Psychiatry - H.T. Sonnyk 2003

Mental disorders in vascular diseases

Vascular mental disorders occur predominantly in old age and are typically part of a broader complex of generalized vascular pathology.

Historical Background.

Conditions currently classified as arteriosclerotic dementia were first described by A. Voisin (1879) and subsequently by M. Klippel (1891), who differentiated them from general paralysis of the insane. Their nosological independence was finally established in 1894 by O. Binswanger, and they were incorporated into the psychiatric Classification system newly developed by E. Kraepelin. An important milestone in studying Mental Disorders Associated with Vascular Diseases was the distinction made by N.K. Bogolepov and E. Krapf (1936) between hypertensive and arteriosclerotic psychoses.

Significant contributions to The Study of this problem were made by I.N. Vedensky and S.A. Sukhanov (1904), E.F. Lang (1922), N.I. Ozeretsky (1948), and A.L. Myasnikov (1960).

PREVALENCE.

Among all mental illnesses, disorders associated with cerebral vascular pathology rank second in prevalence after Schizophrenia (V.V. Kirsanova, 1987), and after the age of 60, they move to first place, affecting one in every five individuals (S.I. Gavrilova, 1977). Non-psychotic mental disorders account for approximately 80% of all cases within the vascular-related psychiatric spectrum.

Etiology.

Vascular mental disorders primarily arise as complications of cerebral atherosclerosis, Hypertension, hypotension, and thromboangiitis obliterans.

The causes underlying The Development of arteriosclerotic and hypertensive psychoses, as well as other psychopathological disorders of cerebrovascular origin, remain insufficiently studied. It is still unclear why mental disorders develop in some cases while being absent in others, given that morphological, biochemical, and clinical analyses of mental disturbances in similar Brain conditions reveal no direct correlations.

A high frequency of external pathogenic factors (such as alcohol abuse, somatic illnesses, and particularly psychological trauma) preceding mental disorders or coinciding with their onset has been noted. Hypertensive patients exhibit an extreme sensitivity even to mundane psychological stressors that would be non-pathogenic to others (such as relocation or family conflicts), which is reflected in their psychopathological manifestations. Thus, external pathogenic factors, alongside the underlying vascular process, play a specific role in this complex etiological framework.

Pathogenesis.

Causal relationships in vascular mental disorders are complex and diverse. The leading role in their development belongs to dyscirculatory disorders (spasms of small Arteries) and Hypoxia, which are constant satellites of the cerebrovascular process. Furthermore, due to increased vascular permeability and impaired Water METABOLISM, cerebral edema serves as a crucial condition for the development of certain psychotic disorders, such as various manifestations of altered consciousness.

Equally important to the development of vascular-origin psychotic manifestations are background pathological changes in a broad sense, which include a burdened heredity, premorbid personality traits, age-related changes in bodily reactivity, as well as various exogenous and psychogenic factors.

In the development of dementia associated with cerebrovascular diseases, destructive brain processes play a greater role than in psychosis. The slow, gradual progression of the vascular process is equally significant in the development of dementia without productive mental symptoms.

Assessing the pathomorphological picture in cerebrovascular diseases with mental disorders, it can be characterized as hypoxic encephalopathy.

CLASSIFICATION.

Three main groups of vascular mental disorders are distinguished:

✵ Non-psychotic disorders — dysphoric and neurosis-like (pseudo-asthenic, neurasthenoid,

asthenohypochondriacal, asthenodepressive, asthenophobic) states emerging at the onset of the disease.

✵ Psychotic disorders — acute-onset variants of clouded consciousness, followed by transitional syndromes such as asthenic (favorable) or pseudo-organic (unfavorable). Among endoform Psychopathological Syndromes of organic origin, hallucinatory (usually verbal), paranoid, hallucinatory-paranoid, and depressive syndromes are observed.

✵ Vascular dementia — lacunar at the initial stage, with a potential progression to a diffuse form.

Clinical Features.

Mental disorders in cerebral atherosclerosis.

The clinical progression of the disease process caused by cerebral atherosclerosis consists of 3 stages:

I — initial;

Stage II – pronounced mental disorders;

Stage III – dementia.

Stage I. The most common manifestation of cerebral atherosclerosis at this stage is a neurasthenic-like syndrome. The Main Features of this condition include rapid fatigue, weakness, exhaustion of mental processes, irritability, and emotional lability. Sometimes, mild depression combined with asthenia occurs. In other cases, psychopath-like (characterized by irritability and conflict) or hypochondriacal syndromes may emerge. During this period, all patients complain of dizziness, tinnitus, and memory impairment.

