General psychopathological syndromes. Psychopathological manifestations (symptoms, syndromes). Syndromotaxis - the order of alternation, combination and disintegration of symptom complexes and syndromes

Symptom– a description of a sign, strictly fixed in form, correlated with a specific pathology. This is a terminological designation for a pathological symptom. Not every sign is a symptom, but only one that has a cause-and-effect relationship with pathology. Psychopathological symptoms are specific to psychiatry. They are divided into productive (positive) and negative.

Productive indicate the introduction of something new into the psyche as a result of a painful process (hallucinations, delusions, catatonic disorders).

Negative include signs of reversible or permanent damage, flaw, defect due to one or another painful mental process (amnesia, abulia, apathy, etc.).

Positive and negative symptoms in the clinical picture of the disease appear in unity, combination and, as a rule, have an inversely proportional relationship: the more pronounced the negative symptoms, the fewer, poorer and more fragmented the positive ones.

The totality of all symptoms identified during the examination of a particular patient forms a symptom complex.

Syndrome– a natural combination of symptoms that are interconnected by a single pathogenesis and correlate with certain nosological forms.

Syndromes, as well as symptoms, are divided into productive and negative.

Based on severity, the following sequence of productive syndromes is distinguished:

Emotional-hyperaesthetic disorders, Affective (depressive and manic), Neurotic (obsessive, hysterical, hypochondriacal), Paranoid, verbal hallucinosis, Hallucinatory-paranoid, paraphrenic, catatonic, Stupefaction (delirium, amentia, twilight), Paramnesia, Convulsive.

Psychoorganic. Negative psychopathological syndromes are presented in the following sequence (according to the severity criterion): Exhaustion of mental activity., Subjectively perceived change in the “I”, Objectively determined change in personality, Personality disharmony, Decrease in energy potential, Decrease in personality level, Personality regression, Amnestic disorders, Total dementia, Mental insanity.

Ranks of mental disorders. In Russia, a detailed diagram of the relationship between productive and negative psychopathological syndromes is widely known. The meaning of this diagram is that each circle of a higher level includes all the underlying layers of mental disorders. This determines the low nosological specificity of lower-level syndromes (minor syndromes).

Psychoses– these are pronounced forms of mental disorders in which the patient’s mental activity is distinguished by a sharp discrepancy with the surrounding reality, the reflection of the real world is grossly distorted, which manifests itself in behavioral disorders and the manifestation in psychosis of pathological abnormalities that are not normally characteristic of it

symptoms and syndromes (disorders of perception, memory, thinking, affectivity, etc.). Psychosis does not give rise to new phenomena, but is the result of a loss of activity at higher levels.

Productive and negative symptoms.

Productive symptoms(positive symptoms, plus symptom) is a new painful phenomenon, a new function that appears as a result of the disease, which is absent in all healthy people. Examples of productive symptoms include delusions and hallucinations, epileptiform paroxysms, psychomotor

excitement, obsessions, strong feelings of melancholy with depression.

Negative symptoms(defect, minus symptom), on the contrary, refers to the damage that the disease causes to the natural healthy functions of the body, the disappearance of any ability. Examples of negative symptoms are loss of memory (amnesia), loss of intelligence (dementia), inability to experience vivid

emotional feelings (apathy). Negative symptoms are, as a rule, an irreversible, irreparable loss. It indicates the duration of the disease and the depth of mental damage. The nature of negative symptoms is quite specific and plays a significant role in the diagnosis of diseases such as schizophrenia, epilepsy, and atrophic processes.

Productive symptoms are very dynamic. It can increase sharply during exacerbation of the disease, and then disappear on its own or under the influence of adequate treatment. Most psychotropic drugs used in psychiatry are intended to treat productive symptoms. She is usually less

is specific and may be similar in several different diseases.

5. Examination methods used in psychiatry. Rules for collecting anamnestic information, their analysis. The use of paraclinical methods (laboratory, instrumental, psychological), their diagnostic capabilities.

Modern methods of examining patients should provide clinical data that is accessible to quantitative accounting and mathematical analysis using computer technology for their processing. Standard questionnaires are used with strict recording of patients' answers and taking into account the severity of mental disorders according to the answers. However, patients’ answers often do not reflect their true condition, and the psychiatrist’s assessment of the severity of mental disorders suffers from subjectivity. In addition, a standard questionnaire cannot provide everything necessary to identify and record features of mental illness.

Registration of mental disorders in the form of symptoms and syndromes is more effective. The symptomatological method, i.e., taking into account all the symptoms observed in the patient during the examination period, is still a difficult task. In addition, the patient’s condition is often assessed differently by doctors. It is more expedient to use the syndromic method in epidemiological studies, since syndromes more fully reflect the mental state of patients and carry greater prognostic information. Research using the syndromic method should be preceded by careful development of standards for examining patients, clarification of the psychopathological content of syndromes, and compilation of glossaries of standardized syndromes for certain nosological forms.

The epidemiological study of schizophrenia using syndromic characteristics has opened up great opportunities for identifying patterns of progression, probabilistic prognosis, pathogenesis, etc. The syndromic method can be considered promising for the epidemiological study of a number of other mental illnesses, including those with large diagnostic discrepancies. In many countries, analysis of statistical data on hospitalized patients is used to study morbidity. The possibilities of such analysis are limited: hospital statistics do not reflect real morbidity or morbidity, since a significant number of patients do not use hospital treatment.

Diagnostics- the process of defining and identifying a disease as accurately as possible, the result of which is a diagnosis. In the diagnosis of mental illnesses, the clinical method remains the leading one, which is divided into the following stages.

1. Identifying and qualifying symptoms.

2. Determination of their relationship and qualification of syndromes.

3. Assessment of the dynamics of development of syndromes in the context of pathogenetic patterns and premorbid characteristics.

4. Making a preliminary diagnosis.

5. Differential diagnosis.

6. Making an individual diagnosis.

7. Making a diagnosis in accordance with the classification requirements (clinical and diagnostic criteria).

Psychiatric examination- part of a general medical examination. Pursues the same goals as in any other medical specialty:

1) find out the reason for the patient (or his relatives, friends, colleagues) seeking medical help;

2) create a trusting relationship with the patient, thereby laying the foundation for interaction with him in the treatment process;

3) formulate a diagnosis and treatment plan;

4) inform the patient and his relatives about your findings.

The psychiatric examination is carried out in a calm, comfortable environment, predisposing to an open conversation. The ability to gain the patient's trust requires experience and self-confidence, but actual examination conditions are often far from ideal. It can be quite difficult to talk face to face in a noisy waiting room or general ward, even if distractions are kept to a minimum (window curtains drawn, etc.). And yet one must always show interest, sympathy, sympathy for the patient, the desire to understand him and help. Sit

should be at some (but small) distance from the patient, being able to look into his eyes. It is important to observe the non-verbal reactions and behavior of the interlocutor (paint on the face, tears). Sometimes it is necessary to write down some information (in order to then more accurately reproduce the flow of the conversation), but this must be done quickly and as rarely as possible so as not to interrupt the flow of the conversation. A convenient way is to make notes on a special form. The process of collecting information for further stages of psychiatric diagnosis is called a psychiatric interview.

Psychopathological syndromes

Relevance of the topic: One of the most important stages of diagnosis in psychiatry is the establishment of the leading psychopathological syndrome. The ability to correctly qualify symptoms of mental disorders allows for timely prescription of emergency treatment, as well as further diagnostic and therapeutic measures.

General goal: learn to identify the leading syndrome of mental disorders and provide adequate assistance to patients.

Theoretical questions:

1. Borderline non-psychotic syndromes, asthenic, neurotic (neurasthenic, obsessive-phobic, dysmorphophobic, hysterical), depressive, hypochondriacal, somatoform.

2. Psychotic syndromes: depressive, manic, paranoid, paranoid, dysmorphomanic, catatonic, hebephrenic, delirious, oneiric, amengic, asthenic confusion, twilight state of consciousness, hallucinosis.

