Mental disorders in somatic pathology. Somatic disorders and violations of physiological functions as a manifestation of mental pathology

Changes in the psyche in somatic diseases can be diverse. They are considered, as a rule, in two directions: 1) the general features of changes and mental disorders in diseases of the internal organs, 2) the clinic of mental disorders in the most common forms of illness.

With a psychogenic cause, it turns out to be such, as a rule, in sensitive individuals, when the objective significance of the underlying internal illness for the psyche is not significant, and the changes in the psyche are more due to the massive fears of the patient or the strength of the psychological conflict between his motives, needs and the alleged decrease due to his illness. opportunities.

This reason is because for a sick person, his desires, expectations often turn out to be subjectively more significant than the achievement of the goal itself. Maybe this also applies to persons with a so-called anxious and suspicious nature.

Clinical variants of changes in the psyche in somatic diseases are often systematized in this way: massive mental disorders, acting mainly at the height of diseases accompanied by fever, which often acquire the qualities of psychosis - somatogenic, infectious. And the most common and typical form of such disorders is delirium.

- acute fear, disorientation in the environment, accompanied by visual illusions and hallucinations.

Borderline forms of neuropsychiatric disorders, which are the most common clinical picture of mental disorders in diseases of the internal organs:

1. In cases of predominantly somatic origin - neurosis-like.

2. The predominance of the psychogenic nature of their occurrence - neurotic disorders.

Neurotic disorders are such neuropsychiatric disorders, in the occurrence of which the leading role belongs to mental trauma or internal mental conflicts.

Basically, they occur on a somatically weakened, altered background, primarily in premorbidly located to psychogenies persons. Their clinical structure is characterized by sharpness, severity of painful experiences, brightness, imagery; painfully heightened imagination; increased fixation on the interpretation of altered well-being, internal discomfort, disorder, as well as preoccupation with anxiety for one's future. At the same time, the preservation of criticism remains, that is, the understanding of these disorders as painful. Neurotic disorders, as a rule, have a temporary connection with a previous trauma or conflict, and the content of painful experiences is often associated with the content of a traumatic circumstance. They are also often characterized by a reverse development and relaxation as the time of the psychic trauma and its de-actualization are removed.

Of great importance for a sick person is his idea of ​​the disease, based on the most diverse information.

It must be remembered that the psyche of the patient from the onset of the disease is in an unusual state. All our knowledge, our behavior in the process of medical activity, moreover, the treatment itself will be unsatisfactory if it is not based on a holistic understanding of the human body, taking into account the complexity of its physical and mental manifestations.

Such an approach to the patient's condition based on a holistic understanding of his body always takes into account the complex relationships that exist between a person's mental state and his illness.

Mental stress, conflict situations can affect the somatic state of the patient and cause so-called psychosomatic diseases. Somatic disease, in turn, affects the mental state of a person, his mood, perception of the world around him, behavior and plans.

With somatic diseases, depending on the severity, duration and nature of the disease, mental disorders can be observed, which are expressed by various syndromes.

Medical psychology, on the basis of mental disorders, studies the forms of behavior of a somatic patient, the features of contacts with others, ways of influencing the psyche for better implementation of therapeutic measures.

Note that in somatic diseases, changes in mental activity are most often expressed by neurotic symptoms. With a high severity of intoxication and the severity of the development of the disease, somatogenic psychoses are possible, accompanied by states of altered consciousness. Sometimes such somatic diseases as hypertension, atherosclerosis, diabetes mellitus, etc. lead to psychoorganic disorders.

A prolonged somatic illness, the need to stay in a hospital for months and years can sometimes lead to personality changes in the form of pathological development, in which character traits arise that were not previously characteristic of this person. Changes in the nature of these patients may prevent or complicate treatment, lead them to disability. In addition, it can create conflicts in medical institutions, cause a negative attitude of others towards these patients. Depending on the characteristics of mental disorders in somatic diseases, a conversation between a doctor and patients, the behavior of medical personnel and the entire tactics of medical measures are built.

Illness Consciousness

It should be noted that it is no coincidence that in the literature there are terms about "consciousness of the disease", about its "external" and "internal" pictures. Consciousness of the disease or the internal picture of the disease– the most common concepts. E. K. Krasnushkin used in these cases the terms “consciousness of the disease”, “representation of the disease”, and E. A. Shevalev - “experience of the disease”. For example, the German internist Goldscheider wrote about the “autoplastic picture of the disease”, highlighting two interacting sides inside it: sensitive (sensual) and intellectual (rational, interpretive). And Schilder wrote about the "position" in relation to the disease.

Internal picture of the disease– a holistic image of his disease arising in the patient, a reflection in the psyche of the patient of his illness.

The concept of "internal picture of the disease" was introduced by R. A. Luria, who continued the development of A. Goldsheider's ideas about the "autoplastic picture of the disease", and is currently widely used in medical psychology.

Compared to a number of similar medical psychology terms such as “experience of the disease”, “consciousness of the disease”, “attitude towards the disease”, the concept of the internal picture of the disease is the most general and integrative.

In the structure of the internal picture of the disease, sensitive and intelligent level. Sensitive level includes a set of painful sensations and the emotional states of the patient associated with them, the second - knowledge of the disease and its rational assessment. The sensitive level of the internal picture of the disease is the totality of all (interoceptive and exteroceptive) sensations caused by the disease. Intellectual level the internal picture of the disease is associated with the patient's reflections on all issues related to the disease, and thus represents the individual's response to new living conditions.

The most common methods for studying the internal picture of the disease are a clinical conversation and special questionnaires. It should be noted that many complaints presented to patients are in clear contradiction with the insignificance, and sometimes the absence of objective disorders in the internal organs. In such cases, the patient's painful reassessment of his condition reveals hypernosognosia in their minds of illness. Hypernosognosia– "flight into illness", "departure into illness". BUT anosognosia- escape from illness. The mental factor in the course of a somatic illness can also be traced in cases where the disease, for example, arising against the background of affective stress, has an organic basis in the form of previous changes in an organ or system. An example of such diseases can be, for example, myocardial infarction following an affective experience in a person suffering from atherosclerosis.

There are certain reasons to believe that the occurrence and course of even infectious diseases, such as pulmonary tuberculosis, cancer, is also associated with a mental factor. And the onset of these diseases is often preceded by long-term traumatic experiences. The dynamics of the tuberculous process characterizes this relationship - exacerbations often occur under the influence of unfortunate life circumstances, disappointments, shocks, losses.

There are interesting data from a number of domestic authors. So, for example, I. E. Ganelina and Ya. M. Kraevsky, having studied premorbid features of higher nervous activity and personality of patients with coronary insufficiency, found the existing similarity. More often they were strong-willed, purposeful, hard-working people with a high level of motivation, as well as a tendency to long-term internal experience of negative emotions. V. N. Myasishchev considers a “socially disharmonic” type of personality, which is found in 60% of patients, to be characteristic of cardiovascular patients. Such a person is self-oriented, with a concentration of attention and interests on a few, subjectively significant aspects. Such persons, as a rule, are dissatisfied with their position, quarrelsome, especially in relations with the administration, highly touchy, proud.

The influence of somatic illness on the psyche in our country was most thoroughly studied by L. L. Rokhlin, who, like E. K. Krasnushkin, uses the term consciousness of illness.

It includes three links in it: 1) the reflection of the disease in the psyche, the gnosis of the disease, its knowledge; 2) changes in the patient's psyche caused by the disease; and 3) the patient's attitude to his own disease or the reaction of the individual to the disease.

The first link is the gnosis of the disease. It is based on the flow of interoceptive and exteroceptive sensations generated by the disease and causing corresponding emotional experiences. At the same time, these sensations are compared with the existing ideas about the disease.

For example, using a mirror, a person tries to determine whether he is sick or healthy. In addition, he also carefully monitors the regularity of his natural functions, their appearance, notes the rash that has appeared on the body, and also listens to various sensations in the internal organs. At the same time, a person notes all the various nuances and changes in his usual sensations and body. However, the opposite is also possible here. That is, asymptomatic, in relation to the mental sphere, somatic diseases, when lesions of internal organs (tuberculosis, heart defects, tumors) are discovered by chance when examining patients who are unaware of their illness. After the discovery of the disease and the awareness of patients about it, people, as a rule, have subjective sensations of the disease that were absent before. Rokhlin connects this fact with the fact that attention paid to the diseased organ lowers the threshold of interoceptive sensations, and they begin to reach consciousness. The absence of consciousness of the disease in the period preceding its discovery, the author explains by the fact that interoception in these cases, apparently, is inhibited by more powerful and actual stimuli from the outside world.

Based on the existence of these two types of patient perception of their disease, L. L. Rokhlin proposes to distinguish: a) asymptomatic, anosognosic, hyponosognosic and b) hypersensitivity variants of the disease consciousness. Hypersensitivity presents certain difficulties for diagnosis, since the art of a doctor requires the ability to highlight the true symptoms of organ damage, embellished by the subjective experience of the patient. The second link in the consciousness of the disease, according to L. L. Rokhlin, are those changes in the psyche that are caused by somatic illness. The author divides these changes into two groups: 1) general changes (asthenization, dysphoria), characteristic of almost all patients with most diseases, 2) special changes, depending, in particular, on which system is affected. For example: fear of death in patients with angina pectoris and myocardial infarction, depression in patients suffering from stomach diseases, increased excitability and irritability in liver diseases caused by an abundance of miteroceptive information entering the brain from the affected organ.

L. L. Rokhlin considers other determinants of changes in the emotional mood of patients: 1) the nature of the disease, for example: agitation and a decrease in sensitivity thresholds in febrile conditions and severe pain syndromes, a drop in mental tone in shock conditions, passivity of patients with typhoid fever, arousal in typhus etc.; 2) the stage of the disease; 3) the third link of "consciousness of the disease" is the reaction of the individual to his disease.

"Consciousness of the disease", "internal picture" covers the entire spectrum of experiences of a sick person associated with his illness.

This should include: a) ideas about the significance for the patient of the first, early manifestations of the disease; b) features of changes in well-being due to the complication of disorders; c) experiences of the state and its probable consequences at the height of the disease; d) an idea of ​​the beginning improvement in well-being at the stage of the reverse development of the disease and the restoration of health after the cessation of the disease; e) an idea of ​​the possible consequences of the disease for oneself, for the family, for activity; an idea of ​​the attitude towards him during the period of illness of family members, employees at work, medical workers.

There are no such aspects of the life of the patient, which would not be reflected in his consciousness modified by the disease.

Disease– it is life under changed conditions.

Features of the consciousness of the disease can be divided into two groups:

1. The usual forms of consciousness of the disease are only features of the psychology of a sick person.

2. States of consciousness of the disease, accompanied by abnormal reactions to it, going beyond the typical reactions for a given person.

It should be noted that in many cases the discrepancy arising in the course of the disease between the remaining or even growing needs of a person and the declining capabilities of a person affects. This kind of conflict, especially in cases of protracted and disabling illnesses, can acquire a complex content in connection with the imposition of contradictions between a person's desire for a speedy recovery and his diminishing opportunities. They can be generated by the consequences of the disease, in particular, a change in his professional and social opportunities.

Mental disorders in somatic diseases

Progress in the treatment of somatic diseases and somatogenic psychoses has led to a decrease in the occurrence of pronounced acute psychotic forms and an increase in protracted sluggish forms. The noted changes in the clinical features of diseases (pathomorphosis) were also manifested in the fact that the number of cases of mental disorders in somatic diseases decreased by 2.5 times, and in forensic psychiatric practice, cases of examination of a mental state in somatic diseases do not occur often. At the same time, there was a change in the quantitative ratio of the forms of the course of these diseases. The proportion of individual somatogenic psychoses (for example, amnestic states) and mental disorders that do not reach the degree of psychosis has decreased.

The stereotype of the development of psychopathological symptoms in somatogenic psychoses is characterized by an onset with asthenic disorders, and then by the replacement of symptoms with psychotic manifestations and endoform "transitional" syndromes. The outcome of psychosis is the recovery or development of a psychoorganic syndrome.

Somatic diseases, in which mental disorders are most often observed, include diseases of the heart, liver, kidneys, pneumonia, peptic ulcer, less often - pernicious anemia, alimentary dystrophy, beriberi, as well as postoperative and postpartum psychoses.

In chronic somatic diseases, signs of personality pathology are found, in the acute and subacute period, mental changes are limited to manifestations of the personality's reaction with its inherent characteristics.

One of the main psychopathological symptom complexes observed in various somatic diseases is asthenic syndrome. This syndrome is characterized by severe weakness, fatigue, irritability and the presence of severe autonomic disorders. In some cases, phobic, hypochondriacal, apathetic, hysterical and other disorders join the asthenic syndrome. Sometimes the pho-oic syndrome comes to the fore. Fear inherent in a sick person,

240 Section III. Separate forms of mental illness

The leading syndrome in somatogenic psychoses is stupefaction (often delirious, amental and less often twilight type). These psychoses develop suddenly, acutely, without precursors against the background of previous asthenic, neurosis-like, affective disorders. Acute psychoses usually last 2-3 days, are replaced by an asthenic condition. With an unfavorable course of a somatic disease, they can take a protracted course with a clinical picture of depressive, hallucinatory-paranoid syndromes, apathetic stupor.

Depressive, depressive-paranoid syndromes, sometimes in combination with hallucinatory (usually tactile hallucinations), are observed in severe lung diseases, cancerous lesions and other diseases of internal organs that have a chronic course and lead to exhaustion.

