Lectures on psychiatry. Electronic textbook "Psychiatry and Narcology"
Mental illness, like any other chronic illness, can be a cause of family crisis. A severe mental disorder imposes restrictions on the organization of family life, requires a change in the usual way of life of all its members, compliance special regime, forces you to give up pleasant habits, change plans for the future, redistribute responsibilities, not to mention feelings of uncertainty, helplessness, fear, both for the patient and his relatives. The relatives of a sick person bear the burden of care and responsibility for the future of their loved one.
Mentally ill people and their relatives are often socially isolated. And this leads to a reduction in connections with the broader social environment, which is one of the most important factors reducing the quality of life of a family.
Diagnosis of a mental disorder often leads to a “feeling of guilt and shame” in the patient’s relatives; many of them hide the very fact of having a mentally ill person in the family; they are afraid that someone will find out about their relative’s illness.
To make it easier for relatives of mentally ill people to cope with emerging problems, they need information about their loved one’s illness, treatment methods, the system of organizing psychiatric and social care, and forms of assistance directly in the community. They can obtain this information in psychiatric literacy courses.
Psychiatric education as a form of informational and socio-psychological support for relatives of patients and the patients themselves has begun to be actively introduced in our country. As a rule, psychiatric education programs combine two components - informational and socio-psychological support.
Psychiatric education serves as the basis for:
· understanding the illness of a loved one and helping him cope with it
· prevention of exacerbations and re-hospitalizations;
· early seeking help in case of exacerbation of the disease;
In our organization, a program of psychiatric education for relatives of mentally ill people has been carried out since 1996. The tasks that we solve by conducting classes with relatives are the following:
1. instilling a scientifically based understanding of mental illnesses, their nature, possible manifestations, course, prognosis, system of care and monitoring of patients, alternatives drug treatment, tactics of modern social rehabilitation measures;
2. preventing relapse of the disease;
3. improving patient compliance with the drug regimen and understanding the importance of psychosocial programs;
4. development and support of realistic expectations regarding the mental state and social functioning of the patient;
5. finding peace of mind through knowledge and mutual emotional support;
6. reducing social alienation and isolation, creating a natural social support network
7. overcoming feelings of guilt, powerlessness, shame, despair associated with the disease;
8. creating an atmosphere of empathy and informed optimism for each participant.
Working with relatives of mentally ill patients involves a less gentle discussion of issues of prognosis, long-term supportive treatment, stigma, and disability than with patients. Other tasks are also addressed in the classes: we pay attention to the development of problem-solving skills, communication with medical staff and in the family.
When conducting an educational program for relatives of mentally ill people, an interactive learning model is used (exchange of opinions, experiences, encouragement to be active during classes, expression of feelings, support). The classes maintain a friendly atmosphere, respectful attitude, and always take into account the expectations and individual needs of program participants.
The classes have a clear structure - each lesson begins with a greeting, identifying the participants’ requests on the topic of the lesson (15 min). Then follows the main part in the form of a lecture, message (1 - 1.5 hours). This part of the lesson is accompanied by an exchange of experience among students; during the course of the message, they can ask a question and exchange opinions. At the end of the lesson, its results are summed up, what has been covered is repeated, and a short discussion (15 minutes).
Class leaders (doctors, psychologists, social workers) present the material in a language that is simple and understandable to listeners. The group consists of 12 - 15 listeners. Classes are held once a week, in the evening. The course of training is usually three months.
The basic training course for relatives of patients suffering from chronic mental illness, as well as the content of the classes (in the form of lectures) are presented below.
1st lesson. Acquaintance. Goals and objectives of the psychiatric education program. Determination of information requests of relatives of patients. Determining the rules for conducting classes. A conversation about the family, its functions, problems that arise when one of its members becomes ill with a mental disorder, and about helping the family during this period.
“The family encounters the disease earlier than the doctor - even at the stage of presymptoms and the first, so-called hidden, unclear symptoms. The reaction to the onset of a disease depends on the severity and speed of its development, ideas about it and prejudices. With an acute - sudden onset, the period of uncertainty in terms of establishing a diagnosis is small. With its slow development, this period, which is very disturbing for loved ones, can stretch for months and even years.»
From the lecture “Family and mental illness: what can help a family overcome the disease”:
“There's no need to rush. The process of restoring health can be lengthy. It is very important to get more rest. Everything will fall into place over time. Keep calm. Showing excessive enthusiasm is a normal reaction. Try to moderate it. Showing disagreement is also normal. Try to take this calmly."
2nd lesson. Psychiatry as a medical discipline. Classification of mental disorders, their prevalence, causes, course, prognosis.
From the lecture “Psychiatry, its boundaries, problems and tasks”: All attempts to draw a clear boundary between concepts mental norm and pathologies so far remain unsuccessful. Therefore, psychiatrists make a conclusion about the absence or presence of such a pathology in a particular person, based on their work experience, studying the characteristics of the manifestations of the disease, the patterns of its development and course in many patients, as well as on the results additional research, and when pathology is identified, it is characterized as a mental disorder, mental illness, symptom or syndrome.
3rd lesson. Symptoms and syndromes of mental illness.
You will learn about the manifestations of mental disorders in the lecture. “Main symptoms and syndromes of mental disorders”.
From the lecture: Talking about depression, we, first of all, have in mind its following manifestations.
1. Decreased mood, a feeling of depression, depression, melancholy, in severe cases physically felt as heaviness or chest pain. This is an extremely painful condition for a person.
2. Decreased mental activity (thoughts become poorer, shorter, more vague). A person in this state does not answer questions immediately - after a pause, gives short, monosyllabic answers, speaks slowly, in a quiet voice. Quite often, patients with depression note that they find it difficult to understand the meaning of the question asked of them, the essence of what they read, and complain of memory loss. Such patients have difficulty making decisions and cannot switch to new activities.
3. Motor inhibition - patients experience weakness, lethargy, muscle relaxation, talk about fatigue, their movements are slow and constrained.
4th lesson. Schizophrenia: clinical picture, course, prognosis.
From the lecture “Some of the most common mental disorders: schizophrenia, affective diseases, neurotic disorders, disorders associated with external factors”: Schizophrenia represents the most important clinical and social problem in psychiatry throughout the world: it affects about 1% of the world's population, and is registered annually in the world 2 million new cases of the disease. In terms of prevalence, schizophrenia ranks among the first among mental illnesses and is the most common cause loss of ability to work.
5th lesson. Identifying signs of disease relapse. The concept of “signature of relapse” (a purely personal combination of precursors of relapse), necessary actions at the early, middle or late stages of relapse.
You can learn about how to communicate with a family member suffering from a mental disorder in the lecture “How loved ones can cope with the everyday problems that arise when living together with a mentally ill person.”
From the lecture: An important point, stabilizing the condition of a sick person is to maintain a familiar, simple life routine in the house, for example, a stable time for getting up in the morning, bedtime, and meal times. It is necessary to create a calm, consistent, as predictable life as possible. This will enable the sick person to cope with feelings of anxiety, confusion, to understand what and at what time you expect from him and what, in turn, to expect from you.
Lesson 6 Treatment of schizophrenia.
From the lecture « Modern therapy schizophrenia: Basic pharmacological action antipsychotics are blocking dopamine receptors, which results in normalization of the activity of the dopamine system of brain cells, namely a decrease in this activity to an optimal level. Clinically, i.e. at the level of symptoms of the disease, this corresponds to a noticeable decrease or complete disappearance of the productive symptoms of the disease (delusions, hallucinations, catatonic symptoms, agitation, attacks of aggression). The ability of antipsychotics to suppress completely or partially such manifestations of psychosis as delusions, hallucinations, and catatonic symptoms is called antipsychotic action.
7th lessons. Treatment of affective disorders.
» . Psychotherapy for schizophrenia and affective disorders: Treatment of depression involves the prescription of antidepressants - drugs that improve mood. Their effect is due to their influence on different neurotransmitter systems, primarily the norepinephrine and serotonin systems.
From the lecture “Treatment of affective disorders » . Psychotherapy for schizophrenia and mood disorders”: ...Psychotherapy for people with schizophrenia or mood disorders can target different levels of functioning. Firstly, with the help of special psychotherapeutic and training techniques, it is possible to influence basic mental - cognitive (cognitive) functions: attention, memory, thinking.
8th lesson. Psychological problems in families, ways to solve them.
From the thematic lecture: Feeling imaginary guilt, relatives strive to atone for it and behave as if they had caused harm to the patient. Many are afraid of being exposed for what they think they did wrong, and they fear society's accusations. They painfully decide whether they are to blame and how much. This leads to an endless search for who else is to blame for the illness of a relative; this, as it were, removes some of the blame from themselves. Finding someone to blame prevents you from experiencing grief and loss. They remain and do not allow you to accept the situation as it is, move on calmly and solve constructively. .
9th lesson. Modern system of psychiatric and social care.
About how it works psychiatric care, its capabilities, current development trends can be read in the lecture "Psychiatric care: history and current state."
