Early diagnosis of mental illness has a number of specific features.
Acute states in psychiatry in the vast majority of cases proceed with a rapidly advancing, pronounced disorganization of behavior, often reaching a degree of excitation, which is traditionally called psychomotor, i.e., excitation in the mental and motor spheres.
Excitation is one of the most frequent symptoms that are an integral part of the structure of acute psychotic states syndromes, and serves as a reflection of certain links in the pathogenesis of the disease. In its occurrence, development, duration, an undoubted role is played not only by endogenous factors, as is the case, for example, with schizophrenia or manic-depressive psychosis, but also by exogenous hazards - intoxication and infection, although it is difficult to draw a clear line between exogenous and endogenous. Most often there is a combination of these and a number of other factors.
At the same time, the disorganization of the behavior of a mentally ill person is associated not only with the internal factors of the disease, but also with the reaction of the individual to the disease due to the fact that the sudden onset of psychosis dramatically changes the patient's perception of the surrounding world.
What really exists is distorted, evaluated pathologically, often acquiring a threatening, sinister meaning for the patient. Acutely developing delirium, hallucinations, disturbances of consciousness stun the patient, cause bewilderment, confusion, fear, anxiety.
The patient's behavior quickly acquires a pathological character, it is now determined not by the reality of the patient's environment, but by his pathological experiences. The balance is lost, the homeostasis of the personality is disturbed, "otherness" begins in the new conditions of mental illness.
Under these conditions, the functioning of the patient's personality is conditioned not only by its own distorted perception of the environment, but also by the reaction of the surrounding persons to a suddenly mentally ill person, which is often expressed in fear, panic, attempts to bind the patient, lock him up, etc. This, in turn, aggravates the disturbed interactions of the personality the patient with the world around him, contributes to an increase in psychopathological symptoms, disorganization of behavior, and an increase in arousal. Thus, a situation of "vicious circle" is created.
Other factors are also included in these complex relationships: the factor of the disease itself, the suffering of the whole organism with a violation of the normal interaction of organs and systems, violations of the regulatory influence of the central nervous system, imbalance of the autonomic nervous system, which in turn causes additional disorganization in the work of internal organs. There are a number of new pathogenetic factors that increase both mental and somatic disorders.
It should also be taken into account that acute psychotic states can develop in people who previously suffered from somatic diseases, psychosis can be a complication of a therapeutic, surgical or infectious disease. In this regard, the interactions of pathogenic factors become even more complicated, aggravating the course of both mental and somatic diseases.
A number of other features of acute psychotic states could be cited, but what has been said is enough to note the specifics of early diagnosis and emergency treatment in psychiatry, which differ from those in somatic medicine.
So, psychoses or psychotic disorders are understood to mean the most striking manifestations of mental illness, in which the mental activity of the patient does not correspond to the surrounding reality, the reflection of the real world in the mind is sharply distorted, which manifests itself in behavioral disorders, the appearance of abnormal pathological symptoms and syndromes.
If we approach the problem under consideration more methodically, then psychotic disorders (psychoses) are characterized by:
gross disintegration of the psyche- inadequacy of mental reactions and reflective activity, processes, phenomena, situations; The most gross disintegration of mental activity corresponds to a number of symptoms - the so-called formal signs of pychosis: hallucinations, delusions (see below), however, the division into psychotic and non-psychotic levels to a greater extent has a clear syndromic orientation - paranoid, oneiroid and other syndromes
the disappearance of criticism (uncriticality)- the impossibility of comprehending what is happening, the real situation and one's place in it, predicting the features of its development, including in connection with one's own actions; the patient is not aware of his mental (painful) mistakes, inclinations, inconsistencies
the loss of the ability to voluntarily lead oneself, one's actions, memory, attention, thinking, behavior based on personal real needs, desires, motives, assessment of situations, one's morality, life values, personality orientation; there is an inadequate reaction to events, facts, situations, objects, people, as well as to oneself.
From the point of view of the positive and negative psychopathological syndromes identified by A. V. Snezhnevsky, psychotic disorders include:
1. Positive Syndromes:
psychotic variants of manic and depressive syndromes III level
syndromes from IV to VIII level (with the exception of psychoorganic syndrome - IX level)
2. Psychotic disorders are equated negative syndromes:
imbecility and idiocy
Acquired mental defect syndromes from V-VI to X level
To make the above criteria more understandable, I give a model of the ratio of positive and negative syndromes and nosological forms, which is presented by A. V. Snezhnevsky in the form of nine circles (layers) of psychopathological disorders included in each other:
positive- emotional-hyperesthetic (in the center - asthenic syndrome inherent in all diseases) (I); affective (depressive, manic, mixed) (II); neurotic (obsessive, hysterical, depersonalization, senestopathic-hypochondriacal (III); paranoid, verbal hallucinosis (IV); hallucinatory-paranoid, paraphrenic, catatonic (V); confusion (delirium, amentia, twilight state) (VI); paramnesia ( VII), convulsive seizures (VIII), psychoorganic disorders (IX);
negative- exhaustion of mental activity (I), subjectively and objectively perceived changes in the “I” (II-III), disharmony of personality (IV), decrease in energy potential (V), decrease in the level and regression of personality (VI-VII), amnestic disorders (VIII ), total dementia and mental insanity (IX).
