affective disorders. Mental disorders due to organic pathologies of the brain

MENTAL DISORDERS IN CRANIO-BRAIN INJURY

Traumatic brain injury (TBI) is one of the most common causes of death and permanent disability. The number of patients with traumatic brain injuries increases by 2% annually. The structure of peacetime injuries is dominated by domestic, transport, industrial, sports injuries. Of great medical importance are complications of traumatic brain injury, such as the development of traumatic cerebrovascular disease, encephalopathy, epileptiform syndrome, pathocharacterological disorders, dementia, as well as their impact on the social adaptation of patients. In more than 20% of cases, skull injuries are the cause of disability due to neuropsychiatric diseases.

There are 5 clinical forms of TBI:

concussion - characterized by a loss of consciousness lasting from a few seconds to several minutes;

mild brain contusion - characterized by a loss of consciousness after an injury lasting from several minutes to 1 hour;

brain contusion of moderate degree - is characterized by a loss of consciousness after an injury lasting from several tens of minutes to 4-6 hours;

severe brain contusion - characterized by a loss of consciousness after an injury lasting from several hours to several weeks;

compression of the brain - characterized by life-threatening cerebral, focal and stem symptoms that occur some time after the injury and are of an increasing nature.

The severity of the victim's condition is determined, first of all, by a violation of the functions of the brain stem and life support systems of the body (respiration, blood circulation). One of the leading signs of damage to the brain stem and parts of the brain located directly above it is a violation of consciousness.

There are 5 gradations of the state of consciousness in TBI.

clear consciousness - complete preservation of consciousness with adequate reactions to surrounding events;

stunning - a violation of perception while maintaining limited verbal contact against the background of an increase in the threshold of perception of external stimuli and a decrease in one's own activity;

sopor - turning off consciousness while maintaining coordinating defensive reactions and closing the eyes in response to pain, sound and other stimuli;

coma - turning off consciousness with a complete loss of perception of the surrounding world and oneself.

Violation of vital functions should also be assessed, which is often associated with damage to the brain stem. These violations are evaluated according to the following criteria:

1) moderate violations:

moderate bradycardia (51-59 per minute) or tachycardia (81-100 per minute);

moderate arterial hypertension (140/80-180/100 mm Hg) or hypotension (below 110/60-90/50 mm Hg);

2) pronounced violations:

bradycardia (41-50 per minute) or tachycardia (101-120 per minute);

tachypnea (31-40 per minute) or bradypnea (8-10 per minute);

Arterial hypertension (180/100-220/120 mm Hg) or hypotension (less than 90/50-70/40 mm Hg);

3) gross violations:

bradycardia (less than 40 per minute) or tachycardia (over 120 per minute);

tachypnea (over 40 per minute) or bradypnea (less than 8 per minute);

arterial hypertension (over 220/180 mm Hg) or hypotension (maximum pressure less than 70 mm Hg);

4) critical violations:

intermittent breathing or apnea;

maximum blood pressure less than 60 mm Hg. Art.;

One of the main and immediate causes The death of victims with severe TBI is the process of acute intracranial dislocation. Its danger is due to the development of axial deformation of the brain stem with its subsequent destruction as a result of irreversible dyscirculatory disorders. An additional, but very important criterion for assessing TBI and its severity is the condition of the head integument. Their damage in conditions of damage to the brain and its barrier functions increases the risk of purulent-septic complications. In this regard, there are:

Closed TBI, in which there is no violation of the integrity of the integument of the head or there are wounds that do not penetrate into the aponeurosis, fractures of the bones of the base of the skull, which are not accompanied by a wound in the nearby area of ​​the scalp;

Open TBI when there are head wounds with damage to the aponeurosis, fractures of the bones of the cranial vault with injury to nearby soft tissues, fractures of the base of the skull, accompanied by bleeding or liquorrhea (ear, nasal):

a) non-penetrating injury - the dura mater remains intact;

b) penetrating trauma - the integrity of the dura mater is violated.

CLASSIFICATION OF MENTAL DISORDERS AS A RESULT OF CRANIO-BRAIN INJURY

The most acute initial period. Stunning, stupor, coma, impaired cardiovascular activity and respiration.

acute period. Non-psychotic syndromes: asthenic, apathicoabolic, epileptiform seizures, anterograde and retrograde amnesia, surdomutism. Psychotic syndromes: twilight state of consciousness, traumatic delirium, dysphoria, Korsakov's syndrome.

late period. Non-psychotic disorders: asthenic, asthenoneurotic, epileptiform, psychopathic (affective instability) syndromes. Late traumatic psychoses: hallucinatory-paranoid, manic-paranoid, depressive-paranoid syndromes.

Long-term consequences of TBI. Cerebrosthenia, encephalopathy, dementia, traumatic epilepsy, post-traumatic personality development.

Mental disorders of the most acute period are mainly represented by states of turning off consciousness of varying degrees: coma, stupor, stupor. The depth of impaired consciousness depends on the mechanism, localization and severity of the injury. With the development of a coma, consciousness is completely absent, patients are immobile, their breathing and cardiac activity are disturbed, blood pressure decreases, pathological reflexes occur, and there is no pupillary reaction to light. In most patients, after mild or moderate traumatic brain injury, stunning develops, characterized by a slowdown in thinking, incomplete orientation. Patients are drowsy, react only to strong stimuli. After exiting the stun, fragmentary memories of this period are possible.

In the acute period of a skull injury, asthenic, asthenoneurotic conditions develop, less often - surdomutism, antero- and retrograde amnesia, some patients develop psychoses that occur in the form of states of altered consciousness: delirium, epileptiform disturbance, twilight disorder of consciousness that occurs immediately after leaving the unconscious state . With asthenic syndrome in the acute period of traumatic brain injury, there is a decrease in mental productivity, increased fatigue, a feeling of fatigue, hyperesthesia, autonomic disorders, and a decrease in motor activity. Patients often complain about headache, clouding of consciousness.

Delirium most often develops in patients who abuse alcohol, or with the development of toxic-infectious complications. Such patients are mobile, jump up, try to run somewhere, experience frightening visual hallucinations. Traumatic delirium is characterized by the presence of vestibular disorders. Prognostically unfavorable is the transition of the delirious syndrome to amental. The twilight state of consciousness develops most often in the evening, manifesting itself as complete disorientation, jerky delusional ideas, individual hallucinations, fear, and motor disorders. The exit from the twilight state occurs through sleep with further amnesia of painful experiences. The twilight state of consciousness can proceed with attacks of motor excitation, stuporous state, motor automatisms, puerile-pseudo-dement behavior.

In the acute period, patients may develop individual or serial epileptiform seizures, hallucinosis, most often auditory, as well as visual and tactile. In cases of severe traumatic brain injury, after the patient comes out of a coma, the development of Korsakoff's syndrome with fixation, retro- or anterograde amnesia, confabulations and pseudo-reminiscences is possible. Sometimes patients lose the ability to critically assess the severity of their condition. Korsakov's syndrome can be transient and disappear after a few days, or it can take a long time and lead to the formation of organic dementia.

The duration of the acute period of traumatic brain injury ranges from 2-3 weeks to several months. During this period, the development of traumatic affective and affective-delusional psychoses is also possible, in which exogenous factors play a significant role: physical activity, fatigue, intoxication, infectious diseases, etc. The clinical picture of these disorders is represented by manic, depressive and affective-delusional disorders, which are combined with confabulations. Depressive states are accompanied by hypochondriacal delusions. The most common are manic states with euphoria, delusions of grandeur, anosognosia, moderate physical activity with the rapid development of exhaustion, headache, lethargy, drowsiness, which disappear after rest. Often there is a mania of anger.

During the period of convalescence or in the late period of acute traumatic disorders, subacute and prolonged traumatic psychoses are observed, which may have a tendency to relapse and a periodic course.

Mental disorders of the remote period are characterized by different variants of the psycho-organic syndrome within the framework of traumatic encephalopathy. The severity of the formed defect is determined by the severity of the traumatic brain injury, the amount of brain damage, the age of the victim, the quality of the treatment, hereditary and personality traits, personality attitudes, additional exogenous hazards, somatic state, etc. Most frequent consequence TBI is a traumatic cerebral palsy that develops in 60-75% of cases. The clinical picture of the disease is dominated by weakness, mental and physical performance combined with irritability and fatigue. Short-term outbreaks of irritability are noted, after which patients, as a rule, regret their incontinence. Autonomic disorders are manifested by fluctuations in blood pressure, tachycardia, clouding of consciousness, headache, sweating, vestibular disorders, sleep-wake rhythm disorder. Patients do not tolerate a trip in transport, they cannot swing on a swing, look at a TV screen or moving objects. Often they complain about the deterioration of health when the weather changes and stay in a stuffy room.

Torpidity and rigidity of nervous processes are characteristic. The ability to quickly switch between activities decreases, and the forced need to perform such work leads to decompensation of the state and an increase in severe cerebrosthenic symptoms.

Traumatic cerebral palsy is often combined with various neurosis-like symptoms, phobias, hysterical reactions, autonomic and somatic disorders, anxiety and subdepressive symptoms, autonomic paroxysms.

