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Transnistrian State University named after. T.G. Shevchenko

Faculty of Medicine

Abstract on the discipline history of medicine

on the topic: “History of the development of psychiatry”

Completed by: student gr.301/1

Tkachenko A.I.

Scientific supervisor:

Assoc. Krachun G.P.

Tiraspol 2014

History of the development of psychiatry

In psychiatry throughout its development, three approaches to solving the problems of treating mental illness can be distinguished:

1. Magical approach - based on the fact that the treatment of diseases is possible by attracting supernatural forces. It is characteristic of the early, ancient period of the development of psychiatry. It is also characteristic of the Middle Ages, when persecutions of witches were carried out. The essence of this approach is that the influence on a person occurred through suggestion. In this aspect it has much in common with the psychological.

2. Organic approach - assumes the idea that all normal and pathological processes of the human psyche can be explained by the laws of the material world, i.e. within the framework of natural science. - chemistry and physics. This approach is characteristic of later studies, starting with the Renaissance.

3. The psychological approach assumes that the cause of mental disorders lies in the field of psychological processes and, therefore, their treatment is possible using psychological methods.

Currently, the treatment of the mentally ill consists of a combination of the last two methods. The first approach is unscientific.

The contribution of the ancients.

The history of psychology began with one person trying to alleviate the suffering of another by influencing him. In those days when mental and physical illnesses were not differentiated, the role of a psychiatrist could be taken on by anyone who sought to alleviate the pain of another. Therefore, the history of psychiatry goes back to the first professional healers.

Babylonian priests and doctors treated internal diseases, especially with mental manifestations, which were attributed to demonic origin, resorting to magical-religious views. Medicines were used, but more effective treatment was associated with belief in the spell. The spell was quite a powerful psychological weapon. The peoples of Mesopotamia discovered some medical methods and began to study the patient’s life history. They also achieved great success in the development of hyena, social. medicine, honey ethics.

The Egyptians achieved quite great success. They treated people with artificial sleep as a form of psychotherapy. Long before the Greeks, they learned to create in temples where the sick were treated an atmosphere that was beneficial to human health: participation in an excursion along the Nile, in a concert; dancing and drawing classes. The Egyptians also identified a type of emotional disorder later called "hysteria." The symptoms of this disease were associated with abnormal position of the uterus. The treatment was fumigation of the vagina. The method was very common outside Egypt.

The medicine of the Israeli people was formed under the influence of the development of medicine among the Babylonians and Egyptians. In contrast, the Jews had such systematic medical texts. The Talmud describes stories that prove the presence of psychological knowledge. The psychological mechanism of judging others for one's own sins or sinful thoughts, now called projection or “scapegoating”, was described; a psychological observation is also described that claims that the righteous also have sinful dreams, which means the recognition that dreams serve to express those desires that in reality are consciously suppressed by our moral principles. Distraction was recommended as psychotherapy, and the patient was encouraged to speak freely about his problems. At the same time, demons were considered the cause of madness, asthma and other incomprehensible conditions. Thanks to the Talmud, Jewish medicine was less magical than the medicine of Babylon and Egypt. It is worth saying that the concern of the Jews for the sick had a significant influence on the formation of the humanitarian aspects of medicine and psychiatry. So, back in 490 BC. A special hospital for the mentally ill was built in Jerusalem.

The first significant period of Persian medicine began in the middle of the 1st millennium BC. Venidad contained several chapters devoted to medicine. Venidad reports 99,999 diseases affecting the human race that are caused by demonic forces. In Venidad, 3 types of doctors are mentioned, one of whom was probably a psychiatrist (equivalent to our time). Magicians or spiritual doctors enjoyed the greatest trust.

Buddhism, which was widespread in the Eastern world, including India, emphasized the process of self-knowledge, which was a central factor that had an invaluable influence on the development of psychiatry. Buddhist meditation has a special psychotherapeutic value: in fact, it can support a person psychotherapeutically not only with mental disorders, but also with difficulties in everyday life. Focus on oneself is the main characteristic of a person. Through self-knowledge, a person establishes a connection with the outside world, of which he is a part. This connection does not contradict, but complements the understanding of the physical world.

Classical era

The cult of Asclepius dominated Greek medicine for centuries. Hundreds of temples were built, which were located in picturesque places. Perhaps the suffering patient found inspiration and hope. Although not everyone who wanted to went to the temple. The most significant event was a therapeutic stay in the temple or incubation - sleep. Apparently, while sleeping in the temple, the patient was exposed to certain influences. Through dreams, the patient was given information about what to do in order to recover. There is a possibility that the priests of these temple hospitals were charlatans who gave patients opium or its derivatives, after which they were indoctrinated with certain prescriptions. They used hypnosis as a healing factor.

Medical thought developed within the framework of Ancient Greece. Hippocrates was an outstanding physician and psychiatrist. He was the first to consistently try to explain diseases on the basis of natural causes. Hippocrates and his students established that the cause of epilepsy is a disease of the brain. All of Hippocrates' ideas were based on the idea of ​​homeostasis, i.e. the constancy of the internal environment of the body, the ratio of which determined the proper functioning of the body. In treatment, he used bloodletting and laxatives, and prescribed medications: hellebore, emetics and laxatives. For mental disorders, he warned about the need for correct dosage and monitoring the patient's reaction. Hippocrates made a great contribution to the development of clinical medicine. He was the first to express the idea that the brain is the most important human organ. Doctors of the Hippocratic circle were the first to describe organic toxic delirium, a symptom of depression, which they called melancholia, characteristic signs of childbirth insanity, phobias, and introduced the term “hysteria.” They proposed the first classification of mental illnesses, including epilepsy, mania, melancholia and paranoia. They also characterized personality traits in terms of their humoral theory.

The Greek experience was further developed in Rome. One of the outstanding scientists of this period is Asclepiades. He used the following methods to treat mental illness: bright, well-ventilated rooms, music, baths, massage. Asclepiades noted the importance of differentiating acute and chronic diseases and the need to distinguish between delusions and hallucinations. He sympathized with the mentally ill and viewed mental illness as a result of emotional overload. Asclepiades and those who followed him used the reverse treatment method, i.e. To get rid of the disease, it must be influenced by the opposite factor.

Arytaeus was another representative of the Roman scientific and medical direction. He observed mentally ill patients and studied them carefully. As a result, he found that manic and depressive states invariably recur, and there are clear intervals between manic and depressive periods. He, considering mental illnesses from the point of view of the way out of them, attaches special importance to the course and prognosis of the disease. Arytheus was the first to describe in detail a person who had suffered mental breakdown, and he also realized that not all mentally ill people suffer from a decrease in intelligence as a result of the disease - a fact that was not recognized by scientists until the 20th century.

The Roman clinician Claudius Galen made a great contribution to the development of the anatomy and physiology of the central nervous system. He drew attention to the fact that brain damage entails dysfunction on the opposite side of the body. He traced the location of the seven cranial nerves and distinguished between sensory and motor nerves. He noted that complete rupture of the spinal cord leads to loss of motor function throughout the entire area of ​​the body below the injury and proposed a theory about the role of nerves in transmitting impulses from the brain and spinal cord. He believed that sudden emotional disruptions could indicate brain damage, however, he persistently looked for connecting threads between mental disorders and physical injuries. As a result, he recognized the active organizing principle behind spiritual force.

The psychological ideas that prevailed in Rome and Greece were too abstract to be useful to the individual. They were effectively divorced from understanding simple human aspirations, fantasies, emotions and motivations. These lofty abstractions could not be suitable for creating the basis for studies of individual individuals, leaving aside the problem of the behavior of mentally ill persons. Cicero put forward the idea that physical health could be influenced by emotional manifestations. He can rightfully be called the first psychosomatologist. He identified two main parameters necessary to identify the similarities and differences between physical and mental illnesses.

Soranus was the most enlightened physician of his time in approaches to understanding mental illness. He refused to treat the mentally ill with harsh methods. Harsh methods were used only in extreme cases when patients became very dangerous. Soran sought to reduce the discomfort of the mentally ill by talking to them. He was against the reverse treatment method.

