Organic non-psychotic disorders. Psychotic disorders: symptoms and treatment Course and prognosis of psychoses

Pathogenesis of reactive states

This group includes mental disorders that are a pathological reaction of a neurotic and psychotic level to mental trauma or unfavorable situations. Under the influence of mental trauma that causes fear, anxiety, apprehension, resentment, melancholy or other negative emotions, various mental disorders can develop.

In forensic psychiatric clinics, the term “reactive state” is more often used as a broader concept of psychogenic mental disorders, covering both reactive psychoses (mental disorders of the psychotic level) and mental disorders of the neurotic (non-psychotic) level, the so-called reactive neuroses. The distinction between reactive mental disorders of the psychotic and neurotic levels in a forensic psychiatric clinic is of fundamental importance, since further tactics in relation to this accused largely depend on the solution of this issue.

The nature and strength of mental trauma, on the one hand, and constitutional characteristics and premorbid state, on the other, are decisive for the occurrence of a reactive state or psychosis. Mental traumas are divided into spicy And chronic, sharp, in turn, - on shocking, depressing And disturbing. Reactive states occur more easily in psychopathic individuals, as well as in persons weakened by infections, severe somatic diseases, intoxications, traumatic brain injuries, vascular diseases, prolonged insomnia, severe vitamin deficiencies, etc. The age factor may also play a predisposing role. Puberty and menopause are the most vulnerable to external influences. Age also matters in the clinical picture of psychosis. Thus, paranoid reactions and psychoses with delusional syndromes are more characteristic of adulthood. In addition, the individual characteristics of the patient and the type of nervous system play a role in the occurrence and clinical implementation of the reactive state. The mechanism of occurrence of reactive states in the aspect of the doctrine of higher nervous activity can be explained as a disruption of the normal activity of the cerebral cortex as a result of overstrain of irritable and inhibitory processes or their mobility. A “mistake” of irritable and inhibitory processes (hidden grief, suppressed anger, etc.) has a strong psychotraumatic effect.

Clinical picture of stress-related mental disorders

Mental disorders of this group are diagnosed by identifying the so-called Jaspers triad, which includes the following conditions:

• mental disorders arise after mental trauma, i.e. there is a direct connection between the development of a mental disorder and psychogenicity;
• the course of mental disorders has a regressive nature, when, as time moves away from mental trauma, mental disorders gradually weaken and eventually disappear completely;
• there is a psychologically understandable connection between the content of traumatic experiences and the plot of painful disorders.

Stress-related mental disorders are divided into:

• 1) to affective-shock psychogenic reactions;
• 2) depressive psychogenic reactions (reactive depression);
• 3) reactive (psychogenic) delusional psychoses;
• 4) hysterical psychotic reactions or hysterical psychoses;
• 5) neuroses.

Affective-shock psychogenic reactions are caused by a sudden strong affect, usually fear due to a threat to life, more often found in mass disasters (fire, earthquake, flood, mountain collapse, etc.). Clinically, these reactions manifest themselves in two forms: hyperkinetic and hypokinetic.

Hyperkinetic form(reactive, psychogenic agitation) - sudden onset of chaotic, meaningless motor restlessness. The patient rushes about, screams, begs for help, sometimes rushes to run without any purpose, often in the direction of a new danger. This behavior occurs against the background of a psychogenic twilight disorder of consciousness with impaired orientation in the environment and subsequent amnesia. With twilight stupefaction, pronounced fear is observed, facial expressions and gestures express horror, despair, fear, and confusion.

The hyperkinetic form of shock reactions also includes acute psychoses of fear. In these cases, in the clinical picture of psychomotor agitation, the leading symptom is panic, uncontrollable fear. Sometimes psychomotor agitation is replaced by psychomotor retardation, patients seem to freeze in a pose expressing horror and despair. This state of fear usually disappears after a few days, but in the future, any reminder of the traumatic experience can lead to an exacerbation of attacks of fear.

Hypokinetic form (reactive, psychogenic stupor) - sudden immobility. Despite the mortal danger, the person freezes, cannot make a single movement, is unable to utter a word (mutism). Jet stupor usually lasts from several minutes to several hours. In severe cases, this condition is prolonged. Severe atony or muscle tension occurs. Patients lie in a fetal position or stretched out on their backs, do not eat, their eyes are wide open, their facial expressions reflect either fear or hopeless despair. When mentioning a psychotraumatic situation, patients turn pale or red, become covered in sweat, and experience rapid heartbeat (vegetative symptoms of reactive stupor). Darkened consciousness during reactive stupor causes subsequent amnesia.

Psychomotor retardation may not reach the level of stupor. In these cases, patients are accessible to contact, although they respond briefly, with a delay, and drawl out their words. Motor skills are constrained, movements are slow. Consciousness is narrowed or the patient is stunned. In rare cases, in response to sudden and strong psycho-traumatic influences, so-called emotional paralysis occurs: prolonged apathy with an indifferent attitude to a threatening situation and indifferent registration of what is happening around. In some cases, due to an acute fear reaction, a protracted fear neurosis may subsequently develop.

Affective-shock reactions are always accompanied by autonomic disorders in the form of tachycardia, sudden pallor or hyperemia of the skin, profuse sweat, and diarrhea. Acute shock reactions last from 15-20 minutes to several hours or days.

Depressive psychogenic reactions (reactive depression)

The death of a loved one and severe failures in life can also cause a natural psychological reaction of sadness in healthy people. The pathological reaction differs from the normal one in its excessive strength and duration. In this state, patients are depressed, sad, tearful, walk hunched over, sit in a bent position with their head bowed to their chest, or lie with their legs crossed. Ideas of self-blame do not always occur, but usually experiences are concentrated around circumstances associated with mental trauma. Thoughts about an unpleasant incident are persistent, detailed, often become overvalued, and sometimes reach the level of delirium. Psychomotor retardation sometimes reaches depressive stupor; patients lie or sit all the time, hunched over, with a frozen face, with an expression of deep melancholy or hopeless despair, they are lacking initiative, cannot serve themselves, the environment does not attract their attention, complex issues are not comprehended.

Reactive depression is sometimes combined with individual hysterical disorders. In these cases, depression manifests itself as shallow psychomotor retardation, an affect of melancholy with expressive external symptoms that do not correspond to the depth of depression: patients gesticulate theatrically, complain of an oppressive feeling of melancholy, take tragic poses, cry loudly, and demonstrate suicidal attempts. During the conversation, they become animated, scold their offenders, and at the mention of a traumatic situation, they become excited to the point of bouts of hysterical despair. Individual puerile, pseudodementia manifestations are often observed.

Sometimes, against the background of a depressed mood, phenomena of derealization, depersonalization, and senestopathic-popochondriacal disorders occur. Against the background of increasing depression with anxiety and fear, individual ideas of relationship, persecution, accusation, etc. may appear. The content of delusion is limited to an incorrect interpretation of the behavior of others and individual random external impressions. The affect of melancholy, when accompanied by anxiety, fear or anger, often develops against the background of psychomotor agitation: patients rush about, cry loudly, wring their hands, bang their heads against the wall, try to throw themselves out of the window, etc. Sometimes this condition takes the form of depressive raptus.

