Mental illness does not block the road to God. In Russian society as a whole, there is no understanding of either what depression is, or what its scale is, and, most importantly, what is its danger.
Vasily Glebovich Kaleda - psychiatrist, doctor of medical sciences. Among the five brothers and sisters of Vasily Kaleda are two priests and the abbess of the monastery.
When Fr. Gleb went to open priestly service, one of the spiritual daughters wanted to fast. But she lived with unbelieving parents, and her observance of Great Lent in relation to food led to very difficult conflicts in the family. Then dad told her: “Eat absolutely everything that your parents give you. They give meat - eat meat, give dairy food - eat. The main thing is not to watch TV. And then his spiritual daughter, at the end of Great Lent, said: “Father Gleb, it was the most serious and difficult Great Lent in my life!" And the approach of parents to the observance of Great Lent was just such.
During Great Lent, the main thing is not food and drink
My memories of the beginning of Great Lent have always been associated with Forgiveness Sunday. In the evening we went to the rite of forgiveness to the temple of Elijah the Ordinary and on the way home we always bought ice cream. Parents said that Great Lent is a time of some restriction, and the child should feel it. We, like all children, loved ice cream. The symbol that we refused during Lent was ice cream. Therefore, in the evening, be sure to eat it. We drove home, in the evening we all prayed together in my father's office, in my father's home church. The prayer of Ephraim the Syrian was our home rite of forgiveness.
Parents set aside three weeks from Great Lent. First Week, Holy Week and Holy Week. During these weeks we always fasted more strictly. The period of our childhood is the seventies. We went to the Soviet school. The elders studied at institutes and universities. Naturally, at school we ate the breakfasts that were given to us. And the students ate what could then be eaten in the student canteen. It is clear that they tried to limit themselves as much as possible so that the dinner was more modest in nature. Didn't take any more fine dining. At the same time, parents always said that Fasting is Fasting, but this does not mean that the child should starve. If a person studies, has a large load, then he should eat normally.
At that time, the products were completely different than they are now. Now every store has a wide variety of different seafood, frozen vegetables. Then everything was unavailable. AND lean food was limited to potatoes, pickles, sauerkraut and various cereals, some mushrooms that we managed to stock up on. I remember that we went to a special store near the church of St. Nicholas in Khamovniki, which was the only one in Moscow that sold frozen vegetables. Of the seafood that we now have in abundance, then there were only squids. And not always.
During Great Lent, we ate food at home as well. Mom always cooked for us all very selectively. I remember that one of the older brothers, when he entered the institute, studied with teachers. It was a big physical activity, and my mother cooked for him alone meat dishes. Another brother, when he studied at the institute in one of the first courses, also experienced considerable physical exertion - the institute was very difficult. Mom also cooked meat dishes and broths for him. I remember this well.
Parents have always tried to set a certain pace at the very beginning of Lent, which is feasible for our family and each of its members, taking into account their age. It often happens that people begin to actively fast and by the end of Great Lent they are already physically exhausted and instead of the joy of the Bright Resurrection of Christ, they experience great fatigue and often associated irritability towards each other.
Mom and dad always noted that during Lent, the main thing is not food and drink. The main thing is to find other restrictions. I remember that they always told us to limit ourselves in terms of cinema during Lent, although we didn’t go often, and we didn’t have a TV at home. There could only be very special exceptions.
Now in our families we try to adhere to this approach. I would like the child, at the moment when he becomes more adult, to choose the measure of Fasting that he is able to bear, and that this be exactly the measure that corresponds to the tradition of our Church.
Material prepared Vladimir Khodakov
According to the forecasts of the World Health Organization, by 2020 depression will become the most common disease in the world. Many call it an epidemic of the 21st century, although even Hippocrates described a condition called “melancholia.” What is depression, why does it occur and how to deal with it? Answers these and other questions psychiatrist, MD Vasily Glebovich Kaleda, Deputy Chief Physician Science Center mental health Russian Academy of Medical Sciences, Professor of PSTGU.
Vasily Glebovich, what are the signs of depression and how to recognize it?
Depression (from the Latin deprimo, which means “oppression”, “suppression”) is a painful condition that is characterized by three main features, the so-called depressive triad. Firstly, this is a sad, sad, melancholy mood (the so-called thymic component of depression), secondly, motor, or motor, lethargy, and finally, ideational lethargy, that is, a slowdown in the pace of thinking and speech.
When we talk about depression, the first thing we think of is a bad mood. But this is not enough! The most important sign diseases - a person loses strength. Outwardly, his movements are smooth, slow, inhibited, while mental activity is also disturbed. Patients often complain about the loss of the meaning of life, a feeling of some kind of stupefaction, internal slowdown, it becomes difficult for them to formulate thoughts, there is a feeling that the head is empty at all.
Characterized by a decrease in self-esteem, the emergence of a conviction that a person is a complete loser in life, that no one needs him, is a burden to his loved ones. At the same time, patients have sleep disturbance, difficulty falling asleep, often there are early awakenings or the inability to get up in the morning, reduced appetite, and a weakening of sexual desire.
The clinical manifestations of depression are very diverse, so there are quite a lot of its varieties, which outwardly can be very different from each other. But one of the main characteristics of depression is its severity: it is relatively mild - subdepression, depression moderate degree severity and severe depression.
If at mild degree disease, a person retains his ability to work and this mood does not greatly affect his daily life and the sphere of communication, then moderate depression already leads to a breakdown and affects the ability to communicate. At severe depression a person practically loses both working capacity and social activity. With this form of depression, a person often has suicidal thoughts - both in a passive form, and in the form of suicidal intentions and even suicidal readiness. Patients suffering from this form of depression often attempt suicide.
According to a WHO study, about 90% of all suicides on the planet are committed by patients with various mental disorders, of which about 60% suffered from depression.
With severe depression, a person suffers unbearable mental suffering; in fact, the soul itself suffers, the perception of the real world narrows, it is difficult or even impossible for a person to communicate with his relatives and friends, in this state he may not hear the words of the priest that are addressed to him, often loses the life values that he had earlier. They already, as a rule, lose their ability to work, because the suffering is very severe.
If we talk about people of faith, they make suicidal attempts much less often, because they have a life-affirming worldview, there is a sense of responsibility before God for their lives. But it happens that even believing people are not able to endure this suffering and do something irreparable.
From sadness to depression
How to understand when a person is already depressed, and when “just sad”? Especially when it comes to close people, whose condition is objectively extremely difficult to assess?
When we talk about depression, we mean specific disease, which has a number of formalized criteria, and one of the most important is its duration. We can talk about depression when this condition lasts for at least two weeks.
Each person is characterized by a state of sadness, sadness, despondency - these are normal manifestations of human emotions. If some unpleasant, psycho-traumatic event happens, then an emotional reaction to it normally appears. But if a person has a misfortune, but he is not upset - this is just a pathology.
However, if a person has a reaction to a traumatic event, then normally it should be adequate to the level of the event. Often in our practice we are faced with the fact that a person has a traumatic situation, but his reaction to this situation is inadequate. For example, being fired from a job is unpleasant, but reacting to it with suicide is not normal. In such cases, we are talking about psychogenic-provoked depression, and this condition needs medical, medication and psychotherapeutic support.
In any case, when a person has this long-term condition with a sad, sad, depressed mood, loss of strength, problems in understanding, loss of the meaning of life, lack of prospects in it - these are the symptoms when you need to see a doctor.
Depression for no reason
It is important to understand that in addition to reactive depression, which occurs as a reaction to some kind of traumatic situation, there are also so-called endogenous depressions, the causes of which are purely biological, associated with certain metabolic disorders. I had to treat people who are no longer there, and who can be called ascetics of the 20th century. And they also had depression!
Some of them had endogenous depressions that arose without any visible, understandable reason. This depression was characterized by some kind of sad, sad, depressed mood, loss of strength. And this condition went very well with drug therapy.
That is, believers are also not immune from depression?
Unfortunately no. They are not immune from both endogenous depression and psychogenic-provoked depression. It must be borne in mind that each person has his own special level of resistance to stress, depending on his character, personality traits and, of course, worldview. One of the greatest psychiatrists of the 20th century, Viktor Frankl, said: “Religion gives a person a spiritual anchor of salvation with a sense of self-confidence that he cannot find anywhere else.”
"Christian" depression
When we talk about people who believe, in addition to the above symptoms associated with mood and lethargy, there is a feeling of God-forsakenness. Such people will say that it is difficult for them to concentrate on prayer, they have lost their sense of grace, they feel on the verge of spiritual death, that they have a cold heart, a petrified insensibility. They can even talk about some special sinfulness and loss of faith. And that feeling of repentance, the degree of their repentance for their sinfulness will not correspond to the real spiritual life, that is, the real misconduct that such people have.
Repentance, the sacraments of Confession and Communion - these are the things that strengthen a person, instill new strength, new hopes. A depressed person comes to a priest, repents of his sins, takes communion, but he does not experience this joy of starting a new life, the joy of meeting the Lord. And for believers, this is one of the main criteria for the presence of a depressive disorder.