In general, Ancient Greece and Rome were noted for their humane approaches to treating mentally ill people. Physicians mainly relied on materialistic and empirical approaches, and the psychological method was used very hesitantly. But there were also doctors (such as Celsus) who believed that only rough measures and intimidation could force a patient to give up illness. Celsus tied up the sick, starved them, placed them in an isolated room, prescribed laxatives, trying to bring them to health through fear.

The Middle Ages brought new approaches to understanding and treating mental illness. Imbued with creationism, science tried to explain all phenomena by divine origin. Medieval psychiatry was hardly different from pre-scientific demonology, and psychiatric treatment was practically no different from exorcism. Although Christian scholastics and Arab doctors made a significant contribution to the development of humanitarian psychiatric care. In the late Middle Ages, Christian ideas began to become obsolete, depending on the authorities. At the same time, supernatural explanations for illness appeared, and the treatment of mental illness became much worse. At the beginning of the Middle Ages, treatment methods were chosen depending on the views of the community to which the sick person belonged, but from the 14th century, the mentally ill began to be considered sorcerers and witches who were persecuted.

Treatment of patients at the beginning of the Middle Ages was more professional and scientific than in the period from 12 to 13 centuries. One of the earliest asylums for the mentally ill, Bethlenham Hospital in London, was originally quite different from the snake pit that later became known as Bedlam. In those early days the sick were treated with great care. In the 13th century, an institution was founded in Geel (Belgium) to help developmentally delayed and mentally ill children.

Byzantine doctors and psychologists made significant contributions to the development of psychiatric thought in the Middle Ages. Aethius described three types of "phrenia" brain diseases involving the anterior, middle and posterior lobes of the brain associated with memory, reason and imagination. Alexander from Tral described mania and melancholy, drawing attention to the fact that these conditions can be observed in the same patient. He recommended baths, wine, and sedatives for mental disorders.

Arab psychiatric thought also developed in parallel with Western medicine. Arab doctors made major contributions to the understanding of mental illness and their treatment. They proceeded mainly from the experimental method, and did not pay attention to speculative guesses.

The most famous among Arab doctors was Razi. He headed the Baghdad Hospital (one of the world's first hospitals for the mentally ill). In the field of psychiatry, Razi was a supporter of the followers of Hippocrates. He described all diseases in detail. He combined psychological methods and psychological analysis. He was against giving a demonological explanation for the disease.

Avicenna drew attention to the dependence of the physiological reaction on the emotional state. He described psychotic delusions and their treatment. Avenzor condemned the method of cauterization, which was widely used by the Arabs in relation to mentally ill patients. The organic approach revived interest in the pathology of the nervous system and especially the brain in the study of mental illness. For example, abscesses of the cerebral ventricles were considered a cause of psychosis and were treated with diet, bloodletting, and medications.

Although in the Middle Ages there were people who preached rational approaches and methods to understanding mental disorders, the overall picture remained sad. The etymology of mental disorders was considered in terms of divine origin or as a consequence of the influence of external forces. The situation of the sick in the late Middle Ages worsened significantly; the sick began to be treated like animals. In addition, during this period the church began mass persecution of witches and sorcerers. The mentally ill began to be considered slaves of Satan and, therefore, appropriate measures were applied to them - mainly the torture of the Inquisition. At that time, the treatment of soul and body was carried out using equivalent methods.

The Renaissance to some extent changed the worldview of doctors and ordinary people. Gradually, the ideas of humanism began to penetrate into scientific circles, in particular psychiatry. Man has become open to study as a specific individual. Now not only the soul, but also the body was fully studied. Psychiatry is becoming a more objective science, free from medieval prejudices.

Leonardo da Vinci dissected the brain and carefully sketched all the grooves and cavities of this organ, making a great contribution to the development of human anatomy. Felix Plater made the first attempt to define clinical criteria for mental illness; he tried to classify all illnesses, including mental illnesses. To this end, he studied the psychological deviations of prisoners. Plater concluded that most mental illnesses depend on certain types of brain damage. His “Practical Medicine” contains a large number of clinical observations.

Gerolamo Cardano realized that in order for patient treatment to be successful, the patient must, first of all, believe in the doctor. Confidence in the correctness of his method, which lies in the idea of ​​the need for a close connection between the treatment process itself and the patient’s desire to be cured, enabled Cardano to use suggestive therapy (suggestion therapy) as one of the components of his general therapeutic effects.

Philip Paracelsus believed that mental illnesses arise from internal disorders and cannot be the result of external influences. He believed that illnesses, both mental and physical, could be cured by medical means, and he prescribed simple medicines in certain dosages.

Johan Weyer argued that witches were just mentally ill people and should be treated rather than interrogated and executed. He noticed that the witches showed symptoms that are characteristic of mentally ill people. This led him to believe that these women were actually suffering from mental illness.

The further development of psychiatry dates back to the 17th century, when the first steps towards a realistic understanding of this science were taken during the Renaissance. Attitudes towards mental illness began to free themselves from prejudices and misconceptions of authorities. The 17th century was destined to lay the foundation for the modern world.

Thomas Sydenham described the clinical manifestations of hysteria, a disease that is widespread and therefore of particular importance to medical practitioners. Sydenham's achievements are the result of his precise clinical observations. In his opinion, men also suffer from hysteria; he called this form hypochondria. Sydenham discovered that hysterical symptoms could simulate almost all forms of organic disease.

William Harvey described the effect of emotional stress on cardiac activity. When affected, the body experiences changes, while blood pressure changes, when angry, the eyes turn red and the eyes narrow, when there is tightness, the cheeks become covered with red spots, etc. Any mental affects of various contents can be accompanied by exhaustion and health disorders or be associated with a violation of chemical processes and their insufficiency, with an exacerbation of all manifestations of the disease and exhaustion of the human body.

Georg Stahl believed that some mental disorders, as well as physical ones, can arise from purely psychological causes, and they can be distinguished from such mental states that are based on organic damage, such as toxic delirium.

Robert Barton recognized the most important components of melancholia and described some of the essential principles of psychoanalysis. He pinpointed that the emotional core of depression is unrelenting hostility. He also reproduced its self-destructive component and correctly described the characteristic internal conflicts that arise against the background of the individual’s constant confrontation with the hostility overwhelming him. He showed how they manifest themselves in jealousy, rivalry and ambivalence. These therapeutic recommendations comprised a fairly large set of remedies - sports, chess, baths, bibliotherapy, music therapy, laxatives, moderation in sexual life.

Many scientists characterize the 18th century as the Age of Enlightenment. Faith in reason has taken hold of all strata of society. The objective point of view had exorcised the demons of human illness, and psychiatry was close to finding its way into medicine through organic channels. In the first decade of the century, doctors looked to damaged matter in the brain as an explanation for mental illness, and concepts such as the "seat of the soul" or the "animal spirit" gradually faded away. The wealth of medical and scientific information was so great that the material required comprehension and systematization. Psychiatrists who tried to classify the symptoms of the mentally ill in the 18th century found themselves in a difficult situation because... had too few direct observations of patients. However, the symptoms of mental illness have been described and classified. Methods of psychiatric treatment were practically not affected by the classifiers.

Herman Boerhaave. Basically a reactionist. For him, psychiatry consisted of the following methods - shock bloodletting, cleansing enemas, immersing the patient in a bath of ice water. He also introduced the first shock instrument into psychiatry - a rotating chair in which the patient lost consciousness. Despite his conservative views, he had many admirers among scientists. In general, scientists of the 18th century were attracted to unusual, strange, out-of-the-ordinary features of mental disorders. This century is also characterized by a deep study of human anatomy, incl. anatomy of the brain and nervous system. Some zones of localization of mental functions have been identified.

Benjamin Rush was a staunch advocate of the swivel chair. He was the founder of American psychiatry and believed that mental illness causes stagnation of blood in the brain and that this condition can be alleviated by rotation. Rush also suggested that mental illness could be caused by physical causes, for example, dropsy, gout, pregnancy or tuberculosis, or excessive sexual activity. He suggested that some mental states, such as fear, anger, loss of freedom, can cause pathology of cerebral vessels.

