Symptoms of mental illness. The main symptoms and syndromes of mental disorders

Asthenia is a whole complex of disorders that characterize the initial stage of a mental disorder. The patient begins to quickly get tired, exhausted. The performance is declining. There is general lethargy, weakness, mood becomes unstable. Frequent headaches, sleep disturbance and constant feeling fatigue - requiring detailed consideration. It is worth noting that asthenia is not always the main symptom of a mental disorder and rather refers to a non-specific symptom, since it can also occur with somatic diseases.

Suicidal thoughts or actions are a reason for emergency hospitalization of a patient in a psychiatric clinic.

A state of obsession. The patient begins to visit special thoughts that cannot be got rid of. Feelings of fear, depression, insecurity and doubt are intensified. The state of obsession may be accompanied by certain rhythmic actions, movements and rituals. Some patients wash their hands thoroughly and for a long time, others repeatedly check whether the door is closed, whether the light, iron, etc. are turned off.

An affective syndrome is the most common first sign of a mental disorder, which is accompanied by a persistent change in mood. Most often, the patient has a depressed mood with a depressive episode, much less often - mania, accompanied by an elevated mood. With effective treatment of a mental disorder, depression or mania is the last to disappear. Against the background of an affective disorder, a decrease is observed. The patient has difficulty making decisions. In addition, depression is accompanied by a number of somatic: indigestion, feeling hot or cold, nausea, heartburn, belching.

If the affective syndrome is accompanied by mania, the patient has an elevated mood. The pace of mental activity is accelerated many times over, a minimum of time is spent on sleep. Excess energy can be replaced by a sharp apathy and drowsiness.

Dementia is the last stage of a mental disorder, which is accompanied by a persistent decrease in intellectual functions and dementia.

Hypochondria, tactile and visual hallucinations, delusions, abuse psychoactive substances and - all this accompanies the psychic. Close relatives of the patient do not always immediately understand

Mental illness is a whole group of mental disorders that affect the state of the human nervous system. Today, such pathologies are much more common than is commonly believed. Symptoms of mental illness are always very variable and varied, but they are all associated with a violation of higher nervous activity. Mental disorders affect the behavior and thinking of a person, his perception of the surrounding reality, memory and other important mental functions.

Clinical manifestations of mental diseases in most cases form whole symptom complexes and syndromes. Thus, in a sick person, very complex combinations of disorders can be observed, which can be assessed for staging accurate diagnosis only an experienced psychiatrist can.

Classification of mental illness

Mental illnesses are very diverse in nature and clinical manifestations. For a number of pathologies, the same symptoms may be characteristic, which often makes it difficult to diagnose the disease in a timely manner. Mental disorders can be short-term and long-term, caused by external and internal factors. Depending on the cause of the occurrence, mental disorders are classified into exogenous and exogenous. However, there are diseases that do not fall into one or the other group.

Group of exocogenic and somatogenic mental illnesses

This group is quite extensive. It does not include a wide variety of mental disorders, the occurrence of which is caused by the adverse effects of external factors. At the same time, endogenous factors may also play a certain role in the development of the disease.

Exogenous and somatogenic diseases of the human psyche include:

  • drug addiction and alcoholism;
  • mental disorders caused by somatic pathologies;
  • mental disorders associated with infectious lesions located outside the brain;
  • mental disorders arising from intoxication of the body;
  • mental disorders caused by brain injuries;
  • mental disorders caused infectious lesion brain;
  • mental disorders caused by oncological diseases of the brain.

Group of endogenous mental illnesses

The occurrence of pathologies belonging to the endogenous group is caused by various internal, primarily genetic factors. The disease develops when a person has a certain predisposition and the participation of external influences. The group of endogenous mental illnesses includes diseases such as schizophrenia, cyclothymia, manic-depressive psychosis, as well as various functional psychoses characteristic of older people.

Separately, in this group, one can single out the so-called endogenous-organic mental illnesses that arise as a result of organic damage to the brain under the influence of internal factors. These pathologies include Parkinson's disease, Alzheimer's disease, epilepsy, senile dementia, Huntington's chorea, atrophic brain damage, and mental disorders caused by vascular pathologies.

Psychogenic disorders and personality pathologies

Psychogenic disorders develop as a result of influence on human psyche stress that can occur against the background of not only unpleasant, but also joyful events. This group includes various psychoses characterized by a reactive course, neuroses and other psychosomatic disorders.

In addition to the above groups in psychiatry, it is customary to single out personality pathologies - this is a group of mental diseases caused by abnormal personality development. These are various psychopathy, oligophrenia (mental underdevelopment) and other defects in mental development.

Classification of mental illness according to ICD 10

In the international classification of psychosis, mental illness is divided into several sections:

  • organic, including symptomatic, mental disorders (F0);
  • mental and behavioral disorders arising from the use of psychotropic substances (F1);
  • delusional and schizotypal disorders, schizophrenia (F2);
  • affective disorders associated with mood (F3);
  • neurotic disorders caused by stress (F4);
  • behavioral syndromes based on physiological defects (F5);
  • mental disorders in adults (F6);
  • mental retardation (F7);
  • defects in psychological development (F8);
  • behavioral disorders and psycho-emotional background in children and adolescents (F9);
  • mental disorders of unknown origin (F99).

Main symptoms and syndromes

The symptomatology of mental illness is so diverse that it is rather difficult to somehow structure the clinical manifestations characteristic of them. Since mental illness negatively affects everything or practically everything nerve functions human body, all aspects of his life suffer. Patients have disorders of thinking, attention, memory, mood, depressive and delusional states occur.

The intensity of the manifestation of symptoms always depends on the severity of the course and the stage of a particular disease. In some people, the pathology can proceed almost imperceptibly to others, while others simply lose the ability to interact normally in society.

affective syndrome

An affective syndrome is usually called a complex of clinical manifestations associated with mood disorders. There are two large groups of affective syndromes. The first group includes states characterized by a pathologically elevated (manic) mood, the second group includes states with a depressive, that is, depressed mood. Depending on the stage and severity of the course of the disease, mood swings can be both mild and very bright.

Depression can be called one of the most common mental disorders. Such states are characterized by extremely depressed mood, volitional and motor inhibition, suppression of natural instincts, such as appetite and the need for sleep, self-deprecating and suicidal thoughts. In particularly excitable people, depression can be accompanied by outbursts of rage. The opposite sign of a mental disorder can be called euphoria, in which a person becomes careless and contented, while his associative processes are not accelerated.

The manic manifestation of the affective syndrome is accompanied by accelerated thinking, fast, often incoherent speech, unmotivated elevated mood, and increased motor activity. In some cases, manifestations of megalomania are possible, as well as an increase in instincts: appetite, sexual needs, etc.

obsession

Compulsive states - another common symptom that accompanies psychiatric disorders. In psychiatry, such disorders are referred to as obsessive-compulsive disorder, in which the patient periodically and involuntarily has unwanted, but very obsessive ideas and thoughts.

This disorder also includes various unfounded fears and phobias, constantly repeated meaningless rituals with which the patient tries to alleviate anxiety. There are a number of features that distinguish patients suffering from obsessive-compulsive disorders. First, their consciousness remains clear, while obsessions are reproduced against their will. Secondly, the occurrence of obsessive states is closely intertwined with negative emotions person. Thirdly, intellectual abilities are preserved, so the patient is aware of the irrationality of his behavior.

Consciousness disorders

Consciousness is usually called the state in which a person is able to navigate in the world around him, as well as in his own personality. Mental disorders very often cause disturbances in consciousness, in which the patient ceases to perceive the surrounding reality adequately. There are several forms of such disorders:

ViewCharacteristic
AmnetiaComplete loss of orientation in the world around and loss of ideas about one's own personality. Often accompanied by threatening speech disorders and hyperexcitability
DeliriumLoss of orientation in the surrounding space and self in combination with psychomotor agitation. Often, delirium causes threatening auditory and visual hallucinations.
OneiroidThe patient's objective perception of the surrounding reality is only partially preserved, interspersed with fantastic experiences. In fact, this state can be described as half-asleep or a fantastic dream.
Twilight clouding of consciousnessDeep disorientation and hallucinations are combined with the preservation of the patient's ability to perform purposeful actions. At the same time, the patient may experience outbreaks of anger, unmotivated fear, aggression.
Ambulatory automatismAutomated form of behavior (sleepwalking)
Turning off consciousnessCan be either partial or complete

Perceptual disturbances

Perceptual disturbances are usually the easiest to recognize in mental disorders. TO simple disorders senestopathy is a sudden unpleasant bodily sensation in the absence of an objective pathological process. Seneostapathia is characteristic of many mental illnesses, as well as hypochondriacal delusions and depressive syndrome. In addition, with such violations, the sensitivity of a sick person may be pathologically reduced or increased.

More complex disorders are considered depersonalization, when a person stops living. own life, but as if watching her from the side. Another manifestation of pathology can be derealization - misunderstanding and rejection of the surrounding reality.

Thinking disorders

Thinking disorders are symptoms of mental illness that are quite difficult to understand for an ordinary person. They can manifest themselves in different ways, for some, thinking becomes inhibited with pronounced difficulties when switching from one object of attention to another, for someone, on the contrary, it is accelerated. A characteristic sign of impaired thinking in mental pathologies is reasoning - the repetition of banal axioms, as well as amorphous thinking - difficulties in orderly presentation of one's own thoughts.

One of the most complex forms of impaired thinking in mental illness is delusional ideas - judgments and conclusions that are completely far from reality. Delusional states can be different. The patient may experience delusions of grandeur, persecution, depressive delusions, characterized by self-abasement. There can be quite a few options for the course of delirium. In severe mental illness, delusional states can persist for months.

Violations of will

Symptoms of a violation of will in patients with mental disorders are a fairly common phenomenon. For example, in schizophrenia, both suppression and strengthening of the will can be observed. If in the first case the patient is prone to weak-willed behavior, then in the second he will forcibly force himself to take any action.

A more complex clinical case is a condition in which the patient has some painful aspirations. This may be one of the forms of sexual preoccupation, kleptomania, etc.

Memory and attention disorders

Pathological increase or decrease in memory accompanies mental illness quite often. So, in the first case, a person is able to remember very large amounts of information that are not characteristic of healthy people. In the second - there is a confusion of memories, the absence of their fragments. A person may not remember something from his past or prescribe to himself the memories of other people. Sometimes whole fragments of life fall out of memory, in this case we will talk about amnesia.

Attention disorders are very closely related to memory disorders. Mental illnesses are very often characterized by absent-mindedness, a decrease in the concentration of the patient. It becomes difficult for a person to maintain a conversation or focus on something, remember simple information because his attention is constantly scattered.

Other clinical manifestations

In addition to the above symptoms, mental illness can be characterized by the following manifestations:

  • Hypochondria. Constant fear of getting sick, increased concern about one's own well-being, assumptions about the presence of any serious or even deadly disease. The development of hypochondriacal syndrome has depressive states, increased anxiety and suspiciousness;
  • Asthenic syndrome is chronic fatigue syndrome. It is characterized by the loss of the ability to conduct normal mental and physical activity due to constant fatigue and a feeling of lethargy, which does not go away even after a night's sleep. Asthenic syndrome in a patient is manifested by increased irritability, bad mood, and headaches. Perhaps the development of photosensitivity or fear of loud sounds;
  • Illusions (visual, acoustic, verbal, etc.). Distorted perception is real existing phenomena and objects;
  • hallucinations. Images that arise in the mind of a sick person in the absence of any stimuli. Most often, this symptom is observed in schizophrenia, alcohol or drug intoxication, some neurological diseases;
  • catatonic syndromes. Movement disorders, which can manifest themselves both in excessive excitement and in stupor. Similar violations often accompany schizophrenia, psychoses, various organic pathologies.