Reactive depressions differ from endogenous ones in that their occurrence coincides with mental trauma; traumatic experiences are reflected in the clinical picture of depression; after the traumatic situation is resolved or after some time, reactive depression disappears. The course of reactive depression depends both on the content of the mental trauma and on the personality characteristics of the patient and his condition at the time of the onset of the mental disorder. Reactive depression in persons who have suffered a traumatic brain injury or are weakened by severe somatic and infectious diseases, as well as in elderly people with cerebral atherosclerosis, may be prolonged. Reactive depressions associated with a severe, unresolved traumatic situation can also be long-lasting.

Reactive (psychogenic) delusional psychoses- a combined group of very different psychogenic reactions.

Reactive paranoid delusional formation - the emergence of paranoid, overvalued delusions that do not go beyond the traumatic situation, are “psychologically understandable” and are accompanied by a lively emotional reaction. These ideas dominate the consciousness, but in the early stages, patients are still amenable to some dissuading. In all other behavior of the patient, not related to the overvalued idea, no noticeable deviations are found. Reactive paranoid delusions, like all reactive states, last until the psychotraumatic situation disappears, and completely reflects it; it is not characterized by progression, and negative symptoms do not arise. All these features distinguish reactive paranoid states from schizophrenic ones. Paranoid reactive disorders have many individual variants, due to the characteristics of psychogenic influence.

Acute paranoid reaction - paranoid delusional formation, characteristic of psychopathic (paranoid) individuals. Relatively minor everyday difficulties can arouse in them suspicion, anxiety, ideas of relationship and persecution. Such reactions are usually short-lived. Their development is facilitated by a temporary weakening of the nervous system (overwork, lack of sleep, etc.).

Hypochondriacal reaction close in structure to acute paranoid. It usually develops in people with increased attention to their health. A careless phrase from a doctor (iatrogeny), a misunderstood medical text, or news of the death of a friend can lead to the emergence of a hypochondriacal overvalued idea. Patients begin to visit different doctors and specialist consultants, and negative research results do not bring reassurance. Depending on the personality of the patient and the behavior of the doctor, hypochondriacal reactions can be short-term or drag on for years.

Delirium of persecution of the hearing impaired occurs in people with poor hearing due to difficult speech contact with others. Similar conditions are observed when communication is difficult due to lack of knowledge of the language (delusions of persecution in a foreign language environment).

Reactive paranoids are characterized by great syndromic diversity. In some cases, the main symptoms in the clinical picture of psychogenic paranoid are ideas of persecution, relationships, and sometimes physical impact against a background of pronounced fear and confusion. The content of delusional ideas usually reflects a traumatic situation; everything that happens is subject to delusional interpretation and acquires special meaning. In other cases, against the background of a psychogenically caused change in consciousness, usually narrowed, in addition to delusional ideas of persecution, relationship and physical impact, the patient experiences abundant both auditory and visual hallucinations and pseudohallucinations; the status is dominated by the affect of fear.

Diagnosing reactive paranoids usually does not cause much difficulty. The main supporting criteria: situational conditionality, specific, figurative, sensory delirium, the connection of its content with a psychotraumatic situation and the reversibility of this state when the external situation changes.

Paranoid in isolation occurs often (for example, among people under investigation). It is longer than reactive and, as a rule, is accompanied by auditory hallucinations and pseudohallucinations, sometimes in the form of acute hallucinosis: the patient constantly hears the voices of relatives and friends, the crying of children. Numerous voices often seem to be divided into two camps: hostile voices that scold and condemn the patient, and friendly voices that defend and justify him.

Paranoid of the external environment (situational) - acute delusional psychosis; occurs suddenly, sometimes without any warning signs, in an extremely unusual (new) situation for the patient. This is an acute figurative delusion of persecution and an unusually sharp affect of fear. The patient, trying to save his life, throws himself out of the train while moving, sometimes defending himself with a weapon in his hands from imaginary pursuers. There are frequent attempts at suicide in order to get rid of the expected torment. Patients may seek protection from persecutors from government officials, police officers, and military personnel. At the height of the affect of fear, a disturbance of consciousness is noted, followed by partial amnesia for a specified period of time. At the height of psychosis, false recognitions, a symptom of a double, can be observed. The occurrence of such acute paranoids is facilitated by prolonged fatigue, insomnia, somatic weakening, and alcoholism. Such paranoids are usually short-term, and when the patient is removed from this environment, delusional ideas disappear, he calms down, and criticism of psychosis appears.

In forensic psychiatric clinics, psychogenic paranoids and hallucinosis are currently rare.

Hysterical reactions or psychoses manifest themselves in a relatively small number of clinical forms (variants):

• 1) hysterical twilight stupefaction (Ganser syndrome);
• 2) pseudodementia;
• 3) puerilism;
• 4) psychogenic stupor.

Hysterical twilight stupefaction, or Ganser's syndrome, manifests itself as an acute twilight disorder of consciousness, phenomena of “mimorya” (incorrect answers to simple questions), hysterical sensitivity disorders and sometimes hysterical hallucinations. The painful condition is acute and lasts several days. After recovery, there is a forgetting of the entire period of psychosis and the psychopathological experiences observed in its structure. Currently, this syndrome practically does not occur in forensic psychiatric clinics.

Pseudodementia syndrome (imaginary dementia) observed more often. This is a hysterical reaction, manifested in incorrect answers ("mimoral speech") and incorrect actions ("mimoral actions"), demonstrating the sudden onset of deep "dementia", which subsequently disappears without a trace. With past exposure, patients cannot perform the simplest usual actions, they cannot dress themselves, and they have difficulty eating. With the phenomena of “fleeting speech,” the patient gives incorrect answers to simple questions, cannot name the current year, month, is unable to say how many fingers he has on his hand, etc. Often the answers to questions asked are in the nature of denial (“I don’t know,” “ I don’t remember”) or are directly opposite to the correct answer (the window is called a door, the floor is a ceiling, etc.), or are similar in meaning, or are the answer to the previous question. Incorrect answers are always related to the correct ones, lie in the plane of the question posed and affect the range of correct ideas. In the content of the answer, one can discern a connection with a real traumatic situation, for example, instead of the current date, the patient names the date of arrest or trial, says that everyone is in white coats, which means he is in the store where he was arrested, etc.

Pseudodementia syndrome develops gradually against the background of a depressive-anxious mood, more often in persons with an organic mental disorder of a traumatic, vascular or infectious nature, as well as in psychopathic individuals of emotionally unstable and hysterical types. Unlike Ganser's syndrome, pseudodementia occurs against the background of a hysterically constricted rather than twilight disorder of consciousness. With timely initiation of therapy, and sometimes without it, pseudodementia undergoes reverse development after 2-3 weeks and restoration of all mental functions occurs.

Currently, pseudodementia syndrome as an independent form of reactive psychosis almost never occurs; its individual clinical manifestations are more often noted in the clinical picture of hysterical depression or delusional fantasies.

