Psychiatry - H.T. Sonnyk 2003

Psychosomatic and Somatopsychic Disorders

The division of diseases into Psychosomatic and Somatopsychic is largely conventional. Mentioning psychological or physiological processes implies a different approach to the same phenomenon, yet the phenomenon itself is indivisible. Therefore, in this sense, there are neither somatogenic nor psychogenic diseases, but simply illness.

PSYCHOSOMATIC DISORDERS.

Psychosomatics is a branch of psychiatry that studies disorders of Internal Organs and systems arising under METABOLISM/18.html">The Influence of psychotraumatic factors, as well as the links between The Nature of a psychological stress factor and the impairment of specific organs and systems.

Historical Background.

Observations regarding the close connection between emotional reactions and somatic Changes in the body appeared quite a long time ago. Well-known idiomatic expressions for the feeling of fear include "Heart in one's Mouth" or "cold feet"; for resentment, "a lump in one's throat"; for surprise, "breath taken away," and so on. Prominent physicians and philosophers such as Hippocrates, Cos, Plato, Spinoza, and Descartes drew attention to the interaction between the body and the psyche (soul). The term "psychosomatics" itself was proposed by Heinrot in 1918.

An important milestone in The Study of this pathology was the psychoanalytic theory developed by S. Freud at the beginning of the twentieth century. It posited that affects unrealized due to social constraints could transform into symptoms of various diseases. This conversion process was termed "conversion." Psychoanalysts considered diseases such as Bronchial Asthma, gastric ulcers, cholelithiasis, and others to be psychogenically induced. Such views were met with considerable ambiguity in the scientific community from the very beginning. In particular, M.I. Astvatsaturov (1935) noted that "...psychoanalysis, through its attempts to explain everything while remaining infallible, discredited for many years the justified view that somatic symptoms can arise as direct manifestations of psychological (affective) experiences." Nonetheless, many psychological and psychiatric schools still understand psychosomatics as a method for diagnosing and treating somatic diseases primarily from a psychoanalytic perspective.

The idea of organismic integrity and Structure/149.html">The problem of its interaction with the environment have long been studied by domestic medicine, which has enriched world science with the works of V.M. Bekhterev (1928), E.K. Krasnushkin (1936), V.A. Gilyarovsky (1947), P.K. Anokhin (1970), A.D. Zurabashvili (1970), A.G. Ivanov-Smolensky (1974), and many other scientists.

I.M. Sechenov laid the foundations of reflex theory; I.P. Pavlov (1936) developed a method for studying the Organism's interactions with the environment and advanced the idea of nervism, demonstrating how the Central Nervous system and its highest division—the Cerebral Cortex—"keeps under its control all phenomena occurring in the body." The Theory of nervism provided the foundation for studying The Role of various living conditions in the onset and development of neurogenic diseases.

The founders of modern psychosomatic theory consider it a universal principle of medicine, based on the thesis of organismic indivisibility. "Psychosomatic medicine is understood as the Treatment of disorders, adaptation impairments, and, accordingly, the Study of the organism, the environment, and their mutual interaction" (W. Franz, 1988).

PREVALENCE.

The relevance of this problem is growing. According to WHO experts, nearly 50% of inpatient hospital beds worldwide are occupied by patients with psychosomatic pathology. It has been calculated that 22% of individuals presenting with psychosomatic Complaints consume up to 50% of physicians' working time (Lunn, 1984).

As evidenced by a study conducted by O.K. Napreienko (1991), nearly 70% of somatic patients exhibit signs of mental disorders of various registers and degrees of severity. Moreover, certain psychosomatic disorders, such as cardiovascular conditions, have reached pandemic proportions in virtually all industrialized countries.

Epidemiological studies show that middle-aged and elderly individuals, as well as those with low socioeconomic status, are more prone to psychosomatic pathology. Women suffer from psychosomatic disorders more frequently than men.

It is worth noting that these figures are quite heterogeneous due to significant discrepancies in views on nosological boundaries, differences in the epidemic situation across various regions, and the subjectivity of assessments by different specialists.

