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State budgetary educational institution of higher professional education "Orenburg State Medical University" of the Ministry of Health of the Russian Federation

Department of Psychiatry

Head Department - Prof., Doctor of Medical Sciences V.G. Budza

Teacher - Associate Professor, Ph.D. BY. Bomov

ABSTRACT

Etiological factors of psychosis.Principles of classdiagnosis of mental illness

Completed by: student of group 516

Gurova Maria

Orenburg, 2014

Plan

1. Etiology of psychoses

1.1 Endogenous factors in the development of psychosis

1.2 Exogenous factors in the development of psychoses

2. Principles of classification of psychoses

References

1. Etiology of psychoses

Psychosis is a severe form of mental disorder, which is accompanied by delusions, deep and sudden mood swings, hallucinations, a state of uncontrolled excitement or, conversely, deep depression, as well as profound disturbances in the thought process and a complete lack of a critical attitude towards one’s state. According to Pavlov, psychosis is a clearly expressed disorder of mental activity, in which mental reactions grossly contradict the real situation, which is reflected in a disorder of perception of the real world and disorganization of behavior.

In 1893, P. Yu. Mobius first proposed that all causes of psychosis be divided into external ones ( exogenous) and internal ( endogenous). In accordance with this dichotomy, mental illnesses themselves are divided into exogenous and endogenous.

In practical psychiatry, it is well known that exogenous and endogenous factors often act together, while in some cases the endogenous radical predominates, and in others, the exogenous radical predominates. For example, the toxic effects of alcohol can manifest themselves in different ways. In some cases, this exogenous factor can become a trigger for an endogenous process (schizophrenia), in other cases it causes a typical exogenous psychosis, which can have various clinical shades, sometimes creating schizoform pictures. This circumstance must be taken into account when diagnosing the underlying disease. The main causative factor of mental illness should be considered the one that determines the pattern of the onset and is noted throughout the disease process, emphasizing the features of its dynamics, the picture of remission and the initial state. In a number of cases, there is evidence of an external factor triggering the disease, which subsequently loses its role and is not decisive in the formation of the psychopathological structure of the underlying disease. These factors are considered provoking factors. The difference in the causal mechanisms of psychoses is clearly visible in the examples of the development of “axial” (“axial”, according to A. Gokha) syndromes - such as exogenous-organic, which underlies exogenous-organic diseases; endogenous symptom complex underlying endogenous procedural diseases (schizophrenia); personality development syndrome underlying decompensation of psychopathy (personality disorder). Personal characteristics largely determine the risk of developing mental illness (risk factors). In each specific case, the doctor takes into account and analyzes the role of all factors leading to the onset of psychosis, establishes the main causal mechanism, which plays a decisive role in establishing the final diagnosis of the disease.

Thus, there is reason to assert that there is a causative (etiological) factor, which, however, does not entirely determine the development of the disease. In some cases, this factor is only a trigger for the disease. The further course of the pathological process with its complication and modification occurs within the framework of certain patterns (stereotype of process development), without close dependence on the cause that directly caused it.

psychosis heredity stress trauma

1.1 Endogenous factors in the development of psychosis

Among the endogenous causes of the disease, the following are of particular importance:

Ш genetic factors;

Ш developmental disorders at an early age;

Ш somatic diseases that complicate and worsen brain function due to ischemia;

Ш autointoxication;

Sh endocrinopathies.

Endogenous psychoses include schizophrenia, schizoaffective disorder, and psychotic forms of affective disorders.

The role of heredity in the development of psychosis

Mental illnesses in the development of which the hereditary factor plays a significant role include manic-depressive psychosis, schizophrenia and epilepsy. Thus, according to P.B. Gannushkin, hereditary burden in manic-depressive psychosis reaches 92%. However, such a summary definition of hereditary burden does not give a clear idea of ​​the true meaning of the hereditary factor. It has long been established that in families of patients with manic-depressive psychosis, the same psychosis can be traced in a number of generations, transmitted according to a dominant (direct) type of inheritance: from grandfather to father, from father to children. Hereditary burden in families of patients with schizophrenia does not have the character of a dominant transmission of diseases. Clinically specified cases with a hereditary burden of schizophrenia indicate the predominant importance of inheritance according to the recessive type. The question of the role of a hereditary factor in epilepsy cannot yet be considered resolved, since patients with a history of a similar disease in their immediate relatives constitute a minority. It should be emphasized that in patients with schizophrenia and epilepsy with an established hereditary burden, the clinical type of psychosis in subsequent generations does not remain the same. Often, in the families of these patients, only rudimentary manifestations of the same illness or disease are observed, different in their clinical essence, including pathological personality traits (psychopathy). Studies of mental illness in families of identical and fraternal twins confirm the important role of genetic factors in the development of some mental illnesses, in particular schizophrenia. At the same time, there is no doubt that additional harmful factors play a certain role in the implementation of hereditary predisposition.

The successful development of progressive trends in medical genetics poses new challenges for researchers, in particular the genetic study of patients with mental disorders due to vascular diseases. The validity of such studies is confirmed by new data concerning the components of coagulating mechanisms transmitted by recessive inheritance. Atrophic psychoses: Pick's disease and Alzheimer's disease have been little studied from the standpoint of hereditary transmission. Determinations of sex chromatin are very promising and necessary to establish the true nature of some forms of pathology (impotence, intersexuality).

1.2 Exogenous factors in the development of psychosis

Exogenous factors are mainly divided into two groups. The first includes organic brain-damaging effects such as:

Ш injuries;

Ш intoxication;

Ш infections;

Ш radiation injuries.