They are not lazy
Another important complaint of a person suffering from depression is that he does not want to do anything. This is the so-called apathy, the loss of desire to do something, the loss of the meaning to do something. At the same time, people often complain of a lack of strength, of rapid fatigue - both during physical and mental work. And often people around perceive it as if a person is lazy. They tell him: "Pull yourself together, force yourself to do something."
When such symptoms appear in adolescence, the relatives surrounding them, stern fathers sometimes try to influence them physically and force them to do something, not realizing that the child, the young man, is simply in a painful state.
Here it is worth emphasizing one important point: when we talk about depression, we are talking about the fact that it is a painful condition that arose at a certain moment and caused certain changes in a person's behavior. We all have personality traits, and they tend to accompany us throughout our lives.
It is clear that with age a person changes, some character traits change. But here is the situation: before, everything was fine with a person, he was cheerful and sociable, he was engaged in vigorous activity, studied successfully, and suddenly something happened to him, something happened, and now he looks somehow sad, sad and dreary, and there seems to be no reason for sadness - here there is a reason to suspect depression.
Not so long ago, the peak of depression was between 30 and 40 years old, but today depression has dramatically “younger”, and people under 25 often get sick with it.
Among the varieties of depression, the so-called depression with "youthful asthenic failure" is distinguished, when it is the manifestations of the decline of intellectual, mental strength that come to the fore, when a person loses the ability to think.
This is especially noticeable among students, especially when a person successfully studies at an institute, has completed one course, a second, a third, and then there comes a moment when he looks at a book and cannot understand anything. He reads the material, but he cannot master it. He tries to read it again, but again he cannot understand anything. Then, at some stage, he drops all his textbooks and starts walking.
Relatives can't figure out what's going on. They try to influence him in some way, and this condition is painful. At the same time, there are interesting cases, for example, “depression without depression”, when the mood is normal, but at the same time the person is motorally inhibited, he cannot do anything, he has neither physical strength nor desire to do anything, his intellectual abilities have disappeared somewhere.
Is fasting depression a reality?
If one of the signs of depression is the loss of the physical ability to work, think, then how safe is it for people to fast mental labor? Can a man, working in a responsible leadership position, feel good eating porridge or carrots? Or, for example, a woman accountant who has just the reporting period during Lent, and no one has canceled household duties? To what extent can such situations cause stress, lead an organism weakened after winter to depression?
First, the time of fasting is not the time of hunger strike. Be that as it may, lean foods contain enough necessary for the body substances. One can cite as an example a large number of people who strictly observed the fast and at the same time fulfilled the serious duties assigned to them.
I remember Metropolitan John of Yaroslavl and Rostov (Wendland), who, of course, led an entire diocese, a metropolis, who had a unique dish during Lent - semolina porridge on potato broth. Not everyone who tried this lean food was ready to eat it.
My dad, Father Gleb, always, as far as I remember, strictly fasted, and combined fasting with serious scientific and administrative work, and at one time he had to drive one and a half to two hours one way to his place of work. There was quite a serious physical load, but he coped with it.
It has become much easier to fast now than it was 30 years ago. Now you can go to any supermarket, and there will be a huge selection of dishes marked “ lean product". IN Lately seafood appeared that we did not know before, a large number of frozen and fresh vegetables appeared. Earlier, in childhood, relatively speaking, we knew only sauerkraut, pickles, potatoes during Lent. That is, the current variety of products was not.
I repeat: fasting is not a time of starvation and not a time when a person simply follows a certain diet. If fasting is perceived only as observing a certain diet, then this is not fasting, but just a fasting diet, which, however, can also be quite useful.
Fasting has other purposes - spiritual ones. And probably, here each person, together with his confessor, must determine the measure of fasting that he can really endure. People may be spiritually weak or, due to various reasons and circumstances, begin to fast very strictly, and by the end of the fast, all physical and psychic powers, and instead of the joy of Christ's Resurrection - fatigue and irritation. Probably, in such cases it is better to discuss this with the confessor and, perhaps, get a blessing for some weakening of the fast.
If we talk about us, about people who work, then in any case, lean food differs from ordinary food in that it is more “labor-intensive”. In particular, with regard to cooking - it needs to be cooked longer and more in quantity. Not every person at work has a buffet where lean food is offered, or at least close to lean. In this case, a person must somehow understand what fast he can endure and what his personal fast will consist of.
My dad once gave an example - his spiritual daughter came to him (it was the beginning of the nineties or the end of the eighties). She lived with unbelieving parents, and it was very difficult for her to fast at home, causing constant conflicts with her parents, tension in the family situation.
It is clear that because of these conflicts, a person approached the bright holiday of Easter not at all in a festive mood. And dad told her as an obedience to eat absolutely everything that her parents prepare at home. Just can't watch TV. As a result, after Easter, she said that it was the hardest post in her life.
Probably, those people who, due to some circumstances, find it difficult to fully observe the fast in relation to food - and all of us - need to set some individual goals during the fast. Everyone knows their weaknesses and can impose some feasible restrictions on themselves. This will be a real fast, which has primarily spiritual goals, and not just abstaining from food, a diet.
You and I must always remember that Orthodoxy is the joyful fullness of life in Christ. A person by nature consists of three parts: spirit, soul and body, and we must strive to ensure that our life is full and harmonious, but at the same time the spirit must dominate. Only when spiritual life dominates in a person is he truly mentally healthy.
Interviewed by Lika Sideleva (
- “Get together, rag” is a common expression and a rude form of support for a depressed person. How do you feel about this kind of encouragement?
“I remember a young man with depression. His dad was sthenic, active and in life successful man, and he himself is thin, sensitive. For a long time, as a psychiatrist, I treated him for depression. Of course, I analyzed his behavior in terms of suicidal intentions. With all responsibility I say, he had no such thoughts.
The circumstances so developed that he soon left for another city for practice, to work for his father, who held a serious position. It so happened that he was delayed in practice for two months and was left without medicine.
In addition, his father, seeing that his son was completely different in character, literally every day tried to educate him: “Why are you passive? What are you sad about? Can we find a wife for you? Stay calm and carry on. Be a man, don't be sour." And now the father returns home somehow, and the guy hangs in the middle of the room. Previously, he ran to the store and bought groceries for dinner according to the list that his father left him ...
You need to understand that conversations from the series “get together, rag” in severe conditions can end in just that.
- There is clinical depression, and there are a lot of other conditions that we call it: fatigue, blues, melancholy, burnout. Where is the line between true depression and what is often called it?
- The term "depression" has become extremely common, although people do not always realize what is really behind it. In everyday life, this word describes a state of mild sadness and melancholy.
In medical terms, depression is a well-defined condition. It suggests not only a sad mood. In some forms of depression, a sad mood is not observed at all.
There is a classic depressive triad. In addition to depressed mood, it includes motor retardation, that is, the lack of physical strength to do anything. Outwardly, the movements of such a person look inhibited, slowed down. The third component - ideation - involves changes in thinking. The movement of thought is inhibited, in a conversation it is difficult for such a person to find words, focus on something, and absorb information.
In depression, there is inadequate low self-esteem, a pessimistic perception of the future, sleep disturbance, decreased appetite, however, there are times when the patient eats a lot to mitigate depression.
And although the depressed mood is classic symptom, cases of "ironic", smiling depression are not uncommon. Such a person treats his experiences with irony, which he hides, but inside he experiences a difficult condition, which he describes with the words “cats scratch at the soul.”
With classical depression, the phenomenon of anhedonia occurs - the loss of the ability to rejoice and emotionally respond even to significant events in life. The essence of the disease is the lack of will and the inability to mobilize. The Holy Fathers noted that in these states a person loses his taste for everything and loses the ability to feel pleasure.
- A non-specialist cannot always figure out where depression is, and where Bad mood and fatigue?
- Outwardly, the state of depression is not always clear. There are depressions that occur without an external cause, endogenous. Their cause is within the person, not outside. It can be impossible for a non-specialist to separate “depression” from a sad mood. Imagine a serious young man from a decent university who did not complain about anything, did not look sad or retarded, but suddenly committed a suicidal act. Even retrospectively evaluating the last days of his life, one cannot find psychotrauma: a failed test or unrequited love.
But immediately there are conversations from the series “teenagers today are not the same, they do not value anything, even their own lives.” I often have to deal with young men who at the last moment manage to change their minds and turn to a psychiatrist. They talk about a state of loss of the meaning of life, anti-vital reflections, although formally and outwardly everything is fine with them.
Photo: Alexander Vaganov, photosight.ru
Severe depression can happen to anyone
– The term “depression” is used widely today, all you hear is that about depression – what do people usually mean?
- I won’t say that in my environment, but it’s obvious that in certain circles this term is popular and sometimes it really looks like outward coquetry. However, this does not mean that there is nothing behind the words.