3. Defective organic syndromes: psychoorganic, Korsakov amnestic, mental retardation, dementia, mental insanity.

4. The main psychopathological syndromes of childhood: neuropathy, childhood autism, hyperdynamic, childhood pathological fears, anorexia nervosa, infantilism.

5. The importance of diagnosing a psychopathological syndrome for choosing a method
emergency treatment and further examination of the patient.

Psychopathological syndrome is a more or less stable set of pathogenetically related symptoms. Definition of the syndrome (syndromological diagnosis) is the initial stage of the diagnostic process, which is of great practical importance.

There are different classifications of syndromes: according to the predominant damage to one or another mental function, according to the depth of damage to the personality.

Classification of psychopathological syndromes according to the predominant damage to certain mental functions

1. Syndromes with a predominance of disorders of sensations and perceptions.

Hallucinosis syndrome (verbal, tactile, visual).

Syndromes of derealization and depersonalization.

2. Syndromes with a predominance of mnestic disorders

Korsakoff's amnestic syndrome.

3. Syndromes with a predominance of thinking disorders.

Paranoid syndrome (hallucinatory-paranoid, Kandinsky-Clerambault, hypochondriacal, dysmorphomanic, etc.);

Paranoid;

Paraphrenic;

4. Syndromes with a predominance of intellectual impairment.

Infantilism syndrome;

Psychoorganic (encephalopathic) syndrome;

Oligophrenic syndrome;

Dementia syndrome.

5. Syndromes with a predominance of emotional and effector-volitional disorders.

Neurotic (asthenic and neurasthenic, hysterical, obsession syndrome);

Psychopathic-like;

Apatico-abulic;

Hebephrenic;

Catatonic.

6. Syndromes with a predominance of disturbances of consciousness.

Non-psychotic syndromes (fainting, stupor, stupor, coma)

Psychotic syndromes (delirious; oneiric; amentive; twilight state of consciousness)

Classification of psychopathological syndromes depending on the depth of personality damage.

I. Non-psychotic borderline syndromes:

1. Asthenic (astheno-neurotic, astheno-depressive, astheno-hypochondriacal, astheno-abulic).

2. Apatico-abulic.

3. Neurotic and neurosis-like (neurasthenic, obsessive-compulsive disorder, dysmorphophobic, depressive-hypochondriacal).

4. Psychopathic and psychopath-like.

II. Psychotic syndromes:

1. Syndromes of confusion:

1. asthenic confusion;

2. confusion syndrome;

3. delirious;

4. amentive;

5. oneiroid;

6. twilight state of consciousness.

2. Depressive (psychotic variant);

3. Hallucinosis syndrome (verbal, tactile, visual);

4. Manic;

5. Paranoid (including hallucinatory-paranoid, hypochondriacal, dysmorphomanic, Kandinsky-Clerambault syndrome of mental automatism);

6. Paranoid;

7. Paraphrenic;

8. Hebephrenic;

9. Catatonic.

Sh. Organic defect syndromes:

1. Psychoorganic (explosive, apathetic, euphoric, asthenic options);

2. Korsakovsky amnestic;

3. Mental retardation;

4. Dementia (total and lacunar).

Psychopathological symptom represents a single clinical sign of mental disorder. Psychopathological syndrome is a set of pathogenetically related symptoms.

Asthenic syndrome(Greek a-absence, steno - strength) manifests itself in pronounced physical And mental fatigue that occurs after minor exertion. Patients find it difficult to concentrate and therefore have trouble remembering. Emotional incontinence, lability, and increased sensitivity to sounds, light, and colors appear. The pace of thinking slows down, patients experience difficulty solving complex intellectual problems.

At astheno-neurotic states, the described phenomena of asthenia are accompanied by short temper, increased irritability, tearfulness, and moodiness.

At astheno-depressive states, the phenomena of asthenia are combined with low mood.

At astheno-hypochondriacal - asthenic symptoms are combined with increased attention to their physical health; patients attach great importance to various unpleasant sensations coming from the internal organs. They often have thoughts about the presence of some incurable disease.

At astheno-abulic syndrome, patients, starting any work, get tired so quickly that they practically cannot complete even the simplest tasks and become practically inactive.

Asthenic syndrome in various variants it occurs in all somatic, exogenous-organic, and psychogenic diseases.

Neurotic syndrome- a symptom complex that includes phenomena of instability of the emotional, volitional and effector spheres with increased mental and physical exhaustion, with a critical attitude towards one’s condition and behavior

Depending on the personality characteristics, neurotic syndrome can be neurasthenic, hysterical and psychasthenic in nature.

Neurasthenic syndrome(irritable weakness syndrome) is characterized, on the one hand, by increased excitability, incontinence of affect, a tendency to violent affective reactions with volitional instability, on the other hand by increased exhaustion, tearfulness, and lack of will.

Hysterical syndrome- characterized by increased emotional excitability, theatrical behavior, a tendency to fantasize and deceit, to violent affective reactions, hysterical attacks, functional paralysis and paresis, etc.

Obsessive syndrome (obsessive syndrome)- manifested by obsessive thoughts, phobias, obsessive desires and actions. Obsession phenomena usually arise suddenly and do not correspond to the content of the patient’s thoughts at the moment; the patient is critical of them and struggles with them.

Obsession syndrome occurs in neuroses, somatic, exogenous-organic diseases of the brain.

Body dysmorphic syndrome- patients overestimate the importance of their physical disabilities, actively seek help from specialists, and demand cosmetic surgery. Most often it occurs during puberty due to a psychogenic mechanism. For example, if teenagers are convinced that they are overweight, they severely limit themselves in food (mental anorskia).

Depressive-hypochondriacal syndrome- characterized by the appearance of thoughts in the patient O the presence of any serious, even incurable, disease, which is accompanied by a melancholy mood. Such patients persistently seek help from doctors, require various examinations, and prescription of drug therapy.

Psychopathic-like syndrome- a symptom complex of emotional and effector-volitional disorders that are more or less persistent in nature and determine the main type of neuropsychic response and behavior, usually not adequately adequate to the real situation. Includes increased emotional excitability, inadequacy of voluntary actions and actions, increased subordination to instinctive drives.

Depending on the characteristics of the type of higher nervous activity and the conditions of upbringing, it can have an asthenic, hysterical, psychasthenic, excitable, paranoid or schizoid character. It is the basis of various forms of psychopathy and psychopathic states of organic and other origin. Often accompanied by sexual and other perversions.

Delirious syndrome(from Latin delirium - madness) - hallucinatory clouding of consciousness with a predominance of true visual hallucinations, visual illusions, figurative delirium, motor excitation while maintaining self-awareness.

Amentive syndrome- severe confusion of consciousness with incoherent thinking, complete inaccessibility to contact, disorientation, abrupt deceptions of perception and signs of severe physical exhaustion.

Oneiric clouding of consciousness. Distinguished by the extreme fantastic nature of psychotic experiences. Characterized by duality, inconsistency of experiences and actions taken, a feeling of global changes in the world, catastrophe and triumph at the same time.

Depressive syndrome characterized depressive triad: depressed, sad, melancholy mood, slow thinking and motor retardation.

Manic syndrome - x characteristic manic triad: euphoria (inappropriately elevated mood), acceleration of associative processes and motor excitation with a desire for activity.

Hallucinatory syndrome (hallucinosis) - an influx of abundant hallucinations (verbal, visual, tactile) against the background of clear consciousness, lasting from 1-2 weeks (acute hallucinosis) to several years (chronic hallucinosis). Hallucinosis may be accompanied by affective disorders (anxiety, fear), as well as delusional ideas. Hallucinosis is observed in alcoholism, schizophrenia, epilepsy, organic brain lesions, including syphilitic etiology.

Paranoid syndrome- characterized by the presence of unsystematized delusional ideas of various contents in combination with hallucinations and pseudohalucinations. Kandinsky-Clerambault syndrome is a type of paranoid syndrome and is characterized by the phenomena mental automatism, i.e. feelings that someone is directing the patient’s thoughts and actions, the presence pseudohallucinations, most often auditory, delusional ideas influence, mentalism, symptoms of openness of thoughts (the feeling that the patient’s thoughts are accessible to other people) and nesting of thoughts(the feeling that the patient’s thoughts are alien, transmitted to him).

