Mental disorders in somatic diseases (K.K. Telia). Somatic mental disorders Medical educational literature

The patterns described in the previous section apply not only to intoxication, but also to a wide variety of exogenous mental disorders (radiation injury, prolonged compression, hypoxia, condition after severe surgical intervention), as well as to many somatic diseases.

Symptoms are largely determined by the stage of the disease. Thus, chronic somatic diseases, states of incomplete remission and convalescence are characterized by severe asthenia, hypochondriacal symptoms and affective disorders (euphoria, dysphoria, depression). A sharp exacerbation of a somatic illness can lead to acute psychosis (delirium, amentia, hallucinosis, depressive-delusional state). As a result of the disease, a psychoorganic syndrome may be observed (Korsakov's syndrome, dementia, organic personality changes, convulsive seizures).

Mental disorders in somatic diseases correlate quite accurately with changes in the general somatic condition. Thus, delirious episodes are observed at the height of a febrile state, a deep disorder of the basic metabolic processes corresponds to states of switching off consciousness (stunning, stupor, coma), an improvement in the state corresponds to an increase in mood (euphoria of convalescents).

Mental disorders of an organic nature in somatic diseases are quite difficult to separate from psychogenic worries about the severity of a somatic illness, fears about the possibility of recovery, and depression caused by the awareness of one’s helplessness. Thus, the very need to see an oncologist can be a cause of severe depression. Many diseases (skin, endocrine) are associated with the possibility of developing a cosmetic defect, which is also a strong psychological trauma. The treatment process may cause concern in patients due to the possibility of developing side effects and complications.

Let's consider the psychiatric aspect of the most common diseases.

Chronic heart disease (ischemic disease heart disease, heart failure, rheumatism) are often manifested by asthenic symptoms (fatigue, irritability, lethargy), increased interest in the state of one’s health (hypochondria), decreased memory and attention. If complications occur (for example, myocardial infarction), acute psychosis may develop (usually amentia or delirium). Often, against the background of myocardial infarction, euphoria develops with an underestimation of the severity of the disease. Similar disorders are observed after heart surgery. Psychosis in this case usually occurs on the 2nd or 3rd day after surgery.

Malignant tumors may already in the initial period of the disease manifest themselves as increased fatigue and irritability, and subdepressive states often form. Psychoses usually develop in the terminal stage of the disease and correspond to the severity of concomitant intoxication.

Systemic collagenoses (systemic lupus erythematosus) have a wide variety of manifestations. In addition to asthenic and hypochondriacal symptoms, against the background of exacerbation, psychoses of a complex structure are often observed - affective, delusional, oneiric, catatonic; Delirium may develop against the background of fever.

For renal failure All mental disorders occur against a background of severe adynamia and passivity: adynamic depression, low-symptomatic delirious and amental states with mild arousal, catatonic stupor.

Nonspecific pneumonia often accompanied by hyperthermia, which leads to delirium. In the typical course of tuberculosis, psychosis is rarely observed - asthenic symptoms, euphoria, and underestimation of the severity of the disease are more common. Emergence seizures may indicate the appearance of tubercles in the brain. The cause of tuberculosis psychoses (manic, hallucinatory-paranoid) may not be the infectious process itself, but anti-tuberculosis chemotherapy.

Therapy for somatogenic disorders should be primarily aimed at treating the underlying somatic disease, reducing body temperature, restoring blood circulation, as well as normalizing general metabolic processes (acid-base and electrolyte balance, preventing hypoxia) and detoxification. From psychotropic drugs special meaning have nootropic drugs (aminalon, piracetam, encephabol). If psychosis occurs, neuroleptics (haloperidol, droperidol, chlorprothixene, tizercin) must be used with caution. Safe remedies for anxiety and restlessness are tranquilizers. Among antidepressants, preference should be given to those with a small amount side effects(pirazidol, befol, fluoxetine, coaxil, heptral). With timely treatment of many acute somatogenic psychoses, complete restoration of mental health is noted. In the presence of clear signs of encephalopathy, the mental defect persists even after the improvement of the somatic condition.

A special position among somatogenic causes mental disorders occupyendocrine diseases .Severe manifestations of encephalopathy in these diseases are detected much later. At the first stages, affective symptoms and drive disorders predominate, which may resemble manifestations of endogenous mental illnesses (schizophrenia and MDP). The psychopathological phenomena themselves are not specific: similar manifestations can occur when the various glands internal secretion, sometimes an increase and decrease in hormone production are manifested by the same symptoms. M. Bleuler (1954) described the psychoendocrine syndrome, which is considered as one of the variants of the psychoorganic syndrome. Its main manifestations are affective instability and drive disorders, manifested by a kind of psychopathic behavior. What is more characteristic is not the perversion of drives, but their disproportionate strengthening or weakening. Of the emotional disorders, depression is the most common. They often occur with hypofunction thyroid gland, adrenal glands, parathyroid glands. Affective disorders somewhat different from pure depressions and manias typical of MDP. More often, mixed states are observed, accompanied by irritability, fatigue or irascibility and anger.

Describe some features of each endocrinopathy. ForItsenko-Cushing's diseasecharacterized by adynamia, passivity, increased appetite, decreased libido without pronounced emotional dullness characteristic of schizophrenia.