ETIOPATHOGENESIS.

The question of THE ORIGIN OF psychogenically induced somatic diseases is closely linked to the problem of psychological conflicts and neuroses. According to V.N. Myasishchev, all psychogenic diseases are characterized by:

1) a connection with a psychotraumatic situation;

2) the presence of a disease motive (pathogenetic);

3) the reflection of premorbid personality traits in the clinical manifestations of the disease;

4) the dependence of the therapeutic effect on the resolution of the psychotraumatic situation.

V.B. Zakharzhevsky points out that despite the presence of identical components—psychogenic and biological—in the clinical picture of neuroses and psychosomatic disorders, their ratios differ. In neuroses, the psychogenic factor plays the primary role, while risk factors play a supplementary one; whereas in psychosomatic disorders, the Specificity of the disease is determined by biological factors, with psychogenic factors playing a decisive (initiating) role.

The Autonomic nervous system acts as the intermediary between the CNS and internal organs, and as the "conductor" of emotional states, sometimes justly referred to as the "organ of affect expression." Physiological reactions to psychological (cognitive, emotional, volitional) processes occur continuously across various physiological systems: cardiovascular (changes in heart rate and Blood pressure, vasoconstriction and vasodilation); respiratory (acceleration or deceleration of breathing); digestive (enhancement or slowing of motility, nausea); muscular (tremor, agitation, stupor, etc.), and reproductive.

However, psychosomatic shifts are also possible without an emotional component. According to I.P. Pavlov's theory, psychosomatic reactions can occur with the participation of the first signaling system, as in the textbook example of boys marching with lemons in front of a brass band until the musicians stopped playing due to excessive salivation. The initial stimulus can also be mediated by the second signaling system: for example, a verbal description of that same lemon repeatedly evokes the mental image of it and the corresponding somatic response.

Various noxious factors that are stressogenic for a specific organism cause overstrain of adaptation processes in the cerebral cortex, where, against the background of general dynamic shifts, functional foci of stagnant Excitation and Inhibition arise, associated with pathologically fixed negative emotions in response to the stress factor. These phenomena of pathological stasis spread to the autonomic nervous system and for a long time create a specific functional state within it that corresponds to a particular negative emotion, limiting The flexibility of its adaptation to external and internal changes. Stasis and inertia can persist for a long time even after the removal of the external factors that triggered them.

Autonomic and metabolic insufficiency develops, along with disruptions in the functioning of internal organs. Initially, these changes are functional and reversible, but with prolonged and frequent recurrence, they can become organic and irreversible.

This theory champions THE PRINCIPLE OF non-specificity, which posits that any prolonged stress can trigger somatic disorders. However, depending on the patient's ontogeny and medical history, the site of primary pathology and the most severely affected physiological function vary from case to case. The reason for this "selectivity" is that the damaged organ (or system) was already in a pre-pathological state. A "nervous Shock" merely facilitates the culmination of the pathology known as "locus minoris resistentiae" — the "site of least resistance".

A different viewpoint is held by proponents of the specificity theory. They provide evidence suggesting that "organ Selection" is primarily driven by the Nature of the psychotraumatic agent or the reactive personality. Notably, F. Dunbar described Type A personality traits specific to The Development of coronary pathology.

H. Selye investigated the General adaptation syndrome, which represents the sum of the body's non-specific reactions to prolonged stress. The central component of this response is the hypothalamic-pituitary-adrenal axis, which reacts to stress with excessive cortisol secretion, ultimately leading to structural changes in internal organs. The Neurotransmitters mediating stress responses include Hormones such as cortisol, thyroxine, and adrenaline.

Classification OF PSYCHOSOMATIC DISORDERS.

Some contemporary researchers distinguish between psychosomatic reactions and actual psychosomatic disorders. The former do not yet constitute a true pathology and manifest in healthy individuals as isolated, transient bodily responses to stressors. Examples of such reactions include frequent urination and diarrhea in students prior to major examinations.

The term "psychosomatics" is used in multiple Senses. According to M. Bleuler (1970), psychosomatic disorders are divided into three types.

