list of pathological conditions and headings of the ICD. They, too, are only transient conditions, but not “disorders.” In this case, the authors interpret the medically unclear term disorder closer to the concept of a disease than a syndrome, although according to the general (for all specialties) conceptual model used to prepare ICD-11, the term “disorder” may include both diseases and syndromes. |
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The next steps in the development of the ICD-11 project on disorders directly related to stress will be public discussion and field testing.
Acquaintance with the project and discussion of proposals will be carried out using the ICD-11 beta platform ( http://apps.who.int/classifications/icd11/browse/f/en). Field studies will evaluate the clinical acceptability, clinical utility (eg, ease of use), reliability, and, to the extent possible, validity of draft definitions and diagnostic guidelines, particularly in comparison with ICD-10.
WHO will use two main approaches to test draft ICD-11 sections: online studies and studies in clinical settings. Online research will be conducted primarily within , which currently includes more than 7,000 psychiatric and primary care physicians. Research into disorders directly related to stress is already planned. Research in clinical settings will be carried out through the international network of WHO Collaborating Clinical Research Centres.
The Working Group looks forward to collaborating with colleagues around the world to test and further refine proposals for diagnostic guidelines for disorders specifically related to stress in ICD-11.
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This group of disorders differs from other groups in that it includes disorders identified not only on the basis of symptoms and course, but also on the basis of the evidence of the influence of one or even both causes: an exceptionally adverse life event that caused an acute stress reaction, or a significant changes in life leading to prolonged unpleasant circumstances and causing adaptation disorders. Although less severe psychosocial stress (life circumstances) may precipitate the onset or contribute to the manifestation of the wide range of disorders represented in this class of diseases, its etiological significance is not always clear, and in each case there will be a recognition of dependence on the individual, often on his/her hypersensitivity and vulnerability (i.e. i.e. life events are not necessary or sufficient to explain the occurrence and form of the disorder). In contrast, the disorders collected under this heading are always considered to be a direct consequence of acute severe stress or prolonged trauma. Stressful events or prolonged unpleasant circumstances are the primary or predominant causative factor and the disorder would not have occurred without their influence. Thus, the disorders classified under this heading may be viewed as perverse adaptive responses to severe or prolonged stress, interfering with successful stress management and consequently leading to problems in social functioning.
Acute reaction to stress
A transient disorder that develops in a person without any other mental health symptoms in response to unusual physical or mental stress and usually subsides after a few hours or days. Individual vulnerability and self-control play a role in the prevalence and severity of stress reactions. Symptoms show a typically mixed and variable pattern and include an initial state of "dazedness" with some narrowing of the area of consciousness and attention, inability to fully become aware of stimuli, and disorientation. This state may be accompanied by subsequent “withdrawal” from the surrounding situation (to a state of dissociative stupor - F44.2) or agitation and hyperactivity (flight or fugue reaction). Typically, some features of panic disorder are present (tachycardia, excessive sweating, flushing). Symptoms usually begin within minutes of exposure to a stressful stimulus or event and disappear within 2-3 days (often within a few hours). Partial or complete amnesia (F44.0) for the stressful event may be present. If the above symptoms are persistent, it is necessary to change the diagnosis. Acute: crisis reaction, reaction to stress, nervous demobilization, crisis state, mental shock.
A. Exposure to a purely medical or physical stressor.
B. Symptoms occur immediately following exposure to the stressor (within 1 hour).
B. There are two groups of symptoms; The reaction to acute stress is divided into:
F43.00 light only the following criterion is met 1)
F43.01 moderate criterion 1) is met and any two symptoms from criterion 2) are present
F43.02 severe criterion 1) is met and any 4 symptoms from criterion 2 are present); or there is dissociative stupor (see F44.2).
1. criteria B, C and D for generalized anxiety disorder (F41.1) are met.
2. a) Avoidance of upcoming social interactions.
b) Narrowing of attention.
c) Manifestations of disorientation.
d) Anger or verbal aggression.
e) Despair or hopelessness.
f) Inappropriate or aimless hyperactivity.
g) Uncontrollable and excessive grief experience (considered in accordance with
local cultural standards).
D. If the stressor is temporary or can be relieved, symptoms should begin
decrease after no more than eight hours. If the stressor persists,
Symptoms should begin to subside in no more than 48 hours.