I do not rule out that often people try to cover up their psychological problems with the word “depression”. For example, a person does not have a clear goal in life, there is no awareness of why he lives, why he works, why he needs a family. This pause, the desire to find meaning and fill life with it, is really covered up with the expression “I have depression.” Some use “depression” to cover up their unwillingness and unwillingness to take life seriously and understand that it is a gift from God.
There is a fact of seasonal change in mood. Many people in autumn weather and in winter, when the duration is shortened daylight hours, hard to perceive it in effect physiological features. In one of the northern Swedish cities there is a saying that we may not understand at all: "Do not show the rope to the Swede in winter." Not only in Scandinavia and in the north of Russia, the prolonged absence of the sun is hard for people to endure. But in the southern countries, depression is rare, there are more often opposite depression states - manic excitement.
I came across a man who left for Italy from a northern city, lived there in difficult conditions, but would never agree to return home, where there was work, an apartment, friends. To my reasonable question, what are you doing here, you have everything there, he answered: “Everything is there, but there is not enough sun.”
- There is an opinion that losers, weaklings, internally dissolute people suffer from depression. Successful, purposeful, disciplined people cannot have depression. This is true?
- No, it's not. Both successful and those who are disciplined in life, and active people experience depression. I’ll say more, in such people, depression occurs in an extremely severe forms. After all, for them this state is incomprehensible. A person who has been active for many years, leading large groups, suddenly experiences melancholy, depression, finds himself in a state of helplessness. He cannot recognize himself, he cannot take control of himself, he does not have the physical strength and desire to do what he used to do better than others in his life, for example, to achieve success.
Among famous people different areas culture and science, there are many who suffered from classical depression. These are Jack London, Mark Twain, Van Gogh, Vrubel, Shostakovich, Mozart. One can recall many prominent people in whose lives there were distinct depressive states that have happened to them on numerous occasions.
There is such a thing - psychopathy (personality disorder) - a character trait from which a person suffers himself and / or those around him.
One of the varieties of psychopathy is the constitutional-depressive type. This term describes born pessimists. People who go through life and perceive everything in gloomy colors. They perceive Christianity not as a joyful fullness of life in God, but as a depressive religion. The horror is that they often try to instill a similar view of Christianity in others. In other words, they are in a state of constant subdepression.
Along with them, there is their complete opposite - very optimistic people, whose life is a continuous bright spot. But both the former and the latter can have severe depression, as it can be with "losers" and successful people.
sickness or sin
- Synonyms of depression, especially among believers, are despondency, sadness, which are interpreted as states of sin.
Sadness is a normal human condition. It occurs in a serious psychotraumatic situation. Remember Christ, who was sad and grieved when he learned that Lazarus had died. Sadness in and of itself is not a sin.
In general, if you carefully look at the writings of the holy fathers, it turns out that they describe the classic depressive triad in the finest nuances. In particular, they write about the state of sadness and discouragement, the state of physical and mental heaviness, the lack of will, constraint. Athanasius the Great, for example, called despondency a state of aggravation of the body and soul.
But this state becomes a disease when, stuck in a depressed mood, a person loses hope in God's mercy, ceases to realize that what is sent to him can have an inner meaning.
– Did the ascetics of piety suffer from depression, or did prayer books bypass this trouble?
- If we take the lives of Russian ascetics of the last century, for example, the lives of Tikhon Zadonsky, Ignaty Brianchaninov, then upon careful reading we will be convinced that they clearly experienced a state that can be interpreted as clinical depression.
Silouan of Athos had the same difficult conditions. He described them as a feeling of being abandoned by God.
Depression happens even to very pious people. I had to treat a man who went down in the history of the Russian Orthodox Church as a righteous man.
When we talk about classic depression, we are talking about a purely biological condition that can affect anyone. Another thing is that a person who is predisposed to a serious spiritual life, who perceives his condition as a cross sent to him, really achieves transfiguration or, as believers say, holiness.
– That is, depression can affect the spiritual growth of a person?
- In a state of subdepression, that is, in mild form, the person really gets deeper. For example, he understands that many things that he does every day are, by and large, of secondary importance. He begins to think about the meaning of life, about his relationship with God. At the same time, such a person is more vulnerable, more sensitive to injustice and his own sinfulness.
But if we talk about severe forms of depression, then it is often felt as being at the bottom of the abyss and a total feeling of being abandoned by God. There can be no talk of any positive influence on spiritual growth here.
In psychiatry, there is the concept of "anesthesia of feelings" - this is a complete loss of feelings, including in spiritual and prayerful work. In this state, a person feels neither joy nor grace even from participating in the sacraments.
- It turns out that non-believers endure depression even harder?
- Undoubtedly. A person with a Christian worldview perceives life as a kind of school. We go through life, and the Lord sends us trials for our spiritual maturation. I have seen many cases when in this state people came to Church and turned to God.
Even more often I met people who perceived depression as a providence of God, as a condition through which it was important for them to go through. One of my patients said: "Christ endured and we must endure." To the layman, these words sound wild. But I remember how that patient said them. He said this from the heart, and not for a red word, with humility and a clear realization that this is for him a deep inner meaning of the disease.
The hardest thing for a depressed person is to come to the realization that life has meaning. We did not come into this world ourselves, it is not for us to decide when to leave it. For unbelievers, this thought is difficult: “Why endure suffering when everything is hopeless ahead?” Understand, a depressed person is a person who has put on black glasses. The past is a series of mistakes and falls, the present is impenetrable, nothing looms ahead of him and does not shine.
It is important to understand that depression is treated
- What are the statistics? How common is clinical depression compared to other conditions we call it that?
I only know general numbers. In the world, more than 350 million people suffer from clinical depression, in Russia - about eight million. In the northern regions, in percentage terms, the number is more pronounced, in the southern - less. But to say what percentage of those who consider themselves "depressed" in the broad sense of the word and are in a state of sadness, I'm not ready.
The problem is that even with classic depression, people are in no hurry to see a doctor.
In Russian society as a whole, there is no understanding of either what depression is, or what its scale is, and, most importantly, what its danger is. "Pull yourself together, rag" - that's our expression.
I will again give a textbook example of a young man whose arms and legs are intact, has a separate apartment and work, and he suddenly lies down on the sofa and cannot do anything. It seems, well, it’s ridiculous to lie like that: “Come on, get up, go to work.” In addition to the hackneyed phrase “get together, rag,” such young people are also told stories about the hard lot of grandparents who found a way to mobilize even in war.
This is all correct, of course, but more often leads to self-blame, the decision not to be a burden on the family, and suicidal intentions. A depressed person should not be pressured or rudely stimulated. This one is like coaxing a person with paralysis lower extremities get up and walk. Alas, this is not yet obvious to everyone.
The main danger of depression is that it leads to suicide. Therefore, in a number of countries there are medical programs for the prevention of suicide and the detection of depressive conditions in loved ones, among employees at work. In Japan, for example, there are popular brochures that explain everything from A to Z: what kind of disease, what are the signs, what is dangerous for a person, how to behave if such a condition is suspected in another.
- The problem objectively exists, this is understandable. What is the trend?
“According to the WHO, the incidence of depression is on the rise. There is an opinion that in the XXI century there will be a pandemic of depressions. The rapid growth that we are seeing is partly due to better detection. The scientific community is actively engaged in the topic of depression. Thanks to education, even at the everyday level, depressive states are more often noticed. With this problem, patients began to turn to doctors more often.
There are other factors as well. For example, an increase in the number of depressions is directly related to the increase in life expectancy around the world. The fact is that depression is a companion of human aging due to biological reasons, such as brain restructuring. Also, depression accompanies severe somatic diseases: oncological, serious forms coronary disease hearts. In such people, depression is detected in 30-50% of cases.
WHO experts note that one of the reasons for the prevalence of depression is the loss of traditional family and religious values. Previously, a person lived in his own house with his parents, grandparents, that is, a large family. A person lived for decades in the same place and clearly understood that one day he would grow up, become an adult, then grow old and live in a large family where the younger generation would take care of him. Now many live in separate comfortable apartments, and at a certain stage of life they find themselves lonely, despite material wealth and the presence of children and grandchildren, who, due to the modern rhythm of life, do not have time to take care of them. Disunity is a phenomenon of our time and certainly the cause of depression.
Finally, there was a loss of traditional religious values. It is human nature to think about the meaning of life. But if in adulthood there is no religious faith that gives many people the meaning of life, then it becomes quite difficult for a person. There are even a number of studies conducted by domestic experts that show that in old age, in a situation of severe loss, the absence of religious values is an extremely unfavorable prognostic factor.
In other words, depression is not a fashionable illness, it is a serious problem of the present.
Unfortunately, to this day there is one of the myths about psychiatry, they say, falling into the hands of a psychiatrist, a person will inevitably be “zombified”, “turn into a vegetable”. Meanwhile, science has advanced a long time ago. Today we have a large arsenal of drugs and antidepressants with different mechanisms of action and different tolerability, with minimal side effects and high therapeutic productivity, with the ability to use drugs in outpatient practice.