Traumatic encephalopathy develops as a result of residual effects of organic brain damage, the localization and severity of which determine the features of the clinical picture - psychopathic syndromes, traumatic psychoses, or defective organic conditions. Most often, affective disorders occur against the background of psychopathic disorders of excitable and hysterical types. Patients with an apathetic variant of encephalopathy are characterized by severe asthenic disorders, mainly exhaustion and fatigue, they are lethargic, inactive, there is a decrease in their range of interests, memory impairment, and difficulty in intellectual activity.

In traumatic encephalopathy, emotional arousal predominates more often than lethargy. Such patients are rude, quick-tempered, prone to aggressive actions. They have mood swings, easily occurring outbursts of anger that are not adequate to the cause that caused them. Productive activity can be hindered by affective disturbances, which further causes self-dissatisfaction and irritation reactions. The thinking of patients is characterized by inertia, a tendency to get stuck on unpleasant emotional experiences. It is possible to develop dysphoria in the form of bouts of melancholy-angry or anxious mood lasting several days, during which patients can commit aggressive and auto-aggressive acts, show a tendency to vagrancy (dro-mania).

In addition to traumatic encephalopathy, in the late period of traumatic brain injury, cyclothymoid-like disorders may develop, which are usually combined with asthenic or psychopathic syndromes and are accompanied by a dysphoric component. The most common subdepressive states are characterized by suspiciousness, tearfulness, senestopathies, vegetovascular disorders, hypochondriacal mood regarding one's health, sometimes reaching the degree of overvalued ideas with the desire to receive exactly the treatment that, according to the patient, he needs.

The symptomatology of hypomanic states is characterized by an enthusiastic attitude of patients to the environment, emotional lability, and weakness of mind. It is also possible the appearance of overvalued ideas about one's health, litigious behavior, increased irritability, a tendency to conflict. The duration of these states is different. Monopolar seizures are common. Alcohol abuse often occurs against the background of affective disorders.

epileptiform paroxysmal disorders(traumatic epilepsy) can form in different dates after a traumatic brain injury, most often after a few years. They differ in polymorphism - there are generalized, Jacksonian seizures, non-convulsive paroxysms: absences, catalepsy attacks, so-called epileptic dreams, psychosensory disorders (metamorphopsia and body schema disorders). Perhaps the appearance of vegetative paroxysms with severe anxiety, fear, hyperpathy and general hyperesthesia. Quite often, after convulsive seizures, twilight states of consciousness occur, which usually indicates an unfavorable course of the disease. They are often caused by additional exogenous factors, primarily alcohol intoxication, as well as mental trauma. The duration of twilight states is insignificant, but sometimes reaches several hours.

In the late period of traumatic brain injury, so-called endoform psychoses can be observed: affective and hallucinatory-delusional, paranoid.

Affective psychoses proceed in the form of monopolar manic or (less often) depressive states and are characterized by an acute onset, alternating euphoria and anger, and Morio-like mindless behavior. In most cases, a manic state occurs against the background of exogenous factors (intoxication, repeated injuries, surgery, somatic disease).

Depressive states can be provoked by mental trauma. In addition to melancholy, there is anxiety, hypochondriacal experiences with a dysphoric assessment of one's condition and the environment.

Hallucinatory-delusional psychoses, as a rule, occur acutely against the background of symptoms of traumatic encephalopathy with the advantage of apathetic disorders. The risk of the disease increases in patients with somatic disorders, as well as after surgery. Unsystematic specific delusions, real hallucinations, alternation of psychomotor agitation and lethargy are observed, affective experiences are caused by delusions and hallucinations.

Paranoid psychoses develop most often in men within 10 years or more after a traumatic brain injury. The clinical picture is characterized by the presence of overvalued and delusional ideas of jealousy with litigious and querulant tendencies. Paranoid ideas of jealousy can be combined with ideas of damage, poisoning, persecution. Psychosis proceeds chronically and is accompanied by the formation of a psychoorganic syndrome.

Traumatic dementia after traumatic brain injury develops in 3-5% of cases. It may be a consequence of traumatic psychoses or a progressive course traumatic illness with repeated injuries, and also arise as a result of developing cerebral atherosclerosis. In patients with traumatic dementia, memory impairment, a decrease in the range of interests, lethargy, weak-mindedness, sometimes importunity, euphoria, disinhibition of drives, overestimation of one's capabilities, and lack of criticism predominate.

Rare types of injuries in peacetime include blast injury, which is a complex lesion in the form of concussion, brain contusion, trauma to the sound analyzer, cerebrovascular accident due to sharp fluctuations atmospheric pressure. When injured by a blast wave, a person feels, as it were, a blow by an elastic body to the back of the head, he has a short-term loss of consciousness, during which he is immobile, blood flows from his ears, nose, mouth. After clarification of consciousness, pronounced adynamia may develop: patients are inactive, lethargic, indifferent to the environment, they want to lie down even in uncomfortable positions. Retro- and anterograde amnesia are rare, constant complaints - headache, heaviness, noise in the head.

The development of adynamic asthenia, a feeling of physical or mental discomfort, irritability, a feeling of weakness and impotence are possible. Vegetative and vestibular disorders are often noted in the form of headache, confusion, a sudden feeling of heat, shortness of breath, pressure in the head or heart area. Patients show various hypochondriacal complaints, there is hyperesthesia to sounds, light, smells. They often get worse in the evening. The process of falling asleep, as a rule, is disturbed, the dream consists of unpleasant, vivid, often frightening dreams of a military theme.

The most characteristic sign of a traumatic blast injury is deafness. Hearing, as a rule, is restored before speech, patients begin to hear, but cannot speak. Restoration of speech occurs spontaneously under the influence of emotional significant situations. An objective examination reveals mild diffuse neurological symptoms: anisocoria, impaired eye movements, tongue deviation.

The acute period of these disorders ranges from 4 to 6 weeks, then other mental disorders appear. During this period, mood swings are possible, and young people may experience a state of euphoria with increased irritability and a tendency to bouts of anger or hysterical seizures. In adulthood, a depressed mood with a dysphoric tinge or apathy predominates, complaints of poor physical health, hyperesthesia in relation to all stimuli are often noted.

AGE FEATURES OF TRAUMATIC ILLNESS

Development of mental disorders traumatic genesis children have their own characteristics. Head injuries are quite common, especially in children aged 6 to 14 years. Mental disorders in the acute period in children occur against the background of increased intracranial pressure: there are cerebral and meningeal disorders, pronounced vegetative and vestibular symptoms, as well as signs of local brain damage. The most severe symptoms in children develop a few days after the traumatic brain injury. The most frequent of them are paroxysmal disorders, which are observed both in the acute period and in the period of convalescence.

The course of traumatic disease in children is usually benign, even severe local disorders undergo regression. Asthenia in the long-term period is poorly expressed, motor disinhibition, emotional lability, and excitability predominate. Sometimes, after severe traumatic brain injuries suffered in early childhood, an intellectual defect resembling oligophrenia appears.

In young children (up to 3 years), a complete shutdown of consciousness, as a rule, is not observed, cerebral disorders are erased. Clear signs of a traumatic brain injury are vomiting, often repeated, and vegetative symptoms: fever, hyperhidrosis, tachycardia, confusion, etc. Characteristic disturbances in the rhythm of sleep and wakefulness. The child does not sleep at night and is sleepy during the day.

Traumatic cerebral palsy in children is often manifested by a headache that occurs suddenly or under certain conditions (in a stuffy room, while running, in noisy places), confusion and vestibular disorders are less common. Actually, asthenia is mild, motor disinhibition, emotional lability, excitability, vegetative-vascular disorders (increased vasomotor reactions, bright dermographism, tachycardia, hyperhidrosis) predominate.

Apathy-adynamic syndrome in children is characterized by lethargy, apathy, slowness, decreased activity and desire for activity, limited contact with people around them due to rapid exhaustion, lack of interest. These kids can't handle school curriculum, but do not interfere with others and do not cause complaints from teachers.

In children with hyperdynamic syndrome, motor disinhibition, fussiness, and sometimes elevated mood with a hint of euphoria predominate. Children are restless, run, make noise, often jump up, grab some things, but immediately throw them away. The mood is characterized by instability and carelessness. Patients are good-natured, sometimes foolish. There is a decrease in criticism, difficulties in mastering new material. Further development of these disorders often leads to more differentiated psychopathic behavior. Children behave badly in a team, do not learn educational material, violate discipline, interfere with others, and terrorize teachers. Since such patients do not complain about their health, their inappropriate behavior is not regarded as painful for a long time and disciplinary requirements are imposed on them.

Mental disorders in traumatic brain injury in the elderly are usually accompanied by loss of consciousness. In the acute period, vegetative and vascular disorders, confusion, fluctuations in blood pressure predominate, and nausea and vomiting are relatively rare. In connection with the inferiority of the vascular system, intracranial hemorrhages are often observed, which can develop after some time and are manifested by a clinical picture resembling a tumor or epileptiform seizures.

