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Syndromes included in the group of affective ones. Affective syndromes

Affective disorders (mood disorders) are mental disorders manifested by changes in the dynamics of natural human emotions or their excessive expression.

Affective disorders are a common pathology. It often disguises itself as various diseases, including somatic ones. According to statistics, affective disorders of varying severity are observed in every fourth adult inhabitant of our planet. However, no more than 25% of patients receive specific treatment.

Lack of interest in the outside world is one of the symptoms of affective disorder

Reasons

The exact causes leading to the development of affective disorders are currently unknown. Some researchers believe that the cause of this pathology lies in dysfunction of the pineal gland, hypothalamic-pituitary and limbic systems. Such disorders entail a disruption in the cyclical release of liberins and melatonin. As a result, the circadian rhythms of sleep and wakefulness, sexual activity, and nutrition are disrupted.

Affective disorders can also be caused by a genetic factor. It is known that approximately every second patient suffering from bipolar syndrome (a variant of affective disorder) had mood disorders in at least one of the parents. Geneticists have suggested that affective disorders may arise due to a mutation of a gene localized on the 11th chromosome. This gene is responsible for the synthesis of tyrosine hydroxylase, an enzyme that regulates the production of catecholamines by the adrenal glands.

Affective disorders, especially in the absence of adequate therapy, worsen the patient’s socialization, interfere with the establishment of friendly and family relationships, and reduce ability to work.

Psychosocial factors are often the cause of affective disorders. Long-term, both negative and positive stress causes overstrain of the nervous system, which is subsequently replaced by its exhaustion, which can lead to the formation of a depressive syndrome. The most severe stressors:

  • loss of economic status;
  • death of a close relative (child, parent, spouse);
  • family quarrels.

Species

Depending on the prevailing symptoms, affective disorders are divided into several large groups:

  1. Depression. The most common cause of depressive disorder is a metabolic disorder of brain tissue. As a result, a state of extreme hopelessness and despondency develops. In the absence of specific therapy, this condition can last a long time. Often, at the height of depression, patients try to commit suicide.
  2. Dysthymia. One of the variants of depressive disorder, characterized by a milder course compared to depression. Characterized by a bad mood, increased anxiety every day.
  3. Bipolar disorder. The outdated name is manic-depressive syndrome, as it consists of two alternating phases, depressive and manic. In the depressive phase, the patient is in a depressed mood and apathy. The transition to the manic phase is manifested by increased mood, vigor and activity, often excessive. Some patients in the manic phase may experience delusions, aggression, and irritability. Bipolar disorders with mild symptoms are called cyclothymia.
  4. Anxiety disorders. Patients complain of feelings of fear and anxiety, internal restlessness. They are almost constantly in anticipation of impending disaster, tragedy, trouble. In severe cases, motor restlessness is noted, the feeling of anxiety gives way to a panic attack.

Diagnosis of affective disorders must necessarily include an examination of the patient by a neurologist and endocrinologist, since affective symptoms can be observed against the background of endocrine diseases, nervous system, and mental disorders.

Signs

Each type of affective disorder has characteristic manifestations.

Main symptoms of depressive syndrome:

  • lack of interest in the outside world;
  • a state of prolonged sadness or melancholy;
  • passivity, apathy;
  • disturbances in concentration;
  • feeling of worthlessness;
  • sleep disorders;
  • decreased appetite;
  • deterioration in work ability;
  • recurrent thoughts of suicide;
  • deterioration in general health that cannot be explained during examination.

Bipolar disorder is characterized by:

  • alternating phases of depression and mania;
  • depressed mood during the depressive phase;
  • during the manic period - recklessness, irritability, aggression, hallucinations and/or delusions.

Anxiety disorder has the following manifestations:

  • heavy, obsessive thoughts;
  • sleep disorders;
  • decreased appetite;
  • constant feeling of anxiety or fear;
  • dyspnea;
  • tachycardia;
  • deterioration in concentration.

Features of the course in children and adolescents

The clinical picture of affective disorders in children and adolescents has distinctive features. Somatic and vegetative symptoms come to the fore. Signs of depression are:

  • night terrors, including fear of the dark;
  • problems falling asleep;
  • pale skin;
  • complaints of chest or abdominal pain;
  • increased fatigue;
  • a sharp decrease in appetite;
  • moodiness;
  • refusal to play with peers;
  • slowness;
  • learning difficulties.

Manic states in children and adolescents also occur atypically. They are characterized by such signs as:

  • increased cheerfulness;
  • disinhibition;
  • uncontrollability;
  • sparkle of eyes;
  • facial hyperemia;
  • accelerated speech;
  • constant laughter.

Diagnostics

Diagnosis of affective disorders is carried out by a psychiatrist. It begins with a thorough history taking. For an in-depth study of the characteristics of mental activity, a medical and psychological examination may be prescribed.

Affective symptoms can be observed against the background of diseases:

  • endocrine system (adrenogenital syndrome, hypothyroidism, thyrotoxicosis);
  • nervous system (epilepsy, multiple sclerosis, brain tumors);
  • mental disorders (schizophrenia, personality disorders, dementia).

That is why the diagnosis of affective disorders must necessarily include an examination of the patient by a neurologist and endocrinologist.

Treatment

The modern approach to the treatment of affective disorders is based on the simultaneous use of psychotherapeutic techniques and antidepressant medications. The first results of the treatment become noticeable after 1-2 weeks from its start. The patient and his relatives should be informed about the inadmissibility of spontaneous discontinuation of medications, even in the case of persistent improvement in mental health. Antidepressants can be discontinued only gradually, under the supervision of the attending physician.

According to statistics, affective disorders of varying severity are observed in every fourth adult inhabitant of our planet. However, no more than 25% of patients receive specific treatment.

Prevention

Due to the unknown nature of the exact causes underlying the development of affective disorders, there are no specific preventive measures.

