Emotional disorders or affective personality disorders. Affective syndromes Affective disorders classification

What is Affective Disorder

Affective disorder (Mood disorder)- a mental disorder associated with disturbances in the emotional sphere. Combines several diagnoses in the DSM IV TR classification, when the main symptom is a violation of the emotional state.

The two most widely recognized types of disorders are differentiated based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, among which the most well-known and studied are major depressive disorder, which is also called clinical depression, and bipolar affective disorder, formerly known as manic-depressive psychosis and described by intermittent periods of manic episodes (lasting from 2 weeks to 4 -5 months) and depressive (average duration 6 months) episodes.

What Causes Affective Disorder?

Causes of affective disorders unknown, but biological and psychosocial hypotheses have been proposed.

Biological aspects. Norepinephrine and serotonin are two neurotransmitters that are most responsible for the pathophysiological manifestations of mood disorders. Animal models have shown that effective biological treatment antidepressants (AD) are always associated with inhibition of the sensitivity of postsynaptic b-adrenergic and 5HT2 receptors after a long course of therapy. This may be consistent with decreased serotonin receptor function following chronic exposure to AD, which reduces the number of serotonin reuptake sites, and increased serotonin concentrations found in the brains of suicide patients. There is evidence that dopaminergic activity is reduced in depression and increased in mania. Recent studies have shown that muscarinic receptors are increased in fibrinogen tissue culture, urine, blood, and cerebrospinal fluid in patients with mood disorders. Mood disorders appear to be associated with heterogeneous dysregulation of the biogenic amine system.

It is assumed that secondary regulation systems, such as adenylate cyclase, calcium, and phosphatidyl inositol, may also be etiological factors.

Neuroendocrine disorders are thought to reflect dysregulation of the entry of biogenic amines into the hypothalamus. Deviations along the limbic-hypothalamic-pituitary-adrenal axis are described. In some patients, there is hypersecretion of cortisol and thyroxine, a decrease in nocturnal secretion of melatonin, and a decrease in the basal levels of FSH and LH.

Sleep disturbances are one of the strongest markers of depression. The main disorders consist of a decrease in the latent period of REM sleep, an increase in the duration of the first period of REM sleep and the volume of REM sleep in the first phase. It has been suggested that depression is a disorder of chronobiological regulation.
A decrease in cerebral blood flow, especially in the basal ganglia, a decrease in metabolism, and disturbances in the late components of the visual evoked potential were found.
It is assumed that the basis for disturbances in sleep, gait, mood, appetite, and sexual behavior is a dysfunction of the limbic-hypothalamic system and basal ganglia.

Genetic aspects. Approximately 50% of bipolar patients have at least one parent with a mood disorder. The concordance rate was 0.67 for bipolar disorder in monozygotic twins and 0.2 for bipolar disorder in dizygotic twins. A dominant gene located on the short arm of chromosome 11 was found to confer a strong predisposition to bipolar disorder in one family. This gene is possibly involved in the regulation of tyrosine hydroxylase, an enzyme required for the synthesis of catecholamines.

Psychosocial aspects. Life events and stress, premorbid personality factors (suggestible personalities), psychoanalytic factors, cognitive theories (depression due to misunderstanding of life events).

Symptoms of Affective Disorders

Depressive disorders
Major depressive disorder, often called clinical depression, occurs when a person has experienced at least one depressive episode. Depression without periods of mania is often called unipolar depression because the mood remains in one emotional state or “pole.” When diagnosing, there are several subtypes or specifications for the course of treatment:

- Atypical depression characterized by reactivity and positivity of mood (paradoxical anhedonia), significant weight gain, or increased appetite(“eating to relieve anxiety”), excessive sleep or sleepiness (hypersomnia), a feeling of heaviness in the limbs, and a significant lack of socialization as a consequence of hypersensitivity to perceived social rejection. Difficulties in assessing this subtype have led to questions about its validity and its distribution.

- Melancholic depression(acute depression) characterized by loss of pleasure (anhedonia) from most or all activities, inability to respond to pleasurable stimuli, feelings of low mood more pronounced than feelings of regret or loss, worsening symptoms in the morning, waking up early in the morning, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or strong feeling guilt.

- Psychotic depression- a term for a long-term depressive period, particularly in a melancholic nature, when the patient experiences psychotic symptoms such as delusions, or, less commonly, hallucinations. These symptoms almost always correspond to the mood (the content coincides with depressive themes).

- Depression solidifying - involutional- rare and severe form clinical depression, including motor dysfunction and other symptoms. In this case, the person is silent and almost in a state of stupor, and is either motionless or makes aimless or even abnormal movements. Similar catatonic symptoms also occur in schizophrenia, manic episodes, or as a consequence of neuroleptic malignant syndrome.

- Postpartum depression noted as a qualifying term in DSM-IV-TR; it refers to the excessive, persistent and sometimes disabling depression experienced by women after the birth of a child. Postpartum depression, which has an estimated chance of 10-15%, usually appears within three working months and lasts no longer than three months.

- Seasonal affective disorder- this is a clarifying term. Depression for some people is seasonal, with episodes of depression occurring in the fall or winter and returning to normal in the spring. The diagnosis is made if depression manifests itself in at least twice in the cold months and never at any other time of year for two years or more.

- Dysthymia- chronic, moderate impairment mood when a person complains of almost daily bad mood for at least two years. Symptoms are not as severe as those of clinical depression, although people with dysthymia are also susceptible to recurrent episodes of clinical depression (sometimes called “double depression”).

- Other depressive disorders(DD-NOS) are designated by code 311 and include depressive disorders that cause harm but do not fit officially defined diagnoses. According to DSM-IV, DD-NOS covers “all depressive disorders that do not meet criteria for any specified disorder.” They include research into diagnoses

Recurrent fulminant depression, and minor depression, listed below:
- Recurrent fulminant disorder(RBD) is distinguished from major depressive disorder primarily due to differences in duration. People with RBD experience depressive episodes once a month, with individual episodes lasting less than two weeks and usually less than 2-3 days. To be diagnosed with RBD, episodes must occur for at least one year and, if the patient is female, regardless of the menstrual cycle. People with clinical depression can develop RBD, as well as vice versa.

- Minor depression, which does not meet all the criteria for clinical depression, but in which at least two symptoms are present for two weeks.

Bipolar disorders
- Bipolar affective disorder, formerly known as “manic-depressive psychosis,” is described as alternating periods of manic and depressive states (sometimes very quickly succeeding each other or mixing into one state in which the patient experiences symptoms of depression and mania simultaneously).

Subtypes include:
- Bipolar I disorder defined as one or more manic episodes with or without episodes of clinical depression. For a DSM-IV-TR diagnosis, at least one manic or mixed episode is required. Although depressive episodes are not required for a diagnosis of Bipolar I disorder, they occur quite often.

- Bipolar II disorder consists of repeated alternating hypomanic and depressive episodes.

- Cyclothymia- This is a milder form of bipolar disorder that manifests itself in occasional hypomanic and dysthymic episodes, without any further severe forms mania or depression.

The main disorder is a change in affect or mood, level of motor activity, and social functioning. Other symptoms, such as changes in the pace of thinking, psychosensory disturbances, statements of self-blame or overestimation, are secondary to these changes. The clinic manifests itself in the form of episodes (manic, depressive), bipolar (biphasic) and recurrent disorders, as well as in the form of chronic mood disorders. Intermissions without psychopathological symptoms are observed between psychoses. Affective disorders almost always reflected in the somatic sphere (physiological functions, weight, skin turgor, etc.).