Puerilism syndrome manifests itself in childish behavior (from lat. puer - child) in combination with a hysterically narrowed consciousness. Puerilism syndrome, like pseudodementia syndrome, usually occurs in individuals with histrionic personality disorder. The most common and persistent symptoms of puerilism are children's speech, children's movements and children's emotional reactions. Patients with all their behavior reproduce the characteristics of a child’s psyche; they speak in a thin voice with childish capricious intonations, construct phrases like a child, address everyone as “you,” call everyone “uncles” and “aunts.” Motor skills acquire a childlike character, patients are mobile, run in small steps, and reach for shiny objects. Emotional reactions are also childish: patients are capricious, offended, pout, cry when they are not given what they ask for. However, in children's forms of behavior of puerile patients, one can note the participation of the entire life experience of an adult, which creates the impression of some uneven disintegration of functions, for example, a child's lisping speech and automated motor skills while eating and smoking, which reflects the experience of an adult. Therefore, the behavior of patients with puerile syndrome differs significantly from true child behavior. Manifestations of childishness in speech and facial expressions, external liveliness of children sharply contrast with the dominant depressive emotional background, affective tension and anxiety observed in all patients. In forensic psychiatric practice, individual features of puerilism are more common than the entire pueril syndrome.

Psychogenic stupor - a state of complete motor immobility with mutism. If there is psychomotor retardation that does not reach the level of stupor, then they speak of a criminal state. Currently, psychogenic stupor does not occur as an independent form of reactive psychoses. In certain forms of reactive psychoses, more often depression, short-term states of psychomotor retardation may occur that do not reach the degree of stupor or substupor.

Hysterical psychoses in recent decades, they have changed significantly in their clinical picture and are not found in forensic psychiatric practice in such diverse, clinically holistic and vibrant forms as they were in the past.

At present, from the group of hysterical psychoses, only delusional fantasies. The term arose for the first time in forensic psychiatric practice to designate clinical forms that occur primarily in prison conditions and are characterized primarily by the presence of fantastic ideas. These psychogenically arising fantastic ideas occupy, as it were, an intermediate position between delusions and fantasies: approaching delusional ideas in content, delusional fantasies differ from them in their liveliness, mobility, lack of cohesion with the personality, lack of the patient’s strong conviction in their reliability, as well as direct dependence on external circumstances . Pathological fantastic creativity is characterized by the rapid development of delusional constructions, characterized by variability, mobility, and volatility. Unstable ideas of greatness and wealth predominate, which in a fantastically hyperbolic form reflect the replacement of a difficult, unbearable situation with content-specific fictions and a desire for rehabilitation. Patients talk about their flights into space, the countless riches they possess, and great discoveries of national importance. Individual fantastic delusional constructions do not add up to a system; they are varied and often contradictory. The content of delusional fantasies bears a pronounced imprint of the influence of a traumatic situation, the worldview of patients, the degree of their intellectual development and life experience and contradicts the main anxious background of the mood. It changes depending on external factors, questions from the doctor.

In other cases, delusional fantastic ideas are more complex and persistent in nature, showing a tendency towards systematization. Just as with unstable, changeable fantastic constructions, all the anxieties, concerns and fears of patients are associated not with the content of ideas, but with a real unfavorable situation. Patients can talk for hours about their “projects” and “works,” emphasizing that in comparison with the “great significance of the discoveries they made,” their guilt is insignificant. During the period of reverse development of reactive psychosis, situationally determined depression comes to the fore, fantastic statements fade, reviving only for a short time when the patients are excited.

Reactive psychosis with delusional fantasy syndrome it is necessary to distinguish it from the peculiar non-pathological creativity that occurs in conditions of imprisonment, which reflects the severity of the situation and the need for self-affirmation. In these cases, patients also write “scientific” treatises with absurd, naive content, offering various methods of fighting crime, curing serious illnesses, prolonging life, etc. However, unlike reactive psychosis with delusional fantasy syndrome, in these cases there is no pronounced emotional stress with elements of anxiety, as well as other psychotic hysterical symptoms.

In forensic psychiatric practice, it is often observed hysterical depression. They often develop subacutely after a period of situationally determined emotional stress and emotional depression. The clinical picture of hysterical depression is distinguished by its particular brightness and mobility of psychopathological symptoms. The affect of melancholy in hysterical depression is characterized by particular expressiveness and is often combined with equally expressive anxiety, directly related to the real situation. The patients' voluntary movements and gestures are also distinguished by their expressiveness, plasticity, theatricality, and subtle differentiation, which creates a special pathetic design in the presentation of their suffering. Sometimes a feeling of melancholy is combined with anger, but even in these cases, motor skills and facial expressions remain just as expressive. Often patients harm themselves or make demonstrative suicide attempts. They are not prone to delusional ideas of self-accusation; externally blaming tendencies and a tendency to self-justification are more often noted. Patients blame others for everything, express exaggerated and unjustified fears about their health, and present a wide variety of variable complaints.

The clinical picture of depression may become more complicated, combined with other hysterical manifestations (pseudo-dementia, puerilism).

The listed forms of hysterical states can change from one to another, which is explained in the general pathophysiological mechanisms of their occurrence.

Neuroses are reactive states, the occurrence of which is associated with a long-term psychogenically traumatic situation that causes constant mental stress. In the development of neuroses, personality traits are of great importance, which reflect the low limit of physiological endurance in relation to psychogenies of different subjective significance. Therefore, the occurrence of neurosis depends on the structure of the personality and the nature of the situation, which, due to individual personal properties, turns out to be selectively traumatic and insoluble.

In ICD-10, neuroses are grouped under the rubric of neurotic stress-related disorders. At the same time, many independent forms are distinguished. The most common and traditional in the Russian literature is the classification of neuroses according to clinical manifestations. In accordance with this, three independent types of neuroses are considered: neurasthenia, hysterical neurosis, obsessive-compulsive neurosis.

Neurasthenia is the most common form of neuroses, developing more often in people with an asthenic constitution in conditions of a long-term insoluble conflict situation that causes constant mental stress. In the clinical picture, the leading place is occupied by asthenic syndrome, which is characterized by a combination of asthenia itself with autonomic disorders and sleep disorders. Asthenia is characterized by symptoms of mental and physical exhaustion. Increased fatigue is accompanied by a constant feeling of tiredness. Increased excitability and incontinence that appear at first are subsequently combined with irritable weakness and intolerance to ordinary stimuli - loud sounds, noise, bright light. Subsequently, the components of mental and physical asthenia itself become more and more pronounced. As a result of a constant feeling of fatigue and physical lethargy, a decrease in working capacity appears; due to exhaustion of active attention and absent-mindedness, the assimilation of new material and the ability to memorize deteriorate, and there is a decrease in creative activity and productivity. Low mood can acquire a depressive overtones with the formation in some cases of neurotic depression. Various autonomic disorders are also constant manifestations of neurasthenia: headaches, sleep disturbances, fixation of attention on subjective unpleasant physical sensations. The course of neurasthenia is usually long-term and depends, on the one hand, on the cessation or ongoing action of a traumatic situation (especially if this situation causes constant anxiety, expectation of trouble), on the other, on the characteristics of the individual and the general condition of the body. Under changed conditions, the symptoms of neurasthenia may completely disappear.

Hysterical neurosis usually develops in individuals with histrionic personality disorder. The clinical picture of hysterical neurosis is extremely diverse. The following four groups of mental disorders are characteristic:

• 1) movement disorders;
• 2) sensory and sensitivity disorders;
• 3) autonomic disorders;
• 4) mental disorders.