After suffering somatogenic psychoses, a psychoorganic syndrome may form. However, the manifestations of this symptom complex are smoothed over time. The clinical picture of the psychoorganic syndrome is expressed by intellectual disorders of various intensity, a decrease in a critical attitude to one's condition, and affective lability. With a pronounced degree of this state, there is spontaneousness, indifference to one's own personality and the environment, significant mnestic-intellectual disorders.

Among patients with heart pathology, the most common mental disorders occur in patients with myocardial infarction.

Mental disorders in general are one of the most common manifestations in patients with myocardial infarction, aggravating the course of the disease (I. P. Lapin, N. A. Akalova, 1997; A. L. Syrkin, 1998; S. Sjtisbury, 1996, etc. .), increasing rates of death and disability (U. Herlitz et al., 1988;

Mental disorders develop in 33-85% of patients with myocardial infarction (L. G. Ursova, 1993; V. P. Zaitsev, 1975; A. B. Smulevich, 1999; Z. A. Doezfler et al., 1994; M. J Razada, 1996). The heterogeneity of the statistical data given by various authors is explained by a wide range of mental disorders, from psychotic to neurosis-like and pathocharacterological disorders.

There are different opinions about the preference for causes that contribute to the occurrence of mental disorders in myocardial infarction. The significance of individual conditions is reflected, in particular the characteristics of the clinical course and severity of myocardial infarction (M. A. Tsivilko et al., 1991; N. N. Cassem, T. R. Naskett, 1978, etc.), constitutional-biological and social - environmental factors (V. S. Volkov, N. A. Belyakova, 1990; F. Bonaduidi et al., S. Roose, E. Spatz, 1998), comorbid pathology (I. Shvets, 1996; R. M. Carme et al., 1997), personality traits of the patient, adverse mental and social influences (V. P. Zaitsev, 1975; A. Appels, 1997).

The harbingers of psychosis in myocardial infarction are usually pronounced affective disorders, anxiety, fear of death, motor agitation, autonomic and cerebrovascular disorders. Among other precursors of psychosis, a state of euphoria, sleep disturbances, and hypnogogic hallucinations are described. Violation of the behavior and regimen of these patients dramatically worsens their somatic condition and can even lead to death. Most often, psychosis occurs within the first week after myocardial infarction.

In the acute stage of psychosis in myocardial infarction most often occur with a picture of an upset consciousness, more often in a delirious type: patients experience fears, anxiety, are disoriented in place and time, experience hallucinations (visual and auditory). Patients have motor restlessness, they tend to go somewhere, they are not critical. The duration of this psychosis does not exceed a few days.

Depressive states are also observed: patients are depressed, do not believe in the success of treatment and the possibility of recovery, intellectual and motor retardation, hypochondria, anxiety, fears, especially at night, early awakenings and anxiety are noted.

242 Section III. Separate forms of mental illness

When diagnosing somatogenic psychosis, it becomes necessary to distinguish it from schizophrenia and other endoform psychoses (manic-depressive and involutional). The main diagnostic criteria are: a clear connection between a somatic disease, a characteristic stereotype of the development of the disease with a change in syndromes from asthenic to states of disturbed consciousness, a pronounced asthenic background and a way out of psychosis that is favorable for the individual with an improvement in somatogenic pathology.

Treatment, prevention of mental disorders in somatic diseases. Treatment of mental disorders in somatic diseases should be directed to the underlying disease, be comprehensive and individual. The therapy provides for both the impact on the pathological focus, and detoxification, the normalization of immunobiological processes. It is necessary to provide for strict round-the-clock medical supervision of patients, especially those with acute psychosis. Treatment of patients with mental disorders is based on general syndromic principles - on the use of psychotropic drugs based on the clinical picture. With asthenic and psychoorganic syndromes, a massive general strengthening therapy is prescribed - vitamins and nootropics (piracetam, nootropil).

Prevention of somatogenic mental disorders consists in the timely and active treatment of the underlying disease, detoxification measures and the use of tranquilizers with increasing anxiety and sleep disorders.

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SOMATIC DISORDERS AND DISORDERS OF PHYSIOLOGICAL FUNCTIONS AS A MANIFESTATION OF MENTAL PATHOLOGY

An analysis of the somatic state in patients with mental illness allows us to clearly demonstrate the close relationship between the mental and the somatic. The brain, as the main regulatory organ, determines not only the effectiveness of all physiological processes, but also the degree of psychological well-being (well-being) and self-satisfaction. Disruption of the brain can lead both to a true disorder in the regulation of physiological processes (appetite disorders, dyspepsia, tachycardia, sweating, impotence), and to a false sense of discomfort, dissatisfaction, dissatisfaction with one's physical health (in the actual absence of somatic pathology). Examples of somatic disorders resulting from mental pathology are the panic attacks described in the previous chapter.

The disorders listed in this chapter usually occur secondarily, i.e. are only symptoms of any other disorders (syndromes, diseases). However, they cause such significant anxiety to patients that they require special attention of the doctor, discussion, psychotherapeutic correction and, in many cases, the appointment of special symptomatic agents. Separate rubrics are proposed in the ICD-10 for these disorders.

eating disorders

Eating disorders (In the foreign literature in these cases they speak of “eating disorders.”) can be a manifestation of a wide variety of diseases. A sharp decrease in appetite is characteristic of a depressive syndrome, although overeating is also possible in some cases. Decreased appetite also occurs in many neuroses. With a catatonic syndrome, food refusal is often observed (although when such patients are disinhibited, their pronounced need for food is detected). But in some cases, eating disorders become the most important manifestation of the disease. In this regard, for example, anorexia nervosa syndrome and bulimia attacks are isolated (they can be combined in the same patient).

Anorexia nervosa syndrome (anorexia nervosa) develops more often in girls in puberty and adolescence and is expressed in a conscious refusal to eat in order to lose weight. Patients are characterized by dissatisfaction with their appearance (dysmorphomania - dysmorphophobia), about a third of them had a slight excess of weight before the onset of the disease. Dissatisfaction with imaginary obesity patients carefully hide, do not discuss it with any of the outsiders. Weight loss is achieved by limiting the amount of food, excluding high-calorie and fatty foods from the diet, a complex of heavy physical exercises, taking large doses of laxatives and diuretics. Periods of severe food restriction are interspersed with bouts of bulimia, when a strong feeling of hunger does not go away even after eating a large amount of food. In this case, patients artificially induce vomiting.

A sharp decrease in body weight, disturbances in electrolyte metabolism and a lack of vitamins lead to serious somatic complications - amenorrhea, pallor and dryness of the skin, chilliness, brittle nails, hair loss, tooth decay, intestinal atony, bradycardia, lowering blood pressure, etc. The presence of all of these symptoms indicates the formation of the cachexic stage of the process, accompanied by adynamia, disability. If this syndrome occurs during puberty, there may be a delay in puberty.

Bulimia is the uncontrolled and rapid absorption of large amounts of food. It can be combined with both anorexia nervosa and obesity. Women are more often affected. Each bulimic episode is accompanied by feelings of guilt, self-hatred. The patient seeks to empty the stomach, causing vomiting, taking laxatives and diuretics.

Anorexia nervosa and bulimia in some cases are the initial manifestation of a progressive mental illness (schizophrenia). In this case, autism, violation of contacts with close relatives, pretentious (sometimes delusional) interpretation of the goals of fasting come to the fore. Another common cause of anorexia nervosa is psychopathic traits. Such patients are characterized by sthenicity, stubbornness and perseverance. They persistently strive to achieve the ideal in everything (usually study hard).

Treatment of patients with eating disorders should be based on the underlying diagnosis, but several general guidelines should be considered that are useful in any type of eating disorder.

Inpatient treatment in such cases is often more effective than outpatient treatment, because at home it is not possible to control food intake well enough. It should be borne in mind that replenishment of dietary defects, normalization of body weight by organizing fractional nutrition and improving the activity of the gastrointestinal tract, restorative therapy is a prerequisite for the success of further therapy. Antipsychotics are used to suppress an overvalued attitude to food intake. Psychotropic drugs are also used to regulate appetite. Many antipsychotics (frenolone, etaperazine, chlorpromazine) and other histamine receptor blockers (pipolphen, cyproheptadine), as well as tricyclic antidepressants (amitriptyline) increase appetite and cause weight gain. To reduce appetite, psychostimulants (fepranone) and antidepressants from the group of serotonin reuptake inhibitors (fluoxetine, sertraline) are used. Properly organized psychotherapy is of great importance for recovery.

Sleep disturbance is one of the most frequent complaints in a variety of mental and somatic diseases. In many cases, the subjective sensations of patients are not accompanied by any changes in physiological parameters. In this regard, some basic characteristics of sleep should be given.

Normal sleep has varying durations and consists of a series of cyclic fluctuations in the level of wakefulness. The greatest decrease in CNS activity is observed in the non-REM sleep phase. Awakening during this period is associated with amnesia, sleepwalking, enuresis, and nightmares. REM sleep occurs for the first time approximately 90 minutes after falling asleep and is accompanied by rapid eye movements, a sharp drop in muscle tone, increased blood pressure, and penis erection. The EEG in this period differs little from the state of wakefulness; upon awakening, people talk about the presence of dreams. In a newborn, REM sleep accounts for about 50% of the total sleep duration; in adults, slow-wave and REM sleep each occupy 25% of the total sleep period.

Insomnia is one of the most frequent complaints among somatic and mental patients. Insomnia is associated not so much with a decrease in the duration of sleep, but with a deterioration in its quality, a feeling of dissatisfaction.

This symptom manifests itself differently depending on the cause of insomnia. Thus, sleep disorders in patients with neurosis are primarily associated with a severe psychotraumatic situation. Patients can, lying in bed, think for a long time about the facts that disturb them, look for a way out of the conflict. The main problem in this case is the process of falling asleep. Often a traumatic situation is played again in nightmares. With asthenic syndrome, characteristic of neurasthenia and vascular diseases of the brain (atherosclerosis), when irritability and hyperesthesia take place, patients are especially sensitive to any extraneous sounds: the ticking of an alarm clock, the sounds of dripping water, the noise of transport - everything does not let them fall asleep. At night they sleep lightly, often wake up, and in the morning they feel completely overwhelmed and unrested. People suffering from depression are characterized not only by difficulty falling asleep, but also by early awakening, as well as the lack of a sense of sleep. In the morning, such patients lie with their eyes open. The approach of a new day gives rise to the most painful feelings and thoughts of suicide in them. Patients with manic syndrome never complain of sleep disorders, although their total duration may be 2-3 hours. Insomnia is one of the early symptoms of any acute psychosis (acute attack of schizophrenia, delirium tremens, etc.). Usually, the lack of sleep in psychotic patients is combined with extremely pronounced anxiety, a feeling of confusion, unsystematized delusions, and separate delusions of perception (illusions, hypnagogic hallucinations, nightmares). A common cause of insomnia is a state of withdrawal due to the abuse of psychotropic drugs or alcohol. The state of abstinence is often accompanied by somatovegetative disorders (tachycardia, fluctuations in blood pressure, hyperhidrosis, tremor) and a pronounced desire to re-take alcohol and drugs. Snoring and its accompanying sleep apnea are also causes of insomnia.

The variety of causes of insomnia requires careful differential diagnosis. In many cases, individually tailored hypnotics are required (see section 15.1.8), but it should be borne in mind that psychotherapy is often more effective and safer in this case. For example, behavioral psychotherapy involves adherence to a strict regime (waking up always at the same time, the ritual of preparing for sleep, the regular use of non-specific means - a warm bath, a glass of warm milk, a spoonful of honey, etc.). Quite painful for many older people is the natural decrease in the need for sleep associated with age. They need to explain that taking sleeping pills in this case is meaningless. Patients should be advised not to go to bed before drowsiness sets in, not to lie in bed for a long time, trying to fall asleep by force of will. It is better to get up, occupy yourself with quiet reading or complete small household chores and go to bed later when the need arises.

Hypersomnia may accompany insomnia. So, for patients who do not get enough sleep at night, drowsiness in the daytime is characteristic. When hypersomnia occurs, it is necessary to carry out differential diagnostics with organic diseases of the brain (meningitis, tumors, endocrine pathology), narcolepsy and Klein-Levin syndrome.

Narcolepsy is a relatively rare pathology of a hereditary nature, not associated with either epilepsy or psychogenic disorders. Characteristic is the frequent and rapid onset of REM sleep (already 10 minutes after falling asleep), which is clinically manifested by attacks of a sharp drop in muscle tone (cataplexy), vivid hypnagogic hallucinations, episodes of turning off consciousness with automatic behavior or states of "wakeful paralysis" in the morning after waking up. The disease occurs before the age of 30 and then progresses little. In some patients, the cure was achieved by forced sleep during the daytime, always at the same hour, in other cases, stimulants and antidepressants are used.

Klein-Levin syndrome is an extremely rare disorder in which hypersomnia is accompanied by episodes of constriction of consciousness. Patients retire, looking for a quiet place to sleep. The sleep is very long, but the patient can be awoken, although this is often associated with irritation, depression, disorientation, incoherent speech, and amnesia. The disorder occurs in adolescence, and after 40 years, spontaneous remission is often observed.