Paranoid syndrome characterized by the presence of a systematic delirium, in the absence of disturbances of perception and mental automatisms. Delusional ideas are based on real facts, but the ability of patients to explain logical connections between the phenomena of reality suffers; facts are selected one-sidedly, in accordance with the plot of the delusion.

Paraphrenic syndrome - combination of systematized or unsystematized delirium with mental automatisms, verbal hallucinations, confabulatory experiences of fantastic content, and a tendency to increase mood.

Body dysmorphomania syndrome characterized by a triad of symptoms: delusional ideas of physical disability, delusional attitude, low mood. Patients actively strive to correct their shortcomings. When they are denied surgery, they sometimes try to change the shape of their ugly body parts. It is observed in schizophrenia.

Catatonic syndrome- manifests itself in the form of catatonic, absurd and senseless excitement or stupor, or periodic changes in these states. It is observed in schizophrenia, infectious and other psychoses.

Hebephrenic syndrome- a combination of hebephrenic excitement with foolishness and fragmented thinking. It is observed mainly in schizophrenia.

Apathetic-abulic syndrome- a combination of indifference, indifference (apathy) and absence or weakening of incentives to activity (abulia). It is observed in debilitating somatic diseases, after traumatic brain injuries, intoxication, and schizophrenia.

Psychoorganic syndrome- characterized by mild intellectual impairments. Patients' attention and fixation memory decrease; they have difficulty remembering events about their lives and well-known historical events. The pace of thinking slows down. Patients experience difficulties in acquiring new knowledge and skills. There is either a leveling of personality or a sharpening of character traits. Depending on which emotional reactions predominate, there are explosive version - patients exhibit explosiveness, rudeness, and aggressiveness; euphoric version (inappropriate cheerfulness, carelessness), apathetic option (indifference). Partial reversibility is possible, more often there is a gradual worsening and development of dementia syndrome. Characteristic of exogenous organic brain lesions.

Korsakov's amnestic syndrome-includes memory impairment for current events (fixational amnesia), retro- and anterograde amnesia, pseudoreminiscences, confabulations, and amnestic disorientation.

Dementia - persistent decline in intelligence level. There are two types of dementia - congenital (oligophrenia) and acquired (dementia).

Acquired dementia is caused by schizophrenia, epilepsy, as well as organic diseases in which atrophic processes occur in the brain (syphilitic and senile psychoses, vascular or inflammatory diseases of the brain, severe traumatic brain injury).

Confusion syndrome characterized by a misunderstanding of what is happening, a lack of understanding of the questions asked, and not always adequate answers. The expression on the patients' faces is confused and perplexed. They often ask questions: “what is this?”, “why?”, “why?”. Occurs when recovering from a coma, as well as during paranoid syndrome.

Frontal syndrome- a combination of signs of total dementia with spontaneity, or vice versa - with general disinhibition. It is observed in organic diseases of the brain with predominant damage to the frontal parts of the brain - tumors, head injury, Pick's disease.

Main psychopathological syndromes

A syndrome is a complex of symptoms. Psychopathological syndrome is a complex, more or less typical set of internally (pathogenetically) interconnected psychopathological symptoms, in the particular clinical manifestations of which the volume and depth of damage to mental functions, the severity and massiveness of the effect of pathogenic harmfulness on the brain are expressed.

Psychopathological syndromes are the clinical expression of various types of mental pathology, which include mental illnesses of the psychotic (psychosis) and non-psychotic (neuroses, borderline) types, short-term reactions and persistent psychopathological conditions.

6.1. Positive psychopathological syndromes

There is currently practically no single view on the concept of positive, and therefore negative, syndromes. Syndromes that are qualitatively new, absent normally, are considered positive syndromes (they are also called pathological positive, “plus” disorders, phenomena of “irritation”), indicating the progression of a mental illness, qualitatively changing the mental activity and behavior of the patient.

6.1.1. Asthenic syndromes. Asthenic syndrome - a state of neuropsychic weakness - is the most common in psychiatry, neurology and general medicine and at the same time a simple syndrome of predominantly quantitative mental disorders. The leading manifestation is mental asthenia itself. There are two main variants of asthenic syndrome - emotional-hyperesthetic weakness (hypersthenic and hyposthenic).

With emotional-hyperesthetic weakness, short-term emotional reactions of dissatisfaction, irritability, anger on minor occasions (the “match” symptom), emotional lability, weakness arise easily and quickly; patients are capricious, gloomy, dissatisfied. Drives are also labile: appetite, thirst, food cravings, decreased libido and potency. Characterized by hyperesthesia to loud sounds, bright light, touch, smells, etc., intolerance and poor tolerance of anticipation. Replaced by exhaustion of voluntary attention and its concentration, distractibility and absent-mindedness increase, concentration becomes difficult, a decrease in the volume of memorization and active recollection appears, which is combined with difficulties in thinking, speed and originality in solving logical and professional problems. All this complicates neuropsychic performance, fatigue, lethargy, passivity, and a desire for rest appear.

Typically there is an abundance of somato-vegetative disorders: headaches, hyperhidrosis, acrocyanosis, lability of the cardiovascular system, sleep disturbances, predominantly shallow sleep with an abundance of everyday dreams, frequent awakenings up to persistent insomnia. There is often a dependence of somato-vegetative manifestations on meteorological factors and fatigue.

In the hyposthenic variant, physical asthenia, lethargy, fatigue, weakness, fatigue, pessimistic mood with decreased performance, increased drowsiness with lack of satisfaction from sleep and a feeling of weakness and heaviness in the head in the morning come to the fore.

Asthenic syndrome occurs in somatic (infectious and non-infectious) diseases, intoxications, organic and endogenous mental illnesses, and neuroses. It constitutes the essence of neurasthenia (asthenic neurosis), going through three stages: hypersthenic, irritable weakness, hyposthenic.

6.1.2. Affective syndromes. The syndromes of affective disorders are very diverse. The modern classification of affective syndromes is based on three parameters: the affective pole itself (depressive, manic, mixed), the structure of the syndrome (harmonious - disharmonious; typical - atypical) and the degree of severity of the syndrome (non-psychotic, psychotic).

Typical (harmonious) syndromes include a uniformly depressive or manic triad of obligatory symptoms: pathology of emotions (depression, mania), changes in the course of the associative process (slowdown, acceleration) and motor-volitional disorders / inhibition (substupor) - disinhibition (excitement), hypobulia-hyperbulia /. The main (core) among them are emotional. Additional symptoms are: low or high self-esteem, disturbances of self-awareness, obsessive, overvalued or delusional ideas, suppression or increased desires, suicidal thoughts and actions during depression. In the most classic form, endogenous affective psychoses occur and, as a sign of endogeneity, include the somato-vegetative symptom complex of V.P. Protopopov (arterial hypertension, tachycardia, constipation, miosis, hyperglycemia, menstrual irregularities, changes in body weight), daily fluctuations in affect (improved well-being during afternoon), seasonality, periodicity and autochthony.

Atypical affective syndromes are characterized by a predominance of optional symptoms (anxiety, fear, senestopathies, phobias, obsessions, derealization, depersonalization, non-holothymic delusions, hallucinations, catatonic symptoms) over the main affective syndromes. Mixed affective syndromes include those disorders that seem to be introduced from the opposite triad (for example, motor agitation during the affect of melancholy - depressive agitation).

There are also subaffective disorders (subdepression, hypomania; they are also non-psychotic), classical affective and complex affective disorders (affective-delusional: depressive-paranoid, depressive-hallucinatory-paranoid, depressive-paraphrenic or manic-paranoid. manic-hallucinatory-paranoid , matsnakal-paraphrenic).