He also compared enlarged positive syndromes with nosologically independent diseases. Level I considers the most common positive syndromes with the least nosological preference and common to all mental and many somatic diseases.
Syndromes of I-III levels correspond to the clinic of a typical manic-depressive psychosis
I-IV - complex (atypical) manic-depressive psychosis and marginal psychosis (intermediate between manic-depressive psychosis and schizophrenia)
I-V - schizophrenia
I-VI - exogenous psychoses
I-VII - clinic of diseases occupying an intermediate position between exogenous and organic psychoses
I-VIII - epileptic disease
Levels I-IX correspond to the syndromic spectrum of the dynamics of mental illness associated with a gross organic pathology of the brain
The main manifestations of psychosis are:
1.hallucinations
Depending on the analyzer, auditory, visual, olfactory, gustatory, tactile are distinguished.
Hallucinations can be simple (ringing, noise, hailing) or complex (speech, scenes).
The most common are auditory hallucinations, the so-called "voices" that a person can hear coming from outside or sounding inside the head, and sometimes the body. In most cases, voices are perceived so vividly that the patient does not have the slightest doubt about their reality. Voices can be threatening, accusing, neutral, imperative (ordering). The latter are rightfully considered the most dangerous, since often patients obey the orders of voices and commit acts that are dangerous to themselves or others.
2. crazy ideas
These are judgments that have arisen on painful grounds, conclusions that do not correspond to reality, completely seize the patient's consciousness, and cannot be corrected by dissuasion and explanation.
The content of delusional ideas can be very diverse, but most often there are:
delusions of persecution (patients believe that they are being followed, they want to be killed, intrigues are woven around them, conspiracies are organized)
delirium of influence (from psychics, aliens, special services with the help of radiation, radiation, "black" energy, witchcraft, damage)
delirium of damage (sprinkle poison, steal or spoil things, want to survive from the apartment)
hypochondriacal delirium (the patient is convinced that he suffers from some kind of disease, often terrible and incurable, stubbornly proves that his internal organs are affected, requires surgical intervention)
there are also delusions of jealousy, invention, greatness, reformism, of a different origin, amorous, litigious, etc.
3. Movement disorders
Manifested in the form of inhibition (stupor) or excitation. With stupor, the patient freezes in one position, becomes inactive, stops answering questions, looks at one point, refuses to eat. Patients in a state of psychomotor agitation, on the contrary, are constantly on the move, speak incessantly, sometimes make faces, mimic, are foolish, aggressive and impulsive (perform unexpected, unmotivated actions).
4. Mood disorders
Manifested by depressive or manic states:
depression is characterized, first of all, low mood, melancholy, depression, motor and intellectual retardation, disappearance of desires and urges, decreased energy, pessimistic assessment of the past, present and future, ideas of self-blame, thoughts of suicide
manic state manifests itself unreasonably elevated mood, acceleration of thinking and motor activity, overestimation of the capabilities of one's own personality with the construction of unrealistic, sometimes fantastic plans and projects, the disappearance of the need for sleep, disinhibition of drives (alcohol abuse, drugs, promiscuity)
Psychosis can have a complex structure and combine hallucinatory, delusional and emotional disorders (mood disorders) in various proportions..
The following signs of an incipient psychotic state may appear with the disease all without exception, or separately.
Manifestations of auditory and visual hallucinations
:
Conversations with oneself, resembling a conversation or remarks in response to someone's questions (excluding comments aloud like "Where did I put my glasses?").
Laughter for no apparent reason.
Sudden silence, as if the person is listening to something.
An alarmed, preoccupied look; inability to focus on a topic of conversation or a specific task.
The impression that the patient sees or hears something that you cannot perceive.
The appearance of delirium can be recognized by the following signs
:
Changed behavior towards relatives and friends, the appearance of unreasonable hostility or secrecy.
Direct statements of implausible or dubious content (for example, about persecution, about one's own greatness, about one's inexcusable guilt.)
Protective actions in the form of curtaining windows, locking doors, obvious manifestations of fear, anxiety, panic.
A statement without obvious grounds for fear for one's life and well-being, for the life and health of loved ones.
Separate, incomprehensible to others, meaningful statements that give mystery and special significance to everyday topics.
Refusal to eat or carefully check the content of the food.
Active litigious activity (for example, letters to the police, various organizations with complaints about neighbors, colleagues, etc.).
