Borderline forms of psychotic disorders, or borderline states, usually include various neurotic disorders. This concept is not generally accepted, but is still used by many healthcare professionals. As a rule, it is used to combine milder disorders and separate them from psychotic disorders. Moreover, borderline states are generally not the initial, intermediate, or buffer phases or stages of the main psychoses, but represent a special group of pathological manifestations that, in clinical terms, have their onset, dynamics and outcome, depending on the form or type of the disease process.
Characteristic disorders for borderline states:
- predominance of neurotic level psychopathological manifestations throughout the course of the disease;
- the leading role of psychogenic factors in the occurrence and decompensation of painful disorders;
- the relationship between mental disorders themselves and autonomic dysfunctions, night sleep disorders and somatic diseases;
- the relationship of painful disorders with the personality and typological characteristics of the patient;
- the presence in most cases of an “organic predisposition” for the development and decompensation of painful disorders;
- maintaining a critical attitude by patients towards their condition and the main pathological manifestations.
- Along with this, in borderline states there may be a complete absence of psychotic symptoms, progressively increasing dementia and personality changes characteristic of endogenous mental illness, for example, and .
Borderline mental disorders can arise acutely or develop gradually; their course can be of different nature and limited to a short-term reaction, a relatively long-term condition or a chronic course. Taking this into account, as well as based on an analysis of the causes of occurrence in clinical practice There are various forms and variants of borderline disorders. At the same time, different principles and approaches are used (nosological, syndromic, symptomatic assessment), and they also analyze the course of the borderline state, its severity, stabilization, and the dynamic relationship of various clinical manifestations.
Clinical diagnosis
Due to the non-specificity of many symptoms that fill the syndromic and nosological structures of borderline states, the external, formal differences between asthenic, vegetative, dyssomnic and depressive disorders are insignificant. Considered separately, they do not provide grounds either for differentiating mental disorders in the physiological reactions of healthy people who find themselves in stressful conditions, or for a comprehensive assessment of the patient’s condition and determining the prognosis. The key to diagnosis is the dynamic assessment of a particular painful manifestation, detection of the causes of occurrence and analysis of the relationship with individual typological psychological characteristics, as well as other psychopathological disorders.
In real medical practice, it is often not easy to answer the most important question for differential diagnostic assessment: when did this or that disorder begin; Is it a strengthening, sharpening of personal characteristics or is it fundamentally new in the individual uniqueness of a person’s mental activity? The answer to this seemingly trivial question requires, in turn, the solution of a number of problems. In particular, it is necessary to assess the typological and characterological characteristics of a person in the pre-morbid period. This allows us to see the individual norm in the neurotic complaints presented or qualitatively new, actually painful disorders not related to premorbid characteristics.
Paying great attention In a pre-morbid assessment of the condition of a person who has come to see a doctor in connection with his neurotic manifestations, it is necessary to take into account the characteristics of his character, which undergo dynamic changes under the influence of age-related, psychogenic, somatogenic and many social factors. Analysis of premorbid characteristics makes it possible to create a unique psychophysiological portrait of the patient, the starting point that is necessary for a differential assessment of the disease state.
Assessing current symptoms
What matters is not the individual symptom or syndrome itself, but its assessment in conjunction with other psychopathological manifestations, their visible and hidden causes, the rate of increase and stabilization of general neurotic and more specific psychopathological disorders neurotic level (senestopathy, obsession, hypochondria). In the development of these disorders, both psychogenic and physiogenic factors, most often their varied combination, are important. The causes of neurotic disorders are not always visible to others; they can lie in a person’s personal experiences, caused primarily by the discrepancy between the ideological and psychological attitude and physical capabilities of reality. This discrepancy can be viewed as follows:
- from the point of view of lack of interest (including moral and economic) in a particular activity, in a lack of understanding of its goals and prospects;
- from the position of irrational organization of purposeful activity, accompanied by frequent distractions from it;
- from the point of view of physical and psychological unpreparedness to perform the activity.
What does borderline disorder include?
Taking into account the diversity of various etiopathogenetic factors, borderline forms of mental disorders include neurotic reactions, reactive states (but not psychoses), neuroses, character accentuations, pathological personality development, psychopathy, as well as a wide range of neurosis-like and psychopath-like manifestations in somatic, neurological and other diseases. In ICD-10, these disorders are generally considered as various variants of neurotic, stress-related and somatoform disorders, behavioral syndromes caused by physiological disorders and physical factors, and disorders of mature personality and behavior in adults.
Borderline states usually do not include endogenous mental illnesses (including sluggish schizophrenia), at certain stages of development of which neurosis- and psychopath-like disorders, which largely imitate the main forms and variants of borderline states themselves, predominate and even determine the clinical course.
What to consider when diagnosing:
- the onset of the disease (when neurosis or a neurosis-like state arose), the presence or absence of its connection with psychogeny or somatogeny;
- stability of psychopathological manifestations, their relationship with the personality-typological characteristics of the patient (are they further development the latter or are not associated with pre-painful accentuations);
- interdependence and dynamics of neurotic disorders in conditions of persistence of traumatic and significant somatogenic factors or a subjective decrease in their relevance.
What are mental disorders and how are they expressed?
The term "mental disorder" refers to a huge number of different illness conditions.
Psychotic disorders are a very common type of pathology. Statistical data in different regions differ from each other, which is associated with different approaches and capabilities for identifying and accounting for these sometimes difficult to diagnose conditions. On average, the frequency of endogenous psychoses is 3-5% of the population.Accurate information about the prevalence of exogenous psychoses among the population (Greek exo - outside, genesis - origin.
There is no option for the development of a mental disorder due to the influence of external causes located outside the body, and this is explained by the fact that most of these conditions occur in patients drug addiction and alcoholism.
Psychotic disorders can occur in a number of mental illnesses: Alzheimer's disease, senile dementia, chronic alcoholism, drug addiction, epilepsy, mental retardation, etc.
A person can suffer a transient psychotic state caused by taking certain medications, drugs, or the so-called psychogenic or “reactive” psychosis that occurs as a result of exposure to severe mental trauma (stressful situation with a danger to life, loss of a loved one, etc.). Often there are so-called infectious diseases (developing as a result of severe infectious disease), somatogenic (caused by severe somatic pathology, such as myocardial infarction) and intoxication psychoses. The most striking example of the latter is delirium tremens - delirium tremens.
