Mental disorders in infectious diseases. Chapter IX Mental Disorders in Infectious Diseases

Mental disorders occur in almost all acute and chronic infections. However, their clinical picture depends on many factors, including the characteristics of the infectious agent (virulence and neurotropism of the pathogen), the nature of the damage to brain structures, the severity of the pathological process, the localization of the disease process, the premorbid personality traits of the patient, his age, gender, etc. P.

Prevalence and Infectious psychosis over the past decades has a noticeable downward trend, while non-psychotic forms of mental disorders of infectious origin are more common. Psychotic disorders most often occur with infectious diseases such as typhus and rabies, and are much less common in diseases such as diphtheria and tetanus. The likelihood of developing psychosis in infectious diseases is determined by a complex of factors, primarily the individual resistance of the patient to the effects of adverse exogenous influences and the characteristics of the underlying infectious disease, and the clinical picture of mental disorders is a reflection of the degree of progression of brain damage.

With a sufficient degree of conditionality, acute (transient) and chronic (protracted) infectious diseases are distinguished, which are also reflected in the clinical picture of mental disorders of infectious origin. At acute infections and exacerbations of chronic diseases, psychopathological symptoms are more pronounced, often accompanied by disorders of consciousness in the form of delirious, amental, oneiric syndromes, stunning, twilight disorder of consciousness (epileptiform disorder). At the same time, chronic psychoses are most often characterized by endoform manifestations (hallucinosis, hallucinatory-paranoid state, apathetic stupor, confabulosis). In some cases, organic, irreversible conditions are formed in the form of psycho-organic, Korsakov's syndrome and dementia.

Depending on the nature of the brain damage, there are:

symptomatic mental disorders resulting from intoxication, impaired cerebral hemodynamics, hyperthermia;

meningoencephalitic and encephalitic mental disorders, caused by inflammatory processes in the membranes, vessels and substance of the brain;

encephalopathic disorders resulting from post-infectious degenerative and dystrophic changes in brain structures.

CLASSIFICATION OF MENTAL DISORDERS IN INFECTIOUS DISEASES

Syndromes of impaired consciousness (non-psychotic changes): obnubilation, stunning, stupor, coma.

Functional non-psychotic syndromes: asthenic, asthenoneurotic, astheno-abulic, apathic-abulic, psychopathic.

Psychotic syndromes: asthenic confusion, delirious, oneiric, amental, twilight state of consciousness, catatonic, paranoid and hallucinatory-paranoid, hallucinatory.

Psychoorganic syndromes: simple psychoorganic, Korsakov's amnestic, epileptiform, dementia.

Clinical manifestations of mental disorders depend on the stage and severity of the infectious disease. So, in the initial (initial) period, the following syndromes most often occur: asthenic, asthenoneurotic (neurosis-like), individual signs of a delirious syndrome. The manifest period of an infectious disease is characterized by the presence of asthenic and asthenoneurotic syndromes, episodes of depression or clouding of consciousness, hallucinosis syndrome, hallucinatory-paranoid, paranoid, depressive and manic-paranoid syndromes are possible.

During the recovery period there are asthenic, asthenoneurotic, psychopathic, psychoorganic syndromes, dementia, epileptiform, Korsakov's amnestic syndrome, residual delirium, other psychotic syndromes (paranoid, hallucinatory-paranoid).

IN lung case the course of an infectious disease, mental disorders are limited to non-psychotic manifestations, while in severe acute infections and exacerbations chronic infections asthenic conditions are accompanied by syndromes of oppression and clouding of consciousness.

Recently, in connection with the pathomorphosis of mental pathology, the most common manifestations of mental disorders in infectious diseases are non-psychotic disorders, represented mainly by asthenic syndrome, which is accompanied by severe autonomic disorders, senestopathic, hypochondriacal, obsessive phenomena, sensory synthesis disorders. Emotional disorders are most often characterized by depressive manifestations, often with a dysphoric tinge - sadness, malice, irritability. With a protracted course of the disease, personality disorders are formed, the character changes, increased excitability or a feeling of self-doubt, anxiety, and concern appear. These symptoms can be quite persistent.

The most common psychotic syndrome in infectious diseases, especially in young age, is delirious syndrome . Infectious delirium is characterized by disorientation in the environment, but sometimes it is possible to attract the patient's attention for a short time, he has vivid visual illusions and hallucinations, fears, ideas of persecution. These symptoms are worse in the evening. Patients see scenes of fire, death, destruction. It seems to them that they are traveling, getting into terrible disasters. Behavior and speech are due to hallucinatory-delusional experiences. The patient may notice pain sensations in different organs, it seems to him that he is being quartered, his leg is amputated, his side is shot through, etc. A double symptom may occur: the patient thinks that his double is next to him. Often, professional delirium develops, during which the patient performs actions characteristic of his profession, ordinary work activity.

Another type of mental disorder that is quite common in infectious diseases is amental syndrome , which usually develops in patients with a severe somatic condition. Amentia is characterized by a deep stupefaction of consciousness, a violation of orientation in the environment and in the personality itself. There may be a sharp psychomotor agitation, hallucinatory experiences. Thinking is incoherent, patients are confused. The excitation is monotonous, within the limits of the bed, the patient rushes about in disorder from side to side (yactation), shudders, stretches out, may try to run somewhere, feels fear. Such patients require strict supervision and care.

Oneiroid syndrome in infectious diseases it is characterized by the presence of stupor or psychomotor agitation; patients feel a change in the world around them, anxiety, fear. Their experiences are dramatic, fantastic. The affective state is extremely unstable. Patients can be active participants in the events they see.

Amnestic disorders rarely occurs in transient psychoses. They are represented by transient retrograde or anterograde amnesia. As infectious psychosis decreases, patients develop asthenia with emotional hyperesthesia, irritability, tearfulness, severe weakness, intolerance to loud sounds, light and other external stimuli.

Protracted (protracted) psychosis can occur with a protracted or chronic infection. In these cases, mental disorders often occur without clouding of consciousness. There is a depressive-paranoid or manic syndrome with elevated mood, rich speech production. In the future, ideas of persecution, hypochondriacal delusions, hallucinatory experiences may arise. In the initial states, prolonged asthenia occurs, and in an unfavorable course, a Korsakovsky or psychoorganic syndrome may form.

Mental disorders in syphilitic infection Syphilitic damage to the brain is divided into: 1) early neurosyphilis (actual syphilis of the brain), the morphological substrate of which is the primary lesion of mesodermal tissues (vessels, membranes); 2) late neurosyphilis (progressive paralysis and tuberculosis spinal cord), in which a combination of mesenchymal manifestations and significant atrophic changes in the brain parenchyma is determined.

Mental disorders in neurosyphilis can occur on different stages disease, most often in the tertiary or secondary period of the course of the disease, 5-7 years after infection. The etiological factor of the disease is pale treponema. The incubation period of progressive paralysis lasts much longer (8-12 years or more). Neurosyphilis is characterized by a progressive course.

There are the following forms of syphilis of the brain: syphilitic pseudoneurasthenia; hallucinatory-paranoid form; syphilitic pseudoparalysis; epileptiform form; apoplectiform syphilis; pseudotumorous syphilis; syphilitic meningitis; congenital syphilis.

Syphilitic pseudoneurasthenia due to both a reaction to the very fact of the disease with syphilis, and general intoxication of the body and brain. The disease is characterized by the development of neurosis-like symptoms in the form of headache, increased irritability, sleep disturbance, fatigue, mood deterioration, anxiety, and depression.

Hallucinatory-paranoid form characterized by the occurrence of perceptual disorders and delusional ideas. Hallucinations are most often auditory, but visual, tactile, visceral, etc. are possible. Patients hear calls, sometimes music, but most often unpleasant conversations, threats, accusations and cynical statements addressed to them. Visual hallucinations, as a rule, are also unpleasant and even frightening: the patient sees terrible muzzles, shaggy hands reaching for his throat, running rats. The patient often retains a critical attitude towards hallucinations, especially when they are weakened.

Crazy ideas are most often simple, they are devoid of symbolism, presented in the form of delusions of persecution, less often hypochondria, grandeur, self-accusation; their plot is often associated with hallucinations.

In the neurological status of patients, mild diffuse changes are noted. Characterized by anisocoria and sluggish reaction of pupils to light. There are asymmetry of the face, slight ptosis, deviation of the tongue to the side, etc.

With the development syphilitic pseudoparalysis patients are characterized by benevolence, euphoria against the background of memory impairment, dementia. Crazy ideas of greatness of fantastic content may be noted.

epileptiform form syphilis of the brain is characterized by the development of convulsive paroxysms, periods of altered consciousness and mood, memory loss. Neurological symptoms in this form are determined by the nature of the brain damage: meningitis, meningoencephalitis, endarteritis of small vessels, gum formation.

