Psychiatry: A Course of Lectures - V. S. Bitensky 2004

Exogenous-organic and symptomatic mental disorders

Historical Overview of The Development of the Exogenous Reaction Type Concept

This branch of psychiatry may at first glance seem the most straightforward to comprehend, as its core material fits neatly into the standard logic of medical specialization: Etiology (exogenous factor) — Pathogenesis (organic Brain damage) — Clinical presentation (specific symptoms and syndromes) — Treatment (simultaneously targeting impaired interneuronal connections and purely psychopathological manifestations of the illness). On the other hand, psychiatry textbooks contain a vast amount of material dedicated specifically to "exogenous-organic and symptomatic mental disorders" and "late-life mental disorders (gerontological foundations)." These apparent contradictions are easily resolved if one builds a logical framework—grounded in the historical formation of leading medical paradigms and concepts in modern psychiatry—that successfully accommodates all clinical material regarding the so-called exogenous conditions accumulated by generations of psychiatrists.

Psychiatry intersects with philosophy more closely than any other medical discipline. For instance, the relationship between the mental and the physical, their interplay and mutual influence, is a deeply serious question for the psychiatrist, who encounters it constantly in daily practice. One might expect psychiatrists to have pioneered fields where "slippery philosophical ground" hinders other specialists. However, for a long time, this was not the case. Having emerged relatively late as a scientific branch of medicine, psychiatry long functioned merely by borrowing concepts from more advanced specialties rooted in pathological anatomy and microbiology. Virchow's concept of cellular pathology, built on Cell Theory, directed researchers to seek the substrate of any disease in specific changes within Organs and Tissues, while breakthroughs in microbiology allowed the specific cause of a disease to be identified for the first time in medical history. Thus arose the mechanistic, mono-causal paradigm (i.e., a system of views within a specific branch of science) associated with the name of Louis Pasteur. It persisted through almost the entire 19th and part of the 20th century, eventually giving way to Hans Selye's paradigm, which prioritized the Adaptation of living organisms to their environment. Naturally, Pasteur's paradigm implies a unitary cause-and-effect relationship: a specific etiological agent must provoke specific changes in Cells and Internal Organs, manifesting as a specific clinical picture unique to that agent alone (the nosological principle). Despite the fact that almost nothing was known at the time about the etiology or pathogenesis of mental illnesses (nor, for that matter, about their Morphology), the coryphaeus of world psychiatry Emil Kraepelin (who interestingly began his career at the Russian Imperial University of Dorpat, now Tartu) boldly applied the general medical views of his prominent contemporaries to the needs of psychiatry in the 1860s, thereby establishing the nosological approach. Yet, for the reasons mentioned above, he based his Classification not on etiological factors or morphological changes, but on the Similarities and differences in the course of Mental Illnesses and their ultimate outcomes (defective states dominated by negative symptoms).

Kraepelin's concept was not immediately embraced by all psychiatrists across Europe. Among its active critics was our distinguished compatriot S. S. Korsakoff, whose authority was already recognized by fellow psychiatrists in France, Austria, Germany, and Switzerland. Gradually, however, this concept assumed a leading role, shaping the developmental trajectory of psychiatry for a certain period.

The 20th century in science was marked by a departure from mono-causalism. In medicine, we owe this shift to Hans Selye. According to his teaching, an etiological factor, regardless of its nature, triggers a stereotyped mechanism of the pathological process within the Organism. Initially, the direction of this process is not disease-driven, but rather protective; only The breakdown of this defense system renders it pathological. Every organism possesses a hereditarily determined repertoire of reactions, the exhaustion of which leads to the demise of the biological entity.

Psychiatric science managed to outpace certain aspects of Selye's doctrine by several decades. Undoubtedly, the philosophical orientation of psychiatry was bound to assert itself, and it did so precisely at the dawn of the 20th century, largely thanks to the German psychiatrist and neuropathologist Karl Bonhoeffer, who formulated The Doctrine of the exogenous reaction type.

Kraepelin initially opposed Bonhoeffer's views, but later not only accepted them but also incorporated them into his own registry theory. Historical justice also requires mentioning another monumental figure in psychiatry: the German scientist Wilhelm Griesinger, who long before Bonhoeffer formulated METABOLISM/2.html">THE CONCEPT OF the "single psychosis" (Einheitspsychose), postulating that Various Forms of mental illness are merely stages of a single pathological process that may either halt at one of them or progress. However, Griesinger himself later came to believe in primary delusions, which contradicted the single psychosis concept. Such were the dramatic pathways along which psychiatric science advanced.

Karl Bonhoeffer was among the first in medical science to question the Specificity of an organism's response to noxious influences and whether that response depends on The Nature of the pathogen. His papers describing the classical types of exogenous reactions appeared nearly 30 years before Hans Selye's works on the General adaptation syndrome (1908 and 1936, respectively). Bonhoeffer's research focused on clinical settings, whereas Selye worked experimentally in laboratory conditions. Yet, comparing their overarching Conclusions, it becomes evident that each of these brilliant scientists independently formulated a foundational concept underlying modern medical science.