The spectrum of affective disorders includes seasonal weight changes (usually weight gain in winter and weight loss in summer within 10%), evening cravings for carbohydrates, in particular for sweets before bed, premenstrual syndromes, expressed in decreased mood and anxiety before menstruation, as well as “ “northern depression”, which affects migrants to northern latitudes; it occurs more often during the polar night and is caused by a lack of photons.

Diagnosis of Affective Disorders

The main signs are changes in affect or mood; other symptoms are inferred from these changes and are secondary.

Affective disorders are observed in many endocrine diseases (thyrotoxicosis and hypothyroidism), Parkinson's disease, and vascular pathology of the brain. In organic affective disorders, there are symptoms of cognitive deficit or disturbance of consciousness, which is not typical for endogenous affective disorders. They should also be differentiated in schizophrenia, however, with this disease there are other characteristic productive or negative symptoms In addition, manic and depressive states are usually atypical and closer to manic-hebephrenic or apathetic depression. The greatest difficulties and disputes arise when differential diagnosis with schizoaffective disorder, if secondary ideas of revaluation or self-blame arise in the structure of affective disorders. However, with true affective disorders, they disappear as soon as the affect is normalized and do not determine the clinical picture.

Treatment of Affective Disorders

Therapy for affective disorders consists of the treatment of depression and mania itself, as well as preventive therapy. Therapy for depression includes, depending on the depth, a wide range of drugs from fluoxetine, lerivone, Zoloft, mianserin to tricyclic antidepressants and ECT. Sleep deprivation therapy and photon therapy are also used. Therapy for mania consists of therapy with increasing doses of lithium while controlling them in the blood, the use of antipsychotics or carbamazepine, and sometimes beta blockers. Maintenance treatment is provided with lithium carbonate, carbamazepine or sodium valprate.

Treatment of psychogenic depression start with prescribing antidepressants. Depression, as mentioned above, can have an anxiety component or, conversely, the leading one can be asthenic syndrome. Treatment will be based on this. Doses are titrated as needed.

In the presence of asthenic syndrome, SSRIs are prescribed such as: fluoxetine, fevarin, paxil.

If there is anxiety, SSRIs are prescribed such as: cipramil, Zoloft. Additionally, alprazolam (Xanax) or mild antipsychotics - chlorprothixene, sonapax - are prescribed.
As treatment progresses, the patient may enter a hypomanic state, in which case it is necessary to prescribe mood stabilizers, for example Finlepsin 200 mg and above. Psychotherapy is also prescribed (cognitive therapy, behavioral therapy, interpersonal therapy, group and family therapy).

From the moment of improvement, treatment with antidepressants is continued for at least 6 weeks, then the dose of the drug is reduced, and maintenance therapy is prescribed if necessary.

Treatment of endogenous depression start with prescribing antidepressants. The most effective are selective and non-selective serotonin and norepinephrine reuptake inhibitors.

If anxiety is present, amitriptyline and other sedative antidepressants are prescribed. Selective inhibitors include ludiomil, desipramine, as well as remeron (a central alpha-2 adrenergic blocker), moclobemide, and additional prescription of anxiolytics or antipsychotics is possible. If ineffective, non-selective MAOIs, but always in combination with anxiolytics or antipsychotics, because MAOIs only have a pronounced activating effect.

If melancholy prevails and there is no anxiety, anafranil, protriptyline, nortriptyline are prescribed - activating antidepressants. If ineffective, you can also prescribe an MAOI - tranylcipramil (non-hydrogenated) - a positive effect after 2-3 days. When using hydrosed ones - nialamide - after 2-3 weeks.
From the moment of improvement, treatment is continued for 6 months (according to WHO recommendations). 2-3 weeks before the dose reduction, mood stabilizers are prescribed (finlepsin from 1000 mg). Amitriptyline is reduced by 25 mg per week, and after discontinuation, treatment with mood stabilizers is continued for 1-2 weeks. If necessary, maintenance therapy.

If the patient gives allergic reaction for all antidepressants or treatment is ineffective - ECT is prescribed ( electroconvulsive therapy). It is possible to conduct up to 15 sessions in elderly patients with endogenous depression.

Treatment of mania comes down to the prescription of antipsychotics of the buterophenone or phenothiazine series, mood stabilizers, and psychotherapy. ECT - 10-15 sessions.

Treatment of cyclothymia comes down to prescribing antidepressants (from small doses, due to the possibility of phase reversal), mood stabilizers, psychotherapy - see endogenous depression.

Which doctors should you contact if you have an affective disorder?

Psychiatrist

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Affective disorders, or mood disorders, are a general name for a group of mental disorders that are associated with a disturbance in the internal experience and external expression of a person's mood (affect).

The disorder is expressed in changes in the emotional sphere and mood: excessive elation (mania) or depression. Along with the mood, the individual’s activity level also changes. These conditions have a significant impact on human behavior and social function and can lead to maladjustment.

Modern classification

There are two main mood disorders that are polar in their manifestation. These conditions are depression and mania. When classifying affective disorders, the presence or absence of a manic episode in the patient's history is taken into account.

The most widely used classification is distinguishing three forms of the disorder.

Depressive spectrum disorders

Depressive disorders are mental disorders in which motor retardation, negative thinking, depressed mood and the inability to experience feelings of joy are manifested. The following types of depressive disorders are distinguished:

Seasonal affective disorder is also highlighted as a separate item; more about it in the video:

Manic spectrum disorders

Manic disorders:

1. Classic mania– a pathological condition characterized by increased mood, mental agitation, and increased motor activity. This condition differs from the usual psycho-emotional upsurge, and is not due to visible reasons.
2. Hypomania –light form classic mania, characterized by a less pronounced manifestation of symptoms.

Bipolar spectrum disorders

(outdated name - manic-depressive psychosis) is a mental disorder in which alternating manic and depressive phases occur. Episodes replace each other, or alternate with “bright” intervals (states of mental health).

Features of the clinical picture

Manifestations of affective disorders vary and depend on the form of the disorder.

Depressive disorders

Major depressive affective disorder is characterized by the following symptoms:

Symptoms of other types of affective disorders of the depressive spectrum:

1. At melancholic depression, there is a vitality of affect - a physical sensation of pain in the solar plexus, which is caused by deep melancholy. There is an increased feeling of guilt.
2. At psychopathic depression, hallucinations and delusions are present.
3. At involutionary depression, the patient's motor functions are impaired. This manifests itself in either aimless or abnormal movements.
4. Symptoms postpartum depression are similar to the symptoms of major depressive disorder. The criterion for assessing the condition is postnatal depression, which indicates the development of pathology in the postpartum period.
5. At small depression, symptoms of major depressive disorder are observed, but they are less intense and do not have a significant impact on the patient’s social function and life activities.
6. Similar symptoms are observed with recurrent disorder, the main difference is the duration of the condition. Episodes of depression occur periodically and last from 2 days to 2 weeks. During the year, episodes are repeated several times and do not depend on the menstrual cycle (in women).
7. At atypical form of a mood disorder, the symptoms of clinical depression are complemented by emotional reactivity, increased appetite, weight gain, and increased drowsiness.

The patient experiences alternating periods of low mood (depression) and increased activity (mania). Phases can replace each other quite quickly.

The average duration of one period is about 3-7 months, however, it can be several days and several years, with depressive phases often three times longer than manic ones. The manic phase can be a single episode against the background of a depressive state.

In cases of the organic nature of affective disorder, patients experience a decrease mental abilities And .

Health care

The choice of therapeutic course depends on the form of affective disorder, but in any case, patients are recommended to undergo outpatient treatment.

Patients are prescribed medications and psychotherapy sessions. The selection of drugs is carried out depending on the existing symptoms.