Unpleasant sensations in the body are a frequent manifestation of mental disorders, but they do not always take on the character of pain itself. Extremely unpleasant artsy subjectively colored sensations - senestopathies (see section 4.1) should be distinguished from pain sensations. Psychogenic pain can occur in the head, heart, joints, back. The point of view is expressed that in case of psychogenies, the part of the body that, according to the patient, is the most important, vital, receptacle of the personality, is most disturbing.

Heart pain is a common symptom of depression. Often they are expressed by a heavy feeling of tightness in the chest, "a stone on the heart." Such pains are very persistent, worse in the morning, accompanied by a feeling of hopelessness. Unpleasant sensations in the region of the heart often accompany anxiety episodes (panic attacks) in those suffering from neuroses. These acute pains are always combined with severe anxiety, fear of death. Unlike an acute heart attack, they are well stopped by sedatives and validol, but do not decrease from taking nitroglycerin.

Headache may indicate the presence of an organic disease of the brain, but often occurs psychogenic.

Psychogenic headache is sometimes the result of tension in the muscles of the aponeurotic helmet and neck (with severe anxiety), a general state of depression (with subdepression) or self-hypnosis (with hysteria). Anxious, suspicious, pedantic personalities often complain of bilateral pulling and pressing pains in the occiput and crown of the head radiating to the shoulders, aggravated in the evening, especially after a traumatic situation. The scalp often becomes painful as well (“it hurts to comb your hair”). In this case, drugs that reduce muscle tone (benzodiazepine tranquilizers, massage, warming procedures) help. Quiet rest (watching TV) or pleasant physical exercises distract patients and reduce suffering. Headaches are often observed with mild depression and, as a rule, disappear when the condition worsens. Such pains increase in the morning in parallel with the general increase in melancholy. In hysteria, pain can take the most unexpected forms: “drilling and squeezing”, “pulls the head with a hoop”, “skull splits in half”, “pierces the temples”.

Organic causes of headache are vascular diseases of the brain, increased intracranial pressure, facial neuralgia, cervical osteochondrosis. In vascular diseases, painful sensations, as a rule, have a pulsating character, depend on an increase or decrease in blood pressure, are relieved by clamping the carotid arteries, and are enhanced by the introduction of vasodilators (histamine, nitroglycerin). Attacks of vascular origin can be the result of a hypertensive crisis, alcohol withdrawal syndrome, fever. Headache is an important symptom for diagnosing volumetric processes in the brain. It is associated with an increase in intracranial pressure, increases in the morning, increases with head movements, is accompanied by vomiting without previous nausea. An increase in intracranial pressure is accompanied by symptoms such as bradycardia, a decrease in the level of consciousness (stunning, obnubilation) and a characteristic picture in the fundus (congestive optic discs). Neuralgic pains are more often localized in the face, which almost never occurs in psychogenies.

Migraine attacks have a very characteristic clinical picture. These are intermittent episodes of extremely severe headache lasting several hours, usually affecting half of the head. The attack may be preceded by an aura in the form of distinct mental disorders (lethargy or agitation, hearing loss or auditory hallucinations, scotomas or visual hallucinations, aphasia, dizziness or an unpleasant smell). Shortly before the resolution of the attack, vomiting is often observed.

With schizophrenia, true headaches are very rare. Much more often, extremely fanciful senestopathic sensations are observed: “the brain melts”, “the convolutions shrink”, “the bones of the skull breathe”.

Disorders of sexual functions

The concept of sexual dysfunction is not entirely clear, as studies show that the manifestations of normal sexuality vary considerably. The most important criterion for diagnosis is the subjective feeling of dissatisfaction, depression, anxiety, guilt that arises in an individual in connection with sexual intercourse. Sometimes this feeling occurs with quite physiological sexual relations.

There are the following variants of disorders: a decrease and an extreme increase in sexual desire, insufficient sexual arousal (impotence in men, frigidity in women), orgasmic disorders (anorgasmia, premature or delayed ejaculation), pain during sexual intercourse (dyspareunia, vaginismus, postcoital headaches). pain) and some others.

As experience shows, quite often the cause of sexual dysfunction is psychological factors - a personal predisposition to anxiety and anxiety, forced long breaks in sexual relations, the absence of a permanent partner, a feeling of unattractiveness, unconscious hostility, a significant difference in the expected stereotypes of sexual behavior in a couple, upbringing that condemns sexual relations, etc. Often, disorders are associated with fear of the onset of sexual activity or, conversely, after 40 years - with an approaching involution and fear of losing sexual attractiveness.

Much less often, the cause of sexual dysfunction is a severe mental disorder (depression, endocrine and vascular diseases, parkinsonism, epilepsy). Even less often, sexual disorders are caused by general somatic diseases and local pathology of the genital area. Perhaps a disorder of sexual function when prescribing certain drugs (tricyclic antidepressants, irreversible MAO inhibitors, neuroleptics, lithium, antihypertensive drugs - clonidine, etc., diuretics - spironolactone, hypothiazide, antiparkinsonian drugs, cardiac glycosides, anaprilin, indomethacin, clofibrate, etc.) . A fairly common cause of sexual dysfunction is the abuse of psychoactive substances (alcohol, barbiturates, opiates, hashish, cocaine, phenamine, etc.).

Correct diagnosis of the cause of the disorder allows you to develop the most effective treatment tactics. The psychogenic nature of the disorders determines the high effectiveness of psychotherapeutic treatment. The ideal option is to work simultaneously with both partners of 2 cooperating groups of specialists, however, individual psychotherapy also gives a positive result. Drugs and biological methods are used in most cases only as additional factors, for example, tranquilizers and antidepressants - to reduce anxiety and fear, cooling the sacrum with chlorethyl and the use of weak antipsychotics - to delay premature ejaculation, non-specific therapy - in case of severe asthenia (vitamins, nootropics, reflexology, electrosleep, biostimulants such as ginseng).

Hypochondria is called unreasonable concern about one's own health, constant thoughts about an imaginary somatic disorder, possibly a serious incurable disease. Hypochondria is not a nosologically specific symptom and, depending on the severity of the disease, can take the form of obsessive thoughts, overvalued ideas, or delusions.

Obsessive (obsessive) hypochondria is expressed by constant doubts, anxious fears, persistent analysis of the processes occurring in the body. Patients with obsessive hypochondria well accept explanations and soothing words of specialists, sometimes they themselves lament over their suspiciousness, but cannot get rid of painful thoughts without outside help. Obsessive hypochondria is a manifestation of obsessive-phobic neurosis, decompensation in anxious and suspicious individuals (psychasthenics). Sometimes such thoughts are spurred on by a careless statement by a doctor (yat-rogenia) or misinterpreted medical information (advertising, “second-year illness” among medical students).

Overvalued hypochondria is manifested by inadequate attention to minor discomfort or mild physical defect. Patients make incredible efforts to achieve the desired state, develop their own diets and unique training systems. They defend their innocence, seek to punish doctors who, from their point of view, are guilty of illness. Such behavior is a manifestation of paranoid psychopathy or indicates the onset of mental illness (schizophrenia).

Delusional hypochondria is expressed by unshakable confidence in the presence of a serious, incurable disease. Any statement of the doctor in this case is interpreted as an attempt to deceive, to hide the true danger, and the refusal of the operation convinces the patient that the disease has reached the terminal stage. Hypochondriacal thoughts can act as primary delusions without perceptual delusions (paranoid hypochondria) or be accompanied by senestopathies, olfactory hallucinations, sensations of extraneous influences, automatisms (paranoid hypochondria).

Quite often, hypochondriacal thoughts accompany a typical depressive syndrome. In this case, hopelessness and suicidal tendencies are especially pronounced.

In schizophrenia, hypochondriacal thoughts are almost always accompanied by senestopathic sensations - senestopathic-hypochondriac syndrome. Emotional-volitional impoverishment in these patients often makes them, due to the alleged illness, refuse to work, stop going out, and avoid communication.

masked depression

In connection with the widespread use of antidepressant drugs, it became obvious that among patients who turn to therapists, a significant proportion are patients with endogenous depression, in whom hypothymia (sadness) is masked by somatic and vegetative disorders prevailing in the clinical picture. Sometimes other psychopathological phenomena of a non-depressive register - obsessions, alcoholism - act as manifestations of depression. Unlike classical depression, such depression is referred to as masked (larvated, somatized, latent).

Diagnosis of such conditions is difficult, since the patients themselves may not notice or even deny the presence of melancholy. Complaints are dominated by pain (heart, headache, abdominal, pseudoradicular and articular), sleep disorders, chest tightness, fluctuations in blood pressure, appetite disorders (both decrease and increase), constipation, weight loss or increase. Although patients usually answer a direct question about the presence of longing and psychological experiences in the negative, however, with careful questioning, one can reveal an inability to experience joy, a desire to get away from communication, a feeling of hopelessness, dejection that the usual household chores and favorite work began to burden the patient. Quite characteristic is the exacerbation of symptoms in the morning. Often there are characteristic somatic "stigmas" - dry mouth, dilated pupils. An important sign of masked depression is the gap between the abundance of painful sensations and the scarcity of objective data.

It is important to take into account the characteristic dynamics of endogenous depressive attacks, a tendency to a protracted course and unexpected causeless resolution. Interestingly, the addition of an infection with a high body temperature (flu, tonsillitis) may be accompanied by an alleviation of feelings of melancholy or even interrupt an attack of depression. In the history of such patients, periods of unreasonable "spleen" are often found, accompanied by excessive smoking, alcoholism and passing without treatment.

In differential diagnosis, one should not neglect the data of an objective examination, since the simultaneous existence of both somatic and mental disorders is not excluded (in particular, depression is an early manifestation of malignant tumors).

hysterical conversion disorder

Conversion is considered as one of the psychological defense mechanisms (see Section 1.1.4 and Table 1.4). It is assumed that during conversion, internal painful experiences associated with emotional stress are transformed into somatic and neurological symptoms that develop according to the mechanism of self-hypnosis. Conversion is one of the most important manifestations of a wide range of hysterical disorders (hysterical neurosis, hysterical psychopathy, hysterical reactions).

The amazing variety of conversion symptoms, their similarity to the most diverse organic diseases, allowed J. M. Charcot (1825-1893) to call hysteria the "great malingerer". At the same time, hysterical disorders should be clearly distinguished from real simulation, which is always purposeful, completely subject to the control of the will, and can be extended or terminated at the request of the individual. Hysterical symptoms have no specific purpose, cause true inner suffering of the patient and cannot be stopped at his will.

According to the hysterical mechanism, dysfunctions of various body systems are formed. In the last century, neurological symptoms were more common than others: paresis and paralysis, fainting and seizures, sensitivity disorders, astasia-abasia, mutism, blindness and deafness. In our century, the symptoms correspond to diseases that have become widespread in recent years. These are heart, headache and "radicular" pains, a feeling of lack of air, swallowing disorders, weakness in the arms and legs, stuttering, aphonia, a feeling of chills, vague sensations of tingling and crawling.

With all the variety of conversion symptoms, a number of common properties characteristic of any of them can be distinguished. First, it is the psychogenic nature of the symptoms. Not only the occurrence of a disorder is associated with psychotrauma, but its further course depends on the relevance of psychological experiences, the presence of additional traumatic factors. Secondly, one should take into account a strange set of symptoms that does not correspond to the typical picture of a somatic disease. The manifestations of hysterical disorders are as the patient imagines them, therefore, the patient's experience of communicating with somatic patients makes his symptoms more similar to organic ones. Thirdly, it should be borne in mind that conversion symptoms are designed to attract the attention of others, so they never occur when the patient is alone with himself. Patients often try to emphasize the uniqueness of their symptoms. The more attention the doctor pays to the disorder, the more pronounced it becomes. For example, asking a doctor to speak a little louder can cause complete loss of voice. On the contrary, distraction of the patient's attention leads to the disappearance of symptoms. Finally, it should be borne in mind that not all body functions can be controlled through autosuggestion. A number of unconditioned reflexes and objective indicators of the body's work can be used for reliable diagnosis.

Occasionally, conversion symptoms are the reason for repeated appeals of patients to surgeons with a request for serious surgical interventions and traumatic diagnostic procedures. This disorder is known as Munchausen's syndrome. The aimlessness of such a fiction, the painfulness of numerous transferred procedures, the obvious maladaptive nature of behavior distinguish this disorder from simulation.

Asthenic syndrome

One of the most common disorders not only in psychiatric, but also in general somatic practice is asthenic syndrome. Manifestations of asthenia are extremely diverse, but it is always possible to detect such main components of the syndrome as severe exhaustion (fatigue), increased irritability (hyperesthesia) and somatovegetative disorders. It is important to take into account not only the subjective complaints of patients, but also the objective manifestations of the listed disorders. So, exhaustion is clearly visible during a long conversation: with increasing fatigue, it becomes increasingly difficult for the patient to understand each next question, his answers become more and more inaccurate, and finally he refuses to continue the conversation, because he no longer has the strength to maintain a conversation. Increased irritability is manifested by a bright vegetative reaction on the face, a tendency to tears, resentment, sometimes unexpected harshness in the answers, sometimes accompanied by subsequent apologies.

Somatovegetative disorders in asthenic syndrome are nonspecific. These may be complaints of pain (headaches, in the region of the heart, in the joints or abdomen). Often there is increased sweating, a feeling of "tides", dizziness, nausea, severe muscle weakness. Usually there are fluctuations in blood pressure (rise, fall, fainting), tachycardia.

