Psychiatry - O. K. Napriyenko 2001

Clinical Psychiatry
Affective Disorders

Affective disorders are fundamentally rooted in mood anomalies—namely, hypo- or hyperthymia.

The primary manifestations of depressive disorders include: persistent low mood; a pessimistic style of thinking; psychomotor retardation accompanied by a reduction in overall activity and "energy"; and the loss of The ability to experience pleasure (anhedonia). Persistent, unmotivated anxiety was previously included here as well, but modern classifications treat it separately from depression. Manic states are characterized primarily by inappropriate euphoria or irritability, hyperactivity, and accelerated thinking accompanied by grandiose ideas of self-importance.

According to WHO expert projections, these disorders ranked among the most widespread at the turn of the 21st century, with so-called unipolar depression projected to take second place after ischemic Heart disease among the top ten conditions leading to disability.

The symptoms mentioned above may form part of the clinical picture of numerous psychiatric, neurological, and somatic illnesses, which will be discussed in the relevant sections. The focus here is on distinct affective pathological conditions, such as manic-depressive psychosis and cyclothymia.

Classification

According to ICD-10

F 3 Mood [affective] disorders

F 30 Manic episode

F 31 Bipolar affective disorder

F 32 Depressive episode

F 33 Recurrent depressive disorder

F 34 Persistent mood [affective] disorders (includes F 34.0 Cyclothymia)

F 38 Other mood [affective] disorders

F 39 Unspecified mood [affective] disorder

According to DSM-IV

Mood Disorders

Depressive Disorders

296 Major Depressive Disorder

300.4 Dysthymic Disorder

311 Depressive Disorder Not Otherwise Specified

Bipolar Disorders

296 Bipolar Disorder

301.13 Cyclothymic Disorder

296.8 Bipolar Disorder Not Otherwise Specified

293.83 Mood Disorder Due to... (indicate the general medical or neurological condition)

296.60 Unspecified mood disorder

MANIC-DEPRESSIVE (CIRCULAR) PSYCHOSIS

Manic-depressive psychosis (MDP), or circular psychosis, also known as cyclophrenia, is an endogenous mental disorder manifested exclusively by emotional disturbances in the form of manic and depressive states with a phasic course. A characteristic feature of the disease is that even with multiple recurrences of attacks, a prolonged course of affective states, and a significant overall duration of the illness, personality changes—let alone signs of mental deficit—rarely develop. This provides grounds to classify MDP as a psychiatric condition with a favorable prognosis.

MDP was first named and delineated as an independent nosological entity by Emil Kraepelin in the late 19th century.

Epidemiology. Today, reliable data on the prevalence of MDP are generally limited to patients admitted to psychiatric inpatient facilities; patients with this form of pathology account for an average of 2% to 6% of the total hospitalized population. The frequency of MDP in the general population varies widely across different studies. This discrepancy is explained not only by differing diagnostic thresholds for this condition and variations in statistical record-keeping, but also by the fact that a significant proportion of patients with outpatient, cyclothymic, or masked forms of the disorder remain uncounted.

Studies show that women are affected by MDP nearly twice as frequently as men. The only exception is atypical MDP with an onset in childhood or adolescence, where no significant gender difference in prevalence has been observed between girls and boys.

Etiology AND Pathogenesis. A hereditary predisposition to affective psychoses plays a substantial role in The Development of MDP. Consequently, children of affected parents face a significantly elevated risk of developing the disorder. Research indicates that the concordance rate for MDP is approximately 67% in monozygotic twins and 23% in dizygotic twins.

While there is further indirect evidence supporting the genetic and constitutional etiology of this illness, no specific Gene or set of genes responsible for its onset has yet been identified, although associations between mood disorders and genetic markers on Chromosomes 5, 11, and X have been reported.

Constitutional-typological factors are undoubtedly important, manifesting predominantly in MDP patients with a pyknic body habitus. Premorbid psychological predisposition also plays a significant role. Retrospective analysis of patients' premorbid personality traits reveals a predominance of cycloid, hyperthymic, or hypothymic character traits.

The onset of the disease can be triggered by acute endocrine disruptions associated with Puberty, Pregnancy, childbirth, or menopause. Psychoreactive factors linked to severe psychological trauma also hold some significance. Cases triggered by TRAUMATIC Brain INJURIES and infectious diseases have been documented. Furthermore, intoxications—such as those accompanying alcohol abuse, particularly in young people—can act as precipitating factors.

The pathogenesis of MDP involves a dysfunction of the diencephalic and hypothalamic brain structures responsible for regulating emotional states. Neurochemical alterations within the monoamine system (including catecholamines and indolamines) are of undeniable importance. There is also evidence suggesting a role for opioid Peptides, particularly beta-endorphin and leu-enkephalin, in the genesis of this psychosis. Nevertheless, it is evident that no single hypothesis based on neurochemical brain research can fully account for the pathogenesis of affective pathology. The alterations in specific neurochemical pathways emphasized by proponents of various hypotheses should not be viewed in isolation, but rather in combination, as they undoubtedly Complement one another (A. D. Mashkovsky et al., 1983). Psychoanalytic and cognitive theories regarding THE ORIGIN OF affective disorders also exist.

