Psychiatry - O. K. Napryeyenko 2001

Clinical Psychiatry
Psychogenic Disorders

Psychogenic disorders are a group of mental conditions primarily caused by an intrapsychic conflict resulting from a traumatic psychological situation. These psychogenically traumatic circumstances act as an exogenous-stressor agent that disrupts the body's Homeostasis.

EMOTIONAL STRESS AND PSYCHOLOGICAL TRAUMA

G. Selye (1974) defined stress as "the non-specific response of the body to any demand made upon it." Stress-generating factors, or stressors, can include physical, chemical, biological, social, and psychological influences. The pathogenic role of stressors is complex. Under normal conditions, the body's response to a stressor is adaptive and protective, serving as a universal physiological mechanism for the interaction between the Organism and its environment. In this context, The impact of situations—that is, stressors—has a positive value: it maintains a certain functional tone of the body and prevents detraining. Stressors become pathogenic only when the response to them is inadequate; in such cases, we speak of distress. Distress develops when the action of a stressor is excessively prolonged, intense, or of an unfavorable modality. It can primarily exert a cognitive or emotional impact on a person's mental sphere. However, when it exceeds the adaptive capacities of the Central Nervous system, it leads to mental disorders. Such psychological impairments most frequently develop in accentuated, infantile, and psychopathic personalities, and they may also be triggered by somatogenic factors resulting from chronic illnesses or adverse exogenous influences such as intoxications, ionizing radiation, and others. A general pattern is observed regarding the inversely proportional relationship between the sensitivity of The Nervous System and the magnitude of the psychological trauma required to trigger a psychogeny. Thus, two main components play a leading role in the onset of psychogenic disorders: the psychotraumatic factor and the state of the subject experiencing its impact. Psychotraumatic factors are divided into several groups:

1) sudden (massive, catastrophic) events of general social significance, such as natural, transport, and technological disasters, social upheaval, wars, etc.;

2) acute situational events of specific personal significance, such as the loss of social or material status, the death of relatives and loved ones, etc.;

3) chronic situational factors of relatively low intensity that act continuously or over a prolonged period (family, occupational, and others).

A common feature of psychogenic factors is that they affect the sphere of an individual's most significant relationships (V. N. Myasishchev, 1960). According to researchers, in most developed countries, interpersonal conflicts resulting in severe psychological disorders involve partnership, marital, and family life in 50% of cases, work-related troubles in 20%, and mixed problems in 30%.

Cytology/cytology/25.html">General characteristics and Classification of Psychogenies

The GENERAL PATTERNS OF clinical manifestations of psychogenic disorders were formulated by K. Jaspers (1923) as a triad:

1) the disorder develops As a result of psychological trauma;

2) the theme of the psychopathological symptoms reflects the content of the psychotraumatic factor;

3) the regression of psychopathological symptoms depends on the resolution of the psychotraumatic situation.

Among psychogenically induced mental disorders, a distinction is made between psychogenic reactions, neuroses, and reactive psychoses.

The impact of any external factor on a person elicits a reaction within the physiological norm. An inadequate response to a certain influence renders it pathological. The Main Features of a pathological response are inadequate duration, intensity, and modality (content). The reaction usually lasts a short time (from a few hours to several days) and resolves completely.

Based on their clinical manifestations, such reactions are divided into psychotic and non-psychotic. Psychotic reactions include paranoid, hallucinatory, twilight, affective, and psychomotor states. Non-psychotic reactions include neurotic, neurosis-like, psychopathic, and psychopath-like states. Neurotic reactions are subject to critical self-assessment, whereas psychopathic reactions are so only to a certain degree. The genesis of neurosis- and psychopath-like reactions involves an exo- or endogenously organic factor.

The psychopathological phenomenology of neurotic disorders consists of the following components:

1) symptoms of emotional-Affective Disorders reflecting a thematic connection with the psychotraumatic situation;

2) symptoms of secondary affective Processing of one's own somatovegetative manifestations;

3) a decrease in conscious, content-logical information processing and an increase in emotional-heuristic, unconscious processing;

4) the absence of psychotic mental disorders (delusions, hallucinations);

5) recovery (without personality defect).

Depending on the dynamics of the course of neurotic disorders, researchers distinguish: neurotic reactions — persistent neurotic states — neurotic personality development.

Obligate symptom complexes of reactive psychoses. Consciousness disorders range from deep twilight clouding to affectively narrowed states. The most characteristic feature is the concentration of the patient's mental sphere on specific experiences related to the psychological trauma. Memory impairments include complete or partial retrograde and anterograde amnesia. Affective disorders are dominated by depressive, anxious, or dysphoric affects. The paranoid syndrome features dominant delusions of persecution and reference. The hallucinatory syndrome most frequently involves threatening or commenting auditory hallucinations. Depending on their duration, reactive psychoses are classified as: acute — from a few hours to 2–3 days; subacute — up to 7–10 days; protracted — from 10 days to several months.

Etiology

Today, the multifactorial theory of the etiopathogenesis of psychogenic disorders is universally recognized. Three main groups of etiological factors can be distinguished.

I. Biogenic factors. Examinations of parents, siblings, and twins of patients with psychogenic disorders have demonstrated a statistically significant high prevalence of mental illness compared to the general population.

Sexual factors. Females predominate among patients with psychogenic disorders, whereas males predominate among those with reactive psychoses.

Premorbid and intercurrent conditions. An important factor is somatoneurological predisposition resulting from past illnesses (neuroinfections, traumatic Brain injury, intoxications, etc.), as well as the combined effect of psychogenic and somatic factors.

II. Psychological factors.

Constitutional-typological factors.

Various types of personality accentuation (K. Leonhard, 1981) or character accentuation (A. E. Lichko, 1985): asthenoneurotic, labile, sensitive, psychasthenic, hysteroid, epileptoid, schizoid, and mixed.

Exogenous psychotraumatic factors: family and domestic, sexual, and occupational.

III. Social factors: microsocial and macrosocial.

Various etiological factors play a varying role in the genesis of psychogenic disorders. For instance, clinical variants of acute reactive psychoses depend to a lesser extent on constitutional-typological personal characteristics. At the same time, these characteristics are of primary importance in The formation of clinical variants of neuroses.

Pathogenesis

MODERN CONCEPTS OF the pathogenesis of psychogenic disorders can be formulated within the framework of a systems-level approach.

Neurophysiological level. The onset of psychogenic disorders and their clinical manifestations depend on the typology of the central nervous system and the state of the brain's integrative systems responsible for regulatory, adaptive, motivational, and activational Functions.

Neurochemical level. The main pathogenetic link in psychogenic disorders is a catecholamine imbalance (elevated norepinephrine and decreased dopamine levels), as well as evidence of depleted synthesis of endogenous opioids (emotion-competent Neuropeptides).

Psychophysiological level. Numerous studies have revealed multi-link pathophysiological chains: the psychogenic factor — central emotional-autonomic regulatory systems at the limbic-hypothalamic level — peripheral somato-autonomic correlates.

Pathopsychological level. The leading pathogenetic link is The Emergence of an acute or chronic psychological conflict that the individual is unable to resolve.

All variants of psychological conflicts are divided into two groups: the inability to achieve a goal causes anxiety, while the deprivation of need satisfaction leads to frustration. At the same time, the following pathopsychological mechanisms of conflict situation development are possible: elevated personal level of aspirations and self-esteem; discrepancy between needs and the personal value system — a conflict between "duty and desire"; discrepancy between objective personal capabilities and self- or hetero-demands. The individual reacts to the aforementioned intrapersonal conflicts predominantly through four MAIN TYPES OF compensatory-adaptive psychological defense mechanisms, which are significant for the syndromogenesis of psychogenic disorders: goal shifting — changing activities, "immersing oneself in work," hobbies, etc.; repression — psychological ignoring and denial of the conflict's existence; altering The Significance of the conflict — "intellectualization" and "rationalization"; maladaptation — the formation of pathological symptoms as a mechanism that relieves responsibility — "escape into illness" ("flight into health/disease").