In the remote period, more permanent persistent asthenic disorders, lethargy, adynamia and various psychopathological symptoms are observed.

The pathogenesis of mental disorders. The occurrence of mental disorders in the acute period of traumatic brain injury is due to mechanical damage and swelling of the brain tissue, hemodynamic disorders and brain hypoxia. Conduction of impulses in synapses is disrupted, disorders in mediator metabolism and dysfunction of the reticular formation, brain stem and hypothalamus occur.

Light craniocerebral injuries are accompanied by minor disturbances in the structure of nerve cells with subsequent restoration of their functions, while in severe injuries neurons die with the formation of glial or cystic formations. Synaptic connections between nerve cells- traumatic asynapsia.

The treatment of mental disorders in traumatic brain injuries is determined by the stage of the disease, its severity and the severity of clinical manifestations. All persons, even after a mild head injury, need hospitalization, bed rest for 7-10 days, and children and the elderly should be in the hospital for a longer time.

Therapeutic measures for TBI have several directions..

Support is vital important functions: a) correction of respiratory disorders: restoration of airway patency, tracheostomy, mechanical ventilation; 10 ml of 2.4% solution of aminophylline intravenously; b) correction of violations of systemic hemodynamics: the fight against arterial hypertension(clofelin, dibazol, chlorpromazine); the use of intramuscularly lytic mixtures containing neurotropic, antihistamine and vasoplegic agents (pipolphen 2 ml + tizercin 2 ml + analgin 2 ml + droperidol 4-6 ml or pipolfen 2 ml + chlorpromazine 2 ml + pentamine 20-40 mg + analgin 2 ml ) 4-6 times a day; fight against arterial hypotension infusion therapy- reopoliglyukin or 5% albumin solution) + 0.5-1 ml of 0.6% corglicon solution and 10 ml of 10% calcium chloride solution for every 500 ml of fluid injected.

Specific treatment: a) concussion: bed rest for 1-2 days; analgesics; tranquilizers; b) brain contusion of mild and moderate severity: improvement of cerebral circulation (intravenous drip reopoliglyukin or 5% albumin solution + intravenous cavinton); improvement of the energy supply of the brain (intravenously drip 5-20% glucose solution + insulin); restoration of the function of the blood-brain barrier (eufillin, papaverine, 5% ascorbic acid solution); elimination of pathological changes in the water sectors of the brain (combined use of saluretics - lasix, furosemide, urex, hypothiazide - and osmodiuretics - mannitol, glycerin); in the presence of subarachnoid hemorrhage (5% solution of aminocaproic acid, countercal, trasilol, Gordox intravenously 25,000-50,000 IU 2-3 times a day); anti-inflammatory therapy (combination of penicillin and long-acting sulfanilamide); metabolic therapy (nootropil, cerebrolysin); c) severe brain contusion and acute traumatic compression: emergency surgical intervention aimed at eliminating the causes of compression and its consequences; energy supply of the brain (glucose solution + insulin + 10% calcium chloride solution for every 500 ml of solution); improvement of cerebral circulation (reopoliglyukin, albumin); elimination of brain hypoxia (sodium thiopental 2-3 mg per 1 kg of body weight per hour for 8-10 days after injury or gamma hydroxybutyric acid (GHB) 25-50 mg per 1 kg of body weight per hour for 8-10 days + hyperbaric oxygenation, oxygen mask); correction of intracranial hypertension (dehydration, corticosteroids, aldosterone antagonists).

MINISTRY OF JUSTICE OF THE RUSSIAN FEDERATION

STATE EDUCATIONAL INSTITUTION

HIGHER PROFESSIONAL EDUCATION

"RUSSIAN LEGAL ACADEMY

OF THE MINISTRY OF JUSTICE OF THE RUSSIAN FEDERATION»

Kaluga (Kaluga) branch

ON THE TOPIC: Mental disorders in brain injuries

Performed:

INTRODUCTION…………………………………………………………………………2

CLINICAL PICTURE…………………………………………………..3

SYNDROMES OF CONSCIOUSNESS DURING CRANIO-BERIN INJURY……………………………………………………………………………..6

MEMORY DISORDER IN Craniocerebral Injury…….9

TRAUMATIC EPILEPSY AND MENTAL DISORDERS WITH IT …………………………………………………………………………..12

PECULIARITIES OF CLOSED BRAIN INJURY IN CHILDREN………………………………………………………………………………14

FORENSIC PSYCHIATRIC EXAMINATION………………………..15

CONCLUSION………………………………………………………………….17

REFERENCES………………………………………………………...18

INTRODUCTION

Any head injury is fraught with the danger of future complications. Currently, craniocerebral occupies one of the leading places in brain damage and is most widespread in young working age, and severe forms often lead to death or disability.

In connection with the acceleration of the pace of life, the problem of traumatic brain injuries in general and mental disorders associated with them in particular is becoming increasingly relevant. The most common cause of this group of disorders is morphological structural damage to the brain as a result of traumatic brain injury.

Due to brain damage, the physicochemical properties of the brain and metabolic processes change, in general, the normal life activity the whole organism. Among all exogenous - organic diseases traumatic brain injury ranks first, with buried traumatic brain injuries accounting for about 90%. Mental disorders caused by trauma are determined by the nature of the trauma, the conditions for its receipt, and the premorbid background. Traumatic brain injuries are divided into closed and open. At closed injuries ah of the skull, the integrity of the soft integuments is not violated and the closedness of the cranial trauma of the skull is preserved, they are divided into penetrating and non-penetrating: violation of the integrity of only the soft integuments and bones of the skull, and accompanied by damage to the dura mater and brain substance. Closed craniocerebral injuries usually remain aseptic, open craniocereberal injuries may be complicated by infection.

The classification of closed craniocerebral injuries distinguishes:

concussion - concussion

ü contusion - bruises of the brain and trauma by a blast wave

Mental disorders, directly caused by traumatic brain injury, are formed in stages, characterized by polymorphism mental syndromes and, as a rule, their regressive development.

Four stages of the development of mental disorders after a traumatic brain injury are identified: initial, acute, convalescence and long-term consequences.

CLINICAL PICTURE

Pathological manifestations in traumatic brain injury depend on the nature of the injury, comorbidity, age and premorbid background. There are three degrees of severity of traumatic brain injury - mild, moderate, severe; and four periods of development of the traumatic process.

1. The initial period, the period of acute manifestations. The acute period occurs immediately after the injury, lasting 7-10 days. In most cases, accompanied by loss of consciousness, different depth and duration. The duration of the unconscious state indicates the severity of the condition. However, loss of consciousness is not a mandatory symptom. Fixation amnesias of varying degrees are noted, covering an insignificant period before the injury and the fact of the injury itself, and there is a deterioration in visual memory. The severity and nature of mnestic disorders is an indicator of the severity of the injury. A constant symptom of the acute period is asthenia, with a pronounced adynamic component. Low mood, resentment, capriciousness, weakness and somatic complaints - indicate a less pronounced asthenia. The phenomenon of hyperesthesia. Sleep disturbance, superficial sleep. Permanent vestibular disorders, sharply intensifying with a change in body position - dizziness. May be accompanied by nausea and vomiting. With a gap in the convergence and movement of the eyeballs, the patient feels dizzy and falls - an oculostatic phenomenon. There may be transient anisocorria, mild pyramidal insufficiency in the form of asymmetry of deep reflexes. Constant vasomotor - autonomic disorders: lability of the pulse with a predominance of bradycardia, fluctuations in blood pressure, sweating and acrocyanosis, thermoregulation disorders with increased chilliness, dermographism - persistent and diffuse, redness of the face, aggravated by slight physical exertion. Increased salivation or vice versa dry mouth. Possible local neurological symptoms, motor disorders in the form of paresis and paralysis, there are selective sensitivity disorders. With fractures of the bones of the base of the skull, signs of damage to the cranial nerves are revealed - paralysis of half of the muscles of the face, eye movement disorders - diplopia, strabismus. Meningeal symptoms may appear - rigidity neck muscles, Kernig's symptom. Recovery of consciousness occurs gradually. During the period of recovery of consciousness, drowsiness, a sharp general lethargy, slurred speech, lack of orientation in place, time, weakening of memory, amnesia - due to the dynamics of transcendental inhibition, after an injury, it undergoes a slow reverse development, the recovery of the second signaling system takes the longest.