As for mood disorders of the depressive spectrum within the framework of a psychotic state, in this situation patients may have thoughts of unwillingness to live. But depressions accompanied by delusions (for example, guilt, impoverishment, an incurable somatic disease) are especially dangerous. These patients at the height of the severity of the condition almost always have thoughts of suicide and suicidal readiness..
The following signs warn of the possibility of suicide
:
Statements of the patient about his uselessness, sinfulness, guilt.
Hopelessness and pessimism about the future, unwillingness to make any plans.
The presence of voices advising or ordering suicide.
The patient's belief that he has a fatal, incurable disease.
Sudden calming of the patient after a long period of melancholy and anxiety. Others may have the false impression that the patient's condition has improved. He puts his affairs in order, for example, writing a will or meeting up with old friends whom he has not seen for a long time.
All mental disorders, being biosocial, cause certain medical problems and have social consequences.
Both in psychotic and non-psychotic disorders, the medical tasks are the same - these are detection, diagnosis, examination, dynamic observation, development of tactics and implementation of treatment, rehabilitation, readaptation, and their prevention.
The social consequences of psychotic and non-psychotic disorders differ. In particular, the psychotic level of disorders makes it possible to use involuntary examination and hospitalization, clinical examination, issuing a conclusion on insanity and incapacity, recognizing a transaction made in a psychotic state as invalid, etc. Therefore, early identification of patients with signs of a psychotic disorder is so important.
All mental disorders are usually divided into two levels: neurotic and psychotic.
The boundary between these levels is conditional, but it is assumed that rough, pronounced symptoms are a sign of psychosis ...
Neurotic (and neurosis-like) disorders, on the contrary, are distinguished by mildness and smoothness of symptoms.
Mental disorders are called neurosis-like if they are clinically similar to neurotic disorders, but, unlike the latter, are not caused by psychogenic factors and have a different origin. Thus, the concept of a neurotic level of mental disorders is not identical with the concept of neuroses as a group of psychogenic diseases with a non-psychotic clinical picture. In this regard, a number of psychiatrists avoid using the traditional concept of "neurotic level", preferring to it more precise concepts of "non-psychotic level", "non-psychotic disorders".
The concepts of neurotic and psychotic levels are not associated with any particular disease.
Progredient mental illnesses often debut as disorders of the neurotic level, which subsequently, as the symptoms become more severe, give a picture of psychosis. In some mental illnesses, such as neuroses, mental disturbances never exceed the neurotic (non-psychotic) level.
P. B. Gannushkin suggested calling the entire group of non-psychotic mental disorders "small", and V. A. Gilyarovsky - "borderline" psychiatry.
The concept of borderline mental disorders is used to refer to mild disorders that border on a state of health and separate it from the actual pathological mental manifestations, accompanied by significant deviations from the norm. Disorders of this group violate only certain areas of mental activity. Social factors play a significant role in their occurrence and course, which, with a certain degree of conventionality, allows us to characterize them as disruption of mental adaptation. The group of borderline mental disorders does not include neurotic and neurosis-like symptom complexes associated with psychotic (schizophrenia, etc.), somatic and neurological diseases.
Borderline mental disorders according to Yu.A. Aleksandrovsky (1993)
1) the predominance of the neurotic level of psychopathology;
2) the relationship of a mental disorder with autonomic dysfunctions, night sleep disorders and somatic disorders;
3) the leading role of psychogenic factors in the occurrence and decompensation of painful disorders;
4) the presence of "organic" predisposition (MMD), which facilitates the development and decompensation of the disease;
5) the relationship of painful disorders with the personality and typological characteristics of the patient;
6) maintaining criticism of one's condition and the main morbid disorders;
7) the absence of psychosis, progressive dementia or personal endogenous (schizoform, epileptic) changes.
The most characteristic signs borderline psychopathologist:
neurotic level = functional character and reversibility existing violations;
vegetative "accompaniment", the presence of comorbid asthenic, dyssomnic and somatoform disorders;
association of disease with traumatic circumstances and
personal-typological characteristics;
ego-dystonicity(unacceptability for the "I" of the patient) of painful manifestations and maintaining a critical attitude towards the disease.
Neurotic disorders(neurosis) - a group of psychogenically conditioned disease states characterized by partiality and ego-dystonicity of diverse clinical manifestations that do not change the self-awareness of the individual and awareness of the disease.
Neurotic disorders violate only certain areas of mental activity, not accompanied psychotic phenomena and severe behavioral disorders, but they can significantly affect the quality of life.
Definition of neuroses
Neuroses is understood as a group of functional neuropsychiatric disorders, including emotional-affective and somatovegetative disorders caused by psychogenic factors that lead to a breakdown in mental adaptation and self-regulation.
Neurosis is a psychogenic disease without organic pathology of the brain.