You can suspect a mental illness in a loved one by characteristic changes in his behavior: he stopped coping with the simplest household tasks and everyday problems, began to express strange or unrealistic ideas, and shows anxiety. Changes in the usual daily routine and nutrition should also alert. Outbursts of anger and aggression, long-term depression, suicidal thoughts, alcohol abuse or drug use will be signals of the need to seek help.

Of course, some of the above symptoms may occur from time to time in healthy people under the influence of stressful situations, overwork, exhaustion of the body due to an illness, etc. Mental illness will be discussed when pathological manifestations become very pronounced and negatively affect the quality of life of a person and his environment. In this case, the help of a specialist is needed and the sooner the better.

The weaker sex is more prone to ailments associated with the psyche. Emotional involvement in social life and natural sensitivity increase the risk of developing diseases. They need to be diagnosed in time in order to start the right treatment and return life to its usual course.

Mental illnesses in different age periods of a woman's life

For each age period (girl, girl, woman), a group of the most likely mental illnesses was identified. At these critical stages of development for the psyche, situations occur that most often provoke development.

Girls are less susceptible to mental illness than boys, however, they are not immune from the appearance of school phobias, attention deficit. They are at increased risk for anxiety and learning disorders.

Young girls in 2% of cases may be victims of premenstrual dysphoria after the first episode of bleeding during the menstrual period. After puberty, it is believed that girls are 2 times more likely to develop depression than boys.

Women who are included in the group of patients with mental disorders are not included in the planning drug treatment. This causes them to relapse. After childbirth, there is a high probability of the appearance of signs of depression, which, however, can go away without medical treatment.

A small percentage of women do develop psychotic disorders, the treatment of which is complicated by the limited number of approved drugs. For each individual situation, the degree of benefit and risk of drug treatment during breastfeeding is determined.

Women between 35 and 45 are at risk for developing anxiety disorders, they are prone to mood changes, and are not immune from the onset of schizophrenia. Decreased sexual function may occur due to the use of antidepressants.

Menopause changes the usual course of a woman's life, her social role and relationships with loved ones. From caring for their children, they switch to looking after their parents. This period is associated with depressive moods and disorders, but the connection between the phenomena has not been officially proven.

In old age, women are prone to the appearance of dementia and complications somatic pathologies mental disorders. This is due to their longevity, the risk of developing dementia (acquired dementia) increases in proportion to the number of years lived. Older women who take a lot and suffer from somatic diseases are more prone to insanity than others.

Those over 60 should pay attention to the symptoms of paraphrenia (severe delusional syndrome), they are at the highest risk. Emotional involvement in the lives of others and loved ones at a respectable age, when many complete their life path may cause mental disorders.

The division of a woman's existence into periods allows doctors to single out the only true one from the whole variety of diseases with similar symptoms.

Signs of mental disorders in girls

In childhood, the development of the nervous system occurs continuously, but unevenly. However, the peak of mental development by 70% falls on this period, the personality of the future adult is formed. It is important to timely diagnose the symptoms of certain diseases from a specialist.
Signs:

  • Decreased appetite. Occurs with sudden changes in diet and forced food intake.
  • Increased activity. Is different sudden forms motor excitation (jumping, monotonous running, shouting)
  • Hostility. It is expressed in the child's confidence in the negative attitude of others and relatives towards him, which is not confirmed by facts. It seems to such a child that everyone laughs at him and despise him. On the other hand, he himself will show baseless hatred and aggression, or even fear towards relatives. He becomes rude in everyday communication with relatives.
  • Painful perception of a physical defect (dysmorphophobia). The child chooses a minor or apparent flaw in appearance and tries with all his might to disguise or eliminate it, even turning to adults with a request for plastic surgery.
  • Game activity. It comes down to a monotonous and primitive manipulation of objects not intended for play (cups, shoes, bottles), the nature of such a game does not change over time.
  • Painful preoccupation with health. Excessive attention to one's physical condition, complaints about fictitious ones.
  • Repetitive word movements. They are involuntary or obsessive, for example, the desire to touch an object, rub hands, tap.
  • Mood disorder. The state of melancholy and meaninglessness of what is happening does not leave the child. He becomes whiny and irritable, the mood does not improve for a long time.

  • Nervous state. Change from hyperactivity to lethargy and passivity and vice versa. Bright light and loud and unexpected sounds are hard to bear. The child cannot strain his attention for a long time, which is why he has difficulty studying. He may have visions of animals, frightening looking people, or voices.
  • Disorders in the form of repetitive spasms or convulsions. The child may freeze for a few seconds, while turning pale or rolling his eyes. An attack can manifest itself in a shudder of the shoulders, arms, less often, similar to squats. Systematic walking and talking in sleep at the same time.
  • Violations in daily behavior. Excitability coupled with aggression, expressed in a tendency to violence, conflict and rudeness. Unsteady attention against the background of lack of discipline and motor disinhibition.
  • A pronounced desire to cause harm and the subsequent receipt of pleasure from this. The desire for hedonism, increased suggestibility, a tendency to leave home. Negative thinking along with vindictiveness and bitterness against the backdrop of a general tendency to cruelty.
  • Painfully abnormal habit. Biting off nails, pulling out hair from the scalp and at the same time reducing psychological stress.
  • Intrusive fears. day forms accompanied by redness of the face, increased sweating and palpitations. At night, they are manifested by screaming and crying from frightening dreams and motor anxiety; in such a situation, the child may not recognize loved ones and brush off someone.
  • Violation of reading, writing and counting skills. In the first case, children have difficulty relating the type of letter to the sound, or they have difficulty recognizing images of vowels or consonants. With dysgraphia (writing disorder), it is difficult for them to write what they say out loud.

These signs are not always a direct consequence of the development of a mental illness, but require qualified diagnosis.

Symptoms of diseases characteristic of adolescence

Adolescent girls are characterized by anorexia nervosa and bulimia, premenstrual dysphoria and depression.

To anorexia frolicking on nervous ground, include:

  • Denying an Existing Problem
  • Painful obsessive feeling of excess weight in its apparent absence
  • Eating food standing up or in small bites
  • Violated mode
  • Fear of gaining weight
  • Depressed mood
  • Anger and unreasonable resentment
  • Passion for cooking, cooking meals for the family without personal participation in the meal
  • Avoidance general techniques food, minimal contact with loved ones, long stays in the bathroom or playing sports outside the home.

Anorexia also causes physical disorders. Due to weight loss, problems with the menstrual cycle begin, arrhythmia appears, it is felt constant weakness and muscle pain. Attitude towards oneself depends on the amount of weight lost to gained. A person with anorexia nervosa tends to bias his condition up to the point of no return.

Signs of bulimia nervosa:

  • The amount of food consumed at a time exceeds the norm for a person of a certain build. Pieces of food are not chewed, but quickly swallowed.
  • After eating, the person intentionally tries to induce vomiting to clear the stomach.
  • The behavior is dominated by mood swings, closeness and unsociableness.
  • A person feels helpless and alone.
  • General malaise and lack of energy, frequent illnesses, upset digestion.
  • Destroyed tooth enamel - a consequence frequent vomiting containing gastric juice.
  • Enlarged salivary glands on the cheeks.
  • Denying there is a problem.

Signs of premenstrual dysphoria:

  • The disease is typical for girls who form premenstrual syndrome. It, in turn, is expressed in depression, gloomy mood, unpleasant physical sensations and an uncomfortable psychological state, tearfulness, disruption of the usual sleep and eating patterns.
  • Dysphoria occurs 5 days before the onset of menstruation, and ends on the first day. The girl during this period is completely defocused, she cannot concentrate on anything, she is overcome by fatigue. The diagnosis is made if the symptoms are pronounced and interfere with the woman.

Most of the diseases of adolescents develop on the basis of nervous disorders and characteristics of puberty.

Postpartum mental disorders

In the field of medicine, 3 negative psychological conditions of a woman in labor are distinguished:

  • Neurotic. There is an exacerbation of problems with the psyche, which were even when carrying a child. This disease is accompanied by depression, nervous exhaustion.
  • Traumatic neurosis. Appears after a long and difficult childbirth, subsequent pregnancies are accompanied by fear and anxiety.
  • Melancholy with delusional ideas. A woman feels guilty, may not recognize loved ones and see hallucinations. This disease is a prerequisite for the development of manic-depressive psychosis.

A mental disorder can manifest itself as:

  • Depressed state and tearfulness.
  • Unreasonable anxiety, feelings of anxiety.
  • Irritability and excessive activity.
  • Distrust of others and feeling.

  • Incoherence of speech and decreased or increased appetite.
  • Obsession with communication or a desire to isolate oneself from everyone.
  • Confusion in the mind and lack of concentration.
  • Inadequate self-esteem.
  • Thoughts of suicide or murder.

In the first week or a month later, these symptoms will make themselves felt in the event of the development of postpartum psychosis. Its duration is four months on average.

Middle age period. Mental illnesses that develop against the background of the onset of menopause

During menopause, the reverse development of the hormonal glands of sexual secretion occurs, this symptom is most pronounced in women in the period from 45 to 50 years. inhibits cell renewal. As a result, those diseases and disorders begin to appear that were completely absent before or proceeded hidden.

Mental illnesses characteristic of the menopause period develop either 2-3 months before the final completion of the menstrual cycle or even after 5 years. These reactions are temporary, most often they are:

  • mood swings
  • Anxiety about the future
  • Hypersensitivity

Women at this age are prone to self-criticism and dissatisfaction with themselves, which entails the development of depressive moods and hypochondriacal experiences.

With physical discomfort during menopause, associated with flushing or fainting, tantrums appear. Serious disorders associated with menopause develop only in women who initially had such problems.

Mental disorders in women in senile and presenile period

Involutional paranoid. This psychosis, which appears at the time of involution, is accompanied by delusional thoughts combined with unsolicited memories of traumatic situations from the past.

Involutional melancholy is typical for women starting from 50 years old. The main prerequisite for the appearance of this disease is anxiety-delusional depression. Usually involutional paranoid appears after a change in lifestyle or a stressful situation.

dementia of late age. The disease is an acquired dementia, which intensifies over time. Based on clinical manifestations, there are:

  • total dementia. In this variant, perception, the level of thinking, the ability to be creative and solve problems are reduced. There is an erasing of the facets of personality. A person is not capable of critical self-assessment.
  • Lacunar dementia. Memory impairment occurs when the level of cognitive functions is preserved. The patient can critically evaluate himself, the personality basically remains unchanged. This disease manifests itself with syphilis of the brain.
  • These diseases are a warning sign. The mortality of patients with dementia after a stroke is several times higher than that of those who avoided this fate and did not become demented.

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Treatment of mental disorders is divided into medication and complex psychotherapy. For eating disorders that are common in young girls, a combination of these treatments will be effective. However, even if most of the symptoms coincide with the described disorders, it is necessary to consult a psychotherapist or psychiatrist before any type of treatment.

This chapter provides an overview of the psychiatric disorders common in women, including their epidemiology, diagnosis, and treatment approach (Table 28-1). Mental disorders are very common. The monthly incidence among American adults exceeds 15%. The lifetime incidence is 32%. Most common in women are major depression, seasonal affective disorders, manic-depressive psychosis, eating behavior, panic disorders, phobias, generalized anxiety states, somatized mental disorders, pain states, borderline and hysterical disorders, and suicidal attempts.

In addition to the fact that anxiety and depressive disorders are much more common in women, they are more resistant to drug therapy. However, most studies and clinical trials are conducted on men and then extrapolated to women, despite differences in metabolism, drug sensitivity, side effects. Such generalizations lead to the fact that 75% psychotropic drugs prescribed to women, and they are more likely to experience serious side effects.

All doctors should be aware of the symptoms of mental disorders, first aid for them and available methods of maintaining mental health. Unfortunately, many cases of mental illness remain undiagnosed and untreated or undertreated. Only a small part of them reaches the psychiatrist. Most patients are seen by other specialists, so only 50% of mental disorders are recognized at the initial visit. Most patients present somatic complaints and do not focus on psycho-emotional symptoms, which again reduces the frequency of diagnosis of this pathology by non-psychiatrists. In particular, affective disorders are very common in patients with chronic diseases. The incidence of mental illness in GP patients is twice as high as in the general population, and even higher in severely ill hospitalized patients and those who seek medical attention frequently. Neurological disorders such as stroke, Parkinson's disease and Meniere's syndrome are associated with psychiatric disorders.