2. Acute, secondary period from several days to 1 month. It begins as the elimination of the switching off of consciousness. It is difficult to comprehend what is happening, mnestic disturbances are noted against the background of cerebrosthenic manifestations, mood instability, hyperesthesia and hyperpathia (increased susceptibility to psychogenic influences). Along with mental disorders, neurological, vegetative-vascular, vestibular disorders are detected, epileptiform seizures and the development of acute psychoses are possible. Irritability, emotional instability, fatigue are persistent symptoms that accompany brain injury. In the process of reverse development of psychopathological disorders of traumatic origin, a period occurs when the cortex has not yet completely freed itself from protective inhibition, and therefore, subcortical functions begin to predominate over cortical ones. The first signal system prevails over the second signal system, which creates a state characteristic of hysteria - hysteriod-like post-traumatic conditions. There is a connection between the development of traumatic asthenia and premorbid personality traits, constitutional features of the higher nervous activity of the victim. Neurasthenic syndrome occurs more easily in unbalanced individuals - irritable weakness, lability, rapid exhaustion. Protective inhibition contributes to the regenerative metabolic processes of the brain, restoring its performance. The appearance of post-traumatic depression is based on the phenomenon of exhaustion and diffuse protective inhibition on the cortex and subcortical structures. The occurrence of hypochondria in asthenia is explained by the formation of foci congestive arousal in a weakened cerebral cortex - fear of illness, may be associated with the predominance of subcortical influences and influences from the first signaling system (fears, fears, unpleasant sensations - sensory lining). Clinical basis neurasthenia are - weakness, exhaustion of cortical cells, deficiency of internal inhibition - the result is intolerance of weak stimuli, sleep disturbance, prevalence of lower structures over higher ones, weakening of the second signal system. Clinical course and duration of acute and subacute period suggest possible consequences traumatic brain injury: the more severe the injury, the more severe the consequences and the longer the period of disability will be.

3. Recovalescence period, duration up to 1 year. There is a gradual full or partial restoration of impaired functions. The mildest consequences will be moderately pronounced distractibility, instability of voluntary attention, asthenization, touchiness, tearfulness, vegetative-vascular insufficiency. The predominance in the clinical picture of cerebral, somato-vegetative and vestibular disorders, gastrointestinal dyskinesias, fluctuations in blood pressure, meteosensitivity, increased sweating. In the structure of cerebro-asthenic manifestations, there are separate intellectual-mnestic disorders.

4. Long-term consequences of a craniocerebral injury occur after 1 year, manifest as a psycho-organic syndrome, characterized by increased exhaustion and low productivity of all mental processes, phenomena of misunderstanding, decreased memory and intelligence, incontinence of affects. It is possible to form pathological personality traits according to the asthenic, hippochondriacal, paranoid-querulant, hysterical, epileptoid type. Persistent manifestations include cerebral manifestations: headaches, dizziness, noise and heaviness in the head, hot flashes or a feeling of coldness in the head. At the heart of this symptomatology are circulatory disorders remaining for a long period. Post-traumatic asthenia is expressed in persistent headaches, intolerance to noise, disorders of optical perception and vestibular functions. Trauma can lead to persistent traumatic dementia, in which case a stable defective state occurs immediately after the disappearance of acute phenomena, in combination with a violation of the affective sphere. Serious craniocerebral injuries leave an imprint on the whole appearance of the patient, his activity, making him incapable of working and compensating for his defect. The affective-volitional sphere is extremely labile, the prevailing mood is hypochondriacal. The most severe and refractory to the methods of active therapy manifestations of apathy - akinetic - abulic syndrome. Accompanied by a sharp disorder of the emotional sphere, the phenomena of asthenia and violation of vital functions. Characterized by protracted reactive states with symptoms of deafness.

CONSCIOUSNESS SYNDROMES IN CRANIO-BERIN INJURY.

Impairment of consciousness depends on the extent of damage to the cerebral vessels. With any type of impaired consciousness, there is a pathology of cortical activity with a violation of cortical-subcortical relationships, which primarily affects the processes of the second signaling system. Irradiation of transboundary inhibition and its distribution to subcortical, stem formations underlie vitally dangerous forms of unconscious states. Consciousness is a function of the brain and is directly dependent on blood flow to the brain. Sudden cessation of blood flow leads to the disappearance of consciousness. Violation of consciousness is a symptom of oxygen and energy starvation of the brain. The loss of the activating influence of the reticular formation of the brain stem on the cerebral cortex also leads to loss of consciousness. The ascending effect of the reticular formation on the cerebral cortex is known, activating cellular supply systems and a certain level of activity state. Based on the teachings of Jaspers and Penfield about the centrencephalic system, which provides different levels consciousness. Paralysis of the brain, due to damage to the hemispheric tract, manifests itself in loss of consciousness, on electroencephalography it manifests itself as the effect of silence of the cortex. Under conditions of diffuse unconditioned inhibition in the cerebral cortex, the interaction of specific and non-specific systems afferentations - that is, the functions of the reticular formation.

Flowing without disturbance of consciousness (transient, intermediate syndromes), which include hallucinosis, hallucinatory-paranoid state, apathetic stupor, confabulosis; 3) irreversible mental disorders with signs of organic damage to the central nervous system - Korsakovsky, psychoorganic syndromes. transient psychoses. These psychoses are transient. Delirium is one of...

Primary and specialized psychiatric care for patients with impaired memory and intelligence. To achieve the goals, it is necessary to solve the following TASKS: 1) to know the features of the clinic of memory and intelligence disorders; 2) to know their nosological affiliation and clinical features in various organic brain lesions; 3) to be able, in the course of communication with patients, to identify this ...

The number of patients with acute traumatic brain injury increases annually by an average of 2% (E. I. Babichenko, A. S. Khurina, 1982). They make up from 39 to 49% of people who have received injuries and are subject to hospitalization (L. G. Erokhina et al., 1981; V. V. Bolshagin, P. M. Karpov, 1982). In the first place among peacetime injuries are domestic, followed by transport, industrial, sports (M. G. Abeleva, 1982; A. P. Romanov et al., 1982). In recent years, there has been a trend towards an increase in the frequency of severe craniocerebral injuries (EM Boeva ​​et al., 1974; Yu. D. Arbatskaya, 1981). Among the disabled due to neuropsychiatric diseases, persons with the consequences of craniocerebral injuries account for 20-24% (O. G. Vilensky et al., 1981; I. A. Golovan et al., 1981; I. A. Polyakov, 1981 ). A large number of severe injuries people get in a state of intoxication, which makes diagnosis difficult (A. P. Romadanov et al., 1982; O. I. Speranskaya, 1982).
With craniocerebral injuries (commotions, contusions and compression of the brain), functional and organic, local and diffuse changes: destruction of the structure of the brain tissue, its edema and swelling, hemorrhages, later - purulent or aseptic inflammation, processes of atrophy of cellular elements and fibers, cicatricial replacement of damaged tissue. There are violations of hemo- and liquorodynamics, neuroreflex mechanisms that regulate metabolism, the activity of the cardiovascular, respiratory systems.
L. I. Smirnov (1947, 1949) combined these processes under the name of traumatic disease and identified five periods of its development. Damage to cortical and subcortical-stem formations finds its expression in the polymorphism of somato-neurological and psychopathological symptoms (A. G. Ivanov-Smolensky, 1949, 1974; N. K. Bogolepov et al., 1973; E. L. Macheret, I. 3. Samosyuk, 1981; X. X. Yarullin, 1983).
There are four periods in the course of a traumatic illness. The initial period occurs immediately after the injury, characterized by stunning, soporous or unconscious state. An acute period lasting 2-3 weeks follows after the recovery of consciousness and continues until the first signs of improvement. Late period (lasting up to 1 year or more) - restoration of somatic, neurological and mental functions. The period of long-term consequences (residual effects) is characterized by functional or organic disorders, decreased tolerance of physical and neuropsychic stress, and vestibular irritations. The influence of additional hazards at this stage, the presence of an organic defect and the instability of regulatory mechanisms create conditions for the development of mental disorders.
The classification proposed below takes into account the requirements of the ICD 9th revision.

Classification of mental pathology of traumatic genesis

I. Non-psychotic mental disorders resulting from traumatic brain injury:
1. Postconcussion syndrome (code 310.2):
a) asthenic, asthenoneurotic, asthenohypochondriac, asthenodepressive, asthenoabulic syndromes;
b) traumatic cerebral palsy;
c) traumatic encephalopathy with non-psychotic disorders (affective instability syndrome, psychopathic syndrome);
d) organic psychosyndrome without psychotic disorders.
II. Psychotic mental disorders developing as a result of trauma:
1. Acute transient psychotic state (293.04) - delirious syndrome, twilight state of consciousness.
2. Subacute transient psychotic state (293.14) - hallucinatory, paranoid, etc.
3. Another (more than 6 months) transient psychotic state (293.84) - hallucinatory-paranoid, depressive-paranoid, manic-paranoid, catatonic-paranoid syndromes.
4. Transient psychotic state, unspecified in duration (293.94).
5. Chronic psychotic states (294.83) - hallucinatory-paranoid, etc.
III. Defect-organic states:
1. Frontal lobe syndrome (310.01).
2. Korsakov's syndrome (294.02).
3. Dementia due to brain injury (294.13).
4. Epileptiform (convulsive) syndrome.