Clinical picture. The primary manifestations of MDP include depressive and manic episodes characterized by affective disturbances, altered velocities of mental processes, and motor activity changes. Depending on the psychopathological Structure, MDP variants are categorized into simple, mixed, atypical, and complex forms.

The manic phase presents with the following typical features: manic affect, motor and verbal hyperactivity, and accelerated mental activity manifesting as intellectual excitation.

The intensity of the manic syndrome can vary. In mild cases (hypomanic states), elevation of mood is subtle. Patients experience an inner surge of energy, feel cheerful and content, and perceive their environment through an optimistic lens, coloring their surroundings in bright, cheerful tones.

During this period, patients exhibit increased productivity. They become more active and experience an influx of strength. Appetite notably increases, while The Need for rest and Sleep diminishes, leading to a marked reduction in nighttime sleep duration.

Unlike depressions, manic syndromes frequently develop at a subclinical level—namely, as hypomania—and less commonly progress to severe forms.

In more severe cases, patients are excessively cheerful, remain in a constant state of euphoria (ecstasy), and experience a profound sense of exaltation, inspiration, and omnipotence. Manic patients typically appear younger, more energetic, and full of vitality, displaying lively and expressive mimicry.

In this state, the content of their thoughts shifts in accordance with their affect: their thinking is optimistic, and their judgments and evaluations are superficial. Self-esteem is inflated; patients believe they possess extraordinary abilities and talents. They may develop ideas of invention, reform, or grandeur, sometimes reaching the level of fantastic delusions. In cases of extreme manic excitation, thought processes can become fragmented and lose their directional flow, bordering on a "flight of ideas." Alongside this, attention is impaired while memory is heightened. Patients do not tire, experiencing a surge of energy and unusual vigor. During this period, they are talkative, and their speech is rapid.

In pronounced manic states, individuals feel tireless, experiencing a robust influx of physical and spiritual energy. However, due to excessive motor agitation and distractibility, purposeful behavior may be lost. Everything happening around them—whether significant or trivial—captures their attention, though only momentarily. Sometimes these shifts reach a degree characterized by extreme distractibility or hypermetamorphosis (as described by Wernicke). In such instances, the patient fixes their gaze on and comments upon virtually everything entering their field of Vision.

An elevated drive for activity manifests as patients taking on multiple tasks at once and attempting numerous projects, yet failing to finish any of them because they are constantly distracted by something new. This hyperactivity and frantic busyness often lead to job loss and create general turmoil around them.

During a manic episode, patients may engage in reckless behaviors that harm themselves and their loved ones; they become extravagant, giving away belongings and money. They may also enter into intimate relationships with casual acquaintances. Occasionally, this escalates into acts of aggression, antisocial behavior, or even criminal offenses.

Mixed Variants of the syndrome include angry mania, while atypical variants include unproductive and confused mania.

Angry mania is dominated by irritability, fault-finding, quarrelsome behavior, peevishness, anger, and, in certain cases, aggressiveness.

Unproductive mania is characterized by sparse associations and inactivity. Amidst an elevated mood, functional activity is lost.

Confused mania is a state marked by an extreme acceleration of thought processes, leading to confusion and fragmented ideas. Ideational excitation is prominently expressed. Speech becomes incoherent and fails to keep pace with associations. Patients notice everything, even minor details, offering constant commentary, remarks, and evaluations. They generate an atmosphere of mirth, but occasionally also one of tension. Due to heightened agitation, they may become tactless, and at times rude or cynical.

Complex variants of the syndrome include manic states characterized by the development of overvalued delusions against the Background of mania, where grandiose ideas predominate, closely linked to and driven by affective disorders.

Unlike patients with similar disturbances within other pathological frameworks, individuals with manic-depressive psychosis (MDP) do not direct their self-awareness, interests, and aspirations toward delusional imagery. Rather, these phenomena serve as a manifestation of surges of well-being, optimism, and energy. Patients "fabricate" situations to give concrete meaning to their inner sense of spiritual and physical might. This explains the rudeness and deliberate affectation observed during conversations with patients when their plans and capabilities are touched upon. Even in cases of so-called manic paraphrenia, the consciousness and personality of the patients are not consumed by fantastic delusional ideas. Their statements contain numerous unstable assertions that patients can readily abandon if persuaded otherwise.

Depressive phases occur significantly more frequently than manic ones. The clinical picture of endogenous depression consists of a symptom triad: a pathologically lowered (sad) mood, alongside psychomotor and intellectual retardation.