D. Most commonly used exclusion criteria. The reaction must develop in
absence of any other mental or behavioral disorder in the ICD-10 (except for F41.1 (generalized anxiety disorders) and F60- (personality disorders)) and at least three months after the end of an episode of any other mental or behavioral disorder.
Post-traumatic stress disorder
Occurs as a delayed or protracted response to a stressful event (brief or long-term) of an exceptionally threatening or catastrophic nature, which can cause profound stress in almost anyone. Predisposing factors, such as personality traits (compulsiveness, asthenia) or a history of nervous illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are never necessary or sufficient to explain its occurrence. Typical signs include episodes of repeated reliving of the traumatic event in intrusive memories (“flashbacks”), thoughts, or nightmares that appear against a persistent background of feelings of numbness, emotional inhibition, detachment from other people, unresponsiveness to the environment, and avoidance of activities and situations that remind of the trauma. Overexcitement and severe hypervigilance, increased startle response and insomnia usually occur. Anxiety and depression are often associated with the above symptoms, and suicidal ideation is not uncommon. The onset of symptoms of the disorder is preceded by a latent period after the injury, ranging from several weeks to several months. The course of the disorder varies, but in most cases recovery can be expected. In some cases, the condition may become chronic over many years, with possible progression to permanent personality changes (F62.0). Traumatic neurosis
A. The patient must be exposed to a stressful event or situation (both short-term and long-lasting) of an extremely threatening or catastrophic nature, which can cause general distress in almost any individual.
B. Persistent memories or “reliving” of the stressor in intrusive flashbacks, vivid memories, or recurring dreams, or re-experiencing grief when exposed to circumstances reminiscent of or associated with the stressor.
B. The patient must exhibit actual avoidance or a desire to avoid circumstances that resemble or are associated with the stressor (which was not observed before exposure to the stressor).
D. Either of the two:
1. psychogenic amnesia (F44.0), either partial or complete regarding important aspects of the period of exposure to the stressor;
2. Persistent symptoms of increased psychological sensitivity or excitability (not observed before the stressor), represented by any two of the following:
a) difficulty falling asleep or staying asleep;
b) irritability or outbursts of anger;
c) difficulty concentrating;
d) increasing the level of wakefulness;
e) enhanced quadrigeminal reflex.
Criteria B, C and D occur within six months of the stressful situation or at the end of a period of stress (for some purposes, the onset of the disorder delayed by more than six months may be included, but these cases must be clearly defined separately).
Adjustment disorder
A state of subjective distress and emotional disturbance that creates difficulties in social activities and behavior, occurring during the period of adaptation to a significant life change or stressful event. A stressful event may disrupt the integrity of an individual's social networks (bereavement, separation) or a broader system of social support and values (migration, refugee status) or represent a wide range of changes and turning points in life (entry to school, becoming a parent, failure to achieve a cherished personal goals, retirement). Individual predisposition or vulnerability play an important role in the risk of occurrence and form of manifestation of disorders of adaptive reactions, but the possibility of such disorders occurring without a traumatic factor is not allowed. Manifestations are highly variable and include depressed mood, wariness or anxiety (or a combination of these), feelings of inability to cope, plan ahead, or decide to stay in the present situation, and also include some degree of decreased ability to function in daily life. At the same time, behavioral disorders may occur, especially in adolescence. A characteristic feature may be a short or long-term depressive reaction or disturbance of other emotions and behavior: Culture shock, Grief reaction, Hospitalization in children. Excludes: separation anxiety disorder in children (F93.0)
A. The development of symptoms must occur within one month of exposure to an identifiable psychosocial stressor that is not of an unusual or catastrophic type.
B. Symptoms or behavioral disturbance of the type found in other affective disorders (F30-F39) (excluding delusions and hallucinations), any of the disorders in F40-F48 (neurotic, stress-related and somatoform disorders) and conduct disorders (F91-) , but in the absence of criteria for these specific disorders. Symptoms can vary in form and severity. The predominant features of symptoms can be determined using the fifth character:
F43.20 Short depressive reaction.
Transient mild depressive state, lasting no more than one month
F43.21 Prolonged depressive reaction.
A mild depressive state resulting from prolonged exposure to a stressful situation, but lasting no more than two years.
F43.22 Mixed anxious and depressive reaction.
Symptoms of both anxiety and depression are prominent, but at levels no higher than those defined for mixed anxiety and depressive disorder (F41.2) or other mixed anxiety disorders (F41.3).