In ICD-10, psychogenic disorders are listed under category F4 (F40—F48).

F4 Neurotic, stress-related and somatoform disorders

F40 Phobic anxiety disorders

F40.00 Agoraphobia without panic disorder:

01 with panic disorder

F40.1 Social phobias

F40.3 Specific (isolated) phobias

F40.8 Other phobic anxiety disorders

F40.9 Phobic anxiety disorder, unspecified

F41 Other anxiety disorders

F41.0 Panic disorder (episodic paroxysmal anxiety)

F41.1 Generalized anxiety disorder

F41.2 Mixed anxiety and depressive disorder

F41.3 Other mixed anxiety disorders

F41.8 Other specified anxiety disorders

F41.9 Anxiety disorder, unspecified

F42 Obsessive-compulsive disorder

F41.0 Predominantly obsessional thoughts or ruminations

F42.1 Predominantly compulsive acts (obsessional rituals)

F42.2 Mixed obsessional thoughts and acts

F42.8 Other obsessive-compulsive disorders

F42.9 Obsessive-compulsive disorder, unspecified

F43 Reaction to severe stress, and adjustment disorders

F43.0 Acute stress reaction

F43.1 Post-traumatic stress disorder

F43.2 Adjustment disorder

20 Brief depressive reaction

21 Prolonged depressive reaction

22 Mixed anxiety and depressive reaction

23 With predominant disturbance of other emotions

24 With predominant disturbance of conduct

25 With mixed disturbance of emotions and conduct

28 Other specified predominant symptoms

F43.8 Other reactions to severe stress

F43.9 Reaction to severe stress, unspecified

F44 Dissociative (conversion) disorders

F44.0 Dissociative amnesia

F44.1 Dissociative fugue

F44.2 Dissociative stupor

F44.3 Trance and possession states

F44.4 Dissociative motor disorders

F44.5 Dissociative convulsions

F44.6 Dissociative anesthesia and sensory loss

F44.7 Mixed dissociative (conversion) disorders

F44.8 Other dissociative (conversion) disorders

80 Ganser's syndrome

81 Multiple personality disorder

82 Transient dissociative (conversion) disorders occurring in childhood and adolescence

88 Other specified dissociative (conversion) disorders

F44.9 Dissociative (conversion) disorder, unspecified

F45 Somatoform disorders

F45.0 Somatization disorder

F45.1 Undifferentiated somatoform disorder

F45.2 Hypochondriacal disorder

F45.3 Somatoform autonomic dysfunction

30 of Heart and Cardiovascular system

31 of upper gastrointestinal tract

32 of lower gastrointestinal tract

33 of Respiratory system

34 Genitourinary system

38 other organ or system

F45.4 Chronic somatoform pain disorder

F45.8 Other somatoform disorders

F45.9 Somatoform disorder, unspecified

F48 Other neurotic disorders

F48.0 Neurasthenia

F48.1 Depersonalization-derealization syndrome

F48.8 Other specified neurotic disorders

F48.9 Neurotic disorder, unspecified

According to DSM-IV, psychogenic conditions are coded under the following categories:

Anxiety disorders

300.1 Panic disorder without agoraphobia

300.21 Panic disorder with agoraphobia

300.22 Agoraphobia without history of panic disorder

300.29 Specific phobia

— animal type / natural environment type / Blood-injection-injury type / situational type / other type

300.23 Social phobia

— generalized

300.3 Obsessive-compulsive disorder

— with poor insight

309.81 Posttraumatic stress disorder

— acute / chronic

— with delayed onset

308.3 Acute stress reaction

300.02 Generalized Anxiety Disorder

300.00 Anxiety Disorder Unspecified

— Somatoform Disorders

300.81 Somatization Disorder

300.70 Undifferentiated Somatoform Disorder

300.11 Conversion Disorder

— with motor symptoms or deficits / with sensory symptoms or deficits / with seizures or convulsions / with mixed presentation

307.XX Pain Disorder Associated with Psychological Factors

.80 Associated with psychological factors

.89 Associated with both psychological factors and a general medical condition

— acute / chronic

300.7 Hypochondriasis

— with poor insight

300.7 — Body Dysmorphic Disorder

300.81 Somatoform Disorder Unspecified

Dissociative Disorder

301.12 Dissociative Amnesia

301.13 Dissociative Fugue

301.14 Dissociative Identity Disorder

300.6 Depersonalization Disorder

300.15 Dissociative Disorder Unspecified

Eating Disorder

307.1 Anorexia Nervosa

307.51 Bulimia Nervosa

307.50 Eating Disorder Unspecified

Adjustment disorders

309.XX Adjustment disorder

.0 With depressed mood

.24 With anxiety

.28 With mixed anxiety and depressed mood

.3 With disturbance of conduct

.4 With mixed disturbance of emotions and conduct

.9 Unspecified

— acute/chronic

NEUROSES (NEUROTIC DISORDERS)

The term "neurosis" was introduced into medical practice by the Scottish physician W. Cullen (1776). Initially, it encompassed not only a wide range of mental disorders but also A number of neurological and somatic conditions unaccompanied by morphological changes. Later on, A. Strümpell (1894), C. Westphal (1877),

J. Charcot (1889), P. Janet (1905), and P. Dubois (1912) shaped the modern understanding of neuroses as psychogenetically induced diseases. Neuroses were described quite comprehensively by V. A. Gilyarovsky (1954). He pointed out a specific personality predisposition, the frequent onset of neuroses against the Background of somato-neurological burden, their psychogenic nature, the essential role of autonomic and functional somatic disorders in the clinical picture, the patient's critical processing of painful experiences, and the drive to overcome them. The definition of neuroses by B. D. Karvasarsky (1990) can be considered the most acceptable. Neurosis is a psychogenic (usually conflict-induced) neuropsychiatric disorder arising from the disruption of a person's highly significant life relations, manifesting in specific clinical phenomena in the absence of psychotic symptoms.

On average over 25 years, the number of patients with neuroses worldwide has increased by 10%. On average, it ranges from 20 to 25 per 1,000 population. In The Structure of overall mental morbidity, neuroses account for 20 to 30%. In ICD-10, The concepts of "neurosis" and "hysteria" have been abolished. Instead, "neurotic disorder" and "conversion disorder" are used respectively.

According to the traditional classification of neurotic disorders, their clinical forms include:

1) neurasthenia;

2) hysterical neurosis;

3) obsessive-compulsive neurosis;

4) depressive neurosis;

5) hypochondriacal neurosis;

6) dysmorphophobic neurosis;

7) phobic neurosis;

8) systemic neuroses;

9) anorexia nervosa and bulimia nervosa.

Neurasthenia

The term "neurasthenia" was proposed by the American psychiatrist G. Beard (1869). Asthenic syndrome is the leading feature in the clinical picture of neurasthenia. The characteristic triad includes increased irritability, headache, and Sleep disturbances. The patient complains of "general weakness, malaise, feeling shattered, and intolerance to usual loads. Sensory disturbances and hyperpathies are characteristic (most commonly in the form of hyperacusis, when ordinary sounds "grate" on the ears, and natural scents are perceived too sharply; daylight is poorly tolerated, etc.). Against the background of optical hyperesthesia, eye fatigue — asthenopia — frequently occurs; patients are unable to fix their gaze on objects for long, especially text. Asthenopia rapidly worsens while reading.

