Psychic trauma is a situation of sudden withdrawal of the most significant relationships for a person: a child, a spouse, money, power, etc.

Psychogenic disorders

Psychogenic (reactive) disorders are disorders of the neurotic psychotic level that arise as a result of the impact of shocks that are very significant for a person, negative life situations, loss of loved ones.

This is a whole group of disorders, including reactive psychoses, depression, hysterical psychosis, etc. In the International Classification of Diseases, ICD 10, psychogenies are included in the heading “Reaction to severe stress and adaptation disorders”, which does not fully reflect the picture of reactive (psychogenic) psychoses.

Causes and factors contributing to the development of a psychogenic disorder

The main and in fact the only reason for the appearance of a reactive state is the impact of mental trauma, which acts as a trigger. Many troubles happen in a person's life: natural disasters, wars, man-made accidents, death of loved ones, severe unforeseen circumstances. It is not always possible to withstand the pressure of the negative that surrounds us. Therefore, many do not withstand the load, lose self-control, do inadequate actions.

A distinctive feature from mental illnesses such as schizophrenia or bipolar disorder is that psychogenic disorders are not associated with heredity. The presence of reactive psychosis in relatives is not the reason for its manifestation in a particular person. In addition, after leaving the psychogenic state, behavioral disorders (adaptation) do not progress, they completely disappear, leaving residual changes in the form of asthenia (exhaustion).

Despite the lack of a clear connection with a genetic predisposition, different people react individually to a traumatic situation. This is due to constitutional features, comorbidities, the duration of the trigger and the level of mental exhaustion of the person.

Classification of reactive states

Reactive states exist within neurosis and psychosis. In the first case, the patient remains critical of his condition. During psychosis, a person cannot control himself, he acts destructively and thoughtlessly, often under the influence of hallucinations and delusions.

There are the following forms of reactive psychoses:

• Acute reaction to a stressor (synonym - affective-shock reaction) - reactive psychosis
• Hysterical psychosis - hyperkinetic forms (hysterical excitement - Ganzer psychosis in jailers, during abduction), hypokinetic forms (mutism, stupor, pseudo-dementia).
• Psychogenic paranoid
• Psychogenic depression

Symptoms of psychogenic disorders

Psychogenic disorders are divided into 3 groups:

1. Acute psychogenic-traumatic psychoses (reactive)

Acute reaction to stress- this is a state of shock that occurs under the influence of an extreme situation (a natural disaster, exhausting military operations in a war). These include two options: hypokinetic and hyperkinetic.

The classic description of these variants belongs to Ernst Kretschmer.

hypokinetic This variant is called psychogenic stupor. Kretschmer called it "the imaginary death reflex." Why reflex? Because it is accepted in animals - this is the norm of response. bug, rabbit, etc. pretend to be dead in times of danger. A person after a sudden massive injury has a motor numbness with a twilight disturbance of consciousness. Such a stupor lasts from a couple of hours to 2 days. In most cases, the acute period is not remembered by patients. After leaving the state for 2-3 weeks, a person feels exhaustion.

hyperkinetic variant is called reactive excitation. According to Kretschmer, this is a “reflex of a motor storm”. Since it is observed in the norm again in animals. In those conditions when the animal cannot escape, it turns on the reflex of chaotic chaotic motor excitation - suddenly a random movement will help to escape and survive. And in humans, this is a pathological reaction. There is also increasing anxiety, fear, chaotic psychomotor agitation. There is no criticism, but such a sharp psychotic disorder lasts 15-30 minutes. After these people do not remember anything, because they had a twilight state of consciousness.

A vivid example is the episode from the film “All Quiet on the Western Front”, where a soldier tried to run out of the dugout during an artillery shelling, chaotically waving his arms, and did not understand the speech addressed to him - he had a motor storm reflex.

1. hysterical psychosis

In many ways, it is similar to the affective-shock reaction. However, consciousness is only partially impaired, and the higher functions of the cerebral cortex are preserved. The main types of reactive hysteria:

• Hysterical constriction of consciousness. Demonstration is observed in the behavior of patients, they laugh, sing, shout, "fight in convulsive seizures." The person is disoriented, he has perceptual deceptions, and at the exit from the state - partial amnesia.
• pseudodementia- the patient has an imaginary dementia. He cannot carry out elementary arithmetic calculations, forgets the names of objects, performs illogical actions.
• Puerilism- a form of hysterical reaction in which the patient behaves like a child. He calls those around him "aunt" and "uncle", puts shoes on his hands, crawls on the floor, speaks with a childish intonation.

1. Prolonged reactive psychoses and neuroses

Reactive depression and reactive paranoid. These forms have the classical definition given by Karl Jaspers (Jaspers triad).

1. Psychosis occurs after and as a result of mental trauma.
2. The symptomatology of psychosis reflects the content of mental trauma.
3. Psychosis ends at the end of the trauma and depends on the type of personality and the nature of the trauma. Psychosthenic, for example, will give depression, and explosive - paranoid.

Psychogenic paranoid - a rather rare reactive state, which requires either a very high amplitude of the stress factor, or prolonged exposure to a trigger situation. A person has delusional ideas that have a clear connection with this event. For example, wartime paranoia is indicative. A soldier who has survived the fighting cannot get rid of the feeling of insecurity, readiness to strike at any moment. He seeks cover, mistaking oncoming people for enemy soldiers. An example of such a state is well described in Remarque's novel The Return. Reactive paranoid is often named after a typical situation of occurrence: road paranoid, foreign language environment, prison, etc. Here it is necessary to note another form of reactive paranoid, such as induced. It occurs in the presence of a donor (a mentally ill person) and a recipient (located next to the donor).

It is imperative to conduct a differential diagnosis of a psychogenic paranoid with a procedural disease - schizophrenia, where paranoid symptoms are also often observed. With psychogenic paranoid, paranoid (paranoid, systematized) delusions of interpretation are observed. In schizophrenia, the typical delusion is primary (synonymous with paranoid, unsystematized) - the delusion of ready-made knowledge.

Psychogenic depression observed when the patient indicates a clear connection between low mood, depression and a traumatic situation. Depressive symptoms do not always reach the psychotic level, and modern classification ICD 10 is then interpreted as "Short-term depressive reaction" and "Prolonged reaction of adaptation" (lasts up to two years). In the first case, painful experiences follow immediately after the misfortune. A person feels fear, despair, he has suicidal thoughts. Protracted depression is characterized by a long delay between the trigger and the onset of symptoms. It can reach 6-12 months (no more than 2 years). The patient complains of a feeling of hopelessness, depression, insomnia. The memory of a traumatic situation is enough to aggravate the symptoms.

If depressive symptoms reach a psychotic level, then we observe the characteristic manifestations that are observed in severe depression: a significant decrease in self-esteem, ideas of self-abasement (own insignificance) and self-blame (guilt), significant psychomotor retardation and then the usual household and social functioning becomes impossible. There may be emaciation and dehydration. Delusions that may occur in the clinical picture, as a rule, are congruent to the mood and reflect the content of the mental trauma. Often there are suicidal thoughts and even intentions, and this can lead to suicidal attempts and loss of the patient.

3 Neuroses - neurotic disorders in the modern classification of ICD 10

Clinically, neuroses (neurotic disorders) exist. Their main forms are neurasthenia, hysterical neurosis and psychosthenic neurosis.

The etiology of neuroses (neurotic disorders) is (intrapsychic) ​​conflict.

At neurasthenia- this is a conflict between the requirements for oneself and one's capabilities - "I want, but I can't."

Hysterical the type of conflict is the conflict between the requirements for others and what they provide “I want, but they don’t give”. The requirements of the individual are too high, and "the palace is not given."

psychosthenic type of conflict - a conflict between two important, but not compatible needs - "I want both." For example, between moral and material needs.

Healthy people have all these types of internal conflicts, but they do not get sick, because for the occurrence of a disease, these requirements must be overestimated, well-established with upbringing. Epidemiologists have proven that there are no neuroses as independent diseases (Hamburg multicenter epidemiological study, 1978). In fact, neuroses are only a form of decompensation of certain types of personality, more often psychopathic ( personality disorder), asthenic, hysteroid (dissociative), psychosthenic (anancast), etc. Since there are many concepts of neuroses, only some of their common subspecies are included in international classifications - social phobia, panic disorder, phobic, anxiety disorder, etc.

Here it is necessary to mention such diseases as nosogeny, the occurrence of which is due to the influence of psychotraumatic factors associated with a somatic disease.

Acute mental disorder - treatment

Reactive psychoses require immediate isolation from the traumatic environment and hospitalization. Neurotic spectrum disorders in non-severe cases are treated on an outpatient basis.

In reactive (psychogenic) paranoid, antipsychotic therapy is preferably not recommended. It is necessary to prescribe sedative drugs, although they are not etiotropic therapy. The patient needs to get a good night's sleep.

In psychogenic depression, antidepressants are prescribed if the severity of the depressive state is significantly pronounced, and psychotherapy does not help the patient feel comfortable. With severe anxiety, anxiolytics and tranquilizers are used, and sleeping pills are used to normalize sleep.

The most important place in the treatment of psychogenic disorders is occupied by psychotherapeutic work with the patient at different stages of treatment.

To reactive states include reactive psychoses and neuroses, as well as diseases that occur immediately after mental trauma, which include affects of fear and anger, feelings of resentment and insult, and other types of negatively colored emotional experiences. For childhood, traumatic moments can be the placement of a child in a kindergarten or boarding school, a change in the usual way of life, the departure of the father from the family, the death of loved ones, everything that causes an overstrain of functional systems.

Experience is one of the indispensable and constant parties mental activity person. Therefore, when it comes to the pathogenic role of certain emotions, it is always necessary to take into account the current situation, the reaction to which these emotions are, as well as the general state of the person that preceded the psychotrauma, i.e., the premorbid ("morbus" - illness) state of the person.

To understand the mechanisms of the reactive state, it is necessary to take into account some sections from the teachings of I.P. Pavlov about the types of higher nervous activity. I.P. Pavlov and A.A. Ukhtomsky pointed out that a large number of stimuli of various strengths from internal organs and external environment, causing mental stress, the mobilization of all apparatuses of mental activity in a state of combat readiness, i.e., to the most optimal level of performance. These are the conditions for the perception of stimuli under normal conditions.

For the emergence reactive state two conditions are required:

Weakening of the activity of the cerebral cortex, occurring under the influence of various diseases: infections, intoxication, trauma of the skull, lack of sleep, physical exhaustion, age factor;

Super strong irritant for this person.

Under these conditions, the stimulus that has reached the cerebral cortex does not linger at one point, but spreads over the cortex. A diffuse excitation arises, which cannot be restrained by a weakened inhibitory process, a collision of nervous processes occurs. Excitation covers the entire cortex and reaches the subcortex, concentrating there. At the site of excitation, diffuse protective inhibition is formed in the cortex. Depending on the strength of the stimulus and the type of nervous activity, various psychogenies develop: reactive psychoses and neuroses.

However, as G.E. Sukharev, the division of reactive states into psychoses and neuroses is very conditional, since the boundary between them is often blurred, not sharply expressed. There are cases when the disease begins with neurotic reactions and passes into psychotic. Hence the emergence of such a generalized term as “psychoneurosis” (S.S. Lyapidevsky), to refer to such conditions, the pathophysiological mechanism of which is also common (overstrain of neurodynamic processes in the brain, disruption of the interaction between the main processes of excitation and inhibition).