Hysterical movement disorders accompanied by tears, moans, screams. Hysterical paralysis and contractures are observed in the muscles of the limbs, sometimes in the muscles of the neck and torso. They do not correspond to anatomical muscle innervation, but reflect the patient’s ideas about the anatomical innervation of the limbs. With long-term paralysis, secondary atrophy of the affected muscle groups may develop. In the past, the phenomenon of astasia-abasia was often encountered, when, with complete preservation of the musculoskeletal system, patients refused to stand and walk. Lying in bed, the patients were able to make certain voluntary movements with their limbs, they could change the position of their body, but when they tried to put them on their feet, they fell and could not lean on their legs. In recent decades, these disorders have given way to less severe movement disorders in the form of weakness of individual limbs. More often there is hysterical paralysis of the vocal cords, hysterical aphonia (loss of sonority of the voice), hysterical spasm of one or both eyelids. With hysterical mutism (muteness), the ability to write is preserved and voluntary movements of the tongue are not impaired. Hysterical hyperkinesis is often observed, which manifests itself in trembling of the limbs of varying amplitude. Trembling increases with excitement and disappears in a calm environment, as well as during sleep. Sometimes tics are observed in the form of convulsive contractions of individual muscle groups. Convulsive phenomena in speech manifest themselves in hysterical stuttering.

Sensory hysterical disturbances most often manifest themselves in a decrease or loss of skin sensitivity, which also does not correspond to the zones of innervation, but reflects ideas about the anatomical structure of the limbs and parts of the body (like gloves, stockings). Pain sensations may be observed in different parts of the body and different organs. Disturbances in the activity of individual sense organs are quite common: hysterical blindness (amaurosis), deafness. Often hysterical deafness is combined with hysterical mutism, and a picture of hysterical deaf-muteness (surdomutism) arises.

Autonomic disorders diverse. A spasm of smooth muscles is often observed, which is associated with such typical hysterical disorders as a feeling of a lump in the throat, a feeling of obstruction of the esophagus, and a feeling of lack of air. Hysterical vomiting is often encountered, which is not associated with any disease of the gastrointestinal tract and is caused solely by spasm of the pylorus. Functional disorders of internal organs may be observed (for example, palpitations, vomiting, shortness of breath, diarrhea, etc.), which usually arise in a subjectively traumatic situation.

Mental disorders also expressive and diverse. Emotional disturbances predominate: fears, mood swings, states of depression, depression. At the same time, very superficial emotions are often hidden behind external expressiveness. Hysterical disorders, when they occur, usually have the character of “conditioned desirability.” In the future, they can be fixed and repeatedly reproduced in subjectively difficult situations through hysterical mechanisms of “flight into illness.” In some cases, the reaction to a traumatic situation manifests itself in increased fantasizing. The content of fantasies reflects the replacement of reality with fictions that are contrasting in content, reflecting the desire to escape from an unbearable situation.

Obsessive-compulsive disorder occurs in forensic psychiatric practice less frequently than hysterical neurosis and neurasthenia. Obsessive phenomena are divided into two main types:

• 1) obsessions, the content of which is abstract, affectively neutral;
• 2) sensory-imaginative obsessions with affective, usually extremely painful content.

Abstract obsessions include obsessive counting, obsessive memories of forgotten names, formulations, terms, obsessive philosophizing (mental chewing gum).

Obsessions, predominantly sensory-figurative, with painful affective content are more diverse:

• obsessive doubts, constantly arising uncertainty about the correctness and completeness of the actions taken;
• obsessive ideas that, despite their obvious implausibility and absurd nature, cannot be eliminated (for example, a mother who has buried a child suddenly has a sensory-figurative idea that the child is buried alive);
• intrusive memories - an irresistible, intrusive memory of some unpleasant, negatively emotionally charged event in the past, despite constant efforts not to think about it; obsessive fears about the possibility of performing habitual, automated behaviors and actions;
• obsessive fears (phobias) are especially diverse in content, characterized by insurmountability and, despite their senselessness, the inability to cope with them, for example, an obsessive senseless fear of heights, open spaces, squares or enclosed spaces, an obsessive fear for the state of one’s heart (cardiophobia) or the fear of getting sick cancer (cancerophobia);
• obsessive actions are movements performed against the wishes of patients, despite all efforts made to restrain them.

Phobias can be accompanied by obsessive movements and actions that arise simultaneously with the phobias, they are given a defensive nature and quickly take the form of rituals. Ritual actions are aimed at preventing imaginary misfortune and have a protective, protective nature. Despite the critical attitude towards them, they are produced by patients against reason to overcome obsessive fear. In mild cases, due to the complete preservation of criticism and awareness of the painful nature of these phenomena, those suffering from neuroses hide their obsessions and do not switch off from life.

In cases of severe neurosis, the critical attitude towards obsessions disappears for some time and is revealed as a concomitant severe asthenic syndrome and depressed mood. During a forensic psychiatric examination, it should be borne in mind that only in some, very rare cases of severe neurotic conditions, obsessional phenomena can lead to antisocial actions. In the overwhelming majority of cases, patients with obsessive-compulsive neuroses, due to a critical attitude towards them and the fight against them, do not commit criminal acts related to the phenomena of obsession.

In some cases, reactive states take a protracted course, in such cases they speak of the development of protracted reactive psychoses. The concept of protracted reactive psychosis is determined not only by the duration of the course (six months, a year and up to five years), but also by the clinical features of individual forms and the characteristic patterns of the dynamics of the disease.

In recent decades, against the background of successful psychopharmacotherapy, only in isolated cases has a prognostically unfavorable course of protracted reactive psychoses been encountered, which is characterized by the irreversibility of profound personal changes and general disability. Such an unfavorable development of reactive psychoses is possible only in the presence of the so-called pathological soil - an organic mental disorder after a head injury, with cerebral atherosclerosis and arterial hypertension, as well as at the age of reverse development (after 50 years).

Among protracted reactive psychoses, “erased forms” currently predominate, and the frequency and severity of hysterical manifestations has sharply decreased. Hysterical symptoms such as hysterical paralysis, paresis, the phenomenon of astasia-abasia, hysterical mutism, which in the past were leading in the clinical picture of protracted reactive psychoses, are practically not observed. The main place is occupied by clinically diverse forms of depression, as well as erased depressive states that do not reach a psychotic level and nevertheless have a protracted course. Patients note a depressed mood, elements of anxiety, they are gloomy, sad, complain of emotional stress, a premonition of misfortune. Usually these complaints are combined with unjustified fears about one’s health. Patients are fixated on their unpleasant somatic sensations, constantly think about the troubles awaiting them, and seek sympathy from others. This condition is accompanied by more or less pronounced disorganization of mental activity. Patients usually associate their experiences with a real psychotraumatic situation; they are concerned about the outcome of the case.

