Organic non-psychotic disorders accompanied by cognitive impairment. Organic non-psychotic disorders Clinical picture of mental disorders associated with stress

Borderline forms of psychotic disorders, or borderline states, as a rule, include various neurotic disorders. This concept is not universally recognized, but still it is used by many professionals in the field of health. As a rule, it is used to group mild disorders and separate them from psychotic disorders. At the same time, borderline states are generally not initial, intermediate, or buffer phases or stages of major psychoses, but represent a special group of pathological manifestations that have their onset, dynamics, and outcome in clinical terms, depending on the form or type of the disease process.

Characteristic disorders for borderline conditions:

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 of mental disorders proper with autonomic dysfunctions, night sleep disturbances and somatic diseases;
the relationship of painful disorders with the personality and typological characteristics of the patient;
the presence in most cases of "organic predisposition" for the development and decompensation of painful disorders;
preservation by the patient of a critical attitude to his condition and the main pathological manifestations.
Along with this, in borderline states, psychotic symptoms, progressive dementia and personality changes characteristic of endogenous mental illness, for example, and may be completely absent.

Borderline mental disorders may occur acutely or develop gradually, their course may have a different character and be limited to a short-term reaction, a relatively long-term condition or a chronic course. With this in mind, as well as on the basis of an analysis of the causes of occurrence in clinical practice, various forms and variants of borderline disorders are distinguished. At the same time, different principles and approaches are used (nosological, syndromic, symptomatic assessment), and they also analyze the course of the borderline state, its severity, stabilization, and the dynamic relationship of various clinical manifestations.

Clinical diagnostics

Due to the non-specificity of many symptoms that fill the syndromic and nosological structures of borderline conditions, external, formal differences in asthenic, autonomic, dyssomnic and depressive disorders are insignificant. Considered separately, they do not give 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 morbid manifestation, the discovery of the causes of occurrence and the analysis of the relationship with individual typological psychological characteristics, as well as other psychopathological disorders.

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

Paying great attention to the pre-painful assessment of the state of a person who came to see a doctor in connection with his neurotic manifestations, it is necessary to take into account the peculiarities of his character, which undergo a dynamic change under the influence of age, psychogenic, somatogenic and many social factors. An analysis of premorbid features allows you to create a kind of psychophysiological portrait of the patient, the starting point that is necessary for a differential assessment of the disease state.

Assessment of present symptoms

What matters is not the individual symptom or syndrome in 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 (senestopathies, obsessions, hypochondria). In the development of these disorders, both psychogenic and physiogenic factors are important, most often their diverse combination. The causes of neurotic disorders are far from always visible to others, they may lie in the personal experiences of a person, primarily due to the discrepancy between the ideological and psychological attitude and physical capabilities of reality. This discrepancy can be seen as follows:

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

What is included in borderline disorders

Taking into account the variety 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 psychopathic manifestations in somatic, neurological and other diseases. In ICD-10, these disorders are usually considered as different variants of neurotic, stress-related and somatoform disorders, behavioral syndromes due to 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 psychopathic-like disorders also predominate and even determine the clinical course, largely imitating the main forms and variants of borderline states proper.

What to consider when diagnosing:

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

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 are much more common in the unfavorable course of epilepsy.

In the last few years, as statistical studies show, there has been an increase in forms of epilepsy with non-psychotic disorders in the structure of mental morbidity. At the same time, the share of epileptic psychoses decreases, which reflects the obvious pathomorphism of the clinical manifestations of the disease, due to the influence of a number of biological and social factors.

One of the leading places in the clinic of non-psychotic forms of epilepsy is occupied by affective disorders, which often show a tendency to chronicity. This confirms the position that despite the achieved remission of seizures, emotional disorders are an obstacle to the full restoration of the health of patients (Maksutova EL, Fresher V., 1998).

In the clinical qualification of certain syndromes of the affective register, it is important to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes proper. In this regard, it is conditionally possible to distinguish two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders proper, and secondary - without a causal relationship with an attack, and based on various manifestations of reactions to the disease, as well as to additional psychotraumatic influences.

So, according to the data of studies of patients of the specialized hospital of the Moscow Research Institute of Psychiatry, it was found that phenomenologically non-psychotic mental disorders are represented by three types of conditions:

1) depressive disorder in the form of depressions and subdepressions;

2) obsessive-phobic disorders;

3) other affective disorders.

Depressive spectrum disorders include the following options:

1. Sad depressions and subdepressions were observed in 47.8% of patients. Anxious-dreary affect with a persistent decrease in mood, often accompanied by irritability, was predominant in the clinic here. Patients noted mental discomfort, heaviness in the chest. In some patients, these sensations were associated with physical malaise (headache, discomfort behind the sternum) and were accompanied by motor restlessness, less often they were combined with adynamia.

2. Adynamic depressions and subdepressions were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. Most of the time they were in bed, with difficulty they performed simple self-service functions, complaints of rapid fatigue and irritability were characteristic.

3. Hypochondriacal depressions and subdepressions were observed in 13% of patients and were accompanied by a constant feeling of physical damage, heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death may occur during an attack or they will not be provided with help in time. Rarely did the interpretation of phobias go beyond the specified plot. Hypochondriacal fixation was distinguished by senestopathies, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.

The variant of hypochondriacal depression was more characteristic of the interictal period, especially in the conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.

4. Anxious depressions and subdepressions occurred in 8.7% of patients. Anxiety, as a component of an attack (more rarely, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experience vague fear or anxiety, the cause of which they do not understand. A short-term disturbing 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 seizure itself or the post-seizure state).

5. Depressions with depersonalization disorders were observed in 0.5% of patients. In this variant, the dominant sensations were the altered perception of one's own body, often with a feeling of alienation. The perception of the environment, time, also changed. So, along with a feeling of weakness, hypothymia, patients noted periods when the environment "changed", time "accelerated", it seemed that the head, arms, etc. were increasing. These experiences, in contrast to the true paroxysms of depersonalization, were characterized by the preservation of consciousness with a complete orientation and were of a fragmentary nature.

Psychopathological syndromes with a predominance of anxious affect made up mainly the second group of patients with "obsessive-phobic disorders". An analysis of the structure of these disorders showed that they are closely related to almost all components of a seizure, starting with precursors, aura, the seizure itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, more often of an indefinite content, which the patients described as an “imminent threat”, increasing anxiety, giving rise to a desire to do something urgently or seek help from others. Individual patients often indicated the fear of death from an attack, the fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, less often sociophobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection of obsessive-phobic disorders with the autonomic component, reaching a particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, thoughts were observed.

