Classifications mental illness diagnostic and syndromic assessments, essentially not used until the middle of the 20th century. These include:
Post-traumatic stress disorder.
Social stress disorders.
radiation phobia.
Combat fatigue.
Syndromes:
Vietnamese".
- "Afghan".
- "Chechen", etc.
As well as pre-morbid neurotic manifestations, reactions to acute stress, adaptation disorders, combat stress and a number of others. Are these disorders the "new" diseases of our century? The answers to this question in the existing literature are ambiguous. From our point of view, we are talking only about the placement of accents of psychopathological disorders in large groups people, primarily generated by the costs modern civilization and social conflicts. These disturbances have been described in the phenomenological plan before, but they have not been specifically generalized or singled out. This happened mainly because society was not ready to accept social causes that worsen mental health, and to realize the need for appropriate preventive and rehabilitative measures. Psychogenic disorders observed in life-threatening situations during and after natural disasters and catastrophes.
Table 1 - Psychogenic disorders
|
Reactions and psychogenic disorders |
Clinical Features |
|
|
Non-pathological (physiological) reactions |
The predominance of emotional tension, psychomotor, psychovegetative, hypothymic manifestations, maintaining a critical assessment of what is happening and the ability to purposeful activity |
|
|
Psychogenic pathological reactions |
Neurotic level of disorders - acute asthenic, depressive, hysterical and other syndromes, a decrease in the critical assessment of what is happening and the possibilities of purposeful activity |
|
|
Psychogenic neurotic states |
Stabilized and complicating neurotic disorders - neurasthenia (exhaustion neurosis, asthenic neurosis), hysterical neurosis, neurosis obsessive states, depressive neurosis, in some cases, the loss of a critical understanding of what is happening and the possibilities of purposeful activity |
|
|
Rective psychoses |
Acute affective-shock reactions, twilight states of consciousness with motor excitation or motor inhibition |
In recent years, the analysis of the state of mental health of the population indicates the growth of non-psychotic, so-called borderline mental disorders, primarily neurotic and somatoform disorders and adaptation reactions, directly related to negative changes in the socio-economic situation and the spiritual life of the general population. At the same time, over the past 10 years, the total number of people with disabilities due to mental disorders (the main group of which are patients with non-psychotic disorders) has increased. A survey of individual sample groups of the population showed that, firstly, a significant proportion of patients, especially those with unexpressed neurotic disorders, remain outside the field of view of specialists and, secondly, the largest number of patients is observed in groups of victims during and after emergencies.
Employees of the SSC (State science Center) pay great attention medical, psychological and psychiatric assistance to the population exposed to stress, including those affected after natural disasters, catastrophes, local wars, ethnic conflicts.
In these cases, the systemic nature of the dynamics of biological and personality-typological mechanisms in the formation of psychophysiological disorders of the neurotic level, considered in Figure 1, is especially clearly revealed.
extreme psychogenic stress disorder
Figure 1 - The main factors influencing the formation of psychopathological manifestations of the neurotic level
Taking into account the whole complex of rescue, social and medical measures makes it possible to schematically distinguish three periods in the development of situations that cause various psychogenic disorders.
The first - an acute period - is characterized by a sudden threat to one's own life and the death of loved ones. It lasts from the beginning of the impact to the organization of rescue operations (minutes, hours). A powerful extreme impact at this moment mainly affects life instincts (self-preservation) and leads to the development of non-specific, extra-personal psychogenic reactions, the basis of which is fear of varying intensity. At this time, predominantly psychogenic reactions of psychotic and non-psychotic reactions are observed. psychotic level. A special place in this period is occupied by mental disorders in those who received injuries and wounds. In such cases, a qualified differential diagnostic analysis is required, aimed at identifying a causal relationship of mental disorders both directly with psychogenic disorders and with injuries received (traumatic brain injury, intoxication due to burns, etc.).
In the second period, which takes place during the deployment of rescue operations, figuratively speaking, "normal life in extreme conditions" begins. At this time, in the formation of states of maladjustment and mental disorders, the personality characteristics of the victims, as well as their awareness of not only the life-threatening situation that continues in some cases, but also new stressful influences, such as the loss of relatives, separation of families, loss of home, property, are much more important. An important element of prolonged stress during this period is the expectation of repeated impacts, mismatch of expectations with the results of rescue operations, and the need to identify deceased relatives. The psycho-emotional stress characteristic of the beginning of the second period is replaced by its end, as a rule, by increased fatigue and "demobilization" with astheno-depressive manifestations.
In the third period, which begins for the victims after their evacuation to safe areas, many people go through a complex emotional and cognitive processing of the situation, an assessment of their own experiences and feelings, a kind of "calculation" of losses. At the same time, psychogenic traumatic factors associated with a change in life stereotype, living in a destroyed area or place of evacuation also become relevant. Becoming chronic, these factors contribute to the formation of relatively persistent psychogenic disorders. Along with the persisting nonspecific neurotic reactions and conditions, protracted and developing pathocharacterological changes, post-traumatic and social stress disorders begin to predominate during this period. Somatogenic mental disorders in this case can be of a diverse "subacute" nature. In these cases, it is observed as "somatization" of many neurotic disorders, and to a certain extent opposite to this process "neuroticization" and "psychopathization", associated with the awareness of existing traumatic injuries and somatic diseases, as well as with the real difficulties of the life of the victims.
In all these periods, the development and compensation of psychogenic disorders in emergency situations depend on three groups of factors: the peculiarity of the situation, individual response to what is happening, social and organizational measures. However, the importance of these factors in different periods situation is not the same. Figure 2 schematically shows the proportion of dynamically changing factors that primarily affect mental health during and after any emergency. The data presented show that over time, the nature of the emergency and individual characteristics victims and, on the contrary, not only the actual medical, but also socio-psychological assistance and organizational factors are increasing and occupying fundamental importance. It follows that social programs in addressing issues of protection and restoration of mental health in victims after emergencies are of paramount importance.
An extreme situation is a situation that is characterized by significant socio-ecological and economic damage, the need for evacuation and rescue operations and the elimination of the negative consequences of what happened.
Psychological overstrain resulting from a threat to life and health can serve as a source of maladaptation with its various manifestations in the form of mental disorders and violations of the psychotic register.
