Syndrome – a stable set of symptoms united by a single pathogenetic mechanism.
“Recognition of any disease, including mental illness, begins with a symptom. However, a symptom is a multi-valued sign, and on its basis it is impossible to diagnose a disease. An individual symptom acquires diagnostic significance only in its totality and in relationship with other symptoms, that is, in a symptom complex - a syndrome” ( A.V. Snezhnevsky, 1983).
The diagnostic significance of the syndrome is due to the fact that the symptoms included in it are in a natural internal connection. Syndrome is the status of the patient at the time of examination.
Modern syndrome classifications are built on the principle of levels or “registers”, first put forward by E. Kraepelin (1920). According to this principle, syndromes are grouped depending on the severity of pathological processes. Each level includes several syndromes that are different in their external manifestations, but the level of depth of the disorders underlying them is approximately the same.
There are 5 levels (registers) of syndromes based on severity.
Neurotic and neurosis-like syndromes.
asthenic
obsessive
hysterical
Affective syndromes.
depressive
manic
apato-abulic
Delusional and hallucinatory syndromes.
paranoid
paranoid
mental automatism syndrome (Kandinsky-Clerambault)
paraphrenic
hallucinosis
Syndromes of impaired consciousness.
delirious
oneiroid
amentive
twilight stupefaction
Amnestic syndromes.
psychoorganic
Korsakov's syndrome
dementia
NEUROTIC AND NEUROSIS-LIKE SYNDROMES
Conditions manifested by functional (reversible) non-psychotic disorders. They can be of different nature. A patient suffering from neurosis (psychogenic disorder) experiences constant emotional stress. Its resources, protective forces, are depleted. The same thing happens in a patient suffering from almost any physical disease. Therefore, many of the symptoms observed withneurotic and neurosis-like syndromes similar. This is rapid fatigue with a feeling of psychological and physical discomfort, accompanied by anxiety, restlessness and internal tension. At the slightest reason they intensify. They are accompanied by emotional lability and increased irritability, early insomnia, distractibility, etc.
Neurotic syndromes are psychopathological syndromes in which disorders characteristic of neurasthenia, obsessive-compulsive neurosis or hysteria are observed.
1. ASTHENIC SYNDROME (ASTHENIA) - a state of increased fatigue, irritability and unstable mood, combined with vegetative symptoms and sleep disturbances.
Increased fatigue with asthenia is always combined with a decrease in productivity at work, especially noticeable during intellectual stress. Patients complain of poor intelligence, forgetfulness, and unstable attention. They find it difficult to concentrate on one thing. They try by force of will to force themselves to think about a certain subject, but soon they notice that in their head, involuntarily, completely different thoughts appear that have nothing to do with what they are doing. The number of presentations is reduced. Their verbal expression becomes difficult: it is not possible to find the right words. The ideas themselves lose their clarity. The formulated thought seems to the patient to be inaccurate, poorly reflecting the meaning of what he wanted to express with it. Patients are annoyed at their inadequacy. Some take breaks from work, but a short rest does not improve their well-being. Others strive through an effort of will to overcome the difficulties that arise, they try to analyze the issue as a whole, but in parts, but the result is either even greater fatigue or scatteredness in their studies. The work begins to seem overwhelming and insurmountable. There is a feeling of tension, anxiety, and a belief in one’s intellectual inadequacy
Along with increased fatigue and unproductiveness of intellectual activity, mental balance is always lost during asthenia. The patient easily loses self-control, becomes irritable, hot-tempered, grumpy, picky, and quarrelsome. Mood fluctuates easily. Both unpleasant and joyful events often lead to the appearance of tears (irritable weakness).
Hyperesthesia is often observed, i.e. intolerance to loud sounds and bright light. Fatigue, mental imbalance, and irritability are combined with asthenia in various proportions.
Asthenia is almost always accompanied by autonomic disorders. Often they can occupy a predominant position in the clinical picture. The most common disorders of the cardiovascular system are: fluctuations in blood pressure, tachycardia and pulse lability, various unpleasant or simply painful sensations in the heart area.
Easy redness or paleness of the skin, feeling of heatn.p.and normal body temperature or, on the contrary, increased chilliness. Increased sweating is especially often observed - sometimes local (palms, feet, armpits), sometimes generalized.
Dyspeptic disorders are common - loss of appetite, pain along the intestines, spastic constipation. Men often experience a decrease in potency. In many patients, headaches of varying manifestations and localization can be identified. They often complain of a feeling of heaviness in the head, squeezing headaches.
Sleep disorders in the initial period of asthenia are manifested by difficulty falling asleep, shallow sleep with an abundance of disturbing dreams, awakenings in the middle of the night, difficulty falling asleep later, and early awakening. After sleep they do not feel rested. There may be a lack of feeling of sleep at night, although in fact patients sleep at night. With increasing asthenia, and especially during physical or mental stress, a feeling of drowsiness occurs during the daytime, without, however, simultaneously improving sleep at night.
As a rule, the symptoms of asthenia are less pronounced or even (in mild cases) completely absent in the morning and, on the contrary, intensify or appear in the second half of the day, especially in the evening. One of the reliable signs of asthenia is a condition in which relatively satisfactory health is observed in the morning, deterioration occurs at work and reaches a maximum in the evening. In this regard, before performing any homework, the patient must first rest.
The symptomatology of asthenia is very diverse, which is due to a number of reasons. Manifestations of asthenia depend on which of the main disorders included in its structure is predominant.
If the picture of asthenia is dominated by hot temper, explosiveness, impatience, a feeling of internal tension, inability to restrain, i.e. symptoms of irritation - talk aboutasthenia with hypersthenia . This is the mildest form of asthenia.
In cases where the picture is dominated by fatigue and a feeling of powerlessness, asthenia is defined ashyposthenic , the most severe asthenia. An increase in the depth of asthenic disorders leads to a sequential change from milder hypersthenic asthenia to more severe stages. With the improvement of the mental state, hyposthenic asthenia is replaced by milder forms of asthenia.
The clinical picture of asthenia is determined not only by the depth of the existing disorders, but also by such two important factors as the constitutional characteristics of the patient and the etiological factor. Very often both of these factors are closely intertwined. Thus, in individuals with epileptoid character traits, asthenia is characterized by pronounced excitability and irritability; Individuals with traits of anxious suspiciousness experience various anxious fears or obsessions.
Asthenia is the most common and most common mental disorder. It can be found in any mental and somatic disease. It is often combined with other neurotic syndromes. Asthenia must be differentiated from depression. In many cases, it is very difficult to distinguish between these conditions, which is why the term astheno-depressive syndrome is used.
2. OBSESSIVE SYNDROME (obsessive-compulsive syndrome) - a psychopathological condition with a predominance of obsessive phenomena (i.e., involuntarily arising in the mind of painful and unpleasant thoughts, ideas, memories, fears, drives, actions, to which a critical attitude remains and the desire to resist them) .
As a rule, it is observed in anxious and suspicious individuals during the period of asthenia and is perceived critically by patients.
Obsessive syndrome is often accompanied by subdepressive mood, asthenia and autonomic disorders. Obsessions in obsessive syndrome can be limited to one type, for example, obsessive counting, obsessive doubts, phenomena of mental chewing gum, obsessive fears (phobias), etc. In other cases, obsessions that are very different in their manifestations coexist at the same time. The occurrence and duration of obsessions vary. They can develop gradually and exist continuously for a long time: obsessive counting, mental chewing phenomena, etc.; they can appear suddenly, last a short period of time, and in some cases occur in series, thereby resembling paroxysmal disorders.
Obsessive syndrome, in which obsessive phenomena occur in the form of distinct attacks, is often accompanied by pronounced vegetative symptoms: paleness or redness of the skin, cold sweat, tachy- or bradycardia, a feeling of lack of air, increased intestinal motility, polyuria, etc. Dizziness and lightheadedness may occur.
Obsessive syndrome is a common disorder in borderline mental illnesses, mature personality disorders (obsessive-compulsive personality disorder), and depression in anxious and suspicious individuals.
3. HYSTERICAL SYNDROME - a symptom complex of mental, autonomic, motor and sensory disorders, often occurs in immature, infantile, self-centered individuals after mental trauma. Often these are individuals of an artistic bent, prone to posing, deceit, and demonstrativeness.
Such persons always strive to be the center of attention and to be noticed by others. They don’t care what feelings they evoke in others, the main thing is that they don’t leave anyone around indifferent.
Mental disorders are manifested, first of all, by instability of the emotional sphere: stormy, but quickly replacing each other feelings of indignation, protest, joy, hostility, sympathy, etc. Facial expressions and movements are expressive, overly expressive, theatrical.
Characteristic is figurative, often pathetically passionate speech, in which the patient’s “I” is in the foreground and the desire at any cost to convince the interlocutor of the truth of what they believe in and what they want to prove.
Events are always presented in such a way that those listening should get the impression that the reported facts are the truth. Most often, the information presented is exaggerated, often distorted, and in some cases represents a deliberate lie, in particular in the form of a slander. The untruth may be well understood by the patient, but they often believe in it as an immutable truth. The latter circumstance is associated with increased suggestibility and self-hypnosis of patients.
Hysterical symptoms can be of any kind and appear according to the type of “conditional desirability” for the patient, i.e. brings him a certain benefit (for example, a way out of a difficult situation, an escape from reality). In other words, we can say that hysteria is “an unconscious flight into illness.”
Tears and crying, sometimes passing quickly, are frequent companions of hysterical syndrome. Autonomic disorders are manifested by tachycardia, changes in blood pressure, shortness of breath, sensations of compression of the throat - the so-called. hysterical coma, vomiting, redness or blanching of the skin, etc.
Grand hysterical attack is very rare, and usually occurs with hysterical syndrome that occurs in persons with organic lesions of the central nervous system. Usually, movement disorders in hysterical syndrome are limited to tremor of the limbs or the whole body, elements of astasia-abasia - wobbly legs, slow sagging, difficulty walking.
There is hysterical aphonia - complete, but more often partial; hysterical mutism and stuttering. Hysterical mutism can be combined with deafness - surdomutism.
Occasionally, hysterical blindness can be encountered, usually in the form of loss of individual visual fields. Disorders of skin sensitivity (hypesthesia, anesthesia) reflect the “anatomical” ideas of patients about the zones of innervation. Therefore, disorders involve, for example, entire parts or an entire limb on one and the other half of the body. The most pronounced hysterical syndrome is with hysterical reactions within the framework of psychopathy, hysterical neurosis and reactive states. In the latter case, the hysterical syndrome can be replaced by states of psychosis in the form of delusional fantasies, puerilism and pseudodementia.
AFFECTIVE SYNDROMES
These syndromes are an expression of the next, deeper level of mental disorder. With affective syndromes, a change occurs in the functioning of the brain at the diencephalic level, which regulates the body’s biotone, mood and pace of mental processes.
Affective (emotional) syndromes are psychopathological conditions in the form of persistent changes in mood, most often manifested by its decrease (depression) or increase (mania) and apatoabulic syndrome.
Depression and mania are the most common mental disorders. In terms of frequency, they occupy first place in the clinic of major psychiatry and are very common in borderline mental illnesses. Affective syndromes are constantly encountered at the onset of mental illnesses; they can remain the predominant disorder throughout their entire course, and when the disease becomes more complicated, they can coexist for a long time with various other, more severe psychopathological disorders. When the disease pattern reverses, depression and mania are often the last to disappear.
DEPRESSIVE SYNDROME
(syn.: depression, melancholy) is characterized by a triad of main symptoms:
Unreasonably low, depressed mood with a feeling of melancholy
Psychomotor retardation.
Slower pace of thinking.
Somatic and vegetative disorders.
A depressed, depressed mood in patients is combined with a loss of interest in the environment. They experience heaviness “in the soul”, in the chest, neck, in the head, a feeling of melancholy or mental pain, which they experience as more painful than physical pain. A depressive melancholy affect (if sufficiently expressed) takes over the field of consciousness, completely determining the thinking and behavior of patients who lose interest in their surroundings, see everything as a bad omen for themselves, a source of failure and suffering, and perceive the whole world in a gloomy light. They tend to blame themselves for everything, are filled with a sense of futility and do not see a way out of their current situation.
The appearance of the patients corresponds to their difficult mental state: the posture is bent, the head is lowered, the expression is mournful, the gaze is extinguished. In this state, patients are not able to enjoy even very good events that are important to them, that is, they are inaccessible to the opposite affects. They look clearly older than their age.
Motor retardation is usually quite pronounced. Patients are inactive, most of the time they lie or sit in a characteristic bent position. In some cases, motor retardation is expressed mildly, in others - sharply, reaching an extreme degree in the form of a depressive “stupor”, from time to time interrupted by an explosion of motor excitement - melancholic raptus. Motor retardation, as well as all depressive symptoms, being pronounced in the morning, noticeably weakens in the evening. Patients complain that there is no memory, there is no strength or desire to do anything, “everything falls out of hand,” “I’ve forgotten how to work,” etc., which is a consequence of the collapse of both complex and even simple skills, motor conditioned reflexes .
A pronounced slowdown in thinking and the flow of associative processes is striking. Patients are silent, speak little, in a quiet voice, answer questions with a great delay, often with one short word, sometimes only with a nod of the head. Ideas of self-blame are characteristic, patients are immersed in a world of sad experiences, their own “vice,” “worthlessness,” and hopelessness; they complain that there are few thoughts in their head, “one thought,” etc.