Treatment of depressive affective disorders

The main course of treatment includes taking selective and non-selective norepinephrine and serotonin uptake inhibitors.

Anxiety is relieved with:

If there is an increased manifestation of melancholy, the following is prescribed:

• activating antidepressants (Nortriptyline, Protriptyline);
• non-selective monoamine oxidase inhibitors (Tranylcipramil);

Affective disorders are a group mental disorders, which are manifested by excessive expression natural emotions person or a violation of their dynamics (instability or stiffness). Affective disorders are spoken of in cases where emotional manifestations generally change the patient’s behavior and lead to his serious maladjustment.

Why Emotional Disorders Develop

Today, there are several theories of the occurrence of affective disorders. Each of them has the right to its existence, but there is no single reliable theory.

Genetic causes of emotional disorders may be an abnormal gene on chromosome 11. Scientists suggest the presence of recessive, dominant, and polygenic forms of affective disorders.

Neuroendocrine causes include dysfunction of the hypothalamic-pituitary system, limbic system and pineal gland. In this case, disruptions occur in the rhythm of the release of liberins, which stimulate the synthesis and entry into the blood of pituitary hormones, and melatonin, which regulates circadian rhythms. As a result, there is a change in the overall rhythm of the body, including the rhythm of sleep/wakefulness, eating, and sexual activity.

Stress (negative or distress and positive or eustress) can also lead to the development of affective disorders. Stress negatively affects the body, causing it to become overstrained and subsequently exhausted, and also contributes to the occurrence of depression in constitutionally predisposed individuals. The most significant stressors are the death of a child, death of a spouse, arguments, and loss of economic status.

Classification of affective disorders

1) Single depressive episode
2) Single manic episode
3) Bipolar affective disorder
4) Recurrent depressive disorder
5) Chronic mood disorders

Non-psychotic affective disorders include diverse manifestations of depressive states that have a significant Negative influence on the quality of human life and prevent full social adaptation. Affective disorders are characterized by a persistent deterioration in a person’s mood – hypothymia. The individual loses the opportunity to fully experience positive emotions: he does not experience joy from the positive moments of life, does not receive pleasure from pleasant activities.

With depression, a person has a pessimistic assessment of his life and current situation in society, and views his own personality from a negative point of view. He is sure that there are no prospects in his future.

In case of affective disorders, a decrease in the patient’s intellectual potential and a significant inhibition of motor activity are determined. A subject suffering from depression lacks motivation to be active and has reduced drive. A person loses all desire to do routine things.

Affective disorders are manifested by various somatic and autonomic disorders. The characterological portrait of the individual undergoes changes: a person develops excessive irritability, a hostile and aggressive attitude towards others, intolerance to the weaknesses of others, and conflict.

Currently, affective disorders occupy the first position in the number of patients among all psychopathological conditions. Symptoms of depression in varying degrees of severity have been identified in more than 350 million contemporaries. The ratio of male to female patients varies depending on the type of affective disorder. Most often, the first depressive episodes occur between the ages of twenty and forty.

Depression is manifested not only by typical affective syndromes. Atypical affective states are often recorded, which in some patients occur in a hidden and erased form.

Affective disorders: causes

To date, there is no common understanding in the scientific community of the causes and mechanisms of development of affective disorders. The creators and followers of various scientific hypotheses to this day they debate and present their arguments about the causes of depressive conditions. The most proven versions are three groups of theories:

• genetic;
• biological (physiological);
• socio-psychological.

Genetic version

Numerous studies have established that there is a family pattern in the formation of inadequate, psychotic reactions. A predisposition to neurotic and psychotic diseases is transmitted from ancestors to descendants at the genetic level. Mood disorders are more likely to occur in people whose parents suffered from some type of depression. However, the hereditary tendency to depressive reactions is not the direct cause of affective syndromes, but acts only as a basis for the formation of a disorder that starts when negative life circumstances arise.

Physiological version

Proponents of biological hypotheses believe that the cause of affective disorders is disturbances in the functioning of organs and systems of the body. Scientists call the leading cause of depressive states a decrease in the production of certain neurotransmitters, an imbalance of these biologically active chemical elements, and disruptions in the metabolism of certain neurotransmitters.

Long-term treatment with certain pharmacological agents, for example: benzodiazepines, can provoke the development of affective disorders. Depressive syndromes are often caused by endocrine diseases. Thus, hyperfunction of the thyroid gland makes itself felt with unpleasant symptoms: sad mood, excessive tearfulness, insomnia.

Affective disorders often occur with metabolic disorders and an imbalance in the ratio of certain mineral elements in the blood. Depressive status is often recorded in many infectious diseases of viral and bacterial etiology, especially if the infection affects the central nervous system. Affective disorders almost always accompany severe chronic diseases, which are characterized by intense pain syndrome.

A common cause of depression is human addiction: chronic alcoholism, drug addiction, uncontrolled reception medicines. Particularly severe depressive episodes develop during withdrawal symptoms.

Social-psychological version

Many psychotherapists are confident that affective disorders take root in a person’s childhood. Unfavorable conditions growing up, injuries received in childhood, cause irreparable harm to the fragile psyche of the child. Particularly dangerous circumstances for a young person are the death of parents and subsequent stay in an orphanage or boarding school. Asocial morals in the family, especially living with drinking parents, have a negative impact on the baby’s future. The lack of a unified education strategy also negatively affects the formation of a person’s personal portrait. Anxiety, suspiciousness, lack of confidence in one’s abilities, excessive responsibility, and trying to please everyone are the ideal foundation for the formation of neurotic reactions.

Any chronic stress or sudden extreme situation can trigger the development of symptoms of affective disorders. At the same time, it is important how a person is used to reacting to stress factors, how he interprets the changes that occur. It is a negative assessment of an accomplished event, excessive fixation of attention on a newly discovered circumstance that leads a person into a state of depression.

Mood disorders: types and symptoms

Typical and atypical affective disorders are divided into separate types depending on the predominance of positive (productive) or negative (unproductive) symptoms. Let us describe the signs of the most common types of depressive syndromes in more detail.

Vital depression

A frequently recorded type of affective disorder is vital (melancholy depression). The main characteristics of the disease are severe melancholy, an unreasonable negative outlook on life, hopeless sadness, and depression. Among clinical symptoms In this type of affective disorder, the patient’s dominant feeling of melancholy comes first. The person feels hopelessness and despair.

He develops ideas of his own worthlessness, depravity, and sinfulness. The patient describes his past as a series of mistakes and troubles. He denies his own merits and reduces the successes actually achieved. The subject blames himself for something he did not do. He obsessively engages in introspection, constantly reproducing past mistakes from memory. The patient is sure that a terrible tragedy is coming in the future.

A common symptom of vital depression is suicidal behavior. The patient considers his existence meaningless. He has a conscious desire to die. He stubbornly strives to commit suicide.

It is worth noting that the symptoms of this type of affective disorder follow a circadian rhythm. The maximum deterioration of the condition is observed in the early morning hours. After lunch, the mood background partially stabilizes.

Apathetic depression

A characteristic symptom of this type of affective disorder is a lack of motivation to act. The person indicates a lack of vitality. He complains of a persistent feeling of internal discomfort. The patient looks lethargic and depressed.

He is indifferent to his own situation. The person is not interested in his surroundings. He is indifferent to the results of his own labor.

Outwardly, the impoverishment of gestures and facial expressions becomes noticeable. The patient's speech is monotonous and laconic. Others get the impression that the subject acts automatically.

A decrease in intellectual potential is determined. The patient has difficulty concentrating. Due to problems with concentration, he cannot perform his duties efficiently.