10th and 11th lessons. general review legislation relating to the provision of mental health care. Rights and benefits of mentally ill people.
We recommend reading the following thematic lectures: and “Involuntary (forced) hospitalization of citizens in a psychiatric hospital”
From the lecture: “General overview of legislation on mental health care. Compulsory medical measures" “Everyone has the right to health protection and medical care” - this is what Article 41 of the Constitution says. Russian Federation. This right of every citizen of Russia and a person located on its territory requires appropriate legislative regulation. The main normative act regulating this range of legal relations on the territory of the Russian Federation is the Fundamentals of the Legislation of the Russian Federation on the protection of the health of citizens.
From the lecture:“Involuntary (forced) hospitalization of citizens in a psychiatric hospital” Article 29The Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens during its provision” defines the grounds for placing a citizen in a psychiatric hospital. The structure of this article includes three criteria necessary for involuntary (forced) hospitalization to a psychiatric hospital.
Lesson 12 (final). Psychosocial rehabilitation: basic concepts, forms and methods of work. Family assistance in patient rehabilitation. Community organizations, support groups, other community resources. Parting. Obtaining books, brochures intended for help users. Tea party.
You can get acquainted with the basic principles, methods and types of psychosocial rehabilitation in the thematic lecture "Psychosocial rehabilitation: a modern approach."
From the lecture: Rehabilitation for patients with mental disorders, as well as for somatic diseases, is recommended to begin when the condition has stabilized and the pathological manifestations have weakened. For example, rehabilitation of a patient with schizophrenia should begin when the severity of symptoms such as delusions, hallucinations, thinking disorders, etc. decreases. But even if the symptoms of the disease remain, rehabilitation can be carried out within the limits of the patient’s ability to learn and respond to psychosocial interventions.
In our experience, after patients’ relatives complete a course of psychoeducation, their knowledge in the field of psychiatry increases, the skills of effective communication with the patient are formed, and their social network, and, what is very important, a general idea of one’s own psychological problems and a request for help in solving them. Therefore, after completing a course of psychoeducation, depending on the nature of the problems and the degree of readiness (motivation) to solve them, we offer relatives short-term forms of psychological assistance (psychological counseling, trainings) or long-term psychotherapy.
Here are some reviews from parents who participated in the family mental health education program.
“I have been a participant in an educational program in psychiatry for several months now and realized that the feelings I was experiencing were a normal reaction to my daughter’s illness: I was very afraid that I was sick myself. Now I have someone to talk to, they understand me, I don’t feel as lonely as before. And the most important thing is that every time I come to class, I learn something important and new for myself.”
(I.G., 62 years old).
“The neighbors don’t understand me and are afraid of my son. Now I sometimes tell them about psychiatry, about how people like my sick son are treated in England. They are surprised and even once, when my son got sick again, they asked how they could help me.”
(T.S., 52 years old).
“I take advice. Previously, it seemed to me that nothing was changing in my wife’s illness. And now, looking back, as I was taught, I compare what was before and what is now, and I see improvements - small, but they are there.” (P.G., 48 years old).
Title: Psychiatry. Lecture notes.
Lecture notes on psychiatry are intended for students of medical colleges and universities. This publication examines the issues of modern classification of mental disorders, the main syndromes of mental illness, affective disorders, as well as modern aspects narcology. The book will an indispensable assistant for those who want to quickly prepare for the exam and pass it successfully.
Organization of psychiatric care. Basic provisions of the Russian Federation law on psychiatric care. Basic psychopathological syndromes. The concept of nosology. Etiology of mental illness. Principles of modern classification of mental disorders. General psychopathology.
Psychiatry is a medical discipline that studies the diagnosis and treatment, etiology, pathogenesis and prevalence of mental illnesses, as well as the organization of mental health care for the population.
Psychiatry literally translated from Greek means healing of the soul. This terminology does not correspond to our modern ideas about mental illness. In order to understand the origin of this definition, it is necessary to recall the history of the formation of the human worldview. In ancient times, people saw surrounding phenomena and objects, endowing them with a soul. Phenomena such as death and sleep seemed to primitive man obscure and incomprehensible. According to ancient beliefs, the soul, flying out of the body in a dream, sees various events, wanders somewhere, participating in them, and this is what a person observes in a dream. IN Ancient Greece they believed that if you wake up a sleeping person, the soul may not have time to return back to the body, and in those cases when the soul left and did not return, the person died. In the same Ancient Greece, a little later, an attempt is made to combine psychic experiences and mental illness with one or another organ of the human body, for example, the liver was considered the organ of love, and only in later images the heart pierced by Cupid’s arrow becomes the organ of love.
Table of contents
LECTURE No. 1. General psychopathology
1. Subject and tasks of psychiatry. History of development
2. Organization of psychiatric care
3. Basic psychopathological syndromes. The concept of nosology
4. Principles of modern classification of mental disorders
5. Sections International classification mental disorders 10th revision (ICD-10)
6. General psychopathology
6.1. Perceptual disorders
6.2. Thought disorders
6.3. Disorders of cognitive activity (memory and intelligence)
6.4. Speech disorders
6.5. Emotional disorders (affective disorders)
6.6. Disorders of will, motor skills and desires
6.7. Disorders of consciousness
6.8. Attention disorders
LECTURE No. 2. Syndromes of mental illness
1. Positive (psychoproductive) syndromes
2. Negative (deficit) syndromes
LECTURE No. 3. The concept of psychogenics and personality disorders
1. Premorbid personality types
2. Personality disorders
LECTURE No. 4. Affective mood disorders. Current state of the question about the essence of schizophrenia
1. Affective mood disorders
2. Current state of the question about the essence of schizophrenia
LECTURE No. 5. Modern aspects of narcology: alcohol addiction, drug addiction and substance abuse
1. Alcohol addiction
2. Drug and substance abuse
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Lecture notes on psychiatry are intended for students of medical colleges and universities. This publication examines the issues of modern classification of mental disorders, the main syndromes of mental illness, affective disorders, as well as modern aspects of drug addiction. The book will be an indispensable assistant for those who want to quickly prepare for the exam and pass it successfully.
LECTURE No. 1. General psychopathology
Organization of psychiatric care. Basic provisions of the Russian Federation law on psychiatric care. Basic psychopathological syndromes. The concept of nosology. Etiology of mental illness. Principles of modern classification of mental disorders. General psychopathology.
1. Subject and tasks of psychiatry. History of development
Psychiatry is a medical discipline that studies the diagnosis and treatment, etiology, pathogenesis and prevalence of mental illnesses, as well as the organization of mental health care for the population.
Psychiatry literally translated from Greek means healing of the soul. This terminology does not correspond to our modern ideas about mental illness. In order to understand the origin of this definition, it is necessary to recall the history of the formation of the human worldview. In ancient times, people saw surrounding phenomena and objects, endowing them with a soul. Phenomena such as death and sleep seemed obscure and incomprehensible to primitive man. According to ancient beliefs, the soul, flying out of the body in a dream, sees various events, wanders somewhere, participating in them, and this is what a person observes in a dream. In Ancient Greece, it was believed that if you wake up a sleeping person, the soul may not have time to return back to the body, and in those cases when the soul left and did not return, the person died. In the same Ancient Greece, a little later, an attempt was made to combine mental experiences and mental illnesses with one or another organ of the human body, for example, the liver was considered the organ of love, and only in later images the heart pierced by Cupid’s arrow becomes the organ of love.
Psychiatry is a specialty of medicine that is part of clinical medicine. In addition to the basic research methods used in clinical medicine, such as examination, palpation and auscultation, to study mental illness a number of techniques are used to identify and assess the patient’s mental state - observation and conversation with him. In the case of mental disorders, as a result of observing the patient, one can discover the originality of his actions and behavior. If the patient is bothered by auditory or olfactory hallucinations, he may plug his ears or nose. During observation, it can be noted that patients seal windows and ventilation holes so that the gas that the neighbors allegedly let in does not penetrate into the apartment. This behavior may indicate the presence of olfactory hallucinations. In the case of obsessive fears, patients may make movements that are incomprehensible to others, which are rituals. An example would be endless hand washing in fear of contamination, or stepping over cracks in the asphalt “so that nothing bad happens.”
When talking with a psychiatrist, the patient himself can tell him about his experiences, concerns, fears, bad mood, explaining incorrect behavior, as well as expressing inappropriate judgments and delusional experiences.
To correctly assess the patient's condition great importance has collection of information about his past life, attitude to current events, relationships with people around him.
As a rule, when collecting such information, painful interpretations of certain events and phenomena are revealed. In this case, we are talking not so much about the anamnesis, but about the mental state of the patient.
An important point in assessing the patient’s mental state is the data from the objective history, as well as information received from the patient’s close relatives and people around him.