It is important to understand that depression is treated, and after therapy there is a significant improvement in the condition. To neglect this is unacceptable and stupid.
The Church has always emphasized the medical ministry. Among the apostles was professional doctor- Apostle Luke. In the book of wisdom of Jesus the son of Sirach, the Lord says: “Honor the doctor with honor according to need in him; for the Lord created him, and healing is from the Most High ... And give place to the doctor, for the Lord also created him, and let him not depart from you, for he is needed ”(Sir.38: 1-2, 12). We must always address the Doctor with a capital letter, but we have no right to demand from the Lord to constantly perform a miracle. Yes, Christ said to the paralytic, "Get up and walk." But this is a special case.
I am convinced that we must go to doctors (with a small letter), so that through medicine and these doctors the Lord will give us His help.
As a manuscriptCaleda
Vasily Glebovich
YOUTHFUL
ENDOGENOUS PARTSIC
PSYCHOSIS
(psychopathological, pathogenetic and prognostic
Aspects of the first attack)
14.01.06 - Psychiatry
A b u r e f e r a t
Dissertations for a degree
Doctors of Medical Sciences
Moscow - 2010
Work is done
at the Institution of the Russian Academy of Medical Sciences
Scientific Center for Mental Health of the Russian Academy of Medical Sciences
^ Official Opponents
Corresponding Member of the Russian Academy of Medical Sciences,
Doctor of Medical Sciences,
Professor Zharikov Nikolai Mikhailovich
Doctor of Medical Sciences,
Professor Kurashov Andrey Sergeevich
Doctor of Medical Sciences Simashkova Natalia Valentinovna
^ Lead organization
FGU "Moscow Research Institute of Psychiatry of Roszdrav"
The defense will take place on __ ______________ 2010 at 12 noon
At a meeting of the Dissertation Council D 001.028.01
In the Institution of the Russian Academy of Medical Sciences
Scientific Center for Mental Health of the Russian Academy of Medical Sciences
Address: 115522, Moscow, Kashirskoe highway, 34
The dissertation can be found in the library
Scientific Center for Mental Health of the Russian Academy of Medical Sciences
Scientific Secretary
dissertation council,
Candidate of Medical Sciences Nikiforova Irina Yurievna
^ GENERAL DESCRIPTION OF WORK
The relevance of research The relevance of the study of endogenous paroxysmal psychoses, which occupy one of the central places in clinical psychiatry, is determined by their social significance and high prevalence. The main direction of the current stage of development of medical science is the study of the etiopathogenetic foundations of diseases with the involvement of the latest paraclinical methods. This approach is most promising in psychiatry as well. As pointed out by many leading researchers on different stages psychiatric science [Snezhnevsky A.V., 1972; Vartanyan M.E., 1999; Tiganov A.S., 2002], the establishment of clinical and pathogenetic correlations is possible only if there are reliable clinical, psychopathological and clinical and dynamic data on the patterns of manifestation and course of endogenous psychoses, starting from the early stages of the disease. Of particular interest in this regard is the targeted study of the first psychotic seizures, which at the present stage of the development of psychiatry has increasingly attracted the attention of many researchers [Gurovich I.Ya, et al., 2003; Movina L.G., 2005; Bessonova A.A., 2008; Shmukler A.B., 2009; Malla A. Payne J., 2005; Freedman R. et al., 2005; Addington J., Addingtona D., 2008; Pantelisa C. et al., 2009]. On the one hand, this direction is based on the possibility of clinical and biological study of patients at the early stages of the disease, and on the other hand, the concept of the determining role of adequate diagnostic evaluation and, accordingly, the choice of therapy and methods of its implementation at the stage of the first manifestation of the disease for its further course and outcome [Smulevich A.B., 2005; Zaitseva Yu.S., 2007; Wyatt R. et al., 1997; Jeppesen P. et al., 2008; Mihalopoulos C. et al., 2009].
Of particular relevance is the study of endogenous diseases, taking into account the age factor. Among the so-called crisis stages, which largely determine the specific psychopathological and dynamic features of endogenous psychoses, adolescence occupies a special place. During this period, there is a whole complex of rapidly flowing psychobiological processes, the formation of cognitive functions, the formation of personality, the choice of a future profession, a change in the stereotype of life. At the same time, in adolescence, due to the incompleteness of biological and psychological maturation, the brain retains relatively high plasticity, which increases its susceptibility to external influences and in particular to adequate therapy.
According to epidemiological data, the peak of manifestation of endogenous psychoses falls on adolescence [Shmaonova LM, Liberman Yu.I., 1979; Davidson M. et al., 2005; Lauronen E., 2007]. And in this age period the frequency of manifestations of psychosis is especially high in men, who also have a worse outcome of the course of schizophrenic spectrum diseases.
Described by a number of researchers [Tsutsulkovskaya M.Ya., 1967; Kurashov A.S., 1973; Geller B. et al., 1995; McClellan J., Wery J., 2000] clinical isomorphism characteristic of endogenous psychoses of adolescence, as well as noted at the present stage [Dvirsky A.E., 2002, 2004; Vilyanov V.B., Tsygankov B.D., 2005; Tiganov A.S., 2009] general and therapeutic pathomorphosis of mental illnesses with a significant modification of their clinical picture and patterns of course significantly complicate their differential diagnostic and prognostic assessment.
The problem of paroxysmal forms of endogenous psychoses, manifesting in adolescence, was reflected in a number of studies devoted to both the clinic of schizophrenia and schizoaffective psychosis, [Kurashov AS, 1973; Mikhailova V.A., 1978; Gutin V.N., 1994; Barkhatova A.N., 2005; Kuzyakova A.A., 2007; Omelchenko M.A., 2009; Cohen D. et al., 1999; Jarbin H. et al., 2003]. However, the psychopathological features of the first seizures, due to the pathogenetic and pathoplastic influence of adolescence, remain insufficiently studied, criteria have not been developed. early diagnosis and prognosis of juvenile endogenous paroxysmal psychosis, taking into account not only clinical and psychopathological, but also clinical and pathogenetic parameters . The conducted studies did not reflect the study of cognitive disorders in the structure of the first attack, which, along with positive and negative disorders, are now considered as one of the main manifestations of diseases of the schizophrenic process [Magomedova M.V., 2003; Sidorova M.A., Korsakova N.K., 2004; Fitzgerald D. et al., 2004; Milev P. et al., 2005; Keefe R., 2008]. Also, the issues of the pathogenetic participation of a number of biological factors in the formation of the picture of the first attack remain unexplored. So, according to a number of researchers, based on the concept of the functional unity of the nervous and immune systems [Akmaev I.G., 1998; Zozulya A.A., 2005; Hosoi T. et al., 2002; Zhang X. et al., 2005], especially important is the analysis of innate and acquired immunity at the first manifestation of the disease, as well as the study of the effect immune factors on the effectiveness of antipsychotic therapy [Abrosimova Yu.S. 2009; Maes M. et al. 2002; Drzyzga L. et al., 2006].
The study of adolescent patients with the first attack of endogenous psychosis is the most optimal model for studying the fundamental pathogenetic foundations of endogenous diseases, as it allows you to determine the features of the functioning various structures of the brain at the time of the manifestation of the disease, still beyond the influence of antipsychotic therapy on them.
Thus, all of the above determined the relevance of a special multidisciplinary approach to the study of the first attacks of juvenile endogenous psychoses.
Purpose and main objectives of the study The purpose of this work is to substantiate the defining influence of the age factor on the clinical and psychopathological parameters of the first seizures juvenile endogenous paroxysmal psychosis (SEPP), with the establishment of their characteristic clinical and pathogenetic patterns, differential diagnostic and prognostic evaluation criteria.
The following tasks were set for resolution:
The study of the features of clinical and psychopathological manifestations of the first attacks of JEPP with the identification of their main typological varieties and the determination of the role of the age factor in the formation of their clinical picture.
The study of cognitive disorders that occur in patients in the structure of the first attack, both at the stage of its manifestation, and at the stage of the formation of the first remission, taking into account the differences in its psychopathological patterns.
Determination of a number of indicators of innate and acquired immunity during the manifestation of the first attack and at the stage of remission, as well as the study of their influence on the effectiveness of antipsychotic therapy.
Analyzing the conditions for the formation of pictures of the first attack and determining the main patterns of the subsequent course and outcome of JEPP.
Identification of clinical-psychopathological and clinical-pathogenetic parameters of the first attack, significant for assessing the prognosis of juvenile endogenous psychoses in general.
Carrying out a comparative clinical and nosological analysis of UEPP with the selection of criteria for their nosological differentiation.
The study of the pathomorphosis of the course and outcome of juvenile endogenous paroxysmal psychosis in modern conditions.