Reversible disorder of mental activity, caused by the influence of psychotraumatic factors and proceeding with the patient's awareness of the fact of his disease and without disturbing the reflection of the real world.
The doctrine of neuroses: two tendencies:
1 . Researchers proceed from the recognition of the determinism of neurotic phenomena as certain pathologicalbiological mechanisms , although they do not deny the role of mental trauma as a trigger and a possible condition for the onset of the disease. However, the psychotrauma itself acts as one of the possible and equivalent exogenies that violate homeostasis.
As part of negative diagnosis indicates the absence of disorders of a different level, neurosis-like and pseudo-neurotic disorders of organic, somatic or schizophrenic origin.
2. The second trend in the study of the nature of neurosis is the assumption that the entire clinical picture of a neurosis can be derived from one only psychological mechanisms . Supporters of this trend believe that information of a somatic nature is fundamentally insignificant for understanding the clinic, genesis and therapy of neurotic conditions.
concept positive diagnosis neurosis is presented in the works of V.N. Myasishchev.
A positive diagnosis follows from the recognition of the substantive nature of the category "psychogenic".
The concept of V.N. Myasishcheva In 1934
V. N. Myasishchev noted that neurosis is personality disease, primarily a disease of personality development.
By personality disease, he understood that category of neuropsychiatric disorders, which is caused by how a person processes or experiences his reality, his place and his destiny in this reality.
At the heart of neuroses lie the contradictions between him and the aspects of reality that are significant for him, which are unsuccessfully, irrationally and unproductively resolved by the person, causing painful and painful experiences:
failures in the struggle of life, dissatisfaction with needs, unattained goals, irreparable loss.
The inability to find a rational and productive way out entails the mental and physiological disorganization of the personality.
Neurosis is a psychogenic (usually conflictogenic) neuropsychiatric disorder that occurs as a result of violations of especially significant life relationships personality and manifests itself in specific clinical phenomena in the absence of psychotic phenomena.
The main symptom of non-psychotic depressive disorder is sleep disturbance - patients experience prolonged insomnia. They also lack a range of positive emotions, they can react sharply to random words, and there is increased anxiety. Treatment is carried out in several ways. The most effective in this case is drug therapy.
At the current stage of development of psychological sciences, there are a huge number of classified mental disorders. But, by no means can it be said that each disorder could be distinguished by just one criterion. It is worth mentioning that k from the side of neurology. This statement cannot be called generally accepted, but it is used by at least 80% of professionals. This concept can be used to combine mild disorders and psychotic conditions. Non-psychotic depressive disorders are not incipient or intermediate stages of psychosis. These disorders are manifestations of pathologies that have a beginning and an end.
Methods for diagnosing non-psychotic depressive disorder
by themselves in terms of depth, as well as the severity of depressive manifestations. The disorder may be aggravated or manifested due to the loss of a loved one, caused moral or material damage. In the clinical picture of such disorders, persistent depressed mood is increasingly brought to the fore.How can non-psychotic depressive disorder be diagnosed?
With this disease, it is not possible to make a diagnosis on your own. Only a qualified doctor can help diagnose the disorder, as well as prescribe an effective and correct treatment that can return you or your loved ones to a full life. However, there are symptoms that may indicate the development of a non-psychotic depressive disorder:
- the first sign of the disease is a violation of full sleep, as well as autonomic dysfunction;
- excessive emotional reaction to events or words;
- psychopathic manifestations on an ongoing basis throughout any somatic illness;
- reduced mood background, tearfulness, but at the same time maintaining a critical attitude towards one's condition, as well as to the manifestations of the disease;
Treatment of non-psychotic depressive disorder
- the appointment of potent drugs that will need to be taken for the entire period of treatment. This is the easiest way to get rid of a depressive disorder;
- the appointment of prolonged drugs in the form of injections to exit the acute stage of the disease and prevent its occurrence;
- appointment of a course of psychotherapeutic treatment.
E pylepsy is one of the most common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8-1.2%.
It is known that mental disorders are an essential component of the clinical picture of epilepsy, complicating its course. According to A. Trimble (1983), A. Moller, W. Mombouer (1992), there is a close relationship between the severity of the disease and mental disorders, which are much more common in the unfavorable course of epilepsy.
In the last few years, as statistical studies show, in the structure of mental morbidity there is an increase in forms of epilepsy with non-psychotic disorders . At the same time, the share of epileptic psychoses decreases, which reflects the obvious pathomorphism of the clinical manifestations of the disease, due to the influence of a number of biological and social factors.
One of the leading places in the clinic of non-psychotic forms of epilepsy is occupied by affective disorders , which often show a tendency to chronification. This confirms the position that despite the achieved remission of seizures, emotional disorders are an obstacle to the full restoration of the health of patients (Maksutova EL, Fresher V., 1998).