In extreme conditions, the victims include psychological defense mechanisms - Various types response to the situation. The primary forms of mental disorders are abnormal (inadequate to the stimulus) reactions.
In addition, most people, although not consistently, have a constitutional predisposition to the development of certain diseases. Their manifestation is most likely in persons with psychopathy and with accentuated (latent forms of psychopathy) character traits.
Knowing the frequency mental structure and clinical dynamics of mental disorders arising in extreme conditions make it possible to organize adequate medical and preventive care.
At the initial stage, when an accident is detected, it is important to first realize its danger, to report the accident in a timely manner in accordance with the accepted schemes; assessment of the situation and decision-making on the use of existing plans, the necessary forces and means, the involvement of consultants and specialists.
Among psychoprophylactic measures, clear management occupies an important place. If, when moral upheavals appear, people are not constantly notified with specific information, they do not provide clear control, timely communication of signals and the procedure for acting on them, weaken the leadership of the masses, panic and other negative phenomena are inevitable.
Along with educating the ability not to get lost in difficult life situations that develop in extreme conditions, competence, professional knowledge and skills, moral qualities of people who operate complex mechanisms and technological processes.
The training of personnel of sanitary posts, sanitary squads, first aid teams should be carried out in compliance with the basic rule of didactics: first, curricula are developed and the acquisition of theoretical knowledge is planned, then practical skills are formed and the ability to provide assistance, brought to automatism, is developed. In particular, the personnel of sanitary posts and sanitary teams, first aid teams should know the main syndromes of violation mental activity V extreme situations and be able to use modern means of assisting with motor excitation.
It is not without reason that they believe that uncontrolled fear indicates a lack of self-confidence, their knowledge, and skills. It can also lead to panic reactions, to prevent which it is necessary to stop the spread of false rumors, show firmness with the "leaders" of the alarmists, direct people's energy to rescue work.
In modern conditions, there is every reason to more widely use the data of psychology, psychotherapy, psychohygiene and other disciplines in order to optimize the activities of people in extreme situations, which is necessary to overcome increased psychological and physical stress.
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Prevention of psychogeny in extreme conditions
Severe natural calamities and catastrophes, not to mention the possible mass sanitary losses during the war, are a difficult test for many people. A mental reaction to extreme conditions, especially in cases of significant material losses, death of people, can permanently deprive a person of the ability to rational actions and actions, despite the “psychological protection” that helps prevent the disorganization of mental activity and behavior. Many researchers conclude that preventive health care is the most effective way to prevent the impact of trauma on a person's mental health. A group of American researchers (Fullerton S., Ursano R. et al., 1997), based on a generalization of their own data, came to the conclusion that preventive medical care in anticipation of mental trauma, during an emergency event and during overcoming its consequences can be considered in the following three directions.
I. Primary prevention
Information about what to expect.
Teaching control and mastery skills.
Impact limitation.
Sleep hygiene.
Filling the psychological need for support and rest.
Informing and educating loved ones to increase “natural support”.
II. Secondary prevention
Restoring security and public services.
Primary care training.
Sorting of the sick and wounded.
Early diagnosis of the wounded.
Diagnosis of somatization as a possible mental distress.
Training teachers for early distress deactivation.
Collection of information.
III. Tertiary prevention
Treatment of comorbid disorders.
Increased attention to family distress of loss and demoralization, violence against loved ones or children in the family.
Compensation.
Deactivation of the processes of "withdrawal" and social avoidance.
Psychotherapy and necessary medical treatment.
Practical measures aimed at preventing psychiatric and medical-psychological consequences of emergencies can be divided into those carried out in the period before the onset, during the action of psycho-traumatic extreme factors and after the termination of their impact.
Before an emergency occurs, it is necessary to prepare the medical service of the Civil Defense (GO) and rescuers to work in extreme conditions. It should include:
Training the personnel of sanitary posts and squads to provide medical care to victims with psychogenic disorders;
Formation and development of high psychological qualities, the ability to behave correctly in extreme situations, the ability to overcome fear, determine priorities and act purposefully; development of organizational skills for psychoprophylactic work with the population;
Informing medical workers and the public about the possibilities of using psychotherapeutic and medications for psychoprophylaxis.
The list of these ways of preventing states of mental maladjustment in extreme conditions, directly addressed primarily to various departments of the medical service of the Civil Defense, should be supplemented by a wide range of educational and organizational measures aimed at overcoming carelessness and neglect of certain life-threatening effects on a person, both in those cases when "harmfulness" is visually tangible, and when it is hidden for a certain time from the sight and understanding of ignorant people. Great importance has a mental hardening, i.e. the development by a person of courage, will, composure, endurance and the ability to overcome a sense of fear.
The need for this kind of preventive work follows from the analysis of many emergencies including the Chernobyl disaster.
“... From Minsk, in my car, I (an engineer, an employee of a nuclear power plant) was driving towards the city of Pripyat ... I drove up to the city at about two and a half hours in the morning ... I saw a fire over the fourth power unit. A ventilation pipe lit by flames with transverse red stripes was clearly visible. I remember well that the flame was higher than the chimney. That is, it reached a height of about one hundred and seventy meters above the ground. I didn’t turn back home, but decided to drive closer to the fourth power unit in order to get a better look ... I stopped about a hundred meters from the end of the emergency unit (in this place, as it will be calculated later, at that time the radiation background reached 800--1500 roentgens per hour mainly from graphite scattered by the explosion, fuel and a flying radioactive cloud). I saw in the passing light of the fire that the building was dilapidated, there was no central hall, separator rooms, the separator drums shifted from their places gleamed reddish. It hurt my heart from such a picture ... I stood for a minute, there was an oppressive feeling of incomprehensible anxiety, numbness, my eyes absorbed everything and remembered forever. And the anxiety all went to the soul, and involuntary fear appeared. Feeling an invisible close threat. It smelled like after a strong lightning strike, still tart smoke, it began to burn the eyes, dry the throat. Suffocated cough. And I also lowered the glass to get a better look. It was such a spring night. I turned the car around and drove to my house. When I entered the house, mine were asleep. It was about three in the morning. They woke up and said they heard explosions but didn't know what they were. Soon an excited neighbor came running, whose husband was already on the block. She told us about the accident and offered to drink a bottle of vodka to decontaminate the body...”.