In contrast to paroxysmal anxiety, the anxious affect in remissions approaches in form the classical variants in the form of unmotivated fears for one's health, the health of loved ones, etc. A number of patients have a tendency to form obsessive-phobic disorders with obsessive fears, fears, actions, actions, etc. In some cases, there are protective mechanisms of behavior with peculiar measures to counteract the disease, such as rituals, etc. In terms of therapy, the most unfavorable option is a complex symptom complex, including obsessive-phobic disorders, as well as depressive formations.

The third type of borderline forms of mental disorders in the clinic of epilepsy were affective disorders, designated by us as "other affective disorders".

Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.

Among this group of borderline disorders, acting both in the form of paroxysms and prolonged states, epileptic dysphoria was more often observed. Dysphoria occurring in the form of short episodes more often occurred in the structure of the aura, preceding an epileptic seizure or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriac manifestations, irritability, affect of anger prevailed in their structure. Protest reactions were often formed. A number of patients showed aggressive actions.

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

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

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

Within the framework of the so-called precursors of seizures, various functional disorders are well-known, mainly of a vegetative nature (nausea, yawning, chills, salivation, fatigue, loss of appetite), against the background of which there is anxiety, a decrease in mood or its fluctuations with a predominance of irritated-moody affect. In a number of observations in this period, emotional lability with explosiveness and a tendency to conflict reactions were noted. These symptoms are extremely labile, short-lived and can self-limit.

An aura with affective experiences is a frequent component of the subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "lightheadedness". Pleasant sensations are less often observed (an increase in vitality, a feeling of special lightness and high spirits), which are then replaced by an anxious expectation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety can occur, or a neutral (rarely excited, upbeat) mood is noted.

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

As you know, motivational-emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly mediobasal formations that are part of the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.

When the focus is localized in the right temporal lobe, depressive disorders are more common and have a more delineated clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The specified clinic fits completely into the allocated "right-hemispheric affective disorder" in the systematics of organic syndromes of the ICD-10.

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

"Affective" seizures occur either in isolation or are included in the structure of other seizures, including convulsive ones. Most often they are included in the structure of the aura of a psychomotor seizure, less often - vegetative-visceral paroxysms.

The group of paroxysmal affective disorders within the framework of temporal lobe epilepsy includes dysphoric states, the duration of which can vary from several hours to several days. In some cases, dysphoria in the form of short episodes precedes the development of the next epileptic seizure or a series of seizures.

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

The classic manifestations of crisis disorders include suddenly developed: shortness of breath, a feeling of lack of air, discomfort from the organs of the chest cavity and abdomen with "fading heart", "interruptions", "pulsation", etc. These phenomena are usually accompanied by dizziness, chills, tremor , various paresthesias. Possible increased stool, urination. The strongest manifestations are anxiety, fear of death, fear of going crazy.

Affective symptoms in the form of separate unstable fears can be transformed both into an affective paroxysm itself and into permanent variants with fluctuations in the severity of these disorders. In more severe cases, a transition to a persistent dysphoric state with aggression (less often, auto-aggressive actions) is possible.

In epileptological practice, vegetative crises occur mainly in combination with other types of (convulsive or non-convulsive) paroxysms, causing polymorphism of the disease clinic.

Concerning the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we have attributed to them 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 states. They are more often manifested in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual-personal 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 clinic of emerging secondary-reactive disorders is also reflected in the degree of personal (epithymic) changes.

As part of reactive inclusions in patients with epilepsy, fears often arise:

development of a seizure on the street, at work

be injured or die during a seizure

go crazy

hereditary transmission of disease

side effects of anticonvulsants

forced withdrawal of drugs or untimely completion of treatment without guarantees for recurrence of seizures.

The reaction to the occurrence of a seizure at work is usually much more severe than when it occurs at home. Because of the fear that a seizure will happen, some patients stop studying, work, do not go out.

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

Fear of the onset of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness get used to them so much that, as a rule, they almost do not experience such fear. So, in patients with frequent seizures and a longer duration of the disease, signs of anosognosia and uncritical behavior are usually noted.

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

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

This distinction between affective disorders is of fundamental importance in determining further therapy.

Principles of therapy

The main direction of therapeutic tactics in relation to individual affective components of the attack itself and closely related post-seizure emotional disorders is the adequate use of anticonvulsants with a thymoleptic effect (cardimizepine, valproate, lamotrigine).

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

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

In various forms of affective disorders with a depressive radical, antidepressants are most effective. At the same time, on an outpatient basis, agents with minimal side effects, such as tianeptil, miakserin, fluoxetine, are preferred.

In the case of the predominance of the obsessive-compulsive component in the structure of depression, the appointment of paroxetine is justified.

It should be noted that a number of mental disorders in patients with epilepsy may be due not so much to the disease itself, but to long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, and elements of mental and motor retardation that are manifested in some patients. With the advent of highly effective anticonvulsants in recent years, it has become possible to avoid side effects of therapy and classify epilepsy as a curable disease.

E pylepsy is one of the most common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8-1.2%.

In the last few years, as statistical studies show, in the structure of mental morbidity there is an increase in forms of epilepsy with non-psychotic disorders . At the same time, the share of epileptic psychoses decreases, which reflects the obvious pathomorphism of the clinical manifestations of the disease, due to the influence of a number of biological and social factors.

One of the leading places in the clinic of non-psychotic forms of epilepsy is occupied by affective disorders , which often show a tendency to chronification. This confirms the position that despite the achieved remission of seizures, emotional disorders are an obstacle to the full restoration of the health of patients (Maksutova EL, Fresher V., 1998).

In the clinical qualification of certain syndromes of the affective register, it is important to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes proper. In this regard, it is possible to single out two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders proper, and secondary - without a causal relationship with an attack, but based on various manifestations of reactions to the disease, as well as to additional psycho-traumatic influences.

1) depressive disorder in the form of depressions and subdepressions;
2) obsessive-phobic disorders;
3) other affective disorders.