There is another important feature that divides mental disorders into two distinctly different classes:
psychoses and non-psychotic disorders.
Non-psychotic disorders are manifested mainly by psychological phenomena characteristic and healthy people. We are talking about mood changes, fears, anxiety, sleep disturbances, obsessive thoughts and doubts, etc.
Non-psychotic disorders are much more common than psychosis.
As mentioned above, every third person suffers the mildest of them at least once in his life.
Psychoses are much less common.
The most severe of them are most often found within the framework of schizophrenia, an illness that constitutes the central problem of modern psychiatry. The prevalence of schizophrenia is 1% of the population, that is, it affects approximately one person in every hundred.
The difference is that in healthy people all these phenomena occur in a clear and adequate connection with the situation, while in patients they occur without such connection. In addition, the duration and intensity of painful phenomena of this kind cannot be compared with similar phenomena that occur in healthy people.
Psychoses characterized by the emergence of psychological phenomena that never occur normally.
The most important of them are delusions and hallucinations.
These disorders can radically change the patient’s understanding of the world around him and even of himself.
Psychosis is also associated with severe behavioral disorders.
WHAT ARE PSYCHOSES?
About what psychosis is.
Let's imagine that our psyche is a mirror whose task is to reflect reality as accurately as possible. We judge reality precisely with the help of this reflection, because we have no other way. We ourselves are also part of reality, so our “mirror” must correctly reflect not only the world around us, but also ourselves in this world. If the mirror is intact, smooth, well polished and clean, the world is reflected in it correctly (let’s not quibble with the fact that none of us perceives reality absolutely adequately - this is a completely different problem).
But what happens if the mirror gets dirty, or warped, or breaks into pieces? The reflection in it will more or less suffer. This “more or less” is very important. The essence of any mental disorder is that the patient perceives reality not quite as it really is. The degree of distortion of reality in the patient’s perception determines whether he has psychosis or a milder painful state.
Unfortunately, there is no generally accepted definition of the concept of “psychosis.” It is always emphasized that the main sign of psychosis is a serious distortion of reality, a gross deformation of the perception of the surrounding world. The picture of the world that appears to the patient can be so different from reality that they talk about the “new reality” that psychosis creates. Even if the structure of psychosis does not contain disorders directly related to disturbances in thinking and purposeful behavior, the patient’s statements and actions are perceived by others as strange and absurd; after all, he lives in a “new reality”, which may have nothing to do with the objective situation.
The distortion of reality is caused by phenomena that are never found normally in any form (even in a hint). The most characteristic of them are delusions and hallucinations; they are involved in the structure of most syndromes that are commonly called psychoses.
Simultaneously with their occurrence, the ability to critically assess one’s condition is lost,” in other words, the patient cannot admit the idea that everything that is happening only seems to him.
A “gross deformation of the perception of the surrounding world” arises because the “mirror” with which we judge it begins to reflect phenomena that are not there.
So, psychosis is a painful condition that is determined by the occurrence of symptoms that never occur normally, most often delusions and hallucinations. They lead to the fact that reality as perceived by the patient is very different from the objective state of affairs. Psychosis is accompanied by behavioral disorder, sometimes very severe. It may depend on how the patient imagines the situation in which he is (for example, he may be fleeing from an imaginary threat), and on the loss of the ability to perform purposeful activities.
Excerpt from a book.
Rotshtein V.G. "Psychiatry is a science or an art?"
Psychoses (psychotic disorders) are understood as the most striking manifestations of mental illnesses, in which the patient’s mental activity does not correspond to the surrounding reality, the reflection of the real world in the mind is sharply distorted, which manifests itself in behavioral disorders, the appearance of unusual pathological symptoms and syndromes.
Manifestations of mental illness are disorders of the psyche and behavior of a person. Based on the severity of the pathological process, more pronounced forms of mental illness are distinguished - psychoses and milder ones - neuroses, psychopathic states, and some forms of affective pathology.
COURSE AND PROGNOSIS OF PSYCHOSES.
The most common type (especially with endogenous diseases) is the periodic type of psychosis with occasional episodes of psychosis. acute attacks illnesses, both provoked by physical and psychological factors, and spontaneous. It should be noted that there is also a single-attack course, observed more often in adolescence.
Patients, having suffered one, sometimes protracted attack, gradually recover from the painful state, restore their ability to work and never come to the attention of a psychiatrist.
In some cases, psychoses can become chronic and develop into continuous flow without disappearance of symptoms throughout life.
In uncomplicated and unadvanced cases, inpatient treatment usually lasts one and a half to two months. This is exactly the period doctors need to fully cope with the symptoms of psychosis and select the optimal supportive therapy. In cases where the symptoms of the disease turn out to be resistant to drugs, several courses of therapy are required, which can delay the hospital stay for up to six months or more.
The main thing that the patient’s family needs to remember is - DO NOT HURRY DOCTORS, do not insist on an urgent discharge “on receipt”! To completely stabilize the condition, it is necessary certain time and by insisting on early discharge, you risk getting an undertreated patient, which is dangerous for both him and you.
One of the most important factors influencing the prognosis of psychotic disorders is the timeliness of initiation and intensity of active therapy in combination with social and rehabilitation measures.
Maksutova E.L., Zheleznova E.V.
Research Institute of Psychiatry, Ministry of Health of the Russian Federation, Moscow
Epilepsy is one of the most common neuropsychiatric diseases: its prevalence in the population is in the range of 0.8–1.2%.
It is known that mental disorders are an essential component of the clinical picture of epilepsy, complicating its course. According to A. Trimble (1983), A. Moller, W. Mombouer (1992), there is a close relationship between the severity of the disease and mental disorders, which occur much more often with an unfavorable course of epilepsy.
In the last few years, as statistical studies show, in the structure of mental morbidity there has been an increase in forms of epilepsy with non-psychotic disorders. At the same time, the proportion of epileptic psychoses is decreasing, which reflects the obvious pathomorphism of the clinical manifestations of the disease, caused by the influence of a number of biological and social factors.