The second group includes:

The impact of emotional stress due to intrapersonal or interpersonal conflicts, various unfavorable environmental, negative social influences on the individual.

The characteristics of the personality itself, primarily those that determine individual reactions.

The second group of exogenous causes is sometimes called psychogenics. The occurrence of psychogenic diseases is associated with emotional stress, family and social problems.

The role of certain drugs in the development of psychosis

Abuse of certain psychoactive substances (alcohol, amphetamines and cocaine, NMDA antagonists, etc.) can provoke psychosis. In particular, NMDA antagonists with long-term use cause conditions resembling schizophrenia.

As a rule, psychoses that are caused by taking a particular psychoactive substance are coded under the appropriate heading from section F10--F19 (“Mental and behavioral disorders associated with the use of psychoactive substances”) of the International Classification of Diseases. For example, stimulant psychosis (caused by the use of stimulants) is coded under F15.5 in ICD-10.

Psychosis can also be caused by certain medications: anticholinergic drugs, glucocorticoids and adrenocorticotropic hormone (ACTH), isoniazid, levodopa and other dopamine agonists, non-steroidal anti-inflammatory drugs. In addition, the development of psychotic symptoms is possible during withdrawal syndrome of certain medications: for example, hypnotics, monoamine oxidase inhibitors.

Role infectious factor in the development of psychoses

In infectious psychoses, both general disorders caused by the reaction of the brain and specific ones, characteristic of a particular infectious disease, are observed. Sterz (1927) believed that the symptoms and syndromes that are observed in exogenous, including infectious psychoses, can be divided into obligate (mandatory in the clinical picture of the disease) and facultative (non-permanent), appearing periodically. Syndromes of stupefaction and dementia were considered obligate, as a possible consequence of severe forms of illness. Optional manifestations of infectious psychoses were characterized by affective disorders, schizoform symptoms, and convulsive states.

Wieck (1961) divided exogenous psychoses into functional, or reversible, and those that contribute to the development of psychoorganic changes, i.e. defect-syndrome. In his opinion, between acute exogenous reactions, which are manifested by stupefaction syndromes, and the organic defective syndrome, there is a group of transitional syndromes, or registries. These included conditions that manifest themselves as changes in motivations, affective and schizoform disorders, amnestic and Korsakoff syndromes. If a particular syndrome is present, the prognosis of the disease can be determined. He considered affective states to be favorable, and organic registry syndromes to be unfavorable. The appearance of the latter indicated the development of dementia.

In addition to psychotic disorders of infectious origin, mental disorders of a non-psychotic nature may develop. First of all, these are asthenic conditions, manifesting both in the prodromal period of the disease and at the final stage. Asthenic conditions are accompanied by mood changes, more often by depression with hypochondriacal experiences. Hypochondria indicates dysfunction of the autonomic nervous system, which precedes the appearance of specific manifestations of an infectious disease.

2. Principles of classification of psychoses

Classification of mental disorders is one of the most important and complex problems in psychiatry. There are three main principles for classifying psychoses.

Syndromological principle . The theoretical basis of the syndromological approach is the concept of “single psychosis”. The concept is based on the idea of ​​the unified nature of various mental disorders. That is, psychoses are classified according to the leading clinical picture, according to the predominant symptoms into:

· Paranoid;

· Hypochondriacal;

· Depressed;

· Manic and others, including combinations (depressive-paranoid, depressive-hypochondriacal, etc.).

The difference in the clinical picture is explained by observing patients at different stages of the disease. The establishment of the etiological factors of individual mental illnesses has called into question the concept of a single psychosis. However, since the second half of the 20th century, the syndromic approach has again begun to be widely used in creating classifications. The renaissance of the syndromic approach is largely associated with the achievements of experimental and clinical psychopharmacology.

Nosological principle. The classification of mental disorders based on the nosological principle became possible as a result of discoveries of the relationship between the cause, clinical manifestations, course and outcome of the disease. The nosological principle consists in the division of diseases based on the common etiology, pathogenesis and uniformity of the clinical picture.

As mentioned earlier, according to etiological principles, mental disorders are divided into:

· Endogenous;

· Exogenous.

The traditional division of mental disorders into:

· Organic;

· Functional.

The presence of distinct changes in the structure of the brain leads to the appearance of persistent negative symptoms - memory impairment and intellect. Organic psychoses include conditions in which there is a pathological change in the structure of the brain, such as Alzheimer's disease, or psychoses secondary to vascular diseases of the brain, as well as conditions in which there are no signs of organic brain damage, for example, delirium, associated with typhoid fever, pneumococcal pneumonia, or alcohol withdrawal syndrome.

According to the characteristics of the course and occurrence, the following are distinguished:

· Reactive psychoses;

· Acute psychoses.

Reactive psychosis refers to temporary reversible mental disorders that arise under the influence of any mental trauma. This type of psychosis is also commonly called situational. Acute psychosis occurs suddenly and develops very quickly, for example, with unexpected news of the loss of a loved one, loss of property, and so on.

Pragmatic (statistical, eclectic) principle is of particular importance in connection with the creation of national and international organizations regulating economic, social and legal issues of mental health care.

Planning medical and social measures is impossible without reliable data on the prevalence of mental disorders. Resolution of legal issues depends on the accuracy and reliability of the diagnosis. In Russia, the international classification of mental and behavioral disorders (ICD 10), developed by WHO, is used. The ICD was developed with the aim of unifying the diagnostic approach when conducting statistical, scientific and social research.