An almost constant manifestation of asthenia is sleep disturbance. In the daytime, patients, as a rule, experience drowsiness, tend to retire and relax. However, at night, they often cannot sleep because any extraneous sounds, the bright light of the moon, folds in the bed, bed springs, etc. interfere with them. In the middle of the night, completely exhausted, they finally fall asleep, but they sleep very sensitively, they are tormented by "nightmares". Therefore, in the morning hours, patients feel that they have not rested at all, they want to sleep.

Asthenic syndrome is the simplest disorder in a number of psychopathological syndromes (see Section 3.5 and Table 3.1), so the signs of asthenia may be included in some more complex syndrome (depressive, psychoorganic). An attempt should always be made to determine whether there is some more gross disorder, so as not to be mistaken in the diagnosis. In particular, in depression, vital signs of melancholy are clearly visible (weight loss, chest tightness, daily mood swings, sharp suppression of desires, dry skin, absence of tears, ideas of self-accusation), with a psychoorganic syndrome, intellectual-mnestic decline and personality changes are noticeable (substantiality, weakness, dysphoria, hypomnesia, etc.). Unlike hysterical somatoform disorders, patients with asthenia do not need society and sympathy, they tend to retire, get irritated and cry when they are disturbed once again.

Asthenic syndrome is the least specific of all mental disorders. It can occur in almost any mental illness, often appears in somatic patients. However, this syndrome is most clearly seen in patients with neurasthenia (see section 21.3.1) and various exogenous diseases - infectious, traumatic, intoxication or vascular lesions of the brain (see section 16.1). With endogenous diseases (schizophrenia, MDP), distinct signs of asthenia are rarely determined. The passivity of patients with schizophrenia is usually explained not by a lack of strength, but by a lack of will. Depression in patients with MDP is usually considered as a strong (stenic) emotion; this corresponds to overvalued and delusional ideas of self-accusation and self-abasement.

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Somatic mental disorders

General and clinical characteristics

Classification of somatogenic mental disorders

a) asthenic, neurosis-like conditions caused by somatic non-communicable diseases (code 300.94), metabolic disorders, growth and nutrition (300.95);

b) non-psychotic depressive disorders due to somatic non-communicable diseases (311.4), metabolic, growth and nutrition disorders (311.5), other and unspecified organic diseases of the brain (311.89 and 311.9);

c) neurosis- and psychopath-like disorders due to somatogenic organic lesions of the brain (310.88 and 310.89).

2. Psychotic states that have developed as a result of functional or organic damage to the brain:

a) acute psychoses (298.9 and 293.08) - asthenic confusion, delirious, amentiviy and other syndromes of clouding of consciousness;

b) subacute protracted psychoses (298.9 and 293.18) - paranoid, depressive-paranoid, anxiety-paranoid, hallucinatory-paranoid, catatonic and other syndromes;

c) chronic psychosis (294) - Korsakov's syndrome (294.08), hallucinatory-paranoid, senestopatho-hypochondriac, verbal hallucinosis, etc. (294.8).

3. Defect-organic states:

a) simple psychoorganic syndrome (310.08 and 310.18);

b) Korsakov's syndrome (294.08);

c) dementia (294.18).

Somatic diseases acquire independent significance in the occurrence of a mental disorder, in relation to which they are an exogenous factor. The mechanisms of brain hypoxia, intoxication, metabolic disorders, neuroreflex, immune, autoimmune reactions are important. On the other hand, as B. A. Tselibeev (1972) noted, somatogenic psychoses cannot be understood only as the result of a somatic disease. In their development, a predisposition to a psychopathological type of response, psychological characteristics of a person, and psychogenic influences play a role.

The problem of somatogenic mental pathology is becoming increasingly important due to the growth of cardiovascular pathology. The pathomorphism of mental illness is manifested by the so-called somatization, the predominance of non-psychotic disorders over psychotic, "bodily" symptoms over psychopathological. Patients with sluggish, “erased” forms of psychosis sometimes end up in general somatic hospitals, and severe forms of somatic diseases are often unrecognized due to the fact that the subjective manifestations of the disease “cover” the objective somatic symptoms.

Mental disorders are observed in acute short-term, protracted and chronic somatic diseases. They manifest themselves in the form of non-psychotic (asthenic, astheno-denpressive, astheno-dysthymic, astheno-hypochondriac, anxiety-phobic, hysteroform), psychotic (delirious, delirious-amental, oneiric, twilight, catatonic, hallucinatory-iaranoid), defective organic (psycho-organic syndrome and dementia) states .

According to V. A. Romasenko and K. A. Skvortsov (1961), B. A. Tselibeev (1972), A. K. Dobzhanskaya (1973), the exogenous nature of mental disorders of nonspecific tin is usually observed in the acute course of somatic illness. In cases of its chronic course with diffuse brain damage of a toxic-anoxic nature, more often than with infections, there is a tendency to endoformity of psychopathological symptoms.

Mental disorders in certain somatic diseases

Mental disorders in heart disease

Mental disorders resulting from acute heart failure can be expressed by syndromes of disturbed consciousness, most often in the form of deafness and delirium, characterized by instability of hallucinatory experiences.

Mental disorders in myocardial infarction have been systematically studied in recent decades (I. G. Ravkin, 1957, 1959; L. G. Ursova, 1967, 1969). Depressive conditions, syndromes of disturbed consciousness with psychomotor agitation, euphoria are described. Overvalued formations are often formed. With small-focal myocardial infarction, a pronounced asthenic syndrome develops with tearfulness, general weakness, sometimes nausea, chills, tachycardia, low-grade body temperature. With a macrofocal infarction with damage to the anterior wall of the left ventricle, anxiety and fear of death arise; with a heart attack of the posterior wall of the left ventricle, euphoria, verbosity, lack of criticism of one's condition with attempts to get out of bed, requests for some kind of work are observed. In the postinfarction state, lethargy, severe fatigue, and hypochondria are noted. A phobic syndrome often develops - expectation of pain, fear of a second heart attack, getting out of bed at a time when doctors recommend an active regimen.

Mental disorders also occur with heart defects, as pointed out by V. M. Banshchikov, I. S. Romanova (1961), G. V. Morozov, M. S. Lebedinsky (1972). With rheumatic heart disease V. V. Kovalev (1974) identified the following types of mental disorders:

1) borderline (asthenic), neurosis-like (neurasthenic-like) with vegetative disorders, cerebrosteic with mild manifestations of organic cerebral insufficiency, euphoric or depressive-dysthymic mood, hysteroform, asthenoinochondriacal states; neurotic reactions of depressive, depressive-hypochondriac and pseudo-euphoric types; pathological personality development (psychopathic);

2) psychotic (cardiogenic psychosis) - acute with delirious or amental symptoms and subacute, protracted (anxious-depressive, depressive-paranoid, hallucinatory-paranoid); 3) encephalopathic c (psychoorganic) - psychoorganic, epileptiform and corsage syndromes. Congenital heart defects are often accompanied by signs of psychophysical infantilism, asthenic, neurosis-like and psychopathic states, neurotic reactions, intellectual retardation.

Currently, heart operations are widely performed. Surgeons and cardiologists-therapists note the disproportion between the objective physical capabilities of operated patients and the relatively low actual indicators of rehabilitation of persons who have undergone heart surgery (E. I. Chazov, 1975; N. M. Amosov et al., 1980; C. Bernard, 1968 ). One of the most significant reasons for this disproportion is the psychological maladjustment of persons who have undergone heart surgery. When examining patients with pathology of the cardiovascular system, it was established that they had pronounced forms of personality reactions (G.V. Morozov, M.S. Lebedinsky, 1972; A.M. Wayne et al., 1974). N. K. Bogolepov (1938), L. O. Badalyan (1963), V. V. Mikheev (1979) indicate a high frequency of these disorders (70-100%). Changes in the nervous system in heart defects were described by L. O. Badalyan (1973, 1976). Circulatory insufficiency that occurs with heart defects leads to chronic hypoxia of the brain, the occurrence of cerebral and focal neurological symptoms, including convulsive seizures.

Patients operated on for rheumatic heart disease usually complain of headache, dizziness, insomnia, numbness and cold extremities, pain in the heart and behind the sternum, suffocation, fatigue, shortness of breath, aggravated by physical exertion, weakness of convergence, decreased corneal reflexes, hypotension of muscles, decreased periosteal and tendon reflexes, disorders of consciousness, more often in the form of fainting, indicating a violation of blood circulation in the system of vertebral and basilar arteries and in the basin of the internal carotid artery.

Mental disorders that occur after cardiac surgery are the result of not only cerebrovascular disorders, but also a personal reaction. V. A. Skumin (1978, 1980) singled out a “cardioprosthetic psychopathological syndrome”, which often occurs during mitral valve implantation or multivalve prosthetics. Due to noise phenomena associated with the activity of the artificial valve, disturbances in the receptive fields at the site of its implantation, and disturbances in the rhythm of cardiac activity, the attention of patients is riveted to the work of the heart. They have concerns and fears about a possible “valve break”, its breakdown. The depressed mood intensifies at night, when the noise from the work of artificial valves is heard especially clearly. Only during the day, when the patient is seen nearby by medical staff, can he fall asleep. A negative attitude towards vigorous activity is developed, an anxious-depressive background of mood arises with the possibility of suicidal actions.

In V. Kovalev (1974), in the immediate postoperative period, he noted in patients astheno-dynamic conditions, sensitivity, transient or persistent intellectual-mneetic insufficiency. After operations with somatic complications, acute psychoses with clouding of consciousness often occur (delirious, delirious-amental and delirious-opeiroid syndromes), subacute abortive and protracted psychoses (anxiety-depressive, depressive-hypochondriac, depressive-paranoid syndromes) and epileptiform paroxysms.

Mental disorders in patients with renal pathology

Asthenia in renal pathology, as a rule, precedes the diagnosis of kidney damage. There are unpleasant sensations in the body, a “stale head”, especially in the morning, nightmares, difficulty concentrating, a feeling of weakness, depressed mood, somatic neurological manifestations (coated tongue, grayish-pale complexion, instability of blood pressure, chills and profuse sweating along at night, discomfort in the lower back).

The asthenic nephrogenic symptom complex is characterized by a constant complication and an increase in symptoms, up to the state of asthenic confusion, in which patients do not catch changes in the situation, do not notice the objects they need, nearby. With an increase in renal failure, the asthenic condition may be replaced by amentia. A characteristic feature of nephrogenic asthenia is adynamia with the inability or difficulty to mobilize oneself to perform an action while understanding the need for such mobilization. Patients spend most of their time in bed, which is not always justified by the severity of renal pathology. According to A. G. Naku and G. N. German (1981), the often observed change of astheno-dynamic states by astheno-subdepressive ones is an indicator of improvement in the patient’s somatic state, a sign of “affective activation”, although it goes through a pronounced stage of a depressive state with ideas of self-abasement (uselessness, worthlessness, burdens on the family).

Syndromes of clouded consciousness in the form of delirium and amentia in nephropathies are severe, often patients die. There are two variants of the amental syndrome (A. G. Maku, G. II. German, 1981), reflecting the severity of renal pathology and having prognostic value: hyperkinetic, in which uremic intoxication is not pronounced, and hypokinetic with increasing decompensation of kidney activity, a sharp increase in arterial pressure.

Severe forms of uremia are sometimes accompanied by psychoses of the type of acute delirium and end in death after a period of stunnedness about sharp motor restlessness, fragmentary delusional ideas. When the condition worsens, the productive forms of the frustrated consciousness are replaced by unproductive ones, adynamia and doubt increase.

Psychotic disorders in the case of protracted and chronic kidney diseases are manifested by complex syndromes observed against the background of asthenia: anxiety-depressive, depressive and hallucinatory-paranoid and catatonic. The increase in uremic toxicosis is accompanied by episodes of psychotic stupefaction, signs of organic damage to the central nervous system, epileptiform paroxysms and intellectual-mnestic disorders.

According to B. A. Lebedev (1979), 33% of the examined patients against the background of severe asthenia have mental reactions of depressive and hysterical types, the rest have an adequate assessment of their condition with a decrease in mood, an understanding of the possible outcome. Asthenia can often prevent the development of neurotic reactions. Sometimes, in cases of slight severity of asthenic symptoms, hysterical reactions occur, which disappear with an increase in the severity of the disease.

Rheoencephalographic examination of patients with chronic kidney diseases makes it possible to detect a decrease in vascular tone with a slight decrease in their elasticity and signs of impaired venous flow, which are manifested by an increase in the venous wave (presystolic) at the end of the catacrotic phase and are observed in persons suffering from arterial hypertension for a long time. The instability of vascular tone is characteristic, mainly in the system of vertebral and basilar arteries. In mild forms of kidney disease, there are no pronounced deviations from the norm in pulse blood filling (L. V. Pletneva, 1979).

In the late stages of chronic renal failure and with severe intoxication, organ-replacement operations and hemodialysis are performed. After kidney transplantation and during dialysis stable suburemia, chronic nephrogenic toxicodishomeostatic encephalopathy is observed (MA Tsivilko et al., 1979). Patients have weakness, sleep disorders, mood depression, sometimes a rapid increase in adynamia, stupor, and convulsive seizures appear. It is believed that the syndromes of clouded consciousness (delirium, amentia) arise as a result of vascular disorders and postoperative asthenia, and the syndromes of turning off consciousness - as a result of uremic intoxication. In the process of hemodialysis treatment, there are cases of intellectual-mnestic disorders, organic brain damage with a gradual increase in lethargy, loss of interest in the environment. With prolonged use of dialysis, a psychoorganic syndrome develops - "dialysis-uremic dementia", which is characterized by deep asthenia.