Boerhaave's students became interested in the symptoms of neurotic disorders, and each of them proposed their own system of classification of mental illnesses based on physiology. Witt divided neuroses into hysteria, hypochondria and nervous exhaustion. The system proposed by Witt is not very different from the modern clinical descriptive classification. He was also the first to describe the pupillary reflex and study shock as a consequence of spinal injury.

The most complete classification was William Cullen's classification of diseases. Using diagnostic and treatment methods, he classified almost all diseases known at that time according to their symptoms. He was also the first to use the term "nervous" to refer to diseases not accompanied by fever or localized pathology. He believed that neurosis is caused by a disorder of either the intellect, or the voluntary and involuntary nervous system. All neurotic illnesses must be based on some physiological malfunction. Cullen's treatments were based on diet, physical therapy, exercise, cleansing, forehead burning, cold baths, bloodletting and emetics, which were common methods used to combat physical illness. Disorders. Cullen treated severely mentally ill patients using strict isolation, threats and straitjackets

Giovanni Morgagna was a pathologist whose main interest was brain pathology. He revealed that the symptoms that appear during a stroke are not the result of a disease of the brain itself, but only the result of rupture of blood vessels that have a secondary effect on the brain. Neurologists, neuroanatomists, and therapists were influenced by Blink’s concept that illness can be localized and began to deeply and thoroughly examine the brain when studying the causes of mental illness.0

Philippe Pinel created a new, simple classification of mental illnesses. He divided all disorders into melancholia, mania without delirium, mania with delirium, dementia (mental retardation and idiocy), and he described hallucinations. His description of symptoms is presented in a system; he distinguished between disorders of memory, attention, and judgment abilities, and recognized the significance of affects. He believed that the basis of the disorders was damage to the central nervous system. His descriptions of illnesses are simple and accurate. Pinel believed that traditional methods of treatment were not suitable. He followed the psychological method - you have to live among the insane. Not only heredity, but also improper upbringing can lead to mental disorders. Pinel's main merit is that he changed society's attitude towards the insane. He said that it is impossible to determine what is the cause of disorders - internal causes or the result of disorders. But the conditions of detention for the mentally ill were monstrous. It should be noted here that in Spain, and then in other countries, under the influence of the views of Pinel and other psychiatrists, a humane approach to the maintenance and treatment of the insane is gradually beginning to be introduced. It should be noted that in Russia humane methods were mainly used.

Despite the promotion of scientific ideas by scientists such as Rush, Pinel, etc., charlatans also appeared who put forward anti-scientific ideas. For example, Franz Meismer - the idea of ​​animal magnetism; John Brown, who gave his patients drugs that reversed their symptoms; Franz Gall, who believed that by feeling the bumps and depressions on the head one can determine a person’s character.

Johann Reil - the first systematic treatise on psychiatry, an adherent of the psychotherapeutic approach, believed that diseases should be treated with psychological methods, but at the same time the specialist must have extensive training, believed that somatic diseases can be cured by the same method. Pushed for the importance of psychiatry. He spoke in defense of the insane, describing the horror of keeping them in hospitals and society’s attitude towards them.

Moreau de Tours, a leading psychiatrist, considered introspection to be the main method; he himself tried hashish to feel the patient’s condition. Moreau was the first to point out that dreams contain the key to understanding mental disorders. Dreams are of the same nature as hallucinations, being a borderline link. He said that a mad person dreams in reality. In this way he anticipated the idea of ​​the unconscious. Genius and madness are close concepts.

In the mid-19th century, medicine adopted the principles of physics and chemistry. Psychiatry also tried to join this trend - behavioral disorders due to the destruction of nervous structure and functions - materialistic theories. Biological, medical and anatomical discoveries are taking place.

Neuropsychiatry

Clinical medicine made significant advances in the first half of the 19th century. The syndromes and essence of the diseases were described in detail.

Wilhelm Griesinger. Great contribution to psychiatry, a guide to psychiatry. He paid special attention to the analysis of the connection between physiological and anatomical phenomena. He believed that all mental disorders could be viewed in terms of the correct or incorrect functioning of brain cells. Therapeutic methods did not include crude techniques such as emetics; he used them only in extreme cases. He insisted on equal use of organic and psychological methods. He also determined that the personality problem in mental illness is closely related to the loss of the ability to self-esteem, alienation from oneself, and therefore, in order to understand the disease, the doctor must study the patient’s personality in detail. Griesinger renewed hope that honey. Psychology will certainly become a legitimate medical science, and psychiatry will be able to develop hand in hand with other medical disciplines, as absolute equals. psychiatry cullen disease physiology

The development of physiology and psychiatry in Russia was carried out by such scientists as I. Sechenov - the book “Reflexes of the Brain”. He argued that human mental activity depends on external stimuli, therefore, behavior should be studied from the point of view of physiology. I.P. Pavlov followed the ideas of Sechenov and developed the theory of conditioned and unconditioned reflexes. Then behaviorists used all this. The most complex mental functions develop from simple conditioned reflexes. Higher processes are inhibited by lower functions of the brain.

Vladimir Bekhterev. Head of the psychophysiological laboratory in Kazan, founder of the Psychoneurological Institute in St. Petersburg. Used Pavlov's theories in his work. He trained in Wundt's laboratory and studied hypnosis with Charcot. After this, he opened his own laboratory, where he studied physiological phenomena associated with hypnosis, and also experimented in psychosurgery.

The second half of the 19th century was marked by a largely organic understanding of mental disorders, but at the same time many mental illnesses were studied, in many cases through discoveries in the field of human anatomy and physiology. A large amount of factual and experimental material was collected. All this required systematization.

Emil Kreppelin. He carried out a systematization of mental disorders, using mainly an organic approach. He differentiated between dementia and manic depression based on prognosis. He concluded that with the first disease, recovery occurs much less frequently than with the second. Kröppelin showed the importance of generalization in psychiatric research, the need for a careful description of medical observations and an accurate presentation of the findings. Without such an approach, psychiatry would never have become a special clinical branch of medicine.

Jean Charcot became interested in the phenomenon of hypnosis. He came to the conclusion that hysterical paralysis is associated with the mental apparatus. Proof of this was his inducing paralysis in hysterical patients using hypnosis. At the same time, he managed to cure the resulting paralysis. Charcot also suspected that sexual impulses played a role in the origin of hysterical symptoms.

Psychoanalysis and psychiatry

Sigmund Freud is rightfully considered the founder of psychoanalysis, who revealed unconscious processes in the human psyche. He was the first to prove that unconscious processes are important in human behavior, and in many cases determine it. Freud's entire activity can be divided into four periods, two of which intersect each other.

1) Contributions to the anatomy of the nervous system and neuroscience

2) Study of hypnotism and hysteria

3) Detection and study of subconscious phenomena and the development of the method of psychoanalysis as a therapeutic factor

5) Systematic study of human personality and the structure of society.

Soon after working with Breuer, Freud realized that, despite all the usefulness of hypnosis, it still had limitations as a therapeutic method. On the one hand, not every person can be hypnotized. On the other hand, Freud was convinced that the therapeutic effect is often transient: in the place of a disappeared symptom, another appears. The reason is that during hypnosis the subject temporarily loses the functions of the self, especially the functions of critical analysis, and completely entrusts himself to the hypnotist. Thus, he can remember traumatic events that his “I” would normally repress from memory; but subconscious memories do not become part of his conscious personality, and upon awakening the subject usually does not remember what happened during hypnosis. Consequently, hypnotic memories do not eliminate the causes of forgetting - the resistance of the conscious personality to unbearable, suppressed thoughts. Hence the outburst of suppressed emotions under hypnosis - denoted by the term “reaction” - which does not lead to a cure, but gives only a temporary effect of relief from accumulated tension.