At the onset of the phase, or in mild cases, the mood may assume A wide variety of shades (feelings of boredom, sadness, depression, gloom, or anxiety). In the mildest cases, where affective disturbances are poorly differentiated, the depressive coloring of the mood is manifested by a weakening of emotionality during social interactions, and a loss of the capacity for joy and amusement. Patients frequently experience fatigue and become lethargic. There is a noticeable overall drop in vital tone (both psychic and physical), a feeling of discontent with oneself—sometimes significant—and a loss of the capacity for creative activity. Patients often mistake this for laziness or weakness of will, attributing it to the "impossibility of pulling oneself together." As the sufferers evaluate their own abilities and the realities of life, pessimism begins to dominate their character. Nothing brings them joy, they feel lonely, and they realize they have changed.

Sleep and appetite disturbances, headaches, Digestive System dysfunctions, and generalized unpleasant bodily sensations are also frequent.

The described disturbances constitute the clinical picture of a cyclothymic type of depression, which is characterized by a mild degree of severity. Consequently, in this type of depression, subjective disturbances predominate, with no visible signs apparent in the patient's appearance or behavior. This complicates the clinical recognition of affective disorders. Targeted identification of these symptoms and the dynamics of the disturbances throughout the day makes it possible to diagnose a cyclothymic phase or the onset of a depressive one.

As depression deepens, affective disorders intensify, making the depressive affect easier to differentiate. Beyond subjective sensations and experiences, the patient's appearance, statements, and behavior point toward depression. Intellectual and psychomotor retardation become more pronounced. Patients are depressed and hypomimic, with sadness and sorrow in their eyes. Their eyelids are lowered, forming the characteristic Veragut fold (upper eyelids angled upward), giving them a suffering posture. Thinking is slowed, and associations are impoverished. Speech is quiet, monotonous, and sparse, with brief responses. Pessimistic evaluations of the past, present, and future dominate their statements, accompanied by ideas of personal inadequacy and guilt. Movements are sluggish, and their gaze is lifeless. The clinical picture at this stage of development is defined as clinical endogenous depression. Overall, the disorders developing at this stage of depression help illuminate the course of the illness in subsequent stages, specifically the content of depressive delusions.

In complex cases, a severe depressive affect develops, characterized by profound anguish accompanied by physical sensations of heaviness in the chest and heart. The HEAD feels as if it is in a vise, stuffed with "heavy stones."

The reduction in motor activity may reach the degree of a depressive stupor. Patients lie or sit motionless, immersed in heavy thoughts. Their faces resemble a mask of suffering and grief.

Sleep and appetite are disrupted, and constipation is common. Patients lose weight, making the reduction in Skin turgor and elasticity very noticeable. Autonomic changes manifest as distal hyperhidrosis, hypothermia, and cyanosis of the extremities. Furthermore, the illness affects endocrine Functions: in women, the Menstrual cycle changes, sometimes ceasing altogether, while in both men and women, libido disappears.

The state of depressive stupor is occasionally interrupted by bouts of melancholic frenzy, bursts of despair, and helplessness. During these periods, patients may self-harm or attempt suicide.

Fluctuations in the patient's condition depending on the time of day are characteristic, with some relief observed in the evening hours. However, in very severe forms of depression, these fluctuations are barely noticeable.

Ideational disorders manifest as lethargy, slowed thinking, a narrowing of the associative range, and a monothematic focus. Patients feel incapable of thinking, experience a dulling of the mind, memory loss, and an inability to concentrate. Speech becomes not only slow but overly laconic and elementary. Their gaze is sorrowful; in severe depression, it becomes fixed, reflecting profound mental pain and suffering. Their posture is gloomy and practically unchanged, with the head and arms lowered. Patients move by slowly lifting their feet.

Cenestopathies are observed, attesting to the vital character of the affective disturbances. Unpleasant sensations sometimes arise in the chest, head, and other body parts, though patients find it difficult to specify these sensations and their exact localization.

Perceptual disorders manifest in everything around the patient turning gray and monotonous, finding no Resonance within their soul. Time passes slowly, making the day feel excessively long.

Patients express thoughts of personal worthlessness (self-deprecation) and blame themselves for everything. As depression deepens, these ideas transition from overvalued concepts to actual delusions.

Hypochondriacal disorders are most often associated with the general mental state rather than specific unpleasant sensations. Patients believe themselves to be gravely ill.

Depending on which affective disorders predominate, several variants of depression are distinguished: melancholic, anesthetic, and anxious. When anguish dominates, patients are sorrowful, depressed, grieving, and feel hopelessly trapped.