Sometimes doctors encounter the phenomenon of anosognosia - denial of the disease by the patient himself and his close relatives, which is typical for mental illnesses such as epilepsy, mental retardation, and schizophrenia. In medical practice, there are cases when the patient’s parents do not seem to see obvious signs of the disease, being fairly educated people and even doctors. Sometimes, despite denying that a relative has the disease, some of them agree to carry out the necessary diagnosis and treatment. In such situations, the psychiatrist must show maximum professionalism, flexibility and tact. It is necessary to carry out treatment without specifying the diagnosis, without insisting on it and without convincing relatives of anything, based on the interests of the patient. Sometimes relatives, denying the disease, refuse to carry out the course of necessary therapy. This behavior can lead to worsening of the symptoms of the disease and its transition to chronic course.
Mental illnesses, unlike somatic illnesses, which are an episode in the patient’s life, continue for years, and sometimes throughout life. Such a long course of mental illness provokes the emergence of a number of social problems: relationship with the outside world, people, etc.
The patient’s personal qualities, level of personality maturity, as well as formed character traits play a large role in the process of assessing mental illness and its consequences, which is most clearly revealed when studying clinical variants of neuroses.
Gradually (as psychiatry developed and studied), several independent areas emerged: child and adolescent psychiatry, geriatric, forensic, military psychiatry, narcology, psychotherapy. These areas are based on general psychiatric knowledge and are developed in the practical activities of a doctor.
It has been established that there is a close relationship between somatic and mental illnesses, since absolutely any somatic disorder has a pronounced impact on the patient’s personality and his mental activity. The severity of mental disorders in various diseases different. For example, for diseases of cardio-vascular system, such as hypertonic disease, atherosclerosis, the decisive role belongs to the somatogenic factor. Personality reactions are more pronounced in those diseases that result in facial defects and disfiguring scars.
Many factors influence a person’s reaction and illness:
1) the nature of the disease, its severity and rate of development;
2) the patient’s own understanding of this disease;
3) the nature of the treatment and the psychotherapeutic environment in the hospital;
4) personal qualities of the patient;
5) attitude towards the illness of the patient, as well as his relatives and colleagues.
According to L.L. Rokhlin, there are five options for a person’s reaction to illness:
1) asthenodepressive;
2) psychasthenic;
3) hypochondriacal;
4) hysterical;
5) euphoric-anosognosic.
The now widely used term “somatically caused psychosis” was proposed by K. Schneider. In order to make such a diagnosis, the following conditions are necessary:
1) clear symptoms of a somatic disease;
2) an obvious connection in time between somatic and mental disorders;
3) parallel course of mental and somatic disorders;
4) exogenous or organic symptoms.
Somatogenically caused mental illnesses and mental disorders can be psychotic, neurotic and psychopathic in nature, thus, it would be correct to talk not about the nature of mental disorders, but about the level of mental disorders. The psychotic level of mental disorders is a condition in which the patient is not able to adequately assess himself, the environment, the relationship of external events to himself and his situation. This level of mental disorders is accompanied by disturbances in mental reactions, behavior, as well as disorganization of the patient’s psyche. Psychosis– a painful mental disorder that manifests itself entirely or predominantly as an inadequate reflection of the real world with behavioral disturbances and changes in various aspects of mental activity. As a rule, psychosis is accompanied by the appearance of phenomena that are not characteristic of the normal psyche: hallucinations, delusions, psychomotor and affective disorders.
The neurotic level of mental disorders is characterized by the fact that the correct assessment of one’s own condition as painful, correct behavior, as well as disorders in the sphere of vegetative, sensorimotor and affective manifestations are preserved. This level of disturbance of mental activity, disorders of mental activity is not accompanied by a change in attitude towards ongoing events. According to the definition of A. A. Portnov, these disorders are a violation of involuntary adaptation.
The psychopathic level of mental disorders is manifested by persistent disharmony of the patient’s personality, which is expressed in a violation of adaptation to environment, which is associated with excessive affectivity and an affective assessment of the environment. The level of mental disorders described above can be observed in the patient throughout his life or arise in connection with previous somatic diseases, as well as with anomalies of personality development.
Severe psychotic disorders in the form of psychoses are much less common than other disorders. Often, patients first turn to general practitioners, which is associated with the onset of the disease in the form of the appearance of vegetative and somatic symptoms.
The course of somatic diseases is adversely affected by mental trauma. As a result of the patient’s unpleasant experiences, sleep is disturbed, appetite decreases, and the body’s activity and resistance to diseases decrease.
The initial stages of the development of mental illness differ in that somatic disorders are more pronounced compared to mental disorders.
1. A young food service worker began to complain of rapid heartbeat, increased blood pressure. At the appointment with the therapist, no pathology was noted; the doctor assessed these disorders as age-related functional ones. Subsequently, her menstrual function disappeared. At the appointment with the gynecologist, no pathology was also detected. The girl began to rapidly gain weight; the endocrinologist also did not note any abnormalities. None of the specialists paid attention to low mood, motor retardation and decreased performance. The decrease in performance was explained by the girl’s anxiety and the presence of somatic pathology. After attempting to commit suicide, the girl, at the insistence of her close relatives, was consulted by a psychiatrist, who diagnosed her with a depressive state.
2. A 56-year-old man, after a holiday at sea, began to complain of chest pain and poor health, and therefore was taken to the therapeutic department of the city clinical hospital. After the examination, the presence of cardiac pathology was not confirmed. Close relatives visited him, assuring him that everything was fine, although the man felt much worse every day. Then he had the idea that those around him considered him a malingerer and thought that he was specifically complaining about heart pain so as not to work. The patient's condition deteriorated every day, especially in the mornings.
Unexpectedly in the morning, the patient walked into the operating room and, taking a scalpel, attempted to commit suicide. Hospital workers called an ambulance to the patient together with a psychiatric team, which later found out that the patient was depressed. This disease in the patient was accompanied by all the signs of a depressive state, such as melancholy, motor retardation, decreased intellectual activity, slowed mental activity, and weight loss.
3. During a movie show, the child started vomiting. His parents consulted a doctor with this complaint. At the hospital, the stomach and liver were examined, and the child was examined by a neurologist. After these procedures, no pathology was found. When collecting an anamnesis from the child’s parents, it was possible to find out that vomiting first occurred after the child ate a chocolate bar, ice cream, an apple, and candy in a movie theater. While watching a movie, the child began to vomit, which subsequently took on the character of a conditioned reflex.
Whatever field of medicine he works in, whatever specialty the doctor prefers, he must necessarily proceed from the fact that he is dealing primarily with a living person, a person, with all its individual subtleties. Every doctor needs knowledge of psychiatric science, since most patients with mental disorders first of all turn not to psychiatrists, but to representatives of another medical specialty. It often takes a considerable period of time before a patient comes under the care of a psychiatrist. Typically, a general practitioner deals with patients who suffer from minor forms of mental disorders– neuroses and psychopathy. Minor or borderline psychiatry deals with such pathology.
Soviet psychiatrist O.V. Kerbikov argued that borderline psychiatry is the area of medicine in which contact between a psychiatrist and general practitioners is most necessary. The latter in this case are at the forefront of protecting the mental health of the population.
To avoid mistreatment of a patient, a doctor needs knowledge of psychiatric science in general and borderline science in particular. If you treat a mentally ill person incorrectly, you can provoke the occurrence of iatrogenicity - an illness involuntarily caused by a doctor. The occurrence of this pathology can be facilitated not only by words that frighten the patient, but also by facial expressions and gestures. A doctor, a person directly responsible for the health of his patient, must not only behave correctly himself, but also control the behavior of the nurse and teach her the intricacies of communication with the patient, while observing all the rules of deontology. In order to avoid additional trauma to the patient’s psyche, the doctor must understand the internal picture of the disease, that is, how his patient relates to his disease, what his reaction to it is.
General practitioners are often the first to encounter psychoses in their most initial stage, when the painful manifestations are not yet very pronounced, not too noticeable. Quite often, a doctor of any profile may encounter initial manifestations, especially if the initial form of mental illness superficially resembles some kind of somatic disease. Often, a pronounced mental illness initiates somatic pathology, and the patient himself is firmly “convinced” that he has some (actually non-existent) disease (cancer, syphilis, some kind of disfiguring physical handicap) and persistently demands special or surgical treatment. Quite often, diseases such as blindness, deafness, and paralysis are a manifestation of hysterical disorders, hidden depression, occurring under the guise of a somatic illness.
Almost any doctor can find himself in a situation where emergency psychiatric care is required, for example, to relieve a state of acute psychomotor agitation in a patient with delirium tremens, to do everything possible in the event of status epilepticus or suicide attempts.
Nosological direction in modern psychiatry (from Greek. nosos- “disease”) is widespread both in our country and in some European countries. Based on the structure of this direction, all mental disorders are presented in the form of separate mental illnesses, such as schizophrenia, manic-depressive, alcoholic and other psychoses. It is believed that each disease has a variety of provoking and predisposing factors, a characteristic clinical picture and course, its own etiopathogenesis, although various types and variants are distinguished, as well as the most likely prognosis. As a rule, everything is modern psychotropic drugs effective for certain symptoms and syndromes, regardless of the disease in which they occur. Another rather serious drawback of this direction is the unclear position of those mental disorders that do not fit into the clinical picture and course of certain diseases. For example, according to some authors, disorders that occupy an intermediate position between schizophrenia and manic-depressive psychosis are special schizoaffective psychoses. According to others, these disorders should be included in schizophrenia, while others interpret them as atypical forms manic-depressive psychosis.