When transplanting kidneys, large doses of hormones are used, which can lead to autonomic regulation disorders. During the period of acute graft failure, when azotemia reaches 32.1-33.6 mmol, and hyperkalemia - up to 7.0 mEq / l, hemorrhagic phenomena (profuse epistaxis and hemorrhagic rash), paresis, paralysis may occur. An electroencephalographic study reveals persistent desynchronization with an almost complete disappearance of alpha activity and a predominance of slow-wave activity. A rheoencephalographic study reveals pronounced changes in vascular tone: irregularity of waves in shape and size, additional venous waves. Asthenia sharply increases, subcomatous and coma states develop.

Mental disorders in diseases of the digestive tract

Violations of mental functions in the pathology of the digestive tract are more often limited to sharpening of character traits, asthenic syndrome and neurosis-like conditions. Gastritis, peptic ulcer and nonspecific colitis are accompanied by exhaustion of mental functions, sensitivity, lability or torpidity of emotional reactions, anger, a tendency to a hypochondriacal interpretation of the disease, carcinophobia. With gastroesophageal reflux, neurotic disorders (neurasthenic syndrome and obsessive phenomena) are observed that precede the symptoms of the digestive tract. The statements of patients about the possibility of a malignant neoplasm in them are noted in the framework of overvalued hypochondriacal and paranoid formations. Complaints about memory impairment are associated with attention disorder caused by both fixation on the sensations caused by the underlying disease and depressive mood.

A complication of stomach resection operations for peptic ulcer is dumping syndrome, which should be distinguished from hysterical disorders. Dumping syndrome is understood as vegetative crises that occur paroxysmal as hypo- or hyperglycemic ones immediately after a meal or after 20-30 minutes, sometimes 1-2 hours.

Hyperglycemic crises appear after ingestion of hot food containing easily digestible carbohydrates. Suddenly there is a headache with dizziness, tinnitus, less often - vomiting, drowsiness, tremor. “Black dots”, “flies” before the eyes, disorders of the body scheme, instability, unsteadiness of objects may appear. They end with profuse urination, drowsiness. At the height of the attack, the level of sugar and blood pressure rise.

Hypoglycemic crises occur outside the meal: weakness, sweating, headache, dizziness appear. After eating, they quickly stop. During a crisis, blood sugar levels drop and blood pressure drops. Possible disorders of consciousness at the height of the crisis. Sometimes crises develop in the morning hours after sleep (RE Galperina, 1969). In the absence of timely therapeutic correction, hysterical fixation of this condition is not excluded.

Mental disorders in cancer

With malignant neoplasms of extracranial localization, V. A. Romasenko and K. A. Skvortsov (1961) noted the dependence of mental disorders on the stage of the course of cancer. In the initial period, sharpening of the characterological traits of patients, neurotic reactions, and asthenic phenomena are observed. In the extended phase, astheno-depressive states, anosognosias are most often noted. With cancer of the internal organs in the manifest and predominantly terminal stages, states of "silent delirium" are observed with adynamia, episodes of delirious and oneiric experiences, followed by deafening or bouts of excitement with fragmentary delusional statements; delirious-amental states; paranoid states with delusions of relationship, poisoning, damage; depressive states with depersonalization phenomena, senestopathies; reactive hysterical psychoses. Characterized by instability, dynamism, frequent change of psychotic syndromes. In the terminal stage, the oppression of consciousness gradually increases (stupor, stupor, coma).

Mental disorders of the postpartum period

2) actually postpartum;

3) lactation period psychoses;

4) endogenous psychoses provoked by childbirth.

Mental pathology of the postpartum period does not represent an independent nosological form. Common to the entire group of psychoses is the situation in which they occur.

Childbirth psychoses are psychogenic reactions that develop, as a rule, in nulliparous women. They are caused by the fear of waiting for pain, an unknown, frightening event. At the first signs of incipient labor, some women in labor may develop a neurotic or psychotic reaction, in which, against the background of a narrowed consciousness, hysterical crying, laughter, screaming, sometimes fugiform reactions, and less often hysterical mutism appear. Women in labor refuse to follow the instructions offered by medical personnel. Duration of reactions - from several minutes to 0.5 h, sometimes longer.

Postpartum psychoses are conventionally divided into postpartum and lactation psychoses proper.

Actually postpartum psychosis develop during the first 1-6 weeks after childbirth, often in the maternity hospital. The reasons for their occurrence: toxicosis of the second half of pregnancy, difficult childbirth with massive tissue trauma, retained placenta, bleeding, endometritis, mastitis, etc. The decisive role in their appearance belongs to a generic infection, the predisposing moment is toxicosis of the second half of pregnancy. At the same time, psychoses are observed, the occurrence of which cannot be explained by postpartum infection. The main reasons for their development are traumatization of the birth canal, intoxication, neuroreflex and psychotraumatic factors in their totality. Actually postpartum psychoses are more often observed in nulliparous women. The number of sick women who gave birth to boys is almost 2 times more than women who gave birth to girls.

Psychopathological symptoms are characterized by an acute onset, occur after 2-3 weeks, and sometimes 2-3 days after childbirth against the background of elevated body temperature. Women in childbirth are restless, gradually their actions become erratic, speech contact is lost. Amenia develops, which in severe cases passes into a soporous state.

Amentia in postpartum psychosis is characterized by mild dynamics throughout the entire period of the disease. The exit from the amental state is critical, followed by lacunar amnesia. Prolonged asthenic conditions are not observed, as is the case with lactation psychoses.

The catatonic (katatono-oneiric) form is less common. A feature of postpartum catatonia is the weak severity and instability of symptoms, its combination with oneiric disorders of consciousness. With postpartum catatonia, there is no pattern of increasing stiffness, as with endogenous catatonia, there is no active negativism. Characterized by instability of catatonic symptoms, episodic oneiroid experiences, their alternation with states of stupor. With the weakening of catatonic phenomena, patients begin to eat, answer questions. After recovery, they are critical of the experience.

Depressive-paranoid syndrome develops against the background of unsharply pronounced stupor. It is characterized by "matte" depression. If the stupor intensifies, the depression is smoothed out, the patients are indifferent, do not answer questions. Ideas of self-accusation are connected with the failure of patients during this period. Quite often find the phenomena of mental anesthesia.

Differential diagnosis of postpartum and endogenous depression is based on the presence of changes in its depth during postpartum depression depending on the state of consciousness, worsening of depression by night. In such patients, in a delusional interpretation of their insolvency, the somatic component sounds more, while in endogenous depression, low self-esteem concerns personal qualities.

Psychoses during lactation occur 6-8 weeks after birth. They occur about twice as often as postpartum psychosis itself. This can be explained by the trend towards rejuvenation of marriages and the psychological immaturity of the mother, the lack of experience in caring for children - younger brothers and sisters. The factors preceding the onset of lactational psychosis include shortening of hours of rest in connection with caring for a child and deprivation of night sleep (K. V. Mikhailova, 1978), emotional overstrain, lactation with irregular meals and rest, leading to rapid weight loss.

The disease begins with impaired attention, fixative amnesia. Young mothers do not have time to do everything necessary due to the lack of composure. At first, they try to “make up time” by reducing rest hours, “put things in order” at night, do not go to bed, and start washing children's clothes. Patients forget where they put this or that thing, they look for it for a long time, breaking the rhythm of work and putting things in order with difficulty. Difficulty comprehending the situation quickly grows, confusion appears. The purposefulness of behavior is gradually lost, fear, the affect of bewilderment, fragmentary interpretive delirium develop.

In addition, there are changes in the state during the day: during the day, patients are more collected, and therefore it seems that the state returns to pre-painful. However, with each passing day, periods of improvement are reduced, anxiety and lack of concentration are growing, and fear for the life and well-being of the child is increasing. An amental syndrome or stunning develops, the depth of which is also variable. The exit from the amental state is protracted, accompanied by frequent relapses. The amental syndrome is sometimes replaced by a short period of a catatonic-oneiric state. There is a tendency to increase the depth of disorders of consciousness when trying to maintain lactation, which is often asked by the patient's relatives.

An astheno-depressive form of psychosis is often observed: general weakness, emaciation, deterioration of skin turgor; patients become depressed, express fears for the life of the child, ideas of low value. The way out of depression is protracted: in patients for a long time there is a feeling of instability in their condition, weakness, anxiety are noted that the disease may return.

Endocrine diseases

Endocrine disorders in adults, as a rule, are accompanied by the development of non-psychotic syndromes (asthenic, neurosis-like and psychopathic) with paroxysmal vegetative disorders, and with an increase in the pathological process - psychotic states: syndromes of clouded consciousness, affective and paranoid psychoses. With congenital forms of endocrinopathy or their occurrence in early childhood, the formation of a psychoorganic neuroendocrine syndrome is clearly visible. If an endocrine disease appears in adult women or in adolescence, then they often have personal reactions associated with changes in somatic condition and appearance.

In the early stages of all endocrine diseases and with their relatively benign course, the gradual development of a psychoendocrine syndrome (endocrine psychosyndrome, according to M. Bleuler, 1948), its transition with the progression of the disease into a psychoorganic (amnestic-organic) syndrome and the occurrence of acute or prolonged psychoses against the background of these syndromes (D. D. Orlovskaya, 1983).

Most often, asthenic syndrome appears, which is observed in all forms of endocrine pathology and is included in the structure of the psychoendocrine syndrome. It is one of the earliest and most persistent manifestations of endocrine dysfunction. In cases of acquired endocrine pathology, asthenic phenomena may long precede the detection of gland dysfunction.

"Endocrine" asthenia is characterized by a feeling of pronounced physical weakness and weakness, accompanied by a myasthenic component. At the same time, the urges to activity that persist in other forms of asthenic conditions are leveled. Asthenic syndrome very soon acquires the features of an apatoabulic state with impaired motivation. Such a transformation of the syndrome usually serves as the first signs of the formation of a psychoorganic neuroendocrine syndrome, an indicator of the progression of the pathological process.

Neurosis-like changes are usually accompanied by manifestations of asthenia. Neurastheno-like, hysteroform, anxiety-phobic, astheno-depressive, depressive-hypochondriac, asthenic-abulic states are observed. They are persistent. In patients, mental activity decreases, drives change, and mood lability is noted.

Neuroendocrine syndrome in typical cases is manifested by a "triad" of changes - in the sphere of thinking, emotions and will. As a result of the destruction of higher regulatory mechanisms, there is a disinhibition of drives: sexual promiscuity, a tendency to vagrancy, theft, and aggression are observed. Decrease in intelligence can reach the degree of organic dementia. Often there are epileptiform paroxysms, mainly in the form of convulsive seizures.

Acute psychoses with impaired consciousness: asthenic confusion, delirious, delirious-amental, oneiroid, twilight, acute paranoid states - occur in the acute course of an endocrine disease, for example, with thyrotoxicosis, as well as as a result of acute exposure to additional external harmful factors (intoxication, infection, mental trauma) and in the postoperative period (after thyroidectomy, etc.).

Among psychoses with a protracted and recurrent course, depressive-paranoid, hallucinatory-paranoid, senestopatho-hypochondriac states and verbal hallucinosis syndrome are most often detected. They are observed with an infectious lesion of the hypothalamus - pituitary gland, after removal of the ovaries. In the clinical picture of psychosis, elements of the Kandinsky-Clerambault syndrome are often found: the phenomena of ideational, sensory or motor automatism, verbal pseudohallucinations, delusional ideas of influence. Features of mental disorders depend on the defeat of a certain link in the neuroendocrine system.

Itsenko-Kushnga disease occurs as a result of damage to the hypothalamus-pituitary-adrenal cortex system and is manifested by obesity, gonadal hypoplasia, hirsutism, severe asthenia, depressive, senestopatho-hypochondriac or hallucinatory-paranoid states, epileptiform seizures, decreased intellectual-mnestic functions, Korsakov's syndrome. After radiation therapy and adrenalectomy, acute psychoses with clouding of consciousness may develop.

In patients with acromegaly resulting from damage to the anterior pituitary gland - eosinophilic adenoma or proliferation of eosinophilic cells, there is increased excitability, malice, anger, a tendency to solitude, a narrowing of the circle of interests, depressive reactions, dysphoria, sometimes psychoses with impaired consciousness, usually occurring after additional external influences. Adiposogenital dystrophy develops as a result of hypoplasia of the posterior pituitary gland. The characteristic somatic signs include obesity, the appearance of circular ridges around the neck (“necklace”).

If the disease begins at an early age, there is an underdevelopment of the genital organs and secondary sexual characteristics. AK Dobzhanskaya (1973) noted that in primary lesions of the hypothalamic-pituitary system, obesity and mental changes long precede sexual dysfunction. Psychopathological manifestations depend on the etiology (tumor, traumatic injury, inflammatory process) and the severity of the pathological process. In the initial period and with a mildly pronounced dynamics, the symptoms for a long time manifest themselves as asthenic syndrome. In the future, epileptiform seizures, personality changes of the epileptoid type (pedantry, stinginess, sweetness), acute and prolonged psychoses, including the endoform type, apatoabulic syndrome, and organic dementia are often observed.

Cerebral-pituitary insufficiency (Symonds' disease and Shien's syndrome) is manifested by severe weight loss, underdevelopment of the genital organs, astheno-adynamic, depressive, hallucinatory-paranoid syndromes, intellectual-mnestic disorders.