Depressive spectrum disorders include the following options:

1. Sad depressions and sub-depressions were observed in 47.8% of patients. Anxious-dreary affect with a persistent decrease in mood, often accompanied by irritability, was predominant in the clinic here. Patients noted mental discomfort, heaviness in the chest. In some patients, these sensations were associated with physical malaise (headache, discomfort behind the sternum) and were accompanied by motor restlessness, less often they were combined with adynamia.

2. Adynamic depressions and subdepressions observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. Most of the time they were in bed, with difficulty they performed simple self-service functions, complaints of rapid fatigue and irritability were characteristic.

3. Hypochondriacal depressions and subdepressions were observed in 13% of patients and were accompanied by a constant feeling of physical damage, heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death may occur during an attack or they will not be provided with help in time. Rarely did the interpretation of phobias go beyond the specified plot. Hypochondriacal fixation was distinguished by senestopathies, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.

4. Anxiety depressions and subdepressions occurred in 8.7% of patients. Anxiety, as a component of an attack (more rarely, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experience vague fear or anxiety, the cause of which they do not understand. A short-term anxious affect (a few minutes, less often within 1-2 hours), as a rule, is characteristic of a variant of phobias, as a component of a seizure (within the aura, the seizure itself or the post-seizure state).

5. Depression with depersonalization disorders observed in 0.5% of patients. In this variant, the dominant sensations were the altered perception of one's own body, often with a feeling of alienation. The perception of the environment, time, also changed. So, along with a feeling of weakness, hypothymia, patients noted periods when the environment "changed", time "accelerated", it seemed that the head, arms, etc. were increasing. These experiences, in contrast to the true paroxysms of depersonalization, were characterized by the preservation of consciousness with a complete orientation and were of a fragmentary nature.

Psychopathological syndromes with a predominance of anxious affect constituted predominantly the second group of patients with "obsessive-phobic disorders". An analysis of the structure of these disorders showed that they are closely related to almost all components of a seizure, starting with precursors, aura, the seizure itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, more often of an indefinite content, which the patients described as an “imminent threat”, increasing anxiety, giving rise to a desire to do something urgently or seek help from others. Individual patients often indicated the fear of death from an attack, the fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, less often sociophobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection of obsessive-phobic disorders with the vegetative component, reaching a particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, thoughts were observed.

The third type of borderline forms of mental disorders in the clinic of epilepsy was affective disorders , designated by us as "other affective disorders".

Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.

Among this group of borderline disorders, acting both in the form of paroxysms and prolonged states, more often were observed epileptic dysphoria . Dysphoria occurring in the form of short episodes more often occurred in the structure of the aura, preceding an epileptic seizure or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, asthenic-hypochondriac manifestations, irritability, and the affect of malice prevailed in their structure. Protest reactions were often formed. A number of patients showed aggressive actions.

Within the framework of the so-called precursors of seizures, various functional disorders are well-known, mainly of a vegetative nature (nausea, yawning, chills, salivation, fatigue, loss of appetite), against the background of which there is anxiety, a decrease in mood or its fluctuations with a predominance of irritated-sullen affect. In a number of observations in this period, emotional lability with explosiveness and a tendency to conflict reactions were noted. These symptoms are extremely labile, short-lived and can self-limit.

Aura with affective experiences - a frequent component of the subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "lightheadedness". Pleasant sensations are less often observed (an increase in vitality, a feeling of special lightness and high spirits), which are then replaced by an anxious expectation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety may occur, or a neutral (rarely excited, upbeat) mood is noted.

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

As is known, motivational-emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly mediobasal formations that are part of the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.

When the focus is localized in the right temporal lobe, depressive disorders are more common and have a more delineated clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The specified clinic fits completely into the allocated "right hemispheric affective disorder" in the systematics of organic syndromes of the ICD-10.

To paroxysmal affective disorders (as part of an attack) include sudden and lasting for several seconds (rarely minutes) attacks of fear, unaccountable anxiety, sometimes with a feeling of longing. There may be impulsive short-term states of increased sexual (food) desire, a feeling of strength, joyful expectation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. The predominantly violent nature of these experiences should be emphasized, although individual cases of their arbitrary correction by conditioned reflex techniques indicate a more complex pathogenesis.

The second most common affective disorder is clinical forms with dominant vegetative paroxysms within the framework of diencephalic epilepsy . The analogues of the common designation of paroxysmal (crisis) disorders as "vegetative seizures" are widely used concepts in neurological and psychiatric practice such as "diencephalic" seizure, "panic attacks" and other conditions with a large autonomic accompaniment.

In epileptological practice, vegetative crises occur mainly in combination with other types of (convulsive or non-convulsive) paroxysms, causing polymorphism of the disease clinic.

Concerning the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we have classified them as diverse psychologically understandable reactions to the disease that occur in epilepsy. At the same time, side effects as a response to therapy, as well as a number of professional restrictions and other social consequences of the disease include both transient and prolonged states. They are more often manifested in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual personality characteristics of the patient and additional psychogenies. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficient) changes, which gives them a number of features associated with organic soil. The degree of personal (epithymic) changes is also reflected in the clinic of emerging secondary-reactive disorders.

As part of reactive inclusions Patients with epilepsy often have concerns about:

development of a seizure on the street, at work
be injured or die during a seizure
go crazy
hereditary transmission of disease
side effects of anticonvulsants
forced withdrawal of drugs or untimely completion of treatment without guarantees for recurrence of seizures.

This distinction between affective disorders is of fundamental importance in determining further therapy.

Principles of therapy

The main direction of therapeutic tactics in relation to individual affective components of the attack itself and closely related post-seizure emotional disorders is the adequate use of anticonvulsants with thymoleptic effect (cardimizepine, valproate, lamotrigine).

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

Recently, anti-anxiety and sedative effects have been widely used. clonazepam , which is highly effective in absence seizures.

In various forms of affective disorders with a depressive radical, the most effective antidepressants . At the same time, on an outpatient basis, agents with minimal side effects, such as tianeptil, miakserin, fluoxetine, are preferred.

In the case of the predominance of the obsessive-compulsive component in the structure of depression, the appointment of paroxetine is justified.

With open brain injuries complicated by purulent meningitis, large doses of antibiotics are prescribed (benzylpenicillin up to 30,000,000 IU per day), endolumbar injections of antibiotics, sulfanilamide preparations.

