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Forensic psychiatric assessment of stress-related mental disorders. simulation of mental disorders

Psychotherapeutic correction of non-psychotic mental disorders and psychological factors associated with the disease in the system of treatment and rehabilitation of young patients with psychosomatic diseases.

Common psychosomatic disorders in the classical sense, such as bronchial asthma, peptic ulcer disease, arterial hypertension, are a significant problem of modern medicine due to their chronic course and significant impairment of the quality of life of patients.

The proportion of identified cases of mental disorders in patients with psychosomatic disorders remains unknown. It is believed that approximately 30% of the adult population, due to various life circumstances, experience short-term depressive and anxious episodes of a non-psychotic level, of which no more than 5% of cases are diagnosed. “Subsyndromal” and “prenosological” changes in the mental sphere, more often manifestations of anxiety, which do not meet the diagnostic criteria of ICD-10, generally remain unattended by specialists in the field of mental health. Such disorders, on the one hand, are objectively difficult to detect, and on the other hand, persons who are in a state of mild depression or anxiety rarely proactively seek medical help, subjectively assessing their condition as a purely personal psychological problem that does not require medical intervention. However, subsyndromal manifestations of depression and anxiety, according to the observations of general practitioners, exist in many patients and can significantly affect their health. In particular, a connection has been shown between subsyndromal symptoms of anxiety and depression and development.

Among the identified mental disorders, the proportion of neurotic, stress-related disorders was 43.5% (prolonged depressive reaction, adaptation disorder with a predominance of disturbances of other emotions, somatization, hypochondriacal, panic and generalized anxiety disorders), affective - 24.1% (depressive episode, recurrent depressive disorder), personal - 19.7% (dependent, hysterical personality disorder), organic - 12.7% (organic asthenic disorder) disorders. As can be seen from the data obtained, in young patients with psychosomatic diseases, functional-dynamic mental disorders of the neurotic register predominate over organic neurosis-like disorders.

Depending on the leading psychopathological syndrome in the structure of non-psychotic mental disorders in patients with psychosomatic diseases: patients with axial asthenic syndrome - 51.7%, with a predominance of depressive syndrome - 32.5%, with severe hypochondriacal syndrome - 15.8% of the number of patients with NPPR.

The basis of therapeutic tactics for psychosomatic disorders was a complex combination of biological and socio-rehabilitative influences, in which psychotherapy played a leading role. All therapeutic and psychotherapeutic measures were carried out taking into account the personal structure and clinical dynamics.

According to the biopsychosocial model, the following treatment and rehabilitation measures were distinguished: psychotherapeutic complex (PTC), psychoprophylactic complex (PPC), pharmacological (FC) and psychopharmacological (PFC) complexes, as well as physiotherapeutic (PTK) in combination with a physical therapy complex (PT).

Stages of therapy:

"Crisis" stage used in acute stages of the disease, requiring a comprehensive assessment of the patient’s current condition, his psychosomatic, socio-psychological status, as well as the prevention of self-destructive behavior. The “crisis” stage included therapeutic measures that were protective in nature and aimed at relieving acute psychopathological and somatic symptoms. From the moment of admission to the clinic, intensive integrative psychotherapy began, the purpose of which was to form compliance and constructive relationships in the doctor-patient system.

An atmosphere of trust and active participation in the fate of the patient was created: in the shortest possible time it was necessary to choose a strategy and tactics for managing the patient, analyze internal and external influences, outline the paths of adequate therapy, give a prognostic assessment of the condition under study: the main requirement of this regime was constant, continuous monitoring carried out within a specialized hospital (preferably in a department for borderline conditions). The “crisis” stage lasted 7 - 14 days.

"Basic" stage recommended for stabilization of the mental state, in which temporary deterioration of the condition is possible; associated with the influence of the external environment. Psychopharmacotherapy was combined with physiotherapeutic procedures and physical therapy. Both individual and family psychotherapy were carried out:

The “basic” stage provided for a more thorough consideration of the “internal picture of the disease” of relative stabilization, which previously acquired a character (due to the restructuring of interpersonal relationships, changes in social status). The main therapeutic work was carried out precisely at this stage and consisted of overcoming the constitutional and biological basis of the disease and mental crisis. This regimen was assessed as therapeutic-activating and took place in a specialized hospital (department of borderline conditions). The “baseline” stage lasted from 14 to 21 days.