Reactive psychoses

Reactive states in childhood and adolescence. Reactive states can be observed in both childhood and adolescence. A number of authors (Yu.S. Shevchenko, G.I. Bobyleva, E.I. Morozova, 1989) observed reactive states in children aged 1 to 5 years who attended specialized round-the-clock nurseries for children with borderline neuropsychiatric pathology. Separation from the usual home environment and parents was a superstrong irritant for children, to which they gave a severe reaction in the form of reactive depression, which lasted for a long time.

Reactive depression developed in connection with the difficult adaptation to the children's institution, which the children continued to visit during the entire period of dynamic study. Children were not prepared for a long separation from the family. The authors conventionally identified five stages in the dynamics of protracted reactive depression in young children.

First stage - stage of acute affective-shock reactions characterized by the resistance of the child to stay in new conditions in isolation from their parents. This condition manifested itself in the form of psychomotor agitation with a pronounced vegetative component (flushing of the face, rapid heartbeat, fever), a violent reaction of protest, screaming, and tears. The children could not calm down for a long time, called for their mother, stood at the window or at the door, refused food, walks, daytime sleep did not follow the teacher's instructions. In the process of observation, a refusal to verbal communication, contact with other children was revealed. When parents appeared, the children gave an aggressive reaction: they beat and scolded their parents, did not listen to them.

Second phase - stage of subacute reactive depression was characterized by the subordination of the child, depression by the new conditions of life. The leading psychopathological symptoms were melancholy-apathetic affect and regressive behavior (return to behavioral reactions of an earlier age). Attention was drawn to a sad or aloof facial expression, inhibition and poverty of movements, passivity and indifference in the performance of tasks, refusal to play activities and expressive manifestations of discontent indicated the presence of a severe depressive state. Somatovegetative manifestations of psychogenic depression included decreased response to discomfort, hunger, wet clothes, daytime enuresis, weight loss and loss of appetite, weakening of resistance viral infections and other somatogenic hazards.

Third stage - stage of a protracted polymorphic depressive-neurotic state characterized by neurotic and behavioral disorders. The duration of this stage is from several months to 1 year or more. At this stage, depressive symptoms smoothed out: general depression was replaced by an adequate emotional interest in music lessons, during an individual game with adults. Free play was carried out alone and, as a rule, unstable, short-term. At the same time, any change in the environment, an increase in tone when addressing the child, caused him an anxious-panic reaction: the children went to the side, sat down on a chair and swayed for a long time, shaking their legs or arms, fingering.

Neurotic reactions grew and were characterized by polymorphism. Attention was drawn to the phenomenon of identity, which gives the child's behavior a ritual character. The children tried to keep the route from home to the nursery unchanged, they did not want to part with their favorite toy.

Pathologically habitual actions and systemic disorders (enuresis, encopresis, mutism) were accompanied by fears of darkness, loneliness, cars, and fairy-tale characters. The polymorphism of the clinical manifestations of this stage expanded due to the addition of inhibitory character traits, expressed in an increase in timidity, anxiety, vulnerability, passive obedience, and delayed psychoverbal development.

Fourth stage - stage of the reverse development of the disease, compensation of the state. Clinically, it was characterized by a gradual (over many months, sometimes before the end of the nursery period) process of getting out of a painful state, which was expressed in a weakening of affective and neurotic disorders and an equalization of the pace of mental development.

Reduced level the mood was gradually replaced by a more adequate environment: children actively began to play with toys, laughed, selective attachment to children and adults appeared, behavior became more adequate. Despite the improvement in the general condition, neurotic elements remained in children: anxiety, inhibition, somatovegetative symptoms.

Fifth stage - stage of the post-reactive state, characterizing the outcome of psychogeny. Observation of children for a long time after the end of the reactive period showed two outcomes:

Recovery with residual symptoms;

Post-reactive personality formation.

For first option characterized by a fairly complete completion of the period of the reactive state. The remaining neurotic and somatovegetative disorders are due to the main neurological disorder(speech and motor), for which the child was in a specialized nursery.

For second option the preservation of neurotic disorders is characteristic: fears, rituals, pathologically habitual actions, residual manifestations of mutism, a tendency to freeze in emotional situations, sleep disturbance, appetite, autonomic lability. But even in the absence of these violations, such character traits as inhibition, timidity, timidity, anxiety, shyness, resentment, tearfulness, to a large extent made it difficult social adaptation that manifested itself during the transition to a preschool or school institution. Neurotic reactions reflected the psychomotor level of neuropsychic response (tics, elective mutism, obsessive movements). These observations indicated post-reactive personality formation.

These data showed that children with various organic neurological symptoms react differently to placement in specialized institutions, need constant monitoring, attention, and preparedness for being in a closed institution. Similar reactions can be observed in various young and middle-aged children when sent to a boarding school or hospital. In these cases, a large role in helping children belongs to the educator and teacher-defectologist.

Reactive states in emergency situations. military conflicts, Act of terrorism, catastrophes, natural disasters - emergencies that affect the psyche of adults and children involved in them. Acute reactive states are divided into several groups according to the timing of occurrence and course:

Acute affective reactions that occur immediately after a psychotrauma with a duration of 1–2 hours; assistance to the victims is provided on the spot, and patients are not hospitalized;

Short-term acute reactive states that occur immediately after a psychotrauma, with a duration of a few hours to 5–7 days; patients can be placed in general somatic hospitals, where they must receive psychotherapeutic and medical care;

Acute reactive states of moderate severity with a course of up to 15–20 days (victims are sent to day hospitals of a neuropsychiatric or psychiatric hospital);

Psychotic and protracted forms of reactive states with a course of more than 2–3 weeks (need specialized medical care and treatment in a psychiatric clinic).

Children give more protracted forms of reactive states and with great difficulty get out of them. Long-term psychotherapeutic and psychological work of specialists is required to bring children out of reactive states.

Reactive psychoses in adults. Severe psychotrauma (death of loved ones, fire, earthquake, etc.) can lead to psychogenic (reactive) psychoses. More often they develop in people weakened by infectious or somatic diseases, in psychopaths or accentuated personalities, after suffering a traumatic brain injury or prolonged insomnia. Reactive psychoses can be divided into three groups: acute, subacute and protracted.

Acute psychogenic psychoses(affective-shock reactions). In life-threatening circumstances, a person may suddenly develop a twilight disorder of consciousness with a motor stupor (“imaginary death reaction”) or with chaotic, disordered and inadequate active activity (“motor storm reaction”). Such states usually last from several minutes to several hours.

Subacute psychogenic psychoses(reactive-hysterical). In various psychotraumatic situations, especially with a protracted, agonizing wait (for example, a court verdict), against the background of a twilight state of consciousness, the patient may experience the following psychopathological disorders:

Acute speech confusion - incoherence of speech and thinking of the patient with the impossibility of establishing productive contact with him;

Puerilism - children's behavior, when the speech, facial expressions, actions of the patient resemble exaggerated forms of behavior of a young child;

Pseudo-dementia syndrome - the patient suddenly begins to behave like an imbecile person, giving wrong answers to the simplest questions;

Syndrome of the archaic psyche - the patient behaves like a wild animal: he does not use speech, runs on all fours, barks, howls, bites others, grabs food from the floor with his mouth, etc. The duration of such psychotic states is from several days to 2-3 weeks.

Protracted psychogenic psychoses last 2-3 months or more. There are two types: reactive depression and reactive paranoid.

Reactive depression much deeper than neurotic depression. Patients stop taking care of themselves, do not look after their appearance, do not go out, do not eat, do not adequately blame themselves and others for the accident, and do not consider themselves sick. They try to realize their suicidal plans, considering the situation hopeless. Somatovegetative components of depression are pronounced.

Reactive paranoid. In patients, delusional ideas are formed, their plot associated with psychotraumatic circumstances. Sometimes the distorted delusional logic sounds so convincing to relatives that they also begin to share and support the patient's false conclusions (the so-called induced psychoses). Due to delusional ideas, such people are dangerous for themselves and for others, therefore, they need to be hospitalized.

In cases of reactive psychosis in adults, there are mental disorders characterized by hallucinations and delusions. Special literature contains an extract from the medical history of one woman who came after a long break to the hospital to visit her child and found out that the child had died and was buried. There was not enough information about the parents in the hospital. Having received the news of the death of the child, the mother developed an acute reactive psychotic state, she kept saying that "the child was buried alive as she hears his voice from the earth, the child calls her." The mother demanded exhumation and could not calm down. The presence in this case of hallucinations and delusional statements suggests reactive psychosis. Thus, reactive psychosis is a consequence of psychogenic trauma and is manifested by delusions and hallucinations.

Psychogenic psychoses are usually reversible and end in recovery. However, when the situation develops unfavorably and for a long time there are additional psychotraumas of a similar plot, then, despite the cessation of psychosis, a pathological development of the personality is formed in patients (especially often - paranoid development).

neuroses

Neuroses are psychogenic functional disorders of the nervous system, in which, unlike reactive psychoses, a critical attitude to the disease is maintained and the ability to control one's behavior is not lost. This is the definition proposed by V.V. Kovalev (1979), emphasizes the essence of neurosis: reversibility of symptoms, dynamism clinical picture, the absence of organic symptoms of the lesion.

The doctrine of neurosis has its own history. In medicine of the XVII-XVIII centuries. organic lesions of the nervous system (trauma, tumors, hemorrhages) and mental illness(disorders of consciousness, delusions, hallucinations). Everything that, when presented with complaints by patients, did not fit into the picture of organic and mental disorders, was called "borderline states", and later - "neuroses".

The term "neuroses" was introduced in 1776 by the Scottish physician W. Kellen, who designated them movement and sensation disorders that are not accompanied by fever and do not depend on the defeat of any particular organ, and are due to general suffering. From Kellen's formulation arose and consolidated the idea of ​​neuroses as border states between neurological and mental diseases, i.e. disorders of the nervous system without pronounced symptoms. This position allowed various, not sharply expressed forms of neurological and mental disorders with an unexplained etiology to be included in the group of neuroses. Not only were the clinical manifestations of neuroses unclear, but also their etiology and pathogenesis. As the diagnosis was refined, many of the symptoms included in the concept of "neuroses" were combined with their underlying disease. The term "neuroses" remained without a definite clinical picture. Only thanks to the works of I.P. Pavlov and his school it was possible to prove the etiology, pathogenesis and manifestations this disease. The term "neuroses" combined three diseases: "neurasthenia", "compulsive disorder" and "hysteria", which were previously considered independent, had their own history of study and clinical picture of the disease. The works of I.P. helped to combine them into one clinical form. Pavlov, who experimentally proved that the disruption of higher nervous activity can be caused by overstrain:

Excitatory process;

braking process;

Mobility of nervous processes.

M.K. Petrova, student and colleague of I.P. Pavlova, on the basis of experimental material, showed that neurosis is limited not only by a violation of the function of the GNA, but also affects all organs and tissues of the body. K.M. Bykov (1947) in his work "The Cortex and Internal Organs" proved the enormous role of the cerebral cortex in the regulation of the activity of internal organs and possible changes in them with impaired brain function.

The clinical manifestations of neurosis were described by the American physician D. Beard (1860) under the title "Diseases of the Big City". He drew attention to the fact that workers who worked at this production often complained of drowsiness, fatigue, headaches, pain in the heart, stomach, discomfort in the internal organs, restless sleep and frightening dreams. After interviewing patients, Beard found that many workers live far from production and in difficult conditions, sleep anxiously at night, afraid to be late for work, eat poorly, worry about possible loss work. In production, monotonous work and work at the assembly line, requiring a fast pace of activity, which led to tension and fatigue, and with them drowsiness. Examining the patients, Beard did not find any disease on the part of the internal organs, and connected the expressed complaints with constant unrest and tension of the nervous system. He gave appropriate recommendations: medication and psychotherapy. Subsequently, the symptoms described by Beard entered the clinic. "neurasthenia".