Binswanger considered an elevated pupillary reflex, various general hyperesthesias, paresthesias, asystemic and migratory hyperalgesias to be typical of neurasthenia. An obligate symptom is headache. It presents in various ways: as a pressing, burning, or stabbing sensation; sharp, dull, or pulling; migrating (frontal, temporal, occipital, etc.). Headache is frequently accompanied by hyperesthesia and paresthesia. One of the constant signs is the sensation of a constricting band around the HEAD, known as the "neurasthenic helmet." Scalp hyperesthesia is also commonly observed. Along with headaches, patients may experience motion sickness, nausea, and tinnitus. Muscular hypotonia and extremity tremor often join the clinical picture, sharply increasing under physical and emotional stress. Characteristic features include hyperreflexia with expanded elicitation zones, as well as FOOT and patellar clonus. Marked autonomic lability is also noted: blood pressure instability, pulse dysrhythmia, persistent red dermographism, rapid facial flushing, a tendency toward subfebrile temperatures, and acrocyanosis. Orthostatic syndrome is typical for a younger age. Pronounced dyspeptic disorders and digestive tract dysfunction are frequently detected. The main mental alterations, alongside the asthenic symptom complex, are emotional and affective disturbances. Against the backdrop of a subjective sense of constant fatigue, one observes a depressed, negative general mood background, typically accompanied by a pessimistic assessment of one's own health. The patient focuses all attention on their physical well-being—hyperprosexia. At the same time, an emotionally positive external stimulus quickly distracts the patient from painful experiences: the subjective feeling of illness disappears. As mentioned above, an obligate manifestation is heightened irritability accompanied by an angry-wrathful affect. This state can alternate with phenomena of irritable weakness, asthenia, and tearfulness. It should be borne in mind that patients can briefly control their own state through willpower when urgently needed; however, this ultimately leads to an exacerbation of the primary symptoms and phenomena of partial hypobulia. Various sexual dysfunction disorders are also characteristic.

Traditionally, two main Clinical forms of neurasthenia are distinguished: hypersthenic and asthenic. The hypersthenic form is characterized by hyperesthesia: irritability, a tendency toward affective reactions, and insomnia. The asthenic form is marked by a constant feeling of fatigue, lethargy, somnolence, exhaustion, and a diminished interest in the environment. In the course of neurasthenia, a transition from the hypersthenic to the asthenic form occurs. Taking into account the significant polymorphism of clinical manifestations of this neurosis and The Need for differentiated symptomatic therapy, it is practically expedient to distinguish the following clinical forms of neurasthenia (M. E. Teleshevsky, 1988): those dominated by emotional-autonomic-diencephalic and systemic somatic disorders.

Hysterical Neurosis

The term "hysteria" is one of the oldest Definitions in medicine, traditionally attributed to Hippocrates. The Development of The Doctrine of hysteria is associated with the names of J. Charcot (1889), P. Janet (1905), and E. Kretschmer (1924). Hysteria is most frequently observed in women. It typically affects individuals with premorbid traits of psychological infantilism, egocentrism, and demonstrativeness. The primary mechanism of symptomogenesis in hysterical neurosis is conversion, meaning the resolution of a psychogenic conflict through somato-neurological manifestations. The most severe hysterical Disorders of the dissociative type include twilight states, stupor, and others characteristic of reactive hysterical psychosis.

The clinical picture of hysterical neurosis features three main symptom complexes: motor, sensory, and autonomic disorders. Motor disorders are represented by hyperkinesia. These hyperkinesias are quite diverse: coarse rhythmic tremor of the head and limbs, tics, choreiform twitching, blepharospasm, glossolabial spasm, and others. Hyperkinesias correlate with the patients' emotional state and are combined with other hysteroid symptoms. Akinesias manifest as hysterical paresis and paralysis. Their course follows the pattern of mono-, para-, and more rarely, hemiparesis and plegia. They can mimic central spastic and peripheral flaccid paralyses. Classical gait disturbances include abasia or the inability to stand—astasia. At the same time, Muscle tone, strength, and range of motion in the limbs are preserved in the supine position. Relatively rare manifestations include voice loss (aphonia), paralysis of the Tongue, Neck Muscles, or limbs, and hysterical contractures. The localization of hysterical paralyses does not coincide with nerve topography; pathological Reflexes, unlike organic paralysis, are absent.

One of the characteristic hysterical manifestations is seizures. The structure of a typical hysterical seizure (according to J. Charcot, 1888) comprises four periods.

Prodromal: a state of discomfort, depressed mood, heightened irritability, mutism, and frequently a hysterical aura (abdominal pain, clouding of consciousness, lump in the throat, ringing in the ears, throbbing temporal pain).

Convulsive. Tonic phase: affective narrowing of consciousness, hysterical "arc" (arching of the trunk with the head thrown back so that the body rests on the heels and occiput); clonic phase: rapid, chaotic contractions of individual muscles and twitching.

Resolution phase: intermittent breathing, salivation. Patients assume bizarre postures ("passionate movements" or "passionate postures") of a suffering or erotic nature, accompanied by appropriate facial expressions and body movements, shouting words or phrases relevant to psychotraumatic circumstances.

Residual contractures. The duration of the seizure is up to 30 minutes. In modern practice, classical seizures are rarely observed; abortive and atypical forms predominate: hysterical convulsive seizures—short-lived "arcs" or tonic-clonic convulsions without narrowing of consciousness; hysterical psychomotor agitation seizures—tremor resembling shaking with elements of "passionate postures"; hysterical stupor; minor polymorphic seizures—hiccups, tremor, rocking, turning, tics, muscle twitching, smiling, crying, etc.; pediatric hysterical situational seizure—shaking in children during a suddenly arising stressful situation.

Sensory disorders most commonly present as sensitivity disturbances and pain syndromes: hyper-, hypo-, anesthesia, and -algia. Disturbances of superficial sensitivity can vary in localization and configuration, most frequently appearing in the limbs in the form of "gloves," "socks," "stockings," etc. As with motor disorders, there is no anatomical-topographical correspondence.

Hysterical algias are equally diverse. They include headaches resembling a driven nail (clavus hystericus), joint pain, limb pain, back pain, and abdominal pain.

In the 1960s–1980s, the clinical picture of hysterical neurosis changed noticeably. Seizures, conversion symptoms, and gross demonstrative disorders became significantly less frequent. Somato-neurological and autonomic disturbances came to the forefront. Very often, hysterical symptomatology "cliches" somatic and neurological syndromes. Furthermore, since the early 1990s, alongside a deepened "somatization" of hysteria, the opposite trend has also been observed—the return of classical clinical manifestations.

Obsessive-Compulsive Neurosis

Described as an independent disorder by P. Janet (1905) under the name "psychasthenia" and systematized by S. A. Sukhanov (1905). Depending on the predominance of psychopathological symptomatology, obsessive, phobic, and compulsive variants of obsessive-compulsive neurosis are distinguished.

The Clinical presentation of the obsessive variant is characterized by intrusive thoughts, mental representations, and ideas. Obsessive doubts are the most common. Their content varies and is typically related to everyday life (whether doors, windows are locked, or electricity, gas, Water are turned off) or professional duties (whether calculations, addresses, or formulations are correct).

The phobic variant is represented by various fears. Based on the thematic content of these fears, the following variants are distinguished: nosophobia—fear for one's health status (cardiophobia, cancerophobia, syphilophobia, AIDSophobia, etc.); mysophobia—fear of contamination; aichmophobia—fear of sharp objects; thanatophobia—fear of death. A special place is occupied by the fear of going mad—maniophobia or lysophobia. Unlike other nosophobias, this phobia is frequently a symptom of Schizophrenia. Spatial fears include agoraphobia (fear of open spaces) and claustrophobia (fear of enclosed spaces).

A separate subgroup comprises phobias manifesting as anxious anticipation of failure (expectation neurosis, according to E. Kraepelin). Physiological phobias (associated with the execution of swallowing, walking, urination, sexual acts, etc.), occupational phobias (phobias of functions and actions, according to P. Janet), and sociophobia (fear of public speaking, fear of blushing in public—erythrophobia, etc.) are distinguished.

Phobias may Complement each other or transition from one type into another, forming secondary, tertiary phobias, etc.