In diseases of the thyroid gland, either its hyperfunction (Graves' disease, thyrotoxicosis) or hypofunction (myxedema) is noted. The cause of the disease can be tumors, infections, intoxications. Graves' disease is characterized by a triad of somatic symptoms such as goiter, bulging eyes and tachycardia. At the onset of the disease, neurosis-like disorders are noted:

irritability, fearfulness, anxiety, or high spirits. In a severe course of the disease, delirious states, acute paranoid, agitated depression, depressive-hypochondriacal syndrome may develop. In differential diagnosis, the presence of somato-neurological signs of thyrotoxicosis should be taken into account, including exophthalmos, Moebius's symptom (weak convergence), Graefe's symptom (upper eyelid lagging behind the iris when looking down - a white strip of sclera remains). Myxedema is characterized by bradypsychia, a decrease in intelligence. The congenital form of myxedema is cretinism, which used to be often endemic in areas where there is not enough iodine in drinking water.

With Addison's disease (insufficient function of the adrenal cortex), there are phenomena of irritable weakness, intolerance to external stimuli, increased exhaustion with an increase in adynamia and monotonous depression, sometimes delirious states occur. Diabetes mellitus is often accompanied by non-psychotic and psychotic mental disorders, including delirious ones, which are characterized by the presence of vivid visual hallucinations.

Treatment, prevention and social and labor rehabilitation of patients with somatogenic disorders

Correction of non-psychotic disorders is carried out against the background of the main somatic therapy with the help of sleeping pills, tranquilizers, antidepressants; prescribe psychostimulants of plant and animal origin: tinctures of ginseng, magnolia vine, aralia, eleutherococcus extract, pantocrine. It should be borne in mind that many antispasmodic vasodilators and antihypertensives - clonidine (hemiton), daukarin, dibazol, carbocromen (intecordin), cinnarizine (stugeron), raunatin, reserpine - have a slight sedative effect, and tranquilizers amizil, oxylidine, sibazon (diazepam, relanium ), nozepam (oxazepam), chlozepid (chlordiazepoxide), phenazepam - antispasmodic and hypotensive. Therefore, when using them together, it is necessary to be careful about the dosage, to monitor the state of the cardiovascular system.

Acute psychoses usually indicate a high degree of intoxication, impaired cerebral circulation, and clouding of consciousness indicates a severe course of the process. Psychomotor agitation leads to further exhaustion of the nervous system and can cause a sharp deterioration in the general condition. V. V. Kovalev (1974), A. G. Naku, G. N. German (1981), D. D. Orlovskaya (1983) recommend prescribing chlorpromazine, thioridazine (sonapax), alimemazine (teralen) and other neuroleptics to patients , which do not have a pronounced extrapyramidal effect, in small or medium doses orally, intramuscularly and intravenously under the control of blood pressure. In some cases, it is possible to stop acute psychosis with the help of intramuscular or intravenous administration of tranquilizers (seduxen, relanium). With prolonged forms of somatogenic psychosis, tranquilizers, antidepressants, psychostimulants, neuroleptics and anticonvulsants are used. Some drugs are poorly tolerated, especially from the group of antipsychotics, so it is necessary to individually select doses, gradually increase them, replace one drug with another if complications appear or there is no positive effect.

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… according to clinical manifestations, psychogenic states in somatic patients are extremely diverse.

Somatic diseases, consisting in the defeat of internal organs (including endocrine) or entire systems, often cause various mental disorders, most often called "somatically conditioned psychoses" (K. Schneider).

K. Schneider proposed to consider the presence of the following signs as a condition for the appearance of somatically conditioned psychoses: (1) the presence of a pronounced clinical picture of a somatic disease; (2) the presence of a marked relationship in time between somatic and mental disorders; (3) a certain parallelism in the course of mental and somatic disorders; (4) the possible, but not obligatory appearance of organic symptoms.

There is no single view on the reliability of this “quadriad”. The clinical picture of somatogenic disorders depends on the nature of the underlying disease, its severity, the stage of the course, the level of effectiveness of therapeutic effects, as well as on such individual properties as heredity, constitution, premorbid personality, age, sometimes gender, reactivity of the organism, the presence of previous hazards ( the possibility of the reaction of "altered soil" - S.G. Zhislin).

The section of the so-called somatopsychiatry includes a number of closely related, but at the same time, different groups of painful manifestations in their clinical picture. First of all, this is actually somatogeny, that is, mental disorders caused by a somatic factor, which belong to a large section of exogenous organic mental disorders. No less place in the clinic of mental disorders in somatic diseases is occupied by psychogenic disorders (the reaction to the disease not only with the restriction of human life, but also with possible very dangerous consequences).

It should be noted that in the ICD-10, mental disorders in somatic diseases are described mainly in sections F4 (“Neurotic stress-related and somatoform disorders”) - F45 (“Somatoform disorders”), F5 (“Behavioral syndromes associated with with physiological disorders and physical factors") and F06 (Other mental disorders due to damage and dysfunction of the brain or physical illness).

Clinical manifestations. Different stages of the disease may be accompanied by different syndromes. At the same time, there is a certain range of pathological conditions, especially characteristic of somatogenic mental disorders at the present time. These are the following disorders: (1) asthenic; (2) neurosis-like; (3) affective; (4) psychopathic; (5) delusional states; (6) states of clouding of consciousness; (7) organic psychosyndrome.

Asthenia is the most typical phenomenon in somatogeny. often happens the so-called core or through syndrome. It is asthenia at present, due to the pathomorphosis of somatogenic mental disorders, that may be the only manifestation of mental changes. In the event of a psychotic state, asthenia, as a rule, can be its debut, as well as completion.

Asthenic conditions are expressed in various ways, but fatigue is always typical, sometimes in the morning, difficulty concentrating, slowing down perception. Emotional lability, increased vulnerability and resentment, and quick distractibility are also characteristic. Patients do not tolerate even a slight emotional stress, quickly get tired, upset because of any trifle. Hyperesthesia is characteristic, expressed in intolerance to sharp stimuli in the form of loud sounds, bright lights, smells, touches. Sometimes hyperesthesia is so pronounced that patients are irritated even by low voices, ordinary light, and the touch of linen on the body. Sleep disturbances are common.

In addition to asthenia in its purest form, its combination with depression, anxiety, obsessive fears, and hypochondriacal manifestations is quite common. The depth of asthenic disorders is usually associated with the severity of the underlying disease.

neurotic disorders. These disorders are associated with the somatic status and occur when the latter is aggravated, usually with an almost complete absence or a small role of psychogenic influences. A feature of neurosis-like disorders, in contrast to neurotic disorders, is their rudimentary nature, monotony, a combination with autonomic disorders, most often of a paroxysmal nature. However, vegetative disorders can be persistent, long-term.

affective disorders. For somatogenic mental disorders, dysthymic disorders are very characteristic, primarily depression in its various variants. In the context of a complex interweaving of somatogenic, psychogenic and personal factors in the origin of depressive symptoms, the share of each of them varies significantly depending on the nature and stage of the somatic disease. In general, the role of psychogenic and personal factors in the formation of depressive symptoms (with the progression of the underlying disease) first increases, and then, with further aggravation of the somatic condition and, accordingly, deepening of asthenia, it significantly decreases.

Some features of depressive disorders can be noted, depending on the somatic pathology in which they are observed. In cardiovascular diseases, the clinical picture is dominated by lethargy, fatigue, weakness, lethargy, apathy with disbelief in the possibility of recovery, thoughts about the supposedly inevitable “physical failure” that occurs with any heart disease. Patients are melancholy, immersed in their experiences, show a tendency to constant introspection, spend a lot of time in bed, and are reluctant to come into contact with roommates and staff. In a conversation, they talk mainly about their “serious” illness, that they do not see a way out of the situation. Complaints are typical of a sharp decline in strength, the loss of all desires and aspirations, the inability to concentrate on anything (it is difficult to read, watch TV, it is even difficult to speak). Patients often make all sorts of assumptions about their poor physical condition, about the possibility of an unfavorable prognosis, and express uncertainty about the correctness of the treatment being carried out.

In those cases when the internal picture of the disease is dominated by ideas about disorders in the gastrointestinal tract, the condition of patients is determined by persistent dreary affect, anxious doubts about their future, subordination of attention exclusively to one object - the activity of the stomach and intestines with fixation on various unpleasant things emanating from them. sensations. Complaints are noted for a "pinching" feeling localized in the epigastric region and in the lower abdomen, for almost non-passing heaviness, squeezing, bursting and other unpleasant sensations in the intestines. Patients in these cases often associate such disorders with "nervous tension", a state of depression, depression, interpreting them as secondary.

With the progression of a somatic disease, the long course of the disease, the gradual formation of chronic encephalopathy, dreary depression gradually acquires the character of a dysphoric depression, with grouchiness, dissatisfaction with others, pickiness, exactingness, capriciousness. Unlike an earlier stage, anxiety is not constant, but usually occurs during periods of exacerbation of the disease, especially with a real threat of developing dangerous consequences. On remote taps of a severe somatic disease with pronounced symptoms of encephalopathy, often against the background of dystrophic phenomena, asthenic syndrome includes depression with a predominance of adynamia and apathy, indifference to the environment.

During a period of significant deterioration in the somatic state, attacks of anxious and dreary excitement occur, at the height of which suicidal acts can occur.

psychopathic disorders. Most often they are expressed in the growth of egoism, egocentrism, suspicion, gloom, hostile, wary or even hostile attitude towards others, hysteriform reactions with a possible tendency to aggravate one's state, the desire to constantly be in the center of attention, elements of attitudinal behavior. Perhaps the development of a psychopathic state with an increase in anxiety, suspiciousness, difficulties in making any decision.

Delusional states. In patients with chronic somatic diseases, delusional states usually occur against the background of a depressive, astheno-depressive, anxiety-depressive state. Most often, this is a delusion of attitude, condemnation, material damage, less often nihilistic, damage or poisoning. At the same time, delusional ideas are unstable, episodic, often have the character of delusional doubts with a noticeable exhaustion of patients, and are accompanied by verbal illusions. If a somatic disease entailed some kind of disfiguring change in appearance, then a syndrome of dysmorphomania (an overvalued idea of ​​a physical defect, an idea of ​​a relationship, a depressive state) may form, arising through the mechanisms of a reactive state.

A state of clouded consciousness. The episodes of stunning that occur against an asthenic-adynamic background are most often noted. The degree of stunning can be fluctuating in this case. The lightest degrees of stunning in the form of an obnubilation of consciousness, with an aggravation of the general condition, can pass stupor and even to coma. Delirious disorders are often episodic, sometimes manifesting themselves in the form of so-called abortive deliriums, often combined with stunning or with oneiric (dreaming) states.

Severe somatic diseases are characterized by such variants of delirium as mushing and professional with a frequent transition to coma, as well as a group of so-called silent delirium. Silent delirium and similar conditions are observed in chronic diseases of the liver, kidneys, heart, gastrointestinal tract and can proceed almost imperceptibly to others. Patients are usually inactive, are in a monotonous pose, indifferent to the environment, often give the impression of dozing, sometimes muttering something. They seem to be present when viewing oneiric paintings. Periodically, these oneiroid-like states may alternate with a state of excitement, most often in the form of erratic fussiness. Illusory-hallucinatory experiences in this state are characterized by brilliance, brightness, scene-like. Possible depersonalization experiences, disorders of sensory synthesis.

Amentative clouding of consciousness in its pure form is rare, mainly with the development of a somatic disease on the so-called changed soil, in the form of a previous weakening of the body. Much more often this is an amental state with a rapidly changing depth of stupefaction, often approaching disorders such as silent delirium, with clarification of consciousness, emotional lability. The twilight state of consciousness in its pure form in somatic diseases is rare, usually with the development of an organic psychosyndrome (encephalopathy). Oneiroid in its classical form is also not very typical, much more often delirious-oneiric or oneiric (dreaming) states, usually without motor excitation and pronounced emotional disorders.

The main feature of the syndromes of stupefaction in somatic diseases is their effacement, rapid transition from one syndrome to another, the presence of mixed conditions, the occurrence, as a rule, on an asthenic background.

Typical psychoorganic syndrome. In somatic diseases, it occurs infrequently, occurs, as a rule, with long-term diseases with a severe course, such as chronic renal failure or long-term cirrhosis of the liver with symptoms of total hypertension. In somatic diseases, the asthenic variant of the psycho-organic syndrome is more common with increasing mental weakness, increased exhaustion, tearfulness, asthenodysphoric mood shade (see also the article " Psycho-organic syndrome" in the "Psychiatry" section of the medical portal site).

Oxford Manual of Psychiatry Michael Gelder

Psychiatric disorders manifesting with somatic symptoms

GENERAL INFORMATION

The presence of somatic symptoms in the absence of any significant physical cause is a common occurrence both in the general population and in those who visit general practitioners (Goldberg and Huxley 1980) or are treated in general hospitals (Mayou and Hawton 1986). ). Most somatic symptoms are transient and not associated with mental disorders; many patients improve when they begin to adhere to the recommendations given to them by the doctor, as well as under the influence of explanatory work carried out with them. Much less frequently, symptoms are persistent and difficult to treat; quite atypical are those cases, which make up a very small percentage, when a patient is observed by a psychiatrist for this reason (Barsky, Klerman 1983).