With a prolonged course, depression fluctuates in its intensity and its clinical manifestations and their severity depend significantly on external circumstances. A gradual deepening of depression is possible with an increase in psychomotor retardation, the appearance of elements of melancholy, and the inclusion of delusional ideas. Despite the deepening of depression, the condition of patients is characterized by external inexpressiveness, weariness, and suppression of all mental functions. Patients usually do not show initiative in conversation and do not complain about anything. They spend most of their time in bed, remaining indifferent to their surroundings. The depth of melancholy depression is evidenced by the prevailing feeling of hopelessness in the clinical picture, a pessimistic assessment of the future, and thoughts of not wanting to live. Somatovegetative disorders in the form of insomnia, decreased appetite, constipation, physical asthenia and weight loss complement the clinical picture of prolonged depression. This condition can last up to a year or more. In the process of active therapy, a gradual recovery is observed, in which melancholy depression is replaced by situational depression. After the reverse development of painful symptoms, asthenia remains for a long time.

Hysterical depression, when it is prolonged, does not show a tendency to deepen. The leading syndrome, formed in the subacute period of reactive psychosis, remains fixed at a protracted stage. At the same time, the expressiveness of emotional manifestations inherent in hysterical depression, the direct dependence of the basic mood on the characteristics of the situation, the constant readiness to intensify affective manifestations when the circumstances associated with a given situation worsen or only during conversations on this topic are preserved. Therefore, the depth of depression has a wave-like character. Often, in the clinical picture of depression, individual unstable pseudodementia-puerile inclusions or delusional fantasies are noted, reflecting the hysterical tendency to “flight into illness,” avoidance of an unbearable real situation, and hysterical repression. Hysterical depression can be long-lasting - up to two years or more. However, in the process of treatment or with a favorable resolution of the situation, sometimes an unexpectedly acute, but more often a gradual exit from the painful state occurs without any subsequent changes in the psyche.

In persons who have suffered prolonged hysterical depression, when the traumatic situation is resumed, relapses and repeated reactive psychoses are possible, the clinical picture of which reproduces the symptoms of the initial reactive psychosis according to the type of well-worn clichés.

The described variants of the course of protracted reactive psychoses, especially with psychogenic delusions, are now relatively rare, however, a clear understanding of the dynamics of individual, even rare forms is of great importance for assessing the prognosis of these conditions, which is necessary when solving expert issues.

The purpose of this review is to consider phenomenology of psychosis from the perspective of a neurologist and a general practitioner, which will make it possible to apply some of the theses outlined here for the early diagnosis of psychotic disorders and the timely involvement of a psychiatrist in the supervision of the patient.

Early diagnosis of mental illness has a number of specific features.

Acute conditions in psychiatry in the vast majority of cases occur with a quickly onset, pronounced disorganization of behavior, often reaching a degree of excitement, which is traditionally called psychomotor, i.e., excitement in the mental and motor spheres.

Excitement is one of the most common symptoms that are an integral part of the structure of syndromes of acute psychotic states, and serves as a reflection of certain links in the pathogenesis of the disease. In its occurrence, development, and 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 harm - 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, disorganization of the behavior of a mentally ill person is associated not only with internal factors of the disease, but also with the individual’s reaction to the disease due to the fact that the sudden onset of psychosis dramatically changes the patient’s perception of the world around him.

What really exists is distorted, evaluated pathologically, and often acquires a threatening, ominous meaning for the patient. Acutely developing delirium, hallucinations, and disturbances of consciousness stun the patient, causing bewilderment, confusion, fear, and 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. Balance is lost, personality homeostasis is disrupted, and “otherness” begins in the new conditions of mental illness.

Under these conditions, the functioning of the patient’s personality is determined not only by her own distorted perception of the environment, but also by the reaction of those around her to a suddenly mentally ill person, which is often expressed in fear, panic, attempts to tie up the patient, lock him up, etc. This, in turn, aggravates the disrupted interactions of the personality the patient with the world around him, contributes to increased psychopathological symptoms, disorganization of behavior, and increased agitation. Thus, a “vicious circle” situation is created.

These complex relationships also include other factors: the factor of the disease itself, the suffering of the entire organism with disruption of the usual interaction of organs and systems, disturbances in 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. A number of new pathogenetic factors arise that enhance 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 physical illness.

It would be possible to cite a number of other features of acute psychotic conditions, 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 mean the most striking manifestations of mental illnesses, in which the patient’s mental activity 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 at hand 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 severe disintegration of mental activity corresponds to a number of symptoms - the so-called formal signs of psychosis: hallucinations, delusions (see below), however, the division into psychotic and non-psychotic levels to a greater extent has a clear syndromic orientation - paranoid, oneiric and other syndromes

disappearance of criticism (non-criticism)– the impossibility of understanding 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

loss of ability to control voluntarily yourself, your actions, memory, attention, thinking, behavior based on personal real needs, desires, motives, assessment of situations, your morals, 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 of level III
syndromes from level IV to VIII (with the exception of psychoorganic syndrome - level IX)

2. Equated with psychotic disorders negative syndromes:
imbecility and idiocy
acquired mental defect syndromes from levels V – VI to X

To make the above criteria more clear, I present a model of the relationship between positive and negative syndromes and nosological forms, which A.V. Snezhnevsky presents in the form of nine circles (layers) of psychopathological disorders included in each other:

positive- emotional-hyperaesthetic (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); clouding of consciousness (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), personality disharmony (IV), decreased energy potential (V), decreased 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 characteristic of all mental and many somatic diseases.

Levels I-III syndromes correspond to the clinical picture of 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 dynamics of mental illnesses associated with gross organic pathology of the brain

The main manifestations of psychosis are:

1.Hallucinations
Depending on the analyzer, auditory, visual, olfactory, gustatory, and tactile are distinguished.
Hallucinations can be simple (bells, noise, calls) or complex (speech, scenes).
The most common are auditory hallucinations, the so-called “voices,” which a person can hear coming from outside or sounding inside the head, and sometimes the body. In most cases, voices are perceived so clearly that the patient does not have the slightest doubt about their reality. Voices can be threatening, accusing, neutral, imperative (commanding). The latter are rightfully considered the most dangerous, since patients often obey the orders of voices and commit acts that are dangerous to themselves or others.

2. Delusional ideas
These are judgments and conclusions that have arisen on a painful basis, do not correspond to reality, completely take possession of the patient’s consciousness, and cannot be corrected by dissuading and explaining.
The content of delusional ideas can be very diverse, but most often they occur:
delusions of persecution (patients believe that they are being watched, they want to kill them, intrigues are woven around them, conspiracies are being organized)
delusions of influence (from psychics, aliens, special services with the help of radiation, radiation, “black” energy, witchcraft, damage)
delusions of damage (they add poison, steal or damage things, want to survive from the apartment)
hypochondriacal delusion (the patient is convinced that he is suffering from some kind of disease, often terrible and incurable, persistently proves that his internal organs are damaged, requiring surgical intervention)
There are also delusions of jealousy, invention, greatness, reformism, other origins, love, litigious, etc.

3. Movement disorders
Manifest in the form of inhibition (stupor) or agitation. When stupor occurs, the patient freezes in one position, becomes inactive, stops answering questions, looks at one point, and refuses to eat. Patients in a state of psychomotor agitation, on the contrary, are constantly on the move, talk incessantly, sometimes grimace, mimic, are foolish, aggressive and impulsive (they commit 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 motivations, 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 physical activity, overestimation of one’s own capabilities with the construction of unrealistic, sometimes fantastic plans and projections, disappearance of the need for sleep, disinhibition of drives (abuse of alcohol, drugs, promiscuous sexual intercourse)

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 during the disease, all without exception, or separately.