The compulsive variant is represented by obsessive urges and ideas. The latter are also quite diverse: obsessive counting of objects or arranging them in a specific manner; obsessive tidying, adjusting clothing; obsessive hand washing, and others. Most commonly, compulsions are associated with corresponding phobias and their consequences. Unlike impulsive urges, compulsive urges and actions are subject to situational volitional control, which serves as a relevant differential-diagnostic criterion. Patients frequently develop secondary obsessive actions, or rituals, that help overcome primary obsessiveness. For example, to avoid returning home to check whether the door is locked, the patient may first walk around the table three times or hold the key with both hands, etc.

A special place is occupied by obsessive actions in the form of isolated, monosymptomatic motor disorders. Most frequently these include tics and exaggeration of physiological movements that have lost their primary meaning (Movements of the head, hands, fingers, eyelids, etc.). Tics should be differentiated from hyperkinesia of organic origin, which usually represents less organized motor acts, and from habitual actions (spitting, hand rubbing, joint cracking, lip biting, etc.).

Depressive Neurosis

The term "neurotic depression" was introduced by E. Kraepelin (1985). Its clinical structure is dominated by a depressive syndrome against an asthenic background. The depression lacks a vital character, and its manifestation is situation-dependent. Melancholia is shallow, bradykinesia (general slowing of movements) is absent, and somato-autonomic stigmata are weakly expressed. Daily dynamics are reversible compared to endogenous depression (in neurosis, the condition worsens in the evening hours). Depressive neurosis most frequently develops at a later age and is associated with a specific situation. It is characterized by diffuse hypochondriacal and asthenic Complaints, tearfulness, and sleep disturbances with frequent awakenings. During these intervals, anxiety appears, accompanied by palpitations, fears, concerns about one's life, or suicidal thoughts with a tendency toward realization.

Hypochondriacal Neurosis

The primary clinical manifestation of hypochondriacal neurosis is the formation of an inadequately exaggerated preoccupation with one's own health status. The obligate Components of the clinical picture of hypochondriacal neurosis include: cenesthesias, emotional-affective disorders, and overvalued-type Thought Disorders.

Fear neurosis

Characterized by the development of a clearly defined fear with a specific plot, accompanied by adequate critical insight. Against the background of acute panic attacks, this critical faculty may be lost, leading patients to perceive the danger as real. A phobic neurosis in its "pure" form, without an obsessive component, is distinguished by a passive pattern of behavioral response.

Anorexia and bulimia

Anorexia nervosa (W. Gull, 1868) is characterized by a conscious refusal to eat. The pathogenetic mechanism involves dysmorphophobia or dysmorphomania, which manifests as a pathological conviction of being excessively overweight. It is most commonly observed in women. Characteristic somatovegetative components include Amenorrhea, decreased blood pressure, bradycardia, dry Skin, hypothermia, and metabolic alkalosis. Onset typically occurs during Puberty or the post-pubertal period (14–18 years of age).

Anorexia is frequently interspersed with a pathological, obsessive craving for food, known as neurotic bulimia. The latter requires Differential Diagnosis from psychotic bulimia as a manifestation of schizophrenia.

Dysmorphophobic neurosis

A relatively rare form of neurosis characterized by the emergence of overvalued ideas regarding changes in one's own body, deformity, or physical defects. While these thoughts are subject to partial critical evaluation and situational correction, they remain persistent in nature.

NEUROTIC DISORDERS OF SYSTEM AND ORGAN FUNCTIONS (SYSTEMIC, ORGANIC NEUROSES)

All types of neuroses are accompanied by massive vegeto-somatoneurological symptoms. The latter provides grounds for defining a so-called general psychogenic syndrome of vegetative-vascular dystonia. At the same time, in a subset of patients, a monomorphic "affiliation" of neurotic experiences to specific systems and Organs is noticeable. It should be noted that terms pertaining to "visceral neuroses" are relatively conventional. Therefore, the terminology presented holds more practical than theoretical significance; it can be applied during differential Diagnosis and Treatment when somatic discomfort and functional disorders of organs and systems prominently predominate.

Cardioneurosis is characterized by cardialgia and palpitations of non-cardiogenic or vertebrogenic origin. This is accompanied by affective distress (fear of physical exertion, myocardial infarction, loss of vitality, fear of being left alone, etc.).

Laryngospasm — a sensation of suffocation triggered by a psychological trauma situation.

Hyperventilation syndrome — an increased respiratory rate (subjective feeling of air hunger).

Neurotic hiccup — a rare form that occurs most frequently in individuals with a low intellectual and educational level.

Digestive function disorder syndromes: esophageal spasm, cardiospasm, eructation, vomiting, gastralgia, and intestinal crises.

Neurotic pollakiuria — excessively frequent urination with no signs of organic pathology in the Urinary System.

Neurotic surdomutism — intermittent, situation-induced functional deaf-mutism.

Neurotic anesthesia — functional disorders of superficial sensitivity, most commonly presenting in a "stocking" or "glove" distribution, etc.

DIFFERENTIAL DIAGNOSIS

In clinical practice, neuroses must be differentiated from psychoses, primarily schizophrenia and related psychopathies. The challenges of differential diagnosis stem from the low Specificity of neurotic symptoms. Neurotic syndromes are observed in virtually all mental disorders and in the majority of somato-neurological conditions. The main principles for differentiating neurotic syndromes include: preservation of orientation, awareness of illness and morbid symptoms; preservation of fundamental personality traits and behaviors; and a clear link between the dynamics of pathological experiences and the external situation.

DIFFERENTIAL DIAGNOSIS OF the main syndromes and clinical forms of neuroses (neurotic disorders)

The differential diagnosis of asthenic syndrome of neurotic origin must be carried out against manifestations of this syndrome in endogenous diseases, psychopathies, and organic brain lesions. An asthenic state is a frequent presentation at the onset of schizophrenia. In such cases, deepening asthenia and a lesser dependence on the patient's living conditions are characteristic. The physical component of asthenia features distinct elements of apathy, hypobulia, and emotional impoverishment.

Asthenic syndrome within the STRUCTURE OF THE corresponding psychopathy is characterized by persistence, which intensifies under METABOLISM/18.html">The Influence of intercurrent harmful factors. Within the context of organic disorders, particularly TRAUMATIC BRAIN INJURIES, it is characterized by explosiveness, affective lability with rapid exhaustion, and clear vegetative and mnemonic impairments.

Obsessive syndrome of neurotic origin must be differentiated from similar conditions in schizophrenia and organic brain lesions. Characteristic criteria for schizophrenic obsessions include: emotional poverty, monotony, rigidity, uniformity, lack of imagery, and a multitude of ideational and motor rituals—often nonsensical and independent of the external situation.

Obsessions are frequently observed in chronic subcortical-Brainstem encephalitis. In such cases, based on Clinical Features, obsessive experiences are closer to compulsive phenomena; they are stereotyped and amenable to resistance.

Differentiation should also be performed regarding phobic syndrome. Phobias within the structure of schizophrenia are distinguished by inertia, a lack of affective coloring, and systematic Organization due to the incorporation of ideational and motor rituals with overvalued elements. Phobias associated with encephalitis typically develop against the background of distinct somato-vegetative components.

Significant difficulties are posed by the differentiation of hypochondriacal syndrome of neurotic origin. This syndrome within the structure of schizophrenia is characterized by unusual, florid, and numerous coenestpopathies, along with frequent dysmorphophobia. Coenestpopathies are most pronounced (vivid) in organic disorders, particularly infectious brain lesions.

Neurotic depression syndrome is characterized by: a meaningful reflection of psychotraumatic circumstances; intensification of depressive experiences in the evening; preservation of personality; and critical judgment. Criteria for endogenous depression include: loss of connection with psychogenic factors; paranoid ideas of guilt; self-deprecation; suicidal ideation; and a "lucid interval" in the evening hours. The most challenging to differentiate are masked, somatized, and larvated depressions. Here, the somato-vegetative symptom complex must be distinguished from corresponding disorders within the framework of vegetative-vascular dystonia—both as an independent condition and as a syndrome of organic (vascular, traumatic, infectious) brain lesions and somatic illnesses. Differential diagnosis is carried out based on establishing the nosological affiliation of a specific syndrome.