One of the leading places in the clinic of non-psychotic forms of epilepsy is occupied by affective disorders, which often tend to become chronic. This confirms the position that despite the achieved remission of seizures, impairments are an obstacle to the full restoration of patients’ health. emotional sphere(Maksutova E.L., Fresher V., 1998).
When clinically qualifying certain syndromes of the affective register, it is fundamental to assess their place in the structure of the disease, the characteristics of the dynamics, as well as the relationship with the range of paroxysmal syndromes themselves. In this regard, we can conditionally distinguish two mechanisms of syndrome formation of a group of affective disorders - primary, where these symptoms act as components of paroxysmal disorders themselves, and secondary - without a cause-and-effect relationship with the attack, but based on various manifestations of reactions to the disease, as well as to additional psychotraumatic influences.
Thus, according to studies of patients in a specialized hospital at the Moscow Research Institute of Psychiatry, it has been established that phenomenologically non-psychotic mental disorders are represented by three types of conditions:
1) depressive disorder in the form of depression and subdepression;
2) obsessive-phobic disorders;
3) others affective disorders.
Depressive spectrum disorders include the following:
1. Melancholy depression and subdepression were observed in 47.8% of patients. The predominant feeling in the clinic here was an anxious and melancholy affect with a persistent decrease in mood, often accompanied by irritability. Patients noted mental discomfort and heaviness in the chest. In some patients, there was a connection between these sensations and physical illness (headache, unpleasant sensations in the chest) and were accompanied by motor restlessness, less often they were combined with adynamia.
2. Adynamic depression and subdepression were observed in 30% of patients. These patients were distinguished by the course of depression against the background of adynamia and hypobulia. They spent most of the time in bed, had difficulty performing simple self-care functions, and were characterized by complaints about fatigue and irritability.
3. Hypochondriacal depression and subdepression were observed in 13% of patients and were accompanied by a constant feeling of physical damage and heart disease. In the clinical picture of the disease, the leading place was occupied by hypochondriacal phobias with fears that during an attack a sudden death or they will not receive help on time. Rarely did the interpretation of phobias go beyond the specified plot. Senestopathies were characterized by hypochondriacal fixation, the peculiarity of which was the frequency of their intracranial localization, as well as various vestibular inclusions (dizziness, ataxia). Less commonly, the basis of senestopathies was vegetative disorders.
The variant of hypochondriacal depression was more typical for the interictal period, especially in conditions of chronicity of these disorders. However, their transient forms were often noted in the early postictal period.
4. Anxiety depression and subdepression occurred in 8.7% of patients. Anxiety, as a component of an attack (less commonly, an interictal state), was distinguished by an amorphous plot. Patients more often could not determine the motives for anxiety or the presence of any specific fears and reported that they experienced vague fear or anxiety, the cause of which was unclear to them. A short-term anxious affect (several minutes, less often within 1–2 hours), as a rule, is characteristic of a variant of phobias as a component of a seizure (within the aura, the attack itself or the post-seizure state).
5. Depression with depersonalization disorders was observed in 0.5% of patients. In this variant, the dominant sensations were changes in the perception of one’s own body, often with a feeling of alienation. The perception of the environment and time also changed. Thus, patients, along with a feeling of adynamia and hypothymia, noted periods when the environment “changed”, time “accelerated”, it seemed that the head, arms, etc. were enlarged. These experiences, in contrast to true paroxysms of depersonalization, were characterized by the preservation of consciousness with full orientation and were fragmentary in nature.
Psychopathological syndromes with a predominance of anxious affect comprised predominantly the second group of patients with “obsessive-phobic disorders.” Analysis of the structure of these disorders showed that their close connections can be traced with almost all components of a seizure, starting with precursors, aura, the attack itself and the post-seizure state, where anxiety acts as a component of these states. Anxiety in the form of a paroxysm, preceding or accompanying an attack, was manifested by a sudden fear, often of uncertain content, which patients described as an “impending threat”, increasing anxiety, giving rise to a desire to urgently do something or seek help from others. Individual patients often indicated fear of death from an attack, fear of paralysis, insanity, etc. In several cases, there were symptoms of cardiophobia, agoraphobia, and less frequently, social phobic experiences were noted (fear of falling in the presence of employees at work, etc.). Often in the interictal period, these symptoms were intertwined with disorders of the hysterical circle. There was a close connection between obsessive-phobic disorders and the vegetative component, reaching particular severity in viscero-vegetative seizures. Among other obsessive-phobic disorders, obsessive states, actions, and thoughts were observed.
Unlike paroxysmal anxiety, anxious affect in remissions approaches in form the classical variants in the form of unmotivated fears for one’s health, the health of loved ones, etc. A number of patients have a tendency to develop obsessive-phobic disorders with obsessive concerns, fears, behaviors, actions, etc. In some cases, there are protective mechanisms of behavior with unique measures to counteract the disease, such as rituals, etc. In terms of therapy, the most unfavorable option is a complex symptom complex, including obsessive-phobic disorders, as well as depressive disorders.
The third type of borderline forms of mental disorders in the epilepsy clinic were affective disorders, which we designated as “other affective disorders.”
Being phenomenologically close, there were incomplete or abortive manifestations of affective disorders in the form of affective fluctuations, dysphoria, etc.
Among this group of borderline disorders, occurring both in the form of paroxysms and prolonged states, epileptic dysphoria was more often observed. Dysphoria, occurring in the form of short episodes, more often took place in the structure of the aura, preceding an epileptic attack or a series of seizures, but they were most widely represented in the interictal period. According to clinical features and severity, astheno-hypochondriacal manifestations, irritability, and anger affect prevailed in their structure. Protest reactions often formed. Aggressive actions were observed in a number of patients.
The emotional lability syndrome was characterized by a significant amplitude of affective fluctuations (from euphoria to anger), but without noticeable behavioral disturbances characteristic of dysphoria.
Among other forms of affective disorders, mainly in the form of short episodes, there were reactions of weakness, manifested in the form of incontinence of affect. Usually they acted outside the framework of a formalized depressive or anxiety disorder, representing an independent phenomenon.
