psychogenic symptoms. Psychogenic disorders. Reactive psychosis of hysterical type

Psychogenic diseases (psychogeny) - a class of mental disorders caused by the impact on a person of adverse mental factors. These include reactive psychoses, psychosomatic disorders, neuroses, abnormal reactions (pathocharacterological and neurotic), and psychogenic development of the personality that occurs under the influence of a psychic trauma or in a traumatic situation. It should be emphasized that in cases of psychogeny, the disease occurs after a person has been mentally traumatized. It is accompanied, as a rule, by a range of negative emotions: anger, intense fear, hatred, disgust, etc. At the same time, it is always possible to identify psychologically understandable relationships between the characteristics of a traumatic situation and the content of psychopathological manifestations. In addition, the course of psychogenic disorders depends on the very presence of a traumatic situation, and when it is deactualized, as a rule, there is a weakening of symptoms.

neuroses- mental disorders that arise as a result of a violation of especially significant life relationships of a person and are manifested mainly by psychogenic conditioned emotional and somatovegetative disorders in the absence of psychotic phenomena.

In the definition of V. A. Gilyarovsky, several signs are given that characterize neuroses: the psychogenic nature of the occurrence, the patient's personality traits, vegetative and somatic disorders, the desire to overcome the disease, the personality's processing of the current situation and the resulting painful symptoms. Usually, when defining a neurosis, the first three signs are evaluated, although the criterion characterizing the attitude towards the situation of the disease that has arisen and the struggle to overcome it are very important for the diagnosis of neurosis.

Within the framework of psychodynamic theory, the definition of neuroses is based on the established relationship between the symptom, the triggering situation, and the nature of early childhood traumatization.

Neurasthenia is the most common form of neurotic disorder. It is characterized by increased excitability, irritability, fatigue and rapid exhaustion. Neurasthenia occurs against the background of nervous exhaustion caused by overwork. The cause of this overwork is intrapersonal conflict. The essence of this conflict lies in the discrepancy between the neuropsychic capabilities of a person and the requirements that he makes to himself in the process of performing activities. The state of fatigue acts in this case as a signal for its termination. However, the demands that a person places on himself make him overcome this fatigue by an effort of will and continue, for example, to perform a large amount of work in a short time. All this is often combined with a reduction in sleep time, and as a result, a person is on the verge of complete nervous exhaustion. As a result, symptoms appear, which are considered as a core disorder in neurasthenia - "irritable weakness" (as defined by I.P. Pavlov).

The patient reacts violently on the most insignificant occasion, which was uncharacteristic for him before, emotional reactions are short-lived, as exhaustion sets in quickly. Often all this is accompanied by tears and sobs against the background of vegetative reactions (tachycardia, sweating, cold extremities), which pass rather quickly. As a rule, sleep is disturbed, becoming restless and intermittent.

The state of health of a neurasthenic is worst in the morning, by the evening it can improve. However, a feeling of fatigue and fatigue accompanies him almost all the time. Intellectual activity is hampered, absent-mindedness appears, working capacity drops sharply. Sometimes the patient has short-term and frightening sensations that his mental activity has stopped - “thinking has stopped”. Headaches appear, which are constricting, pressing in nature (“neurasthenic helmet”). Sensitivity to external stimuli increases, the patient reacts to bright light and noise with irritation and increased headache. Both men and women experience sexual dysfunction. Decreased or lost appetite.

Mild neurasthenic manifestations can be observed in any person with overwork. In the treatment of neurasthenia, psychotherapy is indicated, aimed at identifying external and intrapersonal causes that caused this neurosis.

Hysterical neurosis (hysteria) is a disease that the famous French psychiatrist J. M. Charcot called the "great simulator", since its symptoms can resemble manifestations of a wide variety of diseases. He also singled out the main symptoms of this form of neurosis, which in frequency takes second place among neuroses after neurasthenia.

Hysterical neurosis most often occurs at a young age, its development is due to the presence of a certain "hysterical" personality set of traits. First of all, these are suggestibility and self-suggestion, personal immaturity (infantilism), a tendency to demonstrative expression of emotions, egocentrism, emotional instability, impressionability and “thirst for recognition”.

Neurosis is a mental disorder that occurs as a result of a violation of especially significant life relationships of a person and is manifested mainly by psychogenic conditioned emotional and somatovegetative disorders in the absence of psychotic phenomena.

E. Kraepelin believed that during hysteria, emotions spread to all areas of mental and somatic functions and turn them into symptoms of the disease, which correspond to distorted and exaggerated forms of mental experiences. He also believed that in every person with very strong excitement, the voice can disappear, legs give way, etc. In a hysterical personality, as a result of mental lability, these disorders occur very easily and are just as easily fixed.

The manifestations of hysterical neurosis are diverse: from paralysis and paresis to the loss of the ability to speak. The sensations that patients experience and describe may be similar to organic disorders, which makes timely diagnosis difficult.

However, previously typical paralysis and paresis, astasia-abasia are now rarely observed. Psychiatrists talk about the "intellectualization" of hysteria. Instead of paralysis, patients complain of weakness in the arms and legs, usually arising from unrest. They note that the legs become like cotton, give way, one leg suddenly weakens, or heaviness appears, staggering when walking. These symptoms are usually demonstrative: when the patient is no longer monitored, they become less pronounced. Mutism (inability to speak) is also less common nowadays; instead, stuttering, stuttering in speech, difficulty in pronouncing individual words, etc. are more often observed.

In hysterical neurosis, patients, on the one hand, always emphasize the exclusivity of their suffering, speak of "terrible", "unbearable" pains, in every possible way emphasize the unusual, previously unknown nature of the symptoms. Emotional disturbances are characterized by lability, the mood changes rapidly, violent affective reactions often occur with tears and sobs.

The course of hysterical neurosis is undulating. Under unfavorable circumstances, hysterical neurotic symptoms intensify, and affective disorders gradually come to the fore. In intellectual activity, features of emotional logic appear, an egocentric assessment of oneself and one's condition, in behavior - elements of demonstrativeness, theatricality with the desire to attract attention at any cost. Hysterical neurosis must be treated by a psychotherapist, especially paying attention to deontological aspects.

Obsessive-compulsive disorder (psychasthenia, or obsessional neurosis) manifests itself in the form of obsessive fears (phobias), ideas, memories, doubts and obsessive actions. This neurosis, compared with hysteria and neurasthenia, is much less common and, as a rule, occurs in people of a thinking type with an anxious and suspicious character.

The disease, as in other forms of neuroses, begins after exposure to a traumatic factor, which, after personal “working through”, can be difficult to determine in the process of psychotherapeutic treatment. The symptoms of this neurosis consist of obsessive fears (phobias), obsessive thoughts (obsessions) and obsessive actions (compulsive disorders). Common to these symptoms is their constancy and recurrence, as well as the subjective impossibility of getting rid of them when the patient is critical of them. Phobias in obsessive-compulsive disorder are varied, and their combination with obsessive actions makes the condition of such patients very difficult. Psychotherapy is also used in the treatment.

Under reactive psychosis understand a mental disorder that occurs under the influence of mental trauma and manifests itself entirely or mainly as an inadequate reflection of the real world with a violation of behavior, a change in various aspects of mental activity with the appearance of phenomena that are not characteristic of the normal psyche (delusions, hallucinations, etc.).

All reactive psychoses are characterized by the presence of productive psychopathological symptoms, an affectively narrowed state of consciousness, as a result of which the ability to adequately assess the situation and one's condition is lost.

Reactive psychoses can be divided into three groups depending on the nature of the mental trauma and the clinical picture:

1) affective-shock reactions that usually occur when there is a global threat to life for large contingents of people (earthquakes, floods, disasters, etc.);

2) hysterical reactive psychoses, which occur, as a rule, in situations that threaten the freedom of the individual;

3) psychogenic psychotic disorders (paranoids, depressions) caused by subjectively significant mental traumas, i.e., mental traumas that are important for a particular person.

Reactive psychosis - a mental disorder that occurs under the influence of mental trauma and manifests itself entirely or mainly as an inadequate reflection of the real world with a violation of behavior, a change in various aspects of mental activity with the appearance of phenomena that are not characteristic of the normal psyche (delusions, hallucinations, etc.).

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Psychogenic disorders

Psychogenic disorders include various pathologies of mental activity: acute and prolonged psychoses, psychosomatic disorders, neurosis, abnormal reactions (pathocharacterological and neurotic) and psychogenic development of the personality that occurs under the influence of mental trauma or in a traumatic situation.
By its nature, psychic trauma is a very complex phenomenon, in the center of which is the subclinical response of consciousness to the psychic trauma itself, accompanied by a kind of protective restructuring that occurs in the system of psychological attitudes in the subjective hierarchy of the meaningful. Such a protective restructuring usually neutralizes the pathogenic effect of mental trauma, thereby preventing the development of a psychogenic illness. In these cases, we are talking about psychological protection, which acts as a very significant form of the reaction of consciousness to the transferred mental trauma.
The concept of "psychological defense" was formed in the psychoanalytic school, and according to the views of the representatives of this school, psychological defense includes specific methods of processing experiences that neutralize their pathogenic influence. They include phenomena such as repression, rationalization, sublimation.
Psychological defense is a normal everyday psychological mechanism that plays a large role in the body's resistance to disease and is able to prevent the disorganization of mental activity.
As a result of the research, people were singled out who are “well psychologically protected, capable of intensive processing of pathogenic influences, and poorly psychologically protected, who are not able to develop this protective activity. It is easier for them to develop clinically defined forms of psychogenic diseases.
A common feature of all psychogenic disorders is the conditionality of their affective psychogenic state - horror, despair, offended pride, anxiety, fear. The sharper and more pronounced the affective experience, the more distinct is the affective-narrowed change in consciousness. A feature of these disorders is the unity of the structure of all observed disorders and their connection with affective experiences.
Among psychogenic disorders, productive and negative ones are distinguished. To distinguish productive disorders of a psychogenic nature from other mental illnesses, the criteria of K. Jaspers are used, which, despite their formal nature, are important for diagnosis:
1) the disease occurs after a mental trauma;
2) the content of psychopathological manifestations follows from the nature of the mental trauma, and there are psychologically understandable connections between them;
3) the entire course of the disease is associated with a traumatic situation, the disappearance or deactivation of which is accompanied by the cessation (weakening) of the disease.

Psychogenic abnormal reactions
The term "psychogenic reaction" refers to pathological changes in mental activity that occur in response to mental trauma or mental stress and are psychologically understandable with them.
A characteristic feature of abnormal reactions is the inadequacy of the stimulus both in strength and content.
Neurotic (psychogenic) are also reactions, the content of which is critically evaluated by the patient and which are manifested mainly by vegetative and somatic disorders.
Psychopathic (situational) reactions are characterized by the lack of a critical attitude towards them. Psychopathic reactions are evaluated as personality reactions, but personality reactions are a broader concept. Under the reaction of the individual is understood a time-limited state of altered behavior, due to certain situational influences that are subjectively significant for the individual. The nature and severity of the reaction are determined, on the one hand, by the influences of the environment, and on the other hand, by the characteristics of the personality, including the history of its development, socially and biologically determined components.
Pathocharacterological reactions are manifested in pronounced and stereotypically repetitive deviations in behavior, accompanied by somatovegetative and other neurotic disorders and leading to temporary disturbances in social adaptation.
Conventionally, reactions of opposition, refusal, imitation, compensation, hypercompensation are distinguished.
Opposition reactions arise when excessive demands are made on a child or adolescent and as a result of the loss of their usual attention and care from relatives and especially mothers. The manifestations of such reactions are different - from leaving home, skipping school to suicide attempts, often of a demonstrative nature.
Refusal reactions are observed in children with a sudden separation from their mother, family, placement in a children's institution and are manifested in the refusal of contacts, games and sometimes food. In adolescents, such reactions are rare and indicate pronounced infantilism.
Imitation reactions are manifested in the imitation of the behavior of a certain person, a literary or cinematic hero, leaders of teenage companies, idols of youth fashion.
The negative reaction of imitation is manifested in the fact that all behavior is built as the opposite of a certain person, in contrast to a rude father who drinks and arranges constant scandals, a teenager develops restraint, goodwill, caring for loved ones.
Reactions of compensation lie in the fact that adolescents seek to compensate for failures in one area in another. For example: a physically weak boy compensates for his inferiority with academic success, and, conversely, learning difficulties are compensated for by certain forms of behavior, bold deeds, and mischief.
Pathological behavioral reactions are characterized by the following features:
1) a tendency to generalization, i.e. they can occur in different situations and due to inadequate reasons;
2) the tendency to repeat the same type of actions for different reasons;
3) exceeding a certain threshold of behavioral disorders;
4) violation of social adaptation (A. E. Lichko).

Classification according to the International Classification of Diseases-10
Since the International Classification of Diseases is built according to the syndromological type, it does not have a section “Psychogenic diseases”, and therefore psychogenic psychoses are presented in various sections corresponding to the leading syndrome.
Affective-shock reactions are assigned to the section "Neurotic stress-related and somatoform disorders" F 40-F 48 and are coded as "Acute stress reaction". This is a transient disorder of significant severity that develops in individuals without apparent mental disorder previously in response to exceptional physical and psychological stress, and which usually lasts for hours or days.
Hysterical psychoses (pseudo-dementia, puerilism, mental regression) are not reflected in the International Classification of Diseases-10, only hysterical twilight states of consciousness (fugue, trance, stupor) and Ganser's syndrome occur.
Reactive depression is classified under "Mood disorders (affective disorders)" F 30-F 39 and is considered as "Severe depressive episode with psychotic symptoms": psychotic symptoms are delirium, hallucinations, depressive stupor associated with a mood disorder; "Recurrent depressive disorder, current severe episode with psychotic symptoms" refers to recurrent severe episodes of reactive depressive psychosis.
Acute reactive paranoids are classified under Schizophrenia, Schizotypal and Delusional Disorders F 20-F 29 and are referred to as Other Acute, Predominantly Delusional Psychotic Disorders and Induced Delusional Disorder.

Etiology and pathogenesis
The cause of reactive psychosis is psychic trauma. It should be noted that mental trauma does not cause reactive psychosis in every person, and not even always in the same person. Everything depends not only on the mental trauma, but also on its significance at the moment for a given person and also on the state of the nervous system of this person. It is easier to have painful conditions in people weakened by somatic diseases, prolonged lack of sleep, fatigue, emotional stress.
For such reactive psychoses as affective-shock reactions, premorbid personality traits are not of great importance. In this situation, the force and significance of mental trauma acts - a threat to life.
In hysterical psychosis, the disease occurs through the mechanisms of suggestion and self-hypnosis and through the mechanisms of protection from an unbearable situation for the individual. In the occurrence of hysterical psychoses, apparently, the mechanism of the idea of ​​mental illness, which is common among insufficiently literate and educated people, plays a role: “he went crazy”, “turned into a child”. Hysterical psychoses have lost their originality and clarity. In situations of subjectively significant, the main role belongs to premorbid personality traits.

Differential Diagnosis
Diagnosis of reactive psychoses in the majority of difficulties does not cause. Psychosis is formed after a mental trauma, the clinical picture reflects the experiences associated with mental trauma. These signs are not indisputable, since mental trauma can provoke another mental illness: manic-depressive psychosis, schizophrenia, vascular psychosis. The structure of syndromes of psychogenic disorders is of great importance for diagnosis. Typical is the centrality of all experiences and the close connection of all disorders with affective symptoms, which are determined by a more or less pronounced affective narrowing of consciousness. If a different plot appears in delusional disorders that is not associated with mental trauma, this gives grounds to suspect a disease of a non-psychogenic nature.

Prevalence and prognosis
There is no specific information on the prevalence of reactive psychoses. Women suffer from them twice as often as men. There is evidence that among reactive psychoses, reactive depressions are most often noted, and in recent decades they have accounted for 40-50% of all reactive psychoses.
The prognosis of reactive psychoses is usually favorable; after the disappearance or deactivation of the mental trauma, the manifestations of the disease disappear. Full recovery is preceded by more or less pronounced asthenic manifestations.
It was noted that some variants of reactive depression during recovery go through the stage of hysterical symptoms, while patients often develop hysterical forms of behavior.
In a small part of patients, a complete recovery does not occur, the course of the disease takes on a chronic character, and gradually, psychogenic symptoms of the disease are replaced by character disorders, psychopathization of the patient occurs, or post-reactive abnormal development of the personality begins. Depending on the predominance of pathocharacterological disorders, asthenic, hysterical, obsessive, explosive and paranoid development are distinguished. Symptoms of abnormal development indicate that the picture of the disease is determined by negative symptoms, with the appearance of which the prognosis worsens significantly.

Treatment
The treatment of reactive psychoses is complex and depends on the leading clinical syndrome and the timing of the development of the disease.
With affective-shock reactions and acute reactive paranoids with severe psychomotor agitation, the patient needs immediate hospitalization in a psychiatric hospital. Affective disorders and arousal are stopped by intramuscular administration of neuroleptics - chlorpromazine at a dose of 100-300 mg / day, tizercine - 50-150-200 mg / day.
In hysterical psychosis, phenothiazine derivatives are prescribed: melleril, sonapax, neuleptil in medium therapeutic doses, intramuscular administration of chlorpromazine and tisercin in doses of 100 to 300 mg / day is recommended.
Psychotherapy is carried out at all stages of the development of reactive psychoses. At the first stage of the development of reactive depression, the psychotherapeutic effect is calming; in the future, the doctor is faced with the task of creating a new life goal for the patient, a new life dominant. At the same time, the patient's capabilities should be taken into account and oriented towards quite achievable goals.
In severe reactive depression with anxiety, it is recommended to prescribe amitriptyline at doses up to 150 mg / day with sonapax up to 30 mg / day. In milder depressive states, pyrazidol is indicated up to 100-200 mg / day with the addition of small doses of antipsychotics (for example, sonapax at a dosage of 20 mg / day). In some cases, it is advisable to add a few drops of a 0.2% solution of haloperidol to the antidepressant, with which a calming effect is achieved with anxiety, but there is no sedative effect, as with tranquilizers. With mild depression in the elderly, especially in men, it is advisable to prescribe azafen in doses up to 200-300 mg / day.
With reactive paranoids, intensive therapy with neuroleptic drugs is necessary.
In the treatment of reactive psychoses in persons of involutionary age, psychotropic drugs are used cautiously and in smaller doses, since hypersensitivity to drugs at this age is often noted. This also applies to the treatment of patients in senile age.
Reactive depression in adolescents is difficult to treat with antidepressants; active psychotherapy is of great importance. It is possible to soften the intense affect in a teenager with small doses of amitriptyline or tranquilizers (tazepam, seduxen, elenium).
With the delinquent equivalent of reactive depression, it is advisable to prescribe behavior correctors: neuleptil, melleril in doses up to 40 mg / day.
Psychotherapy in adolescents should be aimed at finding a way out of the current situation, if it is insoluble, at creating a new life goal in another direction accessible to the teenager.
With reactive paranoids, it is necessary to prescribe antipsychotics intramuscularly to suppress anxiety and fear. Psychotherapeutic conversations should initially be calming in nature, and in the future cognitive psychotherapy should be aimed at forming a critical attitude towards delusional symptoms.
For adolescents, group and family psychotherapy is of great importance.

Expertise
Labor expertise. During reactive psychosis, patients are unable to work. With prolonged reactive psychosis or abnormal post-reactive (especially hypochondriacal) personality development, patients may need disability, but this issue must be resolved individually in each case.
Forensic psychiatric examination. The question of a forensic psychiatric examination may arise in two cases: when the patient, while in a reactive psychosis, committed a socially dangerous act and when a reactive psychosis arose after such an act.
Socially dangerous acts in a state of reactive psychosis are rarely committed; in these cases, patients are recognized as insane in relation to the acts incriminated to them.
If reactive psychoses occur after the commission of an offense, then for the period of illness it is possible to temporarily suspend the criminal case until the person under investigation recovers, after which he must again be brought before the court.

PSYCHOGENIC DISORDERS

Scientific and technical encyclopedic dictionary.

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Psychogenic depression

Psychogenic depressionI - a disorder that occurs under the influence of external negative or positive factors (both long-acting and one-time) after situations of loss/change of values ​​significant to a person. For persons suffering from this disorder, hypersensitivity, impressionability, timidity, suspiciousness, pedantic traits are characteristic. Psychogenic depression can develop immediately after a traumatic situation, although in some patients a depressive episode occurs after a period of time after a stressful event.

Patients often have a fixation on the fact that has happened, they are characterized by intense and constant internal tension, which cannot be weakened by the efforts of the will. Persons suffering from psychogenic depression show irrational concern for the fate, health, well-being of themselves and their loved ones.