1. Psychosomatoses — classic psychosomatic diseases accompanied by the development of organic pathology driven by psychological factors. Treatment in such cases should focus primarily on the psyche (psychotherapy and psychopharmacotherapy). This group predominantly includes Hypertension, PEPTIC ULCER DISEASE, bronchial asthma, Ulcerative Colitis, neurodermatitis, myocardial infarction, and migraine. While psychological and behavioral factors alter bodily reactivity and play a significant role in the onset and course of other diseases (endocrine, infectious, malignant), they are not the primary etiological factors.

2. Functional psychosomatic disorders, sometimes referred to as systemic neuroses — unstable dysfunctions of organs and systems associated with neuropsychic factors (such as specific emotional reactions or the experience of psychological trauma). These include stuttering, enuresis, neurotic tics, constipation, psychogenic impotence, etc.

3. Psychosomatic disorders associated with specific patterns of emotional and personal reactivity (used in a broader, indirect sense). Health impairments in these cases are caused by specific behavioral patterns stemming from particular personality traits and personal experiences. This category encompasses accident proneness, obesity, alcoholism, substance abuse, and others.

In ICD-10, the term "psychosomatics" is avoided to prevent the misconception that psychological factors play no role in the onset of diseases not classified under this specific heading. In essence, psychosomatic disorders are distributed across various categories:

F 45 — Somatoform disorders;

F 50 — Eating disorders;

F 52 — Sexual dysfunction;

F 54 — Psychological and behavioral factors associated with disorders or diseases classified elsewhere.

Clinical presentation.

Dentists frequently encounter manifestations of so-called masked or somatized depression, where genuine depressive symptoms (persistently depressed mood) are hidden behind a "mask" of pain or autonomic disorders. The most common variants of masked depression include:

a) Algic-cenestopathic form — dominated by pain and unpleasant sensations in various PARTS OF THE body. Cephalic, abdominal, and cardiac variants are possible. A glossalgic variant is frequently observed in women, which is particularly relevant in dental practice.

b) Agrippnic form — dominated by Sleep disturbances.

c) Diencephalic form — manifested through various autonomic crises.

d) Obsessive-phobic form — characterized by intrusive thoughts and fears.

Sensory disturbances in the soft Tissues of the face and oral mucosa can be categorized into: paresthesias — tingling, burning, tightness; pain — a sensation of fullness, throbbing; taste disorders — bitterness, dryness. In diagnosing somatized depression, clinicians consider the patient's complaints, medical history, and the dynamics of the illness, as well as the response to dental treatment. The physician must acknowledge the reality of any existing somatic pathology, first conducting a thorough instrumental examination; if results are negative and relevant psychopathological signs are present, a Diagnosis of depression should be established.

Cardiovascular system. Ischemic heart disease and myocardial infarction most commonly occur in so-called "coronary personalities". Their character type has been termed the "stress-coronary profile", "Type A", or the "Sisyphanean type", reflecting a drive to maintain a state of continuous emotional tension. Premorbidly, such individuals exhibit pronounced perfectionism — ambition, elevated aspirations aimed at achieving high societal standards, and a strong motivation for high social achievement. They are characterized by competitiveness, haste in managing affairs, impatience, a high sense of responsibility for assigned tasks, competitiveness, and occasionally hostility. "Work immersion" is typical, as they simply lack time for anything else. Furthermore, this is explained by the fact that such individuals cope better with situations oriented toward achieving high socially significant goals than with family problems or socializing with friends.

Angina pectoris, arrhythmia, and coronary spasm occur against a backdrop of prolonged distress, anxiety, anger, and frustration. Anginal pain often exhibits atypical character and localization. Panic reactions may be accompanied by pronounced arrhythmia, tachycardia, and a feeling of suffocation. Death may occur due to ventricular extrasystole during severe stress.

During the American Civil War (1871), Da Costa's syndrome ("soldier's heart") was described. In this condition, an unfounded conviction of having developed severe heart disease is accompanied by tachycardia, dyspnea, angina pectoris, and excessive fatigue.