AGE-RELATED CHARACTERISTICS AND PATHOMORPHOSIS OF NEUROSES

Neuroses most frequently develop in middle-aged and elderly individuals. Childhood neuroses are characterized by clinical uniformity, with a predominance of somato-vegetative and motor disorders. The main manifestations of childhood neuroses include enuresis, habitual vomiting, tics, hysterical paralysis, and logoneurosis. "Pure" neuroses of the involutional age are rare. Their structure is dominated by hystero-hypochondriacal, anxiety-depressive, and astheno-depressive symptomatology. In recent decades, neuroses, like other mental illnesses, have been characterized by quantitative and qualitative pathomorphosis of their clinical presentation. There is an increase in the number of cases of hysterical neurosis (especially in men), as well as obsessive-phobic disorders, cardiophobia, and anorexia nervosa. The number of patients with protracted forms of neurosis is growing noticeably. All forms of neurosis are characterized by an increase in somato-vegetative neurological disorders and the "somatization" of neuroses. There is also a general trend toward the impoverishment of the psychopathological phenomenology itself (an erased, mixed character of symptom complexes across Various Forms of neurosis). Since the mid-1980s, an opposite trend has also been observed: a return to classical, fully developed forms of neurosis, especially hysterical ones. This is likely related to socio-psychological factors, mass neurotization of the population, the spread of pseudoscience, occult-mystical views, and primitive-archaic quackery and faith healing.

NEUROTIC PERSONALITY DEVELOPMENT

According to O. V. Kerbikov (1971), neurotic personality disorders represent an intermediate clinical form between neuroses and personality disorders (psychopathies). They form as a result of a prolonged and unfavorable course of neuroses, manifesting as a marked expansion of neurotic symptomatology, its detachment from the psychogenically traumatic situation, or a collateral connection with it. At the same time, neurotic experiences alien to the personality become persistent and complex, altering the direction of the patients' main interests. The manifestation of autonomic and somato-neurological disorders characteristic of neuroses diminishes. Certain premorbid personality traits of the patient become aggravated and acquire an exaggerated character. Signs of psychosocial maladaptation become increasingly prominent, resulting in a decline in the patient's level of daily functioning, including work capacity. A negative impact on the incidence of neurotic personality development is exerted by the intensification of the previously described (predominantly pathological) somatogenic influences, alongside new unfavorable ecological, occupational, economic, and socio-political factors (O. K. Napreenko, K. M. Loganovsky, 1997).

According to the works of N. D. Lakosina (1970), the following clinical variants of neurotic development are distinguished: hysterical, characterized by demonstrativeness, pronounced egocentrism, manifestations of affective thinking, and behavioral infantilism; obsessive, marked by the aggravation of psychasthenic traits, reduced insight into progressive phobias, dominance of intrusive ideas, development of obsessive drives, emergence of doubts, narrowing of the range of interests, instability, and overvalued ideas regarding one's health; and explosive, characterized by a significant decrease in The ability to control one's own behavior, irritability, explosiveness, spitefulness, preoccupation with negative experiences, and a tendency toward persistent, overvalued hypochondriacal ideas.

Treatment of Neuroses (Neurotic Disorders)

Therapy for neuroses is structured according to General Principles and is divided into etiological, pathogenetic, and symptomatic. Etiological therapy aims at patients' awareness and deactivation of the content of the psychogenically conflictual situation. Pathogenetic Therapy involves acting on the leading links of syndromogenesis: pathopsychological, neurochemical, and integrative-regulatory. Symptomatic therapy includes targeting specific mental, somatic, and autonomic manifestations.

General principles of neurosis therapy: stage-by-stage approach, individuality, comprehensiveness, continuity, and personal and social orientation.

Four stages of treatment are distinguished: preparatory, primary, maintenance, and relapse-Prevention. The method of choice is psychotherapy, which is a system of therapeutic influence on the patient mediated through the mental sphere. The choice of a specific psychotherapeutic technique depends on the patient's characteristics, the clinical form of the neurosis, and the qualifications and personality of the psychotherapist.

The following types of psychotherapy are used for treating neuroses:

✵ autopsychotherapy (conducted by the patient independently);

✵ heteropsychotherapy (conducted by a psychotherapist);

✵ individual (involving a single patient);

✵ group (involving a therapeutic group).

According to The Nature of the technique used, the psychotherapy of neuroses is divided into suggestive, rational, group, analytical, behavioral, existential, etc.

Suggestive therapy is based on the Implementation of therapeutic suggestion, which is perceived by the patient uncritically and involuntarily. Under its influence, the patient develops a certain sensation or attitude toward something, including their own condition.

1. Hypnotherapeutic suggestion (Hypnotherapy). Suggestion is carried out in a special, hypnotic state of the patient. Based on depth, three degrees of hypnosis are distinguished: somnolence, hypotaxis, and somnambulism. Therapeutic suggestion is implemented in the I–II degrees of hypnosis. It is believed that approximately 20% of people are sufficiently hypnotizable for this type of treatment. Initially, hypnotizability tests are performed: Koe-Baudouin I — falling backward; Koe-Baudouin II — falling forward; Koe-Baudouin III — swinging the Chevreul pendulum; Katkov — arms parting; Rozhnov — unclasping hands locked together; Filatova — "glUing the eyelids," etc.

The following Methods of induction into hypnosis are used: fascination; gaze fixation; passes; rhythmic stimulation; verbal formulas.

The session consists of 4 phases: induction; therapeutic suggestion; therapeutic rest; dehypnotization.

2. Narco-psychotherapy — suggestion against the background of superficial narcosis (under the influence of barbamyl, sodium thiopental, hexenal, nitrous oxide, etc.).

3. Emotional-stress therapy — suggestion using verbally formulated statements of deep emotional-content load against the background of stimuli of threshold-to-suprathreshold strength applied to analyzers. In this process, the conflicting emotional state is "provoked," as if objectifying the neurotic tension and transforming it into a goal-directed emotion, which relieves the patient's condition.

4. Imperative suggestion is conducted in an extremely affectively charged manner, in the form of a command that causes the patient to experience anticipated feelings and a defined attitude toward previous experiences.

5. Object-mediated suggestion — suggestion using some material object related to medical Procedures or an indifferent one (for example, placebo therapy).

6. Autosuggestion. This group of psychotherapy methods includes autosuggestion according to Coue (E. Coue, 1928), Schultz's autogenic training (J. Schultz, 1987), Jacobson's progressive relaxation, operant reinforcement—biofeedback, and bioadaptation self-regulation (N. Miller, 1981).

Rational (or intellectual, according to I. Z. Velvovsky, 1984) psychotherapy is a system of therapeutic influence through conversation, mediated by the patient's critical, logically meaningful comprehension (V. M. Bekhterev, 1911; P. Dubuis, 1912; J. Dejerine et al., 1912).

Group psychotherapy is the purposeful use of the totality of interactions and relationships that arise within a group among its participants—that is, group psychodynamics—for therapeutic purposes regarding each participant (S. S. Libikh, 1974; B. D. Karvasarsky, S. Leder, 1990, etc.). The main provisions of this type of therapy are outlined below.

Types of groups: open—constantly replenished with participants to replace those who have left; closed—begin and end therapy with the same composition of patients. Group sessions are conducted for 1.5 hours daily or weekly. The main form of the sessions is Discussion. Topics are determined in advance and relate to the biography, behavior of group members, and life situations. Principles of group therapy include strict confidentiality, concreteness of topics, sincerity and openness of group members, and experiencing the "here and now." Sessions are supplemented by role-playing situations, psychogymnastics, and pantomime.

Family psychotherapy is a subtype of group therapy based on the resolution of intra-family conflict (E. G. Eidemiller, V. V. Yustitsky, 1990).

