Psychotic and non-psychotic mental disorders. Non-psychotic mental disorders of a pochranial nature

Epilepsy is one of the most common neurological mental illness: its prevalence in the population is in the range of 0.8–1.2%.

It is known that mental disorders are an essential component of the clinical picture of epilepsy, complicating its course. According to A. Trimble (1983), A. Moller, W. Mombouer (1992), there is a close relationship between the severity of the disease and mental disorders, which are much more common in the unfavorable course of epilepsy.

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

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

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

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

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

Depressive spectrum disorders include the following options:

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

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

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

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

4. Anxiety depressions and subdepressions occurred in 8.7% of patients. Anxiety, as a component of an attack (more rarely, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experience vague fear or anxiety, the cause of which they do not understand. Short-term anxious affect (several minutes, less often within 12 hours), as a rule, is characteristic of a variant of phobias, as a component of a seizure (within the aura, the seizure itself or the post-seizure state).

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

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

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

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

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

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

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

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

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

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

Aura with affective experiences not uncommon component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension, a feeling of "lightheadedness". Pleasant sensations are less often observed (an increase in vitality, a feeling of special lightness and high spirits), which are then replaced by an anxious expectation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either the affect of fear and anxiety can occur, or a neutral (rarely excitedly upbeat) mood is noted.

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

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

With the localization of the focus in the right temporal lobe depressive disorders are more common and have a more delineated clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with a different plot of phobias and episodes of arousal. The specified clinic fits completely into the allocated ｫright-hemispheric affective disorderｻ in the systematics of organic syndromes of the ICD10.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Principles of therapy

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

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

AT recent times widely used anti-anxiety and sedative effect clonazepam , which is highly effective in absence seizures.

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

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

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

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

Characteristic disorders for borderline conditions:

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

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

Clinical diagnostics

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

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

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

Assessment of present symptoms

What matters is not a single symptom or syndrome in itself, but its assessment in conjunction with other psychopathological manifestations, their visible and hidden causes, the rate of increase and stabilization of general neurotic and more specific psychopathological disorders of the neurotic level (senestopathies, obsessions, hypochondria). In the development of these disorders, both psychogenic and physiogenic factors are important, most often their diverse combination. The causes of neurotic disorders are far from always visible to others, they may lie in the personal experiences of a person, primarily due to the discrepancy between the ideological and psychological attitude and physical capabilities of reality. This discrepancy can be seen as follows:

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

What is included in borderline disorders

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

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

What to consider when diagnosing:

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

The pathogenesis of reactive states

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

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

Of decisive importance for the emergence of a reactive state or psychosis are the nature and strength of mental trauma, on the one hand, and constitutional features and the premorbid state, on the other. Mental trauma is divided into sharp and chronic, sharp, in turn, - on shock, oppressive and disturbing. Reactive states occur more easily in psychopathic personalities, as well as in persons weakened by infections, severe somatic diseases, intoxication, traumatic brain injuries, vascular diseases, prolonged insomnia, severe beriberi, etc. The age factor can also play a predisposing role. The most vulnerable to external influences are pubertal and menopause. Age also matters in the design of the clinical picture of psychosis. Thus, paranoid reactions and psychoses with delusional syndromes are more characteristic of adulthood. In addition, in the occurrence and clinical implementation of the reactive state play a role individual characteristics patient, type nervous system. The mechanism of the emergence of reactive states in the aspect of the doctrine of higher nervous activity can be explained as a disruption of the normal activity of the cerebral cortex as a result of an overstrain of the irritable and inhibitory processes or their mobility. A strong psycho-traumatic effect is exerted by a "mistake" of the irritable and inhibitory processes (concealed grief, suppressed anger, etc.).