The studied sample consisted of 575 male patients hospitalized with the first attack of juvenile endogenous paroxysmal psychosis (JEPP) at the Clinic of the National Center for Health Care of the Russian Academy of Medical Sciences (VNTSPZ of the USSR Academy of Medical Sciences). Of these, the clinical group consisted of 297 patients who were first admitted and examined from 1996 to 2005, the follow-up group - 278 patients who were first hospitalized in the period from 1984 to 1995. with the first attack, the clinical features of which were assessed retrospectively based on the study of case histories. The patients of this group were subsequently examined by the clinical follow-up method.
The sample of patients for the study was formed in accordance with the following inclusion criteria: the onset of the disease within adolescence; manifestation endogenous psychosis(schizophrenia or schizoaffective psychosis) in adolescence (16-25 years); the presence in the first attack of psychotic disorders incongruent to affect; the duration of observation of patients (for the follow-up group) is at least 10 years. The exclusion criteria were: the presence of signs of a continuous course of the disease; the presence of concomitant mental pathology(mental and behavioral disorders due to the use of psychoactive substances, alcoholism, mental retardation), as well as somatic or neurological pathology (chronic somatic diseases, epilepsy, severe traumatic brain injury, etc.), which complicates the study.
To solve the tasks set in the study, clinical-psychopathological, clinical-catamnestic, psychometric methods, as well as in cooperation with the relevant departments and laboratories of the NTsPZ RAMS - neuropsychological, experimental psychological, neurophysiological, clinical and immunological. Statistical processing and counting were carried out using the Statistica 6.0 software package.
Scientific novelty of the research Developed and substantiated new scientific direction in the clinical and psychopathological study of juvenile endogenous paroxysmal psychoses, in which the decisive importance is attached to the pathogenetic and pathoplastic influence of the youthful age-related psychobiological stage of development and the clinical and psychopathological and predictive value features of the first attack for the dynamics of the disease as a whole. For the first time, the problem of the influence of the age factor on the formation of clinical and psychopathological manifestations, dynamics, and also the prognosis of the first attacks of endogenous paroxysmal psychoses was solved. The relationship and specificity of biological markers of the clinical and psychopathological state of patients with the first manifestation of endogenous psychosis in adolescence, which in turn can be considered as age-specific parameters of pathogenesis that determine the prognosis and individual sensitivity of the drug response to therapy, have been established. The specificity of cognitive disorders in patients with the first seizure in adolescence was revealed, reflecting its impact on the characteristics of their cognitive activity and personal characteristics. For the first time, a relationship has been established between differences in the topography of structural and functional anomalies of the brain, which cause differences in the configuration of cognitive impairment, with the clinical and psychopathological features of the first seizures. On the basis of a comparison of the data of clinical-psychopathological and clinical-catamnestic studies of patients and taking into account clinical and pathogenetic parameters, nosological heterogeneity of juvenile endogenous psychoses was established.
The practical significance of the work The data obtained in the course of the study provide a solution to the problems associated with timely diagnosis and determination of an individual prognosis in juvenile endogenous paroxysmal psychosis, which is especially important in this age period: at this stage, significant psychological and physiological, as well as social change in the life of the individual. The patterns of clinical manifestations and the course of endogenous psychoses that manifest in adolescence, the features of cognitive disorders and immunological parameters in patients with the first attack, established during the study, will contribute to the optimal solution of issues related to the diagnosis and prognosis of the disease, as well as to the choice of an adequate therapeutic tactics management of these patients and substantiation of indications for preventive drug therapy, including its duration, and ways to optimize social rehabilitation measures. The data obtained in the study of the patterns of the course and outcome of JEPP have found application in the practical work of Psychoneurological dispensaries in Moscow No. 10 and No. 18, Moscow City medical center for youth, medical and pedagogical rehabilitation center at PB No. 15, as well as the seminar " Modern Aspects clinical, expert and social problems adolescent and youth psychiatry. The results of the study can be used in the lecture process and pedagogical activities of the departments of psychiatry of medical universities and the system of postgraduate education.
Basic provisions for defense
The first attacks of endogenous paroxysmal psychosis manifesting in adolescence are characterized by distinct psychopathological and psychobiological features due to the pathoplastic and pathogenetic influence of the pubertal stage of maturation, which must be taken into account when solving both differential diagnostic and prognostic, as well as therapeutic and social rehabilitation tasks.
The manifestation of endogenous psychoses in adolescence is accompanied by severe cognitive impairments that have different configurations and dynamics depending on the psychopathological picture of the first attack, which indicates that these patients have differences in the topography of their structural and functional brain disorders.
The manifestation of endogenous paroxysmal psychosis in adolescence is accompanied by changes in the parameters of innate and acquired immunity, which correlate with the effectiveness of antipsychotic therapy, but do not have significant differences depending on the psychopathological structure of the attack.
The course of juvenile endogenous paroxysmal psychoses is characterized by a pronounced tendency to the development of repeated attacks while maintaining the psychopathological features of the first attack in their syndromic structure, while the period of the most intense attack formation occurs here in the first ten years of catamnesis.
The prognosis of the further course and outcome of juvenile endogenous paroxysmal psychoses in patients with the first attack should be based on the totality of the clinical, psychopathological and clinical pathogenetic parameters that characterize them.
According to the nosological affiliation, juvenile endogenous paroxysmal psychoses seem to be most adequately assessed within the framework of schizophrenia, and less often - within the framework of schizoaffective psychosis.
At the present stage, in comparison with previous time periods, juvenile endogenous paroxysmal psychoses have a more favorable course.
Scope and structure of work The thesis is presented on 347 pages of typewritten text, consists of an introduction, 8 chapters, a conclusion, conclusions, a bibliographic index containing 458 titles (207 works by domestic and 251 foreign authors), and an appendix. The introduction substantiates the relevance of the study, formulates its goals and objectives, presents the scientific novelty and practical significance of the work. The first chapter presents data from domestic and foreign literature covering the development and state of the art problems of a complex, multidisciplinary study of the first attack of JEP, as well as the features of the course and outcome of the disease. The second chapter describes the characteristics of the clinical material and research methods. The third chapter presents the features of clinical and psychopathological manifestations of the first seizures and their typological varieties. The fourth chapter presents data concerning the features of the structure and dynamics of anomalies of cognitive processes in patients with the first attack and their relationship with the psychopathological type of attack. The fifth chapter presents the characteristics of a number of indicators of innate and acquired immunity during the manifestation of the first attack, and also shows the significance of these immunological factors for predicting the effectiveness of antipsychotic therapy. The sixth chapter reflects the main patterns of the course and outcome of JEPD, obtained on the basis of a clinical follow-up study. The seventh chapter presents some clinical and pathogenetic correlations and prognostic criteria. The eighth chapter highlights the issues of nosological differentiation of JEPP. In conclusion, the results of the study are summarized and 7 conclusions are presented. Thesis is illustrated clinical histories diseases, 34 tables and 12 figures.
^ RESULTS OF THE STUDY
In the course of the clinical and psychopathological study of patients with the first psychotic attacks of juvenile endogenous paroxysmal psychosis (JEPP), the determining role of the age factor in the formation of their clinical and psychopathological features was established. These include: polymorphism of the clinical picture with incompleteness, fragmentation and variability of psychopathological symptoms; high representation of varying degrees of severity affective disorders, which are characterized by a distinct age-related atypicality of manifestations; the frequency of catatonic disorders, which have a wide range of manifestations from generalized forms to symptoms of "minor catatonia", accompanied, as a rule, by severe somatovegetative disorders; the predominance of sensual delirium with a rare occurrence of seizures with systematized interpretive delirium; the presence of "pubertal features" in the picture of productive symptoms, which are manifested both in the subject of delusional and hallucinatory disorders, and in the frequency of delusional fantasies and hallucinations of the imagination; the predominance of ideational automatisms in the structure of the Kandinsky-Clerambault syndrome in comparison with sensory and kinesthetic ones; dominance of autochthonous mechanisms of occurrence of an attack over psychogenic and somatogenic ones; the protracted nature of the entire attack, as well as the stage of formation ("ripening") of remissions; significant representation in their picture of cognitive disorders.
Based on the clinical and psychopathological study of the pictures of the first seizures in the studied patients of the clinical group, three types of them were distinguished, differing in their syndromic characteristics: with the dominance of catatonic symptoms without symptoms of clouding of consciousness and distinct affective disorders (23.9% of cases), with the dominance of hallucinatory-delusional ( 34.7%) or affective-delusional (41.4%) symptoms. In the course of a more detailed analysis of the structure of these states, it was found that in addition to their differentiation depending on the clinical characteristics of the leading syndrome, their subdivision according to the mechanism of delusion formation is justified (Fig. 1).
Rice. 1. Typology of the first attacks of juvenile endogenous
paroxysmal psychoses
At the first attacks with dominance of catatonic symptoms (type I) two subtypes have been identified: lucid-catatonic (9.7%), in which there was a predominance throughout the attack of catatonic symptoms, represented by both its hypokinetic and hyperkinetic variants, in the presence of fragmentary and rudimentary unsystematic delusions, and catatonic-hallucinatory-delusional (14.2%), characterized by a combination throughout the attack of severe catatonic disorders, presented in most cases by substuporous symptoms, interrupted by impulsive outbursts of excitement, with delusional disorders (represented mainly by delusions of perception) and massive, often verbal, pseudohallucinations.