In Europe, the problems of neurosis were dealt with by 3. Freud (1895), who developed the theory of psychoanalysis. According to the theory of 3. Freud, the occurrence of neurosis is due to the dissatisfaction of drives and instincts in childhood. 3. Freud denied the importance of external factors for the emergence of neuroses, he transferred the center of gravity to the "sphere of the subconscious", to the uncontrolled realm of primitive instincts and drives. According to 3. Freud, most people suffering from neuroses are born sick, and do not become sick. Freud's follower in Germany was A. Kretschmer, who was a representative of the constitutional genetic theory in psychiatry, also denied the pathogenetic significance of external hazards, believed that all disorders of the neuropsychic sphere are due to congenital mechanisms.

France in the second half of the 19th century. of great importance in understanding the clinic of neuroses were the works of J. Charcot and P. Janet, who developed methods therapeutic effect in obsessive-compulsive disorder and hysteria.

In domestic literature, the theory of 3. Freud, A. Kretschmer and their followers has not received sufficient distribution. Based on the works of I.P. Pavlov and his school, the problem of neuroses was considered as a disruption of higher nervous activity due to exposure to social factors on prepared biological soil.

In 1974, the Canadian endocrinologist G. Selye put forward the theory of stress - emotional overstrain, which underlies the occurrence of neuroses. According to G. Selye, emotional overstrain is due to the growing pace of life, urbanization (urban life), information overload, weakness, which is one of the leading causes of the ever-increasing neurotic and cardiovascular diseases of modern man.

For understanding the mechanism of neuroses, the works of P.K. Anokhin, "On functional systems". PC. Anokhin is a physiologist, student and follower of the works of I.P. Pavlov, believed that functional systems are dynamic, self-regulating organizations, all constituent components which interact in order to achieve adaptive reactions that are beneficial for the body. Unlike the theory of stress by G. Selye, according to which stress of any origin is caused by an external stimulus, a special stressor, the theory of functional systems by P.K. Anokhin proves that emotional stress develops only in those cases when one or another the dominant behavioral functional system cannot provide an adaptive result vital for the organism.

According to the theory of P.K. Anokhin, emotions as a subject of experience, arose in in the course of evolution as a means of quickly assessing the needs that arise in animals, their satisfaction, as well as assessment of the biological significance of the action of external factors. In evolutionary in terms of these mechanisms proved to be very important in adaptation(fixtures). In humans, emotions play a certain role in assessing not only biological, but also social needs, as well as their satisfaction. Even the biological needs of a person have acquired a socio-emotional coloring.

The clinical picture of neurosis is considered as a psychogenic (conflict) neuropsychiatric disorder, which occurs as a result of a violation of especially significant life relationships of a person and manifests itself in specific clinical phenomena in the absence of psychotic (delusions and hallucinations) phenomena. There are three forms of neurosis: neurasthenia, obsessive-compulsive disorder, and hysteria.

Neurasthenia

The term "neurasthenia" emphasizes rapid exhaustion, weakening of nervous activity, tearfulness, headaches. These conditions are observed in individuals with balanced signaling systems due to overstrain of the main nervous processes. The predominance of the excitatory process over the inhibitory one is noted. Clinical manifestations are characterized by increased excitability, irritability, incontinence, tearfulness.

Predisposing causes: infections, intoxications, excessive physical and mental strain, malnutrition, chronic sleep deprivation, endocrine disorders.

Causing causes: conflict situation at work, in the family, at school, in the children's team, various experiences, loss of loved ones and others. Causing causes can be one-time, strong or not strong, but repetitive, affecting a person.

Parents often "educate" the child, gathering together at the dinner table or at dinner. The reasons for "educational" moments are unsatisfactory grades of the student or the teacher's diary entries about bad behavior at school, the teacher's complaints about the difficulties of the child's behavior in kindergarten. As a reaction to the constant remarks and offensive conversations of the parents, the child develops hiccups, vomiting, refusal to eat, abdominal pain, a feeling of suffocation and other symptoms of a manifestation of a neurotic reaction.

obsessive-compulsive disorder

Obsessive-compulsive disorder develops in people with anxious and suspicious character traits. The development of this form of neurosis is facilitated by overwork, infections, intoxication, constant unrest and worries. Obsessive states can also be in a healthy person, but they do not subjugate his behavior, they are short-lived and easily overcome.

The obsessive states characteristic of neurosis, despite the understanding of meaninglessness and groundlessness, forcibly enter the process of thinking, subjugate and change behavior, and lead to disability. Obsessive states are characterized by affective saturation and manifest themselves in the form of obsessive fears (phobias), obsessive memories, obsessive thoughts. In patients, rituals gradually appear - obsessive actions that are protective in nature, as if protecting a person from danger threatening him or facilitating his speech statement (for example, stuttering).

The dynamics of clinical manifestations is varied. In chronic cases, the disease proceeds for a long time. There are obsessive doubts, indecision, a tendency to mental chewing gum, obsessive memories of names, dates, events, their figurative nature is replaced by an abstract one. The age aspect is of great importance. On the way to school, a schoolboy obsessively remembers whether he took the necessary notebooks or books with him; during a lesson at school, he constantly thinks whether he will be called or not, whether the lesson will be able to answer correctly, whether he will blush, whether they will laugh at him, etc., which constitutes the characteristic basis of “mental chewing gum”. There are obsessive fears of heights, open areas, closed spaces, loneliness, etc. All these experiences make the student indecisive, give reason to feel inferior. Despite the fact that the teenager understands the groundlessness of his thoughts, treats them critically, but cannot cope with his condition. Obsession can turn into an overvalued idea.

It should be noted that the autonomic and affective components of obsessive-compulsive disorder weaken over time. Gradually, the tendency to "mental chewing gum", anxiety and suspiciousness become character traits and begin to determine the neurotic development of the personality. In these cases, medical and psychological and pedagogical assistance is widely used: suggestion, psychotherapy, autogenic training.

Hysteria

Hysteria is one of the most ancient diseases reflected in the literature. Even in ancient Greece, the physician Plato described a disease that was observed only in women. He associated this disease with a dysfunction of the internal organs, in particular, migration or excitation of the uterus, which was the defining term (“hystera” - uterus). In the 17th century there were works pointing to the possibility of hysterical disorders in men. But only in the XIX century. a view of hysteria as a disease of the nervous system that develops under the influence of mental trauma was firmly formed (J. Charcot, Ya. Babinsky, P. Janet).

During the period of study of hysteria, various theories her origin. Some authors explained the symptoms of the disorder by increased affectivity, suggestibility, and infantile personality traits. Others (A. Kretschmer and his followers) believed that hysterical attacks are the result of the release of phylogenetically more ancient mechanisms, and the inhibitory influence of later levels of the psyche is lost. According to 3. Freud, hysteria arises as a result of the suppression of the intensity of affect by the patient and symbolically replaces an action that, due to the suppression of affect, is not realized in behavior.

I.P. Pavlov substantiated and introduced his concept into the theory of the study of hysteria. He believed that in The origin of hysteria is based on two main points:

The weakness of the second signal system and the first signal system is predominant (therefore, hysteria often occurs in people of an artistic type);

Relative weakness of the cerebral cortex, causing external inhibition of the corresponding individuals.

With regard to the "somatic" components found in patients with hysteria, the mechanism of suggestion and self-hypnosis is of great importance. I.P. Pavlov wrote that the remaining symptoms of fear and the temporary security of life due to these components coincide in time and will be required by law conditioned reflexes associate, connect. Hence, the sensation of various "somatic" symptoms and the idea of ​​them receive a positive emotional coloring and, of course, are repeatedly reproduced.

The clinical manifestations of hysteria are varied and variable. G.K. Ushakov (1973) gives several examples from literary sources, which indicate that hysteria is a "proteus" that takes on an infinite number of different forms, that it is a "chameleon" that constantly changes its colors. J. Charcot wrote that in hysteria, the symptoms of manifestation can resemble any disease and called it "the great malingerer." This understanding of hysteria, as a simulation of a disease, existed in the clinic for a long time, and only the works of I.P. Pavlova proved that hysteria is a kind of functional disease nervous system and is a consequence of psychotrauma.

In the clinical picture of hysteria, several conditions are distinguished: hysterical autonomic and sensorimotor disorders; hysterical fit; hysterical personality change. With all the variety of manifestations, they are distinguished by their psychogenic origin, the presence of an element of conditional pleasantness and desirability, as well as the correspondence of the symptom that has arisen to ideas about the disease (the element of self-hypnosis).

Vegetative disorders include: spasms in the throat and loss of voice during excitement (hysterical coma), stomach cramps, belching, nausea and vomiting, hiccups, palpitations, a feeling of heat, swelling and hyperemia, coughing, difficulty breathing (chest tightness) - all symptoms that occur in certain psychotraumatic situations.

Sensorimotor disorders include: feeling of numbness and tingling in the hands, hysterical hypoesthesia or anesthesia (decrease or loss of sensitivity), blindness, narrowing of the visual fields, deafness, paralysis, contractures, mutism and deafness, aphonia, astasia, abasia (inability to walk in the absence of paralysis). Unlike organic paralysis and paresis, hysterical paralysis does not correspond to the localization of the lesion in the nervous system, their symptoms, but reflect the presentation of the patient. In hysteria, patients complain of loss of sensation in the hands of the "gloves" type and on the legs of the "sock" type, which does not correspond to loss of sensitivity when a certain nerve is affected.

hysterical attack always due to a psychogenic conflict situation (refusal to get what you want), a collision of nervous processes (excitation and inhibition) occurs, as a result of which a person complains of pain in the heart area, with the words “I feel bad, I’m dying”, sits down or falls, consciousness is narrowed or absent. Such a state is accompanied by violent motor reactions, sobs, facial expressions and movements correspond to experiences. In clinical and pedagogical practice, it is often necessary to differentiate between a hysterical and an epileptic seizure.

Exist differential diagnosis between a hysterical and an epileptic seizure, which psychologists and teachers need to know in order to provide the necessary assistance (Table 4).

Reactive states are temporary, reversible disturbances of mental activity that occur under the influence of exogenous, psychogenic disorders that are subjectively hard to mentally experience, but are of a functional nature, i.e. not accompanied by organic changes in the GM, but expressed only in the disorder of its functions. Damaging factors can be both habitual and beyond known human experience. There are several forms of reactive states, let's consider some of them.

Acute reactions to stress (they are also called reactive psychoses) can be short and amount to several hours or days (for example, affective-shock reactions, hysterical neurosis), or they can take a protracted form (for weeks or months) and manifest as reactive depression, the development of delirium and hallucinations (reactive paranoid). The causes of acute reactions to stress are different: natural disasters, earthquakes, floods, circumstances that threaten the life of a person, people close to him. Clinically, they manifest themselves in 2 variants:

Reactive stupor (the inability of a person to move, answer questions, take action in a life-threatening situation);

reactive excitation (characterized by chaotic activity, screaming, throwing, panic, "flight reaction").

Both reactive stupor and reactive excitation occur against the background of clouding of consciousness, followed by complete or partial amnesia.

Post-traumatic stress disorder (PTSD) or traumatic neurosis. For PTSD to occur, the person must have been exposed to a stressful event or situation of an exceptionally threatening or catastrophic nature (e.g., car accident, military action, severe accident, witnessing the violent death of others, being a victim of torture, rape, other serious crime)*.