Depersonalization depression

This type of affective disorder is also called anesthetic depression. The main symptom of the disease is depletion of the emotional background. The patient experiences a loss of belonging to his own emotions and feelings. He ceases to experience emotional involvement in environmental phenomena.

Alienation of emotions can take the form of painful insensitivity. The person indicates that he does not experience any worries regarding close relatives. He complains that all his desires have disappeared. Describes that he has no mood or any emotions. Any events in the outside world do not resonate with his condition. The patient perceives the environment as an alien and unnatural world. He loses the ability to experience pleasure and pleasure.

Another symptom of depersonalization depression is loss or weakening of sensitivity to one’s own feelings. The patient may not feel thirsty or hungry.

Neurotic depression

The leading affective signs of this type of disorder are illogical, incomprehensible, uncontrollable mood swings. The predominant symptoms are depression, depressed mood, and a pessimistic outlook.

All negative experiences of the patient manifest themselves at the physiological level. The patient indicates a burning sensation in chest area, debilitating soreness in the larynx, feeling of cold in the pit of the stomach. It is somatic and autonomic defects that are the main complaint of the patient, since negative experiences are never perceived by the patient as a global depressed state.

Masked depression

In some patients, mental discomfort completely fades into the background, giving way to painful physiological sensations. In this case, one can suspect that the patient has another type of affective disorder - masked depression. Very often, patients complain of heart problems: they indicate instability of the heart rhythm, pain, and a feeling of lack of air. Or they indicate anomalies in the functioning of other organs.

Almost always with masked depression, problems with sleep occur. The person sleeps in fits and starts with nightmares. He wakes up very early, but his rise requires volitional efforts.

A separate type of masked depression is the anorectic form. Its symptoms are nausea that occurs in the morning, loss of appetite, aversion to food, weight loss.

Characterological dysthymia

This type of affective disorder is characterized by the presence of dysphoria in the structure of depression. Along with a gloomy vision of the world around him, the patient is distinguished by an angry, angry attitude towards others. He demonstrates dissatisfaction with other people: the patient is picky, cruel, and grumpy. Such a person is conflictual and gets into arguments with others. He is prone to demonstrative behavior. Likes to manipulate people.

A feature of characterological dysthymia is the absence of ideas of self-blame. The patient shifts all the blame and responsibility for unpleasant situations onto other people.

Asthenic depression

This type of affective syndrome is clinically similar to asthenic disorder. The patient is distinguished by excessive sensitivity to external stimuli. The patient's main complaint is decreased performance, rapid depletion of nervous and mental resources. He complains of physical weakness and the inability to work at his usual rhythm. With asthenic depression, the patient is depressed and irritable, prone to tearfulness. The maximum symptoms occur in the morning.

Other types of affective disorders are depression:

• hysterical, which most often occurs as a pathological reaction of grief;
• alarming characterized by constant thinking about impending misfortune;
• hypochondriacal, which manifests itself as excessive concern about health.

Affective disorders: treatment methods

The method of treating affective disorders is selected for each person individually, depending on the type of depression, the severity of the syndrome, the presence concomitant diseases. In most cases, treatment is carried out on an outpatient basis. However, if there is a threat to life and if the patient demonstrates suicidal behavior, treatment should be carried out in a specialized medical institution.

The basis of treatment of pathological conditions is drug therapy with the help of antidepressants. As a rule, the patient is recommended to take antidepressants for a long period of time - about six months. Treatment with antidepressants allows you to stabilize the patient’s emotional state, restore intellectual potential, and eliminate motor retardation. The use of antidepressants also helps relieve a person from anxiety, worry and restlessness.

In parallel with drug treatment, various physiotherapeutic manipulations are carried out. Electroconvulsive therapy and transcranial magnetic stimulation show good results in the treatment of affective disorders.

As a rule, pharmacological treatment of patients with affective disorders is accompanied by psychotherapeutic assistance. The maximum result can be achieved using methods of cognitive-behavioral and rational therapy. For some patients, hypnosis sessions are also included in the treatment program.

Of particular importance for overcoming affective disorders is the elimination of stress factors, normalization of work and rest, regular physical activity and a balanced diet.

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As a result of mastering the material in this chapter, the student should:

know

• – main clinical manifestations of affective mood disorders;
• – forensic psychiatric significance of affective mood disorders;

be able to

• – determine the main clinical manifestations of affective mood disorders;
• – highlight the etiology, pathogenesis and patterns of the course of affective mood disorders;
• – establish legally significant clinical manifestations of affective mood disorders;

own

– skills in identifying and forensic psychiatric assessment of affective mood disorders.

The separation of affect and mood is due to the fact that affect is understood as a vivid expression of emotions, which is directly reflected in behavior, and mood is the sum of emotions over a certain period of time, which is often, but not always, manifested in behavior and can be successfully hidden. The range of affective disorders includes mania, depression, bipolar, recurrent and chronic affective disorders.

Emotions are manifested in behavior (facial expressions, posture, gesture, features of social interactions), as well as in thinking and are subjectively described in the structure of the individual’s experiences. When control over emotions is lost, they reach the level of affect and can lead to destructive (aggressive) or self-destructive (suicide, self-harm) actions. Affective disorders have several links in etiology and pathogenesis:

• genetic causes – there are theories about the genetic diversity of affective disorders. The existence of dominant, recessive and polygenic forms of the disorder is assumed;
• biochemical reasons– disturbance of neurotransmitter metabolism. Their level decreases with depression and increases with mania;
• neuroendocrine causes - deregulation of the functioning of the hypothalamic-pituitary, limbic system and pineal gland. This indirectly affects the overall rhythm of the body, in particular the rhythm of sleep/wakefulness, sexual activity, nutrition, which is clearly manifested in affective disorders;
• loss of social contacts and psychosocial stress. Long-term and massive and (or) multiple social stress impacts lead to overstrain and then depletion of the individual’s personal and biological resources and to the development of depression in constitutionally predisposed individuals. The most significant stressors are the death of a spouse, child, family breakdown, imprisonment, and loss of economic status.

Thus, affective disorders are polyetiological. At manic disorders the leading ones are hereditary (genetic) factors (primarily in bipolar disorder). In depressive disorders, both hereditary factors and external (social stress, psychogenic) causes play a role in the presence of a constitutional predisposition. Therefore, a distinction is made between endogenous and psychogenic depression. It should be assumed that in chronic and recurrent (repeating) depressive disorders, hereditary factors (including congenital neurotransmitter deficiency) are most significant. In the case of isolated depressive episodes that develop in connection with psychogenic influences, the etiological factor is psychosocial stress in the presence of weakness in the individual’s psychological and biological regulation systems.

The prevalence of affective disorders among the population, according to some data, is up to 20%.

Manic disorders. Classification of manic episodes based on severity includes hypomania, mania without psychotic episodes, and mania with psychotic episodes.

Under hypomania understand mild degree mania, in which changes in mood and behavior are long-term and pronounced, not accompanied by delusions and hallucinations. Elevated mood manifests itself in the sphere of emotions as joyful serenity, irritability, in the sphere of speech - as increased talkativeness with relief and superficial judgments, increased contact. In the sphere of behavior, there is an increase in appetite, sexuality, distractibility, a decrease in the need for sleep, and certain actions that go beyond morality. Subjectively, ease of associations, increased performance and creative productivity are felt. Objectively, the number of social contacts and success increase. At the same time, there are episodes of reckless or irresponsible behavior, increased sociability or familiarity.

The main diagnostic criterion is an elevated or irritable mood that is abnormal for the individual, persists for at least several days, and is accompanied by the symptoms listed above.