"Recovery" stage was intended for individuals who experienced regression of painful disorders, a transition to a compensated or non-painful state, which implied more active assistance from the patient himself. This stage contained mainly individual-oriented psychotherapy, as well as general strengthening measures. It was performed in semi-stationary units (night or day hospital) and made it possible to successfully solve the problem of overcoming the delay in the torpidity of the pathological process. During rehabilitation, the patient's position changed from passive-acceptive to active, partner. A wide range of personality-oriented psychological techniques and course reflexology were used. The “recovery” stage lasted from 14 to 2 - 3 months.

The psychoprophylactic stage began with a significant improvement in the condition, issues of family correction, social adaptation were discussed, a system was formed for switching emotions and focusing on the minimal symptoms of decompensation, the possibility of drug and psychological correction. When forming psychoprophylactic strategies, attention was focused on one’s own responsibility for the disease and the need to include regular drug treatment in the psychoprophylactic strategy.

As can be seen from the table, complete and practical recovery was observed: in the group of patients with hypertension in 98.5% of cases, in the group of patients with peptic ulcer disease in 94.3%, in the group of patients with bronchial asthma - 91.5%. Remissions of types “D” and “E” were not noted in our observations.

Korostiy V.I. - Doctor of Medical Sciences, Professor of the Department of Psychiatry, Narcology and Medical Psychology, Kharkov National Medical University.

Borderline forms of psychotic disorders, or borderline states, usually include various neurotic disorders. This concept is not generally accepted, but is still used by many healthcare professionals. As a rule, it is used to combine milder disorders and separate them from psychotic disorders. Moreover, borderline states are generally not initial, intermediate, or buffer phases or stages of major psychoses, but represent a special group of pathological manifestations that, in clinical terms, have their onset, dynamics and outcome, depending on the form or type of the disease process.

Characteristic disorders for borderline states:

  • the predominance of the neurotic level of psychopathological manifestations throughout the course of the disease;
  • the leading role of psychogenic factors in the occurrence and decompensation of painful disorders;
  • the relationship between mental disorders themselves and autonomic dysfunctions, night sleep disorders and somatic diseases;
  • the relationship of painful disorders with the personality and typological characteristics of the patient;
  • the presence in most cases of an “organic predisposition” for the development and decompensation of painful disorders;
  • maintaining a critical attitude by patients towards their condition and the main pathological manifestations.
  • Along with this, in borderline states there may be a complete absence of psychotic symptoms, progressively increasing dementia and personality changes characteristic of endogenous mental illnesses, for example, and.

Borderline mental disorders can arise acutely or develop gradually; their course can be of different nature and limited to a short-term reaction, a relatively long-term condition or a chronic course. Taking this into account, as well as based on an analysis of the causes of occurrence, various forms and variants of borderline disorders are distinguished in clinical practice. In this case, different principles and approaches are used (nosological, syndromic, symptomatic assessment), and the course of the borderline state, its severity, stabilization, and the dynamic relationship of various clinical manifestations are analyzed.

Clinical diagnosis

Due to the non-specificity of many symptoms that fill the syndromic and nosological structures of borderline states, the external, formal differences between asthenic, vegetative, dyssomnic and depressive disorders are insignificant. Considered separately, they do not provide grounds either for differentiating mental disorders in the physiological reactions of healthy people who find themselves in stressful conditions, or for a comprehensive assessment of the patient’s condition and determining the prognosis. The key to diagnosis is the dynamic assessment of a particular painful manifestation, detection of the causes of occurrence and analysis of the relationship with individual typological psychological characteristics, as well as other psychopathological disorders.

In real medical practice, it is often not easy to answer the most important question for differential diagnostic assessment: when did this or that disorder begin; Is it a strengthening, sharpening of personal characteristics or is it fundamentally new in the individual uniqueness of a person’s mental activity? The answer to this seemingly trivial question requires, in turn, the solution of a number of problems. In particular, it is necessary to assess the typological and characterological characteristics of a person in the pre-morbid period. This allows us to see the individual norm in the neurotic complaints presented or qualitatively new, actually painful disorders that are not related to premorbid characteristics.