Within 6 months of the stress response, the following symptoms occur: persistent flashbacks or "revivals" of the stressor in intrusive memories, dreams ("flashbacks"), or re-experiencing grief when exposed to circumstances resembling the stressor; there is a desire to actually avoid the stressor or a desire to avoid circumstances resembling or associated with the stressor (which was not observed before its impact); forgetting important aspects the period of exposure to the stressor; the presence of persistent signs of increased psychological sensitivity or excitability (not observed before the action of the stressor), represented by difficulty falling asleep or frequent awakening, irritability or outbursts of anger, difficulty concentrating, increased wakefulness, increased orienting reactions (reflex "watchdog").

Adjustment disorder – is a decrease in productivity in daily activities and impaired social functioning after stressful situation or major life changes. Clinical manifestations: irritability, emotional conflict with increased exhaustion, fixation on the psychogenic aspects of an unpleasant event. The immediate cause of adjustment disorders can be: a situation of adaptation to new living conditions, for example, after arrest, death of loved ones, severe somatic illness, etc.

Dissociative (conversion) disorders. Previously, in psychiatric practice, they were considered as hysterical neuroses. They have two features: the psychogenic nature of the disease (occur after a psychotrauma) and the benefit of the disease for the patient.

* - In the US, women are 10 times more likely to be victims of violence and other sexual assaults than men. In this country, a violent crime occurs every 16 seconds, a rape every 5 minutes, a murder every 21 minutes (from the official FBI crime report).

The mechanism of occurrence of hysterical phenomena is as follows: there are functional, reversible mental disorders based on self-hypnosis and conversion (transfer) of internal anxiety into vivid, demonstrative (hysterical) forms of behavior.

There are several forms of these disorders:

- dissociative amnesia is the loss of memory associated with psychotrauma. amnesia, partial, unrelated organic pathology;

- dissociative fugue - characterized by unconscious departures from home, from work, trips to other cities. Outwardly, a person's behavior is ordered; upon exiting a painful state, he has complete amnesia;

- dissociative stupor - immobility (but at the same time the person does not sleep, does not lose consciousness), upon careful examination, eye movements are noticeable, muscle tone, respiratory movements are preserved;

- trance and loss of personal identity - this is the loss of the patient's assessment of the environment and his own "I";

- dissociative motor and sensory disorders - manifested by paresis, paralysis (decrease or absence of motor function with impaired sensitivity), hyperkinesis (involuntary muscle twitching) and others movement disorders, as well as sensitivity disorders in the form of anesthesia (loss of sensitivity), hypo- and hyperesthesia (its decrease or increase), skin paresthesia (sensations of tickling, tingling, crawling), loss of vision, hearing. In this case, the zones of upset skin sensitivity do not correspond to the zones of innervation of certain nerves, which excludes the presence of nervous diseases. Hysteroid pains are possible, which can be localized anywhere.

Munchausen's syndrome- various hysteroid pains that are not associated with real bodily diseases can be the reason for making incorrect diagnoses, performing erroneous surgical operations;

- somato-vegetative disorders can refer to any of the body systems. More often they are manifested by a feeling of a lump in the throat, lack of air, swallowing disorders, nausea, vomiting, sweating, loss of appetite, constipation, diarrhea, imaginary pregnancy;

- hysterical psychosis have their own characteristics - they are short-lived, closely related to the urgency of the traumatic situation, as a result - they always end in a complete recovery (and even without the participation of a doctor), with the exception of reactive depression and reactive paranoid;

- Ganser's syndrome- as a form of a reactive state manifests itself in helplessness in answering the simplest questions, inability to correctly name parts of the body, to distinguish between the “right” and “left” sides of it, combined with disorientation and “childishness”. The patient understands the meaning of the question, but answers as if "past", hallucinations are possible. May occur during prolonged detention in solitary confinement in places of deprivation of liberty;

- savagery syndrome– similar in external manifestations to Ganser's syndrome, manifested by animal behavior (patients walk on all fours, lap from a plate, howl, bare their teeth, try to bite ...).

- puerilism– this reactive state is characterized by childish behavior (statements like: “I’m still small…”, “Hey, uncle or aunt…”), patients play with dolls, jump on a stick, ask for hands, suck their thumb, stick out their tongue. They speak with a childlike intonation, making childish grimaces.

- pseudodementia– this is an imaginary loss of the acquired simplest knowledge and skills (for example, they cannot multiply 2 x 2; dress themselves, they cannot count the fingers on their hand, etc.).

As a kind of reactive states, development is possible somatoform disorders("soma" - body), which are manifested by various false bodily disorders that allegedly take place. They are usually associated with emotional conflicts, psychological and social problems. Their peculiarity is that there are repeated complaints of patients about various painful sensations, their doubts about the possibility of the presence of various diseases with an objective laboratory and instrumental norm. It is important for the doctor to clarify the presence of anxiety-depressive symptoms in such patients. These include hypochondriacal disorders When a patient has a constant concern about the possible presence of one or more progressive diseases in him, not a single doctor finds anything wrong with him.

Reactive states can proceed with derealization-depersonalization syndrome. Derealization is the patient's feeling that the surrounding world has changed: "unreal", "alien", "rigged". Depersonalization is a painful experience by the patient of his own change, loss of identity, split or loss of his "I".

Reactive states are temporary reversible disorders of mental activity that occur as a reaction in response to the impact of mental trauma.

The term "reactive states" is accepted mainly in the domestic psychiatric literature. In Western European and American literature, similar states are described by various authors under various names: abnormal reactions, psychogenic reactions, stress reactions, etc.

Reactive states make up two main subgroups: 1) neuroses and 2) reactive (or psychogenic) psychoses.

The main clinical sign of the second subgroup is productive psychotic symptoms, which are absent in neuroses. Neurosis develops most often under the influence of prolonged exposure psychogenic factors, while reactive psychoses - as a result of acute, severe mental trauma.

The possibility of developing a reactive psychosis after the stage of neurosis, as well as the formation of a neurotic state after a reactive psychosis, testifies to the nosological unity of psychogenic psychoses and neuroses.

Clinical manifestations of neuroses. Neuroses are called reactive states, the occurrence of which is associated with a long-term psychogenic traumatic situation that causes constant mental stress. In the development of neuroses, personality traits are of great importance, which reflect the low limit of physiological endurance in relation to psychogenies that are different in their subjective significance. Therefore, the emergence of neurosis depends on the structure of the personality and the nature of the situation, which, due to individual personality properties, turns out to be selectively traumatizing and insoluble.

AT international classification diseases, neuroses are combined under the rubric of neurotic, stress-related disorders. In this case, many independent forms are distinguished. The most common and traditional in the domestic literature is the classification of neuroses according to clinical manifestations. In accordance with this, three independent types of neuroses are considered: neurasthenia; hysterical neurosis; obsessional neurosis.

Neurasthenia is the most common form of neurosis; it develops more often in people with an asthenic constitution in conditions of a long-term insoluble conflict situation that causes constant mental stress. In the clinical picture, the leading place is occupied by asthenic syndrome, which is characterized by a combination of asthenia proper with autonomic disorders and sleep disorders. Asthenia is characterized by phenomena of mental and physical exhaustion. Increased fatigue is accompanied by a constant feeling of fatigue. Increased excitability that appears at first, incontinence is subsequently combined with exhaustion, irritable weakness, intolerance to ordinary stimuli - loud sounds, noise, bright light. In the future, the components of asthenia proper, mental and physical exhaustion become more and more pronounced. A constant feeling of fatigue, lethargy underlie the decline in working capacity. Due to the exhaustion of active attention, absent-mindedness, the assimilation of new material, the ability to memorize, worsens, a decrease in creative activity and productivity is noted. Low mood can acquire a depressive color, and as it develops, neurotic depression is sometimes formed. Constant manifestations of neurasthenia are also diverse vegetative disorders, headaches, sleep disturbances, fixing attention on one's unpleasant physical sensations. The course of neurasthenia is usually long and depends, on the one hand, on the cessation or continued action of the traumatic situation (especially if this situation causes constant anxiety, expectation of trouble), on the other hand, on the characteristics of the individual and the general condition of the body. Under changed conditions, the symptoms of neurasthenia disappear without a trace.

In forensic psychiatric practice, hysterical neurosis is more common, often occurring in hysterical psychopathy, as well as in persons with other pathological character traits; however, it can also occur in the absence of appropriate personality traits.

The clinical picture of hysterical neurosis is extremely diverse. Schematically, all hysterical manifestations can be divided into four main groups: 1) movement disorders; 2) sensory disturbances and disturbances of sensitivity; 3) autonomic disorders; 4) mental disorders.

Hysterical seizures are distinguished by expressiveness, duration, accompanied by tears, groans, screams. Hysterical disorders of the motor sphere usually do not depend on innervation, but correspond to the concept of the anatomical division of the limbs (paralysis of one arm, both arms or legs, all four limbs). Hysterical contractures are noted in the muscles of the limbs, sometimes the muscles of the neck, trunk. In the past, the phenomena of astasia-abasia (refusal to stand and walk with the complete preservation of the musculoskeletal system) were often encountered. Such patients, lying in bed, make arbitrary movements with their limbs, change the position of the body. However, when you try to put them on, they fall down, do not rest on their feet. Sometimes, with long-term paralysis, secondary atrophies occur.

In recent decades, these disorders have given way to less pronounced movement disorders in the form of weakness of individual limbs. Hysterical paralysis is more common vocal cords, hysterical aphonia (loss of sonority of the voice), hysterical spasm of one or both eyelids. With hysterical mutism (dumbness), the ability of written speech is preserved and arbitrary movements of the tongue are not violated. Recently, hysterical hyperkinesis, which manifests itself in trembling of the limbs of various amplitudes, is very characteristic. Trembling increases with excitement and disappears in a calm environment, as well as in sleep. Sometimes there are tics in the form of convulsive contractions individual groups muscles. Convulsive phenomena on the part of speech are manifested in hysterical stuttering.

Sensory disturbances are most often manifested in a decrease or loss of skin sensitivity. It is characteristic that changes in sensitivity also do not correspond to the zones of innervation, but reflect ideas about the anatomical structure of the limbs and parts of the body (like gloves, stockings). There are also pain sensations in various parts of the body and various organs. Quite often there are violations of the activity of individual sense organs: hysterical blindness (amaurosis), deafness. Often, hysterical deafness is combined with hysterical mutism, a picture of hysterical deaf-muteness (deaf-muteness) arises.

Autonomic disorders occupy a large place in the clinical picture of hysterical neurosis. Often noted spasm of smooth muscles determines such characteristic symptoms as a feeling of constriction of the throat (hysterical lump), a feeling of obstruction of the esophagus, lack of air. Often there is hysterical vomiting, not associated with any disease gastrointestinal tract and due to spasm of the pylorus of the stomach. With excitement, palpitations, heart rhythm disturbance, shortness of breath, diarrhea and other functional disorders of internal organs are noted.

Mental disorders are even more expressive and diverse than all other manifestations of hysterical neurosis. Emotional disorders predominate: fears, mood swings, states of depression, depression. At the same time, very superficial emotions are often hidden behind external expressiveness.

Often the leading place is occupied by fears about their health. Sometimes noted in hysterical neurosis, functional disturbances of internal organs (for example, palpitations, vomiting, etc.), usually occurring in a traumatic situation, contribute to removal from this situation. Thus, these hysterical manifestations take on the character of "conditional desirability." In the future, they can be fixed and re-reproduced in subjectively difficult situations according to the hysterical mechanisms of "escape to the disease." In some cases, the reaction to a traumatic situation is manifested in increased fantasizing. The content of fantasies reflects the replacement of reality with fictions of contrasting content, reflecting the desire to escape from an unbearable situation.

Obsessive-compulsive disorder is relatively less common in forensic psychiatric practice than hysterical and neurasthenia.