The Emergence of an intrapsychic conflict between aggressive impulses and the need to depend on significant others can lead to the development of hypertension. Conflict situations play a significant role in its Etiology, as individuals prone to hypertension generally adapt poorly to stressful situations, and their personalities are characterized by introversion, emotional lability, and histrionic traits. Such traits predispose them to psychosomatic responses.

Peripheral vascular spasms in Raynaud's disease can be considered directly linked to tobacco smoking as a form of substance addiction (the third type of psychosomatic disorders according to M. Bleuler).

Respiratory system. Among the personality traits predisposing to bronchial asthma are histrionic tendencies, hypochondria, and unconscious anxiety. Psychoanalysts view the symptom of bronchospasm as a symbolic reflection of an internal conflict between The Need for affection and the fear of it. Asthmatic wheezing represents an unconscious plea for love and protection. A key factor in the development of bronchial asthma is the mother's suppression of the child's emotional expressions in early childhood, such as crying, screaming, and others.

Families of patients with bronchial asthma are characterized by restrained emotional expression; parents tend to control their children's initiative and block unauthorized actions. Asthma attacks become more intense the harder the patient must struggle against feelings of anger toward authority figures who withhold desired love.

Gastrointestinal tract. Occasionally, the onset of gastric and duodenal ulcers is unrelated to infection or physical irritation. The premorbid profile of such patients typically features a tendency to repress dependency needs while intensely craving love and care. To date, seven personality profiles have been identified that drive not only the development of peptic ulcer disease but also its clinical course. The most common among them include:

a) the "tyrannical patient" — characterized by an inner dependency on the environment coupled with a fear of this dependency. As a hypercompensatory behavioral reaction, they strive to tyrannically suppress others, showing outbursts of aggression when facing failure; some of these patients are prone to alcohol abuse;

b) patients with psychopathic and compulsive-depressive character traits. They tend to "disperse" aggressive tension onto those around them, mocking others and expressing chronic dissatisfaction. This provokes a negative reaction from the environment, which in turn fuels the patient's aggression even further, thus creating a "vicious circle".

Endocrine System disorders and metabolic disturbances. Three psychological mechanisms contributing to the development of Diabetes Mellitus are distinguished:

a) intrapsychic conflicts and needs are compensatorily satisfied through the act of eating (the formula: food = love). An intense appetite and a tendency toward obesity lead to persistent hyperglycemia, which ultimately functionally weakens the secretory activity of the pancreatic islets of Langerhans;

b) the identification of food with love. Blocking this emotion induces a state of hunger that intensifies regardless of food intake. A "starved" metabolism is formed, which mirrors the metabolism of a diabetic patient;

c) lifelong unconscious fears lead to persistent "fight-or-flight" responses accompanied by hyperglycemia. Since psychological tension is not adequately discharged, diabetes may develop out of initial hyperglycemia.

The drive for excessive food consumption and the resulting obesity may serve as a defense against an unwanted marriage or social failure, frequently occurring in individuals with unfulfilled self-actualization needs or as a compensation for an unhappy family life.

TREATMENT.

The comprehensive treatment plan includes psychotherapeutic work with the patient; psychological and psychotherapeutic support for family members and close contacts; and The Use of effective psychotropic and other biological psychocorrective agents. These therapeutic Methods are applied alongside conventional medical interventions administered by relevant specialists in somatic hospital settings, with the involvement of a consulting psychiatrist rather than the primary attending physician (liaison psychiatry).

Patients with severe mental disorders are best treated in psychosomatic units of multidisciplinary hospitals or in psychiatric wards (if their somatic condition permits). For patients who do not require inpatient care, this type of specialized medical assistance is provided on an outpatient basis, likewise following a liaison rather than a substitutional model (where a psychiatrist replaces a physician of another specialty), due to the organizational and economic inefficiency of the latter.