In relation to the individual phases of an attack, the frequency of borderline mental disorders associated with it is presented as follows: in the aura structure - 3.5%, in the attack structure - 22.8%, in the post-ictal period - 29.8%, in the interictal period - 43.9 %.
Within the framework of the so-called precursors of attacks, various functional disorders are well known, mainly of a vegetative nature (nausea, yawning, chills, drooling, fatigue, loss of appetite), against the background of which anxiety, decreased mood or its fluctuations with a predominance of irritable-sullen affect occur. A number of observations during this period noted emotional lability with explosiveness and a tendency to conflict reactions. These symptoms are extremely labile, short-lived and can be self-limiting.
An aura with affective feelings is a common component of subsequent paroxysmal disorder. Among them, the most common is sudden anxiety with increasing tension and a feeling of “lightheadedness.” Less common are pleasant sensations (increased vitality, a feeling of particular lightness and elation), which are then replaced by anxious anticipation of an attack. Within the framework of an illusory (hallucinatory) aura, depending on its plot, either an affect of fear and anxiety may occur, or a neutral (less often excited-elated) mood may be noted.
In the structure of the paroxysm itself, affective syndromes most often occur within the framework of the so-called temporal lobe epilepsy.
As is known, motivational and emotional disorders are one of the leading symptoms of damage to the temporal structures, mainly the mediobasal formations, which are part of the limbic system. At the same time, affective disorders are most widely represented in the presence of a temporal focus in one or both temporal lobes.
When the focus is localized in the right temporal lobe, depressive disorders are more common and have a more defined clinical picture. As a rule, the right-sided localization of the process is characterized by a predominantly anxious type of depression with various plots of phobias and episodes of agitation. This clinic fits completely into the distinguished “right hemisphere affective disorder” in the taxonomy of organic syndromes ICD-10.
Paroxysmal affective disorders (within an attack) include attacks of fear, unaccountable anxiety, and sometimes with a feeling of melancholy that suddenly appear and last for several seconds (less often than minutes). There may be impulsive short-term states of increased sexual (food) desire, a feeling of increased strength, and joyful anticipation. When combined with depersonalization-derealization inclusions, affective experiences can acquire both positive and negative tones. It is necessary to emphasize the predominantly violent nature of these experiences, although individual cases of their arbitrary correction using conditioned reflex techniques indicate a more complex pathogenesis.
“Affective” seizures occur either in isolation or are part of the structure of other seizures, including convulsive ones. Most often they are included in the structure of the aura of a psychomotor seizure, less often - vegetative-visceral paroxysms.
The group of paroxysmal affective disorders within temporal lobe epilepsy includes dysphoric states, the duration of which can range from several hours to several days. In some cases, dysphoria in the form of short episodes precedes the development of the next epileptic seizure or series of attacks.
The second place in the frequency of affective disorders is occupied by clinical forms with dominant vegetative paroxysms within the framework of diencephalic epilepsy. Analogues of the common designation of paroxysmal (crisis) disorders as “vegetative attacks” are concepts such as “diencephalic” attack, “diencephalic” attack, which are widely used in neurological and psychiatric practice. panic attacks"and other conditions with great vegetative accompaniment.
Classic manifestations of crisis disorders include sudden development: shortness of breath, a feeling of lack of air, discomfort from the organs of the chest cavity and abdomen with “heart sinking,” “interruptions,” “pulsation,” etc. These phenomena are usually accompanied by dizziness, chills, and tremor , various paresthesias. Possible increased frequency of bowel movements and urination. Most strong manifestations– anxiety, fear of death, fear of going crazy.
Affective symptoms in the form of individual unstable fears can be transformed into both affective paroxysm itself and permanent variants with fluctuations in the severity of these disorders. In more severe cases, a transition to a persistent dysphoric state with aggression (less often, auto-aggressive actions) is possible.
In epileptological practice, vegetative crises occur mainly in combination with other types (convulsive or non-convulsive) paroxysms, causing polymorphism in the clinical picture of the disease.
Regarding the clinical characteristics of the so-called secondary reactive disorders, it should be noted that we include a variety of psychologically understandable reactions to the disease that occur with epilepsy. At the same time, side effects as a response to therapy, as well as a number of professional restrictions and other social consequences of the disease, include both transient and prolonged conditions. They more often manifest themselves in the form of phobic, obsessive-phobic and other symptoms, in the formation of which a large role belongs to the individual personality characteristics of the patient and additional psychogenies. At the same time, the clinic of protracted forms in a broad sense of situational (reactive) symptoms is largely determined by the nature of cerebral (deficient) changes, which gives them a number of features associated with organic soil. The clinical picture of emerging secondary reactive disorders is also reflected in the degree of personal (epithymic) changes.
As part of reactive inclusions, patients with epilepsy often have concerns:
development of a seizure on the street, at work
be injured or die during a seizure
go crazy
transmission of disease by inheritance
side effects of anticonvulsants
forced withdrawal of drugs or untimely completion of treatment without guarantees for relapse of attacks.
The reaction to a seizure at work is usually much more severe than when it occurs at home. Due to the fear that a seizure will occur, some patients stop studying, working, and do not go out.
It should be pointed out that, according to induction mechanisms, fear of a seizure may also appear in relatives of patients, which requires a large participation of family psychotherapeutic assistance.
Fear of a seizure is more often observed in patients with rare paroxysms. Patients with frequent attacks during a long illness become so accustomed to them that, as a rule, they hardly experience such fear. Thus, in patients with frequent seizures and a longer duration of the disease, signs of anosognosia and uncritical behavior are usually observed.
Fear of bodily harm or fear of death during a seizure is more easily formed in patients with psychasthenic personality traits. It also matters that they have previously had accidents and bruises due to seizures. Some patients fear not so much the attack itself as the possibility of bodily harm.
Sometimes the fear of a seizure is largely due to the unpleasant subjective sensations that appear during an attack. These experiences include frightening illusory, hallucinatory inclusions, as well as body schema disorders.
This distinction between affective disorders is of fundamental importance in determining further therapy.