Apoplectiform form syphilis of the brain is the most common. It is based on a specific lesion of the vessels of the brain. Clinical manifestations are frequent strokes followed by focal lesions, which become more and more numerous and permanent as the disease progresses. Significant neurological disorders depend on the location of the lesion and are represented by paralysis and paresis of the limbs, lesions cranial nerves, apraxia, agnosia, pseudobulbar phenomena, etc. Almost constant sign is a weakening of the reaction of the pupil to light. Patients often have a headache, confusion, memory loss, irritability, pickiness, weakness, depression. There are episodes of clouding of consciousness, mainly of the twilight type. As the severity of neurological symptoms increases, lacunar dementia with Korsakov's syndrome develops. Possible death during a stroke.

Hummous (pseudotumorous) form neurosyphilis is less common than others. The clinical picture is characterized mainly by focal symptoms and is determined by the localization and size of the gums. There may be symptoms characteristic of a brain tumor: increased intracranial pressure, vomiting, severe headache, weakness, less often - clouding of consciousness, convulsive states. An ophthalmological examination reveals congestive optic nipples.

Syphilitic meningitis develops mainly in the secondary period of syphilis and is characterized by the development of cerebral symptoms in the form of headache, confusion, vomiting, fever, the appearance of typical meningeal symptoms (Kernig, neck muscle stiffness), cranial nerve damage. Often there are epileptiform convulsions and symptoms of clouding of consciousness such as stunning, confusion or delirium.

Most often, the inflammatory process in the membranes of the brain proceeds chronically, affecting the substance of the brain (chronic syphilitic meningitis and meningoencephalitis). Patients have headache, irritability, affective reactions, often depressed mood, severe cranial nerve pathology (ptosis, strabismus, anisocoria, nystagmus, hearing loss, damage to the facial and trigeminal nerves, etc.). Agraphia, apraxia, hemi- and monoplegia are also possible. Pupillary symptoms are characteristic in the form of anisocoria, pupillary deformity, sluggish reaction to light and accommodation; at the same time, the Argyle-Robertson symptom does not always appear.

congenital syphilis characterized by the development of meningitis, meningoencephalitis, vascular lesions of the brain. It is also possible to develop hydrocephalus. The characteristic clinical manifestations of the disease are paroxysmal states (apoplectiform and especially epileptiform seizures), the development of oligophrenia, and psychopathic states. Congenital syphilis is characterized by the presence of the Getchinson triad (curvature of the limbs, jagged edges teeth, saddle nose).

Pathological anatomical substrate of neurosyphilis are meningitis and meningoencephalitis, endarteritis, gummous nodes. In leptomeningitis, the inflammatory process is most often localized at the base of the brain, characterized by tissue infiltration with lymphocytes, plasma cells, and fibroblasts. The course of endarteritis can be complicated by the development of hemorrhagic or ischemic strokes. The clinical picture during the formation of gummous nodes depends on their size and localization, most often resembling the clinic of a brain tumor. Intoxication, altered reactivity of the body, and metabolic disorders also play an important role in the development of neurosyphilis.

Diagnosis of syphilis the brain is carried out on the basis of a complex mental, somato-neurological and serological examination of the patient. When assessing the neurological status, the presence of the Argyle-Robertson symptom, anisocoria, and pupillary deformity are taken into account. In laboratory studies of blood and cerebrospinal fluid, the reactions of Wassermann, Lange are evaluated.

Unlike progressive paralysis, syphilis of the brain is characterized by an earlier onset (against the background of primary, secondary or tertiary syphilis), differs in the polymorphism of the clinical picture, dementia is less common and has a lacunar character. The Lange reaction in syphilis of the brain has a characteristic "tooth". The course and prognosis of the disease are more favorable.

Treatment of syphilis of the brain carried out with the help of antibiotics, bismuth and iodine preparations (biyoquinol, bismoverol, potassium iodide, sodium iodide), vitamin therapy. Psychotropic drugs are prescribed taking into account the main psychopathological syndrome.

Labor and forensic psychiatric examination of brain syphilis is based on the clinical picture. The patient can be declared insane when committing a crime under the influence of delusional ideas or with severe dementia.

progressive paralysis- a disease that is characterized by the development of organic total progressive dementia with a gross violation of intelligence, emotions, memory, attention, critical assessment of behavior. The morphological basis of progressive paralysis is degeneration and atrophy. nervous tissue, inflammatory changes in the membranes and vessels of the brain, proliferative reaction of neuroglia.

The etiological factor of progressive paralysis is pale treponema. The disease develops only in 5-10% of people with syphilis, which is due to changes in the body's reactivity, as well as the availability and quality of the treatment of the early stages of syphilis. At present, the disease is rare. The incubation period is 10-15 years. Men aged 35-45 are more often ill.

Allocate three stages of progressive paralysis: 1) initial (pseudoneurasthenic); 2) the heyday of the disease and 3) terminal (marasmus stage).

Pseudoneurasthenic stage of progressive paralysis characterized by the development of neurosis-like symptoms in the form of numerous somatic complaints. In patients, general weakness, weakness, fatigue, irritability increase, headache appears, sleep is disturbed, and working capacity decreases. There are complaints of shooting pains of the radicular type in the lumbar region, back of the thighs, back of the forearms, in the fingers and toes. These symptoms are accompanied by behavioral disorders with loss of ethical habits and self-control. Patients allow inappropriate and vulgar jokes, behave cheekily, rudely, become untidy, tactless, cynical. Work is treated carelessly, irresponsibly. Patients do not feel emotional experiences and anxiety in connection with a decrease in working capacity, they become carefree.

During disease development memory disorder and weakness of judgments increase, the self-criticism of the state decreases even more. Total dementia develops. Rough sexual promiscuity is observed, the sense of shame is completely lost. Patients can commit senseless, rash acts, borrow and spend money, buying unnecessary things. Characterized by lability of emotions, easily arising short-term outbursts of irritation up to expressed anger. It is also possible to develop delusional ideas, especially delusions of grandeur, wealth, which are distinguished by absurdity and grandiose size, less often - ideas of persecution, hypochondriacal delusions. Occasionally there are hallucinations, mostly auditory. Mental disorders stage II determine the clinical form of progressive paralysis.

Terminal stage of the disease most often develops within 1.5-2 years from the onset of the first symptoms of progressive paralysis. It is characterized by deep dementia, complete mental and physical marasmus. Not only the disintegration of the intellect is observed, but also the loss of elementary skills of neatness, self-service. Trophic processes are disturbed, hair loss, brittle nails, trophic ulcers are observed. The causes of death of patients are cerebral hemorrhage, dystrophic changes in internal organs, pneumonia.

Clinical forms of progressive paralysis:

The expansive (classic, manic) form is characterized by the development against the background of total progressive dementia of pronounced euphoria, ridiculous ideas of greatness, gross exposure of instincts, and motor excitement. Brief outbursts of anger are possible.

The dementia form is currently the most common (up to 70% of all cases). It is characterized by the development of total dementia, emotional dullness, decreased activity. Patients are inactive, eat a lot, as a result of which they become stout. The face becomes pasty, amimic.

The depressive form is characterized by the development of a depressive-hypochondriac state: patients are lethargic, depressed, they often have delusional ideas of self-accusation. Ideas of hypochondriacal content also do not make sense and can reach the delirium of Cotard.

The hallucinatory-paranoid form of progressive paralysis is characterized by the presence of delusional ideas of persecution in combination with hallucinations.

Atypical forms of progressive paralysis include:

1. Juvenile form (children's and youthful progressive paralysis). The disease develops as a result of intrauterine infection with syphilis and manifests itself at the age of 6-7 to 12-15 years. The most characteristic are acute onset, epileptiform seizures, a rapid increase in general dementia with severe speech disorders up to its complete loss. Patients become apathetic and inactive, very quickly lose their acquired knowledge and interests, and discover ever-increasing memory disorders. Somato-neurological status of patients includes the Hutchinson triad, poor muscle development, frequent cerebellar symptoms, optic nerve atrophy, complete pupillary areflexia.

Taboparalysis is characterized by a combination of damage to the brain and spinal cord. In the clinical picture of the disease, against the background of general dementia, symptoms of dysfunction of the spinal cord develop in the form of the complete disappearance of the knee and Achilles reflexes, impaired sensitivity, especially pain.

Lissauer's paralysis (rare form). It is characterized by a combination of symptoms of dementia with focal neurological symptoms (apraxia, agnosia).

neurological disorders. Of the neurological disorders, it should be noted Argyle-Robertson's symptom (lack of pupillary response to light while maintaining its convergence and accommodation), sharp miosis, anisocoria, and pupillary deformity. Often there is asymmetry of the nasolabial folds, ptosis, mask-like face, deviation of the tongue to the side, separate fibrillar twitching of the circular muscles of the mouth, dysarthria appears early. The speech of patients is fuzzy, with omissions of individual words or, conversely, repeated repetition of any syllables (logoclonia). Scanned speech, rhinolalia are possible.