On the 8-10th day of the disease, resolving therapy is prescribed (64 units of lidase and biyoquinol intramuscularly up to 15 injections), massage, exercise therapy. Correction of dysfunction of the catecholamine system is carried out with maintenance doses of levodopa (0.5 g 3 times a day after meals), Further, intravenous infusions of sodium iodide (10 ml of a 10% solution; for a course of 10-15 injections) are added to the absorbable therapy, saiodine is prescribed orally or 3% solution of potassium iodide in milk, ATP, phosphrene, thiamine, cyanocobalamin. Recommend cerebrolysin, anabolic steroids, biogenic stimulants (liquid aloe extract for injection, vitreous body, FiBS).

With asthenic syndrome, it is necessary to combine stimulating therapy and sedatives, hypnotics (eunoctin, radedorm). Preventive anticonvulsant therapy should be prescribed if there is a history of seizures and their appearance after trauma, the presence of paroxysmal epileptic discharges and focal epileptiform changes on the EEG during wakefulness and sleep (A. I. Nyagu, 1982; V. S. Mertsalov, 1932) . Depending on the type of convulsive activity, 0.05 g of phenobarbital is used day and night, or benzonal 0.1 g 2-3 times a day, gluferal 1 tablet 2 times a day, as well as a mixture of phenobarbital (0.1 g) , dilantin (0.05 g), nicotinic acid (0.03 g), glucose (0.3 g) - 1 powder at night and 10-20 mg of seduxen at night

In the late period of traumatic brain injury, the choice of psychotropic drugs is determined by the psychopathological syndrome (see Appendix 1). In an asthenic state with emotional instability and explosiveness, trioxazine is prescribed at 0.3-0.9 g, nitrazepam (radedorm, eunoctin) but 0.01 g at night; with asthenia with general weakness and abulic component - saparal 0.05 g 2-3 times, sidnofen or sidnocarb 0.005-0.01 g per day, tinctures of ginseng, lemongrass, aralia, azafen 0.1-0.3 g each per day. Patients with long-term consequences of trauma, in the clinical picture of which vegetative-vascular and liquorodynamic disorders predominate against the background of severe asthenia, laser puncture is recommended (Y. V. Pishel, M. P. Shapiro, 1982).

In psychopathic states, pericyazine (neuleptil) is prescribed at 0.015 g per day, small doses of sulfozine, neuroleptics in medium doses; with manic syndrome - alimemazine (teralen), periciazip (neuleptil), chlorprothixen. Haloperidol, triftazin (stelazin) cause pronounced extrapyramidal disorders, so their use is not recommended. Anxiety-depressive and hypochondriacal syndromes are stopped with frenolone (0.005-0.03 g), eglonil (0.2-0.6 g), amitriptyline (0.025-0.2 g), carbidine (0.025-0.15 g). With dysphoria and twilight states of consciousness, chlorpromazine is effective up to 300 mg per day, seduxen (4 ml of a 0.5% solution) intramuscularly, etaperazine up to 100 mg; with paranoid and hallucinatory-torno-paranoid states - chlorpromazine, sonapax, haloperidol; with "traumatic epilepsy" - anticonvulsants.

The formation of the residual period depends on the timeliness and adequacy of social readaptation measures. At the initial stages, it is necessary to carry out activities aimed at creating a benevolent moral and psychological climate in the environment of the patient, inspiring him with confidence in his recovery and the possibility of continuing his work. The recommended work should correspond to the functional capabilities, special and general educational training, and the personal inclinations of the patient. Work is contraindicated in conditions of noise, at height, transport, in hot and

stuffy room. A clear regime of the day is needed - regular rest, exclusion of overloads.

One of the important factors in the complex system of restoring working capacity and reducing the severity of disability is medical examination with, if necessary, courses of pathogenetic and symptomatic treatment, including psychotherapy, in outpatient, inpatient, sanatorium conditions. The most favorable labor prognosis for patients with asthenic syndrome, relatively favorable - for psychopathic syndrome in the absence of pronounced progression. In patients with paroxysmal disorders, the labor prognosis depends on the severity and nature of personality changes. Professional ability to work in people with dementia syndrome is persistently reduced or lost. Labor adaptation is possible only in specially created conditions. Professional retraining should be carried out taking into account the characteristics of the disease, work skills, interests and functional capabilities of patients. During medical examination, all possibilities of restorative treatment and rehabilitation measures should be used. The conclusion about insanity and incapacity is usually made in traumatic psychosis, dementia, or a pronounced degree of psychoorganic syndrome.

SOMATOGENIC MENTAL

DISORDERS

GENERAL AND CLINICAL CHARACTERISTICS

Somatogenic mental illnesses are a combined group of mental disorders resulting from somatic non-communicable diseases. These include mental disorders in cardiovascular, gastrointestinal, renal, endocrine, metabolic and other diseases. Mental disorders of vascular origin (with hypertension, arterial hypotension and atherosclerosis) are traditionally distinguished into an independent group,

Classification of somatogenic mental disorders

1. Borderline non-psychotic disorders: a) asthenic, neurosis-like conditions caused by somatic non-communicable diseases (code 300.94), metabolic disorders, growth and nutrition (300.95); b) non-psychotic depressive disorders due to somatic non-communicable diseases (311.4), metabolic, growth and nutrition disorders (311.5), other and unspecified organic diseases of the brain (311.89 and 311.9); c) neurosis- and psychopathic disorders due to somatogenic organic lesions of the brain (310.88 and 310.89).

2. Psychotic states developed as a result of functional or organic damage to the brain: a) acute psychoses (298.9 and
293.08) - asthenic confusion, delirious, amental and others
syndromes of clouding of consciousness; b) subacute lingering psychoses (298.9
and 293.18) - paranoid, depressive-paranoid, anxious-paranoid, hallucinatory-paranoid. catatonic and other syndromes;
c) chronic psychoses (294) - Korsakov's syndrome (294.08), hallucinations
cynatory-paranoid, senestopatho-hypochondriac, verbal hallucinosis, etc. (294.8).

3. Defective-organic states: a) simple psycho-organic
syndrome (310.08 and 310.18); b) Korsakov's syndrome (294.08); c) de-
mentia (294.18).

Somatic diseases acquire independent significance in the occurrence of a mental disorder, in relation to which they are an exogenous factor. The mechanisms of brain hypoxia, intoxication, metabolic disorders, neuroreflex, immune, autoimmune reactions are important. On the other hand, as B. A. Tselibeev (1972) noted, somatogenic psychoses cannot be understood only as the result of a somatic disease. In their development, a predisposition to a psychopathological type of response, psychological characteristics of a person, and psychogenic influences play a role.