Paying great attention to the pre-morbid assessment of the condition of a person who has come to see a doctor in connection with his neurotic manifestations, it is necessary to take into account the characteristics of his character, which undergo dynamic changes under the influence of age-related, psychogenic, somatogenic and many social factors. Analysis of premorbid characteristics makes it possible to create a unique psychophysiological portrait of the patient, the starting point that is necessary for a differential assessment of the disease state.

Assessing current symptoms

What matters is not the individual symptom or syndrome itself, but its assessment in conjunction with other psychopathological manifestations, their visible and hidden causes, the rate of increase and stabilization of general neurotic and more specific psychopathological disorders of the neurotic level (senestopathy, obsession, hypochondria). In the development of these disorders, both psychogenic and physiogenic factors, most often their varied combination, are important. The causes of neurotic disorders are not always visible to others; they can lie in a person’s personal experiences, caused primarily by the discrepancy between the ideological and psychological attitude and physical capabilities of reality. This discrepancy can be viewed as follows:

  1. from the point of view of lack of interest (including moral and economic) in a particular activity, in a lack of understanding of its goals and prospects;
  2. from the position of irrational organization of purposeful activity, accompanied by frequent distractions from it;
  3. from the point of view of physical and psychological unpreparedness to perform the activity.

What does borderline disorder include?

Taking into account the diversity of various etiopathogenetic factors, borderline forms of mental disorders include neurotic reactions, reactive states (but not psychoses), neuroses, character accentuations, pathological personality development, psychopathy, as well as a wide range of neurosis-like and psychopath-like manifestations in somatic, neurological and other diseases. In ICD-10, these disorders are generally considered as various variants of neurotic, stress-related and somatoform disorders, behavioral syndromes caused by physiological disorders and physical factors, and disorders of mature personality and behavior in adults.

Borderline states usually do not include endogenous mental illnesses (including sluggish schizophrenia), at certain stages of development of which neurosis- and psychopath-like disorders, which largely imitate the main forms and variants of borderline states themselves, predominate and even determine the clinical course.

What to consider when diagnosing:

  • the onset of the disease (when neurosis or a neurosis-like state arose), the presence or absence of its connection with psychogenicity or somatogeny;
  • stability of psychopathological manifestations, their relationship with the patient’s personal-typological characteristics (whether they are a further development of the latter or not related to pre-morbid accentuations);
  • interdependence and dynamics of neurotic disorders in conditions of persistence of traumatic and significant somatogenic factors or a subjective decrease in their relevance.

What are mental disorders and how are they expressed?

The term "mental disorder" refers to a huge number of different illness conditions.

Psychotic disorders are a very common type of pathology. Statistical data in different regions differ from each other, which is associated with different approaches and capabilities for identifying and accounting for these sometimes difficult to diagnose conditions. On average, the frequency of endogenous psychoses is 3-5% of the population.

Accurate information about the prevalence of exogenous psychoses among the population (Greek exo - outside, genesis - origin.
There is no option for the development of a mental disorder due to the influence of external causes located outside the body, and this is explained by the fact that most of these conditions occur in patients drug addiction and alcoholism.

The concepts of psychosis and schizophrenia are often equated, which is fundamentally incorrect,

Psychotic disorders can occur in a number of mental illnesses: Alzheimer's disease, senile dementia, chronic alcoholism, drug addiction, epilepsy, mental retardation, etc.

A person can suffer a transient psychotic state caused by taking certain medications, drugs, or the so-called psychogenic or “reactive” psychosis that occurs as a result of exposure to severe mental trauma (stressful situation with a danger to life, loss of a loved one, etc.). Often there are so-called infectious (developing as a result of a severe infectious disease), somatogenic (caused by severe somatic pathology, such as myocardial infarction) and intoxication psychoses. The most striking example of the latter is delirium tremens - delirium tremens.

There is another important sign that divides mental disorders into two sharply different classes:
psychoses and non-psychotic disorders.

Non-psychotic disorders are manifested mainly by psychological phenomena characteristic of healthy people. We are talking about mood changes, fears, anxiety, sleep disturbances, obsessive thoughts and doubts, etc.

Non-psychotic disorders are much more common than psychosis.
As mentioned above, every third person suffers the mildest of them at least once in his life.