Freud began experimenting with other psychotherapeutic techniques. Only later did he realize the limitations of hypnosis. The next logical step taken by Freud was to try to overcome, rather than circumvent, by means of hypnosis the threshold of resistance of the conscious personality to repressed material; that is, to try to encourage patients to consciously face the unbearable, to force patients to consciously remember forgotten, painful moments in their lives. Based on Bernheim's theory that suggestion is the essence of hypnosis, Freud first tried to use suggestion by inducing his patients, while fully conscious, to recall traumatic life events associated with the symptoms of their illness. After a short period of unsuccessful experimentation with various techniques, Freud discovered the method of free association in 1895.

Freud's new technique was to ask his patients to give up conscious control over their thoughts and say the first thing that came to mind. Free association promotes the involuntary release of subconscious material that seeks this release, but is suppressed by repressive opposition. When the patient ceases to direct his mental processes, spontaneous associations are guided by repressed material rather than by conscious motivations; the uncontrolled flow of thought thus reveals the interaction of two opposing tendencies - to express or suppress the subconscious. Free association, as Freud found out, after a sufficiently long time led the patient to forgotten events, which he not only remembered, but also lived again emotionally. The emotional response during free association is essentially similar to that experienced by the patient during hypnosis, but it is not as sudden and violent; and since the response comes in portions, with full consciousness, the conscious “I” is able to cope with emotions, gradually “cutting a path” through subconscious conflicts. It was this process that Freud called “psychoanalysis,” using the term for the first time in 1896.

Subconscious material does not immediately appear during free association; rather, it directs the flow of thoughts in a certain direction, which is not always realized. Listening to the free flow, Freud learned to read between the lines and gradually understood the meaning of the symbols with which patients expressed deeply hidden things. He called the translation of this language of subconscious processes into the language of everyday life “the art of interpretation.” However, all this was truly realized and understood only after Freud revealed the meaning of dreams.

Freud became interested in dreams after noticing that many of his patients, in the process of free association, suddenly began to talk about their dreams. Then he began to ask questions about what thoughts came to them in connection with this or that element of the dream. And he noticed that often these associations revealed the secret meaning of the dream. He then tried, using the external content of these associations, to reconstruct the secret meaning of the dream - its latent content - and in this way discovered a special language of subconscious mental processes. He published his findings in The Interpretation of Dreams in 1900; this book can rightfully be considered his most significant contribution to science.

The core of Freud's theory of dreams is the idea that dreams are an attempt to relieve emotional tension that interferes with a feeling of complete peace. These tensions accumulate during the day due to unfulfilled aspirations and desires, and the sleeper frees himself from them, drawing in his imagination a picture of the satisfaction of his aspirations. The clearest example of this process can be children's dreams of “wish fulfillment,” where all desires and dreams that were not realized during the day seem to be fulfilled. In adults, the process of satisfying aspirations through dreams is much more complicated. Many adult desires, unlike children’s, are suppressed not so much by external obstacles as by internal conflicts. Quite often, these internal conflicts are the result of unfulfilled aspirations of adolescence due to the negative attitude of parents towards them. This is the so-called “alien I” or “It”. In their dreams, adults express the desires of their “alien self” in a distorted form. This is a defense against the internal conflicts that would inevitably arise if the tendencies of the “It” were to manifest themselves openly. Adult dreams are a compromise: they satisfy the desires of the “It” in a veiled, symbolic form, expressed in the infantile language of unconscious processes, in expressions no longer accessible to the adult. In this way, the internal conflict is circumvented, and the dream fulfills its function as a guardian of sleep.

The study of dreams has provided the necessary key to understanding psychopathological phenomena. The technique of free association and interpretation opened a wide path into the subconscious and offered a path to understanding psychopathological phenomena, because these phenomena, like dreams, are a product of the unconscious aspirations of the “superego”. Psychopathological symptoms and dreams are products of primitive thinking - Freud called these "primary processes" - and they are not subject to the usual restrictions imposed by the social environment. The study of dreams revealed to Freud a number of psychological mechanisms. One of them is “condensation,” the reduction of various thoughts that have a certain common denominator into a single symbol. For example, a person may see in a dream a face with the eyebrows of his father, the nose of a teacher, the mouth of a brother, the ears of his wife, and at first glance the face will not resemble any of the people mentioned. If an individual with such a face is killed in a dream, then subconsciously the people who are represented in this face are precisely those against whom the sleeping person has bad feelings.

The next mechanism can be thought of as “displacement.” In a dream, the patient can transfer hatred or love from one person to another, to one for whom he can harbor these feelings without experiencing internal conflict. Freud also discovered several other different characteristics of unconscious processes. These include the use of allegories, symbols, allusions, parts instead of wholes, and “expressing something by its opposite.” “Expression through the opposite” means the denial of what is desired, which for some reason is unacceptable. For example, a person experiencing unconscious enmity towards his brother wants to bypass him, say, in search of a job. But the internal rejection of this hostile desire leads to the fact that in a dream he cedes this job to his brother. The essence of these complex dream mechanisms is to hide, disguise an unacceptable subconscious desire.

Freud paid much attention to demonstrating the “dynamic subconscious” in its various appearances - slips of the tongue, witticisms, forgettings. In his brilliant work “The Psychopathology of Everyday Life,” he showed that seemingly random slips of the tongue, seemingly causeless forgetting of words (or actions, intentions, etc.) - all this is the result of suppressed aspirations.

When analyzing the dreams of his patients, Freud discovered that sexual impulses play a very significant role in the occurrence of neuroses. He found out that the content of the “Alien I” (“It”), which is repressed into the subconscious and subsequently manifests itself in dreams and neurotic symptoms, invariably has a sexual connotation. Freud delved extremely deeply and carefully into the essence of the phenomenon, but, once convinced of the results of his observations, he fearlessly and firmly defended them. His own introspection, the interpretation of his own dreams, gave Freud the first hint of the Oedipus complex - the sexual attraction of a child to a parent of the opposite sex and a feeling of rivalry with a parent of the same sex. His conclusions, supported by observations of patients, were published in Three Essays on the Theory of Sexuality (1905). His theoretical conclusions regarding the sexual nature of man became known as the "libido theory", and this theory, together with the discovery of childhood sexuality, was one of the main reasons that Freud was rejected by his fellow professionals and the general public.

The libido theory revised traditional views of the sexual instinct as an instinct for procreation. Freud came to the conclusion that many aspects of a child's behavior, such as thumb sucking or bodily functions, are a source of sensual (sexual) pleasure, having nothing to do with procreation. Thus, this conclusion moved the concept of sexuality beyond the concept of reproduction. Freud's theory of libido replaced the previous narrow definition of sexuality with a comprehensive theory of personality development in which biological (including sexual) and psychological development are closely intertwined. The baby, still completely dependent on the mother for the pleasure it experiences in the mouth, is in the oral phase and in the biological stage characterized by rapid growth. His psychology is dominated by the desire to absorb food. At this stage of development, the infant exhibits receptive dependence: when he is upset, he becomes demanding and aggressive. The oral period is followed by an “anal phase,” during which he first begins to control his bodily functions. This phase begins at approximately eighteen months of age. Learning toilet habits prevents the child from receiving the pleasure he experiences from holding or excreting excrement, and his psychology during this period is dominated by aggression, envy, stubbornness, and possessive feelings. He develops defensive reactions against coprophilic tendencies (the desire to touch feces), such as disgust and cleanliness.

These phases and psychosexual development occur unevenly, overlapping and mixing. The next phase begins at approximately three years of age. It is characterized by childhood masturbation, sexual curiosity, competitive and ambitious feelings, and most of all the Oedipus complex. These years are referred to as the "phallic phase." Around the age of six, a “latent” period begins when the child’s previous curiosity about sexual manifestations gives way to curiosity about the entire world around him. He goes to school and most of his energy goes into studying.

Around the age of twelve, with the onset of adolescence, when the reproductive system matures, sexual interest reappears. The central psychological characteristic of this turbulent period is uncertainty and instability, explained by the fact that a fully developed body is controlled by an inexperienced brain. The desire to test oneself and establish oneself is expressed in excessive competition and awkward attempts to show one’s maturity and independence, although these attempts are undermined by internal doubts. During these years, a revival of the Oedipus complex may occur.