The problem of somatogenic mental pathology is becoming increasingly important due to the growth of cardiovascular pathology. The pathomorphosis of mental illness is manifested by the so-called somatization, the predominance of non-psychotic disorders over psychotic, "bodily" symptoms over psychopathological ones. Patients with sluggish, “erased” forms of psychosis sometimes end up in general somatic hospitals, and severe forms of somatic diseases are often unrecognized due to the fact that the subjective manifestations of the disease “cover” the objective somatic symptoms.

Mental disorders are observed in acute short-term, protracted and chronic somatic diseases. They manifest themselves in the form of non-psychotic (asthenic, astheno-depressive, asthenodysthymic, astheno-hypochondriac, anxiety-phobic, hysteroform), psychotic (delirious, delirious-amental, oneiric, twilight, catatonic, hallucinatory-paranoid), defective organic ( psychoorganic syndrome and dementia) conditions.

According to V. A. Romassenko and K. A. Skvortsov (1961), B. A. Tseli-beev (1972), A. K. Dobzhanskaya (1973), the exogenous nature of mental disorders of a nonspecific type is usually observed in the acute course of a somatic disease . In cases of its chronic course with diffuse brain damage of a toxic-anoxic nature, more often than with infections, there is a tendency to endoformity of psychopathological symptoms.

MENTAL DISORDERS IN SELECTED SOMATIC DISEASES

Mental disorders in heart disease. One of the most frequently diagnosed forms of heart disease is coronary heart disease (CHD). In accordance with the WHO classification, coronary artery disease includes angina pectoris and rest, acute focal myocardial dystrophy, small- and large-focal myocardial infarction. Coronary-cerebral disorders are always combined. With heart diseases, cerebral hypoxia is noted, with lesions of the cerebral vessels, hypoxic changes in the heart are detected.

Panic disorders arising from acute heart failure can be expressed by syndromes of disturbed consciousness, most often in the form of deafness and delirium, characterized by
instability of hallucinatory experiences.

Mental disorders in myocardial infarction have been systematically studied in recent decades (I. G. Ravkin, 1957, 1959; L. G. Ursova, 1967, 1968). Depressive conditions, syndromes of disturbed consciousness with psychomotor agitation, euphoria are described. Overvalued formations are often formed. With small-focal myocardial infarction, a pronounced asthenic syndrome develops with tearfulness, general weakness, sometimes nausea, chills, tachycardia, low-grade body temperature. With a macrofocal infarction with damage to the anterior wall of the left ventricle, anxiety and fear of death arise; with a heart attack of the posterior wall of the left ventricle, euphoria, verbosity, lack of criticism of one's condition with attempts to get out of bed, requests for some kind of work are observed. In the postinfarction state, lethargy, severe fatigue, and hypochondria are noted. A phobic syndrome often develops - expectation of pain, fear of a second heart attack, getting out of bed at a time when doctors recommend an active regimen.

Mental disorders also occur with heart defects, as pointed out by V. M. Banshchikov, I. S. Romanova (1961), G. V. Morozov, M. S. Lebedinsky (1972). With rheumatic heart disease, V.V. Kovalev (1974) identified the following types of mental disorders: 1) borderline (asthenic), neurosis-like (neurasthenic-like) with vegetative disorders, cerebrasthenic with mild manifestations of organic cerebral insufficiency, euphoric or depressive-dysthymic mood, hysteroform, asthenohypochondriacal conditions; neurotic reactions of depressive, depressive-hypochondriac and pseudo-euphoric types; pathological personality development (psychopathic); 2) psychotic cardiogenic psychoses) - acute with delirious or amental symptoms and subacute, protracted (anxious-depressive, depressive-paranoid, hallucinatory-paraioid); 3) encephalopathic (psychoorganic) - psychoorganic, epileptoform and corsa-

kovsky syndromes. Congenital heart defects are often accompanied by signs of psychophysical infantilism, asthenic, neurotic and psychopathic states, neurotic reactions, intellectual retardation.

Currently, heart operations are widely performed. Surgeons and cardiologists-therapists note the disproportion between the objective physical capabilities of operated patients and the relatively low actual indicators of rehabilitation of persons who have undergone heart surgery (E. I. Chazov, 1975; N. M. Amosov et al., 1980; C. Bernard, 1968 ). One of the most significant reasons for this disproportion is the psychological maladjustment of persons who have undergone heart surgery. When examining patients with pathology of the cardiovascular system, it was established that they had pronounced forms of personality reactions (G. V. Morozov, M. S. Lebedinsky, 1972; A. M. Wein et al., 1974). N. K. Bogolepov (1938), L. O. Badalyan (1963), V. V. Mikheev (1979) indicate a high frequency of these disorders (70-100%). Changes in the nervous system with heart defects were described by L. O. Badalyan (1973. 1976). Circulatory insufficiency that occurs with heart defects leads to chronic hypoxia of the brain, the occurrence of cerebral and focal neurological symptoms, including convulsive seizures.

Patients operated on for rheumatic heart disease usually complain of headache, dizziness, insomnia, numbness and cold extremities, pain in the heart and behind the sternum, suffocation, fatigue, shortness of breath, aggravated by physical exertion, weakness of convergence, decreased corneal reflexes, hypotension of muscles, decreased periosteal and tendon reflexes, disorders of consciousness, more often in the form of fainting, indicating a violation of blood circulation in the system of vertebral and basilar arteries and in the basin of the internal carotid artery.

Mental disorders that occur after cardiac surgery are the result of not only cerebrovascular disorders, but also a personal reaction. V. A. Skumin (1978, 1980) singled out a “cardioprosthetic psychopathological syndrome”, which often occurs during mitral valve implantation or multivalve prosthetics. Due to noise phenomena associated with the activity of the artificial valve, disturbances in the receptive fields at the site of its implantation, and disturbances in the rhythm of cardiac activity, the attention of patients is riveted to the work of the heart. They have concerns and fears about a possible “valve break”, its breakdown. The depressed mood intensifies at night, when the noise from the work of artificial valves is heard especially clearly. Only during the day, when the patient sees medical staff nearby, can he fall asleep. A negative attitude towards vigorous activity is developed, an anxious-depressive background of mood arises with the possibility of suicidal actions.