Consequences and complications

Affective disorders, especially in the absence of adequate therapy, worsen the patient’s socialization, interfere with the establishment of friendly and family relationships, and reduce ability to work. Such negative consequences worsen the quality of life not only of the patient himself, but also of his close circle.

Suicide attempts can be a complication of some mood disorders.

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Affective syndromes are symptom complexes of mental disorders, defined by mood disorders.

Affective syndromes are divided into two main groups - with a predominance of high (manic) and low (depressive) mood. Patients with are found many times more often than with, and special attention should be paid to them, since approximately 50% of people who attempt suicide suffer from depression.

Affective syndromes are observed in all mental illnesses. In some cases they are the only manifestations of the disease (circular psychosis), in others - its initial manifestations (brain tumors, vascular psychoses). The latter circumstance, as well as the very high frequency of suicides among patients with depressive syndromes, determines the tactics of behavior of medical workers. These patients should be under strict medical supervision around the clock and should be referred to a psychiatrist as soon as possible. It must be remembered that not only rude, but simply careless treatment of manic patients always leads to increased agitation in them. On the contrary, attention and sympathy for them allow, even for a short time, to achieve their relative calm, which is very important when transporting these patients.

Affective syndromes are syndromes in the clinical picture of which the leading place is occupied by disturbances in the emotional sphere - from mood swings to expressed mood disorders (affects). By nature, affects are divided into sthenic, occurring with a predominance of excitement (joy, delight), and asthenic, with a predominance of inhibition (fear, melancholy, sadness, despair). Affective syndromes include dysphoria, euphoria, depression, and mania.

Dysphoria- a mood disorder characterized by a tense, angry-sad affect with severe irritability, leading to outbursts of anger and aggressiveness. Dysphoria is most common in epilepsy; with this disease they begin suddenly, without any external reason, last for several days and also end suddenly. Dysphoria is also observed in organic diseases of the central nervous system, in psychopaths of the excitable type. Sometimes dysphoria is combined with binge drinking.

Euphoria- elevated mood with a hint of contentment, carelessness, serenity, without accelerating associative processes and increasing productivity. Signs of passivity and inactivity predominate. Euphoria occurs in the clinic of progressive paralysis, atherosclerosis, and brain injury.

Pathological affect- a short-term psychotic state that occurs in connection with mental trauma in persons who do not suffer from mental illness, but are characterized by mood instability and asthenia. The intensity of affect, anger and rage in this state are immeasurably greater than those characteristic of physiological affects.

The dynamics of pathological affect are characterized by three phases: a) asthenic affect of resentment, fear, which is accompanied by disturbances in thinking (incompleteness of individual thoughts, their slight incoherence) and autonomic disorders (pallor of the face, trembling hands, dry mouth, decreased muscle tone); b) affect becomes sthenic, rage and anger predominate; consciousness sharply narrows, mental trauma dominates in its content; disorders of consciousness deepen, accompanied by agitation and aggression; the nature of vegetative changes becomes different: the face turns red, the pulse quickens, muscle tone increases; c) recovery from pathological affect, which is realized by prostration or sleep, followed by complete or partial amnesia.

Treatment of affective states. The presence of one or another affective syndrome in patients requires the doctor to take emergency measures: establishing supervision over the patient, referring him to a psychiatrist. Depressed patients who may attempt suicide are admitted to a unit with enhanced supervision. They must be transported to the hospital under the close supervision of medical staff. On an outpatient basis (before hospitalization), patients in a state of agitated depression or depression with persistent suicidal attempts are prescribed an injection of 5 ml of a 2.5% solution of aminazine.

When prescribing therapy, the nosological diagnosis and characteristics of the patient’s condition are taken into account. If depression is a phase of circular psychosis, then treatment is carried out with psychotropic drugs - antidepressants. If there is agitation and anxiety in the structure of this depression, combination therapy with antidepressants (in the first half of the day) and antipsychotic drugs (in the afternoon) is prescribed, or treatment is carried out with nosinane, amitriptyline.

For psychogenic depression, if it is not deep, hospitalization is not necessary, since its course is regressive. Treatment is carried out with sedatives and antidepressants.

Patients in a manic state are usually hospitalized, since it is necessary to protect both those around them and the patients themselves from their incorrect and often unethical actions. To treat manic states, neuroleptic drugs are used - aminazine, propazine, etc. Patients with euphoria are subject to hospitalization, since this condition indicates either intoxication (which requires quick recognition to take emergency measures), or an organic brain disease, the essence of which must be clarified . The euphoria of convalescents who have suffered an infectious or general somatic disease at home or in a somatic (infectious diseases) hospital is not an indication for hospitalization in a psychiatric hospital. Such patients should be under constant supervision of a doctor and staff. For their treatment, along with general restoratives, sedatives can be used. Patients in a state of epileptic dysphoria are also hospitalized due to the possibility of aggression.

Affective psychoses is a group of mental illnesses that occur mainly with affective syndromes: depressive, manic or mixed.

The significant psychopathological polymorphism of these syndromes and the variability of their dynamics make attempts to create a typology of the phases of manic-depressive psychosis extremely difficult. The complexity of this problem is aggravated by the fact that to date there is no unified classification of affective syndromes.

By dividing affective syndromes into relatively simple and complex ones, highlighting a number of psychopathological variants in each of these groups, one can get the most complete picture of their diversity:
to relatively simple affective syndromes These include conditions whose manifestations do not go beyond the affective register - primarily classic circular depression and mania; Their characteristic feature is the harmonious expression of the affective triad of symptoms: with depression - depressed mood, motor and ideational inhibition, with mania - elevated mood, ideational and motor excitation
To psychopathologically complex include syndromes combining affective disorders with manifestations of other psychopathological registers

Circular (vital) depression

Classic circular (vital) depression is characterized by:
depressive delusional or overvalued ideas of self-blame and self-humiliation
manifestations of depressive anesthesia
suicidal thoughts and attempts
daily mood swings
somatovegetative manifestations (sleep disorders, appetite disorders, menstrual irregularities, constipation, etc.)