Untreated major depression can worsen the prognosis of physical illness and increase the amount of medical care required. Depression can intensify and increase the number of somatic complaints, lower the pain threshold, and increase functional disability. A study of patients who frequently use medical care found depression in 50% of them. Only those who had a decrease in the severity of their depressive symptoms during the year of observation showed an improvement in functional activity. Symptoms of depression (low mood, hopelessness, lack of satisfaction with life, fatigue, impaired concentration and memory) disrupt the motivation to seek medical help. Timely diagnosis and treatment of depression in chronic patients helps to improve prognosis and increase the effectiveness of therapy.

The socioeconomic cost of mental illness is very high. Approximately 60% of suicidal cases are due to affective disorders alone, and 95% meet diagnostic criteria for mental illness. The cost of treatment, death, and disability due to clinically diagnosed depression is estimated to be more than $43 billion per year in the United States. Because more than half of people with mood disorders are either left untreated or undertreated, this figure is far below the total cost that depression is costing society. Mortality and disability in this undertreated population, most of which? women are particularly depressing, as 70 to 90% of depressed patients respond to antidepressant therapy.

Table 28-1

Major Mental Disorders in Women

1. Eating disorders

Anorexia nervosa

bulimia nervosa

Bouts of gluttony

2. Mood disorders

big depression

Adjustment disorder with depressed mood

postpartum affective disorder

seasonal affective disorder

Affective insanity

Dysthymia

3. Alcohol abuse and alcohol dependence

4. Sexual disorders

Libido disorders

sexual arousal disorders

Orgasmic disorders

Painful sexual disorders:

vaginismus

dyspareunia

5. Anxiety disorders

specific phobias

social phobia

agoraphobia

Panic Disorders

Generalized Anxiety Disorders

obsessive-compulsive disorder

post-traumatic stress

6. Somatoform disorders and false disorders

False Disorders:

simulation

Somatoform disorders:

somatization

conversion

hypochondria

somatoform pain

7. Schizophrenic disorders

Schizophrenia

paraphrenia

8. Delirium

Mental illness during a woman's life

There are specific periods in a woman's life during which she is at increased risk of developing mental illness. While major mental disorders? mood disorders and anxiety? can occur at any age, various triggering conditions are more common at specific age periods. During these critical periods, the clinician should include specific questions to identify psychiatric disorders by taking the history and examining the patient's mental status.

Girls have an increased risk of school phobias, anxiety disorders, attention deficit hyperactivity disorder and learning disorders. Adolescents are at increased risk for eating disorders. During menarche, 2% of girls develop premenstrual dysphoria. After puberty, the risk of developing depression rises sharply, and in women it is twice as high as in men of the same age. In childhood, by contrast, girls have less or the same incidence of mental illness as boys their age.

Women are prone to mental disorders during and after pregnancy. Women with a history of psychiatric disorders often refuse medical support when planning a pregnancy, which increases the risk of relapse. After giving birth, most women experience mood swings. Most have a short period of depression "baby blues" that does not require treatment. Others develop more severe, disabling symptoms of depression in the postpartum period, and a small number of women develop psychotic disorders. The relative risk of taking drugs during pregnancy and lactation makes it difficult to choose a treatment, in each case the question of the ratio of benefits and risks of therapy depends on the severity of symptoms.

The middle age period is associated with a continued high risk of anxiety and mood disorders, as well as other psychiatric disorders such as schizophrenia. Women may have impaired sexual function, and if they take antidepressants for mood or anxiety disorders, they are at increased risk of side effects, including reduced sexual function. Although there is no clear evidence that menopause is associated with an increased risk of depression, most women experience major life changes during this period, especially in the family. For most women, their active role in relation to children is replaced by the role of carers for elderly parents. Elderly parents are almost always cared for by women. It is necessary to monitor the mental status of this group of women to identify possible violations of the quality of life.

As women age, their risk of developing dementia and psychiatric complications of somatic conditions, such as stroke, increases. Because women live longer than men and the risk of dementia increases with age, most women develop dementia. Elderly women with multiple medical conditions and high medication use are at high risk of delirium. Are women at increased risk of paraphrenia? psychotic disorder, usually occurring after age 60. Due to the long life expectancy and greater involvement in interpersonal relationships, women experience the loss of loved ones more often and more strongly, which also increases the risk of developing mental illness.

Examination of a psychiatric patient

Psychiatry deals with the study of affective, cognitive and behavioral disorders arising from the preservation of consciousness. Psychiatric diagnosis and treatment selection follow the same logic of history taking, examination, differential diagnosis and treatment planning as in other clinical areas. A psychiatric diagnosis must answer four questions:

1) mental illness (what the patient has)

2) temperamental disorders (what the patient is)

3) behavioral disorders (what the patient is doing)

4) disorders that arose in certain life circumstances (what the patient encounters in life)

Mental illness

Examples of mental illnesses are schizophrenia and major depression. Are they similar to other nosological forms? have a discrete onset, course, clinical symptoms that can be clearly defined as present or absent in each individual patient. Like other nosologies, are they the result of genetic or neurogenic disorders of the organ, in this case? brain. With obvious abnormal symptoms? auditory hallucinations, manias, severe obsessive-compulsive states? The diagnosis of a mental disorder is easy to make. In other cases, it can be difficult to distinguish pathological symptoms, such as low mood in major depression, from normal feelings of sadness or disappointment caused by life circumstances. We need to focus on identifying known stereotyped symptom complexes that are characteristic of mental illness, while keeping in mind the diseases that are most common in women.

Temperament disorders

Understanding the characteristics of the patient's personality increases the effectiveness of treatment. Are personality traits such as perfectionism, indecisiveness, impulsiveness somehow quantified in humans, as well as physiological ones? height and weight. Unlike mental disorders, do they not have clear characteristics? "symptoms" opposed to "normal" values, and individual differences are normal in a population. Psychopathology or functional disorders personalities arise when traits take on the character of extremes. When the temperament leads to impaired professional or interpersonal functioning, this is enough to qualify it as a possible personality disorder; in this case, medical assistance and cooperation with a psychiatrist is needed.

Conduct violations

Conduct disorders are self-reinforcing. They are characterized by purposeful, irresistible forms of behavior that subjugate all other activities of the patient. Examples of such disorders are eating disorders and abuse. The first goals of treatment are switching the patient's activity and attention, stopping problem behavior and neutralizing precipitating factors. Concomitant mental disorders, such as depression or anxiety disorders, illogical thoughts (the anorectic opinion that? If I eat more than 800 calories a day, will I become fat?) can be provoking factors. Group therapy can be effective in treating behavioral disorders. The final step in treatment is relapse prevention, since recurrence? this is a normal course of behavioral disorders.

Patient history

Stressors, life circumstances, social circumstances? factors that can modulate the severity of the disease, personality traits and behavior. Various life periods, including puberty, pregnancy, and menopause, may be associated with an increased risk of certain diseases. Social conditions and gender role differences may help explain the increased incidence of specific symptom complexes in women. For example, the focus of media attention on the ideal figure in Western society is a provoking factor in the development of eating disorders in women. Such contradictory female roles in today's Western society, like a "devoted wife", "madly loving mother? and ?successful business woman? add stress. The purpose of collecting an anamnesis of life is a more accurate selection of methods of internally oriented psychotherapy, finding "the meaning of life". The healing process is facilitated when the patient comes to self-understanding, a clear separation of her past and recognition of the priority of the present for the future.

Thus, the formulation of a psychiatric case should include answers to four questions:

1. Whether the patient has a disease with a clear time of onset, a specific etiology, and a response to pharmacotherapy.

2. What personality traits of the patient influence her interaction with the environment and how.

3. Does the patient have goal-directed conduct disorders

4. What events in the life of a woman contributed to the formation of her personality, and what conclusions did she draw from them.

Eating Disorders

Of all the mental disorders, almost exclusively in women, only eating disorders occur: anorexia and bulimia. For every 10 women who suffer from them, there is only one man. The incidence and incidence of these disorders is increasing. Young white women and girls from the middle and upper classes of Western society have the most high risk developing anorexia or bulimia? 4%. However, the prevalence of these disorders in other age, racial, and socioeconomic groups is also on the rise.

As with abuse, eating disorders are formulated as behavioral disorders caused by dysregulation of hunger, satiety, and absorption. Behavioral disorders associated with anorexia nervosa include restriction of food intake, cleansing manipulations (vomiting, abuse of laxatives and diuretics), debilitating physical exertion, abuse of stimulants. These behavioral responses are compulsive in nature, supported by the psychological attitude towards food and weight. These thoughts and behaviors dominate every aspect of a woman's life, disrupting physical, psychological and social functions. As with abuse, treatment can only be effective if the patient is willing to change the situation.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), anorexia nervosa includes three criteria: voluntary fasting with a refusal to maintain more than 85% of the required weight; psychological attitude with fear of obesity and dissatisfaction with one's own weight and body shape; endocrine disorders leading to amenorrhea.

Bulimia nervosa is characterized by the same fear of obesity and discontent own body, as in anorexia nervosa, accompanied by bouts of gluttony, and then compensatory behavior aimed at maintaining a low body weight. In DSM-IV, anorexia and bulimia are distinguished primarily on the basis of underweight and amenorrhea, and not on the basis of the behavior by which weight is controlled. Compensatory behaviors include intermittent fasting, exhausting exercise, laxatives, diuretics, stimulants, and vomiting.

Binge eating disorder differs from bulimia nervosa in the absence of compensatory weight-maintenance behaviors, resulting in obesity in these patients. Some patients change from one eating disorder to another during their lifetime; most often, the change goes in the direction from the restrictive type of anorexia nervosa (when food restriction and excessive physical activity predominate in behavior) towards bulimia nervosa. There is no single cause of eating disorders, they are considered as multifactorial. Known Factors risk can be divided into genetic, social predispositions and features of temperament.

Studies have shown a higher concordance of identical twins compared to fraternal twins for anorexia. One family study found tenfold increased risk anorexia in female relatives. In contrast, for bulimia, neither familial nor twin studies have shown a hereditary predisposition.

Temperamental and personality traits that contribute to the development of eating disorders include introversion, perfectionism, and self-criticism. Patients with anorexia who restrict food intake but do not engage in cleansing procedures are likely to have predominant anxiety that keeps them from life-threatening behavior; those suffering from bulimia expressed such personality traits as impulsiveness, the search for novelty. Women with binge eating and subsequent cleansing procedures may have other impulsive behaviors such as abuse, sexual promiscuity, kleptomania, self-harm.

Social conditions conducive to the development of eating disorders are associated with the idealization of a slender androgynous figure with underweight, common in modern Western society. Do most young women follow a restrictive diet? behaviors that increase the risk of developing eating disorders. Women compare their appearance with each other, as well as with the generally accepted ideal of beauty and strive to be like it. This pressure is especially pronounced in adolescents and young women, as the endocrine changes at puberty increase the amount of adipose tissue in a woman's body by 50%, and the psyche of adolescents simultaneously overcomes such problems as personality development, separation from parents and puberty. The incidence of eating disorders in young women has increased over the past few decades in parallel with increased media attention to slimness as a symbol of a woman's success.

Other risk factors for developing eating disorders are family conflict, loss of significant person such as a parent, physical illness, sexual conflict, and trauma. Triggers can also be marriage and pregnancy. Do some professions require you to stay slim? ballerinas and models.