6.1.2.1. Depressive syndromes. The classic depressive syndrome includes the depressive triad: severe melancholy, depressed gloomy mood with a touch of vitality; intellectual or motor retardation. Hopeless melancholy is often experienced as mental pain, accompanied by painful feelings of emptiness, heaviness in the heart, mediastinum or epigastric region. Additional symptoms - a pessimistic assessment of the present, past and future, reaching the level of holothym overvalued or delusional ideas of guilt, self-humiliation, self-blame, sinfulness, low self-esteem, disturbances in self-awareness of activity, vitality, simplicity, identity, suicidal thoughts and actions, sleep disorders in the form of insomnia, sleep agnosia, shallow sleep with frequent awakenings.

Subdepressive (non-psychotic) syndrome is represented by not clearly expressed melancholy with a tinge of sadness, boredom, depression, pessimism. Other main components include hypobulia in the form of lethargy, fatigue, tiredness and decreased productivity and slowing of the associative process in the form of difficulty finding words, decreased mental activity, and memory impairment. Additional symptoms include obsessive doubts, low self-esteem, and disturbances in self-awareness and activity.

Classic depressive syndrome is characteristic of endogenous depressions (manic-depressive psychosis, schizophrenia); subdepression in reactive psychoses, neuroses.

Atypical depressive syndromes include subdepressive ones. relatively simple and complex depression.

The most common subdepressive syndromes are:

Astheno-subdepressive syndrome - low mood, spleen, sadness, boredom, combined with a feeling of loss of vitality and activity. Symptoms of physical and mental fatigue, exhaustion, weakness combined with emotional lability, and mental hyperesthesia predominate.

Adynamic subdepression includes low mood with a hint of indifference, physical inactivity, lethargy, lack of desire, and a feeling of physical impotence.

Anesthetic subdepression is a low mood with a change in affective resonance, the disappearance of feelings of closeness, sympathy, antipathy, empathy, etc. with a decrease in motivation for activity and a pessimistic assessment of the present and future.

Masked (manifested, hidden, somatized) depression (MD) is a group of atypical subdepressive syndromes in which facultative symptoms (senestopathies, algia, paresthesia, intrusiveness, vegetative-visneral, drug addiction, sexual disorders) come to the fore, and the actual affective (subdepressive manifestations) erased, inexpressive, appear in the background.The structure and severity of optional symptoms determine various variants of MD (Desyatnikov V.F., Nosachev G.N., Kukoleva I.I., Pavlova I.I., 1976).

The following variants of MD have been identified: 1) algic-senestopathic (cardialgic, cephalgic, abdominal, arthralgic, panalgic); agrypnic, vegetative-visceral, obsessive-phobic, psychopathic, drug addict, variants of MD with sexual disorders.

Algic-senestopathic variants of MD. Optional symptoms are represented by a variety of senestopathies, paresthesias, algias in the heart area (cardialgic), in the head area (cephalgic), in the epigastric area (abdominal), in the joint area (arthralgic), and various “walking” symptoms (panalgic). They constituted the main content of the patients’ complaints and experiences, and subdepressive manifestations were assessed as secondary, insignificant.

The agripnic variant of MD is represented by pronounced sleep disturbances: difficulty falling asleep, shallow sleep, early awakening, lack of a feeling of rest from sleep, etc., while experiencing weakness, decreased mood, and lethargy.

The vegetative-visceral variant of MD includes painful, diverse manifestations of vegetative-visceral disorders: pulse lability, increased blood pressure, dipnea, tachypnea, hyperhidrosis, feeling of chills or heat, low-grade fever, dysuric disorders, false urge to defecate, flatulence, etc. By structure and in character they resemble diencephalic or hypothalamic paroxysms, episodes of bronchial asthma or vasomotor allergic disorders.

The psychopathic-like variant is represented by behavioral disorders, most often in adolescence and adolescence: periods of laziness, spleen, leaving home, periods of disobedience, etc.

The drug-addicted variant of MD is manifested by episodes of alcohol or drug intoxication with subdepression without a clear connection with external causes and reasons and without signs of alcoholism or drug addiction.

A variant of MD with disorders in the sexual sphere (periodic and seasonal impotence or frigidity) against the background of subdepression.

Diagnosis of MD presents significant difficulties, since complaints are represented only by optional symptoms, and only a special questioning allows one to identify the leading and obligatory symptoms, but they are often assessed as secondary personal reactions to the disease. But all variants of MD are characterized by the obligatory presence in the clinical picture, in addition to somato-vegetative manifestations, senestopathies, paresthesias, and algia, of affective disorders in the form of subdepression; signs of endogeneity (daily hypothmic disorders of both leading and obligatory symptoms and (optional; periodicity, seasonality, autochthony of occurrence, recurrence of MD, distinct somato-vegetative components of depression), lack of effect from somatic therapy and success of treatment with antidepressants.

Subdepressive disorders occur in neuroses, cyclothymia, cyclophrenia, schizophrenia, involutional and reactive depression, and organic diseases of the brain.

Simple depressions include:

Adynamic depression is a combination of melancholy with weakness, lethargy, powerlessness, lack of motivation and desires.

Anesthetic depression is the predominance of mental anesthesia, painful insensibility with painful experience.

Tearful depression is a depressed mood with tearfulness, weakness and asthenia.

Anxious depression, in which, against a background of melancholy, anxiety with obsessive doubts, fears, and ideas about relationships predominate.

Complex depression is a combination of depression with symptoms of other psychopathological syndromes.

Depression with delusions of enormity (Cotard's syndrome) is a combination of melancholy depression with nihilistic delirium of megalomaniac fantastic content and delirium of self-blame, guilt in serious crimes, expectation of terrible punishment and cruel executions.

Depression with delusions of persecution and poisoning (depressive-paranoid syndrome) is characterized by a picture of sad or anxious depression combined with delusions of persecution and poisoning.

Depressive-paranoid mentaldromas, in addition to those described above, include depressive-hallucinatory-paranoid, depressive-paraphrenic. In the first case, in combination with melancholy, less often anxious depression, there are verbal true or pseudo-hallucinations of accusing, condemning and slanderous content. phenomena of mental automatism, delusions of persecution and influence. Depressive-paraphrenic, in addition to the listed symptoms, includes megalomanic delusional ideas of nihilistic, cosmic and apoplectic content, up to depressive oneiroid.

Characteristic of affective psychoses, schizophrenia, psychogenic disorders, organic and infectious mental diseases.

6.1.2.2. Manic syndromes. Classic manic syndrome includes severe mania with a feeling of immense happiness, joy, delight, ecstasy (obligatory symptoms are manic hyperbulia with many plans, their extreme instability, significant distractibility, which is caused by impaired productivity of thinking, acceleration of its pace, “jumping” ideas, inconsistency logical operations, and increased motor activity, they take on a lot of things without bringing any of them to the end, they are verbose, they talk incessantly. Additional symptoms are an overestimation of the qualities of their personality, reaching unstable holotymic ideas of greatness, disinhibition and increased drives.

Hypomanic (non-psychotic) syndrome includes a confidently expressed increase in mood with a predominant feeling of the joy of being, fun, and cheerfulness; with a subjective feeling of creative enthusiasm and increased productivity, some acceleration of the pace of thinking, with fairly productive activity, although with elements of distraction, behavior is not seriously affected,

Atypical manic syndromes. Unproductive mania involves elevated mood, but is not accompanied by a desire for activity, although it may be accompanied by a slight acceleration of the associative process.

Angry mania is characterized by increased mood with incontinence, irritability, pickiness with the transition to anger; inconsistency of thinking and activity.

Complex mania is a combination of mania with other non-affective syndromes, mainly delusional ones. The structure of the manic syndrome is joined by delusions of persecution, relationships, poisoning (manic-paranoid), verbal true and pseudohallucinations, phenomena of mental automatism with delusions of influence (manic-hallucinatory-paranoid), fantastic delusions and delusions of grandeur (manic-paraphrenic) up to oneiroid.

Manic syndromes are observed in cyclophrenia, schizophrenia, epilepsy, symptomatic, intoxication and organic psychoses.

6.1.2.3. Mixed affective syndromes. Agitated depression is characterized by an anxious affect combined with fussy anxiety and delusional ideas of condemnation and self-blame. Fussy anxiety can be replaced by motor agitation up to depressive raptus with increased suicidal danger.