It should be noted that hypomanic episodes are possible in some somatic and mental disorders. For example, with hyperthyroidism, anorexia or therapeutic fasting in the phase of food arousal; with intoxication with certain psychoactive substances (amphetamines, alcohol, marijuana, cocaine), however, there are other manifestations of somatic and mental pathology and intoxication with ΠΛΒ.

In typical form full-blown manic state manifests itself in the so-called manic triad: painfully elevated mood, accelerated flow of thoughts and motor agitation. The leading sign of a manic state is manic affect, manifested in elevated mood, a feeling of happiness, contentment, well-being, an influx of pleasant memories and associations. It is characterized by an intensification of sensations and perceptions, strengthening of mechanical and some weakening of logical memory, superficiality of thinking, ease and unproductivity of judgments and conclusions, ideas of overestimation of one’s own personality, up to delusional ideas of greatness, disinhibition of drives and weakening of higher feelings, instability, ease of switching attention .

Mania without psychotic symptoms. The main difference from hypomania is that elevated mood affects changes in the norms of social functioning and manifests itself in inappropriate actions that are not controlled by the patient. The pace of time accelerates and the need for sleep is significantly reduced. Tolerance and need for alcohol increase, sexual energy and appetite increase, and a craving for travel and adventure arises. Thanks to the leap of ideas, many plans arise, the implementation of which is not carried out. The patient strives for bright and catchy clothes, speaks in a loud voice, makes a lot of debts and gives money to people he barely knows. He easily falls in love and is confident in the love of the whole world. Gathering many random people, he arranges holidays on credit. There is reckless driving, a noticeable increase in sexual energy, or sexual promiscuity. There are no hallucinations or delusions, although there may be perceptual disturbances (eg, subjective hyperacusis, vivid color perception).

The main symptom is an elevated, expansive, irritable (angry) or suspicious mood that is not typical for the individual. The change in mood should be clear and last for a week.

Mania should be differentiated from affective disorders in diseases of addiction (euphoria when using cocaine, marijuana), with organic affective disorders and with manic-hebephrenic agitation in schizophrenia and schizoaffective disorders.

Mania with psychotic symptoms. It is a pronounced mania with a vivid leap of ideas and manic excitement, which is joined by secondary delusional ideas of grandeur, high birth, hypereroticism, values. There may be hallucinatory calls confirming the importance of the individual, or “voices”, telling the patient about emotionally neutral things, or delusions of meaning and persecution. The greatest difficulties lie in differential diagnosis with schizoaffective disorders, but these disorders must have symptoms characteristic of schizophrenia, and delusions in them are less consistent with mood. However, the diagnosis can be considered as an initial diagnosis for the evaluation of schizoaffective disorder (first episode).

Bipolar affective disorder is a mental disorder formerly called manic-depressive psychosis (MDP). Characterized by repeated (but at least two) manic, depressive and mixed episodes, which are replaced without a specific sequence. A feature of this psychosis is considered to be the presence of light interphase intervals (intermissions), during which all signs of the disease disappear, a complete restoration of a critical attitude towards the suffered painful state is observed, premorbid characterological and personal properties are preserved, professional knowledge and skills. Its non-psychotic form (cyclothymia) is clinically a reduced (weakened, ambulatory) version of the disease.

Manic episodes usually begin suddenly and last from two weeks to 4–5 months (the average episode duration is about 4 months). Depression tends to last longer (average duration is about 6 months), although rarely more than a year (excluding elderly patients). Both episodes often follow stressful situations or mental trauma, although their presence is not required for diagnosis. The first episode can occur at any age. The frequency of episodes and the nature of remissions and exacerbations are quite variable, but remissions tend to shorten with age, and depressions become more frequent and prolonged after middle age.

Although the previous concept of manic depressive psychosis included patients who suffered only from depression, the term "MDP" is now used mainly as a synonym for bipolar disorder.

Bipolar affective disorder is often differentiated from schizoaffective disorder. Schizoaffective disorder is transient endogenous functional disorder, which is practically not accompanied by a defect and in which affective disorders last longer than the productive symptoms of schizophrenia, which are not characteristic of bipolar affective disorder.

Depressive episode. Depressive disorders are characterized by the “depressive triad”: low mood (depression), intellectual, verbal and motor retardation, sometimes reaching the level of stunorosis. Depressive coloration of sensations and perceptions, delusional ideas of self-accusation and self-abasement, vital melancholy, anxiety, and mental anesthesia are also observed. Patients experience sad facial expressions, decreased goal-directed activity, weakened drives, refusal of treatment and food, and weakened attention. In addition to complaints of a senestopathic, algic and vegetative nature, Protopopov’s somatic triad is typical for the depressive phase - tachycardia, mydriasis (persistent dilation of the pupils), constipation, as well as a moderate increase in blood pressure, dry mucous membranes and skin, weight loss, anorexia, dysmenorrhea, lack of tears. A depressive episode can be limited to a mild or moderate degree of mental disorders, but can, gradually deepening, reach the level of psychosis (severe depressive episode).

As already mentioned, in ICD-10 depressive episodes (of a one-time nature) include disorders of various etiologies(both endogenous and psychogenic depression). It should be noted that endogenous depression (in which hereditary factors are leading) can be limited to a single episode during life, while psychogenic depression (including severe - reactive psychoses) under unfavorable conditions can have a recurrent and protracted course. At the same time, there are certain differences in the clinical picture of severe depressive episodes of endogenous and psychogenic etiology. Thus, in psychogenic disorders, depressive experiences are associated with a traumatic situation and directly follow from it. For psychogenic disorders, an incomplete depressive triad is more typical. Ideational and motor retardation is clinically expressed only in disorders of the psychotic level, and in affective disorders the anxiety component predominates. Whereas when endogenous depressions sad experiences with vitalization of affect and suicidal tendencies are more represented. In psychogenic disorders, in contrast to endogenous depression, there are usually no diurnal mood swings. The course, depth and duration of psychogenic disorders completely depend on changes in the external situation - this is especially clearly seen in the practice of forensic psychiatry. Thus, the termination of a criminal case against a person with a severe psychogenic disorder or an amnesty against a convicted person leads to a rapid reduction of psychopathological symptoms.

It is necessary to note the different significance of endogenous and psychogenic depression for the practice of forensic psychiatry. With endogenous depression, suicides are more often committed, including extended ones - when the patient first kills family members and then commits suicide, which can serve as a reason for initiating a criminal case and ordering a post-mortem forensic psychiatric examination. Then how heavy psychogenic disorders usually develop in accused persons already after committing an offense, during the proceedings, or in persons already convicted, due to a sharp change in life pattern, sensory deprivation, severe restrictive regimes and other psychotraumatic factors. All this, within the framework of the criminal process, determines the various legal consequences of the diagnosis and forensic psychiatric assessment of these disorders.

Please note that diagnostic criteria, given in the guidelines and classifications for severe depression, are more typical for affective disorders of the endogenous circle. And in general, severe psychogenic disorders (reactive psychoses), due to the diversity of clinical manifestations (although despite the various striking external clinical manifestations, they are always based on affective disorders) ended up in different diagnostic sections of the ICD-10. Thus, psychogenic paranoids belong to section F2; psychogenic depression - to the TK section; acute reactions to stress and hysteroconversion disorders - to section F4.