The founder of the nosological direction is considered to be the famous German psychiatrist E. Kraepelin. He was the first to conceptualize most mental disorders as distinct illnesses. Although even before E. Kraepelin’s taxonomy, some mental illnesses were identified as independent: circular insanity, described by the French psychiatrist J. - P. Falret, later called manic-depressive psychosis, alcoholic polyneuritic psychosis, studied and described by S. S. Korsakov, progressive paralysis, which is one of the forms of syphilitic brain damage, described by the French psychiatrist A. Bayle.
The fundamental method of nosological direction is detailed description the clinical picture and course of mental disorders, for which representatives of other areas call this direction E. Kraepelin’s descriptive psychiatry. The main branches of modern psychiatry include: geriatric, adolescent and child psychiatry. They are areas of clinical psychiatry devoted to the characteristics of the manifestations, course, treatment and prevention of mental disorders at appropriate ages.
The branch of psychiatry called narcology studies the diagnosis, prevention and treatment of drug addiction, substance abuse and alcoholism. In Western countries, doctors specializing in the field of addiction are called addictionists (from English word addiction – “addiction, dependence”).
Forensic psychiatry develops the fundamentals of forensic psychiatric examination, and also works to prevent socially dangerous actions of mentally ill persons.
Social psychiatry studies the role of social factors in the occurrence, course, prevention and treatment of mental illnesses and the organization of mental health care.
Transcultural psychiatry is a section of clinical psychiatry devoted to the comparative study of the characteristics of mental disorders and the level of mental health among different nations and cultures.
A section such as orthopsychiatry brings together the approaches of psychiatry, psychology and other medical sciences to the diagnosis and treatment of behavioral disorders. Special attention is given to preventive measures aimed at preventing the development of these disorders in children. Sections of psychiatry also include sexopathology and suicidology (studying the causes and developing measures to prevent suicide at the level of preventing suicidal behavior that precedes it).
Borderline with psychiatry and at the same time isolated scientific disciplines are psychotherapy, medical psychology, as well as psychopharmacology.
2. Organization of psychiatric care
The organization of psychiatric care in any country is based on the rights of the citizens to whom this assistance is provided. It cannot be carried out without resolving issues of the legal status of mentally ill people. According to the legislation of our state, which contains provisions concerning both the mentally ill person and the doctor and psychiatric service, it is necessary to maximally protect the interests of the mentally ill and at the same time protect society from the dangerous actions of the mentally ill. Psychiatric care can be provided to the population both in inpatient and outpatient settings.
Inpatient psychiatric care
To provide inpatient care to the population, there are psychiatric hospitals and psychiatric departments, which can be specialized for the treatment of patients with borderline non-psychotic conditions, neuroses and neurosis-like conditions, cerebroasthenic disorders, psychosomatic diseases, as well as patients suffering from psychoses and at the same time somatic diseases requiring active therapy or surgical intervention.
Patients from a certain area or section of a psychoneurological dispensary are admitted to the same department of a psychiatric hospital (territorial principle of patient distribution).
In addition, each hospital has departments for the treatment of elderly patients, children, adolescents, and people with borderline conditions. More recently, in large psychiatric hospitals ah, special psycho-reanimation departments began to appear.
According to WHO experts, a sufficient supply of psychiatric beds is considered to be 1.0–1.5 beds per 1000 population; in Russia there are 1.2 per 1000 population or 10% of the total number of beds. In the children's and adolescent departments, patients not only receive treatment, but also study according to the public school program.
For certain groups of patients, mainly those with borderline neuropsychiatric illnesses, in order to reduce the adverse effects of isolation of the mentally ill from society, an “open door” system is used in some departments of psychiatric hospitals. In connection with the increasing life expectancy of the population, there is an urgent need for the development of psychiatric care for the elderly.
Out-of-hospital care for mentally ill people
Psychoneurological dispensaries, operating on a territorial basis, were established in 1923. Currently, psychiatric care outside the walls of the hospital is developing in three directions: care for patients in the psychoneurological dispensary is being improved; is being formed the new kind consultative psychiatric care without registering the patient with this institution; Psychiatric care is being improved outside the dispensary, in the general medical care system - in the psychotherapeutic rooms of polyclinics - to provide it to patients with borderline disorders and early identification of patients with other mental illnesses.
Besides, in Lately began to practice treatment in day hospitals, where patients come in the morning, receive appropriate treatment, participate in work processes, entertainment, and return home in the evening. There are also night hospitals, where patients stay after work in the evening and at night. During this time they conduct therapeutic measures, for example, a course of intravenous infusions, acupuncture, massotherapy, and in the morning the patients return to work.
For children with various neurotic conditions, there are sanatoriums, so-called forest schools, in which weakened children receive appropriate therapy and study for one quarter.
In the prevention and treatment of mental illnesses, the creation of a work and rest regime, prolonged exposure to the fresh air, and physical education are of great importance. Patients suffering from chronic mental illnesses are placed in psychoneurological boarding schools, where they receive the necessary treatment.
Children falling behind mental development, study in special auxiliary schools. They can come there from home or live permanently in boarding schools at schools, where constant special observation and systematic treatment are provided. Children with organic lesions of the central nervous system, and those with stuttering receive the necessary medical care in specialized nurseries, where psychiatrists, psychologists and speech therapists work together with educators.
As part of the psychoneurological dispensary, in addition to the rooms in which the necessary health care, includes occupational therapy workshops where people with mental illness work. Being in occupational therapy workshops makes it possible to carry out systematic treatment, provide patients with food, and also for the patients themselves to earn a small amount of money.
IN last years In connection with the increasing incidence of suicide, a special service to combat suicide has been developed, mainly represented by the “Helpline”, which can be used by any person who is in a serious mental state due to failures in life at any time of the day. Qualified psychological assistance is provided by telephone by psychiatrists and psychologists who have undergone special training.
General somatic clinics have special rooms to provide psychotherapeutic and psychological assistance to adults and adolescents. In most large cities there are special crisis departments, the work of which is aimed at preventing suicidal behavior.
In rural areas there are psychiatric departments in central district hospitals, as well as a network of psychiatric offices in rural hospitals and district clinics.
Narcological service
In 1976, a special drug treatment clinic was introduced into health care institutions, which is the basis of the drug treatment service.
The drug treatment service has stationary, semi-stationary and out-of-hospital units and is a network of specialized institutions providing medico-legal, medico-social, as well as treatment and preventive assistance to patients with drug addiction, alcoholism and substance abuse.
Rights of mentally ill people
For the first time, “Regulations on the conditions and procedure for providing psychiatric care aimed at protecting the rights of the mentally ill” were adopted by the Decree of the Presidium of the Supreme Soviet of the USSR on January 5, 1988. Subsequently (1993), a special law “On psychiatric care and guarantees of the rights of citizens” was adopted when providing it,” according to which qualified psychiatric care is provided free of charge, taking into account all the achievements of science and practice. This law is based on regulations according to which the dignity of the patient must not be violated when providing psychiatric care. This law also regulates the procedure for conducting psychiatric examinations. This law states that psychiatric examination and preventive examinations are carried out only at the request or with the consent of the person being examined, and examinations and examinations of a minor under 15 years old - at the request or with the consent of his parents or legal representative.
When conducting a psychiatric examination, the doctor is obliged to introduce himself to the patient, as well as his legal representative, as a psychiatrist. The exception is those cases when the examination can be carried out without the consent of the subject or his legal representative: in the presence of a severe mental disorder with an immediate danger of the patient to himself and others, if the subject is under dispensary observation. Outpatient psychiatric care for persons with mental illnesses is provided depending on medical indications and is carried out in the form of consultative and therapeutic care and dispensary observation.
Persons with mental disorders are placed under dispensary observation, regardless of their consent or the consent of their legal representative (in cases where they are declared legally incompetent). At the same time, the attending physician constantly monitors the state of their mental health through regular examinations and provision of the necessary medical and social assistance.
In cases of inpatient treatment of a patient with mental disorders, consent is required. this treatment in writing, with the exception of patients who are on compulsory treatment by court decision, as well as patients hospitalized involuntarily by law enforcement agencies. Without the consent of the patient, i.e. involuntarily, persons with mental disorders that make them dangerous to themselves and others, as well as patients in conditions where they are unable to satisfy basic life needs (for example, catatonic stupor, severe dementia) and can cause significant harm to their health due to deterioration of their mental state if left without psychiatric help.
A patient admitted to a hospital as a result of involuntary hospitalization must be examined within 48 hours by a commission of doctors, which determines the validity of hospitalization. In cases where hospitalization is considered justified, the commission’s conclusion is submitted to the court to decide the issue of the patient’s further stay in the hospital at the location of the hospital.