The differential diagnosis with schizophrenia is complicated by the appearance of strange, pretentious sensations in the body - senestopathies (“the brain is dry,” “something is shimmering in the head,” “the insides are squirming”). These patients have an extremely difficult time experiencing their cosmetic defect. At hyperthyroidism, on the contrary, there are increased activity, fussiness, emotional lability with a rapid transition from crying to laughter. There is often a decrease in criticism with a false feeling that it is not the patient who has changed, but the situation (“life has become hectic”). Occasionally, acute psychosis occurs (depression, delirium, confusion). Psychosis may also occur after strumectomy surgery. At hypothyroidism signs of mental exhaustion are quickly joined by manifestations of psychoorganic syndrome (decreased memory, intelligence, attention). Characterized by grumpiness, hypochondriasis, and stereotypical behavior. An early signAddison's diseaseis an increasing lethargy, noticeable at first only in the evening and disappearing after rest. Patients are irritable, touchy; always trying to sleep; libido decreases sharply. Subsequently, the organic defect rapidly increases. A sharp deterioration in condition (Addisonian crisis) can be manifested by disturbances of consciousness and acute psychoses of a complex structure (depression with dysphoria, euphoria with delusions of persecution or erotic delusions, etc.). Acromegaly usually accompanied by some slowness, drowsiness, and mild euphoria (at times replaced by tears or outbursts of anger). If hyperproduction of prolactin is observed in parallel, increased caring and a desire to take care of others (especially children) may be observed. Organic defect in patients withdiabetes mellitusis mainly caused by concomitant vascular pathology and is similar to the manifestations of other vascular diseases.

In some endocrinopathies, psychopathological symptoms are completely devoid of specificity and it is almost impossible to make a diagnosis without a special hormonal study (for example, in case of dysfunction of the parathyroid glands). Hypogonadism, arising from childhood, manifests itself only in increased daydreaming, vulnerability, sensitivity, shyness and suggestibility (mental infantilism). Castration in an adult rarely leads to severe mental pathology - much more often the experiences of patients are associated with the awareness of their defect.

Changes in hormonal status can cause some mental discomfort in women inmenopause(usually in premenopause). Patients complain of hot flashes, sweating, increased blood pressure, and neurosis-like symptoms (hysterical, asthenic, subdepressive). INpremenstrual periodThe so-called premenstrual syndrome often occurs, characterized by irritability, decreased performance, depression, sleep disturbances, migraine-like headaches and nausea, and sometimes tachycardia, blood pressure fluctuations, flatulence and edema.

Although the treatment of psychoendocrine syndrome often requires specific hormone replacement therapy, the use of only hormonal drugs does not always allow for complete restoration of mental well-being. Quite often it is necessary to simultaneously prescribe psychotropic drugs (tranquilizers, antidepressants, mild antipsychotics) to correct emotional disorders. In some cases, the use of hormonal drugs should be avoided. Thus, it is better to start the treatment of post-castration, menopausal and severe premenstrual syndrome with psychopharmacological drugs, since the unreasonable prescription of replacement hormone therapy can lead to psychosis (depression, mania, manic-delusional states). In many cases, doctors general practice underestimate the importance of psychotherapy in the treatment of endocrinopathies. Almost all patients with endocrine pathology need psychotherapy, and with menopause and premenstrual syndrome, psychotherapy often gives a good effect without the use of medicines.