So, at a mild, non-psychotic level, somatovegetative disorders and disturbances in well-being appear - worsening sleep with early and night awakenings, decreased appetite, general lethargy, and stool retention. These signs are combined with a “turn to pessimism” [Desyatnikov, Sorokina, 1981] in the form of hypohedonia, unclear perspective, decreased creative activity while maintaining the ability to perform habitual actions, which has characteristic daily fluctuations (most pronounced in the morning). Subsequently, a noticeable decrease in mood occurs, feelings of guilt and inferiority appear, painful sensations in the chest area - pressure, compression, heaviness, “a stone in the soul”; less often - melancholy, a feeling of inexplicable anxiety, vague anxiety, uncertainty, indecision, a tendency to doubt, painful introspection, thoughts about the aimlessness and meaninglessness of life. In patients with a psychotic level of disorders, a critical attitude towards painful experiences disappears, the depth of depressive affect increases with a feeling of “longing” in the chest area, which can reach the level of excruciating physical pain. It seems to them that time flows slowly or seems to stop; taste disappears, unpleasant sensations emanating from the internal organs are frequent. Patients remember “unseemly” actions, minor insults inflicted on others, on the basis of which they express self-accusations of immorality, uncleanliness, and crime with delusional steadfastness. They regard the sympathetic attitude of relatives and medical personnel as a consequence of an error or misconception; Requests to change this attitude to a sharply negative one are typical. Patients' thinking is usually slow, associations are poor, speech is monotonous, poor, with pauses, and quiet. The instinctive sphere is depressed, the scope of purposeful activity is narrowed, motor retardation is accompanied by a feeling of stiffness. The development of depressive stupor is possible. In the deep psychotic stages of depression, isolated perceptual deceptions in the form of auditory illusions and delusional ideas of relation may be noted. The recovery from depression is slow, with a gradual attenuation of daily mood fluctuations. During this period, a critical attitude towards one’s illness may appear; Personal reactions to the disease become noticeable, which requires psychotherapeutic correction.

Most clinicians classify suicidal behavior as typical symptoms of depression, which can be used to assess the depth and severity of a depressive state. However, suicidal phenomena can also occur in mentally healthy individuals. Data from A. G. Ambrumova, V. A. Tikhonenko (1980) show that suicidal phenomena within the framework of a depressive episode are mainly the result of personal processing of changes introduced by the disease into a person’s inner world and socio-psychological status, as well as individual symptoms of depression and situational factors.

According to ICD-10, with all of the following types of depressive episode (mild, moderate and severe), the patient suffers from low mood, loss of interests and pleasure, and decreased energy, which can lead to increased fatigue and decreased activity. There is marked fatigue even with little effort. Other symptoms include: a) decreased ability to concentrate and pay attention; b) decreased self-esteem and sense of self-confidence; c) ideas of guilt and humiliation (even with a slight muddy episode); d) gloomy and pessimistic vision of the future; e) ideas or actions aimed at self-harm or suicide; e) disturbed sleep; g) decreased appetite.

In some cases, anxiety, despair and motor agitation may at times be more pronounced than depression, and mood changes may also be masked by additional symptoms: irritability, excessive alcohol consumption, hysterical behavior, exacerbation of previous phobic or obsessive symptoms, hypochondriacal ideas.

In addition, there are somatic symptoms: loss of interest and pleasure in activities that are normally enjoyable; loss of emotional reactivity to the environment and events that are normally pleasant; waking up in the morning 2 or more hours earlier than usual; depression is worse in the morning; objective evidence of clear psychomotor retardation or agitation (noted by a stranger); a clear decrease in appetite; weight loss (considered to be indicated by a 5% weight loss in the last month); pronounced decrease in libido.

For depressive episodes of all three levels of severity, the duration of the episode should be at least 2 weeks, but the diagnosis can be made for shorter periods if the symptoms are unusually severe and occur quickly.

Mild depressive episode characterized by decreased mood, loss of interests and the ability to experience pleasure, increased fatigue, which is usually considered the most typical symptoms of depression. For a definitive diagnosis, at least two of these three symptoms must be present, plus at least two more of the other symptoms described above. None of these symptoms should be severe, and the minimum duration of the entire episode is approximately 2 weeks. Man with mildly depressed episode, is usually concerned about these symptoms, finds it difficult to perform regular work and be socially active, but is unlikely to stop functioning completely.

Depressive episode medium degree characterized by at least two of the three most typical symptoms for mild depression (F32.0) plus the presence of at least three or four other symptoms. Several symptoms may be severe, but this is not necessary if there are many symptoms. The minimum duration of the entire episode is about two weeks. A patient with a moderate depressive episode experiences significant difficulties in fulfilling social responsibilities, household chores, and finds it difficult to continue working.

Severe depressive episode without psychotic symptoms is characterized by significant anxiety and agitation of the patient, but severe lethargy may also be observed. Loss of self-esteem or feelings of worthlessness or guilt may be significant. Suicides are dangerous in especially severe cases. It is assumed that somatic syndrome almost always present during a major depressive episode. All three of the most typical symptoms characteristic of mild and moderate degree depressive episode, plus four or more other symptoms, some of which must be severe. However, if symptoms such as agitation or lethargy are present, it is likely that the patient will be unwilling or unable to describe many other symptoms in detail. In these cases, labeling the condition as a severe episode may be justified. The depressive episode must last for at least 2 weeks. If the symptoms are particularly severe and the onset is very acute, then a diagnosis of severe depression is warranted even if the episode lasts less than 2 weeks. It is unlikely that the patient is able to continue social and home activities during a severe episode, or perform his job. Such activities can be carried out on a very limited basis.

Severe depressive episode with psychotic symptoms characterized additionally by the presence of delusions, hallucinations or depressive stupor. Delusions usually contain the following content: sinfulness, impoverishment, impending misfortunes for which the patient is responsible. Auditory or olfactory hallucinations - ego, usually an accusing and insulting "voice" in nature, and smells - rotting meat or dirt. Severe motor retardation may develop into stupor. Depressive stupor must be differentiated from catatonic schizophrenia (F20.2), dissociative stupor (F44.2) and organic forms of stupor.

Recurrent depressive disorder characterized by repeated episodes of depression - mild, moderate or severe depressive episodes. However, this category can be used if there is evidence of brief episodes of mild elation and hyperactivity that meet the criteria for hypomania and immediately follow a depressive episode. The age of onset, severity, duration and frequency of depressive episodes vary greatly. Individual episodes of any severity in most cases are provoked stressful situation and are observed 2 times more often in women than in men.

Below are two clinical observations: in relation to a defendant with a severe depressive episode that developed during criminal proceedings, and a post-mortem forensic psychiatric examination of a person with a severe depressive episode on the fact of an extended suicide.

Subject A., 40 years old, is accused of committing indecent and violent acts of a sexual nature against his youngest daughter (11 years old). The subject has a secondary education, is married, and has three daughters from his marriage. Born the second of two children in a working-class family. Early development without any features, suffered childhood infections without complications. He graduated from 8 classes and a vocational school with a degree in cabinetmaking. By nature he was impressionable, touchy, prone to bravado and telling fictitious stories to others. There were few friends with whom I often communicated. Served compulsory military service. During his service, the truck in which the expert was driving overturned, and a close friend died before his eyes. This event made a strong impression on A. long time felt depressed, he often dreamed of his friend; he became more irritable and impressionable. Soon after demobilization he got married. The relationship with his wife was uneven, there were conflicts and quarrels. He worked in his specialty, but changed jobs several times because he believed that he was underpaid and his professional skills were underestimated.

According to the investigation, A. systematically committed sexual assault against his daughter for two years. During the investigation, he denied his guilt. While in custody, he made numerous somatic complaints in the pre-trial detention center and demanded a doctor and a prosecutor. Psychomotor agitation was noted, he banged on the cell door with his fists, and self-cut himself in the abdominal area. Then he became lethargic, lethargic, stopped taking care of himself, did not answer questions, and could not get out of bed. He was sent for a forensic psychiatric examination.