Depressive depersonalization, presenting as painful psychic anesthesia with a dominant melancholic affect, is usually most fully expressed. Patients experience emotional impoverishment. The most agonizing experiences involve the loss of natural feelings toward loved ones (psychic anesthesia). Furthermore, their emotional engagement with their surroundings, activities, and entertainment diminishes or disappears entirely. Patients react with extreme distress to their inability to empathize or experience joy (anhedonia), and they grieve the loss of "vital emotions": the feeling of being rested after sleep, feelings of hunger and thirst, sexual satisfaction, and pleasant fatigue following physical exertion ("muscular joy"). Painful psychic anesthesia is also accompanied by distress over personality changes and inner emptiness. During melancholic depression, suicidal thoughts most frequently arise, leading to intentions of self-harm and suicide. The vital nature of these experiences in patients with pronounced anguish can trigger impulsive suicide attempts. The behavior of such patients is characterized by withdrawal, immobility, and an inability to perform routine or even elementary tasks. Anxiety, fear, inner turmoil, tension, and painful restlessness predominate. Patients express fears regarding the well-being of their loved ones. Ideational disorders are characterized by accelerated and disordered thinking with unstable attention concentrated on distressing topics. Patients express doubt and uncertainty regarding decisions, dwell on potential troubles, and cannot shake off grim thoughts. Speech is fragmented, indistinct, and confused.

In an anxious-agitated state, psychomotor retardation gives way to motor restlessness: the patient wrings their hands, paces stereotypically, cries, groans, wrings their hands, or laments. Their gaze in this state of anxiety is restless ("darting") and tense, and their facial expressions are changeable. Somatopsychic disorders play a significant role. Patients may complain of burning, scorching, or cold sensations, yet are unable to clearly pinpoint their localization. Most commonly, these unpleasant sensations occur in the retrosternal and epigastric regions, the head, and the distal extremities.

In anxious depression, the environment is perceived with suspicion and hypersensitivity. Patients obsess over potential troubles and failures awaiting them in the future. Time is perceived as accelerated, while the past day feels protracted.

Obsessive fears are frequently observed within The structure of the anxious variant of depression. Patients fear going mad or dying. These phobias may be accompanied by unpleasant sensations in various PARTS OF THE body, and patients develop hypochondriacal anxieties directed at their somatic health. Such disturbances sometimes reach the level of sudden-onset states characterized by an escalation of the fear of going mad and dying, acute psychomotor agitation, weeping, a tendency toward self-harm, and even impulsive suicide attempts.

Amid varying degrees of anxiety, patients fall asleep poorly, experience insomnia, or wake up frequently. Appetite may increase to the point where patients feel unable to eat or drink their fill. They become overly intrusive and constantly active; in pronounced cases, their movements are chaotic.

Anesthetic depression is characterized by a predominance of affective insensitivity. In cases of minor psychomotor retardation, depression develops with a perceived loss of affective resonance, manifested by a reduced response to the environment. Patients become seemingly "emotionally stony" or "wooden," incapable of empathy. Nothing brings them joy or disturbs them, not even matters concerning their own children and relatives. Patients in this state typically complain of a loss of emotions and feelings—a hallmark of depressive depersonalization or anesthetic depression.

In addition to the three described types of depressive phases, atypical forms of depression may also occur. These include cenestopathic-hypochondriacal depression and depression with obsessive-compulsive manifestations, where the aforementioned disturbances play a leading role in the STRUCTURE OF THE depressive syndrome.

Mixed depression includes agitated melancholia, in which a melancholic-depressed affect is combined with anxiety and timidity. Against this background, motor agitation develops, occasionally reaching a state of fury.

Special forms of depression can be observed within the framework of manic-depressive psychosis (MDP). First and foremost, these are depressions that most frequently manifest with physical or autonomic symptoms, usually accompanied by somatic symptomatology. The true causes of the autonomic and physical anomalies are concealed behind the somatic disorders. This creates difficulties in recognizing the depressive disorders that underlie the somatovegetative manifestations.

Among the wide variety of terms used to denote these states, the most common are "depression without depression," "masked," "somatic," "hidden," and "larvated" depression.

The manifestations of depression are diverse and can mimic any physical ailment. Patients with signs of hidden depression typically perceive their condition as a somatic illness. However, upon examination, objective changes are either absent or too negligible to account for the patients' Complaints. At the same time, late recognition of these conditions is dangerous, as patients with hidden depression frequently resort to suicide.

The manifestations of somatic depression are divided into several variants (V. F. Desyatnikov et al., 1976; V. F. Desyatnikov, 1979), namely: algic-senestopathic—abdominal, cardiological, cephalalgic, panalgic, agrypnic, and diencephalic; obsessive-phobic; and narcomanic.

The algic-senestopathic variant of hidden depression includes cases where the leading complaints are pain and unpleasant sensations in various parts of the body. Characteristic features include peculiar, unbearable pain, unpleasant sensations of a protopathic nature (cenestopathies), and paresthesias. This is also reflected in the name of the variant.

