PRIVATE PSYCHIATRY

Chapter 16. Organic diseases of the brain. Exogenous and somatogenic mental disorders

General questions of taxonomy

This chapter deals with diseases that arise as a result of primary or secondary damage to the brain tissue, i.e. organic diseases. Although the division into "organic and functional disorders is widely used in medicine, in some cases it is not possible to draw a clear line between these concepts. Thus, in schizophrenia, traditionally considered as a functional psychosis, nonspecific signs of organic changes in the brain are often found. Authors ICD-10 emphasizes that the term "organic" does not imply that in all other mental illnesses there are no changes in the structure of the nervous tissue, but indicates that in this case the cause of brain damage or the nature of such damage is known.

In contrast to functional mental disorders, methods for studying the structure and function of the brain are widely used in the diagnosis of organic diseases (see sections 2.2-2.4). However, the absence of distinct signs of pathology during paraclinical examination does not reject the diagnosis of an organic disease. In this sense, the term "organic" is used somewhat more broadly in psychiatry than in neurology, and the diagnosis of organic diseases is largely based on their general clinical manifestations.

The main distinguishing features of organic diseases are a distinct deterioration in memory, impaired intelligence, emotional incontinence and personality changes. To designate the whole complex of organic psyches

Productive psychotic symptoms

neurological

symptoms

Somatic

condition

The course of the disease

Violated at the very beginning of the disease (repetitions and omissions of letters in a letter)

Elements of complacency with sociability and talkativeness at the beginning of the disease and indifference to the environment later

Delusions of damage or persecution in the initial period of the disease

Occurs gradually in the later stages of the course of the disease; frequent epileptic seizures

Somatic well-being is noted for a long time

steady progression

Can be stored for a long time

Passivity, spontaneity or disinhibition of drives, rudeness, lack of modesty

Uncharacteristic

Uncharacteristic

Somatic well-being is noted for a long time

Rapid steady progression

Changing handwriting without gross spelling errors

Weakness and emotional lability

Occurs acutely against the background of a violation of cerebral blood flow, often clouding of consciousness

Occurs acutely due to acute cerebrovascular accident, sometimes epileptic seizures

Complaints of headaches and dizziness are typical, often associated heart damage.

Wavy, "flickering" nature of the course against the background of a general increase in symptoms

tin disorders and anamnestic data confirming the presence of vascular disease. Violation of cerebral circulation can be confirmed by the data of an oculist examination (sclerosis, narrowing and tortuosity of the fundus vessels), as well as using rheoencephalography and dopplerography of the vessels of the head. This disease should be differentiated from the initial manifestations of atrophic diseases of the brain (Table 16.1). If there are signs of local brain damage on the EEG and signs of increased intracranial pressure, a brain tumor should be excluded. It should be taken into account that the clinical picture of mental disorders in case of damage to vessels of various nature (hypertension, syphilitic mesarteritis, diabetes mellitus, systemic collagenoses, etc.) is almost identical to that described above.

Treatment of cerebral atherosclerosis is effective only in the early stages of the disease, when adequate therapy can significantly slow down the further development of the process and contribute to better health. Assign vasodilators (cavinton, xanthinol nicotinate, cinnarizine, sermion, tanakan), anticoagulants and antiaggregants (aspirin, trental), drugs that regulate lipid metabolism (clofibrate, lipostabil). With combined hypertension, it is important to prescribe antihypertensive drugs. Riboxin and ATP preparations can improve not only cardiac, but also brain activity. Typical nootropics (piracetam and pyriditol) are often beneficial but should be used with caution as they can cause increased anxiety and insomnia. Drugs with concomitant sedative and vasodilating effects (picamilon, glycine) are somewhat better tolerated. Aminalon and Cerebrolysin are widely used in violation of cerebral circulation. Depression of patients, depressive background of mood indicate the need to prescribe antidepressants. However, they try not to use typical TCAs in atherosclerosis due to the risk of cardiac complications. Safe agents are azafen, pyrazidol, coaxil, gerfonal, zoloft and paxil. In the treatment of insomnia and the relief of acute psychoses, the increased sensitivity of these patients to benzodiazepine tranquilizers should be taken into account, therefore short-acting drugs in reduced doses are preferable. It is better not to use chlorpromazine and tizercin for the relief of acute psychoses, since they sharply reduce blood pressure. It is more advisable to use a combination of low doses of haloperidol and tranquilizers in combination with vasotropic therapy. It should be recommended to correct the diet of patients with restriction of animal fats and a decrease in total calorie content: this

especially important in the presence of signs of latent diabetes. Quitting smoking usually improves cerebral circulation.

In the presence of stable signs of vascular dementia, nootropic and vasotropic therapy is usually ineffective. Psychotropic symptomatic drugs are prescribed to correct behavioral disorders (sonapax, neuleptil, small doses of haloperidol) and improve sleep (imovan, nozepam, lorazepam).

Hypertonic disease in most cases it is combined with atherosclerosis. In this regard, the symptoms of the disease are similar to those of cerebral atherosclerosis. Only the disorders accompanying hypertensive crises differ in special psychopathology. In this period, against the background of severe headaches, dizziness, elementary visual deceptions often occur in the form of flies, fog. The condition is characterized by a sharp increase in anxiety, confusion, fear of death. Delirious episodes and transient delusional psychoses may occur.

In the treatment of patients with atherosclerosis and hypertension, the psychosomatic nature of these diseases should be taken into account. Seizures are often preceded by psychotrauma and states of emotional stress. Therefore, the timely appointment of tranquilizers and antidepressants is an effective way to prevent new attacks of the disease. Although drug treatment of vascular disorders is the main method, psychotherapy should not be neglected. In this case, you need to use the increased suggestibility of patients. On the other hand, increased suggestibility requires caution in discussing the manifestations of the disease with the patient, since the doctor's excessive attention to one or another symptom can cause iatrogenesis in the form of hypochondriacal personality development.

Mental disorders of an infectious nature

Almost any brain and general infectious processes can lead to mental disorders. Although a number of characteristic manifestations and a special type of course are described for each of the diseases, it should be borne in mind that the main set of mental manifestations as a whole corresponds to the concept of an exogenous type of reactions described above. The specificity of each individual infection is determined by the speed of progression, the severity of concomitant signs of intoxication (increased body temperature, vascular permeability, phenomena

tissue edema), direct involvement of the meninges and brain structures in the pathological process.

The most fully studied manifestations of syphilitic brain infection.

Neurosyphilis [A52.1, F02.8]

It should be borne in mind that syphilitic psychoses are not a mandatory manifestation of chronic syphilitic infection. Even in the last century, when there were no effective treatments for syphilis, syphilitic psychoses developed in only 5% of all infected people. As a rule, mental disorders appear rather late (through

15 years after the initial infection), so the timely diagnosis of these diseases presents significant difficulties. As a rule, the patient himself and his relatives do not report the infection and quite often do not know that such an infection has taken place. There are 2 main forms of syphilitic psychoses: syphilis of the brain and progressive paralysis.

Syphilis of the brain(lues cerebri) - a specific inflammatory disease with a primary lesion of the vessels and membranes of the brain. The disease usually begins somewhat earlier than progressive paralysis - 4-6 years after infection. The diffuse nature of brain damage corresponds to extremely polymorphic symptoms, reminiscent of nonspecific vascular diseases described in the previous section. The onset of the disease is gradual, with an increase in neurosis-like symptoms: fatigue, memory loss, irritability. However, compared with atherosclerosis, attention is drawn to the relatively early onset of the disease and more rapid progression without the “flickering” symptoms typical of vascular disorders. Characterized by the early onset of attacks of cerebrovascular accident. Although each of the apoplexy episodes may result in some improvement in the condition and partial restoration of lost functions (paresis, speech disorders), however, repeated hemorrhages are soon observed and a picture of lacunar dementia develops rapidly. At different stages, manifestations of organic brain damage can be Korsakov's syndrome, epileptiform seizures, long-term depressive states and psychoses with delusional and hallucinatory symptoms. The plot of delirium is usually ideas of persecution and jealousy, hypochondriacal delirium. Hallucinosis (usually auditory) is manifested by threatening and accusing statements. At a late stage of the disease, individual catatonic symptoms (negativism, stereotypes, impulsivity) can be observed.