Principles of therapy
The main direction of therapeutic tactics in relation to individual affective components of the attack itself and post-ictal emotional disorders closely associated with it is the adequate use of anticonvulsants with a thymoleptic effect (cardimizepine, valproate, lamotrigine).
Not being anticonvulsants, many tranquilizers have an anticonvulsant spectrum of action (diazepam, phenazepam, nitrazepam). Their inclusion in the therapeutic regimen has a positive effect on both the paroxysms themselves and secondary affective disorders. However, it is advisable to limit the time of their use to three years due to the risk of addiction.
Recently, the anti-anxiety and sedative effect of clonazepam, which is highly effective in absence seizures, has been widely used.
In various forms affective disorders with depressive radicals, antidepressants are most effective. At the same time, in outpatient setting Preferred drugs with minimal side effects, such as tianeptil, miaxerin, fluoxetine.
If the obsessive-compulsive component predominates in the structure of depression, the prescription of paroxetine is justified.
It should be noted that a number of mental disorders in patients with epilepsy may be caused not so much by the disease itself as by long-term therapy with phenobarbital drugs. In particular, this can explain the slowness, rigidity, elements of mental and motor retardation. With the appearance in last years highly effective anticonvulsants, it became possible to avoid side effects therapy and classify epilepsy as a curable disease.
Psychotic disorders are a group of serious mental illnesses. They lead to impaired clarity of thinking, the ability to make correct judgments, react emotionally, communicate with people and adequately perceive reality. People with severe symptoms of the disease are often unable to cope with everyday tasks. Interestingly, such deviations are most often observed among residents of developed countries.
However, even severe types of diseases are amenable to drug treatment to one degree or another.
Definition
Psychotic-level disorders cover a range of illnesses and associated symptoms. Essentially, such disorders are some form of altered or distorted consciousness that persists for a significant period of time and interferes with the normal functioning of a person as a full member of society.
Psychotic episodes may occur as isolated events, but most often they are a sign of significant mental health problems.
Risk factors for the occurrence of psychotic disorders include heredity (especially for schizophrenia), frequent drug use (mainly hallucinogenic drugs). The onset of a psychotic episode can also be triggered by stressful situations.
Kinds
Psychotic disorders have not yet been fully considered; some points differ depending on the approach to their study, so certain disagreements may arise in classifications. This is especially true due to conflicting data on the nature of their occurrence. In addition, it is not always possible to clearly determine the cause of a particular symptom.
Nevertheless, the following main, most common types of psychotic disorders can be distinguished: schizophrenia, psychosis, bipolar disorder, polymorphic psychotic disorder.
Schizophrenia
The disorder is diagnosed when symptoms such as delusions or hallucinations persist for at least 6 months (with at least 2 symptoms occurring continuously for a month or more), with corresponding changes in behavior. Most often, the result is difficulty performing everyday tasks (for example, at work or while studying).
Diagnosis of schizophrenia is often complicated by the fact that similar symptoms can also occur with other disorders, and patients can often lie about the degree of their manifestation. For example, a person may not want to admit to hearing voices because paranoid delusions or fear of stigmatization and so on.
Also distinguished:
- Schizophreniform disorder. It includes but lasts a shorter period of time: from 1 to 6 months.
- Schizoaffective disorder. It is characterized by symptoms of both schizophrenia and diseases such as bipolar disorder.
Psychosis
Characterized by some distorted sense of reality.
A psychotic episode may include so-called positive symptoms: visual and auditory hallucinations, crazy ideas, paranoid reasoning, disoriented thinking. Negative symptoms include difficulties in constructing indirect speech, commenting and maintaining a coherent dialogue.
Bipolar disorder
Characterized by sudden mood swings. The condition of people with this disease usually changes sharply from maximum excitement (mania and hypomania) to minimum (depression).
Any episode of bipolar disorder may be characterized as an “acute psychotic disorder,” but not vice versa.
Some psychotic symptoms may only subside during the onset of mania or depression. For example, during a manic episode a person may experience grandiose feelings and believe that they have incredible abilities(for example, the ability to always win any lottery).
Polymorphic psychotic disorder
It can often be mistaken for a manifestation of psychosis. Since it develops like psychosis, with everyone associated symptoms, but also not schizophrenia in its original definition. Refers to the type of acute and transient psychotic disorders. Symptoms appear unexpectedly and constantly change (for example, a person sees new hallucinations each time, completely different from each other), general clinical picture The disease usually develops quite quickly. This episode usually lasts from 3 to 4 months.
There are polymorphic psychotic disorder with and without symptoms of schizophrenia. In the first case, the disease is characterized by the presence of signs of schizophrenia, such as prolonged persistent hallucinations and a corresponding change in behavior. In the second case, they are unstable, the visions often have an unclear direction, and the person’s mood constantly and unpredictably changes.
Symptoms
And with schizophrenia, and with psychosis and all other similar types of diseases, a person always has the following symptoms characterizing a psychotic disorder. They are often called “positive”, but not in the sense that they are good and useful to others. In medicine, a similar name is used in the context of the expected manifestations of the disease or normal type behavior in its extreme form. TO positive symptoms include hallucinations, delusions, strange body movements or lack of movement (catatonic stupor), peculiar speech and strange or primitive behavior.
Hallucinations
They include sensations that do not have a corresponding objective reality. Hallucinations can appear in various forms that parallel the human senses.
- Visual hallucinations include deception and seeing objects that don't exist.
- The most common type of hearing is voices in the head. Sometimes these two types of hallucinations can be mixed, that is, a person not only hears voices, but also sees their owners.
- Olfactory. A person perceives non-existent odors.
- Somatic. The name comes from the Greek “soma” - body. Accordingly, these hallucinations are physical, for example, the feeling of the presence of something on or under the skin.
Mania
This symptom most often characterizes an acute psychotic disorder with symptoms of schizophrenia.
Manias are strong irrational and unrealistic beliefs of a person that are difficult to change, even in the presence of irrefutable evidence. Most people not associated with medicine believe that mania is only paranoia, persecution mania, excessive suspicion, when a person believes that everything around him is a conspiracy. However, this category also includes unfounded beliefs, manic love fantasies and jealousy bordering on aggression.