Obsessive phenomena are divided into two main forms: 1) obsessions, the content of which is abstract, affectively neutral in nature, and 2) sensual-figurative obsessions with affective, usually extremely painful content. The clinical picture always presents neurasthenic symptoms- irritable weakness, increased exhaustion, sleep disturbances.

Abstract obsessions include obsessive counting, obsessive memories of forgotten names, formulations, terms, obsessive sophistication (mental chewing gum).

Obsessions, predominantly sensuous-figurative with painful affective content, are more diverse. This group includes: 1) obsessive doubts, constantly arising uncertainty about the correctness and completeness of the actions taken; 2) obsessive ideas that, despite their obvious implausibility, absurd nature, cannot be eliminated (for example, a mother who has buried a child suddenly has a sensory-figurative idea that the child is buried alive); 3) obsessive memories - an irresistible, intrusive memory of some unpleasant, negative emotionally colored event in the past, despite constant efforts not to think about it. The same series of obsessive phenomena includes obsessive fears about the possibility of performing habitual automated actions and actions; 4) obsessive fears (phobias) are especially diverse in content, characterized by irresistibility and, despite their senselessness, the inability to cope with them. Sometimes there is an obsessive senseless fear of heights, open spaces, squares or enclosed spaces. In some patients, an obsessive fear for the state of their heart (cardiophobia) or a fear of getting cancer (carcinophobia) prevails; 5) obsessive actions - movements made against the wishes of patients, despite all the efforts made to restrain them. Sometimes the initial actions are purposeful (for example, coughing with laryngitis or characteristic stretching of the neck when too narrow a collar interferes, etc.). In the future, they are fixed, losing their meaning and purpose.

Another group of obsessive movements and actions accompanies phobias, occurs simultaneously with them and has the character of rituals. These actions, which have the meaning of a kind of spells aimed at preventing an imaginary misfortune, have a protective, protective character. Despite the critical attitude towards them, they are produced by patients contrary to reason in order to overcome obsessive fear. In mild cases, in connection with the complete preservation of criticism and the consciousness of the morbid nature of these phenomena, those suffering from neuroses hide their obsessions and are not excluded from life.

In cases of a severe form of neurosis, a critical attitude towards obsessions disappears for a while, and is revealed as a concomitant pronounced asthenic syndrome, depressed mood. In a forensic psychiatric examination, it should be borne in mind that only in some, very rare cases severe neurotic states, the phenomena of obsession can lead to antisocial actions. In the vast majority of cases, patients with obsessive-compulsive disorder due to a critical attitude towards them and struggle with them do not commit criminal acts associated with the phenomena of obsession.

reactive psychoses. According to the clinical picture, severity, nature and duration of the course, reactive psychoses can be divided into acute shock reactive psychoses, subacute reactive psychoses and protracted reactive psychoses.

Acute shock reactive psychosis occurs under the influence of a sudden very strong psychogenic trauma that poses a threat to existence, most often during mass disasters (earthquake, accident, flood, etc.), with a severe shock associated with unexpected, unpredictable news, arrest, etc. Acute shock reactions are rare.

Acute shock reactive psychosis clinically manifests itself in two forms: hypokinetic and hyperkinetic.

The hypokinetic form (or psychogenic psychomotor retardation) is manifested by a sudden onset of a state of stupor, complete immobility, impaired perception of external stimuli and the absence of speech. This condition is accompanied by vegetative disturbances and deep stupefaction of consciousness by the type of sleep-like stupor, followed by amnesia.

The hyperkinetic form (or psychogenic psychomotor agitation) is characterized by a sudden onset of chaotic disorderly throwing, a senseless flight, often in the direction of danger. Patients strive somewhere, their movements are aimless, undifferentiated and inappropriate. Facial expressions reflect frightening experiences, statements are incoherent, fragmentary. Sometimes this is dominated by acute speech confusion in the form of an incoherent speech flow.

Vegetative disorders are expressed by tachycardia, a sharp blanching or redness, profuse sweats, diarrhea. The state of excitement is accompanied by a twilight disorder of consciousness, followed by complete amnesia. Acute anxiety psychoses should also be referred to the hyperkinetic form of shock reactions. In these cases, in the clinical picture of psychomotor agitation, the leading symptom is panic, unbridled fear. Sometimes psychomotor agitation is replaced by psychomotor retardation, patients seem to freeze in a pose expressing horror, despair. This state of fear usually disappears after a few days, but in the future, any reminder of a traumatic experience can lead to an exacerbation of fear attacks.

In some cases, on the basis of the transferred acute reaction of fear, a protracted neurosis of fear may develop in the future.

Acute shock reactions last from 15-20 minutes to several hours or days.

Subacute reactive psychoses. In the forensic psychiatric clinic, subacute reactive psychoses are most common. According to the psychopathological picture, subacute reactive psychoses are more complex and diverse than acute shock reactions. They develop more slowly and gradually. After the impact of psychogenic trauma, a certain period of processing of the traumatic experience passes.

Sometimes subacute reactive psychoses have an acute stage at first, which then passes into a subacute one. In other cases, subacute reactive psychoses are preceded by a neurotic stage. The duration of subacute reactive psychoses is from 2-3 weeks to 2-3 months. These include: psychogenic depression, psychogenic paranoid and hallucinosis, hysterical psychoses.

Psychogenic depressions are called such psychogenic reactions, in the clinical picture of which the depressive syndrome occupies a leading place, manifested in the affect of melancholy, anxiety and more or less pronounced general psychomotor retardation.

The clinical picture of psychogenic depression is diverse and variable. It is conditionally possible to distinguish four clinical variants that are most often encountered at present in forensic psychiatric practice: 1) simple or, according to the terminology of some authors, “pure” reactive depressions; 2) depressive-paranoid; 3) astheno-depressive; 4) depressive-hysterical syndromes.

Simple reactive depression can also develop in mentally healthy individuals in direct connection with a traumatic experience. Features of the formation of the clinical picture, the rate of development of painful symptoms and the duration of the pathological depressive reaction are determined by the strength and nature of the impact of mental trauma. In the structure of depression, the leading ones are emotional disorders, accompanied by some psychomotor retardation. Depressive affect is motivated, sadness is associated with a psychogenic traumatizing situation, combined with internal stress. This variant of depression is characterized by dynamism, mobility of psychopathological symptoms, depending on external circumstances. Depression can range from mild depression to relatively deep depression. The inhibition of intellectual activity is not sharply expressed, more characteristic is a peculiar violation of the flow of ideas, due to the concentration on a narrow circle of ideas directly related to psychogeny - the upcoming investigation, trial, possible punishment. Patients cannot distract themselves from heavy thoughts and experiences; they evaluate their past in gloomy tones, perceive the present, and fear for the future. In psycho-traumatic situations (conversations about the case, letters from home, etc.), there is a temporary deterioration in the state, as well as a worsening of depression in the evening. The depressive reaction ends with a complete recovery.

Depressive-paranoid syndrome develops preferably in psychopathic personalities, as well as against the background of post-traumatic and cerebrosthenic psychopathic states. The slow and gradual development and growth of the state of depression and anxiety is preceded by a long period of mental processing of the traumatic experience. Often there is insomnia, loss of appetite, various unpleasant physical sensations. At first, depression usually has the character of a more or less adequate and psychologically understandable reaction and is formed at a neurotic level. Patients are concerned about their future, express real fears for their fate, the fate of loved ones, the outcome of the case.

Further, along with elements of timid expectation, anxiety, and severe forebodings, depression and melancholy deepen, accompanied by some psychomotor retardation. Against the background of deepening depression, ideas of a persecutory relationship appear, a delusional interpretation of the environment, directly related to the traumatic occasion. Patients notice that those around them are looking at them in a special way, they believe that they are being watched on behalf of the investigating authorities, their neighbors in the ward “hint” with their movements and gestures that they will face severe punishment, in newspapers and on the radio " allegorically" report on the grave crimes allegedly committed by them.

The course is usually long (2-3 months). At the same time, patients lose weight, they have pronounced vegetative disorders - tachycardia, fluctuations in blood pressure, a feeling of pressure, pain and heaviness in the region of the heart. Persistent suicidal tendencies and attempts are not uncommon, which, due to the lack of demonstrativeness, can be especially dangerous. When the situation changes or during treatment, first of all, the delusional interpretation of the environment disappears. Depression becomes less deep and more adequate, psychomotor retardation gradually disappears, criticism of the transferred painful condition appears.

Astheno-depressive states often occur in psychopathic individuals of an inhibited circle, with post-traumatic and vascular cerebrovascular disease, as well as in people who were previously healthy. This clinical variant of depression begins with the phenomena of neuropsychic exhaustion, reaching the degree of deep physical and mental asthenia. As the disease develops, psychomotor retardation increases, which, however, in recent decades has not reached the degree of stupor (general immobility with mutism (dumbness).

The affect of melancholy is of an inexpressive nature, being replaced by a state of monotonous despondency, apathy. The slowness of the pace of mental processes, the increase in the threshold of perception reflect changes in consciousness by the type of mild stupor. This is also evidenced by the fact that after the patients leave the reactive state, they have indistinct vague memories of the period of the most pronounced lethargy. With the deepening of this state, especially when additional unfavorable factors (infections, intoxications) are included, the state of depression can deepen and take a protracted course. With spontaneous reverse development, as well as as a result of therapy or a change in an unfavorable situation, psychomotor retardation decreases, depressive affect begins to sound more clearly, anxiety and anxiety appear, adequate specific situation. Gradually, mental activity is restored, but for a long time there is a state of post-reactive asthenia.

Hysterical depression is most common in forensic psychiatric practice, mainly in psychopathic personalities of the hysterical circle, with similar clinical manifestations of psychopathic states of an organic nature, and sometimes in healthy people.

In recent years, hysterical depression often develops subacutely after a period of situationally determined emotional stress, depression with elements of irritability and hysterical reactions with outwardly accusing tendencies. Sometimes, as in the past, there is an acute development of depression after a short period of hysterical excitement. The clinical picture of this variant of depression is notable for its particular brightness and mobility of symptoms. The affect of melancholy in hysterical depression is characterized by particular expressiveness, often combined with equally expressive anxiety, directly related to the real situation. Voluntary movements of patients and gesticulation are also distinguished by expressiveness, plasticity, theatricality, subtle differentiation, which creates a special pathetic design in the presentation of their suffering. Sometimes longing is combined with anger, but in these cases, motor skills and facial expressions remain just as expressive. Often, patients injure themselves or make suicidal attempts of a demonstrative nature. They are not prone to delusional ideas of self-accusation, externally accusing tendencies, a tendency to self-justification are more often noted. Patients blame others for everything, express exaggerated and unjustified fears about their health, present a wide variety of variable complaints.

Perhaps the complication of the clinical picture of depression, a combination with other hysterical manifestations. The structure of depression includes elements of pseudodementia. At the same time, patients either refuse to answer questions, repeating “I don’t know”, “I don’t remember”, or answer with a delay, incorrectly. Usually a short one-syllable answer is given to one of the questions, which is repeated for all subsequent ones. Sometimes pseudo-dementia symptoms are combined with puerile ones, patients speak with childish-capricious intonations in their voices, cry inconsolably like a child. Fluctuations in the intensity of depression directly depend on the traumatic circumstances. At the mention of an exciting experience, patients experience short-term states of psychomotor agitation, which are in the nature of hysterical despair. Patients cry loudly, sob, sometimes an angry-dreary intense affective background prevails with statements like a pathetic monologue, reflecting a psychogenic-traumatic situation with aggression and demonstrative self-harm. When the situation worsens, patients experience short-term states of psychomotor retardation, while the expressiveness of symptoms inherent in hysterical depressions is not lost. However, the current remains favorable. The way out of a painful state can occur immediately after a change in the situation or treatment, it can be gradual.