It is important to distinguish primary factors risks that trigger the pathological process, from those that support the already existing conduct disorder. Eating disorders periodically cease to depend on the etiological factor that triggered them. Supporting factors include the development of abnormal eating habits and voluntary fasting. Patients with anorexia start by maintaining a diet. They are often encouraged by their initial weight loss, receiving compliments on their looks and self-discipline. Over time, thoughts and behaviors related to nutrition become the dominant and subjective goal, the only one that relieves anxiety. Patients resort more and more intensely to these thoughts and behaviors to maintain their mood, as alcoholics increase the dose of alcohol to relieve stress and translate other ways of discharge into drinking alcohol.

Eating disorders are often underdiagnosed. Patients hide symptoms associated with a sense of shame, internal conflict, fear of condemnation. Physiological signs of eating disorders can be seen on examination. In addition to reduced body weight, fasting can lead to bradycardia, hypotension, chronic constipation, delayed gastric emptying, osteoporosis, and menstrual irregularities. Cleansing procedures lead to violations electrolyte balance, dental problems, hypertrophy of the parotid salivary glands and dyspeptic disorders. Hyponatremia can lead to the development of a heart attack. In the presence of such complaints, the clinician should conduct a standard questionnaire, including the patient's minimum and maximum weight during adulthood, a brief history of eating habits, such as counting calories and grams of fat in the diet. A further survey may reveal the presence of binge eating, the frequency of resorting to compensatory measures to restore weight. It is also necessary to find out whether the patient herself, her friends and family members believe that she has an eating disorder - and whether this bothers her.

Patients with anorexia who resort to cleansing procedures are at high risk serious complications. Does anorexia have the highest mortality of all mental illnesses? more than 20% of anorectics die after 33 years. Death usually occurs due to physiological complications of starvation or due to suicide. In bulimia nervosa, death is often the result of hypokalemia-induced arrhythmias or suicide.

Psychological signs of eating disorders are regarded as secondary to or concomitant with the underlying psychiatric diagnosis. Symptoms of depression and obsessive-compulsive disorder can be associated with fasting: low mood, constant thoughts about food, decreased concentration, ritualistic behavior, decreased libido, social isolation. In bulimia nervosa, shame and the desire to hide binge eating and cleansing routines lead to increased social isolation, self-critical thoughts, and demoralization.

Most patients with eating disorders are at increased risk for other psychiatric disorders, with major depression, anxiety disorders, abuse, and personality disorders being the most common. Concomitant major depression or dysthymia was noted in 50-75% of patients with anorexia and in 24-88% of patients with bulimia. Obsessive neurosis during life occurred in 26% of anorectics.

Patients with eating disorders are characterized by social isolation, communication difficulties, problems in intimate life and professional activities.

Treatment of eating disorders occurs in several stages, begins with an assessment of the severity of the pathology, identification of concomitant mental diagnoses and establishing motivation for change. It is necessary to consult a nutritionist and a psychotherapist specializing in the treatment of patients with eating disorders. It must be understood that, first of all, it is necessary to stop pathological behavior, and only after it is brought under control, it will be possible to prescribe treatment aimed at internal processes. A parallel can be drawn with the primacy of withdrawal in the treatment of abuse, when therapy given concomitantly with continued alcohol intake fails.

Treatment by a general psychiatrist is less desirable from the point of view of maintaining the motivation for treatment, is treatment in special inpatient institutions such as sanatoriums more effective? the mortality rate in patients of such institutions is lower. Group therapy and rigorous monitoring of food intake and toilet use by medical staff in these facilities minimizes the chance of relapse.

Several classes of psychotherapy are used in patients with eating disorders. pharmacological agents. Double-blind, placebo-controlled studies have proven the effectiveness of a wide range of antidepressants in reducing the frequency of binge eating and subsequent cleansing procedures in bulimia nervosa. Imipramine, desipramine, trazodone and fluoxetine reduce the frequency of such attacks, regardless of the presence or absence of comorbid depression. When using fluoxetine, a more effective dose is more effective than is usually used in the treatment of depression - 60 mg. Monoamine oxidase inhibitors (MAOIs) and buproprion are relatively contraindicated because dietary restrictions are required when using MAOIs, and buproprion increases the risk of a heart attack in bulimia. In general, treatment for bulimia should include an attempt to use tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) along with psychotherapy.

In anorexia nervosa, no weight gain medication has been shown to be effective in controlled trials. Unless the patient is severely depressed or has clear signs of obsessive-compulsive disorder, most clinicians recommend monitoring the mental status of patients during remission rather than prescribing medical preparations until the weight has been gained. Most of the symptoms of depression, ritualistic behavior, obsessions disappear when the weight approaches normal. When deciding to prescribe antidepressants, low-dose SSRIs are the safest choice, given the high potential risk of cardiac arrhythmia and hypotension with tricyclic antidepressants, as well as the generally higher risk of drug side effects in people who are underweight. A recent double-blind, placebo-controlled trial of fluoxetine in anorexia nervosa found that the drug may be useful in preventing post-weight loss.

Few studies have been conducted on the levels of neurotransmitters and neuropeptides in patients and recovered patients with eating disorders, but their results show dysfunction of the serotonin, noradrenergic and opiate systems of the CNS. Studies of eating behavior in animal models give the same results.

The efficacy of serotonergic and noradrenergic antidepressants in bulimia also supports the physiology of this disorder.

Evidence from human studies is conflicting and it remains unclear whether neurotransmitter level disturbances in patients with eating disorders are related to the condition, whether they occur in response to fasting and binge eating and purging, or precede psychiatric disturbance and are personality traits of the patient susceptible to this disorder.

Studies of the effectiveness of the treatment of anorexia nervosa show that among hospitalized patients, after 4 years of follow-up, 44% had a good result with the restoration of normal body weight and menstrual cycle; in 28% the result was temporary, in 24% it was not and 4% died. Unfavorable prognostic factors are the variant of the course of anorexia with bouts of binge eating and purging, low minimum weight and the ineffectiveness of therapy in the past. More than 40% of anorexics develop bulimic behavior over time.

The long-term prognosis for bulimia is unknown. Episodic relapses are most likely. A decrease in the severity of bulimic symptoms is observed in 70% of patients with a short follow-up period after treatment with drugs in combination with psychotherapy. As with anorexia, the severity of symptoms in bulimia affects prognosis. Among patients with severe bulimia, 33% failed after three years.

Eating disorders are a complex psychiatric disorder most commonly seen in women. Their frequency of occurrence in Western society is growing, they are combined with high morbidity. The use of psychotherapeutic, educational and pharmacological techniques in treatment can improve the prognosis. Although no specific help may be needed initially, treatment failure requires early referral to a psychiatrist. Further research is needed to elucidate the reasons for the predominance of women among patients, to assess the real risk factors and to develop an effective treatment.

affective disorders

affective disorders? These are mental illnesses, the main symptom of which is mood changes. Everyone has mood swings in their lives, but their extreme expressions? affective disorders? few have. Depression and mania? the two main mood disturbances seen in affective disorders. These diseases include major depression, manic-depressive psychosis, dysthymia, adjustment disorder with depressive mood. Features of the hormonal status can serve as risk factors for the development of affective disorders during a woman's life, exacerbations are associated with menstruation and pregnancy.

Depression

Depression? one of the most common mental disorders, which is more common in women. Most studies estimate the incidence of depression in women to be twice as high as in men. This pattern may be partly explained by the fact that women have a better memory of past bouts of depression. This condition is difficult to diagnose a wide range symptoms and the absence of specific signs or laboratory tests.

When diagnosing, it is quite difficult to distinguish between short-term periods of sad mood associated with life circumstances and depression as a mental disorder. The key to differential diagnosis is recognizing the typical symptoms and monitoring their progress. A person without mental disorders usually there are no disturbances in self-esteem, suicidal thoughts, feelings of hopelessness, neurovegetative symptoms such as sleep disturbances, appetite, lack of vital energy within weeks and months.

The diagnosis of major depression is based on history taking and mental status examination. The main symptoms include low mood and anhedonia? loss of desire and ability to enjoy ordinary life manifestations. In addition to depression and anhedonia lasting for at least two weeks, episodes of major depression are characterized by the presence of at least four of the following neurovegetative symptoms: significant weight loss or gain, insomnia, or increased drowsiness, psychomotor retardation or revival, fatigue and loss of strength, reduced ability to concentrate and make decisions. In addition, many people suffer from increased self-criticism with feelings of hopelessness, excessive guilt, suicidal thoughts, feeling like a burden to their loved ones and friends.

The duration of symptoms for more than two weeks helps to distinguish an episode of major depression from a short-term adjustment disorder with lowered mood. Adjustment disorder? it is reactive depression, in which the depressive symptoms are a response to an overt stressor, are limited in number, and respond to minimal therapy. This does not mean that an episode of major depression cannot be triggered by a stressful event or cannot be treated. An episode of major depression differs from an adjustment disorder in the severity and duration of symptoms.

In some groups, in particular the elderly, the classic symptoms of depression, such as lowered mood, are often not observed, which leads to an underestimation of the frequency of depression in such groups. There is also evidence that in some ethnic groups, depression is more pronounced with somatic signs than with classic symptoms. In older women, complaints of feelings of social worthlessness and a set of characteristic somatic complaints should be taken seriously as they may require medical antidepressant help. Although some laboratory tests, such as the dexamethasone test, have been suggested for diagnosis, they are not specific. The diagnosis of major depression remains clinical and is made after a thorough history and assessment of mental status.

In childhood, the incidence of depression in boys and girls is the same. Differences become noticeable at puberty. Angola and Worthman attribute these differences to hormonal factors and conclude that hormonal changes may be a trigger mechanism for a depressive episode. Starting with menarche, women are at increased risk of developing premenstrual dysphoria. This mood disorder is characterized by symptoms of major depression, including anxiety and mood lability, occurring at last week menstrual cycle and ending in the first days of the folliculin phase. Although premenstrual emotional lability occurs in 20-30% of women, is its severe form quite rare? in 3-5% of the female population. A recent multicenter, randomized, placebo-controlled trial of sertraline 5-150 mg showed significant improvement in symptoms with treatment. 62% of women in the main group and 34% in the placebo group responded to treatment. Fluoxetine at a dose of 20-60 mg per day also reduces the severity of premenstrual disorders in more than 50% of women? according to a multicenter placebo-controlled study. In women with major depression, as with manic-depressive psychosis, do mental disorders worsen in the premenstrual period? it is unclear whether this is an exacerbation of one condition or a superimposition of two (an underlying psychiatric disorder and premenstrual dysphoria).

Pregnant women experience a full range of affective symptoms both during pregnancy and after childbirth. The incidence of major depression (about 10%) is the same as in non-pregnant women. In addition, pregnant women may experience less severe symptoms depression, mania, periods of psychosis with hallucinations. The use of medications during pregnancy is used both during an exacerbation of a mental state and for the prevention of relapses. Interruption of medication during pregnancy in women with pre-existing mental disorders leads to a sharp increase in the risk of exacerbations. To make a decision about drug treatment, the risk of potential drug harm to the fetus must be weighed against the risk to both the fetus and the mother of recurrence.

In a recent review, Altshuler et al described existing therapeutic guidelines for the treatment of various psychiatric disorders during pregnancy. In general, medications should be avoided during the first trimester if possible due to the risk of teratogenic effects. However, if symptoms are severe, treatment with antidepressants or mood stabilizers may be necessary. Initial studies with fluoxetine have shown that SSRIs are relatively safe, but there are no reliable data on the prenatal effects of these new drugs. The use of tricyclic antidepressants does not lead to a high risk of congenital anomalies. Electroconvulsive therapy? another relatively safe treatment for severe depression during pregnancy. Taking lithium preparations in the first trimester increases the risk of congenital pathologies of the cardiovascular system. Antiepileptic drugs and benzodiazepines are also associated with an increased risk of congenital anomalies and should be avoided if possible. In each case, it is necessary to evaluate all indications and risks individually, depending on the severity of the symptoms. To compare the risk of untreated mental illness and the risk of pharmacological complications for the mother and fetus, a psychiatric consultation is necessary.