VV Kovalev (1974) in the uncomplicated postoperative period noted in patients with astheno-dynamic conditions, sensitivity, transient or persistent intellectual-mnestic insufficiency. After operations with somatic complications, acute psychoses often occur with clouding of consciousness (delirious, delirious-amentiviy and delirious-oneiric syndromes), subacute abortive and protracted psychoses (anxiety-depressive, depressive-hypochondriacal, depressive-paranoid syndromes) and epileptiform paroxysms.

Mental disorders in patients with renal pathology. Mental disorders in renal pathology are observed in 20-25% of sick people (V. G. Vogralik, 1948), but not all of them fall into the field of view of psychiatrists (A. G. Naku, G. N. German, 1981). Marked mental disorders that develop after kidney transplantation and hemodialysis. A. G. Naku and G. N. German (1981) identified typical nephrogenic and atypical nephrogenic psychoses with the obligatory presence of an asthenic background. To the 1st group, the authors include asthenia, psychotic and non-psychotic forms of disturbed consciousness, to the 2nd - endoform and organic psychotic syndromes (we consider the inclusion of asthenia syndromes and non-psychotic impairment of consciousness in the composition of psychotic states to be erroneous).

Asthenia in renal pathology, as a rule, precedes the diagnosis of kidney damage. Unpleasant sensations in the body, a “stale head”, especially in the morning, nightmares, difficulty in concentrating, a feeling of weakness, depressed mood, somato-neurological manifestations (coated tongue, grayish-pale complexion, instability of blood pressure, chills and profuse sweating along the at night, discomfort in the lower back).

The asthenic nephrogenic symptom complex is characterized by a constant complication and an increase in symptoms, up to the state of asthenic confusion, in which patients do not catch changes in the situation, do not notice the objects they need, nearby. With an increase in renal failure, the asthenic condition may be replaced by amentia. A characteristic feature of nephrogenic asthenia is adynamia with the inability or difficulty to mobilize oneself to perform an action while understanding the need for such mobilization. Patients spend most of their time in bed, which is not always justified by the severity of renal pathology. According to A. G. Naku and G. N. German (1981), the often observed change of asthenoadinamic states by asthenosubdepressive ones is an indicator of improvement in the somatic state of the patient, a sign of “affective activation”, although it goes through a pronounced stage of a depressive state with ideas of self-abasement ( uselessness, worthlessness, burdens for the family).

Syndromes of clouded consciousness in the form of delirium and amentia in pephropathies are severe, often patients die. Vyde-

There are two variants of the amental syndrome (A. G. Naku, G. N. German, 1981). reflecting the severity of renal pathology and having prognostic value: hyperkinetic, in which uremic intoxication is not pronounced, and hypokinetic, with increasing decompensation of kidney activity, a sharp increase in blood pressure. Severe forms of uremia are sometimes accompanied by psychoses of the type of acute delirium and end in death after a period of deafness with sharp motor restlessness, fragmentary delusional ideas. When the condition worsens, the productive forms of disturbed consciousness are replaced by unproductive ones, adynamia and drowsiness increase.

Psychotic disorders in the case of protracted and chronic kidney diseases are manifested by complex syndromes observed against the background of asthenia: anxiety-depressive, depressive and hallucinatory-paranoid and catatonic. The increase in uremic toxicosis is accompanied by episodes of psychotic stupefaction, signs of organic damage to the central nervous system, epileptiform paroxysms and intellectual-mnestic disorders.

According to B. A. Lebedev (1979), 33% of the examined patients against the background of severe asthenia have mental reactions of depressive and hysterical types, the rest have an adequate assessment of their condition with a decrease in mood, an understanding of the possible outcome. Asthenia can often prevent the development of neurotic reactions. Sometimes, in cases of slight severity of asthenic symptoms, hysterical reactions occur, which disappear with an increase in the severity of the disease,

Rheoencephalographic examination of patients with chronic kidney diseases makes it possible to detect a decrease in vascular tone with a slight decrease in their elasticity and signs of impaired venous flow, which are manifested by an increase in the venous wave (presystolic) at the end of the catacrotic phase and are observed in persons suffering from arterial hypertension for a long time. The instability of vascular tone is characteristic, mainly in the system of vertebral and basilar arteries. In mild forms of kidney disease, there are no pronounced deviations from the norm in pulse blood filling (L.V. Pletneva. 1979).

In the late stages of chronic renal failure and with severe intoxication, organ-replacement operations and hemodialysis are performed. After kidney transplantation and during dialysis stable suburemia, chronic nephrogenic toxicodishomeostatic encephalopathy is observed (MA Tsivilko et al., 1979). Patients have weakness, sleep disorders, mood depression, sometimes a rapid increase in adynamia, stupor, and convulsive seizures appear. It is believed that syndromes of clouded consciousness (delirium, amentia) arise due to vascular disorders and postoperative

rational asthenia, and syndromes of turning off consciousness - as a result of uremic intoxication. In the process of hemodialysis treatment, there are cases of intellectual-mnestic disorders, organic brain damage with a gradual increase in lethargy, loss of interest in the environment. With prolonged use of dialysis, a psycho-organic syndrome develops - "dialysis-uremnic dementia", which is characterized by deep asthenia.

When transplanting kidneys, large doses of hormones are used, which can lead to autonomic regulation disorders. In the period of acute graft failure, when azotemia reaches 32.1-33.6 mmol, and hyperkalemia - up to 7.0 mEq / l, hemorrhagic phenomena (profuse epistaxis and hemorrhagic rash), paresis, paralysis may occur. An electroencephalographic study reveals persistent desynchronization with an almost complete disappearance of alpha activity and a predominance of slow-wave activity. A rheoencephalographic study reveals pronounced changes in vascular tone: irregularity of waves in shape and size, additional venous waves. Asthenia sharply increases, subcomatous and coma states develop.

Mental disorders in diseases of the digestive tract. Diseases of the digestive system take the second place in the general morbidity of the population, second only to cardiovascular pathology.