In the algic-senestopathic variant, According to the localization of pain, abdominal, cardialgic, cephalic, and panalgic syndromes can be distinguished.

Abdominal syndrome is characterized by pain, spasms, and paresthesias in the epigastric region, along the course of the intestines, as well as in the Liver area. Patients experience a sensation of heaviness, pressure, "overfeeding," "expansion," or "vibration" in The Stomach, along with nausea and painful eructation. The pain is usually prolonged, aching, distending, and dull in character, though short-term severe algias periodically arise against this background. Its intensity depends on the time of day, with the pain being most severe at night and in the morning. It is not related ³ to the intake or character of food.

Appetite typically decreases. Patients lose weight and experience constipation, or more rarely, diarrhea. In addition to pain, a constant manifestation of this syndrome* is meteorism—a sensation of bloating, fullness, and rumbling in the intestines.

In the case of cardiological syndrome, the leading complaints are pain and unpleasant sensations of various characters and intensities in the cardiac region (squeezing, aching, boring), burning, searing, tightness in the precordial region, spasms, pulsations, strong palpitations, and the like. Patients describe their sensations atypically: "fire burning in the chest"; "noise in The Heart"; "thumping"; "cramps"; "pricking"; "expansion"; "spasms behind the Sternum"; "constriction of the chest," etc. Most often, the pain is prolonged (ranging from a week to several months), dull, or more rarely, paroxysmal, quite sharp, stabbing, and burning. The localization of the pain is limited to the sternal area and the apex of the heart, yet the patient points to its deep Location ("somewhere deep," "far away," "inside"). The pain radiates to the neck, scapula, abdomen, and head. Cardiac and analgesic drugs reduce the intensity of the pain, but do not eliminate it entirely.

In cephalic syndrome, patients predominantly complain of headache, which is frequently observed within the structure of Various Forms of hidden depression and is regarded as one of the dominant somatic symptoms. Patients find it difficult to describe the Specific features of the headache, yet they note its persistent and severe character. Often, the pain is accompanied by unpleasant sensations of a cenestopathic shade; patients experience burning, expansion, heaviness, pressure, pulsation, constriction, numbness, and emptiness.

In the case of panalgic syndrome, the main feature is migrating pain without a fixed localization (moving from one part of the body to another, sometimes encompassing the entire body).

The agrypnic variant of hidden depression includes those cases where sleep disorders are the leading and sometimes the sole manifestation of the illness. A characteristic sign of this variant can be considered persistent, prolonged somnic disorders manifested by early awakening (at 3:00–4:00 AM) and, correspondingly, a shortening of the duration of night sleep. Sleeping pills are ineffective.

The diencephalic variant of hidden depression is the most complex in structure and the most diverse in clinical manifestations, and therefore difficult to classify. The validity of singling out this variant is justified by the similarity of its clinical picture to well-known syndromes of hypothalamic region damage.

The diencephalic variant includes cases of the disease manifested by pseudo-asthmatic, vasomotor-allergic disorders, and paroxysmal crises of a vegetative-vascular or vegetative-visceral nature against the background of somatic and affective disorders.

The obsessive-phobic variant of hidden depression also includes cases of the disease where the clinical picture is dominated by various obsessive ideas and fears, accompanied by an awareness of their morbid nature, a violation of one's own "Ego," and a desire to overcome these states. The external manifestations of personally depressive disorders are negligible, and sometimes entirely absent. This variant of hidden depression stands out among those described above in that The Diversity of the clinical picture is determined not by somatovegetative, but by psychical phenomena. This is a peculiar "psychic" mask of depression, a special form combining obsessions, phobias, and depressive symptomatology.

The symptomatology of the obsessive-phobic variant of masked depression overshadows various vegetative, somatic, and, most importantly, affective disorders. Patients complain of obsessive counting, memories, images, and apprehensions. Phobias are particularly frequent, such as the fear of dying from cardiac arrest, going crazy, suffocating, or the fear of solitude, heights, open spaces, or closed doors. However, the most frequent is the fear of death. Patients are critical of these fears, understanding their groundlessness, and try to overcome them. Nevertheless, during an attack, patients are completely in the grip of their fears. They carry medications with them, plan routes bypassing medical institutions, and avoid using public transport. Against the background of constant phobias, paroxysms of acute fear and unmotivated anxiety occur, accompanied by vegetative manifestations. The overall clinical picture of the disease is complemented by feelings of weakness, heaviness, decreased appetite, and sleep disturbances.

The narcomanic variant includes states where the leading manifestations of the illness are bouts of alcoholization caused by periodic Disorders of the affective or somatovegetative spheres, or an emerging alcoholism.

Among the named symptoms, the mandatory manifestations of hidden depression include erased, rudimentary affective disorders in the form of subdepressions. These are detected during targeted questioning and careful observation. It is precisely these unexpressed signs of depressive disorders that unite the entire variety of somatovegetative manifestations of depression and serve as a reliable diagnostic criterion for the illness. The complexities of diagnosing these states lie primarily in isolating the affective disorders themselves and establishing the described cause-and-effect relationships.