Low self-esteem often reaches the level of delusional ideas of self-abasement and self-blame, when patients define themselves as dull, mediocre, untalented people; They attribute various vices to themselves, accuse them of imaginary “crimes”, call them criminals, citing minor mistakes and mistakes of the past to justify this.
Patients often experiencehypochondriacal delirium against the background of a melancholy or anxious-melancholy mood. Patients claim that they suffer from an incurable disease (syphilis, cancer) and complain of weakness and impotence. Sometimes patients report changes, thinning and atrophy of their internal organs: the esophagus has become thinner, the stomach does not digest food, the intestines have “stopped”, so delirium gradually developsKotara (described about a hundred years agoJ. Cotard). Patients claim that their internal organs are rotten, their stomach, esophagus and intestines are missing (a nihilistic version of Cotard's delusion).
In other cases, patients claim that their torment is endless, that hundreds and thousands of years will pass, and death, which could save them from suffering, will never come, they are immortal (delirium of painful immortality). ;
Sometimes, in cases (where at first the ideas of sinfulness, self-worth and guilt dominated), patients declare that they are the most terrible criminals that humanity has never known, that such people have never existed and will never be in the world again (delirium of enormity, delirium own negative exclusivity). This (the most severe and unfavorable) variant of depression occurs more often in late-life psychoses (involutional, vascular, organic) and allows recovery in only about a quarter of cases.
Endogenous depression is characterized by:
daily mood fluctuations (sad mood in the morning and improvement in the evening).
Sleep disorders. (early awakenings, at 4-5 o’clock in the morning, sometimes patients claim that they did not sleep a minute at night - “lack of a sense of sleep”).
Somatovegetative disorders.
Appetite is sharply reduced or completely absent. The body weight of patients decreases, the skin is pale, the complexion is sallow, the mucous membranes are dry. Sexual and other instinctive impulses are also suppressed. Men lack libido, women develop amenorrhea. As a reflection of the severity of the condition, peripheral sympathicotonia is observed. Protopopov's characteristic triad is described: tachycardia, pupil dilation, and constipation. The appearance of the patient is noticeable. The skin is dry, pale, flaky. A decrease in the secretory function of the glands is expressed in the absence of tears. Hair loss and brittle nails are often observed. A decrease in skin turgor is expressed in the fact that wrinkles deepen and patients look older than their years. Blood pressure increases. Senesthopathy is common. Especially in old age.
Suicidal thoughts are the most dangerous symptom of depression. It is usually preceded by a milder disorder of this kind - thoughts of not wanting to live, when the patient does not yet have specific plans to commit suicide, but would not regret if he had to give up his life due to circumstances beyond his control. This is like a passive stage of suicidal thoughts. Suicidal thoughts are common in depression, but are much less likely to be realized due to motor retardation and passivity of patients. This not always expressed, but often experienced symptom is an absolute indication for hospitalization of patients. This manifestation of depression usually clearly correlates with the degree of melancholy and depression and is closely related to other signs of suppression of instinctive activity and, in fact, is a private manifestation of the suppression of the self-protective instinct, but due to its great clinical significance, it stands out as an independent symptom
The basis classification of depressive syndromes their affective structure must be based, since it is this that is most determined by the pathogenetic mechanisms of the disease state and, accordingly, serves as a criterion for choosing adequate therapy.
There are 4 main depressive syndromes:
Anxious-depressive, in which anxiety is clearly expressed along with melancholy;
Melancholic, in which the leading and most pronounced affect is melancholy,
Anergic depression, in which melancholy and anxiety are weakly expressed and a general decrease in the activity of all mental processes comes to the fore in the clinical picture.
The fourth syndrome is depressive-depersonalization syndrome. Although depersonalization is not an affect, it occurs in response to intense anxiety (and sometimes melancholy) and blocks these and other affects.
Anergic depression. In this state, there is no distinct melancholy and anxiety, mood is slightly reduced, somewhat more so in the mornings, and there is no pronounced psychomotor retardation.
Patients complain not so much of weakness as of the inability to force themselves to do anything, a kind of mental inertia develops, the level of motivation decreases, a feeling of their own lack of will arises, decision-making is extremely difficult, simple questions become problems, interests fade. The feeling of hopelessness, loss of purpose, one’s own powerlessness, helplessness increases, and the ability to experience joy is lost. Ideas of low value usually arise only as a result of failures, inability to cope with emerging tasks, there are no ideas of guilt, often a feeling of envy of others, “even the disabled, crippled” and self-pity.
Somatic symptoms of depression are mild; there may not even be a significant decrease in appetite or weight loss; patients do not want to eat, but they force themselves to eat. As a rule, there are no suicidal intentions, although patients often say that they do not want to live. Obsessions are possible, which are usually of the nature of obsessive doubts and hypochondriacal ideas, but these symptoms are not necessary.
Melancholic syndrome (sometimes referred to as “simple” or “classic” depression). It is characterized by distinct melancholy with daily fluctuations and a vital component, tension, although external manifestations of anxiety may be insignificant or absent, psychomotor retardation. Suicidal tendencies, as a rule, are present, ideas of low value and guilt are possible. Obsessions are rare and are in the nature of blasphemous thoughts or obsessive thoughts about suicide. In severe, intense melancholic syndrome, as a rule, there are depersonalization phenomena: painful insensibility, accompanied by mental pain, lack of feelings of hunger, satiety, and sometimes sleep. Sleep is heavy, with early morning awakenings, appetite is sharply reduced, weight loss and constipation are observed.
Anxiety-depressive syndrome characterized by a significant proportion of anxiety, which, along with melancholy, constitutes the affective core of the syndrome. The mood is sharply reduced, melancholy with a vital component is possible, diurnal mood swings are usually pronounced. In the motor sphere - either motor restlessness to one degree or another, up to severe agitation, or anxious numbness up to immobility. As a rule, anxiety is noted much more often. Depressive ideas are of an ambiguous nature (“I’m guilty, but I’m afraid of punishment”), and hypochondriacal ideas are common. If there are obsessions, then they are in the nature of phobias. Phenomena of auto- and somatopsychic depersonalization are possible. In addition to decreased appetite, weight loss and constipation, muscle spasms, pain and discomfort are noted, which often serve as the basis for hypochondriacal experiences.
Depressive-depersonalization syndrome significantly different in structure from other depressive syndromes observed within the framework of endogenous depression, the nature of which is determined by the intensity and ratio of the affects of melancholy and anxiety. It is distinguished by the presence of depersonalization (or, using other terms, mental anesthesia), which occupies a leading place in the clinical picture and blocks the affect of melancholy and anxiety.
Such patients do not complain of low mood, stating that they do not feel any mood at all, that the mood is completely absent. With sufficiently pronounced depersonalization, the depressive symptoms themselves are obscured: facial expressions are more absent than sad, hypomimia is common, the eyes are not dull, sunken, as in the melancholic syndrome, but shiny, sedentary, slightly exophthalmic. During a conversation, patients can smile with a polite, familiar, expressionless smile, which sometimes misleads the doctor about the depth of depression and the danger of suicide. There is no distinct psychomotor retardation. The feeling of affection, love, and warmth towards loved ones, especially children, disappears, which further enhances the feeling of mental pain caused by the lack of emotions.
Everything around stops being touched, it is perceived as if through a film, somatopsychic depersonalization manifests itself in the absence of a feeling of hunger, satiety, the urge to defecate, a feeling of relief after it, the absence of a sense of sleep, partial or complete analgesia. Still, in most cases, depersonalization does not reach such a degree as to completely block melancholy, and patients, along with insensibility, may also experience a fairly pronounced decrease in mood. In addition, they often experience various unusual tactile sensations, which, together with somatopsychic depersonalization, serve as the basis for the emergence of hypochondriacal ideas. With a fairly severe melancholic or anxiety-depressive syndrome, phenomena of auto- and, more often, somatopsychic depersonalization are almost always detected, but they do not dominate the clinical picture.
MANIC SYNDROME
(syn. mania) is characterized by a triad of main symptoms:
1. Unreasonable and persistent elevated mood,
By accelerating the pace of thinking
Psychomotor agitation.
All the patients’ experiences are colored only in pleasant tones. Patients are carefree and have no problems. Past troubles and misfortunes are forgotten, negative events of the present are not perceived, the future is painted only in rosy colors. True, the cheerful and friendly mood of patients at times, especially under the influence of external reasons (patients’ reluctance to obey the instructions of staff, disputes with others, etc.), gives way to irritation and even anger, but these are usually just outbreaks that quickly disappear, especially if you talk to sick in a peaceful tone.
Patients consider their own physical well-being to be excellent, and the feeling of excess energy is a constant phenomenon. The opportunities to realize numerous plans and desires seem unlimited, and they see no obstacles to their implementation. Self-esteem is always increased. It is easy to overestimate your capabilities - professional, physical, related to entrepreneurship, etc. Some patients can be dissuaded for some time from the exaggeration of their self-esteem. Others are unshakably confident that they are truly capable of making a discovery, implementing important social measures, occupying a high social position, etc. This is most often observed in mature and elderly patients. Typically, delusional ideas are few in number, represent a statement of fact, and are only relatively rarely accompanied by any evidence.
Patients talk a lot, loudly, quickly, often without stopping. With prolonged speech stimulation, the voice becomes hoarse or hoarse. The content of the statements is inconsistent. They easily jump from one topic to another, constantly deviating from the main subject of the conversation. There is an increased distraction of patients' attention to all sorts of external, even minor, stimuli. With increased speech excitation, a thought that does not have time to finish is already replaced by another, as a result of which statements become fragmentary (jump of ideas). The speech is interspersed with jokes, witticisms, puns, foreign words, and quotes. Associations are superficial (in consonance). Strong words and expressions are often used. Speech is interrupted by inappropriate laughter, whistling, and singing. In a conversation, patients easily and quickly parry questions asked of them and immediately seize the initiative themselves. There is an increase in memory (hypermnesia).
The appearance of the patients is characteristic. The eyes are shiny, the face is hyperemic, and splashes of saliva often fly out of the mouth when talking. Facial expressions are lively, movements are fast and impetuous, gestures and postures are emphatically expressive. Patients are often completely unable to sit still. During conversations with the doctor, they change their position, spin, jump up, and often begin to walk and even run around the office. They can eat while standing, hastily swallowing poorly chewed food. Appetite is usually significantly increased. Both in men and especially in women, sexual desire increases. The increase in symptoms of manic excitement usually occurs in the evening. Some patients experience insomnia at night, others sleep little but soundly.
Depending on the predominance of certain disorders in the picture of a manic state, separate forms of mania are distinguished: “sunny” mania (increasedly optimistic mood with moderate speech and motor agitation); “angry” mania (a combination of high mood with dissatisfaction, pickiness, irritation); “confused” mania (occurring against the background of an elevated mood, incoherent speech and disordered motor agitation).
Manic violence described in the past (furormaniacalis) - a state of pronounced psychomotor agitation with rage or malice, accompanied by destructive actions and aggression, currently occurs as an exception.
3. APATHIC-ABULIC SYNDROME
Manifests expressed
Emotional dullness
Abulia
Indifference and indifference make patients quite calm. They are hardly noticeable in the department, spend a lot of time in bed or sitting alone, and can also spend hours watching TV. It turns out that they did not remember a single program they watched. Laziness is evident in their entire behavior: they don’t wash their face, don’t brush their teeth, refuse to take a shower or cut their hair. They go to bed dressed because they are too lazy to take off and put on clothes. It is impossible to involve them in activities. The conversation does not arouse interest among patients. They speak monotonously and often refuse to talk, declaring that they are tired. If the doctor manages to insist on the need for dialogue, it often turns out that the patient can talk for a long time without showing signs of fatigue. At 6ece jIt turns out that patients do not experience any suffering, do not feel sick, and do not make any complaints.
Apathetic-abulic syndrome is a manifestation of negative (deficient) symptoms and has no tendency to develop reversely. Most often, the cause of apathy and depression are the final states of schizophrenia, in which the emotional-volitional defect increases gradually - from mild indifference and passivity to states of emotional dullness. Another reason for the occurrence of apathetic-abulic syndrome is organic damage to the frontal lobes of the brain (trauma, tumor, atrophy, etc.).
HALLUCINATORY-DELUSIONAL SYNDROMES
This extensive and heterogeneous group of psychopathological conditions is an expression of the next level of mental disorders in depth and breadth.
1. PARANOIAL SYNDROME manifests itself as a systematic monothematic delusion, not accompanied by hallucinations, mental automatisms, or memory impairment. These may be delusional ideas of invention, reform, persecution, jealousy. Delusion develops gradually, on the basis of a one-sided interpretation of real life events, which the patient gets involved in and is brought into an orderly system of views, which acquires the meaning of a dominant in the patient’s consciousness. Everything that happens is refracted through the prism of these views, assessed accordingly, accepted or rejected by the patient. Patients with paranoid syndrome are distinguished by sthenic affectivity and great activity in terms of implementing their “inventions,” exposing their unfaithful spouse, fighting their “persecutors, etc.
Full-blown paranoid syndrome is constantly combined with increased activity. Patients with expansive delusions usually experience an open struggle for their imaginary rights and achievements. In such a struggle, patients are able to induce other people, primarily from among those in their immediate environment. In patients with paranoid delusions, such a struggle is often hidden and can end in a sudden attack on imaginary opponents. Delusional behavior in paranoid syndrome usually indicates a fairly systematized delusion.