The group of simple depressions includes:
depression with delusions of self-blame
anesthetic depression
anxious depression
agitated depression
stuporous depression
dysphoric (grumpy) depression
tearful depression
smiling (ironic) depression
adynamic depression

Complex types of depression include:
depression with delusions of blame and condemnation
depression with delusional ideas close to paranoid (damage, everyday relationships, following, poisoning, etc.)
depression with Cotard's syndrome
depression with sensual delirium
depression with hallucinosis and manifestations of Kandinsky-Clerambault syndrome
depression, senestopathies, hypochondriacal delusions, obsessions
depression with psychasthenic manifestations, vegetative and somatic disorders

Circular mania

Circular manias, in addition to manifestations of the affective triad, are characterized by:
ideas of overvaluation or grandeur
disinhibition of drives
distractibility
sleep disorder
increased appetite, etc.

The most common variants of simple manic syndrome are:
unproductive mania
confused mania
angry mania

Complex variants of manic syndrome include:
mania with sensual delirium
mania with hallucinosis and phenomena of mental automatism
mania with senestopathies and hypochondriacal delirium

Manic-depressive psychosis

Manic-depressive psychosis(circular disease, circular psychosis, cyclophrenia, cyclothymia) is a disease that occurs in the form of affective phases, separated by intermissions, which does not lead to a change in personality, to the formation of a defect, even over a long (many years) course with multiple relapses. The main manifestations of manic-depressive psychosis are depressive and manic phases of various structures.

Manic-depressive psychosis is more characterized by phases with relatively simple affective syndromes. At the same time, there is a significant diversity of affective manifestations, expressed in varying degrees of their severity and features of the psychopathological structure.

The phases of manic-depressive psychosis can be divided:
into typical ones, the picture of which is limited to affective manifestations
to atypical with the occurrence of:
- complex affective syndromes
- mixed states (combining manifestations of depression and mania in various ways)
- inharmonious development of the main components of affective states

Within the phases of manic-depressive psychosis, depressive and manic states undergo modifications in the structure and intensity of manifestations:
in the initial stages depression, somatovegetative disorders with a decrease in affective tone and asthenic disorders are observed. Sleep and appetite are disturbed, constipation appears. There is a feeling of compression, heaviness in the head, in the heart area, hyperesthesia, tearfulness, lethargy, “laziness,” and decreased performance. The depressive coloring of the state is manifested by a weakening of contacts, the ability to rejoice, and a tendency toward pessimism. Identifying these symptoms in combination with their daily fluctuations makes it possible to recognize the cyclothymic phase and serves the purpose of early diagnosis of more severe depression.
at the next stage During the depressive phase, depression becomes more intense and manifests itself in the appearance, statements and behavior of patients. An affect of melancholy or vague anxiety, physical discomfort, stiffness of movement, and pessimistic self-esteem are noted. Depressive facial expressions, quiet, monotonous speech, somato-autonomic disorders intensify. Pale skin, weight loss, anorexia, constipation, and a coated tongue are noted. The assessment of the past, present and future is pessimistic. There are daily mood swings and ideas of inferiority.
when the phenomena deepen depression, all these symptoms reach particular severity (“classical melancholy”). At the height of development, depression can occur without daily fluctuations, which indicates its significant intensity. Often the extreme degrees of development of depressive phases are states of melancholic paraphrenia. Suicidal attempts are possible with depression of any severity. Most often they occur during periods of less pronounced motor retardation, i.e. in the initial or final stage of the phase.

Types of depressive phases:
cyclothymic depression - the clinical picture is limited to disorders characteristic of the initial stage
simple circular depression is the most common and typical variant of endogenous depression
delusional circular depression - a combination of severe depressive affect with depressive delusional ideas
melancholic paraphrenia

Degrees of severity of the manic phase:
mild - hypomania
pronounced - typical circular mania
severe - mania with delusions of grandeur, mania with confusion

In some manic phases, all stages of development from hypomania to severe manic states can be traced:
in the initial stages In such phases, there is an increase in physical and mental tone, the emergence of a feeling of vigor, physical and mental well-being, good mood and optimism. The behavior of patients is characterized by liveliness. Self-esteem is increased. Patients do not feel tired, their appetite is increased, sleep duration is shortened, then all manifestations of mania become especially clinically distinct (simple mania)
at the next stage severe mania (psychotic mania) with a significantly elevated mood, a “jump of ideas” appears, sometimes reaching the point of confusion. Agitation may be accompanied by erratic aggression.
with further strengthening phenomena of mania, delusional ideas of grandeur appear, sometimes acquiring a fantastic character.

Symptoms of mania at almost all stages of phase development are more noticeable than symptoms of depression. At the same time, the uniqueness of the initial stage of mania, which creates the impression of complete well-being, makes it difficult for the patient and others to assess the hypomanic state.

Phases of manic-depressive psychosis can occur in the form of mixed states. More often, these states are observed not as independent phase states, but at the junction of depressive and manic states with a dual or continuum version of the course of manic-depressive psychosis. The typical typology of mixed conditions is extremely difficult.

Variants of the course of manic-depressive psychosis:
cyclothymic(outpatient) - observed in 70% of cases; with it, more severe phases at the psychotic level may occur; with this option, the most common flow is of the “cliché” type - with the same structure and duration of the phases; depressive phases predominate with a clear expression of all components of the depressive triad
cyclophrenic(occurring with the so-called psychotic phases) - a significant psychopathological variety of phases is observed - almost all types of simple and complex endogenous depressions and manias
atypical – in phases of manic-depressive psychosis, affective-delusional disorders may also be observed
continuous - continuous change of polar affective phases

The course of manic-depressive psychoses can be:
monopolar - in the form of phases of the same type
bipolar - depressive and manic phases are combined in different ways

Directive phases during manic-depressive psychoses can be strictly defined, i.e. end with intermissions. However, quite often a course is observed in the form of “double”, “triple” phases, when depressive and manic states replace each other without clear intervals.