Examining Bonhoeffer's views in greater detail and comparing them with Selye's theory, one should recall that by grouping all possible exogenous factors of mental disorders under the umbrella term *Noxae*, Bonhoeffer concluded that this aggregate of harmful factors acts upon the brain not directly, but via a so-called "intermediate etiological link." Consequently, various morbid psychopathological phenomena should be viewed as reactions to this secondary autotoxic influence. As known from Pathophysiology, Selye used a very similar definition—the "first mediator"—referring to any factor activating the Hypothalamus-pituitary-adrenal cortex axis. The pivotal idea in both concepts is that, despite the vast diversity and multiplicity of pathogenic factors, the organism has a quite limited number of ways to respond to them.

In 1908, Bonhoeffer identified the well-known five types of exogenous reactions: delirium, twilight state of consciousness (originally termed the epileptiform type), acute hallucinosis, ammentia, and stupor (clouding of consciousness). Today, THE SPECTRUM OF exogenous mental disorders is much broader, but the German scientist's brilliant insight has lost none of its relevance.

Another commonality between the doctrines of Selye and Bonhoeffer is that they addressed the problem not only in stasis, but also in dynamics. The well-known staged description of stress as an initial alarm phase, followed by resistance, and ultimately exhaustion, is universally recognized. Bonhoeffer similarly sought to uncover the dynamic Regularities of the exogenous reactions he described. For instance, for infectious diseases, he outlined the following sequence: asthenia during the prodromal phase, delirium or another form of psychomotor agitation at the fever's peak, ammentia corresponding to the drop in Temperature (the latter is rarely seen in clinical practice today, but we must remember that Bonhoeffer formulated his concept long before the advent of Antibiotics), and an asthenic syndrome dominating the convalescence period. Both researchers also accounted for internal factors, particularly the organism's hereditarily predisposed vulnerability to a specific reaction pattern.

Bonhoeffer described the development of states during exogenous psychoses that were previously considered strictly endogenous (maniform, depressive, paranoid, and catatoniform syndromes). Later, Kraepelin, by advancing the registry theory, explained The Emergence of Schizophrenia-like states across various entirely dissimilar diseases. We should also note that most of the exogenous reactions proposed by Bonhoeffer and his followers belong to productive disorders; that is, they are not the direct consequence of the destruction of specific brain structures, but rather the result of the functioning of mental layers preserved in the dramatic "duel" between the brain and the *Noxae*. This confirms the initially adaptive nature of these reactions, much like the reactions pointed out by Selye in his theory of adaptation breakdown.

Thus, having examined The Essence of exogenous-organic and symptomatic mental disorders and clarified their Historical Background, we can move on to a detailed analysis of specific syndromes (brain reactions) outlined in the current International Classification of Diseases (ICD-10) under diagnostic category F0: "Organic, including symptomatic, mental disorders." The logic of our presentation is as follows: we will first examine a given typical syndrome or disorder, and then illustrate and Supplement it with a range of impairments typically observed under The Influence of a specific etiological factor (such as trauma or ionizing radiation). Subsequently, dementing diseases of late life will be discussed.

Let us begin with personality and behavioral disorders due to brain disease, damage, and dysfunction, which can be viewed to some extent as the mildest manifestations of exogenous conditions. However, classifying any mental or behavioral disorder under category F0 is justified only when its etiological factor (the type of *Noxae*) is definitively known, or when Instrumental Diagnostic Methods (CT, EEG, Echo-EG, REG, Doppler sonography, MRI, etc.) clearly indicate the presence of brain tissue damage.

Personality and Behavioral Disorders Due to Brain Disease, Damage, and Dysfunction

We have previously reviewed the classification and Clinical Features of various personality and behavioral disorders in adults, which were attributed exclusively to genetic factors or upbringing flaws. Clinically similar disorders can also arise from exogenous causes (most commonly HEAD trauma in modern society), in which case they are regarded precisely as exogenous-organic. Such disorders may predominantly affect the emotional-volitional sphere of the personality (impulsive—sometimes called explosive, derived from "explosion"; anxious), The system of interpersonal relationships (schizoid, dependent), the cognitive system (paranoid, obsessive-compulsive), the sphere of drives and instincts (kleptomania, Sexual Perversions), or even the entire spectrum of a person's social functioning (histrionic, dissocial). Let us focus on cases where paraclinical examination methods have documented organic brain damage of any etiology. Naturally, identifying the specific factor based solely on a particular personality disorder is entirely unrealistic, but in some instances, one can roughly infer the locus of the lesion. For example, in frontal lobe syndrome, an individual loses The ability to anticipate the consequences of their actions and plan their behavior accordingly; untidiness and reduced initiative (bordering on aspontaneity) make them "difficult" for their microsocial environment.

In diagnosing personality and behavioral disorders resulting from brain disease or injury, one must bear in mind that the capacity for goal-directed activity is significantly diminished. Emotional manifestations alter in the form of emotional lability, unmotivated euphoria abruptly shifting to irritability, and bouts of aggression and anger (dysphoria), although in certain cases (chiefly with frontal lobe damage), apathy is the leading emotional manifestation. Furthermore, in these patients, the realization of needs and drives (especially sexual ones, which frequently assume a perverted character) occurs without regard for the consequences of their actions. This very often leads to conflicts with the law. Cognitive impairments are typically secondary; however, heightened suspiciousness or an obsessive fixation on some Abstract idea (such as "what is good and what is evil") very frequently coexists with the aforementioned symptoms. The speech of such patients reflects numerous circumstantial associations, with peripheral associations overly intruding into the conversation's theme. Occasionally, the patient's speech is viscous. Hypergraphia (litigiousness/querulousness) is also frequently observed. Yet, all this diversity of manifestations is united by a common feature—the asthenic symptom complex, which becomes apparent to the physician through rapid exhaustion under prolonged cognitive stress in individuals suffering from organic personality changes.