Taking into account The structure of Psychopathological Syndromes, sedatives (bromides, valerian, Novopassit) and tranquilizers (sibazon, tranxene, tazepam, medazepam) are primarily prescribed. These groups of medications are sufficient in the presence of incomplete (subsyndromal) clinical manifestations. Vitamins, beta-blockers producing an anxiolytic (anti-anxiety) effect, as well as nifedipine and verapamil, which possess mood-stabilizing properties, physiotherapeutic Procedures (electrosleep, solarium), and general restorative therapy (multivitamins, Magne B6) may also be utilized.

For fully developed psychopathological states, antidepressants (amitriptyline, melipramine, Coaxil, Zoloft, citalopram) are prescribed. To correct maladaptive behavior, the use of neuroleptics such as neuleptil and Sonapax is primarily justified.

At the same time, one must keep in mind the heightened sensitivity of somatic patients to psychotropic medications, and occasionally their paradoxical response to them. Therefore, these drugs are initially prescribed at minimal doses and subsequently increased, taking into account individual psychological reactions and somatic status.

SOMATOPSYCHIC DISORDERS.

Somatopsychic disorders are psychiatric conditions that arise secondarily as a consequence of somatic (non-infectious) extracranial illnesses.

They encompass closely interrelated yet syndromologically distinct groups of pathological manifestations. On the one hand, these are exogenous-organic mental disorders caused by somatogenic influences; on the other hand, they are psychogenic disturbances, such as reactions to illness and its potential consequences. Special attention is warranted regarding the problem of the internal picture of illness and closely related issues of deontology in somatic clinics.

HISTORICAL BACKGROUND.

The active study of this problem has taken place primarily over the past hundred and fifty years within the framework of research on so-called symptomatic psychoses (M. Baillarger, 1880). To this day, The Doctrine of somatogenic mental disorders has not reached a definitive form. During the exploration of this issue, E. Kraepelin pointed out the specificity of psychoses in each specific somatic disease. Conversely, K. Bonhoeffer (1908) emphasized their etiological non-specificity in his theory of exogenous reaction types. Among the important Milestones in the theoretical substantiation of the doctrine of somatopsychic disorders are the diagnostic criteria proposed by K. Schneider (1936):

1) the presence of clear somatic symptomatology;

2) a distinct temporal correlation between somatic and mental disorders;

3) parallelism in their clinical course;

4) the presence of exogenous psychopathological symptoms.

ETIOLOGY AND Pathogenesis.

The presence of a somatic disease with its direct toxic, reflex-interoceptive, or neurohumoral (incretory) impact on the central nervous system is the primary etiological factor in somatogenic psychoses. Alongside this, one should not underestimate the influence of a history of psychological trauma (which leaves areas of least resistance in the CNS), prolonged and severe bodily exhaustion, intoxications, consequences of traumatic Brain injury (TBI), pronounced infantile or psychopathic premorbid personality traits, and other factors capable of significantly influencing the onset and course of neuropsychiatric disorders.

The most critical links in the pathogenesis of somatopsychic disorders:

a) Hypoxia;

b) pathological interoception from the affected organ to the CNS;

c) intoxication resulting from internal organ pathology;

d) disorders of complex neurohumoral interactions due to the enhancement, attenuation, or distortion of endocrine gland Functions;

e) disruptions in cerebral neurodynamics and higher nervous reflex activity.

All of these components participate in the overall disease mechanism, though their relative significance may vary. For instance, in cardiogenic psychoses, hypoxic, interoceptive, and cerebral factors are central, whereas in nephrogenous psychoses, toxic and hypoxic components play the leading role (uremic coma).

CLASSIFICATION OF SOMATOPSYCHIC DISORDERS.

Based on etiopathogenetic and clinical-dynamic features, somatopsychic disorders are classified (O.K. Napryeyenko, 1995) as follows:

1. Non-psychotic - obtundation, sopor, coma, as well as neurotic, psychopathic, neurosis-like, and psychopath-like disorders (asthenic, astheno-depressive, astheno-hypochondriacal, astheno-abulic, astheno-apathetic, anxiety-phobic, obsessive-phobic, depressive, depressive-hypochondriacal, hysterical-hypochondriacal syndromes, pseudodementia), which manifest in the form of:

a) a reaction;

b) a persistent state;

c) pathological personality development.