References

1. Wittchen G. Encyclopedia of mental health / Transl. with him. AND I. Sapozhnikova - M.: Aletheya, 2006;

2. Kisker K.P. Psychiatry, psychosomatics, psychotherapy - M.: Aletheya, 1999;

3. Psychiatry. Textbook for students of medical universities. Ed. V.P. Samokhvalova. - Rostov: Phoenix, 2002;

4. Psychiatry. Textbook for medical students. Edited by M.V. Korkina, N.D. Lakosina, A.E. Lichko. - M.: Medicine, 2006;

5. Tiganov A.S., Snezhnevsky A.V. General psychiatry // Guide to psychiatry / Ed. Academician of the Russian Academy of Medical Sciences A.S. Tiganova - M.: Medicine, 1999.

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From the standpoint of practical expediency, mental illnesses are classified as endogenous in origin. Exogenous diseases are a consequence of the pathological influence of “in” on brain activity

various external (relative to brain tissue) physical, chemical and psychogenic-traumatic factors. These include harmful infectious-allergic, metabolic, intoxication, thermal, mechanical cerebrotraumatic, radiation and other physical and chemical effects, as well as those caused by unfavorable social circumstances, in particular, those entailing intrapersonal conflicts. Most researchers of psychogenic-traumatic mental disorders belong to a third independent group called “psychogeny.”

If the main causes of exogenous diseases are well known, then the questions of the etiology of endogenous mental illnesses (schizophrenia, manic-depressive or bipolar psychosis, so-called idiopathic or genuin epilepsy, some psychoses of late age) cannot be called resolved. Diseases develop under the influence of hereditary, constitutional, age-related and other characteristics of the body, which dictate certain biochemical, immune and other changes, which leads to primary pathological disorders of mental activity. According to generally accepted ideas, any external factors can influence the onset and further course of endogenous diseases, and not be their root cause.

However, some authors consider it inappropriate to distinguish groups of endogenous mental diseases, because they associate the occurrence of these disorders with the consequences of exogenous influences that are fixed in the genetic matrix for future generations. That is, the listed diseases in a particular patient are caused by certain exogenous (or environmental) influences on his close or distant relatives, which are inherited by the patient.

Thus, the doctrine of the etiology of mental illness is still far from perfect. At the same time, the least known, as in all other pathologies, are the cause-and-effect relationships of many factors influencing mental activity.

A person’s encounter with any potentially pathogenic agent does not at all mean the fatal inevitability of mental illness. Whether or not the disease develops depends on a number of factors. they can be divided as follows: constitutional-typological (genetic and congenital zoomlet ~ yakbstT, features, morphological and functional constitution, individual characteristics of biochemical, immune, vegetative and other processes) somatic (acquired characteristics of metabolic processes due to the state of internal organs and systems and ecology) psychosocial (the uniqueness of interpersonal, including industrial, family, etc. relationships of the patient in the micro- and macro-environment).

By analyzing the mutual influence of constitutional-typological, somatogenic and psychosocial aspects in each specific case, we can come closer to understanding why, for example, during an influenza epidemic, the mental reaction of one patient is limited to an adequate individual reaction within the limits of mental reserves, while another is limited to a short-term pathological reaction of the psyche , in another patient it takes the form of a stable neurosis-like or neurotic state, or an obvious mental disorder of a similar nature is observed. Therefore, the occurrence of mental illness cannot be methodologically made strictly dependent on any, even powerful factors. It is more correct to talk about the interaction of a certain factor with the individual mechanisms of biological, psychological and social adaptation of a person. So, mental illness is a consequence of an individual’s unsatisfactory integral adaptation to biopsychological influences. Moreover, each mental illness has its own main cause, without which the disease cannot develop. For example, post-traumatic encephalopathy will not occur without traumatic brain injury.

It should be noted the high importance of all three of the above groups of factors leading to mental disorders, and emphasize the not absolutely pathogenic significance of each of them separately. For example, pointing out the important role of heredity in the occurrence of diseases such as schizophrenia and manic-depressive psychosis, we must remember that even if one of the identical twins has any of these diseases, the risk of this disease in the other is quite large, but it is not 100 %. Therefore, we should talk about heredity not of endogenous mental pathology, but of predisposition to it. This also applies to the influence of innate personality traits, morphological constitution, typical vegetological characteristics, etc.

In the implementation of hereditary predisposition, the influence of additional harmful factors plays a large role. Most researchers indicate that the onset of schizophrenia and its relapses in almost two-thirds of cases are provoked by mental or physical trauma, somatic illness, intoxication, etc. Psychogenies (neuroses, reactive psychoses), delirium delirium and other disorders of consciousness most often occur against the background of somatic problems.

The origin of some mental illnesses is directly related to age. For example, oligophrenia causes mental retardation, forms in early childhood, or is a consequence of congenital underdevelopment of the brain. Pycnoleptic attacks in children stop during puberty. Pre-senile and senile psychoses occur at a late age. During crisis age periods (puberty and menopause), mental disorders such as neuroses and psychopathy more often debut or decompensate.

The gender of patients is of some importance. Thus, affective mental disorders occur more often in women than in men. In women, the following diseases predominate: Pick, Alzheimer's, involutional, hypertensive and menopausal psychoses. Naturally, they experience mental disorders due to hormonal and other changes during pregnancy or childbirth. And among people with atherosclerotic, intoxication, syphilitic psychoses, as well as patients with alcoholism and alcoholic psychoses, with neuropsychic disorders caused by traumatic brain injuries, men predominate.