Given the high prevalence of environmental harmful factors (complicated labor, frequent trauma, somatic illnesses, poisoning—primarily by ethanol and its metabolic derivatives, radiation, infections, etc.), it is clear that organic personality disorders are very common in the population. Scarcely anyone would dare even to roughly estimate their "specific weight," since only the most severe forms come to the attention of a psychiatrist. At the same time, these very individuals frequently use psychoactive substances as a form of self-medication at certain stages of life, and dependence on addictogens develops in them much faster than in the general population. Consequently, they often seek treatment as dependent patients (alcoholism, substance abuse), while the underlying organic manifestations may be misjudged by the physician as secondary.

For practitioners of any specialty, understanding the behavioral peculiarities of patients with organic personality changes is crucial both from a deontological standpoint (preventing unnecessary conflicts that frequently arise during treatment) and for planning a therapeutic program for the primary disease (given the significant impact of organic personality changes on the internal picture of the illness, patient compliance, and adherence to medical recommendations).

Post-Encephalitic and Post-Concussional Syndromes

Based on the foregoing considerations, let us examine post-encephalitic and post-concussional syndromes.

Post-Encephalitic Syndrome

This refers to residual changes following recovery from bacterial or viral encephalitis. Unlike organic personality disorder, these changes are more frequently reversible. Symptoms include malaise, apathy or irritability, difficulties in acquiring new knowledge and skills, Sleep and appetite disturbances, and sexual dysfunction. In many cases, residual neurological deficits are observed: parkinsonism in epidemic encephalitis, Kozhevnikov's Epilepsy in tick-borne (spring-summer) encephalitis, signs of intracranial Hypertension in mumps, hemiparesis, aphasia, and cranial nerve innervation disorders in measles encephalitis, and the Argyll Robertson pupil, dysarthria, etc., in neurosyphilis.

Post-Concussional Syndrome

This arises following head trauma and manifests as headache, dizziness, fatigue, irritability, sleep disturbances, rapid cognitive exhaustion accompanied by reduced memory span, and decreased tolerance to alcohol and emotional stress.

Given the prevalence of traumatic brain injury in the population, driven by current realities (the technical revolution, transport development, wars, and the accelerating pace of life), it is logical to examine specific clinical features of post-traumatic illness (TBI sequelae) across various stages of its course.

Delirium not induced by alcohol or other psychoactive substances

Examining the essence of C. Bonhoeffer's concept, it was emphasized that delirium is an etiologically non-specific syndrome characterized by concurrent disturbances in consciousness, attention, perception, thinking, memory, psychomotor behavior, emotions, and the sleep-wake cycle. It can occur as a reaction to any pathogenic factor and at any age, though individuals over 60 are more susceptible to delirious clouding of consciousness. Regarding its dynamics, delirium tends to fluctuate in intensity and belongs to short-term psychotic states. Recovery from delirium typically occurs within a week and is always preceded by deep, critical sleep. In some cases, recovery takes up to 1 month. However, fluctuating delirium lasting up to 6 months is not uncommon, especially when occurring against the backdrop of chronic Liver disease, carcinoma, or bacterial endocarditis. A delirious state may occur alongside dementia or progress into dementia or Korsakoff's syndrome. In a previous lecture, we discussed alcohol-induced delirium or delirium caused by any other psychoactive substance. In its intrinsic content, it was also delirium of exogenous origin, yet it is considered separately from other intoxication deliriums due to its specific etiology and its association with addiction issues.

Let us recall the diagnostic criteria for a delirious state:

— altered consciousness and attention (reduced ability to direct, focus, sustain, and shift attention); characteristic is the so-called dissociation of orientation — patients are well-oriented regarding themselves and their interpersonal relationships with real people, but are disoriented in space and time to varying degrees;

— global Impairment of the cognitive system (perceptual disturbances — illusions and hallucinations, predominantly visual; impairment of abstract thinking and comprehension with secondary, unstable delusions or without them; impairment of immediate recall and memory for recent events with relative preservation of remote memory; disorientation in time, in more severe cases — in place, and very rarely — regarding one's own personality);

— psychomotor disturbances (hypoactivity, or more frequently hyperactivity, and unpredictability in transitioning from one state to another; increased or decreased speech output);

— sleep-wake cycle disturbances (insomnia, in severe cases — total loss of sleep or inversion of the sleep-wake cycle; restless sleep and nightmares, which may persist as hallucinations upon awakening);

— emotional disturbances (depression, anxiety, or fear); irritability, euphoria, and apathy may also be observed;

— typically rapid onset of the disorder; fluctuation in the depth of impaired consciousness throughout the day; the total duration of the delirious disorder should not exceed 6 months in individual cases; as a rule, within 1 week delirium either resolves, progresses to dementia, or leads to the patient's death due to cerebral edema and Swelling.