Psychogenic paranoid and hallucinosis, acute paranoids (without hallucinatory phenomena) are relatively rare forms of reactive psychoses. They occur, as a rule, in psychopathic and ancentuated personalities of the inhibited circle, in persons at the age of reverse development (after 50 years), as well as with consequences organic damage of the brain (traumatic and vascular nature) usually after arrest, in prison, often against the background of insomnia. In the initial stage, patients develop an incomprehensible excruciating anxiety, general emotional stress and anxiety. With the preservation of orientation, a slight change in consciousness is noted, it is characterized by insufficient clarity in the differentiation of perceptions. Everything seems to the patient strange, incomprehensible, perceived as if in a fog (the phenomena of derealization). Delusions of special significance, attitudes and persecution are interpretive. The theme of paranoid reflects a traumatic situation. Patients believe that in the cell where they are, they are surrounded by "dummy persons" who watch them "day and night", "wink at each other", thus giving "some signals", are going to "kill", "poison" . In previously unfamiliar faces, they recognize the investigator, the “judge”, “their former enemies” (phenomena of false recognition). The state of melancholy and anxiety is replaced by a pointless expectation of death. Patients defend themselves from imaginary persecutors, being afraid of being poisoned, refuse to eat, become restless, sometimes aggressive. This state does not last long - two weeks - a month. Gradually, usually after being transferred to a hospital, the patients calm down, the state of fear is replaced by melancholy and depression, corresponding to the real situation. The delusional interpretation disappears. However, without expressing any new delusional ideas, the patients still remain unshakably confident in the reality of everything experienced. Criticism of past painful experiences is restored gradually. Asthenia has been noted for a long time.

Subacute psychogenic hallucinatory-paranoid syndrome develops against the background of the same personality characteristics as psychogenic paranoid, as well as in mentally healthy people. This form of reactive psychosis occurs in a situation of relative isolation. In the past - in solitary confinement. At present, this form of reactive psychosis is relatively rare, when conditions of relative isolation are created due to various random circumstances (placement in a separate ward due to quarantine or any disease, stay in a temporary detention cell in the absence of other detainees, etc.) . It is characterized by the acute development of all psychotic manifestations. Against the background of anxiety, insomnia associated with constant thinking and searching for a way out of the current situation, active mental activity is difficult.

In the initial stage, patients develop an incomprehensible excruciating anxiety, phenomena of derealization and false recognition are noted. Gradually goal-directed thinking is replaced by a continuous stream of ideas. Separate words and unfinished phrases quickly replace each other without getting a clear design. Memories of long-forgotten episodes unfold. Patients complain that, in addition to their will, they are forced to think about trifles. Along with the influx of thoughts, there is a feeling of "stretching", "reading" thoughts, a feeling of "internal openness", auditory pseudo-hallucinations, patients hear voices "inside the head" of accusatory, threatening content.

On high psychotic state, against the background of the growing affect of fear, true auditory hallucinations predominate, the content of which is also directly related to the traumatic situation. The voices are multiple in nature, they belong to relatives, a judge, an investigator, often in the form of a dialogue they discuss the behavior of the patient, threaten, predict death. Patients hear the cry of their children, relatives, cries for help.

A large place in the clinical picture is occupied by the delirium of a relationship of special significance and persecution, constant control and influence, supposedly carried out with the help of hypnosis, special devices. All crazy ideas combined general content associated with a psychogenic traumatic situation. At the height of the psychotic state, fear prevails, the behavior of patients is completely determined by their pathological experiences.

A fracture in the condition of patients occurs immediately after their transfer to the hospital. Hallucinations usually disappear first of all, the intense affect of fear is replaced by dreary depression with elements of anxiety, and subsequently by general asthenia. Brad does not show a tendency to further development. However, for a long time, full criticism of what has been experienced is not restored. Often in such cases there is a protracted course of reactive psychosis.

In the forensic psychiatric clinic, pure psychogenic paranoids or psychogenic hallucinosis are now very rare.

Hysterical psychoses in recent decades have changed significantly in their clinical picture and do not occur in forensic psychiatric practice in such diverse, clinically holistic and vivid forms as it was in the past.

At present, from the group of hysterical psychoses, only delusional fantasies have remained in the most unchanged form. The term arose for the first time in forensic psychiatric practice to refer to clinical forms that occur mainly in prison conditions and are characterized primarily by the presence of fantastic ideas. These psychogenically emerging fantastic ideas occupy, as it were, an intermediate position between delusions and fantasies: approaching delusional ideas in content, delusional fantasies differ from them in liveliness, mobility, lack of solidarity with the personality, the lack of a patient’s strong conviction in their reliability, and also direct dependence on external circumstances. . More often, this form develops in individuals with the consequences of a traumatic brain injury, as well as in psychopathic personalities, mostly of a hysterical and excitable circle. In some cases, delusional fantasies develop acutely, against the background of depressed mood, emotional stress with elements of anxiety. Pathological fantastic creativity is characterized by the rapid development of delusional constructions, characterized by variability, mobility, and volatility. Unstable ideas of greatness and wealth predominate, which in a fantastically hyperbolic form reflect the replacement of a difficult unbearable situation with fictions specific in content, the desire for rehabilitation. Patients talk about their flights into space, about the untold riches that they possess, about great discoveries of national importance. Separate fantastic delusional constructions do not add up to a system, they are distinguished by variegation and often inconsistency. The content of delusional fantasies bears a pronounced imprint of the influence of a traumatic situation, the worldview of patients, the degree of their intellectual development and life experience and contradicts the main disturbing mood background. It changes from external moments, questions from the doctor.

During the exit period, anxiety and fear disappear, delusional fantasies become paler and more monotonous, the brightness and mobility characteristic of them at the beginning of the disease are lost, the statements of patients acquire a frozen, “worked out” character, turn into stereotypically repetitive phrases.

In other cases, delusional fantastic ideas are more complex and persistent, showing a tendency to systematization. Just as with unstable, changeable fantastic constructions, all anxieties, worries, and fears of patients are not connected with the content of ideas, but with a real unfavorable situation. Also, patients can talk for hours about their “projects” and “works”, emphasizing that in comparison with the “great significance of their discoveries”, their guilt is negligible. During the period of reactive psychosis regression, situational depression comes to the fore, fantastic statements turn pale, reviving only for a short time when the patients are agitated.

Reactive psychosis with a syndrome of delusional fantasies must be distinguished from a kind of non-pathological creativity that occurs in conditions of imprisonment, which reflects the severity of the situation and the need for self-affirmation. In these cases, patients also write "scientific" treatises of ridiculous naive content, offer various methods of fighting crime, curing serious diseases, prolonging life, etc. However, unlike reactive psychosis with the syndrome of delusional fantasies, in these cases there is no pronounced emotional stress with elements of anxiety, as well as other psychotic hysterical symptoms.

Diagnostic difficulties also arise when delimiting psychogenic delusional fantasies from pseudology and fantasizing in hysterical psychopathy. In reactive psychosis, delusional fantasies arise acutely against the background of emotional stress of anxiety and fear, while the pseudology of psychopathic personalities is a form of reaction that is constantly inherent in them in various stressful situations.

Other clinical forms of hysterical psychoses described in the past are now extremely rare in forensic psychiatric practice or do not occur at all. However, the possible probability of the occurrence of such rare conditions determines the need for at least a brief description of them. General representations about these clinical forms are also important because at the present time there are individual manifestations of these rare forms in the clinical picture of other reactive psychoses.

Ganser's syndrome is manifested by an acute twilight disorder of consciousness, phenomena of "mimorech" (incorrect answers to simple questions), hysterical disorders of sensitivity and sometimes hysterical hallucinations. The disease is acute and lasts for several days. After recovery, the memory of this period of time is noted.

Currently, this syndrome does not occur in the forensic psychiatric clinic.

Pseudo-dementia syndrome (imaginary dementia) is more often observed - a hysterical reaction manifested in incorrect answers (“mimorech”) and incorrect actions (“mimicry”), demonstrating a sudden onset of deep “dementia”, which subsequently disappears without a trace.

The syndrome of pseudodementia is formed gradually against the background of depressive and anxious mood, more often in people with the consequences of organic brain damage, traumatic, vascular or infectious nature, as well as in psychotic personalities of the excitable and hysterical circle. In contrast to the Ganser syndrome, pseudodementia occurs against the background of a hysterically narrowed, rather than a twilight disorder of consciousness. Patients complain of headaches, weakening of memory, weakness, increasing with every movement and even conversation.

The phenomena of “mimorepech” consist in the fact that the patient gives incorrect answers to simple questions, cannot name the current year, month, is not able to say how many fingers he has on his hand, etc. Often the answers to the questions asked are in the nature of denial (“not know”, “I don’t remember”) or are directly opposite to the correct one (a window is called a door, a floor is a ceiling, etc.), or are similar in meaning, or are the answer to the previous question. It should be emphasized that incorrect answers are always related to the correct ones, they lie in the plane of the question posed and affect the circle of correct ideas. In the content of the answer, one can catch a connection with a real traumatic situation (for example, instead of the current date, the patient names the date of arrest or trial, says that everyone around is in white coats, which means he is in the store where he was arrested, etc.). Often such patients cannot perform the simplest habitual actions - to get dressed (symptom of "miacting"). With timely therapy, and sometimes without it, pseudodementia undergoes regression in 2-3 weeks and recovery of all mental functions occurs.

Currently, pseudo-dementia syndrome as an independent form of reactive psychosis almost never occurs, its individual clinical manifestations are more often noted in the clinical picture of hysterical depression or delusional fantasies.

The syndrome of puerilism manifests itself in childish behavior (puer - boy), against the background of a hysterically narrowed consciousness. It occurs in individuals with the same characterological features as pseudodementia.

In forensic psychiatric practice, individual features of puerilism are more common than a holistic puerile syndrome. The most common and persistent symptoms of puerilism are child speech, child movement, and child emotional reactions. Patients with all their behavior reproduce the characteristics of the child's psyche, they speak in a thin voice with childish capricious intonations, build phrases in a childish way, address everyone as you, call everyone "uncles", "aunts". Motor skills acquire a childish character, patients are mobile, run in small steps, reach for shiny objects. Emotional reactions are also made out in a childish way: patients are capricious, offended, pout their lips, cry when they are not given what they ask for.

However, in the children's forms of behavior of puerile patients, one can note the participation of the entire life experience of an adult, which creates the impression of some uneven decay of functions (for example, children's lisping speech and automated motor skills during eating, smoking, which reflects the experience of an adult). Therefore, the behavior of patients with puerile syndrome differs significantly from the true behavior of children.

Manifestations of childishness in speech and facial expressions, external children's liveliness contrast sharply with the dominant depressive emotional background, affective tension and anxiety observed in all patients.

Psychogenic stupor - a state of complete immobility with mutism. In cases where there is psychomotor retardation that does not reach the degree of stupor, they speak of a criminal state. Currently, as an independent form of reactive psychosis does not occur. During certain forms of reactive psychosis, more often depression, short-term states of psychomotor retardation may occur, not reaching the degree of stupor or substupor.

Prolonged reactive psychoses. The concept of protracted reactive psychosis is determined not only by the duration of the course (6 months, a year and up to 5 years), but also by the clinical features of individual forms and the characteristic patterns of the disease dynamics.

It should be emphasized that in recent decades, according to the observations of authors studying reactive states, the clinical picture of reactive psychoses has changed significantly. There is a general trend towards a lighter "simplified" course.

Such a change in the clinical picture of reactive psychoses is due to a number of factors: massive adequate treatment, softening of legislative norms, and other reasons.