A number of psychosocial and exogenous factors that lead to mental disorders, directly related to the patient’s professional activities. We are talking about such harmful production factors as mental and physical overload, emotional stress, intoxication, hypothermia and overheating, high levels of vibration, radiation pollution, noise, hypoxia, physical inactivity, various types of deprivation, etc. Each of these adverse effects has psychopathological consequences are quite typical. For example, psychosocial situations accompanied by excessive mental stress more often lead to neurotic disorders. While a pronounced deficit of sensory and other types of stimulation predominantly causes deviations in the psychotic register.

It is advisable to mention seasonal changes in mental activity. In some psychopathological conditions, especially endogenous psychoses with a phase course, exacerbations are observed in the autumn and spring periods. The adverse effects of intense changes in meteorological factors should be noted. Patients with vascular, cerebrotraumatic and other organic brain disorders are very sensitive to them.

The situation negatively affects the neuropsychic state, leading to so-called desynchronosis. This refers to disturbances in biological rhythms, for example, daytime wakefulness and sleep at night, the division of mental and physical stress in an inadequate type of character (“night owl” and “lark”), artificially provoked disturbances of the menstrual cycle, etc.

The pathogenesis (or mechanism of development) of mental illness is determined by the interaction in the prenatal and postnatal periods of hereditarily determined factors in the individual’s body and unfavorable psychosocial, physical and chemical effects on his personality, brain and extracerebral somatic sphere. Biochemical, electrophysiological, immune, morphological, systemic and personal changes that arise as a result of such interaction and which can be studied using modern methods are accompanied by characteristic pathophysiological disorders. In turn, such changes are subject to certain spatiotemporal patterns, which ultimately determine the stereotypical manifestations of painful neuropsychic signs, their dynamics and specificity.

Thus, the pathogenesis, and consequently the form of mental illness, is determined by the unique individual reactions that have developed in the process of ontogenesis and phylogenesis to many situations of both an exogenous and endogenous nature. It should be noted that the neuropsychic sphere of each individual person responds to various pathogenic influences with typical limitations for a given individual and a stereotypical set of reactions.

Moreover, the same harmful effect in different people, depending on the individual compensatory capabilities of the body and a number of other circumstances, can lead to a variety of psychopathological complexes. For example, alcohol abuse is accompanied by psychotic states, which differ markedly from each other. Here it is worth recalling alcoholic delirium, acute and chronic alcoholic hallucinosis, acute and chronic alcoholic paranoid, Korsakov's polyneurotic psychosis, alcoholic pseudoparalysis, Gaye-Wernicke encephalopathy. The same infectious disease can lead to febrile delirium, or amentia, epileptiform syndrome, symptomatic mania, and in the long term - to Korsakoff amnestic syndrome, post-infectious encephalopathy, etc.

Examples of monoetiological monopatho-genetic diseases should also be given. Thus, genetically determined metabolic disorders play a leading role in the origin of phenylpyruvic-minor mental retardation. Or a second example: cytological studies have revealed a specific chromosomal disorder on which the pathogenesis of Down disease is based.

At the same time, various etiological factors can “trigger” the same pathogenetic mechanisms that form the same psychopathological syndrome. As already mentioned, a delirious state, for example, occurs in patients with alcoholism and infectious diseases in a state of fever. It is also observed after traumatic brain injury, intoxication with various substances, and in somatic diseases (somatogenic psychosis). A convincing illustration of the existence of such psychopathological conditions that arise for various reasons is epilepsy, which belongs to the polyetiological monopathogenetic diseases.

However, the stability of an individual psychopathological reaction is relative. Qualitative and quantitative characteristics of painful symptoms depend on many circumstances. In particular, on the age of the person. So, for children, due to the morphological immaturity of the central nervous system, and then the insufficiency of abstract-logical, mental processes, atypical ideational, formerly delusional, deviations. For this reason, pathological psychomotor (convulsions, agitation, stupor), as well as emotional (weakness, excessive lability, fear, aggression) phenomena are observed quite often in them. As the child transitions to adolescence, adolescence and adulthood, elements of delusion may first appear, and then delusional disorders, and finally persistent delusional states.

The study of the etiology of a mental disorder in each case is a mandatory prerequisite for the rational construction of so-called etiological therapy, the purpose of which is to sanitize the external and internal environment of the patient. Disclosure of pathogenesis contributes to the choice of strategy, tactics and methods of pathogenetic treatment, aimed at destroying internal pathological connections that determine individual symptoms and syndrokinesis.

Knowledge of the etiological factors and pathogenetic mechanisms of mental illness, along with the analysis of clinical psychopathological and somatoneurological signs, is the basis for classifying the disorder, and therefore predicting, solving social problems of psychiatric care.

Any mental illness can only be considered as an independent nosological unit if (along with other characteristics) it has its own etiology and pathogenesis. These two features of the disease are the most important, and without them there is no separate disease. Being independent characteristics of the disease, etiology and pathogenesis are, however, closely related.

Any pathogenic factors (infections, intoxications, mechanical and mental injuries, etc.) acting on the body are not an etiology in themselves. They acquire etiological significance only by forming their own pathogenetic mechanisms and refracting through them. The formed pathogenetic mechanism is not only strengthened and supported by the further action of etiological factors, but it can persist (sometimes for a long time), when the influence of pathogenic factors has already disappeared, it has completely stopped. In this case, the remaining pathogenesis further develops its own dynamics, i.e., it begins to live an independent life.

Pathogenesis, being unfolded in space (in mental illness - the central nervous system) as a pathophysiological process, underlies the clinical manifestations of the disease and determines its clinical picture. The course of the disease and its varied dynamics reflect externally pathogenetic mechanisms, or rather, their modifications. It follows from this that knowledge of pathogenesis opens up the possibility of foreseeing, i.e., predicting the further course of the disease. Even more important is the relationship between the clinical picture and pathogenesis within a particular disease. From the above it follows that clinical symptoms correlate with the pathogenesis of the disease as a phenomenon with an essence, i.e., in other words, pathogenesis is the essence of the disease. That is why the most effective treatment for the disease is its pathogenetically based therapy.