Psychopathological characteristics of the initial and acute periods of traumatic illness

The main disorder in the initial period of a closed craniocerebral injury is the loss of consciousness of varying depth and duration - from mild stupor (obnubilation) to complete loss of consciousness within the framework of coma. Traumatic coma is characterized by complete loss of consciousness, extinction of reflex reactions, and immobility. The pupils are dilated or narrow, blood pressure and muscle tone decrease, breathing and cardiac activity are disturbed. The exit from the coma is gradual. Initially, respiratory functions normalize, independent motor reactions appear, patients change position in bed, begin to open their eyes. At times, motor excitation with uncoordinated movements can be observed. Gradually, patients begin to respond to questions addressed to them by turning their heads, eyes, and their speech is restored.
A protracted coma is manifested by apallic syndrome (“awake coma”). Patients are motionless, indifferent to the environment. Electroencephalographic studies indicate the restoration of the functions of the mesencephalic reticular ascending activating system, the improvement of the functions of the descending reticular systems, the function of the cortex big brain completely absent (M. A. Myagin, 1969). Such patients die against the background of deep general insanity. With a traumatic brain injury with a predominant lesion of the median structures of the brain, after the patient comes out of a coma, akinetic mutism, immobility are observed, only eye movements are preserved. The patient follows the actions of the doctor with his eyes, but there are no speech reactions, the patient does not respond to questions and instructions, and does not make purposeful movements. Hyperkinesis may occur.
The most common variant of the oppression of consciousness is stupor, which can be observed immediately after the injury or after the patient comes out of stupor and coma. When stunned, the threshold for the perception of external stimuli rises; a response can only be obtained to strong stimuli. Disturbed orientation in the environment. Questions are comprehended with difficulty, answers are slowed down, patients do not understand complex questions. Often there are perseverations. The facial expression of the patients is indifferent. Drowsiness and drowsiness easily set in. Memories of this period are fragmentary. A quick exit from a coma, its change with stupor and stupor is prognostically favorable. A protracted period of recovery of consciousness with a change various degrees stupor, the occurrence of motor excitation against this background, the appearance of stupor or stupor after a period of clear consciousness, along with neurological symptoms, indicate the severity of the injury or complications intracranial hemorrhages, fat embolism.
The severity and dynamics of the stupor syndrome make it possible to assess the severity of the injury (S. S. Kaliner, 1974; B. G. Budashevsky, Yu. V. Zotov, 1982). In severe stupor, the reaction to external stimuli weak, patients do not answer questions, but respond to orders. The duration of sleep during the day is 18-20 hours. The first phase of the swallowing test is absent. With an average degree of stunned answers to simple questions are possible, but with a long delay. The duration of sleep during the day is 12-14 hours, the swallowing test is slowed down. With a mild degree of stupor, the reaction to external stimuli is lively, the patient answers questions and can ask them himself, but comprehends difficult questions poorly, orientation in the environment is incomplete. Sleep duration - 9-10 hours. Affective and motor-volitional functions are preserved, but slowed down. Swallowing test is not broken. The short duration of impaired consciousness does not always indicate a favorable prognosis.

Non-psychotic syndromes of the acute period of traumatic illness

In the acute period of traumatic disease, asthenic syndrome is most often detected. The mental state of patients is characterized by exhaustion, a decrease in mental productivity, a feeling of fatigue, auditory and visual hyperesthesia. The structure of asthenic syndrome includes an adynamic component. In some cases asthenic symptoms combined with capriciousness, tearfulness, an abundance of somatic complaints. An experimental psychological study reveals a lengthening of the latent period of responses, an increase in erroneous and refusing responses, and perseveration. Patients often ask to stop the study, complain of increased headache, dizziness. They have hyperhidrosis, tachycardia, flushing of the face. Some of the patients examined by us, having answered 2-3 questions, fell asleep.
In the acute period of traumatic brain injury, emotional disturbances often appear in the form of a Morio-like syndrome. We observed them in 29 out of 100 examined patients. Such patients are characterized by a complacent and carefree mood background, a tendency to flat jokes, underestimation of the severity of their condition, fast speech in the absence of lively facial expressions and productive activity. Patients did not comply with bed rest, refused treatment, declared that nothing special had happened, did not complain and insisted on being discharged from the hospital, often they had affective outbursts that quickly passed. Asthenohypobulic syndrome is less common. The mental state of patients is accompanied by passivity, aspoptism, motor lethargy, weakening of motives, and a decrease in interest in their condition and ongoing treatment. The condition of the patients outwardly resembles stupor. However, during our experimental psychological study, the patients quite clearly comprehended the task, made fewer mistakes than patients of other groups.
Often there is retrograde amnesia, which may be complete or partial; over time, it undergoes reduction. In some cases, fixation amnesia is noted. Difficulties in remembering current events are partly due to the asthenic condition, and as the phenomena of asthenia smooth out, memorization improves. The severity and nature of mnestic disorders is an important sign of the severity and nature of the injury.
In severe brain injuries, complicated by skull fractures or intracranial hemorrhages, Jackson-type seizures and epileptiform excitation often occur, which occur against the background of impaired consciousness.
With a concussion of the brain, the listed non-psychotic mental disorders detected in the acute period usually smooth out within 3-4 weeks. Brain contusions are accompanied by local symptoms that appear as they disappear cerebral symptoms. With damage to the upper frontal parts of the cerebral cortex, an apathetic syndrome is observed with impaired attention and memory; with a disorder of the basal-frontal - euphoria, foolishness, moria; lower parietal and parietal-occipital - amnesia, amnestic aphasia, alexia, agraphia, acalculia, disturbances in perception, body schemes, size and shape of objects, perspectives; temporal - sensory aphasia, impaired smell and taste, epileptiform seizures; areas of the central convolutions - paralysis, paresis, Jacksonian and generalized seizures, sensitivity disorders, twilight state of consciousness; occipital areas - blindness, impaired recognition of objects, their shape, size, location, color, visual hallucinations; upper surfaces both hemispheres - twilight state, severe dementia (MO Gurevich, 1948); with damage to the cerebellum - imbalance, coordination of movements, nystagmus, chanted speech. With a predominant lesion of the left hemisphere, speech disorders predominate in patients.
A complication of brain contusions are intracranial bleeding. The most common are subarachnoid bleeding, which occur as a result of rupture of small vessels, mainly veins, the pia mater of the brain. The duration of the "light" interval between the injury and the onset of symptoms of subarachnoid hemorrhage depends on the degree of damage to the walls of the vessel and the duration of the patient's stay in bed. Subarachnoid hemorrhages are lamellar in nature. Spreading over a considerable distance under the arachnoid, they do not create local compression of the brain. The main symptom of a brain injury is the head gul, localized mainly in the forehead, superciliary arches and the back of the head, radiating into eyeballs, aggravated by head movement, straining, percussion of the cranial vault, accompanied by nausea and vomiting, autonomic disorders, hyperthermia. Shell symptoms appear - neck muscle stiffness, Kernig's symptom. Mental disorders are expressed in psychomotor agitation, impaired consciousness with disorientation in the environment. Some patients experience vivid visual hallucinations of a frightening nature. Epileptic seizures are rare. Traumatic subarachnoid bleeding is accompanied by both an increase and a decrease in the pressure of the cerebrospinal fluid. It contains a large number of erythrocytes, protein, high pleocytosis due to neutrophilic granulocytes.
Epidural hematomas are often associated with fractures of the parietal and temporal bones. Initially, with acute epidural bleeding, stupor or stupor develops, combined with collapse. After a few hours, improvement occurs - consciousness clears up, cerebral symptoms subside, but there remains lethargy, drowsiness. On the side of the hematoma, pupil dilation is observed, its reaction to light is absent. The patient lies on the side opposite to the hematoma, complains of a local headache. After a few hours, sometimes days, the condition deteriorates sharply: lethargy and drowsiness turn into stupor and stupor, breathing and swallowing worsen, monoparesis and paralysis appear on the side opposite to the hematoma, body temperature rises. Phenomena compression syndrome occur due to the accumulation of outflowing blood from the damaged middle meningeal artery or its branches.
With subdural bleeding, wide lamellar hematomas appear, covering the anterior or posterior surface of the hemisphere, sometimes spreading widely over the entire surface of the hemispheres. Lamellar hematomas differ from epidural hematomas by a slower course of the process and a long “light interval”, a phase of psychopathological disorders, when periods of psychomotor agitation are replaced by lethargy, lethargy. Intracerebral (parenchymal) hemorrhages occur suddenly after an injury, develop as a brain stroke.
A sharp deterioration in the patient's condition between the 1st and 9th days after injury may indicate fat embolism. Signs of a fat embolism are yellowish foci in the fundus, skin petechiae in the subclavian region, in the neck, less often in the abdomen, the presence of fat in the cerebrospinal fluid, and a decrease in hemoglobin. Fat embolism is more common in fractures of the lower part of the thigh, tibia.
Defeat by a blast wave (barotrauma) occurs during the explosion of shells and air bombs (MO Gurevich, 1949). There are several damaging factors: air wave impact, sharp rise and then a decrease in atmospheric pressure, the action of a sound wave, the tossing of the body and hitting the ground. An explosive air wave caused a concussion, bruising it on the bone of the base of the skull, concussion of the walls of the III and IV ventricles and the aqueduct of the brain with a liquor wave. Clinically observed extrapyramidal symptoms, hyperkinesis, seizures with a predominance of tonic seizures, deafness, weakness, vasomotor, vegetative and vestibular disorders. Stuporous states may develop, less often - twilight states of consciousness.
With open wounds of the frontal lobes, the joint syndrome is often absent. There are examples in the literature when patients wounded in the frontal parts of the brain retained the ability to understand the situation, correctly manage their actions, and continue to give commands on the battlefield. In the future, such patients experience euphoric-ecstatic states, then activity is lost, and aspontaneity appears as a result of a decrease in the “frontal impulse”. R. Ya. Goland (1950) described confabulations in patients wounded in the frontal lobe with preservation of orientation in place and time. Some patients develop fragmentary delusions based on pseudo-reminiscences. For open wounds parietal lobes there is a state of ecstasy, similar to the aura observed in patients with epilepsy.