The handwriting of patients changes, becomes uneven, trembling, coordination of fine movements is disrupted, while writing, more and more gross errors appear in the form of omissions or permutations of syllables, replacement of some letters by others, repetition of the same syllables. There is a violation of coordination of movements, changes in tendon reflexes in the form of anisoreflexia, an increase, decrease or absence of knee and Achilles reflexes, as well as a pronounced decrease in sensitivity are often found. The appearance of pathological reflexes is possible. Often disrupted innervation pelvic organs. Sometimes epileptiform seizures develop, especially in stage III of the disease, when seizure statuses occur.

Somatic disorders in progressive paralysis are due to the presence of syphilitic mesaortitis, specific lesions of the liver, lungs, skin and mucous membranes. Possible trophic disorders skin up to the formation of ulcers, increased fragility of bones, hair loss, the occurrence of edema. Even with a good and increased appetite, sharply progressive exhaustion is possible. There is a decrease in the body's resistance, intercurrent infections easily occur.

In the diagnosis of progressive paralysis, it is necessary to take into account the data of a serological study: in the cerebrospinal fluid, the Wassermann reaction, the immobilization reaction of pale treponema (RIT) and the immunofluorescence reaction (RIF) are sharply positive, pleocytosis, an increased amount of protein, a change in the ratio of protein fractions with an increase in the amount of globulins, in particular gammaglobulin. The Lange reaction is very indicative, which gives a complete discoloration of colloidal gold in the first 3-4 test tubes, and then gradually changes the pale blue color to the usual one ("paralytic bucket").

The course of progressive paralysis depends on the clinical form. Galloping paralysis proceeds most malignantly, in which somato-neurological and psychopathological changes rapidly increase. In the absence of treatment, progressive paralysis after 2 years - 5 years leads to complete insanity and death.

Treatment of progressive paralysis consists in the use of combined specific therapy: antibiotics (penicillins, erythromycin), bismuth and iodine preparations (biyoquinol, bismoverol, potassium iodide, sodium iodide), which are prescribed repeatedly (5-6 courses with an interval of 2-3 weeks) in combination with lyrotherapy, most often with the use of pyrogenal. In the process of pyrotherapy, it is important to carefully monitor the somatic condition of the patient (especially cardiac activity), with each rise in body temperature, in order to avoid heart weakness, prescribe cardiac agents, best of all cordiamine.

The role of the zemstvo doctor Rozemblyum, who worked in Odessa, should be emphasized, who was the first to propose the use of relapsing fever vaccines in the treatment of progressive paralysis. This idea was subsequently supported by Wagner-Jaureg and proposed the use of malaria vaccination as a therapy.

The prognosis for life and recovery is determined by the timing and quality of the therapy.

Expertise. Patients with severe irreversible mental disorders are recognized as disabled. The degree of disability is determined by the severity mental state. After the disease encephalitis and | often) meningitis reduces the ability to work. Patients who have committed socially dangerous acts in a state of infectious psychosis are recognized as insane. Expert evaluation in residual mental disorders is determined by their severity. Patients with short-term mental disorders after treatment are recognized as fit for military service. In the presence of persistent and pronounced disorders of mental activity, patients are recognized as unfit for military service.

Mental disorders in acquired immunodeficiency syndrome

Acquired Immune Deficiency Syndrome (AIDS) is one of the most dramatic and mysterious problems of modern medicine.

Etiology and pathogenesis. Human Immunodeficiency Virus Infection Unparalleled in History medical science and poses a direct threat to the survival of mankind.

Acute (transient) and chronic (protracted) infectious diseases are distinguished, which is also reflected in the clinical picture of mental disorders of infectious genesis: in acute infections and exacerbations of chronic diseases, psychopathological symptoms are more vivid and expressive, often accompanied by disorders of consciousness in the form of delirious, amental, oneiric syndromes, stupor, twilight disorder of consciousness (epileptiform excitation). At the same time, chronic psychoses are more often characterized by endoform manifestations (hallucinosis, hallucinatory-paranoid syndrome, apathetic stupor, confabulosis). In some cases, organic, irreversible conditions are formed in the form of psycho-organic, Korsakov's syndrome and dementia.

Depending on the nature of the brain damage, there are: 1) symptomatic mental disorders resulting from intoxication, impaired cerebral hemodynamics, hyperemia; 2) meningoencephalitic and encephalitic mental disorders, caused by inflammatory processes in the membranes, vessels and substance of the brain; 3) encephalopathic disorders resulting from post-infectious degenerative and dystrophic changes in brain structures.

Classification of mental disorders of infectious genesis:

a) Syndromes of oppression of consciousness (non-psychotic changes): obnubilation, stupor, stupor, coma; b) functional non-psychotic syndromes: asthenic, astheno-neurotic, astheno-abulic, apathetic-abulic, psychopathic; c) psychotic syndromes: asthenic confusion, delirious, oneiroid, amental, twilight state of consciousness, catatonic, paranoid and hallucinatory-paranoid, hallucinosis; d) psychoorganic syndromes: simple psychoorganic, Korsakovsky amnestic, epileptiform, dementia, parkinsonism.

Clinical manifestations of mental disorders depend on the stage and severity of the infectious disease. So, in the initial (initial) period, syndromes occur more often: asthenic, astheno-neurotic (neurosis-like), individual signs of a delirious syndrome. The manifest period of an infectious disease is characterized by the presence of asthenic and asthenic-neurotic syndromes, syndromes of depression of consciousness, clouding of consciousness, hallucinosis syndrome, hallucinatory-paranoid, paranoid, depressive and manic-paranoid syndromes. In the period of convalescence, there are asthenic, astheno-neurotic, psychopathic, psychoorganic syndromes, dementia, epileptiform, Korsakovsky amnestic syndrome, residual delirium, other psychotic syndromes (paranoid, hallucinatory-paranoid).

When light flow In an infectious disease, mental disorders are limited to non-psychotic manifestations, while in severe acute infections and exacerbations of chronic infections, asthenic conditions are combined with syndromes of depression and clouding of consciousness.

Recently, in connection with the pathomorphosis of mental pathology, the most frequent manifestations of mental disorders in infectious diseases are violations of non-psychotic, border level, mainly represented by asthenic syndrome, which is accompanied by severe vegetative disorders, senestopathic, hypochondriacal, obsessive phenomena, sensory synthesis disorders. Emotional disorders are more often characterized by depressive manifestations, often with a dysphoric tinge - with melancholy, malice, irritability. With a protracted course of the disease, personality shifts are formed, character changes, excitability or features of self-doubt, anxiety, suspiciousness appear. These symptoms can be quite persistent.

The most common psychotic syndrome in infectious diseases, especially at a young age, is a delirious syndrome. Infectious delirium is characterized by disorientation in the environment, bright visual illusions and hallucinations, fear, delusions of persecution. These symptoms are worse in the evening. Patients see scenes of fire, death, destruction. It seems to them that they travel, fall into terrible disasters. Behavior and speech are due to hallucinatory-delusional experiences. The patient may experience pain in various bodies, it seems to him that he is being quartered, his leg amputated, shot through his side, etc. There may be a symptom of a double: it seems to the patient that his double is next to him. Often, professional delirium develops, during which the patient performs actions characteristic of his profession, ordinary work activity.

Another fairly common type of mental disorder in infectious diseases is the amental syndrome, which usually develops in patients with a severe somatic condition. Amentia is characterized by a deep stupefaction of consciousness, a violation of orientation in the environment and one's own personality. Perhaps a sharp psychomotor agitation, hallucinatory experiences. Thinking is incoherent, incoregent, patients are confused. The excitation is monotonous, within the limits of the bed, the patient randomly rushes from side to side (yactation), shudders, stretches out, may try to run somewhere, is afraid. Such patients need strict supervision and care.

Oneiroid syndrome in infectious diseases is accompanied by stupor or psychomotor agitation; patients are detached from the outside world, anxious, fearful. Their experiences are dramatic, fantastic. The affective state is very unstable. Patients can be active participants in the events they see.

Protracted (protracted) psychoses can occur with a protracted or chronic infection. In these cases, mental disorders often occur without clouding of consciousness. Depressive-paranoid or manic syndrome is noted. In the future, ideas of persecution, hypochondriacal delusions, hallucinatory experiences may arise. In the initial states, prolonged asthenia occurs, and in an unfavorable course, a Korsakoff or psychoorganic syndrome may form.

Mental disorders in encephalitis are represented by acute psychoses with clouding of consciousness, affective, hallucinatory, delusional and catatonic disorders, the development of psycho-organic and Korsakov's syndromes.