Average duration of phases Manic-depressive psychosis lasts several months, and depressive phases are usually longer than manic phases. Phases, especially depressive ones, lasting more than a year, sometimes several years, are not uncommon. Chronic phases of the disease are possible, in most cases depressive. The onset of chronic depression can occur after phases of normal duration.

Duration of intermissions is also extremely variable. There may be cases of the disease with the first phase - at a young age and a second phase - during the period of involution. Frequent recurrence of the disease is possible, especially in the later stages. Phases of manic-depressive psychoses, especially in the initial stages of the disease, can be provoked by exogenous factors. However, more typical for manic-depressive psychoses is the autochthonous occurrence of phase states. Less typical, although possible, is the provocability of all or most of the phases during manic-depressive psychoses. One of the features of the course of manic-depressive psychoses is the seasonal preference for the occurrence of affective phases. Although this property is not exclusive to manic-depressive psychoses, it is quite often observed in the paroxysmal course of schizophrenia.

More typical for manic-depressive psychosis is debut of the disease in the form of depressive phases. The onset of the disease with manic states often indicates a less favorable prognosis. Quite often, with the manic debut of the disease in further affective phases, signs of atypia appear in the form of interpretive or sensory delusions, hallucinatory disorders, manifestations of Kandinsky syndrome - in such cases we can talk about affective-delusional attacks of schizophrenia. At the stage of development of atypical affective states, it is usually possible to detect certain negative signs. The debut of manic-depressive psychosis in the form of mania is often a sign indicating the possibility of the emergence of double or combined affective phases in the subsequent course or a transition to a continuum course. Continua course clearly correlates with a poorer prognosis- the possibility of personal changes and complication of affective states due to various kinds of “additional” symptoms, i.e. gives reason to suspect quite early the procedural nature of the disease.

Mood disorders are often characterized by a certain set of symptoms that already indicate that a particular illness is developing. There are such a large number of symptoms, in all their variations and degrees of severity, that the diseases themselves have different names. But there is one common sign that determines whether a person has an affective syndrome—mood disturbance.

During the day, every person's mood changes. The sun shone - the mood rose, someone was rude - the spirit fell. Of course, all people undergo changes in their mood during the day, but at the same time they do not become sick! We are not talking about easy and completely manageable changes, but about constant emotional states in which a person remains for a long time in the absence of a good reason.

The main signs of an affective disorder are the presence of depressive or elevated mood, anxiety. The constant presence of a person in these states without justifiable reasons indicates a violation of mental health. We repeat once again that all people’s moods change after the occurrence of certain pleasant or shocking events.

But a healthy individual eventually returns to his usual calm state, forgets about what happened, and switches to something else. A sick person gets stuck in his emotional state for a long time, sometimes not being able to change it, because he is not aware that this is an anomaly.

Often the side effects of these conditions are psychosomatic diseases - the mood begins to affect the health of the physical body. If you do not eliminate the harmful mood, you will not cure the disease.

Depressive disorder

Depressed mood, decreased energy, lack of ability to enjoy life, lethargy, and a pessimistic outlook characterize a disorder called depressive disorder. This is included in the category of symptoms that form depressive affective syndrome. The person is in a constantly depressed mood. However, other signs accompanying this deviation are so diverse that it seems as if the person is suffering from several diseases at once.

Elation or mania

The flip side of a depressed mood is an elevated one. In a healthy person, the emotional state changes for the better when he is in appropriate conditions, such as fun, holiday, celebration, receiving good news, etc. Where a person encounters good luck or happiness, his mood rises.

The pathological condition is mania syndrome, characterized by the following symptoms:

  • Hyperactivity
  • Ideas of self-importance (greatness)
  • Mood changes towards elation or irritability

Previously, the term “hypomania” was applied to illnesses with less severe degrees of mania. But the symptoms of these disorders are almost the same, so it was customary to call mania “mild,” “moderate,” or “severe.”

As you can see, a person’s natural ability to change his mood may indicate psychopathic illness. If a person is in conditions that cause completely natural reactions that do not last long, we are talking about a healthy individual.

But if a person, after a certain situation, plunges into his own state and continues to experience it in other conditions of life, then we are talking about a sick individual. And the degree of the disease also differs depending on the condition of the sick person.

Affective (emotional) syndromes- psychopathological conditions in the form of persistent changes in mood, most often manifested by its decrease (depression) or increase (mania).

Depression and mania are the most common mental disorders. In terms of frequency, they occupy first place in the clinic of major psychiatry and are very common in borderline mental illnesses. Affective syndromes are constantly encountered at the onset of mental illnesses; they can remain the predominant disorder throughout their entire course, and when the disease becomes more complicated, they can coexist for a long time with various other, more severe psychopathological disorders. When the disease pattern reverses, depression and mania are often the last to disappear.

DEPRESSIVE SYNDROME(syn.: depression, melancholy) - a combination of depressed mood, decreased mental and motor activity with somatic, primarily autonomic, disorders.