The pathogenesis of any mental illness is a multi-link pathological process. Its stages, which are ambiguous in complexity, are deployed at various levels of the body’s vital activity, and in relation to mental pathology - at various levels of the nervous system and especially in the central nervous system. In mental illnesses, toxic, endocrine, hypoxic, interoceptive, biochemical, immunological, bioelectric and neurodynamic pathogenesis can be distinguished [Smetannikov P. G., 1970]. Considering their far unequal share in the occurrence and detection of mental illnesses, we will focus most attention on considering the last four links of pathogenesis mentioned here.

Chapter 1. General theoretical foundations of mental pathology

Currently, a large number of factors that can cause mental disorders have been described and studied. It should be noted that a disruption of any physiological process in the human body, caused by internal (genetic defect, metabolic disorder, endocrinopathy) or external (infection, intoxication, trauma, hypoxia and others) can lead to the appearance of mental pathology. In addition, factors of emotional stress, disturbances in interpersonal relationships and socio-psychological climate play an important role in the occurrence of mental disorders.

When diagnosing mental disorders, the doctor is always faced with the difficulty of determining the leading causes of the disease. The problem is that, firstly, the mechanisms of development of the most common mental illnesses (schizophrenia, manic-depressive psychosis, epilepsy, atrophic diseases of late age and others) have not yet been determined. Secondly, the same patient may be exposed to several pathogenic factors at once. Thirdly, the influence of a damaging factor does not necessarily cause the occurrence of a mental disorder, since people differ significantly in mental stability. Thus, the same damaging effect can be assessed differently by a doctor, depending on the specific situation.

A factor that determines the entire course of the disease, equally significant during the onset of the disease, its exacerbations and remissions, the cessation of which leads to the cessation of the disease, should be defined as main causal. Influences that play an important role in starting the disease process, but after the onset of the disease cease to determine its further course, should be considered as triggering, or trigger. Some features of the human body, natural phases of development cannot in any way be recognized as pathological and at the same time often create certain conditions for the development of the disease and contribute to the manifestation of hidden genetic pathology; and in this sense they are considered as risk factors. Finally, some of the circumstances and factors are only random, not directly related to the essence of the disease process (they should not be included in the circle of etiological factors).

Many questions regarding the etiology of mental disorders have not yet been answered, but the following materials from some biological and psychological studies provide important information for understanding the essence of mental illness. Of particular importance are the results of epidemiological studies, which allow, on the basis of large statistical material, to analyze the degree of influence of a wide variety of biological, geographical, climatic and sociocultural factors.

1.1. Etiology and pathogenesis of mental disorders

In practical psychiatry, the causative factors of mental illness are conventionally divided into internal and external. This division is really arbitrary, since many internal somatic diseases in relation to the human brain act as a kind of external agent, and in this case, the clinical manifestations of the disease sometimes differ little from disorders caused by such external causes as trauma, infection and intoxication. At the same time, many external conditions, even with a significant force of influence, do not cause mental disorders if there is no internal predisposition of the body for this. Among external influences, psychogenic factors, such as emotional stress, occupy a special position because they do not directly lead to disruption of the structure of brain tissue or gross disruption of basic physiological processes. Therefore, diseases caused by psychotrauma are usually classified as a separate group. In studies devoted to the study of the etiology and pathogenesis of mental illnesses, the greatest attention is paid to genetic, biochemical, immunological, neurophysiological and structural-morphological, as well as socio-psychological mechanisms.

Modern teaching about the etiology of mental illnesses is still imperfect. And now, to some extent, the old statement of H. Maudsley (1871) has not lost its significance: “The causes of insanity, usually listed by authors, are so general and vague that it is very difficult when meeting face to face with a reliable case of insanity and under all favorable research conditions determine with certainty the causes of the disease."

In psychiatry, as in all other pathology, the connection between cause and effect represents the most unknown area.

For the occurrence of mental illness, like any other, the external and internal conditions in which the cause operates are of decisive importance. The cause does not always cause the disease, not fatally, but only when a number of circumstances coincide, and for different causes the significance of the conditions determining their action is different. This applies to all causes, including pathogens of infectious diseases. One type of infection, once in the body, almost inevitably causes illness (the causative agent of plague, smallpox), other infectious diseases develop only in appropriate conditions (scarlet fever, influenza, diphtheria, dysentery). Not every infection causes illness, and not every infectious disease leads to psychosis. It follows from this that a “linear” understanding of etiology does not explain the complexity of the occurrence of mental illnesses, as well as any others [Davydovsky I.V., 1962]. The “linear” understanding of influenza as the cause of infectious psychosis and mental trauma as the cause of neurosis is obvious. At the same time, such an unconditionally correct interpretation of cause and effect at first glance becomes simplified and helpless when interpreting not only the nature of the diseases that arise in such cases, but also the disease of the individual patient. It is impossible, for example, to answer the question why the same cause, in this case the flu, causes transient psychosis in one person, chronic psychosis in another, and does not lead to any mental disorder at all in the vast majority of people. The same applies to psychogenic trauma, in some cases causing neurosis, in others - decompensation of psychopathy, and in others - not causing any painful abnormalities. Further, it is discovered that very often the cause that directly caused the pathology is not equal to the effect - an insignificant cause results in far-reaching changes. Thus, at first glance, the main and only cause of the disease, the same flu or mental trauma, as the mental pathological process develops, it turns into something completely secondary, into one of the conditions for the occurrence of the disease. An example of this is a chronic progressive mental illness (schizophrenia), which occurs immediately after influenza or psychogenic trauma, or even a physiological process - normal childbirth.