Epidemic encephalitis (lethargic encephalitis, Economo's encephalitis) is a disease with a viral etiology. For the acute stage of the disease lasting from 3-5 weeks to several months, sleep disturbance is characteristic, more often in the form of drowsiness. Often, drowsiness occurs after delirious or hyperkinetic disorders. Sometimes patients may experience persistent insomnia. These disorders are caused by the vascular-inflammatory and infiltrative process in the gray matter of the brain. Psychotic disorders in the acute stage of the disease are manifested by delirious, amental and manic syndromes. In the delirious form, impaired consciousness may precede the appearance of neurological symptoms in the form of paresis of the oculomotor and especially abducens nerves, diplopia, and ptosis. Delirium is characterized by the occurrence of polymorphic hallucinations of a dreamlike, frightening nature, or elementary visual (lightning, light); auditory (music, ringing), verbal and tactile (burning) perceptual deceptions. The plot of hallucinations in epidemic encephalitis reflects the events of the past. Often develops professional delirium. Perhaps the development of delusional ideas. Delirium often develops against the background of general intoxication (fever, severe hyperkinesis, vegetative disorders); with a severe course of the disease, mushing delirium is possible. With the amental-delirious form, the delirious syndrome is replaced by an amental syndrome after a few days. The duration of this form is 3-4 weeks, after which there is a disappearance of psychopathological symptoms and subsequent asthenia. The outcome of the acute stage is different. During periods of epidemics, about a third of patients die at this stage of the disease. Perhaps full recovery, but more often it is apparent, since after a few months or years symptoms of the chronic stage are revealed.

The chronic stage is accompanied degenerative changes in nerve cells and secondary growth of glia. In her clinical picture, the leading symptoms of parkinsonism are: muscle rigidity, a peculiar posture of the patient with arms brought to the body and slightly bent knees, constant tremor of the hands, slowing down of movements, especially when performing arbitrary acts, the patient falling back, forward or sideways when trying to move (retro -, antero- and lateropulsion). Personality changes in the form of bradyphrenia are characteristic (significant weakness of motives, decreased initiative and spontaneity, indifference and indifference). Parkinsonian akinesia can be interrupted suddenly by short, very fast movements. observed and paroxysmal disorders(convulsions of gaze, violent attacks of screaming - klasomania, episodes of dream-like clouding of consciousness with oneiric experiences). Described and relatively rare cases hallucinatory-paranoid psychoses, occasionally even with the Kandinsky-Clerambault syndrome, as well as prolonged catatonic forms.

For the acute stage of tick-borne (spring-summer) and mosquito (summer-autumn) encephalitis, symptoms of clouding of consciousness are characteristic. In the chronic stage, the syndrome of Kozhevnikov epilepsy and other paroxysmal disorders (psychosensory disorders, twilight disorders of consciousness) are most common.

The most severe encephalitis, which always occurs with mental disorders, is rabies. In the first (prodromal) stage of the disease, general well-being worsens, depression and hyperesthesia occur, in particular to the movement of air (aerophobia). In the second stage, against the background of an increase in body temperature and headaches, motor restlessness and agitation increase. Patients develop depression, fear of death, often there are delirious and amental states, convulsions, speech disorders, increased salivation, tremor. Characteristic is hydrophobia (hydrophobia), which consists in the appearance of convulsive spasms in the larynx, suffocation, often with motor excitation, even at the idea of ​​water. In the third stage (paralytic), paresis and paralysis of the limbs occur. Speech disorders intensify, there is a stupor, turning into a stupor. Death occurs with symptoms of paralysis of the heart and breathing. The course of the disease in children is more rapid and catastrophic, the prodromal stage is shorter.

Mental disorders in meningitis can be different and depend on the nature of the inflammatory process in the brain. Prodromal period of meningococcal purulent meningitis characterized by the presence asthenic symptoms. During the height of the disease, states of stupor, episodes of delirious and amental clouding of consciousness are mainly observed, in the most severe cases, the development of soporous and coma is possible.

The course of mental disorders in infectious diseases has age-related features. So, in children with acute infections, which are manifested by an increase in body temperature, mental disorders are vivid with general disinhibition, obstinacy, anxiety, attacks of fear, nightmares, delirium episodes with frightening hallucinations. In the initial period of an infectious disease, children may complain of general weakness, headache, sleep disturbance (difficulty falling asleep, night terrors), capriciousness, tearfulness, individual visual hallucinations, especially at night. During the manifest period, there may be episodes of asthenic confusion, fear and febrile delirium. The originality of the initial (residual) period of an infectious disease lies in its influence on the further mental development of the child. Under adverse conditions (in case of brain damage of infectious etiology, with insufficient treatment, overload at school, unfavorable family environment, etc.), the formation of psychophysical infantilism, oligophrenia and psychopathic personality development, epileptiform syndrome is possible.

Children in the acute stage of infection often develop stupor, stupor and coma, predelirious states: irritability, moodiness, anxiety, anxiety, hypersensitivity, weakness, superficiality of perception, attention, memorization, hypnagogic illusions and hallucinations. In children under 5 years of age, convulsive states, hyperkinesis are frequent, while productive symptoms are very rare in them and manifest themselves in motor excitation, lethargy, rudimentary delirious states, and illusions.

In the period of convalescence in children on the background asthenic syndrome there may be fears, psychopathic disorders, puerile forms of behavior, memory loss for current events, a delay in psychophysical development. In epidemic encephalitis, children and adolescents develop psychopathic disorders, impulsive restlessness, drive disorders, foolishness, antisocial behavior, inability to systematic mental activity in the absence of dementia. Meningitis in children younger age accompanied by lethargy, adynamia, drowsiness, stunning with periods of motor restlessness. Convulsive paroxysms are possible.

In the elderly, infectious psychoses often proceed abortively, with a predominance of asthenic and asthenic-abulic manifestations. Gender differences are characterized by a higher frequency infectious psychoses in women than in men.

The diagnosis of infectious psychosis can only be established in the presence of an infectious disease. Acute psychoses with impaired consciousness syndromes most often develop against the background of acute infectious diseases, protracted psychoses are characteristic of under acute course infectious disease.

Treatment of infectious psychoses is carried out in psychiatric hospitals or infectious diseases hospitals under the supervision of a psychiatrist and staff supervision and includes active treatment the underlying disease in the form of immunotherapy, antibiotics, detoxification, dehydration, restorative therapy. Purpose psychotropic drugs is carried out taking into account the leading psychopathological syndrome.

In acute infectious psychoses with clouding of consciousness, acute hallucinosis, antipsychotics are indicated. Treatment of protracted psychoses is carried out with neuroleptics, taking into account psychopathological symptoms: chlorpromazine and other antipsychotics with sedative effect. In depressive conditions, antidepressants are prescribed, which, with agitation of patients, can be combined with neuroleptics. Nootropic drugs are widely used in Korsakoff and psychoorganic syndromes. In patients with long-term protracted psychoses, as well as irreversible psychoorganic disorders, it is important to rehabilitation measures including adequately addressing social and labor issues.

Acute infectious psychoses usually pass without a trace, but often after infectious diseases there is severe asthenia with emotional lability, hyperesthesia. Prognostically unfavorable is the occurrence of excruciating delirium with a deep stupefaction of consciousness, a pronounced excitation in the form of erratic throwing, especially if this condition persists with a drop in body temperature. Protracted psychoses can lead to personality changes according to the organic type.

INFECTIOUS PSYCHOSIS- a group of mental illnesses caused by infections.

Not all psychoses that develop in infectious diseases are symptomatic; there are frequent cases when an infection provokes an endogenous mental illness (schizophrenia, manic-depressive psychosis, etc.). Depending on duration and intensity of the intoxication acting on an organism And. and. may proceed differently.

Distinguish between acute infectious (symptomatic) psychoses, in most cases proceeding with clouding of consciousness, and Protracted, or intermediate, infectious (symptomatic) psychoses with a predominance of endoform pictures.

At long and intensive influence of intoxication on a brain the picture of organic psychosis can develop (see).

Clinical picture

Acute infectious (symptomatic) psychoses occur with a wedge, pictures of stunning (see), delirium (see Delirious syndrome), amentia (see Amentative syndrome), epileptiform excitation, acute hallucinosis (see Hallucinations) and oneiroid (see Oneiric syndrome).

Epileptiform excitation - a sudden disorder of consciousness with a sharp excitement and fear. The patient rushes about, runs from imaginary pursuers, repeats the same words, screams, on his face - an expression of fear, horror. Psychosis ends in the same way as it arises - suddenly. It is replaced by a deep, often soporous sleep; sometimes psychosis can turn into a picture of amentia, which should be considered a prognostically unfavorable sign. Often, epileptiform excitation may precede a detailed picture of an infectious disease, occurring during initial period illness; during this period, before the appearance of epileptiform excitation, delirium may develop.

Acute verbal hallucinosis develops suddenly with the appearance of verbal hallucinations of various content. Hallucinations are accompanied by confusion, fear, anxiety. Under the influence of hallucinations, especially imperative content, certain dangerous actions can be performed in relation to others or one's own personality.

Verbal hallucinosis tends to get worse at night. The duration of the described state is from several days to a month or more.

Oneiroid states are characterized by complete detachment of patients from the environment, the dramatic content of often fantastic events that arise in the imagination of patients, Active participation in them. Motor restlessness in most cases is manifested by confused and fussy excitement. The effect is highly variable. Ecstasy, fear, anxiety prevail.

In some cases, patients develop a picture resembling oneiroid - a oneiroid-like state with involuntary fantasizing, lethargy, aspontaneity, and detachment. At the same time, patients find the correct orientation in place and time, surrounding persons, and their own personality. This state can be interrupted external influence: call, touch.