Analytical therapy (founded, as already noted, by S. Freud) is based on three main principles, namely:

1) the internal determinism of personal conflict and neurosis;

2) the interpretation of the symbolism of dreams, slips of the tongue, and errors as a pathopsychological mechanism of syndromogenesis;

3) therapeutic technique—the method of free associations.

Behavioral (conditioned-reflex) therapy.

It is conducted in three main directions:

1) systematic desensitization (J. Wolpe, 1973)—against the background of Jacobson's relaxation, the patient is "immersed" in a simulated psychotraumatic situation;

2) implosion—the escalation and intensification of the psychotraumatic situation;

3) paradoxical intention (V. E. Frankl, 1966)—the excessive provocation of psychotraumatic situations.

The therapeutic effect of behavioral therapy is based on the psychological phenomenon of response extinction during the repeated repetition of a stimulus.

Existential therapy has several components.

1. Non-directive (C. Rogers, 1951). The principle is mutual positive regard between patient and therapist; an appeal to the patient's ideal self.

2. Transactional analysis (E. Berne, 1988)—role-playing of typical situations by patients.

3. Psychodrama (J. L. Moreno, 1965)—acting out scenes from dramatic works whose plots resemble the patients' own psychotraumatic situations.

4. Gestalt therapy (F. Perls, 1969)—modeling experimental situations with patients to test imaginative experience (figure-gestalts).

Non-verbal methods of psychotherapy are based on various influences.

1. Music therapy (melotherapy). It is divided into receptive (listening) and active (e.g., choral singing). It utilizes musical works that evoke experiences related to the content of psychogeny and shape the desired emotional state

(C. Schwabe, 1972; L. S. Brusilovsky, 1985).

2. Art therapy (drawing and modeling)—the patient's artistic reproduction of their own experiences (S. Kratochvil, 1978).

3. Choreotherapy (dance and pantomime)—the reproduction of internal experiences through postures, gestures, movements, and Touch. Development of communication skills (Z. Aleszko, 1975; N. Junova, 1975).

5. Bibliotherapy involves supplementing a lack of or reinforcing one's own images and concepts through reading literature (A. I. Alekseychik, 1985).

Pharmacotherapy. Psychopharmacological agents most commonly used include tranquilizers, behavioral correctors, and "mild" antidepressants. Vegetotropic agents (belloid, bellaspon, bellataminal), nootropics, biostimulators, adaptogens (ginseng, schisandra chinensis, eleutherococcus, pantocrine extracts, etc.), and vitamin supplements are also widely prescribed. Alongside these, physical therapy, reflexology, balneotherapy, diet therapy, and therapeutic fasting are employed.

Phobic syndrome (obsessive-phobic, anxiety-phobic). Recommended agents include benzodiazepine derivatives: Rudotel (medazepam) at 10–30 mg; Radedorm (nitrazepam) at 5–10 mg; Tranxene at 20–200 mg; Stilnox (zolpidem) at 10–15 mg; chlordiazepoxide at 20–60 mg; diazepam at 15–20 mg; phenazepam at 1.5–2.0 mg daily. Parenteral psychopharmacotherapy is effective during acute exacerbations. For pronounced obsessive components, frenolone is used up to 30 mg/day.

In hypochondriacal syndrome, alongside tranquilizers, antidepressants are utilized, including imipramine (up to 50 mg), amitriptyline (up to 100 mg), citalopram (up to 60 mg), Prozac (up to 60 mg daily), Zoloft (25–100 mg daily), and psychostimulants (syдноcarb, sydnofen — up to 10–15 mg daily).

Treatment of patients with depressive syndrome is carried out using the aforementioned and other antidepressants, as well as tranquilizers in average therapeutic doses.

In asthenic syndrome, average therapeutic doses of sedatives and psychostimulatory agents are combined (sydnocarb, sydnofen — 10–20 mg daily, caffeine, cordiamine — up to 10 mg daily), along with herbal adaptogens, biostimulators, Vitamins, and nootropic medications.

For the treatment of organ system neuroses, alpha- and beta-blockers (pyroxan — up to 100 mg daily, propranolol — up to 40 mg daily, and their analogs), M-cholinolytics (amizil — up to 3 mg daily), nicotinic acid preparations, and ganglion blockers (gangleron — up to 100 mg daily) are additionally prescribed.

Treatment of sexual disorders of neurotic origin is conducted depending on the form and Specific characteristics of these disturbances, taking into account the paired nature of sexual function. To this end, the therapeutic approaches described in this chapter and specialized methods of therapy used in sexopathology are applied.

REACTIVE PSYCHOSES

Reactive psychoses (reactive states) are short-term disorders of mental activity caused by psychological trauma, characterized clinically by symptoms at a psychotic level. Compared to neuroses, reactive psychoses exhibit significantly greater acuity, dynamism, and severity of psychopathological symptoms. They are characterized by a hyperacute onset with pronounced affective and psychomotor disturbances, delusions, and hallucinations against the background of altered consciousness. Reactive psychoses feature a much faster regression of psychopathological symptoms than neuroses. Among all psychogenias, reactive psychoses correspond most closely to K. Jaspers' criteria.

Acute Reactive Psychoses

Fugue-like reactions. These are the most acutely developing reactive psychoses, characterized by pronounced and profound disturbances of the mental sphere with significant somato-vegetative components. They have been described under various names: emotive Shock, acute reactions, and extreme situation reactions. They were first systematized by K. Kleist (1917) as "terror psychoses." Their main clinical forms were described by E. Kretschmer (1924). The following fugue-like reactions are distinguished.

Acute twilight state has the most acute onset; it is characterized by complete disorientation, the inability to establish verbal contact with the patient, psychomotor agitation, and a chaotic flight reaction (often running directly toward real danger). This state unfolds against the background of a fear affect with corresponding facial and autonomic correlates. Duration is up to half an hour, followed by amnesia.

Acute reactive stupor. Corresponds to the hypokinetic form of affective-shock reactions, or "feigned death," according to E. Kretschmer. It is characterized by a state of oligokinesia, bordering on complete immobility. Mutism is frequently observed. Due to immobility, patients are typically unable to move away from the psychogenic traumatic factor. Verbal contact is impossible. Tactile contact with the patient intensifies the affect of fear. The duration of stupor ranges from several hours to 2–3 days.

The hyperacute period is completely erased from memory, while the recovery period is recalled only fragmentarily.

Acute reactive confusion. Develops acutely in the form of a twilight state of consciousness accompanied by psychomotor agitation and an affect of fear. Against this background, continuous "speech production" in the form of "word salad" is observed. Duration is 2–3 days.

Acute reactive paranoid. A state of bewilderment develops acutely, accompanied by an affect of fear, anxiety, and paranoid ideas of persecution and reference. The paranoid experiences are affectively intense, and the plot of the delusion reflects the psychotravumatic situation. At the peak of the paranoid state, consciousness may be impaired—ranging from affectively narrowed to a twilight state. True and pseudo-hallucinations, along with Other components of the Kandinsky-Clérambault syndrome, may occur.

Subacute Reactive Psychoses

Hysterical psychoses. Psychoses with a polymorphic clinical structure manifested as a combination or transformation of various hysterical disorders.

Hysterical twilight state. Unlike the acute twilight state, it is characterized by affectively narrowed consciousness. Consequently, fragmentary perception of the external world is observed. Subsequent amnesia is also fragmentary in nature. The clinical picture is mosaic and dynamic. The patient's behavior is demonstrative. Periods of short-lived psychomotor agitation alternate with a substuporous state. Affects of fear, anxiety, and grief with weeping are characteristic. Manic-like manifestations with laughter and singing are observed, and typical hysterical convulsive seizures occasionally develop. Illusory-eidetic visual phenomena may arise. The question of visual hallucinations remains controversial, although some authors describe them.