Many women experience mood disturbances after childbirth. The severity of symptoms ranges from ?baby blues? to severe major depression or psychotic episodes. For most women, these mood changes occur in the first six months after childbirth, at the end of this period, all signs of dysphoria disappear on their own. However, in some women, depressive symptoms persist for many months or years. In a study of 119 women after their first childbirth, half of the women who received medical treatment after childbirth had a relapse within the next three years. Early identification of symptoms and adequate treatment is essential for both mother and child, as depression can affect the mother's ability to adequately care for her child. However, antidepressant treatment in breastfeeding mothers requires caution and comparative risk assessment.

Mood changes during menopause have been known for a long time. Recent studies, however, have not confirmed a clear link between menopause and affective disorders. In a review on this issue, Schmidt and Rubinow found very few published studies to support this association.

Mood changes associated with menopausal hormonal changes may resolve with HRT. For most women, HRT is the first step in treatment before psychotherapy and antidepressants. If symptoms are severe, initial treatment with antidepressants is indicated.

Due to the long life expectancy of women compared to men, most women outlive their spouses, which is a stress factor in older age. At this age, monitoring is needed to identify symptoms of severe depression. History taking and examination of mental status in older women should include screening for somatic symptoms and identifying feelings of worthlessness, a burden on loved ones, because depression in the elderly is not characterized by a decrease in mood as a primary complaint. Treatment of depression in the elderly is often complicated by low tolerance to antidepressants, so they must be prescribed at a minimum dose, which can then be gradually increased. Are SSRIs undesirable at this age due to their anticholinergic side effects? sedation and orthostasis. When a patient takes several drugs, drug monitoring in the blood is necessary due to the mutual influence on metabolism.

There is no single cause of depression. The main demographic risk factor is female gender. Analysis of population data shows that the risk of developing major depression is increased in divorced, single and unemployed people. The role of psychological causes is being actively studied, but so far no consensus has been reached on this issue. Family studies have demonstrated an increased incidence of affective disorders in the closest relatives of the proband. Twin studies also support the idea of ​​a genetic predisposition in some patients. Especially strongly hereditary predisposition plays a role in the genesis of manic-depressive psychosis and major depression. The likely cause is a malfunction of the serotonergic and noradrenergic systems.

Is the usual therapeutic approach to treatment a combination of pharmacological agents? antidepressants? and psychotherapy. The advent of a new generation of antidepressants with minimal side effects has increased the therapeutic options for patients with depression. Are 4 main types of antidepressants used: tricyclic antidepressants, SSRIs, MAO inhibitors, and others? see table. 28-2.

A key principle in the use of antidepressants is an adequate time to take them? a minimum of 6-8 weeks for each drug in a therapeutic dose. Unfortunately, many patients stop taking antidepressants before the effect develops, because they do not see improvement in the first week. When taking tricyclic antidepressants, drug monitoring can help confirm that adequate therapeutic blood levels have been achieved. For SSRIs, this method is less useful, their therapeutic level varies greatly. If the patient did not take full course antidepressant and continues to experience symptoms of major depression, a new course of treatment with another class of drug should be initiated.

All patients treated with antidepressants should be monitored for the development of manic symptoms. Although it's enough rare complication taking antidepressants, it does happen, especially if there is a family or personal history of manic-depressive psychosis. Symptoms of mania include reduced need for sleep, a feeling of increased energy, and agitation. Prior to initiating therapy, patients should have a thorough history taken to identify symptoms of mania or hypomania, and if these symptoms are present or if there is a family history of manic-depressive psychosis, will a psychiatric consultation help to select therapy with mood stabilizers? preparations of lithium, valproic acid, possibly in combination with antidepressants.

Seasonal affective disorders

For some people, the course of depression is seasonal, worsening in the winter. severity clinical symptoms varies widely. For moderate symptoms, exposure to full-spectrum non-ultraviolet light (fluorescent lamps - 10,000 lux) for 15-30 minutes every morning during the winter months is sufficient. If symptoms meet the criteria for major depression, antidepressant treatment should be added to light therapy.

Bipolar disorders (manic-depressive psychosis)

The main difference between this disease and major depression is the presence of both episodes of depression and mania. Criteria for depressive episodes? just like the big depression. Episodes of mania are characterized by bouts of high, irritable, or aggressive mood lasting at least a week. These mood changes are accompanied by the following symptoms: increased self-esteem, reduced need for sleep, loud and rapid speech, racing thoughts, agitation, flashes of ideas. Such an increase in vital energy is usually accompanied by excessive behavior aimed at obtaining pleasure: spending large sums of money, drug addiction, promiscuity and hypersexuality, risky business projects.

There are several types of manic-depressive disorder: the first type? the classic form, type 2 includes a change in episodes of depression and hypomania. Episodes of hypomania are milder than classical mania, with the same symptoms but without disrupting the patient's social life. Other forms of bipolar disorder include rapid mood swings and mixed states, where the patient has both manic and depressive symptoms at the same time.

Mood stabilizers such as lithium and valproate are first-line drugs for the treatment of all forms of bipolar disorder. Lithium starting dose? 300 mg once or twice daily, then adjusted to maintain blood levels of 0.8-1.0 mEq/L for bipolar I disorder. The level of valproate in the blood, effective for the treatment of these diseases, has not been precisely established; one can focus on the level recommended for the treatment of epilepsy: 50-150 mcg / ml. Some patients require a combination of mood stabilizers with antidepressants to treat symptoms of depression. A combination of mood stabilizers with low doses of neuroleptics is used to control the symptoms of acute mania.

Dysthymia

Dysthymia? This is a chronic depressive condition lasting at least two years, with symptoms less pronounced than in major depression. The severity and number of symptoms are not sufficient to meet the criteria for major depression, but they interfere with social functioning. Typically, symptoms include appetite disturbances, decreased energy, impaired concentration, sleep disturbances, and feelings of hopelessness. Studies conducted in different countries claim a high prevalence of dysthymia in women. Although there are few reports of therapy for this disorder, there is evidence that SSRIs such as fluoxetine and sertraline may be used. Some patients with dysthymia may experience episodes of major depression.

Coexisting affective and neurological disorders

There is much evidence of associations between neurological disorders and affective disorders, more often with depression than with bipolar disorders. Episodes of major depression are common in Huntington's chorea, Parkinson's disease, and Alzheimer's disease. Do 40% of patients with parkinsonism have episodes of depression? half? major depression, half? dysthymia. In a study of 221 patients with multiple sclerosis, 35% were diagnosed with major depression. Some studies have shown an association between stroke in the left frontal lobe and major depression. AIDS patients develop both depression and mania.

Neurological patients with features that meet the criteria for affective disorders should be treated with drugs, since drug treatment of mental disorders improves the prognosis of the underlying neurological diagnosis. If the clinical picture does not meet the criteria for affective disorders, psychotherapy is sufficient to help the patient cope with the difficulties. The combination of several diseases increases the number of prescribed drugs and sensitivity to them, and hence the risk of delirium. In patients receiving a large number of drugs, antidepressants should be started at a low dose and increased gradually, monitoring for possible symptoms of delirium.

Alcohol abuse

Alcohol? most commonly abused substance in the US, 6% of adult females have serious problems with alcohol. Although the rate of alcohol abuse in women is lower than in men, alcohol dependence and alcohol-related morbidity and mortality are significantly higher in women. Studies of alcoholism are focused on the male population, the validity of extrapolating their data to the female population is questionable. For diagnosis, questionnaires are usually used to identify problems with the law and employment, which are much less common in women. Women are more likely to drink alone and are less likely to have tantrums when intoxicated. One of the main risk factors for the development of alcoholism in a woman is an alcoholic partner who inclines her to drinking companionship and does not allow her to seek help. In women, the signs of alcoholism are more pronounced than in men, but doctors determine it in women less often. All this makes it possible to consider the official frequency of occurrence of alcoholism in women underestimated.

Complications associated with alcoholism (fatty liver, cirrhosis, hypertension, gastrointestinal bleeding, anemia, and digestive disorders) in women develop faster and at lower doses of alcohol than in men, because women have lower levels of gastric alcohol dehydrogenase than men. Dependence on alcohol, as well as on other substances? opiates, cocaine? women develops after a shorter time of admission than men.

There is evidence that the incidence of alcoholism and related medical problems is on the rise in women born after 1950. During the phases of the menstrual cycle, changes in the metabolism of alcohol in the body are not observed, however, in drinking women irregular menstruation and infertility are more common. During pregnancy, a complication is usually fetal alcohol syndrome. The incidence of cirrhosis increases dramatically after menopause, and alcoholism increases the risk of alcoholism in older women.

Women with alcoholism have an increased risk of comorbid psychiatric diagnoses, especially drug addiction, mood disorders, bulimia nervosa, anxiety and psychosexual disorders. Depression occurs in 19% of alcoholic women and 7% of women who do not abuse alcohol. Although alcohol brings temporary relaxation, it exacerbates the course of mental disorders in susceptible people. It takes several weeks of withdrawal to achieve remission. Women with a paternal family history of alcoholism, anxiety disorder, and premenstrual syndrome drink more during the second phase of their cycle, possibly in an attempt to reduce symptoms of anxiety and depression. Alcoholic women are at high risk of suicide attempts.

Women usually seek relief from alcoholism in a roundabout way, turning to psychoanalysts or general practitioners with complaints of family problems, physical or emotional complaints. They rarely go to alcoholism treatment centers. Alcoholic patients need a special approach due to their frequent inadequacy and reduced sense of shame.

Although it is almost impossible to directly ask such patients about the amount of alcohol taken, screening for alcohol abuse should not be limited to indirect signs such as anemia, elevated liver enzymes and triglycerides. Q: Have you ever had problems with alcohol? and the CAGE questionnaire (Table 28-3) provides rapid screening with over 80% sensitivity for more than two positive responses. Support, explanation, and discussion with the doctor, psychologist, and members of Alcoholics Anonymous help the patient adhere to treatment. During the withdrawal period, it is possible to prescribe diazepam at a starting dose of 10-20 mg with a gradual increase by 5 mg every 3 days. Control visits should be at least twice a week, they assess the severity of signs of withdrawal syndrome (sweating, tachycardia, hypertension, tremor) and adjust the dose of the drug.

Although alcohol misuse is less common in women than in men, its harm to women, taking into account the associated morbidity and mortality, is much higher. New studies are needed to elucidate the pathophysiology and psychopathology of the sexual characteristics of the course of the disease.

Table 28-3

CAGE Questionnaire

1. Have you ever felt like you need to drink less?

2. Have people ever bothered you with their criticism of your drinking?

3. Have you ever felt guilty about drinking alcohol?

4. Has it ever happened that alcohol was the only remedy that helps to become cheerful in the morning (open your eyes)

Sexual disorders

Sexual dysfunctions have three successive stages: disturbances of desire, arousal and orgasm. The DSM-IV considers painful sexual disorders as a fourth category of sexual dysfunction. Desire disorders are further subdivided into reduced sexual desire and perversions. Painful sexual disorders include vaginismus and dyspareunia. Clinically, women often have a combination of several sexual dysfunctions.

The role of sex hormones and menstrual disorders in the regulation of sexual desire remains unclear. Most researchers suggest that endogenous fluctuations in estrogen and progesterone do not significantly affect sexual desire in women of reproductive age. However, there is clear evidence of a decrease in desire in women with surgical menopause, which can be restored by the administration of estradiol or testosterone. Studies of the relationship between arousal and orgasm with cyclic fluctuations in hormones do not give unambiguous conclusions. There is a clear correlation between the plasma level of oxytocin and the psychophysiological magnitude of orgasm.

In postmenopausal women, the number of sexual problems increases: a decrease in vaginal lubrication, atrophic vaginitis, a decrease in blood supply, which are effectively solved with estrogen replacement therapy. The addition of testosterone helps to increase sexual desire, although there is no clear evidence of the supportive effect of androgens on blood flow.

Psychological factors, communication problems play a much more important role in the development of sexual disorders in women than organic dysfunction.