F43.23 With a predominance of disorders of other emotions
Symptoms are usually of several emotional types, such as anxiety, depression, restlessness, tension and anger. Symptoms of anxiety and depression may meet criteria for mixed anxiety-depressive disorder (F41.2) or other mixed anxiety disorders (F41.3), but they are not so dominant that other more specific depressive or anxiety disorders would be diagnosed. This category should also be used for reactions in children who also have regressive behaviors such as bedwetting or thumb sucking.
F43.24 With a predominance of behavioral disorders. The main disorder involves behavior, for example, in adolescents, the grief reaction manifests itself as aggressive or antisocial behavior.
F43.25 With mixed disorders of emotions and behavior. Both emotional symptoms and behavioral disturbances are pronounced.
F43.28 With other specified predominant symptoms
B. Symptoms do not last more than six months after the stress or its consequences cease, with the exception of F43.21 (prolonged depressive reaction), but this criterion should not preclude a provisional diagnosis.
This group of disorders differs from other groups in that it includes disorders identified not only on the basis of symptoms and course, but also on the basis of the evidence of the influence of one or even both causes: an exceptionally adverse life event that caused an acute stress reaction, or a significant changes in life leading to prolonged unpleasant circumstances and causing adaptation disorders. Although less severe psychosocial stress (life circumstances) may precipitate the onset or contribute to the manifestation of the wide range of disorders represented in this class of diseases, its etiological significance is not always clear, and in each case there will be a recognition of dependence on the individual, often on his/her hypersensitivity and vulnerability (i.e. i.e. life events are not necessary or sufficient to explain the occurrence and form of the disorder). In contrast, the disorders collected under this heading are always considered to be a direct consequence of acute severe stress or prolonged trauma. Stressful events or prolonged unpleasant circumstances are the primary or predominant causative factor and the disorder would not have occurred without their influence. Thus, the disorders classified under this heading may be viewed as perverse adaptive responses to severe or prolonged stress, interfering with successful stress management and consequently leading to problems in social functioning.
Acute reaction to stress
A transient disorder that develops in a person without any other mental health symptoms in response to unusual physical or mental stress and usually subsides after a few hours or days. Individual vulnerability and self-control play a role in the prevalence and severity of stress reactions. Symptoms show a typically mixed and variable pattern and include an initial state of "dazedness" with some narrowing of the range of consciousness and attention, inability to fully become aware of stimuli, and disorientation. This state may be accompanied by subsequent “withdrawal” from the surrounding situation (to a state of dissociative stupor - F44.2) or agitation and hyperactivity (flight or fugue reaction). Typically, some features of panic disorder are present (tachycardia, excessive sweating, flushing). Symptoms usually begin within minutes of exposure to a stressful stimulus or event and disappear within 2-3 days (often within a few hours). Partial or complete amnesia (F44.0) for the stressful event may be present. If the above symptoms are persistent, it is necessary to change the diagnosis.
- crisis response
- stress response
Nervous demobilization
Crisis state
Mental shock
Post-traumatic stress disorder
Occurs as a delayed or protracted response to a stressful event (brief or long-term) of an exceptionally threatening or catastrophic nature, which can cause profound stress in almost anyone. Predisposing factors, such as personality traits (compulsiveness, asthenia) or a history of nervous illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are never necessary or sufficient to explain its occurrence. Typical signs include episodes of repeated reliving of the traumatic event in intrusive memories (“flashbacks”), thoughts, or nightmares that appear against a persistent background of feelings of numbness, emotional inhibition, detachment from other people, unresponsiveness to the environment, and avoidance of activities and situations that remind of the trauma. Overexcitement and severe hypervigilance, increased startle response and insomnia usually occur. Anxiety and depression are often associated with the above symptoms, and suicidal ideation is not uncommon. The onset of symptoms of the disorder is preceded by a latent period after the injury, ranging from several weeks to several months. The course of the disorder varies, but in most cases recovery can be expected. In some cases, the condition may become chronic over many years, with possible progression to permanent personality changes (F62.0).