Patients with paranoid syndrome are characterized by thoroughness of thinking - the so-called delusional thoroughness, which is most clearly manifested when presenting the content of delusional ideas.
Paranoid delusions are generally difficult to treat.
2. PARANOID SYNDROME occurs most often and is characterized by unsystematized polythematic delusions, combined with deceptions of perception (most often in the form of verbal, less often olfactory or tactile hallucinations) and, often, with certain phenomena of mental automatism. The content of delusions includes ideas of relationship, persecution, poisoning, damage, external influence, sometimes ideas of witchcraft, damage, and in some cases hypochondriacal. The theme of delusions, the content of hallucinations and the nature of mental automatisms are closely related. This syndrome is observed both in acute psychotic attacks (acute paranoid) and in chronic mental illnesses. Paranoid syndrome can occur against the background of altered depressive mood or anxiety and be accompanied by delusional ideas of the corresponding content. In such cases they speak of depressive-paranoid or anxiety-paranoid syndromes
Paranoid syndrome is treated more successfully than paranoid syndrome.
SYNDROME MENTAL AUTOMATISM or KANDINSKY-CLERAMBO.
The core of the mental picture is a variety of mental automatisms (mental, sensory, motor), combined with delusions of physical or mental influence.
The first comprehensive description of the symptomatology of this disorder belongs to V.Kh. Kandinsky (1885). In the worksG. deGlerambault(1920-1926) a classification was given of the previously identified V.Kh. Kandinsky symptoms and combined them into a syndrome. There are three types of mental automatisms:
1) associative (ideational, ideo-verbal);
2) sensory (senestopathic, sensual);
3) motor (motor, kinesthetic)
Ideational mental automatisms manifest themselves in influxes of thoughts (mentism), “unwinding” of memories, “stealing” the patient’s thoughts or “voicing” them, “putting” other people’s “made” thoughts into him, a feeling of openness of the patient’s subjective thoughts to others and “reading” his thoughts others,"echo thoughts".
These symptoms are accompanied by phenomena of sensory automatism (a feeling of being done, of biological processes being imposed from outside ) Can manifest itself as violent changes in the affective sphere - “they make the mood”, “cause joy, anger, sadness, fear, delight”, etc. Sensory automatism is manifested by the occurrence, often in the internal organs, of unpleasant, painful or painful sensations, accompanied by the conviction that they are caused for a special purpose by external influence - delusion of physical influence. Patients report sensations of squeezing, tightening, twisting, tension, pain, coldness, burning, etc. Sensory automatism also includes the impact on the physiological functions of the patient’s body: they cause sexual arousal, distort appetite, smell, taste, delay or, on the contrary, cause defecation and urination.
Motor (motor) automatism is the conviction of patients that the movements and actions they perform occur under the influence of an external force. Initially, individual unnecessary, involuntary gestures or facial movements appear, and instantly passing states of immobility arise. They are accompanied by a feeling of involuntariness and alienness to the subject. Expanded motor automatism is accompanied by a delusional belief that actions are caused by external influences.
Motor automatism also includes psychomotor hallucinations (J. Seglas, 1895, 1914). The author identified three degrees of development of this disorder. Initially, when mentally pronouncing words, there is a feeling of movements in the lips and tongue, which remain motionless. Then the mentally spoken words acquire sound, and at the same time they begin to experience slight movement of the lips and tongue. Finally, real articulatory movements arise in them, accompanied by the forced pronunciation of words or phrases out loud. Psychomotor hallucinations are a disorder that combines associative and motor automatism.
Such alienation, a feeling of loss of belonging to one’s own “I” and one’s own mental acts, is interpreted by patients as a result of the influence of an outside force - hypnotic, some kind of technical devices. Patients talk about external influences on their thoughts, physical functions, the effects of hypnosis, special devices, rays, atomic energy, etc.
Pseudohallucinations are a “core” disorder of Kandinsky-Clerambault syndrome. According to the definition of V.Kh. Kandinsky (1890), these are “very lively and sensual, extremely definite images.” They differ from true hallucinations only in the absence of the nature of objective reality. Pseudohallucinations are often limited to the sphere of ideas, but they can also be projected outside, i.e. just like true hallucinations, have extraprojection. Pseudohallucinations are always accompanied by a delusional belief that their occurrence is due to the intervention of an external, extraneous force - delusion of influence. The impact on mental processes is called delirium of mental influence. The source of influence is various devices, the names of which reflect the existing level of technical development: electricity, radio, X-rays, atomic energy, etc. The influence is carried out with the aim of causing harm to the patient, much less often with a benevolent purpose - to re-educate, strengthen the will, prepare for the future, etc. .p. The subsequent complication of ideational automatisms is associated with the emergence of “mental, internal dialogues”, “mental, silent conversations with the mind”, “telepathic mental communication”, “transmission of thoughts”, affecting the most diverse, including intimate, aspects of the life of patients. More often than not, such “talks” are unpleasant, sometimes painful, and accompanied by depressive affect.
4. PARAPHRENIC SYNDROME (paraphrenia, paraphrenic delusions, delusions of imaginationE. Dupre, 1914) - is a combination of fantastic delusions of grandeur with more or less systematized delusions of persecution or influence. Delusional ideas are constantly accompanied by auditory hallucinations or pseudohallucinations, as well as mental automatisms. Memory deceptions in the form of fantastic confabulations are also often observed. Patients consider themselves rulers of the world, attribute to themselves immortality, divine origin, claim that they have written books by all the great writers under pseudonyms, etc. The content of confabulations is also connected with these grandiose ideas of greatness - memories of space flights, life in the ancient world. The mood of patients is usually high, but there is also a depressive version of this syndrome - Cotard's syndrome: the patient considers himself the greatest criminal, the source of all evil on earth, the cause of wars, natural disasters, illnesses and deaths. He deserves endless torment as punishment, and is therefore doomed to immortality. At the same time, he can claim that his internal organs have rotted, his body is collapsing, he has no brain, or that he has already died, is turning into a corpse and will exist in this form forever.
With paraphrenic syndrome, along with delusions of grandeur, ideas of wealth, reformism, messianism, high origin, and erotic content may arise. Expansive delusions often coexist with delusions of persecution, poisoning, and physical destruction. Patients are accused of persecution, poisoning, etc. persons of high social origin, various government organizations, international organizations, etc. The patient is always at the center of unusual and sometimes grandiose events.
Patients outwardly become arrogant, significant, mysterious, euphoric
The development of paraphrenic syndrome is evidence of chronicity and progression of the disease. Most often, paraphrenic syndrome occurs in schizophrenia. Occasionally, chronic confabulatory paraphrenia occurs in psychoses of traumatic, alcoholic and syphilitic origin, as well as in senile psychoses, more often in senile dementia.
VERBAL HALLUCINOSIS - a state of continuous hallucination caused by an influx of predominantly one type of hallucination.
The term "hallucinosis" was introducedK. Wernicke(1900). French psychiatrists (H. Claude, 1932; N.Ey, 1973) classify as hallucinosis only those psychopathological conditions in which patients retain a critical attitude towards them. Hallucinosis (visual and auditory) is usually a psychopathological disorder in this case, indicating local neurological damage to the brain. In Russian and German psychiatry, the main sign of hallucinosis has always been considered the existence of a clear, unclouded consciousness. Depending on the type of hallucinations or pseudohallucinations, auditory (verbal) and much more rare - visual, tactile and olfactory hallucinosis are distinguished; according to developmental characteristics - acute and chronic hallucinosis.
Verbal hallucinosis. This condition is close to paranoid syndrome, in which auditory hallucinations are also obligatory components of the clinical picture. However, if in the structure of paranoid the processes of delusion formation are of leading importance, i.e. disorders at the level of thinking, then in hallucinosis the main role belongs to perception disorders in the form of constant or periodically occurring, sensually vivid and usually multiple verbal hallucinations. Their content determines the mood and behavior of the patient and can serve as a starting point for the formation of delusions, which in this case will be of a secondary nature. The content of verbal hallucinations can be mono- or polythematic, for example, only threats or threats, abuse, ridicule, exhortation, etc. In cases where true verbal hallucinations exist, the “voices” are usually localized within “auditory reach” - on the street, in the attic, on the stairs, behind the door, etc. With auditory pseudohallucinosis, “voices”, “mental, mental conversations” are localized either in the head or in a space that is undefined in relation to the patient.
Hallucinosis occurs in a wide variety of mental illnesses, both somatically caused and endogenous (schizophrenia). In the latter case, the most common form of hallucinosis - auditory hallucinosis - usually occurs in cases where in the past the patients had chronic or protracted somatic diseases (rheumatism, sepsis, long-term suppurative processes, etc.), or intoxication (alcoholism), i.e. in the presence of “pathologically altered soil” (S.G. Zhislin, 1965). Auditory pseudohallucinosis is characteristic almost exclusively of schizophrenia. “Pathologically altered soil” is not at all necessary here.
CATATONIC SYNDROME (catatonia) is a symptom complex of mental disorders in which movement disorders predominate in the form of catatonic stupor), or in the form of hyperkinesis (catatonic agitation). The term "catatonia" and a detailed clinical description of the syndrome belong toK. Kahlbaum" y (1863, 1874).
These syndromes are based on disorders of mental activity that reach an even deeper level and involve, after the emotional sphere and cognitive processes, the subsystem of volitional regulation of behavior or psychomotor skills, which manifests itself in a variety of parabulic symptoms.
1. Catatonic excitement.It is manifested by an untargeted desire to move (in contrast to the desire for activity observed in manic states). Speech is interrupted, the movements and facial expressions of patients are mannered, theatrical and stereotypical, impulsive actions, the phenomena of echolalia and echopraxia can be observed. Active or passive negativism is observed with great consistency, less often - passive subordination or ambivalence, signs of intensification and perversion of instinctive actions.
Catatonic arousal lacks internal unity and purpose. The actions of patients are unnatural, inconsistent, often unmotivated and sudden (impulsivity); they contain a lot of monotony (stereotypy), repetition of gestures, movements and poses of others (echopraxia). The facial expressions of patients do not correspond to their actions and mood (paramimicry). Speech is most often incoherent, accompanied by symbolic statements, neologisms, repetition of the same phrases and words (verbigeration); The words and statements of others are also repeated (echolalia). Rhymed speech may be observed. The questions asked are followed by answers that do not correspond to the meaning of these questions (in passing, in passing).
Continuous incoherent speech excitement is suddenly replaced by complete silence for a short time. Catatonic excitement is accompanied by various affective disorders - pathos, ecstasy, anger, rage, and at times indifference and indifference.
2. Catatonic stuporoutwardly very different from excitement:
With catatonic stupor, there is increased muscle tone (catatonia), which initially occurs in the masticatory muscles, then moves to the cervical and occipital muscles, then to the muscles of the shoulders, forearms, hands, and lastly to the leg muscles. Increased muscle tone in some cases is accompanied by the patient’s ability to maintain the forced position given to his members (waxy flexibility, catalepsy). Waxy flexibility appears first in the muscles of the neck, and later in the muscles of the lower extremities.
One of the manifestations of waxy flexibility is the air cushion symptom (psychic cushion symptomE. Dupre): if you raise the head of a patient lying on his back, then his head, and in some cases his shoulders, remain in an elevated position for some time.
A common symptom of catatonic stupor is passive submission: the patient has no resistance to changes in the position of his limbs, posture and other actions performed on him. Catalepsy characterizes not only the state of muscle tone, but is also one of the manifestations of passive submission. Along with the latter, during stupor, the opposite disorder is observed - negativism, which is manifested by the patient’s unmotivated opposition to the words and especially the actions of the person entering into communication with him.
There are several forms of negativism. With passive negativism, the patient does not fulfill requests made to him, and during external interventions - an attempt to feed him, change clothes, examine him, etc., he puts up resistance, accompanied by a sharp increase in muscle tone. Active negativism is accompanied by performing other actions instead of the proposed ones or directly opposite ones.
Speech impairment during catatonic stupor can be expressed by mutism - the absence of verbal communication between the patient and others while the speech apparatus is intact. Patients with catatonic stupor are often in characteristic positions: lying on their side, in the fetal position, standing with their head bowed and arms extended along the body, in a squatting position. Some patients pull a robe or blanket over their heads, leaving their face open - a symptom of a hood (P.A. Ostankov, 1936).
Catatonic stupor is accompanied by somatic disorders. Patients lose weight and may experience symptoms of vitamin deficiency. The extremities are cyanotic, and swelling is noted on the dorsum of the feet and hands. Erythematous spots appear on the skin. There are constant violations of secretory functions: salivation, increased sweating, seborrhea. The pupils are constricted. In some cases, there is a lack of reaction of the pupils to painful stimuli. Blood pressure is reduced.
Catatonic syndrome is nonspecific and can be observed in the structure of any mental disorder (schizophrenia, affective psychosis, mental retardation, etc.)..