Psychoses are much less common.
The most severe of them are most often found within the framework of schizophrenia, an illness that constitutes the central problem of modern psychiatry. The prevalence of schizophrenia is 1% of the population, that is, it affects approximately one person in every hundred.

The difference is that in healthy people all these phenomena occur in a clear and adequate connection with the situation, while in patients they occur without such connection. In addition, the duration and intensity of painful phenomena of this kind cannot be compared with similar phenomena that occur in healthy people.


Psychoses characterized by the emergence of psychological phenomena that never occur normally.
The most important of them are delusions and hallucinations.
These disorders can radically change the patient’s understanding of the world around him and even of himself.

Psychosis is also associated with severe behavioral disorders.

WHAT ARE PSYCHOSES?

About what psychosis is.

Let's imagine that our psyche is a mirror, whose task is to reflect reality as accurately as possible. We judge reality precisely with the help of this reflection, because we have no other way. We ourselves are also part of reality, so our “mirror” must correctly reflect not only the world around us, but also ourselves in this world. If the mirror is intact, smooth, well polished and clean, the world is reflected in it correctly (let’s not quibble with the fact that none of us perceives reality absolutely adequately - this is a completely different problem).

But what happens if the mirror gets dirty, or warped, or breaks into pieces? The reflection in it will more or less suffer. This “more or less” is very important. The essence of any mental disorder is that the patient perceives reality not quite as it really is. The degree of distortion of reality in the patient’s perception determines whether he has psychosis or a milder painful state.

Unfortunately, there is no generally accepted definition of the concept of “psychosis.” It is always emphasized that the main sign of psychosis is a serious distortion of reality, a gross deformation of the perception of the surrounding world. The picture of the world that appears to the patient can be so different from reality that they talk about the “new reality” that psychosis creates. Even if the structure of psychosis does not contain disorders directly related to disturbances in thinking and purposeful behavior, the patient’s statements and actions are perceived by others as strange and absurd; after all, he lives in a “new reality”, which may have nothing to do with the objective situation.

The distortion of reality is caused by phenomena that are never found normally in any form (even in a hint). The most characteristic of them are delusions and hallucinations; they are involved in the structure of most syndromes that are commonly called psychoses.
Simultaneously with their occurrence, the ability to critically assess one’s condition is lost,” in other words, the patient cannot admit the idea that everything that is happening only seems to him.
A “gross deformation of the perception of the surrounding world” arises because the “mirror” with which we judge it begins to reflect phenomena that are not there.

So, psychosis is a painful condition that is determined by the occurrence of symptoms that never occur normally, most often delusions and hallucinations. They lead to the fact that reality as perceived by the patient is very different from the objective state of affairs. Psychosis is accompanied by behavioral disorder, sometimes very severe. It may depend on how the patient imagines the situation in which he is (for example, he may be fleeing from an imaginary threat), and on the loss of the ability to perform purposeful activities.

Excerpt from the book.
Rotshtein V.G. "Psychiatry is a science or an art?"


Psychoses (psychotic disorders) are understood as the most striking manifestations of mental illnesses, in which the patient’s mental activity does not correspond to the surrounding reality, the reflection of the real world in the mind is sharply distorted, which manifests itself in behavioral disorders, the appearance of abnormal pathological symptoms and syndromes.


Manifestations of mental illness are disorders of the psyche and behavior of a person. Based on the severity of the pathological process, more pronounced forms of mental illness are distinguished - psychoses and milder ones - neuroses, psychopathic states, and some forms of affective pathology.

COURSE AND PROGNOSIS OF PSYCHOSES.

The most common type (especially with endogenous diseases) is the periodic type of psychosis with acute attacks of the disease occurring from time to time, both provoked by physical and psychological factors, and spontaneous. It should be noted that there is also a single-attack course, observed more often in adolescence.

Patients, having suffered one, sometimes protracted attack, gradually recover from the painful state, restore their ability to work and never come to the attention of a psychiatrist.
In some cases, psychoses can become chronic and develop into a continuous course without disappearance of symptoms throughout life.

In uncomplicated and unadvanced cases, inpatient treatment usually lasts one and a half to two months. This is exactly the period doctors need to fully cope with the symptoms of psychosis and select the optimal supportive therapy. In cases where the symptoms of the disease turn out to be resistant to drugs, several courses of therapy are required, which can delay the hospital stay for up to six months or more.