It is possible to develop delirious-oneiric (dream) states, in which dream disorders with a fabulous, fantastic or everyday theme come to the fore, and patients are active participants in events, then abundant colorful, nari oramically e scene-like visual hallucinations, when patients feel like spectators or victims. Patients usually experience anxiety, fear, horror.

After infectious diseases with a picture of acute symptomatic psychoses, a state of emotional-hyperesthetic weakness is observed with severe asthenia, extreme lability of affect, intolerance to slight emotional stress, loud sounds, bright light, etc. In some cases, this condition precedes the onset of acute I. p., its development in the prodrome of the disease indicates the severe nature of the developing infectious disease.

Protracted infectious (symptomatic) psychoses occur with a picture of depression, a depressive-paranoid and hallucinatory-paranoid state, with a picture of manic disorders, confabulosis (see), transient Korsakov's syndrome (see).

Depressive states in some cases are accompanied by ideational and motor retardation and outwardly resemble the phase of manic-depressive psychosis (see), differing from it by constant asthenia, which increases in the evening. In other cases, the picture of depression is similar to that of involutionary melancholia: patients are excited, agitated, anxious, repeating the same words or phrases. The difference lies in the gradual weakening of excitation, in asthenia, tearfulness. In the evening and at night, episodes of delirium are not uncommon. The change of the described states by disorders of a depressive-paranoid nature is a sign of the increasing severity of an infectious disease.

Depressive-paranoid states are characterized by the presence of verbal hallucinations, delusions of condemnation, nihilistic delusions. At the same time, there are always asthenic disorders, tearfulness, delirious episodes.

It is possible to change the depressive-paranoid state into a hallucinatory-paranoid state, which is an indicator of deterioration somatic condition sick.

Hallucinatory-paranoid states according to the wedge, the picture is close to acute paranoid with delusions of persecution, verbal hallucinations and illusions, false recognitions. A feature of these hallucinatory-delusional states is asthenia and the frequent disappearance of disorders with a change of scenery. In severe cases, hallucinatory-paranoid states are replaced by a picture of apathetic stupor.

Apathetic stupor - a state of immobility, aspontaneity, accompanied by a feeling of apathy, indifference, indifference to what is happening around and to one's own state. The picture of an apathetic stupor must be distinguished from a state of depression with lethargy.

Manic states are manifested by unproductive cheerful manias with inactivity, often with the development of their pseudo-paralytic states with euphoria at a height.

Confabulosis is a psychosis expressed by patients' fictional stories about exploits, adventures, incredible events, but not accompanied by memory disorders, clouding of consciousness. Typically elevated mood, however, the story about the events allegedly taking place, the patients are calm, in the tone of a "chronicler".

Transient Korsakoff's syndrome is manifested by memory disorders for present events (fixation amnesia), accompanied by disorientation in the environment (amnestic disorientation), with relative preservation of memory for past events. Its peculiarity is the transient nature of the memory disorder, which is then completely restored.

All the disorders described are not only accompanied by, but also leave behind a long-term asthenia. In a number of cases, after protracted (infectious) psychoses, organic personality changes are observed, expressed to one degree or another - psychopathic changes, sometimes an organic psychosyndrome.

Psychosis in various infectious diseases

With influenza, acute symptomatic psychoses occur in the form of delirium or epileptiform excitation, protracted - in the form of protracted depressive states with asthenia and tearfulness. In severe cases, psychopathic states can be observed and the development of an organic psychosyndrome is possible. In viral pneumonia, the occurrence of protracted psychoses in the form of prolonged depressions with agitation, anxiety and hallucinatory-delusional psychoses.

Often, mental disorders are observed in typhus. In the acute period of the disease, psychoses usually occur, proceeding with clouding of consciousness. In cases with a severe course, depressive-paranoid states, hallucinatory-paranoid disorders, as well as pictures of confabulosis are observed. After typhus with mental disorders, severe asthenia always remains, psychopathic personality changes can be observed, and in some cases an organic psychosyndrome.

Mental disorders in other infectious diseases - see Rabies, Brucellosis, Viral hepatitis, Dysentery, Measles, Malaria, Meningitis, Erysipelas, Scarlet fever, Toxoplasmosis, Respiratory tuberculosis, Encephalitis.

To I. p. include psychoses associated with postpartum septic processes. They have a similar wedge, a picture with schizophrenia and manic-depressive psychosis, provoked by childbirth. Often there are amental states with catatonic disorders and manic states with confusion. The presence of delirious episodes and the development of catatonic disorders at the height of the amental state indicate infectious psychosis, while the development of amentia following catatonic excitation is more characteristic of schizophrenia.

There are cases of puerperal psychosis, accompanied by hyperazotemia, albuminuria, increased blood pressure with a fatal outcome.

The onset of psychosis two weeks or more after childbirth with uncomplicated postpartum period calls into question the diagnosis of infectious psychosis.

Etiology and pathogenesis

The same cause can cause acute and protracted symptomatic psychoses, and in some cases lead to an organic psychosyndrome.

The point of view has become widespread that acute psychoses with clouding of consciousness occur when exposed to intense, but short-acting harmfulness, while Protracted psychoses, approaching the wedge, manifestations of endogenous, occur with prolonged exposure to harmfulness of a weaker intensity. Of great importance age factor: in elderly patients, for example, I. p. proceed abortively. The constitutional and genetic factor also has a certain significance in the development of I. p.

As a result of the evolution of the relationship between the pathogen and the human body and the emergence of effective methods of treatment, the course of infectious diseases and infectious psychoses has changed. This is manifested by a decrease in the number of acute psychotic states that occur with clouding of consciousness, and the predominance of endoform psychoses (primarily depression, depressive-paranoid and hallucinatory-paranoid states).

Diagnosis

The diagnosis is possible if the patient is diagnosed with an infectious disease, and also if the wedge, the picture of psychosis is typical for exogenous types of reactions (acute or protracted infectious psychoses). The acute course of an infectious disease is characterized by acute I. p., manifested in most cases by one or another type of clouding of consciousness, while subacute and hron, the course of infectious diseases, as a rule, is accompanied by the development of psychoses of a protracted character.

Differential Diagnosis I. p. causes certain difficulties. They should be distinguished from endogenous psychoses (most often attacks of schizophrenia or phases of manic-depressive psychosis) provoked by infection. In these cases, the onset of psychosis may be similar to that of acute symptomatic psychosis, but as the attack develops mental illness the endogenous structure of psychosis comes to light more and more clearly. Often, differentiation is necessary I. p. febrile seizures schizophrenia, which in all cases begin with a state of catatonic excitation or stupor with oneiroid stupefaction, which is not typical and not typical for I. p. With infections, the development of substuporous and stuporous conditions is also possible, but they occur, as a rule, in the later stages of infectious diseases and testify to the extreme severity of the somatic condition of patients. The replacement of catatonic disorders by a picture of excitation resembling amentia is also not typical for infectious diseases, in which catatonic disorders can develop only at the height of amentia.

Treatment

Patients with acute and protracted infectious psychoses are subject to hospitalization in infectious departments psychiatric b-c or must be in infectious diseases hospitals under the supervision of an infectious disease specialist and a psychiatrist. They need to be monitored around the clock. Treatment should be aimed at eliminating the cause that caused the psychotic state, that is, the underlying disease should be treated, as well as active detoxification therapy should be carried out (see). Treatment of psychosis is determined by psychopathol. picture of the disease.

Psychoses that occur with clouding of consciousness, as well as a picture of hallucinosis, are treated with chlorpromazine.

Protracted psychoses are treated depending on the characteristics of the wedge, pictures. With hallucinatory-paranoid and manic states, as well as pictures of confabulosis, in addition to chlorpromazine, other antipsychotics with a pronounced sedative effect are also prescribed. The use of drugs such as triftazin (stelazin), mazheptil, haloperidol, triperidol, tizercin (nosinane) should be avoided, since they cause a hyperthermic reaction in patients.

If severe infectious diseases are accompanied by a drop in blood pressure or impaired liver function, then small doses of frenolon or seduxen are prescribed intramuscularly.

Forecast

As a rule, acute I. p. pass without a trace. After infectious diseases that occur with a picture of protracted psychoses, personality changes can be observed according to the organic type of varying degrees of severity. Often, the same infectious disease can lead to acute, protracted psychoses and lead to organic change personality. The course of psychosis and its outcome also depend on the age of the patient and the state of the organism's reactivity.

Bibliography: Dvorkina N. Ya. Infectious psychoses, M., 1975, bibliogr.; Zhislin S. G. The role of the age and somatogenic factor in the occurrence and course of some forms of psychosis, M., 1956, bibliogr.; Polishchuk I. A. Contemporary Issues toxic-infectious and other somatogenic psychoses, Doctor, case, No. 9, p. 1, 1974; Port-n about in A, A., B o g and h e n to about V. P. and L y s-kov B. D. Catamnesis of patients treated for infectious psychoses, Zhurn, neuropath, and psychiat., vol. 67, no. 5, p. 735, 1967; With N of e of N of e in with to and y AV About late symptomatic psychoses, Works Ying-that psychiat, it. P. B. Gannushkina, v. 5, p. 156, M., 1940; F 1 e c k U. Sympto-matische Psychosen, Fortschr. Neurol. Psychiat., Bd 28, S. 1, 1960; Schneider K. Klinische Psychopathologie, Stuttgart, 1962.