HEBEPHRENIC SYNDROME - a combination of motor and speech excitation with foolishness and changeable affect. Motor excitement is accompanied by clowning, antics, grimacing, and buffoonish copying of the actions and words of others." Using hospital clothes, newspapers, etc., patients come up with extravagant outfits for themselves. They pester others stupidly e with honest or cynical questions, they try to hinder them in something, throwing themselves at their feet, grabbing clothes, pushing and pushing them aside. Excitement may be accompanied by elements of behavioral regression. Thus, patients refuse to sit down to eat at the dinner table and eat while standing; in other cases, they climb onto the table with their feet. They eat without using a spoon, but grab food with their hands, slurp, spit, and burp. Patients are either cheerful, laughing and cackling out of place, then they begin to whine, squeal, sob or howl, or they become tense, angry and aggressive. Speech is often incoherent to one degree or another, and may be accompanied by neologisms, the use of rarely used words and phrases that are pretentious in construction, and echolalia. In other cases, patients sing obscene ditties or use foul language. In the structure of hebephrenic syndrome, unstable hallucinatory and delusional disorders occur. Catatonic symptoms are often observed. If they are constant, they speak of hebephrenic-catatonic syndrome.
Hebephrenic syndrome exists in an expanded form in young patients. Most often, hebephrenic syndrome occurs in schizophrenia; occasionally in epilepsy in states of altered consciousness, psychoses associated with traumatic brain injury, reactive and intoxication psychoses.
SYNDROMES OF DISTURBED CONSCIOUSNESS
There is no clinical definition of the term stupefaction. There are only psychological, physiological and philosophical definitions of consciousness. The difficulty of clinical definition is due to the fact that this term unites syndromes that are very different in their characteristics.
This syndrome (disorder of consciousness) is almost beyond description. The easiest way to characterize it is with a negative attribute - “the ability to correctly evaluate the environment.”
Syndromes of impaired consciousness are the deepest degree of disorganization of mental activity. With them, there is a simultaneous violation of all mental functions, including the ability to navigate in place, time, and environment, and sometimes in one’s own personality. The main symptom of syndromes of impaired consciousness is the loss of communication between the patient and others.
At the same time, all syndromes of impaired consciousness have a number of common features. The first to give them a listK. Jaspers, 1965.
The state of confusion is indicated by:
1) the patient’s detachment from the environment with unclear, difficult, fragmentary perception of it;
2) various types of disorientation - in place, time, surrounding persons, situation, self, existing in isolation, in certain combinations, or all at the same time;
3) one or another degree of incoherent thinking, accompanied by weakness or impossibility of judgment and speech disorders;
4) complete or partial amnesia during the period of stupefaction; Only fragmentary memories of the psychopathological disorders observed during that period are preserved - hallucinations, delusions, and much less often - fragments of environmental events.
The main common symptom of syndromes of impaired consciousness is the loss of the patient’s connection with the outside world, expressed in the complete or almost complete impossibility of perceiving, understanding and remembering current events. During these states, thinking is disorganized, and after their end, the period of disturbed consciousness is completely or partially amnesic. Syndromes of impaired consciousness are rightfully compared with the physiological state, because in a dream, a person also temporarily loses contact with the outside world. It is known, however, that physiologically sleep is not a homogeneous state; it clearly distinguishes two phases that repeatedly change during the night: orthodox or slow sleep, which occurs with signs of significant brain activity and is devoid of dreams, and paradoxical or rapid sleep, which occurs with signs of significant activation brain and accompanied by dreams. In a similar way, among the syndromes of impaired consciousness, two groups of conditions are distinguished:
Syndromes of switched off consciousness, in which mental activity is reduced to the extreme or completely ceases
Syndromes of clouded consciousness , in which intensive mental activity continues in the brain, isolated from the outside world, in a form largely reminiscent of dreams.
SYNDROMES OFF CONSCIOUSNESS .
Depending on the depth of the decrease in clarity of consciousness, the following stages of switched off consciousness are distinguished: obscurity, somnolence, stupor, coma. In many cases, as the condition worsens, these stages successively replace each other.
1. NUBILIATION - “cloudiness of consciousness”, “veil on consciousness”. The patients' reactions, primarily speech, slow down. Absent-mindedness, inattention, and errors in answers appear. A carefree mood is often noted. Such conditions in some cases last minutes, in others, for example, in some initial forms of progressive paralysis or brain tumors, there are long periods.
2. STUN - a decrease in the clarity of consciousness and its simultaneous devastation. The main manifestations of stunning are an increase in the threshold of excitability for all external stimuli. Patients are indifferent, their surroundings do not attract their attention. Patients do not immediately perceive the questions asked of them and are able to comprehend only relatively simple or only the simplest ones. Thinking is slow and difficult. The answers are monosyllabic. Motor activity is reduced: patients are inactive, their movements are slow; motor awkwardness is noted. Facial reactions are always impoverished. The period of stunning is usually complete or almost complete amnesia.
3. SUPOR - accompanied by a complete cessation of mental activity. The patient lies motionless, eyes closed, face expressionless. Verbal communication with the patient is impossible. Strong stimuli (bright light, strong sound, painful stimuli) cause undifferentiated, stereotypical protective motor and, occasionally, vocal reactions.
4. COMA - complete loss of consciousness with lack of response to any stimuli. Not only conditioned, but also unconditioned reflexes are lost: the reaction of the pupils to light, the blink reflex, the corneal reflex.
Syndromes of switched off consciousness occur with intoxication (alcohol, carbon monoxide, etc.), metabolic disorders (uremia, diabetes, liver failure), traumatic brain injuries, brain tumors, vascular and other organic diseases of the central nervous system.
SYNDROMES OF BLACKED CONSCIOUSNESS.
DELIRIOUS SYNDROME (delirium) - confusion of consciousness with a predominance of true visual hallucinations and illusions, changeable affect, in which fear and motor agitation predominate. Delirium is the most common form of confusion.
Delirium occurs with impaired orientation in time and surroundings. Self-orientation is preserved. Multiple illusions and true hallucinations (visual, auditory, tactile) are observed. Patients experience anxiety and fear. Motor agitation is observed, their behavior usually corresponds to the content of hallucinations, often frightening. Actions are defensive or aggressive.
In a state of delirium, all the signs of a disorder of consciousness are observed. Patients are so immersed in hallucinatory experiences that they do not immediately hear speech addressed to them. You have to speak louder or repeat the phrase several times. Objects of the real situation are so transformed in their consciousness that they cease to understand the essence of what is happening, cannot understand the situation, and do not realize that they are in a medical facility. Thinking becomes inconsistent and chaotic. Upon completion of psychosis, partial amnesia is observed: hallucinatory images are better remembered and real events are poorly remembered.
The course of delirium is characterized by a number of features. Although this psychosis occurs acutely, the symptoms increase in a certain sequence. It takes from several hours to 2 days for complete development of psychosis. Its immediate onset is usually associated with the approach of evening and night. There are several stages in the development of delirium. Early signs of incipient psychosis are increasing anxiety, restlessness, a vague premonition of a threat, and a general increase in sensitivity(hyperesthesia). Patients suffer from insomnia, listen to random sounds in the apartment, and pay attention to small, insignificant details of the situation. If they try to fall asleep, then vivid, frightening images immediately appear before their eyes(hypnagogic hallucinations), immediately causing them to wake up. Sometimes hallucinations continue immediately after waking up(hypnopompic hallucinations). Anxiety grows more and more, and soon bright illusory deceptions appear. Characterized by a fantastic transformation in the minds of patients of the details of the situation (wallpaper pattern, furniture upholstery, cracks on the floor and stains on the tablecloth) into specific figures and images. Flowers on the wallpaper become convex and grow out of the wall; spots are mistaken for small bugs; the stripes on the upholstery of the chair form into the face, it begins to smile and grimace(pareidolic illusions). During this period, it is possible to identify patients’ readiness for hallucinations using Lipman’s symptoms (the appearance of hallucinations when pressing on the eyeballs).
The first hallucinatory images often represent intertwined stripes (bundles of rope, shavings hanging from the ceiling, serpentine, shreds of cobwebs, tangles of snakes). Then more complex hallucinations occur: the room is filled with people or animals. Patients try to protect themselves from them, kick them out of the apartment, try to grab them with their hands, and wave a knife. Finally, the expanded picture of delirium leads to a complete transformation of the entire situation. Patients believe that they are at work or in a liquor store, see people chasing them, flee and cannot find a way out, since they do not see real objects in the environment. This period is characterized by extreme fear and sharp psychomotor agitation.
The typical duration of delirium is several (2-5) days. All this time the patient has no sleep. Although during the day he behaves much calmer, he can lie in bed in a state of light drowsiness, but upon questioning it turns out that the hallucinations persist. In the evening, the state of health worsens, more and more deceptions of perception appear, and psychomotor agitation increases. The cessation of delirium is critical: the patient falls asleep and after 8-12 hours of deep sleep wakes up without signs of psychosis. For some time, the conviction may remain that everything that happened during the moment of psychosis actually happened.(residual delirium), however, such erroneous judgments are unstable and resolve over the next few hours without special treatment. In the typical course of remembering psychosis, the patient can tell a lot about the deceptions of perception he experienced, but does not remember the real events that took place at that time. The onset of psychosis is better remembered.
The cause of delirium is a variety of exogenous and somatogenic diseases (intoxication, infections, febrile states, head injury, burn disease, vascular insufficiency).
Unfavorable development of the underlying disease (somatic, infectious, caused by intoxication, etc.) can lead to the development of severe forms of delirium - occupational and delirium.
Occupational delirium (delirium of employment, delirium of occupation) - delirium with a predominance of monotonous motor excitation in the form of habitual actions performed in everyday life: eating, drinking, cleaning, etc., or actions directly related to the profession of the sick person - dispensing goods, sewing , working on a cash register, etc. Motor agitation in occupational delirium occurs, as a rule, in a confined space. It is accompanied either by the pronunciation of individual words or is “silent”. Hallucinations and delusions are either absent or rudimentary. Speech contact is often impossible. Sometimes you can get a one-word answer. Its content reflects pathological experiences.
delirious delirium (delirium with muttering, quiet delirium) - delirium with uncoordinated motor excitation, which is devoid of holistic actions and monotonous inhis manifestations occur within the bed. Patients take something off, shake it off, feel it, grab it. These actions are often defined by the word "robbing". Speech agitation is a quiet and indistinct pronunciation of individual sounds, syllables, and interjections. It is impossible to communicate with patients; they are completely detached from their surroundings. Delirious delirium usually gives way to professional delirium. Occupational and especially excruciating delirium during the daytime can be replaced by symptoms of stunning. The deepening of stunning in these cases indicates a worsening of the underlying disease.
Depending on the etiological factor (with the greatest frequency during intoxication), delirium may be accompanied by autonomic and neurological disorders. Autonomic disorders include tachycardia, tachypnea, sweating, fluctuations in blood pressure with a tendency to increase, and neurological symptoms include muscle hypotension, hyperreflexia, tremor, ataxia, convergence weakness, nystagmoid, and Marinescu's symptom. In severe delirium, primarily in delirium delirium, blood pressure drops, collapsed states may develop, severe hyperthermia of central origin is often observed, and symptoms of dehydration are observed. Neurological symptoms include nuchal rigidity, Kernig's sign, symptoms of oral automatism, ocular symptoms (nystagmus, ptosis, strobism, fixed gaze), athetoid and choreoform hyperkinesis.
The duration of delirium usually ranges from three to seven days. The disappearance of disorders often occurs critically, after prolonged sleep. Deviations from the average duration are possible both in the direction of shortening and in the direction of significantly prolonging the existence of symptoms defining delirium. In somatically weakened patients, primarily in the elderly, extensive and severe delirious patterns can be observed for a number of weeks.
Patients who have experienced full-blown delirium partially remember the content of their experiences. Usually these memories are fragmentary and relate to psychopathological symptoms - hallucinations, affect, delusions. In patients with occupational and excruciating delirium, complete amnesia is observed.
Most often, delirium is replaced by asthenia; in severe cases, Korsakoff syndrome may develop.
ONEIROID SYNDROME (oneiroid, oneiroid clouding of consciousness, dream-like clouding of consciousness) - a dream-like clouding of consciousness with an influx of fantastic visual pseudo-hallucinations.
Orientation in the surrounding time is disturbed. Self-orientation is preserved. This is a deeper clouding of consciousness than delirium. It is usually observed in depression, mania and is associated with pathology of the midbrain.
The experiences of patients are much more complex and fantastic: scenes of wars, world catastrophes, flights to other planets, travel in a “time machine” to the distant past, stays in heaven, hell, etc.
Illusory images are perceived not as facts of the real world, but as phenomena belonging to other spheres inaccessible to ordinary perception(pseudohallucinations). Often patients mentally participate in amazing adventures, but they have the opportunity to, as it were, observe themselves from the outside. Their behavior does not in any way reflect the full richness of the fantastic events they experience. The patients' movements are manifestations of the catatonic syndrome - stereotypical swaying, mutism, negativism, waxy flexibility, impulsive actions. Sometimes the speech of patients is completely incomprehensible(tornness), sometimes they answer questions, and then it is possible to identify disturbances in orientation.
With oneiroid a symptom is possibledouble false orientation, when patients consider themselves ordinary patients in a psychiatric clinic and at the same time participants in incredible fantastic events (“a messenger from another galaxy”, “a knight without fear or reproach”, “a magic crystal bringing people the light of knowledge”, etc.). Often there are sensations of rapid movement, movement of large masses: patients feel that they are piercing space and time, that all the forces of evil and good are locked in mortal combat, that humanity is threatened with death.