Modern ideas about the essence of the concept of disease involve taking into account the entire set of changes affecting both the biological level of disorders (somatic symptoms and syndromes) and the social level of the patient’s functioning with a change in role positions, values, interests, social circle, with a transition to a fundamentally new social situation with with its specific prohibitions, regulations and restrictions.
The influence of a somatic state on the psyche can be both sanogenic and pathogenic. The latter refers to mental disorders in conditions of somatic illness.
There are two types of pathogenic influence of somatic illness on the human psyche: somatogenic (due to intoxication, hypoxia and other effects on the central nervous system) and psychogenic, associated with psychological reaction personality on the disease and its possible consequences. Somatogenic and psychogenic components influence the mental sphere in different proportions depending on the nosology of the disease. For example, somatogenic influences play a particularly important role in the genesis of mental disorders in kidney diseases, congenital defects hearts.
In patients with chronic renal failure(N18) note the phenomena of intoxication. Asthenia develops against the background of intoxication. As a result of increasing asthenia, changes occur primarily in the structure of cognitive processes such as memory and attention - prerequisites for intelligence. There is a narrowing of the attention span, disruption of the processes of imprinting and storing information. As asthenia increases, disturbances in the processes of attention and memory are accompanied by other changes in the intellectual sphere: the level of analytical-synthetic
thinking activity with a predominance of visual-figurative thinking over abstract-logical thinking.
Cognitive activity begins to bear the features of concreteness and situationality. Intellectual deficiency gradually develops, and the productivity of thinking decreases. Changes in the cognitive sphere of patients with chronic renal failure are inextricably linked with changes in emotionality. The structure of asthenia includes irritability with decreased control over emotional reactions. Depression is a psychological reaction to the patient’s awareness and experience of emerging intellectual failure (especially in the later stages of the disease). Anxious and hypochondriacal traits may develop.
Forced abandonment of usual professional activities, the need to change profession due to illness or transition to disability, becoming an object of family care, isolation from the usual social environment (due to long-term inpatient treatment) - all this significantly affects the personality of the patient, who develops traits of egocentrism, increased demands, and touchiness.
Severe chronic somatic disease significantly changes the entire social situation of human development. It changes his ability to implement various types activities, leads to a limitation of the circle of contacts with other people, leads to a change in the place he occupies in life. In this regard, there is a decrease in volitional activity, a limitation in the range of interests, lethargy, apathy, disturbances in purposeful activity with a fall
efficiency, impoverishment and impoverishment of the entire mental appearance.
Nikolaeva notes another important mechanism of the relationship between the mental and somatic levels of human functioning - the “vicious circle” mechanism. It lies in the fact that a disorder that initially occurs in the somatic sphere causes psychopathological reactions that disorganize the personality, and they, in turn, are the cause of further somatic disorders. Thus, in a “vicious circle”, a complete picture of the disease unfolds.
The most striking example of the “vicious circle” mechanism is the reaction to pain, often encountered in the clinic of internal medicine. Under the influence of pain and chronic physical discomfort, patients with severe somatic disorders develop a variety of emotional disturbances. Long-term affective states change the parameters of physiological processes, transferring the body to a different mode of functioning associated with tension in adaptive systems. Chronic tension of adaptive and compensatory mechanisms can ultimately lead to the formation of secondary somatic disorders.
Korkina proposes the concept of a “psychosomatic cycle”, when periodic actualization psychological problems and associated prolonged or intense emotional experiences leads to somatic decompensation, exacerbation of a chronic somatic disease or the formation of new somatic symptoms.
Unlike acute pathology, in which successful treatment leads to complete restoration of the previous state of health, chronic diseases are characterized by long-term pathological processes without clearly defined boundaries. The patient never becomes completely healthy again; he is constantly, that is, chronically, ill. The patient must be prepared for a further deterioration in his health, a continued decline in performance, and come to terms with the fact that he will never be able to do everything he wants as before.
Because of these limitations, a person often finds himself in conflict with what he expects from himself and what others expect from him. A chronic patient, due to the psychosocial consequences of his functional limitations (family reaction, decrease in the social sphere of activity, damage to professional performance, etc.), is in danger of becoming an “inferior” person, a disabled person.
In opposition chronic disease There are two behavioral strategies - passive and active. The patient must realize overall change life situation and try to actively overcome obstacles with the help of a new lifestyle adapted to the disease. The requirement to “live with the disease” is easier to declare than to fulfill, and this leads to the fact that many people react to changes in their functioning caused by the disease with psychopathological disorders such as fear, apathy, depression, etc. Passive behavior includes protective mechanisms : reactions of downplaying the severity of the illness such as ignoring, self-deception, rationalization or overcontrol. However, the value of these passive attempts to cope with the psychological and social consequences of long-term illness is often questionable. More significant are the patient’s active efforts to solve the problems he faces related to the disease. According to Kallinka, the patient should strive to: mitigate harmful influences environment and increase the chances of improving your condition, adequately assess unpleasant events and facts and adapt to them, maintain your own positive image, maintain emotional balance and calm, normal relationships with others.
This is possible if the patient:

• receives and assimilates necessary information about the disease; seeks and finds advice and emotional support from specialists, acquaintances or fellow sufferers (self-help groups);
• acquires self-care skills at certain moments of illness and thereby avoids unnecessary dependence;
• sets new goals related to the presence of the disease and tries to achieve them step by step.

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

With a psychogenic cause, it turns out to be such, as a rule, in sensitive individuals, when the objective meaning of the main internal medicine for the psyche is unimportant, and changes in the psyche in to a greater extent are caused by the massiveness of the patient’s fears or the strength of the psychological conflict between his motives, needs and the expected decrease in his capabilities due to the disease.

This reason is because for a sick person, his desires and expectations often turn out to be subjectively more significant than achieving the goal itself. This may also apply to persons with a so-called anxious-suspicious character.

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

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

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

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

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

Neurotic disorders are neuropsychic disorders in which the leading role is played by mental trauma or internal mental conflicts.

Basically, they arise on a somatically weakened, altered background, primarily in premorbidly located to psychogeniuses persons Their clinical structure is characterized by acuteness, severity of painful experiences, brightness, imagery; painfully heightened imagination; increased fixation on the interpretation of altered well-being, internal discomfort, disorder, as well as anxiety for one’s future. At the same time, criticism remains intact, i.e., the understanding of these disorders as painful. Neurotic disorders, as a rule, have a temporary connection with a previous trauma or conflict, and the content of painful experiences is often associated with the content of a traumatic circumstance. They are also often characterized by reverse development and weakening as time passes. mental trauma and its deactualization.

Great importance for a sick person has his idea of ​​the disease, based on the most diverse information.

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

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

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

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

Based on mental disorders, medical psychology studies the forms of behavior of a somatically ill patient, the characteristics of contacts with others, and ways of influencing the psyche for better implementation of therapeutic measures.