Manifestations of auditory and visual hallucinations :
Conversations with oneself that resemble a conversation or remarks in response to someone else's questions (excluding comments out loud like “Where did I put my glasses?”).
Laughter for no apparent reason.
Sudden silence, as if a person is listening to something.
Alarmed, preoccupied look; inability to concentrate on the 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 irredeemable guilt.)
Protective actions in the form of curtaining windows, locking doors, obvious manifestations of fear, anxiety, panic.
Expressing, without obvious grounds, fears for one’s life and well-being, or for the life and health of loved ones.
Separate, meaningful statements that are incomprehensible to others, adding mystery and special significance to everyday topics.
Refusal to eat or careful checking of food contents.
Active litigious activity (for example, letters to the police, various organizations with complaints about neighbors, co-workers, etc.).

As for mood disorders of the depressive spectrum within the framework of a psychotic state, in this situation Patients may have thoughts of not wanting to live. But depression accompanied by delusions (for example, guilt, impoverishment, incurable somatic illness) is 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: :
The patient’s statements about his uselessness, sinfulness, and guilt.
Hopelessness and pessimism about the future, reluctance to make any plans.
The presence of voices advising or ordering suicide.
The patient's conviction that he has a fatal, incurable disease.
Sudden calming of the patient after a long period of sadness and anxiety. Others may have the false impression that the patient's condition has improved. He puts his affairs in order, for example, writes a will or meets 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 - identification, 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, medical examination, making a conclusion about insanity and incapacity, recognizing a transaction made in a psychotic state as invalid, etc. This is why early identification of patients with signs of a psychotic disorder is so important.

Maksutova E.L., Zheleznova E.V.

Research Institute of Psychiatry, Ministry of Health of the Russian Federation, Moscow

Epilepsy 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 occur much more often with an unfavorable course of epilepsy.

In the last few years, as statistical studies show, in the structure of mental morbidity there has been an increase in forms of epilepsy with non-psychotic disorders. At the same time, the proportion of epileptic psychoses is decreasing, which reflects the obvious pathomorphism of the clinical manifestations of the disease, caused by 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 tend to become chronic. This confirms the position that despite the achieved remission of seizures, disturbances in the emotional sphere are an obstacle to the full restoration of patients’ health (Maksutova E.L., Fresher V., 1998).

When clinically qualifying 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 themselves. In this regard, we can conditionally distinguish two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders themselves, and secondary - without a cause-and-effect relationship with the attack, but based on various manifestations of reactions to the disease, as well as to additional psychotraumatic influences.

Thus, according to studies of patients in a specialized hospital at the Moscow Research Institute of Psychiatry, it has been established that phenomenologically non-psychotic mental disorders are represented by three types of conditions:

1) depressive disorder in the form of depression and subdepression;

2) obsessive-phobic disorders;

3) other affective disorders.

Depressive spectrum disorders include the following:

1. Melancholy depression and subdepression were observed in 47.8% of patients. The predominant feeling in the clinic here was an anxious and melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort and heaviness in the chest. In some patients, there was a connection between these sensations and physical illness (headache, unpleasant sensations in the chest) and were accompanied by motor restlessness, less often they were combined with adynamia.

2. Adynamic depression and subdepression were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. They spent most of the time in bed, had difficulty performing simple self-care functions, and were characterized by complaints of fatigue and irritability.

3. Hypochondriacal depression and subdepression were observed in 13% of patients and were accompanied by a constant feeling of physical damage and heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death might occur during an attack or that they would not receive help in time. Rarely did the interpretation of phobias go beyond the specified plot. Senestopathies were characterized by hypochondriacal fixation, 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 typical for the interictal period, especially in conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.

4. Anxiety depression and subdepression occurred in 8.7% of patients. Anxiety, as a component of an attack (less commonly, 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 experienced vague fear or anxiety, the cause of which was unclear to them. A short-term anxious affect (several 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 attack itself or the post-seizure state).

5. Depression with depersonalization disorders was observed in 0.5% of patients. In this variant, the dominant sensations were changes in the perception of one’s own body, often with a feeling of alienation. The perception of the environment and time also changed. Thus, patients, along with a feeling of adynamia and hypothymia, noted periods when the environment “changed”, time “accelerated”, it seemed that the head, arms, etc. were enlarged. These experiences, in contrast to true paroxysms of depersonalization, were characterized by the preservation of consciousness with full orientation and were fragmentary in nature.

Psychopathological syndromes with a predominance of anxious affect comprised predominantly the second group of patients with “obsessive-phobic disorders.” Analysis of the structure of these disorders showed that their close connections can be traced with almost all components of a seizure, starting with precursors, aura, the attack 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, often of uncertain content, which patients described as an “impending threat”, increasing anxiety, giving rise to a desire to urgently do something or seek help from others. Individual patients often indicated fear of death from an attack, fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, and less frequently, social phobic 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 between obsessive-phobic disorders and the vegetative component, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, and thoughts were observed.

Unlike paroxysmal anxiety, 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 develop obsessive-phobic disorders with obsessive concerns, fears, behaviors, actions, etc. In some cases, there are protective mechanisms of behavior with unique 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 disorders.

The third type of borderline forms of mental disorders in the epilepsy clinic were affective disorders, which we designated 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, occurring both in the form of paroxysms and prolonged states, epileptic dysphoria was more often observed. Dysphoria, occurring in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic attack or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriacal manifestations, irritability, and anger affect prevailed in their structure. Protest reactions often formed. Aggressive actions were observed in a number of patients.

The emotional lability syndrome was characterized by a significant amplitude of affective fluctuations (from euphoria to anger), but without noticeable behavioral disturbances characteristic of dysphoria.

Among other forms of affective disorders, mainly in the form of short episodes, there were reactions of weakness, manifested in the form of incontinence of affect. Usually they acted outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.

In relation to the individual phases of an attack, the frequency of borderline mental disorders associated with it is presented as follows: in the aura structure - 3.5%, in the attack structure - 22.8%, in the post-ictal period - 29.8%, in the interictal period - 43.9 %.

Within the framework of the so-called precursors of attacks, various functional disorders are well known, mainly of a vegetative nature (nausea, yawning, chills, drooling, fatigue, loss of appetite), against the background of which anxiety, decreased mood or its fluctuations with a predominance of irritable-sullen affect occur. A number of observations during this period noted emotional lability with explosiveness and a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can be self-limiting.

An aura with affective feelings is a common component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension and a feeling of “lightheadedness.” Less common are pleasant sensations (increased vitality, a feeling of particular lightness and elation), which are then replaced by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either an affect of fear and anxiety may occur, or a neutral (less often excited-elated) mood may be noted.

In the structure of the paroxysm itself, affective syndromes most often occur within the framework of the so-called temporal lobe epilepsy.

As is known, motivational and emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly the mediobasal formations, which 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 defined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with various plots of phobias and episodes of agitation. This clinic fits completely into the distinguished “right hemisphere affective disorder” in the taxonomy of organic syndromes ICD-10.