Diffuse nonspecific neurological symptoms are almost always found with asymmetric motor and sensitivity disorders, anisocoria, pupillary unevenness, and a decrease in their reaction to light. In diagnosis, the most important sign of syphilis is positive serological tests (Wasserman reaction, RIF, RIBT). At the same time, with syphilis of the brain, in contrast to progressive paralysis, negative results of blood samples can be observed more often. In this case, reactions with cerebrospinal fluid should be carried out. Other characteristic colloidal reactions can be detected on puncture (see section 2.2.4), in particular the specific "syphilitic tooth" in the Lange reaction.

The course of syphilis of the brain is slow, mental disorders can increase over several years and even decades. Sometimes there is sudden death after another stroke. Timely initiated specific treatment can not only stop the progression of the disease, but also be accompanied by a partial regression of symptoms. In the later stages, there is a persistent mental defect in the form of lacunar (later total) dementia.

progressive paralysis(Bayle's disease, paralysis progressiva afienorum) - syphilitic meningoencephalitis with a gross violation of intellectual-mental functions and a variety of neurological symptoms. The difference between this disease is the direct damage to the substance of the brain, accompanied by multiple symptoms of loss of mental functions. The clinical manifestations of the disease have been described by A. J.T. J. Baylem in 1822. Although during the XX century. the syphilitic nature of this disease has been repeatedly suggested; it was possible to directly detect a pale spirochete in the brain of patients only in 1911 by the Japanese researcher X. Noguchi.

The disease occurs against the background of full health 10-15 years after the initial infection. The first sign of an onset of the disease is nonspecific pseudoneurasthenic symptoms in the form of irritability, fatigue, tearfulness, sleep disturbances. A thorough examination makes it possible already in this phase of the disease to detect some neurological signs of the disease (violation of the reaction of the pupils to light, anisocoria) and serological reactions. Attention is drawn to the special behavior of patients with a decrease in criticism and an inadequate attitude to the existing violations.

Quite quickly, the disease reaches the phase of full bloom. Occasionally, the transition to this phase is accompanied by transient psychotic episodes with clouding of consciousness, disorientation, or delusions of persecution. The main manifestation of the disease at this stage is gross personality changes according to

organic type with loss of criticism, absurdity, underestimation of the situation. Behavior is characterized by disorderliness; the patient gives the impression of being loose on those around him. It seems that a person acts in a state of intoxication. He leaves home, spends money thoughtlessly, loses it, leaves things anywhere. Often the patient makes casual acquaintances, enters into a relationship, often becomes a victim of the dishonesty of his acquaintances, since he is distinguished by amazing gullibility and suggestibility. Patients do not notice a mess in their clothes, they can leave the house half-dressed.

The main content of the disease is a gross disorder of the intellect ( total dementia) with a constant increase in intellectual-mnestic disorders. At first, there may not be a gross violation of memorization, however, a targeted assessment of abstract thinking reveals a lack of understanding of the essence of tasks, superficiality in judgments. At the same time, patients never notice the mistakes they have made, they are complacent, not embarrassed by others, they strive to demonstrate their abilities, they try to sing and dance.

The typical manifestations of the disease described above may be accompanied by some optional symptoms that determine the individual characteristics of each patient. In the last century, delusions of grandeur with absurd ideas of material wealth were more common than other disorders. In this case, one is always surprised by the grandiosity and obvious senselessness of the boasting of the sick. The patient not only promises to give expensive gifts to everyone around him, but wants to “shower them with diamonds”, claims that he “has 500 boxes of gold under his bed at home.” A similar variant of progressive paralysis is designated as expansive form. In recent years, it has been much less common - in 70% of cases there is a predominance of intellectual disorders in the clinical picture without a concomitant mood disorder ( dementia form). Quite rarely, there are variants of the disease with a decrease in mood, ideas of self-abasement and hypochondriacal delusions ( depressive form) or distinct ideas of persecution and isolated hallucinations ( paranoid form).

Various neurological symptoms are very characteristic. Almost constantly there is a symptom of Argyle Robertson (lack of pupil reaction to light while maintaining a reaction to convergence and accommodation). Quite often, the pupils are narrow (like a pinprick), sometimes anisocoria or deformation of the pupils is noted, vision is reduced. Many patients have dysarthria. Other speech disorders are often observed (nasal, logoclonia, skan

slurred speech). Asymmetry of the nasolabial folds, paresis of the facial nerve, masking of the face, deviation of the tongue, twitching of the muscles of the face are not mandatory symptoms, but can be observed. When writing, both a violation of handwriting and gross spelling errors (omissions and repetition of letters) are detected. Often there is asymmetry of tendon reflexes, a decrease or absence of knee or Achilles reflexes. In the later stages of the course of the disease, epileptiform seizures often occur. Describe special forms of the disease with a predominance of focal neurological symptoms: taboparalysis - a combination of dementia with manifestations of dorsal tabes (tabes dorsalis is manifested by a violation of superficial and deep sensitivity and the disappearance of tendon reflexes in the lower extremities, combined with shooting pains), Lissauer form- focal loss of mental functions with a predominance of aphasia and apraxia.

A 45-year-old patient, deputy director of a large department store, was referred to a psychiatric clinic due to misbehavior and helplessness at work.

Heredity is not burdened. The patient is the eldest of two daughters. The patient's mother is healthy, the father died of a heart attack. In childhood it developed normally. She graduated from school and the Institute of National Economy. Plekhanov. She has always worked in trade, distinguished by prudence and insight. She was not very beautiful, but had a light, mobile character, was a success with men. She married at the age of 22 for a man who was 5 years older than her. Family life was going well. Has two sons.

About six months before the real hospitalization, she became less diligent at work, laughed a lot. In the spring at the dacha there was an episode when she could not sleep at night: she ran around the house; didn't know where it was. In the morning, the husband asked the children to come. The patient did not recognize her eldest son, she was afraid of him. Relatives turned to a private doctor. He was treated with a number of drugs, including antibiotics.

Her condition improved significantly: she was fully oriented, tried to go to work. However, she could not cope with her official duties, joked stupidly, and boasted to her employees about her wealth. Once she tried to leave the house for work without wearing a skirt, she did not emotionally react to her husband’s remark about this - she simply dressed in the proper way.

Upon admission to the hospital does not show any complaints, but does not object to hospitalization. Accurately calls his name, year of birth, but is mistaken in determining the real date. Makes compliments to doctors, especially men. He looks at the interlocutor, dressed in a white coat, and cannot determine his profession. Speaks indistinctly, sometimes swallows separate syllables. She laughs, without hesitation declares that she is very rich: “I work in a store - I can get whatever you want. Money is trash."

He makes gross mistakes in the simplest account, cannot remember the name of the attending physician: "Such a young charming young man serves me." He writes his name and address without errors, but the handwriting is unusual, with uneven pressure and crooked lines. Describes himself as a cheerful, sociable person. Willingly sings songs, although he can not always pronounce the words. He beats the time with his palms, gets up, starts dancing.

Miosis and lack of pupillary response to light are noted. The tendon reflexes on the right and left are the same, the Achilles reflex is reduced on both sides. A laboratory examination revealed a sharply positive Wasserman reaction (“++++”), positive reactions of RIF and RIBT. The cerebrospinal fluid is clear, its pressure is not increased, pleocytosis is 30 cells per 1 μl, the globulin/albumin ratio is 1.0; Lange reaction - 4444332111111111.

Treatment with iodine salts, bioquinol and penicillin was carried out. As a result of treatment, she became more calm, obedient, but there was no significant improvement in mnestic-intellectual processes. Issued 2nd group of disability.