Clinical picture of mental disorders associated with stress

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

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

Stress-related mental disorders are classified as:

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

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

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

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

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

Psychomotor retardation may not reach the degree of stupor. In these cases, patients are available for contact, although they answer briefly, with a delay, drawing out words. Motor skills are constrained, movements are slow. The consciousness is narrowed or the patient is stunned. In rare cases, in response to sudden and strong psycho-traumatic effects, the so-called emotional paralysis occurs: prolonged apathy with an indifferent attitude to a threatening situation and an indifferent registration of what is happening around. In some cases, on the basis of the transferred acute reaction of fear, a protracted neurosis of fear may develop in the future.

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

Depressive psychogenic reactions (reactive depression)

Death loved one, severe life failures are capable of causing a natural psychological reaction of sadness in healthy people. Pathological reaction differs from the normal excessive force and duration. In this state, patients are depressed, dreary, tearful, walk hunched over, sit in a bent position with their heads down on their chests, or lie with their legs crossed. Ideas of self-accusation are not always present, but usually experiences are concentrated around the circumstances associated with mental trauma. Thoughts about an unpleasant incident are relentless, detailed, often become overvalued, sometimes reaching the degree of delirium. Psychomotor retardation sometimes reaches a depressive stupor; patients lie or sit all the time, hunched over, with a frozen face, with an expression of deep melancholy or hopeless despair, they are lack of initiative, cannot serve themselves, the environment does not attract their attention, complex issues are not comprehended.

Reactive depression is sometimes combined with individual hysterical disorders. In these cases, depression is manifested by a shallow psychomotor retardation, an affect of melancholy with expressive external symptoms that do not correspond to the depth of depression: patients gesticulate theatrically, complain of an oppressive feeling of longing, take tragic poses, cry loudly, demonstrate suicidal attempts. During the conversation, they perk up, scold their offenders, at the mention of a traumatic situation, they get excited up to bouts of hysterical despair. Often there are separate puerile, pseudo-dementia manifestations.

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

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

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

Reactive paranoid delusions - the emergence of paranoid overvalued delusions that do not go beyond the traumatic situation, "psychologically understandable" and accompanied by a lively emotional reaction. These ideas dominate in consciousness, but at the first stages patients still give in to some dissuasion. In all other behavior of the patient, not associated with an overvalued idea, no noticeable deviations are found. Reactive paranoid delirium, like all reactive states, lasts until the traumatic situation disappears, and completely reflects it, it is not characterized by progressiveness, and negative symptoms do not appear. All these features distinguish reactive paranoid states from schizophrenic ones. Paranoid reactive disorders have many individual variants due to the characteristics of psychogenic effects.

Acute paranoid reaction - paranoid delusions, characteristic of psychopathic (paranoid) personalities. Relatively small everyday difficulties can cause them suspicion, anxiety, ideas of attitude and persecution. Such reactions are usually short-lived. Their development is facilitated by a temporary weakening of the nervous system (overwork, lack of sleep, etc.).

hypochondriacal reaction close in structure to acute paranoid. It usually develops in people with increased attention to their health. A doctor's careless phrase (iatrogenesis), a misunderstood medical text, the news of the death of a friend can lead to the emergence of a hypochondriacal overvalued idea. Patients begin to visit different doctors, specialist consultants, and negative test results do not bring peace. Depending on the characteristics of the patient's personality and the behavior of the doctor, hypochondriacal reactions are short-lived or delayed for years.

Delusions of persecution of the deaf occurs in people with hearing loss due to difficulty in verbal contact with others. Similar conditions are also observed when communication is difficult due to ignorance of the language (delusions of persecution in a foreign language environment).

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

Diagnosis of reactive paranoids usually does not cause much difficulty. The main reference criteria: situational conditionality, specific, figurative, sensual delirium, the connection of its content with a traumatic situation and the reversibility of this state when the external environment changes.