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

A long-term somatic illness, the need to stay in a hospital for months or years can sometimes lead to personality changes in the form of pathological development, in which character traits arise that were previously not characteristic of this person. Character changes in these patients can interfere with or complicate treatment and lead to disability. In addition, this may create conflicts in medical institutions, cause a negative attitude of others towards these patients. Depending on the characteristics of mental disorders in somatic diseases, the doctor’s conversation with patients, the behavior of medical personnel and all the tactics of medical measures are structured.

Consciousness of illness

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Consciousness of illness”, “internal picture” covers the entire range of experiences of a sick person associated with his illness.

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

There are no aspects of a patient’s life that are not reflected in his consciousness, modified by the disease.

Disease– this is life in changed conditions.

Features of illness consciousness can be divided into two groups:

1. Conventional forms of consciousness of illness represent only features of the psychology of a sick person.

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

It should be noted that in many cases, the discrepancy that arises during the course of the disease between the remaining or even growing needs of a person and his diminishing capabilities is reflected. This kind of conflict, especially in cases of protracted and disabling illnesses, can acquire complex content due to the imposition of contradictions between a person’s desire for a speedy recovery and his diminishing capabilities. They can be generated by the consequences of the disease, in particular by changes in his professional and social opportunities.

With somatic diseases, depending on the severity, duration and nature of the disease, various mental disorders can be observed, which are expressed by various symptoms. In somatic diseases, changes in mental activity are most often expressed by neurotic symptoms. With a high severity of intoxication and the severity of the disease, somatogenic psychoses are possible, accompanied by states of altered consciousness. In some cases, somatic diseases (hypertension, atherosclerosis, diabetes mellitus) lead to the occurrence of psychoorganic disorders. A long-term somatic illness, the need to stay in a hospital for months or years, and the “special situation of the patient” in some cases lead to personality changes in the form of pathological development, in which character traits arise that were previously not characteristic of this person. Character changes in these patients can hinder or complicate treatment, lead to disability, create conflicts in medical institutions, and cause a negative attitude of others towards these patients. The doctor must be able to recognize these painful changes in the psyche, foresee and anticipate their occurrence, medicinal methods and through psychotherapeutic conversations, mitigate their manifestations.

Depending on the characteristics of mental disorders in somatic diseases, the doctor’s conversation with patients, the behavior of medical personnel and all the tactics of medical measures are structured. With increasing intoxication, patients' sleep and appetite are disturbed, irritability, increased sensitivity and tearfulness appear. The sleep of such patients becomes superficial - they wake up easily, noises, light, conversations, and the touch of clothing become unpleasant. Sometimes with insomnia, influxes of memories appear, which also prevent the patient from falling asleep. Patients become anxious, experience fears, and often ask to keep the lights on at night or to sit near them. Not every patient can tell the doctor that he felt fear at night because of false shame of a mental disorder or a reluctance to look like a coward.

Habitual noises become unbearable, the light from a street lamp becomes irritating. The doctor must understand the patient in his condition, pay close attention to his complaints and, if possible, eliminate irritants, place him in a quieter room, in a more comfortable place. Against the background of asthenic symptoms (irritable weakness) sometimes appear obsessive fears for their health or previously uncharacteristic hysterical reactions. The doctor must always remember that a hysterical reaction is a painful manifestation and must be treated as a disease.

Some psychosomatic diseases are accompanied by a depressive state; this is one of the manifestations of diseases such as spastic ulcerative colitis. Such patients are often depressed, gloomy, and inactive. They experience anxiety in the early hours of the morning, exhaustion and weakness, but sometimes, against the background of this depression and lethargy, they develop unusual talkativeness and liveliness when they joke, laugh, and amuse those around them. Doctors should know that such conditions often arise, but these conditions do not determine the main background of mood, but apparent cheerfulness is a temporary phenomenon. In this condition, patients often violate their prescribed treatment regimen.

Acute psychotic disorders, or psychoses, that occur in severe somatic diseases, most often have the character of a disorder of consciousness in the form of delirium, stunnedness, and less often amentia. Harbingers of confusion are often mental disorders that occur when the eyes are closed (psychosensory disorder and hypnagogic hallucinations). In this regard, questioning patients is of great importance, especially when complaining of insomnia. Following sleep disorders and hypnagogic hallucinations, delirious stupefaction with abnormal behavior may develop.

Not every somatic illness is accompanied by psychotic disorders. Yes, when peptic ulcer, colitis, hypertension, heart failure, neurotic disorders and pathological character traits are more often observed, and with hypertension and atherosclerosis, the occurrence of psychosis is possible.

The severity and quality of changes in mental activity in somatic diseases depend on many reasons, and primarily on the nature of the disease itself (whether it directly or indirectly affects brain activity), as well as on the type of course and severity of the disease. Thus, with an acute and violent onset, in the presence of severe intoxication, disorders are observed that reach stupefaction, with subacute or chronic course Neurotic symptoms are more common.

Changes in mental activity are also influenced by the stage of development of somatic illness: if in acute period There are states of altered consciousness and neurotic symptoms, then at a distant stage of its development changes in character, personality, asthenia and psychoorganic disorders can be observed. Mental activity in somatic diseases is influenced by associated harm. Thus, pneumonia or myocardial infarction occur with severe disturbances in mental activity in persons who abuse alcohol.