The brightness of mental and neurological disorders in typical cases of progressive paralysis makes it possible to diagnose the disease during clinical examination. However, difficult-to-diagnose atypical cases have become more frequent in recent years. In addition, due to a sharp decrease in the incidence of this disease, modern doctors do not always have sufficient clinical experience to detect it. Serological tests are the most reliable diagnostic method. The Wasserman reaction in 95% of cases gives a sharply positive result; to exclude false-positive cases, RIF and RIBT are always carried out. Although with a clear positive result of serological tests, a lumbar puncture can be omitted, however, the study of the cerebrospinal fluid is desirable, since it allows you to clarify the degree of activity of the disease process. Thus, the presence of inflammatory phenomena is indicated by an increase in the formed elements of the cerebrospinal fluid up to 100 in 1 μl, the predominance of the globulin fraction of proteins, the discoloration of colloidal gold in test tubes with the lowest dilution of the cerebrospinal fluid (“paralytic type of curve” in the Lange reaction).

In the last century, the disease proceeded extremely malignantly and in most cases ended in death after 3-8 years. In the terminal (marasmic) phase, there were gross violations of physiological functions (impaired pelvic functions, swallowing and breathing disorders), epileptic seizures, impaired tissue trophism (trophic ulcers on the legs, hair loss, bedsores). In recent years, timely treatment of the disease allows not only to save the lives of patients, but in some cases to achieve a clear positive dynamics of the condition.

Proposed at the beginning of the century, the treatment of progressive steam

Lich vaccinations for malaria [Wagner-Jauregg Yu., 1917] are no longer used in connection with the introduction of antibiotics into practice. However, when conducting antibiotic therapy, possible complications should be taken into account. So in the later stages of a syphilitic infection, the occurrence of gum is very likely. In this case, the appointment of antibiotics can lead to massive death of the pathogen and death as a result of intoxication. Therefore, treatment often begins with the appointment of iodine and bismuth preparations. In the presence of an allergy to the penicillin group, erythromycin is prescribed. The effectiveness of antibiotic therapy may be higher when combined with pyrotherapy. Soft neuroleptics are used to correct the behavior of patients.

Mental disorders in AIDS

The human immunodeficiency virus has a pronounced affinity for both the lymphatic system and the nervous tissue. In this regard, mental disorders at different stages of the course of the disease are observed in almost all patients. It is quite difficult to differentiate disorders caused by an organic process and mental disorders of a psychogenic nature associated with the realization of the fact of an incurable disease.

Mental disorders in AIDS basically correspond to reactions of the exogenous type. In the initial period, phenomena of persistent asthenia are often observed with a constant feeling of fatigue, excessive sweating, sleep disturbances, and a decrease in appetite. Depression, melancholy, depression may occur before the diagnosis is established. Personality changes are manifested by an increase in irritability, irascibility, capriciousness or disinhibition of drives. Already at an early stage of the course of the disease, acute psychoses often develop in the form of delirium, twilight stupefaction, hallucinosis, less often acute paranoid psychoses, a state of arousal with manic affect. Quite often there are epileptiform seizures.

Subsequently, quickly (within a few weeks or months) negative symptoms in the form of dementia increase. In 25% of cases, signs of dementia are detected already in the initial phase of the disease. Manifestations of dementia are nonspecific and depend on the nature of the brain process. With focal processes (cerebral lymphoma, hemorrhage), focal loss of individual functions can be observed (speech disorders, frontal symptoms, convulsive seizures, paresis and paralysis), diffuse lesions (diffuse subacute encephalitis, meningitis, cerebral arteritis) are manifested by a general increase in passivity, lack of initiative ,

drowsiness, impaired attention, memory loss. In the later stages of the disease, dementia reaches the degree of total. Dysfunctions of the pelvic organs, respiratory and cardiac disorders join. The cause of death in patients is usually intercurrent infections and malignant neoplasms.

Organic mental disorders are almost always accompanied by psychologically understandable experiences of patients. The psychological reaction to the disease can manifest itself as a distinct depressive symptomatology, as well as persistent denial of the fact of the disease as a protective mechanism (see section 1.1.4). Often, patients demand a second examination, accuse doctors of incompetence, and try to bring down their anger on others. Sometimes, with hatred for healthy people, they try to infect others.

An important problem associated with HIV infection is the danger of overdiagnosis of AIDS by both doctors and HIV carriers. Thus, infected patients may take any discomfort in the body as signs of a manifestation of the disease and have a hard time responding to the examination, considering this to be evidence of its occurrence. In these cases, the desire to commit suicide is possible.

There is no effective treatment for AIDS, but medical assistance can help prolong the life of patients, as well as improve the quality of life during the period of the disease. In cases of acute psychosis, antipsychotics (haloperidol, chlorpromazine, droperidol) and tranquilizers are used in doses reduced in accordance with the severity of the organic defect. If there are signs of depression, antidepressants are prescribed, taking into account their side effects. Correction of personality disorders is carried out with the help of tranquilizers and mild antipsychotics (such as thioridazine and neuleptil). The most important factor in maintaining psychological balance is properly organized psychotherapy.

Prion diseases

The isolation of this group of diseases is associated with the discovery in 1983 of the prion protein, which is a natural protein in humans and animals (the gene encoding this protein is found on the short arm of chromosome 20). The possibility of infection with mutant forms of this protein has been established, and its accumulation in brain tissues has been shown. Currently, 4 human diseases and 6 animal diseases have been described from prion-related diseases. Among them are sporadic, infectious and hereditary diseases. However, there

data showing that prion proteins formed by random mutation (sporadic cases of the disease) have the same degree of contagiousness as infectious ones.

An example of a typically infectious human prion disease is kuru- a disease discovered in one of the tribes of Papua New Guinea, where the ritual eating of the brain of dead tribesmen was accepted. At present, along with the change in rituals, this disease has practically disappeared. Hereditary prion diseases include Gerstmann-Streussler-Scheinker syndrome, fatal familial insomnia, and familial forms of Creutzfeldt-Jakob disease. Familial and infectious diseases account for no more than 10% of all cases, in 90% of cases there are sporadic cases of the disease (sporadic form of Creutzfeldt-I-Koba disease).

Creutzfeldt-Jakob disease[Kreutzfeld X., 1920, Jacob A., 1921] is a malignant rapidly progressive disease characterized by spongy degeneration of the cerebral cortex, cerebellar cortex and gray matter of the subcortical nuclei. The main manifestation of the disease is dementia with gross impairment of brain functions (agnosia, aphasia, alexia, apraxia) and movement disorders (myoclonus, ataxia, intentional tremor, oculomotor disorders, seizures, pyramidal and extrapyramidal disorders).

In 30% of cases, the development of the disease is preceded by nonspecific prodromal symptoms in the form of asthenia, sleep and appetite disorders, memory impairment, behavioral changes, and weight loss. The immediate onset of the disease is evidenced by visual disturbances, headaches, dizziness, unsteadiness and paresthesia. Usually the disease occurs at the age of 50-65 years, men are more often ill. Effective methods of treatment have not been found, most of the sick people die within the first year, but sometimes the disease stretches for 2 years or more.

Timely diagnosis of the disease presents significant difficulties. Important diagnostic features are the rapid progression of symptoms, the absence of inflammatory changes in the blood and CSF (no fever, increased ESR, leukocytosis in the blood and pleocytosis in the cerebrospinal fluid), specific EEG changes (repeated three-phase and polyphasic activity with an amplitude of at least 200 μV, occurring every 1-2 s).

Particular interest in prion diseases arose in connection with the epidemic of bovine spongiform encephalopathy in England and the appearance in the same period in England and France of 11 cases of Creutzfeldt-Jakob disease with an atypically early onset.

Although no obvious evidence of a connection between these two facts has been found, scientists have to take into account the high persistence of prion proteins (formalin treatment of the tissues of the dead does not reduce their contagiousness). In documented cases of transmission of Creutzfeldt-Jakob disease from one person to another, the incubation period was 1.5-2 years.