Somatoneurological condition. Height 180 cm, weight 60 kg, blood pressure = 140/90 mm Hg. Art. There are marks from self-cuts on the skin in the abdomen. An EEG study reveals slight changes in the bioelectrical activity of the brain. Blood and urine tests are within normal limits. The therapist diagnosed “vegetative-vascular dystonia”.

Mental condition. The sub-expert is oriented formally correctly. He walks hunched over and has a shuffling gait. There is an expression of sorrow on the face, and tears periodically appear in the eyes. Inaccessible to productive contact, inhibited, speech is quiet, monotonous, slurred. It is difficult to provide anamnestic information. When questioned, he intensively makes somatic complaints, mainly about cardiac dysfunction (heaviness in the chest, palpitations, interruptions in heart function). In addition, he complains of difficulty falling asleep, early awakening, unpleasant dreams, heaviness in the chest, dizziness, and a feeling of a lump in the throat. Rapid mental exhaustion is noted. In conversations he said that he had previously repeatedly cut himself on his stomach. When asked about the act he is accused of, tears appear in his eyes, he stutters, and says that “there was a mistake.” The department is located within the bed. Appetite is sharply reduced. Refuses medication prescriptions.

During an experimental psychological examination, the foreground is the distance and formality of the position, low productivity of activity, selectivity in the implementation of techniques, difficulties in following instructions, and low quality of work in general. Inexpressiveness of emotional reactions, their low motivation, immersion in internal experiences with fixation on the incriminated act are noted. Memory is reduced.

The expert panel concluded that A. exhibits signs of histrionic personality disorder (F60.4). However, this disorder did not prevent him from fully realizing the actual nature and social danger of his actions and directing them. During the period of time relating to the act accused of him, L. did not show signs of any temporary painful disorder and could fully understand the actual nature and social danger of his actions and direct them. After being brought to criminal responsibility, A. developed a temporary painful disorder mental activity in the form of a “severe depressive episode without psychotic symptoms.” Currently, A. cannot realize the actual nature of his actions and manage them and needs to be sent for compulsory treatment to a general psychiatric hospital until he leaves this state, with subsequent referral to the disposal of judicial investigative authorities.

Subject P., age 33 at the time of death. The examination was carried out on the fact of murder II. his two young children and subsequent suicide. There is no information about hereditary burden of mental illness. Early development proceeded without any special features. She suffered childhood infections without complications. She got married at the age of 24. From her marriage she had two children - a 7-year-old girl and a 5-year-old boy. P. worked as a dispatcher, and then was at home and raised children. But according to the testimony of her neighbors, I. was a good woman, strong-willed and persistent in character, she and her husband lived in abundance, and did not deny themselves anything. The neighbors did not notice any mental abnormalities in P. The relationship with my husband was normal, but sometimes quarrels arose because he drank alcohol. She had not worked for the last three years because she believed that her husband should support her. P. treated her children well and took care of them. According to the testimony of P.’s husband, their marriage was happy, they had common interests and affections, the wife was a very strong, strong-willed woman, she always approached life with optimism. According to his testimony, about 4 months before what happened, she said that she needed to get a job, otherwise everything would become more expensive, once about 1.5 months before that, she told her husband that he was a soft and spineless person and if there was something wrong with her happens, she has no idea how he will take care of the children. The husband notes that about 2 weeks before the incident, P. often cried and said that she began to fear for the children, for her husband, for herself. Allegedly, she does not know how to live further, since she does not have enough money and a price increase is coming, she began to often pray that everything would be fine in the family. She stopped sleeping at night, woke up her husband, said that she was thinking and praying all the time, that she was afraid to live and that she would not live like that. P.’s husband believes that gradually negative moments from her life and troubles accumulated in her soul. One of these troubles had to do with her father, who married against their will, and P. was worried, and she was also worried about the general rise in prices. By nature, she was inclined to accumulate everything within herself, and the bad accumulated to a critical limit and resulted in such actions. He never noticed any mental abnormalities in her. According to the testimony of her apartment neighbor, P. asked to get a job, said that there was no money, that she did not know how to continue living, that she needed to place her children somewhere, that her life reminded her of “a state between life and death.”

As can be seen from the materials of the criminal case, P. strangled her two young children in her room and then committed suicide. According to the neighbor's testimony, she knocked on her room, but no one answered the door. The neighbor heard some muffled sound in her room, then footsteps in the kitchen, the sound of the window opening, and soon a neighbor from another apartment called on the phone and said that P. had jumped out of the window. After the incident, P. was taken to the hospital with the diagnosis: “Severe combined injury, closed craniocerebral injury, severe brain contusion, multiple fractures of the ribs on the left, closed fracture of the left humerus. on the day of suicide, his wife wrote and gave him a letter addressed to her father, asked him to send this letter. He did not notice any strangeness in his wife’s behavior on that day. In the letter to her father, P. wrote that it had become difficult to live, that there was no money, that she ruined herself and her children, asked her to forgive her and said goodbye to her father. In a suicide note to her husband, P. asked to forgive her, wrote that she was to blame for everything, cursed Yeltsin and the democrats, since they had “brought her down.” In conclusion According to the forensic medical examination, the death of both children II - a 7-year-old girl and a 5-year-old boy - was caused by mechanical asphyxia, which developed as a result of closing the openings of the nose and mouth with a soft object - a pillow.

The expert commission came to the conclusion that P., during the extended suicide, showed clinical signs of depressive psychosis (severe depressive episode) of unknown etiology. This is evidenced by anamnesis data that P., about two weeks before the incident, was depressed, anxious, cried a lot, prayed at night, had trouble sleeping, had fear for her future life, a pronounced decrease in mood, concern for the fate of her children, fixation on negatively emotionally charged experiences with suicidal thoughts. During the commission of aggressive actions and a suicidal act, the indicated painful manifestations in P. were expressed so significantly that they deprived her of the opportunity to realize the actual nature and social danger of her actions and to manage them. According to the psychologist's conclusion, in the period immediately preceding the suicide, P. had a pronounced decrease in mood - depression, depression, anxiety, concern, fear, fixation on negatively colored emotional experiences, a feeling of futility in future life, ideas of self-blame, self-abasement, persistent suicidal thoughts.

This observation is a fairly typical example of posthumous PPE in criminal cases. Its feature is complete absence lifetime medical psychiatric documentation - the subject was never observed or examined by a psychiatrist. However, eyewitness testimony and pre-mortem written products make it possible to reconstruct clinical picture with sufficient completeness. A person with a peculiar make-up (apparently at the level of accentuation - personal disharmony of a subclinical nature) develops neurotic symptoms that were not characteristic of her before, in the form of depressive disorders, which gradually increase to a psychotic level. Ideas of self-blame, hypochondriacal experiences (“no health”), and suicidal statements appear. The killing of children is associated with painful “altruistic” motives (“so as not to suffer”).

Sustainable (chronic ) mood disorders. Disorders included in this category are chronic and usually fluctuating in nature. Individual episodes are not profound enough to qualify as hypomania or mild depression. Because they last for years, and sometimes throughout the patient's life, they are distressing and can impair productivity.

Cyclothymia. A state of chronic mood instability with numerous episodes of mild depression and mild elation. Often since childhood or adolescence There are seasonal mood swings. However, this diagnosis is considered adequate only in post-puberty, when unstable mood with periods of subdepression and hypomania lasts for at least 2 years. Typically, distinct instability at a young age takes chronic course, although at times the mood may be normal and stable for many months in a row. Changes in mood are usually perceived by a person as unrelated to life events. It is not easy to make a diagnosis if the patient has not been observed long enough or there is no good description of past behavior. Due to the fact that changes in mood are relatively mild, and periods of elation are enjoyable, cyclothymia rarely comes to the attention of doctors. Sometimes this is because mood changes, although present, are less pronounced than cyclical changes in activity, self-confidence, sociability, or changes in appetite. If necessary, you can indicate when the onset was: early (in adolescence or before 30 years) or later.