Patients note mental retardation, difficulty concentrating and the predominance of ideas of their own worthlessness in their thoughts. They describe their past and present in pessimistic colors, they are convinced that the future existence is futile and meaningless. Often, the idea of ​​suicide is considered by them to be the only correct decision and a “reasonable” way out of the current situation. People with a diagnosis of "psychogenic depression" lack the desire to overcome difficulties, to resolve problems. They prefer to hide their emotions in themselves, not to express their dissatisfaction, but to “go with the flow”.

Personalities with predominant hysterical character traits show symptoms of depression in demonstrative capriciousness, nervousness, irritability, fussiness. Such persons often make suicide attempts, and all their actions are distinguished by a simulated, unnatural “theatricality”.

Depression of a psychogenic nature has recently been considered within the framework of dysthymic disorder - a chronic disease of moderate severity of symptoms with asthenic and neurasthenic manifestations. They have a certain similarity with psychogenically provoked forms of recurrent depression: psychological clarity of the cause of experiences, chronological and semantic connection with a stressful event, lack of autochthonousness (the ability to develop without the presence of a causative factor).

Provoking stressors preceding and/or accompanying psychogenic depression testify to their diversity and heterogeneity. However, in most patients, the development of a depressive syndrome was preceded by unfavorable latent causes of personal, domestic, professional aspects.

A distinctive feature of psychogenic depression is a change in the patient's condition when exposed to external factors of various content. The opposite of typical endogenous depression, which does not change its structure under the influence of external factors, are diverse variations in the ways of emotional response and behavioral reactions. The prospect of the possibility of compensation for painful sensations by methods of psychotherapeutic influence has also been established.

As a rule, oppressive melancholy and irrational anxiety are dominant in the emotional aspect of a psychogenic disorder, although dysphoric manifestations and sensory hyperesthesia are often recorded. In most cases, the clinical picture contains manifestations of autonomic nervous system lability:

frequent fluctuations in blood pressure,

heart rate changes,

increased sweating,

dryness of the oral mucosa.

Moreover, vegetative-vascular fluctuations increase and are more clearly expressed in situations of physical or emotional overload that occur in the afternoon, and are combined with feelings of lethargy, muscle weakness, bodily discomfort.

Vital drives, impoverishment of interest in ongoing events, loss of interest in former hobbies and pleasures are, as a rule, rudimentary and they are characterized by fluctuations in intensity. It should be noted that in patients with psychogenic depression, anesthesia of vital sensations is combined with an exacerbation of the ways of emotional response in the event of circumstances that are especially significant for the individual, often associated with a traumatic situation.

The classification of psychogenic depression is a rather difficult diagnostic decision, since the disease can be a manifestation of dysthymia, a severe form of adjustment disorder, or act as a primary depressive episode.

According to the content, psychogenic depressions are divided into diseases of a neurotic and psychotic nature. A neurotic level disorder is a relatively shallow depressive state with a predominance of dreary mood, tearfulness, feelings of inferiority, hysterical manifestations, and asthenic conditions in the clinical picture. The psychotic level disorder (reactive psychosis) is characterized by irrational pathological anxiety, pronounced psychomotor agitation and / or inhibition, depersonalization and derealization phenomena, hypochondriacal moods, puerile manifestations, delusional ideas of persecution and accusation, suicidal thoughts.

For psychogenic depression:

• hereditary (genetic) predisposition is not characteristic;
• there is a connection with a specific traumatic event;
• the primary depressive episode develops as a result of a stressful situation;
• the intensity of depressive reactions depends on the individual sensitivity threshold;
• deterioration occurs in the evening;
• awareness of the disease is maintained;
• there is no motor retardation;
• depressed mood is expressed by tearfulness;
• accusations directed at others.

Psychogenic depression: causes

This disease occurs as a result of a prolonged or single exposure to psycho-traumatic (stressful) external factors that caused a strong emotional reaction, subsequently recorded in the subconscious.

One of the leading factors provoking psychogenic depression is the emotional dissatisfaction of the individual due to the moral conflict with the requirements of society, the neglect of others to the needs of the individual, excessive criticism, humiliation or indifference from others. Personal character traits: suspiciousness, vulnerability, impressionability, humility, along with an accentuated feature of getting stuck (fixing) on ​​events, forces a person to put up with the requirements of modernity. Instead of adequately resisting negative pressure, the category of timid, shy, pedantic people prefer to restrain their anger and suppress their disagreement with what is happening. In order to meet the template requirements of the norm, to be accepted, understood and demanded by society, people try to displace negative emotions, externally demonstrating consent, humility and pleasure. The result of the displacement of experienced emotions is that the person begins to stay in a fantasy, fictional world, living someone else's life and hiding real feelings not only from others, but also from himself. The consequence of such a “play by someone else's rules”: excessive demands on oneself, low self-esteem, dissatisfaction with oneself and the resulting feeling of loneliness are direct prerequisites for the onset of a depressive disorder.

Unable to readapt, that is, to effectively change the way of adapting to stressors, in unusual situations, the individual feels a state of strong emotional stress. In moments of crisis, the significance of which does not correspond to the intensity of the subsequent reaction, a person falls into a depressive state and feels the painful symptoms of the disease.

Factors provoking the development of psychogenic depression can be both negative and positive life situations. In terms of the strength of influence on the human psyche, the leading positions are occupied by events:

• death of a spouse or close relative;
• divorce or separation from a loved one;
• own illness or injury;
• imprisonment;
• marriage;
• job loss;
• reconciliation of spouses;
• retirement;
• deterioration in the health of a family member;
• pregnancy or the arrival of a new family member;
• sexual problems;
• change in social status or financial situation;
• change of activity;
• inability to repay credit obligations;
• outstanding personal achievement;
• change in living conditions or place of residence;
• change in personal habits, routine or working conditions, the usual type of leisure;
• change in social activity or change in religious beliefs;
• start or end of training.

It is worth noting that the symptoms of psychogenic depression can be delayed, that is, they can appear after a certain period of time after a traumatic situation.

Psychogenic depression: symptoms

This disease manifests itself in the form of:

• causeless tearfulness;
• oppressive feeling of loneliness;
• depression, feeling of inner emptiness;
• violations in the "wakefulness-sleep" mode;
• insomnia;
• thoughts about the aimlessness of existence and the futility of the future;
• feelings of worthlessness;
• suicidal thoughts;
• amplification of negative feelings in the evening.

Often, those suffering from psychogenic depression have low self-esteem, but patients do not engage in self-accusation, but place all responsibility and blame for the injury on the people around them.

With psychogenic depression that has arisen after a significant loss, there is a natural dynamics of manifestations and changes in sensations. During the first stage, most people are in a state of shock, feeling detached and empty. The second stage, which is quite long in time, can be characterized as a period of search and awareness of the lost. During the third stage, rage, anger, aggression often join the feelings of loss and feelings of sadness. Moreover, depressive and manic manifestations can alternate and change several times a day.

Psychogenic depression deprives patients of the joy of existence, no habitual activities and pleasures inspire or inspire them. Often, behind an external artificial mask of success, people suffering from this disorder mask a painful feeling, fear of loneliness and a feeling of spiritual emptiness, inner vacuum. Most patients categorically refuse to take part in or even watch any recreational activities, preferring to be alone with themselves and "chew mental gum", analyzing their past mistakes and criticizing their present.

In addition to changes in the habitual lifestyle and behavioral reactions, such persons radically change their gestures and facial expressions: their faces never light up with a smile, the corners of the lips are lowered, and aging wrinkles are clearly visible. Patients regard the past and present from a pessimistic point of view, they are confident that their future is meaningless, hopeless and aimless.

The neurotic stage of the development of the disease is characterized by the absence of vital components of depression, lability (variability and instability) of the symptoms and physiological equivalents of the disorder, which often mask the main components of depression. Therefore, at this stage, most patients are not under the supervision of psychotherapists and psychiatrists, seeking medical help from general practitioners or other specialists.

Psychogenic depression: treatment

When choosing methods for treating psychogenic depression, the severity and duration of the impact on the individual of psycho-traumatic factors, the characteristics of the course of premorbid (a condition that precedes and contributes to the development of the disease), and the patient's personal characteristics are taken into account.

The leading, mandatory component of the treatment of psychogenic depression is psychotherapy. Psychotherapeutic techniques are very effective and efficient, they help to overcome the manifestations of the disease, get out of depression, prevent the occurrence of a new depressive episode, and restore vitality. Psychotherapy techniques help the patient to work productively on the development, change and improvement of a new worldview and a different model of more universal behavior. By remembering, re-living and rethinking the wounds received, a person can completely get rid of a depressive state.

Modern methods of various teachings direct the patient to rethink and reassess the significance of the traumatic event, they allow the individual to look at the past and present from a different point of view and help form a new picture of a realistic perception of the world. The process of psychotherapeutic treatment is not fast, it requires the investment of mental strength and willpower, the support of an experienced doctor and the attention of loved ones.

In combination with psychotherapeutic consultations, in order to achieve a stable positive result in psychogenic depression, antidepressants are used for a course of at least 6 months. These drugs restore the required level of neurotransmitters: serotonin, dopamine, norepinephrine, which are responsible for the emotional sphere of a person.

Since antidepressants differ in their mechanism of action, only a qualified specialist should select and determine the dosage of the drug. Self-medication for depression is fraught with negative consequences up to the strengthening of suicidal thoughts and actions.

SUBSCRIBE TO THE VKontakte GROUP dedicated to anxiety disorders: phobias, fears, depression, obsessive thoughts, VSD, neurosis.

There is currently no unified classification of depressive disorders. Most Russian and foreign psychiatrists use several options for systematization. Among them are the following types: Classification by types of depression: simple (apathetic, melancholic, anxious); complex (states accompanied by obsession, delirium). Classification according to the course of depression (ICD-10): a single depressive episode, recurrent (recurring) depression, bipolar disorder (change of depressive and manic phases), […].



There is a direct relationship between alcohol dependence and depressive disorders: depression also affects the aggravation of alcoholism, as well as excessive drinking causes anxiety, melancholic, manic states.



Causes of depression

Research conducted by experts from the University of Kansas, examining the causes of depression in more than 2,500 patients in psychiatric clinics in the United States, established the main risk factors for developing depression. These include: Age between 20 and 40 years; Change in social position; Divorce, rupture of relations with a loved one; The presence in previous generations of acts of suicide; Loss of close relatives under the age of 11; dominance […].

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To reactive states include reactive psychoses and neuroses, as well as diseases that occur immediately after mental trauma, which include affects of fear and anger, feelings of resentment and insult, and other types of negatively colored emotional experiences. For childhood, traumatic moments can be the placement of a child in a kindergarten or boarding school, a change in the usual way of life, the departure of the father from the family, the death of loved ones, everything that causes an overstrain of functional systems.

Experience is one of the indispensable and constant aspects of human mental activity. Therefore, when it comes to the pathogenic role of certain emotions, it is always necessary to take into account the current situation, the reaction to which these emotions are, as well as the general state of the person that preceded the psychotrauma, i.e., the premorbid ("morbus" - illness) state of the person.

To understand the mechanisms of the reactive state, it is necessary to take into account some sections from the teachings of I.P. Pavlov about the types of higher nervous activity. I.P. Pavlov and A.A. Ukhtomsky pointed out that a person is constantly exposed to a large number of stimuli of various strengths from internal organs and the external environment, causing mental stress, mobilization of all mental activity apparatuses in a state of combat readiness, i.e., to the most optimal level of performance. These are the conditions for the perception of stimuli under normal conditions.

For the emergence reactive state two conditions are required:

Weakening of the activity of the cerebral cortex, occurring under the influence of various diseases: infections, intoxication, trauma of the skull, lack of sleep, physical exhaustion, age factor;

Super strong irritant for this person.

Under these conditions, the stimulus that has reached the cerebral cortex does not linger at one point, but spreads over the cortex. A diffuse excitation arises, which cannot be restrained by a weakened inhibitory process, a collision of nervous processes occurs. Excitation covers the entire cortex and reaches the subcortex, concentrating there. At the site of excitation, diffuse protective inhibition is formed in the cortex. Depending on the strength of the stimulus and the type of nervous activity, various psychogenies develop: reactive psychoses and neuroses.

However, as G.E. Sukharev, the division of reactive states into psychoses and neuroses is very conditional, since the boundary between them is often blurred, not sharply expressed. There are cases when the disease begins with neurotic reactions and passes into psychotic. Hence the emergence of such a generalized term as "psychoneurosis" (S.S. Lyapidevsky), to refer to such conditions, the pathophysiological mechanism of which is also common (overstrain of neurodynamic processes in the brain, disruption of the interaction between the main processes of excitation and inhibition).

Reactive psychoses

Reactive states in childhood and adolescence. Reactive states can be observed in both childhood and adolescence. A number of authors (Yu.S. Shevchenko, G.I. Bobyleva, E.I. Morozova, 1989) observed reactive states in children aged 1 to 5 years who attended specialized round-the-clock nurseries for children with borderline neuropsychiatric pathology. Separation from the usual home environment and parents was a superstrong irritant for children, to which they gave a severe reaction in the form of reactive depression, which lasted for a long time.

Reactive depression developed in connection with the difficult adaptation to the children's institution, which the children continued to visit during the entire period of dynamic study. Children were not prepared for a long separation from the family. The authors conventionally identified five stages in the dynamics of protracted reactive depression in young children.

First stage - stage of acute affective-shock reactions characterized by the resistance of the child to stay in new conditions in isolation from their parents. This condition manifested itself in the form of psychomotor agitation with a pronounced vegetative component (flushing of the face, rapid heartbeat, fever), a violent reaction of protest, screaming, and tears. The children could not calm down for a long time, called for their mother, stood at the window or at the door, refused food, walks, daytime sleep, did not follow the instructions of the teacher. In the process of observation, a refusal to verbal communication, contact with other children was revealed. When parents appeared, the children gave an aggressive reaction: they beat and scolded their parents, did not listen to them.

Second phase - stage of subacute reactive depression was characterized by the subordination of the child, depression by the new conditions of life. The leading psychopathological symptoms were melancholy-apathetic affect and regressive behavior (return to behavioral reactions of an earlier age). Attention was drawn to a sad or aloof facial expression, inhibition and poverty of movements, passivity and indifference in the performance of tasks, refusal to play activities and expressive manifestations of discontent indicated the presence of a severe depressive state. Somatovegetative manifestations of psychogenic depression included decreased response to discomfort, hunger, wet clothes, daytime enuresis, weight loss and loss of appetite, weakened resistance to viral infections and other somatogenic hazards.

Third stage - stage of a protracted polymorphic depressive-neurotic state characterized by neurotic and behavioral disorders. The duration of this stage is from several months to 1 year or more. At this stage, depressive symptoms smoothed out: general depression was replaced by an adequate emotional interest in music lessons, during an individual game with adults. Free play was carried out alone and, as a rule, unstable, short-term. At the same time, any change in the environment, an increase in tone when addressing the child, caused him an anxious-panic reaction: the children went to the side, sat down on a chair and swayed for a long time, shaking their legs or arms, fingering.

Neurotic reactions grew and were characterized by polymorphism. Attention was drawn to the phenomenon of identity, which gives the child's behavior a ritual character. The children tried to keep the route from home to the nursery unchanged, they did not want to part with their favorite toy.

Pathologically habitual actions and systemic disorders (enuresis, encopresis, mutism) were accompanied by fears of the dark, loneliness, cars, and fairy tale characters. The polymorphism of the clinical manifestations of this stage expanded due to the addition of inhibitory character traits, expressed in an increase in timidity, anxiety, vulnerability, passive obedience, and delayed psychoverbal development.

Fourth stage - stage of the reverse development of the disease, compensation of the state. Clinically, it was characterized by a gradual (over many months, sometimes before the end of the nursery period) process of getting out of a painful state, which was expressed in a weakening of affective and neurotic disorders and an equalization of the pace of mental development.

The lowered level of mood was gradually replaced by a more adequate environment: the children actively began to play with toys, laughed, selective attachment to children and adults appeared, and their behavior became more adequate. Despite the improvement in the general condition, neurotic elements persisted in children: anxiety, inhibition, somatovegetative symptoms.

Fifth stage - stage of the post-reactive state, characterizing the outcome of psychogeny. Observation of children for a long time after the end of the reactive period showed two outcomes:

Recovery with residual symptoms;

Post-reactive personality formation.

For first option characterized by a fairly complete completion of the period of the reactive state. Some remaining neurotic and somatovegetative disorders were due to the main neurological disorder (speech and motor), for which the child was in a specialized nursery.

For second option the preservation of neurotic disorders is characteristic: fears, rituals, pathologically habitual actions, residual manifestations of mutism, a tendency to freeze in emotional situations, sleep disturbance, appetite, autonomic lability. But even in the absence of these violations, such character traits as inhibition, timidity, timidity, anxiety, shyness, resentment, tearfulness, to a large extent hampered social adaptation, which manifested itself during the transition to a preschool or school institution. Neurotic reactions reflected the psychomotor level of neuropsychic response (tics, elective mutism, obsessive movements). These observations indicated post-reactive personality formation.

These data showed that children with various organic neurological symptoms react differently to placement in specialized institutions, need constant monitoring, attention, and preparedness for being in a closed institution. Similar reactions can be observed in various young and middle-aged children when sent to a boarding school or hospital. In these cases, a large role in helping children belongs to the educator and teacher-defectologist.

Reactive states in emergency situations. Military conflicts, acts of terrorism, catastrophes, natural disasters are emergencies that affect the psyche of adults and children involved in them. Acute reactive states are divided into several groups according to the timing of occurrence and course:

Acute affective reactions that occur immediately after a psychotrauma with a duration of 1–2 hours; assistance to the victims is provided on the spot, and patients are not hospitalized;

Short-term acute reactive states that occur immediately after a psychotrauma, with a duration of a few hours to 5–7 days; patients can be placed in general somatic hospitals, where they must receive psychotherapeutic and medical care;

Acute reactive states of moderate severity with a course of up to 15–20 days (victims are sent to day hospitals of a neuropsychiatric or psychiatric hospital);

Psychotic and protracted forms of reactive states with a course of more than 2–3 weeks (need specialized medical care and treatment in a psychiatric clinic).

Children give more protracted forms of reactive states and with great difficulty get out of them. Long-term psychotherapeutic and psychological work of specialists is required to bring children out of reactive states.

Reactive psychoses in adults. Severe psychotrauma (death of loved ones, fire, earthquake, etc.) can lead to psychogenic (reactive) psychoses. More often they develop in people weakened by infectious or somatic diseases, in psychopaths or accentuated personalities, after suffering a traumatic brain injury or prolonged insomnia. Reactive psychoses can be divided into three groups: acute, subacute and protracted.

Acute psychogenic psychoses(affective-shock reactions). In life-threatening circumstances, a person may suddenly develop a twilight disorder of consciousness with a motor stupor (“imaginary death reaction”) or with chaotic, disordered and inadequate active activity (“motor storm reaction”). Such states usually last from several minutes to several hours.

Subacute psychogenic psychoses(reactive-hysterical). In various psycho-traumatic situations, especially with a protracted, agonizing wait (for example, a court verdict), against the background of a twilight state of consciousness, the patient may experience the following psychopathological disorders:

Acute speech confusion - incoherence of speech and thinking of the patient with the impossibility of establishing productive contact with him;

Puerilism - children's behavior, when the speech, facial expressions, actions of the patient resemble exaggerated forms of behavior of a young child;

Pseudo-dementia syndrome - the patient suddenly begins to behave like an imbecile person, giving wrong answers to the simplest questions;

Syndrome of the archaic psyche - the patient behaves like a wild animal: he does not use speech, runs on all fours, barks, howls, bites others, grabs food from the floor with his mouth, etc. The duration of such psychotic states is from several days to 2-3 weeks.

Protracted psychogenic psychoses last 2-3 months or more. There are two types: reactive depression and reactive paranoid.

Reactive depression much deeper than neurotic depression. Patients stop taking care of themselves, do not look after their appearance, do not go out, do not eat, do not adequately blame themselves and others for the accident, and do not consider themselves sick. They try to realize their suicidal plans, considering the situation hopeless. Somatovegetative components of depression are pronounced.

Reactive paranoid. In patients, delusional ideas are formed, their plot associated with psychotraumatic circumstances. Sometimes the distorted delusional logic sounds so convincing to relatives that they also begin to share and support the patient's false conclusions (the so-called induced psychoses). Due to delusional ideas, such people are dangerous for themselves and for others, therefore, they need to be hospitalized.