Mental disorders in acute brain and extracerebral infections

Disorders of mental functions can occur with almost any brain or general infection. Specific brain infections include epidemic encephalitis, tick-borne and mosquito encephalitis, and rabies. It is not always possible to draw a clear line between cerebral and extracerebral processes, since encephalitis, meningitis and brain vascular damage can occur with such common infections as influenza, measles, scarlet fever, rheumatism, mumps, chickenpox, tuberculosis, brucellosis, malaria, etc. In addition, mediated brain damage against the background of hyperthermia, general intoxication, hypoxia in nonspecific pneumonia, purulent surgical lesions can also lead to psychoses similar in their manifestations to brain infections.

In various infections, the same psychopathological syndromes are often observed. Usually they fit into the concept of an exogenous type of reactions. So, acute psychoses are manifested by switching off or stupefaction of consciousness (delirium, amentia, much less often seizures similar to oneiroid). Psychosis occurs, as a rule, in the evening against a background of severe fever, accompanied by signs of inflammation in blood and cerebrospinal fluid tests. Factors that increase the risk of psychosis include previous organic diseases of the central nervous system (trauma, impaired liquorodynamics), intoxication (alcoholism and substance abuse). More likely to develop psychosis in children.

With prolonged sluggish infections, hallucinatory and hallucinatory-delusional disorders sometimes occur. Debilitating diseases lead to prolonged asthenia. As an outcome of a severe infectious process, Korsakov's syndrome or dementia (psychoorganic syndrome) may occur. A very common complication of severe infectious diseases is depression, which sometimes develops against the background of a gradual resolution of acute manifestations of the disease. Manic and catatonic disorders are much less common.

The most specific clinical picture is epidemic encephalitis(sleeping sickness). The disease was described in 1917 by the Austrian psychiatrist K. Ekonomo during the pandemic of 1916-1922. In recent years, epidemics of this disease have not been observed - only isolated sporadic cases are described.

The disease is characterized by a significant variety of manifestations. Both acute, quickly leading to death cases, and gradually developing low-symptomatic variants are described. Often, after the resolution of the acute phase of the disease, there is a return of symptoms expressed to a lesser extent. In the acute phase of the disease, against the background of subfebrile condition (37.5-38.5 °), a variety of neurological symptoms are observed: diplopia, ptosis, anisocoria, motor retardation, amimia, rare blinking, violation of friendly movements of the arms and legs. With the most acute onset, there may be severe headache and muscle pain, vomiting, impaired consciousness with hallucinations, delirium, hyperkinesis, and sometimes epileptic seizures. An almost obligatory symptom is sleep disturbance, either in the form of periods of pathological hibernation lasting several days or weeks, or in the form of a disturbance in the sleep-wake cycle with pathological daytime sleepiness and insomnia at night. Sometimes at night, excitement and hallucinations are observed.

In addition to the typical variants of the disease, atypical forms are often observed with a predominance of mental disorders - delirium, reminiscent of alcohol; depression with pronounced hypochondriacal ideas and suicidal tendencies; atypical manic states with chaotic unproductive excitement; phenomena of apathy, adynamia, catatonia, hallucinatory-delusional states, which must be differentiated from the onset of schizophrenia.

In previous epidemics, up to "/3 patients died in the acute phase of the disease. Many had a long-term persistent course of the disease. In the long-term period, motor disorders were especially pronounced in the form of muscle stiffness, tremor, bradykinesia (parkinsonism). Often for a long time there were extremely unpleasant sensations in the head and the whole body (crawling, itching).Voices in the head, visual pseudo-hallucinatory images, a violation of the sense of internal unity resembled schizophrenic symptoms.

The diagnosis is confirmed by signs of flaccid inflammation in the cerebrospinal fluid - an increase in the amount of protein and sugar, a pathological Lange reaction (less distinct than in syphilis).

Treatment of infectious diseases is primarily based on etiotropic therapy. Unfortunately, in the case of

For infections, chemotherapy is usually ineffective. Sometimes convalescent serum is used. Non-specific anti-inflammatory therapy includes the use of nonsteroidal agents or corticosteroid hormones and ACTH. Antibiotics are used to prevent the addition of a secondary infection. In the case of severe general intoxication (for example, with pneumonia), detoxification measures in the form of infusions of polyionic and colloidal solutions (hemodez, rheopolyglucin) are of great importance. To combat cerebral edema, diuretics, corticosteroids and oxygen are used, sometimes a lumbar puncture. In acute psychosis, neuroleptics and tranquilizers (usually in reduced doses) have to be prescribed. For a more complete restoration of brain functions during the period of convalescence, nootropics (piracetam, pyriditol) and mild stimulants-adaptogens (eleutherococcus, ginseng, pantocrine, Chinese magnolia vine) are prescribed. Treatment with antidepressants is prescribed in case of a persistent decrease in mood after the acute phase of the disease has passed (in the acute phase of the disease, TCA and other anticholinergic drugs can provoke the onset of delirium).

Mental disorders in brain tumors

In most cases, the first manifestations of intracranial tumors are various neurological symptoms, so patients turn primarily to neuropathologists. Only in some cases, mental disorders are an early and main manifestation of the disease. Their nature largely depends on the localization of the process (see Section 1.1.3 and Table 1.3). Typically, mental disorders become leading in the case of tumors located in such neurologically "silent" areas as the frontal lobes, corpus callosum, deep temporal lobes. The variety of symptoms of tumors makes the diagnosis difficult. This explains the fact that up to 50% of brain tumors in psychiatric practice are diagnosed for the first time during post-mortem examination.

Symptoms of intracranial tumors include cerebral and local symptoms. The general cerebral include signs of increased intracranial pressure and manifestations of intoxication. The earliest sign of increased intracranial pressure is bursting headaches, persistent, aggravated after sleep and with a change in head position, combined with bradycardia. Often at the height of pain, vomiting is noted, not associated with eating.

Another manifestation of an increase in intracranial pressure is periods of impaired consciousness (stunning, obnubilation, somnolence, less often delirious attacks) with difficulty in understanding speech addressed to the patient, mental retardation. Usually such episodes are characterized by instability; often they occur in the evening. Sometimes there are vague pains in the muscles and limbs. Cerebral symptoms in children may be mild due to the compliance of the skull bones.

Local symptoms of tumors can be manifested by signs of both irritation (hallucinations, convulsions, seizures) and prolapse (dementia, aphasia, amnesia, apraxia, apathy, abulia, paresis). For example, with damage to the occipital lobe, both loss of visual field sections, hemianopsia, and episodes of elementary visual deceptions (photopsies) are noted. With damage to the temporal lobe, auditory, olfactory, and less often visual hallucinations often occur, but hearing loss, sensory aphasia, and memory impairment (up to Korsakoff's syndrome) can also be observed. Tumors of the frontal lobes are the most difficult to diagnose, manifested by personality changes with an increase in adynamia and passivity, or, on the contrary, disinhibition of drives and a sharp decrease in criticism. Doctors should be especially wary of epileptic paroxysms (both convulsive and non-convulsive) that first appeared at the age of 30 and older. For brain tumors, partial seizures are primarily typical (see Section 11.1 and Table 11.1). Characterized by a rapid increase in the frequency of seizures, sometimes the occurrence of status epilepticus.

Diagnosis of tumors is largely based on data from special examination methods (see Chapter 2). Signs of increased intracranial pressure can be detected on a traditional craniogram (increased digital impressions, vasodilation, change in the shape of the Turkish saddle), with spinal puncture (if a tumor of the posterior cranial fossa is suspected, this procedure is not performed due to the danger of the “wedging” phenomenon), and also when examined by an ophthalmologist (congestive optic discs, uneven increase in intraocular pressure, unilateral exophthalmos). EEG reveals both cerebral symptoms (increased slow-wave activity) and local disorders (pronounced asymmetry, focal paroxysmal activity). Localization of the process can be established using ultrasonic determination of the position of the M-echo. Particularly valuable for the diagnosis of tumors are modern methods of intravital imaging of brain structures - CT and MRI.