Dysphoric depression, when a feeling of melancholy and displeasure is replaced by irritability, grumbling, spreading to everything around and to one’s well-being, outbursts of rage, aggression against others and self-aggression.

Manic stupor occurs at the height of manic excitement or a change from a depressive phase to a manic phase, when increasing mania is accompanied (or replaced) by persistent motor and intellectual retardation.

Occurs in endogenous psychoses, infectious, somatogenic, intoxicating and organic mental diseases.

6.1.3. Neurotic syndromes. It is necessary to distinguish between neurotic syndromes themselves and the neurotic level of disorders. The neurotic level of the disorder (borderline neuropsychiatric disorders), according to most domestic psychiatrists, also includes asthenic syndromes and non-psychotic affective disorders (subdepression, hypomania).

The actual neurotic syndromes include obsessive (obsessive-phobic, obsessive-compulsive syndrome), senestopathic and hypochondriacal, hysterical syndromes, as well as depersonalization-derealization syndromes, syndromes of overvalued ideas.

6.1.3.1. Obsessive-compulsive syndromes. The most common types are obsessive and phobic syndromes.

6.1.3.1.1. Obsessive syndrome includes as the main symptoms obsessive doubts, memories, ideas, an obsessive feeling of antipathy (blasphemous and blasphemous thoughts), “mental chewing gum,” obsessive desires and associated motor rituals. Additional symptoms include emotional stress, a state of mental discomfort, powerlessness and helplessness in the fight against obsessions. In their “pure” form, affectively neutral obsessions are rare and are represented by obsessive philosophizing, counting, obsessive remembering of forgotten terms, formulas, phone numbers, etc.

Obsessive syndrome (without phobias) occurs in psychopathy, low-grade schizophrenia, and organic diseases of the brain.

6.1.3.1.2. Phobic syndrome represented predominantly by a variety of obsessive fears. The most unusual and senseless fears may arise, but most often at the beginning of the disease there is a distinct monophobia, which gradually grows “like a snowball” with more and more new phobias. For example, cardiophobia is joined by agoraphobia, claustophobia, thanatophobia, phobophobia, etc. Social phobias can be isolated for quite a long time.

The most common and diverse nosophobias are: cardiophobia, cancerophobia, AIDS phobia, alienophobia, etc. Phobias are accompanied by numerous somato-vegetative disorders: tachycardia, increased blood pressure, hyperhidrosis, persistent red dermographism, peristalsis and antiperistalsis, diarrhea, vomiting, etc. They join very quickly motor rituals, in some cases turning into additional obsessive actions performed against the desire and will of the patient, and abstract obsessions become rituals.

Phobic syndrome occurs in all forms of neuroses, schizophrenia, and organic diseases of the brain.

6.1.3.2. Senestopathic-hypochondriacal syndromes. They include a number of options: from “pure” senestopathic and hypochondriacal syndromes to senestopathosis. For the neurotic level of the syndrome, the hypochondriacal component can only be represented by overvalued ideas or obsessions.

At the initial stage of development of the syndrome, numerous senestopathies occur in various parts of the body, accompanied by dull depressiveness, anxiety, and mild restlessness. Gradually, a monothematic overvalued idea of hypochondriacal content emerges and is formed on the basis of senestolations. Based on unpleasant, painful, extremely painful sensations and existing experience of communication, diagnosis and treatment, health workers develop judgment: using senestopathies and real circumstances to explain and form a pathological “concept of illness”, which occupies a significant place in the patient’s experiences and behavior and disorganizes mental activity .

The place of overvalued ideas can be taken by obsessive doubts, fears regarding senesthopathy, with the rapid addition of obsessive fears and rituals.

They are found in various forms of neuroses, sluggish schizophrenia, and organic diseases of the brain. With hypochondriacal personality development, sluggish schizophrenia, senestopathic disorders with hypochondriacal overvalued ideas are gradually transformed into paranoid (delusional) syndrome.

Senestopathosis is the simplest syndrome, represented by monotonous senestopathies, accompanied by autonomic disorders and hypochondriacal fixation of attention on senestopathies. Occurs with organic lesions of the thalamo-hypothalamic region of the brain.

6.1.3.3. Depersonalization-derealization syndromes. The most poorly defined in general psychopathology. Symptoms and partly syndromes of impaired self-awareness are described in Chapter 4.7.2. Usually the following variants of depersonalization are distinguished: allopsychic, autopsychic, somatopsychic, bodily, anesthetic, delusional. The last two cannot be attributed to the neurotic level of disorders.

6.1.3.3.1. Depersonalization syndrome at the neurotic level includes violations of self-awareness of activity, unity and constancy of the “I”, slight blurring of the boundaries of existence (allopsychic depersonalization). In the future, the blurring of the boundaries of self-awareness, the impenetrability of the “I” (autopsychic depersonalization) and vitality (somatopsychic depersonalization) becomes more complicated. But there are never any gross changes in the boundaries of self-awareness, alienation of the “I” and stability of the “I” in time and space. It is found in the structure of neuroses, personality disorders, neurosopod schizophrenia, cyclothymia, and residual organic diseases of the brain.

6.1.3.3.2. Derealization syndrome includes as a leading symptom a distorted perception of the surrounding world, the surrounding environment is perceived by patients as “ghostly,” unclear, indistinct, “like in a fog,” colorless, frozen, lifeless, decorative, unreal. Individual metamorphopsia may also be observed (impaired perception of individual parameters of objects - shape, size, color, quantity, relative position, etc.).

Usually accompanied by various symptoms of impaired self-awareness, subdepression, confusion, and fear. Most often occurs in organic diseases of the brain, as part of epileptic paroxysms, and intoxication.

Derealization also includes: “already experienced,” “already seen,” “never seen,” “never heard.” They are found mainly in epilepsy, residual organic diseases of the brain, and some intoxications.

6.1.3.4. Hysterical syndromes. A group of functional polymorphic and extremely variable symptoms and syndromes of mental, motor, sensitivity, speech and somatovegetative disorders. Hysterical disorders also include a psychotic level of disorders: affective (hysterical) twilight states of consciousness, ambulatory automatisms (trances, Ganser syndrome, pseudodementia, puerilism (see section 5.1.6.3.1.1.).

Common to hysterical symptoms are egocentrism, a clear connection with the traumatic situation and the degree of its personal significance, demonstrativeness, external deliberateness, great suggestibility and self-hypnosis of patients (“a great simulator” of other diseases and syndromes), the ability to derive external or “internal” benefit from their painful states that are poorly understood or not even recognized by the patient (“flight into illness,” “desirability or conditional pleasantness” of manifestations of the disease).

Mental disorders: severe asthenia with physical and mental fatigue, phobias, subdepression, amnesia, hypochondriacal experiences, pathological deceit and fantasies, emotional lability, weakness, sensitivity, impressionability, demonstrativeness, suicidal statements and demonstrative preparations for suicide.

Motor disorders: classic grand mal hysterical attack (“motor storm”, “hysterical arc”, clowning, etc.), hysterical paresis and paralysis, both spastic and flaccid; paralysis of the vocal cords (aphonia), stupor, contractures (trismus, torticollis-torticollis, strabismus, joint contractures, flexion of the body at an angle - captocormia); hyperkinesis, professional dyskinesia, astasia-abasia, hysterical lump in the throat, swallowing disorders, etc.

Sensory disorders: various paresthesias, decreased sensitivity and anesthesia of the “gloves”, “stockings”, “panties”, “jackets” type, etc.; painful sensations (pains), loss of function of the sensory organs - amaurosis (blindness), hemianopsia, scotomas, deafness, loss of smell and taste.

Speech disorders: stuttering, dysarthria, aphonia, mutism (sometimes surdomutism), aphasia.

Somato-vegetative disorders occupy the largest place in hysterical disorders and are the most diverse. Among them are spasms of smooth muscles in the form of lack of air, which sometimes simulates asthma, dysphagia (disorders of the passage of the esophagus), paresis of the gastrointestinal tract, simulating intestinal obstruction, constipation, and urinary retention. Vomiting, hiccups, regurgitation, nausea, anorexia, and flatulence occur. Disorders of the cardiovascular system are common: pulse lability, blood pressure fluctuations, hyperemia or pallor of the skin, acrocyanosis, dizziness, fainting, pain in the heart area simulating heart disease.