Maturity, or the so-called genital phase, is characterized mainly by self-awareness, a sense of self-confidence and the capacity for mature love. This form and manner of behavior is possible only when the concentration on one’s own personality decreases. All pregenital phases are basically centripetal, narcissistic, because the individual is concerned with his own development, studying his physical and mental environment. Only after development reaches a certain limit and a person realizes himself as a given, can he turn his love to other objects.

Of Freud's many concepts, it was "consolidation" and "regression" that helped explain the essence of neurotic and psychotic symptoms. Consolidation is an individual's tendency to retain behaviors, feelings, and thoughts that have served him well in the past. Regression is the tendency to return to the most successful skills developed in the past, in cases where a situation arises that requires some other skills, adaptation and training, for which one’s own “I” is not yet ready. Neurotics have a special tendency to regress, and neurotic symptoms are a disguised expression of former habits of the “Id” which are not applicable in the present situation. For example, a child finds out that by shouting he can achieve what he is not allowed to do. Later, when he goes to school, the teacher may forbid him to play with something. And then he “regresses,” trying to get permission by shouting, instead of accepting the teacher’s conditions or getting permission in some other, less aggressive way.

The “I” uses defense mechanisms to prevent the outdated tendencies of the “It” from breaking through to the surface, into consciousness. Among these mechanisms, the most important are “overcompensation”, or “reverse action” (say, when a weak person behaves like a very strong one, sometimes to the point of hooliganism), “rationalization”, “directing the hostile impulses of the “It” against oneself” (in cases self-destructive actions or thoughts) and “projection,” that is, attributing unacceptable intentions to other people. There are other defense mechanisms, such as “sublimation” (directing forbidden impulses into acceptable behavior, say, voyeuristic tendencies turn into photography) and “transferring” hostility or love from an unsuitable object to an acceptable one (transferring love for a mother to love for a girl). All these defense mechanisms serve to avoid conflict between the social essence of the individual and his internal, primitive aspirations. They serve to reduce the anxiety that arises when repressed impulses from the “alien Self” (“It”) threaten to force their way into the sphere of consciousness.

Neurotic symptoms, when viewed in this light, can be defined as unsuccessful attempts at self-medication. They are unsuccessful because the defense itself becomes the source of the disease. For example, a person who is angry with his father is ready to shout at him. This desire contradicts his morality, which rejects the possibility of expressing anger towards his parents. As a result, he loses his voice. Now he cannot work, because work requires conversation. What was originally a defense mechanism against his father's insult (loss of voice) became an illness. Example: The following person feels that he is weak. Nobody loves the weak, so he tries to gain love by trying to act like a strong person. But he may overdo it (overcompensation) and come across as a bully. However, no one likes hooligans either. Thus, a defensive action (strong behavior) itself turns into a disadvantage.

An important point in psychoanalytic treatment is “transference”. It is based on the fact that during treatment the patient not only remembers the events of his past, but, more importantly, transfers to the doctor the feelings that he had for people from his past who meant a lot to him - most often his parents. He behaves with the doctor the same way he behaved with his parents. Experiencing and reproducing initial neurotic reactions gives the patient the opportunity to correct them. By reliving past events, the adult patient has the opportunity to overcome some traumatic events or emotions of childhood: his adult experience helps him resolve those emotional difficulties that turned out to be insurmountable for him in childhood. Freud's main thesis was that in order to heal, it is necessary for there to be recollection of past events and insight into the meaning of these events.

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1. Subject and tasks of psychiatry. History of development

Psychiatry is a medical discipline that studies the diagnosis and treatment, etiology, pathogenesis and prevalence of mental illnesses, as well as the organization of mental health care for the population.

Psychiatry literally translated from Greek means healing of the soul. This terminology does not correspond to our modern ideas about mental illness. In order to understand the origin of this definition, it is necessary to recall the history of the formation of the human worldview. In ancient times, people saw surrounding phenomena and objects, endowing them with a soul. Phenomena such as death and sleep seemed obscure and incomprehensible to primitive man. According to ancient beliefs, the soul, flying out of the body in a dream, sees various events, wanders somewhere, participating in them, and this is what a person observes in a dream. In Ancient Greece, it was believed that if you wake up a sleeping person, the soul may not have time to return back to the body, and in those cases when the soul left and did not return, the person died. In the same Ancient Greece, a little later, an attempt was made to combine mental experiences and mental illnesses with one or another organ of the human body, for example, the liver was considered the organ of love, and only in later images the heart pierced by Cupid’s arrow becomes the organ of love.

Psychiatry is a specialty of medicine that is part of clinical medicine. In addition to the basic research methods used in clinical medicine, such as examination, palpation and auscultation, to study mental illness a number of techniques are used to identify and assess the patient’s mental state - observation and conversation with him. In the case of mental disorders, as a result of observing the patient, one can discover the originality of his actions and behavior. If the patient is bothered by auditory or olfactory hallucinations, he may plug his ears or nose. During observation, it can be noted that patients seal windows and ventilation holes so that the gas that the neighbors allegedly let in does not penetrate into the apartment. This behavior may indicate the presence of olfactory hallucinations. In the case of obsessive fears, patients may make movements that are incomprehensible to others, which are rituals. An example would be endless hand washing in fear of contamination, or stepping over cracks in the asphalt “so that nothing bad happens.”

When talking with a psychiatrist, the patient can tell him about his experiences, concerns, fears, bad mood, explaining incorrect behavior, as well as express judgments that are inappropriate to the situation and delusional experiences.

To correctly assess the patient’s condition, collecting information about his past life, attitude to current events, and relationships with people around him is of great importance.

As a rule, when collecting such information, painful interpretations of certain events and phenomena are revealed. In this case, we are talking not so much about the anamnesis, but about the mental state of the patient.

An important point in assessing the patient’s mental state is the data from the objective history, as well as information received from the patient’s close relatives and people around him.

Sometimes doctors encounter the phenomenon of anosognosia - denial of the disease by the patient himself and his close relatives, which is typical for mental illnesses such as epilepsy, mental retardation, and schizophrenia. In medical practice, there are cases when the patient’s parents do not seem to see obvious signs of the disease, being fairly educated people and even doctors. Sometimes, despite denying that a relative has the disease, some of them agree to carry out the necessary diagnosis and treatment. In such situations, the psychiatrist must show maximum professionalism, flexibility and tact. It is necessary to carry out treatment without specifying the diagnosis, without insisting on it and without convincing relatives of anything, based on the interests of the patient. Sometimes relatives, denying the disease, refuse to carry out the course of necessary therapy. This behavior can lead to worsening of the symptoms of the disease and its transition to a chronic course.

Mental illnesses, unlike somatic illnesses, which are an episode in the patient’s life, continue for years, and sometimes throughout life. Such a long course of mental illness provokes the emergence of a number of social problems: relationships with the outside world, people, etc.

The patient’s personal qualities, level of personality maturity, as well as formed character traits play a large role in the process of assessing mental illness and its consequences, which is most clearly revealed when studying clinical variants of neuroses.

Gradually (as psychiatry developed and studied), several independent areas emerged: child and adolescent psychiatry, geriatric, forensic, military psychiatry, narcology, psychotherapy. These areas are based on general psychiatric knowledge and are developed in the practical activities of a doctor.

It has been established that there is a close relationship between somatic and mental illnesses, since absolutely any somatic disorder has a pronounced impact on the patient’s personality and his mental activity. The severity of mental disorders in different diseases varies. For example, in diseases of the cardiovascular system, such as hypertension, atherosclerosis, the decisive role is played by the somatogenic factor. Personality reactions are more pronounced in those diseases that result in facial defects and disfiguring scars.

Many factors influence a person’s reaction and illness:

1) the nature of the disease, its severity and rate of development;

2) the patient’s own understanding of this disease;

3) the nature of the treatment and the psychotherapeutic environment in the hospital;

4) personal qualities of the patient;

5) attitude towards the illness of the patient, as well as his relatives and colleagues.

According to L.L. Rokhlin, there are five options for a person’s reaction to illness:

1) asthenodepressive;

2) psychasthenic;

3) hypochondriacal;

4) hysterical;

5) euphoric-anosognosic.