Traumatic psychoses of the acute period

Traumatic psychoses of the acute period often develop after severe craniocerebral injuries in the presence of additional exogenous hazards. There is a certain relationship between the duration of impaired consciousness after trauma and the picture of psychosis: a coma or stupor lasting more than 3 days is more often replaced by Korsakoff's syndrome, a coma lasting up to 1 day - a twilight state of consciousness.
Among the psychotic syndromes, delirious is most often observed, which usually occurs against the background of stupor during the patient's exit from a coma or stupor. The patient's erratic, chaotic movements are replaced by more purposeful ones, resembling grasping, catching and sorting out, a symptom of awakening is noted (with loud, repeated calls, it is possible to attract the patient's attention, get several monosyllabic answers from him), visual hallucinations and illusions. The patient is disoriented, fearful or angry. Daily fluctuations of disturbances of consciousness are not characteristic. The duration of delirium is 1-3 days or more. There may be relapses of psychosis after a short (several days) "light period". Memories of the delirium state are incomplete. Traumatic delirium occurs 3-4 times more often in people who abuse alcohol (V. I. Pleshakov, V. V. Shabutin, 1977; M. V. Semenova-Tyanshanskaya, 1978).
Twilight states of consciousness usually develop a few days after the clarification of consciousness in the presence of additional harmfulness. In patients, orientation in the environment is disturbed, psychomotor agitation, fear, fragmentary deceptions of perception occur. In some cases, puerile and pseudo-demented behavior is observed. The twilight state ends with sleep, followed by amnesia of painful experiences. S. S. Kaliner (1967) identified several variants of the twilight state of consciousness: with attacks of motor excitation, stuporous state, motor automatisms, puerile-pseudo-dement behavior. They occur against the background of severe post-traumatic asthenia, occur in the evening hours and end with sleep.
Oneiroid states are manifested by foam-like hallucinatory experiences of fantastic events, motor retardation, frozen enthusiastic facial expressions. There are sometimes pathetic statements, excitement within the bed. Amentative states usually occur against the background of stupor - there is a violation of orientation in the environment and one's own personality, incoherence of thinking, non-purposeful motor excitation. Possible special conditions consciousness with abundant psychosensory disorders.
In severe craniocerebral injuries after a prolonged coma, Korsakoff's syndrome develops, more often with a lesion posterior divisions the right hemisphere of the cerebrum and the diencephalic region (M. V. Semenova-Tyanshanskaya, 1978; T. A. Dobrokhotova, O. I. Speranskaya, 1981; V. M. Banshchikov et al., 1981). In some cases it is preceded by acute psychoses. As consciousness is restored and behavior is streamlined, patients show memory disorders, retro- and anterograde amnesia, amnestic disorientation in place, time and surrounding persons. There is a complacent euphoric background of mood, the absence of criticism of one's condition. Pseudo-reminiscences include everyday events and events related to professional activity. Coifabulations are less pronounced than in Korsakov's psychosis. Often, amnestic phenomena are smoothed out over 1-1.5 months, criticism is restored. Some patients during this period have mood swings, fragmentary ideas of attitude. In some cases, against the background of a complacent euphoric mood, bright coifabulations predominate with unexpressed phenomena of fixation and anterograde amnesia.
Affective psychotic states in the acute period are expressed by depressive or manic states with dysphoric episodes. Depressive states are characterized by anxiety, unstable delusional ideas of attitude, hypochondriacal complaints, vegetative-vascular paroxysms, and for manic states - euphoria, overestimation of one's own personality, anosognosia and motor hyperactivity. In some patients, euphoria is combined with a weakening of impulses, motor lethargy. In such "euphoric-aspontaneous patients" during questioning, abundant coifabulations, carelessness and combined with sexual disinhibition are found. Patients can express delusional ideas of grandeur, which in some cases are stubborn and monotonous, in others they are changeable. Delusional transient psychoses in the acute period of a traumatic illness usually occur against a background of mild stupor immediately after the injury.
With craniocerebral injuries in the acute period, local neurological symptoms, epileptiform seizures come to the fore, in a mental state - asthenoabolic syndrome, sometimes with a small number of complaints, despite a serious condition. Psychoses manifest themselves more often in the form of twilight states of consciousness, Korsakoff's syndrome, and a Morio-like state. Complications are often meningitis, encephalitis, brain abscess.

Mental disorders of the late and remote periods

After the initial and acute periods of a traumatic disease, with a favorable outcome, a period of recovery begins. The fourth stage of the development of a traumatic disease is the period of long-term consequences. The frequency, persistence and severity of mental disorders depend on gender, age, somatic condition of patients, severity of injury (V. D. Bogaty et al., 1978; V. E. Smirnov, 1979; Ya. K. Averbakh, 1981), lack of treatment at previous stages (E. V. Svirina, R. S. Shpizel, 1973; A. I. Nyagu, 1982). In the long term, mental disorders often lead to a decrease or loss of ability to work - disability occurs in 12-40% of cases (L. N. Panova et al., 1979; Yu. D. Arbatskaya, 1981).
Mental disorders in the late period of traumatic illness are observed not only after severe, but also after mild traumatic brain injuries. Therefore, it is reasonable to warn that minor injuries should not be " easy attitude". Patients have a combination of vegetative-vascular and liquorodynamic disorders, emotional disturbances in the form of affective excitability, dysphoric and hysterical reactions (V. P. Belov et al., 1985; E. M. Burtsev, A. S. Bobrov, 1986). Insufficient severity of focal neurological symptoms long time served as a reason for classifying these conditions as psychogenic, close to hysteria (“traumatic neurosis”), S. S. Korsakov (1890) was one of the first to point out the illegality of including them in the circle of hysteria, ignoring the importance of an organic traumatic factor in the occurrence of mental disorders.
The difficulty of distinguishing between organic and functional factors affects the systematization of non-psychotic traumatic disorders in the long term. The concept of "traumatic encephalopathy" is not without flaws, as it indicates mainly the presence of structural and organic changes. The concepts of "post-concussion syndrome" and "post-concussion syndrome" in the ICD 9th revision include various non-psychotic conditions, functional and organic. In the remote period, along with non-psychotic disorders, paroxysmal disorders, acute and prolonged traumatic psychoses, endoform psychoses, and traumatic dementia are observed.