Occasionally, vicarious bleeding (from intact areas of the skin, uterine and throat bleeding), sexual dysfunction, and false pregnancy occur. As a rule, hysterical disorders are caused by psychogenic diseases, but they also occur in schizophrenia and organic diseases of the brain.

6.1.3.5. Anorectic syndrome (anorexia nervosa syndrome) It is characterized by progressive self-limitation in food, selective consumption of food by the patient in combination with incomprehensible arguments about the need to “lose weight”, “get rid of fat”, “correct the figure”. Less common is the bulimic variant of the syndrome, when patients consume a lot of food and then induce vomiting. Often combined with body dysmorphomania syndrome. Occurs in neurotic conditions, schizophrenia, endocrine diseases.

Close to this group of syndromes are psychopathic syndromes, which can include both positive and negative symptoms (see section 5.2.4.).

6.1.3.6. Heboid syndrome. The core disorders in this syndrome are considered to be disturbances of drives in the form of painful intensification and especially their perversion. There is an exaggeration and distortion of affective and personal characteristics characteristic of adolescence, exaggerated oppositional tendencies, negativism, aggressive manifestations appear, there is a loss, or weakening, or slowdown in the development of higher moral principles (the concepts of good and evil, permitted and unlawful, etc.), sexual perversions, tendencies towards vagrancy, and the use of alcohol and drugs are observed. Occurs in psychopathy and schizophrenia.

Characteristics of the main apathetic disorders: apathy, asthenia, autism, affective and delusional disorders. Pathology of desire, its clinical manifestations. Hallucinatory syndromes. Manifestations of depression, sleep disorders. Manic state.

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Psychopathological manifestations (symptoms, syndromes)

Apathy(indifference). At the initial stages of the development of apathetic disorders, there is a slight weakening of hobbies, desires and aspirations. In case of psycho-affective indifference, during questioning the patient expresses relevant complaints. With a shallow emotional decline, for example in schizophrenia, the patient calmly reacts to events of an exciting, unpleasant nature, although in general the patient is not indifferent to external events.

In a number of cases, the patient’s facial expressions are impoverished, he is not interested in events that do not concern him personally, and almost does not participate in entertainment. Some patients are not even affected by their own situation and family affairs. Sometimes there are complaints about “stupidity”, “indifference”. The extreme degree of apathy is characterized by complete indifference to everything. The patient's facial expression is indifferent, indifference is noted, including to his appearance and cleanliness of his body, to his stay in the hospital, to the appearance of relatives.

Asthenia(increased fatigue). In minor cases, fatigue occurs with increased exertion, usually in the afternoon.

In more pronounced cases, even with relatively uncomplicated activities, there is a feeling of fatigue, weakness, an objective deterioration in the quality and pace of work, rest helps little. Asthenia is noticeable at the end of a conversation with a doctor (for example, the patient talks sluggishly, tries to quickly lie down or lean on something). Among vegetative disorders, excessive sweating and pallor of the face predominate. Extreme degrees of asthenia are characterized by severe weakness. Any activity, movement, short-term conversation is tiring. Rest doesn't help.

Autism(“absorption” in oneself). The patient exists in his “inner world”; the words of those around him and the events happening around him do not seem to reach him or take on a special, symbolic meaning.

Affective disorders characterized by instability (lability) of mood, a change in affect towards depression (depression - see below) or elevation (manic state - see below). At the same time, the level of intellectual and motor activity changes, and various somatic equivalents of the condition are observed.

Affective lability(increased emotional reactivity). With unexpressed disorders, the range of situations and reasons in connection with which affect arises or mood changes are somewhat expanded compared to the individual norm, but these are still quite intense emotional factors (for example, actual failures). Typically, affect (anger, despair, resentment) occurs rarely and its intensity largely corresponds to the situation that caused it.

With more severe affective disorders, mood often changes for minor and varied reasons. The intensity of the disorders does not correspond to the real significance of psychogenicity. In this case, affects can become significant, arise for completely insignificant reasons or without a perceptible external reason, change several times within a short time, which makes goal-directed activity extremely difficult.

Delusional disorders. Delusion is a false, but not amenable to logical correction, belief or judgment that does not correspond to reality, as well as to the social and cultural attitudes of the patient. Delusions must be differentiated from delusional ideas that characterize erroneous judgments expressed with excessive persistence. Delusional disorders are characteristic of many mental illnesses; as a rule, they are combined with other mental disorders, forming complex psychopathological syndromes. Depending on the plot, they distinguish delusions of relationship and persecution(the patient's pathological belief that he is a victim of persecution), greatness(belief in a high, divine purpose and special self-importance), changes in your own body(belief in physical, often bizarre changes in body parts), the appearance of a serious illness(hypochondriacal delusion, in which, on the basis of real somatic sensations or without them, concern develops, and then a belief in the development of a particular disease in the absence of its obvious signs), jealousy(usually a painful conviction of a spouse’s infidelity is formed on the basis of a complex emotional state). There are also primary delusions, the content of which and the patient’s actions arising from it cannot be associated with the history of his life and personality characteristics, and secondary delusion, conditionally “arising” from other mental disorders (for example, from hallucinations, affective disorders, etc.). From the point of view of dynamics, relative specificity of signs of mental illness and prognosis, three main types of delusions are distinguished - paranoid, paranoid and paraphrenic.

At paranoid delusions the content of pathological experiences follows from ordinary life situations; it is, as a rule, logically constructed, reasoned and not of an absurd or fantastic nature. Typical delirium of reformation and invention, jealousy, etc. In some cases, there is a tendency towards a constant expansion of delusional constructions, when new real life circumstances seem to be “strung” onto the pathological “core” of a painful idea. This helps to systematize delirium.

Paranoid delusions less logical. More often, ideas of persecution and influence are characteristic, often combined with pseudohallucinations and phenomena of mental automatism.

Paraphrenic delirium usually fantastic and completely absurd. More often it is delusions of grandeur. Patients consider themselves the owners of enormous wealth, the creators of civilization. They are usually in high spirits and often have false memories (confabulation).

Attractions (disorders). The pathology of desire reflects a weakening as a result of various reasons (hypothalamic disorders, organic disorders of the central nervous system, states of intoxication, etc.) of volitional, motivated mental activity. The consequence of this is a “deep sensory need” for the realization of impulses and the strengthening of various drives. Clinical manifestations of desire disorders include bulimia(sharp increase in food instinct), dromomania(desire to wander) pyromania(desire for arson), kleptomania(the desire to steal), hypersexuality, various variants of perversion of sexual desire, etc. Pathological attraction can have the nature of obsessions, be determined by mental and physical discomfort (dependence), and also arise acutely, as impulsive reactions. Unlike other options, in the latter case there is often a complete lack of critical assessment of the situation in which the patient is trying to implement an action determined by pathological attraction.

Violation of drives can be observed in various mental disorders; their differential diagnostic assessment is based, as in other cases, taking into account the entire complex of painful manifestations and the personality-typological characteristics of the patient.

Hallucinatory syndromes. Hallucinations are a truly felt sensory perception that occurs in the absence of an external object or stimulus, displaces actual stimuli and occurs without phenomena of impaired consciousness. Distinguish auditory, visual, olfactory, tactile(the feeling of insects crawling under the skin) and other hallucinations are not specific psychopathological manifestations of endogenous or other mental illnesses. A special place belongs to verbal hallucinations, which can be commentary or imperative, manifesting themselves in the form of a monologue or dialogue. Hallucinations can appear in healthy people while half asleep (hypnagogic hallucinations). They are observed in schizophrenia, epilepsy, intoxication, organic and other psychoses, and can be both acute and chronic. As a rule, hallucinations are combined with other mental disorders; most often various variants of hallucinatory-paranoid syndrome are formed.