The patient's involuntary stay in a psychiatric hospital lasts as long as the reasons for the involuntary hospitalization remain (aggressive actions due to delusions and hallucinations, active suicidal tendencies).
To extend involuntary hospitalization, a re-examination by the commission is carried out once a month for the first six months, and then once every 6 months.
An important achievement in respecting the rights of mentally ill citizens is the release of them from responsibility for socially dangerous actions (crimes) committed by them during illness.
3. Basic psychopathological syndromes. The concept of nosology
Translated from Greek, “syndrome” means “accumulation”, “confluence”. At the moment, the medical term “syndrome” means a set of symptoms united by a single pathogenesis, a natural combination of productive and negative symptoms. The German psychiatrist K. Kahlbaum in 1863, when describing catatonia, proposed the term “symptom complex”. At that time, catatonia was considered a separate disease, but later it became clear that this was a typical variant of the symptom complex.
The syndrome as a stage of the disease can be the same for various mental disorders, which is due to the body’s adaptation to changed living conditions (diseases) and is achieved using the same type of response methods. This manifestation is observed in the form of symptoms and syndromes, which become more complex as the disease develops, transforming from simple to complex or from small to large. With various mental illnesses, the clinical picture changes in a certain sequence, that is, there is a developmental stereotype characteristic of each disease. There is a general pathological developmental stereotype, characteristic of all diseases, and a nosological stereotype, which is typical for individual diseases.
A general pathological stereotype of the development of diseases assumes the presence of general patterns in their course. At the initial stages of progressive mental illnesses, neurotic disorders are more often detected, and only then affective, delusional and psychoorganic disorders appear, i.e., with the progression of mental illnesses, the clinical picture steadily becomes more complicated and deepens.
For example, the formation clinical manifestations in patients with schizophrenia it is as follows: at the initial stages, disorders of a neurotic level, asthenic, phobic, are detected, then affective disorders appear, delusional symptoms, complicated by hallucinations and pseudohallucinations, Kandinsky-Clerambault syndrome is added, accompanied by paraphrenic delusions and leading to apathetic dementia.
Nosological diagnosis reflects the integrity of productive and negative disorders.
It should be noted that neither productive nor negative disorders have absolute nosological specificity and only apply to a type of disease or group of diseases - psychogenic, endogenous and exogenous-organic. In each of these groups of diseases, all identified productive symptoms occur. For example: asthenic and neurotic syndromes are characteristic of neuroses and neurotic personality development; affective, delusional, hallucinatory, motor - for reactive psychoses, such as depression, paranoid, stuporous states, transient intellectual disorders - for hysterical psychoses.
Both exogenous-organic and endogenous diseases have all of the above syndromes. There is also a certain preference, which consists in their greatest frequency and severity for a particular group of diseases. Despite the general pathological patterns of the formation of personality defects, negative mental disorders in connection with the disease have ambiguous trends in groups of diseases.
As a rule, negative disorders are represented by the following syndromes: asthenic or cerebroasthenic personality changes, including psychopathic-like disorders, which in psychogenic diseases manifest themselves in the form of pathocharacterological disorders. Negative disorders in exogenous-organic diseases are characterized by psychopathic personality changes, manifested by excessive intensity of experiences, inadequacy in strength and severity emotional reactions and aggressive behavior.
In schizophrenia, personality changes are characterized by emotional impoverishment and dissociation of emotional manifestations, their disorder and inadequacy.
As a rule, memory does not suffer in patients with schizophrenia, however, there are well-known cases when patients, being in the department for a long time, do not know the name of the attending physician, roommates, and find it difficult to name dates. These memory disorders are not true, but are caused by affective disorders.
4. Principles of modern classification of mental disorders
Throughout the world, there are officially two types of classifications of mental disorders: national classifications and the International one, developed within the framework of World Organization Health (WHO) and regularly updated.
Today there is an international classification of mental disorders and behavioral disorders, 10th revision (ICD-10), which differs significantly from previous versions of the International Classification of Mental Disorders and is quite progressive, reflecting recent achievements in world psychiatry. However, according to most of the various psychiatric schools and directions, there are significant shortcomings in the ICD-10 classification.
These include: atheoreticality, inconsistency and excessive complexity of the classification of mental disorders in general.
In addition to the above-described imperfections of ICD-10, one can add an unfounded, although partial, departure from clinical and nosological positions, the identification of mental disorders, psychopathological syndromes and even symptoms as independent diseases, a skeptical attitude towards the fundamental concepts and provisions of psychiatry, tested by world clinical practice.
Due to specified features using ICD-10 as a basis for presentation educational material in psychiatry is very difficult for students to master this medical discipline. In this regard, the third part of the textbook (“Private Psychiatry”), which describes mental illnesses and more or less independent forms of mental disorders, is built on the basis of the domestic classification of mental disorders. This classification is more consistent, logical, mainly based on clinical nosological principles and is widely used in Russian psychiatry.
For example: the chapters of “Private Psychiatry” reflect the relationship of clinical and nosological forms of mental disorders in the domestic understanding with those in ICD-10.
Domestic classification of mental disorders
In the domestic classification of mental disorders, clinical and nosological forms are divided on the basis of the close relationship between established etiological factors and pathogenetic mechanisms, as well as similarities in clinical manifestations, dynamics and outcomes of mental illnesses.
1. Endogenous mental illnesses:
1) schizophrenia;
2) manic-depressive psychosis;
3) cyclothymia;
4) functional mental disorders of late age.
As a rule, these diseases are caused by internal pathogenic factors, including hereditary predisposition, with a certain participation in their occurrence of various external negative factors.
2. Endogenous-organic mental illnesses:
1) epilepsy (epileptic disease);
2) atrophic diseases of the brain, Alzheimer's type dementia;
3) Alzheimer's disease;
4) senile dementia;
5) Pick's disease;
6) Huntington's chorea;
7) Parkinson's disease;
8) mental disorders caused by vascular diseases brain.
In the development of these diseases, the root cause can be both internal factors leading to organic damage to the brain and cerebral-organic pathology, and external factors caused by external influences of a biological nature: traumatic brain injuries, neuroinfections, intoxication.
3. Somatogenic, exogenous and exogenous-organic mental disorders:
1) mental disorders in somatic diseases;
2) exogenous mental disorders;
3) mental disorders with infectious diseases extracerebral localization;
4) alcoholism;
5) drug addiction and substance abuse;
6) mental disorders due to medicinal, industrial and other intoxications;
7) exogenous-organic mental disorders;
8) mental disorders due to traumatic brain injury;
9) mental disorders due to neuroinfections;
10) mental disorders due to brain tumors.
This fairly large group includes: mental disorders caused by somatic diseases and various exogenous factors of extracerebral localization, often leading to cerebral-organic damage. As a rule, endogenous factors play a certain but not dominant role in the formation of mental disorders of this group. It is worth emphasizing that mental illnesses that have developed in connection with brain tumors can, with a large degree of convention, be classified as disorders of an exogenous nature.
4. Psychogenic disorders:
1) reactive psychoses;
2) neuroses;
3) psychosomatic (somatoform) disorders.
This group of disorders develops as a result of the impact of stressful situations on the personality and physical sphere.
5. Pathology of personality development:
1) psychopathy (personality disorders);
2) oligophrenia (state of mental underdevelopment);
3) other delays and distortions of mental development.
This group includes mental states caused by abnormal personality formation.
5. Sections of the International Classification of Mental Disorders, 10th revision (ICD-10)
This classification includes 11 sections.
F0 – organic, including symptomatic, mental disorders.
F1 – mental and behavioral disorders due to the use of psychoactive substances.
F2 – schizophrenia, schizotypal and delusional disorders.
F3 – mood disorders (affective disorders).
F4 – neurotic, stress-related and somatoform disorders.
F5 – behavioral syndromes associated with physiological disorders and physical factors.
F6 – disorders of mature personality and behavior in adults.
F7 – mental retardation.
F8 – disorders of psychological development.
F9 – behavioral and emotional disorders, usually beginning in childhood and adolescence.
F99 – unspecified mental disorder.
6. General psychopathology
6.1. Perceptual disorders
Perception is the initial stage of higher nervous activity. Thanks to perception, external and internal stimuli become facts of consciousness, reflecting individual properties of objects and events.
Stimulus → sensation → perception → idea.
Sensation is the simplest mental process, consisting in the reflection of individual properties of objects and phenomena, arising in the process of their impact on the senses.
Perception is the mental process of reflecting objects and phenomena as a whole, in the totality of their properties. Does not depend on the will of the individual.
Representation is an image of an object or phenomenon, reproduced in the mind based on past impressions. Depends on the will of the individual.
Symptoms of Perceptual Disorders
Hyperesthesia– increased sensitivity to irritants of normal strength. Often occurs with exogenous organic lesions of the central nervous system (intoxication, trauma, infection), manic states.