Other mental disorders due to brain damage and dysfunction, or to physical disease

This category encompasses various conditions causally related to brain dysfunction resulting from primary cerebral disease, systemic disease secondarily affecting the brain, endocrine disorders such as Cushing's syndrome, and other somatic illnesses associated with the effects of certain toxic substances or Hormones.

Organic hallucinosis — a disorder characterized by persistent or recurrent hallucinations, usually visual or auditory, occurring against the background of clear consciousness. Insight is typically preserved. Other characteristic features include the absence of marked intellectual decline, no dominant mood disorder, no dominant delusional disorders, and, importantly, no clouding of consciousness.

Organic catatonic disorder — In addition to general criteria indicating an organic etiology, the following must be present:

— either stupor (diminished or complete absence of spontaneous movement, with partial or complete mutism, negativism, or posturing);

— or excitement (general hypermobility with or without a tendency toward aggression);

— or both states (rapidly and unpredictably alternating states of hypo- and hyper-reactivity observed in the same patient).

Other catatonic phenomena that increase diagnostic reliability include stereotypies, waxy flexibility, and impulsive acts.

Organic delusional (schizophrenia-like) disorder — a disorder in which persistent or recurrent delusions (of persecution, jealousy, illness, or death of the patient or another person) dominate the clinical picture. Delusions may be accompanied by hallucinations, but are not firmly tied to their content. Thinking disorders or isolated catatonic phenomena may be present. Consciousness and memory are unimpaired. A Diagnosis of organic delusional disorder cannot be made when organic evidence is limited, relies solely on physical findings (e.g., enlarged cerebral ventricles), or soft neurological signs. In other words, diagnosing an organic delusional (schizophrenia-like) disorder requires a comprehensive set of both anamnestic and diagnostically objectifying data.

Organic mood disorders — disorders characterized by mood changes, usually accompanied by shifts in overall activity levels. The sole criterion for including such disorders in this section is their direct causation by a cerebral or physical disorder, the presence of which must be demonstrated by independent methods or supported by adequate anamnestic data. An example of such a disorder is post-infectious depression (following Influenza).

Organic anxiety disorder — a disorder characterized by features of generalized anxiety disorder, panic disorder, or a combination thereof, arising as a consequence of an organic factor capable of causing cerebral dysfunction.

Having summarized mental disorders of exogenous-organic origin, let us now examine the Specific features of their clinical course under individual etiological factors.

Features of exogenous-organic and symptomatic mental disorders under the influence of mechanical and physical factors

Traumatic brain disease (sequelae of traumatic brain injury)

TRAUMATIC BRAIN INJURIES are classified into open injuries, where the integrity of the cranial cavity is breached, and closed injuries. However, this division is rather conventional. For instance, closed injuries may involve various Skull fractures (such as a skull base fracture), giving the injury certain characteristics of an open one. This is examined in greater detail in the course of neurosurgery; for the psychiatrist, what matters is the overall severity of the injury, the aforementioned individual psychological response patterns of the personality, the time elapsed since the injury, complicating factors in the course of the traumatic illness (exhaustion, injuries to other body parts, age, massive Blood loss, presence of alcohol intoxication), as well as various concurrent psychogenic situations (e.g., the horrors of destruction and human casualties during bombings or terrorist attacks). In other words, it is difficult to imagine a traumatic brain injury that is not simultaneously a psychotrauma.

The course of traumatic disease is divided into four periods: initial, acute, convalescence, and remote consequences.

In the initial period, impaired consciousness of varying depth is observed—ranging from mild obtundation to coma.

In the acute period, consciousness is restored (not always immediately); instead, various disorders of mental functioning appear that are characteristic of exogenous-organic disorders—hallucinosis, delirium, amencephaly, twilight state of consciousness, epileptiform seizures, retrograde and anterograde amnesia, Korsakoff's syndrome, etc. Asthenic syndrome remains central.

During the convalescence period, which lasts from 1–2 months to 1 year, all manifestations of the acute period gradually subside, and a significant number of patients recover. In more severe cases, asthenia, paroxysmal disorders, various manifestations of psycho-organic or Korsakoff's syndrome, and occasionally twilight states predominate. It is during this period that the aforementioned organic personality disorders become clearly outlined. Prolonged psychoses (e.g., hallucinatory-delusional or affective) are also characteristic of this third period. In mild cases, recovery occurs, but asthenic syndrome (which may not be purely asthenic, but asthenodepressive, asthenoadynamic, asthenoapathetic, etc.) is invariably present, a fact that physicians of any specialty should always keep in mind. In the remote period, maladaptation syndrome (impaired social functioning) is most frequently observed, and in complicated cases (most commonly by alcoholism), encephalopathic syndrome (psycho-organic), paroxysmal states (epileptiform syndrome being most typical), or even dementia may occur. Sometimes personality changes, alongside hallucinatory-paranoid disorders, reach such a severe degree that it becomes very difficult to differentiate the consequences of traumatic brain injury from schizophrenia. Key differential diagnostic features include an extraordinarily high depletion of cognitive Functions in those who have suffered trauma and the absence of structural Thought Disorders characteristic of schizophrenia.