Special attention deserves the influence of medications taken by psychiatric patients on all phases of sexual function. Antidepressants and antipsychotics? two main classes of drugs associated with similar side effects. Anorgasmia has been observed with the use of SSRIs. Despite clinical reports on the effectiveness of adding cyproheptadine or interrupting the main drug for the weekend, is it still more acceptable to change the class of antidepressant to another one with less side effects in this area, most often? for buproprion and nefazodone. Except side effects psychopharmacological agents, the chronic mental disorder itself can lead to a decrease in sexual interest, as well as physical illness accompanied by chronic pain, low self-esteem, changes in appearance, fatigue. A history of depression may be the cause of reduced sexual desire. In such cases, sexual dysfunction occurs during the manifestation of an affective disorder, but does not disappear after the end of its episode.

Anxiety disorders

Anxiety? it is a normal adaptive emotion that develops in response to a threat. It works as a signal to activate behavior and minimize physical and psychological vulnerability. Anxiety reduction is achieved either by overcoming or avoiding a provoking situation. Pathological anxiety states differ from normal anxiety in the severity and chronicity of the disorder, provocative stimuli, or adaptive behavioral response.

Anxiety disorders are widespread, with a monthly incidence of 10% among women. Average age of onset of anxiety disorders? teenage years and youth. Many patients never seek help for this or go to non-psychiatrists complaining of somatic symptoms associated with anxiety. Overdosing or withdrawal of medications, use of caffeine, weight loss drugs, pseudoephedrine can exacerbate anxiety disorder. medical examination should include a thorough history taking, routine laboratory tests, ECG, and urinalysis. Some species neurological pathology accompanied by anxiety disorders: movement disorders, brain tumors, circulatory disorders of the brain, migraine, epilepsy. Somatic diseases accompanied by anxiety disorders: cardiovascular, thyrotoxicosis, systemic lupus erythematosus.

Anxiety disorders are divided into 5 main groups: phobias, panic disorders, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress syndrome. With the exception of obsessive compulsive disorder, which is equally common in men and women, anxiety disorders are more common in women. Women are three times more likely to have specific phobias and agoraphobia, 1.5 times more common? panic with agoraphobia, 2 times more often? generalized anxiety disorder and 2 times more often? post-traumatic stress syndrome. The reasons for the predominance of anxiety disorders in the female population are unknown; hormonal and sociological theories have been proposed.

Sociological theory focuses on traditional sex-role stereotypes that prescribe helplessness, dependence, and avoidance of active behavior to a woman. Young mothers often worry about whether they will be able to ensure the safety of their children, reluctance to become pregnant, infertility? All of these conditions can exacerbate anxiety disorders. A large number of expectations and conflicting roles of a woman as a mother, wife, housewife and successful worker also increase the frequency of anxiety disorders in women.

Hormonal fluctuations exacerbate anxiety in the premenstrual period, during pregnancy and after childbirth. Progesterone metabolites function as partial GABA agonists and possible modulators of the serotonergic system. Alpha-2 receptor binding also changes throughout the menstrual cycle.

For anxiety disorders high combination with other psychiatric diagnoses, most often? affective disorders, drug addiction, other anxiety disorders and personality disorders. At panic disorder oh, for example, the combination with depression is more common than 50%, but with alcohol addiction? in 20-40%. Social phobia is combined with panic disorder in more than 50%.

The general principle of the treatment of anxiety disorders is the combination of pharmacotherapy with psychotherapy? the effectiveness of such a combination is higher than the use of these methods in isolation from each other. Drug treatment affects three major neurotransmitter systems: noradrenergic, serotonergic, and GABAergic. The following classes of drugs are effective: antidepressants, benzodiazepines, beta-blockers.

All drugs should be started at low doses and then gradually increased by a factor of two every 2 to 3 days or less frequently to minimize side effects. Patients with anxiety disorders are very sensitive to side effects, so gradually increasing the dose increases compliance with therapy. Patients need to be explained that most antidepressants take 8-12 weeks to work, tell them about the main side effects, help them continue the drug for the required amount of time, and explain that some of the side effects go away with time. The choice of antidepressant depends on the patient's set of complaints and on their side effects. For example, patients with insomnia may be better off starting with more sedating antidepressants such as imipramine. If effective, should treatment be continued for 6 months? of the year.

At the beginning of treatment, before the effect of antidepressants develops, the addition of benzodiazepines is useful, which can dramatically reduce symptoms. Long-term use of benzodiazepines should be avoided due to the risk of dependence, tolerance and withdrawal. When prescribing benzodiazepines, it is necessary to warn the patient about their side effects, the risk associated with their long-term use and the need to consider them only as a temporary measure. Clonazepam 0.5 mg twice daily or lorazepam 0.5 mg four times daily for a limited period of 4–6 weeks may improve initial antidepressant compliance. When taking benzodiazepines for more than 6 weeks, discontinuation should be gradual to reduce anxiety associated with a possible withdrawal syndrome.

In pregnant women, anxiolytics should be used with caution, the safest drugs in this case are tricyclic antidepressants. Benzodiazepines can cause hypotension, respiratory distress syndrome and a low Apgar score in neonates. Clonazepam has a minimal potential teratogenic effect and may be used with caution in pregnant women with severe anxiety disorders. Should the first step be to try a non-pharmacological treatment? cognitive (training) and psychotherapy.

Phobic disorders

There are three types of phobic disorders: specific phobias, social phobia, and agoraphobia. In all cases, in a provoking situation, anxiety occurs and a panic attack may develop.

Specific phobias? they are irrational fears of specific situations or objects that cause them to be avoided. Examples are fear of heights, fear of flying, fear of spiders. They usually occur at the age of under 25, women are the first to develop a fear of animals. Such women rarely seek treatment because many phobias do not interfere with normal life and their stimuli (such as snakes) are fairly easy to avoid. However, in some cases, such as fear of flying, phobias can interfere with a career, in which case treatment is indicated. Simple phobias are fairly easy to deal with with psychotherapeutic techniques and systemic desensitization. Additionally, a single dose of 0.5 or 1 mg of lorazepam before flying helps to reduce this specific fear.

social phobia(fear of society) ? it is the fear of a situation in which a person is available for the close attention of other people. Avoidance of provocative situations with this phobia severely limits the working conditions and social function. Although social phobia is more common in women, it is easier for them to avoid a provoking situation and engage in homework Therefore, in the clinical practice of psychiatrists and psychotherapists, men with social phobia are more common. Social phobia can be associated with movement disorders and epilepsy. In a study of patients with Parkinson's disease, the presence of social phobia was revealed in 17%. Pharmacological treatment of social phobia is based on the use of beta-blockers: propranolol at a dose of 20-40 mg an hour before an alarming presentation or atenolol at a dose of 50-100 mg per day. These drugs block the activation of the autonomic nervous system in connection with anxiety. Antidepressants, including tricyclics, SSRIs, MAO blockers, can also be used? in the same doses as in the treatment of depression. The combination of pharmacotherapy with psychotherapy is preferred: short-term use of benzodiazepines or low doses of clonazepam or lorazepam in combination with cognitive therapy and systemic desensitization.

Agoraphobia? fear and avoidance large cluster people. Often combined with panic attacks. It is very difficult to avoid provoking situations in this case. As with social phobia, agoraphobia is more common in women, but men seek help more often because its symptoms interfere with their personal and social lives. Treatment for agoraphobia is systemic desensitization and cognitive psychotherapy. Because of their high association with panic disorder and major depression, antidepressants are also effective.

Panic Disorders

Panic attack? it is a sudden onset of intense fear and discomfort lasting several minutes, resolving gradually and including at least 4 symptoms: chest discomfort, sweating, trembling, hot flashes, shortness of breath, paresthesias, weakness, dizziness, palpitations, nausea, stool disorders, fear of death, loss of self-control. Panic attacks can occur with any anxiety disorder. They are unexpected and accompanied by a constant fear of expecting new attacks, which changes behavior, directs it to minimize the risk of new attacks. Panic attacks also occur in many conditions of intoxication and some diseases such as emphysema. In the absence of therapy, the course of panic disorders becomes chronic, but treatment is effective, and the combination of pharmacotherapy with cognitive-behavioral psychotherapy causes a dramatic improvement in most patients. Antidepressants, especially tricyclics, SSRIs, and MAO inhibitors, at doses comparable to those used in the treatment of depression, are the drug of choice (Table 28-2). Imipramine or nortriptyline is started at a low dose of 10–25 mg daily and increased by 25 mg every three days to minimize side effects and improve compliance. Blood levels of nortriptyline should be maintained between 50 and 150 ng/mL. Fluoxetine, fluvoxamine, tranylcypromine, or phenelzine may also be used.

generalized anxiety disorder

DSM-IV defines generalized anxiety disorder as persistent, severe, poorly controlled anxiety associated with daily activities such as work, school, that interferes with life and is not limited to symptoms of other anxiety disorders. At least three of the following symptoms are present: fatigue, poor concentration, irritability, sleep disturbances, restlessness, muscle tension.

Treatment includes medication and psychotherapy. Buspirone is the first line treatment for generalized anxiety disorder. Starting dose? 5 mg twice a day, gradually increase it over several weeks to 10-15 mg twice a day. An alternative is imipramine or an SSRI (sertraline) (see Table 28-2). Short-term use of long-acting benzodiazepines, such as clonazepam, may help manage symptoms in the first 4 to 8 weeks, before mainstream treatment takes effect.

Psychotherapeutic techniques used in the treatment of generalized anxiety disorder include cognitive behavioral therapy, supportive therapy, and an inward-oriented approach that aims to increase the patient's tolerance for anxiety.

Compulsive disorder syndrome (obsessive-compulsive disorder)

Obsessions (obsessions) ? This disturbing, repetitive, imperative thoughts, images. Examples include fear of infection, fear of committing a shameful or aggressive act. The patient always perceives obsessions as abnormal, excessive, irrational and tries to resist them.

Obsessive actions (compulsions)? it is repetitive behavior such as washing hands, counting, picking things up. Could it be mental actions? counting to oneself, repeating words, praying. The patient feels it necessary to perform these rituals in order to alleviate the anxiety caused by the obsessions, or to comply with some irrational rules supposedly preventing some danger. Obsessions and compulsions interfere with the patient's normal behavior, taking up most of her time.

The incidence of obsessive-compulsive disorder is the same in both sexes, but in women they begin later (at the age of 26-35 years), may occur at the beginning of the development of an episode of major depression, but persist after it ends. What is the course of the disorder? combined with depression? better amenable to therapy. Obsessions related to food and weight are more common in women. In one study, 12% of women with obsessive-compulsive disorder had previously had anorexia nervosa. Neurological disorders associated with obsessive-compulsive disorder include Tourette's syndrome (combined with obsessive-compulsive disorder in 60% of cases), temporal-dose epilepsy, and post-encephalitis conditions.

The treatment of this syndrome is quite effective, based on a combination of cognitive behavioral therapy and pharmacological treatment. Serotonergic antidepressants are the drugs of choice (clomipramine, fluoxetine, sertraline, fluvoxamine). Doses should be higher than those used for depression in particular? fluoxetine? 80-100 mg per day. All drugs begin to be used in minimum doses and gradually increase every 7-10 days until a clinical response is obtained. To achieve the maximum therapeutic effect, 8-16 weeks of treatment are most often needed.

Post Traumatic Stress Disorder

Post-traumatic stress disorder develops after situations that can be traumatic for many people, so it is difficult to diagnose. Such situations can be war, life threat, rape, etc. The patient constantly returns her thoughts to the traumatic event and at the same time tries to avoid reminders of it. personality traits, life stresses, genetic predisposition, family history of psychiatric disorders explain why some people develop PTSD and some don't under the same triggering conditions. Studies show that women are more susceptible to developing this syndrome. Biological theories of the pathogenesis of post-traumatic stress disorder include dysfunction of the limbic system, dysregulation of the catecholamine and opiate systems. In women in the luteal phase of the menstrual cycle, symptoms worsen.