The main thing that the patient’s family needs to remember is - DO NOT HURRY DOCTORS, do not insist on an urgent discharge “on receipt”! To completely stabilize the condition, it is necessary certain time and by insisting on early discharge, you risk getting an undertreated patient, which is dangerous for both him and you.

One of the most important factors influencing the prognosis of psychotic disorders is the timeliness of initiation and intensity of active therapy in combination with social and rehabilitation measures.

Maksutova E.L., Zheleznova E.V.

Research Institute of Psychiatry, Ministry of Health of the Russian Federation, Moscow

Epilepsy is one of the most common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8–1.2%.

It is known that mental disorders are an essential component of the clinical picture of epilepsy, complicating its course. According to A. Trimble (1983), A. Moller, W. Mombouer (1992), there is a close relationship between the severity of the disease and mental disorders, which occur much more often with an unfavorable course of epilepsy.

In the last few years, as statistical studies show, in the structure of mental morbidity there has been an increase in forms of epilepsy with non-psychotic disorders. At the same time, the proportion of epileptic psychoses is decreasing, which reflects the obvious pathomorphism of the clinical manifestations of the disease, caused by the influence of a number of biological and social factors.

One of the leading places in the clinical picture of non-psychotic forms of epilepsy is occupied by affective disorders, which often tend to become chronic. This confirms the position that despite the achieved remission of seizures, disturbances in the emotional sphere are an obstacle to the full restoration of patients’ health (Maksutova E.L., Fresher V., 1998).

When clinically qualifying certain syndromes of the affective register, it is fundamental to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes themselves. In this regard, we can conditionally distinguish two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders themselves, and secondary - without a cause-and-effect relationship with the attack, but based on various manifestations of reactions to the disease, as well as to additional psychotraumatic influences.

Thus, according to studies of patients in a specialized hospital at the Moscow Research Institute of Psychiatry, it has been established that phenomenologically non-psychotic mental disorders are represented by three types of conditions:

1) depressive disorder in the form of depression and subdepression;

2) obsessive-phobic disorders;

3) other affective disorders.

Depressive spectrum disorders include the following:

1. Melancholy depression and subdepression were observed in 47.8% of patients. The predominant feeling in the clinic here was an anxious and melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort and heaviness in the chest. In some patients, there was a connection between these sensations and physical illness (headache, unpleasant sensations in the chest) and were accompanied by motor restlessness, less often they were combined with adynamia.

2. Adynamic depression and subdepression were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. They spent most of the time in bed, had difficulty performing simple self-care functions, and were characterized by complaints of fatigue and irritability.

3. Hypochondriacal depression and subdepression were observed in 13% of patients and were accompanied by a constant feeling of physical damage and heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that sudden death might occur during an attack or that they would not receive help in time. Rarely did the interpretation of phobias go beyond the specified plot. Senestopathies were characterized by hypochondriacal fixation, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.

The variant of hypochondriacal depression was more typical for the interictal period, especially in conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.

4. Anxiety depression and subdepression occurred in 8.7% of patients. Anxiety, as a component of an attack (less commonly, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experienced vague fear or anxiety, the cause of which was unclear to them. A short-term anxious affect (several minutes, less often within 1–2 hours), as a rule, is characteristic of a variant of phobias as a component of a seizure (within the aura, the attack itself or the post-seizure state).

5. Depression with depersonalization disorders was observed in 0.5% of patients. In this variant, the dominant sensations were changes in the perception of one’s own body, often with a feeling of alienation. The perception of the environment and time also changed. Thus, patients, along with a feeling of adynamia and hypothymia, noted periods when the environment “changed”, time “accelerated”, it seemed that the head, arms, etc. were enlarged. These experiences, in contrast to true paroxysms of depersonalization, were characterized by the preservation of consciousness with full orientation and were fragmentary in nature.

Psychopathological syndromes with a predominance of anxious affect comprised predominantly the second group of patients with “obsessive-phobic disorders.” Analysis of the structure of these disorders showed that their close connections can be traced with almost all components of a seizure, starting with precursors, aura, the attack itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, often of uncertain content, which patients described as an “impending threat”, increasing anxiety, giving rise to a desire to urgently do something or seek help from others. Individual patients often indicated fear of death from an attack, fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, and less frequently, social phobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection between obsessive-phobic disorders and the vegetative component, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, and thoughts were observed.