One should not overlook the neurological symptoms most frequently observed in traumatic brain injuries: vestibular disorders, particularly orthostatic dizziness and loss of balance, nausea and vomiting, headache, nystagmus, etc. A specific feature of a psychiatrist's work is the integration of general somatic and neurological symptomatology into the diagnostic and treatment process, without which a psychiatric diagnosis loses its integrity and becomes limited by phenomenological dogmatism. This also applies to the patient's personality traits, which physicians of other specialties, unfortunately, most often ignore. It is forgotten that even acute appendicitis occurs in living people with their own character, temperament, worldview, and existential problems. And what is there to say about mental disorders?..

The well-being of an injured person can sometimes be deceptive, which confuses the physician: the injury is not severe, and the symptoms quickly subsided, but after a few days, the patient complains of intense headache, which may be accompanied by mild chills and hypodynamia. In these cases, intracerebral Hemorrhage (most commonly subarachnoid) is suspected. It is characterized by a triad: CEREBROSPINAL FLUID and arterial hypertension against the background of bradycardia. This condition is an absolute indication for surgical intervention. The physician should also bear in mind that a clinical picture resembling hemorrhage can also be observed in cerebral fat embolism, which most frequently occurs with concomitant fractures of long tubular bones. In such cases, Skin petechiae in the occipital region and above the clavicle, fundus congestion, and a decrease in blood Hemoglobin levels are also observed.

A special case of traumatic brain injury is blast-wave trauma. Consciousness is lost even before the victim hears the explosion. Prior to falling, one feels The impact of an elastic body on the occipital region of the head, regardless of where the shell detonated. The unconscious state lasts from a few minutes to 5–6 hours. Bleeding from the Nose, throat, and ears is very frequent. After regaining consciousness, brief states of agitation with negativism may occur. Subsequently, patients behave as if stunned and hypoactive. They try to lie down, even in an awkward posture. Retrograde amnesia does not occur, while anterograde amnesia is quite rare. Instead, The phenomenon of surdomutism (patients lose the ability to speak and understand spoken language addressed to them) is almost always observed. Surdomutism tends to resolve spontaneously. Patients complain of heaviness, noise, and ringing in the head. During the period of symptom reduction in the acute phase, asthenia and mood changes are characteristic. Affective Disorders last up to 1.5–2 months, eventually giving way to asthenia. Sometimes, spontaneously or after provoking psychotraumatic moments, paroxysmal dysphoric states arise. Lasting from a few hours to several days, these states in the most severe cases may culminate in an epileptic paroxysm or a twilight state of consciousness.

The period of remote consequences in the course of traumatic disease is of great importance for understanding the psychiatric aspect of the problem. Knowledge of the potential mental manifestations of the remote period of traumatic brain injury is relevant for general practitioners. Remote consequences include those neuropsychiatric disorders which, having arisen in the acute or later period, do not resolve but persist and significantly affect behavior long after the injury. These disorders manifest as various forms of asthenia, psychopath-like and cyclothymic states, paroxysmal states (including various forms of clouded consciousness), endomorphic psychoses (affective, hallucinatory-delusional, paranoid), dementia states, or psycho-organic syndrome.

Among the remote consequences of traumatic brain injury, traumatic asthenia is the most common, often referred to as the "pervasive" disorder throughout the entire period of remote consequences. Manifestations of irritability and exhaustion in various proportions are characteristic against the background of asthenia. Irritability accounts for loss of self-control, impatience, and reactions of discontent. These outbursts are short-lived and end in remorse. In addition to increased physical and mental exhaustion, indecisiveness, touchiness, and a lack of faith in one's strength and capabilities are noted. Patients are hypersensitive to minor life events and therefore often avoid conflict-ridden, psychotraumatic situations ("sheltering" themselves). In all cases, various vasomotor disorders are observed—fluctuations in blood pressure, hyperhidrosis, and vascular lability. Numerous Complaints regarding cerebral-organic disorders are noted—headache, dizziness, forgetfulness, and difficulty concentrating. Vestibular disturbances, manifesting during travel in transport, along with various and persistent sleep disorders, are frequent. Various external factors, both physical and mental, worsen the patients' condition. In the mildest cases, asthenic disorders remain hidden and manifest overtly only periodically. The predominance of irritability over exhaustion indicates a lesser severity of asthenia.

Traumatic asthenia with a predominance of apathy (traumatic encephalopathy with apathy). The clinical picture is dominated by increased exhaustion, observed alongside lethargy, general inhibition, and a sharp decrease in drives: interests are limited to a narrow circle of domestic issues. Memory disorders are common. Sometimes traumatic asthenia with apathy develops after the acute period ends and persists unchanged for many years. In other cases, it serves as a transitional stage to prognostically less formidable forms of asthenia.

Psychopath-like personality disorders (former name: traumatic encephalopathy with personality psychopathization). These have already been discussed, but Structure/19.html">The Importance of these conditions for the clinician prompts a revisit. Hysterical traits, explosiveness, and their combination are most frequently observed. The external manifestations and severity of psychopath-like disorders, as well as their correlation with the asthenic background, depend on the victim's age at the time of injury, its severity, premorbid personality traits, microsocial conditions, and additional factors, among which alcoholism holds the primary place.