The formation of psychosis occurs relatively quickly, but can last for several weeks. The first signs of incipient psychosis are sleep disturbances and a growing feeling of anxiety. Concern quickly reaches the point of confusion. Vivid emotions and derealization phenomena serve as the basis for fragmentary, unsystematized delusional ideas(acute sensual delirium). The initial fear is soon replaced by an affect of bewilderment or exalted ecstasy. The patients become quiet, look around in fascination, admiring the colors and sounds. Later, catatonic stupor or agitation often develops. The duration of oneiric stupefaction varies. More often, psychosis resolves within a few weeks. The exit from psychosis is gradual: Upon exit from psychosis, amnesia is more pronounced than with delirium. Patients can describe some fragments of painful experiences, but their story is inconsistent, like the events themselves.
AMENCIA (amentive syndrome, amentive stupefaction) is a form of stupefaction with a predominance of incoherent speech, motor skills and confusion.
Meinert - “acute nonsense.”
Occurs in severe and long-term somatic and infectious diseases. It begins with deep asthenia, then exhaustion sets in. The patient is disoriented in time, surroundings and his own personality. Voice contact is not possible. The thinking of patients is incoherent, speech is of a registering nature (consists of individual words of everyday content, syllables, inarticulate sounds pronounced quietly, loudly or in a chant with the same intonations). Perseverations are often observed. The mood of patients is changeable - sometimes depressed and anxious, sometimes slightly elevated with features of enthusiasm, sometimes indifferent.
There may be deceptions of perception, patients are listening to something. By facial expressions you can notice a change in emotional reactions.
Motor excitation during amentia occurs in a limited space, usually within the bed. It is limited to individual movements: patients spin, make rotational movements, bend, shudder, throw their limbs to the sides, throw themselves in bed..
It is not possible to enter into verbal communication with patients. Based on some of their statements, we can conclude that they have an affect of bewilderment and a vague awareness of their helplessness - symptoms that are constantly encountered in confusion. The usually perplexed expression on the patients’ faces also indicates confusion.
The duration of amentia can be several weeks or months. The period of the amentive state is completely amnesic. Upon recovery, amentia is replaced by either long-term asthenia or psychoorganic syndrome.
Externally, patients with amentia look like severe somatic patients (sharpened facial features, pale, emaciated, with low temperature, low A/D).
Nowadays it is more commonasthenic confusion . Patients are anxious, their mood is low, they are confused, and they cannot remember the topic of the conversation. Frequent perseverations are observed, jumping from one topic to another. Unsystematized ideas of special significance may appear, but after a few minutes they express criticism of the nonsense. Outwardly they look emaciated, pale, characterized by crocyanosis, hyperhidrosis, and in women - amenorrhea. As a rule, during this period, patients lose weight, despite adequate food intake.
The way out of asthenic confusion through asthenia.
Twilight blackout is a typical epileptiform paroxysm. Psychosis is characterized by a sudden onset, a relatively short duration (from tens of minutes to several hours), an abrupt (sometimes sudden) cessation and complete amnesia for the entire period of impaired consciousness.
Twilight develops suddenly. Orientation is completely disrupted. Patients are disconnected from reality. They stop answering questions. It is impossible to communicate with them. Spontaneous speech is either absent or limited to the stereotypical repetition of individual interjections, words, and short phrases.
In some cases, consistent, more often relatively simple, but outwardly purposeful actions are preserved. If they are accompanied by involuntary wandering, they speak of ambulatory automatism. Ambulatory automatism that lasts minutes is called a fugue or trance; ambulatory automatism that occurs during sleep - somnambulism or sleepwalking. Patients perform automated movements (go somewhere, move furniture, put clothes in order).
In some cases, patients in a twilight state of consciousness commit extremely dangerous aggressive actions. In such cases, after clearing consciousness, a depressive reaction to the committed act and its consequences may occur. These absurd and dangerous actions of patients, as well as sometimes their fragmentary cries while performing such actions, indicate that twilight disorders of consciousness can be accompanied by hallucinatory-delusional experiences.
The restoration of clarity of consciousness usually occurs gradually and may be accompanied by the occurrence of a transient, sharp impoverishment of mental activity, due to which patients seem weak-minded. In some cases, terminal sleep occurs. Twilight stupefaction usually lasts minutes to hours and is accompanied by complete amnesia.
SYNDROMES OF THE AMNESTIC REGISTER.
PSYCHOORGANIC SYNDROME is a symptom complex accompanied by a decrease in memory, intelligence and affective lability.
The disturbances characteristic of psychoorganic syndrome differ in varying degrees of severity. If they are mild, they speak of an organic decline in the level of personality; if severe, they are defined by the term “organic dementia”.
Memory impairments in psychoorganic syndrome affect, to one degree or another, all three of its main aspects: memorization, retention (the ability to retain what is perceived) and reproduction (the ability to activate memory reserves). In some cases, dysmnestic disorders predominate, in others - amnestic ones, primarily fixation and (or) progressive amnesia. Memory impairments, especially in the form of amnesia, are often accompanied by the appearance of figurative memories of past life events, and in some cases, confabulations.
Psychoorganic syndrome is accompanied by a violation of the perception of the environment - a decrease or even the inability to grasp any situation as a whole: patients perceive only particulars in it. The amount of attention is limited, especially passive attention - the automatic reaction to an emerging stimulus. Impairments in memory, perception and attention are closely related to deterioration of orientation - first in the environment, and as the condition worsens - in one’s own personality.
Various aspects of intellectual activity are lost unevenly. So far, no other rule has been discovered here, except that the later acquired skills suffer first, while the old ones persist for a long time and in them patients are even able to surpass healthy individuals. Violation of intellectual activity is evidenced by a decrease in the level of judgment (the ability to understand received information, weigh various alternatives and form a clear plan of action) and inferences (establishing relationships and interconnections between individual objects of the external and internal world).
One of the earliest signs of a decline in intelligence is a violation of critical abilities regarding self-esteem and assessment of the environment.
Affective reactions are unstable, sometimes change every minute, manifest themselves violently (incontinence of affect, affective lability), but usually are short-lived and quickly fade away. Changes in affect occur both spontaneously and under the influence of external factors, sometimes the most insignificant. In particular, the patient's affect changes easily and repeatedly as a function of addiction; from the tone in which the conversation is conducted with him. Affective lability easily subjugates the actions of patients, and a simultaneous decrease in criticism can lead to them committing illegal acts.
Limitation of the range of interests, the inability to comprehend complex situations, impoverishment of ideas, violation of subtle emotions (tact, sense of duty, etc.) cause emotional indifference of patients to what is not directly related to the prevailing affect and their interest at the moment. Impaired affectivity and decreased critical abilities are combined either with increased suggestibility, or with increased and even uncontrollable stubbornness, or both coexist. Usually the pace of mental processes is more or less slowed down. The vocabulary decreases, speech is often accompanied by the use of auxiliary words and verbal patterns. They easily get stuck on the same ideas, cannot immediately switch from one thought to another, are unable to highlight the main thing in a conversation, and get stuck on unimportant details. Dysarthria and perseveration are common.
In the initial stages of the development of psychoorganic syndrome and in cases where its manifestations are weakly expressed, the characterological traits inherent in the patient are more often sharpened, in particular, psychopathic-like disorders appear. With a pronounced psycho-organic syndrome, personal characteristics are leveled out - up to their complete disappearance. In some diseases (progressive paralysis, Pick's disease), leveling of personality is observed from the very beginning of the disease, thereby indicating its severity.
Psychoorganic syndrome is often accompanied by headaches, a feeling of pressure in the head, dizziness, poor tolerance to heat, changes in atmospheric pressure; it may be accompanied by a variety of neurological symptoms.
A significant number of patients with psychoorganic syndrome are characterized by the occurrence of exogenous types of reactions under the influence of intercurrent diseases and various intoxications, and in some cases, therapy, including psychotropic drugs. More often than others, usually at night, delirium occurs, less often - twilight stupefaction.
The causes of the development of psychoorganic syndrome are diverse: vascular diseases of the brain, traumatic brain injury, intoxication (alcohol, drugs, lead and other heavy metals, carbon monoxide), encephalitis, chronic metabolic disorders, syphilitic diseases of the central nervous system, brain tumors and abscesses , atrophic processes of presenile age, as well as epilepsy and all diseases accompanied by epileptiform syndrome.
KORSAKOV SYNDROME (amnestic syndrome) is a combination of fixation amnesia (memory disorder for the present), pseudoreminiscences and confabulations. Described for the first time by S.S. Korsakov in 1887 in his doctoral dissertation “On Alcoholic Paralysis.”
Memory disorders in Korsakoff's syndrome primarily relate to remembering current and recent events. The patient almost immediately forgets the impressions he receives. The time during which they are smoothed can be counted in seconds. The patient immediately forgets not only the name, but also the appearance of the person with whom he had to talk, and therefore he repeatedly greets the same person, and the patient answers the latter’s questions why he does this if they have already seen each other today what a given person sees for the first time. The patient does not know what he ate today or whether he ate at all, retells the same stories, does not remember how long he has been sick and how long he has been in the hospital. When talking with a doctor, the patient often repeats the same questions and asks for advice that he has already received many times while reading, the patient rereads the same thing many times, each time as something new for him, etc. Verbal memory suffers the most. At the same time, affective memory (memory for events associated with unpleasant experiences for the patient) suffers to a lesser extent.
Disorientation disorders, often called amnestic disorientation, are expressed in varying degrees. Most of all, orientation in time is disturbed. The patient is often unable to name not only the date, day of the week and month, but also the time of year, as well as the current year. Orientation in place, including spatial orientation, is significantly affected. Therefore, the patient is not able to understand the premises of the department, in particular, he does not know where his bed, toilet, etc. are located. Many patients are unable to say what kind of people surround them, and in some cases they call strangers by the names of their acquaintances.
Pseudo-reminiscences usually arise when asked appropriate questions, and not spontaneously. Their content concerns mainly past events of everyday life or situations related to professional activities. In these cases we talk about substitute (mnemonic) pseudo-reminiscences. Confabulations of fantastic content are much less common. There is usually no parallel between the degree of memory impairment and the severity of confabulation.
Patients with Korsakov's syndrome are always characterized by some degree of intellectual decline, including a decrease in critical attitude towards their condition. At the same time, they retain much of the knowledge and skills of the past quite satisfactorily. For example, patients retain professional knowledge, are able to play card games and chess well, solve various problems, and reason logically correctly about issues related to their previous experience and knowledge. The former personality structure of the patients is sufficiently preserved. For the majority, despite the decrease in criticism, there is always an awareness of the disease, primarily regarding memory disorders; patients, using various tricks, try to hide their mnestic defect.
Patients with Korsakoff's syndrome always have a decreased level of judgment and activity. Mental and physical fatigue can be constantly detected. These disorders are more pronounced in older people.
In most cases, Korsakoff syndrome occurs acutely, following states of confusion, most often following delirium, usually severe.
Korsakoff syndrome is observed in various intoxications (primarily alcoholism), after traumatic brain injury, in brain tumors and infectious diseases, after acute hypoxia (carbon monoxide poisoning, hanging, etc.), in atrophic and vascular processes.
DEMENTIA.
(acquired decrease in intelligence).
Intelligence is the ability to acquire knowledge and use it in practice.
The core of intelligence is thinking. In addition, emotions, will, perception, and memory suffer.
Signs of dementia are loss of accumulated abilities and knowledge, a general decrease in the productivity of mental activity, and personality changes. The dynamics of dementia vary. With brain tumors, atrophic diseases and atherosclerosis, mental defects constantly increase. In the case of post-traumatic and post-stroke dementia, restoration of some mental functions in the first months of the disease and a stable nature of symptoms over many subsequent years are possible. However, in general, the negative nature of dementia disorders determines its relative persistence and the impossibility of complete recovery.
The clinical picture of dementia varies significantly with major mental illnesses - organic processes, epilepsy and schizophrenia.
CLINICAL FORMS OF DEMENTIA.
Total dementia
All components of the intellect suffer (thinking, memory, emotions, will, perception, personality as a whole).
Total (paralytic) dementia is manifested by the primary loss of the ability to logic and understand reality. Memory impairments can be very severe, progressive amnesia of the Ribot type is observed, but they may lag behind disorders of abstract thinking. Noticeably sharp decrease or complete absence Cree tic attitude towards the disease. Emotional impoverishment is observed, the moral qualities of the individual suffer: the sense of duty, delicacy, correctness, politeness, and modesty disappear. There is a gradual disinhibition of lower emotions associated with instincts. Patients can cynically swear, expose themselves, urinate and defecate right in the ward, and are sexually disinhibited. Desires increase. This is especially true for appetite that reaches the level of bulimia. Patients are sloppy and do not take care of their appearance. Elements of behavioral regression may be observed - they eat with their hands, pick up scraps, lie down on the bed dressed, take food and things from others without asking, etc.
Personality disorders are so pronounced that patients cease to be like themselves (the “core of personality” collapses):
The cause of total dementia is a direct expression of the cerebral cortex. These can be diffuse processes, for example, degenerative diseases (Alzheimer's and Pick's disease), meningoencephalitis (for example, syphilitic meningoencephalitis - progressive paralysis), alcoholism. However, sometimes a small pathological process in the area of the frontal lobes (local injury, tumor, partial atrophy) leads to a similar clinical picture.