Unlike paroxysmal anxiety, anxious affect in remissions approaches in form the classical variants in the form of unmotivated fears for one’s health, the health of loved ones, etc. A number of patients have a tendency to develop obsessive-phobic disorders with obsessive concerns, fears, behaviors, actions, etc. In some cases, there are protective mechanisms of behavior with unique measures to counteract the disease, such as rituals, etc. In terms of therapy, the most unfavorable option is a complex symptom complex, including obsessive-phobic disorders, as well as depressive disorders.

The third type of borderline forms of mental disorders in the epilepsy clinic were affective disorders, which we designated as “other affective disorders.”

Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.

Among this group of borderline disorders, occurring both in the form of paroxysms and prolonged states, epileptic dysphoria was more often observed. Dysphoria, occurring in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic attack or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriacal manifestations, irritability, and anger affect prevailed in their structure. Protest reactions often formed. Aggressive actions were observed in a number of patients.

The emotional lability syndrome was characterized by a significant amplitude of affective fluctuations (from euphoria to anger), but without noticeable behavioral disturbances characteristic of dysphoria.

Among other forms of affective disorders, mainly in the form of short episodes, there were reactions of weakness, manifested in the form of incontinence of affect. Usually they acted outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.

In relation to the individual phases of an attack, the frequency of borderline mental disorders associated with it is presented as follows: in the aura structure - 3.5%, in the attack structure - 22.8%, in the post-ictal period - 29.8%, in the interictal period - 43.9 %.

Within the framework of the so-called precursors of attacks, various functional disorders are well known, mainly of a vegetative nature (nausea, yawning, chills, drooling, fatigue, loss of appetite), against the background of which anxiety, decreased mood or its fluctuations with a predominance of irritable-sullen affect occur. A number of observations during this period noted emotional lability with explosiveness and a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can be self-limiting.

An aura with affective feelings is a common component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension and a feeling of “lightheadedness.” Less common are pleasant sensations (increased vitality, a feeling of particular lightness and elation), which are then replaced by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either an affect of fear and anxiety may occur, or a neutral (less often excited-elated) mood may be noted.

In the structure of the paroxysm itself, affective syndromes most often occur within the framework of the so-called temporal lobe epilepsy.

As is known, motivational and emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly the mediobasal formations, which are part of the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.

When the focus is localized in the right temporal lobe, depressive disorders are more common and have a more defined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with various plots of phobias and episodes of agitation. This clinic fits completely into the distinguished “right hemisphere affective disorder” in the taxonomy of organic syndromes ICD-10.

Paroxysmal affective disorders (within an attack) include attacks of fear, unaccountable anxiety, and sometimes with a feeling of melancholy that suddenly appear and last for several seconds (less often than minutes). There may be impulsive short-term states of increased sexual (food) desire, a feeling of increased strength, and joyful anticipation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. It is necessary to emphasize the predominantly violent nature of these experiences, although individual cases of their arbitrary correction using conditioned reflex techniques indicate a more complex pathogenesis.

“Affective” seizures occur either in isolation or are part of the structure of other seizures, including convulsive ones. Most often they are included in the structure of the aura of a psychomotor seizure, less often - vegetative-visceral paroxysms.

The group of paroxysmal affective disorders within temporal lobe epilepsy includes dysphoric states, the duration of which can range from several hours to several days. In some cases, dysphoria in the form of short episodes precedes the development of the next epileptic seizure or series of seizures.

The second place in the frequency of affective disorders is occupied by clinical forms with dominant autonomic paroxysms within the framework of diencephalic epilepsy. Analogues of the common designation of paroxysmal (crisis) disorders as “vegetative attacks” are concepts widely used in neurological and psychiatric practice such as “diencephalic” attack, “panic attacks” and other conditions with large vegetative accompaniment.

Classic manifestations of crisis disorders include sudden development: shortness of breath, a feeling of lack of air, discomfort from the organs of the chest cavity and abdomen with “heart sinking,” “interruptions,” “pulsation,” etc. These phenomena are usually accompanied by dizziness, chills, and tremor , various paresthesias. Possible increased frequency of bowel movements and urination. The most powerful manifestations are anxiety, fear of death, fear of going crazy.