Cyclothymic disorders are always accompanied by asthenic or psychopath-like disturbances and therefore cannot be considered an isolated phenomenon. Subdepressive mood disorders are more common than hypomanic (hypertymic) ones. All of them feature a pronounced dysphoric component, which is significant. The duration of affective disorders varies: sometimes they are transitory and resemble reactive lability; in other cases, they last for days, weeks, or months. Traumatic asthenia is usually accompanied by circularity in the form of reactive lability and subdepressive states of varying duration. The dysphoric component is weakly expressed, while hypochondria persists constantly. Psychopath-like states with hysterical disorders are accompanied by reactive lability, in which distinct dysphoric traits alternate with exaltation. In these cases, prolonged depressions with overvalued hypochondria are more frequently observed. Psychopath-like states with explosiveness are accompanied by depression with a pronounced dysphoric component or attenuated prolonged bipolar mood disorders. Affective disorders frequently lead to alcohol abuse.

Neurological disorders in the aforementioned conditions are often mildly expressed, limited only to a slight increase in tendon Reflexes, finger tremor, unsteadiness in the Romberg position, and dermographism phenomena. So-called focal symptomatology is possible but not obligatory.

Paroxysmal disorders and states of altered consciousness (traumatic epilepsy, traumatic encephalopathy with epileptiform syndrome). The frequency of these disorders varies considerably. Paroxysmal disorders occur both within the first year after injury and in the remote period. A polymorphism of paroxysmal phenomena has been noted. Various non-convulsive (or minimally convulsive) paroxysms occur much more frequently than convulsive ones: these include minor seizures, absences, dream-like states occurring day or night, cataplectic paroxysms, as well as so-called epileptic dreams, consciousness auras, psychosensory disorders of various manifestations (metamorphopsias and body schema disorders), and paroxysms of vasomotor-vegetative disorders accompanied by rudimentary tonic convulsions (mesodiencephalic attacks) or without a convulsive component (diencephalic attacks). Convulsive and non-convulsive paroxysms can be combined. Incidentally, dysphorias also belong to paroxysms. Personality changes are determined primarily by psychopath-like disorders with phenomena of circularity. Intellectual impairments do not exceed the level of personality decline.

States of clouded consciousness occur more frequently when various paroxysmal disorders, primarily convulsive ones, are present. Twilight states of varying structure predominate, occurring more often immediately after major convulsive seizures and less frequently after minor ones. Twilight states follow a "cliché" pattern (i.e., two separate attacks resemble each other like twins). In other cases, independently of paroxysms, but usually following additional somatic insults, including alcohol excesses, precursors exist in the form of disturbed sleep, cerebral-organic symptoms, and a depressed-anxious mood. This is followed by clouding of consciousness with various productive disorders, primarily delusional, hallucinatory, and affective, and less frequently psychosensory. Some researchers of the life of the genius painter Vincent van Gogh believe that he experienced precisely such a state when, in a morbid condition, he cut off his ear. Pronounced vasomotor-vegetative symptoms lasting up to 3–5 days are constant. Lucid (i.e., non-psychotic) periods are characteristic. Emergence from the twilight state is critical, following prolonged sleep. Incomplete and retarded amnesia is frequently observed. The onset of twilight states, especially in the post-seizure period, indicates a tendency of the traumatic disease toward a progressive course.

Endomorphic psychoses. The development of affective, hallucinatory-delusional, and less frequently paranoid psychoses in the remote period of TBI is generally preceded by a specific combination of psychopathological disorders. Symptoms of asthenia, psychopath-like, cyclothymic, or paroxysmal disturbances appear in combination with symptoms of organic decline, the degree and characteristics of which are closely linked to the type of endomorphic psychosis.

Affective psychoses proceed in the form of single or recurrent depressions and manias, as well as bipolar forms. The development of depressions is preceded by asthenia with pronounced irritability, while psychopath-like disorders are defined by hysterical disturbances with explosiveness. In manias and bipolar psychoses during the preceding period, the asthenic component is minimally expressed, dominated instead by explosiveness with brutal affective discharge, a clear tendency toward litigiousness, and reactive lability "colored" by a pronounced dysphoric component. Organic decline can reach the level of a mild psycho-organic syndrome. Among paroxysmal disorders, various non-convulsive attacks accompanied by short-term and mild alterations of consciousness are most frequently observed.

Hallucinatory-delusional psychoses are more common in men. The psychosis is preceded by asthenic states with sluggishness, apathy, and a decrease in drives, while psychopath-like disorders are minimally expressed. The psychosis typically develops following somatic deterioration. It more frequently debuts with a twilight or, less commonly, delirious clouding of consciousness, accompanied by pronounced hallucinatory-delusional disorders where hallucinosis outweighs delusions, and the psychosis may become chronic. In some cases, it "freezes" at the level of relatively pure hallucinosis; in others, the clinical picture gradually becomes complicated by symptoms of hallucinatory paraphrenia. Insight into the illness is partially preserved. A depressed mood prevails (in contrast to analogous psychoses of schizophrenic origin).

Paranoid states and paranoid psychoses most frequently manifest in the form of overvalued or delusional jealousy, or prolonged litigious reactions.