Non-psychotic mental disorders

Non-psychotic functional and functional-organic disorders in the late period of traumatic brain injury are represented by asthenic, neurosis- and psychopathic-like syndromes.
Asthenic syndrome, being "cross-cutting" in traumatic disease, in the long term occurs in 30% of patients (V. M. Shumakov et al., 1981) and is characterized by a predominance of irritability, increased excitability of patients, exhaustion of affect.
Asthenic syndrome in the long term is often combined with subdepressive, anxious and hypochondriacal reactions, accompanied by severe vegetative-vascular disorders:
redness of the skin, lability of the pulse, sweating. Affective outbursts usually end in tears, remorse, a feeling of weakness, a dreary mood with ideas of self-blame. Increased exhaustion, impatience are noted when performing fine work that require attention and concentration. In the process of work, the number of errors increases in patients, the work seems impossible, and they refuse to continue it with irritation. Often there are phenomena of hyperesthesia to sound and light stimuli.
Due to the increased distractibility of attention, the assimilation of new material is difficult. Sleep disturbances are noted - difficulty falling asleep, nightmarish frightening dreams, reflecting events associated with trauma. Constant complaints of headache, palpitations, especially with sharp fluctuations in atmospheric pressure. Vestibular disorders are often observed: dizziness, nausea when watching movies, reading, riding in transport. Patients do not tolerate the hot season, stay in stuffy rooms. Asthenic symptoms fluctuate in their intensity and qualitative diversity depending on external influences. Of great importance is the personal processing of a diseased state.
Electroencephalographic studies reveal changes that indicate the weakness of cortical structures and increased excitability of subcortical formations, primarily the brain stem.
Psychopathic syndrome in the late period of cherish-brain injury is manifested by explosiveness, vicious, brutal affect with a tendency to aggressive actions. The mood is unstable, dysthymia is often noted, which occurs on minor occasions or without a direct connection with them. The behavior of patients can acquire features of theatricality, demonstrativeness, in some cases, at the height of affect, functional convulsive seizures appear (a hysterical variant of a psychopathic syndrome). Patients conflict, do not get along in a team, often change jobs. Intellectual mnestic disturbances are insignificant. Under the influence of additional exogenous hazards, most often alcoholic beverages, repeated craniocerebral injuries and psychotraumatic situations, which are often created by the patients themselves, the features of explosiveness increase, thinking becomes concrete, inert. Overvalued ideas of jealousy arise, an overvalued attitude towards one's health, litigious-querulant tendencies. Some patients develop zpileptoid traits - pedantry, sweetness, a tendency to talk "about outrageous things." Criticism and memory are reduced, the amount of attention is limited.
In some cases, the psychopathic syndrome is characterized by an elevated background of mood with a hint of carelessness, complacency (hyperthymic variant of the syndrome): patients are talkative, fussy, frivolous, suggestible, uncritical to their condition (A. A. Kornilov, 1981). Against this background, there is a disinhibition of drives - drunkenness, vagrancy, sexual excesses. In turn, the systematic use of alcoholic beverages increases affective excitability, propensity to delinquency, prevents social and labor adaptation, resulting in a kind of vicious circle.
Psychopathic disorders in the absence of additional exogenous hazards proceed regressively (N. G. Shumsky, 1983). In the late period of traumatic brain injury, it is necessary to differentiate between psychopathic disorders and psychopathy. Psychopathic disorders, unlike psychopathy, are manifested by affective reactions that do not add up to a holistic clinical picture of a pathological nature. The formation of a psychopathic syndrome is due to the severity and localization of the traumatic brain injury. The age of the victim, the duration of the disease, the addition of additional harmful factors matter. Data of the neurological status, vegetative and vestibular disorders, symptoms of cerebrospinal fluid hypertension, found on radiographs of the skull and in the fundus, indicate a psychopathic syndrome of an organic nature.
Disorders observed in the late period of traumatic brain injury include dysphoria that occurs against the background of cerebro-asthenic phenomena. They are accompanied by bouts of melancholy-malicious or melancholy-anxious mood, lasting from one to several days. They proceed in waves, often accompanied by senesto- and hyperpathies, vegetative-vascular crises, psychosensory disorders and a delusional interpretation of the environment, an affective narrowing of consciousness. Disorders of inclinations are sometimes noted - sexual perversions, pyro- and dromania. A sudden action (arson, leaving the house) leads to a decrease in affective tension, the appearance of a feeling of relief. Like other paroxysmal conditions, dysphorias are provoked by traumatic situations or become more frequent when they are present, which makes them similar to psychopathic reactions.
Mental disorders in traumatic brain injuries are usually correlated with the corresponding stages in the development of a traumatic disease:

• 1) mental disorders initial period, manifested mainly by disorders of consciousness (stupor, stupor, coma) and subsequent asthenia;
• 2) subacute or protracted psychoses that occur immediately after an injury to the head mole in the initial and acute periods;
• 3) subacute or prolonged traumatic psychoses, which are a continuation of acute psychoses or appear for the first time several months after the injury;
• 4) mental disorders of the late period of traumatic brain injury (long-term, or residual consequences), appearing for the first time after several years or arising from earlier mental disorders.

Symptoms and course.

Psychiatric disorders that occur during or immediately after an injury are usually manifested by some degree of consciousness shutdown (stunning, stupor, coma), which corresponds to the severity of the traumatic brain injury. Loss of consciousness is usually observed with concussion and bruising of the brain. When consciousness returns, the patient has a loss of memory for a certain period of time - following the injury, and often - and preceding the injury. The duration of this period is different - from several minutes to several months. Memories of events are not restored immediately and not completely, and in some cases - only as a result of treatment. After each injury with impaired consciousness, post-traumatic asthenia is noted with a predominance of either irritability or exhaustion. In the first variant, patients become easily excitable, sensitive to various stimuli, with complaints of superficial sleep with nightmares. The second option is characterized by a decrease in desires, activity, efficiency, lethargy. Often there are complaints of headache, nausea, vomiting, dizziness, unsteady gait, as well as fluctuations in blood pressure, palpitations, sweating, salivation, and focal neurological disorders.

Acute traumatic psychoses develop in the first days after a closed craniocerebral injury, more often with bruises than with concussions. According to the clinical picture, these psychoses are similar to those in somatic diseases (see) and are manifested mainly by confusion syndromes, as well as memory disorders and vestibular disorders. Most frequent form traumatic psychosis is twilight clouding of consciousness, the duration of which can be from several hours to several days and even weeks. It occurs, as a rule, after a short period of clarification of consciousness and the action of additional hazards (alcohol intake, premature transportation, etc.). The clinical picture of twilight stupefaction is different. In some cases, the patient is completely disoriented, excited, aspires somewhere, rushes about, does not answer questions. Speech is fragmentary, inconsistent, consists of separate words and cries. With hallucinations and delusions, the patient becomes angry, aggressive, and may attack others. Some childishness and deliberateness may be noted in behavior. The condition can proceed with disorientation, but without excitation. It manifests itself in the form of a special persistent drowsiness, from which the patient can be taken out for a while, but as soon as the stimulus ceases to act, the patient falls asleep again. There are described twilight states with outwardly ordered behavior of patients who made escapes, committed offenses and subsequently did not remember their actions at all.

The second most common form of confusion is delirium, which develops a few days after the restoration of consciousness when exposed to additional hazards (there is an opinion that delirium usually occurs in people who abuse alcohol). The condition usually worsens in the evening and at night, and during the day there is an orientation in place and time, and even a critical attitude towards one's condition (light intervals). The duration of psychosis is from several days to 2 weeks. Leading in the clinical picture are visual hallucinations - approaching crowds of people, large animals, cars. The patient is in anxiety, fear, tries to escape, escape or takes defensive actions, attacks. Memories of the experience are fragmentary. Psychosis either ends up recovering after a long sleep, or passes into another state with gross memory impairment - Korsakoff's syndrome.

The oneiroid state is relatively rare. Oneiroid usually develops in the first days of the acute period against the background of drowsiness and immobility. Patients observe hallucinatory scenes in which fantastic events are interspersed with ordinary ones. The facial expression is either frozen, absent, or enthusiastic, reflecting an overflow of happiness. Quite often there are disorders of sensations such as a sharp acceleration or, conversely, a slowdown in the passage of time. Memories of the experienced state are preserved to a greater extent than with delirium. After coming out of psychosis, patients talk about the content of their experiences.

Korsakov's syndrome is a protracted form of acute traumatic psychosis, which usually occurs as a result of severe craniocerebral trauma either after a period of deafness, or after delirious or twilight stupefaction. The duration of Korsakov's syndrome is from several days to several months. Heavier and longer it occurs in persons who abuse alcohol (see Korsakov's psychosis). The main content of this syndrome is memory impairment, in particular, memory impairment, fixation of current events. Therefore, the patient cannot name the date, month, year, day of the week. He does not know where he is, who his doctor is. Fills in gaps in memory with fictitious events or past events. Consciousness is not impaired. The patient is available for contact, but criticism of his condition is sharply reduced.

Affective psychoses are less common than clouding of consciousness, and usually last for 1-2 weeks after the injury. The mood is often upbeat, euphoric with talkativeness, carelessness, unproductive excitement. elevated mood may also be accompanied by lethargy and inactivity. During such periods, consciousness may be somewhat altered, due to which patients do not fully reproduce the events of these days in memory.

Depressive states are observed less frequently than excitement. The low mood is usually tinged with discontent, irritability, gloominess, or combined with anxiety, fear, and fixation on one's health.

Paroxysmal disorders (attacks) often develop with brain contusions and open craniocerebral injuries. Seizures with loss of consciousness and convulsions predominate, different severity and duration (from a few seconds to 3 minutes). There are also symptoms of "already seen" (when you get into an unfamiliar place, it seems that you have already been here, everything is familiar) and vice versa, "never seen" (in a well-known place, the patient feels like in a completely unfamiliar, unseen before). The clinical picture of paroxysms depends on the location of the focus of brain damage and its size.

Long-term consequences of craniocerebral injuries occur when, after the injury, there is no full recovery. It depends on many factors: the severity of the injury, the age of the patient at that moment, the state of his health, the characteristics of his character, the effectiveness of the treatment and the impact of additional factors, such as alcoholism.

Traumatic encephalopathy is the most common form of mental disorders in the period of long-term consequences of brain injury. There are several variants of it.

Traumatic asthenia (cerebrosthenia) is expressed mainly in irritability and exhaustion. Patients become unrestrained, quick-tempered, impatient, uncompromising, quarrelsome. They easily come into conflict, then repent of their deeds. Along with this, patients are characterized by fatigue, indecision, disbelief in own forces and opportunities. Patients complain of distraction, forgetfulness, inability to concentrate, sleep disturbances, as well as headaches, dizziness, aggravated by "bad" weather, changes in atmospheric pressure.

Traumatic apathy is manifested in a combination of increased exhaustion with lethargy, lethargy, decreased activity. Interests are limited to a narrow circle of concerns about their own health and the necessary conditions of existence. Memory is usually impaired.