A. S. Tiganov.

Almost any brain and general infectious processes can lead to mental disorders. Although for each of the diseases a number of characteristic manifestations And special type course, it should be borne in mind that the main set of mental manifestations as a whole corresponds to the concept of the exogenous type of reactions described above. The specificity of each individual infection is determined by the speed of progression, the severity of the accompanying signs of intoxication (increased body temperature, vascular permeability, tissue edema), and the direct involvement of the meninges and brain structures in the pathological process.

The most fully studied manifestations of syphilitic brain infection.

Neurosyphilis [A52.1, F02.8]

It should be borne in mind that syphilitic psychoses are not a mandatory manifestation of chronic syphilitic infection. Even in the last century, when there were no effective treatments for syphilis, syphilitic psychoses developed in only 5% of all infected people. As a rule, mental disorders appear rather late (through4-15 years after initial infection), so timely diagnosis these diseases presents significant challenges. As a rule, the patient himself and his relatives do not report the infection and quite often do not know that such an infection has taken place. There are 2 main forms of syphilitic psychoses: syphilis of the brain and progressive paralysis.

Syphilis of the brain (lues cerebri) - specific inflammatory disease with a predominant lesion of blood vessels and membranes of the brain. The disease usually begins somewhat earlier than progressive paralysis - 4-6 years after infection. The diffuse nature of brain damage corresponds to an extremely polymorphic symptomatology, resembling nonspecific vascular diseases described in the previous section. The onset of the disease is gradual, with an increase in neurosis-like symptoms: fatigue, memory loss, irritability. However, compared with atherosclerosis, attention is paid to relatively early start disease and more rapid progression without typical vascular disorders"flickering" symptoms. Characteristically early occurrence episodes of cerebrovascular accident. Although each of the apoplexy episodes may end in some improvement and partial recovery lost functions (paresis, speech disorders), however, repeated hemorrhages are soon observed and a picture of lacunar dementia develops rapidly. On different stages a manifestation of organic brain damage can be Korsakoff's syndrome, epileptiform seizures, which last for a long time depressive states and psychoses with delusional and hallucinatory symptoms. The plot of delirium is usually ideas of persecution and jealousy, hypochondriacal delirium. Hallucinosis (usually auditory) is manifested by threatening and accusing statements. At a late stage of the disease, individual catatonic symptoms (negativism, stereotypes, impulsivity) can be observed.

Diffuse nonspecific neurological symptoms are almost always found with asymmetric motor and sensitivity disorders, anisocoria, uneven pupils, and a decrease in their reaction to light. In diagnostics the most important sign syphilis are positive serological tests (Wasserman reaction, RIF, RIBT). At the same time, with syphilis of the brain, in contrast to progressive paralysis, more often negative results blood samples. In this case, reactions should be carried out with cerebrospinal fluid. Other characteristic colloidal reactions can be detected on puncture (see section 2.2.4), in particular the specific "syphilitic tooth" in the Lange reaction.

The course of syphilis of the brain is slow, mental disorders can increase over several years and even decades. Sometimes observed sudden death after another stroke. Timely started specific treatment can not only stop the progression of the disease, but also be accompanied by a partial regression of symptoms. In the later stages, persistent mental defect in the form of lacunar (later total) dementia.

progressive paralysis (Bayle's disease, paralysis progressiva afienorum) is a syphilitic meningoencephalitis with a gross impairment of intellectual-mnestic functions and a variety of neurological symptoms. honors this disease is a direct lesion of the substance of the brain, accompanied by multiple symptoms of prolapse mental functions. The clinical manifestations of the disease have been described by A. JT. J. Baylem in 1822. Although during the XX century. the syphilitic nature of this disease has been repeatedly suggested; it was possible to directly detect a pale spirochete in the brain of patients only in 1911 by the Japanese researcher X. Noguchi.

The disease occurs against the background of full health 10-15 years after the initial infection. The first sign of an onset of the disease is nonspecificpseudoneurasthenic symptomsin the form of irritability, fatigue, tearfulness, sleep disturbances. A thorough examination allows, already in this phase of the disease, to detect some neurological signs of the disease (violation of the reaction of pupils to light, anisocoria) and serological reactions. Attention is drawn to the special behavior of patients with a decrease in criticism and an inadequate attitude to the existing violations.

Quite quickly, the disease reaches the phase of full bloom. Occasionally, the transition to this phase is accompanied by transient psychotic episodes with clouding of consciousness, disorientation, or delusions of persecution. The main manifestation of the disease at this stage is gross personality changes according to the organic type with the loss of criticism, absurdity, and underestimation of the situation. Behavior is characterized by disorderliness; the patient gives the impression of being loose on those around him. It seems that a person acts in a state of intoxication. He leaves home, spends money thoughtlessly, loses it, leaves things anywhere. Often the patient makes casual acquaintances, enters into a relationship, often becomes a victim of the dishonesty of his acquaintances, since he is distinguished by amazing gullibility and suggestibility. Patients do not notice a mess in their clothes, they can leave the house half-dressed.

The main content of the disease is a gross disorder of the intellect (total dementia), with a constant increase in intellectual-mnestic disorders. At first, there may not be a gross violation of memorization, however, a targeted assessment of abstract thinking reveals a lack of understanding of the essence of tasks, superficiality in judgments. At the same time, patients never notice the mistakes they have made, they are complacent, not embarrassed by others, they strive to demonstrate their abilities, they try to sing and dance.

described above typical manifestations diseases may be accompanied by some optional symptoms that determine individual characteristics every patient. In the last century, delusions of grandeur with absurd ideas of material wealth were more common than other disorders. In this case, one is always surprised by the grandiosity and obvious senselessness of the boasting of the sick. The patient not only promises to give expensive gifts to everyone around him, but wants to “shower them with diamonds”, claims that he “has 500 boxes of gold under his bed at home.” A similar variant of progressive paralysis is designated asexpansive form. IN last years it is much less common - in 70% of cases there is a predominance of intellectual disorders in the clinical picture without a concomitant mood disorder (dementia form).Quite rarely, there are variants of the disease with a decrease in mood, ideas of self-abasement and hypochondriacal delusions (depressive form) or distinct ideas of persecution and isolated hallucinations (paranoid form).

Various neurological symptoms are very characteristic. Almost constantly there is a symptom of Argyle Robertson (lack of pupil reaction to light while maintaining a reaction to convergence and accommodation). Quite often, the pupils are narrow (like a pinprick), sometimes anisocoria or deformation of the pupils is noted, vision is reduced. Many patients have dysarthria. Other speech disorders are often observed (nasal, logoclonia, scanned speech). Asymmetry of the nasolabial folds, paresis of the facial nerve, masking of the face, deviation of the tongue, twitching of the muscles of the face are not mandatory symptoms, but can be observed. When writing, both a violation of handwriting and gross spelling errors (omissions and repetition of letters) are detected. Often there is asymmetry of tendon reflexes, a decrease or absence of knee or Achilles reflexes. In the later stages of the course of the disease, epileptiform seizures often occur. Describe special forms of the disease with a predominance of focal neurological symptoms:

• taboparalysis - a combination of dementia with manifestations of dorsal tabes (tabes dorsalis is manifested by a violation of superficial and deep sensitivity and the disappearance of tendon reflexes in the lower extremities, combined with shooting pains),
• Lissauer form - focal loss of mental functions with a predominance of aphasia and apraxia.

A 45-year-old patient, deputy director of a large department store, was referred to a psychiatric clinic due to misbehavior and helplessness at work.

Heredity is not burdened. The patient is the eldest of two daughters. The patient's mother is healthy, the father died of a heart attack. IN childhood developed normally. Graduated from school And Institute of National Economy. Plekhanov. She has always worked in trade, distinguished by prudence and insight. She was not very beautiful, but had a light, mobile character, was a success with men. She married at the age of 22 for a man who was 5 years older than her. Family life was going well. Has two sons.

About six months before the real hospitalization, she became less diligent at work, laughed a lot. In the spring at the dacha there was an episode when she could not sleep at night: she ran around the house; didn't know where it was. In the morning, the husband asked the children to come. The patient did not recognize her eldest son, she was afraid of him. Relatives turned to a private doctor. He was treated with a number of drugs, including antibiotics.

Her condition improved significantly: she was fully oriented, tried to go to work. However, she could not cope with her official duties, joked stupidly, and boasted to her employees about her wealth. Once she tried to leave the house for work without wearing a skirt, she did not emotionally react to her husband’s remark about this - she simply dressed in the proper way.