At the first attacks With dominance of hallucinatory-delusional disorders (type II) three subtypes have been identified. Seizures were the least common (5.7%) with acute systematized interpretive delirium, where the interpretative nature of delusional formation was represented by the delusions of other people's parents, relationships, hypochondriacal, dysmorphophobic content, less often - reformism, invention or love content. At the same time, the picture of interpretive delirium was supplemented by vaguely expressed phenomena of mental automatism, delusional ideas of influence in the presence of the relationship of all these disorders on the basis of a single delusional plot. For subtype with acute unsystematic interpretive delusions and verbal hallucinosis (11.4%) was characterized by the almost simultaneous appearance of unsystematized interpretive delusional ideas and verbal hallucinations, followed by the addition of manifestations of the Kandinsky-Clerambault syndrome (primarily ideational automatisms in the form of a symptom of openness of thoughts). With subtype with a mixed (sensual and interpretive) nature of delusion formation (17.6%,) there was a simultaneous coexistence of both delusional perception and delusional unsystematized interpretive ideas. Crystallization of delirium occurred according to the type of insight, in most patients the psychopathological picture of the attack was determined by the varying degree of representation of the manifestations of the Kandinsky-Clerambault syndrome. With this type of syndromes, in all its subtypes, the psychopathological picture in a number of observations was supplemented by affective disorders, which, however, did not have a decisive role in the formation of the attack structure.
First attacks with dominance of affective-delusional disorders (type III) were characterized by a double - affective and perceptual-delusional mechanism of delusion formation . Three subtypes have also been identified here. At the first - with the dominance of intellectual delirium of the imagination(9.8%) - in the psychopathological picture of the attack, delusional ideas of fantastic content came to the fore, formed according to the mechanism of delusion of imagination, often in combination with manifestations of acute delusion of perception. With a subtype with dominance of visual-figurative delusions of imagination (14.8%) the sharpness, polymorphism and variability of the psychopathological picture were most pronounced. There was a combination of acute figurative delirium, characterized by the appearance of "antagonistic" delirium of a megalomanic nature, the phenomena of the Kandinsky-Clerambault syndrome and catatonic-oneiric symptoms. In the cases studied, the pole of affect could often change during an attack, and therefore it was sometimes difficult to determine the dominant mood background. With a subtype with dominance of delusions of perception (16.8%) characteristic was the appearance of these delusional disorders of the type of acute paranoid against the background of a pronounced depressive or manic affect.
The study of cognitive disorders in the studied patients during the manifestation of the first attack and after the reduction of acute psychotic symptoms at the stage of formation of subsequent remission, carried out using neuropsychological, neurophysiological and experimental psychological methods, established significant differences in their structure and dynamics, correlating with the psychopathological symptoms identified in them. types of seizures, which confirmed the validity of their clinical typology based on the identification of the leading syndromes.
Data obtained from neuropsychological research showed that patients with JEPD already at the initial stage of the first psychotic attack demonstrate distinct violations of the regulatory, neurodynamic and operational components of cognitive processes. At the same time, each type of first seizures corresponds to a special configuration of the neuropsychological symptom complex, which differs not only in the presence or absence of certain disorders, but also in their different hierarchical organization, as well as the severity of these disorders (Fig. 2).
Rice. 2. Neurocognitive profile of patients with different types of first
seizures
Thus, in patients with I (catatonic) type of seizures, the least diffuse picture of cognitive disorders occurred in comparison with patients of the other two types of seizures. The disorder of the dynamic component in the motor, intellectual and mnestic spheres of the psyche came to the fore. In addition to these disorders in these patients, there was a decrease in control over the course of various kinds mental activity, which indicated the insufficiency of the mechanisms of its arbitrary regulation. In addition, there were some limitations in auditory-speech and visual memory.
In patients with II (hallucinatory-delusional) type of seizures, the identified neurocognitive symptoms were of a "generalized" nature, i.e. affected almost all components of cognitive processes and was characterized by a significant degree of severity. The most deficient in the structure of the neuropsychological symptom complex were voluntary regulation of activity and energy supply of mental activity. Disorders of auditory-speech and visual memory, as well as visual-spatial, tactile and acoustic non-verbal gnosis in these patients were more pronounced. There were also violations of the dynamic component in the motor, intellectual and mnestic spheres, however, unlike patients with type I seizures, they did not have the character of a leading syndrome.
In patients with type III (affective-delusional) seizures, the general pattern of neurocognitive disorders (with a lesser degree of their severity) was similar to that described above in patients with type II seizures. This was especially true for violations of voluntary regulation of activity, its neurodynamic parameters and energy supply, as well as auditory-speech memory, acoustic non-verbal gnosis and optical-spatial disorders. At the same time, distinct violations of spatial praxis were observed here.
When assessing the dynamics of established disorders in cognitive sphere in the studied patients, based on a comparison of the data of their primary and repeated examinations (at the stage of the formation of remission), it was found that with different types of first attacks, changes in neurocognitive functioning not only differentially affect different components of this symptom complex, but also vary in intensity of their reduction during an attack . During the re-examination of patients with all three types of seizures, an increase in the resources of voluntary regulation of mental activity was noted, which serves as an indication of the actualization of their autoregulatory behavioral strategies during the formation of remission. Positive shifts in the cognitive sphere in patients with type I and II seizures were not statistically significant (p> 0.05), which reflects the lack of determinism of neurocognitive deficit by the severity of clinical symptoms, which is characteristic of patients with schizophrenia according to a number of other researchers. While in patients with type III first seizures, as shown by the analysis, the severity of neurocognitive anomalies corresponded to the severity of psychopathological disorders, i.e. here, after the reduction of acute psychotic symptoms, there was a clear positive dynamics in the indicators of neurocognitive deficit (p
The study of cognitive functions in patients with the first attack of juvenile endogenous paroxysmal psychosis was also carried out using neurophysiological method
in conditions of selective attention, the so-called. oddball paradigm, or P300, according to which different components of evoked potentials are associated with different stages of auditory information processing. Thus, the analysis of the physical parameters of sounds is associated with the N100 wave, the classification of stimuli with the N200 wave, the assessment of the significance of incoming information, the activation of attention resources - with the P300 wave. It was found that in all the examined patients at the initial stage of the first attack, the early stages of information processing were not so strongly affected, although in all three types of the first attacks, violations of the processes of analyzing the physical parameters of sound were noted. It has been established that at the initial stage of the first attack, patients quite successfully keep the set-task for differentiation proposed by them. At the same time, it turned out that significant pathological changes were recorded in the studied patients when assessing the significance of incoming information, recording it in memory, and choosing a reaction.
Based on the comparison of the obtained data with the psychopathological type of the first attack, it was found that in the studied patients, despite the unidirectional anomalies of the neurophysiological parameters of cognitive functions, there are certain features of the studied characteristics that correlate with the dominance of various psychopathological syndromes in the picture of the first attack. So, in patients with I (catatonic) type of seizures, the deceleration of mental processes, which began at the stage of classification of stimuli and remains in the interval associated with the activation of attention resources, preparation for the performance of an action. At the same time, deviations in the values of the P300 amplitude do not reach the level of significance in the parietal zones here, which allows us to assume the relative structural safety in this group of patients with P300 generators projecting maximum activity to these departments. In type II (hallucinatory-delusional) seizures, the slowdown in mental processes at the stage of stimulus classification was less pronounced, moreover, when moving to the next stage of information processing, this slowdown persisted only in a few topographic zones. In contrast to the above data, in the III (affective-delusional) type of seizures, there were practically no disturbances in the processes of classification of stimuli. At the same time, with this type of seizures (compared to the two above), there were more distinct deviations for the P300 wave. A possible explanation for this is that, according to clinical characteristics, in patients of this group there were pronounced disorders in affective sphere, which, possibly, led to greater desynchronization of processes at the late cognitive stage, associated, among other things, with the assessment of the significance of stimuli.
During re-examination at the stage of formation of remission in the majority of the studied patients and, first of all, in types I and II of seizures, “normalization” of the amplitude characteristics of the late cognitive component P300 was noted while maintaining the slowdown of the N200 and P300 components. At the same time, a re-examination of patients with type III seizures revealed the persistence of anomalies in both amplitude and time parameters of P300.
Thus, the neuropsychological and neurophysiological methods used in this study to study cognitive functions in patients with various psychopathological types of the first seizure made it possible to approach the solution of one of the main tasks in the field of biological psychiatry - "identification of the brain mechanisms that mediate clinical picture mental illness” [Iznak A.F., 2008; Flor-Henry P., 1983; Andrewsen N., 2000]. The results obtained by us using modern neuropsychological and neurophysiological methods for studying cognitive functions in these patients allowed us to confirm Karl Kleist's hypothesis that the psychopathological picture of an attack is determined by the different topography of structural and functional disorders of the brain (Fig. 3).