In Stage II, mnemonic and intellectual disorders typically progress: memory deteriorates significantly, especially fixation memory; thinking becomes sluggish and inert; and emotional lability and lachrymosity increase.

At this stage, atherosclerotic psychoses may debut: depressive, paranoid, accompanied by clouded consciousness, or hallucinosis. In addition, epileptic seizures may be observed during this period, which can serve as the leading syndrome (epileptiform syndrome).

The most common manifestation of the period of pronounced mental disorders (occurring in approximately 1/3 of patients with psychoses) is paranoid syndrome. Premorbidly, such patients are characterized by withdrawal and suspicion, or possess an anxious-suspicious personality trait. Their family history is frequently burdened by mental illness or alcoholism. The content of delusions varies: ideas of persecution, jealousy, poisoning, and occasionally hypochondriasis or damage are most commonly expressed. Delusions in such patients tend to become chronic.

Depression is observed less frequently than other atherosclerotic psychoses. Unlike the asthenodepressive syndrome of the initial period, feelings of deep sorrow intensify, mood drops sharply, and psychomotor and particularly intellectual retardation, along with anxiety, are observed. Patients express ideas of self-blame and self-deprecation. These disorders are combined with Complaints of headache, dizziness, and ringing or buzzing in the ears. Atherosclerotic depression lasts from several weeks to several months, and is frequently accompanied by hypochondriacal complaints and asthenia. Following recovery from the depressive state, patients do not exhibit pronounced dementia, but they display lachrymosity, and their mood fluctuates. Atherosclerotic intellectual and mnemonic disorders arising after psychosis may be compensated. Within 1–3 years, depression may recur. A more progredient course is observed when depression develops at a late age with The addition of other adverse factors.

Atherosclerotic psychoses with consciousness disturbance syndromes may be observed in patients with a history of multiple adverse factors: traumatic brain injury with loss of consciousness, alcoholism, and severe somatic diseases. The most common form of consciousness disorder is delirium, and less frequently, a twilight state of consciousness. The duration of these disorders is usually limited to a few days, although relapses are possible. Cases of cerebral atherosclerosis complicated by consciousness disorders are prognostically unfavorable, and dementia may rapidly progress after recovery from psychosis.

The progression of cerebral atherosclerosis does not always follow the described pattern. Sometimes, clinical manifestations of the initial period are mild, while psychotic disorders appear abruptly.

A manifestation of Stage III is sometimes an epileptiform disorder. This syndrome is characterized by paroxysmal shifts: most commonly atypical major convulsive seizures with loss of consciousness, consciousness disorders resembling ambulatory automatisms, and dysphoria. Alongside paroxysms, disturbances typical of cerebral atherosclerosis are observed, and in some cases, personality changes close to epileptic ones occur. The rate of dementia progression in these cases is slow, with pronounced dementia developing 8–10 years after the onset of this syndrome.

Hallucinosis develops relatively rarely. This condition almost invariably arises at an advanced age. Patients hear voices “from the side” that provide a running commentary. Very rarely, the clinical picture of hallucinosis is manifested by visual hallucinations.

Mental manifestations in such patients are combined with somatic disorders (aortic atherosclerosis, coronary vessel disease, cardiosclerosis) and organic neurological symptoms (sluggish pupillary reaction to light, smoothing of the nasolabial folds, swaying in the Romberg position, hand tremor, and oral automatism syndromes). Gross neurological symptoms in the form of amnestic and motor-sensory aphasia, as well as residual effects of hemiparesis, are also observed. A direct parallelism between the development of neurological and psychopathological symptoms is usually absent.

Cerebral atherosclerosis is frequently combined with hypertension.

Mental disorders in hypertension.

The manifestations of atherosclerosis and hypertension represent different forms of a single vascular pathology. Patients with hypertensive and atherosclerotic psychoses share many common features: age period, heredity, premorbid traits, various exogenous factors (alcoholism, TRAUMATIC BRAIN INJURIES), and psychogenic factors. All of this explains the commonality of pathogenesis, clinical features, and pathomorphological pictures of these Variants of the general cerebrovascular process, particularly in the Cytology/cytology/16.html">Early stages of its development.