Megalomania is a common irrational belief that results in different ways the importance of a person is exaggerated. For example, the patient may consider himself a president or a king. Often delusions of grandeur take on religious overtones. A person may consider himself a messiah or, for example, sincerely assure others that he is the reincarnation of the Virgin Mary.
Misconceptions related to the characteristics and functioning of the body can also often arise. There have been cases where people refused to eat due to the belief that all the muscles in the throat were completely paralyzed and all they could swallow was water. However, there were no real reasons for this.
Other symptoms
Other signs tend to characterize short-term psychotic disorders. These include strange body movements, constant grimaces and facial expressions uncharacteristic for the person and situation or, as the opposite, catatonic stupor - lack of movement.
There are distortions of speech: incorrect sequence of words in a sentence, answers that make no sense or do not relate to the context of the conversation, mimicking the opponent.
Aspects of childishness are also often present: singing and jumping in inappropriate circumstances, moodiness, unconventional uses of ordinary objects, for example, creating a tin foil hat.
Of course, a person with psychotic disorders will not experience all symptoms at the same time. The basis for diagnosis is the presence of one or more symptoms over a long period of time.
Causes
The following are the main causes of psychotic disorders:
- Reaction to stress. From time to time, under severe prolonged stress, temporary psychotic reactions may occur. At the same time, the cause of stress can be both situations that many people face throughout life, for example, the death of a spouse or divorce, as well as more severe ones - a natural disaster, being in a place of war or in captivity. Usually the psychotic episode ends as the stress decreases, but sometimes the condition can drag on or become chronic.
- Postpartum psychosis. For some women, significant hormonal changes as a result of childbirth can cause. Unfortunately, these conditions are often misdiagnosed and mistreated, resulting in cases where the new mother kills her child or commits suicide.
- Protective reaction of the body. It is believed that people with personality disorders are more susceptible to stress and are less able to cope with adult life. In the end, when life circumstances become more severe, a psychotic episode may occur.
- Psychotic disorders based on cultural characteristics. Culture - important factor in definition mental health. In many cultures, what is usually considered a deviation from the generally accepted norm of mental health is part of traditions, beliefs, references to historical events. For example, in some regions of Japan there is a very strong, even manic, belief that the genitals can shrink and be pulled into the body, causing death.
If a behavior is acceptable in a given society or religion and occurs under appropriate conditions, then it cannot be diagnosed as an acute psychotic disorder. Treatment, accordingly, is not required under such conditions.
Diagnostics
In order for a doctor to diagnose a psychotic disorder general practice it is necessary to conduct a conversation with the patient, as well as check the general state of health in order to exclude other causes of such symptoms. Most often, blood and brain tests are performed (for example, using MRI) to rule out mechanical damage to the brain and drug addiction.
If no physiological reasons for such behavior are found, the patient is referred to a psychiatrist for further diagnosis and determination of whether this person have a psychotic disorder.
Treatment
The most common combination used to treat psychotic disorders drug treatment and psychotherapy.
As medicine specialists most often prescribe neuroleptics or atypical antipsychotics, which are effective in relieving such alarming symptoms as delusions, hallucinations and distorted perception of reality. These include: "Aripiprazole", "Azenapine", "Brexpiprazole", "Clozapine" and so on.
Some drugs come in the form of tablets that need to be taken daily, others come in the form of injections that only need to be given once or twice a month.
Psychotherapy includes different kinds counseling. Depending on the patient’s personality characteristics and how the psychotic disorder progresses, individual, group or family psychotherapy may be prescribed.
For the most part, people with psychotic disorders receive outpatient treatment, meaning they are not constantly in a medical facility. But sometimes, if there are severe symptoms, there is a threat of harm to oneself and loved ones, or if the patient is unable to take care of himself, hospitalization is performed.
Each patient being treated for a psychotic disorder may respond differently to therapy. For some, progress is noticeable from the first day, for others it will take months of treatment. Sometimes, if you have several severe episodes, you may need to take medication on an ongoing basis. Usually in such cases a minimum dose is prescribed to avoid side effects as much as possible.
Psychotic disorders cannot be prevented. But the sooner you seek help, the easier it will be to undergo treatment.
People with high risk occurrence of such disorders, for example, those who have schizophrenics among close relatives should avoid drinking alcohol and any drugs.
The most typical manifestations of non-psychotic (neurotic) disorders at various stages of development of the situation are acute reactions to stress, adaptive (adaptive) neurotic reactions, neuroses (anxiety, fear, depressive, hypochondriacal, neurasthenia).
Acute reactions to stress are characterized by quickly passing non-psychotic disorders of any nature that arise as a reaction to extreme physical activity or psychogenic situation during a natural disaster and usually disappear after a few hours or days. These reactions occur with a predominance of emotional disturbances (states of panic, fear, anxiety and depression) or psychomotor disorders(states of motor excitation or retardation).
Adaptive (adaptive) reactions are expressed in mild or transient non-psychotic disorders that last longer than acute reactions to stress. They are observed in people of any age without any obvious preexisting mental disorder.
The most frequently observed adaptive reactions under extreme conditions include:
· short-term depressive reaction (loss reaction);
· prolonged depressive reaction;
· reaction with a predominant disorder of other emotions (reaction of anxiety, fear, anxiety, etc.).
The main observable forms of neuroses include anxiety neurosis (fear), which is characterized by a combination of mental and somatic manifestations of anxiety that do not correspond to real danger and manifest themselves either in the form of attacks or in the form of a stable state. Anxiety is usually diffuse and can increase to a state of panic.
Panic(from rpe4.panikos- sudden, strong (about fear), letters, inspired by the god of forests Pan) - a person’s mental state - an unaccountable, uncontrollable fear caused by a real or imaginary danger, covering a person or many people; an uncontrollable desire to avoid a dangerous situation.
Panic is a state of horror accompanied by a sharp weakening of volitional self-control. A person becomes completely weak-willed, unable to control his behavior. The consequence is either stupor, or what E. Kretschmer called a “whirlwind of movement,” i.e. disorganization of planned actions. Behavior becomes anti-volitional: needs directly or indirectly related to physical self-preservation suppress needs related to personal self-esteem. At the same time, the person’s heart rate increases significantly, breathing becomes deep and frequent, as there is a feeling of lack of air, sweating increases, and the fear of death increases. It is known that 90% of people who escaped from a shipwreck die from hunger and thirst during the first three days, which cannot be explained by physiological reasons, because a person is capable of not eating or drinking for much longer. It turns out that they die not from hunger and thirst, but from panic (i.e., in fact, from the chosen role).