Traumatic neurosis
Adjustment disorder
A state of subjective distress and emotional disturbance that creates difficulties in social activities and behavior, occurring during the period of adaptation to a significant life change or stressful event. A stressful event may disrupt the integrity of an individual's social networks (bereavement, separation) or a broader system of social support and values (migration, refugee status) or represent a wide range of changes and turning points in life (entry to school, becoming a parent, failure to achieve a cherished personal goals, retirement). Individual predisposition or vulnerability play an important role in the risk of occurrence and form of manifestation of disorders of adaptive reactions, but the possibility of such disorders occurring without a traumatic factor is not allowed. Manifestations are highly variable and include depressed mood, wariness or anxiety (or a combination of these), feelings of inability to cope, plan ahead, or decide to stay in the present situation, and also include some degree of decreased ability to function in daily life. At the same time, behavioral disorders may occur, especially in adolescence. The characteristic feature may be a short or long-term depressive reaction or disturbance of other emotions and behavior.
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GOU DPO "ST. PETERSBURG MEDICAL ACADEMY OF POSTGRADUATE EDUCATION"
DEPARTMENT OF CHILD PSYCHIATRY, PSYCHOPATHY AND MEDICAL PSYCHOLOGY
ABSTRACT TOPIC:
ADAPTATION DISORDERS. SOMATOFORM DISORDERS
PERFORMER: STOLNIKOVA YU.N.
PLACE OF WORK: GUZ
"REGIONAL PSYCHONEUROLOGICAL
HOSPITAL No. 5"
MAGNITOGORSK, 2008.
INTRODUCTION
The entire history of psychiatry bears witness to the fact that the object of study of psychiatrists has almost always been psychotic forms of mental pathology and organic pathology, as the most clinically pronounced diseases, leading to the most severe forms of maladjustment and requiring urgent measures to treat and prevent complications. Naturally, many clinically unexpressed, amorphous, atypical, non-psychotic forms of mental pathology with a completely different developmental stereotype were often not noticed, ignored, and, perhaps, not interpreted as such. Today they are usually referred to as borderline (minor) mental disorders - neuroses, neurotic reactions and conditions, personality disorders, behavioral manifestations, adaptation disorders, somatoform disorders, psychosomatic disorders.
ADAPTATION DISORDERS
Definition of adaptation disorders, etiology
Adaptation disorders (F43.2) according to ICD-10 are characterized by a state of subjective distress and emotional disturbances that arise during the period of adaptation to a significant change in life or a stressful event and create difficulties for life. A stressful event can disrupt the integrity of an individual’s social connections or the system of social support and values (migration, refugee status) or introduce changes in life (entry to an educational institution, the beginning or end of a professional activity, failure to achieve a desired goal, etc.). Individual predisposition and vulnerability matter, but adaptation disorder occurs precisely in response to a traumatic factor. So, for example, adaptation disorders are more common in people with extremely high personal anxiety, with serious somatic diseases, people with disabilities, people who lost their parents in early childhood or experienced a lack of maternal care. Adaptation disorders are most typical for adolescence, which, however, does not exclude the possibility of their occurrence at any age. Most symptoms improve over time without treatment, especially after the stressor ends; with a possible chronic course, there is a risk of secondary depression, anxiety and substance abuse.
Diagnosis of adaptation disorders
Adaptation disorders are diagnosed when the condition meets the following criteria:
1) identified psychosocial stress that does not reach an extreme or catastrophic scale, symptoms appear within a month;
2) individual symptoms (with the exception of delusional and hallucinatory symptoms) that meet the criteria for affective (F3), neurotic, stress and somatoform (F4) disorders and disorders of social behavior (F91), which do not fully correspond to any of them;
3) symptoms do not exceed 6 months in duration from the moment the stress or its consequences ceased, with the exception of prolonged depressive reactions (F43.21).
Symptoms can vary in pattern and severity. Adaptation disorders, depending on the dominant manifestations in the clinical picture, are differentiated as follows:
F43.20 short-term depressive reaction a transient state of mild depression lasting no more than a month;
F43.21 prolonged depressive reaction - a mild depressive state as a reaction to a prolonged stressful situation, lasting no more than two years;
F43.22 mixed anxiety and depressive reaction - both anxiety and depressive symptoms are presented, the intensity not exceeding mixed anxiety and depressive disorder (F41.2) or other mixed anxiety disorders (F41.3);
F43.23 with a predominance of disturbances of other emotions - symptoms have a varied structure of affect, anxiety, depression, restlessness, tension and anger are presented. Symptoms of anxiety and depression may meet the criteria for mixed anxiety and depressive disorder (F41.2) or other mixed anxiety disorders (F41.3), but their severity is not sufficient to diagnose more specific anxiety or depressive disorders. This category should also be used for reactions of childhood, where additional signs of regressive behavior such as enuresis or thumb sucking are present;
F43.24 with a predominance of behavioral disorder - the disorder affects predominantly social behavior, for example, its aggressive or dissocial forms in the structure of the grief reaction in adolescence;
F43.25 mixed disorder of emotions and behavior - both emotional manifestations and disturbances in social behavior are defining;
F43.28 other specific predominant symptoms.