Differential diagnosis should be carried out with other volumetric processes in the brain (hematomas, abscesses,

cysts, cysticercosis, etc.). Frontal symptoms can be very reminiscent of manifestations of progressive paralysis, especially since some pupillary reflexes have a similar picture with tumors and syphilis. The predominance of prolapse symptoms may resemble a picture of an atrophic process. It should be borne in mind that age-related changes in the brain (atherosclerosis, atrophic phenomena), affecting the clinical manifestations of tumors, may complicate their diagnosis.

The only method of radical treatment is surgery. If it is impossible to radically remove the tumor, palliative methods (X-ray therapy, chemotherapy, hormonal treatment) are sometimes used. After surgical removal of the tumor, both partial restoration of lost functions and return to work, as well as persistent preservation of symptoms of an organic defect (dementia) are possible. Correction of mental disorders is carried out with the help of mild antipsychotic drugs (thioridazine, chlorprothixene, neuleptil), anticonvulsants (carbamazepine), and tranquilizers are widely used. The use of nootropics should be carried out taking into account the possible increase in tumor growth.

Brain injury and post-traumatic psychosis

Symptoms of traumatic brain damage depend on the location, form (concussion, bruise, compression) and severity of the brain defect. At concussion(commotio cerebri) mainly affects the base of the brain and the stem part, followed by a violation of the general hemodynamics and liquorodynamics of the brain. At brain injury(contusio cerebri) local damage to blood vessels and brain matter occurs on the surface of the hemispheres. This corresponds to massive loss of cortical functions. It should be borne in mind that in most cases there is a combination of bruising and concussion. Some features differ organic disorders in patients rescued from self-hanging.

The general patterns of the course of any trauma are staging and a tendency to regress psychopathological symptoms. Immediately after the injury, there is a violation of consciousness (up to coma). The duration of the coma can be different (from several minutes and days to several weeks). Some patients die without regaining consciousness. In milder cases, impaired consciousness is expressed by stunning. Cases of a delayed (occurring some time after the injury) impairment of consciousness are described. Usually in these cases, a growing hematoma should be excluded.

After the restoration of consciousness, various disorders related to the exogenous type of reactions can be observed - severe asthenic symptoms, vestibular disorders, nausea, impaired attention, memory. In acute periodotraumatic illness, psychosis with clouding of consciousness (twilight disorder, delirium, much less often oneiroid), hallucinosis, Korsakoff's syndrome, depression with irritability or euphoria with confabulation, attacks of unsystematized delirium may occur. Acute traumatic psychoses are prone to an undulating course (symptoms worsen in the evening), are characterized by short duration, a tendency to spontaneous resolution. After a prolonged coma and with inadequate resuscitation, apallic syndrome (the result of decortication) may occur with a complete lack of contact with the patient, while some reflexes are preserved, and the ability to swallow independently is possible.

During the period of convalescence, there is a gradual improvement in the condition, although in some cases a complete restoration of lost functions does not occur. Within a few months after the injury, pronounced somatovegetative disorders (dizziness, nausea, sweating, headaches, tachycardia, fatigue, feeling of heat) and general cerebral neurological symptoms (nystagmus, impaired coordination of movements, tremor, instability in the Romberg position) persist. Most likely, these phenomena are explained by a temporary violation of hemo- and liquorodynamics. In most patients, the completion of the convalescence period leads to a complete recovery of health, however, the trauma can affect the characteristics of the patient's psychological response to stress (increased vulnerability, irritability) and cause changes in tolerance to certain drugs and alcohol.

In some patients, traumatic disease acquires a chronic course. Depending on the severity of the organic defect in the period of long-term consequences, injuries describe the state of cerebrostenia and encephalopathy. Signs post-traumatic cerebral palsy are mild neurotic level mental disorders - fatigue, frequent headaches, sleep disturbances, attention disorders, irritability, hypochondriacal thoughts. An improvement in the condition after rest is characteristic, however, any new load again causes a sharp decompensation. Post-traumatic encephalopathy is manifested by distinct signs of a persistent organic defect - a persistent memory disorder (Korsakov's syndrome), a decrease in

intelligence (up to total dementia), epileptic seizures (usually partial or secondary generalized). A typical manifestation of encephalopathy is personality changes according to the organic type (see section

with an increase in pettiness, torpidity, stubbornness, vindictiveness and at the same time irascibility, intolerance, emotional lability, sometimes weakness.

Describe acute psychoses that occur in the remote period of a traumatic illness. Typical manifestations of such psychoses are recurrent hallucinations, psychosensory disorders, episodes of derealization. At the same time, hallucinations (usually true) are rather stereotyped, simple in content. Quite often psychotic episodes take the form of paroxysms. Some delusional statements of patients are closely related to disorders of memory and intelligence, more like confabulations. Hallucinatory-delusional episodes are usually unstable, but may recur at regular intervals. Perhaps the cause of psychoses are temporary disturbances in liquorodynamics. A more persistent disorder may be depression, sometimes persisting for many months. However, a constant increase in symptoms in traumatic disease is not observed.

A 25-year-old patient was transferred to a psychiatric hospital from the neurology department of a general hospital due to absurd behavior. From the anamnesis the following is known: heredity is not burdened. The patient is the eldest of 2 children; father is a former officer, demanding, at times despotic; mother is a housewife. Early development without features. He studied well, after graduating from school he entered the Riga Higher Military Aviation School. He successfully completed it and worked at an aircraft factory. He was somatically healthy, did not abuse alcohol, lived with his parents and brother.

At the age of 22, while driving while intoxicated, he received a severe craniocerebral injury, was unconscious for 20 days. After coming out of the coma, speech disorders, paralysis were observed, and he was treated for a hip fracture. Over the next few months, speech was restored, he began to walk. Retired from the Armed Forces. The disability of the 2nd group was issued. Doctors suggested taking psychotropic drugs (Finlepsin and Nozepam) all the time. In the future, gross intellectual-mnestic disorders and a sharp change in personality with a decrease in criticism persisted. Not understanding the severity of the existing violations, he tried to get a job in his specialty, attended paid courses in management and English. He refused unskilled work offered to him. He was irritable and short-tempered. He complained to his mother about the lack of a regular sexual life. Six months before this hospitalization, he stopped taking the recommended funds. Soon anxiety and insomnia set in. He stated that his parents prevented him from getting married; did not sleep at home, abused alcohol. Accused mother of cohabitation with his younger

brother, demanded closeness from his mother. A month before entering the clinic, he was beaten and robbed on the street. Spent several days in the hospital. During this period, the delusions of persecution arose. He didn't remember anything about the fight. Claimed to be harassed by homosexuals; believed that he was raped by a neighbor, the commander of a military unit and his father. He often went to the station, got on trains in order to watch unfamiliar girls. He wrote down in a notebook how they were dressed; thought they were all prostitutes. Occasionally refused to take food, considering it poisoned. He refused to dress, suspected that his clothes had been changed. In this condition, he was hospitalized in a neurological hospital, where there was no gross violation of neurological functions. The patient's absurd statements, refusal to take medication, insomnia and restlessness at night served as the basis for transfer to a psychiatric clinic.

Upon admission, tense, suspicious, cautiously looks around. Before sitting down, he carefully examines the seat, is interested in the names of all the interlocutors. Correctly indicates the day, month, year, but finds it difficult to name the day of the week. To all the doctors' questions about his condition, he tensely answers that he is perfectly healthy. He notes some difficulties with memory, but believes that he should work. He cannot remember the names of doctors, he does not remember anything about the recent fight, he persistently denies that he was beaten. When interpreting proverbs and sayings, he demonstrates the concreteness of thinking. Left to himself, anxious, restless, not kept in the ward. He complains about the “bad atmosphere” in the clinic, as doctors and patients have “bulging eyes”. And his eyes, too, "puffed up so that the eyelids could burst." Refuses to eat, stating that "something was added" to the food. He threatens to break glass on the windows, refuses to take medicines and injections. Of the neurological disorders, only a distinct dysarthria is noted; no paresis or paralysis.

Finlepsin was treated in combination with small doses of neuroleptics (haloperidol and neuleptil). As a non-specific therapy, injections of magnesium sulfate, nootropil and vitamins of group B were performed. Anxiety significantly decreased, crazy ideas were deactivated. At discharge, he could not remember anything about his misbehavior upon admission. Violations of memory, intellect and a decrease in criticism are persistently preserved.