An analysis of symptomatology, the course of the illness, and the response to therapy makes it possible to distinguish three groups of diagnostic criteria for hidden depression (V. F. Desyatnikov, 1979, 1980).

The first group unites criteria based on the Analysis of the disease's symptomatology.

Affective disorders in the form of various subdepressive states (erased, unelaborated, mild depression) are invariably present in the clinical picture. There is A large number of constant and diverse complaints of a somatovegetative nature that do not fit into the framework of a specific disease. Disorders of vital functions are inherent.

Characteristically, there are sleep disturbances (reduced duration and early awakening), decreased appetite, diminished potency, weight loss, and Changes in the menstrual cycle.

Daily fluctuations are typical not only for the subdepressive state, but also for certain somatovegetative disorders: they intensify at night and towards morning. The general condition improves in the evening.

The second group includes criteria that take into account the specific Features of the disease's course. Periodicity and wave-like manifestations of somatovegetative and mental disorders are characteristic. The Anamnesis points to periods of inexplicable somatic disorders (deviations), psychosomatic changes, erased affective fluctuations, classic depressive phases, or, more rarely, manic phases. Attacks of the illness appear and disappear spontaneously. The character of affective attacks is phasic: mono- or bipolar.

Characteristic seasonal (autumn-spring) exacerbations of the disorder, along with a polymorphism of manifestations.

The third group is formed based on Treatment efficacy criteria (non-responsiveness to somatic therapy, positive response to antidepressants).

Course of the disease. In the case of a bipolar course (bipolar affective disorder according to ICD-10; bipolar disorder according to DSM-IV), manic episodes lasting from 2 to 4–5 weeks (averaging 4 months) alternate with depressive episodes that are longer (averaging nearly 6 months), followed by recovery. A monopolar course is rarely observed, which is why international classifications most commonly refer to this type of manic-depressive illness (MDI) as recurrent depressive disorder (ICD-10) or major depressive disorder (DSM-IV). In such cases, only depressive states periodically occur. Depressive phases are significantly more frequent than manic ones, both in mild forms of MDI and in cases with psychotic symptom manifestations.

At various Stages of the illness, there may be both cyclothymic phases (usually in the early stages) and psychotic ones. The type of disease course depends on the nature, duration, frequency, or number of phases. MDI exhibits a multitude of course variants: from single-occurrence phases to endless, i.e., continuous alternation; from short attacks to variants with distinct prolonged phases. From the perspective of the MDI course, phase duration is a crucial factor. On average, they last for several months, and sometimes over a year, or even several years.

Another indicator of the MDI course is the duration of remissions (intermissions). This metric also varies within wide ranges. An essential point is that the duration of lucid intervals is in no way related to the severity of the clinical signs of the illness. Both cyclothymic-level disorders and severe (psychotic) ones can be short-lived or extremely prolonged.

CYCLOTHYMIA

Cyclothymia (from Greek: circle, cycle + mood, feeling) is understood as a form of MDI with attenuated affective symptomatology (hypomanic and subdepressive) that has not reached a psychotic level. E. Kretschmer (1921), P. B. Gannushkin (1933), and K. Leonhard (1964) considered cyclothymia to be a constitutionally determined personality type prone to significant mood fluctuations.

Hypomanic phases are manifested by excessive activity and inflated self-esteem, which can provoke conflicts in the social microenvironment. However, although the behavior is exalted, it remains relatively orderly. Consequently, such patients generally do not end up in psychiatric institutions.

The subdepressive phase (cyclothymic depression) is accompanied by a depressed mood, a pessimistic perception of one's surroundings, psychomotor retardation, melancholy, anxiety, fears and apathy, hypochondria, asthenia, and occasionally suicidal tendencies.

Such states are relatively short-lived (1.5–2 months) and may present with a bipolar or unipolar course.

Atypical cyclothymia. The atypia of the disorder is revealed in the frequency, duration, and alternation of phases (shifting over the course of several days or even hours), as well as in The Nature of the symptomatology (asthenia and its variants—hysteriform, obsessive; manifestations of masked depression, fear of loneliness, fear of death, etc.). These changes occur against the background of pronounced individual character traits of the patient.

Cyclothymia may be observed throughout a person's life with periods of stable mood lasting many months, it may cease entirely, or it may transform into typical manifestations of MDI.

DYSTHYMIA

Chronic depressive moods that do not reach the severity of pronounced depression in MDI are termed dysthymia. Characteristic features include persistent fatigue, anhedonia, a sense of inner discomfort, gloomy thoughts, and poor sleep. At the same time, such individuals are generally well-adapted in everyday life and at work. There may be periods of well-being lasting several days or even weeks.