In cases of reactive psychosis in adults, there are mental disorders characterized by hallucinations and delusions. Special literature contains an extract from the medical history of one woman who came after a long break to the hospital to visit her child and found out that the child had died and was buried. There was not enough information about the parents in the hospital. Having received the news of the death of the child, the mother developed an acute reactive psychotic state, she kept saying that "the child was buried alive as she hears his voice from the earth, the child calls her." The mother demanded exhumation and could not calm down. The presence in this case of hallucinations and delusional statements suggests reactive psychosis. Thus, reactive psychosis is a consequence of psychogenic trauma and is manifested by delusions and hallucinations.

Psychogenic psychoses are usually reversible and end in recovery. However, when the situation develops unfavorably and for a long time there are additional psychotraumas of a similar plot, then, despite the cessation of psychosis, a pathological development of the personality is formed in patients (especially often - paranoid development).

neuroses

Neuroses are psychogenic functional disorders of the nervous system, in which, unlike reactive psychoses, a critical attitude to the disease is maintained and the ability to control one's behavior is not lost. This is the definition proposed by V.V. Kovalev (1979), emphasizes the essence of neurosis: the reversibility of symptoms, the dynamism of the clinical picture, the absence of organic symptoms of the lesion.

The doctrine of neurosis has its own history. In medicine of the XVII-XVIII centuries. organic lesions of the nervous system (injuries, tumors, hemorrhages) and mental illnesses (disorders of consciousness, delirium, hallucinations) were known. Everything that, when presented with complaints by patients, did not fit into the picture of organic and mental disorders, was called "borderline states", and later - "neuroses".

The term "neuroses" was introduced in 1776 by the Scottish physician W. Kellen, who designated them movement and sensation disorders that are not accompanied by fever and do not depend on the defeat of any particular organ, and are due to general suffering. From Kellen's formulation, the idea of ​​neurosis arose and became stronger as a borderline state between neurological and mental diseases, that is, disorders of the nervous system without pronounced symptoms. This position allowed various, not sharply expressed forms of neurological and mental disorders with an unexplained etiology to be included in the group of neuroses. Not only were the clinical manifestations of neuroses unclear, but also their etiology and pathogenesis. As the diagnosis was refined, many of the symptoms included in the concept of "neuroses" were combined with their underlying disease. The term "neuroses" remained without a definite clinical picture. Only thanks to the works of I.P. Pavlov and his school could prove the etiology, pathogenesis and manifestations of this disease. The term "neuroses" combined three diseases: "neurasthenia", "compulsive disorder" and "hysteria", which were previously considered independent, had their own history of study and clinical picture of the disease. The works of I.P. helped to combine them into one clinical form. Pavlov, who experimentally proved that the disruption of higher nervous activity can be caused by overstrain:

Excitatory process;

braking process;

Mobility of nervous processes.

M.K. Petrova, student and colleague of I.P. Pavlova, on the basis of experimental material, showed that neurosis is limited not only by a violation of the function of the GNA, but also affects all organs and tissues of the body. K.M. Bykov (1947) in his work "The Cortex and Internal Organs" proved the enormous role of the cerebral cortex in the regulation of the activity of internal organs and possible changes in them in case of impaired brain function.

The clinical manifestations of neurosis were described by the American physician D. Beard (1860) under the title "Diseases of the Big City". He drew attention to the fact that workers who worked at this production often complained of drowsiness, fatigue, headaches, pain in the heart, stomach, discomfort in the internal organs, restless sleep and frightening dreams. After interviewing patients, Beard found that many workers live far from production and in difficult conditions, sleep anxiously at night, afraid to be late for work, eat poorly, worry about the possible loss of work. In production, monotonous work and work at the assembly line, requiring a fast pace of activity, which led to tension and fatigue, and with them drowsiness. Examining the patients, Beard did not find any disease on the part of the internal organs, and connected the expressed complaints with constant unrest and tension of the nervous system. He gave appropriate recommendations: medication and psychotherapy. Subsequently, the symptoms described by Beard entered the clinic. "neurasthenia".

In Europe, the problems of neurosis were dealt with by 3. Freud (1895), who developed the theory of psychoanalysis. According to the theory of 3. Freud, the occurrence of neurosis is due to the dissatisfaction of drives and instincts in childhood. 3. Freud denied the importance of external factors for the emergence of neuroses, he transferred the center of gravity to the "sphere of the subconscious", to the uncontrolled realm of primitive instincts and drives. According to 3. Freud, most people suffering from neuroses are born sick, and do not become sick. Freud's follower in Germany was A. Kretschmer, who was a representative of the constitutional genetic theory in psychiatry, also denied the pathogenetic significance of external hazards, believed that all disorders of the neuropsychic sphere are due to congenital mechanisms.

France in the second half of the 19th century. of great importance in understanding the clinic of neuroses was the work of J. Charcot and P. Janet, who developed methods of therapeutic influence in obsessive-compulsive disorder and hysteria.

In domestic literature, the theory of 3. Freud, A. Kretschmer and their followers has not received sufficient distribution. Based on the works of I.P. Pavlov and his school, the problem of neuroses was considered as a breakdown of higher nervous activity due to the influence of social factors on the prepared biological soil.

In 1974, the Canadian endocrinologist G. Selye put forward the theory of stress - emotional overstrain, which underlies the occurrence of neuroses. According to G. Selye, emotional overstrain is due to the growing pace of life, urbanization (urban life), information overload, weakness, which is one of the leading causes of the ever-increasing neurotic and cardiovascular diseases of modern man.

For understanding the mechanism of neuroses, the works of P.K. Anokhin, "On functional systems". PC. Anokhin is a physiologist, student and follower of the works of I.P. Pavlov, believed that functional systems are dynamic, self-regulating organizations, all the constituent components of which interact in order to achieve adaptive reactions useful for the body. Unlike the theory of stress by G. Selye, according to which stress of any origin is caused by an external stimulus, a special stressor, the theory of functional systems by P.K. Anokhin proves that emotional stress develops only in those cases when one or another the dominant behavioral functional system cannot provide an adaptive result vital for the organism.

According to the theory of P.K. Anokhin, emotions as a subject of experience, arose in in the course of evolution as a means of quickly assessing the needs that arise in animals, their satisfaction, as well as assessment of the biological significance of the action of external factors. In evolutionary in terms of these mechanisms proved to be very important in adaptation(fixtures). In humans, emotions play a certain role in assessing not only biological, but also social needs, as well as their satisfaction. Even the biological needs of a person have acquired a socio-emotional coloring.

The clinical picture of neurosis is considered as a psychogenic (conflict) neuropsychiatric disorder, which occurs as a result of a violation of especially significant life relationships of a person and manifests itself in specific clinical phenomena in the absence of psychotic (delusions and hallucinations) phenomena. There are three forms of neurosis: neurasthenia, obsessive-compulsive disorder, and hysteria.

Neurasthenia

The term "neurasthenia" emphasizes rapid exhaustion, weakening of nervous activity, tearfulness, headaches. These conditions are observed in individuals with balanced signaling systems due to overstrain of the main nervous processes. The predominance of the excitatory process over the inhibitory one is noted. Clinical manifestations are characterized by increased excitability, irritability, incontinence, tearfulness.

Predisposing causes: infections, intoxications, excessive physical and mental strain, malnutrition, chronic sleep deprivation, endocrine disorders.

Causing causes: conflict situation at work, in the family, at school, in the children's team, various experiences, loss of loved ones and others. Causing causes can be one-time, strong or not strong, but repetitive, affecting a person.

Parents often "educate" the child, gathering together at the dinner table or at dinner. The reasons for "educational" moments are unsatisfactory grades of the student or the teacher's diary entries about bad behavior at school, the teacher's complaints about the difficulties of the child's behavior in kindergarten. As a reaction to the constant remarks and offensive conversations of the parents, the child develops hiccups, vomiting, refusal to eat, abdominal pain, a feeling of suffocation and other symptoms of a manifestation of a neurotic reaction.

obsessive-compulsive disorder

Obsessive-compulsive disorder develops in people with anxious and suspicious character traits. The development of this form of neurosis is facilitated by overwork, infections, intoxication, constant unrest and worries. Obsessive states can also be in a healthy person, but they do not subjugate his behavior, they are short-lived and easily overcome.

The obsessive states characteristic of neurosis, despite the understanding of meaninglessness and groundlessness, forcibly enter the process of thinking, subjugate and change behavior, and lead to disability. Obsessive states are characterized by affective saturation and manifest themselves in the form of obsessive fears (phobias), obsessive memories, obsessive thoughts. In patients, rituals gradually appear - obsessive actions that are protective in nature, as if protecting a person from danger threatening him or facilitating his speech statement (for example, stuttering).

The dynamics of clinical manifestations is varied. In chronic cases, the disease proceeds for a long time. There are obsessive doubts, indecision, a tendency to mental chewing gum, obsessive memories of names, dates, events, their figurative nature is replaced by an abstract one. The age aspect is of great importance. On the way to school, a schoolboy obsessively remembers whether he took the necessary notebooks or books with him; during a lesson at school, he constantly thinks whether he will be called or not, whether the lesson will be able to answer correctly, whether he will blush, whether they will laugh at him, etc., which constitutes the characteristic basis of “mental chewing gum”. There are obsessive fears of heights, open areas, closed spaces, loneliness, etc. All these experiences make the student indecisive, give reason to feel inferior. Despite the fact that the teenager understands the groundlessness of his thoughts, treats them critically, but cannot cope with his condition. Obsession can turn into an overvalued idea.

It should be noted that the autonomic and affective components of obsessive-compulsive disorder weaken over time. Gradually, the tendency to "mental chewing gum", anxiety and suspiciousness become character traits and begin to determine the neurotic development of the personality. In these cases, medical and psychological and pedagogical assistance is widely used: suggestion, psychotherapy, autogenic training.

Hysteria

Hysteria is one of the most ancient diseases reflected in the literature. Even in ancient Greece, the physician Plato described a disease that was observed only in women. He associated this disease with a dysfunction of the internal organs, in particular, migration or excitation of the uterus, which was the defining term (“hystera” - uterus). In the 17th century there were works pointing to the possibility of hysterical disorders in men. But only in the XIX century. a view of hysteria as a disease of the nervous system that develops under the influence of mental trauma was firmly formed (J. Charcot, Ya. Babinsky, P. Janet).

During the period of study of hysteria, various theories of its origin were created. Some authors explained the symptoms of the disorder by increased affectivity, suggestibility, and infantile personality traits. Others (A. Kretschmer and his followers) believed that hysterical attacks are the result of the release of phylogenetically more ancient mechanisms, and the inhibitory influence of later levels of the psyche is lost. According to 3. Freud, hysteria arises as a result of the suppression of the intensity of affect by the patient and symbolically replaces an action that, due to the suppression of affect, is not realized in behavior.

I.P. Pavlov substantiated and introduced his concept into the theory of the study of hysteria. He believed that in The origin of hysteria is based on two main points:

The weakness of the second signal system and the first signal system is predominant (therefore, hysteria often occurs in people of an artistic type);

Relative weakness of the cerebral cortex, causing external inhibition of the corresponding individuals.

With regard to the "somatic" components found in patients with hysteria, the mechanism of suggestion and self-hypnosis is of great importance. I.P. Pavlov wrote that the remaining symptoms of fear and the temporary security of life due to these components coincide in time and will have to be associated and connected according to the law of conditioned reflexes. Hence, the sensation of various "somatic" symptoms and the idea of ​​them receive a positive emotional coloring and, of course, are repeatedly reproduced.

The clinical manifestations of hysteria are varied and variable. G.K. Ushakov (1973) gives several examples from literary sources, which indicate that hysteria is a "proteus" that takes on an infinite number of different forms, that it is a "chameleon" that constantly changes its colors. J. Charcot wrote that in hysteria, the symptoms of manifestation can resemble any disease and called it "the great malingerer." This understanding of hysteria, as a simulation of a disease, existed in the clinic for a long time, and only the works of I.P. Pavlova proved that hysteria is a kind of functional disease of the nervous system and is a consequence of psychotrauma.

In the clinical picture of hysteria, several conditions are distinguished: hysterical autonomic and sensorimotor disorders; hysterical fit; hysterical personality change. With all the variety of manifestations, they are distinguished by their psychogenic origin, the presence of an element of conditional pleasantness and desirability, as well as the correspondence of the symptom that has arisen to ideas about the disease (the element of self-hypnosis).

Vegetative disorders include: spasms in the throat and loss of voice during excitement (hysterical coma), stomach cramps, belching, nausea and vomiting, hiccups, palpitations, a feeling of heat, swelling and hyperemia, coughing, difficulty breathing (chest tightness) - all symptoms that occur in certain psychotraumatic situations.

Sensorimotor disorders include: feeling of numbness and tingling in the hands, hysterical hypoesthesia or anesthesia (decrease or loss of sensitivity), blindness, narrowing of the visual fields, deafness, paralysis, contractures, mutism and deafness, aphonia, astasia, abasia (inability to walk in the absence of paralysis). Unlike organic paralysis and paresis, hysterical paralysis does not correspond to the localization of the lesion in the nervous system, their symptoms, but reflect the presentation of the patient. In hysteria, patients complain of loss of sensation in the hands of the "gloves" type and on the legs of the "sock" type, which does not correspond to loss of sensitivity when a certain nerve is affected.

hysterical attack always due to a psychogenic conflict situation (refusal to get what you want), a collision of nervous processes (excitation and inhibition) occurs, as a result of which a person complains of pain in the heart area, with the words “I feel bad, I’m dying”, sits down or falls, consciousness is narrowed or absent. Such a state is accompanied by violent motor reactions, sobs, facial expressions and movements correspond to experiences. In clinical and pedagogical practice, it is often necessary to differentiate between a hysterical and an epileptic seizure.

There is a differential diagnosis between a hysterical and an epileptic seizure, which psychologists and teachers need to know in order to provide the necessary assistance (Table 4).

Psychiatry of childhood: A guide for doctors.- M.: Medicine, 1979.- S. 97–110.

Psychogenic diseases (psychogenies) in modern psychiatry include a group of painful conditions causally associated with the action of psycho-traumatic factors, i.e., those in which mental trauma determines not only the occurrence, but also the symptoms and course of the disease (Sukhareva G.E., 1959 ).

In Western countries, Freud's psychoanalysis (Freud S., 1953) had a special influence on the development of the problem of psychogenic diseases, mainly neuroses, including in childhood. One of the reasons for this was the popularity of the theory of development of child sexuality formulated by Freud. According to it, unsatisfied or suppressed due to social (for example, educational) influences at different stages of development (“oral”, “anal”, “genital”), the child’s sexuality, together with its characteristic charge of “psychic energy”, is either “sublimated”, i.e. . manifests itself in higher forms of socially acceptable activity (including scientific creativity, art, social activity, etc.), or sooner or later becomes a source of certain neurotic disorders. At the same time, the latter represent, as it were, symbolic manifestations of the unreacted psychic energy of the "repressed" sexual impulses.

The obvious speculation of Freud's concept, its pansexualism, ignoring the role of social factors and individual consciousness caused its revision and the appearance of various modifications, united by the term neo-Freudianism. Unlike Freud, representatives of neo-Freudianism (Horney K., Fromm E., Sullivan H. et al., cited by Morozov V.M., 1961) explain the occurrence of neurotic disorders not by the pathogenic influence of repressed sexual desire, but by the conflict between the culture of society , "moral self-consciousness" and immanent internal mental forces, called "real inner self" (K. Norney), "compulsive dynamism" (H. Sullivan), etc., which are also based on instincts. At the same time, a special psycho-traumatic role in the origin of neuroses in children (and later in adults) is given to violations of the relationship between mother and child in the first months and years of life, as well as to incorrect methods of instilling neatness skills in the child, which clearly sounds like the influence of Freud's theory of the development of child sexuality. .

However, it should be pointed out that despite the speculative nature and lack of scientific justification for Freud's concept of the origin of neuroses, certain provisions of psychoanalysis, for example, the hypothesis about the role of unconscious experiences in the origin and manifestations of neurotic disorders, as well as those developed by some representatives of the psychoanalytic direction (Freud A., op. . according to Volpert I.E., 1972) provisions on the role of mechanisms of "psychological protection", i.e. psychological compensatory mechanisms in the psychogenesis of neuroses and in their psychotherapy, proved to be productive and are used in the study of the problem of neuroses and the development of psychotherapy issues both in modern foreign and Soviet psychiatry (Ivanov N.V., 1974; Bassin F.V., Rozhnov V. E., Rozhnova M.A., 1974; Karvasarsky B.D., 1975).

Another expression of one-sidedness in the approach to the human personality in norm and pathology, in particular in the interpretation of psychogenic diseases, is the so-called phenomenological direction. According to the views of representatives of this trend, primarily the German psychopathologist and philosopher K. Jaspers (Jaspers K., 1960), the mental is not reducible to the physiological and can only be understood “from itself”. From here it is concluded that the establishment of the essence of psychogenic diseases (as well as the essence of psychopathological phenomena in other mental illnesses) can only be achieved by clarifying "understandable psychological connections" by "feeling into the experiences of the patient" (Morozov V.M., 1961) . It is quite obvious that the criterion of “psychological clarity” proposed by K. Jaspers (1960), which is practically very important for the diagnosis of psychogenic disorders, cannot explain the essence of psychogenic diseases, the elucidation of which requires a natural scientific, physiological or psychophysiological approach.

A reaction to one-sided psychologism and ignoring the natural-scientific, primarily physiological, approach to the study of human behavior in normal and pathological conditions was the emergence in the 30s of the 20th century in the United States of the so-called "behavior science", or behaviorism. (Watson J., Thorndike E. et al., cited by Petrovsky A.V., 1970). The ideas of behaviorism are based on the mechanistic use of the conditioned reflex theory of I.P. Pavlov to explain the origin of complex behavioral acts. Individual acts and actions of a person are considered by behaviorists as a direct conditioned reflex response of the central nervous system to external influences according to the “stimulus-response” principle. At the same time, the role of the personality with its social experience is ignored. Consequently, despite the external physiology and apparent natural-scientific validity, behaviorism also stands on the position of opposing the physiological to the mental and, like the psychoanalytic direction, underestimates the role of the social principle in a person. In this regard, attempts to explain the psychological conflict in neuroses from the standpoint of behaviorism (N. Miller, J. Brown), as well as its psychoanalytic interpretation, lead to a dead end of speculative and theoretically helpless constructions. At the same time, the individual specific methods of treating certain neurotic disorders proposed by representatives of the behavioral direction in psychiatry, based on the conditioned reflex "learning theory", deserve attention and study (Zachepitsky R.A., 1975).

In Soviet psychiatry, the theoretical basis for the study of psychogenic diseases, and above all neuroses, are the teachings of I.P. Pavlov about the physiology and pathology of the higher nervous activity of a person and the materialistic concept of personality, understood from the standpoint of the psychology of relations (Myasishchev V.N., 1960). The synthesis of physiological and psychological approaches to the study of the essence of psychogenic diseases should be facilitated by the psychophysiological studies of neuroses developed in recent years (Karvasarsky B. D. et al., 1974). The methodological positions of Soviet psychiatry in its approach to the problem of psychogenic illnesses are clearly reflected in the understanding of these illnesses in childhood. It is also typical here to use data from the study of the physiology and pathology of the higher nervous activity of the child (Ivanov-Smolensky A.G., 1949; Krasnogorsky N.I., 1958; Kasatkin N.I., 1951), on the one hand, and the results of a study of the psychology of conflict experiences in children with neurotic disorders (Myasishchev V.N., 1960), on the other.

Epidemiology. Although there are no exact data on the prevalence of psychogenic diseases among children and adolescents, some statistical data and the results of selective epidemiological studies indirectly indicate that they are among the most common forms of mental pathology in childhood. Conducted in Moscow in 1931 by E.A. Osipova and S.Ya. Rabinovich, a census of children and adolescents under the age of 18 who suffered from neuropsychiatric disorders showed that the incidence of neuroses, reactive states, as well as cases of character pathology (partly also psychogenic-related) was 22 per 1000 children and adolescents of this age (Kolegova V.A., 1973). According to V.A. Kolegova (1973), patients with neurosis and reactive states accounted for 23.3% of the total number of children and adolescents (up to 17 years old inclusive) observed in psychoneurological clinics in Moscow in the period from 1957 to 1969.