The now widely used term “somatically caused psychosis” was proposed by K. Schneider. In order to make such a diagnosis, the following conditions are necessary:

1) clear symptoms of a somatic disease;

2) an obvious connection in time between somatic and mental disorders;

3) parallel course of mental and somatic disorders;

4) exogenous or organic symptoms.

Somatogenically caused mental illnesses and mental disorders can be of a psychotic, neurotic and psychopathic nature, thus, it would be correct to talk not about the nature of mental disorders, but about the level of mental disorders. The psychotic level of mental disorders is a condition in which the patient is not able to adequately assess himself, the environment, the relationship of external events to himself and his situation. This level of mental disorders is accompanied by disturbances in mental reactions, behavior, as well as disorganization of the patient’s psyche. Psychosis– a painful mental disorder that manifests itself entirely or predominantly as an inadequate reflection of the real world with behavioral disturbances and changes in various aspects of mental activity. As a rule, psychosis is accompanied by the appearance of phenomena that are not characteristic of the normal psyche: hallucinations, delusions, psychomotor and affective disorders.

The neurotic level of mental disorders is characterized by the fact that the correct assessment of one’s own condition as painful, correct behavior, as well as disorders in the sphere of vegetative, sensorimotor and affective manifestations are preserved. This level of disturbance of mental activity, disorders of mental activity is not accompanied by a change in attitude towards the events taking place. According to A. A. Portnov’s definition, these disorders are a violation of involuntary adaptation.

The psychopathic level of mental disorders is manifested by persistent disharmony of the patient’s personality, which is expressed in a violation of adaptation to the environment, which is associated with excessive affectivity and an affective assessment of the environment. The level of mental disorders described above can be observed in the patient throughout his life or arise in connection with previous somatic diseases, as well as with anomalies of personality development.

Severe psychotic disorders in the form of psychoses are much less common than other disorders. Often, patients first turn to general practitioners, which is associated with the onset of the disease in the form of the appearance of vegetative and somatic symptoms.

The course of somatic diseases is adversely affected by mental trauma. As a result of the patient’s unpleasant experiences, sleep is disturbed, appetite decreases, and the body’s activity and resistance to diseases decrease.

The initial stages of the development of mental illness differ in that somatic disorders are more pronounced compared to mental disorders.

1. A young food service worker began to complain of rapid heartbeat and increased blood pressure. At the appointment with the therapist, no pathology was noted; the doctor assessed these disorders as age-related functional ones. Subsequently, her menstrual function disappeared. At the appointment with the gynecologist, no pathology was also detected. The girl began to gain weight rapidly, and the endocrinologist also did not note any abnormalities. None of the specialists paid attention to low mood, motor retardation and decreased performance. The decrease in performance was explained by the girl’s anxiety and the presence of somatic pathology. After attempting to commit suicide, the girl, at the insistence of her close relatives, was consulted by a psychiatrist, who diagnosed her with a depressive state.

2. A 56-year-old man, after a holiday at sea, began to complain of chest pain and poor health, and therefore was taken to the therapeutic department of a city clinical hospital. After the examination, the presence of cardiac pathology was not confirmed. Close relatives visited him, assuring him that everything was fine, although the man felt much worse every day. Then he had the idea that those around him considered him a malingerer and thought that he was specifically complaining about heart pain so as not to work. The patient's condition deteriorated every day, especially in the mornings.

Unexpectedly in the morning, the patient walked into the operating room and, taking a scalpel, attempted to commit suicide. Hospital workers called an ambulance to the patient together with a psychiatric team, which later found out that the patient was depressed. This disease in the patient was accompanied by all the signs of a depressive state, such as melancholy, motor retardation, decreased intellectual activity, slowed mental activity, and weight loss.

3. During a movie show, the child started vomiting. His parents consulted a doctor with this complaint. At the hospital, the stomach and liver were examined, and the child was examined by a neurologist. After these procedures, no pathology was found. When collecting an anamnesis from the child’s parents, it was possible to find out that vomiting first occurred after the child ate a chocolate bar, ice cream, an apple, and candy in a movie theater. While watching a movie, the child began to vomit, which subsequently took on the character of a conditioned reflex.

Whatever field of medicine he works in, whatever specialty the doctor prefers, he must proceed from the fact that he is dealing primarily with a living person, a person, with all its individual subtleties. Every doctor needs knowledge of psychiatric science, since most patients with mental disorders first of all turn not to psychiatrists, but to representatives of another medical specialty. It often takes a considerable period of time before a patient comes under the care of a psychiatrist. As a rule, a general practitioner deals with patients who suffer from minor forms of mental disorders - neuroses and psychopathy. Minor or borderline psychiatry deals with such pathology.

Soviet psychiatrist O.V. Kerbikov argued that borderline psychiatry is the area of ​​medicine in which contact between a psychiatrist and general practitioners is most necessary. The latter in this case are at the forefront of protecting the mental health of the population.

To avoid mistreatment of a patient, a doctor needs knowledge of psychiatric science in general and borderline science in particular. If you treat a mentally ill person incorrectly, you can provoke the occurrence of iatrogenicity - an illness involuntarily caused by a doctor. The occurrence of this pathology can be facilitated not only by words that frighten the patient, but also by facial expressions and gestures. A doctor, a person directly responsible for the health of his patient, must not only behave correctly himself, but also control the behavior of the nurse and teach her the intricacies of communication with the patient, while observing all the rules of deontology. In order to avoid additional trauma to the patient’s psyche, the doctor must understand the internal picture of the disease, that is, how his patient relates to his disease, what his reaction to it is.

General practitioners are often the first to encounter psychoses in their very initial stages, when the painful manifestations are not yet very pronounced and not too noticeable. Quite often, a doctor of any profile may encounter initial manifestations, especially if the initial form of mental illness superficially resembles some kind of somatic disease. Often, a pronounced mental illness initiates somatic pathology, and the patient himself is firmly “convinced” that he has some (actually non-existent) disease (cancer, syphilis, some kind of disfiguring physical defect) and persistently demands special or surgical treatment. Quite often, diseases such as blindness, deafness, and paralysis are a manifestation of hysterical disorders, hidden depression, occurring under the guise of a somatic illness.

Almost any doctor can find himself in a situation where emergency psychiatric care is required, for example, to relieve a state of acute psychomotor agitation in a patient with delirium tremens, to do everything possible in the event of status epilepticus or suicide attempts.

Nosological direction in modern psychiatry (from Greek. nosos- “disease”) is widespread both in our country and in some European countries. Based on the structure of this direction, all mental disorders are presented in the form of separate mental illnesses, such as schizophrenia, manic-depressive, alcoholic and other psychoses. It is believed that each disease has a variety of provoking and predisposing factors, a characteristic clinical picture and course, its own etiopathogenesis, although various types and variants are distinguished, as well as the most likely prognosis. As a rule, all modern psychotropic drugs are effective for certain symptoms and syndromes, regardless of the disease in which they occur. Another rather serious drawback of this direction is the unclear position of those mental disorders that do not fit into the clinical picture and course of certain diseases. For example, according to some authors, disorders that occupy an intermediate position between schizophrenia and manic-depressive psychosis are special schizoaffective psychoses. According to others, these disorders should be included in schizophrenia, while others interpret them as atypical forms of manic-depressive psychosis.

The founder of the nosological direction is considered to be the famous German psychiatrist E. Kraepelin. He was the first to conceptualize most mental disorders as distinct illnesses. Although even before E. Kraepelin’s taxonomy, some mental illnesses were identified as independent: circular insanity, described by the French psychiatrist J. - P. Falret, later called manic-depressive psychosis, alcoholic polyneuritic psychosis, studied and described by S. S. Korsakov, progressive paralysis, which is one of the forms of syphilitic brain damage, described by the French psychiatrist A. Bayle.

The fundamental method of the nosological direction is a detailed description of the clinical picture and course of mental disorders, for which representatives of other directions call this direction E. Kraepelin’s descriptive psychiatry. The main branches of modern psychiatry include: geriatric, adolescent and child psychiatry. They are areas of clinical psychiatry devoted to the characteristics of the manifestations, course, treatment and prevention of mental disorders at appropriate ages.