In all such cases, inevitably obeying the laws of determinism, the initial “linear” connections begin to expand and, in addition to them, various individual properties of the sick person are introduced. As a result of this, the visible external cause (causa externa) becomes internal (causa interna), i.e. in the process of analyzing the origin and development of the disease, extremely complex cause-and-effect relationships are discovered (I.V. Davydovsky).

The occurrence of diseases, including mental ones, their development, course and outcome depend on the interaction of the cause, various harmful environmental influences and the state of the body, i.e. from the ratio external (exogenous) And internal (endogenous) factors (driving forces).

Endogenous factors are understood as the physiological state of the body, determined by the type of higher nervous activity and its characteristics at the time of exposure to harmful effects, gender, age, hereditary inclinations, immunological and reactive characteristics of the body, trace changes from various harmful effects in the past. Thus, endogenous is not considered either as a purely hereditary condition or as an unchangeable state of the organism [Davydovsky I.V., 1962].

The importance of exogenous and endogenous driving forces varies in different mental illnesses and in different patients. Each disease, arising from a cause, develops as a result of its characteristic interaction of the named driving forces. Thus, acute traumatic psychoses occur when direct external influence predominates. For infectious psychoses, endogenous features are often of great importance (febrile delirium most often develops in children and women). Finally, there are certain mental illnesses in which, in the words of I.V. Davydovsky, the producing etiological factor is not directly felt, and the very development of painful phenomena sometimes comes as if from the basic physiological (endogenous) state of the subject, without a tangible push from the outside. A number of mental illnesses not only begin in infancy, but are also detected in subsequent generations (in children and grandchildren). Each nosologically independent disease has its own history (hystoria morbi), which in some species spans not one, but several generations.

Environmental and internal environmental conditions, depending on specific circumstances, can prevent or contribute to the onset of the disease. At the same time, conditions alone, even in extreme combination, cannot cause illness without a reason. Neutralization of the cause prevents the occurrence of the disease even under all the conditions necessary for it. Thus, timely intensive treatment of infectious diseases with antibiotics and sulfonamide drugs prevents the development of delirium, including with an endogenous predisposition to it. With the beginning of aseptic management of childbirth, the number of septic postpartum psychoses decreased many times in all countries.

The nosological independence of each individual mental illness is determined by the unity of etiology and pathogenesis (Nosology - classification of diseases (Greek nosos - disease). In the classification of animals and plants, the designation taxonomia is used (Greek taxis - order of arrangement, nomos - law). The nomenclature is a list of categories or designations. When compiling the classification itself, it is necessary to define categories according to general and particular characteristics; categories are established according to an ordinal (family, genus, species) or hierarchical principle.). In other words, a nosologically independent mental illness (nosological unit) consists only of those cases of the disease that arise as a result of the same cause and exhibit the same development mechanisms. Diseases that arise from the same cause, but with a different mechanism of development, cannot be combined into a nosologically independent disease. An example of such etiologically homogeneous, but nosologically different diseases can be syphilitic psychosis, tabes dorsalis, and progressive paralysis. All these diseases arise as a result of syphilitic infection, but their pathogenesis is completely different, which makes them nosologically different diseases. The same can be said about delirium tremens, Korsakoff psychosis, alcoholic delirium, jealousy, alcoholic hallucinosis: their etiology is the same - chronic alcoholism, but the pathogenesis is different, so each is an independent disease. In exactly the same way, diseases with the same pathogenesis but different etiologies cannot be considered as a nosologically unified disease. The pathogenesis of delirium is the same in chronic alcoholism, rheumatism, and pellagra, but its etiology is different. In accordance with this, independent diseases (individual nosological units) are distinguished: delirium tremens, rheumatic psychosis, pellagrosis psychosis.

The unity of etiology and pathogenesis has not yet been established for all mental illnesses: in some cases the cause has been found, but the pathogenesis has not yet been studied; in others, the pathogenesis is more completely studied, but the etiology is unknown. Many mental illnesses are identified as nosological units only on the basis of uniformity of clinical expression. This establishment of the nosological independence of diseases is justified by the fact that clinical manifestations, their development and outcome are an external expression of the characteristics of the pathogenesis and pathokinesis of the disease and, therefore, indirectly reflect its etiological characteristics. A historical example of this could be progressive paralysis, which in the middle of the 19th century. identified as a nosological entity only on the basis of clinical examination data. Establishment at the beginning of the 20th century. its syphilitic etiology and pathogenesis, different from other forms of syphilis of the central nervous system, confirmed the nosological independence of this disease, first substantiated exclusively by the clinical method.

Such a significant difference in knowledge of the nature of individual mental illnesses reflects both the history of development and the current state of psychiatry. There is no doubt that further progress in the study of the pathogenesis, etiology and clinical picture of mental illnesses will make further significant adjustments to the modern nosological classification of diseases.

Nosos and pathos(Reproduced in an abbreviated form from the book: “Schizophrenia. Multidisciplinary research.” - M.: Medicine, 1972. - P. 5-15.) . Nosos - disease process, dynamic, ongoing formation; pathos - pathological condition, persistent changes, the result of pathological processes or a defect, developmental deviation. Nosos and pathos are not separated by a rigid boundary. The transition from one state to another can be detected experimentally and modeled. Repeated sensitization of an animal to some protein, bringing sensitivity to it to the highest degree, does not yet cause disease in the animal in the clinical-anatomical sense, but only creates readiness for it in the form of new reactive abilities based on existing physiological specific and individual prerequisites [Davydovsky I.V., 1962]. When a phenomenon of local or general anaphylaxis of this kind is caused in the same animal, the newly emerged mechanisms are realized, creating the disease. Based on the data provided by I.V. Davydovsky argued that the existence of pathogenetic mechanisms should be strictly distinguished from the presence of a pathological process, i.e. pathos and nosos are not identical. Pathogenetic mechanisms consist only in the possibility of a pathological process.