In the clinical qualification of certain syndromes of the affective register, it is fundamental to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes proper. In this regard, it is possible to single out two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders proper, and secondary - without a causal relationship with an attack, but based on various manifestations of reactions to the disease, as well as to additional psycho-traumatic influences.
So, according to the data of studies of patients of the specialized hospital of the Moscow Research Institute of Psychiatry, it was found that phenomenologically non-psychotic mental disorders are represented by three types of conditions:
1) depressive disorder in the form of depressions and subdepressions;
2) obsessive-phobic disorders;
3) other affective disorders.
Depressive spectrum disorders include the following options:
1. Sad depressions and sub-depressions were observed in 47.8% of patients. Anxious-dreary affect with a persistent decrease in mood, often accompanied by irritability, was predominant in the clinic here. Patients noted mental discomfort, heaviness in the chest. In some patients, these sensations were associated with physical malaise (headache, discomfort behind the sternum) and were accompanied by motor restlessness, less often they were combined with adynamia.
2. Adynamic depressions and subdepressions observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. Most of the time they were in bed, with difficulty they performed simple self-service functions, complaints of rapid fatigue and irritability were characteristic.
3. Hypochondriacal depressions and subdepressions were observed in 13% of patients and were accompanied by a constant feeling of physical damage, heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death may occur during an attack or they will not be provided with help in time. Rarely did the interpretation of phobias go beyond the specified plot. Hypochondriacal fixation was distinguished by senestopathies, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.
The variant of hypochondriacal depression was more characteristic of the interictal period, especially in the conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.
4. Anxiety depressions and subdepressions occurred in 8.7% of patients. Anxiety, as a component of an attack (more rarely, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experience vague fear or anxiety, the cause of which they do not understand. A short-term anxious affect (a few minutes, less often within 1-2 hours), as a rule, is characteristic of a variant of phobias, as a component of a seizure (within the aura, the seizure itself or the post-seizure state).
5. Depression with depersonalization disorders observed in 0.5% of patients. In this variant, the dominant sensations were the altered perception of one's own body, often with a feeling of alienation. The perception of the environment, time, also changed. So, along with a feeling of weakness, hypothymia, patients noted periods when the environment "changed", time "accelerated", it seemed that the head, arms, etc. were increasing. These experiences, in contrast to the true paroxysms of depersonalization, were characterized by the preservation of consciousness with a complete orientation and were of a fragmentary nature.
Psychopathological syndromes with a predominance of anxious affect constituted predominantly the second group of patients with "obsessive-phobic disorders". An analysis of the structure of these disorders showed that they are closely related to almost all components of a seizure, starting with precursors, aura, the seizure itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, more often of an indefinite content, which the patients described as an “imminent threat”, increasing anxiety, giving rise to a desire to do something urgently or seek help from others. Individual patients often indicated the fear of death from an attack, the fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, less often sociophobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection of obsessive-phobic disorders with the vegetative component, reaching a particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, thoughts were observed.
In contrast to paroxysmal anxiety, the anxious affect in remissions approaches in form the classical variants in the form of unmotivated fears for one's health, the health of loved ones, etc. A number of patients have a tendency to form obsessive-phobic disorders with obsessive fears, fears, actions, actions, etc. In some cases, there are protective mechanisms of behavior with peculiar measures to counteract the disease, such as rituals, etc. In terms of therapy, the most unfavorable option is a complex symptom complex, including obsessive-phobic disorders, as well as depressive formations.
The third type of borderline forms of mental disorders in the clinic of epilepsy was affective disorders , designated by us as "other affective disorders".
Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.
Among this group of borderline disorders, acting both in the form of paroxysms and prolonged states, more often were observed epileptic dysphoria . Dysphoria occurring in the form of short episodes more often occurred in the structure of the aura, preceding an epileptic seizure or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriac manifestations, irritability, and the affect of malice prevailed in their structure. Protest reactions were often formed. A number of patients showed aggressive actions.
The syndrome of emotional lability was characterized by a significant amplitude of affective fluctuations (from euphoria to anger), but without noticeable behavioral disorders characteristic of dysphoria.
Among other forms of affective disorders, mainly in the form of short episodes, there were reactions of weak-heartedness, manifested in the form of affective incontinence. Usually they acted outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.
In relation to the individual phases of the attack, the frequency of borderline mental disorders associated with it is presented as follows: in the structure of the aura - 3.5%, in the structure of the attack - 22.8%, in the post-seizure period - 29.8%, in the interictal period - 43.9 %.
Within the framework of the so-called precursors of seizures, various functional disorders are well-known, mainly of a vegetative nature (nausea, yawning, chills, salivation, fatigue, loss of appetite), against which anxiety, a decrease in mood or its fluctuations occur with a predominance of irritated-sullen affect. In a number of observations in this period, emotional lability with explosiveness and a tendency to conflict reactions were noted. These symptoms are extremely labile, short-lived and can self-limit.