Age-related features. MDI most frequently manifests in adulthood, but its onset can also occur in young individuals, even during the pre-pubertal period.

In children, depressive and manic phases follow an atypical course, masked by various somato-vegetative disorders and behavioral disturbances. Therefore, a Diagnosis of MDI in childhood is made only when there is an opportunity to study the illness retrospectively or observe its development dynamically.

In adolescents, the course of psychotic phases is similar to the manifestations of affective disorders in adults. However, cyclothymic forms in children are distinguished by a high degree of atypicality in their manifestations, which significantly complicates diagnosis. Adolescents most frequently exhibit polymorphic behavioral changes: from minor differentiated signs to clinically formed behavioral reactions. During the depressive phase, due to these aforementioned disturbances, it is difficult to establish the clinical type of depression in adolescents. The core component of the affective link of depression—the symptom of melancholy and anxiety—is characterized at this age by being rudimentary, insufficiently structured, and volatile.

Hypomanic states during puberty in cyclothymia are likewise distinguished by atypia. Age-related "modification" of this state manifests as psychopath-like disorders: disinhibition, excitability, arrogance, and aggression.

Phase duration tends to increase with age. Prolonged phases of MDI can already be observed during adolescence.

With age, depressive phases occur much more frequently than manic ones. Sometimes the psychosis manifests precisely during this period, presenting a monopolar course. In such cases, the duration of depressive phases may tend to increase, while the periods of remission become shorter. Not infrequently, elderly patients exhibit a chronicization of the illness with a therapy-resistant course, which significantly worsens its prognosis.

Amid age-related changes in the psychopathological structure of depression, hypochondriacal disorders hold a major share, occasionally reaching the degree of hypochondriacal nihilistic delusions. As the depression deepens, the anxious-depressive affect, agitation, and delusional ideas of financial ruin intensify. Sometimes melancholic paraphrenia with Cotard's syndrome is formed.

Manic states are distinguished by non-productiveness and monotony. Some patients exhibit irritability and anger, while in others, a benign disposition prevails. Occasionally, the behavior of patients takes on features of silliness accompanied by hypersexuality and untidiness. Emotional lability and grandiose delusional ideas are frequently detected, creating the impression of organic-type intellectual decline. However, these symptoms disappear after the manic phase passes.

Treatment

The treatment of MDI is carried out taking into account the phase of the illness—manic or depressive, its manifestation (cyclothymic or psychotic), as well as the specific features of the psychopathological structure. Furthermore, one must consider that this psychosis exhibits a pronounced tendency toward bothremissivity and relapse.

Drug dosages must be sufficient to achieve full symptom reduction and remission, because if the required therapeutic effect fails to be attained, the illness assumes a prolonged course. In addition, relapse Prevention must be carried out, and efforts should be made to increase the duration of remissions using lithium preparations, which exert a stabilizing (mood-stabilizing) effect.

Therapeutic tactics in the manic phase of manic-depressive psychosis (MDP) should be based on the Clinical Features of mania. The primary means of arresting a manic state are neuroleptic drugs: chlorpromazine, zuclopenthixol, thioridazine (tiapridal/tisercin), clozapine, olanzapine, risperidone, sulpiride, etc.

The sedative effect of chlorpromazine and zuclopenthixol manifests quite rapidly. The maximum daily doses of chlorpromazine for oral administration are 800–1000 mg (on average, 500 mg); for zuclopenthixol, 75–100 mg or more.

Tisercin exhibits a pronounced sedative effect and less frequently induces depression. The maximum doses for oral administration are 300–400 mg, and for intramuscular administration, up to 200 mg per day. Leponex (azaleptine) acts similarly and is prescribed at a dose of 500–700 mg per day. Butyrophenone derivatives, and above all haloperidol—which practically causes no depression or inhibition—are quite effective in arresting a manic state. It is prescribed at a dose of 60–80 mg per day. To achieve a rapid effect, it is administered intramuscularly (up to 50–60 mg per day).

Along with neuroleptic therapy, lithium salts (lithium carbonate and lithium oxybutyrate) are used in manic states. They have a narrow focus and act "specifically" in circular mania. To maintain an optimal therapeutic effect, the lithium concentration in Blood Plasma should be 0.8–1.2 mmol/L. Monotherapy with lithium preparations is indicated in hypomanic states. In case of frequent phase shifts, carbamazepine (finlepsin) is indicated as a mood stabilizer. It is prescribed at a dose of 0.4–1.4 g per day. Doses are increased gradually to achieve adaptation to the drug.

If the treatment of manic states using psychopharmacotherapy is ineffective, electroconvulsive therapy may be prescribed.