Pathos also include diathesis, characterized by peculiar reactions to physiological stimuli and manifested by more or less pronounced pathological changes and predisposition to certain diseases. Diathesis, interpreted in a broad sense, refers to an illness in the understanding of I.V. Davydovsky. He wrote the following about this: “The ailments of old age, like other illnesses or ailments with a general decline in vital activity, indicate that the range of adaptive abilities is not measured by the alternative - illness or health. Between them there is a whole range of intermediate states indicating special forms of adaptation , close sometimes to health, sometimes to diseases, and yet being neither one nor the other.” Close to the concept of “diathesis”, in particular schizophrenic, schizosis by H. Claude, schizopathy by E. Bleuler, schizophrenic spectrum by S. Kety, P. Wender, D. Rosenthal.

It is quite possible that none of the deviations in the activity of the body of a patient with schizophrenia that have been currently established by biological research are manifestations of the actual processual development of the disease, but represent a sign, a stigma of pathos, of diathesis. In relation to schizophrenia we are talking about pathological, i.e. schizophrenic constitution, as P.B. said for the first time in 1914. Gannushkin in the article “Raising the question of the schizophrenic constitution.”

Nosos and pathos are not identical, but their absolute difference and opposition would be erroneous. In the past, domestic psychiatrists were quite absolutist-critical of E. Kretschmer’s concept of an exclusively quantitative difference between schizoidia and schizophrenia. Meanwhile, the merit of E. Kretschmer, as well as E. Bleuler, I. Berze, E. Stransky and other researchers is that they discovered and described the presence of soil (sources) in the form of schizoidia, latent schizophrenia, on which, under the influence of not yet Under conditions known to us, the schizophrenic process crystallizes in a limited number of cases. In 1941, J. Wyrsch wrote about the relationship between the schizoid constitution and schizophrenia. All these authors described carriers of the pathogenetic mechanisms of schizophrenia, which contained the prerequisites for its development as a disease. I.V. Davydovsky constantly emphasized that pathological processes in humans arose in distant eras as a product of insufficient human adaptation to the environment (social and natural); Many of human diseases are hereditary, the manifestation of a number of them is due to ontogenetic factors - childhood, puberty, old age. S.N. Davydenkov, studying the pathogenesis of obsessional neurosis, also believed that the painful factors of neuroses arose in society a very long time ago and it is likely that prehistoric man was not free from them. In the light of the natural-historical and biological understanding of the problems of medicine, it is indisputable that diseases arose with the first signs of life on Earth, that disease is a natural, adaptive phenomenon (S.P. Botkin (Cit. Borodulin F.R. S.P. Botkin and the neurogenic theory of medicine. - M., 1953.), T. Sokolsky (Cit. Davydovsky I.V. Problems of causality in psychiatry. Etiology. - M., 1962. - 176 p.)).

This adaptation is extremely variable. Its range extends from deviations, indicated by accentuation, pronounced stigmatization, diathesis, to qualitative differences, marking the transformation of pathogenetic mechanisms into a pathogenetic process (pathokinesis).

The above comparisons allow us to consider nosos and pathos in unity, despite their qualitative differences. Now, many years of experience have shown that the most justified study of schizophrenia, as well as many other diseases, is possible if, firstly, it is not limited to statics, but is constantly combined with dynamics, with a thorough study of all the features of the course; secondly, when it is not limited to the clinical picture, but becomes clinical and biological; thirdly, when it is not limited to the study of only the sick person, but extends, if possible, to many relatives, i.e. the study of nosos is combined with the study of pathos. This approach opens up the greatest opportunities for establishing both pathogenetic mechanisms and the reasons that turn them into pathokinesis.

Speaking about nosos and pathos, it should be noted that their relationships are dynamic. A completed schizophrenic process or attack usually leaves behind lasting personality changes. However, complete recovery from any disease “is not a restoration of previously existing health, it is always new health, i.e. some sum of new physiological correlations, a new level of neuroreflex humoral immunological and other relationships” (I.V. Davydovsky).

Differential diagnosis of remissions and persistent personality changes is difficult and becomes even more difficult if there is an additional disorder in the form of continuous cyclothymic phases. Phases such as the expression of a nonspecific disorder can occur not only during schizophrenia, but also many other mental illnesses - epilepsy and organic psychoses (for example, progressive paralysis). It is possible that in some cases this is the result of persistent changes that arise in the process, merging with the pathos. In this regard, it should be recalled that P.B. Gannushkin attributed cyclothymia to constitutional psychopathy, and I.P. Pavlov at one time said: “Disturbed nervous activity seems to fluctuate more or less regularly... One cannot help but see analogies in these fluctuations with cyclothymia and manic-depressive psychosis, it would be most natural to reduce this pathological periodicity to a disruption of the normal relationship between irritable and inhibitory processes, as regards their interaction.” P.D. Gorizontov also notes that the course of any functional changes most often has a wave-like character with alternation of different phases.

Since cyclothymic phases are combined with residual symptoms, there is reason to consider them as an expression of a weakened, but still ongoing process. True, it is not uncommon to encounter patients who have suffered an attack in whom mild continuous cyclothymic phases most likely belong to a persistent, residual condition. The pathogenetic nature of the cyclothymic phases remains far from clear.