Aura with affective experiences - a frequent component of the subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "lightheadedness". Pleasant sensations are less often observed (an increase in vitality, a feeling of special lightness and high spirits), which are then replaced by an anxious expectation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety may occur, or a neutral (rarely excited, upbeat) mood is noted.
In the structure of the paroxysm itself, affective series syndromes are most often found within the framework of the so-called temporal lobe epilepsy.
As is known, motivational-emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly mediobasal formations that are part of the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.
When the focus is localized in the right temporal lobe, depressive disorders are more common and have a more delineated clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The specified clinic fits completely into the allocated "right hemispheric affective disorder" in the systematics of organic syndromes of the ICD-10.
To paroxysmal affective disorders (as part of an attack) include sudden and lasting for several seconds (rarely minutes) attacks of fear, unaccountable anxiety, sometimes with a feeling of longing. There may be impulsive short-term states of increased sexual (food) desire, a feeling of strength, joyful expectation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. The predominantly violent nature of these experiences should be emphasized, although individual cases of their arbitrary correction by conditioned reflex techniques indicate a more complex pathogenesis.
"Affective" seizures occur either in isolation or are included in the structure of other seizures, including convulsive ones. Most often they are included in the structure of the aura of a psychomotor seizure, less often - vegetative-visceral paroxysms.
The group of paroxysmal affective disorders within the framework of temporal lobe epilepsy includes dysphoric states, the duration of which can vary from several hours to several days. In some cases, dysphoria in the form of short episodes precedes the development of the next epileptic seizure or a series of seizures.
The second most common affective disorder is clinical forms with dominant vegetative paroxysms within the framework of diencephalic epilepsy . The analogues of the common designation of paroxysmal (crisis) disorders as "vegetative seizures" are the concepts widely used in neurological and psychiatric practice such as "diencephalic" seizure, "panic attacks" and other conditions with a large autonomic accompaniment.
The classic manifestations of crisis disorders include suddenly developed: shortness of breath, a feeling of lack of air, discomfort from the organs of the chest cavity and abdomen with "fading heart", "interruptions", "pulsation", etc. These phenomena are usually accompanied by dizziness, chills, tremor , various paresthesias. Possible increased stool, urination. The strongest manifestations are anxiety, fear of death, fear of going crazy.
Affective symptoms in the form of separate unstable fears can be transformed both into an affective paroxysm itself and into permanent variants with fluctuations in the severity of these disorders. In more severe cases, a transition to a persistent dysphoric state with aggression (less often, auto-aggressive actions) is possible.
In epileptological practice, vegetative crises occur mainly in combination with other types of (convulsive or non-convulsive) paroxysms, causing polymorphism of the disease clinic.
Concerning the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we have classified them as diverse psychologically understandable reactions to the disease that occur in epilepsy. At the same time, side effects as a response to therapy, as well as a number of professional restrictions and other social consequences of the disease include both transient and prolonged states. They are more often manifested in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual personality characteristics of the patient and additional psychogenies. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficient) changes, which gives them a number of features associated with organic soil. The degree of personal (epithymic) changes is also reflected in the clinic of emerging secondary-reactive disorders.
As part of reactive inclusions Patients with epilepsy often have concerns about:
- development of a seizure on the street, at work
- be injured or die during a seizure
- go crazy
- hereditary transmission of disease
- side effects of anticonvulsants
- forced discontinuation of drugs or untimely completion of treatment without guarantees for recurrence of seizures.
The reaction to the occurrence of a seizure at work is usually much more severe than when it occurs at home. Because of the fear that a seizure will happen, some patients stop studying, work, do not go out.
It should be pointed out that, according to the mechanisms of induction, the fear of a seizure may also appear in the relatives of patients, which requires a large participation of family psychotherapeutic assistance.
Fear of the onset of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness get used to them so much that, as a rule, they almost do not experience such fear. So, in patients with frequent seizures and a longer duration of the disease, signs of anosognosia and uncritical behavior are usually noted.
Fear of bodily injury or fear of death during a seizure is more easily formed in patients with psychasthenic personality traits. It is also important that they have previously had accidents, bruises due to seizures. Some patients fear not so much the attack itself, but the likelihood of getting bodily harm.
Sometimes the fear of a seizure is largely due to unpleasant subjective sensations that appear during an attack. These experiences include frightening illusory, hallucinatory inclusions, as well as disorders of the body schema.
This distinction between affective disorders is of fundamental importance in determining further therapy.
Principles of therapy
The main direction of therapeutic tactics in relation to individual affective components of the attack itself and closely related post-seizure emotional disorders is the adequate use of anticonvulsants with thymoleptic effect (cardimizepine, valproate, lamotrigine).
Not being anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic regimen has a positive effect both on the paroxysms themselves and on secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.
Recently, anti-anxiety and sedative effects have been widely used. clonazepam , which is highly effective in absence seizures.