Treatment for PTSD includes medication and psychotherapy. The drugs of choice are imipramine or SSRIs. Psychotherapy involves gradually coming into contact with stimuli reminiscent of the traumatic event in order to overcome one's attitude towards it.

Anxiety disorders are more common in women than in men. Women rarely seek treatment for fear of being labeled "mentally ill". When women do seek help, they often present only associated somatic symptoms, which impair diagnosis and quality. psychiatric care. Although anxiety disorders are treatable, if not properly diagnosed, they often become chronic and can seriously impair functioning. Future research will help explain sex differences in the incidence of anxiety disorders.

Somatoform and false disorders

Somatization as a psychiatric phenomenon? it is an expression of psychological distress in the form of somatic disorders. This is a common occurrence in many mental disorders. False disorders and simulation are suspected in the presence of unexplained symptoms that do not fit the picture of somatic and neurological disorders. The motivation for the simulation of diseases is the need of the individual to play the role of the patient. This intention can be completely unconscious? as in conversion disorders, and fully conscious? as in simulation. Getting used to the role of the patient leads to increased attention from family members and doctors and reduces the responsibility of the patient.

Most studies confirm the high incidence of this group of disorders in women. This may be due to the difference in the education of the sexes and varying degrees tolerance for physical discomfort.

False Disorders and Simulation

False disorders? conscious production of symptoms of mental illness in order to maintain the role of the patient. An example would be the administration of a dose of insulin to produce a hypoglycemic coma and hospitalization. In simulation, the goal of the patient is not to feel sick, but to achieve other practical results (avoiding arrest, obtaining insane status).

Somatoform disorders

There are four types of somatoform disorders: somatization, conversion, hypochondria, and pain. All of these disorders are physical symptoms, not explainable from the standpoint of existing somatic diseases. Most often, the mechanism for the development of these symptoms is unconscious (as opposed to false disorders). These symptoms must be severe enough to interfere with the patient's social, emotional, occupational, or physical functioning and be associated with an active search for medical care. Since these patients are self-diagnosed, one of the initial difficulties of treatment is their acceptance of the fact of a mental disorder. Only the acceptance of a real diagnosis helps to achieve cooperation with the patient and the implementation of her treatment recommendations. The next step is to find out the connection between exacerbations of symptoms and life stressors, depression or anxiety - and explain this connection to the patient. An illustrative example? exacerbation of peptic ulcer from stress? helps patients to link their complaints to the current psychological state. Treatment of comorbid depression or anxiety is very important.

somatization disorder

Somatization disorder usually includes many somatic symptoms affecting many organs and systems, has a chronic course and begins before the age of 30 years. DSM-IV diagnostic criteria require at least four pain symptoms, two gastrointestinal, one sexual, and one pseudoneurological, none of which are fully explained by physical and laboratory findings. Patients often present with strange and inconsistent combinations of complaints. In women, such disorders are 5 times more common than in men, and the frequency is inversely proportional to educational level and social class. The combination with other mental disorders, especially affective and anxiety disorders, is present in 50%, and its diagnosis is very important for the selection of therapy.

A prerequisite for successful therapy is the choice of one attending physician who coordinates treatment tactics, since such patients often turn to many doctors. Psychotherapy, both individual and group, often helps patients reformulate their condition.

Ovarian hormones and the nervous system

Hormones play an important role in the manifestation of many neurological conditions. Sometimes endocrine disorders are caused by an underlying neurological diagnosis, such as an abnormal insulin response to a glucose load in myodystrophy. In other cases, vice versa neurological disorders caused by endocrine disorders? for example, peripheral neuropathy in diabetes mellitus. In other endocrine disorders, such as primary hypothyroidism, Cushing's disease, Addison's disease, neurological dysfunction may be less noticeable and manifest as a violation of cognitive ability or personality traits. All these conditions are equally common in men and women. In women, cyclic changes in the level of ovarian hormones have specific effects, which are discussed in this chapter.

For a better understanding of the subject, the questions of anatomy, physiology of the ovaries, the pathogenesis of puberty and the physiological effects of ovarian hormones are first considered. There are various genetic conditions that affect the process of sexual development and maturation. Besides the fact that they can have a direct effect on neurological status, they also change it by influencing cyclic hormonal changes. The differential diagnosis with delayed sexual development is considered.

Clinically, congenital or acquired changes in certain brain structures can have a significant impact on sexual and neuronal development. Can damage to the central nervous system, such as tumors, interfere with sexual development or the menstrual cycle? depending on the age at which they develop.

Anatomy, Embryology and Physiology

The cells of the ventromedial and arcuate nuclei and the preoptic zone of the hypothalamus are responsible for the production of GnRH. This hormone controls the release of anterior pituitary hormones: FSH and LH (gonadotropins). Cyclic changes in FSH and LH levels regulate the ovarian cycle, which includes follicle development, ovulation, and maturation of the corpus luteum. Are these stages associated with varying degrees of production of estrogens, progesterone, and testosterone, which in turn have multiple effects on various organs and in a feedback manner? on the hypothalamus and cortical areas associated with the regulation of ovarian function. In the first three months of life, GnRH causes a marked response in LH and FSH production, which then decreases and recovers closer to menarche. This early LH surge is associated with a peak in oocyte replication. Many researchers consider these facts to be related, since the production of new oocytes is practically absent in the future. However, the exact role of FSH and LH in the regulation of oocyte production has not been determined. Immediately before puberty during sleep, the release of GnRH increases dramatically. This fact and the rise in LH and FSH levels are considered markers of approaching puberty.

Influences that increase the tone of the noradrenergic system increase the release of GnRH, and the activation of the opiate system? slows down. GnRH secreting cells are also affected by the levels of dopamine, serotonin, GABA, ACTH, vasopressin, substance P, and neurotensin. Although there are higher, cortical regions that directly influence areas of the hypothalamus that produce GnRH, the amygdala has the strongest influence. Located in front of the limbic system temporal lobe, the amygdala is in reciprocal relationship with many areas of the neocortex and with the hypothalamus. In the amygdala nucleus there are two areas, the fibers of which go as part of various pathways of the brain. Fibers from the cortico-medial region go as part of the stria terminalis, but from the basolateral? in the ventral amygdalofugal tract. Both of these pathways are associated with areas of the hypothalamus containing GnRH-producing cells. Research with stimulation and destruction amygdala and pathways revealed a clear response in LH and FSH levels. Stimulation of the corticomesial nucleus stimulated ovulation and uterine contraction. Stimulation of the basolateral nucleus blocked sexual behavior in females during ovulation. Destruction of the sria terminalis blocked ovulation. Destruction of the ventral amygdalofugal pathway had no effect, but bilateral damage to the basolateral nucleus also blocked ovulation.

GnRH is released into the portal system of the hypothalamus and enters the anterior pituitary gland, where it affects gonadotrophic cells that occupy 10% of the adenohypophysis. They usually secrete both gonadotropic hormones, but among them there are subspecies that secrete only LH or only FSH. GnRH secretion occurs in a circoral pulsatile rhythm. Answer? release of LH and FSH? develops rapidly, in the same pulse mode. The half-lives of these hormones are different: for LH it is 30 minutes, for FSH? about 3 hours. That. when measuring hormone levels in peripheral blood, it is less variable in FSH than in LH. LH regulates the production of testosterone in ovarian theca cells, which in turn is converted to estrogen in granulosa cells. LH also contributes to the maintenance of the corpus luteum. FSH stimulates follicular cells and controls aromatase levels by influencing estradiol synthesis (Fig. 4-1). Just before puberty, the pulsed release of GnRH causes a predominant stimulation of FSH production with little or no effect on LH levels. The sensitivity of LH to stimulation increases after the onset of menarche. During the reproductive period, the LH pulse is more stable than FSH. At the onset of menopause, the LH response begins to decline until postmenopause, when both FSH and LH levels are elevated, but FSH predominates.

In the ovaries, from LDL cholesterol circulating in the blood, under the influence of FSH and LH, sex hormones are synthesized: estrogens, progesterone and testosterone (Fig. 4-1). All cells of the ovary, except for the egg itself, are capable of synthesizing estradiol? main ovarian estrogen. LH regulates the first stage? conversion of cholesterol to pregnenolone, and FSH? final conversion of testosterone to estradiol. Estradiol, when accumulated in sufficient quantities, has a positive feedback effect on the hypothalamus, stimulating the release of GnRH and causing an increase in the pulse amplitude of LH and, to a lesser extent, FSH. The pulsation of gonadotropins reaches its maximum amplitude during ovulation. After ovulation, FSH levels decrease, resulting in a decrease in FSH-dependent estradiol production and hence estradiol-dependent LH secretion. The corpus luteum develops, leading to an increase in the levels of progesterone and estradiol synthesized by the cells of the theca and granulosa of the corpus luteum.

Estrogens? hormones that have many peripheral effects. They are necessary for secondary puberty: the maturation of the vagina, uterus, fallopian tubes, stroma and ducts of the mammary glands. They stimulate the growth of the endometrium during the menstrual cycle. They are also important for the growth of tubular bones and the closure of growth plates. They have an important influence on the distribution of subcutaneous fat and the level of HDL in the blood. Estrogens reduce calcium reabsorption from bones and stimulate blood clotting.

In the brain, estrogens act as both a trophic factor and a neurotransmitter. The density of their receptors is highest in the preoptic zone of the hypothalamus, but there is also a certain amount in the amygdala, CA1 and CA3 regions of the hippocampus, cingulate gyrus, locus coeruleus, raphe nuclei, and central gray matter. In many areas of the brain, the number of estrogen receptors changes throughout the menstrual cycle, in some? specifically in the limbic system? their level depends on serum. Estrogens activate the formation of new synapses, in particular the NMDA mediator system, as well as the reaction of the formation of new dendrites. Both of these processes are further enhanced in the presence of progesterone. The reverse processes do not depend on an isolated decrease in estrogen levels, but only on its decrease in the presence of progesterone. Without progesterone, a decrease in estrogen does not trigger the reverse processes. That. The effects of estrogens are enhanced in non-ovulating women who do not have adequate levels of progesterone during the luteal phase.

Estrogens exert their influence on the level of neurotransmitters (cholinergic system) by activating acetylcholinesterase (AChE). They also increase the number of serotonin receptors and the level of serotonin synthesis, which causes it to fluctuate during the cycle. In human and animal studies, increasing estrogen levels improves fine motor skills but decreases spatial orientation. With an initially reduced level of estrogen in women, its increase improves verbal short-term memory.

In animals treated with estrogens, resistance to convulsions provoked by electric shock decreases, and the threshold of sensitivity to convulsive drugs decreases. Local application of estrogen itself provokes spontaneous convulsions. In animals with structural but non-epileptic lesions, estrogens can also induce seizures. In people intravenous administration estrogen can activate epileptic activity. During periods of higher estrogen concentration, an increase in the basal EEG amplitude is observed compared to periods of minimal concentration. Progesterone has the opposite effect on epileptic activity, raising the threshold for seizure activity.

Disorders with a genetic predisposition

Genetic disorders can disrupt the normal process of puberty. They can directly cause the same neurological disorders, which also depend on hormone levels throughout the menstrual cycle.

Turner Syndrome? example of a chromosomal deletion. One out of every 5,000 live-born girls has a karyotype of 45, XO, i.e. deletion of one X chromosome. This mutation is associated with many somatic developmental anomalies, such as coarctation of the aorta, delayed sexual development due to high level FSH and gonadal dysgenesis. If it is necessary to replenish the level of sex hormones, hormone replacement therapy is possible. It has recently been found that some patients with Turner syndrome have a partial deletion in the long or short arm of the X chromosome or mosaicism, i.e. in some cells of the body, the karyotype is normal, while in others there is a complete or partial deletion of the X chromosome. In these cases, although the process of sexual development may proceed normally, some of the somatic features of the disease, such as short stature, pterygoid neck folds, may be present in patients. There are other cases when there is gonadal dysgenesis, but there are no somatic signs, and development occurs normally until the development of secondary sexual characteristics.