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

Paranoid external environment (situational) - acute delusional psychosis; arises suddenly, sometimes without any precursors, in an extremely unusual (new) situation for the patient. This is an acute figurative delusion of persecution and an unusually sharp affect of fear. The patient, trying to save his life, is thrown out of the train on the move, sometimes defending himself with a weapon in his hands from imaginary pursuers. Suicide attempts are not uncommon in order to get rid of the expected torment. Patients can seek protection from persecutors from government officials, policemen, and military personnel. At the height of the affect of fear, there is a disturbance of consciousness, followed by partial amnesia for a specified period of time. At the height of psychosis, false recognitions, a symptom of a double, can be observed. Prolonged overwork, insomnia, somatic weakness, and alcoholism contribute to the emergence of such acute paranoids. Such paranoids are usually short-lived, and when the patient is removed from this situation, delusional ideas disappear, he calms down, and criticism of psychosis appears.

In a forensic psychiatric clinic, psychogenic paranoids and hallucinosis are now rare.

Hysterical reactions or psychosis appear in relatively small numbers. clinical forms(options):

• 1) hysterical twilight clouding of consciousness (Ganzer syndrome);
• 2) pseudodementia;
• 3) puerilism;
• 4) psychogenic stupor.

Hysterical twilight clouding of consciousness, or Ganser's syndrome, manifested by an acute twilight disorder of consciousness, "mimorechi" phenomena (incorrect answers to simple questions), hysterical sensitivity disorders and sometimes hysterical hallucinations. The disease is acute and lasts for several days. After recovery, the entire period of psychosis and the psychopathological experiences observed in its structure are forgotten. At present, this syndrome practically does not occur in the forensic psychiatric clinic.

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

The syndrome of pseudodementia is formed gradually against the background of depressive-anxious mood, more often in persons with an organic mental disorder of a traumatic, vascular or infectious nature, as well as in psychopathic personalities of emotionally unstable and hysterical types. In contrast to the Ganser syndrome, pseudodementia occurs against the background of a hysterically narrowed, rather than a twilight disorder of consciousness. With timely therapy, and sometimes without it, pseudodementia undergoes regression in 2-3 weeks and all mental functions are restored.

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

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

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

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

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

In other cases, delusional fantastic ideas are more complex and persistent, showing a tendency to systematization. Just as with unstable, changeable fantastic constructions, all anxieties, worries, and fears of patients are not connected with the content of ideas, but with a real unfavorable situation. Patients can talk for hours about their "projects" and "works", emphasizing that in comparison with the "great significance of their discoveries" their fault is negligible. During the period of reactive psychosis regression, situational depression comes to the fore, fantastic statements turn pale, reviving only for a short time when the patients are agitated.

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

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

Perhaps the complication of the clinical picture of depression, a combination with other hysterical manifestations (pseudo-dementia, puerilism).

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

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

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

Neurasthenia is the most common form of neurosis, it develops more often in individuals with an asthenic constitution in conditions of prolonged insoluble conflict situation causing constant mental stress. In the clinical picture, the leading place is occupied by asthenic syndrome, which is characterized by a combination of asthenia proper with autonomic disorders and sleep disorders. Asthenia is characterized by phenomena of mental and physical exhaustion. Increased fatigue is accompanied by a constant feeling of fatigue. Increased excitability that appears at the beginning, incontinence is subsequently combined with irritable weakness, intolerance to ordinary stimuli - loud sounds, noise, bright light. In the future, the components of the actual mental and physical asthenia become more and more pronounced. As a result of a constant feeling of fatigue and physical lethargy, there is a decrease in working capacity, due to the exhaustion of active attention and distraction of attention, the assimilation of new material, the ability to memorize worsens, and a decrease in creative activity and productivity is noted. Decreased mood can acquire a depressive color with the formation in some cases of neurotic depression. Constant manifestations of neurasthenia are also diverse vegetative disorders: headaches, sleep disturbances, fixing attention on subjective unpleasant physical sensations. The course of neurasthenia is usually long and depends, on the one hand, on the cessation or continued action of the traumatic situation (especially if this situation causes constant anxiety, expectation of trouble), on the other hand, on the characteristics of the personality and the general condition of the body. Under changed conditions, the symptoms of neurasthenia may disappear completely.