Affective symptoms in the form of individual unstable fears can be transformed into both affective paroxysm itself and permanent variants with fluctuations in the severity of these disorders. In more severe cases, a transition to a persistent dysphoric state with aggression (less often, auto-aggressive actions) is possible.

In epileptological practice, vegetative crises occur mainly in combination with other types (convulsive or non-convulsive) paroxysms, causing polymorphism in the clinical picture of the disease.

Regarding the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we include a variety of psychologically understandable reactions to the disease that occur with epilepsy. At the same time, side effects as a response to therapy, as well as a number of professional restrictions and other social consequences of the disease, include both transient and prolonged conditions. They more often manifest themselves in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual personality characteristics of the patient and additional psychogenies. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficient) changes, which gives them a number of features associated with organic soil. The clinical picture of emerging secondary reactive disorders is also reflected by the degree of personal (epithymic) changes.

As part of reactive inclusions, patients with epilepsy often have concerns:

    development of a seizure on the street, at work

    be injured or die during a seizure

    go crazy

    transmission of disease by inheritance

    side effects of anticonvulsants

    forced withdrawal of drugs or untimely completion of treatment without guarantees for relapse of attacks.

The reaction to a seizure at work is usually much more severe than when it occurs at home. Because of the fear that a seizure will occur, some patients stop studying, working, and do not go out.

It should be pointed out that, according to induction mechanisms, fear of a seizure may also appear in relatives of patients, which requires a large participation of family psychotherapeutic assistance.

Fear of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness become so accustomed to them that, as a rule, they hardly experience such fear. Thus, in patients with frequent seizures and a longer duration of the disease, signs of anosognosia and uncritical behavior are usually observed.

Fear of bodily harm or fear of death during a seizure is more easily formed in patients with psychasthenic personality traits. It also matters that they have previously had accidents and bruises due to seizures. Some patients fear not so much the attack itself as the possibility of bodily harm.

Sometimes the fear of a seizure is largely due to the unpleasant subjective sensations that appear during an attack. These experiences include frightening illusory, hallucinatory inclusions, as well as body schema disorders.

This distinction between affective disorders is of fundamental importance in determining further therapy.

Principles of therapy

The main direction of therapeutic tactics in relation to individual affective components of the attack itself and post-ictal emotional disorders closely associated with it is the adequate use of anticonvulsants with a thymoleptic effect (cardimizepine, valproate, lamotrigine).

While not anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic regimen has a positive effect on both the paroxysms themselves and secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.

Recently, the anti-anxiety and sedative effect of clonazepam, which is highly effective in absence seizures, has been widely used.

For various forms of affective disorders with depressive radicals, antidepressants are most effective. At the same time, in outpatient settings, drugs with minimal side effects are preferred, such as tianeptil, miaxerin, fluoxetine.

If the obsessive-compulsive component predominates in the structure of depression, the prescription of paroxetine is justified.

It should be noted that a number of mental disorders in patients with epilepsy may be caused not so much by the disease itself as by long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, and elements of mental and motor retardation that appear in some patients. With the advent of highly effective anticonvulsants in recent years, it has become possible to avoid side effects of therapy and classify epilepsy as a curable disease.

All mental disorders are usually divided into two levels: neurotic and psychotic.

The boundary between these levels is arbitrary, but it is assumed that rough, pronounced symptoms are a sign of psychosis...

Neurotic (and neurosis-like) disorders, on the contrary, are distinguished by their mildness and smoothness of symptoms.

Mental disorders are called neurosis-like if they are clinically similar to neurotic disorders, but, unlike the latter, are not caused by psychogenic factors and have a different origin. Thus, the concept of the neurotic level of mental disorders is not identical to the concept of neuroses as a group of psychogenic diseases with a non-psychotic clinical picture. In this regard, a number of psychiatrists avoid using the traditional concept of “neurotic level”, preferring to it the more precise concepts of “non-psychotic level”, “non-psychotic disorders”.

The concepts of neurotic and psychotic level are not associated with any specific disease.

Disorders of the neurotic level often debut with progressive mental illnesses, which subsequently, as the symptoms become more severe, give a picture of psychosis. In some mental illnesses, for example neuroses, mental disorders never exceed the neurotic (non-psychotic) level.