Remissions in patients with paroxysmal affective, hallucinatory-delusional, and paranoid psychoses, given a significant duration of the illness, are characterized by an increase in asthenia and mnestic impairments, with a gradual erasure of psychopath-like disorders and often the complete disappearance of paroxysms. Instead, defect states develop that are nearly indistinguishable from those seen in schizophrenia.

Treatment of TBI Consequences

The Treatment of Mental Disorders resulting from traumatic brain injury involves The Use of both symptomatic antipsychotic agents (e.g., risperidone for hallucinatory-delusional psychoses or cipralex for bipolar affective disorders) and agents aimed at restoring lost brain functions and improving its performance. These are, first and foremost, nootropics. One must also not forget the necessity of correcting cerebrospinal fluid hypertension caused by adhesion formation. Rehabilitation of patients, depending on the severity of consequences, can be carried out on an outpatient basis, but in the most complex cases, it requires long-term hospitalization. This provides an opportunity, in particular, to limit the patient's contact with alcohol, to the consumption of which individuals who have suffered a traumatic brain injury are prone. Alcohol acts as a peculiar adaptogen for such patients, but low tolerance to ethanol in the injured, The high frequency of atypical (primarily dysphoric) forms of intoxication, and other specific factors lead to the rapid formation of dependence with subsequent deepening of encephalopathy and conflict-delinquent actions on the part of patients.

Radiation Sickness. Mental Disorders Resulting from Ionizing Radiation

The clinical picture of this pathology has much in common with traumatic disease. At the very least, its periodicity is nearly identical.

Mental disorders occur upon exposure to X-rays, neutrons, and gamma radiation, which cause deeply destructive changes in tissues, particularly in the cortex and subcortical nuclei, where 35–40% of all cells perish. Brain edema with hemorrhages into its substance, nodular glial hyperplasia, pericellular edema of pyramidal cells, and chromatolysis of nuclei occur. At a radiation dose exceeding 8,000 roentgens, a cerebral (fulminant) form develops, in which neuropsychiatric changes come to the foreground. Immediately after irradiation, a coma occurs or deep ataxia and adynamia are observed, which may be replaced within the first minutes by psychomotor agitation; epileptiform seizures are also observed, and death occurs within the first few hours. At a dose of 5,000–8,000 roentgens, the toxemic form of acute radiation sickness is observed, caused by the intoxication of The Nervous system with tissue breakdown products. The clinical picture exhibits various forms of consciousness impairment, fragmentary hallucinations, psychomotor agitation, and epileptiform seizures. Death generally occurs within the first week.

At an exposure dose of 1000–5000 rad, the gastrointestinal form develops. Symptoms include nausea, vomiting, diarrhea, tenesmus, intestinal paresis, and gastrointestinal bleeding. Patients exhibit asthenia with profound apathy, which may give way to psychomotor agitation within the framework of an amentive syndrome. These patients likewise do not survive beyond the first 10 days.

Exposure doses ranging from 100 to 1000 rad result in the Bone Marrow form of radiation sickness. Most of these patients survive, depending largely on the dose, the promptness and adequacy of medical intervention, and the individual PHYSIOLOGICAL CHARACTERISTICS OF the organism. It is estimated that a cumulative exposure dose of 400 rad will prove fatal in half of the affected individuals.

The Clinical Course of Radiation Sickness

Radiation sickness, much like traumatic disease, unfolds across several distinct stages. The First stage is designated as the initial general reaction. During its first phase, lasting up to 4 days, patients report headaches, tinnitus, blurred Vision, nausea, repeated vomiting, thirst, profound weakness, muscular twitching across various Muscle groups, a sensation of skin burning, palpitations, hyperhidrosis, sleep disturbances, as well as intermittent abdominal and cardiac pain. In mild cases, psychiatric manifestations are limited to insomnia and moderate agitation, whereas severe cases may feature brief losses of consciousness, occasionally accompanied by psychomotor agitation or, conversely, adynamia, somnolence, and apathy. These variations depend on the patient's individual stress response and prior somatopsychic status (for instance, adynamia is more likely if the radiation exposure was preceded by a debilitating illness or a lack of adequate rest).

The second phase, of roughly equal duration, is characterized by extreme Variability of symptoms: dysphoria combined with somnolence, adynamia, and apathy that may alternate with euphoria, alongside a lack of insight into one's condition (the "radiation hangover" symptom). By evening, patients may experience hypnagogic hallucinations, and in some instances, pre-delirious or delirious states. Cognitive impairments of an asthenic origin are quite typical, including rapid fatigue, difficulty in comprehension, and attentional deficits.

Unlike traumatic brain injury, radiation sickness features a distinct latent period that can last up to 4 weeks. Only in the most severe cases do patients report asthenic symptoms during this window. For the most part, they are indistinguishable from individuals who managed to avoid a disease-inducing dose of radiation.