Rice. 3.
Typography of structural and functional anomalies of the brain
(according to neuropsychological and neurophysiological
studies) with different types of first seizures
The neuropsychological and neurophysiological data obtained in this study made it possible to establish both signs of damage to the subcortical and limbic structures and the temporal region of the brain that are common for all types of the first attacks of JEPD, as well as their certain differences: in patients with a catatonic type of seizures, pathological process predominantly premotor and prefrontal sections of the cortex are involved, with the hallucinatory-delusional type - prefrontal and parietal sections, with affective-delusional - parietal-occipital. It should be noted that the topography of cognitive impairments established in this work in the studied patients is also confirmed in the works of a number of researchers conducted using the MRI method, especially with regard to hallucinatory-delusional disorders. At the same time, data concerning patients with dominance of catatonic symptoms, as far as is known from the literature, have been established for the first time.
results experimental psychological research patients with the first attack of JEPP , carried out from the position of the pathopsychological syndrome [Kritskaya V.P., Meleshko T.K., Polyakov Yu.F., 1991; Kritskaya V.P., Meleshko T.K., 2003, 2009] at the stage of remission formation also testified to a different degree of cognitive deficit depending on the type of first seizures, which corresponds to the data established during neuropsychological and neurophysiological studies. In addition, a high representation in patients with all types of first attacks of schizoid personality traits was established, which manifests itself in their cognitive style and gives a peculiar coloring to their appearance and behavior, which is mediated to a certain extent by the influence of the age factor. In general, the majority of the studied patients were characterized by the predominance of inadequate personal self-esteem, the absence of real plans for the future, as well as the field-dependent style of cognitive activity, which, as one might suppose, contributed to the more frequent formation of the first attacks of sensory delirium in their picture, even in the absence of it in its structure. affective disorders. According to the obtained pathopsychological data, the dependence on the perceptual field, characteristic of most of the studied patients, was combined in them with their “release” from the social context, as evidenced by a decrease in the level of communication, which was more pronounced in patients with I and II (catatonic and hallucinatory-delusional) types of the former. seizures. Other significant pathopsychological differences were noted depending on the psychopathological picture of the attack. So, in terms of parameters characterizing mental activity, motivation and self-regulation of activity, patients with types I and II of seizures showed a more pronounced decrease compared to these indicators in patients with type III, where there was a practically intact level of self-regulation and the presence of more than half of the cases high pace of cognitive activity with a high degree of initiative. Others no less important indicator statistically significant differences between the studied groups of patients should be considered in terms of the level of disruption of communication processes and a decrease in emotionality. Thus, in patients with type I and II attacks, the level of communication was sharply reduced, while in patients with type III this occurred only in isolated cases. In addition, proactive communication was practically absent in patients with the first two types of seizures, while it was observed with a significant probability in patients with type III seizures.
Thus, the differences in the pathology of cognitive activity established in the studied patients, correlating with the psychopathological type of the first attack, were additional criteria significant for the prognostic and nosological assessment of their disease at the stage of the first attack of endogenous paroxysmal psychosis manifesting in adolescence.
Taking into account modern data on the involvement of the immune system in pathogenetic processes in schizophrenia [Kolyaskina G.I. et al., 1996; Vetlugina T.P. et al., 1996; Klyushnik T.P., 1997; Shcherbakova I.V., 2006; Abrosimova Yu.S., 2009; Muller N. et al. 2000; Mahendran R., Chan Y., 2004; Drzyzga L. et al., 2006] to elucidate the pathogenetic significance of a number of biological factors in the formation of the picture of the first attack, in the studied patients in the study, a number of indicators of innate and acquired immunity were analyzed during the manifestation of the first attack, as well as at the stage of formation of remission. In addition, the influence of their immune status on the effectiveness of neuroleptic therapy was studied. It was found that in adolescent patients during the first attack, regardless of its psychopathological type, there is an increase in the activity of a number of immunological indicators that reflect the characteristics of the immune response to the first manifestation of endogenous psychosis, as evidenced by a significant (p increase in their activity of leukocyte elastase, α1-proteinase inhibitor, increased production of interleukin-1b and interleukin-10 and the concentration of interleukin-2 in blood serum.At the same time, there were no significant differences in these indicators between groups of patients identified by syndromic types of the first attack.According to the activity of leukocyte elastase and α1-proteinase inhibitor, no there were differences even between manic-delusional and depressive-delusional patients.
On the basis of the data obtained, it was concluded that immunological parameters can simultaneously be considered as the pathogenetic basis for the formation of an individual drug response in patients to the therapy being carried out and thus serve as predictors of its effectiveness. Immunological predictors of the effectiveness of therapy, indicating a high reactivity of the patient's body, include: high level production of interleukin-1b and interleukin-10, low concentration of interleukin-2 in blood serum, high activity of leukocyte elastase, as well as the absence of an increase in the level of antibodies to nerve growth factor during an attack. The high efficiency of ongoing antipsychotic therapy with an increase in the activity of leukocyte elastase, an α1-proteinase inhibitor is explained by their ability to disrupt protective properties blood-brain barrier and, accordingly, increase its permeability for medicines. Thus, the data obtained make it possible to predict the effectiveness of antipsychotic therapy already at the initial stages of its implementation and to guide physicians in the search for options for its optimization.
One of the consequences of the fall of man is his sickness (passionateness), his vulnerability to countless physical dangers and ailments; vulnerability not only of the body, but also of the psyche. Mental illness is the hardest cross! But a mentally ill person is dear to our Creator and Father no less, and perhaps, due to suffering, even more than any of us. We talk about these people, about their opportunities in the Church, about their mental and spiritual health with Vasily Glebovich Kaleda, a psychiatrist, doctor of medical sciences, professor at the Department of Practical Theology at the Orthodox St. Tikhon Humanitarian University.
You grew up in a deeply believing Orthodox family, your grandfather was glorified in the host of holy martyrs and confessors of Russia, your father and brothers are priests, your sister is an abbess, and your mother also took tonsure in her old age. Why did you choose medicine and then psychiatry? What determined your choice?
Indeed, I grew up in a family with deep Orthodox, church traditions. By the way, my grandfather, Hieromartyr Vladimir Ambartsumov, who was shot at the Butovo firing range, was born in Saratov; Our family has a special spiritual connection with your city, and I am pleased to answer questions from the journal of the Saratov Metropolis.
However, before becoming a priest, my father devoted many years to geology; mother dreamed of becoming a doctor, but became a biologist; two of my priest brothers are geologists by first education, and the sisters have a medical education. Doctors were in the family before. Perhaps there is some connection with the name: four Basils were in the Caled family, and all four were doctors. It can be said that by choosing medicine, I continued the family tradition.
And the choice of psychiatry is the influence of the personality of the father. The pope had great respect for medicine and singled out psychiatry among all medical disciplines. He believed that the competence of a psychiatrist somewhere bordered on the competence of a priest. And he told me how important it is that there are believers among psychiatrists, so that a person, if he or his neighbor needs the help of a psychiatrist, has the opportunity to turn to an Orthodox doctor.
A friend of my grandfather, Hieromartyr Vladimir Ambartsumov, was Dmitry Evgenievich Melekhov, one of the patriarchs domestic psychiatry. Shortly after his death (he died in 1979), his work “Psychiatry and Problems of Spiritual Life” was published in samizdat, my father wrote the preface to this publication. Later, this book was published quite legally. Dmitry Evgenievich visited our house, and each of his visits became an event for me - then a teenager. While studying at the medical institute, I finally realized that psychiatry is my calling. And in the future, he never regretted his choice.
What is mental health? Is it possible to say with certainty: this person, even with some problems, is still mentally healthy, but this one is sick?
The problem of the norm in psychiatry is very important and not at all simple. On the one hand, each person is individual, unique and inimitable. Everyone is entitled to their own worldview. We are so different. But, on the other hand, we are all very similar. Life puts before all of us the same, in fact, problems. Mental health is a set of attitudes and qualities, functional abilities that allow an individual to adapt to the environment. It is the ability of a person to cope with the circumstances of his life, maintaining optimal emotional background and appropriate behaviour. A mentally healthy person can and should cope with all the difficulties that exist in his life. Of course, the difficulties are very different. There are some that a person can not seem to withstand. But let's remember our New Martyrs and Confessors, who went through everything: the then methods of investigation, prisons, starvation camps - and remained mentally healthy people, mentally healthy. Let us also remember the greatest psychiatrist and psychotherapist of the 20th century, Viktor Frankl, the founder of logotherapy, that is, the direction of psychotherapy, which is based on the search for the meaning of life. Frankl founded this direction while in Nazi concentration camps. Such is the ability healthy person cope with all the trials, in other words, the temptations that God sends him.
From your answer it follows, in fact, that there is faith or essential condition, or, shall we say, an inexhaustible source of mental health. Any of us, believers, thank God, people, are convinced of this from personal experience. We would perceive our difficulties, sorrows, troubles, losses in a completely different way if we were not believers. Faith gained raises our ability to overcome suffering to a completely different level, impossible for an unbeliever.