In mild cases of depression or in the initial stages of its development, somatic disorders are constant: sweating, tachycardia, fluctuations in blood pressure, sensations of heat, cold, and chilliness. Appetite decreases, food seems tasteless. Constipation appears. More significant dyspeptic disorders may also occur - heartburn, belching, flatulence, nausea. Patients look haggard, mature people look aged. Night sleep becomes shallow, intermittent, accompanied by disturbing dreams and early awakening. There may be loss of the sense of sleep. The coming day is exciting. In the morning they feel lethargic and tired. It takes a strong will to force yourself to stand up. Experience vague fears or specific painful forebodings. What needs to be done seems complex, difficult to accomplish, and beyond personal capabilities. It's hard to think and focus on one issue. They experience absent-mindedness and forgetfulness, and their self-confidence drops. For minor reasons, doubts arise, decisions are made with some difficulty and after hesitation. Habitual work, especially one that does not require mental effort, is still somehow accomplished. If you have to do something new, you often have no idea how to approach it. Patients are well aware of the very fact of their failure, but usually regard it primarily as “lack of will, laziness, inability to pull themselves together”; They are annoyed with their condition, but are unable to overcome it. True, being among people, in particular at work, they often “forget” and feel better for a while. When the patients are again left to their own devices, this improvement disappears.

Spontaneous complaints of bad mood do not always exist. Patients often say that their mood is normal. Nevertheless, upon questioning, it is possible to find out that patients experience “lethargy, apathy, loss of stimuli, anxiety, mental discomfort,” and often one can find such definitions of their condition as sadness, boredom, depression, depression. Many patients complain of a constant feeling of trembling. Upon questioning, it turns out that this is an internal sensation, and not trembling in the usual sense. Often such tremors are localized in the chest, but can be localized throughout the body. Sometimes patients note a constant feeling of irritation, dissatisfaction, an increased tendency to tears and resentment. This type of depression is called hypothymic or cyclothymic. Depending on the predominance of certain disorders, various types of mild depression (subdepression) are distinguished.

If depression is accompanied by a decrease in motivation, it is called adynamic; the presence of irritability and dissatisfaction in the structure of depression is characteristic of “grumpy” (grumpy) depression; when depression is combined with neurasthenic or hysterical disorders, they call it neurotic depression; depression with symptoms of obsession is defined either as neurotic or anankastic depression; depression, combined with easily occurring reactions of weakness, is called “tearful” depression; in cases where the clinical picture of depression is dominated by somatic, primarily vegetative, disorders, and altered affect recedes into the background, we speak of various variants of latent depression (see below); depression, combined with pathological sensations of mental genesis, is called senestopathic, and if at the same time the patient has an assumption that he is physically ill, we are talking about hypochondriacal-senestopathic depression; Depression in which only mild depression predominates is called mild or dull.

As the low mood deepens, patients begin to complain of melancholy. At the same time, many people experience painful sensations in the chest, upper abdomen, and less often in the head. They are defined as a feeling of tightness, constriction, compression, heaviness; They often talk about the inability to take a deep breath. With further intensification of depression, complaints appear about “aching melancholy”, about the fact that “the soul is being squeezed, aching, burning, tearing into pieces.” Many patients begin to talk about feeling pain, but not physical pain, but some other kind. Some patients call this pain moral pain. This is pre-heart melancholy. Some psychiatrists identify depression with precordial melancholy as a separate type.

Already with mild, hypothymic depression, patients begin to complain about a disturbing decrease in affective resonance - a variety of events lose interest for them, they don’t want anything, nothing excites desires. With a distinct melancholy affect, a painful feeling of indifference appears, reaching in pronounced cases a painful feeling of internal emptiness, loss of all feelings - anaesthesia psychica dolorosa. This disorder is a form of melancholic depersonalization. When describing mental anesthesia, patients often say that they “have become petrified, stupefied, become wooden,” etc. In these cases we talk about anesthetic depression. The intensity of mental anesthesia can be so significant that patients cease to feel melancholy and complain only of painful insensibility. There may be a feeling of change in the surroundings - it loses color, clarity, becomes frozen, distant, perceived “as if through a veil.” There are frequent complaints about the slow passage of time, about the feeling that it has stopped and even disappeared completely (melancholic derealization).

With further deepening of depression, delusional ideas of various contents arise. In some cases, this is depressive delirium in the strict sense of the word - delirium of self-abasement and self-blame. The first occurs in its most developed form in patients of mature and late age. Delusions of self-blame have now become less common. But delusions of accusation (condemnation) began to be observed more often in depression. Depressions in which such delusions occur are often complicated by other psychopathological disorders (see Depressive-paranoid syndrome). Hypochondriacal delusions are very common in depression. In some cases, this is delirium of illness. A depressed patient is unshakably convinced that he has a specific incurable disease - hypochondriacal delusional depression; in others, a delusional belief in the destruction of internal organs appears—depression with nihilistic delusions. Nihilistic delusions can be combined with delusions of enormity and denial - Cotard's syndrome (see below). Often, especially in adulthood and late age, depression occurs, accompanied by delusions of persecution, poisoning or harm - paranoid depression. Its peculiarity lies in the fact that the delusional ideas that arise usually come to the fore here and thereby attract the main attention of psychiatrists, while depressive disorders are often underestimated. The danger of such paranoid depression, often not accompanied by ideomotor inhibition, is a high risk of suicide.

In some cases, the intensity of ideomotor inhibition in depression is so significant that depressive stupor develops (see Syndromes of movement disorders).

There is a significant number of depressions, especially in mature and elderly patients, in which there is not just a lack of ideomotor inhibition, but long-term speech motor excitation. In these cases, the depressive affect is complicated by anxiety and less often by fear. Therefore, such depressions are called agitated, anxiety-agitated, or agitated depression with fear. With agitated depression, patients are haunted by painful premonitions of impending misfortune or simply a catastrophe; they often cannot say which one specifically; there are only vague assumptions about them. Only one thing is clear: something terrible is about to happen. In other cases, anxiety is associated with certain facts: awaiting trial, torture, execution, death of loved ones, etc. Patients are under extreme stress and cannot find a place for themselves. They cannot sit or lie down, they are constantly “tempted” to move. Patients want a lot, persistently turn to the staff and others with some kind of request or remark, sometimes they stand at the doors of the department for hours, shifting from foot to foot and grabbing the clothes of those passing by. Agitation does not always manifest itself as pronounced motor agitation. Sometimes patients sit motionless in one place for a long time, and only the constant movement of their fingers and hands indicates their lack of motor inhibition. Speech arousal in agitated depression is often manifested by groans, groans, lamentations, anxious verbalization - monotonous, repeated repetition of the same short phrases or words: “I buried my husband alive,” “kill me,” “I’m dying,” etc. Complex forms of depressive delirium, for example, Cotard's delirium, as a rule, occur not with inhibited depression, but with agitated depression.