Neurological disorders are manifested by dysarthria, anisocoria, sluggish reaction of the pupils to light, miosis, asymmetry of innervation of the facial ditch, Romberg's symptom, anisoreflexia, increased or, conversely, decreased tendon reflexes.
Partial types of dementia.
A) Lacunar (dysmnestic, atherosclerotic) dementia manifests itself primarily as a severe memory disorder. The ability to form concepts and judgments is impaired much later. This significantly complicates the ability to acquire new information, but professional knowledge and automated skills can be retained for a long time in such patients. Although they feel helpless in complex professional activities, they easily cope with daily household chores. Characteristically, there is a critical attitude towards their shortcomings: patients are embarrassed by their lack of independence, apologize for their sluggishness, and try (not always successfully) to compensate for memory impairment by writing down the most important thoughts on paper. Such patients are frank with the doctor, actively present complaints, and deeply experience their condition. Character changes in lacunar dementia are quite mild and do not affect the core of the personality. In general, relatives find that the basic forms of behavior, attachments, and beliefs of patients remain the same. However, more often than not, some sharpening of personality traits and a “caricature” of previous character traits are observed. Thus, frugality can turn into greed and stinginess, mistrust into suspicion, isolation into misanthropy. In the emotional sphere, patients with dysmnestic dementia are characterized by sentimentality, emotional weakness, and tearfulness.
The cause of lacunar dementia is a variety of diffuse vascular diseases of the brain: non-stroke course of atherosclerosis and hypertension, diabetic microangiopathy, damage to systemic vessels due to collagenosis. Changes in the state of the blood supply to the brain (improvement of the rheological properties of blood, taking vasodilators) can cause fluctuations in the condition and short periods of some improvement in these patients.
IN) Schizophrenic dementia differs significantly from dementia due to organic disease. In schizophrenia, memory does not suffer, and there is no loss of the ability to think abstractly. At the same time, its harmony and focus are disrupted. A characteristic symptom is ataxic thinking (schizophasia). There is emotional dullness, up to apathy and abulia. Passivity and indifference are growing. Typically, patients lack the desire to achieve results. This is expressed in the fact that they, without trying to answer the doctor’s question, immediately declare: “I don’t know!” Physically strong patients with a fairly good stock of knowledge are completely unable to work, because they do not feel the slightest need for work, communication, or achieving success. Patients do not take care of themselves, do not attach importance to clothing, and stop washing and brushing their teeth. At the same time, their speech often contains unexpected highly abstract associations (symbolism, neologisms, paralogical thinking). Patients usually do not make gross errors in arithmetic operations. Only at the final stages of the disease does prolonged “inactivity of the intellect” lead to the loss of the accumulated stock of knowledge and skills. Thus, the central disorders in schizophrenic dementia should be considered impoverishment of emotions, lack of will and disruption of the harmony of thinking. More precisely, this state should be designated asapathetic-abulic syndrome.
An individual symptom acquires diagnostic significance only in combination and in relationship with other symptoms, that is, in a symptom complex syndrome. The syndrome is a set of symptoms united by a single pathogenesis. The clinical picture of the disease and its development are formed from the syndromes and their sequential changes.
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PSYCHOPATHOLOGICAL SYNDROMES
Recognition of any disease, including mental illness, begins with a symptom (a sign that reflects certain disorders of one or another function). However, the symptom-sign has many meanings and it is impossible to diagnose the disease on its basis. An individual symptom acquires diagnostic significance only in combination and in association with other symptoms, that is, in a syndrome (symptom complex). A syndrome is a set of symptoms united by a single pathogenesis. The clinical picture of the disease and its development are formed from the syndromes and their sequential changes.
Neurotic (neurosis-like) syndromes
Neurotic syndromes are observed with neurasthenia, hysterical neurosis, obsessive-compulsive neurosis; neurosis-like - for diseases of an organic and endogenous nature and correspond to the mildest level of mental disorders. Common to all neurotic syndromes is the presence of criticism of one’s condition, the absence of pronounced phenomena of disadaptation to ordinary living conditions, and the concentration of pathology in the emotional-volitional sphere.
Asthenic syndrome- characterized by a noticeable decrease in mental activity, increased sensitivity to ordinary irritations (mental hyperesthesia), rapid fatigue, difficulty in the flow of mental processes, incontinence of affect with quickly occurring fatigue (irritating weakness). A number of somatic functional disorders with autonomic disorders are observed.
Obsessive Obsessive Syndrome(anankast syndrome) - manifested by obsessive doubts, ideas, memories, various phobias, obsessive actions, rituals.
Hysterical syndrome- a combination of egocentrism, excessive self-suggestion with increased affectivity and instability of the emotional sphere. An active desire for recognition from others by demonstrating one's own advantage or the desire to arouse sympathy or self-pity. The experiences of patients and behavioral reactions are characterized by exaggeration, hyperbolization (of the merits or severity of one’s condition), increased fixation on painful sensations, demonstrativeness, mannerisms, and exaggeration. These symptoms are accompanied by elementary functional somatoneurological reactions, which are easily recorded in psychogenic situations; functional disorders of the musculoskeletal system (paresis, astasia-abasia), sensitivity, activity of internal organs, analyzers (deaf-mute, aphonia).
Affective disorder syndromes
Dysphoria - grouchy-irritable, angry and gloomy mood with increased sensitivity to any external stimulus, aggressiveness and explosiveness. Accompanied by unfounded accusations of others, scandalousness, and cruelty. There are no disturbances of consciousness. Equivalents of dysphoria can be binge drinking (dipsomania) or aimless wandering (dromomania).
Depression melancholia, depressive syndrome - a suicidal condition, which is characterized by depressed, depressed mood, deep sadness, despondency, melancholy, ideational and motor retardation, agitation (agitated depression). The structure of depression includes possible depressive delusional or overvalued ideas (of low value, worthlessness, self-blame, self-destruction), decreased desire, vital depression of self-feelings. Subdepression is a mild depressive affect.
Cotard's syndrome nihilistic-hypochondriacal delirium combined with ideas of enormity. It is most common in involutional melancholia, much less common in recurrent depression. There are two variants of the syndrome: hypochondriacal is characterized by a combination of anxious-melancholic affect with nihilistic-hypochondriacal delirium; Depressive is characterized by anxious melancholy with predominantly depressive delusions and ideas of denial of the outside world of a megalomaniac nature.
Masked (larvated) depression- characterized by a feeling of general vague diffuse somatic discomfort, vital senestopathic, algic, vegetodystonic, agrypnic disorders, concern, indecision, pessimism without clear depressive changes in affect. Often found in somatic practice.
Mania (manic syndrome) - a painfully elevated joyful mood with increased drives and tireless activity, accelerated thinking and speech, inadequate joy, cheerfulness and optimism. A manic state is characterized by distractibility of attention, verbosity, superficiality of judgment, incompleteness of thoughts, hypermnesia, overvalued ideas of overestimation of one’s own personality, and lack of fatigue. Hypomania is a mildly expressed manic state.
Affective syndromes (depression and mania) are the most common mental disorders and are noted in the onset of mental illnesses; they may remain the predominant disorders throughout the course of the disease.
When diagnosing depression, it is necessary to focus not only on the complaints of patients: sometimes complaints of decreased mood may be absent, and only targeted questioning reveals depression, loss of interest in life (“satiety with life” - taedium vitae), decreased overall vital activity, boredom, sadness, anxiety, etc. In addition to targeted questioning about actual mood changes, it is important to actively identify somatic complaints that can mask depressive symptoms, signs of sympathicotonia (dry mucous membranes, skin, tendency to constipation, tachycardia - the so-called “Protopopov’s sympathicotonic symptom complex”), characteristic of endogenous depression. A large number of diagnostically significant signs can be detected when studying the appearance and behavior of patients by observation: motor retardation or, conversely, fussiness, agitation, neglected appearance, characteristic physical phenomena - a frozen expression of melancholy, a depressive “omega” (fold between eyebrows in the shape of the Greek letter “omega”), Veragut fold (oblique fold on the upper eyelid). Physical and neurological examination reveals objective signs of sympathicotonia. Biological tests such as therapy with tricyclic antidepressants and the dexamethasone test allow paraclinical clarification of the nature of depression. Clinical and psychopathological studies using standardized scales (Zung and Spielberger scales) make it possible to quantify the severity of depression and anxiety.
Hallucinatory and delusional syndromes
Hallucinosis syndrome- influxes of verbal hallucinations such as different “voices” (conversations) against the background of relative preservation of consciousness.
Paranoid syndrome- primary systematized delirium (jealousy, reformism, “struggle for justice”, etc.), is distinguished by the plausibility of the plot, the system of evidence of the “correctness” of one’s statements, and the fundamental impossibility of their correction. The behavior of patients when implementing these ideas is characterized by sthenicity and persistence (delusional behavior). There are no perceptual disturbances.
Paranoid syndrome- characterized by secondary sensory delusions (persecution, relationships, influences), occurs acutely, against the background of emotional disorders (fear, anxiety) and disturbances of perception (illusions, hallucinations). Delirium is unsystematized, inconsistent, and may be accompanied by impulsive, unmotivated actions.
Kandinsky-Clerambault mental automatism syndromeconsists of pseudohallucinations, delusional ideas of influence and various mental automatisms, conviction of impartiality, involuntary occurrence, subjective coercion, violence of mental processes (thinking, speech, etc.)
Paraphrenic syndrome- a combination of senseless delusional ideas of greatness of fantastic content with phenomena of mental automatism, hallucinations, euphoria.
To identify hallucinatory-delusional disorders, it is important not only to take into account the spontaneous complaints of patients, but also to be able to conduct targeted questioning, which allows you to clarify the nature of painful experiences. Objective signs of hallucinations and delusional behavior, which were revealed during observation, significantly complement the clinical impression.
Syndromes of impaired consciousness
All syndromes of impaired consciousness have a number of common features, first described by K. Jaspers:
1. Alienation from the environment, unclear, fragmentary perception of it.
2. Disorientation in time, place, situation, and in the most difficult cases, in one’s own personality.
3. More or less pronounced incoherence of thinking with weakness or impossibility of judgment and speech disorders.
4. Complete or partial amnesia during the period of disorder of consciousness.
Coma - complete shutdown of consciousness with loss of conditioned and unconditioned reflexes, lack of chop activity.
Sopor clouding of consciousness with preservation of defensive and other unconditional reactions.
Stun - a relatively mild form of confusion. It is characterized by unclear orientation in the environment, a sharp increase in the threshold for all external stimuli, slowdown and difficulty in mental activity.
Nullification - slight clouding of consciousness while maintaining all types of orientation and the ability to carry out normal actions, while difficulties arise in understanding the complexity of the situation, the content of what is happening, the content of someone else’s speech.
Delirious syndrome- a form of confused consciousness, which is characterized by disorientation in place, time and situation, an influx of vivid true visual hallucinations, visual illusions and pareidolia, a feeling of fear, imaginative delusions and motor disturbances. Delirium is accompanied by autonomic disorders.
Amentive syndrome- a form of confused consciousness with a sharp depression of mental activity, complete disorientation, fragmented perception, inability to comprehend the situation, disordered motor activity, subsequent complete amnesia of the experience.
Oneiric (dream-like) syndrome- a form of confused consciousness with an influx of involuntarily arising fantastic dream-like delusional ideas; accompanied by partial or complete alienation from the environment, a disorder of self-awareness, depressive or manic affect, signs of catatonia, retention in consciousness of the content of experiences with amnesia of the environment.
Twilight Syndrome- characterized by a sharp narrowing of the volume of consciousness and complete disorientation. The unproductive twilight state is manifested in the implementation of a number of ordinary automated and externally ordered actions in an inappropriate situation for this in the waking state (ambulatory automatism) and during sleep (somnambulism). Productive twilight is characterized by an influx of true, extremely frightening hallucinations, an affect of fear and anger, destructive actions and aggression.
Syndromes caused by gross organic pathology of the brain
Convulsive syndrome- manifests itself in a variety of generalized and focal seizures (suddenly onset, rapidly passing states with impaired consciousness up to its loss and convulsive involuntary movements). More or less pronounced changes (decreases) in personality and intelligence are often woven into the structure of the convulsive syndrome.
Korsakovsky amnestic syndrome - characterized by a complete loss of the ability to remember current events, amnestic disorientation, memory distortions with relative preservation of memory for the past and a diffuse decrease in all components of mental functioning.
Psychoorganic syndrome- a more or less pronounced state of general mental helplessness with decreased memory, weakened understanding, incontinence of affect (Walter-Bühel triad).
Intellectual disability syndromes
Mental retardation- congenital total mental underdevelopment with a predominant lack of intelligence. Degrees: mild, moderate, severe, profound mental retardation.
Dementia syndrome- acquired persistent defect of intelligence, which is characterized by the inability to acquire new knowledge and skills and the loss of previously acquired ones. Lacunar (dysmnestic) dementia is a cellular intellectual defect with partial preservation of criticism, professional skills and the “core of personality.” Total dementia is a violation of all components of the intellect with a lack of criticism and the disintegration of the “core of personality” (moral and ethical properties).
Mental insanity- extreme degree of mental disintegration with extinction of all types of mental activity, loss of language, helplessness.
Syndromes with predominantly motor-volitional disorders
Apathetic-abulic syndrome- a combination of indifference (apathy) and a significant weakening of the motivation to activity (abulia).