One cannot but agree with this! A person's ability to overcome difficulties depends on his worldview and worldview. Let's go back to Viktor Frankl: he said that faith has the most powerful protective ability, and no other worldview can be compared with it in this sense. A person who believes is much more stable than a person who does not have faith. Precisely because he perceives these difficulties as sent down by the Savior. In any of his misfortunes, he seeks and finds a meaning. In Rus', it has long been customary to speak of trouble: "The Lord has visited." Because trouble makes a person think about his spiritual life.
If we still talk not about the norm, but about the disease, then it is important to understand: a severe, genetically determined mental illness can develop in any person - regardless of his worldview. Another thing is borderline mental disorders that occur in people with certain character traits and, again, with a certain worldview. In these cases, the worldview of the patient is of great importance. If he was brought up in a religious environment, if he absorbed with his mother’s milk the conviction that life has a higher meaning and suffering also has meaning, this is the cross that the Savior sends to a person, then he perceives everything that happens to him from this particular point of view . If a person does not have such an outlook on life, he perceives every test, every difficulty as a collapse in life. And here I can confidently say: disorders border type, neurotic diseases in people leading a full spiritual life are much less common than in non-believers.
You teach pastoral psychiatry. What is the essence of this subject? Why is it necessary in the training of future shepherds?
Pastoral psychiatry is a branch of pastoral theology associated with the peculiarities of the counseling of persons suffering from mental disorders. This requires coordination of efforts, cooperation between the pastor and the psychiatrist. In this case, the priest is required to understand the boundaries of mental health, which we just talked about, the ability to see psychopathology in time and make an adequate decision. Psychiatric disorders, both severe and border level, are common: according to medical statistics, 15% of the population suffer from one or another disease of this kind, the only question is the degree of severity. And people suffering from mental illness tend to turn to the Church, to the priests. That is why there are relatively more people with these problems in the church, parish environment than the average for the population. This is fine! This just goes to show that the Church is a medical clinic, both mental and spiritual. Any priest has to communicate with people who have certain disorders - I repeat, the degree of severity can be different. It often happens that it is the priest, and not the doctor, who becomes the first person to whom a person turns with a problem of a psychiatric nature. The shepherd must be able to behave with these people, help them and, most importantly, clearly see those cases when a person needs to be sent to a psychiatrist. Somehow I caught the eye of American statistics: 40% of people who turn to psychiatrists do so on the advice of clergymen of various denominations.
It should be added that at the origins of the course of pastoral psychiatry, which is now taught in many spiritual educational institutions, stood Archimandrite Cyprian (Kern), professor of pastoral theology at the St. Sergius Institute in Paris: in his book on pastoral theology, he devoted a separate chapter to this very subject. He wrote about those human problems that cannot be described by the criteria of moral theology, which have nothing to do with the concept of sin. These problems are manifestations of psychopathology. But the author of the first special manual on pastoral psychiatry was just the professor of psychiatry Dmitry Evgenievich Melekhov, whom we spoke about, the son of a repressed priest. Today it is already quite clear that the standard (if we are not afraid of this word) of pastoral education should also include a course in psychiatry.
Of course, this question is more theological than medical, but still - in your opinion: is there a connection between mental illness and sin? Why are the main types of delusions like grimaces of the main sinful passions? Delusions of grandeur, for example, and, as it were, its shadow, the wrong side - delusions of persecution - what is this, if not a grimace of pride? And depression - isn't it a grimace of despondency? Why is that?
The delusion of grandeur, like any other delusion, has only a remote relation to the sin of pride. Delirium is a manifestation of severe mental illness. The connection with sin is no longer traced here. But in other cases, one can trace the connection between sin and the occurrence of a mental disorder - a disorder, I emphasize, and not an endogenous, genetically determined disease. For example, the sin of sadness, the sin of despondency. A person indulges in sorrow, having suffered damage, having suffered some kind of loss, falls into despondency from his difficulties. Psychologically, this is quite understandable. But here the worldview of this person and his hierarchy of values are especially important. A believing person, having the highest values in life, will try to put everything in its place correctly and gradually overcome his difficulties, but a non-believer person is more likely to experience a state of despair, a complete loss of the meaning of life. The condition will already meet the criteria for depression - the person will need a psychiatrist. The spiritual state, thus, was reflected in the mental state. Such a patient of a psychiatrist has something to turn to and a priest too, there is something to say in confession. And he must receive help - from both sides, both from the pastor and from the doctor. At the same time, it is very important that love lives in the priest, that he is merciful to this person and is able to really support him. It should be noted that, according to WHO, by 2020 depression will be the second most common cause of illness worldwide; and WHO experts see the main reasons for this precisely in the loss of traditional family and religious values.
And how possible is spiritual, church life for people suffering from severe mental illness, for example, various forms of schizophrenia?
There is no fault of a person that he came into this world with a serious, genetically determined disease. And if we are truly believing Christians, we cannot allow the thought that these people are limited in their spiritual life, that the Kingdom of God is closed to them. The cross of mental illness is a very heavy, perhaps the most difficult cross, but a believer, carrying this cross, can save for himself a full spiritual life. He is not limited in anything, this position is fundamental - in nothing, including the possibility of achieving holiness.
It should be added: schizophrenia - after all, it happens very differently, and a patient with schizophrenia can be in different states. He may have an acute psychotic episode with delusions and hallucinations, but then in some cases a very high quality remission occurs. A person is adequate, works successfully, can hold a responsible position, and arrange his family life safely. And his spiritual life is not in the least hampered or distorted by illness: it corresponds to his personal spiritual experience.
It happens that a patient in a state of psychosis experiences a certain special spiritual state, a feeling of special closeness to God. Then this feeling in all its depth is lost - if only because it is difficult to deal with it. ordinary life- but a person remembers him and after an attack comes to faith. And in the future he lives a completely normal (which is important), full-fledged church life. God brings us to Himself different ways, and someone, paradoxically, like this - through mental illness.
But there are, of course, other cases - when psychosis has a religious coloring, but all these quasi-religious experiences are only a product of the disease. Such a patient perceives spiritual concepts distortedly. In such cases, we speak of a "toxic" faith. The trouble is that these patients are often very active. They preach their completely distorted ideas about God, about spiritual life, about the Church and the sacraments, they try to pass on their false experience to other people. This must be kept in mind.
Mental illness is often remembered in connection with demonic possession (or whatever it is called). The spectacle of the so-called reprimands suggests that simply sick people are gathered in the temple. What would you say about this? How to distinguish mental illness from obsession? Who needs to be treated with drugs, and who needs spiritual help?
First of all, I would like to remind you that the ever-remembered His Holiness Patriarch Alexy II was a resolute opponent of the widespread and uncontrolled practice of "reprimanding" that had spread precisely in those years. He said that the rite of exorcism of evil spirits should be performed only in extremely rare, exceptional cases. Personally, I have never been present at mass reprimands, but my colleagues - people, mind you, believers - have watched it. And they said with confidence that the majority of the “reported” are, as they say, our contingent: suffering from mental disorders. Mental illness of one type or another has a certain structure, is characterized by many parameters, and a professional doctor always sees that a person is sick, and sees why he is sick. As for the state of demon possession, spiritual damage - it manifests itself primarily in the reaction to the shrine. This is checked by the “blind method”, as doctors say: a person does not know that he has now been brought to a reliquary or to a bowl of holy water. If he still reacts, then it makes sense to talk about demon possession. And about the help of a priest, of course - not just anyone, but one who has the blessing of a bishop for reading certain prayers over those tormented by unclean spirits. Otherwise, it is a purely psychiatric problem that has nothing to do with the spiritual state. This is a common case, we have many patients who have some kind of religious theme in the structure of their delusions, including this one: "I have a demon in me." Many of these patients are believers, Orthodox people. If there is a church at the clinic where they are located, they attend services, go to confession, take communion, and in fact they have no demonic possession.
You have already said here that a patient whose delirium has a religious connotation can be very active. But there are people who believe him! Does it happen that an ordinary sick person is mistaken for a saint?
Of course it happens. In the same way, it happens that a person talks about his demonic possession or about some unusual visions, about his special closeness to God and special gifts - and all this is really just a disease. That is why we, psychiatrists who teach pastoral psychiatry, say to future priests: there is reason to be wary if your parishioner assures you that he has already reached some high spiritual states, that he is visited by the Mother of God, saints, etc. spiritual path long, complex, thorny, and only a few endure it and become great ascetics who are visited by angels, saints and the Mother of God Herself. Instant ups do not happen here, and if a person is sure that this is exactly what happened to him, in the vast majority of cases this is a manifestation of pathology. And this once again shows us the importance of cooperation between a psychiatrist and a pastor, with a clear delineation of their areas of competence.
Drawings of patients in a psychiatric hospital
Journal "Orthodoxy and Modernity" No. 26 (42)