Treatment of patients with traumatic brain injury in the acute period involves the observance of rest (within 2-4 weeks), the appointment of dehydration therapy (magnesium sulfate, diacarb, lasix, concentrated glucose solution), nootropic drugs (aminalon, nootropil, encephabol , cerebrolysin). To reduce irritability, correct sleep disorders, tranquilizers (phenazepam, diazepam, etc.) are prescribed. In the event of epileptiform paroxysms, anticonvulsants (phenobarbital, carbamazepine) are prescribed. It should be taken into account that carbamazepine (finlepsin) helps to stabilize the mood of patients, prevents irritability, irascibility, and alleviates psychopathic manifestations during post-traumatic changes.

personality, can be prescribed in the absence of paroxysmal symptoms. In case of psychosis, antipsychotics are prescribed along with general strengthening and nootropic drugs. A rather high probability of side effects of neuroleptics should be taken into account, therefore, these drugs are prescribed in combination with correctors in relatively low doses. Preference is given to drugs with fewer side effects (chlorprothixene, neuleptil, sonapax, chlorpromazine, azaleptin). In depression, antidepressants are prescribed, taking into account possible side effects.

Intoxication psychoses

Mental disorders resulting from poisoning with substances of various chemical structures are very similar 1 . In many cases, it is impossible to accurately determine the nature of intoxication only by clinical symptoms, since mental manifestations basically correspond to the concept of an exogenous type of reaction. To a greater extent, disorders caused by acute intoxication and developed as a result of chronic poisoning with small doses of a toxic substance differ. Severe acute intoxication, which significantly disrupts the main indicators of metabolism, is usually accompanied by a loss of consciousness (stupor, stupor or coma). The patient may die without regaining a clear consciousness. Less dangerous poisoning can manifest itself as a state of euphoria with carelessness, foolish cheerfulness, complacency. Frequent early symptoms of acute intoxication are dizziness, headache, nausea and vomiting (for example, in case of poisoning with organic solvents, arsenic salts, organophosphorus compounds). Against this background, acute psychoses are often observed. More often than other psychoses, delirium develops (especially when poisoned with anticholinergic drugs). When the condition worsens, the picture of delirium changes, more and more approaching a masticating delirium or even an amental state. A typical oneiroid during intoxication is observed extremely rarely, however, with some intoxications (psychostimulants, hallucinogens), pictures of a fantastic content may appear, combining signs of delirium and oneiroid. A relatively rare disorder is acute hallucinosis: in tetraethyl lead poisoning, a sensation of the presence of foreign objects and hair in the mouth has been described; psychostimulants and cocaine - a sense of movement

1 In ICD-10, the nature of the toxic substance is indicated by codes from T36 to T65.

insects under the skin. In persons with a decrease in the threshold of convulsive readiness, intoxication may be accompanied by epileptiform symptoms - convulsive seizures or paroxysms of twilight stupefaction. In a state of epileptiform excitation (with dysphoria and twilight states), patients can be aggressive.

The exit from the intoxication state is often prolonged and is accompanied by a variety of mental disorders. X. Wieck (1956) described a number of conditions that occupy a transitional position between acute exogenous psychoses and a persistent organic defect, which he called transitional syndromes. In contrast to the persistent psycho-organic syndrome, transient syndromes tend to regress, and although a complete recovery of health is not always observed, a significant improvement in the condition is possible after some time. Transient syndromes are also a characteristic manifestation of chronic, slowly developing intoxications.

The most favorable variant of transitional symptoms - asthenic syndrome, manifested by severe fatigue, irritability, attention disorder. Relatively favorable prognosis in case of occurrence depressive and depressive-delusional states. Although depression can be prolonged, often accompanied by painful hypochondriacal thoughts and even suicidal tendencies, timely treatment can achieve a full recovery. Quite rarely, chronic intoxication develops manic and hallucinatory-delusional psychosis (for example, with an overdose of steroid hormones, psychostimulants or anti-tuberculosis drugs). In this case, it is necessary to carry out differential diagnostics with endogenous diseases. Unlike schizophrenia, these variants of exogenous psychoses are usually also resolved favorably. A significantly worse prognosis occurs when amnestic (Korsakov's) syndrome. In the latter case, the restoration of memory function is rarely complete; in most cases, an irreversible organic defect develops in the outcome.

In the final stage of severe intoxication of the central nervous system, persistent psychoorganic (encephalopathic) syndrome in the form of a decrease in memory, intelligence, personality changes with an increase in irascibility, carelessness, exhaustion or indifference.

Listed below are some of the most common intoxications 1 .

1 Substance intoxications are discussed in the chapter

organic solvents[T52, T53] (gasoline, acetone, toluene, benzene, chloroethyl, dichloroethane, etc.) in small doses cause euphoria, often accompanied by dizziness and headaches, with increased intoxication and exit from intoxication, nausea and vomiting are often observed. Occasionally, intoxication delirium occurs. Chronic intoxication is accompanied by pronounced signs of encephalopathy with memory loss and personality changes.

M-anticholinergics[T42, T44] (atropine, cyclodol, asthmatol) cause excitation, tachycardia, mydriasis, tremor. Very often, at the height of intoxication, delirious stupefaction is noted. Severe poisoning can cause coma and death. Signs of encephalopathy develop rarely, usually after a coma.

Organophosphorus compounds[T44, T60] (insecticides, karbofos, chlorophos, etc.) are opposite to atropine in the mechanism of action. Cause bradycardia, nausea, vomiting, sweating, bronchospasm and bronchorrhea. Severe intoxication is manifested by coma with convulsions. In chronic intoxication, symptoms are expressed by severe asthenia, nausea, dysarthria, photophobia, and emotional lability.

carbon monoxide(carbon monoxide) [T58] can cause severe stunning, in the absence of timely assistance to coma and death. Delirious stupefaction of consciousness is less often observed. After resuscitation, memory disorders (Korsakov's syndrome), speech (aphasia), personality changes in an organic type are often found.

Diagnosis of chronic poisoning with heavy metals, arsenic and manganese is rather difficult [T56]. Signs of arsenic poisoning are dyspepsia, enlargement of the liver and spleen. Mercury intoxication is manifested by neurological symptoms (ataxia, dysarthria, tremor) in combination with emotional lability, uncriticality, euphoria, and sometimes spontaneity. Poisoning lead manifested by headache, asthenia, irritability, depression. Even more severe depression, accompanied by anxiety, psychosensory disorders, delusional ideas of attitude, is observed in chronic poisoning. manganese. With any of the listed intoxications, encephalopathy quickly develops.

In the treatment, etiopathogenetic methods are mainly used. In some acute intoxications, it is possible to administer antidotes (for example, atropine - in case of poisoning with organophosphorus agents, bemegride - in case of barbituric intoxication, ethyl alcohol - when taking methyl alcohol, sodium chloride - in case of poisoning with lithium salts). Detoxification measures depend on the nature

toxin (oxygen therapy - by inhalation of carbon monoxide, hemodialysis - in case of poisoning with low molecular weight compounds, hemosorption and plasmapheresis - in case of poisoning with high molecular weight poisons). In some cases, with acute intoxication (for example, with barbiturates), gastric lavage is useful. Hemodez and forced diuresis have a nonspecific detoxifying effect. With chronic intoxication, detoxification measures do not give such a quick effect. Manifestations of encephalopathy can also be observed when the body no longer detects the toxic substance that caused them. In this case, as a rule, the appointment of psychotropic drugs is required: neuroleptics - with psychomotor agitation, mania and delirium, antidepressants - with depression, tranquilizers - with anxiety, insomnia and irritability. To prevent the development of encephalopathy, nootropic and metabolic agents (nootropil, cerebrolysin, encephabol, glucose, vitamins) are prescribed quite early.