Variants of patient reactions to somatic illness

Personal reactions to somatic illness in a number of patients can be pathological in nature and manifest themselves in the form of psychogenic neurotic, anxiety-depressive reactions. In other patients, these reactions are expressed by psychologically adequate experiences of the fact of illness. Neuropsychic disorders in somatic diseases usually consist of mental somatogenic disorders and the individual’s reaction to the disease.

In this complex structure of mental disorders, the severity of these factors is not equivalent. Thus, in vascular diseases, especially in hypertension, atherosclerosis, endocrine diseases, the decisive role is played by somatogenic factors, in other diseases - by personal reactions (disfiguring operations, facial defects, loss of vision).

The individual’s reaction to illness is directly dependent on many factors:

The nature of the disease, its severity and rate of development;

The patient’s own ideas about this disease;

The nature of treatment and psychological situation;

Personality of the patient;

Attitudes towards illness at home of relatives and colleagues at work.

There are various options for attitudes towards the disease, mainly determined by the personality characteristics of the patient: asthenodepressive, psychasthenic, hypochondriacal, hysterical and euphoric-anosognosic.

Asthenodepressive reaction

With the asthenodepressive variant of the attitude towards the disease, emotional instability, low endurance in relation to irritants, weakening of the urge to activity, a feeling of weakness and depression, dejection, and anxiety are observed. This condition contributes to an incorrect attitude towards one’s illness and a gloomy perception of all events, which usually has an adverse effect on the course of the disease and reduces the success of treatment.

Psychasthenic reaction

With the psychasthenic variant, the patient is full of anxiety, fears, convinced of the worst outcome, and expects serious consequences. He pesters doctors with questions, goes from one doctor to another. He experiences a lot of unpleasant sensations, remembers the symptoms of the disease that his relatives and friends had, and finds signs of them in himself. A calm, intelligent psychotherapeutic conversation can significantly improve the condition of such patients, but they need a detailed explanation of the reasons for their condition.

Hypochondriacal reaction

A close variant of the reaction to the disease is hypochondriacal. In this version, anxiety and doubt are represented less, and the belief in the presence of the disease is more present. In the hysterical version, the disease is always assessed with exaggeration. Overly emotional, fantasy-prone individuals seem to live with the disease, clothe it in an aura of unusualness, exclusivity, special, unique martyrdom. Such patients require increased attention, accuse others of not understanding their condition and of insufficient sympathy for their suffering.

Euphoric-anosognosic reaction

The euphoric-anosognosic variant of the reaction to the disease consists of inattention to one’s health, denial of the disease, refusal to be examined and medical appointments. The reaction of the individual is influenced by: the nature of the diagnosis; changes in physical fitness and appearance; changes in the situation in the family and society; life restrictions and hardships associated with the disease; the need for treatment or surgery.

Doctors often have to deal with the patient’s denial of the fact of the disease (anosognosia). Denial or repression of the disease most often occurs in severe and dangerous diseases (malignant tumor, tuberculosis, mental illness). Such patients either ignore the disease altogether, or attach importance to less severe symptoms and use them to explain their condition and are treated for the disease that they have invented for themselves.

Some doctors believe that the reason for denying the disease in most cases is the unbearability of the actual state of affairs, the inability to believe in the serious and dangerous disease. The reaction of disease denial can be observed among close relatives of the patient, especially when it comes to mental illness. At the same time, some of them, despite denying the fact of the disease, agree to carry out the necessary therapy.

Great difficulties arise in cases where relatives, denying the disease, refuse treatment, begin to use their own remedies, and resort to the help of witch doctors, healers and psychics. If in psychogenic diseases, especially hysteria, such therapy can sometimes (if the patient has great faith in it) lead to an improvement in the condition through suggestion and self-hypnosis, then in other forms it is possible that the disease may worsen and become chronic.

Insufficient assessment of one's condition can be observed during euphoria due to somatogenic diseases, especially with cerebral hypoxia or intoxication, as well as with endogenous and other mental diseases. In a number of somatic diseases (hypertension, diabetes mellitus, atherosclerosis), organic changes in the brain increase, leading to intellectual decline, as a result of which the patient’s ability to correctly assess his condition and the condition of his loved ones is impaired.

In patients with protracted chronic serious illnesses against the background of asthenic disorders, a hypochondriacal fixation on their condition and sensations is possible. They have many different complaints that do not correspond to somatic suffering. The patient becomes gloomy, gloomy, depressed-irritable, and looks healthy people(smiles, laughter, everyday worries) causes him irritation. Such patients may come into conflict with staff if they notice that they are not paying enough attention to their complaints.

Sometimes such patients develop hysterical forms of behavior when, with their complaints, they seek to attract the attention of others. Attempts to convince the patient that the disease is mild, harmless, and not scary can often cause worsening hysterical reactions. The patient’s behavior during illness and his reactions to the illness are primarily affected by the personality structure of this person before the illness. In some diseases, the personal reaction to the disease manifests itself in the sharpening of premorbid personality characteristics.