Hypesthesia(hypoesthesia) – decreased sensitivity to stimuli. Often observed in disorders of consciousness, organic disorders of the central nervous system, depressive states. Anesthesia is an extreme degree of hypoesthesia. Painful mental anesthesia is a subjectively seemingly very painful weakening of any type of sensitivity due to a decrease in emotional tone ( anesthesia psychica dolorosa). Observed in depression.
Agnosia– failure to recognize the stimulus, occurs with organic lesions of the central nervous system, hysterical sensitivity disorders.
Paresthesia– subjective sensations that arise without an irritant (tingling sensation, crawling sensations, numbness, etc.). The disorders have a localization clearly limited to innervation zones. They are a symptom of a neurological disorder.
Senestopathies(illusions of general feeling) - vague, difficult to localize, unpleasant, painful bodily sensations. They have peculiar descriptions by patients (pulling, spilling, delamination, turning over, drilling, etc.). The sensations have no real basis, are “non-objective”, and do not correspond to the zones of innervation. Often found in the structure of senesto-hypochondriasis syndrome (senestopathies + ideas of an “imaginary” illness + affective disorders), with schizophrenia, depression.
Illusions– erroneous perception of real-life objects and events.
Affectogenic illusions occur with fear, anxiety, depression, ecstasy. Their occurrence is facilitated by unclear perception of the environment (poor lighting, slurred speech, noise, distance of the object). The content of illusions is associated with affective experiences. For example, when there is expressed fear for one’s life, a person hears threats in the conversation of people far away.
Physical– are associated with the characteristics of physical phenomena (a spoon in a glass of water seems crooked).
Pareidolic illusions– visual illusions in which patterns, cracks, tree branches, clouds are replaced by images of fantastic content. Observed in delirium, intoxication with psychomimetics.
With illusions, there is always a real object (as opposed to hallucinations) or a phenomenon of the surrounding world, which is reflected incorrectly in the patient’s consciousness. In some cases, illusions are difficult to differentiate from the patient’s delusional interpretation of the environment, in which objects and phenomena are correctly perceived, but are interpreted absurdly.
Edeitism– a sensually vivid representation of an immediately preceding sensation (especially a vivid memory).
Phantasm– sensually vivid, distinctly fantastic daydreams.
Hallucinations– a disorder of perception in the form of images and ideas that arise without a real object.
Simple hallucinatory images arise in one analyzer (for example, only visual ones).
Complex(complex) – two or more analyzers are involved in the formation of images. The content of hallucinations is connected by a common plot. For example, with alcoholic delirium, the patient “sees” the devil, “feels” his touch and “hears” speech addressed to him.
According to analyzers (by modality), the following types of hallucinations are distinguished.
Visual hallucinations. Elementary (photopsia) lack a clear form - smoke, sparks, spots, stripes. Completed - in the form of individual people, objects and phenomena.
Depending on the subjective assessment of size, the following are distinguished:
1) normoptic - the hallucinatory image corresponds to the real size of objects;
2) microptic hallucinations – reduced in size (cocaineism, alcoholic delirium);
3) macroptic hallucinations – gigantic.
Types of visual hallucinations:
1) extracampal hallucinations – visual images appear outside the field of vision (from the side, from behind);
2) autoscopic hallucinations – the patient’s vision of his own double.
Visual hallucinations usually occur against a background of clouded consciousness.
Hallucinatory images can be painted in one color (with epilepsy they are often monochrome, red), they can be moving and motionless, scene-like (with oneiroid), persistent and fragmentary.
Auditory (verbal) hallucinations. Elementary (acoasms) - noise, crackling, calling by name. Phonemes are individual words and phrases. Hallucinatory experiences are most often represented in the form of voices. This may be one specific voice or several (a choir of voices).
1) imperative, or commanding, hallucinations (are an indication for hospitalization in a psychiatric hospital);
2) commentators (the imaginary interlocutor comments on the patient’s actions and thoughts); threatening, insulting;
3) antagonistic (content opposite in meaning - sometimes accusing, sometimes defending).
Tactile (tactile) hallucinations Unlike senestopathies, they are objective in nature, the patient clearly describes his sensations: “cobwebs on the face,” “insects crawling.” A characteristic symptom for some intoxications, in particular cyclodol, there is a “disappearing cigarette symptom”, in which the patient clearly feels the presence of a cigarette pressed between his fingers, but when he brings his hand to his face, the cigarette disappears. For non-smokers, this may be an imaginary glass of water.
Thermal- feeling of warmth or cold.
Hygric– feeling of moisture on the surface of the body.
Haptic- a sudden sensation of touching, grabbing.
Kinesthetic hallucinations- sensation of imaginary movement.
Speech motor hallucinations– a feeling that the speech apparatus makes movements and pronounces words against the will of the patient. In fact, it is a variant of ideational and motor automatisms.
Hallucinations of general feeling(visceral, bodily, interoceptive, enteroceptive) are manifested by sensations of the presence of foreign objects or living beings inside the body.
For the patient, sensations have precise localization and “objectivity”. Patients clearly describe their sensations (“snakes in the head,” “nails in the stomach,” “worms in the pleural cavity”).
Taste hallucinations– a feeling of unusual taste sensations in the oral cavity, usually unpleasant, not related to food intake. They are often the reason for the patient’s refusal to eat.
Olfactory hallucinations- imaginary perception of odors emanating from objects or from own body, often of an unpleasant nature. Often coexist with taste.
They can be observed as a monosymptom (Bonner's hallucinosis - an unpleasant odor from one's own body).
It is clinically important to distinguish between true and false hallucinations.
True hallucinations– the patient perceives hallucinatory images as part of the real world, the content of hallucinations is reflected in the patient’s behavior. Patients “shake off” imaginary insects, flee from monsters, talk with imaginary interlocutors, plug their ears, which may be an objective sign of their presence. Extraprojection is characteristic, that is, images are projected outward or into real space within reach. The course is usually acute. Characteristic of exogenous psychoses (poisoning, trauma, infection, psychogenicity). There is no criticism of the patient's experiences.
False hallucinations (pseudohallucinations)– patients lack a sense of objective reality. The patient perceives images with the inner “I”. He clearly distinguishes between reality and a hallucinatory image. Interoprojection is characteristic, voices sound “inside the head”, images appear before the inner gaze, or the source is out of reach of the senses (voices from space, telepathic communication, astral plane, etc.). There is almost always a feeling of being done, of violence. The patient “understands” that the images are transmitted only to him. The course is usually chronic. There may be a critical attitude towards experiences, but at the height of psychosis there is no criticism. Observed in endogenous psychoses.
Hypnagogic hallucinations– most often visual hallucinations. They appear when closing the eyes at rest, often precede falling asleep, and are projected onto a dark background.
Hypnapompic hallucinations- the same thing, but upon awakening. These two types of hallucinations are often classified as types of pseudohallucinations. Among this type of hallucination, the following types of pathological ideas are observed: visual (most often), verbal, tactile and combined. These disorders are not yet a symptom of psychosis; they often indicate a prepsychotic state or occur during exacerbation of severe somatic diseases. In some cases, they require correction if they cause sleep disturbances.
Additionally, according to the characteristics of their occurrence, the following types of hallucinations are distinguished.
Functional hallucinations always auditory, appear only with a real sound stimulus. But unlike illusions, the real stimulus does not merge (is not replaced) with the pathological image, but coexists with it.
Reflex hallucinations lie in the fact that correctly perceived real images are immediately accompanied by the appearance of a hallucinatory similar to them. For example, a patient hears a real phrase - and immediately a similar phrase begins to sound in his head.
Apperceptive hallucinations appear after the patient’s volitional effort. For example, patients with schizophrenia often “cause” voices in themselves.
Hallucinations of Charles Bonnet observed when the peripheral part of the analyzer is damaged (blindness, deafness), as well as under conditions of sensory deprivation. Hallucinations always occur in the field of a damaged or informationally limited analyzer.
Psychogenic hallucinations arise under the influence mental trauma or suggestions. Their content reflects a traumatic situation or the essence of the suggestion.
Psychosensory disorders– disturbance of the perception of size, shape, relative position of objects in space and (or) size, weight of one’s own body (body diagram disorder).
Micropsia– reduction in the size of visible objects.
Macropsia– increase in the size of visible objects.
Metamorphopsia– impaired perception of space, shape and size of objects.
Poropsia– violation of the perception of space in perspective (elongated or compressed).
Polyopsia– with the formal preservation of the organ of vision, instead of one object, several are seen.
Optical allesthesia– the patient feels that objects are supposedly out of place.
Dysmegalopsia– changes in the perception of objects, in which the latter seem to be twisted around their axis.
Autometamorphopsia– distorted perception of the shape and size of one’s own body. Disorders occur in the absence of visual control.
Impaired perception of the passage of time(tachychrony is a subjective feeling of time speeding up, bradychrony is a slowing down). Often observed in depression and manic states.
Impaired perception of the sequence of temporal events.