Differential diagnosis
Differential diagnosis of adjustment disorders should include post-traumatic stress disorder, acute stress reaction, brief psychotic disorder, and uncomplicated bereavement. Post-traumatic stress disorder and acute stress reaction are characterized by the fact that these diagnoses are defined by the unusual nature of stress that goes beyond normal human experiences, for example, war, mass disaster, natural disaster, rape, hostage taking. Brief psychotic disorder is characterized by hallucinations and delusions. Uncomplicated bereavement occurs before or shortly after the expected death of a loved one; professional or social functioning deteriorates within the expected period, then spontaneously returns to normal.
Treatment
For the treatment of adaptation disorders, the preferred psychotherapy, which includes exploring the meaning of the stressor for the patient, providing support, encouraging the search for alternative ways to solve the problem, and showing empathy. If anxiety prevails, then it is advisable to use biofeedback, relaxation and hypnosis techniques. Intervention during a crisis is aimed at helping the patient quickly solve the problem through the use of methods of support, suggestion, persuasion, and environmental modification. If necessary, hospitalization is possible. Drug therapy is indicated for severe disorders. Anxiolytics or antidepressants may be used for treatment depending on the type of disorder, but care must be taken to avoid drug dependence (especially with benzodiazepines).
SOMATOFORM DISORDERS
Relevance of the problem of somatoform disorders
The problem of psychosomatic relationships is a subject of debate not only for psychiatry, but also for general human pathology. The question of the influence of normal and pathological bodily sensations on the mental sphere and the development of various psychopathological phenomena is beyond doubt. The presence of somatopsychic disorders is reliable evidence of the existence of a connection between the body and the psyche.
However, increasingly enriched clinical data indicate that changes in the mental sphere can cause bodily (including pathological) changes, thereby causing the development of so-called psychosomatic diseases.
The problem of somatopsychic pathology is covered in sufficient detail in the medical literature. As for psychosomatic disorders, they have not been studied enough and many issues related to this problem are still far from being resolved. Among them, the problem of somatoform disorders remains a particularly controversial and underdeveloped general medical and psychiatric problem. The views of clinicians on this problem are extremely contradictory, and often even diametrically opposed and mutually exclusive.
Timely diagnosis and adequate treatment of these conditions are put forward as priorities for the public health system. The shifts that are taking place in modern psychiatry dictate the relevance and need for a conceptual study of somatoform disorders. These shifts are determined, on the one hand, by a shift in emphasis from “big” to “small” psychiatry, the steady growth of borderline mental pathology; on the other hand, there is a need to understand the accumulated data and information regarding masked depression, conversion disorders, hypochondria, and psychovegetative disorders, which are actually the content of somatized mental disorders. Finally, the need to study somatoform disorders is determined by economic interests - the feasibility of additional, sometimes unjustified material and financial expenses.
Definition
Somatoform disorders are a group of disorders characterized by constant complaints from the patient about a violation of his condition, reminiscent of a somatic disease; at the same time, they do not detect any pathological process that explains their occurrence. The disorder is not caused by another mental illness or substance abuse disorder. If the patient has a physical illness, data from the medical history, physical examination and laboratory tests cannot explain the cause and severity of the complaints. Symptoms are not intentionally invented, unlike artificially demonstrated disorders and malingering. Despite the fact that the onset and persistence of symptoms are often closely related to unpleasant events, difficulties or conflicts, patients usually resist attempts to discuss the possibility of its psychological cause; this may occur even in the presence of distinct depressive and anxiety symptoms. The attainable degree of understanding of the causes of symptoms is often disappointing and frustrating for both the patient and the doctor.
Some researchers are convinced that somatoform symptoms are actually manifestations of latent depression, and on this basis they are treated with antidepressants, others believe that they are special conversion, that is, dissociative disorders, and therefore should be treated with psychotherapeutic methods.
The frequency of somatoform disorders is 0.1-0.5% of the population. Somatoform disorders are more often observed in women.