In some modern foreign reports, significantly higher rates of the prevalence of psychogenic diseases in childhood are given. So, selective studies of Bulgarian psychiatrists (A. Bozhanov, V. Ionchev and K. Konstantinov (report at the III Symposium of Child Psychiatrists of the Socialist Countries, October 1973) revealed from 14.8 to 22% of children with neurotic disorders (including unstable neurotic disorders). reactions) among the examined schoolchildren. The same authors cite data from other foreign researchers that are close to the given prevalence rates of neurotic disorders in school-age children (Weber - 20%; Foxey - 17.1%). According to V.F. Desyatnikov (1974 ), the prevalence of neurosis in childhood is highest in boys of school age (7–14 years).

Etiology. Although a common causal factor in psychogenic diseases is one or another psychotraumatic effect, the nature of the latter can be very different. In our opinion, the classification of psycho-traumatic effects should be built taking into account both quantitative criteria (the strength of the impact, its duration, etc.) and the content of the mental trauma. Proceeding from this, we distinguish the following types of traumatic factors: 1) shock mental trauma; 2) psychotraumatic situations of relatively short duration; 3) chronically acting psychotraumatic situations; 4) factors of emotional deprivation.

Shock psychic traumas are characterized by great force and suddenness of action. As a rule, they are associated with a threat to the life or well-being of a person. This includes the situation of natural disasters, a sudden attack on a child by people or animals, etc. In young children, who are characterized by an increased level of "passive-defensive reflex", we can acquire the value of shock herbs any sudden changes in the external environment (suddenly darkness in the room, a sharp sound, for example, the signal of a diesel locomotive or a car, the sudden appearance of a stranger or a large animal, etc.). In view of the direct impact on the instinctive and lower affective spheres, shock factors are not fully realized and, due to the speed of actions, do not cause a conscious intrapsychic processing of their content and meaning.

Unlike shock factors, traumatic situations act on higher, conscious levels of the individual (Braun E., 1928; Krasnushkin E.K., 1948). They can be relatively short-term, although at the same time subjectively strong and significant: a serious illness and death of one of the parents, the departure of one of them from the family, a school conflict with a teacher, a quarrel with comrades, etc. Situational factors are more important for school-age children and adolescents.

Chronically acting psychotraumatic situations include: prolonged quarrels between parents, including those associated with drunkenness of one or both parents; improper upbringing in the form of a contradictory educational approach, parental despotism, the systematic use of physical punishment of the child; constant school failure associated with the low level of the child's abilities, etc.

A special group of psychotraumatic factors are the factors of emotional deprivation, i.e. various unfavorable conditions in which the child is completely or partially deprived of the emotional influences he needs (affection, parental warmth, attention, care). Emotional deprivation usually occurs as a result of the separation of the child from the mother, in cases where the mother, due to mental illness, severe somatic illness, or due to emotional coldness, does not show sufficient warmth and affection towards the child; when raising a child in an orphanage, a week-long nursery or a boarding school, often in cases of long-term treatment in hospitals and sanatoriums, provided that educational work in these institutions is not well organized. Emotional deprivation is especially pathogenic for children of early and pre-preschool age.

The pathogenicity of one or another psycho-traumatic effect (excluding shock factors) depends not only and not so much on its strength and duration, but on the subjective significance of its content for the child. The significance of the impact is determined by the value nature of traumatic experiences for the child's personality, as well as the connection of the traumatic situation with similar experiences from past life experience. As is known, in the etiology of diseases, causative factors always interact to some extent with factors of external and internal conditions. In the etiology of psychogenic diseases, the role of internal conditions, mainly individual personality traits, is especially great (Sukhareva G.E., 1959). In this case, one should keep in mind not only the constitutional properties of temperament and character, but also, as V.N. Myasishchev (1960), the individual history of the development of the child’s personality, the history of his conscious relationships with others, since under the influence of unfavorably developing relationships with others and improper upbringing, features of the so-called neurotic character are formed: individualism, an increased level of claims, a tendency to a predominantly affective way of processing psychotraumatic experiences , traits of infantilism in the emotional-volitional sphere, a tendency to get stuck on conflict experiences.

That is why Soviet psychiatrists, following V.N. Myasishchev (1960) understand a psychogenic illness, primarily neurosis, as “primarily a disease of personality development” (“developmental neurosis”, according to V.N. Myasishchev). It should be emphasized that, unlike Freud and representatives of neo-Freudianism, Soviet scientists attach primary importance in the development of personality to the accumulation and processing of the experience of the child’s conscious relationships with others, and not to the self-development of imaginary stages of “childish sexuality” or the cumulation of early childhood conflicts that arose due to alleged contradictions between the internal (mostly instinctive) needs of the child and the requirements of education. Thus, an important internal condition for the occurrence of the most common psychogenic diseases - neuroses, and possibly a number of reactive states, is the presence of special personality traits, referred to in foreign literature as "(Binder H., 1960) or "neurotic personality structure" (Nissen G., 1974) and resulting from a previous disturbed process of its formation.

Among the personality traits that contribute to the emergence of a neurotic way of responding in children and adolescents, one should also name a number of accentuations and pathological character traits (anxious and suspicious traits, increased inhibition and a tendency to fear, defiantly hysteroid traits; manifestations of mental infantilism). These personality traits not only contribute to the neurotic way of responding in general, but partly determine the "choice" of neurotic symptoms. So, for example, in children and adolescents with anxious and suspicious and other inhibited character traits, with a tendency to fear, neurotic disorders often manifest themselves in the form of phobias or fears with overvalued content, and children and adolescents with demonstratively hysterical radicals are more prone to hysterical reactions. .

An important factor contributing to the emergence of neurotic disorders in children is residual cerebro-organic insufficiency. So, N. Stutte (1960) reports that according to many authors, from 76 to 93% of children with borderline disorders have signs of encephalopathy. R. Lempp (1964) believes that these manifestations are present in about 2/3 of children with neurotic disorders and behavioral disorders. Changes in the psyche associated with such organic insufficiency (inertia, a tendency to “get stuck” on negative affective experiences and short-circuit reactions, affective excitability and lability) can facilitate the appearance of painful reactions to psycho-traumatic effects and contribute to their fixation. In addition, local organic insufficiency can become a source of acquired weakness of individual functional systems of the brain (for example, motor speech, general motor systems, urination regulation systems, etc.), which can lead to the “choice” of one or another selective response method in case of a psychogenic illness in the form so-called systemic neurotic disorders (Myasishchev V.N., 1966).

An important internal condition in the etiology of neurosis in young children is a neuropathic condition (congenital or acquired). The importance of somatic weakness in children (often ill, who have undergone a "chain" of infections), which contributes to the emergence of reactive states and neurotic reactions, mainly with an asthenic component, is well known.

The age factor in the etiology of psychogenic diseases acts in two directions: firstly, in terms of a general non-specific "increased vulnerability" of the neuropsychic sphere during transitional age periods (von Stockert F., 1966), and secondly, as a more specific etiological factor in the occurrence some reactive states of puberty (such as anorexia nervosa, reactive dysmorphophobia, etc.) with its disharmonious course (Sukhareva G.E., 1974).

A certain role in the etiology of psychogenic diseases in children and adolescents also belongs to external factors, such as unfavorable microsocial and living conditions, undeveloped relationships in the peer group (the position of the child in the role of a loner), inconsistency of the profile of the school (for example, with teaching in a foreign language) to inclinations and child's abilities, etc. Such factors, being a source of constant emotional stress, facilitate the emergence of a psychogenic illness under the influence of various more defined mental traumas.

Thus, the etiology of psychogenic diseases has a complex, multidimensional character. Despite the importance of the named factors in it, the leading role is still assigned to the main causal factor (“leading cause”, according to O.V. Kerbikov, 1972) - a psycho-traumatic effect.

Pathogenesis. Actually, the pathogenesis of most psychogenic diseases, with the exception of affective-shock reactions and reactive states that occur according to the “short circuit” mechanism, is preceded by the stage of psychogenesis, during which the personality processes psychotraumatic experiences. The stage of psychogenesis begins from the moment of the emergence of a complex of psycho-traumatic experiences, charged with more or less intense negative affect (fear, anxiety, indefinite anxiety, discontent, resentment, a sense of insecurity, affective tension). The personality responds to this with the formation of psychological / compensatory mechanisms (“mechanisms of psychological defense”, in the terminology of Western psychotherapists), such as “withdrawal” from psycho-traumatic experiences, suppression of them by various activities, switching, direct resistance to a psycho-traumatic situation (Ivanov N.V. , 1974). The ability of a person to form psychological defense mechanisms and their effectiveness depend on the individual characteristics of the person, the degree of his maturity. With sufficient efficiency of these mechanisms, the personality overcomes the affective tension associated with psycho-traumatic experiences, and psychogenic disorders do not arise. At the same time, in the case of the presence of the unfavorable personality traits described above (Myasishchev N.V., 1960) or the so-called neurotic character (Binder N., 1960), the ability of the individual to compensate and overcome psychotraumatic experiences is insufficient.

With a significant strength and persistence of the negative affect that accompanies psycho-traumatic experiences, and at the same time, the weakness of the mechanisms of psychological defense, a psychological “breakdown” occurs with the occurrence of painful psychogenic manifestations. The intimate psychological essence of such a “breakdown” has not yet been disclosed. Its physiological correlate, apparently, can be considered established by I.P. Pavlov and his collaborators in experimental neurosis, variants of a “breakdown” of higher nervous activity as a result of “overstrain of nervous processes” or their “collision”. The moment of "breakdown" thus becomes the transition from psychogenesis to the proper pathogenesis of neuroses and reactive states. In childhood, due to the immaturity of the personality and the lack of psychological defense mechanisms, the stage of psychogenesis is reduced. Therefore, in young children, psychogenic disorders occur as a direct reaction to a traumatic effect. Only after 8-10 years of age, as the personality matures and the ability to form psychological defense mechanisms develops, the stage of psychogenesis gradually becomes more and more outlined.

With the beginning of the pathogenesis stage, along with the psychological mechanisms mentioned above, pathobiological (pathophysiological) mechanisms come into force. The initial dynamics of psychogenic diseases, primarily neuroses, is thus an example of the regularity of the transition of the social through the stage of the individual psychic (first the socio-psychic, and then the natural-psychic) ​​into the pathobiological (Kovalev V.V., 1973, 1975).

The studies of experimental neuroses initiated by I.P. Pavlov and continued by his students (Petrova M.K., 1941; Birman B.N., 1939; Anokhin P.K., 1956, etc.), as well as research by Soviet scientists in the field of pathophysiology of higher nervous activity in neuroses and others. psychogenic diseases (Ivanov-Smolensky A.G., 1952; Faddeeva V.K., 1948; Seredina M.I., 1947; Yakovleva E.K., 1969, etc.) established the main types and forms of disorders of higher nervous activity in psychogenic diseases. These include the weakening of the strength of the main nervous processes, the violation of their mobility (in the form of pathological inertia and lability), the occurrence of foci of congestive excitation (“sick points” according to I.P. Pavlov), the phenomena of negative and positive induction, the phase states of cortical activity (phenomena leveling, paradoxical and ultraparadoxical phases), violations of the inductive relations of the cortex and subcortical formations, pathological changes in the balance of the first and second signal systems, etc.

A special place in the study of the pathogenesis of neuroses and other borderline conditions belongs to the teachings of I.P. Pavlov about the general types of higher nervous activity (balanced, strong and weak) and about "human types" based on ideas about the correlation of signal systems ("thinking", "artistic" and "average" types). Development by I.P. Pavlov and his school of pathophysiology of neuroses is of great methodological importance for creating a materialistic concept of psychogenic diseases as opposed to psychoanalytic and some other idealistic trends that tried to consider neuroses and reactive states one-sidedly, in the light of only psychological concepts and in isolation from the biological substrate.

Psychogenic diseases, primarily neuroses, are accompanied by changes not only in brain activity, but also by functional changes in other body systems. Certain changes in a number of biochemical indicators have been established: an increase in the content of pyruvic acid, ATP and calcium in the blood with a simultaneous decrease in the amount of lactic acid in it, reduced excretion of phosphates in the urine, fluctuations in blood sugar levels (Kreindler A., ​​1963; Mittelstedt A.A. and others, 1958; Birkengov N.A. et al., 1954, etc.). In the last 10–15 years, new data on the problem of the pathogenesis of neuroses and reactive states have been obtained in physiological and biochemical studies of emotional stress states in animal experiments and in clinical practice. Certain relationships have been established between the nature of emotional stress (acute and chronic) and the functional activity of the hypothalamus - pituitary - adrenal glands, as well as the activity of the thyroid gland (Bakhur V.T., 1974; Karvasarsky B.D., 1974, 1976).

Some differences in the electrical potentials of the cerebral cortex and the anterior parts of the brain stem were found in different neuroses (Bobkova V.V., 1974). An important role in the pathogenesis of neuroses of changes in the functional state of non-specific systems of the brain, primarily the limbic-reticular complex, has been established (Vane A.M., Rodshtat I.V., 1974; Gekht B.M. et al., 1974, etc.).

However, information about the pathogenesis of psychogenic diseases is still rather fragmented; the mechanisms of the pathogenic influence of psychotraumatic experiences on the functional state of the brain systems remain unclear. This is obviously due to the enormous complexity of studying the essence of phenomena that are at the intersection of the social and biological. Almost completely unexplored features of the pathogenesis of psychogenic diseases in children and adolescents.

Systematics. Creating a taxonomy of psychogenic diseases in childhood is associated with particular difficulties due to the rudimentary nature and great variability of their manifestations in children. When constructing the classifications of psychogenic diseases, the etiological criterion was used (based on the content of mental trauma - Kraepelin E., 1913; based on the leading role of the external situation or constitution - P.B. Gannushkin, 1933; the predominant level of personal response - Krasnushkin E.K., 1948 Zurabashvili A.D., 1970, the pathogenetic criterion of the rate of development and duration of the disease (Sukhareva G.E., 1959) and some others. classification of psychogenies using the syndromic principle, which is probably due to the fact that, given the current state of knowledge about the etiology and pathogenesis of psychogenic diseases, the clinical descriptive principle better meets the needs of clinical practice.

Usually in adults (psychogenic illnesses are traditionally divided into two main groups: reactive states and neuroses. The term "reactive states" mainly refers to reactive psychoses: affective-shock, hysterical, reactive paranoid and reactive depression (although the latter is often found in a non-psychotic form) The main criteria for reactive states are 3 features identified by K. Jaspers (1960): 1) the determining role of the psychotraumatic factor in the onset, clinical features and course of the disease; 2) a psychologically understandable connection between the traumatic situation and the content of the reaction; 3) the fundamental reversibility of the disease. The term "neuroses" is commonly used to refer to non-psychotic forms of psychogeny. As G.E. Sukharev (1959), the division into psychotic and non-psychotic forms of psychogeny is very conditional, especially in childhood, since, on the one hand, at different moments the same psychogenic reaction in one patient can appear either in a psychotic or in a neurotic form, and on the other hand, reactive states, such as depression and even affective-shock reactions in children, often manifest as non-psychotic disorders.

To date, there is no generally accepted definition of neurosis. The most complete of those proposed by Soviet psychiatrists (Krasnushkin E.K., 1934; Gilyarovsky V.A., 1942; Gurevich M.O., 1949; Kerbikov O.V., 1961, etc.) can be considered the definition of V.A. Gilyarovsky (1942): "Neurosis is a painfully experienced and manifested mainly by emotional and somato-vegetative disorders, a breakdown of the personality in its relations with others, characterized by its active desire to overcome and compensate for these disorders." O.V. Kerbikov (1961) emphasized such an important quality of neuroses, especially for distinguishing from psychopathy, as their partiality in relation to the personality. In child psychiatry, the division into reactive states and neuroses is even more arbitrary. In our opinion, the reactive state differs from neurosis by a more acute onset, a more distinct connection between painful experiences and a traumatic situation, as well as the frequent absence of experiencing disorders as alien, painful. An unconditional (but not mandatory in childhood) sign of a reactive state is the presence of psychotic disorders (clouded or affectively narrowed consciousness, distinct and persistent perception disorders, delusions, pronounced affective disorders, in particular, depression with suicidal intent). However, these distinguishing features are important only in a static sense, since in the dynamics of psychogenic diseases it is possible to change psychotic states into neurotic ones and vice versa.

It follows from the foregoing that in childhood the reactive state can manifest itself as psychotic and neurotic disorders. Of course, the boundary between neuroses in the proper sense of the word and neurotic forms of reactive states is even more arbitrary.

The questions of the grouping of neuroses are also among the unresolved. The most commonly used clinical-descriptive principle (Gilyarovsky V.A., 1938; Gurevich M.O., 1949; Davidenkov S.N., 1963; Svyadoshch A.M., 1971; Jaspers K., 1960, etc.). The main forms of neurosis included in most classifications are neurasthenia, hysterical neurosis, and obsessional neurosis. In a number of classifications, psychasthenia (Jaspers K., 1960; Davidenkov S.N., 1963) and fear neurosis (Gilyarovsky V.A., 1942; Svyadoshch A.M., 1971) are also classified as independent forms of neuroses. Currently, psychasthenia is considered by most psychiatrists as a variant of psychopathy. In the 50-60s of the XX century, neurotic depression or depressive neurosis began to be attributed to the number of independent forms of neurosis (Lakosina N.D., 1965; Voelkel N., 1959 and others), which is currently distinguished among neuroses of childhood (Nissen G., 1974).

A special group of neuroses in a number of classifications are the so-called. neuroses of organs ("neurosis of the heart", "neurosis of the stomach", etc.) and motor neuroses. V.N. Myasishchev (1966) pointed out the fundamental fallacy of this designation by proposing the term "systemic neurosis". In the classification of G.E. Sukhareva (1959) neuroses in children and adolescents (neurasthenia, hysterical neurosis, anxiety neurosis and obsessional neurosis) are considered as varieties of subacute and prolonged psychogenic reactions. In a number of classifications, neurotic reactions of childhood are distinguished: tics, enuresis, stuttering, appetite disorders, etc. (Gilyarovsky V.A., 1938; Davidenkov S.N., 1963). In the classification of G.E. Sukhareva, they are called monosymptomatic neuroses and are included in the group of psychogenic reactions observed mainly in childhood. G. Nissen and P. Strunk (1974) subdivide neurosis in childhood into two groups: "psychogenic disorders with predominantly mental symptoms" and "psychogenic disorders with predominantly somatic symptoms." In French literature, the grouping of neuroses in children traditionally has a purely symptomatic character (de Ajuriaguerra J., 1970). The currently existing WHO International Classification of Diseases (ICD) (8th revision) includes all of the above main forms of neurosis, but essentially does not reflect the age-related forms of childhood neurotic reactions or classifies them as an amorphous group of specific unclassified symptoms. Taking into account the needs of everyday practice of child psychiatry, in 1974 we proposed a working classification of psychogenic diseases in children and adolescents, built on the basis of the clinical and psychopathological principle, taking into account the supplemented and adapted nomenclature of the WHO ICD of the 8th revision for childhood. Psychogenic illnesses in children and adolescents are divided into three main groups: 1) reactive psychotic states; 2) neuroses and neurotic forms of reactive states; 3) personal (characterological and pathocharacterological) reactions.

Each of these groups combines the corresponding psychogenic diseases, identified mainly on a syndromic basis. In addition, the group of neuroses is divided into two subgroups: the so-called general neuroses ("psychoneurosis") and systemic neuroses (in the understanding of Myasishchev V.N., 1966). The "general" neuroses include psychogenic diseases of the neurotic type, the clinical picture of which is dominated by mental disorders (mainly emotional - fear, anxiety, irritability, emotional lability, etc.). The group of reactive psychotic states includes: affective-shock reactions (hyperkinetic - 298.1.1) and stuporous variants (298.94), hysterical psychoses (298.1.2), psychotic variant of reactive depression (298.0), reactive paranoid (298.3). In the group of neuroses and neurotic forms of reactive states, the subgroup of "general" neuroses includes: fear neurosis (ICD code - 8 - 300.0); hysterical neurosis (300.1), two variants of obsessional neurosis - obsessional neurosis (300.2) and neurosis of obsessive fears, or phobic (300.3); depressive neurosis (300.4); neurasthenia or asthenic neurosis (300.5); hypochondriacal neurosis (300.7); nervous (mental) anorexia of pubertal age (306.52), as well as neurosis undifferentiated according to the psychopathological syndrome (300.9). The subgroup of systemic neuroses combines the following forms: neurotic stuttering (306.01); neurotic tics (306.2); neurotic sleep disorders (306.4), neurotic lack of appetite (306.51); neurotic enuresis (306.6); neurotic encopresis (306.7); and pathological habits of childhood (finger sucking, nail biting, lactation, masturbation, trichotillomania) (306.9). The third group includes a variety of personal reactions (characterological and pathocharacterological reactions, according to our terminology, 1969, 1973), the common clinical feature of which is a variety of behavioral disorders associated with transient changes in the emotional and volitional state of a child or adolescent (reactions of protest, refusal, imitation and etc.). In order to statistically account for these reactions, it is proposed to use ICD codes 8 - 308.1 ("Violations of behavior in childhood" - for children up to 14 years old inclusive) and 307.1 ("Transient situational disorders" - for adolescents 15–17 years old).