This includes phenomena “already seen” - deja vu, “already heard” - deja entendu, “already tested” – deja vecu and “never seen” - jamais vu, “not heard” - jamais entendu, “previously not experienced” – jamais vecu. In the first case, patients in a new, unfamiliar environment have the feeling that this environment is already familiar to them. In the second, a well-known setting seems as if seen for the first time.
Psychosensory disorders occur separately rarely. Typically, individual symptoms of psychosensory disorders are considered within the framework of two main syndromes: derealization syndrome And depersonalization syndrome.
These disorders most often occur in exogenous-organic psychoses, withdrawal states, epilepsy, and neurorheumatism.
Perceptual disorder syndromes
Hallucinosis– a psychopathological syndrome, the leading disorder of which is hallucinations. Hallucinations, as a rule, occur in one analyzer, less often in several. The resulting affective disorders, delusions, and psychomotor agitation are secondary in nature and reflect the content of hallucinatory experiences. Hallucinosis occurs against the background of clear consciousness.
Disorders can be acute, characterized by vivid hallucinatory symptoms, hallucinatory arousal, the affective component of psychosis is pronounced, the formation of delusions is possible, and psychotically narrowed consciousness may be noted.
In the chronic course of hallucinosis, the affective component fades away, hallucinations become a familiar monosymptom for the patient, and a critical attitude towards the disorders often appears.
Acute auditory (verbal) hallucinosis. The leading symptom is auditory (verbal) hallucinations. The prodromal period is characterized by elementary auditory hallucinations (acoasmas, phonemes) and hyperacusis. At the height of psychosis, true hallucinations are characteristic (sounds come from outside - from behind the wall, from another room, from behind). Patients talk about what they hear with an abundance of detail, and it seems as if they see it (scene-like hallucinosis).
There is always an affective component – fear, anxiety, anger, depression. Often a hallucinatory variant of psychomotor agitation occurs, in which the patient’s behavior reflects the content of hallucinations (patients talk with imaginary interlocutors, cover their ears, make suicidal attempts, refuse food). The formation of secondary delusions (hallucinatory delusions) is possible; delusional ideas reflect the content of hallucinations and affective experiences.
There is no criticism of what is happening. Consciousness is formally clear, psychotically narrowed, patients are focused on their experiences.
Chronic verbal hallucinosis– manifestation, as a rule, is limited to hallucinatory symptoms.
May be observed as an unfavorable outcome of acute verbal hallucinosis. In this case, the intensity of affect first decreases, then behavior is streamlined, and delirium disappears. Criticism of experiences appears. Hallucinations lose their brightness, their content becomes monotonous and indifferent to the patient (encapsulation).
Chronic verbal hallucinosis without a stage of acute psychotic state begins with rare hallucinatory episodes that become more frequent and intensified. Sometimes it is possible to form less relevant interpretive delusions.
Occurs in infectious, intoxication, traumatic and vascular lesions of the brain. May be initial sign schizophrenia, while it becomes more complicated and transforms into Kandinsky-Clerambault syndrome.
Peduncular visual hallucinosis (Lhermitte hallucinosis)
occurs when the cerebral peduncles are damaged (tumors, injuries, toxoplasmosis, vascular disorders). The leading symptom is visual hallucinations with extraprojection at a short distance from the eyes, usually from the side. As a rule, hallucinations are mobile, silent, and emotionally neutral. The attitude towards experiences is critical.
Visual hallucinosis of Charles Bonnet occurs with complete or partial blindness. Initially, individual incomplete visual hallucinations appear. Then their number grows, they become three-dimensional, stage-like. At the height of experience, criticism of hallucinations may disappear.
Van Bogart's hallucinosis characterized by persistent true visual hallucinations. More often these are zooptic hallucinations in the form of beautiful butterflies, small animals, and flowers. At first, hallucinations occur against an emotionally neutral background, but over time, the following appear in the structure of the syndrome: affective tension, psychomotor agitation, and delusions. Hallucinosis gives way to delirium. It is characteristic that this hallucinosis is preceded by a stage of somnolence and narcoleptic attacks.
Kandinsky-Clerambault syndrome is a kind of first-rank syndrome in the diagnosis of schizophrenia. The structure of the syndrome includes auditory pseudohallucinations and mental automatisms.
At hallucinatory form syndrome is dominated by auditory pseudohallucinations.
At delusional version V clinical picture delirium of influence (telepathic, hypnotic, physical) predominates. Usually all types of automatisms are present.
Mental automatism– alienation of the patient’s own mental processes and motor acts – their own thoughts, feelings, movements are felt suggested, violent, subordinate to outside influences.
There are several types of mental automatism.
1. Ideatorial (associative) is manifested by the presence of a feeling of investing other people’s thoughts, phenomena of openness of thoughts are noted (the feeling that one’s own thoughts become known to others, they sound, a feeling of theft of thoughts).
2. Sensory (sensory) mental automatism consists in the emergence of sensations and feelings as if under the influence of external ones. Alienation of one's own emotions is characteristic; the patient has the feeling that emotions arise under the influence of an outside force.
3. Motor (kinesthetic, motor) mental automatism is characterized by the patient’s feeling that any movements are carried out under the influence of external influences.
Availability of this syndrome in the clinical picture of the disease indicates the severity of the psychotic process and requires massive complex therapy.
The syndrome is characteristic of schizophrenia, but some authors rarely describe it in cases of intoxication, trauma, or vascular disorders.
It is also possible to develop the so-called inverted version of Kandinsky-Clerambault syndrome, in which the patient himself supposedly has the ability to influence others. These phenomena are usually combined with delusional ideas of greatness and special power.
Derealization syndrome. The leading symptom is an alienated and distorted perception of the surrounding world as a whole. In this case, disturbances in the perception of the tempo of time (time flows faster or slower), colors (everything is in gray tones or, on the contrary, bright), and a distorted perception of the surrounding space are possible. Déjà vu-like symptoms may also occur.
When you are depressed, the world may seem gray and time moves slowly. The predominance of bright colors in the surrounding world is noted by patients when using certain psychoactive drugs.
Perception of the environment in red and yellow tones is typical for twilight epileptic states.
A change in the perception of the shape and size of the surrounding space is characteristic of intoxication with psychoactive substances and for organic lesions brain.
Depersonalization syndrome is expressed in a violation of self-awareness, a distorted perception of one’s own personality and alienation of individual physiological or mental manifestations. Unlike mental automatism, with these disorders there are no sensations of external influence. There are several options for depersonalization.
Allopsychic depersonalization. A feeling of change in one’s own “I”, duality, the appearance of an alien personality that reacts differently to the environment.
Anesthetic depersonalization. Loss of higher emotions, the ability to feel and experience. Complaints of painful insensibility are typical. Patients lose the ability to feel pleasure or displeasure, joy, love, hatred or sadness.
Neurotic depersonalization. Typically, patients complain of inhibition of all mental processes and changes in emotional response. Patients are focused on their experiences; there are an abundance of complaints about difficulty in thinking and difficulty concentrating. Characterized by obsessive “soul-searching” and introspection.
Somato-physical depersonalization. Characteristic changes in perception internal organs, alienation of the perception of individual processes with the loss of their sensory brightness. Lack of satisfaction from urination, defecation, eating, sexual intercourse.
Violation of the layout and size of the body and its individual parts. Feelings of disproportion of the body and limbs, " incorrect location» arms or legs. Under visual control, the phenomena disappear. For example, a patient constantly has a feeling of the enormity of his fingers, but when looking at his hands, these sensations disappear.
Dysmorphophobia. The conviction of the existence of a non-existent defect in oneself occurs without severe mental disorders. It manifests itself mainly in adolescents as a transient age-related phenomenon.
Senesto-hypochondriacal syndrome. The basis of the syndrome is senestopathy, which occurs first. Subsequently, overvalued ideas of hypochondriacal content are added. Patients turn to doctors, the mental nature of the disease is rejected, so they constantly insist on more in-depth examination and treatment. Subsequently, hypochondriacal delusions may develop, which is accompanied by one’s own interpretation of disorders, often of anti-scientific content; there is no trust in health workers at this stage (reaches the level of open confrontation).
6.2. Thought disorders
Thinking is a function of cognition with which a person analyzes, connects, generalizes, and classifies. Thinking is based on two processes: analysis(decomposition of the whole into its component parts in order to highlight the main and secondary) and synthesis(creating a complete image from individual parts). Thinking is judged by a person’s speech and sometimes by actions and deeds.
Disorders of the form of associative process
Accelerated pace (tachyphrenia)– thinking is superficial, thoughts flow quickly and easily replace each other. Characterized by increased distractibility, patients constantly jump to other topics. Speech is accelerated and loud. Patients do not correlate the strength of their voice with the situation. Statements are interspersed with poetic phrases and singing. The associations between thoughts are superficial, but they are still understandable.
The most pronounced degree of accelerated thinking is leap of ideas(fuga idiorum). There are so many thoughts that the patient does not have time to speak them out; unfinished phrases and speech are characteristic. It is necessary to differentiate with broken thinking, in which associations are completely absent, the rate of speech remains normal, and there is no characteristic emotional intensity. An accelerated pace of thinking is characteristic of mania and stimulant intoxication.