“At the moment of the explosion, two hundred and forty meters from the fourth block, just opposite the engine room, two fishermen were sitting on the bank of the supply channel and catching fry. They heard explosions, saw a blinding burst of flame and fireworks flying pieces of hot fuel, graphite, reinforced concrete and steel beams. Both fishermen continued their fishing, unaware of what had happened. We thought that, probably, a barrel of gasoline exploded. Literally in front of their eyes, fire brigades turned around, they felt the heat of the flame, but carelessly continued fishing. The fishermen received 400 roentgens each. Toward morning, they developed indomitable vomiting, according to them, with heat, as if it burned their chest with fire, cut their eyelids, their head was bad, as after a wild hangover. Realizing that something was wrong, they hardly made it to the medical unit ... "
“A resident of Pripyat X., a senior engineer of the production and administrative department of the Chernobyl construction department, testifies: “On Saturday, April 26, 1986, everyone was already preparing for the May 1 holiday. Warm nice day. Spring. Gardens are blooming... Among the majority of builders and installers, no one knew anything yet. Then something leaked out about an accident and a fire at the fourth power unit. But what exactly happened, no one really knew. The children went to school, the kids played outside in the sandboxes, rode bicycles. By the evening of April 26, they all had high activity in their hair and clothes, but then we did not know this. Not far from us on the street they were selling delicious donuts. An ordinary day off... A group of neighbors' guys rode bicycles to the overpass (bridge), from there the emergency block from the side of Yanov station was clearly visible. This, as we later learned, was the most radioactive place in the city, because a cloud of nuclear release passed there. But it became clear later, and then, on the morning of April 26, the guys were just interested in watching the reactor burn. These children then developed severe radiation sickness.”
Both in the above and in many similar examples, belief in a miracle, in “maybe”, in the fact that everything can be easily corrected, paralyzes, makes a person’s thinking inflexible, deprives him of the possibility of an objective and competent analysis of what is happening, even in the case when have the necessary theoretical knowledge and some practical experience. Amazing carelessness! In the case of the Chernobyl accident, it turned out to be criminal.
During the period of action of psychotraumatic extreme factors, the most important psychoprophylactic measures are:
Organization of clear work to provide medical care to victims with psychogenic disorders;
Objective information of the population about medical aspects natural disaster (catastrophe);
Assistance to civil society leaders in suppressing panic moods, statements and actions;
Involvement of lightly injured in rescue and urgent emergency recovery operations.
At the end of a life-threatening catastrophic situation [It should be emphasized that psychotraumatic factors quite often continue to act after the climax of a natural disaster or catastrophe, although less intensely. This is the anxious expectation of repeated shocks during an earthquake, and the ever-increasing fear of a “set of doses” when you are in an area with an increased level of radiation, etc.] psychoprophylaxis should include the following measures:
Complete information of the population about the consequences of a natural disaster (catastrophe) and other impacts and their impact on people's health;
Maximum use of all opportunities to involve large groups of victims in order to make generalized collective decisions on the organization of rescue operations and medical care;
Prevention of the occurrence of relapses or repeated mental disorders (the so-called secondary prevention), as well as the development of psychogenically caused somatic disorders;
Drug prevention of delayed psychogenic reactions;
Involvement of the lightly injured to participate in rescue and urgent emergency recovery operations and in the provision of medical care to the victims.
As experience shows, the main causes of "man-made" tragedies are quite similar in different countries with all kinds of disasters: technical imperfection of machines and mechanisms, violation technical requirements for their operation. However, human flaws stand behind this - incompetence, superficial knowledge, irresponsibility, cowardice, which prevents the timely opening of detected errors, the inability to take into account the capabilities of the body, calculate forces, etc. Such phenomena should be condemned not only by various control bodies, but above all by the conscience of each person. brought up in the spirit of high morality.
One of the most important socio-psychological preventive tasks is information of the population about the situation, carried out permanently. The information must be complete, objective, truthful, but also, within reasonable limits, reassuring. The clarity and brevity of the information make it particularly effective and intelligible. The absence or delay of information necessary for making rational decisions during or after a natural disaster or catastrophe generates unpredictable consequences. For example, untimely and half-true information of the population about the radiation situation in the zone of the Chernobyl accident led to many tragic results both directly for public health and for the adoption organizational decisions to eliminate the accident and its consequences.
This contributed to the development of neuroticism in the general population at the remote stages of the Chernobyl tragedy, the formation of psychogenic mental disorders. In this regard, in the territories where the population lives, to one degree or another affected by the accident (pollution zones, places of residence of migrants), centers for psychological rehabilitation were created, combining socio-psychological and informational assistance and focused on the prevention of preclinical forms of mental maladaptation. .
An important place in the implementation of the primary prevention of psychogenic disorders is given to the understanding that a modern person must be able to behave correctly in any, even the most difficult, situations.
Along with cultivating the ability not to get lost in difficult life situations that develop in extreme conditions, competence, professional knowledge and skills, moral qualities of people who control complex mechanisms and technological processes, and their ability to give clear and constructive instructions are of paramount preventive importance.
Especially dire consequences cause incompetent decisions and the choice of a false course of action in the initial stages of an extreme pre-catastrophic situation or in an already developed catastrophe. Consequently, in the professional selection and training of managers and executors of the most important areas of work in many areas of economic activity, it is necessary to take into account the psychological characteristics and professional competence of a candidate. Prediction of its behavior in extreme conditions should take an important place in the system general prevention the development of life-threatening situations and the psychogenies caused by them.
It is not without reason that they believe that uncontrolled fear indicates a lack of confidence in themselves, their knowledge, and skills. It can also lead to panic reactions, to prevent which it is necessary to stop the spread of false rumors, be firm with the "leaders" of the alarmists, direct people's energy to rescue work, etc. It is known that the spread of panic is facilitated by many factors due to the psychological passivity of a person in extreme situations, the lack of readiness to deal with the elements.
Special mention should be made of the possibilities of primary drug prevention of psychogenic disorders. In recent decades, such prevention has received considerable attention. However, it must be borne in mind that the use of medicinal psychopharmacological drugs for prevention is limited. Such funds can be recommended only to small contingents of people.