2. Psychotic - delirium, oneiroid state, amhenia, twilight state, as well as paranoid, depressive-, anxious-, manic-, and hallucinatory-paranoid, catatonic, and cenesthetico-hypochondriacal syndromes. According to their course:

a) acute symptomatic;

b) subacute (protracted, transitional);

c) chronic (prolonged).

3. Encephalopathic (organic-deficit) - simple psycho-organic, epileptiform, Korsakoff's, pseudoparalytic syndromes, and nonspecific organic dementia.

According to the leading etiological factor, somatopsychic disorders are categorized into those arising from:

1) diseases of internal organs and systems;

2) severe Metabolic Disorders;

3) disorders of endocrine gland function.

CLINICAL PICTURE.

1. Mental disorders in diseases of internal organs systems.

CORONARY HEART DISEASE. Myocardial infarction. In this disease, mental disorders of varying severity occur in 55% of cases. Their onset is facilitated by a history of angina pectoris, cerebral atherosclerosis, and recurrent infarctions.

Already in the prodromal period, against the background of asthenia and angina pectoris (though sometimes without the latter), unmotivated anxiety, depressed mood with a melancholic undertone, and a sense of mental restlessness are observed.

In the acute, painful period, patients are usually overwhelmed by intense vital affects of fear, anguish, and anxiety accompanied by motor agitation. Such states arise acutely and suddenly, typically lasting for several minutes, and manifest as anxious depressions carrying a high risk of suicidal tendencies. A prognostically unfavorable transition of depression into euphoria, or vice versa, is possible. Short-term, "shimmering" states of twilight, delirium, or amentia may also occur.

During the febrile period (days 7–10), melancholic-depressive states are particularly common, as well as torpor, which in severe cases can progress to sopor.

In the subacute period (up to 1–1.5 months), phenomena of pronounced asthenia come to the fore, characterized by increased fatigability, emotional lability, and extreme hyperesthesia (emotional-hyperesthetic weakness).

The remote period is characterized by The addition of neurotic disorders to asthenia, often resulting in the development of a neurotic (predominantly hypochondriacal) personality.

Liver diseases. Chronic progressive liver diseases (acute yellow Atrophy of the liver, hepatolenticular degeneration, biliary cirrhosis) can lead to a variety of mental disorders.

In acute yellow atrophy of the liver, they typically debut with acute asthenia and insomnia, against the background of which severe delirium, twilight states, and convulsive seizures later develop amidst progressive toxemia.

In hepatocerebral degeneration (Wilson-Konovalov disease), subdepressive states initially emerge against a background of emotional lability, which subsequently evolve into full-blown depressions and are sometimes interspersed with episodes of mania. Later, amidst progressive total dementia, hallucinatory, paranoid, and catatonic syndromes manifest, which, as toxemia increases, become overshadowed by delirium and amentia. Convulsive seizures and comatose states are also possible.

Biliary cirrhosis also debuts with severe psychophysical asthenia that transitions into affective clinical pictures. Afterwards, a steady and gradually progressive decline in core mental functions becomes noticeable, accompanied by psychopath-like states that are sometimes overlaid by twilight states or torpor progressing to coma. Such patients may develop delusions of dysmorphophobic content, delusions of influence, reference, and persecution, as well as specific functional hallucinations where patients, upon merely seeing insects, begin to feel their presence on their own Skin and brush them off.

Gastric and duodenal ulcer disease. Mental disorders typically debut As a result of an exacerbation of a long-standing peptic ulcer. However, subsequent episodes (similar to the initial ones) may also occur outside of somatic exacerbations, triggered by psychological trauma, alcohol abuse, or infection. Initially, astheno-depressive, anxio-depressive, and hypochondriacal states arise against an asthenic background, followed by full-blown depressivo-paranoid syndromes featuring fragmented sensory delusions of poisoning, influence, and persecution, and particularly hypochondriacal features. Auditory, olfactory, and visceral hallucinations are also pronounced, with the latter frequently localized in the area of the ulcer. The psychosis lasts from several weeks to 3–4 months and generally ends in recovery.