Somato classificationform disorders (according to ICD-10)
F45.0 Somatization disorder.
F45.1 Undifferentiated somatoform disorder.
F45.2 Hypochondriacal disorder.
F45.3 Somatoform dysfunction of the autonomic nervous system.
F45.4 Persistent somatoform pain disorder.
F45.8 Other somatoform disorders.
F45.9 Somatoform disorder, unspecified.
Selected syndromes found in somatoform disorders
Particularly noteworthy are conversion syndromes, asthenic conditions, depressive syndromes, anorexia nervosa syndrome, dysmorphophobia syndrome (dysmorphomania), which are included in the structure of various somatoform disorders.
Conversion syndromes. Characterized by a change or loss of any body function (anesthesia and paresthesia of the limbs, deafness, blindness, anosmia, pseudoceisis, paresis, choreiform tics, ataxia, etc.) as a result of a psychological conflict or need, while patients are not aware of what psychological the cause determines the disorder, so they cannot control it arbitrarily. Conversion - transformation of emotional disorders into motor, sensory and autonomic equivalents; These symptoms in Russian psychiatry are usually considered within the framework of hysterical neurosis.
Asthenic conditions are among the most frequently encountered in the practice of a general practitioner. Rapid exhaustion occurs in these cases against the background of increased neuropsychic excitability. The somatic complaints that the patient presents with include, first of all, variable and varied headaches, sometimes of the “neurasthenic helmet” type, but also tingling in the forehead and back of the head, a feeling of a “stale head.” The pain intensifies with mental stress and usually becomes more severe. severe in the afternoon. Asthenic conditions can imitate symptoms characteristic of a particular somatic disease. These are, as a rule, palpitations, lability of blood pressure, frequent urination, dysmenorrhea, decreased libido, potency, etc.
Depressive syndromes also occur quite often (in about half of the cases the state of somatoform patients is classified as depressive). Of particular interest is the so-called somatized (masked) depression.
Anorexia nervosa syndrome- progressive self-restraint in eating while maintaining appetite in order to lose weight due to the conviction of being overly fat or for fear of becoming fat. This condition occurs predominantly in females during adolescence. The syndrome, expressed in its entirety, is characterized by a triad: refusal to eat, significant weight loss (about 25% of premorbid weight), amenorrhea.
Dysmorphophobia syndrome (dysmorphomania). This is a type of hypochondriacal syndrome, mainly occurring in adolescence (up to 80%). With dysmorphophobia, there is a pathological belief either in the presence of some physical defect or in the spread of unpleasant odors to the patient. At the same time, patients are afraid that others will notice these shortcomings, discuss them and laugh at them. For severe body dysmorphic syndrome, a triad of signs is typical: ideas of physical disability, ideas of attitude, depressed mood.
Due to the conviction of the existence of an imaginary defect or the presence of any minor physical defect with its excessive exaggeration, patients persistently seek help from doctors of various specialties - cosmetologists, dentists, endocrinologists, plastic surgeons.
Patients with dysmorphophobia are characterized by a tendency to dissimulate their condition. In this regard, it is important to note the presence of two characteristic symptoms that can be identified when questioning patients and their relatives: these are “mirror” symptoms (closely examining oneself in the mirror in order to make sure that there is a physical defect and try to find a facial expression that hides this “defect” ") and "photographs" (the latter is considered as documentary evidence of the inferiority of one's appearance, and therefore photography is avoided).
Clinic of somatoform disorders
Let us consider the most common variants of the course of somatoform disorders.
Somatization disorder. The main symptom is the presence of multiple, recurrent and often changing somatic symptoms, which usually occur over a number of years preceding the patient's visit to a psychiatrist. Most patients have undergone a long and difficult journey, including primary and specialist medical services, during which negative examination results were obtained and useless operations may have been performed. Symptoms can relate to any part of the body or system, but the most common are gastrointestinal sensations (pain, belching, regurgitation, vomiting, nausea, etc.), as well as abnormal skin sensations (itching, burning, tingling, numbness, soreness). etc.). Sexual and menstrual complaints are common.
Clear depression and anxiety are often found. This may justify specific treatment. The course of the disorder is chronic and fluctuating, often combined with long-term disturbances in social, interpersonal and family behavior. The disorder is significantly more common in women than men and often begins at a young age.
Dependence or abuse of drugs (usually sedatives or analgesics) is often discovered as a consequence of frequent drug courses.