In this case, the possibility of developing muscle weakness, drowsiness, decreased attention (tranquilizers, antipsychotics), hyperstimulation (psychoactivators), etc. should be taken into account. Preliminary consideration of the doses of the recommended drug, as well as the nature of the intended activity, is required. Much more widely, it can be used to prevent mental disorders in people who survived after a natural disaster or catastrophe.
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A special place in general medical, and especially in psychiatric, practice in recent years has been occupied by the assessment of the condition of victims of natural disasters and catastrophes and the timely provision of necessary assistance to them.
Extreme situations are understood as situations that are dangerous to the life, health and well-being of significant groups of the population, caused by natural disasters, catastrophes, accidents, and the use of various types of weapons in case of war. Psychogenic impact in extreme conditions consists not only of a direct immediate threat to human life, but also indirect, associated with the expectation of its implementation. The possibility of occurrence and the nature of mental disorders, their frequency, severity, dynamics depend on many factors: characteristics of an extreme situation (its intensity, suddenness of occurrence, duration of action); readiness of individuals to work in extreme conditions, their psychological stability, strong-willed and physical hardening, as well as organization and coordination of actions, support of others, the presence of illustrative examples of courageous overcoming of difficulties.
Psychopathological disorders in extreme situations have much in common with the clinical picture of disorders developing in "normal" conditions. However, there are also significant differences.
Firstly, due to the multiplicity of suddenly acting psychotraumatic factors in extreme situations, a simultaneous occurrence of mental disorders occurs in a large number of people.
Secondly, the clinical picture in these cases is not strictly individual, as in "normal" psychotraumatic circumstances, character, but is reduced to a small number of fairly typical manifestations.
Thirdly, despite the development of psychogenic disorders and the ongoing life-threatening situation, the affected person is forced to continue an active struggle for his life, the lives of his loved ones and those around him.
The occurrence during natural disasters, catastrophes, during the war of large sanitary losses associated with the development of mental disorders in the victims, the need to provide them with modern medical care and speedy return to active labor activity determine the great practical importance of a unified approach to the diagnosis, prevention and treatment of psychogenic mental disorders that occur in extreme situations.
Correctly and timely provided first medical and medical assistance decisively determines the results further treatment victims with psychogenic disorders, its timing and outcomes. Therefore, familiarity with various aspects of the problem of psychogenic disorders that occur directly during extreme exposure and after it is important not only for specialists (psychiatrists, psychotherapists), but also for healthcare organizers, doctors and paramedical personnel who, if necessary, will have to work in the system. medical service of the Civil Defense.
The study of mental disorders caused by extreme exposure and the analysis of the entire complex of rescue, social and medical measures make it possible to distinguish three main periods in the development of a life-threatening situation, during which various states mental maladjustment and painful disorders.
The first period is characterized by a sudden threat to one's own life and the death of loved ones. It lasts from the moment the impact begins to the organization of rescue operations (minutes, hours). During this period, a powerful extreme impact mainly affects vital instincts (self-preservation) and leads to the development of predominantly non-specific, extra-personal psychogenic reactions, which are based on fear of varying degrees of intensity. At this time, predominantly reactive psychoses and non-psychotic psychogenic reactions. In some cases, panic may occur.
In the second period, during the deployment of rescue operations, in the formation of states of mental maladaptation and disorders, much more important belongs to the characteristics of the personality of the victims, as well as their awareness of not only the life-threatening situation that continues in some cases, but also new stressful influences, such as the loss of relatives, separation of families, loss of home, property. Important elements of prolonged stress during this period are the expectation of repeated impacts, mismatch of expectations with the results of rescue operations, and the need to identify deceased relatives. The psycho-emotional tension characteristic of the beginning of the second period is replaced by its end, as a rule, by increased fatigue and "demobilization", accompanied by astheno-depressive or apathetic manifestations.
In the third period, which begins for the victims after their evacuation to safe areas, many of them undergo a complex emotional and cognitive processing of the situation, an assessment of their own experiences and feelings, a kind of "calculation" of losses. At the same time, psychogenic traumatic factors associated with a change in life stereotype, 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. Somatogenic mental disorders in this case can be of a diverse subacute nature. In such cases, both somatization of many neurotic disorders is observed, as well as, to a certain extent, "neuroticization" and "psychopathization" opposite to this process, associated with the awareness of existing traumatic injuries, somatic diseases and real life difficulties.
Clinical Features psychogenic illnesses to a certain extent depend on the specifics of the psychotraumatic effect. However, this does not mean that only the plot of a psychotrauma can determine the clinical content of a mental, including psychotic, reaction. More important is the interaction of various etiopathogenetic factors: the specifics of psychogeny, constitutional predisposition, and somatic condition. Understanding this is necessary for prescribing various medications to victims (primarily psychopharmacological drugs) in different periods development of an extreme situation in order to stop mental disorders and their secondary prevention.
Human behavior in a suddenly developed life-threatening situation is largely determined by the emotion of fear, which, to certain limits, can be considered physiologically normal and conducive to emergency mobilization of the physical and mental state necessary for self-preservation.
The loss of a critical attitude to one's own fear, the appearance of difficulties in expedient activity, the decrease and disappearance of the ability to control actions and make logically sound decisions characterize various psychotic disorders(reactive psychoses, affective-shock reactions), as well as states of panic. They are observed mainly during extreme exposure and immediately after it.
Among reactive psychoses in a situation of mass catastrophes, affective-shock reactions and hysterical psychoses are most often observed. Affective-shock reactions occur with a sudden life-threatening shock, they are always short-lived, lasting from 15-20 minutes to several hours or days. There are two forms shock conditions- hypo- and hyperkinetic. The hypokinetic variant is characterized by phenomena of emotional-motor retardation, general "stupor", sometimes to complete immobility and mutism (affectogenic stupor). Patients freeze in one position, their facial expressions are either indifferent or express fear. Vasomotor-vegetative disturbances and deep stupefaction of consciousness are noted. The hyperkinetic variant is characterized by acute psychomotor agitation(motor storm, fugiform reaction). Patients run somewhere, their movements and statements are chaotic, fragmentary; facial expressions reflect frightening experiences. Sometimes acute speech confusion prevails in the form of incoherent speech flow. Usually patients are disoriented, their consciousness is deeply clouded.