Paroxysmal affective disorders (within an attack) include attacks of fear, unaccountable anxiety, and sometimes with a feeling of melancholy that suddenly appear and last for several seconds (less often than minutes). There may be impulsive short-term states of increased sexual (food) desire, a feeling of increased strength, and joyful anticipation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. It is necessary to emphasize the predominantly violent nature of these experiences, although individual cases of their arbitrary correction using conditioned reflex techniques indicate a more complex pathogenesis.

“Affective” seizures occur either in isolation or are part of 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 temporal lobe epilepsy includes dysphoric states, the duration of which can range 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 series of seizures.

The second place in the frequency of affective disorders is occupied by clinical forms with dominant vegetative paroxysms within the framework of diencephalic epilepsy. Analogues of the common designation of paroxysmal (crisis) disorders as “vegetative attacks” are concepts widely used in neurological and psychiatric practice such as “diencephalic” attack, “panic attacks” and other conditions with large vegetative accompaniment.

Classic manifestations of crisis disorders include sudden development: shortness of breath, a feeling of lack of air, discomfort from the organs of the chest cavity and abdomen with “heart sinking,” “interruptions,” “pulsation,” etc. These phenomena are usually accompanied by dizziness, chills, and tremor , various paresthesias. Possible increased frequency of bowel movements and urination. The most powerful manifestations are anxiety, fear of death, fear of going crazy.

Affective symptoms in the form of individual unstable fears can be transformed into both affective paroxysm itself and 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 (convulsive or non-convulsive) paroxysms, causing polymorphism in the clinical picture of the disease.

Regarding the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we include a variety of psychologically understandable reactions to the disease that occur with 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 conditions. They more often manifest themselves 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 clinical picture of emerging secondary reactive disorders is also reflected in the degree of personal (epithymic) changes.

As part of reactive inclusions, patients with epilepsy often have concerns:

development of a seizure on the street, at work

be injured or die during a seizure

go crazy

transmission of disease by inheritance

side effects of anticonvulsants

forced withdrawal of drugs or untimely completion of treatment without guarantees for relapse of attacks.

The reaction to a seizure at work is usually much more severe than when it occurs at home. Due to the fear that a seizure will occur, some patients stop studying, working, and do not go out.

It should be pointed out that, according to induction mechanisms, fear of a seizure may also appear in relatives of patients, which requires a large participation of family psychotherapeutic assistance.

Fear of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness become so accustomed to them that, as a rule, they hardly experience such fear. Thus, in patients with frequent seizures and a longer duration of the disease, signs of anosognosia and uncritical behavior are usually observed.

Fear of bodily harm or fear of death during a seizure is more easily formed in patients with psychasthenic personality traits. It also matters that they have previously had accidents and bruises due to seizures. Some patients fear not so much the attack itself as the possibility of bodily harm.

Sometimes the fear of a seizure is largely due to the unpleasant subjective sensations that appear during an attack. These experiences include frightening illusory, hallucinatory inclusions, as well as body schema disorders.

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 post-ictal emotional disorders closely associated with it is the adequate use of anticonvulsants with a thymoleptic effect (cardimizepine, valproate, lamotrigine).

While not anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic regimen has a positive effect on both the paroxysms themselves and secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.

Recently, the anti-anxiety and sedative effect of clonazepam, which is highly effective in absence seizures, has been widely used.

For various forms of affective disorders with depressive radicals, antidepressants are most effective. At the same time, in outpatient settings, drugs with minimal side effects are preferred, such as tianeptil, miaxerin, fluoxetine.

If the obsessive-compulsive component predominates in the structure of depression, the prescription of paroxetine is justified.

It should be noted that a number of mental disorders in patients with epilepsy may be caused not so much by the disease itself as by long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, and elements of mental and motor retardation that appear 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 forms of psychotic disorders, or borderline states, usually include various neurotic disorders. This concept is not generally accepted, but is still used by many healthcare professionals. As a rule, it is used to combine milder disorders and separate them from psychotic disorders. Moreover, borderline states are generally not the initial, intermediate, or buffer phases or stages of the main psychoses, but represent a special group of pathological manifestations that, in clinical terms, have their onset, dynamics and outcome, depending on the form or type of the disease process.

Characteristic disorders for borderline states:

• the predominance of the neurotic level of psychopathological manifestations throughout the course of the disease;
• the leading role of psychogenic factors in the occurrence and decompensation of painful disorders;
• the relationship between mental disorders themselves and autonomic dysfunctions, night sleep disorders and somatic diseases;
• the relationship of painful disorders with the personality and typological characteristics of the patient;
• the presence in most cases of an “organic predisposition” for the development and decompensation of painful disorders;
• maintaining a critical attitude by patients towards their condition and the main pathological manifestations.
• Along with this, in borderline states there may be a complete absence of psychotic symptoms, progressively increasing dementia and personality changes characteristic of endogenous mental illnesses, for example, and.

Borderline mental disorders can arise acutely or develop gradually; their course can be of different nature and limited to a short-term reaction, a relatively long-term condition or a chronic course. Taking this into account, as well as based on an analysis of the causes of occurrence, various forms and variants of borderline disorders are distinguished in clinical practice. In this case, different principles and approaches are used (nosological, syndromic, symptomatic assessment), and the course of the borderline state, its severity, stabilization, and the dynamic relationship of various clinical manifestations are analyzed.

Clinical diagnosis

Due to the non-specificity of many symptoms that fill the syndromic and nosological structures of borderline states, the external, formal differences between asthenic, vegetative, dyssomnic and depressive disorders are insignificant. Considered separately, they do not provide grounds either for differentiating mental disorders in the physiological reactions of healthy people who find themselves in stressful conditions, or for a comprehensive assessment of the patient’s condition and determining the prognosis. The key to diagnosis is the dynamic assessment of a particular painful manifestation, detection of the causes of occurrence and analysis of the relationship with individual typological psychological characteristics, as well as other psychopathological disorders.

In real medical practice, it is often not easy to answer the most important question for differential diagnostic assessment: when did this or that disorder begin; Is it a strengthening, sharpening of personal characteristics or is it fundamentally new in the individual uniqueness of a person’s mental activity? The answer to this seemingly trivial question requires, in turn, the solution of a number of problems. In particular, it is necessary to assess the typological and characterological characteristics of a person in the pre-morbid period. This allows us to see the individual norm in the neurotic complaints presented or qualitatively new, actually painful disorders not related to premorbid characteristics.

Paying great attention to the pre-morbid assessment of the condition of a person who has come to see a doctor in connection with his neurotic manifestations, it is necessary to take into account the characteristics of his character, which undergo dynamic changes under the influence of age-related, psychogenic, somatogenic and many social factors. Analysis of premorbid characteristics makes it possible to create a unique psychophysiological portrait of the patient, the starting point that is necessary for a differential assessment of the disease state.

Assessing current symptoms

What matters is not the individual symptom or syndrome itself, but its assessment in conjunction with other psychopathological manifestations, their visible and hidden causes, the rate of increase and stabilization of general neurotic and more specific psychopathological disorders of the neurotic level (senestopathy, obsession, hypochondria). In the development of these disorders, both psychogenic and physiogenic factors, most often their varied combination, are important. The causes of neurotic disorders are not always visible to others; they can lie in a person’s personal experiences, caused primarily by the discrepancy between the ideological and psychological attitude and physical capabilities of reality. This discrepancy can be viewed as follows:

1. from the point of view of lack of interest (including moral and economic) in a particular activity, in a lack of understanding of its goals and prospects;
2. from the position of irrational organization of purposeful activity, accompanied by frequent distractions from it;
3. from the point of view of physical and psychological unpreparedness to perform the activity.