It is known that, along with the term "neurosis", the term "neurotic reaction" is used to designate psychogenic diseases characterized by neurotic disorders. Often these terms are used as synonyms, which cannot be considered correct. In our opinion, the term "neurotic reaction" should be used only to designate neurotic forms of reactive states. The term "neurotic reactions" (rather than "neurosis") should also refer to neurotic disorders in young children (up to about 6-7 years old), since they more closely meet the above criteria for neurotic reactive states, usually arising as an immediate or short-term reaction to circumstances. causing a negative effect on the child.

A number of authors point to significant differences in neurotic disorders in young children from the manifestations of outlined neuroses (Gilyarovsky V.A., 1938; Simeon T.P., 1958; Myasishchev V.N., I960; van Krevelen D.A., 1968). The main distinguishing features of neurotic disorders in early childhood are the absence or insufficient severity of consciousness and the child's experience of these disorders (van Krevelen D.A., 1968), their low psychopathological differentiation, pronounced variability, the predominance of somato-vegetative and motor disorders. That's why D.A. van Krevelen (1968) distinguishes between "childish neuroses" under the age of 6 and "true neuroses in children".

Source of information: Aleksandrovsky Yu.A. Borderline psychiatry. M.: RLS-2006. — 1280 p.
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21.1. General diagnostic criteria. Systematics of psychogenic disorders

Although the possibility of a mental disorder as a result of a traumatic event is recognized by most psychiatrists, the allocation of psychogenic diseases to an independent group causes some controversy and the systematics of these diseases differ significantly depending on the traditions of one or another psychiatric school.

In domestic psychiatry, the diagnosis of psychogenic diseases is traditionally based on a statement of a close relationship between a traumatic event, on the one hand, and the course and clinical manifestations of a mental disorder, on the other. This relationship is expressed most clearly in triad K. Jaspers (1910):

psychogenic illness develops immediately after exposure to psychotrauma;

manifestations of the disease directly follow from the content of psychotrauma, there are psychologically understandable connections between them;

the course of the disease is closely related to the severity and relevance of psychotrauma; resolution of psychotrauma leads to the cessation or significant weakening of the manifestation of the disease.

Although these criteria have not lost their significance to date, their application is sometimes associated with some difficulties. The connection between a traumatic event and a mental disorder is most clearly seen in reactive psychoses. In mild non-psychotic disorders (neurosis), as a rule, psychotrauma exists for a long time, which makes it impossible to accurately correlate the disease and the existing pathogenic situation in time. The patient himself is not always able to realize the connection of existing disorders with psychotrauma, since neuroses are usually actively used psychological defense mechanisms(see Section 1.1.4 and Table 1.4), which involve the involuntary displacement of emotionally unpleasant information from a person's consciousness in order to maintain mental balance. The use of defense mechanisms also leads to the loss of psychologically understandable links between psychotrauma and manifestations of the disease.

Attention is drawn to the fact that not all people develop psychogenic diseases in the same situation. This testifies to the significant role of individual personality traits, traits of the innate psychophysiological constitution (temperament) in the development of psychogeny. The involvement of hereditary factors (perhaps through personality) is confirmed by genealogical research and analysis of the incidence of neuroses in twins. This once again emphasizes the conventionality of the boundary between endogenous and psychogenic diseases.

Unlike endogenous diseases, neuroses and reactive psychoses never arise and do not progress against the background of psychological well-being. The absence of any organic changes in the brain determines the favorable prognosis characteristic of this group of diseases. The leading role of psychological discomfort in the genesis of patients' complaints allows us to count on the high efficiency of psychotherapeutic methods. All this confirms the practical importance of separating these diseases into an independent group.

Particular attention in the diagnosis of psychogenic diseases should be given to premorbid personality traits sick (see chapter 13). In psychogenies, morbid disorders follow directly from characterological traits that existed before the illness. The prolonged existence of the disease leads to the aggravation and sharpening of these features. With progressive endogenous diseases (schizophrenia, epilepsy), on the contrary, there is a transformation of the personality, the loss of individual differences, the acquisition of character traits that have never been traced before.

The classification of psychogenies also causes some difficulties. In Russian psychiatry, it is customary to single out severe disorders with a pronounced behavioral disorder. (reactive psychoses) and soft states without loss of criticism (neurosis). However, it should be borne in mind that there is no sharp line between these diseases. Thus, the term "hysteria" usually denotes both hysterical neurosis and hysterical reactive psychoses, since the development of these diseases is based on similar psychological mechanisms. Even more difficult is the clear separation of neuroses from pathological character traits - psychopathy (see chapter 22), since neuroses are often a manifestation of the decompensation of psychopathy and are observed in psychopathic individuals much more often than the average in the population. In practice, a connection is almost constantly found between hysterical psychopathy and hysterical neurosis and psychasthenia (anxious and suspicious personality) with obsessive neurosis.

In the past, terms describing the essence of a psycho-traumatic situation were repeatedly proposed to designate psychogeny: “prison psychosis”, “railroad paranoid”, “wartime psychoses”. Quite often, the term "iatrogenic" is used, meaning a mental disorder that arose as a result of careless, psychologically unjustified statements by a doctor. In most cases, the specific content of a traumatic situation, although it is of some importance for psychotherapy, does not in itself determine the course and prognosis of the disease and should be considered only in comparison with the patient's personal characteristics.

The term "borderline disorders" is often used to refer to neuroses. The content of this term is not entirely clear, since it can mean disorders that are on the border between psychoses and neuroses, or on the border between illness and mental health. To designate mild short-term psychologically understandable disorders closely related to an obvious psychotraumatic situation, it is more justified to use the term "neurotic reactions". Although the advice of a doctor and the occasional use of psychotropic drugs is often useful for people with neurotic reactions, these phenomena are not considered pathological. Usually neurotic reactions are short-lived (several days) and disappear without special treatment.

In ICD-10, the systematics of psychogeny is based on the identification of a leading syndrome. At the same time, severe psychotic reactive depressions are classified as affective psychoses, and reactive paranoids are considered together with schizophrenia and other delusional disorders. Most of the other psychogenic illnesses are assigned to the class (“neurotic, stress-related and somatoform disorders”). The symptoms observed in hysterical psychosis and hysterical neurosis are included in several subgroups ("dissociative/conversion disorders", - "somatoform disorders"). Various manifestations of obsessional neurosis are included in the subgroups , and . The subgroup contains severe psychotic and mild neurotic reactions to severe acute stress.

21.2. Reactive psychoses

21.2.1. Clinical variants of reactive psychoses

Among reactive psychoses, there are short-term disorders that last several hours or days (affective-shock reactions, hysterical psychoses) and protracted states that last weeks and months (reactive depression and reactive paranoid).

Reactive psychoses are relatively rare in clinical practice. Although it is rather difficult to obtain accurate data on the prevalence due to the short duration and tendency to spontaneous resolution, the number of such patients is ten times less than those with schizophrenia and TIR. Reactive depression is somewhat more common. The frequency of reactive psychoses can increase during periods of mass disasters (war, earthquake, etc.).

Affective-shock reaction (acute reaction to stress) develops as a result of an extremely strong simultaneous psychotrauma. The subject is a direct participant or witness of tragic events (catastrophes, shipwrecks, fires, murders, acts of severe violence, etc.). The strength of the psychotraumatic factor is such that it can cause a mental disorder in almost any person. Observed either reactive stupor(inability to move, answer questions, inability to take any action in a life-threatening situation, “imaginary death reaction”), or reactive excitation(chaotic activity, screaming, throwing, panic, "flight reaction"). In both cases, psychosis is accompanied by clouding of consciousness and subsequent partial or complete amnesia. Random activity or inadequate inactivity in this case is often the cause of death: for example, an excited patient can jump out of a window during a fire. It is affective-shock reactions that cause dangerous panic in crowded places during disasters. Such psychoses are very short-lived (from several minutes to several hours). Special treatment is usually not required. In most cases, the cessation of a dangerous situation leads to a complete restoration of health, however, in some cases, the events experienced continue to disturb the patient for a long time in the form of obsessive memories, nightmares, this may be accompanied by sadness about the death of loved ones, loss of property and housing. The term " post-traumatic stress disorder » (post-traumatic neurosis),

In situations of significant threat to the patient's social status (litigation, mobilization into the army, a sudden break with a partner, etc.), hysterical psychoses. According to the mechanism of occurrence, these disorders do not differ from other hysterical phenomena (functional reversible mental disorders based on self-hypnosis and the conversion of internal anxiety into vivid demonstrative forms of behavior), however, the degree of severity reaches a psychotic level, criticism is sharply impaired. A history of organic brain damage, demonstrative personality traits (see section 13.1) predispose to the onset of hysterical psychoses. Clinical manifestations of hysterical psychosis are extremely diverse: amnesia, psychomotor agitation or stupor, hallucinations, confusion, convulsions, thought disorders. Quite often, in the picture of the disease, the features of mental regression clearly appear - childishness, foolishness, helplessness, savagery. The following conditions are most often distinguished.

Puerilism manifested in childish behavior. Patients declare that they are “still small”, call others “uncles” and “aunts”, play with dolls, ride a stick, roll boxes on the floor like cars, ask to be “handled”, whimper, suck a finger, stick out their tongue . At the same time, they speak with a childlike intonation, making funny faces.

Pseudo-dementia - this is an imaginary loss of the simplest knowledge and skills. Patients give ridiculous answers to the most elementary questions ("twice two - five"), but usually in terms of the question being asked (mimic answers). Patients demonstrate that they cannot dress themselves, eat on their own, do not know how many fingers are on their hands, etc. Attention is drawn to the loss of those skills and knowledge that are so strong that, according to Ribot's law, they must be preserved even with very deep dementia.

Hysterical twilight disorder(hysterical fugue, hysterical trance, hysterical stupor) occurs suddenly in connection with psychotrauma, accompanied by disorientation, absurd actions, sometimes vivid hallucinatory images that reflect a traumatic situation. After the psychosis has passed, amnesia is noted. Disorientation is usually observed: patients cannot tell where they are, they confuse the season.

A 31-year-old patient, a junior researcher, was brought by relatives to a Moscow psychiatric clinic for examination after suffering a psychosis.

From childhood, he was distinguished by sociability, danced in a children's ensemble, and participated in amateur performances at the institute. He was successful with women. He married a classmate, the daughter of wealthy parents. They live in an apartment bought with the money of the wife's parents, they have a 9-year-old son. In recent years, his wife repeatedly reproached him for windiness, inattention to the family, and threatened him with divorce. In this situation, he always apologized, swore allegiance, but did not change his behavior. Having received accurate evidence of infidelity, the wife made a scandal and demanded a divorce. After that, the patient got dressed, slammed the door and disappeared for a month. The wife found out that he did not appear either at work or with his parents, but she could not find him.

The patient himself subsequently could not remember how he ended up at the station in Tambov. He approached the station attendant and began to ask strange questions: “What kind of city is this?”, “What number?”. Since the patient could not give his name and address, a psychiatrist was called, and the patient was taken to the regional psychiatric hospital, where he was kept for a month under the name "Unknown". All this time he could not remember his name, profession, place of residence. He was surprised looking at the engagement ring: “After all, there is a wife somewhere! Maybe even children... About a month later, he asked to be given a phone, because "the finger itself wants to dial some number." Since the number turned out to be seven digits, they began to call Moscow and quickly found the patient's wife. He was glad to see his wife, listened with interest to information about himself, asked for forgiveness for misconduct, which he does not remember at all.

No mental disorders were found in the Moscow psychiatric clinic. The patient is well adapted in the department, willingly communicates with neighbors in the ward. He thanks the doctors for "returning his memory."

At Ganser's syndrome All of the disorders listed above can occur at the same time. Helplessness in answering the simplest questions, the inability to correctly name parts of the body, to distinguish between the right and left sides, is combined in these patients with childishness and disorientation. The answers, although incorrect, testify that the patient understands the meaning of the question asked (mimicry, passing). Hallucinations may occur. The syndrome was first described by S. Ganzer (1898) in a situation of trial, but it can also occur as a result of other psychotraumas. Similar to Ganser's syndrome manifestations has a syndrome of "savagery", manifested by animal behavior. The patient walks on all fours; lapping food from a plate; howls like a wolf; shows his teeth, tries to bite.

Typical delirium in hysterical psychosis rarely develops - more often observed delusional fantasies(see section 5.2.1), in the form of bright, absurd, emotionally colored statements that are very changeable in plot, unstable, easily overgrown with new details, especially when the interlocutor shows interest in them.

Hysterical psychoses are usually short-lived, closely related to the urgency of the traumatic situation, always end in complete recovery, and can disappear without special treatment. Reactive depression and reactive paranoid tend to last longer, often requiring psychiatric intervention.

Symptoms reactive depression fully corresponds to the concept of "depressive syndrome" (see section 8.3.1), which is manifested by a pronounced feeling of melancholy, helplessness, sometimes lethargy, often suicidal thoughts and actions. In contrast to endogenous depression, all experiences are closely related to the past psychotrauma. Usually, the causes of reactive depression are situations of emotional loss - the death of a loved one, divorce, dismissal or retirement, moving from one's home, financial collapse, a mistake or misconduct that can affect the rest of one's life. Any reminder of a traumatic event or, conversely, loneliness, predisposing to sad memories, increase the acuteness of the patient's experience. The ideas of self-accusation, self-abasement reflect the existing psychotrauma. Patients blame themselves for the death of a loved one, for sluggishness, for not being able to save their families. Although such conditions can be prolonged, sometimes ending in suicide, timely medical attention leads to a complete recovery. Repeated attacks of depression in such patients usually do not occur.

A 32-year-old patient, civil engineer, was admitted to the clinic after an unsuccessful attempt at self-hanging.

Heredity is not burdened. Grew up in an intelligent family. The father was distinguished by strictness, completely controlled the entire family life. Died of myocardial infarction. Mother is simple, sincere, caring. The elder sister is active, active. After the death of her father, she took all the initiative in the family into her own hands. The patient himself was always very obedient, attached to his mother, studied well. Graduated with honors from the institute. By distribution, he worked at a construction site as a foreman. Married, had a daughter.

He was seen by his superiors as a responsible and quick-witted specialist. A year after graduation, he was appointed first as an engineer, and then as deputy head of the construction department. He was pleased with his career growth, but he was constantly anxious when it was necessary to make a responsible decision, he was often forced to consult with his boss. However, he did not always understand his uncertainty, sought to promote him. During his studies at the Academy of National Economy, he assigned him the responsibility of managing the entire department. This caused great anxiety in the patient, but he did not dare to object to the boss. In the very first days, I felt that I was completely unable to cope with the leadership. He was afraid of any deviation from the law, showed unnecessary stubbornness, intractability. I could not do anything at home, because I was constantly thinking about my behavior at work. The dream is broken. The wife gently reproached the patient for avoiding intimacy with her. He did not take care of the child and housework. After the next salary, construction workers came in a crowd to his office with accusations, since the earnings turned out to be much less than under the previous boss. I couldn't sleep that night, I smoked a lot. The wife was worried, watched him. I noticed how he took the rope and closed himself in the bathroom; screamed and demanded to open the door.

Upon admission, the patient is depressed; blames himself for not being able to do his job; calls himself "impotent", regrets that his wife got in touch with such a "useless person." closed. He does not seek a meeting with a doctor, does not see any prospects in life. After treatment with antidepressants and psychotherapeutic conversations with the doctor, my mood improved significantly, I felt the “taste of life”. I intend to find myself a more suitable place of work, not associated with high responsibility. Over the next 10 years of observation of such attacks did not recur.

As already indicated, severe psychotic reactive depression in the ICD-10 is referred to as a single depressive episode. Less severe states of depression, closely related to stress, are sometimes referred to as "depressive neurosis",

Jet paranoid - delusional psychosis that occurs as a reaction to psychological stress. Such nonsense is usually unsystematized, emotionally saturated (accompanied by anxiety, fear), occasionally combined with auditory deceptions. In typical cases, the onset of psychosis is facilitated by a sudden change of scenery, the appearance of a large number of strangers (military operations, long journeys through unfamiliar areas), social isolation (solitary confinement, a foreign language environment), increased human responsibility, when any mistake can cause serious consequences. An example of a reactive paranoid can be “railroad paranoids”, which often arose in previous years, when train trips lasted many days, were associated with a constant fear of falling behind the train, losing things, and being the prey of bandits. Social isolation is probably the cause of the appearance of delirium in the deaf, which begins to seem that people are hiding something from them, plotting evil, discussing them among themselves. Reactive paranoids also include induced delusions that occur in primitive individuals who permanently live with the mentally ill and blindly believe in the justice of his judgments (see section 5.2.1). Especially often reactive paranoids were observed in wartime.

A 29-year-old patient, an artillery officer, was admitted to a psychiatric clinic due to misbehavior and fear of persecution.

Heredity is not burdened. Born in the Moscow region in the family of a professional military man. He studied at the middle school, in the senior classes he decided to enter the military school. In the last years of his studies at the school, he married. He was assigned to serve in Germany, where he lived with his wife and child. He received a good salary, worked a lot around the house, and tried to free his wife from unnecessary worries.

After the collapse of the Warsaw Pact, he was transferred to serve in Georgia, where he participated in hostilities. The wife at that time lived in the suburbs with her parents. I could not contact my wife: she had no information about him for about 3 months. His arrival on vacation was greeted coldly by his wife; blamed him for abandoning them. Friends and neighbors hinted to the patient that his wife was not really waiting for him, that she had another. While walking with his son, he met his wife and her lover. There was a fight in which the lover severely beat the patient. He went to live with his parents. He was depressed, did not sleep, experienced the injustice of the situation. He began to notice that people on the street were paying attention to him. He left his city for Moscow to live with his aunt, until "the rumors subside in the city." However, in the train I noticed people whom I considered friends of my wife's lover. He decided that they would pursue him in Moscow as well. I was driving from the station, confusing the road, trying to break away from my pursuers. Aunt immediately noticed his ridiculous behavior and statements, insisted on treatment by a psychiatrist.

The clinic is confused, suspicious of other patients. Finds that they look like one of his relatives. He treats doctors with boundless trust, seeking salvation from his persecutors. He blames himself for not holding back and getting into a fight (“I should have just gotten away from her”). He admits that he continues to love his wife and is ready to forgive her betrayal. Thoughts about persecution against the background of treatment with neuroleptics gradually deactivated within 9-10 days. In the future, he was surprised at the absurdity of his fears, expressed his intention to leave the army, reconcile with his wife and settle down together ("It's my fault that I left her for three months without a livelihood. What else could she do?"). At discharge, no maintenance treatment was prescribed; during the next 9 years of observation, he did not apply to psychiatrists.

In most cases, with reactive paranoid, the delusion is unstable, responds well to treatment with psychotropic drugs (neuroleptics and tranquilizers); disappears without treatment if the traumatic situation is resolved.

21.2.2. Etiology and pathogenesis of reactive psychoses

Although psychotrauma is an obvious and main cause of reactive psychoses, it remains not entirely clear why only a small number of victims develop psychoses in similar pathogenic situations. Factors contributing to the development of psychosis include increasing fatigue, constant stress, concomitant somatic diseases, past head injuries, lack of sleep, intoxication (including alcoholism).

The very nature of a traumatic event to some extent determines the nature of mental disorders: a life-threatening catastrophe - affective-shock reactions; a situation of emotional loss - reactive depression; an uncertain situation that suggests a possible threat in the future - reactive paranoids.

Premorbid personality traits and the established system of life values ​​may be important for the formation of a psychotic reaction. It is assumed that psychosis occurs when the most important, key needs for the individual are infringed ("key experience" according to E. Kretschmer, 1927). It is possible to trace a noticeable correlation of prolonged reactive paranoids with stuck (paranoid) personality traits of the patient, which are manifested by a tendency to form overvalued and paranoid ideas. Reactive depression can develop in any type of personality, but it occurs more easily in pedantic and dysthymic individuals who are initially prone to low self-esteem, pessimism, who prefer to take responsibility for any failures in a stressful situation. It is believed that the likelihood of affective-shock reactions depends little on the personality characteristics of the individual.