Somatoform dysfunction of the autonomic nervous system. Complaints are presented to patients as if they were due to a physical disorder of a system or organ that is mainly or completely under the influence of the autonomic nervous system, that is, the cardiovascular, gastrointestinal or respiratory system. (This also partially includes the genitourinary system). The most common and striking examples relate to the cardiovascular system ("neurosis of the heart"), the respiratory system (psychogenic shortness of breath and hiccups) and the gastrointestinal system ("gastric neurosis" and "nervous diarrhea"). Symptoms are usually of two types, neither of which indicate a physical disorder of the organ or system affected. The first type of symptoms, on which diagnosis is largely based, is characterized by complaints reflecting objective signs of autonomic arousal, such as palpitations, sweating, flushing and tremors. The second type is characterized by more idiosyncratic, subjective and nonspecific symptoms, such as sensations of fleeting pain, burning, heaviness, tension, bloating or stretching. These complaints relate to patients to a specific organ or system (which may also include autonomic symptoms). The characteristic clinical picture consists of a clear involvement of the autonomic nervous system, additional nonspecific subjective complaints and constant references by the patient to a specific organ or system as the cause of his disorder.
Many patients with this disorder have indications of psychological distress or difficulties and problems that appear to be related to the disorder. However, in a significant proportion of patients who meet the criteria for this disorder, aggravating psychological factors are not identified. In some cases, minor disturbances in physiological functions, such as hiccups, flatulence and shortness of breath, may also be present, but these do not in themselves interfere with the basic physiological functioning of the organ or system concerned.
Chronic somatoform pain disorder. Among the causes of chronic somatoform pain disorder, psychodynamic ones are distinguished - pain manifests itself as a way to achieve love, avoid punishment and atone for guilt, a way to manipulate loved ones. What matters, therefore, is the secondary benefit of a given symptom. The presentation of pain may also be a way of holding a love object close to oneself or as a reflex after a long period of somatic or neurological pain. In the etiology of pain, central mechanisms associated with the level of endorphins are important.
The general signs of this disorder are: 1) the duration of algopathic conditions is at least 6 months; 2) the absence of somatic pathology confirmed as a result of special examinations, which could cause the occurrence of pain; 3) the severity of complaints of pain and the associated decrease in adaptation in cases of concomitant somatic pathology significantly exceed the expected consequences of somatic symptoms. Additional general signs of algopathies are: 1) absence of symptoms of endogenous disease (schizophrenia, MDP) and organic damage to the central nervous system; 2) comparability with pain sensations observed in somatic pathology.
Pain often appears in combination with emotional conflict or psychosocial problems, regarded as the main cause. As a rule, headaches, pain in the back, sternum, and neck occur.
Hypochondriacal disorder. Despite the fact that hypochondria is one of the most common psychopathological phenomena, issues of nosological assessment and selection of adequate treatment measures have not been sufficiently developed.
What is hypochondria? This is excessive attention to one’s health that has no real basis, preoccupation with even a minor ailment, or the belief in the presence of a serious illness, disturbances in the physical sphere or deformity.
With hypochondria, we are talking not just about anxious suspiciousness as such, but about the corresponding mental, intellectualized processing of certain painful sensations from the somatic sphere. Often the matter ends with the construction of the concept of a certain disease, followed by the struggle for its recognition and treatment. The psychopathological nature of hypochondria is confirmed by the fact that when it is combined with a real somatic disease, the patient does not pay even a fraction of the attention to the latter that he pays to the imaginary disorder.
Hypochondriacal conditions often develop in adulthood or old age, equally often in men and women.
The leading structural elements of hypochondriacal syndrome primarily include paresthesia - sensations of numbness, tingling, crawling, etc., not caused by external stimuli. This is followed by psychalgia, which is not caused by any specific lesion, but is a consequence of a physiological increase in the pain threshold. These are ordinary pains without any real reason, often multiple. Another such element is senestoalgia, which is more bizarre and peculiar in nature. For example, headaches here are already burning, shooting, piercing, stabbing. This is followed by senestopathies - also occurring spontaneously and extremely painful sensations that do not correspond in localization to specific anatomical formations. Senestopathies are characterized by novelty and variety of sensations; patients find it difficult to accurately describe them. And, finally, synesthesia - a feeling of unclear total physical ill-being or malaise with peculiar, difficult to describe motor disturbances (unexpected physical weakness, swaying and uncertainty when walking, heaviness or emptiness in the body).