Initial psychopathological manifestations in hypertension are marked by the same syndromes as in cerebral atherosclerosis. In The Structure of hypertensive psychoses, which share a clinical picture similar to the Main syndromes of atherosclerotic psychoses, Affective Disorders are more pronounced: anxiety dominates, combined with delusions, depression, and hallucinosis, meaning we are dealing with anxious-delusional and anxious-depressive syndromes. The course of hypertensive psychoses is more dynamic than that of atherosclerosis, but less prolonged.

Mental disorders in cerebral vascular hypotension.

These conditions are similar in origin to analogous manifestations in hypertension and may be accompanied by comparable mental disorders. Asthenic syndrome is the most frequent finding in hypotension. Psychotic disorders may manifest as affective symptoms (anxious depression) and short-term disturbances of consciousness (episodes of twilight states).

Treatment.

In treating mental disorders of vascular origin, the primary focus should be on influencing the underlying vascular pathological process. A comprehensive therapeutic approach is recommended, aimed at improving and normalizing cerebral Blood supply following the alleviation of vascular spasms and cerebral hypoxia.

General conditions include prolonged treatment, cessation of alcohol and smoking, Prevention of mental overexertion, physical therapy regimens, and adherence to a proper work-rest balance.

In cerebral atherosclerosis, dietary management is of great importance, specifically limiting the intake of Cholesterol-rich foods, spices, pungent dishes, and coffee.

Neurotropic antispasmodic effects are exerted by agents that influence various links of autonomic regulation. This group of drugs includes anticholinergics (atropine preparations, metamizil), antiadrenergics (pyroxan, anaprilin), and ganglion blockers (pentamin, dycolin, isoprine). Antispasmodic action is also produced by drugs with a central sedative effect—tranquilizers (seduxen, elenium, grandaxin), hypnotics (eunoctin), and neuroleptics (haloperidol, frenolon).

Cerebral and coronary blood supply is improved by well-known antispasmodic and coronary-dilating agents—No-shpa, complamin, dibazol, curantyl, stugeron, and others. The administration of hypolipidemic agents such as miscleron and nicotinic acid is advisable. A complex of Vitamins E, PP, A, B₁, B₆, B₁₂, hormonal preparations, and anabolic Steroids (nerobol, retabolil) is also widely used. Among agents aimed at combating hypoxia, reopolyglucukin, cocarboxylase, ATP, and Hyperbaric Oxygenation are employed.

Depending on the dominant psychopathological syndrome, neuroleptics are used for delusional states, while antidepressants combined with tranquilizers are prescribed for depression.

When prescribing neuroleptics, it is essential to consider the condition of the patient's Vascular System and overall health, keeping in mind that the doses of these drug classes must be selected with caution. Treatment should begin with minimal doses, usually avoiding an increase to the average therapeutic levels used for Other types of psychosis.

Psychotherapeutic Methods (particularly rational psychotherapy) and occupational therapy can play a vital role in treatment.

EXPERT ASSESSMENT.

Medical and labor expertise. The presence of mental disorders in the early stages of vascular disease allows patients to continue working in their specialty under lighter conditions; in such cases, they are assigned a Group III disability status.

In cases of pronounced dementia and vascular psychosis, complete and permanent loss of working ability is observed, resulting in reassignment to Group II, and occasionally even Group I, disability.

Military medical expertise. Patients with atherosclerotic psychosis and dementia are deemed unfit for military service and are discharged from the register. For neurosis-like states, the fitness of officers for military service is determined on an individual basis, whereas enlisted personnel and sergeants are declared unfit for military service in peacetime and fit for non-combat duties in wartime.

Forensic psychiatric expertise. The mere presence of vascular pathology does not constitute grounds for ruling a person insane at the time an offense was committed. Only patients experiencing acute psychosis or profound dementia are considered legally incompetent and unaccountable for their actions. In non-psychotic states and in the absence of severe dementia, questions of legal capacity and sanity are evaluated individually.

Review Questions.

1. Etiological factors of vascular mental disorders.

2. Pathogenesis of vascular mental disorders.

3. Classification of mental disorders resulting from vascular pathology.

4. Mental disorders in hypertension.

5. Mental disorders in hypotension.

6. Mental disorders in the early stages of cerebral atherosclerosis.

7. Types of atherosclerotic dementia.

8. Mental disorders during hypertensive crises.

9. Mental disorders in neurocirculatory dystonia.

10. Treatment of Mental Disorders in vascular diseases.

11. Expert evaluation of patients with vascular mental disorders.