Pseudodementia. A simulated, transient form of intellectual impairment. It was first described by C. Wernicke (1906). It arises against the background of affectively narrowed consciousness. The MAIN CLINICAL MANIFESTATIONS are: vorbeantworten (approximate Answers)—patients answer questions, but intentionally incorrectly; vorbeihandeln (approximate actions)—they incorrectly perform the simplest actions, usually doing everything backwards. They cannot count to ten, state how many fingers they have on their hands, or name a continent; they call white black, do not know their own last name, fail to recognize close relatives, etc. Pronounced elevated mood, inadequate lightheartedness with complete Displacement of the psychotravumatic situation, and silliness are characteristic.

Ganser syndrome. First described by S. Ganser (1898). It is characterized by a deeper—hysterical, twilight disorder of consciousness and complete disorientation. Productive contact with the patient is impossible. The polymorphic clinical picture includes elements of approximate answers and actions, and puerilism with an anxious-gloomy mood that contrasts with silly, lighthearted behavior.

Regressive forms of hysterical reactive psychoses. The main clinical manifestations are childish speech mannerisms, behaviors, and emotional disturbances. Adult patients use baby talk, lisp, speak in elementary phrases with childish intonations, and play children's games (with dolls, making sandcastles, etc.). Their facial expressions are childish; they throw tantrums, address those around them as "uncle" or "aunt," and ask to be "picked up," etc.

Hysterical psychic regression ("savagery" syndrome) is characterized by a pronounced hysterical twilight state of consciousness accompanied by an affect of fear. Against this background, patients strip naked, crawl on all fours, sleep on the floor in a fetal position, eat straight from a bowl, do not wash, fail to use the toilet, bare their Teeth, growl, sniff everything, and lose expressive speech. There is practically a complete loss of basic human domestic and behavioral skills.

Hysterical stupor. Described by K. Raecke (1926). It can develop primarily or as a stage of other hysterical disorders (puerilism, pseudodementia, etc.). It is characterized by affectively narrowed consciousness and a state of motor inhibition. Patients are inhibited, refuse food, and are often untidy. Verbal contact is impossible, but when addressed, vegetative-motor reactions appear: heart rate changes, the face flushes, and absurd postures are assumed. Components of a pseudodemented-puerile nature and stereotypies are frequent. The development of a substuporous state with bradykinesia, bradyphrenia, and oligomimia is possible.

Delusional-like states syndrome. First described by K. Birnbaum (1918). It is characterized by the emergence of unstable, unsystematized, and fantastically hyperbolic thoughts regarding one's own significance, greatness, inventiveness, wealth, etc. Patients claim that they are famous, world-renowned, hold or await appointment to a high position, are making advantageous marriages, and so forth. The plot of these thoughts is highly variable and usually correlates with the current situation (conversations of others). At the same time, an inverse relationship with the psychotraumatic situation is observed: unseemly actions that compromise the patient are portrayed as feats or acts of charity. A characteristic feature is the dissonance between the thematic content of these thoughts and the predominance of anxiety and fear, often accompanied by components of affectively narrowed consciousness. Symptomatic regression is either gradual or rapid, typically correlating with the primary psychotraumatic situation.

Prolonged reactive psychoses: Reactive depression

Unlike acute reactive psychoses, depressions develop gradually; their course is protracted, and the clinical picture is complex. Characteristic features include depression, a sense of hopelessness, insomnia, and somatovegetative components (Protopopov's triad, etc.). The content of depressive experiences reflects the context of psychotraumatic circumstances and specific psychological experiences. Vital manifestations are less pronounced than in endogenous depression. A critical evaluation of one's condition is preserved, albeit diminished. The sense of guilt is directed outward toward others rather than inward. Motor and ideational retardation are observed at the onset of depression. Unlike endogenous depression, in reactive depression the mental state is situation-dependent. Three clinical variants of reactive depression are distinguished:

1) paranoid-depressive, characterized by paranoid ideas of reference or persecution. Sometimes accompanied by depersonalization and derealization, frightening auditory hallucinations, and fragments of Kandinsky-Clerambault syndrome. It develops against the background of intense anguish-anxiety affect, bradykinesia, and bradypsychia;

2) astheno-depressive, where the leading features in the clinical picture are components of psychogenic asthenia: lethargy, general weakness, inability to concentrate, rapid exhaustion, and lowered mood;

3) hysterico-depressive, characterized by polymorphism, vividness, and demonstrative clinical manifestations. Depression manifests dramatically, with elements of theatricality and a caricatured grotesque quality. A particular feature of hysterical depression is the distinctness of somato-vegetative manifestations, agrypnic syndrome, and endocrine dysfunctions. The clinical picture is dominated by discontent and egocentrism. In addition to theatrical demonstrativeness, the depression is accompanied by crying, fainting, wringing of hands, tragic postures, and corresponding facial expressions. Characteristic features include conversion symptoms (globus hystericus, astasia-abasia, aphonia, etc.) as well as dissociative hallucinosis. Demonstrative suicide attempts are frequent. Despite pronounced symptoms, this variant of reactive depression is characterized by the most rapid, situation-dependent regression.

Reactive paranoid

This is a relatively rare form of reactive psychoses. The clinical picture is characterized by relative simplicity, elementarity, imagery, and affective saturation of paranoid ideas. Most patients develop ideas of persecution and reference. The plot of the delusion reflects psychotraumatic circumstances (either directly or in the form of denials). Auditory hallucinations frequently develop, while visual ones are rare. In the acute period, patients' behavioral reactions exhibit psychopathological features and often culminate in auto- or hetero-aggression, including suicidal acts. Acute psychopathological symptoms usually regress within a few days, although a trail of the described symptoms—most commonly evening and nocturnal fears—persists for 2–4 weeks.

The following forms of reactive paranoids are distinguished.

1. Paranoid type — delusional ideas are unstable, reflect the psychotraumatic situation, form against the background of outwardly orderly behavior, and hallucinations are absent.

2. Hypochondriacal type — develops as a consequence of some somatic illness. Patients express thoughts of having an incurable disease. As a rule, this is combined with ideas of reference, influence, and sometimes dysmorphophobia.

3. Paranoids of external circumstances (S. G. Zhylin, 1940) have several varieties, namely:

a) wartime paranoid. The delusional plot correlates with the situation. Patients fear being taken prisoner, perceive people as enemies, etc. The paranoid unfolds against a background of apprehension affect and is accompanied by impulsive actions, such as flight;

b) "railway" paranoids. They develop during prolonged uncertain journeys, in haste, unfamiliar surroundings, and a state of exhaustion. The delusional plot — persecution and reference — is also determined by general circumstances. Patients "notice" that everyone is looking at them in a special way, whispering, exchanging signs, plotting murder, etc.;

c) prison paranoids. The delusional plot reflects the situation associated with arrest and imprisonment. Typically, the patient develops hallucinations, most often auditory, to the effect that they are being accused, threatened, or having their actions commented upon.

Induced paranoid psychosis. It develops in individuals who have prolonged and close contact with psychiatric patients. Usually, these are primitive people with a low intellectual and cultural level. In content, the recipient's psychopathological phenomena replicate those of the inductor. Most commonly, these include delusions of persecution, reference, litigiousness, or erotoma.

Delusions of the hard of Hearing. (Delusions in a foreign-language environment are close in pathogenesis.) Initially, There is a pathological interpretation of the speech of others, followed — against the background of deepening fear and anxiety affects — by the interpretation of gestures, facial expressions, postures, and actions. Delusional ideas of reference and persecution are formed. Auditory hallucinations and illusions frequently appear.