With hysterical disorders, vivid figurative representations begin to predominate in the experiences of patients, they become extremely suggestible and self-suggestible. At the same time, a specific psycho-traumatic situation is always reflected in the behavior of patients. In the clinical picture, demonstrative behavior with crying, ridiculous laughter, hysteroform seizures is noticeable. Quite often in these cases disturbances of consciousness develop. For the hysterical twilight darkness consciousness is characterized by its incomplete shutdown with disorientation and deceptions of perception.
The vast majority of victims immediately after the onset of one or another catastrophic impact develop non-psychotic disorders. They are expressed in confusion, incomprehension of what is happening. Over this short period, with a simple fear reaction, there is a moderate increase in activity: movements become clear, economical, muscle strength increases, which helps to move many people to a safe place. Speech disorders are limited to the acceleration of its pace, hesitation, the voice becomes loud, sonorous. There is a mobilization of will, attention, ideation processes. Mnestic disturbances during this period are represented by a decrease in the fixation of the environment, fuzzy memories of what happened, however, one's own actions and experiences are remembered in full. Characteristic is the change in the experience of time, the course of which slows down and the duration of the acute period seems to be increased several times.
With complex reactions of fear, more pronounced motor disorders are noted in the first place. In the hyperdynamic variant, a person rushes about aimlessly and randomly, makes many inappropriate movements, which prevents him from quickly making the right decision and hiding in a safe place. In some cases there is a stampede. The hypodynamic variant is characterized by the fact that a person, as it were, freezes in place, often, trying to "decrease in size", takes an embryonic pose: he squats down, clasping his head in his hands. When trying to help, he either passively obeys or becomes negative. Speech production in these cases is fragmentary, limited to exclamations, in some cases aphonia is noted.
Along with mental disorders vegetative disorders are often noted: nausea, dizziness, frequent urination, chill-like tremor, fainting. The perception of space changes, the distance between objects, their size and shape are distorted. For some people, the environment seems "unreal", and this feeling drags on for several hours after the end of a life-threatening situation. Kinetic illusions can also be long-lasting (for example, sensations of the earth shaking after an earthquake). Memories of the event and their behavior in the victims during this period are undifferentiated, total.
With simple and complex reactions of fear, consciousness is narrowed, although accessibility to external influences, selectivity of behavior, and the ability to independently find a way out of a difficult situation remain. The disorders described are usually categorized as " acute reactions to stress."
After the end of the first (acute) period, some victims experience short-term relief, an upsurge in mood, verbosity with multiple repetitions of a story about their experiences, attitudes towards what happened, bravado, discrediting the danger. This phase of euphoria lasts from several minutes to several hours. As a rule, it is replaced by lethargy, indifference, ideational inhibition, difficulty in comprehending the questions asked, and difficulties in performing even simple tasks. Against this background, there are episodes of psycho-emotional stress with a predominance of anxiety. In some cases, peculiar states develop: the victims give the impression of being detached, immersed in themselves, they often and deeply sigh, bradyphasia is noted.
Another option for the development of an anxiety state during this period may be anxiety with activity. Such states are characterized by motor restlessness, fussiness, impatience, verbosity, the desire for an abundance of contacts with others. Expressive movements are somewhat demonstrative, exaggerated. Episodes of psycho-emotional stress are quickly replaced by lethargy, apathy. At this stage, there is a mental "processing" of what happened, the awareness of losses, attempts are made to adapt to new conditions of life.
Neurotic disorders in the third period of development of the situation are more diverse, the range of possible disorders is very wide. According to the nature of manifestations, severity and stability, the observed psychogenic disorders during this period can be divided into initial rudimentary and extended manifestations of mental maladaptation (neurotic, psychopathic and psychosomatic). The former are characterized by instability and partiality of disorders limited to one or two symptoms of a non-psychotic register, the connection of manifestations with specific external influences, the decrease and disappearance of individual disorders after rest, switching attention or activity, lowering the tolerance threshold for various hazards, physical or mental stress, and the absence of a subjective feeling. illness.
With active questioning, patients complain of increased fatigue, muscle weakness, daytime sleepiness, night sleep disorder, dyspeptic symptoms, transient dysrhythmic and dystonic disorders, increased sweating, tremor of the extremities. Increased vulnerability, resentment are often noted. Deeper and relatively stable are asthenic disorders, which are the basis on which various borderline neuropsychiatric disorders are formed. With the development of pronounced and relatively stable affective reactions against their background, asthenic disorders proper are, as it were, pushed into the background. There is a vague anxiety, anxious tension, premonition, expectation of some kind of misfortune. There is a "listening for danger signals", which can be mistaken for ground shaking from moving mechanisms, unexpected noise, or, conversely, silence. All this causes anxiety, accompanied by muscle tension, trembling in the arms and legs, which contributes to the formation phobic disorders. The content of phobic experiences is quite specific and reflects, as a rule, the transferred situation. Along with phobias, uncertainty, difficulty in accepting even simple solutions, doubts about the correctness of their own actions. Often there is a close to obsessive constant discussion of the situation, memories of a past life, its idealization.
A special type of manifestation of neurotic disorders is depressive disorders. A person has a kind of awareness of "his guilt" before the dead, there is an aversion to life, regret that he did not share the fate of the dead relatives. The phenomenology of depressive states is supplemented by asthenic manifestations, and in a number of observations - by apathy, indifference, and the development of a melancholy affect. Often depressive manifestations are less pronounced and somatic discomfort comes to the fore (somatic "masks" of depression): diffuse headache, worse in the evening, cardialgia, disorders heart rate, anorexia. In general, depressive disorders do not reach a psychotic level, patients do not have ideational inhibition, they, although with difficulty, cope with everyday worries.
Along with the indicated neurotic disorders, the victims quite often experience decompensation of character accentuation and individual psychopathic traits. The main group of states of personal decompensation in these cases is usually represented by reactions with a predominance of the excitability and sensitivity radical. In persons with such conditions, an insignificant cause causes violent affective outbursts that objectively do not correspond to one or another psychogenic cause. At the same time, aggressive actions are not uncommon. These episodes are most often short-lived, proceed with some demonstrativeness, theatricality, quickly give way to an astheno-depressive state with lethargy, indifference.