21.2.3. Differential Diagnosis

Diagnosis of affective-shock reactions and hysterical psychoses usually does not present great difficulties. Sometimes such psychoses disappear before the patient gets to the doctor, and the diagnosis has to be carried out according to the anamnestic data (for example, during a forensic psychiatric examination).

Much more difficult is the diagnosis of reactive depression and reactive paranoid, since, as is known, psychotrauma can provoke the occurrence of endogenous psychoses (MDP and schizophrenia). The triad of K. Jaspers is of primary importance for differential diagnosis. Reactive psychoses are characterized not only by their occurrence after a psychotrauma, but also by a close connection with a traumatic event in all manifestations of the disease. All thoughts of the patient are concentrated on the traumatic event. He constantly returns in conversation to the same topic that bothers him. On the contrary, a distinct hereditary burden, autochthonous (not dependent on the relevance of experiences) nature of the course of the disease, noticeable rhythm, periodicity of symptoms, the appearance of atypical symptoms not associated with psychotrauma (for example, mental automatism, catatonia, mania) testify against reactive psychosis.

It should be borne in mind that reactive psychosis is a favorable functional disorder, so the appearance and increase of any negative symptoms (personality changes, intellectual-mnestic defect) should be considered as a phenomenon incompatible with the diagnosis of reactive psychosis.

21.2.4. Treatment of reactive psychoses

The first problem that the doctor has to face when a reactive state occurs is psychomotor agitation, panic, anxiety and fear. In most cases, these phenomena can be stopped by intravenous or intramuscular administration of tranquilizers (diazepam up to 20 mg, lorazepam up to 2 mg, alprazolam up to 2 mg). With the ineffectiveness of tranquilizers, antipsychotics are prescribed (chlorpromazine up to 150 mg, tizercin up to 100 mg, chlorprothixene up to 100 mg).

Affective-shock reactions often resolve without special treatment. Of greater importance are helping the patient in a threatening situation and preventing panic. To prevent the development of post-traumatic stress disorder, mild tranquilizers and antidepressants are prescribed, and psychotherapy is carried out.

Hysterical psychoses are quite well treated with the help of directive methods of psychotherapy (suggestion in the waking state, hypnosis, drug hypnosis). Small doses of neuroleptics (chlorpromazine, tizercinum, neuleptil, sonapax) can give a good effect. Sometimes drug disinhibition is used (see section 9.3).

Treatment of reactive depression begins with the appointment of sedative antidepressants and tranquilizers (amitriptyline, mianserin, alprazolam, diazepam). Elderly and somatically debilitated patients are recommended to prescribe drugs with the least number of side effects (fluvoxamine, gerfonal, azafen, lorazepam, nozepam). As soon as the patient begins to show interest in talking with the doctor, psychotherapeutic treatment begins. Many studies have shown the effectiveness of rational (and similar cognitive) psychotherapy. Through logical reasoning, in which the patient takes an active part, the doctor tries to show the fallacy of the patient's pessimistic views, to identify constructive ways out of the situation, to orient the patient to interesting and accessible goals. You should not simply impose your point of view on the patient - it is better to listen carefully to him and find in his statements those that will help him cope with the traumatic event.

Treatment of reactive paranoids begins with the introduction of antipsychotics. Depending on the leading symptoms, sedatives are chosen (with anxiety, confusion, psychomotor agitation) or anti-sychotic drugs proper (with suspicion, incredulity, delusions of persecution). From sedatives, you can use chlorpromazine, chlorprothixene, tizercin (sometimes in combination with benzodiazepine tranquilizers), from antipsychotics, haloperidol (up to 15 mg per day) and triftazine (up to 30 mg per day) are used more often than others. In the future, psychotherapy is also carried out, contributing to the search for constructive ways to overcome the traumatic situation.

21.3. neuroses

Under neuroses traditionally understand non-psychotic disorders, often associated with long-term, difficult conflict situations. These disorders are functional (non-organic) in nature, usually accompanied by disorders in the somatovegetative sphere, while patients remain critical, understand the painful nature of the symptoms, and strive to get rid of them.

The term "neurosis" has been used in medicine since the 18th century. [Cullen W., 1776], but its understanding differs significantly in different psychiatric schools. With the development of the nosological trend in psychiatry, this term is increasingly used to refer to a group of psychogenic functional, benign diseases with mild symptoms. In this sense, the term “neurotic level of disorders” should be distinguished from the concept of “neurosis”, indicating mild manifestations of the disease, regardless of its nature (see section 3.3).

Although the course of neurosis is generally favorable, the duration of the disease may be different. In most cases, there is a complete recovery. However, often the treatment is stretched for many years. Pathological stereotypes of behavior of patients become habitual, lifestyle changes. Patients "get used to the neurosis", adjust all their behavior to the requirements of the disease. In this case, recovery does not occur. Such a chronic disease state is referred to as " neurotic personality development » (see section 13.2).

There is no single classification of neuroses. In ICD-10, the division is based on the indication of the leading symptom: phobia, anxiety attacks, panic, obsessions, longing, depression, conversion mental and neurological disorders, somatovegetative dysfunction, pain, asthenia, depersonalization.

Since somatovegetative disorders are an almost obligatory manifestation of any neurosis (see Chapter 12), in the past it was proposed to single out neuroses according to the organ, the violations of which are observed: “cardioneurosis”, “angioneurosis”, “gastric neurosis”, “intestinal neurosis”. Modern ideas about the pathogenesis of neuroses and clinical practice show the meaninglessness of such terms, since the disease is primarily due to brain dysfunction, while no obvious pathology is found in the organs themselves.

In domestic psychiatry, 3 variants of neurosis are most often distinguished: neurasthenia, obsessive-compulsive disorder, and hysterical neurosis. Isolation of hypochondriacal neurosis as an independent disease is not common, since somatovegetative dysfunction and concern about the state of one's health are characteristic of patients with any type of neurosis. It should be emphasized that the essence of somatic disorders is fundamentally different in different variants of neurosis: demonstrativeness, the desire to attract attention - with hysteria; fear, anxious apprehensions - in obsessional neurosis; a feeling of fatigue, exhaustion - with neurasthenia. The diagnosis of "depressive neurosis" is also of limited use, since mood depression is an important symptom of any neurosis, but it is never as pronounced as in MDP.

Data on the prevalence of neurosis are contradictory due to discrepancies in existing classifications (data are given for 2-20% of the population). In addition, it is known that most patients with neuroses either do not go to doctors or are treated by therapists, neuropathologists and other specialists. Among those who turn to psychiatrists, patients with neurosis make up 20-25%. Most of the patients are women, young and mature persons (up to 50 years) predominate.

21.3.1. Clinical manifestations of various neuroses

Neurasthenia (asthenic neurosis, exhaustion neurosis) is manifested primarily by asthenic syndrome. The most important manifestation of this syndrome is a combination of irritability with increased fatigue and exhaustion. Patients are extremely sensitive to external influences and sensations from the internal organs: they do not tolerate loud sounds and bright light, temperature changes; complain that they “feel the heart beat”, “the intestines work”. They are often disturbed by headaches, accompanied by a feeling of tension, pulsation, tinnitus. Patients for an insignificant reason are upset to tears, touchy. They themselves regret that they cannot restrain their reactions. Dramatically reduced working capacity, patients complain of memory loss, intellectual failure. An important symptom is a sleep disorder: there are difficulties in falling asleep, superficial sleep with many dreams, in the morning patients experience drowsiness, sleep does not bring rest. Fatigue in the morning can be replaced by a chaotic desire to catch up in the afternoon, which in turn leads to rapid fatigue. Intolerance, irritability of patients becomes the cause of conflicts with relatives and friends, worsening the well-being of patients.

Patients with neurasthenia often turn to therapists, neuropathologists, sexologists with complaints of interruptions in the work of the heart, autonomic lability, decreased libido, and impotence. An objective examination can reveal fluctuations in blood pressure, extrasystole, which is the basis for the diagnosis of "vegetative vascular dystonia", "diencephalic syndrome", "dyskinesia of the gastrointestinal tract", etc.

Among patients with neurasthenia, women and young people who begin an independent life predominate. The disease develops more easily in individuals with an asthenic constitution, untrained, poorly tolerant of stress.

Neurasthenia is considered the most favorable variant of neurosis. Follow-up studies have shown that 10-25 years after going to the doctor, about 3/4 of the patients were practically healthy or noted a stable improvement in well-being.

In recent years, the diagnosis of "neurasthenia" has become much less common than at the beginning of the century, since latent depression or hysteroform symptoms are often found as the cause of asthenia.

Compulsive neurosis (obsessive-phobic neurosis) combines a number of neurotic conditions in which patients have obsessive thoughts, actions, fears, memories that they perceive as painful, alien, unpleasant, from which patients, however, cannot free themselves.

Men and women fall ill with this form of neurosis with approximately the same frequency. An important role in the occurrence of the disease is probably played by constitutional and personal predisposition. Among patients, persons of a “thinking” type predominate, prone to logic, introspection (reflection), seeking to restrain the external manifestation of emotions, anxious and suspicious personalities. One of the variants of psychopathy - psychasthenia almost always manifests itself in more or less pronounced obsessions. In the ICD-10, psychasthenia is listed under neuroses,

Most often, the leading symptomatology of obsessional neurosis is fears (phobias). Often there is a fear of getting sick with severe somatic and infectious diseases: cardiophobia, syphilophobia, carcinophobia, speedophobia. Often fear causes being in a confined space, transport, subway, elevator (claustrophobia), going outside and being in a crowded place (agoraphobia), and sometimes fear occurs when patients only imagine this unpleasant situation. Those suffering from phobias try their best to avoid a situation that causes them fear: they do not go out, do not use transport and elevators, wash and disinfect their hands thoroughly. To get rid of the fear of getting cancer, they often turn to doctors with a request to conduct the necessary examinations. The results of these examinations calm the patients somewhat, but usually not for long. The situation worsens due to the fact that due to the increased attention to their health, patients notice even the smallest deviations in the work of internal organs. Sometimes they have vague pain and discomfort, which they regard as signs of a serious illness.

Sometimes neurosis is manifested by difficulty in performing habitual actions due to the fact that the patient for some reason fears failure. (anticipation neurosis). So psychogenic impotence can occur in people who are afraid that their age or a long break in sexual relations can affect potency. Sometimes expectation neurosis is the cause of professional failure in musicians, athletes, acrobats after a minor injury.

Somewhat less often, a manifestation of neurosis becomes intrusive thoughts(obsessions). Patients cannot get rid of obsessive memories, senselessly counting windows, passing cars, repeating literary passages in their minds many times (“thinking chewing gum”). Patients understand the painful nature of these phenomena, complain that such an excess of thinking prevents them from performing their official duties, tires and irritates them. Patients are especially hard pressed by the emergence of contrasting obsessions, which are expressed in thoughts that they can commit an act that is unacceptable from the point of view of ethics and morality (swearing in a public place, committing violence, killing their own child). Patients have a hard time experiencing such thoughts and never realize them.

Finally, there may be compulsions (compulsions) e.g. compulsive handwashing; returning home in order to check if the door is closed, if the iron and gas are turned off. Often such actions take on a symbolic nature and are performed as some kind of “magical” action in order to reduce anxiety and relieve tension. (rituals). In children, obsessive actions in neurosis are often expressed in tics. Isolated childhood tics usually have a favorable course and disappear completely with the completion of puberty. They must be differentiated from generalized tics - Gilles de la Tourette's syndrome (see section 24.5).

Some experts single out panic attacks- recurrent attacks of intense fear, usually lasting less than an hour (see section 11.2). In these cases, the diagnosis of "sympathoadrenal crisis" or "diencephalic syndrome" was often made before. It is believed that most of these autonomic paroxysmal seizures are closely related to chronic stress, usually at the same time there is a tendency to anxious fears, phobias.

The course of obsessional neurosis is often prolonged. Often there is a gradual expansion of the range of situations that cause fears and obsessions. More often than other neuroses, this disorder is chronic, leading to the formation of neurotic personality development. At the same time, even with a long course, the majority of patients are characterized by a persistent fight against the disease, the desire to maintain their social status and ability to work by any means.

A 30-year-old patient, a professional hockey player, turned to a psychiatric clinic due to an obsessive fear of riding in transport.

Heredity is not burdened. Parents do not have higher education, are currently retired. Early development went uneventfully. He studied well at school, was somewhat shy. He didn't like being noticed. He started playing sports at the age of 12. This affected his academic performance, but the teachers treated him with understanding and gave him good grades. Under the patronage of the coach, he entered the Institute of Physical Education, but did not graduate from the institute, as he was very busy in competitions. He had several relationships with women, but he did not imagine any of them as a wife. In a sports team, he was always rated as a "hard worker", but in recent years the coach began to note that "age makes itself felt." In this regard, he constantly thought about what to do after the end of his sports career. Sometimes I didn't sleep well. I felt somewhat better after drinking alcohol, but did not abuse it, as I was afraid that this would affect his athletic performance. A year before this hospitalization, he was treated by a general practitioner for an exacerbation of peptic ulcer. He became very attached to the doctor, called her several times after to consult.

About 3 months ago, against the background of poor health (the day before, I drank pretty much), I went down to the subway and felt incredible fear. It seemed that he was dying, that "the heart is about to jump out of his chest." The doctor was called. The patient was taken to the hospital, but the ECG was normal; after the introduction of sedatives, the patient was sent home. A day later, when trying to go down to the subway, the attack repeated. Couldn't go to another workout. Several times he asked his comrades to give him a ride in a car, he went in a taxi. There were no seizures in the passenger car, but he felt restless, thinking about his heart all the time. Several times the same fear appeared during training. He asked to be given leave, but did not feel that his condition was improving. I fell asleep badly in the evenings, pondered the future. He went to a general practitioner who treated him for an ulcer. She advised him to be treated by a psychiatrist, but the patient said that he trusted only her. I spent about a month in the gastroenterology department. Received beta-blockers, tranquilizers, vitamins, physiotherapy. The condition has not improved. He was forced to turn to the psychiatrist recommended to him by the gastroenterologist.

Upon admission, he is depressed, treats the psychiatrist with caution, and is depressed by his illness. He claims that he often experiences pain in the region of the heart, sometimes so severe that there is a fear of death. He believes that he would never have thought that the pain was caused by a mental disorder, if the doctor, whom he trusts, had not convinced him of this. He agrees that he is experiencing one of the most difficult periods in his life. He understands that he should leave sports, but does not know what he could do in the future.

She was treated with tranquilizers (phenazepam) and small doses of neuroleptics (etaperazine, sonapax). Psychotherapeutic conversations were conducted daily with the patient. In the clinic, attacks of fear did not recur, but he refused to go home on vacation, because he was afraid that he would become ill. I finally decided that I would leave sports. I talked about this with the coach, and he promised to find him a suitable job. He was discharged after 3 months in a satisfactory condition, thanked the doctors for their help. By this time, pain had not arisen for more than 2 months, however, to go home, he hired a taxi.

Hysterical neurosis (dissociative disorders, conversion disorders) is a psychogenic functional disease, the main manifestation of which are extremely diverse somatic, neurological and mental disorders that occur through the mechanism of self-hypnosis.

In women, hysterical neurosis is observed 2-5 times more often than in men. Often the disease begins in adolescence or in the period of involution (menopause). Among the sick, people with a low level of education, an artistic type of higher nervous activity, extroverts who find themselves in a situation of social isolation (for example, non-working wives of the military) predominate. The features of mental infantilism (non-independence of judgments, increased suggestibility, egocentrism, emotional immaturity, affective lability, slight excitability, increased impressionability) predispose to the onset of the disease. Often hysterical neurosis is a decompensation of hysterical psychopathy and the corresponding personality accentuation (see section 13.1).

Pathological manifestations in hysteria are extremely diverse. Seizures (see section 11.3), somatic, autonomic and neurological disorders (see section 11.3) may occur.

section 12.7). Manifestations of hysteria may resemble endogenous mental illness. The distinct psychogenic nature of the disorders and the demonstrative nature of the behavior of patients often cause a feeling of conditional "desirability", psychological "profitability" of symptoms. At the same time, one should clearly distinguish between hysteria, which is a disease, suffering, and simulation, which is not accompanied by internal discomfort. The behavior of a patient with hysteria is not the purposeful behavior of a person who knows what he wants, but only a way to get rid of the painful feeling of hopelessness, unwillingness to admit his inability to cope with the situation.

In contrast to organic diseases, hysterical disturbances are as they appear to the patients themselves. Usually these are very bright, eye-catching disorders. Additional psychotrauma, the presence of a large number of observers intensify hysterical symptoms. Calming, the action of sedatives and alcohol, hypnosis lead to its disappearance. Patients always emphasize the unusualness, mystery, uniqueness of their disorders.

It is not possible to list all the possible symptoms. In addition, the symptomatology varies significantly under the influence of social factors. Hysterical paralysis, seizures and fainting, common in the last century, have now been replaced by attacks of headaches, shortness of breath and palpitations, loss of voice, impaired coordination of movements, pains resembling those of sciatica. Usually, several hysterical symptoms can be detected in one patient at the same time.

Movement disorders include paralysis, paresis, feeling of weakness in the limbs, ataxia, astasia-abasia, tremor, hyperkinesis, blepharospasm, apraxia, aphonia, dysarthria, dyskinesia up to akinesia. In the past, convulsions were often observed.

Sensory disturbances manifested by a variety of sensitivity disorders in the form of anesthesia, hypesthesia, hyperesthesia and paresthesia (itching, burning), pain, loss of hearing and vision. Sensitivity disorders often do not correspond to innervation zones. Hysterical pains are very bright, unusual, in various parts of the body (for example, a feeling of squeezing the head with a hoop, sudden pain in the back, aching joints). Pain often causes erroneous surgical diagnoses and even abdominal operations (Munchausen's syndrome).

Somatovegetative disorders can refer to any of the body systems. Gastrointestinal disorders - swallowing disorders, a feeling of a lump in the throat (globushystericus), nausea, vomiting, lack of appetite (anorexia), flatulence, constipation, diarrhea. Heart and lung disorders - shortness of breath, feeling short of breath, pain in the heart, palpitations, arrhythmia. Urogenital sphere - cramps during urination, a feeling of overflow of the bladder, sexual disorders (vaginismus), imaginary pregnancy, vicarious bleeding.

Mental disorders manifested by psychogenic amnesia, hysterical illusions and hallucinations, emotional lability, accompanied by sobbing, screaming, loud lamentations.

Unlike patients with obsessive-compulsive disorder, patients with hysteria are usually not inclined to limit their contacts due to illness (they receive guests lying in bed or sitting in a wheelchair, pour tea with their left hand, placing their right "paralyzed" hand in a bandage, willingly participate in a conversation in case of loss of the ability to speak, explaining by signs and gestures), showing unexpected indifference to severe disorders in the body (labelleindifference).

A 28-year-old patient, a housewife, came to the clinic with complaints of tightening headaches, discomfort in the extremities in the form of numbness, tingling, crawling, as well as frequent pains in the heart area, a feeling of lack of air, anxiety and unmotivated fear.

Heredity is not burdened. As a child, she was capricious, demanded constant attention. She learned to read early, before school she knew many poems and songs by heart. She studied well at school, did a lot of social work, studied a foreign language. She reacted with great jealousy to the birth of her younger brother (brother is 8 years younger than the patient), relations with her parents deteriorated sharply. After leaving school, she left for Moscow and entered the Faculty of Physics and Mathematics of Moscow State University. She was extremely active and sociable. Strive to take the lead. She was strict with others, sharply deleted from her life those who did not meet her requirements.

Already in the junior years of the institute, she met her future husband. At first she was in love, idealized him. Later, she noticeably cooled off towards him, felt disappointed, but she was forced to marry him, as she was pregnant. She made great efforts to finish college before giving birth and get a job. After the birth of the child, she was forced to stay at home with him, although she did not feel much affection for her son. I was very tired of this. My husband and I began to have endless quarrels. Against this background, bouts of unreasonable anxiety appeared. She felt tired all the time and complained about it to her husband. The condition worsened every time he was about to leave for work. The husband decided to take a vacation, but for the whole month, while he was at home and helped her, she felt very bad. The condition improved only when, a year after the birth, she again went to work. I felt completely healthy, I decided to go to graduate school.

A year and a half before her hospitalization, she was forced to stop working (the research institute where she worked was closed; her husband began to earn good money and demanded that she raise her son herself). I immediately felt sick. There were headaches, as if "a hoop was tightening the head", unpleasant sensations in the arms and back, pains in the region of the heart. Tried to get rid of them by physical exercises. She got up early, before her husband and child woke up, jogged, swam in the hole. When she returned home, she cooked breakfast and accompanied her husband to work. At that moment, she felt completely exhausted, accused her husband of callousness. Quarrels in the family became more frequent. After another quarrel with her husband, there was a feeling of lack of air, a sharp weakness. It seemed to fall into a deep tunnel. Couldn't speak. Hearing was impaired, did not respond to the words of others. An ambulance was called. The condition was stopped by the introduction of some sedatives. It was recommended to see a psychiatrist.