Dependence of the reaction on the individual qualities of the patient

It is believed that the adequacy of the reaction to the disease depends on the degree of maturity of the individual and his intellectual capabilities. Thus, in infantile subjects, repression or denial of the disease or, conversely, the syndrome of “withdrawal into illness” is often observed. In people who are asthenic, anxious and suspicious, they often do not have much serious illness causes a violent reaction of anxiety, anxiety, followed by depressive-hypochondriacal and persistent disorders.

The individual's reaction to illness depends on the age of the patient. To the same disease with the same outcome, patients have different reactions. For young people, the disease leads to disruption of plans for the future; for middle-aged patients, it prevents the fulfillment of plans; for older people, it is perceived as an inevitable end. In accordance with the reaction of the individual, the doctor must create a new life attitude for the patient, always taking into account his capabilities.

Personal reactions also depend on mental disorders caused by somatic illness. The intensity of neurotic reactions decreases in the presence of severe somatogenic asthenia and organic disorders.

Analysis of the somatic state in patients with mental illness allows us to clearly demonstrate the close relationship between the mental and the somatic. The brain, as the main regulatory organ, determines not only the effectiveness of all physiological processes, but also the degree of psychological well-being (well-being) and self-satisfaction.

Disruption of brain function can lead to both a true disorder in the regulation of physiological processes (appetite disorders, dyspepsia, tachycardia, sweating, impotence) and a false feeling of discomfort, dissatisfaction, dissatisfaction with one’s physical health (in the actual absence of somatic pathology). Examples of somatic disorders arising as a result of mental pathology are those described in the previous chapter panic attacks.

The disorders listed in this chapter usually occur secondaryly, i.e. are only symptoms of any other disorders (syndromes, diseases). However, they cause such significant concern to patients that they require special attention from the doctor, discussion, psychotherapeutic correction and, in many cases, the prescription of special symptomatic remedies. ICD-10 proposes separate categories to designate such disorders.

Eating disorders

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

Anorexia nervosa syndrome(anorexia nervosa) develops more often in girls during puberty and adolescence and is expressed in the conscious refusal of food for the purpose of losing weight. Patients are typically dissatisfied with their appearance (dysmorphomania - dysmorphophobia), about a third of them were slightly overweight before the onset of the disease. Patients carefully hide their dissatisfaction with imaginary obesity and do not discuss it with any strangers. Losing body weight is achieved by limiting the amount of food, excluding high-calorie and fatty foods from the diet, a set of heavy physical exercises, and taking large doses of laxatives and diuretics. Periods of severe food restriction are interspersed with attacks of bulimia, when a strong feeling of hunger does not go away even after taking large quantity food. In this case, patients artificially induce vomiting.

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

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

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

Treatment of patients with eating disorders should be based on the underlying diagnosis, but several factors should be considered. general recommendations, which are useful for any type of nutritional disorder.

Inpatient treatment in such cases is often more effective than outpatient treatment, since food intake cannot be controlled well enough at home. It should be borne in mind that replenishment of dietary defects, normalization of body weight by organizing fractional meals and establishing activities gastrointestinal tract, restorative therapy is a prerequisite for the success of further therapy. To suppress an overvalued attitude towards food intake, antipsychotics are used. Psychotropic drugs are also used to regulate appetite. Many antipsychotics (frenolone, etaprazine, aminazine) and other drugs that block histamine receptors(pipolfen, cyproheptadine), as well as tricyclic antidepressants (amitriptyline) increase appetite and cause weight gain. To reduce appetite, psychostimulants (fepranon) and antidepressants from the group of serotonin reuptake inhibitors (fluoxetine, sertraline) are used. Properly organized psychotherapy is of great importance for recovery.

Sleep disorders

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

Normal sleep varies in duration and consists of a series of cyclical fluctuations in the level of wakefulness. The greatest decrease in central nervous system activity is observed in the slow-wave sleep phase. Awakening in this period is associated with amnesia, sleepwalking, enuresis, and nightmares. The REM sleep phase occurs for the first time approximately 90 minutes after falling asleep and is accompanied by rapid eye movements, a sharp drop in muscle tone, increased blood pressure, and penile erection. The EEG in this period differs little from the waking state; upon awakening, people report having dreams. In a newborn, REM sleep makes up about 50% of the total sleep duration; in adults, slow and fast sleep occupy 25% of the total sleep period.

Bessotitsa is one of the most common complaints among somatic and mentally ill people. Insomnia is associated not so much with a decrease in sleep duration, but with a deterioration in its quality and a feeling of dissatisfaction.

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

The variety of causes of insomnia requires a careful differential diagnosis. In many cases, it is necessary to prescribe individually selected sleeping pills(see section 15.1.8), however, it should be borne in mind that psychotherapy is often a more effective and safe method of treatment in this case. For example, behavioral psychotherapy involves adherence to a strict regime (always waking up at the same time, getting ready for bed, regular use of non-specific remedies - a warm bath, a glass of warm milk, a spoon of honey, etc.). The natural decline in sleep needs associated with age is quite distressing for many older people. They need to be explained that taking sleeping pills in this case is pointless. Patients should be advised not to go to bed before drowsiness occurs, and not to lie in bed for a long time, trying to fall asleep by force of will. It is better to get up, occupy yourself with quiet reading or complete small household chores and go to bed later when the need arises.