The branch of psychiatry called narcology studies the diagnosis, prevention and treatment of drug addiction, substance abuse and alcoholism. In Western countries, doctors specializing in the field of addiction are called addictionists (from the English word addiction - “predilection, dependence”).

Forensic psychiatry develops the fundamentals of forensic psychiatric examination, and also works to prevent socially dangerous actions of mentally ill persons.

Social psychiatry studies the role of social factors in the occurrence, course, prevention and treatment of mental illnesses and the organization of mental health care.

Transcultural psychiatry is a section of clinical psychiatry devoted to the comparative study of the characteristics of mental disorders and the level of mental health among different nations and cultures.

A section such as orthopsychiatry brings together the approaches of psychiatry, psychology and other medical sciences to the diagnosis and treatment of behavioral disorders. Particular attention is paid to preventive measures aimed at preventing the development of these disorders in children. Sections of psychiatry also include sexopathology and suicidology (studying the causes and developing measures to prevent suicide at the level of preventing suicidal behavior that precedes it).

Psychotherapy, medical psychology, and psychopharmacology are borderline with psychiatry and at the same time separate scientific disciplines.

Over many years of working in psychiatry, you get used to some particularly stable stereotypes of patient behavior. One of these is the custom, whether we are talking about discharge from a hospital or the end of a course of outpatient treatment, to say goodbye forever. And this behavior is very understandable: who, tell me, wants to return again and again to these walls, always yellow, no matter what their current color? And you, of course, know that

in most cases, a person will come again sooner or later, he’s just so ardently and sincerely convinced that this time was certainly the last or even the only one that it’s a pity to dissuade him.

But in fact, our psychiatric illness is a persistent thing, and once it has clung to it, it is reluctant to let go. If he lets go at all. No, of course, there are one-time episodes - for example, a reaction to some events or circumstances. Neurotic, depressive, even with hallucinations or delusions - there is still a majority of chances for a complete recovery.

Or delirium tremens. It flows brightly and is remembered by everyone around him - and there are not so many repeated cases, apparently, a person gets scared well, tries in the future not to get drunk with little green men, devils, or whatever the heraldic animal of drug addiction specialists brings with him.

Other mental illnesses, for the most part, tend either to occur constantly, or to worsen or decompensate from time to time. Even such a group as neuroses. And it seems that, from the point of view of psychiatry, there is nothing fatal: exacerbations are not of such a formidable nature as in psychosis, and do not lead to madness, and do not make one disabled - unless the patient pays for this disability himself. And certainly no one has died from neurosis yet. But how tired it is to suffer from this very neurosis! Or, as it is now fashionable to put it, the quality of life is noticeably reduced. So a person asks, once again experiencing all the delights of a decompensated neurotic state: doctor, is neurosis really incurable?

Unfortunately, as the same long-term practice shows, and not only mine, yes, it is incurable. And he stubbornly strives to return. Why is this so?

The main reason lies in the very essence of neurosis. The fact is that it was once considered a psychogenic disease, that is, one that is caused not by brain damage or a malfunction of other systems, but by psychological reasons. In particular, conflicts that are significant for a particular person and, accordingly, predetermine the development of one or another (but for a specific person - strictly defined) type of neurosis.

For example, neurasthenia was considered to be characterized by a conflict between a completely intact, but tired and exhausted personality, and the external unfavorable circumstances and adversities that befell her, and to such an extent that it is not possible to overcome them; Bolivar cannot withstand two.

For hysterical neurosis, the conflict between the childishly impatient desires of the monstrously egocentric “I” and the impossibility of getting it all right now is considered significant. For hypochondriacal neurosis... well, you remember the quote from “The Formula of Love”: hypochondria is a cruel lust that keeps the spirit in a continuous sad state. By the way, almost to the point: the conflict between secret desires, but condemned by moral norms, and the need to suppress them was considered significant for hypochondria.

Accordingly, it was once believed that it was enough to reduce the severity of neurosis with medications, and then involve psychotherapy in order to reveal the essence of the current conflict and make it irrelevant for the patient - and a cure would occur. Or at least a long remission. Until the next brewing conflict.

Only it turned out that this debriefing was not enough for restitutio ad integrum. And further searches revealed that each type of neurosis has its own special... let's say, genetic firmware. It determines the personality type, character traits, and characteristics of mental and biochemical reactions.

On the one hand, it has become clearer why, say, a neurasthenic has a deeply violet type of conflict that successfully cripples a hypochondriac: he is simply not genetically designed to react sharply to such things. What kind of lust is this - you have to plow, overcome and burden yourself with new problems!

On the other hand, genes are stable things. Find me a psychotherapist who knows how to persuade the genetic program to be ashamed and correct itself - and I will go build him a temple and become an apostle. Well, we don’t yet know how to work with genes - at least, so subtly and with such a predictable result, and without dangerous consequences - to tackle the problem from this side as well. So what to do?

There is, it turns out, one more point that both psychiatrists and their neurotic patients know or guess about, but which somehow always escapes the focus of their attention. And it concerns high spheres, the level of worldview. We are talking about the goals that a person sets for himself. Suddenly?

Meanwhile, if the doctor carefully questions, and the patient remembers it well, it turns out that (if we consider a lot of cases and compile some semblance of statistics) there are moments in life when neurosis is not remembered, even if there were episodes before. And these are precisely the moments when a person had a goal that he wanted to achieve with all his soul. Build a house there, raise a son, plant a tree. Well, or something else fundamental, strategic, from the point of view of your own life. For everyone - their own, but their own, so that there is direct light in the window, so that “I see the goal - I see no obstacles.”

And while there was movement towards this goal - albeit with all the difficulties and hassle - the person did not even remember about neurosis. What kind of neurosis is this? No time, I’m busy making dreams come true!

But when a goal is achieved or lost, and a new one is not set, when there is a lull in plans, then this vacuum begins to be filled with all sorts of ailments and worries. Like a top that lost momentum and staggered. And so, instead of resting on the laurels of what has been achieved or enjoying the pause before the next ascent, a person is forced to waste nerves, time and energy on coping with neurosis.

The conclusion seems to be simple: you need constant movement towards some next goal. But there is, as always, a nuance. Not a single psychotherapist, not a single psychiatrist can take it and say: here’s a new goal for you, dear comrade, move in the indicated direction, you have a smartphone with a navigator, you won’t get lost.

It won't work. Why? It's not enough to suggest. It is necessary for a person to make a decision himself, and not just make it, but with all his soul, including this point in his worldview, as another - his own - directive. But this cannot be done from the outside, which, on the one hand, is for the better, otherwise it would be too easy to control us all, but on the other hand, no one will do this work for a person.

Regarding mental illness, initially in Rus' a concept similar to the European one reigned. They were understood to a large extent as the result of the influence of “supernatural forces”, as possession by an evil or good spirit. The sick were considered holy fools, blessed, and were looked after in monasteries.

Later, when the general level of development began to increase, views on the nature of diseases of the body and brain also changed.

In 1776, the first psychiatric institution in the Russian Empire was opened in Riga.

The first scientific work of Russian psychiatry is considered to be the monograph by M.K. Pequena “On the Preservation of Health and Life,” published in 1812. The author believed that existing life situations play a major role in the occurrence of mental illness, and recommended the use of psychotherapy as a method of eliminating the causes of mental disorders.

In 1835, at the medical faculties of Russian universities, professors and therapists began to teach a separate course in psychiatry, which subsequently began to be taught at special departments: in St. Petersburg (1857), Kazan (1866), Moscow (1887) and other cities of the country.

The network of comfortable psychiatric hospitals expanded significantly after the zemstvo reforms of the 1860s.

Significant influence on the development of psychiatry from the mid-19th century. The evolutionary theory of Ch. Darwin and the further development of the doctrine of reflex by Russian physiologists I.M. Sechenov and I.P. Pavlov had an impact.