In a number of observations, dysphoric coloring of mood is noted. In these cases, people are gloomy, gloomy, constantly dissatisfied. They challenge orders, refuse to complete tasks, quarrel with others, quit work they have begun. There are also cases of increased paranoid accentuations.
In the structure of the noted neurotic and psychopathic reactions at all stages of the development of the situation, the victims may have sleep disturbances, vegetative and psychosomatic dysfunctions. Most often, there are difficulties in falling asleep, which is facilitated by a feeling of emotional stress, anxiety, hyperesthesia. Night sleep is superficial, accompanied by nightmares, usually short. The most intense shifts in the functional activity of the autonomic nervous system manifest as fluctuations in blood pressure, pulse lability, hyperhidrosis, chills, headache, vestibular disorders, gastrointestinal disorders. In some cases, these conditions become paroxysmal. Somatic diseases are often exacerbated and persistent psychosomatic disorders appear - more often in the elderly, as well as in organic diseases of the central nervous system of inflammatory, traumatic, vascular origin.
An analysis of the psychopathological manifestations detected in victims during and after extreme exposure indicates the possibility of developing various neuroses, clinical features which do not have fundamental differences from the neurotic states observed in the usual practice of psychiatric medical institutions. Unlike adaptive responses, they are characterized by the stabilization of psychogenically provoked neurotic disorders. The main manifestations include marked fear, anxiety, hysterical disturbances, obsessions, phobias, and depression.
extreme situations are known to be accompanied by injuries and various physical health disorders in a large number of people. In this case, a combination of psychogenic disorders with physical damage is possible. At the same time, mental disorders can be leading in the clinic of somatic pathology (as, for example, in traumatic brain injury) or combined with the main lesion (as in burn disease, radiation injury), etc. In these cases, a qualified differential diagnostic analysis is required, aimed at identifying a causal relationship between the developed mental disorders, both directly with psychogenies and with the resulting injuries. At the same time, a holistic approach that requires treating not the disease, but the patient, implies the obligatory consideration of the complex interweaving of somatogenic factors involved in the genesis of mental disorders.
EMERGENCIES AND PSYCHOGENIC DISORDERS
Recently, emergency situations, paradoxically as it may sound, are increasingly becoming a fact of our Everyday life. During natural disasters, catastrophes and other extreme impacts, mass psychogenic disorders often develop, causing disorganization in the overall course of rescue and recovery work.
Psychopathological disorders in extreme situations have much in common with those developing in normal conditions. However, there are also significant differences. Firstly, due to many psychotraumatic factors, disorders occur simultaneously in a large number of people. Secondly, their clinical picture is not strictly individual, as usual, in nature, but is reduced to fairly typical manifestations. A special feature is that the victim is forced to continue an active struggle with the consequences of a natural disaster (catastrophe) in order to survive himself and protect loved ones.
| "New" diagnostic (terminological) assessments of mental disorders associated with emergency situations, which came into practice in the second half of the 20th century. | |
| Post-traumatic stress disorder (PTSD): | |
| "Vietnamese" "Afghan" "Chechen" and others |
SYNDROMES |
| Radiation phobia (RF) Combat fatigue (BU) Social Stress Disorders (SSR) |
|
Differentiated consideration of clinical forms and variants of disorders, their delimitation from a wide range of neurosis-like and psychopathic conditions require qualified observation, analysis, assessment of the dynamics of the state of patients, paraclinical studies, etc. This is possible only in the conditions of a medical institution in the presence of a psychiatrist, and, if necessary, other specialists. It is clear that in an emergency, a psychiatrist may not be on site.
Express diagnostics are needed to resolve urgent issues (leave the victim in place or evacuate, what medical appointments to make) and evaluate the prognosis. The closer the victim is to the specialized medical institution, the more opportunities for clarifying the initial diagnosis and introducing additional clinical justifications into it. Experience shows that in the overwhelming majority of cases, a doctor, already at the initial stage of triage of persons with psychogenic disorders, quite quickly and correctly solves the fundamental issues of evacuation, prognosis and the need for relief therapy, highlighting as non-pathological (physiological) neurotic phenomena(reactions to stress, adaptive reactions), and neurotic reactions, states and reactive psychoses(see table).
Most often, psychogenic disorders occur in life-threatening situations characterized by catastrophic suddenness. In this case, human behavior is largely determined by fear, which, to certain limits, can be considered physiologically normal and adaptively useful. In fact, tension and fear arise with every catastrophe that a person is aware of. "Fearless" mentally normal people in the conventional sense, these words do not exist. It's all about the time it takes to overcome confusion, make a rational decision, and take action. For a person prepared for an extreme situation, this time period is much less; in a completely unprepared person, persistent confusion determines prolonged inactivity, fussiness and is the most important indicator of the risk of developing a psychogenic disorder.
Table. Mental disorders observed in life-threatening situations during and after natural disasters and catastrophes |
|
Reactions and psychogenic disorders |
Clinical Features |
| Reactive psychoses: sharp |
Acute affective-shock reactions, twilight states of consciousness with motor excitation or motor retardation |
| protracted | Depressive, paranoid, pseudo-dementia syndromes, hysterical and other psychoses |
| Non-pathological (physiological) reactions |
Relatively short-term and directly related to the psychogenic situation, the predominance of emotional tension, psychomotor, psychovegetative, hypothymic manifestations, maintaining a critical assessment of what is happening and the ability to purposeful activity |
| Psychogenic pathological reactions | Neurotic level of disorders - acute asthenic, depressive, hysterical and other syndromes, a decrease in the critical assessment of what is happening and the possibilities of purposeful activity |
| Psychogenic disorders (states) of the neurotic level | Stabilized and becoming more complex neurotic disorders - neurasthenia (exhaustion neurosis, asthenic neurosis), hysterical neurosis, obsessive-compulsive disorder, depressive neurosis, in some cases, loss of a critical understanding of what is happening and the possibilities of purposeful activity |
This is how a nuclear specialist describes his condition in the extreme conditions associated with the accident at the power unit: “At the moment the AZ-5 (emergency protection) button was pressed, the bright illumination of the indicators flashed frighteningly. Even the most experienced and cold-blooded operators’ hearts shrink in such seconds. .. I know the feeling experienced by the operators at the first moment of the accident. I have repeatedly been in their shoes when I worked at the operation of nuclear power plants. At the first moment - numbness in the chest, everything collapses in an avalanche, pours over with a cold wave of involuntary fear, primarily because they are taken by surprise and at first you don’t know what to do, while the arrows of the recorders and instruments scatter in different directions, and your eyes follow them, when the reason and pattern of the emergency mode are still unclear, when at the same time (again involuntarily) you think somewhere in the depths, the third plan, about the responsibility and consequences of what happened. But in the next moment, an extraordinary clarity of head and composure set in ... "
In unprepared people who suddenly find themselves in a life-threatening situation, fear is sometimes accompanied by an altered state of consciousness. Stupefaction most often develops, which is expressed in an incomplete understanding of what is happening, difficulty in its perception, indistinctness (with deep degrees - inadequacy) of life-saving actions.