Upon admission to the hospital does not show any complaints, but does not object to hospitalization. Accurately calls his name, year of birth, but is mistaken in determining the real date. Makes compliments to doctors, especially men. He looks at the interlocutor, dressed in a white coat, and cannot determine his profession. Speaks indistinctly, sometimes swallows separate syllables. She laughs, without hesitation declares that she is very rich: “I work in a store - I can get whatever you want. Money is trash."

He makes gross mistakes in the simplest account, cannot remember the name of the attending physician: "Such a young charming young man serves me." He writes his name and address without errors, but the handwriting is unusual, with uneven pressure and crooked lines. Describes himself as a cheerful, sociable person. Willingly sings songs, although he can not always pronounce the words. He beats the time with his palms, gets up, starts dancing.

Miosis and lack of pupillary response to light are noted. The tendon reflexes on the right and left are the same, the Achilles reflex is reduced on both sides. A laboratory examination revealed a sharply positive Wasserman reaction (“++++”), positive reactions of RIF and RIBT. The cerebrospinal fluid is clear, its pressure is not increased, pleocytosis is 30 cells per 1 μl, the globulin/albumin ratio is 1.0; Lange reaction - 4444332111111111.

Treatment with iodine salts, bioquinol and penicillin was carried out. As a result of treatment, she became more calm, obedient, but there was no significant improvement in mnestic-intellectual processes. Issued 2nd group of disability.

Brightness of mental and neurological disorders in typical cases of progressive paralysis allows the diagnosis of the disease with clinical examination. However, difficult-to-diagnose atypical cases have become more frequent in recent years. In addition, due to a sharp decrease in the incidence of this disease, modern doctors do not always have sufficient clinical experience to identify it. Serological tests are the most reliable diagnostic method. The Wasserman reaction in 95% of cases gives a sharply positive result; to exclude false-positive cases, RIF and RIBT are always carried out. Although with a clear a positive result serological samples, spinal puncture can be omitted, however, the study of cerebrospinal fluid is desirable, since it allows you to clarify the degree of activity of the disease process. Yes, for the presence inflammatory phenomena indicate an increase in CSF formed elements up to 100 in 1 μl, the predominance of the globulin fraction of proteins, discoloration of colloidal gold in test tubes with the lowest CSF dilution (“paralytic type of curve” in the Lange reaction).

In the last century, the disease proceeded extremely malignantly and in most cases ended in death after 3-8 years. In the terminal (marasmic) phase, gross violations were observed physiological functions(impaired pelvic functions, swallowing and breathing disorders), epileptic seizures, violation of tissue trophism (trophic ulcers on the legs, hair loss, bedsores). In recent years, timely treatment of the disease allows not only to save the lives of patients, but in some cases to achieve a clear positive dynamics of the condition.

The treatment of progressive paralysis with malaria vaccinations proposed at the beginning of the century [Wagner-Yauregg Yu., 1917] is no longer used due to the introduction of antibiotics into practice. However, when conducting antibiotic therapy, possible complications should be taken into account. So in the later stages of a syphilitic infection, the occurrence of gum is very likely. In this case, the appointment of antibiotics can lead to massive death of the pathogen and death as a result of intoxication. Therefore, treatment often begins with the appointment of iodine and bismuth preparations. In the presence of an allergy to the penicillin group, erythromycin is prescribed. The effectiveness of antibiotic therapy may be higher when combined with pyrotherapy. Soft neuroleptics are used to correct the behavior of patients.

Mental disorders in AIDS

The human immunodeficiency virus has a pronounced tropism for both the lymphatic system and the nervous tissue. In this regard, mental disorders at different stages of the course of the disease are observed in almost all patients. It is quite difficult to differentiate disorders due to an organic process and mental disorders psychogenic nature associated with the realization of the fact of an incurable disease.

Mental disorders in AIDS basically correspond to reactions of the exogenous type. In the initial period, phenomena of persistent asthenia are often observed with constant feeling fatigue, increased sweating, sleep disturbances, decreased appetite. Depression, melancholy, depression may occur before the diagnosis is established. Personality changes are manifested by an increase in irritability, irascibility, capriciousness or disinhibition of drives. Already at an early stage of the course of the disease, acute psychoses often develop in the form of delirium, twilight stupefaction, hallucinosis, less often acute paranoid psychoses, a state of arousal with manic affect. Quite often there are epileptiform seizures.

Subsequently, rapidly (within a few weeks or months) increases negative symptoms in the form of dementia. In 25% of cases, signs of dementia are detected already in the initial phase of the disease. Manifestations of dementia are nonspecific and depend on the nature of the brain process. With focal processes (cerebral lymphoma, hemorrhage), focal fallout individual functions(speech disorders, frontal symptoms, seizures, paresis and paralysis), diffuse lesion(diffuse subacute encephalitis, meningitis, cerebral arteritis) is manifested by a general increase in passivity, lack of initiative, drowsiness, impaired attention, and memory loss. In the later stages of the disease, dementia reaches the degree of total. Dysfunctions of the pelvic organs, respiratory and cardiac disorders join. The cause of death in patients is usually intercurrent infections and malignant neoplasms.

Organic mental disorders are almost always accompanied by psychologically understandable experiences of patients. Psychological reaction on the disease can be manifested both by distinct depressive symptoms, and by persistent denial of the fact of the disease according to the type defense mechanism(see section 1.1.4). Often, patients demand a second examination, accuse doctors of incompetence, and try to bring down their anger on others. Sometimes, with hatred for healthy people trying to infect others.

An important problem associated with HIV infection is the danger of overdiagnosis of AIDS by both doctors and HIV carriers. Thus, infected patients can take any discomfort in the body for signs of manifestation of the disease and it is difficult to respond to the examination, considering this as evidence of its occurrence. In these cases, the desire to commit suicide is possible.

There is no effective treatment for AIDS, but medical assistance can help prolong the life of patients, as well as improve the quality of life for the period of the disease. In cases of acute psychosis, antipsychotics (haloperidol, chlorpromazine, droperidol) and tranquilizers are used in doses reduced in accordance with the severity of the organic defect. If there are signs of depression, antidepressants are prescribed taking into account their side effects. Correction of personality disorders is carried out with the help of tranquilizers and mild antipsychotics (such as thioridazine and non-uleptil). The most important factor in maintaining psychological balance is properly organized psychotherapy.

Prion diseases

The isolation of this group of diseases is associated with the discovery in 1983 of the prion protein, which is a natural protein in humans and animals (the gene encoding this protein is found on the short arm of chromosome 20). The possibility of infection with mutant forms of this protein has been established, and its accumulation in brain tissues has been shown. Currently, 4 human diseases and 6 animal diseases have been described from prion-related diseases. Among them are sporadic, infectious and hereditary diseases. However, there is data showing that prion proteins formed by random mutation (sporadic cases of the disease) have the same degree of contagiousness as infectious ones.

An example of a typically infectious human prion disease is kuru - a disease discovered in one of the tribes of Papua New Guinea, where the ritual eating of the brain of dead tribesmen was accepted. At present, along with the change in rituals, this disease has practically disappeared. Hereditary prion diseases include Gerstmann-Streussler-Scheinker syndrome, fatal familial insomnia, and familial forms of Creutzfeldt-Jakob disease. Familial and infectious diseases account for no more than 10% of all cases, in 90% of cases there are sporadic cases of the disease (sporadic form of Creutzfeldt-I-Koba disease).

Creutzfeldt-Jakob disease [Kreutzfeld X., 1920, Jacob A., 1921] - a malignant rapidly progressive disease characterized by spongy degeneration of the cerebral cortex, cerebellar cortex and gray matter subcortical nuclei. The main manifestation of the disease is dementia with gross impairment of brain functions (agnosia, aphasia, alexia, apraxia) and movement disorders (myoclonus, ataxia, intentional tremor, oculomotor disorders, seizures, pyramidal and extrapyramidal disorders).

In 30% of cases, the development of the disease is preceded by nonspecific prodromal symptoms in the form of asthenia, sleep and appetite disorders, memory impairment, behavioral changes, and weight loss. The immediate onset of the disease is evidenced by visual disturbances, headaches, dizziness, unsteadiness and paresthesia. Usually the disease occurs at the age of 50-65 years, men are more often ill. Effective methods of treatment have not been found, most of the sick people die within the first year, but sometimes the disease stretches for 2 years or more.

Timely diagnosis of the disease presents significant difficulties. Important diagnostic features are the rapid progression of symptoms, the absence of inflammatory changes in the blood and CSF (no fever, increased ESR, leukocytosis in the blood and pleocytosis in the cerebrospinal fluid), specific EEG changes (repeated three-phase and polyphasic activity with an amplitude of at least 200 μV, occurring every 1-2 s).

Particular interest in prion diseases arose in connection with the epidemic of bovine spongiform encephalopathy in England and the appearance in the same period in England and France of 11 cases of Creutzfeldt-Jakob disease with an atypically early onset.

Although no obvious evidence of a connection between these two facts has been found, scientists have to take into account the high persistence of prion proteins (formalin treatment of the tissues of the dead does not reduce their contagiousness). In documented cases of transmission of Creutzfeldt-Jakob disease from one person to another, the incubation period was 1.5-2 years.