Bronchial asthma. Even before the onset of psychotic symptoms, such patients frequently exhibit psychopath-like states with traits of sensitivity, vulnerability, and reclusiveness. The exacerbation of asthma or an increased frequency of attacks can serve as a prerequisite for the onset of psychoses. Three forms of psychoses in bronchial asthma have been described.

The paroxysmal form manifests as short-term episodes of impaired consciousness (lasting from several hours to several days), predominantly in the form of twilight states.

The hallucinatosy-paranoid form features diverse, but predominantly auditory hallucinations and fragmented sensory delusions of persecution and reference.

The anxious-depressive form is represented by pronounced affects of fear and anxiety, delusions of self-blame and persecution, and hallucinatory inclusions. The latter two forms tend to have a wave-like course, lasting for several weeks and occasionally extending to 3–4 months, but ultimately, as a rule, they end in recovery.

2. Mental disorders in metabolic disorders.

Kidney diseases. Acute nephrogenic psychoses resulting from ACUTE RENAL FAILURE, which in turn stems from metabolic disturbances, can manifest as twilight states, delirium, amentia, as well as states of torpor progressing to uremic coma. Sometimes such patients experience convulsive seizures and dysphoric states. The illness lasts from several days to a month and generally ends in recovery.

In compensated chronic renal failure, pronounced asthenia with passivity and adynamia comes to the foreground; during exacerbations, this may be accompanied by exogenous-type reaction pictures (delirium, amentia, torpor). In pronounced chronic failure, prolonged remittent paranoid, anxious-depressive, and catatonic states are characteristic, frequently with a tendency toward slowly progressive organic dementia.

Diabetes mellitus. This disorder is typically accompanied by pronounced somatogenic asthenia with pseudoneurasthenic or subdepressive syndromes. As the severity of the diabetic process itself increases, a gradual progressive transition from asthenia to adynamia and even apathy is observed, behind the "facade" of which intellectual-mnestic decline is revealed. In severe, prolonged diabetes with recurrent diabetic and hypoglycemic comas, convulsive and amnestic syndromes are possible, as well as delirious and amentive clouding of consciousness.

3. Mental disorders in endocrine system diseases.

Pancreas (insulinoma). As a result of Hyperfunction of the islets of Langerhans, a hypoglycemic state develops acutely, which may be accompanied by twilight states, epileptiform seizures, as well as torpor, sopor, or coma. Agitation with aggressiveness is likely primarily during twilight states.

Cushing's Disease — hyperfunction of the basophilic portion of the anterior Pituitary gland leads to disruption of the normal activity of the Adrenal Glands, pancreas, and Gonads. This accounts for the high prevalence of mental disorders in this pathology (up to 94% of cases).

The central symptom is pronounced psychophysical asthenia with excessive fatigability, lack of initiative, and adynamia, which may debut even before the somatic pathology is detected (initial asthenia). Although such patients have an indifferent facial expression, they do experience specific emotional distress. Occasionally, they exhibit impulsive angry-irritable reactions. Insomnia alternates with periods of somnolence. At the stage of the fully developed process, depressions with dysphoric and paranoid features are observed, but without ideas of self-blame and motor retardation. Cenestopathic-hypochondriacal motifs impart a nihilistic tint to the overall psychopathological picture. Sometimes depressions reach significant depth, accompanied by suicidal ideation that is not realized due to adynamia. The emergence of peculiar manic episodes with hyperthymia against a background of adynamia is possible, which may alternate with episodes of depression.

Psychoses last from several weeks to several months. Dementia may result from early-onset cerebral atherosclerosis.

TREATMENT.

Such patients usually remain for treatment in appropriate general somatic hospital units, but in the event of acute psychotic disorders, their transfer to a psychiatric ward is desirable, provided they are under the constant supervision of both a psychiatrist and a general practitioner.

Treating the underlying somatic pathology in this case is essentially etiological therapy. It must be as comprehensive and effective as possible, but alongside this, There is a need for the widespread use of psychotropic agents.