Hypersomnia may accompany insomnia. Thus, patients who do not get enough sleep at night are characterized by daytime drowsiness. When hypersomnia occurs, it is necessary to carry out differential diagnosis with organic brain diseases (meningitis, tumors, endocrine pathology), narcolepsy and Klein-Levin syndrome.

Narcolepsy is a relatively rare pathology that is hereditary in nature and is not associated with either epilepsy or psychogenic disorders. Characterized by frequent and rapid onset of the REM sleep phase (within 10 minutes after falling asleep), which is clinically manifested by attacks of a sharp drop in muscle tone (cataplexy), vivid hypnagogic hallucinations, episodes of blackouts with automatic behavior or states of “waking paralysis” in the morning after waking up. The disease appears before the age of 30 and progresses little thereafter. In some patients, cure was achieved by forced sleep during the day, always at the same hour, in other cases, stimulants and antidepressants were used.

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

Pain

Unpleasant sensations in the body are a frequent manifestation of mental disorders, but they do not always take on the character of pain itself. Extremely unpleasant, fanciful, subjectively colored sensations - senestopathy - should be distinguished from painful sensations (see section 4.1). Psychogenically caused pain can occur in the head, heart, joints, and back. The point of view is expressed that with psychogenies, the most disturbing thing is that part of the body that, in the opinion of the patient, is the most important, vital, container of the personality.

Heart pain is a common symptom of depression. They are often expressed by a heavy feeling of tightness in the chest, a “stone on the heart.” Such pains are very persistent, intensify in the morning, and are accompanied by a feeling of hopelessness. Unpleasant sensations in the heart area often accompany anxiety episodes (panic attacks) in those suffering from neuroses. These acute pains are always accompanied by severe anxiety and fear of death. Unlike acute heart attack they are well controlled by sedatives and validol, but are not relieved by taking nitroglycerin.

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

Psychogenic headache is sometimes a consequence of muscle tension in the aponeurotic helmet and neck (with severe anxiety), general condition depression (with subdepression) or self-hypnosis (with hysteria). Anxious, suspicious, pedantic individuals often complain of bilateral pulling and pressing pain in the back of the head and crown of the head radiating to the shoulders, intensifying in the evening, especially after a traumatic situation. The scalp often also becomes painful (“it hurts to comb your hair”). In this case, drugs that reduce muscle tone (benzodiazepine tranquilizers, massage, warming procedures) help. Calm, relaxing holiday (watching TV shows) or pleasant physical exercise distract patients and reduce suffering. Headaches are often observed with mild depression and, as a rule, disappear as the condition worsens. Such pains increase in the morning in parallel with a general increase in melancholy. With hysteria, pain can take the most unexpected forms: “drilling and squeezing,” “the head is pulled together with a hoop,” “the skull is split in half,” “pierces the temples.”

Organic causes of headaches are vascular diseases brain, increase intracranial pressure, facial neuralgia, cervical osteochondrosis. In vascular diseases, painful sensations, as a rule, have a pulsating nature, depend on an increase or decrease in blood pressure, are relieved by clamping of the carotid arteries, and intensify when administered vasodilators(histamine, nitroglycerin). Seizures of vascular origin may result from hypertensive crisis, alcohol withdrawal syndrome, increased body temperature. Headache is an important symptom for diagnosing large-scale processes in the brain. It is associated with increased intracranial pressure, increases in the morning, intensifies with head movements, and is accompanied by vomiting without preceding nausea. An increase in intracranial pressure is accompanied by symptoms such as bradycardia, a decrease in the level of consciousness (stunning, obstruction) and a characteristic picture in the fundus (congestive discs optic nerves). Neuralgic pain is more often localized in the face, which almost never occurs with psychogenia.

Migraine attacks have a very characteristic clinical picture. These are periodic episodes of extremely severe headaches that last several hours, usually affecting half of the head. The attack may be preceded by an aura in the form of distinct mental disorders (lethargy or agitation, hearing loss or auditory hallucinations, scotomas or visual hallucinations, aphasia, dizziness or a feeling of unpleasant odor). Vomiting is often observed shortly before the attack resolves.

In schizophrenia, true headaches occur very rarely. Much more often, extremely fanciful senestopathic sensations are observed: “the brain is melting,” “the gyri are shrinking,” “the bones of the skull are breathing.”

Sexual dysfunctions

Concept sexual dysfunction is not entirely certain, since research shows that the expression of normal sexuality varies greatly. The most important criterion for diagnosis is the subjective feeling of dissatisfaction, depression, anxiety, and guilt that an individual experiences in connection with sexual intercourse. Sometimes this feeling occurs during completely physiological sexual relationships.

The following types of disorders are distinguished: decreased and extremely increased sexual desire, insufficient sexual arousal (impotence in men, frigidity in women), orgasm disorders (anorgasmia, premature or delayed ejaculation), painful sensations during sexual intercourse (dyspareunia, vaginismus, postcoital headaches) and some others.