Traumatic encephalopathy with psychopathization is more often formed in patients with pathological character traits in premorbidity (before illness) and is expressed in hysterical forms of behavior and explosive (explosive) reactions. A patient with hysterical personality traits is demonstrative in behavior, egoism and egocentrism: he believes that all the forces of loved ones should be directed to treatment and care for him, insists that all his desires and whims be fulfilled, since he is seriously ill. In individuals with predominantly excitable character traits, rudeness, conflict, anger, aggressiveness, and violations of inclinations are noted. Such patients tend to alcohol abuse, drugs. In a state of intoxication, they arrange fights, pogroms, then they cannot reproduce what they have done in their memory.

Cyclothym-like disorders are combined with either asthenia or psychopathic disorders and are characterized by mood swings in the form of unexpressed depressions and manias (subdepressions and hypomanias). The lowered mood is usually accompanied by tearfulness, self-pity, fears for one's own health, and a stubborn desire to be treated. Elevated mood is distinguished by enthusiasm, tenderness with a tendency to weakness. Sometimes there are overvalued ideas of reassessment of one's own personality and a tendency to write complaints to various authorities.

Traumatic epilepsy usually occurs several years after the injury. There are large and small seizures, absences, twilight stupefaction, mood disorders in the form of dysphoria. At long course diseases are formed epileptic personality changes (see Epilepsy).

Traumatic psychoses in the period of long-term consequences of traumatic brain injury are often a continuation of acute traumatic psychoses.

Affective psychosis manifests itself in the form of recurrent depressions and manias (lasting 1-3 months). Manic attacks are more common than depressive ones and occur predominantly in women. Depressions are accompanied by tearfulness or a gloomy-malicious mood, vegetative-vascular paroxysms and hypochondriacal fixation on one's health. Depression with anxiety and fear is often combined with clouded consciousness (slight stupor, delirious phenomena). If depression is often preceded by psychic trauma, then manic state triggered by alcohol. Elevated mood sometimes takes the form of euphoria and complacency, then excitement with anger, then foolishness with feigned dementia and childish behavior. At severe course psychosis, there is a clouding of consciousness such as twilight or amental (see Somatogenic psychoses), which is less prognostically favorable. Attacks of psychosis are usually similar to each other in their clinical picture, like other paroxysmal disorders, and tend to be repetitive.

Hallucinatory-delusional psychosis is more common in men after 40 years, many years after the injury. Its onset is usually provoked by surgery, taking large doses alcohol. It develops acutely, begins with a clouding of consciousness, and then hearing deceptions ("voices") and delusional ideas become the leading ones. Acute psychosis usually becomes chronic.

Paranoid psychosis is formed, unlike the previous one, gradually, over many years and is expressed in a delusional interpretation of the circumstances of the injury and subsequent events. Ideas of poisoning, persecution may develop. A number of people, especially those who abuse alcohol, develop delusions of jealousy. The course is chronic (continuous or with frequent exacerbations).

Traumatic dementia occurs in about 5% of people who have had a traumatic brain injury. It is more often observed as a result of severe open craniocerebral injuries with damage to the frontal and temporal lobes. Injuries in childhood and later in life cause more pronounced defects in the intellect. Contribute to the development of dementia repeated trauma, frequent psychosis, joining vascular lesions of the brain, alcohol abuse. The main signs of dementia are memory impairment, decreased interests and activity, disinhibition of drives, lack of critical appraisal own state, importunity and misunderstanding of the situation, reassessment of one's own capabilities.

Treatment.

In the acute period, traumatic disorders are treated by neurosurgeons, neuropathologists, otolaryngologists, ophthalmologists, depending on the nature and severity of the injury (see the relevant sections). Psychiatrists, in turn, intervene in the treatment process in the event of mental disorders, both in the acute period and in the stage of long-term consequences. Therapy is prescribed in a complex manner, taking into account the condition and possible complications. In the acute period of injury, bed rest is necessary, good nutrition and caring care. In order to reduce intracranial pressure, diuretic drugs (lasix, urea, mannitol) are prescribed, magnesium sulfate is administered intravenously (course treatment), if necessary, lumbar puncture(in the lumbar region) and remove the cerebrospinal fluid. It is recommended to alternately use metabolic drugs (cerebrolysin, nootropics), as well as drugs that improve blood circulation (trental, stugeron, cavinton). With severe vegetative-vascular disorders, tranquilizers (seduxen, phenazepam), pyrroxane, small doses of neuroleptics (etaperazine) are used. With strong excitement, antipsychotics are used in the form of intramuscular injections (chlorpromazine, tizercin). With hallucinations and delirium, haloperidol, triftazin, etc. are used. In the presence of seizures and other epileptic disorders, it is necessary to use anticonvulsants (phenobarbital, finlepsin, benzonal, etc.). Along with medicinal methods of influence, physiotherapy, acupuncture, various methods psychotherapy. In cases of severe injuries and a long recovery period, painstaking work is needed to restore working capacity and conduct vocational rehabilitation.

Prevention

mental disorders in traumatic brain injury is early and correct diagnosis trauma, timely and adequate treatment of both acute events and possible consequences and complications.

See also:

Mental disorders in case of damage to the vessels of the brain
This group includes mental disorders that occur in various forms of vascular pathology (atherosclerosis, hypertonic disease and their consequences - stroke, heart attack, etc.). These diseases can occur without pronounced mental disorders, with a predominance of general somatic and neurological disorders ...

Psychoendocrine disorders
Psychoendocrine disorders are a kind of psychosomatic diseases. On the one hand, the occurrence of endocrine diseases is often provoked by the influence of psychogenic factors (diabetes, thyrotoxicosis). On the other hand, any endocrine pathology is accompanied by deviations in the mental sphere, which constitute the psychoendocrine syndrome or endocrine psychosyndrome ...

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Psychiatry. A guide for doctors Boris Dmitrievich Tsygankov

MENTAL DISORDERS IN THE LONG PERIOD AFTER CRANIO-BRAIN INJURY

Signs of long-term effects of TBI are fatigue, personality changes, syndromes associated with organic brain damage. IN remote period traumatic psychosis may develop after TBI. They appear, as a rule, in connection with additional effects of a psychogenic or exogenous-toxic nature. The clinical picture of traumatic psychoses is dominated by affective, hallucinatory-delusional syndromes that develop against the background of the already existing organic basis with manifestations of asthenia. Personality changes are characteristic features with instability of mood, manifestations of irritability up to aggressiveness, affectivity, signs of general bradyphrenia with stiffness of thinking with a weakening of critical abilities.

The long-term consequences of closed skull injuries include such mental disorders as asthenic syndrome (an almost constant phenomenon), hysterical reactions often occur, there may be short-term disorders of consciousness, epileptiform seizures, memory impairment, and hypochondriacal disorders. Personality changes represent a kind of secondary organic psychopathization with a weakening of intellectual-mnestic functions. A variety of neurotic and psychopathic disorders are possible not only as long-term consequences of severe injuries, they can also be a consequence of mild, not accompanied by a disorder of consciousness, brain injuries. Such a pathology can be detected both in the coming months after the injury, and several years after it.

Traumatic epilepsy develops due to the presence of local cicatricial changes in the brain, most often it is caused by open injuries skull, as well as bruises and concussions of the brain. There are seizures of the Jacksonian type, generalized convulsive paroxysms. At the same time, the role of provoking factors (alcohol, mental overload, overwork) is significant. Such patients may develop short-term twilight states of consciousness or affective equivalents of convulsive paroxysms (dysphoria). The locality of TBI is important for the clinic. With damage to the frontal lobes of the brain, for example, in the structure of personality changes, lethargy, lethargy, viscosity, and general bradyphrenia prevail. Lack of will, indifference to one's disease progresses. With a traumatic lesion of the frontal part of the brain, counting disorder (acalculia), simplification and flattening of the thought process with the formation of dementia, a tendency to perseveration, and a pronounced decrease in motor, volitional activity (aboulia) can develop. Such symptoms are explained by the lack of a volitional impulse, which does not allow to complete what has been started due to lack of activity. Such patients are characterized by inconsistency of actions, dispersion, negligence in everything, including clothing, inadequacy of actions, carelessness, carelessness. Loss of initiative, activity and spontaneity due to sharp decline"frontal impulse" sometimes leads to the inability to perform daily activities without outside help (eating, washing, going to the toilet).

In the late (initial) stages of the disease, a complete lack of interest, indifference to everything, impoverishment are expressed. vocabulary and mental abilities (deficiency of cognitive functions).

When the basal parts of the temporal lobe of the brain are damaged, heavy changes personalities with pronounced manifestations mental indifference, coldness, disinhibition of instincts, aggressiveness, with antisocial behavior, a perverted assessment of one's personality, one's abilities.

Damage to the temporal lobe itself leads to the appearance of epileptic features: lack of a sense of humor, irritability, incredulity, slowing down of speech, motor skills, and a tendency to litigiousness. Temporal-basal traumatic brain injuries are the cause of irritability, aggressiveness, hypersexuality. When combined with alcoholism, sexual promiscuity, immoral behavior, and cynicism are revealed. Very often noted sexual pathology with an increase in libido and a weakening of erection function, there are also phenomena premature ejaculation in the presence of interest (local lesion) of the paracentral lobules.

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