Persistent post-processual personality changes, manifested by psychopathic disorders in the broad sense (the dynamics of psychopathy), must be distinguished from psychopathic (psychopath-like) changes that characterize the initial period or low-progressive course of the schizophrenic process. Their similarity lies not only in the fact that they are limited to personality changes, but very often in the presence of infantilism or juvenileism in such patients (general or just mental). However, there are also significant differences: changes in personality that arose as a result of post-processual development are unchanged in the intensity of manifestations; with the psychopathic type of onset of schizophrenia, these changes are extremely labile and have a clear tendency to intensify; the personality in the latter case is changed, but not modified, “represents only a pronounced development and strengthening of the outstanding character traits and properties of the individual” (W. Griesinger).

A comparison of the above personality changes - initial and post-processual, as well as cyclothymic - illustrates the unity of nosos and pathos and at the same time their difference. The unity of pathos (persistent changes) and nosos (development of the process) is especially clear in cases of childhood schizophrenia. Its clinical manifestations include, along with schizophrenic disorders themselves, changes in the form of delay or arrest of mental development, i.e. in the form of secondary oligophrenia or in the form of signs of mental infantilism.

Initial psychopathic personality disorder, which arises as an expression of a low-progressive schizophrenic process, indicates a relatively favorable course of the disease and the sufficiency of compensatory and adaptive mechanisms.

E. Kraepelin once defined the special personality type of those predisposed to manic-depressive psychosis as the initial, prodromal, rudimentary manifestation of this psychosis, which can remain throughout life without further dynamics or, under certain circumstances, become the starting point for the full development of the disease. The same thing can apply to schizophrenia to the same extent.

As already mentioned, “compensatory and adaptive mechanisms and reactions become more important the slower the main pathological process unfolds” (I.V. Davydovsky). To the credit of psychiatrists, it must be said that the attempt to understand the symptoms of the disease as a manifestation of adaptive-compensatory mechanisms belongs to them. In the first half of the 19th century. V.F. Sabler considered, for example, delirium as an adaptive, compensatory phenomenon that “relegates into the background and covers the primary melancholy affect.” In this case, he interpreted the adaptive, compensatory meaning of psychopathological disorders in a psychological sense. Psychologically, a number of authors interpret autism as an adaptive disorder, for example, when it is considered as compensation, as a kind of isolation from the outside world due to imperfection and weakness of adaptation to it.

Interpretation by V.F. The understanding of some mental disorders as adaptive mechanisms goes beyond the actual psychological aspect and, in a certain sense, extends to pathogenesis. So, for example, he writes: “In most cases, we observe that with the onset of insanity, the physically formidable symptoms weaken. If, for example, insanity sets in in old people after apoplexy, then we can predict for them several more years of life.”

Considering psychopathological symptoms as manifestations of the action of adaptive mechanisms, it can be assumed that disorders such as changes in personality (psychopathic-like states, psychopathic personality development, cyclothymic disorders, as well as paranoid changes) indicate not only the slow development of the pathological process, but also the defeat relatively shallow levels of biological systems underlying mental activity. The latter is confirmed by the insignificant severity of signs of defect (regression) in the clinical picture of such conditions. G.Schtile believed that negative disorders (dementia) determine the extent of mental disorder. The severity of negative disorders can be judged by the extent of the mental disorder.

From all the above provisions, the conclusion follows about the relative specificity of the clinical manifestations of psychogenic and endogenous psychoses, minor and major psychiatry. Pathological development of personality can occur as a modification of it as a result of psychogenic trauma and as a result of an attack of schizophrenia. Neurotic disorders develop as a reaction to a situation and endogenously, in the form of “minor mental disorders” - asthenic, psychasthenic, hysterical. Psychopathy can be congenital or acquired as a result of a previous or current low-progressive process. V.Kh. spoke about this at one time. Kandinsky and S.S. Korsakov, who divided psychopathy into original (congenital) and acquired. They called the latter constitutional in the sense of a radical modification of the constitution under the influence of an experienced, easily ongoing disease process or, finally, a pathologically occurring age shift - youthful, menopausal, senile. The same applies to cyclothymic disorders. The question of the ambiguity of the concepts of “neurosis,” “psychopathy,” and “psychosis” was first raised by T.I. Yudin. They are both nosological categories and general pathological categories - the severity of a mental disorder.

Exogenous and organic psychoses, as is known, can also occur in the form of endogenous disorders (so-called intermediate syndromes, late symptomatic psychoses, endoform syndromes). All this once again indicates the internal mediation (causa interna) of both mental and somatic manifestations of the disease. This relative specificity of mental disorders, however, does not exclude the nosological conditionality of the manifestations of the disease. The latter represents a set of positive and negative, constitutional and individual characteristics that express the unity of the etiology and pathogenesis of a nosologically independent disease and its implementation in a particular patient. G. Schule once said that the nosological independence of a mental illness (hence, the specificity of manifestations) can be established as a result of a clinical analysis of the quality, characteristics of the course and determination of the volume of a mental disorder.

The result of a clinical-pathogenetic and genealogical study of a nosologically independent disease depends on the detection and accuracy of recognition of all deviations in the mental activity of the proband’s relatives, deviations not only in the form of the disease, but also “pathologies” - true psychopathy, pseudopsychopathy, initial and post-processual states. However, all this can be done only by moving from knowledge of the expressed manifestations of the disease to the unexpressed, from its fully developed forms to barely outlined ones, from illness to illness and health (P.B. Gannushkin).