Violations of mental functions in the pathology of the digestive tract are often limited to sharpening of character traits, asthenic syndrome and neurosis-like conditions. Gastritis, peptic ulcer and nonspecific colitis are accompanied by exhaustion of mental functions, sensitivity, lability or torpidity of emotional reactions, anger, a tendency to a hypochondriacal interpretation of the disease, carcinophobia. With gastroesophageal reflux, neurotic disorders (neurasthenic syndrome and obsessive phenomena) are observed that precede the symptoms of the digestive tract. The statements of patients about the possibility of a malignant neoplasm in them are noted in the framework of overvalued hypochondriacal and paranoid formations. Complaints about memory impairment are associated with attention disorders caused by both fixation on the sensations caused by the underlying disease and depressive mood.

A complication of stomach resection operations for peptic ulcer is dumping syndrome, which should be distinguished from hysterical disorders. Dumping syndrome is understood as vegetative crises, paroxysmal occurring in the form of hypo- or hyperglycemic immediately after a meal or after 20-30 minutes,

sometimes 1-2 hours.

Hyperglycemic crises appear after ingestion of hot food containing easily digestible carbohydrates. Suddenly there is a headache with dizziness, tinnitus, less often - vomiting, drowsiness,

tremor. “Black dots”, “flies” before the eyes, disorders of the body scheme, instability, unsteadiness of objects may appear. They end with profuse urination, drowsiness. At the height of the attack, the level of sugar and blood pressure rise.

Hypoglycemic crises occur outside the meal: weakness, sweating, headache, dizziness appear. After eating, they quickly stop. During a crisis, blood sugar levels drop and blood pressure drops. Possible disorders of consciousness at the height of the crisis. Sometimes crises develop in the morning hours after sleep (RE Galperina, 1969). In the absence of timely therapeutic correction, hysterical fixation of this condition is not excluded.

Mental disorders in cancer. The clinical picture of neoplasms of the brain is determined by their localization. With the growth of the tumor, cerebral symptoms become more prominent. Almost all types of psychopathological syndromes are observed, including asthenic, psychoorganic, paranoid, hallucinatory-paranoid (A. S. Shmaryan, 1949; I. Ya. Razdolsky, 1954; A. L. Abashev-Konstantinovsky, 1973). Sometimes a brain tumor is detected in a section of deceased persons treated for schizophrenia, epilepsy.

With malignant neoplasms of extracranial localization, V. A. Romasenko and K. A. Skvortsov (1961) noted the dependence of mental disorders on the stage of the course of cancer. In the initial period, sharpening of the characterological traits of patients, neurotic reactions, and asthenic phenomena are observed. In the extended phase, astheno-depressive states, anosognosias are most often noted. With cancer of the internal organs in the manifest and predominantly terminal stages, states of "silent delirium" are observed with adynamia, episodes of delirious and oneiric experiences, followed by deafening or bouts of excitement with fragmentary delusional statements; delirious-amental states; paranoid states with delusions of relationship, poisoning, damage; depressive states with depersonalization phenomena, senestopathies; reactive hysterical psychoses. Characterized by instability, dynamism, frequent change of psychotic syndromes. In the terminal stage, the oppression of consciousness gradually increases (stupor, stupor, coma).

Mental disorders of the postpartum period. There are four groups of psychoses arising in connection with childbirth: 1) generic; 2) actually postpartum; 3) lactation period psychoses; 4) endogenous psychoses provoked by childbirth. Mental pathology of the postpartum period does not represent an independent nosological form. Common to the entire group of psychoses is the situation in which they occur. Birth psychoses are psychogenic reactions that develop, as a rule, in nulliparous women. They are caused by the fear of waiting for pain, an unknown, frightening event. At the first signs of

during childbirth, some women in labor may develop neurotic

or a psychotic reaction, in which, against the background of a narrowed consciousness, hysterical crying, laughter, screaming, sometimes fugiform reactions, less often - hysterical mutism appear. Women in labor refuse to follow the instructions offered by medical personnel. The duration of the reactions is from several minutes to 0.5 hours, sometimes longer.

Postpartum psychoses are conventionally divided into postpartum and lactation psychoses proper.

Actually postpartum psychoses develop during the first 1-6 weeks after birth, often in the maternity hospital. The reasons for their occurrence: toxicosis of the second half of pregnancy, severe childbirth with massive tissue trauma, retained placenta, bleeding, endometritis, mastitis, etc. A decisive role in their appearance belongs to a generic infection, the predisposing moment is toxicosis of the second half of pregnancy. At the same time, psychoses are observed, the occurrence of which cannot be explained by postpartum infection. The main reasons for their development are traumatization of the birth canal, intoxication, neuroreflex and psycho-traumatic factors in their totality. Actually postpartum psychoses are more often observed in nulliparous women. The number of sick women who gave birth to boys is almost 2 times more than women who gave birth to girls.

Psychopathological symptoms are characterized by an acute onset, occur after 2-3 weeks, and sometimes 2-3 days after childbirth against the background of elevated body temperature. Women in childbirth are restless, gradually their actions become erratic, speech contact is lost. Amenia develops, which in severe cases passes into a soporous state.

Amenia in postpartum psychosis is characterized by mild dynamics throughout the entire period of the disease. The exit from the amental state is critical, followed by lacunar amnesia. Prolonged asthenic conditions are not observed, as is the case with lactation psychoses.

The catatonic (katatono-oneiric) form is less common. A feature of postpartum catatonia is the weak severity and instability of symptoms, its combination with oneiric disorders of consciousness. With postpartum catatonia, there is no pattern of increasing stiffness, as with endogenous catatonia, there is no active negativism. Characterized by instability of catatonic symptoms, episodic oneiroid experiences, their alternation with states of stupor. With the weakening of catatonic phenomena, patients begin to eat, answer questions. After recovery, they are critical of the experience.

Depressive-paranoid syndrome develops against the background of unsharply pronounced stupor. It is characterized by "matte" depression. If the stupor intensifies, the depression is smoothed out, the patients are indifferent, do not answer questions. Ideas of self-blame are associated with non-

the solvency of patients during this period. Quite often find the phenomena of mental anesthesia.

Differential diagnosis of postpartum and endogenous depression is based on the presence of changes in its depth during postpartum depression depending on the state of consciousness, worsening of depression by night. In such patients, in a delusional interpretation of their insolvency, the somatic component sounds more, while in endogenous depression, low self-esteem concerns personal qualities.

What is and how are mental disorders expressed?

The term "mental disorder" refers to a wide variety of disease states.