Special studies conducted since the 2nd day of the Spitak earthquake in Armenia in December 1988 revealed psychogenic disorders of varying severity and duration in more than 90% of the examined, from lasting several minutes to long and persistent.
Immediately after an acute exposure, when signs of danger appear, confusion arises, a lack of understanding of what is happening. For this short period with a simple fear reaction activity increases moderately, movements become clear, economical, muscle strength increases, which helps to move many people to a safe place. Speech disorders are limited to an acceleration of its pace, stammering, the voice becomes loud, sonorous, will, attention, and ideation processes are mobilized. Mnestic disorders are represented by a decrease in the fixation of the environment, fuzzy memories of what is happening around. However, their own actions and experiences are fully remembered. A change in the idea of time is characteristic: its course slows down, the duration of the acute period seems to be increased several times.
With complex fear reactions first of all, more pronounced movement disorders are noted. Along with mental disorders, nausea, dizziness, frequent urination, chill-like tremors, fainting, and miscarriages are common in pregnant women. The perception of space changes: the distance between objects, their size and shape are distorted. In a number of observations, the environment seems to be "unreal", and this state is delayed for several hours after the impact. Kinesthetic illusions (feelings of vibrations of the earth, flight, swimming, etc.) can also persist for a long time.
Usually such experiences develop during earthquakes, hurricanes. For example, after a tornado, many victims note the action of an incomprehensible force that “as if pulls them into a hole”, they “resist it”, grab various objects with their hands, trying to stay in place. One victim said that he felt as if he was floating through the air, while making the same movements with his hands as when swimming.
With simple and complex reactions of fear, consciousness is narrowed, although in most cases accessibility to external influences, selectivity of behavior, and the ability to independently get out of a difficult situation remain. A special place is occupied by the state of panic. Individual panic reactions are reduced to affective shock. With their development simultaneously in several people, the effect of mutual influence is possible, leading to mass induced emotional disorders, which are accompanied by "animal" fear. Panic inducers are alarmists, people with expressive movements, the hypnotizing power of screams, and false confidence in their actions. Becoming the leaders of the crowd in extreme circumstances, they can create a general disorder that quickly paralyzes the whole group.
Prevent panic by preliminary training in actions in critical situations, truthful and complete information during and at all stages of the development of emergency events, special training active leaders who are able at a critical moment to lead the confused, to direct their actions towards self-rescue and the salvation of other victims.
In the development of an extreme situation, 3 periods are defined, each of which is characterized by certain psychogenic disorders (see diagram).
First - acute - period lasts from the beginning of exposure to the organization of rescue operations (minutes, hours). At this time, predominantly psychogenic reactions of a psychotic and non-psychotic level are observed, among which mental disorders occupy a special place in those who have received injuries and wounds. The doctor has to conduct a qualified differential diagnostic analysis in order to identify a causal relationship of mental disorders both directly with psychogenic disorders and with injuries received (traumatic brain injury, intoxication due to burns, etc.).
Especially it should be noted the features of the beginning of the development of a life-threatening situation during the first period extended in time. The danger at this time may not have signs that allow it to be perceived as threatening (as, for example, during the accident at the Chernobyl nuclear power plant). Awareness of the threat to life and health arises only as a result of official and unofficial (rumors) information from various sources. Therefore, psychogenic reactions develop gradually, with the involvement of ever new groups of the population. Non-pathological neurotic manifestations predominate, as well as reactions of the neurotic level, determined by the anxiety that appeared after the awareness of the danger; the proportion of psychotic forms is usually insignificant. Only in isolated cases, reactive psychoses with anxiety-depressive and depressive-paranoid disorders are detected and already existing mental illnesses become aggravated.
After the end of the acute period, some victims experience short-term relief, a rise in mood, actively participate in rescue work, sometimes verbose, repeating many times, talk about their experiences. This phase of euphoria lasts from several minutes to several hours.. As a rule, it is replaced by lethargy, indifference, ideational inhibition, difficulties in comprehending the questions asked, performing even simple tasks. Against this background, there are episodes of psycho-emotional stress with a predominance of anxiety. In some cases, the victims give the impression of being detached, immersed in themselves, often and deeply sigh, bradyphasia is noted. A retrospective analysis shows that the inner experiences of these people are often associated with mystical-religious ideas. Another option for the development of anxiety during this period may be "alarm with activity", manifested restlessness, fussiness, impatience, verbosity, the desire for an abundance of contacts with others. Expressive movements are somewhat demonstrative, exaggerated. Episodes of psycho-emotional stress are quickly replaced by lethargy, apathy; there is a mental "processing" of what happened, the awareness of losses, attempts are made to adapt to new conditions of life.
Against the background of vegetative dysfunctions are often exacerbated psychosomatic diseases, relatively compensated before the extreme event, persistent psychosomatic disorders appear. Most often it happens in the elderly, as well as in the presence of residual phenomena. organic disease CNS of inflammatory, traumatic, vascular origin.