Differential diagnosis
The differential diagnosis of somatoform disorders is carried out with a whole group of diseases in which patients present somatic complaints. Thus, the differential diagnosis from hypochondriacal delusion is usually based on a careful examination of the case. Although the patient's ideas persist for a long time and seem to contradict common sense, the degree of conviction usually decreases to some extent and for a short time under the influence of argumentation, reassurance and new examinations. In addition, the presence of unpleasant and frightening physical sensations may be considered a culturally acceptable explanation for the development and maintenance of beliefs in physical illness.
A differential diagnosis with somatic disorders is required, although patients usually go to a psychiatrist after somatic doctors. But still, the likelihood of an independent somatic disorder in such patients is no lower than in ordinary people at the same age.
Affective (depressive) and anxiety disorders. Depression and anxiety of varying degrees often accompany somatization disorders, but they should not be described separately unless they are sufficiently obvious and stable to justify their own diagnosis. The appearance of multiple somatic symptoms after the age of 40 may indicate the manifestation of a primary depressive disorder.
It is also necessary to exclude dissociative (conversion) disorders, speech disorders, nail biting, psychological and/or behavioral factors associated with disorders or diseases classified elsewhere, sexual dysfunction not caused by organic disorders or diseases, tics, Gilles de la Tourette syndrome , trichotillomania.
Treatment
Therapy of somatoform disorders includes a wide range of therapeutic and preventive measures that require the participation of both an internist, a psychiatrist and a psychotherapist.
Of great practical importance is the fact that the corresponding mental disorders may not be recognized by the patient himself or may be dissimulated. Patients usually resist attempts to discuss the possibility of a psychological cause of symptoms, even in the presence of clear depressive or anxious manifestations. As a result, the basic direction in the treatment of patients with somatoform disorders is currently psychotherapy. Almost the entire range of modern forms and methods of psychotherapy is used. Rational therapy, autogenic training, hypnotherapy, group, analytical, behavioral, positive, client-centered therapy, etc. are widely used. However, despite the priority of psychotherapeutic correction, the prevalence of somatovegetative components in the clinical picture does not make it possible to do without drug therapy. In the initial period, even strictly directive methods do not allow obtaining the desired result quickly, which ultimately compromises psychotherapy as a method.
Pharmacotherapy of somatoform disorders involves the use of a wide range of psychotropic drugs - primarily anxiolytics, as well as antidepressants, nootropics and antipsychotics. However, the use of psychotropic drugs in the clinic of somatoform disorders has its own characteristics. When prescribing psychotropic drugs, it is advisable to limit oneself to monotherapy using easy-to-use medications. Taking into account the possibility of increased sensitivity, as well as the possibility of side effects, psychotropic drugs are prescribed in small (compared to those used in “big” psychiatry) doses. The requirements also include a minimal effect on somatic functions, body weight, minimal behavioral toxicity and teratogenic effect, the possibility of use during lactation, and a low likelihood of interaction with somatotropic drugs.
CONCLUSION
The pronounced clinical pathomorphosis of somatoform disorders themselves, a significant expansion of their classification rubrication and an increase in the proportion of somatic pathology occurring with borderline mental disorders, requires revision and clarification of the criteria for differential diagnosis and creates the prerequisites for the development of new diagnostic and therapeutic approaches. Timely detection and adequate diagnosis of somatoform disorders is crucial for successful therapy and a favorable prognosis of the disease.
In this regard, it seems appropriate to integrate the system of psychotherapeutic care into general somatic treatment and preventive structures, and open psychosomatic departments in the structure of general somatic hospitals. It is also necessary to emphasize the important role of increasing the knowledge of doctors in the general medical network. For general practitioners, teaching the basics of medical ethics, deontology and psychotherapy should be provided, and for psychotherapists - in-depth professional training. The development of special training programs on specific problems of psychosomatic pathology (clinical, diagnostic, therapy), holding thematic conferences and seminars, and organizing advanced training courses are very relevant.
BIBLIOGRAPHY
1. T.B. Dmitrieva. "Clinical psychiatry. Guide for doctors and students" 1998.
2. G.I. Kaplan. B.J. Sadok. "Clinical psychiatry. From a synopsis on psychiatry in 2 volumes”, 1994.
3. Journal of Neurology and Psychiatry named after S.S. Korsakov.
4. ICD-10. Clinical classification.
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