Catatonic syndrome- manifests itself in the form of a catatonic stupor or in the form of stereotypical impulsive excitement. During stupor, patients freeze in a motionless state, muscle tone increases (rigidity, catalepsy), negativism appears, speech and emotional reactions are absent. During excitement, senseless, absurdly foolish behavior with impulsive actions, speech disturbances with the phenomena of fragmentation, grimacing, and stereotypy are noted.
Other syndromes
Depersonalization syndrome- a disorder of self-awareness with a feeling of alienation from some or all mental processes (thoughts, ideas, memories, relationships to the outside world), which is realized and painfully experienced by the patient himself.
Derealization syndrome- a disorder of mental activity, which is expressed in a painful feeling of unreality, the illusory nature of the surrounding world.
Irritable weakness syndrome- characterized by a combination of affective lability and irritability with decreased ability to work, weakened concentration and increased fatigue.
Hebephrenic syndrome- motor and speech disorders with senseless, mannered and foolish behavior, unmotivated gaiety, emotional devastation, impoverishment of motives, fragmented thinking with progressive disintegration of personality.
Heboid syndrome- a combination of affective-volitional disorders with relative preservation of intellectual functions, which is manifested by rudeness, negativism, weakening of self-control, distorted nature of emotional reactions and drives and leads to pronounced social maladaptation and antisocial behavior.
Withdrawal syndrome- a condition that occurs as a result of a sudden cessation of taking (introducing) substances that caused substance abuse or after the introduction of their antagonists; characterized by mental, vegetative-somatic and neurological disorders; The clinical picture depends on the type of substance, dose and duration of its use.
Hypochondriacal syndrome- consists of an erroneous (overvalued or delusional) belief of the patient that he has a serious somatic illness, in an overestimation (dramatization) of the severity of his painful condition. The syndrome consists of senestopathies and emotional disorders in the form of depressive mood, fear, and anxiety. Hypochondriacal fixation is an excessive focus on the state of one’s health, one or another of its slightest deviations, complications that threaten one’s own health.
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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 include: low or high self-esteem, disturbances in 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 are 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) and actual affective symptoms (subdepressive manifestations) come to the fore 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 the 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 delusional ideas 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 agorophobia, 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, low-grade 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, “as 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 completely unconscious 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 (disturbances in 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.
What are the syndromes?
If the presence of maladjustment is obvious, then the following sequence is assumed when making a diagnosis:
1. detection of symptoms,
2. identification of their typical combinations (syndromes),
3. determining the diagnosis, taking into account the specificity of the identified symptoms and syndromes
A range of possible etiological and pathogenetic factors, analysis of anamnestic information to determine the dynamics of the disease and, finally, the formulation of a nosological diagnosis. This sequence may be significantly shorter if symptoms characteristic of only one or a few diseases are detected. Therefore, of greatest interest to the diagnostician are high C y ph ical symptoms and syndromes .
There are several common features that determine the specificity of symptoms and syndromes,
1. severity of the disorder,
2. its reversibility,
3. degree of damage to basic mental functions.
Psychopathological symptoms
A SYMPTOM of a mental disorder is a certain phenomenon that is repeated in different patients, indicating pathology, a painful deviation from the natural course of mental processes, leading to maladjustment.
symptoms are the basis of diagnosis, but their diagnostic value can vary greatly. In psychiatry, there are practically no pathognomonic symptoms - only some of the painful phenomena can be considered quite specific. Thus, the feeling of reading thoughts, transmitting them at a distance, the feeling of forcibly inserting and taking them away are quite characteristic of paranoid schizophrenia. Most signs in psychiatry are non-specific. For example, sleep disorders, decreased mood, anxiety, restlessness, and increased fatigue occur in almost any mental illness; delusions and hallucinations occur only in severe illnesses; however, they are not specific enough, since they can occur in many psychoses.
Thus, the main diagnostic value of symptoms is realized through the syndromes formed from them. Moreover, the symptoms vary depending on their position in the structure of the syndrome.
In this case, the symptom may appear as obli ugly, syndrome-forming sign . Thus, decreased mood is an obligatory sign of depression, fixation amnesia is a central disorder in Korsakoff's syndrome. on the other hand, it is necessary to take into account optional symptoms , indicating the characteristics of the course of the disease in a given patient. Thus, the appearance of anxiety and psychomotor agitation as part of the depressive syndrome is not typical, but it must be taken into account during diagnosis, since this may indicate a high probability of suicide.
Sometimes a symptom directly indicates to the doctor the need for special measures: for example, psychomotor agitation usually indicates a high severity of the condition and serves as an indication for hospitalization, regardless of the intended nosological diagnosis. Refusal to eat and an active desire for suicide require active action by a doctor even before a final diagnosis is made.
The concepts of neurotic and psychotic level are not associated with any specific disease. Moreover, with the same disease, a person’s state at different periods is sometimes described as neurotic or psychotic. It should be noted that in some diseases, throughout the patient’s life, the symptoms do not go beyond the neurotic level (the group of neuroses proper, clothymia, low-progressive forms of schizophrenia, psychopathy)
The division of disorders into productive and negative is of extreme importance for diagnosis and prognosis.
Productive symptoms (positive symptoms, PLUS symptom) are called a new painful phenomenon, some new function that appears as a result of the disease and is absent in healthy people. Examples of productive disorders are delusions and hallucinations, epileptiform paroxysms, psychomotor agitation, obsessions, a strong feeling of melancholy in depression, and inadequate joy in mania.
Negative symptoms (defect, minus symptom), on the contrary, are 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), intelligence (dementia), and the ability to experience vivid emotional feelings (apathy).
The identification of these concepts belongs to the English neuropathologist J.H. Jackson (l835# 1911), who believed that negative symptoms are caused by the destruction or temporary inactivity of brain cells, and productive ones are a manifestation of pathological activity
living cells and tissues surrounding the painful focus and therefore working in an unnatural, disordered mode. In this sense, negative symptoms seem to indicate which brain structures are destroyed. It is closely related to the etiology of the disease and is more significant for nosological diagnosis than productive. Productive disorders, in turn, are a nonspecific reaction of healthy tissues to the irritating effect of the lesion and therefore can be common to various diseases.
Psychiatrists apply the concept of negative and productive symptoms in relation not only to focal lesions. Productive symptoms are very dynamic.
For doctors, the concept of persistence and irreversibility of negative symptoms is important, but in clinical practice there are rare cases of reverse development of some negative symptoms. Such dynamics are very characteristic of memory disorders in acutely emerging Korsakoff psychosis. Cases of reverse development of negative symptoms of schizophrenia have been repeatedly discussed in the literature. Apparently, it should be assumed that loss of function does not necessarily mean the death of the brain structures that perform this role; in some cases, the defect is due only to their temporary inactivity. Thus, in acute psychoses, excitement and confusion prevent patients from concentrating; they cannot count correctly or solve logical problems. However, after gaining calm and relief from productive symptoms, it becomes clear that these abilities have not been lost forever. Therefore, the depth and severity of negative SYMPTOMS should be assessed only after the acute onset of the disease.
So, the main properties of productive and negative disorders can be presented as follows:
Productive disorders
1. . manifest themselves as new functions that did not exist before the disease;
2. . nonspecific, since they are a product of living functioning brain cells;
3. . reversible, well controlled with medications, can resolve without treatment;
4. . indicate the severity of the process.
Negative disorders (defect)
1. . are expressed in the loss of healthy functions and abilities;
2. . quite specific, indicating a specific affected locus;
3. . usually irreversible (with the exception of disorders in the acute period of the disease);
4. . indicate the outcome of the disease.
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1.2 Main psychopathological syndromes
Syndrome - a complex of symptoms.
Psychopathological syndrome - a complex is a 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 - this is the clinical expression of various types of mental pathology, which include mental illnesses of psychotic (psychosis) and non-psychotic (neuroses, borderline) types, short-term reactions and persistent psychopathological conditions.
1.2.1 Positive psychopathological syndromes
There is currently practically no single view on the concept of positive, and therefore negative, syndromes.
Positive consider syndromes that are qualitatively new, absent normally, symptom complexes (they are also called pathological positive, “plus” - disorders, phenomena of “irritation”), indicating progression mental illness that qualitatively changes the patient’s mental activity and behavior.
1.2.1.1 Asthenic syndromes.
Asthenic syndrome - a state of neuropsychic weakness - 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
1. hypersthenic and
2. hyposthenic.
At emotional-hyperesthetic weakness short-term emotional reactions of dissatisfaction, irritability, anger for minor reasons (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.
With hyposthenic variant Mostly physical asthenia, lethargy, fatigue, weakness, fatigue, a pessimistic mood with a drop in performance, increased drowsiness with a 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 when
1. somatic (infectious and non-infectious) diseases,
2. intoxications,
3. organic and endogenous mental illnesses,
4. neuroses.
It amounts to essence of neurasthenia (asthenic neurosis) , going through three steps:
▪ hypersthenic,
▪ irritable weakness,
▪ hyposthenic.
1.2.1.2 Affective syndromes.
The syndromes of affective disorders are very diverse. The modern classification of affective syndromes is based on three parameters:
1. the actual affective pole (depressive, manic, mixed),
2. structure of the syndrome (harmonious - disharmonious; typical - atypical) and
3. degree of severity of the syndrome (non-psychotic, psychotic).
Typical (harmonious) syndromes include a uniformly depressive or manic triad of obligatory symptoms:
1. pathology of emotions (depression, mania),
2. change in the course of the associative process (slowdown, acceleration) and
3. motor-volitional disorders /inhibition (substupor) - disinhibition (excitement), hypobulia-hyperbulia/.
The main (core) among them are emotional.
Additional symptoms speakers:
1. decreased or increased self-esteem,
2. violations of self-awareness,
3. obsessive, overvalued or delusional ideas,
4. suppression or strengthening of drives,
5. suicidal thoughts and actions in depression.
In the most classic look endogenous affective psychoses occur and, as a sign of endogeneity, include somato-vegetative symptom complex V. P. Protopopov (
· arterial hypertension,
· tachycardia,
· constipation,
· hyperglycemia,
· menstrual irregularities,
change in body weight)
daily fluctuations in affect (improvement of well-being in the second half of the day), seasonality, periodicity and autochthony.
For atypical affective syndromes characterized by a predominance of optional symptoms (.
1. anxiety,
3. senestopathies,
5. obsessions,
6. derealization,
7. depersonalization,
8. delusions of a non-holothymic nature,
9. hallucinations,
10. catatonic symptoms)
over the main affective syndromes.
TO mixed affective syndromes include such disorders that seem to be introduced from the opposite triad (for example, motor agitation during the affect of melancholy - depressive agitation).
There are also
1. sub-affective.(
◦ subdepression,
◦ hypomania; they are non-psychotic)
2. classic affective and
3. complex affective disorders (affective-delusional:
a) depressive-paranoid,
b) depressed-hallucinatory-paranoid,
c) depressive-paraphrenic or manic-paranoid.
d) manic-hallucinatory-paranoid,
e) manic-paraphrenic).
1.2.1.2.1 Depressive syndromes.
Classic depressive syndrome includes the depressive triad:
1. pronounced melancholy,
2. depressed gloomy mood with a touch of vitality;
3. 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 are 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 not presented as a pronounced 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.
TO atypical depressive syndromes include subdepressive. relatively simple and complex depression.
The most common subdepressive syndromes are:
Related information.
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 include: low or high self-esteem, disturbances in 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 are 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) and actual affective symptoms (subdepressive manifestations) come to the fore 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 the 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 delusional ideas 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 agorophobia, 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, low-grade 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, “as 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 completely unconscious 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 (disturbances in 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.
Syndrome of delusional fantasies - unstable, changeable, outwardly similar to delirium, reasoning with fantastic content. Close to some psychopathic individuals prone to daydreaming and daydreaming.
6.1.3.7. Syndromes of overvalued ideas. A group of syndromes that are characterized by judgments that arose as a result of real circumstances and on the basis of actual facts, acquiring in the consciousness the leading pathological monothematic one-sided, affectively-saturated opinion of the patient, without having a distorted, absurd content that does not capture the entire worldview of the patient. They can be an independent syndrome or part of the structure of other more complex psychopathological syndromes. In content they can be hypochondriacal, invention, jealousy, reformism, querulyantism, etc. They are found in psychopathy, reactive diseases, schizophrenia, organic mental illnesses.
6.1.3.7.1. Syndrome of dysmorphophobia and dysmorphomania - painful preoccupation with one’s physical characteristics, which are presented as extremely unpleasant to others and therefore create a hostile attitude towards the patient. Most often, flaws are seen on your face, less often on your figure. Mostly found in adolescence with schizophrenia, neuroses, and reactive states.
6.1.3.7.2. Syndrome of “metaphysical (philosophical intoxication" - monotonously abstract intellectual activity aimed at independent solution by thinking and “solving” “eternal problems” - about the meaning of life, about the purpose of humanity, about the eradication of wars, the search for philosophical, religious and worldview systems. May include ideas of invention, self-improvement, all kinds of intellectual and aesthetic hobbies.
Close to them is the syndrome of pathological hobbies (“pathological hobby”). Unlike the previous syndrome, what is observed here is not so much daydreaming, fantasy and reflection, but active activity, which is characterized by the intensity of obsession, unusualness, pretentiousness and unproductive hobbies. Occurs in neuroses and schizophrenia.