In the clinic, she is calm, active, willingly talks with doctors and students. Looks after herself, uses cosmetics, well combed. He complains of vague pains in the region of the heart and lack of air, however, when talking with the doctor, he breathes normally. During visits to her husband, she is anxious, sometimes suffocates. Similar attacks also occur when the husband does not come on a date for a long time. Several times I could not sleep, called the doctor on duty. She sobbed, saying that nothing would help her.

Antidepressants (azafen) and antipsychotics in small doses (sonapax, etaperazine) were prescribed. At the same time, psychotherapy was carried out. Return to work recommended. She was discharged in a satisfactory condition, satisfied with the treatment.

The course of hysterical neurosis is usually undulating, the severity of symptoms is associated with the action of additional psychotraumas. In the absence of features of hysterical psychopathy, the elimination of the traumatic factor leads to a complete recovery. With the prolonged existence of an insoluble conflict and with ineffective treatment, a protracted course and the formation of neurotic personality development are observed.

21.3.2. Etiology and pathogenesis of neuroses

Although the psychogenic nature of neuroses is recognized by most authors, the identification of a traumatic factor is associated with a number of difficulties. In contrast to reactive psychoses, neuroses are dominated by long-term individually significant experiences that are not always noticeable to others. For most people, prolonged physical activity, interpersonal conflicts do not lead to neurosis. The situation is much more pathogenic intrapersonal conflict(a conflict with one's own conscience, dissatisfaction with the situation and at the same time fear of change, a situation of choice in which each of the decisions leads to irreparable losses, etc.). V.N. Myasishchev (1960) described the specific features of intrapersonal conflict characteristic of each type of neurosis. So, in hysteria, the conflict often consists in an extremely overestimated level of claims with an underestimation of real conditions and opportunities, in obsessional neurosis (and psychasthenia) - in a contradiction between desires and an increased sense of duty, in neurasthenia - in a mismatch of abilities and personal skills, excessive demands on oneself .

Premorbid personality traits are of great importance for the formation of neuroses. So, infantilism, extraversion, demonstrativeness, emotional lability correlate with hysterical symptoms; suspiciousness, anxiety, caution, pedantry, responsibility - with a neurosis of obsessions. I.P. Pavlov associated hysteria with the predominance of the first signal system (artistic type), and obsessional neurosis with the predominance of the second signal system (rational-logical type). Persons who are able to easily transfer responsibility for an unpleasant situation to others, who are prone to aggression and indignation, who strive to overcome the obstacles that have arisen at any cost, rarely develop neurosis.

Since the personal characteristics of patients are largely determined by heredity, genealogical and twin methods show the essential role of heredity in the formation of neuroses. About 20% of relatives of patients with phobias also suffer from this disorder. The concordance for panic attacks is 15% in fraternal twins and 50% in identical twins. The probability of occurrence of neurosis is not the same in different age periods. There are "crisis" periods during which the development of neuroses is especially likely - the puberty period, the period of early maturity (25-35 years) and the time preceding menopause.

Proponents of the biological direction find some features of the biochemical processes in the brain of patients with neuroses. Anxiety states are associated with an excess of catecholamines, insufficiency of GABAergic processes, disorders in the metabolism of serotonin and endorphins. They indicate a tendency to fear reactions when the blue spot (locus coeruleus) of the pons is affected. A predisposition to panic attacks was shown in persons with low tolerance to physical activity (according to the reaction to the introduction of sodium lactate and inhalation of CO 2). Successes in the use of antidepressants for the treatment of obsessions suggest some pathogenetic relationship between depression and obsessions.

Proponents of the psychological trend emphasize the role of improper upbringing in early childhood (in particular, lack of attention from the mother), the features of intra-family relations in the occurrence of neuroses. The nature of neuroses in the concept of psychoanalysis is discussed in particular detail. From the point of view of the psychoanalytic concept, the symptoms of neurosis are pathologically fixed and overused psychological defense mechanisms (see section 1.1.4 and table 1.4). In particular, the mechanisms of repression, conversion, regression, idealization and dissociation are very characteristic of hysteria. Obsessions can be explained by the excessive use of substitution mechanisms (anxiety fixation) and hypercompensation (reactive learning).

In accordance with the behaviorist approach, the mechanism of neurosis is associated with pathological learning. In this sense, obsessions and panic attacks are seen as pathologically persistent conditioned reflexes. Unfortunately, this theory cannot explain why, unlike typical conditioned reflexes, which are prone to extinction, this painful reflex becomes persistent.

21.3.3. Differential Diagnosis

Diagnosis of neurosis is one of the most difficult problems in psychiatry. The mild, smoothed nature of the symptoms, the lack of methods for objective confirmation of the diagnosis lead in many cases to the fact that, under the diagnosis of neurosis, the doctor does not notice the initial signs of more severe and dangerous diseases. According to the theory of evolution and dissolution of mental disorders (see section 3.5), the symptoms characteristic of neuroses can be observed in almost any mental illness.

characteristic of neurasthenia asthenic syndrome may be due to various exogenous and organic causes (trauma, intoxication, somatic disease, infection). Although it is believed that endocrine and somatic dysfunction can contribute to the onset of neurosis, however, if a somatic or endocrine disease is the main cause of a mental disorder, the diagnosis is made not of neurosis, but of a somatogenic disease. Quite often it is necessary to distinguish masked depression and mild manifestations from asthenic syndrome. apathy at the onset of the schizophrenic process. Depression is characterized by a predominance of feelings of melancholy, a decrease in basic drives (appetite, sexual desire, desire for communication), pessimism and low self-esteem. Manifestations of endogenous depression usually increase in the morning. Early awakening of patients is characteristic. Asthenia, on the contrary, increases in the evening; in the morning the patients are drowsy, they feel not rested. Apathy is usually not manifested by fatigue, appetite and sleep are not disturbed. Patients do not feel sick, do not seek help from others; asking to be left alone.

Obsessions can be a manifestation of not only neuroses, but also low-progressive schizophrenia (schizotypal disorder, according to ICD-10). Usually, in schizophrenia, there is a clear increase in symptoms, an expansion of the range of obsessions, the inclusion of disorders atypical for neuroses (mental automatism, reasoning and other disorders of the associative process, mannerisms, elements of catatonia) in the symptoms. Obsessions and phobias in schizophrenia are often extremely abstract, cut off from reality (fear of being buried alive, fear of turning into an animal, etc.). You should be especially careful about the panic fear of going crazy: this condition most often indicates the onset of acute psychosis (schizophrenia). If in neurosis fears are monothematic, then in schizophrenia often there is a “fear of everything”. An important feature of schizophrenia as an endogenous disease is the autochthonous nature of the course, not related to the real psychological situation. Personality changes in low-progressive schizophrenia are usually not as noticeable as in the psychotic variants of this disease. However, compared with patients with neurosis, one can notice the predominance of passivity, the lack of desire to overcome the disease, and rapid disability. It should be taken into account that manifestations of neurosis are clearly associated with premorbid personality traits. In schizophrenia, the disease often contradicts previous personality traits, leads to a significant modification of the personality, the appearance of character traits that have never been noted before.

Hysterical somatoform disorders often cause significant diagnostic difficulties. Although a clear connection of disorders with a traumatic event, a vivid demonstrative nature of the behavior of patients, the absence of objective signs of damage to internal organs in most cases indicate the hysterical nature of the disorders, in some cases hysterical symptoms can mask severe somatic and neurological pathology. So, a tumor of the mediastinum or esophagus can be manifested by a feeling of "lump in the throat." Fainting in endocrine diseases may resemble hysterical seizures. It should be borne in mind that any patient with hysterical character traits, in the event of a severe somatic illness, will react to this with vivid emotional reactions, sobbing, etc. Therefore, in all cases of diagnosing hysteria, a thorough objective examination should be carried out, not relying only on the general impression of the patient's personal characteristics. It should be borne in mind that gross hysterical symptoms can also be a manifestation of other psychopathological conditions (psychoorganic syndrome, acute attack of schizophrenia). Patients with a psychoorganic syndrome (at the onset of an endocrine disease, epilepsy, atrophic process of the brain, tumors of the frontal lobes, progressive paralysis, etc.) are very characterized by emotional lability, personality changes, but these disorders are already in the early stages combined with impaired memory, intelligence, and a decrease in criticism. . In the debut of the schizophrenic process, under the mask of hysteria, catatonic phenomena (stupor, mutism, speech and motor stereotypes) can occur.

21.3.4. Treatment of neuroses

The treatment of neuroses is based on the combination of psychotherapy (see section 15.3) with psychopharmacotherapy. Methods of non-specific influence are widely used - physiotherapy, reflexology, massage, diet therapy. Although quite often the treatment is carried out on an outpatient basis, in some cases hospitalization is indicated to remove the patient from a traumatic situation.

At neurasthenia the appointment of psychopharmacological drugs should be combined with a good rest. More often than other drugs, nootropics, tranquilizers (with a predominance of anxiety, restlessness, insomnia, muscle tension), mild neuroleptics - thioridazine, chlorprothixene, eglonil (with irritability and somatovegetative dysfunction), antidepressants with a minimum number of side effects (pyrazidol, azafen, befol, coaxil, heptral). Nonspecific restorative therapy (vitamins, reflexology, physiotherapy, diet therapy, biostimulants - ginseng, eleutherococcus, pantocrine) and symptomatic agents (beta-blockers, calcium channel blockers) are widely used. The main goal of psychotherapy is to relieve anxiety and tension, relaxation. During the period of convalescence, it is important to develop the patient's resistance to physiological and psychological stress, therefore, autogenic training and physiotherapy exercises are recommended.

In treatment obsessional neurosis psychopharmacological agents are the most important component. In recent years, antidepressants have been playing a leading role in the treatment of obsessions and fear. Although in each individual case a particular drug may be the most effective, there is evidence in the literature about the high effectiveness of all antidepressants (tricyclic - clomipramine, imipramine; serotonin reuptake inhibitors - fluoxetine; MAO inhibitors). Short-acting tranquilizers (lorazepam, alprazolam, diazepam) are widely used to relieve acute anxiety attacks. For long-term prevention of anxiety, long-acting drugs (phenazepam, tranxen, chlordiazepoxide) should be used. Sleeping pills are prescribed to improve sleep. The effectiveness of some anticonvulsants for the prevention of anxiety attacks (carbamazepine, clonazepam) has been shown. When the process is chronic, mild neuroleptics are often prescribed (teralen, thioridazine, chlorprothixene, etaperazine, etc.). Simultaneously with pharmacological treatment, psychotherapy is carried out. Usually patients with obsessional neurosis are less suggestible, so hypnosis and other methods of suggestion are ineffective. More often they use self-hypnosis and relaxation techniques (autogenic training and biofeedback), as well as rational psychotherapy, behavioral therapy (systematic desensitization), group methods, and sometimes psychoanalysis. Nonspecific restorative treatment is usually ineffective.

Psychotherapy is the main method in the treatment hysterical neurosis. Various types of suggestion and hypnosis are especially effective. The high efficiency of non-specific methods (electrosleep, reflexology, physiotherapy, taking medicinal preparations, homeopathy, etc.) has been shown, but the high value of the placebo effect when using these methods in patients should be taken into account. Psychopharmaceuticals are widely used: neuroleptics - with increased excitability, antidepressants - with concomitant depression. In all cases, drugs with a minimum number of side effects that do not cause dependence should be used. It is important at the final stages of treatment to develop in patients the skills of independent (without the support of a doctor) relaxation (with the help of autogenic training, biofeedback), since in many cases signs of a kind of "dependence on the doctor" are formed with the resumption of the disease immediately after the termination of psychotherapeutic sessions.

21.4. Neurotic reactions

Separate symptoms characteristic of neuroses can occasionally occur in mentally healthy people. Tears, grumbling, a single outburst of anger, psychogenic headaches, episodes of obsessions, difficulty falling asleep and other phenomena can be quite natural if they occur briefly against the background of fatigue, an obvious psycho-traumatic event (before an exam, after hard hard work, at the moment short-term family quarrel).

In most cases, these reactions do not require special treatment, they quickly pass after rest. Since the behavior of patients is psychologically understandable, others are treated as him with sympathy and condescension. AT ICD-10 such phenomena are registered as a variant of the norm ("appeal for advice" or - "stress, not classified anywhere else").

Reception benzodiazegshnovy tranquilizers in this case is quite acceptable, promotes better rest, prevents excessive exhaustion and an increase in conflict. Special psychotherapy is usually not required - the doctor should only explain to the patient the non-pathological nature of the observed phenomena, show the groundlessness of his anxiety. It is important to show tact and understanding, not to treat the patient's complaints with disdain.

However, repeated visits to the doctor with such complaints should be alarming. The cause of permanent decompensation may be psychopathic character traits, the debut of an endogenous disease, hidden somatic or endocrine pathology. Persons with psychopathic character traits, in order to avoid the formation of drug dependence, it is recommended to prescribe mild antipsychotic drugs (neuleptil, sonapax) and non-addictive drugs (coaxil, buspirone).

BIBLIOGRAPHY

Aleksandrovsky Yu.A. Borderline neuropsychiatric disorders:

Guide for doctors. - M.: Medicine, 1993. - 400 p. Alexandrovsky Yu.A., Lobastoe O.S., Spivak L.I., Shchukin B.P. Psychogeny in extreme conditions. - M.: Medicine, 1991.- 96 p.

Kabanov M.M., Lichko A.E., Smirnov V.M. Methods of psychological diagnostics and correction in the clinic. - L.: Medicine, 1983. - 312 p.

Karvasarsky B.D. neuroses. - 2nd ed. - M.: Medicine, 1990. -

Kempinski A. Psychopathology of neuroses. - Warsaw: Polish Medical Publishing House, 1975. Konechny R., Bowhal M. Psychology in medicine. - Prague: Aviie-

num, 1974. - 408 p. Kornetov N.A. Psychogenic depressions (clinic, pathogenesis). -

Tomsk: Publishing house Vol. un-ta, 1993. - 238 p. Kretschmer E. About hysteria: Per. with him. / Ed. S.A. Brushtein. -

M.-L.: State. publishing house, 1928. - 159 p. Lakosina N.D. Clinical variants of neurotic development. - M.: Medicine, 1970.

Lakosina I.D., Trunova M.M. Neuroses, neurotic personality development: clinic and treatment. - M.: Medicine, 1994. - 192 p.

Luria R.A. Internal picture of diseases and iatrogenic diseases. - 4th ed. - M.: Medicine, 1977.

Ozeretskovsky D.S. Obsessive states. - M.: Medgiz, 1950. - 168 p.

SvyadoschA. M. neuroses. - 3rd ed. - M.: Medicine, 1982.

Semichev S.B. Premorbid mental disorders. - JI.: Medicine, 1987. - 184 p.

Semke V.Ya. hysterical states. - M.: Medicine, 1988.

Ushakov G.K. Borderline neuropsychiatric disorders. - 2nd ed. - M.: Medicine, 1987. - 304 p.

I am cube A. Hysteria: methodology, theory, psychopathology: Per. from Polish. - M.: Medicine, 1982.

Plan:

1. Psychopathies

2. Personality disorders.

3. Neuroses.

4. Reactive psychoses

5. Anxiety and somatoform disorders.

Psychopathies are pathological conditions that are manifested by a disharmonic disposition of the personality, from which either the patients themselves or society suffer (K. Schneider).

General characteristics. Psychopathies arise on the basis of the interaction of congenital or early acquired biological inferiority of the nervous system and the influence of the external environment.

Classification of psychopathy. There is currently no generally accepted classification of psychopathy.

CONSTITUTIONAL-DEPRESSIVE TYPE. It includes persons with constantly lowered mood; they are gloomy, dull, gloomy, discontented and uncommunicative people. All their reactions are slowed down. In their work, they are conscientious, accurate and pedantic, as they are ready to foresee complications and failures in everything.

HYPERTHYMIC TYPE. Unites people with constantly elevated mood and unbridled optimism. Outwardly, these are sociable, talkative, mobile and lively people. In work, they are energetic, enterprising, often tireless, but at the same time they are inconsistent and prone to adventures, which often leads them either to a significant rise or to an unexpected collapse. They are characterized by self-confidence, arrogance, which, with usually increased self-esteem, makes them unbearable debaters; often they are deceitful, boastful, prone to risky adventures in the complete absence of a critical attitude towards their shortcomings.

CYCLODY TYPE. Includes the most numerous group of persons with affective instability. Their mood is prone to constant fluctuations from feeling mild sadness or slight melancholy to cheerful or joyful. In a calm, average state, they are sociable, friendly and accommodating people. They do not have a sharp opposition of their I to the environment. They find a common language with people in the shortest and most natural way. These are realists who easily, without moralizing, understand someone else's individuality.

EMOTIVNOLABILE (REACTIVELY LABIL) TYPE

Persons of this type are distinguished by extreme variability and inconstancy of mood, richness and polymorphism of emotional shades that reflect the content of specific situations. The mood of these people fluctuates on the most insignificant occasion, they react heavily to mental trauma.

ASTHENIC TYPSYCHOPATHIC personalities are distinguished by a combination of irritability, increased impressionability and sensitivity with significant mental exhaustion and fatigue. These are people with low self-esteem, a sense of their own inferiority, easily vulnerable, vulnerable and proud (“mimosa-like”). They subtly react to the slightest nuances in the behavior of others, painfully perceive rudeness and tactlessness. They feel especially bad in a new environment and unfamiliar society: they become shy, get lost, become discouraged, become silent, more shy and indecisive than usual. Asthenics do not tolerate strong direct stimuli (noise, harsh sounds), they often cannot stand the sight of blood, sudden changes in temperature.

HYSTERIC TYPE. Of the many signs inherent in hysterical psychopathy, the most characteristic is the desire to appear in one's own opinion and in the eyes of others as a significant personality, which does not correspond to real possibilities. Outwardly, these tendencies are manifested in the desire for originality, demonstrations of superiority, passionate search and thirst for recognition from others, exaggeration and coloring of one's experiences, theatricality and drawing in behavior. Hysterical personalities are characterized by posturing, deceit, a tendency to deliberate exaggeration, actions calculated for an external effect.

EXCITABLE EPILEPTOID TYPE. Psychopathic personalities of this type live in constant tension with extreme irritability, reaching fits of rage, and the strength of the reaction does not correspond to the strength of the stimulus. Usually, after an outburst of anger, patients regret what happened, but under appropriate conditions they do the same again. They are characterized by increased demands on others, unwillingness to reckon with their opinion, extreme selfishness and selfishness, resentment and suspicion.

PARANOIC TYPE. The main feature of this psychopathy is the tendency to form overvalued ideas that affect the behavior of the individual. These are people with narrow and one-sided interests, distrustful and suspicious, with heightened conceit and egocentrism, stubborn in defending their convictions, gloomy and vindictive, often rude and tactless, ready to see an ill-wisher in every person.

SCHIZOID TYPE. Psychopathic personalities of the schizoid type are distinguished by pathological isolation, secrecy, isolation from reality, and autism. Emotional disharmony in these individuals is characterized by the so-called psychaesthetic proportion, i.e., a combination of increased sensitivity (hyperesthesia) and emotional coldness (anesthesia) with simultaneous alienation from people (“wood and glass”). Such a person is detached from reality, prone to symbolism, complex theoretical constructions.

UNSTABLE (WILLLESS) TYPE The instability of the mental life of psychopathic personalities of this type is due to their increased subordination to external influences. These are weakly free, suggestible and pliable people, easily falling under the influence of the environment, especially the bad one. The realization of motives, desires and aspirations is determined not by internal targets, but by random external circumstances.

PSYCHASTENIC TYPE: Like the asthenic type, it belongs to inhibited psychopathy (N. I. Felinskaya). In addition to "features of irritable weakness, vulnerability and a sense of inferiority, psychopathic personalities of this type are distinguished by pronounced indecision, self-doubt and a tendency to doubt. Psychasthenic personalities are shy, timid, embarrassed, inactive and poorly adapted to life.

Treatment. The understanding of psychopathy as a congenital personality anomaly puts the doctor in front of the need to use, first of all, compensation mechanisms. In this regard, the most important role in the prevention and treatment of psychopathy belongs to pedagogical measures, as well as social and labor arrangements. Of great importance are the correct, taking into account individual characteristics, professional orientation and work regimen, psychotherapy.