In various forms of affective disorders with a depressive radical, the most effective antidepressants . At the same time, on an outpatient basis, agents with minimal side effects, such as tianeptil, miakserin, fluoxetine, are preferred.
In the case of the predominance of the obsessive-compulsive component in the structure of depression, the appointment of paroxetine is justified.
It should be noted that a number of mental disorders in patients with epilepsy may be due not so much to the disease itself, but to long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, and elements of mental and motor retardation that are manifested in some patients. With the advent of highly effective anticonvulsants in recent years, it has become possible to avoid side effects of therapy and classify epilepsy as a curable disease.
Borderline indicators of intelligence (IQ in the zone of 70-80 units) require the identification of the leading pathopsychological symptom complex.
In contrast to the total defeat in U.O. the organic symptom complex is characterized by such a basic feature as a mosaic of damage to mental activity.
Delayed development (of organic origin) is manifested in the developmental delay the youngest brain structures(functions of regulation, control), non-rough organic damage to the brain with loss of structural and functional elements necessary for analysis, synthesis, abstraction and other intellectual processes. At the same time, potential intellectual capabilities (the ability to learn, accept help, transfer) remain relatively intact.
The phenomena of intellectual insufficiency in the structure of the organic symptom complex are formed against the background of memory deficit, attention in the form of distractibility, exhaustion, and the “flickering” nature of productive activity. Violations of emotional-volitional (uncontrollability, irritability, "nakedness", imbalance) and other components of the emerging personality are characteristic.
2. W.O. should be differentiated with dementia representing a decrease in intellectual functions. Dementia is usually understood as a persistent, irreversible impoverishment of mental activity, its simplification, decline due to destructive changes in the brain tissue. Dementia is characterized by a loss of cognitive abilities due to a disease process that affects the brain, and this loss is so pronounced that it leads to impaired social and professional activities of the patient.
The full clinical picture of dementia in children includes a weakening of cognitive activity in creative thinking, the ability to abstract, up to the impossibility of performing simple logical tasks, memory impairment and criticism of one's state with certain personality changes, as well as impoverishment of feelings. In far-reaching cases, the psyche is "the ruins of mental organization."
In contrast to mental retardation in dementia, the loss of previously acquired intellectual abilities is not correlated with the average value, but with premorbidity, i.e. before the development of the disease (for example, encephalitis, epilepsy), the sick child had a higher level of intellectual development.
3. Mental retardation often has to be differentiated from autistic disorder, the hallmark of which are severe violations of interpersonal contacts and a gross lack of communication skills, which is not observed with intellectual underdevelopment.
In addition, for autistic symptom complex are characterized disorders of social adaptation and communication in combination with stereotyped movements and actions, severe disorders of social and emotional interaction, specific disorders of speech, creativity and fantasy. Often the autistic symptom complex is combined with intellectual underdevelopment.
4. Cerebral attacks, in which there are transient cognitive impairments. Criterion - EEG data in combination with observation of behavior and appropriate experimental psychological techniques.
Landau-Kleffner syndrome (hereditary aphasia with epilepsy): children lose speech after a period of normal speech development, but intelligence may remain intact. Initially, this disorder is accompanied by paroxysmal EEG disturbances and, in most cases, epileptic seizures. The disease begins at the age of 3-7 years, and the loss of speech can occur within a few days or weeks. The presumed etiology is an inflammatory process (encephalitis).
5. Hereditary degenerative diseases, neuroinfections: a thorough history taking, the severity of the organic background, neurological microsymptoms, as well as a serological blood test for certain markers of infectious diseases.
6. Mental retardation must be distinguished from intellectual insufficiency, which develops as a result of severe neglect and insufficient requirements to the child, depriving him of stimulating environmental factors - for example, with sensory or cultural deprivation.
Treatment
Since in most cases the treatment is not etiotropic, but symptomatic, it is necessary to include in the therapeutic plan those areas that are most accessible to therapy and in which the patient experiences more difficulties in everyday life.
The goals of drug treatment are transient severe behavioral disorders, affective excitability, neurosis-like disorders. Among other types of therapeutic interventions, behavioral therapy is used to develop autonomy, the ability to take care of oneself, shop, and occupy oneself.
As a psychological and pedagogical correction, the earliest assistance is offered to sick children and their parents. This assistance includes sensory, emotional stimulation, speech and motor skills development, reading and writing skills. Reading classes contribute to the development of oral speech. Special techniques are offered to facilitate the assimilation of these skills by sick children: reading in whole short words (without sound-letter analysis), assimilation of the account mechanically and on visual material, etc.
Family counseling is carried out for loved ones and the social environment, which indirectly stimulates the development of children, contributes to the achievement of real attitudes towards children with mental retardation, and training in adequate ways to interact with them. Not all parents can cope with such grief on their own. In addition, intellectually safe children often grow up in these families. They also need psychological support.