It is known about the Titanic disaster that the first ships approached the site of the disaster just three hours after the death of the ship. These ships found many dead and insane people in the lifeboats.
How to resist panic? How to get yourself out of the weak-willed state of a doll and turn into an active character? Firstly, It’s good to turn your state into any action, and to do this you can ask yourself the question: “What am I doing?” and answer it with any verb: “I’m sitting,” “I’m thinking,” “I’m losing weight,” etc. This way the role of a passive body is automatically reset and turns into active personality. Secondly, You can use any of the techniques that social psychologists have developed to calm a panicked crowd. For example, rhythmic music or singing works well to relieve panic. This technique has been around since the 1960s. Americans use it by equipping all their embassies in Third World countries with loud music speakers. If an aggressive crowd appears near the embassy, loud music is turned on and the crowd becomes controllable. Humor relieves panic well. As eyewitnesses of the events of 1991 (the State Emergency Committee coup) note, it was Gennady Khazanov’s humorous speech in front of the crowd that psychologically turned the tide of events of the unsuccessful coup.
And the most important tool that specialist psychologists use to prevent group panic is elbow locking. The feeling of closeness of comrades sharply increases psychological stability.
In emergency situations, other neurotic manifestations may develop, such as obsessive or hysterical symptoms:
1. hysterical neurosis, characterized by neurotic disorders in which disturbances of autonomic, sensory and motor functions predominate, selective amnesia; Significant changes in behavior may occur. This behavior may mimic psychosis or, rather, correspond to the patient's idea of psychosis;
2. neurotic phobias, for which it is typical neurotic state with a pathologically expressed fear of certain objects or specific situations;
3. depressive neurosis - it is characterized by depression of inadequate strength and content, which is a consequence of traumatic circumstances;
4. neurasthenia, expressed by autonomic, sensorimotor and affective dysfunctions and characterized by weakness, insomnia, increased fatigue, distractibility, low mood, constant dissatisfaction with oneself and others;
5. hypochondriacal neurosis - manifests itself mainly by excessive preoccupation with one’s own health, the functioning of an organ, or, less commonly, the state of one’s mental abilities. Usually painful experiences are combined with anxiety and depression.
Three periods of development of the situation can be distinguished in which various psychogenic disorders are observed.
First (acute) period characterized by a sudden threat to one’s own life and the death of loved ones. It lasts from the beginning of exposure to an extreme factor until the organization of rescue operations (minutes, hours). Powerful extreme exposure during this period mainly affects vital instincts (for example, self-preservation) and leads to the development of nonspecific, psychogenic reactions, the basis of which is fear of varying intensity. In some cases, panic may develop.
Immediately after acute exposure, when signs of danger appear, people become confused and do not understand what is happening. After this short period, with a simple fear reaction, a moderate increase in activity is observed: movements become clear, muscle strength increases, which facilitates movement in safe place. Speech disturbances are limited to acceleration of its tempo, hesitations, the voice becomes loud, ringing. There is a mobilization of will. Characteristic is a change in the sense of time, the flow of which slows down, so that the duration of the acute period in perception is increased several times. In complex fear reactions, more pronounced movement disorders in the form of anxiety or lethargy. The perception of space changes, the distance between objects, their size and shape are distorted. Kinesthetic illusions (the feeling of the earth swaying, flying, swimming, etc.) can also be long-lasting. Consciousness is narrowed, although in most cases accessibility to external influences, selectivity of behavior, and the ability to independently find a way out of a difficult situation remain.
In the second period, occurring during the deployment of rescue operations, begins, in a figurative expression, “normal life in extreme conditions.” At this time, in the formation of states of maladjustment and mental disorders, a much greater role is played by the personality characteristics of the victims, as well as their awareness of not only the ongoing situation in some cases, but also new stressful influences, such as the loss of relatives, separation of families, loss of home and property. Important elements of prolonged stress during this period are the expectation of repeated impacts, the discrepancy between expectations and the results of rescue operations, and the need to identify dead relatives. Psycho-emotional stress, characteristic of the beginning of the second period, is replaced by its end, as a rule, with increased fatigue and “demobilization” with asthenic and depressive symptoms
After the end of the acute period, some victims experience short-term relief, an uplift in mood, a desire to actively participate in rescue operations, verbosity, endless repetition of the story about their experiences, and discrediting the danger. This phase of euphoria lasts from a few minutes to several hours. As a rule, it gives way to lethargy, indifference, lethargy, and difficulty performing even simple tasks. In some cases, victims give the impression of being detached and self-absorbed. They sigh frequently and deeply, and their inner experiences are often associated with mystical and religious ideas. Another development option anxiety state V
this period can be characterized by the predominance of “anxiety with activity”: motor restlessness, fussiness, impatience, verbosity, desire for an abundance of contacts with others. Episodes psycho-emotional stress quickly give way to lethargy and apathy.
In the third period, beginning for victims after their evacuation to safe areas, many experience complex emotional and cognitive processing of the situation, reassessment of their own experiences and sensations, and awareness of losses. At the same time, psychogenically traumatic factors associated with a change in life pattern, living in a destroyed area or in a place of evacuation also become relevant. Becoming chronic, these factors contribute to the formation of relatively persistent psychogenic disorders.
Essentially, asthenic disorders are the basis on which various borderline neuropsychiatric disorders are formed. In some cases they become protracted and chronic. The victims experience vague anxiety, anxious tension, bad premonitions, and the expectation of some kind of misfortune. “Listening to danger signals” appears, which may be ground shaking from moving mechanisms, unexpected noise, or, conversely, silence. All this causes anxiety, accompanied by muscle tension, trembling in the arms and legs. This contributes to the formation of persistent and long-term phobic disorders. Along with phobias, as a rule, there is uncertainty, difficulty in making even simple decisions, and doubts about the fidelity and correctness of one’s own actions. Often there is a constant discussion of the experienced situation, close to obsession, memories of past life with its idealization.