Drug therapy is of secondary importance and is very individual. With exacerbations of excitable psychopathy, antipsychotics are indicated, especially neuleptil, stelazin, etaperazine. In states of affective tension, anxiety and dysphoria, along with antipsychotics, antidepressants with a sedative or timoneuroleptic effect (tizercin, etc.) are prescribed. In addition to these drugs, in the medical treatment of psychopathic conditions (affective instability, anxiety, emotional stress, phobias, etc.), tranquilizers are widely used: Elenium, Seduxen, tazepam, diazepam, etc.

PERSONALITY DISORDERS

paranoid personality disorder. Individuals with this disorder are highly suspicious and oversensitive to slights or interpersonal conflicts. They are "usually hyper-vigilant about the possibility of harm or deceit by others, so they are always wary, secretive, and often unkind to others.

Schizoid personality disorder. Schizoid individuals are usually loners and seem to have little need for the company of other people. They give the impression of very cold and withdrawn faces, indifferent to praise or criticism; they tend to have no close friends, so they are often socially reclusive.

Personality disorder of the schizophrenic type (schizotypal). Schizotypal personalities are similar to those with schizophrenia in eccentric thinking, perception of the environment, speech and the nature of interpersonal relationships, however, the severity of these features and their coverage of the personality does not reach the degree when a diagnosis of schizophrenia can be made. They have odd speech (e.g., metaphorical, evasive, detailed), referential ideas (i.e.: ideas with an inadequate inference that some neutral events have special relevance to their personality), magical (unrealistic) thinking, and pronounced suspicion.

Borderline Personality Disorder/Persons with this personality disorder have been described as "stable-unstable". They experience constant difficulties in maintaining a stable mood, interpersonal attachments, and also in maintaining a stable self-image. The borderline personality may manifest as impulsive behavior, sometimes self-damaging (eg, self-mutilation, suicidal behavior). The mood of such persons is usually unpredictable.

"Theatrical" (ostentatious, hysterical) personality disorder. / People with a "theatrical" personality type are characterized by very "intense", but in reality superficial interpersonal relationships. They usually give the impression of being very busy people, the events around them are dramatized, and they, of course, are the center of these events.

Narcissistic personality disorder. The narcissistic personality usually has a heightened sense of self-importance, they often see themselves as unique, gifted, and possessing incredible potentialities. Narcissistic personalities find it difficult to see others in a real light, they either over-idealize them or immediately devalue them.

Antisocial personality disorder. Antisocial behavior is characterized by inconsistency with the generally accepted rules of the individual's behavior; he does things that are not expected of him, repeatedly violates the rights of others. This diagnosis can only apply to adults (in patients younger than 18 years of age, antisocial behavior traits are classified as behavioral disorders) in whom antisocial behavior traits appeared before the age of 15 years.

A personality disorder with a tendency to avoid relationships with another person. This personality disorder is characterized by the inability of the patient to respond correctly to refusal or impolite treatment. Therefore, patients often generally avoid close contact with anyone.

However, secretly they still want to communicate with other people. Unlike personalities of the narcissistic type, their self-esteem is often underestimated, they tend to exaggerate their shortcomings.

A personality disorder characterized by dependency on others. "Dependent" individuals easily allow others to solve many of their life problems for them. Due to the fact that they feel helpless and unable to resolve any issue on their own, they tend to subordinate their needs and desires to others, so as not to be responsible for themselves.

Passive-aggressive personality disorder. Individuals with passive-aggressive personality disorder usually reject all responsibility, both social and professional. Instead of expressing it directly, they usually procrastinate indefinitely with the completion of this or that task, as a result of which they are idle or work inefficiently; their frequent reference at the same time is the word "forgot". Thus, they destroy their potential in work and life.

Compulsive personality disorder. This state is characterized by the presence of irresistible cravings. Such persons usually overload themselves with various rules, rituals and details of behavior.

Atypical, mixed and other personality disorders. This last category of DSM-III personality disorders includes those that do not exactly fit into any of the above categories. In this case, the term "mixed personality disorder" is most often used. This means that the behavior of this individual at the same time corresponds to several categories of personality disorders at once. The treatment consists mainly of psychotherapy, applied in one form or another. Only in some cases, psychopharmacological agents are used.

RECTIVE PSYCHOSIS

Reactive psychoses - temporary reversible mental illnesses of various clinical manifestations, occurring in the form of clouding of consciousness, delirium, affective and movement disorders; arise as a result of mental trauma.

In the development of RP, the nature of the mental trauma and the constitutional features of the patient are of decisive importance. Predisposing factors include pathological changes caused by infectious diseases, intoxications, traumatic brain injuries, as well as periods of age-related crises. Acute (shock), subacute and protracted reactive psychoses are distinguished according to the peculiarities of the occurrence and course.

clinical picture.

Acute (shock) reactive psychoses (psychogenic shock) occur under the influence of a sudden superstrong mental trauma that poses a threat to existence (for example, a sudden attack by criminals, an earthquake, flood, fire), or associated with unexpected news of an irreparable loss of the most significant values ​​for a person (death). loved one, loss of property, arrest, etc.) They occur in hypokinetic and hyperkinetic form.

With the hypokinetic form, a stuporous state suddenly develops; the patient seems to be numb with horror, he is unable to make a single movement, utter a single word.

The hyperkinetic form is characterized by the sudden appearance of chaotic motor excitation.

In some cases, there is a change from the hyperkinetic form to the hypokinetic one. Both forms are accompanied by twilight confusion, complete or partial amnesia (see Memory), autonomic disorders (eg, tachycardia, rare changes in blood pressure, profuse sweat); continue for several minutes or hours.

Subacute reactive psychoses are most common, especially in forensic psychiatric practice.

They include psychogenic depression, hysterical psychosis, psychogenic paranoid, psychogenic stupor.

Psychogenic depression is characterized by a depressed or depressed-anxious mood, usually combined with tearfulness (tearful depression), irritability, discontent, irascibility (dysphoric depression). Sometimes psychogenic depression, primarily hysterical, can be complicated by more severe disorders: delusional fantasies, puerilism, pseudodementia.

To reactive hysterical psychosis include the syndrome of delusional fantasies, Ganzer's syndrome, pseudodementia (pseudo-dementia syndrome), puerilism, behavioral regression syndrome (savagery syndrome).

The syndrome of delusional fantasies is manifested by unstable, devoid of a system or poorly systematized, changeable in content, especially under the influence of external circumstances, ideas of reassessment of one's "I" or ideas of greatness, reformism, invention, less often persecution or accusation. As the psychosis progresses, the delusional fantasy syndrome may change into a state of pseudodementia or puerilism.

Ganser's syndrome is a hysterical twilight clouding of consciousness with a predominance of transient phenomena in the clinical picture (simple questions are followed by incorrect, usually unrelated to the content of the question, answers). Patients are disoriented in place, time, environment, self. In some, inhibition predominates, in others - excitation with expressive behavior, emotions are changeable; Everything that happens to the patient during the period of the twilight state is accompanied by complete amnesia. In some cases, Ganser's syndrome is replaced by pseudodementia.

Pseudo-dementia (imaginary dementia) is manifested by incorrect answers or

actions to simple questions or requests. Patients make mistakes

elementary account, they cannot correctly name the number of fingers on the hand,

are able to list the names of the fingers: instead of showing the nose,

point to the ear, put on clothes incorrectly, etc. Characteristic violations

letters - agrammatism, omissions of letters, a sharp deterioration in handwriting. Reading is often impaired. Many patients smile senselessly. pseudodementia

often changed

puerilism. whose clinical picture is dominated by

behaviors and statements characteristic of children. Sick people make toys

for example, from paper, they play with them, collect and paste pictures, candy wrappers from

candy. They speak with childish intonations, use diminutives,

lisping, lisping. At the same time, patients retain the skills inherent in

adults (for example, they skillfully light matches and smoke).

Behavior regression syndrome (running savagery syndrome) is one of the most rare forms of R. p. The patient's behavior seems to be likened to the behavior of an animal. A state of psychomotor agitation is often noted: patients growl, bark, meow, tear their clothes, get naked, eat with their hands or lap: in some cases they become aggressive.

Psychogenic paranoid manifested figurative nonsense (see. Delusional syndromes), the content of which is a threat to the life of the patient. Characterized by anxiety, fear, motor excitement, often in the form of impulsive actions (flight, search for protection, in some cases - an attack on imaginary enemies), confusion. Occurs in an unusual situation, for example, in a foreign language environment, in conditions of a long journey that requires waiting, changing transport, lack of sleep

psychogenic stupor characterized by speech and motor retardation, usually combined with autonomic disorders. It is accompanied by hysterical, much less often depressive, hallucinatory or delusional symptoms.

Protracted reactive psychoses are characterized by delusional fantasies, hysterical depression, pseudo-dementia-puerile disorders. These disorders in the most favorable cases remain unchanged for a year or even longer. Those protracted R. p., in which the initial symptoms are complicated by transient stuporous disorders, have a less favorable course. The most unfavorable are protracted R. p., in which the initial hysterical symptoms disappear, and the condition of the patients begins to be characterized by psychomotor inhibition with progressive physical exhaustion.

Treatment is carried out in a psychiatric hospital. Assign psychotropic drugs: after the disappearance of symptoms in all cases, psychotherapy is indicated. The prognosis is usually favorable. Neurosis (novolat. neurosis, comes from other Greek. vetipov - nerve; synonyms - psychoneurosis, neurotic disorder) - in the clinic: a collective name for a group of functional psychogenic reversible disorders that tend to have a protracted course. The clinical picture of such disorders is characterized by asthenic, obsessive and/or hysterical manifestations, as well as a temporary decrease in mental and physical performance.

In all cases, the psychogenic factor is conflicts (external or internal), the action of circumstances that cause psychological trauma, or a prolonged overstrain of the emotional and / or intellectual spheres of the psyche.

Causes and mechanics of the development of neurosis

I. P. Pavlov, within the framework of his physiological teaching, defined neurosis as a chronic long-term disorder of higher nervous activity (HNA) caused by overstrain of nervous processes in the cerebral cortex by the action of external stimuli inadequate in strength and duration.

Symptoms

Mental symptoms

Emotional distress (often for no apparent reason).

Indecision.

Problems in communication.

Inadequate self-esteem: underestimation or overestimation.

Frequent experience of feelings of anxiety, fear, "anxious expectation of something", phobias, panic attacks, panic disorder are possible.

Uncertainty or inconsistency of the system of values, life desires and preferences, ideas about oneself, about others and about life. Often there is cynicism. - Instability of mood, its frequent and sharp variability, irritability

High sensitivity to stress - people react to a minor stressful event with despair or aggression

Tearfulness

Resentment, vulnerability

Anxiety - fixation on a traumatic situation

When trying to work, they quickly get tired - memory, attention, mental abilities decrease - Sensitivity to loud sounds, bright lights, temperature changes - Sleep disorders: it is often difficult for a person to fall asleep due to overexcitation; sleep superficial, anxious, not bringing relief; drowsiness is often observed in the morning

physical symptoms

Headaches, heartaches, abdominal pains.

Frequent feeling of fatigue, increased fatigue, general decrease in performance

Vegetative-vascular dystonia (VVD), dizziness and darkening in the eyes from pressure drops.

Vestibular disorders: difficulty keeping balance, dizziness. - Appetite disturbance (overeating; malnutrition; feeling of hunger, but fast satiety when eating).

Sleep disorders (insomnia): poor falling asleep, early awakening, waking up at night, lack of feeling of rest after sleep, nightmares.

Psychological experience of physical pain (psychalgia), excessive concern for one's health up to hypochondria.

Vegetative disorders: sweating, palpitations, fluctuations in blood pressure (often downward), disruption of the stomach - Sometimes - a decrease in libido and potency

Common comorbidities

Panic attacks, Panic disorder

Phobias, especially social phobia

Vegetative-vascular dystonia (VVD)

Depression

Neurasthenia

There are many methods and theories for the treatment of neuroses. In the treatment of neurosis, psychotherapy and, in rather severe cases, drug treatment are used.

SOMATOFORM DISORDERS

Somatoform disorders are a group of psychogenic diseases characterized by physical pathological symptoms resembling a somatic disease, but no organic manifestations are found that could be attributed to a disease known in medicine, although there are often non-specific functional disorders.

Etiology Among the risk factors for the development of somatoform disorders, there are two large groups: internal and external.

Internal factors include the innate properties of emotional response to distress of any nature. These reactions are regulated by subcortical centers. There is a large group of people who respond to emotional distress with somatic symptoms.

External factors include:

microsocial - there are families in which they consider external manifestations of emotions not worthy of attention, not accepted, a person from childhood is accustomed to the fact that attention, love, support from parents can only be obtained using "patient behavior"; he uses the same skill in adulthood in response to emotionally significant stressful situations;

cultural and ethnic - in different cultures there are different traditions for the manifestation of emotions; the Chinese language, for example, has a relatively small set of terms for designating various psycho-emotional states; this corresponds to the fact that depressive states in China are represented to a greater extent by somatovegetative manifestations; this can also be facilitated by a rigid upbringing within the strict framework of any religious and ideological fundamentalism, where emotions are not so much poorly verbalized as their expression is condemned.

Classification

Somatoform disorders today include:

I Somatization disorder

II Undifferentiated somatoform disorder

III Hypochondriacal disorder

IV Somatoform autonomic dysfunction

1. heart and cardiovascular system: neurosis of the heart;

Da Costa syndrome; cardiopsychoneurosis.

2. upper gastrointestinal tract: gastric neurosis;

psychogenic aerophagy;

dyspepsia;

pylorospasm.

3. lower gastrointestinal tract: psychogenic flatulence;

irritable bowel syndrome; gas diarrhea syndrome.

4. respiratory system: psychogenic forms of cough and shortness of breath.

5. urogenital system:

psychogenic increase in the frequency of urination; psychogenic dysuria.

6. other organs and systems

V Chronic somatoform pain disorder: psychalgia;

psychogenic back pain or headache; somatoform pain disorder.

Clinical manifestations of somatoform disorders are varied. Patients turn, as a rule, first of all to local therapists, then, being dissatisfied with the lack of treatment results, to narrow specialists. However, behind all these complaints there are mental disorders that can be identified with careful questioning: low mood that does not reach the level of depression, a decline in physical and mental strength, in addition, irritability, a feeling of internal tension and dissatisfaction are often present. The exacerbation of the disease is provoked not by physical activity or changes in weather conditions, but by emotionally significant stressful situations.

Somatized and undifferentiated somatoform disorder

Somatized disorder (Bricke's syndrome) usually begins at the age of about 20 years, and by the age of 30, patients are already sure that they have a serious illness and have rich experience in communicating with doctors, healers, healers. The main symptom is multiple, recurring, often changing somatic symptoms that occur over several years. Patients constantly or periodically complain of a wide variety of disorders, usually with a sequential survey it is possible to identify at least 13 complaints. At the same time, a constant change in the leading somatic syndrome is characteristic.

Somatics is framed by emotional instability, anxiety, low mood. Patients constantly complain about something, complaints are very dramatic. Patients can neither be reassured nor convinced that the painful manifestations are associated with mental factors.

Criteria for somatization disorder^

1. The presence of multiple, changing physical symptoms in the absence of any physical disease that could explain these symptoms.

2. Constant concern in connection with the symptom leads to prolonged suffering and multiple (3 or more) consultations and examinations in the polyclinic service, if consultative assistance is not available for any reason, repeated appeals to representatives of paramedicine.

3. Persistent refusal to accept a medical opinion that there are no sufficient somatic causes for the symptoms present, or only a short-term agreement with it (up to several weeks).

4. Presence of at least 6 symptoms from two or more different groups

A. Cardiovascular symptoms:

Shortness of breath without exertion

Chest pain

B. Gastrointestinal symptoms:

Pain in the abdomen

Feeling of heaviness in the abdomen, fullness, bloating Bad taste in the mouth or unusually furred tongue

Vomiting or food regurgitation

B. Genitourinary symptoms:

Dysuria or frequent urination - Discomfort in or around the genitals

Unusual or very heavy vaginal discharge

D. Skin and pain symptoms:

Spotting or discoloration of the skin

Pain in limbs and joints

Numbness or paresthesia

In somatization disorder, the above symptoms last for at least two years.

hypochondriacal disorder

Hypochondria is the patient's belief in the presence of a serious illness, manifested by obsessive overvalued ideas or delusions. Unlike patients with somatized and undifferentiated somatoform disorders, patients with hypochondria are not only burdened by somatic discomfort, but also experience the fear of having a serious, life-threatening disease that they have not yet found. The symptoms are varied, often affecting the gastrointestinal and cardiovascular systems. Ordinary sensations and phenomena are interpreted as unpleasant. The patient may name the suspected somatic disease, however, the degree of conviction in the presence of severe pathology varies from consultation to consultation, and the patient considers one disease to be probable, then another. Often the patient assumes that in addition to the main disease, there is an additional one. Also, hypochondriacal disorder is characterized by monotonous, emotionally inexpressive presentation of complaints, supported by extensive medical documentation. Usually the patient flares up when trying to dissuade.

Somatoform autonomic dysfunction

Unlike other somatoform disorders, the clinical picture consists of a clear involvement of the ANS and subjective complaints regarding a specific organ or system as the cause of the disorder, and if they are similar in nature to those in the disorders discussed above, then their localization does not change with the course of the disease.

One of the most frequent in the structure of somatoform vegetative dysfunction of the cardiovascular system is cardialgic syndrome, which is characterized by polymorphism and variability, lack of clear irradiation, occurrence at rest against the background of emotional stress, lasting hours - days, physical activity does not provoke, but relieves pain. Often cardialgia is accompanied by anxiety, patients do not find a place for themselves, groan and groan. The sensation of palpitations in this type of disorder is accompanied by an increase in heart rate up to 110-120 beats per minute in only half of the cases, it increases at rest, especially in the supine position. An unstable increase in pressure up to 150-160 / 90-95 mm Hg, which appears on the background of stress, can also occur with somatoform disorders. Characteristically, in the treatment of greater efficiency compared with antihypertensive drugs have tranquilizers. In addition, the so-called. Excited Heart Syndrome or Da Costa Syndrome, which includes palpitations, shortness of breath, fatigue, and chest pain.

The structure of somatoform autonomic dysfunctions of the gastrointestinal tract includes dysphagia, which occurs against the background of acute psychotrauma, accompanied by painful sensations in the retrosternal region. Its peculiarity is that as a result of a functional spasm of the esophagus, it is usually easier to swallow solid food than liquid food. Gastralgias are characterized by instability and lack of connection with food intake. Characteristic for somatoform disorders are also aerophagia, accompanied by a feeling of tightness in the chest and frequent belching of air, hiccups, which usually appears in a public place and resembles a cock crow. Attention is drawn to the absence of signs of pulmonary heart failure, even with a long course of the disease, and the discrepancy between complaints and often normal pneumotachometry.

Chronic somatoform pain disorder

The leading complaint in chronic somatoform pain disorder is persistent, severe and mentally depressing pain in some area of ​​the body that lasts more than 6 months and which cannot be explained by a physiological process or a somatic disorder. It appears in emotional conflict, which can be regarded as its main cause. The onset is usually sudden with increasing intensity over weeks to months. A characteristic feature of this pain is its strength, constancy, inability to stop with conventional analgesics.

The peculiarity of reactions to diagnostic interventions and symptomatic therapy also testifies in favor of somatoform disorder: paradoxical relief from diagnostic manipulations;

a tendency to change the leading somatic syndrome (from exacerbation to exacerbation, and sometimes within the same phase);

instability of the obtained therapeutic effect; prone to idiosyncratic reactions.

Treatment must be preceded by a careful search for a possible organic cause of suffering, the absence of which supports the diagnosis of a somatoform disorder. Patients are almost never able to accept the idea of ​​the mental nature of painful somatic sensations. Therefore, the treatment program should be strictly individualized with an optimal combination of pharmacotherapy, psychotherapy, behavioral methods, social support and carried out in collaboration with a psychiatrist and psychotherapist, mainly on an outpatient basis. Only with a long-term non-remission course of the disease, resistance to standard therapeutic regimens, treatment in a specialized department is possible. Pharmacotherapy:

tranquilizers - short-term (up to 1.5 weeks) or intermittent course of treatment; beta-blockers;

tricyclic antidepressants - small and medium doses in combination with tranquilizers and / or beta-blockers;

selective serotonin reuptake inhibitors (small and medium doses) in combination with tranquilizers, citalopram is preferred, fluvoxamine can also be used. Of the other antidepressants - mianserin.