Mental disorders in acute brain and extracerebral infections

Disorders of mental functions can occur with almost any brain or general infection. Specific brain infections include epidemic encephalitis, tick-borne and mosquito encephalitis, and rabies. It is not always possible to draw a clear line between cerebral and extracerebral processes, since encephalitis, meningitis, and cerebrovascular disease can occur with such common infections such as influenza, measles, scarlet fever, rheumatism, mumps, chicken pox, tuberculosis, brucellosis, malaria, etc. In addition, indirect brain damage against the background of hyperthermia, general intoxication, hypoxia with nonspecific pneumonia, purulent surgical lesions can also lead to psychosis similar in their manifestations to brain infections.

At various infections the same psychopathological syndromes are often observed. Usually they fit into the concept of an exogenous type of reactions. So, acute psychoses are manifested by switching off or stupefaction of consciousness (delirium, amentia, seizures similar to oneiroid are much less common). Psychosis usually occurs in evening time against the background of severe fever, accompanied by signs of inflammation in blood and cerebrospinal fluid tests. Factors that increase the risk of psychosis include previous organic diseases CNS (injuries, disorders of liquorodynamics), intoxication (alcoholism and substance abuse). More likely to develop psychosis in children.

With prolonged sluggish infections, hallucinatory and hallucinatory-delusional disorders sometimes occur. Debilitating diseases lead to prolonged asthenia. As an outcome of a severe infectious process, Korsakov's syndrome or dementia (psychoorganic syndrome) may occur. A very common complication of severe infectious diseases is depression, which sometimes develops against the background of a gradual resolution of acute manifestations of the disease. Manic and catatonic-like disorders are much less common.

The most specific clinical picture isepidemic encephalitis (sleeping sickness). The disease was described in 1917 by the Austrian psychiatrist K. Ekonomo during the pandemic of 1916-1922. In recent years, epidemics of this disease have not been observed - only isolated sporadic cases are described.

The disease is characterized by a significant variety of manifestations. Both acute, quickly leading to death cases, and gradually developing low-symptomatic variants are described. Often, after the resolution of the acute phase of the disease, there is a return of symptoms expressed to a lesser extent. IN acute phase diseases against the background of subfebrile condition (37.5-38.5 °), a variety of neurological symptoms are observed: diplopia, ptosis, anisocoria, motor retardation, amemia, rare blinking, violation of friendly movements of the arms and legs. With the most acute onset, there may be severe headache and muscle pain, vomiting, impaired consciousness with hallucinations, delirium, hyperkinesis, and sometimes epileptic seizures. An almost obligatory symptom is sleep disturbance, either in the form of periods of pathological hibernation lasting several days or weeks, or in the form of a disturbance in the sleep-wake cycle with pathological daytime sleepiness and insomnia at night. Sometimes at night, excitement and hallucinations are observed.

In addition to the typical variants of the disease, there are often atypical forms with a predominance of mental disorders - delirium, reminiscent of alcohol; depression with pronounced hypochondriacal ideas and suicidal tendencies; atypical manic states with chaotic unproductive excitement; phenomena of apathy, adynamia, catatonia, hallucinatory-delusional states, which must be differentiated from the onset of schizophrenia.

In previous epidemics, up to 1/3 of patients died in the acute phase of the disease. Many had a long persistent course of the disease. IN remote period movement disorders were especially pronounced in the form of muscle stiffness, tremor, bradykinesia (parkinsonism). Gross intellectual-mnestic disorders were not usually observed. Often, for a long time, extremely unpleasant sensations in the head and the whole body (crawling, itching) were noted. Voices in the head, visual pseudo-hallucinatory images, impaired sense internal unity resembled schizophrenic symptoms.

The diagnosis is confirmed by signs of flaccid inflammation in the cerebrospinal fluid - an increase in the amount of protein and sugar, a pathological Lange reaction (less distinct than with syphilis).

Treatment of infectious diseases is primarily based on etiotropic therapy. Unfortunately, in the case of viral infections, chemotherapy is usually ineffective. Sometimes convalescent serum is used. Non-specific anti-inflammatory therapy includes the use nonsteroidal drugs or corticosteroid hormones and ACTH. Antibiotics are used to prevent the addition of a secondary infection. In the case of severe general intoxication (for example, with pneumonia), detoxification measures in the form of infusions of polyionic and colloidal solutions (hemodez, reopoliglyukin) are of great importance. To combat cerebral edema, diuretics, corticosteroids and oxygen are used, sometimes a lumbar puncture. In acute psychosis, neuroleptics and tranquilizers (usually in reduced doses) have to be prescribed. For a more complete restoration of brain function during the period of convalescence, nootropics (piracetam, pyriditol) and mild stimulants-adaptogens (eleutherococcus, ginseng, pantocrine, Chinese magnolia vine) are prescribed. Treatment with antidepressants is prescribed in case of a persistent decrease in mood after the acute phase of the disease has passed (in the acute phase of the disease, TCA and other anticholinergic drugs can provoke the onset of delirium).

Encephalitis is an inflammation of the brain resulting from exposure to infections.

Encephalitis usually occurs as a complication of various common infectious diseases: influenza, typhus and intoxication (carbon monoxide, alcohol, etc.) - secondary encephalitis, but can also appear as a result of direct viral infection of the brain - primary encephalitis.

Among primary encephalitis, the most common are epidemic and tick-borne.

Epidemic encephalitis is caused by a filterable virus. The source of the virus is the sick, the carrier and the convalescent. transmitted by airborne droplets. It was first identified in 1917 by the Austrian scientist H. Economo during an epidemic that engulfed most of Europe and America. The disease most often occurs at a young age. Begins elevated temperature, headaches, dizziness, vomiting, sometimes accompanied by a disorder of consciousness with agitation. A typical symptom disease is a sleep disorder, which is expressed either in persistent insomnia, or in increased drowsiness. In the acute period, patients sleep continuously. Sleep takes on the character of lethargic (prolonged hibernation), which is why epidemic encephalitis is called lethargic, as well as "sleeping sickness" (duration - several days, weeks). The patient, of course, cannot commit serious offenses in the acute period. That's why acute period epidemic encephalitis is almost never the subject of a forensic psychiatric examination, which cannot be said about chronic encephalitis.

Chronic stage of encephalitis occurs after a period of relative or practical recovery, sometimes lasting several years, and is characterized by a variety of mental and neurological disorders.

Despite the variety of mental disorders observed in the chronic stage, typical for it are drive disorders, decreased activity and peculiar characterological changes in patients, which determine the forensic psychiatric significance of this disease as a whole. Often there is stagnation, monotony of experiences, disinhibition of sexual and food drives, pathological persistence of patients due to the weakening of the regulatory and controlling functions of the cortex over the subcortical region. These mental disorders in some patients are accompanied by a significant decrease in intelligence and memory disorders.

Significant emotional excitability, affective tension can suddenly eliminate motor retardation and contribute to the commission of sudden actions by patients, including those of an aggressive nature.

In some cases, in connection with long-term various senestopathies, persistent hypochondriacal delusions or delusional ideas of physical impact occur.

The disease of epidemic encephalitis in childhood and adolescence sometimes leads to the development of dementia. However, much more often in children and adolescents, due to encephalitis, psychopathic-like states with excessive mobility, increased food and sexual desire, and cruelty are observed, which increases the risk of such patients.

Tick-borne encephalitis in our country occurs mainly in taiga regions. Far East, Siberia and the Urals. The causative agent is a virus - transmitted through the bite of a tick and affects mainly the brain.

The acute stage of tick-borne encephalitis is accompanied by various disorders of consciousness (delirium, twilight state, stupor).

With long-term consequences, a hallucinatory-paranoid state develops with delusional ideas of persecution, poisoning, visual and auditory hallucinations. Depressive-hypochondriac disorders are also observed. Emotional disorders are manifested mainly by melancholy or high spirits with motor disinhibition, and this disinhibition is so strong that the patient can understand that he is doing something unlawful, but can do nothing. Often there are asthenic conditions.

Forensic psychiatric evaluation.

A significant variety of variants of infectious encephalitis is opposed by the relative uniformity of mental disorders. As a result, there is a certain similarity in the criteria for forensic psychiatric assessment in various encephalitis.

The forensic psychiatric significance of the acute stage of encephalitis is small, since offenses at this stage are extremely rare.

Of greater forensic psychiatric importance are the conditions of patients with long-term consequences of infectious encephalitis.

We can talk about insanity:

1) with severe dementia;

2) in conditions with a slight decrease in intelligence, but with a pronounced disinhibition of drives (in particular, sexual desire). At the same time, the person who committed the offense (most often an attempt at rape, sexual perversion) is recognized as insane, since during this period he lacked the ability to control his actions;

3) if there are hallucinatory-delusional states during the commission of a socially dangerous act.

When resolving questions about the legal capacity of persons who have undergone different forms encephalitis are guided by the same evaluation clinical criteria as when deciding on sanity.