In cases of clouded consciousness, as well as in states of acute psychomotor agitation, neuroleptics with a powerful antipsychotic effect are indicated: chlorpromazine, haloperidol, thioridazine (tizercin). When using such drugs, one must keep in mind the patients' high sensitivity to them, as well as their hypotensive action (risk of collapse). If necessary, a 3-5 ml solution of diazepam (seduxen) intravenously is indicated. These same medications are effective for treating manic states. For moderate depressions, coaxil, tizercin, melleril are indicated, and for severe depressions with agitation, antidepressants (pyrazidol, amitriptyline, citalopram, zoloft). Amitriptyline is effective in somatogenic depressions accompanied by anxiety and fear, without psychomotor retardation. However, it should not be prescribed in cases of glaucoma, Urinary Bladder atonia, and prostate hypertrophy due to the risk of side effects.

For paranoid and hallucinatory-paranoid states, the use of frenolone, melleril, sulpiride (eglonil) is indicated, and if they are ineffective, the prescription of tizercin, clozapine (leponex), chlorpromazine, haloperidol, taking into account the contraindications of the latter neuroleptics in acute kidney and liver diseases. Fewer side effects are observed when using atypical antipsychotics such as risperidone (rispolept), olanzapine (zyprexa), etc.

For neurosis- and psychopathy-like states of hypersthenic and explosive types with psychic tension and dyssomnia, tranquilizers (primarily benzodiazepine derivatives) — phenazepam, chlordiazepoxide (elenium), diazepam (seduxen) — are indicated. Neurosis-like astheno-depressive states are amenable to correction using low doses of antidepressants, mebicar, meprobamate. In cases of pronounced asthenia, and especially in apato-abulic and astheno-apato-abulic states, good results are yielded by the use of nootropics: aminalon, piracetam, pyritinol.

In the treatment of somatogenic mental Disorders of the neurotic register, a major role belongs to rational psychotherapy. Its application is justified as a pathogenetic treatment method, especially considering the high prevalence of psychogenic neurotic overlays on neurosis- and psychopathy-like states in somatogenic (cardiogenic, endocrine, etc.) pathology, which creates a complex polygenic clinical picture.

EXPERT ASSESSMENT.

Medical and labor expertise. Patients suffering from acute somatogenic psychosis are on sick leave and do not require the assignment of a disability group. In prolonged psychoses, a disability group (I or II) assigned to a patient may be revoked after recovery if asthenic manifestations regress. For patients with a mild (yet persistent) mental defect and noticeable somatogenic dementia, the question of assigning a III, II, or even I disability group is decided on an individual basis, taking into account the severity of the mental defect.

Military medical expertise. Psychosis becomes the subject of expert assessment regarding fitness for military service only upon recovery from the underlying somatic pathology. Individuals who have previously undergone somatogenic psychosis are recognized as fit for military service with a postponement if recovery occurred recently. Prolonged somatogenic psychosis with

The formation of a mental defect or dementia serves as grounds for exemption from draft and military service.

Forensic psychiatric expertise. The commission of unlawful acts in a state of somatogenic psychosis serves as grounds for recognizing such individuals as not accountable (insane), with the assignment of a compulsory treatment course.

CONTROL QUESTIONS.

1. Definition of the concepts "psychosomatic" and "somatopsychic" disorders.

2. Etiology and pathogenesis of psychosomatic disorders.

3. Etiology and pathogenesis of somatopsychic disorders.

4. Classification of psychosomatic disorders.

5. Classification of somatopsychic disorders.

6. Clinical manifestations of psychosomatic disorders of The Cardiovascular System.

7. Clinical manifestations of cardiogenic somatopsychic disorders.

8. Clinical Features of somatopsychic disorders in Diseases of the Digestive System.

9. Clinical features of somatopsychic disorders in endocrine pathology.

10. Clinical manifestations of dysmetabolic somatopsychic disorders.

11. Modern treatment of psychosomatic and somatopsychic disorders.

12. Basic principles of expert evaluation in somatopsychic disorders.