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

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

Hysterical movement disorders accompanied by tears, groans, cries. Hysterical paralysis and contractures are noted in the muscles of the limbs, sometimes the muscles of the neck, trunk. They do not correspond to the anatomical muscle innervation, but reflect the patient's ideas about the anatomical innervation of the limbs. With long-term paralysis, secondary atrophies of the affected muscle groups may develop. In the past, the phenomena of astasia-abasia were often encountered, when, with the complete preservation of the musculoskeletal system, patients refused to stand and walk. Lying in bed, the patients were able to make certain voluntary movements with their limbs, they could change the position of the body, but when they tried to put them on their feet, they fell and could not lean on their feet. In recent decades, these disorders have given way to less pronounced movement disorders in the form of weakness of individual limbs. Hysterical paralysis is more common vocal cords, hysterical aphonia (loss of sonority of the voice), hysterical spasm of one or both eyelids. With hysterical mutism (dumbness), the ability of written speech is preserved and arbitrary movements of the tongue are not violated. Hysterical hyperkinesis is often observed, which manifests itself in trembling of the limbs of various amplitudes. Trembling increases with excitement and disappears in a calm environment, as well as in sleep. Sometimes there are tics in the form of convulsive contractions of individual muscle groups. Convulsive phenomena on the part of speech are manifested in hysterical stuttering.

Sensory hysteria disorders most often manifested in a decrease or loss of skin sensitivity, which also does not correspond to the zones of innervation, but reflects ideas about the anatomical structure of the limbs and parts of the body (like gloves, stockings). Pain can be experienced in various parts of the body and various organs. Quite often there are violations of the activity individual bodies feelings: hysterical blindness (amaurosis), deafness. Often, hysterical deafness is combined with hysterical mutism, and a picture of hysterical deaf-muteness (deaf-muteness) arises.

Autonomic disorders are diverse. Spasm of smooth muscles is often noted, which is associated with such typical hysterical disorders as a feeling of a lump in the throat, a feeling of obstruction of the esophagus, a feeling of lack of air. Often there is hysterical vomiting, which is not associated with any disease gastrointestinal tract and is due solely to spasm of the pylorus of the stomach. There may be functional disorders of the internal organs (for example, palpitations, vomiting, shortness of breath, diarrhea, etc.), which usually occur in a subjectively traumatic situation.

Mental disorders also expressive and varied. Emotional disorders predominate: fears, mood swings, states of depression, depression. At the same time, very superficial emotions are often hidden behind external expressiveness. Hysterical disorders when they occur usually have the character of "conditional desirability". In the future, they can be fixed and re-reproduced in subjectively difficult situations according to the hysterical mechanisms of "escape to the disease." In some cases, the reaction to a traumatic situation is manifested in increased fantasizing. The content of fantasies reflects the replacement of reality with fictions of contrasting content, reflecting the desire to escape from an unbearable situation.

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

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

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

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

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

Phobias can be accompanied by obsessive movements and actions that occur simultaneously with phobias, they are given a protective character and they quickly take the form of rituals. Ritual actions are aimed at preventing an imaginary misfortune, they have a protective, protective character. Despite the critical attitude towards them, they are produced by patients contrary to reason in order to overcome obsessive fear. In mild cases, in connection with the complete preservation of criticism and the consciousness of the morbid nature of these phenomena, those suffering from neuroses hide their obsessions and are not excluded from life.

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

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

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

Among protracted reactive psychoses, "erased forms" currently prevail, the frequency and brightness of hysterical manifestations have sharply decreased. Such hysterical symptoms as hysterical paralysis, paresis, phenomena of astasia-abasia, hysterical mutism, which in the past were leading in the clinical picture of protracted reactive psychoses, are practically not observed. The main place is occupied by clinically diverse forms of depression, as well as erased depressive states that do not reach the psychotic level and yet have a protracted course. Patients note a depressed mood, elements of anxiety, they are gloomy, sad, complain of emotional stress, a premonition of misfortune. Usually these complaints are combined with unjustified fears about their health. Patients are fixed on their unpleasant somatic sensations, constantly thinking about the troubles that await them, looking for sympathy from others. This state is accompanied by a more or less pronounced disorganization of mental activity. Patients usually associate their experiences with a real psychotraumatic situation, they are concerned about the outcome of the case.