When mood decreases, an important symptom is anhedonia in relation to previously pleasant activities (food, sex, travel, etc.). The decrease in activity is especially noticeable if it follows an elevated mood. However, there are no suicidal thoughts. An episode can be perceived as a period of idleness, existential emptiness, and if it lasts for a long time, it is assessed as a characterological trait.

The opposite state can arise spontaneously, be stimulated by external events and also be tied to the season. In an elevated mood, energy and activity increase, and the need for sleep decreases. Creative thinking is accelerated or sharpened, which leads to increased self-esteem. The patient tries to demonstrate intelligence, wit, sarcasm, and speed of associations. If the patient’s profession coincides with self-demonstration, then his results are assessed as “brilliant.” Sexual activity increases, interest in other types of instinctive activities increases (food, travel, over-involvement in the interests of one’s own children and relatives arises), the future is perceived optimistically.

The main feature of cyclothymia when diagnosed is persistent, chronic mood instability with numerous periods of mild depression and mild elation, neither of which was sufficiently severe or prolonged to meet the criteria for other diagnostic rubrics in this section.

Dysthymia. This is a chronic depressive mood that does not meet the description of mild or moderate recurrent depressive disorder, either in severity or duration of individual episodes (although there may have been isolated episodes in the past that met the criteria for a mild depressive episode, especially early in the disorder). The balance between individual episodes of mild depression and periods of relatively normal condition very variable. Under the influence of minor stresses in the nostrils for at least two years, they experience periods of constant or periodic depressive mood. Subjects have periods (days or weeks) that they themselves regard as good. Most of the time (often months) they feel tired and depressed. They are whiny, thoughtful and not very sociable, pessimistic. Intermediate periods of normal mood rarely last longer than a few weeks; the entire mood of the individual is colored by subdepression. However, the level of depression is lower than in mild recurrent disorder.

During the period of deepening of the disorder, everything is difficult and nothing gives them pleasure. They tend to brood and complain that they don't sleep well and feel uncomfortable, but generally cope with basic requirements Everyday life. Dysthymia therefore has much in common with the concept of depressive neurosis or neurotic depression.

Forensic psychiatric examination. It should be noted that severe affective disorders (severe manic and depressive episodes) are transient and are often observed in patients once during their lifetime. In bipolar disorders, characterized by alternating manic and depressive episodes, and in recurrent depressive disorder, these episodes are observed many times during the life of patients. At the same time, even with severe bipolar or recurrent disorder, affective phases are separated by states of almost complete recovery - intermissions, when the patient’s ability to consciously voluntarily regulate his behavior is completely restored. During severe depressive episodes, patients often commit suicidal acts, sometimes taking the form of extended suicides. In some cases, self-incrimination of patients is observed when, due to the presence of delusional ideas of self-accusation, they declare allegedly committed socially dangerous acts.

In a manic state with psychomotor disinhibition, hyperactivity, and in the presence of elements of irritability and anger in the structure of mania, patients can be aggressive, commit destructive actions, and cause bodily harm. Due to increased sexual disinhibition, patients in a manic state often commit sexual offenses. The social danger of such patients may increase their tendency to alcoholism. In some cases, manic patients act as victims, since their painful condition can be used to commit fraudulent acts and provoke the commission of sexual offenses against them.

The forensic psychiatric assessment of persons who have committed dangerous acts in a state of full-blown mania or severe depressive episode (even without the presence of psychotic symptoms during a painful attack) does not cause difficulties. The affective sphere is directly connected with the cognitive and volitional links in the regulation of behavior, and painful disorders in the affective sphere entail the inability of a person to consciously volitionally regulate his behavior. Such subjects are recognized as insane in relation to the acts accused of them, and certain medical measures are applied to them. If the crime was committed during the inter-attack period, during intermission, then they are recognized as sane. With short light intervals between affective episodes, patients should be considered as persons suffering from a chronic mental illness with frequent exacerbations of the painful condition, and therefore they should be recognized as insane and medical measures applied to them.

The forensic psychiatric assessment of subjects with hypomanic states and moderately severe depressive episodes may present some difficulty. These affective disorders do not fully violate a person’s ability to consciously voluntarily regulate their behavior, but they can still limit the ability to perceive a social danger and control their actions, therefore their forensic psychiatric assessment can be determined taking into account Art. 22 of the Criminal Code.

In cases where a severe affective disorder has developed after the commission of a crime, but before a verdict is passed, it violates the procedural capacity of the accused and the person is sent for a forensic psychiatric examination, which ascertains a temporary painful disorder of mental activity and recommends compulsory treatment in a psychiatric hospital until the specified painful disorder is cured condition. Greatest legal meaning have subacute reactive (psychogenic) psychoses (severe depressive episodes) as temporary painful disorders of mental activity, depriving a person for a certain time of the ability to understand the actual nature and social danger of their actions or to manage them, i.e. depriving him of procedural capacity. These persons may be sent by the court for compulsory treatment during their illness in accordance with Part 1 of Art. 81 and paragraph “b”, part 1, art. 97 of the Criminal Code. In rare cases, with some variants of protracted reactive psychoses, patients are subject to referral for compulsory treatment with exemption from punishment in accordance with Part 1 of Art. 81 CC.

Reactive (psychogenic) psychoses can occur not only with predominantly depressive manifestations. In addition to psychogenic depression, there are other clinical options subacute reactive psychoses: psychogenic paranoids and hallucinosis; syndrome of delusional fantasies; psychogenic pseudodementia, puerilism, mental regression syndrome (feralization); psychogenic stupor. In these cases, diagnosis is carried out in accordance with other sections of the ICV-10. For example, psychogenic paranoids - in accordance with section F2, and the syndrome of delusional fantasies, psychogenic pseudodementia, puerilism, mental regression syndrome (wildness), psychogenic stupor - F4 (F44 - dissociative/conversion disorders).

Less severe affective disorders, which do not deprive the accused of the ability to understand the actual nature and social danger of his actions, do not entail legal consequences, and these persons receive psychiatric care at the place of their stay - in the medical unit of the pre-trial detention center, and then in the penal system at the place where the sentence is served.

In cases where severe affective disorders develop in a convicted person, this does not entail release from punishment. These persons are placed in psychiatric hospitals URIS, where they receive the necessary treatment and, after relief of the disorders, return to the place of serving their sentence.

A separate question concerns the assessment of affective disorders in victims. First, crime victims may suffer mental disorders, including affective spectrum, which significantly limits or even deprives them of their ability to resist and determines their helpless state. Secondly, victims often, after committing unlawful acts against them, develop psychogenic disorders, which can deprive them of the ability to testify, violate their criminal procedural capacity and qualify as bodily injury (all of these issues are resolved within the framework of relevant expert studies, the latter - within the framework of a comprehensive forensic psychiatric and forensic medical examination).

Within the framework of civil proceedings, there may also be a need to resolve the issue of the mental state of patients with affective disorders. Thus, patients, being in a state of mania, due to disinhibition caused by the disease, increased self-esteem, pathological activity and pseudo-entrepreneurship can make various property transactions, exchange living space, and get married. If such civil acts are committed during a painful affective attack, then an expert opinion is issued on the inability of the citizen during the period of the transaction to understand the meaning of his actions and to manage them, and the civil acts or transactions are declared invalid.

• The events took place in 1992.