Along with this, psychiatry, more than any other field of medicine, was influenced by idealistic movements in philosophy. This was most clearly manifested in Germany, since in German philosophy of the early 19th century. idealistic trends prevailed. In psychiatry, they manifested themselves in the views of the “psychic” school, which defined mental illness as the result of a person’s evil will or sinfulness. In the middle of the 19th century. Another idealistic school of “somatics” came to the fore. Believing that the soul is immortal and cannot be sick, somaticians considered mental illness as a disease of the body, i.e. the material shell of the soul. At the end of the 19th - beginning of the 20th centuries. idealistic trends in psychiatry revived and most widely manifested themselves in psychoanalytic schools.

In Russia, the development of psychiatry was dominated by natural scientific trends, as in other areas of medicine in our country.

A significant contribution to the development of psychiatric science was made by I.M. Balinsky (1824 - 1902), who organized the first department of psychiatry in Russia, the first clinic for mental illness, and the first school of Russian psychiatrists. Balinsky sought to prove the need for a close connection between psychiatry and general somatic clinical disciplines, with physiology. His student, I.P. Merzheevsky (1838 - 1908), an outstanding psychiatrist, neurologist, pathologist, also contributed a lot to the development of domestic and world psychiatry. He studied organic brain damage, alcoholism, epilepsy, and hypnosis.

One of the largest psychiatrists of this period was Sergei Sergeevich Korsakov (1854-1900), one of the founders of the nosological trend in psychiatry, founded at the end of the 19th century. German psychiatrist Emil Kraepelin ( 1856-1926) as opposed to the existing symptomatic direction. S. S. Korsakov was the first to describe a new disease - alcoholic polyneuritis with severe memory disorders (1887, doctoral dissertation “On alcoholic paralysis”), which was already called “Korsakov psychosis” during the author’s lifetime. He was a supporter of freedom for the mentally ill, developed and put into practice a system of keeping them in bed and monitoring them at home, and paid great attention to the issues of preventing mental illness and organizing psychiatric care. His Course in Psychiatry (1893) is considered a classic and has been reprinted several times.

V.Kh. Kandinsky, P.P. Kashchenko, V.P. Serbsky, P.B. Gannushkin, V.M. Bekhterev also made a great contribution to the development of psychiatry in the 20th century. Along with traditional tasks, psychiatrists have paid great attention to helping children suffering from various mental illnesses. Since the 1920s, neuropsychiatric dispensaries began to open. Hospital bed capacity increased, paraclinical research methods and modern treatment methods were introduced. The technical and material support of psychiatric institutions and patient care have improved. A number of research institutes were organized (in Moscow, Leningrad, Kharkov, Tbilisi).

The importance of psychiatrists was great during the Great Patriotic War and after its end.

In the post-war period, further study of topical issues related to the organization of psychiatry, problems of the epidemiology of mental illness, the biological basis of neuropsychiatric disorders, forensic psychiatry and narcology, treatment and rehabilitation of the mentally ill took place.

Psychiatry in Russia was based on the ideas of a humane attitude towards the mentally ill, requiring pity, but not punishment. 11 General psychopathology. Historical sketch of the development of psychiatry. Development of the doctrine of mental illness in ancient times // http//formen.narod.ru/psihiatria_history True, in some cases witchcraft and “apostasy” were attributed to patients, and they, unfortunately, sometimes became victims of popular anger. Thus, in 1411, Pskov residents burned 12 mentally ill women accused of witchcraft, which allegedly led to a massive death of livestock. In most cases, the sick were looked after in monasteries so that they would not be “a hindrance to the healthy... they would receive admonition and guidance to the truth.” Many, “devoid of reason,” were called “fools” and “blessed.”

In 1776 - 1779 The first psychiatric hospitals were created, where patients received medical care and were involved in learning crafts, agriculture, and literacy. The first scientific work of Russian psychiatry is considered to be M. K. Pequin’s monograph “On the Preservation of Health and Life,” published in 1812. Beijing believed that existing life situations play a major role in the occurrence of mental illnesses, and recommended the use of psychotherapy as a method of eliminating the causes of mental disorders .

It should be noted that until the end of the 19th century. Most psychiatrists adhered to the concept of a single psychosis. Until this time, mental illnesses were not differentiated according to the nosological principle, and only the works of S. S. Korsakov, V. Kh. Kandinsky, E. Kraepelin (on the clinic of psychoses), F. Morel (on the etiology of psychoses), I. E. Dyadkovsky and T. Meinert (on the anatomophysiology of psychoses) contributed to the differentiation of complex plexuses of psychopathological symptoms.

In Russia, the revolutionary democrats had a great influence on the development of psychiatry, which determined the predominance of natural scientific trends both in this and other areas of medicine in our country.

Among the world's leading psychiatrists is Sergei Sergeevich Korsakov (1854-1900), one of the founders of the nosological trend in psychiatry, founded at the end of the 19th century. German psychiatrist Emil Kraepelin (Kraepelin, Emil, 1856-1926), as opposed to the previously existing symptomatic direction.

S. S. Korsakov was the first to describe a new disease - alcoholic polyneuritis with severe memory disorders (1887, doctoral dissertation “On alcoholic paralysis”), which was already called “Korsakov psychosis” during the author’s lifetime. He was a supporter of freedom for the mentally ill, developed and put into practice a system of keeping them in bed and monitoring them at home, and paid great attention to the issues of preventing mental illness and organizing psychiatric care. His “course on psychiatry” (1893) is considered a classic and has been reprinted many times.

In general, we can say that the end of the 19th - beginning of the 20th centuries. were marked by the rapid accumulation and generalization of a huge amount of scientific facts in the field of psychiatry. psychiatry treatment of corsacs

After the October Revolution of 1917, psychiatry further developed in Russia. Treatment and prevention institutions and pharmacies were nationalized, women's and children's clinics were established, and a psychiatric service began to function. The Council of Medical Colleges in April 1918 created a special psychiatric commission.

Particular attention was paid to helping children suffering from various mental illnesses. In September 1918, the People's Commissariat of Health organized a department of child psychiatry and an institute for the defective child. Psychiatric care for war invalids was also provided. Gradually, the deployment of public health care began throughout the country, including the provision of assistance to mental patients. Medical examination of the population was carried out as the best method of identifying the disease and providing assistance to those in need. 11 General psychopathology. Historical sketch of the development of psychiatry. Development of the doctrine of mental illness in ancient times // http//formen.narod.ru/psihiatria_history

In 1924, the first neuropsychiatric dispensary was opened in Moscow. Then such dispensaries were created in other cities. Inpatient mental health care has changed significantly. Hospital bed capacity increased, paraclinical research methods and modern treatment methods were introduced. The technical and material support of psychiatric institutions and patient care have improved. A number of research institutes were organized (in Moscow, Leningrad, Kharkov, Tbilisi).

In 1927, the first All-Union Congress of Psychiatrists and Neuropathologists took place, which demonstrated the widespread development of scientific thought at all levels of the country's psychoneurological service. Reports on exogenous psychoses, epilepsy and other problems were deserved. In 1936, the Second All-Russian Congress of Psychiatrists and Neuropathologists took place, where issues of treatment of schizophrenia and traumatic damage to the nervous system were considered.

During the Great Patriotic War, the main task of organizing psychiatric services was to provide assistance to persons who had received a traumatic head injury, which often caused unconsciousness in the victims, and speech and hearing disorders (surdomutism). The leading principle of treatment and evacuation support was the principle of staged treatment with evacuation as directed. During the war, it was important to resolve the issue of the need to bring psychiatric care closer to the front and treat shell-shocked patients, as well as people with borderline conditions, in field conditions.

In recent years, a number of congresses of neurologists and psychiatrists, symposia, and conferences have been held, at which the problems of organizing psychiatric care and ways of its further development, as well as a number of clinical problems relating to vascular pathology of the nervous system, schizophrenia, borderline neuropsychiatric disorders, organic lesions of the nervous system. Scientific societies of neuropathologists and psychiatrists had a great influence on the solution of scientific and organizational problems in providing psychiatric and drug addiction care to the population.