Experience shows that quite often the cause of sexual dysfunction is psychological factors - personal predisposition to anxiety and restlessness, forced long breaks in sexual relationships, lack of a permanent partner, a feeling of one’s own unattractiveness, unconscious hostility, a significant difference in the expected stereotypes of sexual behavior in a couple, a judgmental upbringing sexual relationships, etc. Often disorders are associated with fear of starting sexual activity or, conversely, after 40 years - with approaching involution and fear of losing sexual attractiveness.

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

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

Hypochondria concept

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

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

Overvalued hypochondria manifests itself as inadequate attention to minor discomfort or slight physical defect. Patients make incredible efforts to achieve the desired state, develop their own diets and unique systems training. They defend their rightness and seek to punish doctors who, from their point of view, are to blame for the disease. This behavior is a manifestation of paranoid psychopathy or indicates the onset of a mental illness (schizophrenia).

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

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

In schizophrenia, hypochondriacal thoughts are almost constantly accompanied by senestopathic sensations - senestopathic-hypochondriacal syndrome. Emotional and volitional impoverishment in these patients often forces them, due to a supposed illness, to refuse work, stop going out, and avoid communication.

Masked depression

In connection with the widespread use of antidepressant drugs, it has become obvious that among patients turning to therapists, a significant proportion are patients with endogenous depression, in whom hypothymia (sadness) is masked by the prevailing symptoms. clinical picture somatic and vegetative disorders. Sometimes other psychopathological phenomena of the non-depressive register - obsessions, alcoholism - act as a manifestation of depression. Unlike classical depression, this type of depression is designated as masked. (larded, somatized, latent).

Diagnosis of such conditions is difficult, since patients themselves may not notice or even deny the presence of melancholy. Complaints include pain (heart, headache, abdominal, pseudoradicular and joint pain), sleep disorders, chest tightness, blood pressure fluctuations, appetite disturbances (both decreased and increased), constipation, weight loss or gain. Although patients usually respond negatively to a direct question about the presence of melancholy and psychological experiences, careful questioning can reveal an inability to experience joy, a desire to withdraw from communication, a feeling of hopelessness, and dejection that ordinary household chores and favorite work have become a burden to the patient. It is quite common for symptoms to worsen in the morning. Characteristic somatic “stigmas” are often noted - dry mouth, dilated pupils. An important sign of masked depression is the gap between the abundance of painful sensations and the paucity of objective data.

It is important to take into account the characteristic dynamics of endogenous depressive attacks, the tendency to protracted course and unexpected causeless resolution. It is interesting that the addition of infection with high temperature body (flu, tonsillitis) may be accompanied by a mitigation of feelings of melancholy or even interrupt an attack of depression. The history of such patients often reveals periods of causeless “blueness”, accompanied by excessive smoking, alcoholism and passing without treatment.

At differential diagnosis The data of an objective examination should not be neglected, since the simultaneous existence of both somatic and mental disorders is possible (in particular, depression can be an early manifestation of malignant tumors).

Hysterical conversion disorders

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

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

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

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

Occasionally, conversion symptoms cause patients to repeatedly turn to surgeons with a request to carry out serious surgical interventions and traumatic diagnostic procedures. This disorder is known as Munchausen syndrome. The aimlessness of such fiction, the painfulness of numerous procedures undergone, and the obvious maladaptive nature of behavior distinguish this disorder from simulation.

Asthenic syndrome

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

Somatovegetative disorders in asthenic syndrome are nonspecific. These may be complaints of pain (headaches, in the heart area, in the joints or stomach). Often noted increased sweating, feeling of “hot flashes”, dizziness, nausea, severe muscle weakness. Fluctuations in blood pressure (rises, falls, fainting) and tachycardia are usually observed.

An almost constant manifestation of asthenia is sleep disturbance. During the daytime, patients tend to feel drowsy and tend to retire and relax. However, at night they often cannot fall asleep because they are disturbed by any extraneous sounds, the bright light of the moon, folds in the bed, bed springs, etc. In the middle of the night, completely exhausted, they finally fall asleep, but they sleep very lightly and are tormented by “nightmares.” Therefore, in the morning hours, patients feel that they have not rested at all, they want to sleep.

Asthenic syndrome is the simplest disorder in a number of psychopathological syndromes (see section 3.5 and table 3.1), therefore signs of asthenia may be included in some more complex syndrome (depressive, psychoorganic). You should always make an attempt to determine whether there is some more severe disorder, so as not to make a mistake in the diagnosis. In particular, with depression, vital signs of melancholy are clearly visible (weight loss, tightness in the chest, daily mood swings, sharp suppression of desires, dry skin, lack of tears, ideas of self-blame), with psychoorganic syndrome intellectual-mnestic decline and personality changes are noticeable (thoroughness, weakness, dysphoria, hypomnesia, etc.). Unlike hysterical somatoform disorders, patients with asthenia do not need society and sympathy; they seek privacy, become irritated and cry when they are disturbed once again.

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

BIBLIOGRAPHY

• Bokonjic R. Headache: Trans. with Serbohorvian - M.: Medicine, 1984. - 312 p.
• Vein A.M., Hecht K. Human sleep: Physiology and pathology. - M.: Medicine, 1989.