What does borderline disorder include?

Taking into account the diversity of various etiopathogenetic factors, borderline forms of mental disorders include neurotic reactions, reactive states (but not psychoses), neuroses, character accentuations, pathological personality development, psychopathy, as well as a wide range of neurosis-like and psychopath-like manifestations in somatic, neurological and other diseases. In ICD-10, these disorders are generally considered as various variants of neurotic, stress-related and somatoform disorders, behavioral syndromes caused by physiological disorders and physical factors, and disorders of mature personality and behavior in adults.

Borderline states usually do not include endogenous mental illnesses (including sluggish schizophrenia), at certain stages of development of which neurosis- and psychopath-like disorders, which largely imitate the main forms and variants of borderline states themselves, predominate and even determine the clinical course.

What to consider when diagnosing:

• the onset of the disease (when neurosis or a neurosis-like state arose), the presence or absence of its connection with psychogenicity or somatogeny;
• stability of psychopathological manifestations, their relationship with the patient’s personal-typological characteristics (whether they are a further development of the latter or are not associated with pre-morbid accentuations);
• interdependence and dynamics of neurotic disorders in conditions of persistence of traumatic and significant somatogenic factors or a subjective decrease in their relevance.

Psychotherapeutic correction of non-psychotic mental disorders and psychological factors associated with the disease in the system of treatment and rehabilitation of young patients with psychosomatic diseases.

Common psychosomatic disorders in the classical sense, such as bronchial asthma, peptic ulcer disease, arterial hypertension, are a significant problem of modern medicine due to their chronic course and significant impairment of the quality of life of patients.

The proportion of identified cases of mental disorders in patients with psychosomatic disorders remains unknown. It is believed that approximately 30% of the adult population, due to various life circumstances, experience short-term depressive and anxious episodes of a non-psychotic level, of which no more than 5% of cases are diagnosed. “Subsyndromal” and “prenosological” changes in the mental sphere, more often manifestations of anxiety, which do not meet the diagnostic criteria of ICD-10, generally remain without the attention of specialists in the field of mental health. Such disorders, on the one hand, are objectively difficult to detect, and on the other hand, persons who are in a state of mild depression or anxiety rarely proactively seek medical help, subjectively assessing their condition as a purely personal psychological problem that does not require medical intervention. However, subsyndromal manifestations of depression and anxiety, according to the observations of general practitioners, exist in many patients and can significantly affect their health. In particular, a connection has been shown between subsyndromal symptoms of anxiety and depression and development.

Among the identified mental disorders, the proportion of neurotic, stress-related disorders was 43.5% (prolonged depressive reaction, adaptation disorder with a predominance of disturbances of other emotions, somatization, hypochondriacal, panic and generalized anxiety disorders), affective - 24.1% (depressive episode, recurrent depressive disorder), personal - 19.7% (dependent, hysterical personality disorder), organic - 12.7% (organic asthenic disorder) disorders. As can be seen from the data obtained, in young patients with psychosomatic diseases, functional-dynamic mental disorders of the neurotic register predominate over organic neurosis-like disorders.

Depending on the leading psychopathological syndrome in the structure of non-psychotic mental disorders in patients with psychosomatic diseases: patients with axial asthenic syndrome - 51.7%, with a predominance of depressive syndrome - 32.5%, with severe hypochondriacal syndrome - 15.8% of the number of patients with NPPR.

The basis of therapeutic tactics for psychosomatic disorders was a complex combination of biological and socio-rehabilitative influences, in which psychotherapy played a leading role. All therapeutic and psychotherapeutic measures were carried out taking into account the personal structure and clinical dynamics.

According to the biopsychosocial model, the following treatment and rehabilitation measures were distinguished: psychotherapeutic complex (PTC), psychoprophylactic complex (PPC), pharmacological (FC) and psychopharmacological (PFC) complexes, as well as physiotherapeutic (PTK) in combination with a therapeutic and physical education complex (physical therapy complex).

Stages of therapy:

"Crisis" stage used in acute stages of the disease, requiring a comprehensive assessment of the patient’s current condition, his psychosomatic, socio-psychological status, as well as the prevention of self-destructive behavior. The “crisis” stage included therapeutic measures that were protective in nature and aimed at relieving acute psychopathological and somatic symptoms. From the moment of admission to the clinic, intensive integrative psychotherapy began, the purpose of which was to form compliance and constructive relationships in the doctor-patient system.

An atmosphere of trust and active participation in the fate of the patient was created: in the shortest possible time it was necessary to choose a strategy and tactics for managing the patient, analyze internal and external influences, outline the paths of adequate therapy, give a prognostic assessment of the condition under study: the main requirement of this regime was constant, continuous monitoring carried out within a specialized hospital (preferably in a department for borderline conditions). The “crisis” stage lasted 7 - 14 days.

"Basic" stage recommended for stabilization of the mental state, in which temporary deterioration of the condition is possible; associated with the influence of the external environment. Psychopharmacotherapy was combined with physiotherapeutic procedures and physical therapy. Both individual and family psychotherapy were carried out:

The “basic” stage provided for a more thorough consideration of the “internal picture of the disease” of relative stabilization, which previously acquired a character (due to the restructuring of interpersonal relationships, changes in social status). The main therapeutic work was carried out precisely at this stage and consisted of overcoming the constitutional and biological basis of the disease and mental crisis. This regimen was assessed as therapeutic-activating and took place in a specialized hospital (department of borderline conditions). The “baseline” stage lasted from 14 to 21 days.

"Recovery" stage was intended for individuals who experienced regression of painful disorders, a transition to a compensated or non-painful state, which implied more active assistance from the patient himself. This stage contained mainly individual-oriented psychotherapy, as well as general strengthening measures. It was performed in semi-stationary units (night or day hospital) and made it possible to successfully solve the problem of overcoming the delay in the torpidity of the pathological process. During rehabilitation, the patient's position changed from passive-acceptive to active, partner. A wide range of personality-oriented psychological techniques and course reflexology were used. The “recovery” stage lasted from 14 to 2 - 3 months.

The psychoprophylactic stage began with a significant improvement in the condition, issues of family correction, social adaptation were discussed, a system of switching emotions was formed and focusing on the minimal symptoms of decompensation, the possibility of drug and psychological correction. When forming psychoprophylactic strategies, attention was focused on one’s own responsibility for the disease and the need to include regular drug treatment in the psychoprophylactic strategy.

As can be seen from the table, complete and practical recovery was observed: in the group of patients with hypertension in 98.5% of cases, in the group of patients with peptic ulcer disease in 94.3%, in the group of patients with bronchial asthma - 91.5%. Remissions of types “D” and “E” were not noted in our observations.

Korostiy V.I. - Doctor of Medical Sciences, Professor of the Department of Psychiatry, Narcology and Medical Psychology, Kharkov National Medical University.