Psychiatric disorders that present with somatic symptoms are heterogeneous and difficult to classify. Term hypochondria is used broadly to refer to all mental illnesses with severe somatic symptoms, and more narrowly to a special category of illnesses that will be described later in this chapter (see: Kenyon 1965 - historical review). Currently, the preferred term is somatization, but, unfortunately, it is also used in at least two senses, interpreting either as a psychological mechanism underlying the formation of somatic symptoms, or as a subcategory of somatoform disorders in DSM-III.

There is no clear understanding of the mechanisms underlying somatization, since they are still poorly understood (Barsky, Klerman 1983). It is likely that most of the somatic symptoms that occur in the absence of physical pathology can be partly explained by a misinterpretation of normal bodily sensations; some cases should be attributed to trivial somatic complaints or neurovegetative manifestations of anxiety. Some social and psychological factors may predispose or intensify somatization, such as the past experience of friends or relatives, excessive care of family members for the patient. Cultural characteristics largely determine how much the patient is inclined to describe the discomfort he experiences more in terms of bodily sensations than in expressions that characterize the psychological state.

Somatization occurs in many mental illnesses (see Table 12.1 for a list), but it is most common in adjustment and mood disorders, anxiety disorder (see, for example, Katon et al. 1984), and depressive disorder (Kenyon 1964). . There are specific problems with regard to the nosology of disorders in which there are few psychopathological symptoms (Cloninger 1987), which are now grouped under the rubric of somatoform disorders in both DSM-III and ICD-10. It should also be noted that physicians' approach to interpreting symptoms is largely culturally driven. For example, when the same patients were examined by Chinese and American psychiatrists, it turned out that the former were more likely to diagnose neurasthenia, and the latter - depressive disorder (Kleinman 1982).

Table 12.1. Classification of mental disorders that may present with somatic symptoms

DSM-IIIR

Adjustment disorder (ch. 6)

Adjustment disorder with somatic complaints

Mood disorders (affective disorders) (ch. 8)

Anxiety disorders (ch. 7)

panic disorder

Obsessive Compulsive Disorder

generalized anxiety disorder

Somatoform disorders

Conversion disorder (or hysterical neurosis, conversion type)

somatoform pain disorder

Hypochondria (or hypochondriacal neurosis)

Body dysmorphic disorder

Dissociative disorders (or hysterical neuroses, dissociative type) (ch. 7)

Schizophrenic disorders (ch. 9)

Delusional (paranoid) disorders (ch. 10)

Substance use disorders (ch. 14)

Artificial disorders

With somatic symptoms

With somatic and psychopathological symptoms

Artificial disorder, unspecified

Simulation (code V)

ICD-10

Response to severe stress and adjustment disorders

Acute reaction to stress

Post Traumatic Stress Disorder

Adjustment disorder

Mood disorders (affective disorders)

Other anxiety disorders

Dissociative (conversion) disorders

Somatoform disorders

Somatized disorder

Undifferentiated somatoform disorder

Hypochondriacal disorder (hypochondria, hypochondriacal neurosis)

Somatoform autonomic dysfunction

Chronic somatoform pain disorder

Other somatoform disorders

Somatoform disorder, unspecified

Other neurotic disorders

Neurasthenia

Schizophrenia, schizotypal and delusional disorders

Mental and behavioral disorders caused by the use of psychoactive substances

MANAGEMENT

In the treatment of somatization disorders, the psychiatrist faces two general problems. First, he must make sure that his approach is consistent with that of other physicians. Secondly, it is necessary to make sure that the patient understands that his symptoms are not caused by a medical disease, but are nevertheless taken seriously.

To achieve these goals, the somatologist must explain to the patient the goals and results of the examinations in an accessible form, as well as indicate how important a psychological assessment of his condition can be. The psychiatrist should be aware of the results of somatic examinations, as well as what kind of explanations and recommendations the patient received from other clinicians.

Condition assessment

Many patients find it very difficult to come to terms with the idea that their somatic symptoms may have psychological causes and that they should see a psychiatrist. Therefore, in such cases, the clinician requires special tact and sensitivity; The right approach must be found for each patient. As already noted, it is important to find out the patient's opinion regarding the causes of the symptoms and seriously discuss his version. The patient must be sure that the doctor does not doubt the reality of his symptoms. Somatologists and psychiatrists need to work together to develop a coherent, coherent approach. The usual procedure for taking the history and assessing the patient's condition is followed, although some changes may need to be made during the interview process to suit the patient. It is necessary to pay attention to any thoughts or manifestations of specific behavior that accompany the patient's somatic symptoms, as well as to the reaction of relatives. It is important to obtain information not only from the patient himself, but also from other informants.

An important point regarding the diagnosis should be emphasized. In cases where a patient has unexplained physical symptoms, a psychiatric diagnosis can only be made if there are positive grounds for this (i.e. psychopathological symptoms). It should not be assumed that if somatic symptoms appear in connection with stressful events, then they necessarily have a psychological origin. After all, such events happen quite often, and it is likely that they may coincide in time with a somatic disease that has not yet been diagnosed, but has already developed enough to give such symptoms. When making a diagnosis of a mental disorder, the same strict criteria must be followed as when deciding whether a person is physically healthy or sick.

Treatment

Many patients with somatic complaints persistently turn to medical institutions, seeking re-examination and claiming attention. If all the necessary procedures have already been performed, then the patient in such cases should be made clear that no further examinations are required. This should be stated firmly and authoritatively, while at the same time expressing a willingness to discuss the issue of the scope of research and jointly analyze the results obtained. After this clarification, the main task is to conduct psychological treatment in combination with the treatment of any concomitant somatic disease.

It is important to avoid arguing about the causes of symptoms. Many of the patients, who do not fully agree that the symptoms they have are due to psychological causes, at the same time willingly admit that psychological factors can influence their perception of these symptoms. In the future, such patients often positively perceive the offer to help them learn to live a more active, fulfilling life in the presence of these symptoms, to adapt to them. In recent cases, explanation and support usually work well, but in chronic cases these measures rarely help; sometimes, after repeated clarifications, complaints even intensify (see: Salkovskis, Warwick 1986).

Specific treatment should be based on an understanding of the patient's individual difficulties; this may include the prescription of antidepressants, the use of special behavioral methods, in particular those aimed at eliminating anxiety, and cognitive therapy.

SOMATOFORM DISORDERS

Somatized disorder

According to the DSM-IIIR, the main feature of a somatic disorder is multiple somatic complaints over several years that begin before the age of 30. The DSM-IIIR diagnostic criteria provides a list of somatic symptoms that includes 31 items; a diagnosis requires the presence of complaints of at least 13 of them, provided that these symptoms cannot be explained by organic pathology or pathophysiological mechanisms and are manifested not only during panic attacks. The patient's discomfort forces him to "take medication (but remember that taking aspirin and other painkillers is not considered a sign of a disorder), see a doctor, or make drastic changes in his lifestyle."

The description of such a syndrome was first presented by a group of psychiatrists who conducted research in St. Louis (USA) (Perley, Guze 1962). This syndrome was considered as a form of hysteria and was named the Briquet syndrome (Briquet) in honor of the French physician of the 19th century - the author of an important monograph on hysteria (although he did not describe exactly the syndrome that was named after him).

The St. Louis group believed that there was a genetic link between somatization disorder in women and sociopathy and alcoholism in their male relatives. The results of follow-up observations and data obtained in the study of families, according to the same authors, indicate that somatization disorder is a single stable syndrome (Guze et al. 1986). However, this conclusion is questionable, as there are cases among patients diagnosed with a somatization disorder that meet the criteria for other DSM-III diagnoses (Liskow et al. 1986).

The prevalence of somatization disorder has not been established, but it is known to be much more common in women than in men. The flow is intermittent; the prognosis is poor (see: Cloninger 1986). The disease is difficult to treat, but if the patient is seen by the same doctor for a long time, and the number of studies carried out is reduced to the required minimum, this often reduces the frequency of the patient's visits to medical services and improves his functional state (see: Smith et al . 1986).

conversion disorder

Conversion symptoms are common in people who visit doctors. Conversion (dissociative) disorders, as defined in the DSM-IIIR and ICD-10, are much less common. Among hospital admissions, patients with this diagnosis make up only 1% (see: Mayou, Hawton 1986), although acute conversion syndromes such as amnesia, difficulty walking, sensory disturbances are common in emergency departments. In this manual, conversion disorders and their treatment are described in Chap. 7 (cm). Conversion disorder-related chronic pain is discussed later in this chapter (see).

somatoform pain disorder

This is a special category for patients with chronic pain that is not due to any somatic or specific mental disorder (see: Williams, Spitzer 1982). According to the DSM-IIIR, the dominant disturbance in this disorder is the patient's preoccupation with pain for at least six months; however, the relevant examinations either do not reveal an organic pathology or pathophysiological mechanisms that could explain the presence of pain, or, if such an organic pathology is detected, the pain experienced by the patient or the impairment of social functioning or professional activity associated with it turns out to be much more serious than it should be would be expected in the presence of somatic abnormalities. For more information on pain syndromes, see

Hypochondria

The DSM-IIIR defines hypochondria as “preoccupation (preoccupation) with the fear of the possible presence of a serious illness or belief in its presence, based on the fact that the patient interprets various physical manifestations, sensations as indicative of a physical illness. Adequate physical examination does not confirm the presence of any physical disorder that could cause such physical signs or sensations or would justify their interpretation as evidence of the existence of an illness. Fears about a possible disease or confidence in its presence persist, despite all the explanations of medical workers, despite their efforts to dissuade the patient. Further, conditions are stipulated to exclude patients with panic disorder or delusions, and it is also indicated that the diagnosis of hypochondria is made if complaints of an appropriate nature are presented for at least six months.

The question of whether hypochondria should be placed in a separate diagnostic category has been controversial in the past. Gillespie (1928) and some other authors noted that the diagnosis of primary neurotic hypochondriacal syndrome is common in psychiatric practice. Kenyon (1964), analyzing the records in the case histories of patients with such a diagnosis made in the Maudsley hospital, found that most of them, apparently, had a depressive disorder as the main disease. He came to the conclusion that it makes no sense to continue to adhere to the concept of a primary hypochondriacal syndrome. However, this conclusion was based on the results of a study of patients admitted to a specialized psychiatric hospital. In the opinion of most general hospital psychiatrists, some patients with chronic physical symptoms are best classified as hypochondria, as defined by the DSM-IIIR, or hypochondriacal disorder by the ICD-10.

Dysmorphophobia

Syndrome dysmorphophobia was first described by Morselli (1886) as "the subjective idea present in the patient about the deformity that he allegedly has, a physical defect that, as it seems to him, is noticeable to others." The typical patient with body dysmorphic disorder is convinced that some part of his body is either too big, too small, or ugly. Other people find his appearance quite normal or recognize the presence of a small, insignificant anomaly (in the latter case it is sometimes difficult to decide whether the patient's concern due to this defect is commensurate with a real reason). Patients usually complain about the ugly shape or abnormal size of the nose, ears, mouth, mammary glands, buttocks and penis, but in principle any other part of the body can be the object of such concern. Often the patient is constantly absorbed in thoughts about his "ugliness", while experiencing deep suffering; it seems to him that everyone around is paying attention to the flaw, in the presence of which he is convinced, and discussing among themselves his physical defect. He may consider "ugliness" the cause of all his life's difficulties and failures, arguing, for example, that if he had a prettier nose, he would be more successful in work, social life and in sexual relations.

Some patients with this syndrome meet the diagnostic criteria for other disorders. So, Hay (1970b), having studied 17 patients (12 men and 5 women) with this condition, found that eleven of them had a severe personality disorder, five had schizophrenia, and one had a depressive disorder. In patients with mental disorders, the above-described focus on one's "ugliness" is usually delusional, and in those suffering from personality disorders, as a rule, it is an overvalued idea (see: McKenna 1984).

There are very few descriptions of severe forms of the syndrome in the psychiatric literature, but relatively mild cases of body dysmorphic disorder are quite common, especially in plastic surgery clinics and in the practice of dermatologists. DSM-IIIR introduces a new category - body dysmorphic disorder(dysmorphophobia), - intended for cases where dysmorphophobia is not secondary to any other mental disorder. This term, by definition, refers to "focus on some imaginary defect in appearance", in which "confidence in the presence of such a defect does not reach the intensity characteristic of delusional conviction." The validity of placing this syndrome in a separate category cannot yet be considered proven.

Dysmorphophobia in most cases is difficult to treat. If there is a concomitant mental disorder, it should be treated in the usual way, providing the patient with psychological help and support for any difficulties of a professional, social and sexual nature. It should be as tactfully as possible to explain to the patient that in fact he does not have a deformity and that sometimes a person may form a distorted idea of ​​\u200b\u200bhis own appearance, for example, due to the statements of other people accidentally heard and misunderstood by him. Some patients are helped by such reassurance, combined with long-term support, but many fail to achieve any improvement.

Cosmetic surgery is most often contraindicated in such patients, unless they have very real serious defects in appearance, but sometimes surgery can radically help patients with minor defects (Hay, Heather 1973). There are, although relatively rare, cases when a person who has undergone plastic surgery remains completely dissatisfied with its results. It is very difficult to select patients for surgical intervention. Before making an appropriate decision, it is necessary to find out exactly what the patient expects from such an operation, carefully analyze the information received and evaluate the prognosis (see: Frank 1985 - review).