In the second period (deployment of rescue operations)"normal" life begins in extreme conditions. At this time, for the formation of states of maladjustment and mental disorders, the personality characteristics of the victims, as well as their awareness of not only the preservation of a life-threatening situation in some cases, but also new stressful effects (loss of relatives, separation of families, loss of home, property) become much more important. An important element of prolonged stress is the expectation of repeated impacts, a discrepancy with the results of rescue operations, the need to identify deceased relatives, etc. The psycho-emotional stress characteristic of the beginning of the second period is replaced by its end, as a rule, by increased fatigue and "demobilization" with astheno-depressive manifestations .
In the third period, starting for victims after their evacuation to safe areas, for many, there is a complex emotional and cognitive processing of the situation, a kind of "calculation" of losses. Acquire relevance and psychogenic traumatic factors associated with a change in life stereotype, contributing to the formation of relatively persistent psychogenic disorders. Along with persistent nonspecific neurotic reactions and conditions, protracted and developing pathocharacterological changes, post-traumatic and social stress disorders begin to predominate. Somatogenic mental disorders in this case can be of a diverse "subacute" nature, there are both "somatization" of many neurotic disorders, and, to a certain extent, "neuroticization" and "psychopathization" opposite to this process. The latter are associated with the awareness of traumatic injuries and somatic diseases, as well as with the real difficulties of life.
Each of the mentioned conditions has its own characteristics that predetermine the methodological, organizational and therapeutic tactics. special attention deserve reactive psychoses that occur in the first period of a life-threatening situation. They are characterized by pronounced disorders of mental activity, depriving a person (or a group of people) of the opportunity to adequately perceive what is happening, for a long time disrupting labor and performance. Vegetative and somatic disorders also develop - from the side of the cardiovascular, endocrine and respiratory systems, gastrointestinal tract, etc., in some cases expressed so sharply that they become leading in painful manifestations. Reactive psychoses, as a rule, develop acutely, under the influence of a combination of extreme adverse factors. It is generally accepted that they are promoted by overwork, general asthenia, sleep disturbances, nutrition, preliminary physical and mental trauma (for example, minor injuries to the body and head, concern for the fate of relatives and friends, etc.). Fugoform reactions are short-term - up to several hours, stuporous ones are longer - up to 15-20 days. Complete recovery is observed in almost all cases. These states, typical of life-threatening situations, are interpreted by the mechanisms of occurrence as primitive reactions to a threat to life.
Psychogenic twilight disorders
Consciousness is characterized by a narrowing of the volume of consciousness, predominantly automatic forms of behavior, motor restlessness (less often - inhibition), sometimes - fragmentary hallucinatory and delusional experiences. Usually they are short-lived (in 40% of all patients they end within a day). As a rule, all those who have undergone psychogenic twilight disorders have full recovery health and adapted activities.
Prolonged reactive psychoses are formed more slowly than acute ones, usually within a few days. The depressive form is more common. In terms of symptoms, these are quite typical depressive states with a well-known triad of clinical manifestations (decreased mood, motor retardation, slowing down of thinking). Patients are absorbed by the situation, all their experiences are determined by it. Usually there is a deterioration in appetite, weight loss, poor sleep, constipation, tachycardia, dry mucous membranes, in women - the cessation of menstruation. Severe manifestations of depression without active treatment are often delayed for 2-3 months. The final prognosis in most cases is relatively favorable.
Psychogenic paranoid usually develops slowly, over several days, and is usually protracted. Among the clinical manifestations in the first place are affective disorders: anxiety, fear, depression. Against their background, persistent delusional ideas of relationship and persecution are usually formed. There is a close connection between affective disorders and the severity of delusional experiences.
Pseudo-dement form, like other protracted psychoses, is formed within a few days, although cases are often noted acute development. Psychotic phenomena persist for a month or more, the condition of patients is characterized by deliberately rude demonstrations of intellectual impairment (the inability to name the age, date, list the facts of the anamnesis, the names of relatives, make an elementary account, etc.). The behavior is in the nature of foolishness: inadequate facial expressions, stretching the lips with a "proboscis", lisping speech, etc. Pseudo-dementia is especially pronounced when asked to perform simple arithmetic operations (addition, subtraction, multiplication). The errors are so monstrous that one gets the impression that the patient deliberately gives incorrect answers.
Of particular importance is the possibility of developing psychogeny simultaneously with other lesions - injuries, wounds, burns, which in such cases can be more severe.. Every brain injury is fraught with lung capabilities development of psychogenic, neurotic reactions and fixation of painful symptoms. The uncomplicated course of injuries depends on the tactics of a specialist doctor who provides "mental asepsis".
The greatest difficulties arise in the organization of first medical and pre-medical aid to victims. First priority- identify persons with acute psychomotor agitation, ensure the safety of them and those around them, eliminate the situation of confusion, exclude the possibility of mass panic reactions. Calm, confident actions of those who provide assistance are of particular great "calming" value for people with subshock (subaffective) psychogenic reactions.
Victims with psychogenia react negatively to measures of constraint, which should be resorted to only in cases of extreme necessity (aggressive behavior, pronounced arousal, the desire for self-harm). Restrictions can be limited by intramuscular injection one of the drugs that relieve excitement: chlorpromazine, haloperidol, tizercin, phenazepam, diazepam. Excitation eliminates the medicinal mixture of chlorpromazine, diphenhydramine and magnesium sulfate in various combinations and dosages ( complex use allows you to reduce some side effects of drugs and enhance the stopping effect). It should be borne in mind that chlorpromazine has pronounced general sedative properties, but it reduces blood pressure and predisposes to orthostatic reactions. Diphenhydramine potentiates the neuroplegic effect of chlorpromazine and reduces its hypotensive properties. Magnesium sulfate, along with sedatives, has dehydration properties, which is especially important when closed injury brain. In a stuporous state, a 10% solution of calcium chloride (10-30 ml) is injected intravenously, neuroleptics or tranquilizers are administered intramuscularly, and in some cases raush anesthesia is also used. For anxiety and depressive disorders, amitriptyline or similar drugs are prescribed. sedatives, with inhibited depression - melipramine or other antidepressant activators.
After relief of an acute condition in the second and third periods of development of the situation at the end of the emergency, it is necessary to use a complex of various psychotherapeutic methods, medications and social rehabilitation programs. They are not only necessary therapeutic measures for specific mental disorders, but also serve as a preventive basis for post-traumatic stress disorders.