In recent decades, only in isolated cases, there is a prognostically unfavorable course of protracted reactive psychoses, which was characterized by the irreversibility of the onset of deep personality changes and general disability.

At present, a similar course of reactive psychoses is observed in isolated cases, only in the presence of a "pathological soil" - in individuals who show signs of organic brain damage after an injury, with cerebral atherosclerosis and arterial hypertension, as well as at the age of reverse development (after 50 years ).

Among protracted reactive psychoses, as well as in subacute ones, “erased forms” predominate, the frequency and brightness of hysterical manifestations have sharply decreased. Almost completely disappeared in the clinical picture of the reactive state such hysterical symptoms as hysterical paralysis, paresis, phenomena of astasia-abasia, hysterical dumbness, which in the past were leading in the clinical picture of protracted reactive psychoses. The main place is occupied by clinically diverse forms of depression, observed in subacute reactive psychoses, taking a protracted course. Often found among subacute reactive states, simple or "pure" depression does not show a tendency to a protracted course.

In recent decades, erased depressive states similar to pure depression have appeared, which do not reach the psychotic level and nevertheless have a protracted course. Situationally determined depression with elements of anxiety prevails. Patients associated their condition with a real psychotraumatic situation. They were preoccupied with the outcome of the case, gloomy, sad, complained of emotional stress, a premonition of misfortune. Usually these complaints were combined with unjustified fears about their health. The patients were fixated on their unpleasant somatic sensations, constantly thinking about the troubles that awaited them, looking for sympathy from those around them. This state was accompanied by a more or less pronounced disorganization of mental activity. The depression was prolonged, fluctuating in its intensity depending on external circumstances.

In subacute reactive psychoses with depressive-paranoid, hallucinatory-paranoid and paranoid syndromes at a protracted stage, dreary depression with elements of anxiety takes the leading place. The gradual deepening of depression is accompanied by increasing psychomotor retardation. The delusional ideas of relation, special significance and persecution noted in the subacute period are joined by delusional ideas of self-accusation, sinfulness, pathological delusional interpretation of the surroundings. Patients are convinced that they are somehow looked at in a special way, “they don’t want to sit down at a common table”, because they know about their crimes and “unseemly acts” in the past, which they themselves forgot about and only recently “remembered” on separate hints. surrounding.

Protracted reactive psychoses with a predominance of dreary depression and the inclusion of delusional ideas are characterized by a long course.

Patients need active therapy, during which the reverse development of the disease occurs with the restoration of criticism to the transferred painful experiences.

The astheno-depressive variant of subacute psychogenic depression also tends to be protracted, especially when additional hazards are added (exacerbation of chronic general diseases, etc.).

At the protracted stage, with the deepening of depression, melancholy predominates, and psychomotor retardation increases. Despite the deepening of depression, as in the subacute period, the condition of patients is characterized by outward inexpressiveness, weariness, depression of all mental functions. Patients usually do not show initiative in conversation, do not complain about anything. They spend most of their time in bed, remaining indifferent to their surroundings. The depth of dreary depression is evidenced by the feeling of hopelessness prevailing in the clinical picture, a pessimistic assessment of the future, thoughts about unwillingness to live. Somato-vegetative disorders - insomnia, loss of appetite, constipation, physical asthenia, weight loss - complement the clinical picture of this variant of prolonged depression. This condition can last up to a year or more. In the process of active therapy, a gradual exit is noted, in which dreary depression is replaced by situational depression. After the reverse development of painful symptoms, asthenia remains for a long time.

Hysterical depression in its protracted course does not show a tendency to deepen. The leading syndrome, formed in the subacute period of reactive psychosis, remains fixed at a protracted stage. At the same time, the expressiveness of emotional manifestations inherent in hysterical depression, the direct dependence of the main mood on the characteristics of the situation, the constant readiness to intensify affective manifestations when the circumstances associated with this situation worsen or only during conversations on this topic remain. Therefore, the depth of depression has a wave-like character. Quite often, in the clinical picture of depression, there are separate unstable pseudo-dementia-puerile inclusions, or delusional fantasies, reflecting the hysterical tendency of “escape to the disease”, avoiding an unbearable real situation, its hysterical displacement. Hysterical depression can be prolonged - up to 2 years or more. However, in the process of treatment or with a favorable resolution of the situation, sometimes an unexpectedly acute, but more often a gradual exit from a painful state occurs without any subsequent changes in the psyche.

In persons who have undergone prolonged hysterical depression, with the resumption of a traumatic situation, relapses and repeated reactive psychoses are possible, the clinical picture of which reproduces the symptoms of the initial reactive psychosis according to the type of worked out clichés.

The described variants of the course of protracted reactive psychoses, especially in psychogenic delusions, are now relatively rare, but a clear understanding of the characteristics of the dynamics of individual, even rare, forms is of great importance for assessing the prognosis of these conditions, which is necessary when solving expert issues.

Forensic psychiatric assessment of reactive states. Committing criminal acts in a state of reactive psychosis is rare; usually reactive states develop after an offense.

In those cases when certain unlawful actions are committed in a state of reactive psychosis, naturally, one should talk about the impossibility of a person at that time to realize the actual nature and social danger of his actions and manage them.

However, usually reactive states occur after the commission of an offense during the investigation, as well as at the end of it, before or after the sentencing and during the period of serving the sentence. Therefore, before the examination, the question is raised of assessing the mental state of a person after the commission of an offense in the indicated time periods.

In accordance with Part 1 of Art. 81 of the Criminal Code of the Russian Federation, the establishment of a reactive state that developed after the commission of criminal acts may be the basis for exemption from punishment, but not from criminal liability.

Persons who fell ill with a mental disorder before the court passed a sentence cannot be sentenced. For those who become deranged after the sentence is passed, it is impossible to carry out or further carry out the punishment already imposed. The court may impose compulsory medical measures on such persons (Articles 97, 99 of the Criminal Code of the Russian Federation).

Since reactive states are temporary painful mental disorders, compulsory treatment is prescribed until the exit from the painful state, i.e. to the restoration of the ability to realize the actual nature and social danger of their actions and to manage them.

It is these qualities that are necessary to participate in the proceedings, as well as to understand the meaning of the punishment imposed.

In accordance with Part 4 of Art. 81 of the Criminal Code, these persons, upon recovery, may be subject to criminal liability and punishment.

In acute and subacute reactive psychoses, which are short-term, completely reversible, recovery usually occurs in an expert hospital. Therefore, resolving the issue of the possibility of continuing the investigation, participation of the subject in the trial or staying in places of deprivation of liberty does not cause difficulties. Difficulties arise when solving the same issues in relation to persons with prolonged reactive psychoses.

The main task of the examination in these cases is to determine the depth and severity of the disease state and its possible prognosis. Prolonged reactive psychoses, the clinical picture of which is characterized by hysterical depression, sometimes with separate pseudo-dementia-puerile inclusions, despite a protracted, often undulating course, are prognostically favorable. At the same time, these conditions do not cause difficulties in their differentiation from other mental disorders.

Therefore, in such cases, the question of the possibility of a person during the commission of an offense to be aware of the actual nature and social danger of his actions and manage them can be resolved. However, due to the duration of the course of the reactive state of patients, according to paragraph "b" part 1 and part 2 of Art. 97 of the Criminal Code of the Russian Federation and taking into account the testimony formulated in Art. 101 of the Criminal Code, should be sent for compulsory treatment. In accordance with Art. 409 of the Code of Criminal Procedure of the RSFSR, the establishment of a temporary mental disorder that arose after the commission of the crime is the basis for the suspension of the proceedings.

Upon recovery, persons under investigation may be subject to criminal liability, and convicted persons may continue to serve their sentence.

When deciding on the issue of prognosis and choice of practical measures in relation to patients with relapses with prolonged hysterical depression, it should be emphasized that the clinical picture of repeated episodes in these cases is built according to the type of worked out clichés and does not reflect the deepening of the initial symptoms. Therefore, in the forensic psychiatric assessment of each repeated episode, similar in its clinical picture to the initial one, one should proceed from the same provisions as in the expert assessment of the initial protracted reactive state.

In protracted reactive psychoses, in the clinical picture of which depressive and depressive-paranoid syndromes occupy a leading place, expert difficulties are associated with the difficulty of distinguishing these conditions from schizophrenia that debuted before committing socially dangerous acts. In addition, reactive psychoses with depressive syndromes can acquire a protracted course. Therefore, given the possibility of diagnostic difficulties, as well as the need for prolonged active therapy in such cases, the most appropriate is the direction of patients in accordance with paragraph "b" of Part 1 and Part 2 of Art. 97 of the Criminal Code of the Russian Federation to psycho-neurological hospitals for compulsory treatment until the recovery from this state without resolving the issue of sanity. Usually these measures are quite effective. Subsequently, after the return of these persons to the expert institution, the issues raised before the examination can be resolved.

In those cases when the psychogenic nature of the disease is confirmed in the process of dynamic observation and active therapy in a psychiatric hospital and the patients recover completely, they can be brought to justice and be held responsible for their deeds (accused) or continue to serve their sentence (convicted).

The cessation of compulsory treatment for patients with prolonged dreary depressive and depressive-paranoid reactions should be recommended only after their complete recovery with the disappearance of post-reactive asthenia and the restoration of criticism of the transferred painful experiences.

At the same time, the presence of such a complete recovery can be judged with certainty only after the withdrawal of active therapy, even maintenance doses.

In very rare cases, protracted reactive states are characterized not only by a long, but also by a progressive course, which loses its direct connection with psychogenic trauma, with increasing deep and irreversible changes in the psyche. Usually, these rare variants of protracted reactive psychoses develop on pathological grounds - with an organic disease of the brain (traumatic, vascular nature), in elderly people against the background of exacerbation of chronic somatic diseases, etc. Such conditions, according to all clinical signs, should be considered as a chronic mental illness that developed after the commission of a crime with all the ensuing consequences provided for in Part 1 of Art. 81 of the Criminal Code of the Russian Federation. At the same time, the establishment of the chronic nature of a mental disorder is the basis for the court to terminate the criminal case or release the person from punishment in accordance with Art. 410 and 412 Code of Criminal Procedure of the RSFSR.

In the expert opinion on the transferred reactive psychosis, the time of the onset of the disease must be indicated, since the assessment of the mental state of the person during the investigation period when giving testimony and performing other investigative actions depends on this. Persons with psychogenic depression sometimes show a tendency to self-accusation and self-incrimination. With psychogenic paranoids and depressive-paranoid reactions, the behavior of patients and their testimony during the investigation period may be due to delusional ideas of attitude, persecution and painful interpretation. These specific forensic psychiatric issues can be resolved only on the basis of a comparison of objective information available in the materials of criminal and personal cases, characterizing the behavior of the subject during the investigation, with clinical data. At the same time, the analysis of the features of the clinical picture of reactive psychosis and, most importantly, the stage at which testimony was given, as well as other investigative actions, is of particular importance. In subacute reactive psychoses, which develop at a rapid pace and are characterized in the acute period by a sharp change in behavior and statements, the time of onset of the psychotic state is quite clearly revealed. Therefore, it is not difficult to establish the period of time until which the testimonies of the subject of an expert should be treated as the testimony of a mentally healthy person.

With erased forms of protracted reactive psychoses, the time of onset of a psychotic state is much more difficult to establish. It must be borne in mind that psychosis is often preceded by a neurotic stage of the disease, which does not exclude the possibility of performing investigative actions.

Subsequently, when the reactive state deepens, reaching a psychotic level, it may be undulating, undulating its course, especially depression. At the same time, there are pronounced fluctuations in the depth and intensity of depressive disorders and the possibility of different assessments of the state of the subjects when they perform investigative actions in different time periods.