To treat the depressive phase of MDP, regardless of the clinical picture, antidepressants are prescribed. Tricyclic antidepressants—amitriptyline and imipramine—are effective. The initial daily dose of amitriptyline or imipramine should be at least 50–75 mg. If there are no contraindications, it is increased by 25 mg daily and brought up to 200 mg. After achieving a therapeutic effect, the dose is gradually reduced. When selecting antidepressants, the features of the psychopathological structure of the syndrome are taken into account. Thus, anxiety, restlessness, and tension respond better to the sedative effect of amitriptyline, whereas inhibition, adynamia, and apathy respond to the stimulating effect of imipramine. The antidepressant citalopram (cipramil) should be prescribed at 20 mg per day at any time. Depending on individual response and the severity of depression, the dose is increased to 60 mg per day (for individuals over 65 years of age, up to 40 mg per day). It noticeably reduces the frequency of recurrent depressions and is well tolerated during long-term use. Zoloft is also effective, acting in a balanced manner on various types of depression. It is prescribed once daily at 25–50 mg; if necessary, after a week, the dose is increased to 200 mg/day. To overcome resistance to these drugs, simultaneous discontinuation of the latter is indicated. When this proves ineffective, electroconvulsive therapy is resorted to (provided the patient has no contraindications for it).

The insufficient efficacy of tricyclic antidepressants with their prolonged use may be associated with stable adaptation to these drugs, which necessitates prescribing antidepressants of a different structure, for instance, pyrazidol or MAO inhibitors. After achieving a therapeutic effect, it is advisable to conduct maintenance therapy with antidepressants to prevent relapse. This also serves a preventive function. For this purpose, lithium salts are also used, preventing the development of both the depressive and manic Phases of the illness. Initially, lithium is prescribed in small doses—up to 300 mg—and subsequently increased to 900 mg per day. Treatment is carried out under the control of blood plasma lithium concentration. It should not exceed 0.6–1.2 mmol/l.

For the prevention of affective phases, carbamazepine (finlepsin/finlepsin-retard) is also used. It is prescribed initially at a dose of 0.2 g per day, then gradually increased as the patient adapts to the drug. The average daily dose is 0.8–1 g. The drug is taken 2–3 times a day.

In protracted depressions resistant to antidepressants, the required effect is sometimes achieved by incorporating non-Traditional Methods into complex therapy: craniocerebral hypothermia, light therapy (lux therapy), acupuncture, etc.

In the case of a protracted course of depression, rehabilitation measures aimed at activating the social attitudes of the individual are of great importance. Patients require psychotherapy. Individual, group, and family psychotherapy acquire a primary role. Cognitive and psychoanalytical therapy are also utilized. Psychotherapy should aim at eliminating depression, calming the patient, correcting thinking, and neutralizing feelings of helplessness and hopelessness.

Patients with cyclothymia are more frequently treated on an outpatient basis or in a day hospital Setting. In cases of psychotic forms of the disorder, patients require inpatient treatment. If the condition improves, patients can be gradually transferred to a day hospital, etc.

Prognosis

In affective disorders, the prognosis is generally favorable because mental health is restored after the reduction of the phase state. Nearly 15% of patients recover completely. In 50–60% of patients, satisfactory social adaptation is preserved during remission.

The prognosis worsens in the case of protracted phases and shortened intervals between them. The prognosis is considered unfavorable in the continuous course of severe phases of MDP, as well as in the presence of a high risk of suicide.

Expertise

Medical and social expertise. Most patients are disabled during the period when they exhibit psychotic phases of the illness. During remission, working capacity is restored. If the phases are protracted and excessively frequent, and residual asthenic disorders are present, the illness is equated to chronic mental diseases, and patients are assigned a disability status with regular re-examinations. In cyclothymic phases, determining disability requires taking into account the Nature of the disorders, their duration, and occupational features. In a third of patients, due to the chronic course of the illness, indicators of the level of life functioning significantly deteriorate, i.e., social maladaptation occurs.

Military expertise. In affective disorders with infrequent attacks and prolonged intervals of complete recovery, patients are deemed unfit for military service in peacetime and fit with restrictions in wartime. Conscripts and submariners are unfit for military service in peacetime and wartime.

Forensic psychiatric expertise. During the psychotic phase, patients are legally insane (not responsible for their actions). When determining the legal insanity of patients who committed offenses during a period when they were in an affective state of the cyclothymic level, the incriminated actions and the circumstances under which they were committed must be carefully compared with their mental state.

CONTROL QUESTIONS

1. Definition and classification of affective disorders.

2. Epidemiology of manic-depressive psychosis.

3. Etiology and pathogenesis of MDP.

4. Variants and clinical manifestations of the depressive phase.

5. Clinical manifestations of the manic phase.

6. Mixed states. Atypical phases.

7. Cyclothymia.

8. Special forms of affective disorders: masked depression, dysthymia.

9. Age-related features of clinical manifestations and course of manic-depressive illness.

10. Treatment. Rehabilitation. Expertise. Prognosis.