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

Hysterical depression in its protracted course does not show a tendency to deepen. The leading syndrome, formed in the subacute period of reactive psychosis, remains fixed at a protracted stage. At the same time, the expressiveness of emotional manifestations inherent in hysterical depression, the direct dependence of the main mood on the characteristics of the situation, the constant readiness to intensify affective manifestations with aggravation of circumstances associated with this situation or only during conversations on this topic. Therefore, the depth of depression has a wave-like character. Quite often, in the clinical picture of depression, individual unstable pseudo-dementia-puerile inclusions or delusional fantasies are noted, reflecting the hysterical tendency to "escape into the disease", avoiding an unbearable real situation, se hysterical repression. Hysterical depression can be prolonged - up to two years or more. However, in the process of treatment or with a favorable resolution of the situation, sometimes an unexpectedly acute, but more often a gradual exit from a painful state occurs without any subsequent changes in the psyche.

In persons who have undergone prolonged hysterical depression, with the resumption of a traumatic situation, relapses and repeated reactive psychoses are possible, the clinical picture of which reproduces the symptoms of the initial reactive psychosis according to the type of worked out clichés.

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

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

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

The proportion of identified cases of the presence of mental disorders in patients with psychosomatic disorders remains unknown. It is believed that about 30% of the adult population, due to various life circumstances, experience short depressive and anxiety episodes of a non-psychotic level, of which no more than 5% of cases are diagnosed. "Subsyndromic" and "prenosological" changes mental sphere, more often, manifestations of anxiety that do not meet the diagnostic criteria for ICD-10 are generally ignored by mental health professionals. Such disorders, on the one hand, are objectively difficult to detect, and on the other hand, persons who are in a state of mild depression or anxiety, rarely proactively seek medical help, subjectively regarding their condition as purely personal psychological problem does not require medical intervention. However, subsyndromal manifestations of depression and anxiety, according to the observations of general practitioners, exist in many patients and can significantly affect the state of health. In particular, a relationship has been shown between subsyndromic symptoms of anxiety and depression and development.

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

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

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

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

Stages of therapy:

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

An atmosphere of trust was created, active participation in the fate of the patient: in the shortest possible time, it was necessary to choose a strategy and tactics for managing the patient, analyze internal and external influences, outlining the ways of adequate therapy, and give a prognostic assessment of the condition under study: the main requirement of this regimen was constant within the framework of a specialized hospital (better in the conditions of separation of borderline conditions). The "crisis" stage lasted 7 - 14 days.

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

The "basic" stage provided for a more thorough examination of the "internal picture of the disease" of relative stabilization, which acquires an earlier character (due to the restructuring of interpersonal relations, changes in social status). The main medical work was carried out precisely at this stage and consisted in overcoming the constitutional and biological basis of the disease and mental crisis. This regimen was assessed as a treatment-activating and took place in a specialized hospital (department of borderline conditions). The "basic" stage lasted from 14 to 21 days.

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

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

As can be seen from the table, complete and practical recovery was observed: in the group of patients with hypertension in 98.5% of cases, in the group of patients with peptic ulcer in 94.3%, in the group of patients with bronchial asthma- 91.5%. There were no remissions of types "D" and "E" in our observations.

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

What is and how are mental disorders expressed?

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

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

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

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

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

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

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

Non-psychotic disorders are manifested mainly by psychological phenomena inherent and healthy people. It's about mood changes, fears, anxiety, sleep disturbances, intrusive thoughts and doubts, etc.

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

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

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

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

Psychosis is also associated with gross behavioral disorders.

WHAT IS PSYCHOSIS?

About what is psychosis.

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

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

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

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

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

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

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

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

COURSE AND FORECAST OF PSYCHOSIS.

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

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

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

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

One of the most important factors that affect the prognosis of psychotic disorders is the timeliness of the start and the intensity of active therapy in combination with socio-rehabilitation measures.