Another type of manifestation of emotional stress is psychogenic depressive disorders. A peculiar awareness of “one’s guilt” before the dead appears, an aversion to life arises, and regret that he survived and did not die along with his relatives. The inability to cope with problems leads to passivity, disappointment, decreased self-esteem, and a feeling of inadequacy.
People who have experienced an extreme situation quite often experience decompensation of character accentuations and psychopathic personality traits. In this case, both the individually significant psychotraumatic situation and the previous life experience and personal attitudes of each person are of great importance.
Along with the noted neurotic and psychopathic reactions at all three stages of the development of the situation, the victims experience autonomic dysfunction and sleep disorders. The latter not only reflect the entire complex of neurotic disorders, but also significantly contribute to their stabilization and further aggravation. Most often, it is difficult to fall asleep; it is hampered by a feeling of emotional tension and anxiety. Night sleep is superficial, accompanied by nightmares, and usually short-lived. The most intense changes in the functional activity of the autonomic nervous system manifest themselves in the form of fluctuations in blood pressure, pulse lability, hyperhidrosis ( increased sweating), chills, headaches, vestibular disorders, gastrointestinal disorders.
During all of these periods, the development and compensation of psychogenic disorders in emergency situations depend on three groups of factors:
1. peculiarity of the situation,
2. individual response to what is happening,
3. social and organizational events.
However, the significance of these factors in different periods The development of the situation is not the same. The main factors influencing the development and compensation of mental disorders in emergency situations can be classified as follows:
N directly during an event (catastrophe, natural disaster, etc.):
1) features of the situation: emergency intensity; duration of emergency; suddenness of emergency;
2) individual reactions: somatic state; age emergency preparedness; personal characteristics;
3) social and organizational factors: awareness; organization of rescue operations; "collective behavior"
When carrying out rescue operations after the completion of a dangerous event:
1) features of the situation: “secondary psychogenies”;
2) individual reactions: personal characteristics; individual assessment and perception of the situation; age; somatic condition;
3) social and organizational factors: awareness; organization of rescue operations; "collective behavior";
During the later stages of an emergency:
1) socio-psychological and health care: rehabilitation; somatic condition;
2) social and organizational factors: social structure; compensation.
The main content of psychological trauma is the loss of faith that life is organized in accordance with a certain order and can be controlled. Trauma affects the perception of time, and under its influence the vision of the past, present and future changes. In terms of the intensity of the feelings experienced, traumatic stress is commensurate with the entire previous life. Because of this, it seems like the most significant event in life, like a “watershed” between what happened before and after the traumatic event, as well as everything that will happen afterwards.
An important place is occupied by the question of the dynamics of psychogenic disorders that develop in dangerous situations. There are several classifications of the phases of the dynamics of people’s states after traumatic situations.
Mental reactions during disasters are divided into four phases: heroism, honeymoon, disappointment and recovery.
1. Heroic phase begins immediately at the moment of the disaster and lasts several hours, it is characterized by altruism, heroic behavior caused by the desire to help people, to escape and survive. False assumptions about the possibility of overcoming what happened arise precisely in this phase.
2. Honeymoon phase occurs after a disaster and lasts from a week to 3-6 months. Those who survive feel a strong sense of pride that they have overcome all dangers and survived. In this phase of the disaster, the victims hope and believe that soon all problems and difficulties will be resolved.
3. Disillusionment Phase usually lasts from 3 months to 1-2 years. Intense feelings of disappointment, anger, resentment and bitterness arise from the collapse of hopes. l
4. Recovery phase begins when survivors realize that they themselves need to improve their lives and solve problems that arise, and take responsibility for carrying out these tasks.
Another classification of successive phases or stages in the dynamics of people’s condition after psychotraumatic situations is proposed in the work of M. M. Reshetnikov et al. (1989):
1. Acute emotional shock." Develops after a state of torpor and lasts from 3 to 5 hours; characterized by general mental stress, extreme mobilization of psychophysiological reserves, heightened perception and increased speed thought processes, manifestations of reckless courage (especially when saving loved ones) while simultaneously reducing the critical assessment of the situation, but maintaining the ability to perform purposeful activities.
2. "Psychophysiological demobilization." Duration up to three days. For the vast majority of those surveyed, the onset of this stage is associated with the first contacts with those who were injured and with the bodies of the dead, with an understanding of the scale of the tragedy. It is characterized by a sharp deterioration in well-being and psycho-emotional state with a predominance of feelings of confusion, panic reactions, a decrease in moral normative behavior, a decrease in the level of efficiency of activity and motivation for it, depressive tendencies, some changes in the functions of attention and memory (as a rule, those examined cannot clearly remember what they did these days). The majority of respondents complain in this phase of nausea, “heaviness” in the head, discomfort from the outside gastrointestinal tract, decrease (even absence) of appetite. The same period also included the first refusals to carry out rescue and “clearance” work (especially related to the removal of bodies of the dead), a significant increase in the number of erroneous actions when driving vehicles and special equipment, up to the creation of emergency situations.
3. "Resolution Stage"- 3-12 days after a natural disaster. According to subjective assessment, mood and well-being are gradually stabilizing. However, according to the results of observations, the vast majority of those examined retain a reduced emotional background, limited contact with others, hypomimia (mask-like appearance of the face), decreased intonation of speech, and slowness of movements. Towards the end of this period, a desire to “speak out” appears, implemented selectively, aimed primarily at persons who were not eyewitnesses of the natural disaster. At the same time, dreams appear that were absent in the two previous phases, including disturbing and nightmare dreams, in various options reflecting the impressions of tragic events. Against the background of subjective signs of some improvement in the condition, a further decrease in physiological reserves (by the type of hyperactivation) is objectively noted. The phenomena of overwork are progressively increasing.
4. "Recovery stage" It begins approximately on the 12th day after the disaster and is most clearly manifested in behavioral reactions: interpersonal communication is activated, the emotional coloring of speech and facial reactions begins to normalize, for the first time after the disaster jokes can be noted that evoke an emotional response from others, normal dreams are restored.
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