Delirium-- a nonspecific syndrome characterized by a combined disorder of consciousness, perception, thinking, memory, sleep-wake rhythm, and motor agitation. The delirious state is transient and fluctuating in intensity. It is observed against the background of various intoxicating effects caused by alcohol, psychoactive substances, as well as liver diseases, infectious diseases, bacterial endocarditis and other somatic disorders.

Dementia-- a condition caused by a disease, usually of a chronic or progressive nature, in which there is a decrease in cognitive and intellectual activity, memory, thinking, orientation, understanding of what is happening are impaired, and control over impulses and emotions is lost. At the same time, consciousness is not formally changed; disturbances in behavior, motivation, and emotional response are observed. Characteristic of Alzheimer's disease, cerebrovascular and other diseases that primarily or secondary affect the brain.

Depression. With minor depressive disorders, the patient sometimes develops a noticeably sad expression on his face, sad intonations in conversation, but at the same time his facial expressions are quite varied, his speech is modulated, and the patient can be distracted and cheered up. There are complaints of “feeling sad” or “lack of cheerfulness” and “boredom.” Most often, they realize the connection between their condition and traumatic influences. Pessimistic experiences are usually limited to a conflict situation. There is some overestimation of real difficulties, but the patient hopes for a favorable resolution of the situation. The critical attitude and desire to fight the “painful shock” are preserved. With a decrease in psycho-traumatic influences, the mood normalizes.

As depressive symptoms worsen, facial expressions become more monotonous: not only the face, but also the posture expresses despondency (shoulders are often slumped, the gaze is directed into space or down). There may be sad sighs, tearfulness, a pitiful, guilty smile. The patient complains of a depressed, “decadent” mood, lethargy, and unpleasant sensations in the body. He considers his situation gloomy and does not notice anything positive in it. It is almost impossible to distract and cheer up the patient.

With severe depression on the patient’s face there is a “mask of grief”, the face is elongated, grayish-cyanotic in color, the lips and tongue are dry, the gaze is suffering, expressive, there are usually no tears, blinking is rare, sometimes the eyes are half-closed, the corners of the mouth are downturned, the lips are often compressed. Speech is not modulated to the point of an unintelligible whisper or silent lip movements. Hunched posture with head down, knees together. Raptoid states are also possible: the patient groans, sobs, rushes about, tends to self-harm, and breaks his arms. The predominant complaints are “unbearable melancholy” or “despair.” He considers his situation hopeless, hopeless, hopeless, his existence unbearable.

A special type of depression is the so-called hidden (masked, larved, somatized depression). With its development in patients, mainly observed in general somatic institutions, against the background of a slight change in affect, various somatovegetative (viscerovegetative) disorders develop, imitating various diseases of organs and systems. At the same time, depressive disorders themselves fade into the background, and the patients themselves, in most cases, object to assessing their condition as “depression.” Somatic examination in these cases does not reveal significant disorders that could explain the patient’s persistent and massive complaints. By excluding one or another protracted somatic suffering, taking into account the phase nature of the course of somatovegetative disorders (including diurnal fluctuations with significant deterioration in the morning), identifying with the help of clinical and psychodiagnostic studies the presence of hidden, atypical anxiety and depression, and most importantly - observing the effect of prescribing an antidepressant, one can conclude that there is hidden depression.

Hypochondriacal disorders are characterized by unjustifiably increased attention to one’s health, extreme preoccupation with even minor ailments, and the belief in the presence of a serious illness in the absence of its objective signs. Hypochondria is usually a component of more complex senestopathic-hypochondriacal, anxiety-hypochondriacal and other syndromes, and can also be combined with obsessions, depression, and paranoid delusions.

Manic state. With the development of a manic state, a barely noticeable elation of mood appears at first, in particular the revival of facial expressions. The patient notes vigor, tirelessness, good health, “is in excellent shape,” and somewhat underestimates the real difficulties. Subsequently, there is a clear revival of facial expressions, the patient smiles, his eyes sparkle, he is often prone to humor and witticisms, in some cases he states that he feels a “special surge of strength”, “rejuvenated”, is unreasonably optimistic, considers events with an unfavorable meaning to be trivial, all difficulties - - easily overcome. The posture is relaxed, there are excessively sweeping gestures, and sometimes a raised tone in conversation.

In a pronounced manic state, generalized, non-targeted motor and ideational excitation occurs, with extreme expression of affect - to the point of frenzy. The face often turns red and the voice becomes hoarse, however, the patient notes “unusually good health.”

Thinking (disturbances). Characteristic symptoms are thoroughness of thinking, mentalism, reasoning, obsessions, and increased distractibility. At first, these symptoms are almost invisible and have little effect on the productivity of communication and social contacts. However, as the disease progresses, they become more pronounced and permanent, which makes it difficult to communicate with the patient. When they are most severe, productive contact with patients is practically impossible.

Memory (impaired). For mild hypomnesia on current events the patient generally remembers the events of the next 2-3 days, but sometimes makes minor errors or uncertainty when remembering individual facts (for example, he does not remember the events of the first days of his stay in the hospital). With increasing memory impairment, the patient cannot remember which procedures he took 1-2 days ago; only when reminded does he agree that he already talked to the doctor today; does not remember the dishes he received during yesterday’s dinner or today’s breakfast, and confuses the dates of his next meetings with relatives.

With severe hypomnesia, there is a complete or almost complete absence of memory about immediate events.

Hyponesia for past events begins with the fact that the patient experiences minor difficulties when it comes to remembering the dates of his biography, as well as the timing of well-known events. In this case, sometimes there is a displacement of events in time or dates are named approximately; the patient attributes some of them to the corresponding year, but does not remember the month and day. The observed memory disorders practically do not interfere with normal activities. However, as the disease progresses, the patient finds it difficult to remember the dates of most well-known events or only remembers some of them with great difficulty. At the same time, the memory of events in his personal life is grossly impaired; he answers questions approximately or after complex calculations. With severe hypomnesia, there is a complete or almost complete absence of memory about past events; patients answer “I don’t remember” to the relevant questions. In these cases, they are socially helpless and disabled.

Psychoorganic(organic, encephalopathic) syndrome-- a state of fairly stable mental weakness, expressed in the mildest form by increased exhaustion, emotional lability, instability of attention and other manifestations of asthenia, and in more severe cases - also by psychopathic-like disorders, decreased memory, and increasing mental helplessness. The basis of the pathological process in psychoorganic syndrome is determined by the current disease of the brain of an organic nature (traumatic disease, tumor, inflammation, intoxication) or its consequences. Nonspecific psychopathological symptoms are often combined with focal brain lesions with corresponding neurological and mental disorders. Among the variants of the syndrome are asthenic with a predominance of physical and mental exhaustion; explosive, determined by affective lability; euphoric, accompanied by increased mood, complacency, decreased critical attitude towards oneself, as well as affective outbursts and bouts of anger, ending in tearfulness and helplessness; apathetic, characterized by a decrease in interests, indifference to the environment, weakening of memory and attention.

Increased irritability. In the first stages of the disease, it occurs in connection with a specific emotionally significant situation. The patient sometimes looks irritated and gloomy, but more often irritability is revealed only upon questioning, there is no fixation on it, a critical attitude and the ability to cooperate with others are preserved.

Gradually, however, increased irritability can become almost permanent. It occurs under the influence of not only emotionally significant, but also indifferent stimuli (bright light, loud conversation). The patient looks tense outwardly and has difficulty restraining the affect of anger. He assesses the external situation as “outrageous”; it is difficult to attract him to cooperation.

The most pronounced forms of increased irritability are characterized by rage, fragmentary screams, and swearing that arise at the slightest provocation. In this case, attacks on the object of anger are possible; in extreme cases, a narrowing of consciousness occurs, and there is no consistent self-esteem.