Agitation, both pronounced and subtle, can easily be replaced by melancholic raptus (melancholic violence) - short-term, often “silent”, frantic excitement with the desire to kill or mutilate oneself. An increase in agitated depression in mature patients often occurs due to additional reasons - after conversations with a doctor, medical procedures, various types of movements within the department - a symptom of adaptation disorder (Charpentier's symptom). If depression in general and with distinct ideomotor inhibition in particular usually intensifies in the first half of the day, then anxiety-agitated depression often becomes more pronounced in the evening.

Among patients with depression treated in psychiatric hospitals, patients with agitated depression most often commit suicide attempts. Patients with “smiling depression” often make suicide attempts within the walls of the hospital. Psychiatrists use this term in cases where depressive affect in patients is combined with a mournful or ironic smile. Such patients are usually quiet and inconspicuous, although they often lack distinct motor inhibition. With their behavior they do not attract the attention of the staff, but the patients themselves are able to notice everything that is happening in the department, and, choosing the right moment, commit suicide.

Anxiety-agitated depressions reach their greatest complexity when they are complicated by Cotard's syndrome.

Cotard's syndrome(melancholic paraphrenia, melancholic; delusion of imagination, megalo-melancholic delirium) - a combination of anxious-agitated depression with hypochondriacal-depressive delirium of denial and enormity, extending to the moral and physical properties of the individual, various phenomena of the surrounding world, or to all at the same time. Symptom complex in the 80s. XIX century described by J. Cotard; Russia - V.P. Serbsky (1982). With Cotard's syndrome, a fantastic delusion of denial and enormity occurs. Partial denial usually concerns individual universal human qualities - moral, intellectual, physical (no feelings, conscience, compassion, knowledge, ability to think; no stomach, intestines, lungs, heart, etc.). They may talk not about the absence, but about the destruction of internal organs (the brain has dried out, the lungs have shrunk, the intestines have atrophied, there is feces in the rectum, etc.). The idea of ​​denying the physical self is called hypochondriacal-nihilistic or simply nihilistic delusion. Individual personal categories may be denied (no name, age, education, profession, family, never lived). Denial can extend to various concepts of the external world, which can be dead, destroyed, lose their inherent qualities or disappear altogether (the world is dead, the planet has cooled down, there is no one in the world, there are no seasons, stars, centuries). The patient may claim that he is left alone in the entire Universe - depressive solipsistic delirium.

Fantastic depressive delirium is accompanied by self-blame for world cataclysms that have already occurred or for possible future ones. Patients identify themselves with negative mythical or historical characters (Antichrist, Judas, Hitler, etc.) and list the incredible forms of retribution they expected and deserved for their deeds. Depressive fantasy delusions of self-blame can become retrospective. Statements about eternal torment and the impossibility of dying are common. Torment awaits the sick, even if their physical self disappears - “the body will be burned, but the spirit will remain tormented forever.” Ideas of immortality can be combined with delusions of metamorphosis - transformation into an animal, a corpse, metal, wood, stone, etc.

The combination of depressive delusions of denial and enormity with hypochondriacal-nihilistic delusions characterizes full or full-blown Cotard's syndrome. If any one of these components predominates, they speak of the corresponding variants of Cotard's syndrome - nihilistic or depressive. According to developmental characteristics, acute (mainly with paroxysmal psychoses) and chronic (with the continuous development of psychosis) Cotard syndrome are distinguished. This syndrome in its expanded form occurs mainly in elderly and senile people; In some cases of schizophrenia, quite pronounced Cotard's syndrome can appear already at a young age or even in adolescence. Some manifestations of Cotard's syndrome have been described in children 6-7 years old (M.S.Vrono, 1975).

Depression is complicated by the addition of a variety of productive disorders: obsessions, overvalued ideas, delusions, hallucinations - verbal and occasionally tactile; mental automatisms; catatonic symptoms, oneiric stupefaction. Depression can be combined with shallow manifestations of psychoorganic syndrome (organic depression) and initial symptoms of dementia, often accompanied by psychopathization.

Questioning patients with depression is difficult in cases where depression is either very mild and accompanied by a variety of somatic disorders, or when depression becomes complex due to the fact that it is combined with more severe productive disorders - delusions, hallucinations, mental automatisms, catatonic symptoms. Usually, patients with more or less distinct depression, when questioned, talk quite well about most of the disorders that exist in them. If there is noticeable ideational inhibition, it is better to initially ask patients about their physical well-being and thereby try to “talk” them. In other cases, questions may be asked directly regarding specific psychopathological symptoms. Some of them are features of depressed mood, pre-heart melancholy, self-reproach, difficulties in mental activity, etc. - patients usually describe it quite clearly. Others, such as mild melancholic depersonalization, may be reported somewhat inconsistently.