Education of children is carried out according to special programs, more often differentiated in special schools.
At forensic psychiatric examination adolescents suffering from a mild degree of U.O., experts are faced with the need to apply special knowledge not only in general, medical and social psychology, but also in such theoretical and practical disciplines as the psychology and pathopsychology of children and adolescents, developmental psychology. This predetermines the preference for conducting a comprehensive forensic psychological and psychiatric examination in such cases, taking into account not only the depth of the existing defect, but also the ability of the teenager to predict the consequences of his actions and the presence of other clinical features detected in him. With a mild degree of U.O. Few adolescents are recognized as insane. Adolescents declared sane are taken into account by the court in accordance with Article 22 of the Criminal Code of the Russian Federation, they need increased attention during the preliminary investigation, they deserve leniency, and often during the execution of punishment they are shown treatment.
Rehabilitation
Rehabilitation is understood as the application of all measures that, in case of mental retardation, help to adapt to the requirements of training, professional and social life. Separate components of rehabilitation for mental retardation, as a rule, are distinguished taking into account the international WHO classification. It distinguishes damage (impairment), restrictions on the functions of the individual (disability) and social failure (handicap). Since damage, as a rule, can no longer be eliminated, rehabilitation measures are aimed at the last two components - improving the functional capabilities of the individual and reducing negative social impacts. To this end, step-by-step programs have been developed with the help of which patients are integrated into professional activities and society. It is necessary to name different types of special schools, integrative schools, specialized boarding schools for teaching a profession and receiving vocational education, medical and labor workshops, which have workplaces equipped in accordance with the abilities and capabilities of patients.
Dynamics and forecast depend on the type and severity of intellectual underdevelopment, on the possible progression of the disorder, and on the conditions of development. In recent years, there has been a change in attitudes towards serving mentally retarded children in terms of their greater integration into society. in children's groups.
Disability: mild mental retardation is not an indication for referral to a medical and social examination. Mild mental retardation with behavioral disorders can be presented at the ITU after examination and treatment in day and round-the-clock hospitals with insufficient effectiveness of the therapy performed on an outpatient basis. Disabled children are children with moderate, severe and profound forms of mental retardation.
Prevention of mental retardation
Primary prevention mental retardation:
1. A serious threat to UO is the use of drugs, alcohol, tobacco products and many drugs by a pregnant woman, as well as the effect of a strong magnetic field, high frequency currents.
2. The risk to the fetus is represented by many chemicals (detergents, insecticides, herbicides) that accidentally enter the body of the expectant mother, salts of heavy metals, iodine deficiency of the mother.
3. Severe damage to the fetus is caused by chronic infectious diseases of a pregnant woman (toxoplasmosis, syphilis, tuberculosis, etc.). Acute viral infections are also dangerous: rubella, influenza, hepatitis.
4. Timely diagnosis and treatment of enzymopathies (diet and replacement therapy).
5. Prevention of prematurity of the fetus and proper management of childbirth.
6. Genetic counseling.
Prevention of complications mental retardation:
1. Prevention of the impact of additional exogenous damaging factors: trauma, infection, intoxication, etc.
2. Creation of psychologically favorable conditions for the harmonious development of a child suffering from mental retardation, his professional orientation and social adaptation.
LIST LITERATURE
1. Vilensky O.G. "Psychiatry. Social aspects”, M: Vuzovskaya kniga, 2007
2. Gillberg K., Hellgren D. "Psychiatry of childhood and adolescence", GEOTAR-Media, 2004
3. Hoffman A.G. "Psychiatry. Handbook for doctors”, Medpress-inform, 2010
4. Goodman R., Scott S. "Child psychiatry", Triad-X, 2008.
5. Doletsky S.Ya. Morphofunctional immaturity of the child's body and its significance in pathology// Violation of the maturation of the structures and functions of the child's body and their significance for the clinic and social adaptation. - M.: Medicine, 1996.
6. Zharikov N.N., Tyulpin Yu.G. "Psychiatry", MIA, 2009
7. Isaev D.N. "Psychopathology of childhood", Medpress-inform, 2006
8. Kaplan G.I., Sadok B.J. Clinical Psychiatry. In 2 vols. T. 2. Per. from English. - M: Medicine, 2004.
9. Kovalev V.V. Psychiatry of childhood: A guide for doctors: ed. 2nd, revised and expanded. - M.: Medicine, 1995.
10. Remshid X. Child and adolescent psychiatry \ trans. with him. T.N. Dmitrieva. - M.: EKSMO-Press, 2001.
11. Snezhnevsky A.V. "General psychopathology", Medpress-inform, 2008
12. Sukhareva G.D. "Clinical lectures on childhood psychiatry", Medpress-inform, 2007
13. Ushakov G.K. "Child psychiatry", Medicine, 2007
Loading...