6.1.4. Hallucinatory-delusional syndromes. A group of syndromes, including as leading symptoms delusional ideas of varying content and different types of hallucinations, illusions, and senestopathies.
6.1.4.1. Paranoid syndrome. Primary systematized delirium (persecution, invention, jealousy, hypochondriacal, etc.) with thorough thinking and sthenic affect, developing with unchanged consciousness. In addition to the indicated delusional ideas, monothematic delirium of reformism, erotic, high origin, litigious (querulyant) is less common.
Depending on the course, acute and chronic paranoid syndromes are distinguished.
6.1.4.1.1. Acute paranoid syndrome occurs in diseases in the form of an attack. It is characterized by “insight,” a sudden thought that forms an interpretative delirium, the systematization of which occurs only in general terms without elaborate detail. Accompanied by affective disorders (anxiety, fear, ecstasy), confusion.
6.1.4.1.2. Chronic paranoid syndrome characterized by the consistent development of the plot of delirium, its expansion, systematization and often pronounced detail and “crooked logic”. The full-blown syndrome is combined with increased activity (open struggle for one’s ideas) and mild affective disorders.
Occurs in schizophrenia, psychopathy, organic mental diseases of the brain, involutional psychoses.
6.1.4.2. Hallucinosis. A group of syndromes, predominantly limited to abundant hallucinations, most often of one type, sometimes secondary delusions and not accompanied by clouding of consciousness. There are variants of the syndrome according to the type of hallucinations - verbal, visual, tactile, olfactory; according to the dynamics of occurrence - acute and chronic.
6.1.4.2.1. Verbal hallucinosis- an influx of verbal (verbal) hallucinations or pseudohallucinations in the form of a monologue (monovocal hallucinosis), dialogue, multiple “voices” (polyvocal hallucinosis) of various contents (threatening, imperative, scolding, etc.), accompanied by fear, anxiety, motor restlessness, often figurative delusional. With auditory pseudohallucinosis, “voices” are “mental,” “mental,” “made,” localized in the head, or heard from space, other cities and countries. Occurs in meta-alcoholic psychoses, schizophrenia, and organic mental diseases of the brain.
6.1.4.2.2. Visual hallucinosis characterized by an influx of bright, moving, multiple scene-like visual hallucinations. There are several types of visual hallucinosis. Lhermitte's visual hallucinosis (peduncular hallucinosis), which occurs as a result of a pathological process in the peduncles of the midbrain, is characterized by mobile, multiple, lilliputian, animated visual hallucinations and is accompanied by an affect of surprise and interest when critically assessing them. Bonnet visual hallucinosis, observed with loss of vision or in extreme old age, develops acutely from planar, moving, multiple visual hallucinations. Van Bogart visual hallucinosis occurs in the subacute period of encephalitis and is characterized by multiple, colorful, moving, zooptic hallucinations.
6.1.4.2.4. Olfactory hallucinosis - a rather rare independent syndrome, where the leading place is occupied by olfactory hallucinations in the form of the smell of rot, feces, most often emanating from the patient’s body. Accompanied by hypochondriacal and perfume dysmorphomanic overvalued or delusional ideas.
Hallucinosis occurs in somatic, infectious, intoxication psychoses, and schizophrenia.
6.1.4.3. Paranoid syndrome. A combination of interpretative or interpretative-figurative persecutory delusions (delusions of persecution, relationships, poisoning, surveillance, damage, etc.) with pathology of perception (hallucinations, illusions) and sensations (senesthopathy).
There are acute, subacute and chronic course of the syndrome.
Many psychiatrists identify paranoid syndrome with mental automatism syndrome. Indeed, in a number of mental illnesses (for example, schizophrenia), the paranoid syndrome and the syndrome of mental automatism merge, including in the first pseudohallucinations, the phenomena of mental automatism. However, there is a whole group of diseases, for example, psychogenic paranoid, road paranoid, induced paranoid, where the symptoms of mental automatism are completely absent.
6.I.4.4. Mental automatism syndromeKandinsky-Clerambault (external influence syndrome, alienation syndrome)
Includes the phenomena of alienation, loss, imposition, madeness of mental processes with pronounced violations of self-awareness of simplicity, identity, constancy, impenetrability of the “I”, accompanied by delusions of mental and physical influence and persecution. There are three types of mental automatism: associative (ideational, ideoverbal); sensory (senestopathic, sensual); motor (motor, kinesthetic).
6.1.4.4.1. Associative automatism includes an involuntary influx of thoughts (mentism), interruption of thoughts (sperrung), “parallel”, “intersecting”, “obsessive” thoughts; a symptom of openness of thought, when the patient's thoughts and feelings somehow become known to others; a symptom of “echo thoughts”, when others, in the patient’s opinion, pronounce or repeat his thoughts out loud. As the variant becomes more complex, “mental conversations”, “telepathic mental communication”, “thought transfer”, “silent negotiations” are added, accompanied by anxiety and depressive affect. Transitivism may be observed - the belief that they are not the only ones who hear internal “voices” and feel the impact.
6.1.4.4.2. Sensory automaticity characterized by senestopathies with a component of being made, imposed, caused, affecting sensations, internal organs, physiological functions. Patients report sensations of squeezing, tightening, twisting, burning, cold, heat, pain, etc.; impact on physiological functions: cause peristalsis and antiperistalsis, tachycardia, sexual arousal, urination, increase blood pressure, etc.
6.1.4.4.3. Motor (kinesthetic) automatism manifested by alienation of movements and actions. Patients are convinced that all movements and actions they perform are forcibly caused by outside influence. Because of the unnaturalness and alienness of their motor acts, they call themselves “robots”, “puppets”, “controlled dolls”. There is a feeling of movement in the lips, tongue, throat when thoughts are sounded and arising, up to real articulatory movements, forced speaking (Segle speech-motor hallucinations).
The presence of phenomena of mental automatism in all spheres of mental activity (associative, sensory, kinesthetic automatism) allows us to speak about the developed Kandinsky-Clerambault syndrome of mental automatism.
6.1.4.4.4. There are also delusional and hallucinatory variants of mental automatism syndrome. In the delusional variant, the leading place is occupied by delusions of physical, hypnotic or telepathic influence, mastery, persecution in combination with fragments of all types of automatisms. In the hallucinatory variant, auditory true ones predominate, and later pseudo-hallucinations with delusions of influence, persecution and fragments of other symptoms of mental automatism.
According to the dynamics, acute and chronic variants of the syndrome are distinguished. With the acute development of the syndrome, an essentially acute affective-hallucinatory-delusional syndrome is presented, which was characterized by pronounced affective disorders (fear, anxiety, depression, mania, confusion), insensitive delirium of influence, persecution, staging, verbal hallucinations, and vivid sensory automatisms. May be accompanied by optional symptoms such as catatonic (excitement or stupor).
6.1.4.4.5. Capgras syndrome. The leading symptom is impaired recognition of people. The patient does not recognize his relatives and acquaintances, speaks of them as fake people, twins, doubles (a symptom of a negative double). In other cases, on the contrary, unfamiliar faces are perceived as familiar (positive double symptom). Fregoli's symptom is characteristic, when “pursuers” constantly change their appearance in order to remain unrecognized. Capgras syndrome also includes delusional ideas of persecution, influence, phenomena of “already seen”, “never seen”, with phenomena of mental automatism.
6.1.4.5. Paraphrenic syndrome. The most complex delusional syndrome, including the leading symptoms of fantastic, confabulatory delusions of grandeur, and may also have delusions of persecution and influence, phenomena of mental automatism, and hallucinations. In a number of diseases, this syndrome is the initial stage of chronic delusional formation.
A distinction is made between acute and chronic paraphrenia. In the acute or subacute development of paraphrenic syndrome, the leading place is occupied by sensual, unstable, fantastic delusional ideas of greatness, reformation, high origin, verbal and visual pseudohallucinations, confabulations and pronounced fluctuations in affect from anxious-melancholy to ecstatic-euphoric. Additional symptoms indicating the severity of the development of the syndrome consist of delusions of intermetamorphosis, false recognitions, and delusions of special significance. Occurs in paroxysmal schizophrenia, infectious and intoxication psychoses.
Chronic paraphrenia is characterized by stable, monotonous delusional ideas of grandeur, poverty and monotony of affect and less relevant symptoms of previous delusional syndromes, primarily hallucinatory-delusional syndrome.
6.1.4.5.1. Variants of paraphrenic syndrome . Even E. Kraepelin (1913) distinguished paraphrenia into systematized, expansive, confabulatory and fantastic. Currently, it is customary to distinguish systematized, unsystematized, hallucinatory and confabulatory paraphrenia.
Systematized paraphrenia includes, in a systematized form, delusions of persecution, antagonistic delusions, and delusions of grandeur.
Unsystematized paraphrenia is observed during the acute development of the syndrome.
Hallucinatory paraphrenia is characterized by an influx of verbal true hallucinations or pseudohallucinations of praising, exalting and antagonistic content, which determine the content of delusions of grandeur, less often persecution.
Confabulatory paraphrenia is presented as the leading symptoms by confabulations, combined with the symptom of unwinding memories that define delusions of grandeur, high origin, reformism, and wealth.
6.1.4.5.2. Cotard's syndrome . It is characterized by nihilistic-hypochondriacal delirium combined with ideas of enormity. Patients express ideas of damage, destruction of the world, death, self-accusation, often on a large scale. All these symptoms are combined with anxiety-depressive or depressive syndrome (see section 5.1.2.1.).
Occurs in moderately progressive continuous schizophrenia and involutional psychoses.
6.1.5. Lucid catatonic syndromes. Lucid catatonic syndromes are understood as disorders of the motor sphere against the background of a formally unchanged consciousness, having the form of stupor or agitation without the presence of pathology in other areas of mental activity.
Psychomotor agitation and stupor can be obligate and auxiliary symptoms in many psychopathological syndromes (manic, depressive, delusional, hallucinatory stupor, or manic, depressive, delusional, hallucinatory agitation, with stupefaction syndromes).
6.1.5.1. Catatonic stupor. The main symptoms are hypokinesia, parakinesia. The most common and first symptoms are motor retardation from lethargy, passivity (substupor) up to complete immobility, hypo- and amymia with a mask-like face, mutism. Parakinesia is usually represented by active and (or) passive negativism, pretentiousness and mannerisms of poses, increased muscle tone (catalepsy, including symptoms of “air cushion”, “waxy flexibility”, “proboscis”, “fetal “pose” “hood”, etc.) , passive submission. Neuro-vegetative disorders are also obligatory: greasiness of the skin with acne vulgaris, acrocyanosis and cyanosis of the tips of the ears and nose, less often of the hands, pallor of the skin, tachycardia, fluctuations in blood pressure, often towards hypotension, decreased pain sensitivity up to anesthesia. , tendon hyperreflexia, decreased skin and mucous reflexes, nausea, vomiting, anorexia, up to complete refusal of food with cachexia. Optional symptoms can be represented by fragmentary delusions, hallucinations, preserved from previous stages of the disease, for example, in continuous, paroxysmal schizophrenia.
Based on the nature of the severity of parakinesia, several variants of catatonic stupor are distinguished, sometimes acting as stages in the development of stupor.
“Sluggish” stupor is hypokinesia, represented by lethargy, passivity, not achieving pronounced or complete immobility (substupor). Parakinesias include passive negativism and passive submission.
Stupor with waxy flexibility is manifested by general motor retardation up to complete immobility. Among parakinesias - pronounced passive negativism with elements and episodes of active negativism, clearly expressed waxy flexibility with mannerism, pretentiousness, and a significant increase in muscle tone.
Stupor with numbness - persistent, complete immobility with clearly expressed active negativism with complete refusal of food, retention of urination and defecation. Muscle tone sharply increases, in which tension in the flexors predominates, which is accompanied by an abundance of parakinesia.
6.1.5.2. Catatonic excitement. Includes, as leading symptoms, catatonic hyperkinesia and parakinesia. Hyperkinesia is represented by chaotic, destructive, impulsive psychomotor agitation. Parakinesias include echopraxia, echolalia, motor and speech stereotypies, pretentiousness, mannered postures, passive and active negativism, and impulsiveness. Parakinesia is often combined with parathymia, perversions of drives, motives, and motives for activity (homicidomania, suicidomania, self-mutilation, coprophagia, etc.). Additional symptoms are acceleration of speech, verbigeration, perseveration, and speech interruption.
Impulsive catatonic arousal is characterized by sudden short-term episodes of impulsive behavior and actions, often with aggressive and destructive content. Most often, impulsive agitation occurs as an episode interspersed with catatonic stupor.
Silent catatonic excitation is represented by severe hyperkinesia with mutism, motor stereotypies and “echo” symptoms,
Hebephrenic arousal is considered as a variant or stage of catatonic arousal and as an independent syndrome. The leading symptoms are pretentiousness, mannerism, grimacing, antics, echolalia, echopraxia, echothymia. Pretentiousness, mannerism, grotesqueness concerns both pantomime, facial expressions, and speech activity (stereotypical speech patterns, intonations (puerilism), neologisms, discontinuity, verbiage, flat jokes). Among the optional symptoms are fragmentary delusional ideas and episodic hallucinations.
Lucid catatonic states occur in continuously progressive schizophrenia, organic diseases of the brain, neuroinfections, traumatic brain injuries, tumors in the area of the third ventricle, pituitary gland, optic thalamus and basal ganglia.