Patients usually do not talk about suicidal thoughts in the present and in the past, and especially about previous suicidal attempts, but if asked, they most often answer as it is or was in reality. You should ask about suicidal tendencies when the patient has either started talking, or the doctor has a definite assessment of the patient’s existing disorders and knows how to act. This usually happens in the second half of the conversation. You should not ask questions about suicidal tendencies towards the end of the conversation, much less end the conversation with them. Judging by the circumstances, the doctor can directly ask questions in order to find out: are there (were) suicidal thoughts, are there (were) thoughts about methods of suicide, are (were) the patient making any preparations for suicide. However, it would be more correct to preface direct questions with those that would make the patient feel that his condition is clear to the interlocutor, and, as it were, to “lead” the patient to the idea himself or, perhaps, with certain leading questions from the doctor, to talk about this side of his condition. Then directly posed questions simply won’t be needed. When the patient speaks himself, it means that he believes the doctor. In preliminary questions, you should return to what the patient initially told the doctor about his condition. Only now the doctor formulates his questions differently from the way he initially formulated them in order to identify disorders inherent in a general depressive state. The doctor takes into account the characteristics of the patient’s condition and the verbal expressions with which the patient describes his condition. The doctor’s questions acquire individual content that is most understandable to the patient. With the help of skillful questioning, the doctor not only obtains the necessary information, but often also alleviates the patient’s condition at the time of the conversation. Conscious depressive patients usually remember this circumstance well. At the same time, it should be firmly remembered that patients with depression are very often prone to dissimulation of their condition and, first of all, to dissimulation of thoughts about death and suicidal thoughts. What is especially confusing to psychiatrists is that they often cannot detect the depressive triad that is an indicator of the presence of depressive disorders. Instead of a “triad”, you very often see a talkative, lively, seemingly cheerful person who is pleased with himself. This is the surface, but deep down there is depression and hopelessness. When interviewing depressed patients, very often (in cases of subdepression) one should take into account the holistic picture of the condition, rather than chasing individual components of the triad. Anamnestic information, the patient’s statements, and the entire context of the conversation almost always allow us to give the necessary assessment of the patient’s condition. This is the rule for all psychiatry. It is especially important for depressed patients. After all, approximately 10% of people with depression commit suicide.

A special place among depressive conditions is occupied by a group of depressions, described in the last 25-30 years under a variety of names: vegetative depression, depression without depression, masked depression, somatized depression, etc. In all these cases we are talking about subdepressive states, combined with pronounced, and often dominant, vegetative-somatic disorders in the clinical picture. Their intensity in comparison with a slightly lowered mood, which at the same time seems to be obscured, makes it possible to designate this kind of depression as hidden. The frequency of such hidden depressions, which occur almost, if not exclusively, in outpatient practice, exceeds the number of overt depressions by 10-20 times (B. Jacobowsky, 1961; T.F. Papadopoulos and I.V. Shakhmatova-Pavlova, 1983). Initially, such patients are treated by doctors of various specialties, most often by internists and neurologists, and are admitted under the supervision of psychiatrists (if they are admitted at all), often after long periods of time after the onset of the disease.

The symptomatology of such hidden depressions is extremely diverse. The most common complaints are complaints about disorders of the cardiovascular system and digestive organs: short-term, prolonged, often in the form of paroxysms, pain in the heart area, accompanied in some cases by irradiation of pain, as with angina pectoris; various cardiac rhythm disturbances, up to paroxysms of atrial fibrillation, fluctuations in blood pressure; loss of appetite - up to anorexia, diarrhea, constipation, flatulence, pain along the gastrointestinal tract, etc. Pathological sensations, in particular pain, are very common: neuralgic paresthesia, migrating or localized pain (pain characteristic of lumbago, toothache, headaches). There are disorders resembling bronchial asthma and diencephalic paroxysms. Various sleep disorders are very common. Due to the fact that depressive disorders are difficult to identify, but the connection between somatic disorders and depression is undeniable, many call the vegetative-somatic disorders occurring in latent depression depressive equivalents (I. Lopez Ibor, 1968). The number of such equivalents has been increasing over the years. Comparing the psychopathology of latent depression with the onset of depression in general, one cannot help but notice the similarity between them - the severity of the somatic component. It is possible that latent depression represents the initial stage of the development of depression, in which the deepening of mental disorders does not occur for a long time, and somatic symptoms are distinct. This assumption is supported by cases of prolonged latent depression, in which, 3-5 years after the onset of the disease, a clear depressive component eventually appears, as well as those cases where the disease develops periodically and where, again, years later, another deterioration manifests itself in somatic, and obvious depressive disorders. The positive results of antidepressant therapy also indicate the mental cause of somatic disorders.

There are several signs to suspect “hidden depression”:

1) the patient is treated for a long time, persistently, and most importantly, to no avail by doctors of various specialties;

2) these doctors, despite the use of various research methods, do not find any specific somatic disease in the patient or are limited to making a vague diagnosis, for example, “vegetative-vascular dystonia”; True, a patient can be diagnosed with a real somatic disease, but often only clinically, without confirmation by objective research methods;

3) despite failures in treatment, patients stubbornly continue to visit doctors.

When examining such a patient, it is advisable for a psychiatrist to direct questioning to identify two psychopathological disorders - depression and delirium (they are persistently treated for delusional reasons). Questioning a patient with “hidden depression” is almost always difficult and in all cases takes time. Before visiting the psychiatrist, the patient visited a large number of specialists, in many cases was subjected to various methods of objective research, was treated for a long time, but did not feel any improvement in his condition. He was tired not only of his illness, but also of the doctors. Referral to a psychiatrist by the majority of such patients is regarded either as an annoying circumstance or simply a mistake, or as a desire to get rid of it: “everything can be attributed to nerves.” Such patients often come to see a psychiatrist dissatisfied, agitated, tense, wary, and irritated. A visit to a psychiatrist is often regarded by them as an empty formality. They consider themselves to be somatically ill; they talk only about their physical ill-being, its background and unsuccessful treatment. Often such patients very persistently express their own conjectures about the reasons for their poor health and unsuccessful treatment (you should always remember about delusions). The psychiatrist who makes a mistake is the one who, even if he correctly suspects existing mental disorders, immediately begins to ask questions aimed at identifying them. By the nature of the questions asked, the patient immediately understands who he is being mistaken for. The patient is not prepared for such questions. Even if the question is asked correctly and a certain symptom of depression exists, the patient may say that it does not exist, and this will only confuse the doctor. It is best to first let the patient talk. From the context of his spontaneous statements, it is very often possible to find out the signs of depressive disorders, only the patient will describe them in his own words. These are the ones the doctor must catch, because... It is then better to talk to the patient using his own expressions, which are then translated by the doctor into the language of psychiatric terms and formulations. There is another way to identify hidden depression: ask the patient to tell in detail how his day goes, starting with waking up and ending with it the next day. Typically, patients with “hidden depression” do this quite willingly. During the course of such a story, the doctor can ask clarifying questions or ask the patient to repeat what has already been said - when answering again, the patient often more accurately formulates the initial statements, including those related to the disease. It is better to ask repeated questions using the patient’s words. This makes it easier to win the favor of the patient - the doctor speaks as the patient thinks for himself.