Mental disorders in somatic diseases

The patterns described in the previous section apply not only to intoxications, but also to a wide variety of exogenous mental disorders (radiation injury, prolonged compression syndrome, hypoxia, the state after major surgery), as well as to many somatic diseases.

Symptoms are largely determined by the stage of the course of the disease. So, chronic somatic diseases, states of incomplete remission and convalescence are characterized by severe asthenia, hypochondriacal symptoms and affective disorders (euphoria, dysphoria, depression). A sharp exacerbation of a somatic disease can lead to the onset of acute psychosis (delirium, amentia, hallucinosis, depressive-delusional state). In the outcome of the disease, a psychoorganic syndrome (Korsakov's syndrome, dementia, organic personality changes, seizures) can be observed.

Mental disorders in somatic diseases correlate quite accurately with changes in the general somatic condition. So, delirious episodes are observed at the height of a feverish state, a deep disorder of the main metabolic processes corresponds to a state of turning off consciousness (stupor, stupor, coma), an improvement in the state corresponds to an increase in mood (euphoria of convalescents).

It is rather difficult to separate mental disorders of an organic nature in somatic diseases from psychogenic experiences about the severity of a somatic disease, fears about the possibility of recovery, depression caused by the consciousness of one's helplessness. So, the very need to consult an oncologist can be the cause of severe depression. Many diseases (skin, endocrine) are associated with the possibility of developing a cosmetic defect, which is also a strong psychological trauma. The treatment process can cause concern in patients due to the possibility of side effects and complications.

Consider the psychiatric aspect of the most common diseases.

Chronic heart disease(coronary heart disease, heart failure, rheumatism) are often manifested by asthenic symptoms (fatigue, irritability, lethargy), increased interest in one's health (hypochondria), decreased memory and attention. In the event of complications (for example, myocardial infarction), acute psychosis may develop (more often by the type of amentia or delirium). Often, against the background of myocardial infarction, euphoria develops with an underestimation of the severity of the disease. Similar disorders are observed after heart surgery. Psychoses in this case usually occur on the 2nd or 3rd day after the operation.

Malignant tumors may already in the initial period of the disease manifest increased fatigue and irritability, subdepressive states are often formed. Psychoses usually develop in the terminal stage of the disease and correspond to the severity of concomitant intoxication.

Systemic collagenoses(systemic lupus erythematosus) are characterized by a wide variety of manifestations. In addition to asthenic and hypochondriacal symptoms, against the background of an exacerbation, psychoses of a complex structure are often observed - affective, delusional, oneiroid, catatonic; against the background of fever, delirium may develop.

With kidney failure all mental disorders occur against the background of severe adynamia and passivity: adynamic depressions, low-symptomatic delirious and amental states with mild excitation, catatonic-like stupor.

Nonspecific pneumonia often accompanied by hyperthermia, which leads to delirium. In a typical course of tuberculosis, psychoses are rarely observed - asthenic symptoms, euphoria, and underestimation of the severity of the disease are more often noted. The occurrence of seizures may indicate the occurrence of tubercles in the brain. The cause of tuberculous psychosis (manic, hallucinatory

paranoid) may not be the infectious process itself, but anti-tuberculosis chemotherapy.

Therapy of somatogenic disorders should be primarily aimed at treating the underlying somatic disease, lowering body temperature, restoring blood circulation, as well as normalizing general metabolic processes (acid-base and electrolyte balance, preventing hypoxia) and detoxification. Of the psychotropic drugs, nootropic drugs (aminalon, piracetam, encephabol) are of particular importance. When psychosis occurs, neuroleptics (haloperidol, droperidol, chlorprothixene, tizercin) must be used with caution. Safe means for anxiety, anxiety are tranquilizers. Of the antidepressants, preference should be given to drugs with a small number of side effects (pyrazidol, befol, fluoxetine, coaxil, heptral). With timely treatment of many acute somatogenic psychoses, a complete restoration of mental health is noted. In the presence of distinct signs of encephalopathy, the defect of the psyche persists even after the improvement of the somatic condition.

A special position among the somatogenic causes of mental disorders is occupied by endocrine diseases. Expressed manifestations of encephalopathy in these diseases are detected much later. In the early stages, affective symptoms and drive disorders predominate, which may resemble manifestations of endogenous mental illnesses (schizophrenia and MDP). The psychopathological phenomena themselves do not differ in specificity: similar manifestations can occur when various endocrine glands are affected, sometimes an increase and decrease in hormone production are manifested by the same symptoms. M. Bleuler (1954) described the psychoendocrine syndrome, which is considered as one of the variants of the psychoorganic syndrome. Its main manifestations are affective instability and impulse disorders, manifested by a kind of psychopath-like behavior. More characteristic is not the perversion of drives, but their disproportionate strengthening or weakening. Depression is the most common emotional disorder. They often occur with hypofunction of the thyroid gland, adrenal glands, parathyroid glands. Affective disorders are somewhat different from pure depressions and manias typical of MDP. Mixed states are more often observed, accompanied by irritability, fatigue or irascibility and anger.

Some features of each of the endocrinopathies are described. For Itsenko-Cushing's disease characteristic weakness, passivity, increased appetite, decreased libido without pronounced emotional dullness, characteristic of schizophrenia.

The differential diagnosis with schizophrenia complicates the appearance of strange artsy sensations in the body - senestopathies (“the brain is dry”, “something shimmers in the head”, “the insides are swarming”). These patients are extremely hard to experience their cosmetic defect. At hyperthyroidism, on the contrary, there is increased activity, fussiness, emotional lability with a rapid transition from crying to laughter. There is often a decrease in criticism with a false sense that it is not the patient that has changed, but the situation (“life has become hectic”). Occasionally, acute psychosis occurs (depression, delirium, clouding of consciousness). Psychosis can also occur after strumectomy surgery. At hypothyroidism signs of mental exhaustion are quickly joined by manifestations of a psycho-organic syndrome (decrease in memory, quick wit, attention). Characterized by grouchiness, hypochondria, stereotypical behavior. An early sign Addison's disease is the growing lethargy, noticeable at first only in the evening and disappearing after rest. Patients are irritable, touchy; always trying to sleep; libido drops sharply. In the future, an organic defect rapidly grows. A sharp deterioration in the condition (Addisonian crisis) can be manifested by impaired consciousness and acute psychoses of a complex structure (depression with dysphoria, euphoria with delusions of persecution or erotic delusions, etc.). Acromegaly usually accompanied by some slowness, drowsiness, mild euphoria (sometimes replaced by tears or angry outbursts). If hyperproduction of prolactin is noted in parallel, increased caring, the desire to patronize others (especially children) can be observed. Organic defect in patients with diabetes is mainly due to concomitant vascular pathology and is similar to manifestations of other vascular diseases.

In some endocrinopathies, psychopathological symptoms are completely devoid of specificity, and it is almost impossible to make a diagnosis without a special hormonal study (for example, in violation of the functions of the parathyroid glands). hypogonadism, arising from childhood, manifests itself only in increased daydreaming, vulnerability, sensitivity, shyness and suggestibility (mental infantilism). Castration in an adult rarely leads to gross mental pathology - much more often the experiences of patients are associated with the consciousness of their defect.

Changes in hormonal status can cause some mental discomfort in women in menopause(more often in premenopausal). Patients complain of hot flashes, sweating, increased blood pressure, neurosis-like symptoms (hysterical, asthenic, subdepressive). AT premenstrual period often there is a so-called

my premenstrual syndrome, characterized by irritability, decreased performance, depression, sleep disturbance, migraine headaches and nausea, and sometimes tachycardia, blood pressure fluctuations, flatulence and edema.

Although the treatment of psychoendocrine syndrome often requires special hormone replacement therapy, the use of hormonal agents alone does not always achieve complete restoration of mental well-being. Quite often it is necessary to simultaneously prescribe psychotropic drugs (tranquilizers, antidepressants, mild antipsychotics) to correct emotional disorders. In some cases, the use of hormonal agents should be avoided. So, the treatment of post-castration, menopausal and severe premenstrual syndrome is better to start with psychopharmacological drugs, since the unreasonable appointment of hormone replacement therapy can lead to psychoses (depression, mania, manic-delusional states). In many cases, general practitioners underestimate the importance of psychotherapy in the treatment of endocrinopathies. Almost all patients with endocrine pathology need psychotherapy, and with menopause and premenstrual syndrome, psychotherapy often gives a good effect without the use of drugs.