Differential diagnosis

The basis for the differential diagnosis of reactive psychoses is Jaspers' criteria. In clinical practice, it is very often necessary to differentiate reactive states from endogenous (depression, schizophrenia) and exogenous (alcoholic, etc.) psychoses. Of primary importance for the diagnosis of reactive psychoses is the condition of patients after emerging from the psychotic state. Most commonly, reactive psychoses conclude with complete recovery following a brief period of asthenia. However, residual mental sphere disorders or personality changes (post-psychotic personality) sometimes persist. If complete recovery does not occur, premorbid obligatory, facultative, or latent characterological traits become exacerbated. In particular, following hysterical psychoses, a pronounced hysteroid-excitable accentuation is formed. Following protracted reactive depressions, persistent hypothymia becomes established. The longest-lasting and most difficult to differentiate in the post-reactive period are asthenic states, frequently with elements of psychoorganic syndrome. To designate these states, G. Huber (1968) introduced the term "asthenic defect".

Age-related features, pathomorphosis, and outcomes of reactive psychoses

Most frequently, reactive psychoses occur between the ages of 20 and 40. At an earlier age, they are typically short-lived, fragmentary, and mostly appear as episodes of affectively narrowed or twilight alteration of consciousness without psychopathological components. At an older age, reactive psychoses are characterized by the predominance of a depressive syndrome featuring ideas of self-accusation and self-debasement, along with hypochondriacal delusions.

Clinical pathomorphosis of reactive psychoses in recent years features minor psychopathological symptoms; pseudodementia and puerilism are sometimes observed. Ganser syndrome is virtually nonexistent. Depressive-paranoid symptom complexes predominate. The structure of consciousness disorders takes forms uncharacteristic of reactive psychoses — delirious and ammentive. Following reactive psychoses, critical faculties are fully restored in many cases, or a short-lived residual asthenia persists. Protracted psychoses with a non-progredient course are characterized by a lytic outcome with prolonged residual asthenia.

Transforming, protracted psychoses gradually subside, but Psychopathological Syndromes remain, and relapses of psychosis can occur with a subsequently mild defect. In the case of a sluggishly progredient course, elements of Kandinsky-Clerambault syndrome appear in the clinical picture, and a defect of the apathy-abulia type is formed.

Treatment

Therapeutic tactics are determined by the acuity or clinical form of the reactive psychosis. Acute forms with a predominance of consciousness impairment and psychomotor agitation require emergency care. Immobilization of the patient is sometimes performed. Neuroleptic agents are administered parenterally: chlorpromazine (up to 500 mg per day), haloperidol (up to 40 mg per day), thioridazine (up to 400 mg per day), clopenthixol (up to 400 mg per day), with action corrected by parkopan, trihexyphenidyl, etc. After arresting the most acute period, a transition to benzodiazepine tranquilizers (diazepam, chlordiazepoxide, up to 40–60 mg per day, clorazepate, 50–100 mg) is possible, followed by the oral administration of these or other tranquilizers (medazepam, 20–30 mg, nitrazepam, 5–10 mg).

In the treatment of reactive depressions, thymoleptics play the primary role, combined with neuroleptics and tranquilizers when necessary. For monomorphic depressions dominated by motor and ideational inhibition, imipramine (up to 75–100 mg) and Prozac (60 mg daily) are indicated. Polymorphic depressions whose clinical picture includes psychopathic-like disorders (most commonly of the hysterical spectrum) are treated with broad-spectrum antidepressants featuring a sedative component (amitriptyline up to 100 mg; citalopram up to 60 mg; Zoloft 25–200 mg; thioridazine up to 150 mg; pyrazidol up to 150 mg; insidon up to 50 mg daily).

Tranquilizers play a leading role in the treatment of protracted reactive psychoses. Parenteral administration of diazepam (up to 80 mg daily), phenazepam (up to 5 mg daily), temazepam (30 mg daily), and clorazepate (50–80 mg) is indicated. In severe cases dominated by dissociative symptoms (hallucinations, stupor, paranoid ideation), a combination of tranquilizers, neuroleptics (stelazine, chlorprothixene, flupenthixol, Zyprexa, risperidone, Solian), and behavioral correctors (melleril, sonapax) is used in medium therapeutic doses. Amobarbital-caffeine disinhibition remains valuable in treating the pseudodementing symptom complex.

Following the alleviation of acute psychotic states, rehabilitation measures are implemented, combining general strengthening therapy with psychotherapy. The objectives of psychotherapy are to eliminate pathological fixation caused by the traumatic situation, followed by personal activation and the reinforcement of positive social, occupational, and familial attitudes.

Prognosis

With adequate treatment and rehabilitation, the prognosis is favorable in the majority of cases, leading to recovery. In a small number of patients, a neurotic or psychopathic personality profile develops, significantly worsening the prognosis for social adaptation. Severe depressive disorders accompanied by suicidal tendencies are life-threatening.

Expertise

Medical and social evaluation of neurotic disorders. Impairment of working capacity is typically partial and temporary during the acute phase of the illness. Temporary reassignment to part-time or different work is possible. Temporary disability status is granted quite rarely: only in particularly severe forms of neurosis; in cases of neurotic personality development; in the frequent presence of hysterical paroxysms, motor and sensory disorders; or when obsessive-compulsive symptoms are combined with depression and elaborate rituals. When evaluating the work capacity of hysterical personalities, their tendency toward dramatization and, at times, compensation-seeking behavior must be taken into account.

Forensic psychiatric evaluation of neurotic disorders.

Patients with neuroses are deemed sane and legally competent, as their condition leaves consciousness intact and they are capable of directing their actions. The development of a neurosis following an offense, during the investigative and trial stages, generally does not preclude serving a sentence in places of deprivation of liberty. The diagnosis of neurosis most commonly arises in the context of differential diagnosis with other mental illnesses.

Forensic psychiatric evaluation of reactive psychoses.

Reactive psychoses frequently develop after the commission of unlawful acts as a result of specific situations, such as arrest, investigation, search, and others. In such cases, the evaluation focuses less on establishing sanity or insanity at the time of the offense than on the examinee's ability to participate in the investigation and trial, and to serve a sentence. Due to the reversible nature of acute reactive psychoses, legal proceedings are suspended only for the duration of their development. Protracted reactive psychoses necessitate compulsory treatment followed by trial and sentence service. An exceptionally severe course with a tendency toward chronic progression may be evaluated using criteria applied to endogenous disorders, along with a corresponding recommendation for compulsory treatment.

Medical and social evaluation of reactive psychoses. Temporary disability is established for the duration of psychotic symptoms. Prolonged loss of working capacity is considered in cases of protracted reactive psychoses prone to persistent fixation and relapse. In such instances, other parameters of the patients' life functioning are also differentially evaluated.

Military fitness evaluation for neurotic disorders and reactive psychoses. In cases of sharply pronounced, persistent pathological manifestations, all cohorts of conscripts and military personnel presenting with neurotic disorders and reactive psychoses are deemed unfit for military service and removed from military registration. The same applies to moderately pronounced, prolonged, or recurrent manifestations of the illness (excluding officers, warrant officers, midshipmen, and female service members, whose fitness for military service is determined on an individual basis). In cases of moderately pronounced, short-term manifestations progressing to mild asthenia, all military personnel and conscripts are considered temporarily unfit and are granted leave or discharged. For mild and brief manifestations of the illness resulting in recovery, service members are deemed fit for service in the army and navy, while the fitness of officers, warrant officers, midshipmen, women in airmobile forces, submarine crews, marine corps, special installations, and the naval fleet is determined individually.

Review Questions

1. The concepts of emotional stress and psychotrauma. Jaspers' triad.

2. Definition, Epidemiology, and classification of psychogenic disorders.

3. The three main groups of etiological factors and the pathogenesis of psychogenias.

4. Classification of psychogenic disorders.

5. Clinical forms and diagnosis of reactive psychoses.

6. Issues and manifestations of affective-shock reactive disorders.

7. Reactive depression, paranoid states, and hallucinosis.

8. Hysterical and induced psychoses.

9. Main forms of neurotic disorders, clinical presentation, and diagnosis.

10. Neurosis-like states.

11. Treatment, prevention, rehabilitation, and expert evaluation in psychogenic disorders.