MANIC SYNDROME(syn. mania) - a combination of elevated mood, acceleration of the pace of mental activity and physical activity

The intensity of these disorders, the so-called manic triad, varies over a very wide range. The mildest cases are called hypomania. It is not always easy to correctly assess the painful nature of this condition. For many people around them, they are simply active, although usually somewhat scattered in their actions, cheerful, sociable, resourceful, witty, enterprising and self-confident people. Thanks to their animated facial expressions, quick movements and lively speech, they seem younger than their age. The painful nature of all these manifestations becomes obvious when hypomania changes to depression or when the symptoms of the manic triad deepen.

In a distinctly manic state, a heightened and joyful mood is combined with unshakable optimism. All the patients’ experiences are colored only in pleasant tones. Patients are carefree and have no problems. Past troubles and misfortunes are forgotten, negative events of the present are not perceived, the future is depicted only in rosy colors - “a maniac never thinks about the sunset.” True, the cheerful and friendly mood of patients at times, especially under the influence of external reasons (patients’ reluctance to obey the instructions of staff, disputes with others, etc.), gives way to irritation and even anger, but these are usually just outbreaks that quickly disappear, especially if you talk to sick in a peaceful tone. Patients consider their own physical well-being to be excellent, and the feeling of excess energy is a constant phenomenon. The opportunities to realize numerous plans and desires seem unlimited, and they see no obstacles to their implementation. Self-esteem is always increased. It is easy to overestimate your capabilities - professional, physical, related to entrepreneurship, etc. Some patients can be dissuaded for some time from the exaggeration of their self-esteem. Others are unshakably confident that they are truly capable of making a discovery, implementing important social measures, occupying a high social position, etc. In these cases, we can talk about the occurrence of expansive delirium. This is most often observed in mature and elderly patients. Typically, delusional ideas are few in number, represent a statement of fact, and are only relatively rarely accompanied by any evidence.

Patients talk a lot, loudly, quickly, often without stopping. With prolonged speech stimulation, the voice becomes hoarse or hoarse. The content of the statements is inconsistent. They easily move from one topic to another, constantly deviating from the main subject of the conversation, and if they do get to the end, then with big zigzags. The always existing increased distractibility of patients to all sorts of external, even minor, stimuli also contributes to a new direction in the content of their statements. With increasing speech excitement, a thought that does not have time to finish is already replaced by another, as a result of which statements become fragmentary (jump of ideas). The speech is interspersed with jokes, witticisms, puns, foreign words, and quotes. Strong words and expressions are often used. Speech is interrupted by inappropriate laughter, whistling, and singing. In a conversation, patients easily and quickly parry questions asked of them and immediately seize the initiative themselves.

The appearance of the patients is characteristic. The eyes are shiny, the face is hyperemic, and when talking, splashes of saliva often fly out of the mouth. Facial expressions are lively, movements are fast and impetuous, gestures and postures are emphatically expressive. Patients are often completely unable to sit still. During conversations with the doctor, they change their position, spin, jump up, and often begin to walk and even run around the office. They can eat while standing, hastily swallowing poorly chewed food. Appetite is usually significantly increased. Both in men and especially in women, sexual desire increases. Symptoms of manic agitation usually worsen in the evening. Some patients experience insomnia at night, others sleep little but soundly.

Depending on the predominance of certain disorders in the picture of a manic state, separate forms of mania are distinguished: “cheerful” mania (increasedly optimistic mood with moderate speech and motor excitation); “angry” mania (a combination of high mood with dissatisfaction, pickiness, irritation); “confused” mania (occurring against the background of an elevated mood, incoherent speech and disordered motor agitation); “unproductive” mania (a combination of elevated mood and motor arousal with a lack of desire for activity, poverty of thinking, monotony and unproductive statements), “delusional” mania (a combination of elevated mood with various forms of figurative and, less often, interpretative delirium); “inhibited” mania (a combination of elevated mood, in some cases, speech excitation with motor retardation, reaching the intensity of stupor), mania with foolishness (a combination of elevated mood, speech and motor excitation with mannerisms, childishness, clowning, stupid or flat jokes). The manic rampage described in the past (furormaniacalis) - a state of pronounced psychomotor agitation with rage or anger, accompanied by destructive actions and aggression, is currently encountered as an exception.

Manic states are often accompanied by the same psychopathological disorders of more severe registers as depression. With mania, much more often than with depression, states of darkened consciousness arise, in particular, in the form of numbing, amentia-like and twilight states. Manic states can occur against the background of severe psychoorganic syndrome and dementia.

In a number of cases, combinations of manic affect with other psychopathological disorders received their own separate names (see Symptoms of mental illness).

Questioning patients with manic syndromes is usually not difficult. You should always remember that you should not be assertive in your conversation with them. When it comes to complex syndromes in which manic syndrome is only a component, the questioning must, often first of all, take into account the characteristics of other psychopathological disorders - delirium, catatonic symptoms, etc. In contrast to depression, it is impossible to dissimulate a manic state.