ARTIFICIAL (ARTIFICIALLY CAUSED, PATOMMICRICAL) DISORDER

The category of artificial disorders in the DSM-IIIR covers "the intentional induction or simulation of somatic and psychological symptoms that may be driven by the need to play the role of the patient." There are three subcategories: for cases with only psychological symptoms, only with somatic symptoms, and for cases where both are present. The extreme form of the disorder is commonly known as Munchausen's syndrome (see below). Unlike simulation, an artificial upset is not associated with any external stimuli, such as an interest in monetary compensation.

Reich and Gottfried (1983) described 41 cases, and among the patients examined by them there were 30 women. Most of these patients worked in specialties related to medicine. The studied cases can be divided into four main clinical groups: infections caused by the patient himself; simulation of certain diseases in the absence of real disorders; chronically maintained wounds; self-treatment. Many patients expressed a desire to undergo a psychological examination and a course of treatment.

The most common artificial derangement syndromes include artificially induced dermatitis (Sneddon 1983), pyrexia of unknown origin, hemorrhagic disorder (Ratnoff 1980), and labile diabetes (Schade et al. 1985). Psychological syndromes include feigning psychosis (Nau 1983) or grief over perceived loss. (See: Folks, Freeman 1985 for a review on artificial disorder).

Munchausen syndrome

Asher (1951) proposed the term "Munchausen's syndrome" for cases where a patient "comes to the hospital with what appears to be an acute illness, the clinical picture of which is complemented by a completely plausible or dramatized anamnesis. Usually the stories told by such a patient are built mainly on lies. It soon turns out that he has already managed to visit many hospitals, having deceived an amazing number of medical workers, and almost always was discharged from the clinic against the recommendations of doctors, having previously caused an ugly scandal to doctors and nurses. Patients with this condition tend to have a lot of scarring, which is one of the most characteristic features."

Munchausen's syndrome is observed mainly in adolescence; it is more common among men than among women. Symptoms of any kind may be present, including psychopathological ones; they are accompanied by gross lies (pseudologia fantastica) involving fictitious names and made up medical history (see King and Ford 1988). Some patients with this syndrome intentionally injure themselves; intentional self-infection also occurs. Many of these patients require strong analgesics. Often they try to prevent doctors from obtaining objective information about them and prevent diagnostic tests.

They are always issued ahead of schedule. Upon receipt of more complete information about the patient, it is found that in the past he repeatedly simulated various diseases.

Such patients suffer from a profound personality disorder and often report hardships, hard feelings and hardships suffered in the early periods of life. The prognosis is uncertain, but the outcome seems to be poor more often; however, there are publications about the successful treatment of the syndrome, but such cases are rare.

Munchausen syndrome by proxy

Meadow (1985) described a form of child maltreatment in which parents give false information about the symptoms allegedly observed in their child, and sometimes falsify the signs of the disease. They seek multiple medical examinations of the child's condition and a course of treatment, which in fact is not necessary. Most often in such cases, parents declare the presence of neurological signs, bleeding and rashes of various types. Sometimes children themselves are involved in causing certain symptoms and signs. The syndrome is always associated with the risk of harm to children, including the disruption of learning and social development. The forecast, most likely, unfavorable; some individuals exposed to the treatment described in childhood may develop Munchausen's syndrome by adulthood (Meadow 1985).

SIMULATION

Simulation is the deliberate imitation or exaggeration of symptoms for the purpose of deception. In DSM-IIIR, simulation is classified on axis V and, by definition, differs from artificial (pathomimic) disorder by the presence of external stimuli that motivate the presentation of intentionally caused symptoms, while in artificial disorder there are no such external stimuli, and similar behavior is determined only by an internal psychological need play the role of the patient. Simulation is most often observed among prisoners, the military, and also among those who apply for monetary compensation in connection with an accident. Before making a final decision on the simulation, it is imperative to conduct a full medical examination. If such a diagnosis is finally made, the patient should be tactfully informed about the results of the examination and the conclusions of the doctor. He should be encouraged to look for more adequate methods of solving the problems that prompted the simulation attempt; at the same time, the doctor must take all possible measures to preserve the reputation of the patient.

From the book Official and Traditional Medicine. The most detailed encyclopedia author Uzhegov Genrikh Nikolaevich

author Gelder Michael

Primary Mental Disorders with Paranoid Features As noted in the introduction to this chapter, paranoid features appear in association with primary mental disorders. In clinical practice, such cases are quite common. Because the

From the Oxford Manual of Psychiatry author Gelder Michael

Paranoid states that appear in certain situations The following is information about a number of conditions that occur in special situations, starting with induced psychosis. INDUCED PSYCHOSIS (FOLIE? DEUX)

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11 ORGANIC MENTAL DISORDERS The term "organic mental disorder" is applied to a group of diverse, loosely related disorders. First, it is used to refer to mental disorders that occur in

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SPECIFIC PHYSICAL CONDITIONS CAUSING MENTAL

From the book School Psychologist's Handbook author Kostromina Svetlana Nikolaevna

Mental functions are the most complex multicomponent functional systems that are formed during a person's life and obey certain patterns of development of the psyche. In case of violations, the mental function "does not fall out" and "does not decrease", but only changes its

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author Vyatkina P.

Mental disorders There are several main groups of mental disorders. Psychoses are a pronounced mental pathology, manifested by such disorders as delusions, hallucinations, significant behavioral disorders, mental activity, damage

From the book Complete Medical Diagnostic Handbook author Vyatkina P.

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author Team of authors

11. Mental symptoms

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12. Mental illness

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Chapter 3. Psychosomatic disorders, nervous and mental

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Psychiatry. Mental disorders See also "Complexes", "Nerves" The world is full of madmen; if you don't want to look at them, lock yourself up at home and break the mirror. French saying If it seems to you that everyone has lost their minds, go to a psychiatrist. "Pshekrui" Only those are normal

author Dushenko Konstantin Vasilievich

Diseases See also “Diagnosis”, “Health and well-being”, “Heart attack”, “Sclerosis”, “Cold”, “Psychiatry. Mental disorders”, “Rheumatism”, “Ulcer” A person likes to talk about his illnesses, but meanwhile this is the most uninteresting thing in his life. Anton Chekhov Most of those

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From the book The Big Book of Wisdom author Dushenko Konstantin Vasilievich

Psychiatry. Mental disorders See also "Complexes", "Nerves" The world is full of madmen; if you don't want to look at them, lock yourself up at home and break the mirror. French saying * If you think that everyone has lost their minds, go to a psychiatrist. "Pshekrui" * Normal only

Somatic diseases, consisting in the defeat of individual internal organs (including endocrine) or entire systems, often cause various mental disorders, most often called "somatically conditioned psychoses" (Schneider K.)

K. Schneider proposed to consider the presence of the following signs as a condition for the appearance of somatically conditioned psychoses. 1) the presence of a pronounced clinic of a somatic disease; 2) the presence of a noticeable connection in time between somatic and mental disorders; 3) a certain parallelism in the course of mental and somatic disorders; 4) possible, but not obligatory appearance of organic symptoms.

There is currently no single view on the reliability of this "quadriad".

The clinical picture of somatogenic disorders depends on the nature of the underlying disease, its severity, the stage of the course, the level of effectiveness of therapeutic effects, as well as on such individual properties of the patient as heredity, constitution, premorbid personality, age, sometimes gender, reactivity of the organism, the presence of previous hazards. (the possibility of the reaction of "altered soil" - ZhislinS G).

The section of the so-called somatopsychiatry includes a number of closely related, but at the same time, different groups of painful manifestations in their clinical picture.

First of all, this is actually somatogeny, i.e. mental disorders caused by a somatic factor, which belong to a large section of exogenous-organic mental disorders No less place in the clinic of mental disorders in somatic diseases is occupied by psychogenic disorders (a reaction to a disease not only with a restriction of human life, but also with possible very dangerous consequences).

23.1. Clinical manifestations

Different stages of the disease may be accompanied by different syndromes. At the same time, there is a certain range of pathological conditions that are especially characteristic at present for somatogenic mental disorders. These are the following disorders: I) asthenic; 2) neurosis-like; 3) affective; 4) psychopathic; 5) delusional states; 6) state of clouding of consciousness; 7) organic psychosyndrome.

Chapter 23. Mental disorders in somatic diseases 307

Asthenia is the most typical phenomenon in somatogeny. Often there is a so-called core or through syndrome. It is asthenia at the present time due to the pathomorphosis of somatogenic mental disorders that may be the only manifestation of mental change. In the event of a psychotic state, asthenia, as a rule, can be its debut, as well as completion.

Asthenic conditions are expressed in various ways, but fatigue is always typical, sometimes in the morning, difficulty concentrating, slowing down perception. Emotional lability, increased vulnerability and resentment, quick distractibility are also characteristic. Patients cannot tolerate even slight emotional stress, get tired quickly, become upset over any trifle. Hyperesthesia is characteristic, expressed in intolerance to sharp stimuli in the form of loud sounds, bright lights, smells, touch . Sometimes hyperesthesia is so pronounced that patients are irritated even by low voices, ordinary light, and the touch of linen on the body. Sleep disturbances are common.

In addition to asthenia in its purest form, its combination with depression, anxiety, obsessive fears, and hypochondriacal manifestations is quite common. The depth of asthenic disorders is usually associated with the severity of the underlying disease.

neurotic disorders. These disorders are associated with the somatic status and occur when the latter is aggravated, usually with an almost complete absence or a small role of psychogenic influences. A feature of neurosis-like disorders, in contrast to neurotic ones, is their rudimentary nature, monotony, a combination with autonomic disorders, most often of a paroxysmal nature, is characteristic. However, vegetative disorders can also be persistent, long-term.

affective disorders. For somatogenic mental disorders, dysthymic disorders are very characteristic, primarily depression in its various variants. In the context of a complex interweaving of somatogenic, psychogenic and personal factors in the origin of depressive symptoms, the share of each of them varies significantly depending on the nature and stage of the somatic disease.

In general, the role of psychogenic and personal factors in the formation of depressive symptoms (with the progression of the underlying disease) first increases, and then, with further aggravation of the somatic condition and, accordingly, deepening of asthenia, it significantly decreases.

308 Part III. Private psychiatry

With the progression of a somatic disease, the long course of the disease, the gradual formation of chronic encephalopathy, dreary depression gradually acquires the character of dysphoric depression, with grouchiness, dissatisfaction with others, captiousness, exactingness, capriciousness. Unlike an earlier stage, anxiety is not constant, but usually occurs during periods of exacerbation of the disease, especially with a real threat of the development of dangerous consequences At the late stages of a severe somatic disease with severe symptoms of encephalopathy, often against the background of dystrophic phenomena, asthenic syndrome includes depression with a predominance of adynamia and apathy, indifference to the environment

During a period of significant deterioration of the somatic condition, attacks of anxious and dreary excitement occur, at the height of which suicidal attempts can be made.

psychopathic disorders. Most often they are expressed in the growth of egoism, egocentrism, suspicion, gloom, hostile, wary or even hostile attitude towards others, hysteriform reactions with a possible tendency to aggravate one's state, the desire to constantly be in the center of attention, elements of attitudinal behavior. It is possible to develop a psychopathic state with increasing anxiety, suspiciousness, difficulty in making any decision

Delusional states. In patients with chronic somatic diseases, delusional states usually occur against the background of a depressive, astheno-depressive, anxiety-depressive state. Most often it is a delusion of attitude, condemnation, material damage, less often nihilistic, spoilage or poisoning. doubts with noticeable exhaustion of patients, accompanied by verbal illusions

A state of clouded consciousness. The most frequently observed are episodes of stunning that occur against an asthenic-adynamic background. The degree of stunning in this case can be of a fluctuating nature. The mildest degrees of stunning in the form of obnubilation of consciousness, with a worsening of the general condition, can turn into stupor and even to whom. Delirious disorders are often episodic, sometimes appearing in the form of so-called

Chapter 23 Mental disorders in somatic diseases 309

known abortive deliriums are often combined with stupor or with oneiric (dreaming) states. For severe somatic diseases, such variants of delirium as moussitating and professional with a frequent transition to coma are characteristic, as well as a group of so-called silent delirium Silent delirium and similar conditions are observed with chronic diseases of the liver, kidneys, heart, gastrointestinal tract and can proceed almost imperceptibly to others Patients are usually inactive, are in a monotonous posture, indifferent to the environment, often give the impression of dozing, sometimes muttering something They seem to be present when viewing oneiric pictures Periodically, these onsiroid-like states can alternate with a state of excitation, most often in the form of erratic fussiness. synthesis

Amentative stupefaction in its pure form is rare, mainly with the development of a somatic disease on the so-called altered soil, in the form of a previous weakening of the body emotional lability

The twilight state of consciousness in its pure form in somatic diseases is rare, usually with the development of an organic psychosyndrome (encephalopathy)

Oneiroid in its classical form is also not very typical, much more often it is delirious-oneiroid or oneiric (dreaming) states, usually without motor excitation and pronounced emotional disorders.

The main feature of the syndromes of clouding of consciousness in somatic diseases is their erasure, rapid transition from one syndrome to another, the presence of mixed conditions, the occurrence, as a rule, on an asthenic background.

Typical psychoorganic syndrome. In somatic diseases, it occurs infrequently, occurs, as a rule, with long-term diseases with a severe course, such as, in particular, chronic renal failure or long-term cirrhosis of the liver with symptoms of portal hypertension.

In somatic diseases, the asthenic variant of the psychoorganic syndrome is more common with increasing mental weakness, increased exhaustion, tearfulness, asthenodysphoric mood tint

310 Part III. Private psychiatry