BIBLIOGRAPHY

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Gilyarovsky V.A. Psychiatry. - 2nd ed. - M. - JL: State. Publishing House of Biological and Medical Literature, 1954. - 752 p.

Dvorkina N.Ya. infectious psychoses. - M.: Medicine, 1975. - 184 p.

Dobrokhotova T.A., Bragina N.N. Functional asymmetry and psychopathology of focal brain lesions. - M.: Medicine, 1977. - 360 p.

Zavalishin I.A., Roikhel V.M., Zhuchenko T.D., Shitikova I.E. Prion diseases in humans, Zh. neuropatol. and a psychiatrist. -

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W. Mayer-Gross. - M., 1967. - 832 p.

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brain. - M.: Medicine, 1948. - 147 p.

This chapter deals with diseases that arise as a result of primary or secondary damage to the brain tissue, i.e. organic diseases. Although the division into organic and functional disorders is widely used in medicine, in some cases it is not possible to draw a clear line between these concepts. So, in schizophrenia, traditionally considered as a functional psychosis, nonspecific signs of organic changes in the brain are often found. The authors of ICD-10 emphasize that the term "organic" does not imply that in all other mental illnesses there are no changes in the structure of the nervous tissue, but indicates that in this case the cause of brain damage or the nature of such damage is known.

In contrast to functional mental disorders, methods for studying the structure and function of the brain are widely used in the diagnosis of organic diseases (see sections 2.2-2.4). However, the absence of distinct signs of pathology during paraclinical examination does not reject the diagnosis of an organic disease. In this sense, the term "organic" is used somewhat more broadly in psychiatry than in neurology, and the diagnosis of organic diseases is largely based on their general clinical manifestations.

The main distinguishing features of organic diseases are a distinct deterioration in memory, impaired intelligence, emotional incontinence and personality changes. To refer to the whole complex of organic mental disorders, the concept is used , described in section 13.3.

In accordance with the leading etiological factor, it is customary to divide organic diseases into endogenous and exogenous. It is assumed that psychosocial factors cannot be the main cause of organic diseases. However, one should always take into account the conditionality of the accepted classifications, since the individual manifestations of psychosis reflect the entire complex of interaction of external biological and psychological factors, heredity and constitutional makeup.

Despite the huge variety of causes that can cause organic damage to the brain (infections, intoxications, injuries, tumors, vascular diseases, etc.), there is a significant similarity between the manifestations of various organic diseases. One attempt to explain it isthe concept of exogenous type of reactions,proposed by the German psychiatrist K. Bongeffer (1908, 1910). In his works, the opinion is expressed that in the process of phylogenesis, the human brain has developed a limited number of standard reactions to all possible external influences. Thus, in response to a variety of damaging effects, reactions of the same type arise. K. Bongeffer's conclusions were based on an analysis of the manifestations of infectious, intoxication and traumatic psychoses. Appearance in the 20th century new toxic substances, infections (for example, AIDS), previously unknown damaging factors (radiation injury) demonstrated the fundamental correctness of the main provisions of this concept.

The syndromes of the exogenous type include:

• asthenic syndrome
• syndromes of impaired consciousness (delirium, amentia, twilight disorder, stunning, stupor, coma)
• hallucinosis
• epileptiform paroxysms
• Korsakov's amnestic syndrome
• dementia.

It should be borne in mind that the listed syndromes are not typical for endogenous functional psychoses (schizophrenia and MDP). However, among the manifestations of organic diseases, there may also be disorders similar to manifestations of endogenous psychoses - delirium, depression, catatonic symptoms. To some extent, the appearance of such symptoms can be explained on the basis of the theory of evolution and dissolution of mental disorders (see Section 3.5 and Table 3.1).

The leading syndrome may indicate the acute or chronic nature of the disease, indicate the initial manifestations of the disease or its final stage (outcome). So, asthenic symptoms are observed in the initial period of slowly developing diseases or in the period of convalescence. Abundant psychotic productive symptoms (stupefaction, delirium, hallucinosis) often occur with an acute onset of the disease or with its subsequent exacerbations. The end states correspond to such negative disorders as dementia, Korsakoff's syndrome, gross personality changes, often combined with a violation of criticism, euphoria and complacency.

In the ICD-10, the systematics of organic disorders is based primarily on the identification of the leading syndrome - the rubric:

• F00 - F03 - dementia,
• F04 - Korsakov's syndrome,
• F05 - delirium,
• F06 - other productive organic mental disorders (hallucinosis, delusions, catatonia, depression, asthenia, hysteroform symptoms),
• F07 Personality changes in organic disease.

This chapter does not provide descriptions of certain diseases, which in fact should also be considered as organic. Thus, epilepsy in the ICD-10 is classified as a neurological disorder, but this disease is characterized by mental disorders that correspond to the concept of a psychoorganic syndrome (dementia, personality changes), and this can be taken into account in the diagnosis in the form of an additional code. The psychoorganic syndrome and syndromes of the exogenous type often also arise as a result of the abuse of psychoactive substances (alcoholism, drug addiction, substance abuse), however, due to the special social significance of these diseases, they are separated into a separate class in ICD-10 and discussed in Chapter 18.

Organic brain damage can develop in people of any age and lifestyle. Moreover, there can be many signs of it: a violation of consciousness, which can be expressed in conjunction with confusion, impaired perception, strong and emotional experiences. Then such symptoms are aggravated and are already expressed in personality deformation and deep mental disorders.

Remember that the brain is a complex system that needs to be protected. There are many diseases for which organic brain damage is common. Each person needs to get acquainted with those factors that increase the risk of developing this pathology.

• Injury. Remember that contusion and bruising of the brain do not go unnoticed.
• Damage to the vessels of the brain (stroke, atherosclerosis, hypertension, which causes vascular damage).
• Organic brain damage can occur against the background of epileptic disease and tumors in this area.
• Other causes include neurosyphilis and HIV infection.
• Viral and bacterial infections of various nature.

This disease affects and changes the most subtle functions of the psyche in all directions.

There is such a thing as residual organic brain damage. If the pathology was diagnosed at an early age, then the disease has that name. In particular, in children with this pathology, epileptic seizures, visual impairment, hearing problems, increased fatigue, and decreased sensitivity can be observed. Very often, these violations interact, which leads to serious consequences.

It should be remembered that such signs are not always the reason that an organic brain lesion develops in children. Perhaps they have taken place before, and the reasons for this may be completely different. Therefore, careful diagnosis and appropriate studies are required.

If such a diagnosis was made to a child, in this situation the most difficult thing falls not only to the patient, but also to his parents. They very often begin to suffer depression and nervous breakdowns, because they are not able to cope with a difficult child. As a rule, the difficulty lies in the fact that the mother and father simply do not know how to behave, and therefore they make many mistakes, harming themselves and their offspring. Here you need a detailed consultation of the attending physician, who can explain all the specifics of the child's disease and options for behavior and treatment.

In general, organic brain damage is characterized by the fact that patients with such a diagnosis narrow their horizons, their inner world and emotional experiences are impoverished. The accumulation of unreacted emotions due to inhibited switching leads to the fact that subsequently their aggressive release occurs. The fact is that a person experiences difficulties in adapting to the environment, which is caused by a feeling of constant dissatisfaction and tension. All this leads to increased aggression, the development of paranoia, groundlessness and uncontrollability of behavioral reactions.

Depending on the psychological characteristics of the body of each person, the ways in which the disease manifests itself also differ. So, organic brain damage can be manifested by the development of obsessive fears, increased anxiety.

Based on the foregoing, we conclude that this disease is usually acquired and requires careful treatment. The main task of people who did not have such problems is to prevent their development and protect the body from all kinds of disorders that can cause malfunctions in its work.