P. B. Gannushkin proposed to call the entire group of non-psychotic mental disorders “minor”, ​​and V. A. Gilyarovsky - “borderline” psychiatry.

The concept of borderline mental disorders is used to denote mildly expressed disorders that border on a state of health and separate it from the actual pathological mental manifestations, accompanied by significant deviations from the norm. Disorders of this group disrupt only certain areas of mental activity. Social factors play a significant role in their occurrence and course, which, with a certain degree of convention, allows us to characterize them as failure of mental adaptation. The group of borderline mental disorders does not include neurotic and neurosis-like symptom complexes accompanying psychotic (schizophrenia, etc.), somatic and neurological diseases.

Borderline mental disorders according to Yu.A. Alexandrovsky (1993)

1) the predominance of the neurotic level of psychopathology;

2) the connection of mental disorder with autonomic dysfunctions, night sleep disorders and somatic disorders;

3) the leading role of psychogenic factors in the occurrence and decompensation of painful disorders;

4) the presence of an “organic” predislocation (MMD), facilitating the development and decompensation of the disease;

5) the relationship of painful disorders with the personality and typological characteristics of the patient;

6) maintaining criticism of one’s condition and the main painful disorders;

7) absence of psychosis, progressive dementia or endogenous personal (schizoform, epileptic) changes.

The most characteristic signs borderline psychopathologists:

    neurotic level = functional character and reversibility existing violations;

    vegetative "accompaniment", the presence of comorbid asthenic, dyssomnic and somatoform disorders;

    connection between the occurrence of diseases and psychotraumatic circumstances and

    personal-typological characteristics;

    ego-dystonism(unacceptability for the patient’s “I”) of painful manifestations and maintaining a critical attitude towards the disease.

Neurotic disorders(neuroses) - a group of psychogenically caused painful conditions, characterized by partiality and ego-dystonism of diverse clinical manifestations that do not change the individual’s self-awareness and awareness of the disease.

Neurotic disorders affect only certain areas of mental activity, Not accompanied psychotic phenomena and gross behavioral disorders, but at the same time they can significantly affect the quality of life.

Definition of neuroses

Neuroses are understood as a group of functional neuropsychic disorders, including emotional-affective and somato-vegetative disorders caused by psychogenic factors leading to disruption of mental adaptation and self-regulation.

Neurosis is a psychogenic disease without organic pathology of the brain.

A reversible disorder of mental activity caused by exposure to traumatic factors and occurring with the patient’s awareness of the fact of his illness and without disturbing the reflection of the real world.

The doctrine of neuroses: two trends:

1 . Researchers proceed from the recognition of the determinism of neurotic phenomena by certain pathologicalmechanisms of biological nature , although they do not deny the role of mental trauma as a trigger and a possible condition for the onset of the disease. However, psychotrauma itself acts as one of the possible and equivalent exogenies that disrupt homeostasis.

Within negative diagnosis indicates the absence of disorders of another level, neurosis-like and pseudoneurotic disorders of organic, somatic or schizophrenic origin.

2. The second trend in the study of the nature of neuroses is the assumption that the entire clinical picture of neurosis can be deduced from one only psychological mechanisms . Supporters of this trend believe that somatic information is fundamentally unimportant for understanding the clinic, genesis and treatment of neurotic conditions.

Concept positive diagnosis neuroses are presented in the works of V.N. Myasishcheva.

Positive diagnosis follows from the recognition of the meaningful nature of the category of “psychogenic”.

Concept by V.N. Myasishcheva In 1934

V. N. Myasishchev noted that neurosis represents personality disease, primarily a disease of personality development.

By personality disease he understood that category of neuropsychic disorders that is caused by how a person processes or experiences his reality, his place and his destiny in this reality.

Neuroses are based on unsuccessfully, irrationally and unproductively resolved contradictions between a person and the aspects of reality that are significant for him, causing painful and painful experiences:

    failures in the struggle of life, unmet needs, unachieved goals, irreparable losses.

    The inability to find a rational and productive way out entails mental and physiological disorganization of the individual.

Neurosis is a psychogenic (usually conflictogenic) neuropsychic disorder that occurs as a result violations of particularly significant life relationships personality and manifests itself in specific clinical phenomena in the absence of psychotic phenomena.