Confusion. At the beginning, uncertainty appears, characterized by causeless silence in conversation, and a “puzzled” facial expression. Sometimes the patient reports that he is confused and confused. Believes that the external situation or internal state is generally understandable, but still strange, unclear, perplexing, and requires clarification. As confusion develops, the patient looks closely and listens to the situation with interest, or becomes thoughtful and self-absorbed. In this case, speech loses consistency, becomes confusing, the patient does not finish the sentence, which, however, does not exclude the possibility of establishing productive contact. There is an expression of surprise on his face, he wrinkles his forehead, his eyebrows are raised, his gaze is wandering, searching, his movements and gestures are uncertain, incomplete, contradictory. He often throws up his hands, shrugs his shoulders, and asks to “clarify what is unclear.”

Expressed confusion is accompanied by facial expressions of bewilderment or (with autopsychic confusion) “fascination” with a frozen face, “attention turned inward,” often with the patient having wide open, shining eyes. Speech is chaotic, broken to the point of incoherence, interrupted by silence.

Senestopathic disorders. The most typical manifestation in various parts of the body is unpleasant and painful sensations of pain, burning, tightening, which are of an unusual, sometimes pretentious nature. Doctors, when examining a patient, do not identify a “painful” organ or part of the body and do not find an explanation for the unpleasant sensations. When senestopathic disorders are stabilized, they largely determine the patient’s behavior style, which requires comprehensive additional and, as a rule, inconclusive research. Senestopathic sensations as psychopathological manifestations should be carefully differentiated from the initial symptoms of various somatic and neurological diseases. Senestopathies in mental illness are usually combined with other mental disorders characteristic of schizophrenia, the depressive phase of manic-depressive psychosis and other diseases. Most often, senestopathies are part of the more complex senestopathic-hypochondriacal syndrome.

Sleep (disturbances). Characterized by disorders of falling asleep, disturbances in the depth and duration of sleep, awakening disorders, and daytime sleepiness.

Sleep disorders At first, occasionally, especially with fatigue, there is a delay in the onset of sleep within 1 hour. In this case, paradoxical doubt is sometimes observed (the feeling of drowsiness dissipates when trying to fall asleep), drowsy hyperesthesia of hearing, smell, which does not cause concern. If it is difficult to fall asleep, the patient remains in bed and usually does not pay attention to existing disturbances, noting them only during special questioning.

With more severe disorders, there are almost always sleep disorders that bother the patient. The onset of sleep is delayed - within 2 hours, while along with paradoxical doubt and drowsy hyperesthesia, a feeling of internal tension, anxiety, and various autonomic disorders can be observed. A patient who has difficulty falling asleep sometimes gets out of bed.

Severe sleep disturbances are characterized by a constantly painful, exhausting inability to fall asleep for several hours. Sometimes during this period there is a complete absence of drowsiness. In these cases, the patient lies in bed with his eyes open and tries to sleep in tension. Anxiety, phobias, severe autonomic disorders, and often hyperesthesia and hypnagogic hallucinations may be observed. The patient is alarmed, waits for the night with fear, if it is impossible to sleep, he tries to change the circadian rhythm of sleep, and actively seeks help.

Disturbances in the depth and duration of night sleep.Occasionally, more often with fatigue, sudden night awakenings appear. After which sleep comes again. In some cases, intrasomnic disorders are of a different nature and are expressed in the appearance of periods of shallow sleep with abundant and vivid dreams. The total duration of night sleep is usually unchanged. If these disorders are present, the patient continues to remain in bed at night, without attaching serious importance to them.

In more severe cases, there are almost always disturbances in night sleep in the form of awakenings (dissociated, fragmented night sleep, usually accompanied by senestopathies, phobias, and autonomic disorders). Awakenings are painful for the patient, after which he cannot fall asleep again for a long time. In some cases, intrasomnic disorders are expressed in a superficial state of half-sleep filled with dreams, which does not bring a feeling of vigor and freshness in the morning. The total duration of night sleep, as a rule, decreases by 2-3 hours (sleep duration is 4-5 hours).

The listed disorders are difficult for the patient to bear; he seeks help and strives to follow medical recommendations.

With extreme degrees of disturbance in the depth and duration of sleep, painful, almost daily insomnia is noted, when sleep does not occur at all throughout the night or short periods of shallow sleep are replaced by frequent awakenings. Sometimes intrasomnic disorders are accompanied by frequent sleep talking, somnambulism, and severe night terrors. The patient often has a fear of insomnia (agrypnophobia), he is anxious, irritable, and actively seeks medical help. The duration of night sleep is usually reduced by 4-5 hours in these cases (the duration of sleep is sometimes only 2-3 hours).

Awakening disorders. In mild cases, occasionally, with fatigue, after somato- and psychogenia, there is a delay in awakening, when the patient cannot gain a feeling of vigor and freshness within a few minutes. During this period there is severe drowsiness. Another type of awakening disorder is extremely rapid, sudden awakening in the morning with unpleasant autonomic disorders. Disorders of awakening do not cause concern to the patient; their presence can usually be found out only through special questioning.

As the symptoms become more complicated, disturbances in awakening are almost constant, and in the morning there is no feeling of freshness and vigor characteristic of a rested person. When it is difficult to awaken, along with severe drowsiness, drowsy disorientation is sometimes observed. Disorders of awakening can be expressed in the form of extremely rapid, instantaneous awakening with significant vegetative reactions (palpitations, fear, tremors, etc.). The patient is concerned about disturbances in awakening; when it slows down in the morning, he is usually lethargic and drowsy.

The most pronounced disorders of awakening are characterized by painful, almost constant disturbances in the form of a prolonged inability to engage in vigorous activity after sleep, a feeling of fatigue, and a complete lack of vigor and freshness. During drowsy states, illusory and hypnosomnic hallucinatory disorders, disorientation, and dysphagia are noted. After waking up in the first half of the day, the patient experiences constant lethargy and drowsiness. Along with difficulties in waking up, there may be a sudden awakening with a feeling of lack of sleep (denial of the former dream). A pronounced feeling of weakness, lethargy, lack of vigor and freshness is extremely disturbing to the patient.

Increased sleepiness.The first manifestations of increased drowsiness are detected only upon questioning; the number of hours of sleep per day is increased slightly (by no more than 1 hour). The existing drowsiness is easily overcome by the patient and is not relevant for him. In more severe cases, in the morning the patient sleeps for a long time, wakes up with difficulty, and complains of drowsiness during the day, which he cannot overcome. During a conversation, a “sleepy” facial expression is noticeable (relaxed facial expressions, slightly drooping eyelids). In addition to sleeping at night, he usually sleeps or naps during the day for 3-4 hours.

The greatest drowsiness is characterized by the fact that the patient sleeps or dozes almost all day, and because of this, vigorous activity is extremely difficult for him. When addressing a patient, he has difficulty answering simple questions. In this case, the face is typically “sleepy”, somewhat swollen, the eyelids are drooping, the muscles of the face and the whole body are relaxed.

Anxiety. At first, a feeling of vague anxiety arises only from time to time, more often in specific subjectively significant situations. In this case, the patient’s movements and posture are outwardly calm, but at times the facial expressions change, a moving, restless look appears, speech becomes somewhat confused, with slips of the tongue, hesitations, or excessive detail. At the same time, a critical attitude towards an anxious mood is maintained, which is assessed as “internal discomfort, slight excitement” and is often successfully suppressed. Purposeful activities will often not be disrupted, and performance may even increase.

These violations may become permanent. Small unnecessary movements are noticeable in a conversation; with fear associated with the external environment, the patient is tense, wary, distrustful, shudders, and looks around. The condition is assessed as “internal restlessness” or “tension”, “constraint”. Almost constant thoughts about danger, a threatening situation, alarming events expected in the near future. Purposeful activity is disrupted, tremors, sweating, and rapid pulse appear.

In cases of severe anxiety and panic, sharp motor agitation is observed, most often random throwing, panicked flight, and the desire to hide. Sometimes, on the contrary, a general “stiffness” arises. The pupils and palpebral fissures are dilated, pallor, cold sweat, intermittent breathing, and sometimes involuntary urination are noted. It is impossible to obtain a consistent report on the condition; speech takes the form of inarticulate fragmentary cries: “Save!.. What to do?..” The patient groans, at times begs to be hidden, to be protected; experiences horror, panic fear.