The third period constitutes the stage of manifest radiation sickness, lasting up to 20 days. Throughout this phase, patients exhibit hemorrhages, Burns, Metabolic Disorders, infectious complications, bleeding, epilation, and fever. Neurological findings of note include meningeal signs, hypo- or anisoreflexia, muscular hypotonia, and electroencephalographic (EEG) changes characterized by diminished and dysrhythmic biopotentials alongside slow-wave activity. Patients present with pronounced asthenia and deep apathy. In severe forms of radiation sickness, this period may feature stupor, twilight states of consciousness, and visual hallucinations, while the most severe forms progress to an amentive state. Psychosensory disturbances and memory deficits for recent events are also observed. The onset of seizures and epileptiform episodes is a prognostically unfavorable sign. In all instances, neurosis-like states—such as irritabilityfulness, tearfulness, and mood swings—are obligatory. In mild cases, the clinical picture is confined to these symptoms, followed by recovery.

The fourth period is the convalescence phase, which can extend up to 1.5 years. Hematopoiesis gradually recovers, bleeding tendencies subside, general well-being improves, and anxiety and doubts regarding recovery dissipate. Recovery is marked by lingering asthenia and a profound difficulty in adapting to novel situations and shifting physical factors (maladaptation syndrome). Solar radiation is tolerated particularly poorly, often triggering headaches, dizziness, and occasionally vomiting. Paroxysmal phenomena are frequently observed, including altered states of consciousness, psychosensory disturbances, dysphoria, and diencephalic crises. A subset of patients exhibits personality changes primarily affecting the emotional-volitional sphere, or memory impairments resembling Korsakoff's syndrome. Researchers in this field note striking similarities between the convalescence period of radiation sickness and that following a traumatic brain injury.

When characterizing all four periods of radiation sickness and their associated psychiatric disorders, it is essential to bear in mind that not only physical but also psychological factors shape the clinical picture. This is because radiation sickness typically arises in catastrophic settings involving human casualties, the loss of loved ones, scenes of devastation, mortal danger, and high-stress working conditions.

It is appropriate to delineate a fifth period of radiation sickness—the period of long-term sequelae, which has been thoroughly studied by Japanese researchers who monitored the survivors of the Hiroshima and Nagasaki atomic bombings. They documented psychiatric disorders in 71% of the irradiated cohort, with no direct correlation between the severity of the sequelae and the initial severity of the radiation sickness. These consequences represented a combination of organic brain changes and the individual's psychological reaction to illness. The most frequent manifestations included Memory and Attention deficits, intellectual exhaustion, emotional lability, and occasionally seizure activity, psychosensory disturbances, and vascular crises accompanied by syncopal episodes. Social adaptation and occupational capacity were notably diminished.

Chronic Radiation Sickness

Chronic radiation sickness occurs in individuals occupationally exposed to radiation sources and is driven by a cumulative effect. Its initial stage is marked by cerebral asthenia accompanied by emotional-vegetative lability. An accentuation of character traits is characteristic, frequently precipitating neurosis-like states (obsessive or hysterical). Sexual dysfunctions are also present. In later stages, a psycho-organic syndrome may develop, against the background of which illusions and olfactory hallucinations occasionally appear; severe forms feature bradypsychia, motor retardation, emotional rigidity, and memory impairment. Depressive states are notably characteristic; for instance, suicides were frequent among physicians operating poorly shielded X-ray equipment in the pre-war years. For diagnostic and forensic evaluation purposes, somatic-vegetative and endocrine markers (such as leukopenia, hypotension, and bone marrow alterations) must be taken into account.

The Impact of Microwave Fields on Human Mental Status

Working with high-frequency and ultra-high-frequency (microwave) currents under adverse conditions can induce pathological alterations in the organism. In such cases, patients complain of headaches, dizziness, fatigue, impaired memory, irritability, nocturnal insomnia accompanied by daytime drowsiness, paresthesias, limb pain, anorexia, thirst, epigastric discomfort, precordial sensations, and reduced work capacity. Anxiety and obsessive phobias are frequently reported. Patients often describe a sensation of wearing a tight "helmet" around the head. Weakness progresses, accompanied by escalating irritability and intolerance to light and noise. A secondary intellectual and memory decline of an asthenic type is typical. Women experience menstrual irregularities, while men report impotence. Typical clinical manifestations of prolonged radiofrequency exposure include vegetative dystonia with neurodystrophic disorders, as well as an asthenic state. Autonomic nervous system dysfunctions typically present as arterial hypotension, bradycardia, and other signs of parasympathetic hyperactivity. The severity of these disorders correlates directly with radiation intensity. In severe cases, against the backdrop of a pronounced asthenic state, a distinct vasopathy syndrome induced by prolonged microwave exposure may develop. Vasopathy manifests as vascular pathology accompanied by periodic paroxysms resembling diencephalic crises. Such vascular crises feature angiospastic headaches, facial pallor, generalized hyperhidrosis, adynamia, fears, bodily tremors, pulse and blood pressure instability with a hypertensive tendency, constrictive precordial pain, and occasionally brief syncopal episodes. Emotional fragility, emotional exhaustion, rigidity, and affective stasis—particularly involving anger—frequently occur. These emotional disturbances may present transiently as dysphoria. Some patients exhibit thought perseveration and obsessive fears that transform into hypochondriacal overvalued ideas. In the most severe cases, apathy, euphoria, or dysmnestic disorders are observed, signaling established features of a psycho-organic (encephalopathic) syndrome at this stage of the illness.