Psychotic disorders are a very common pathology. Statistical data in different regions differ from each other, which is associated with different approaches and possibilities for identifying and accounting for these conditions that are sometimes difficult to diagnose. On average, the frequency of endogenous psychoses is 3-5% of the population.

Accurate information about the prevalence among the population of exogenous psychoses (Greek exo - outside, genesis - origin.
There is no option for the development of a mental disorder due to the influence of external causes outside the body), and this is due to the fact that most of these conditions occur in patients drug addiction and alcoholism.

Between the concepts of psychosis and schizophrenia, they often put an equal sign, which is fundamentally wrong.,

Psychotic disorders can occur in a number of mental illnesses: Alzheimer's disease, senile dementia, chronic alcoholism, drug addiction, epilepsy, mental retardation, etc.

A person can endure a transient psychotic state caused by taking certain medications, drugs, or the so-called psychogenic or "reactive" psychosis that occurs as a result of exposure to a strong mental trauma (stressful situation with danger to life, loss of a loved one, etc.). Often there are so-called infectious (developing as a result of a severe infectious disease), somatogenic (caused by severe somatic pathology, such as myocardial infarction) and intoxication psychoses. The most striking example of the latter is alcoholic delirium - "white tremens".

There is another important feature that divides mental disorders into two sharply different classes:
psychoses and non-psychotic disorders.

Non-psychotic disorders are manifested mainly by psychological phenomena characteristic of healthy people. We are talking about mood changes, fears, anxiety, sleep disturbances, obsessive thoughts and doubts, etc.

Non-psychotic disorders are much more common than psychosis.
As mentioned above, the lightest of them at least once in a lifetime endures every third.

Psychoses are much less common.
The most severe of them are most often found within the framework of schizophrenia, a disease that is the central problem of modern psychiatry. The prevalence of schizophrenia is 1% of the population, which means that about one person in every hundred suffers from it.

The difference lies in the fact that in healthy people all these phenomena occur in a clear and adequate connection with the situation, while in patients they do not. In addition, the duration and intensity of painful phenomena of this kind cannot be compared with similar phenomena that occur in healthy people.

Psychoses characterized by the occurrence of psychological phenomena that never occur normally.
The most important of them are delusions and hallucinations.
These disorders can radically change the patient's understanding of the world around him and even of himself.

Psychosis is also associated with gross behavioral disorders.

WHAT IS PSYCHOSIS?

About what is psychosis.

Imagine that our psyche is a mirror whose task is to reflect reality as accurately as possible. We judge reality with the help of this reflection, because we have no other way. We ourselves are also a part of reality, therefore our “mirror” must correctly reflect not only the world around us, but also ourselves in this world. If the mirror is whole, even, well polished and clean, the world is reflected in it correctly (we will not find fault with the fact that none of us perceives reality absolutely adequately - this is a completely different problem).

But what happens if the mirror gets dirty, or twisted, or broken into pieces? The reflection in it will suffer more or less. This "more or less" is very important. The essence of any mental disorder lies in the fact that the patient perceives reality not quite the way it really is. The degree of distortion of reality in the patient's perception determines whether he has psychosis or a milder disease state.

Unfortunately, there is no generally accepted definition of the concept of "psychosis". It is always emphasized that the main symptom of psychosis is a serious distortion of reality, a gross deformation of the perception of the surrounding world. The picture of the world presented to the patient can be so different from reality that they talk about the "new reality" that psychosis creates. Even if there are no disorders in the structure of psychosis that are directly related to impaired thinking and purposeful behavior, the statements and actions of the patient are perceived by others as strange and absurd; for he lives in a "new reality" which may have nothing to do with the objective situation.

Phenomena that never and in any form (even in a hint) are not found in the norm are “guilty” of distorting reality. The most characteristic of them are delusions and hallucinations; they are involved in the structure of most of the syndromes that are commonly called psychoses.
Simultaneously with their occurrence, the ability to critically assess one's condition is lost, "in other words, the patient cannot admit the thought that everything that happens to him only seems to him.
“A gross deformation of the perception of the surrounding world” arises because the “mirror”, with the help of which we judge about it, begins to reflect phenomena that are not in it.

So, psychosis is a painful condition, which is determined by the occurrence of symptoms that never occur normally, most often delusions and hallucinations. They lead to the fact that the reality in the perception of the patient is very different from the objective state of affairs. Psychosis is accompanied by a disorder of behavior, sometimes very rude. It may depend on how the patient imagines the situation in which he is (for example, he can escape from an imaginary threat), and on the loss of the ability to expedient activity.

Excerpt from the book.
Rotstein V.G. "Psychiatry science or art?"

Psychoses (psychotic disorders) are the most striking manifestations of mental illness, in which the mental activity of the patient does not correspond to the surrounding reality, the reflection of the real world in the mind is sharply distorted, which manifests itself in behavioral disorders, the appearance of abnormal pathological symptoms and syndromes.

Manifestations of mental illness are violations of the psyche and behavior of a person. According to the severity of the course of the pathological process, more pronounced forms of mental illness are distinguished - psychoses and lighter ones - neurosis, psychopathic conditions, some forms of affective pathology.

COURSE AND FORECAST OF PSYCHOSIS.

Most often (especially in endogenous diseases) there is a periodic type of psychosis with acute attacks of the disease that occur from time to time, both provoked by physical and psychological factors, and spontaneous. It should be noted that there is also a single-attack course, which is observed more often in adolescence.

Patients, having suffered one, sometimes a protracted attack, gradually come out of the painful state, restore their ability to work and never again come to the attention of a psychiatrist.
In some cases, psychoses can become chronic and become continuous without the disappearance of symptoms throughout life.

In uncomplicated and uncomplicated cases, inpatient treatment lasts, as a rule, one and a half to two months. It is this period that doctors need to fully cope with the symptoms of psychosis and select the optimal supportive therapy. In cases where the symptoms of the disease are resistant to drugs, a change in several courses of therapy is required, which can delay the stay in the hospital for up to six months or more.

The main thing that needs to be remembered by the patient's relatives - DO NOT HURRY DOCTORS, do not insist on an urgent discharge "on receipt"! For complete stabilization of the state, it is necessary certain time and by insisting on an early discharge, you run the risk of getting an undertreated patient, which is dangerous both for him and for you.

One of the most important factors influencing the prognosis of psychotic disorders is the timeliness of initiation and intensity of active therapy in combination with social rehabilitation measures.