Mentism- a subjective feeling when there are a lot of unrelated thoughts in your head. This is a short-term condition. In contrast to accelerated thinking, this is an extremely painful condition for the patient. The symptom is characteristic of Kandinsky-Clerambault syndrome.
Slow pace (bradyphrenia). Thoughts arise with difficulty and remain in consciousness for a long time. Slowly replace one another. Speech is quiet, poor in words, responses are delayed, phrases are short. Subjectively, patients describe that thoughts, when they appear, overcome resistance, “tossing and turning like stones.” Patients consider themselves intellectually incompetent and stupid. The most severe form of delayed thinking is monoideism, when one thought persists in the patient’s mind for a long time. This type of disorder is characteristic of depressive syndrome and organic brain lesions.
Sperung– interruptions of thoughts, “blockage of thinking”, the patient suddenly loses his thoughts. Most often, experiences are subjective and may not be noticeable in speech. In severe cases - sudden cessation of speech. It is often combined with mental influxes, reasoning, and is observed with clear consciousness.
Slipping Thinking– deviation, reasoning slipping into side thoughts, the thread of reasoning is lost.
Disjointed thinking. At this disorder there is a loss of logical connections between individual thoughts. Speech becomes incomprehensible, but the grammatical structure of speech is preserved. The disorder is characteristic of the late stage of schizophrenia.
For incoherent (incoherent) thinking Characterized by a complete loss of logical connections between individual short statements and individual words (verbal okroshka), speech loses grammatical correctness. The disorder occurs when consciousness is impaired. Incoherent thinking is part of the structure of the amentive syndrome (often in a state of agony, with sepsis, severe intoxication, cachexia).
Reasoning- empty, fruitless, vague reasoning, not filled with specific meaning. Idle talk. It is noted in schizophrenia.
Autistic thinking– reasoning is based on the patient’s subjective attitudes, his desires, fantasies, and delusions.
Often there are neologisms - words invented by the patient himself.
Symbolic thinking– patients attach special meaning to random objects, turning them into special symbols. Their content is not clear to others.
Paralogical thinking– reasoning with “crooked logic”, based on a comparison of random facts and events. Characteristic of paranoid syndrome.
Duality (ambivalence)– the patient affirms and denies at the same time the same fact, often found in schizophrenia.
Perseverative thinking- getting stuck in the mind of one thought or idea. It is typical to repeat one answer to different subsequent questions.
Verbigeration– a characteristic speech disorder in the form of repetition of words or endings with their rhyming.
Pathological thoroughness of thinking. There is excessive detail in statements and reasoning. The patient gets “stuck” on circumstances, unnecessary details, and the topic of reasoning is not lost. Characteristic of epilepsy, paranoid syndrome, psychoorganic syndromes, paranoid delusions (especially noticeable when a delusional system is substantiated).
Disorders of the semantic content of the associative process
Super valuable ideas- thoughts that are closely fused with the patient’s personality, determining his behavior, having a basis in the real situation, and arising from it. Criticism of them is flawed and incomplete. In terms of content, they distinguish overvalued ideas of jealousy, invention, reformism, personal superiority, litigious, hypochondriacal content.
The interests of patients are narrowed to overvalued ideas that occupy a dominant position in the consciousness. Most often, overvalued ideas arise in psychopathic individuals (overly self-confident, anxious, suspicious, with low self-esteem) and in the structure of reactive states.
Delusional ideas– false conclusions that arise on a painful basis; the patient is not critical of them and cannot be dissuaded. The content of delusional ideas determines the patient's behavior. The presence of delusions is a symptom of psychosis.
The main signs of delusional ideas: absurdity, incorrect content, complete absence criticism, the impossibility of dissuading, the determining influence on the patient’s behavior.
According to the mechanism of occurrence, they distinguish the following types delirium.
Primary delirium– delusional ideas arise primarily. Sometimes present as a monosymptom (for example, with paranoia), as a rule, systematized, monothematic. Characterized by the presence of successive stages of formation: delusional mood, delusional perception, delusional interpretation, crystallization of delirium.
Secondary delusion– sensual, arises on the basis of other mental disorders.
Affective delirium. Closely associated with severe emotional pathology. It is divided into holothymic and catathymic.
Holothym delirium occurs in polar affective syndromes. With euphoria - ideas with increased self-esteem, and with melancholy - with decreased self-esteem.
Catathymic delirium occurs in certain life situations accompanied by emotional stress. The content of delusions is related to the situation and personality characteristics.
Induced (suggested) delusion. It is observed when the patient (inductor) convinces others of the reality of his conclusions, as a rule, it occurs in families.
Depending on the content of delusional ideas, several characteristic types of delusions are distinguished.
Persecuratory forms of delusion (delusion of influence) At delirium of persecution the patient is convinced that a group of people or one person is persecuting him. Patients are socially dangerous because they themselves begin to pursue suspected persons, the circle of whom is constantly growing. They require hospital treatment and long-term observation.
Delusional relationship– patients are convinced that those around them have changed their attitude towards them, have become hostile, suspicious, and are constantly hinting at something.
Rave special significance – patients believe that TV programs are specially selected for them, everything that happens around has a certain meaning.
Delirium of poisoning– the name itself reflects the essence of delusional experiences. The patient refuses to eat, and olfactory and gustatory hallucinations are often present.
Delirium of influence– the patient is convinced that imaginary pursuers in some special way (evil eye, damage, special electric currents, radiation, hypnosis, etc.) affect his physical and mental state (Kandinsky-Clerambault syndrome). Delusion of influence can be inverted when the patient is convinced that he himself influences and controls those around him (inverted Kandinsky-Clerambault syndrome). Delusions of love influence are often identified separately.
Delusions of property damage(robberies, burglaries) are characteristic of involutional psychoses.
Delusional ideas of greatness. Delusions of grandeur include a group of different delusional ideas that can be combined in the same patient: delirium of power(the patient claims that he is endowed with special abilities, power); reformism(ideas about reorganizing the world); invention(conviction of a great discovery); special origin(patients’ belief that they are descendants of great people).
Manichaean nonsense– the patient is convinced that he is at the center of the struggle between the forces of good and evil.
Mixed forms delirium
Nonsense of staging. Patients are convinced that those around them are performing some kind of performance especially for them. Combined with delirium of intermetamorphosis, which is characterized by delusional forms of false recognition.
Symptom of negative and positive double (Carpg syndrome). With the symptom of a negative double, the patient mistakes close people for strangers. False recognition is typical.
With the symptom of a positive double, strangers and strangers are perceived as acquaintances and relatives.
Fregoli's symptom - the patient thinks that the same person appears to him in different reincarnations.
Delirium of self-blame(they are convinced that they are sinners).
Megalomaniac delirium– the patient believes that because of him all humanity is suffering. The patient is dangerous to himself, extended suicides are possible (the patient kills his family and himself).
End of introductory fragment.
This lecture covers dysthymia in detail. Dysthymia is a prolonged depression that takes a chronic course (lasting at least 2 years). Dysthymia most often begins at a young age, although the onset may be in middle and involutionary age. The clinical picture of dysthymia is characterized by minimal severity of low mood (hypotymia) and the predominance of somatovegetative and pathocharacterological manifestations. main types of dysthymia: somatized (cathesthetic) dysthymia and characterological (characterogenic) dysthymia. Somatized dysthymia is characterized by complaints of general poor health, palpitations, shortness of breath, constipation, tearfulness, bad dream with frequent awakenings. Depressed mood is usually mild with a predominance of anxiety. Often, bodily sensations are overlapped by mood disorders and the formation common symptoms. At the same time, depression and melancholy acquire a physical connotation (burning in the larynx or intestines, “chilling cold” in the pit of the stomach). The clinical picture is dominated by persistent disorders that persist throughout life in the form of anhedonia, a tendency to “the blues,” pessimism, and thoughts about the meaninglessness of life. Over the years, a depressive worldview is gradually formed, at the center of which lies the “loser complex.” Dr. Doherty also covers cyclothymia. Cyclothymia (from the Greek κύκλος, “circle” and θυμός - “spirit, soul”) is a mental disorder in which the patient experiences mood instability, more precisely, a change between mild depression and mild euphoria. The word "cyclothymia" was previously used to describe bipolar disorder. Dalle's conversation touches on issues of affective disorders. Affective disorder (Mood disorder) is the general name for a group of mental disorders associated with disturbances in emotional sphere. Present in the ICD. In the DSM classification, several diagnoses are combined when the main symptom is a disorder emotional state. The two most widely recognized types of disorders are differentiated based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, among which the most famous and studied is major depressive disorder, which is also called clinical depression, and bipolar affective disorder, previously known as manic-depressive psychosis and is described by alternating periods of manic (lasting from 2 weeks to 4-5 months) and depressive (average duration 6 months) episodes. Also carried out comparative analysis unipolar and bipolar disorders.
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