Another disorder with a genetic predisposition and various clinical manifestations is congenital hyperplasia adrenal cortex. This autosomal recessive anomaly has 6 clinical forms and occurs in both men and women. In three of these forms, only the adrenal glands are affected, in the rest? adrenals and ovaries. In all 6 variants, women have virilization, which can delay the time of puberty. This disorder has a high incidence of PCOS.

Another genetic disorder is the P450 aromatase deficiency syndrome. With it, there is a partial violation of the placental conversion of circulating steroids to estradiol, which leads to an increase in the level of circulating androgens. This causes the effect of masculinization of the fetus, in particular the female fetus. Although this effect tends to reverse after delivery, it remains unclear how intrauterine exposure to high levels of androgens may influence neurodevelopment in women in the future, especially given all the diverse influences that these hormones have on neurogenesis.

Structural and physiological disorders

Structural disorders of the brain can affect sexual development or the cyclic nature of the secretion of female sex hormones. If the damage occurs before puberty, it is more likely to be disrupted. Otherwise, damage can change the nature of hormonal secretion, causing the development of conditions such as PCOS, hypothalamic hypogonadism, premature menopause.

Damage leading to menstrual irregularities can be localized in the pituitary gland (intrasellar localization) or hypothalamus (suprasellar). Extrasellar localization of damage is also possible, for example, an increase in intracranial pressure and its effect on both the hypothalamus and the pituitary gland.

Intrasellar damage can be localized in cells that produce adenohypophysis hormones. These hormones (such as growth hormone) may directly affect gonadotropin function, or the size of the lesions may cause a decrease in gonadotrophs. In these cases, the levels of gonadotropins decrease, but the GnRH level remains normal. With suprasellar lesions, the production of hypothalamic releasing factors and a secondary decrease in gonadotropin levels are reduced. Apart from endocrine disorders, suprasellar pathology more often than intrasellar causes neurological symptoms: disturbances in appetite, rhythms of sleep and wakefulness, mood, vision and memory.

Partial epilepsy

Epilepsy is quite common in adults, especially with the localization of the focus in temporal lobe bark. Women experience a peak incidence of epilepsy around the time of menopause. On fig. Figures 4-2 show three different patterns of epilepsy according to the phases of the menstrual cycle. The two most easily recognizable patterns? this is an exacerbation of seizures in the middle of the cycle, during normal ovulation (first) and immediately before and after menstruation (second). The third pattern is observed in women with anovulatory cycles, they develop attacks during the entire "cycle", the duration of which can vary significantly. As noted earlier, estradiol has a proconvulsant effect, but progesterone? anticonvulsant. The main factor determining the pattern of seizures is the ratio of concentrations of estradiol and progesterone. With anovulation, there is a relative predominance of estradiol.

For its part, the presence of focal, with a focus in the temporal lobe of the cerebral cortex, epilepsy, can affect the normal menstrual cycle. Almond nucleus? the structure related to the temporal lobe is in a reciprocal relationship with the hypothalamic structures that affect the secretion of gonadotropins. In our study of 50 women with clinical and electroencephalographic signs of an epileptic focus in the temporal lobe, 19 had significant disorders of the reproductive system. 10 out of 19 had PCOS, 6? hypergonadotropic hypogonadism, in 2? premature menopause, 1? hyperprolactinemia. In humans, there is an advantage of the right temporal lobe over the left in the influence of epileptic foci on the production of gonadotropins. Women with left-sided lesions had more LH peaks during the 8-hour follow-up period compared to controls. All of these women had PCOS. In women with hypergonadotropic hypogonadism, there was a significant decrease in LH peaks during the 8-hour follow-up period compared to controls, and the focus of epilepsy was more often observed in the right temporal lobe (Fig. 4-3).

Menopause can influence the course of epilepsy. In obese women, due to aromatase activity in adipose tissue, adrenal androgens are converted to estradiol. Therefore, obese women may not experience the classic menopausal symptoms of estrogen deficiency. Due to ovarian hypofunction, progesterone deficiency occurs, which leads to a predominance of estrogen levels over progesterone. The same situation can develop in women with normal weight while taking HRT. In both cases, there is an increase in convulsive activity due to the uncompensated influence of estrogens. With an increase in the frequency of seizures, combined estrogen-progestin HRT should be prescribed continuously.

Pregnancy can have a significant impact on seizure activity through the production of endogenous hormones and their effect on the metabolism of anticonvulsants.


___________________________

When observing signs of mental illness, one should pay attention to the appearance of the patient: how he is dressed, whether the style of clothing corresponds to age, gender, season, whether he takes care of his appearance, hairstyle.

If this is a woman - whether she uses cosmetics, jewelry and how she uses it - excessively or in moderation, discreetly or loudly, pretentiously. A facial expression can tell a lot - mournful, angry, enthusiastic, wary, and the expression of the eyes - dull, dull, "glowing", joyful, "sparkling". Each emotion, each state of mind has its own external expression with numerous shades and transitions, you just need to be able to discern them. It is necessary to pay attention to the posture and gait of the patient, the manner of behavior, the position in which he stands, sits and lies.

Attention should also be paid to how the mentally ill person reacts to contact with: benevolently, obsequiously, dismissively, arrogantly, aggressively, negatively. He bursts into the room, without invitation, sits down on a chair, lounging, throwing his legs over, sets the conditions for the doctor on which he agrees to be treated, or, entering the office, modestly shifts from foot to foot. Seeing the doctor, jumps out of bed and runs down the corridor to greet him, or turns to the wall during the round. Answers the doctor's questions in detail, trying not to miss the smallest detail, or answers in monosyllables, reluctantly.

There are several methods of observation. Observation in the course of a conversation with a mentally ill person. It allows you to note the features of the patient's response to the doctor's questions, his reaction to the disease, to the fact of hospitalization. Observation in an artificially created situation, for example, in a situation of “free choice of actions”, when the doctor, sitting in front of the patient, does not ask him anything, giving the patient the opportunity to ask questions, make complaints, express his thoughts, move freely around the office. Observation in a natural situation where the patient does not know that he is being observed. This type of observation is used in a psychiatric hospital, and not only a doctor, but also nurses, orderlies must own it. It is acceptable when visiting a patient at home, in the workshop of medical and labor workshops.

By observing the state of the patient and the signs of his mental illness, one can, for example, distinguish an epileptic seizure from a hysterical one, pathological intoxication from a simple one. It should be noted that in child psychiatry observation is sometimes the only method of identifying mental pathology, because in a child, due to the rudimentary nature of mental disorders, their lack of awareness and verbalization, questioning does not always lead to obtaining the necessary information.

Observing a mental patient for a certain time, paying attention, say, to the severity of catatonic symptoms, signs of delirium, a mask of depression, the doctor can assume the nature of the dynamics of the disease state and evaluate the effectiveness of the therapy.

If a mentally ill person with a severe chronic illness, previously untidy, comes to an appointment in clean and neat clothes, then one can think that the process of social adaptation in this case is going well.

Emphasizing the importance of the method of observation for the diagnosis of mental illness, we will give brief signs of mental illness as examples.

hallucinations

The behavior of a mentally ill patient during hallucinations depends on the nature of hallucinatory experiences: visual, auditory, olfactory, gustatory, tactile, true, false, as well as on the severity of their manifestation. With visual hallucinations, it seems that the patient is peering into something. He can point to the location of hallucinatory images, discuss with those present the details of visual deceptions, and comment on them. The presence of visual hallucinations may be indicated by the patient's attentive, intent gaze in a certain direction, where there are no real objects, as well as his lively facial expressions, permeated with surprise, curiosity. If the hallucinations are pleasant to the patient, facial expressions of pleasure are visible on his face, if they are frightening in nature - the facial expressions of horror, fear.

If a mentally ill person has auditory hallucinations, then he listens, puts his hand to his ear in order to hear better, asks those around him to speak more quietly, or, on the contrary, plugs his ears, covers his head with a blanket. He can mumble something, out of touch with the situation, utter phrases that have the character of questions, answers. He can, "hearing" the call, go to open the door or pick up the phone.

With olfactory hallucinations, the patient feels non-existent smells, plugs his nose or sniffs, makes a scandal with his neighbors, believing that they let gases into his room, or, in order to get rid of smells, exchanges an apartment.

A patient with taste hallucinations, feeling a persistent, unpleasant taste in his mouth, often spits, rinses his mouth with water, interpreting them as manifestations of a disease of the gastrointestinal tract, often turns to a therapist for help. With olfactory and gustatory hallucinations, refusal to eat is characteristic.

Skin scratching may indicate tactile hallucinations.

With true hallucinations, the mentally ill person is emotional, his behavior is largely determined by hallucinatory experiences, and he often discusses their content with others. With pseudohallucinations, the patient's behavior is more monotonous, monotonous, the facial expression is hypomimic, detached, thoughtful, the patient seems to be immersed in himself, in his thoughts, reluctantly talks about his experiences.

In acute hallucinosis, the patient is uncritical of hallucinatory experiences and, without hesitation, follows the orders of the "voices". In chronic hallucinosis, a critical attitude may appear and with it the ability to control one's actions. For example, a patient, feeling a deterioration in his condition, himself comes to an appointment.

Rave

The appearance and behavior of a mentally ill person with delusional experiences is determined by the plot of the delusion. A patient with delusions of jealousy behaves suspiciously in relation to the object of jealousy, watches him, clocks the time of his departure and arrival from home, arranges checks, interrogations.

A patient with delusions of invention tries to introduce his inventions, writes letters to various authorities, on which the recognition of his ideas depends, abandons his main work, does not allow the thought that his inventions are absurd or plagiarism.

The delirium of persecution makes the patient wary, suspicious. The patient hides from his "pursuers", hides, sometimes, defending himself, attacks.

Patients with hypochondriacal delusions are often encountered in the practice of internists. They persistently seek medical and surgical interventions in connection with the existing, in their opinion, incurable disease. Patients with dysmorphomania syndrome are found in the practice of dentists and, demanding to correct one or another imaginary defect in the face or eliminate the disease that is supposedly the cause of halitosis.

Manic state

Manic excitement is characterized by a desire for activity. The patient is constantly busy with something. He takes part in cleaning the premises, recites poetry, sings songs, organizes "amateur arts", helps the orderlies feed the weakened patient. His energy is inexhaustible, his mood is upbeat, joyful. He interferes in all matters, takes on any work, but does not complete it, switching to new activities.

Depression

With depression, the face and eyes acquire a characteristic expression of sadness, grief. A deep fold cuts through the forehead (Melancholic Delta), the corners of the mouth are lowered, the pupils are dilated. Head down. The patient usually sits on the edge of a chair or bed in a bent position.

Catatonic excitation

Catatonic excitation can have the character of a confused-pathetic excitation with pretentiousness, mannerisms, negativism (meaningless counteraction: they give him food - he turns away; when he tries to take away food - it is enough). The movements of the patient do not constitute a complete meaningful action, but acquire the character of motor automatisms, stereotypes, become impulsive, incomprehensible to others. Often there is unmotivated laughter, echolalia, echopraxia, jactation, aimless running in a circle (manage run), monotonous jumps.

hebephrenic arousal

Hebephrenic excitement is manifested by such signs: pronounced motor restlessness with elements of euphoria and foolishness, rude clowning. Patients take unusual poses, senselessly grimacing, grimacing, mimicking others, somersaulting, naked, sometimes their movements resemble the movements of animals. At the height of impulsive excitement, they can show senseless rage: they scatter food, violently resist an attempt to feed them, give medicine.

catatonic stupor

Signs of a catatonic stupor - the mentally ill becomes silent (mutism), immobilized. It increases muscle tone. You can find such manifestations of catatonic stupor as symptoms of a cogwheel, proboscis, wax flexibility, embryo, air cushion. Skin become greasy.

The article was prepared and edited by: surgeon
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