Only an analysis of the clinical picture of the mental state during the period of the patient's stay at the examination gives grounds to judge the previous stages of reactive psychosis and its dynamics in general. These data, in comparison with the case materials, reflecting the behavior of the subject at various stages of the investigation, make it possible to assess his condition during the period of testifying and performing other investigative actions.

New questions arise before the examination in connection with the appearance in recent years of various forms of psychogenic neurotic depressions that have a protracted course. These erased depressions that do not reach the psychotic level are accompanied by a certain disorganization of mental activity. In this case, fluctuations in the intensity of the depressive state, sometimes reaching a considerable depth, are possible. Therefore, in the case of a protracted course of such erased depressions, the referral of subjects for treatment until recovery, and not to court, turns out to be justified, since their ability to fully actively exercise the right provided for by law to protect their interests in court is limited.

In rare cases, a forensic psychiatric examination is faced with the question of assessing the mental state of participants in a civil process who show signs of reactive psychosis at its various stages. It should be emphasized that a reactive state often occurs after the commission of a particular legal act (marriage, exchange of living space, drawing up a will, property transaction, etc.) and does not deprive a person at the time of his conclusion of the opportunity to understand the meaning of his actions or manage them . If the patient, being in a state of reactive psychosis, concludes this or that legal transaction, then this ability is lost.

More difficult is the assessment of the mental state of the participants in the process (plaintiffs and defendants) during the period of legal proceedings, their ability to take part in the proceedings as one of the parties (civil procedural capacity). In such cases, the clinical characteristic of the reactive state, the assessment of the leading psychopathological disorders, their neurotic or psychotic level, which determine the ability of a person to understand the meaning of his actions or manage them at the stage of civil proceedings, is fundamental.

clinical observation. Subject B., born in 1958, examination carried out in 1997. She is accused of committing robbery attacks on citizens as part of a group organized by her. B. graduated from 10 classes and two courses of a trade technical school, and subsequently worked in trade. She was married, has three children from marriage, after bringing her husband to criminal responsibility, she filed a divorce with him. Since 1990, she was the commercial director of the store, then she acquired the store as property, sold goods, and provided for her family well. According to the testimony of relatives and employees, she was always active and active. She had not previously consulted a psychiatrist. In this case, B. was detained on March 2, 1996, and on March 25, 1996, she was charged under Part 2 of Art. 162 of the Criminal Code and she was taken into custody. During the investigation in this case, B. behaved correctly, gave consistent testimony, took part in face-to-face confrontations, actively defended herself. According to the materials of the criminal case, the medical record of SIZO-2, when B. was examined by a therapist on May 31, 1996, she complained of fears, was depressed, anxious, and declared that she would be killed. When examined by a psychiatrist on June 3, 1996, she was anxious, expressed ideas of persecution, declared that she heard voices threatening to kill her, discussing ways of reprisal against her, and cried. With a diagnosis of "reactive psychosis" directed to treatment. Against the background of active therapy, the condition improved, but fears, melancholy and anxiety remained. She willingly reported on her experiences, described the ideas of persecution that appeared after her arrest, voices of a threatening nature.

During the examination at the Center. V.P. Serbian from the internal organs pathological changes not found. Focal neurological symptoms also not found. Mental state: during the conversation depressed, tense. He sits bent over, his head bowed low. He speaks in a monotone, low voice. Answers questions slowly and briefly. At times she becomes anxious, frightened, looks around with fear, listens to something. With tears, she reports that behind the wall she hears voices conspiring to kill her. Having calmed down, she says that after the arrest, “voices” of threatening content “appeared” in the cell, “heard” the screams and cries of children who were “mocked”, “tortured”, saw “scenes of massacre” of children. She heard how behind the wall they “discussed ways” of killing her, “passed information to each other” about the need to deal with her, “organized surveillance”, “specially wrote down everything in the documents about her alleged “heart failure”, in order to thus “justify murder". I heard voices saying that "the children are dead." She believes that she is being persecuted and in the Center, where they intend to poison her, those around her “mock and laugh” at her, support the intention to deal with her. On the radio, she hears her name, in some "special broadcasts" hint "at her guilt and" forthcoming massacre ". Despite active therapy throughout her stay at the Center, she remains dreary, depressed, and anxious. Most of the time he lies in the department, does not communicate with anyone, sleeps poorly, often refuses to eat. From time to time, especially in the evening, she becomes especially anxious, restless, expresses ideas of self-accusation, believes that “children died” through her fault, cries. The critical assessment of his morbid condition and the current situation is violated. Conclusion: before being held accountable in this case, during the period of time related to the alleged acts and at the initial stages of the investigation, B. signs of a chronic or temporary mental disorder that would deprive her of the opportunity to realize the actual nature and social danger of her actions and manage them, did not discover. Sane. After being brought to criminal responsibility in this case (from about June 1996), in a psycho-traumatic situation, B. developed a temporary painful disorder of mental activity in the form of reactive psychosis (depressive-paranoid syndrome), which, in the context of ongoing psychogeny, acquired a protracted relapsing character. Therefore, in its own way mental state at present, B. cannot realize the actual nature and social danger of his actions and manage them; hospital of a general type until the exit from the specified disease state.

Doctors call a reactive state a disorder that occurs as a response of the body to the influence of an adverse factor. This term is used in both somatic medicine and psychiatry. Harmful conditions can cause both disruption of the internal organs (liver, pancreas), and damage to mental health. In the first case, the cause of deviations is bodily ailments, and in the second - serious mental trauma. Such pathologies are usually temporary. Next, the main types of negative reactions from the organs and systems of the body (liver, pancreas and psyche), as well as the causes, symptoms and treatment of these disorders, will be considered.

What is reactive hepatitis

The reactive state of the liver proceeds in the form of hepatitis. However, in this case, the pathology is not caused by a virus, but by diseases of other organs. This is the liver's response to harmful influences. Reactive hepatitis is milder and has a better prognosis than infectious lesions. The disease does not progress. Symptoms are mild, and sometimes the disorder proceeds without painful manifestations and is detected only when medical examination. Deviations in the activity of liver enzymes and the level of bilirubin are insignificant. If the cause of the reactive state of the liver is cured, then all violations are completely stopped.

Causes of reactive hepatitis

This disease is always secondary. The following pathologies can provoke its development:

• gastrointestinal ailments: ulcerative processes, inflammation of the pancreas, nonspecific colitis;
• autoimmune rheumatic lesions: scleroderma, rheumatoid arthritis, dermatomyositis, rheumatism, periarthritis nodosa;
• disruption of the endocrine system: diabetes mellitus, hypo- and hyperthyroidism;
• burns of a large area of ​​the body;
• infectious diseases;
• malignant tumors;
• surgical interventions;
• poisoning;
• long-term use of drugs with a hepatotoxic effect.

The pathological process most often affects only the parenchymal tissue and is reversible.

More common in adults. This is due to the fact that children are less likely to suffer from chronic diseases. But if the child still has this pathology, then it proceeds with severe symptoms. In children, the most common cause is diseases of the digestive tract, as well as helminthic invasion.

Symptoms and treatment of reactive hepatitis

In adulthood, the reactive state is very often asymptomatic, which makes diagnosis difficult. The following discomforts are sometimes observed:

• general malaise;
• feeling tired;
• subfebrile temperature;
• weakness;
• discomfort and pain under the ribs on the right side;
• slightly yellowish skin tone.

The patient does not always associate these signs with impaired liver function. It is very important to identify these deviations in time. During medical examination there may be slight pain during palpation. The liver is slightly enlarged. Assign a blood test for biochemistry. The results of the study determined a slight increase in bilirubin, liver enzymes and a decrease in protein. It is important to separate reactive inflammation from viral hepatitis. To do this, conduct blood tests for the presence of infection.

At timely treatment reactive state has a favorable outcome. All violations are functional. For successful therapy, it is necessary to find out the cause of the disorders that have arisen and cure the underlying disease. In addition, hepatoprotectors are prescribed, the patient is recommended to follow a sparing diet. If the pathology is caused by poisoning or long-term use hepotatoxic drugs, then it is necessary to take enterosorbents.

It is not dangerous, but it is unacceptable to delay contacting a doctor and self-medicate. Without therapy, disorders can become persistent and complicate the course of existing diseases.

What is reactive pancreatitis

The pancreas is closely related to the digestive system. Therefore, many pathologies of the gastrointestinal tract negatively affect the work of this organ. The gland produces pancreatic juice, which then mixes with bile and enters the intestine through the ducts. However, various diseases disrupt this process, and then there is a reactive state of the pancreas (reactive pancreatitis).

Enzymes of pancreatic juice begin to work after entering the intestine. In the pancreas, they are in an inactive form. Special intestinal fluids put these enzymes into action. This is how the digestive process works in a healthy person. But with diseases of the gastrointestinal tract, intestinal fluid can be thrown into bile ducts. In this case, it becomes active while in the pancreas, and the enzymes begin to negatively affect this endocrine organ. Inflammation occurs - reactive pancreatitis.

Causes of reactive pancreatic pathology

The provoking factors in the development of a reactive state of the pancreas are the following diseases and disorders:

• pathologies of the stomach and intestines: gastritis, peptic ulcer, gastroduodenitis, infections and injuries of the digestive system;
• liver disease: gallstones, cirrhosis, biliary dyskinesia;
• operations on the gastrointestinal tract and gallbladder;
• autoimmune pathological processes;
• poisoning;
• alcohol abuse;
• inadequate and malnutrition.

In children, it often develops as a complication of ascariasis. With a strong invasion, helminths clog the bile ducts, which leads to congestion and inflammation of the pancreas.

Symptoms and treatment of reactive pancreatitis

Symptoms of reactive inflammation of the pancreas are usually pronounced. At the initial stage, the patient has the following symptoms:

• There is severe pain in the abdomen and under the ribs, discomfort intensifies after eating.
• Often there is vomiting, which does not bring relief.
• The patient suffers from heartburn and belching.
• Formed in the intestine increased amount gases, bloating is determined.
• There is diarrhea up to several times a day.

Then comes a strong intoxication of the body. The patient's skin turns pale, the limbs become cold, there is a rapid heartbeat, blood pressure falls. The general condition is rapidly deteriorating. At severe forms reactive pancreatitis requires immediate hospitalization.

The clinical picture also depends on the cause of the pathology. If the reactive state has arisen due to diseases of the liver and gallbladder, then patients complain of pain in the solar plexus. If pancreatitis was provoked by lesions of the gastrointestinal tract, then discomfort is localized in the upper abdomen.

The symptomatology of the reactive state of the pancreas in a child has its own characteristics. In addition to the above manifestations, children have heat, plaque on the tongue, dry mouth, diarrhea is replaced by constipation. In the blood test, the level of sugar rises. In infancy, the disease often occurs without pronounced symptoms, but lethargy and reduced appetite in infants can be noticed.

Diagnosis of the disease is carried out using ultrasound. In this case, not only the pancreas is examined, but also all the digestive organs. This is necessary to establish the cause of reactive inflammation. In addition, a urine test for pancreatic enzymes, a blood test for leukocytes and ESR, as well as endoscopy of the duodenum are prescribed.

The underlying disease that caused reactive pancreatitis is being treated. They also prescribe anti-inflammatory drugs, analgesics and antispasmodics. It helps to take off pain syndrome. A diet with a restriction of spicy and fatty foods is necessary.

Reactive pancreatitis has a favorable prognosis. Early therapy leads to full recovery. If left untreated, the inflammatory process can become chronic, in addition, patients often have an increase in blood sugar levels.

Reactive mental disorders

In psychiatry, reactive states are temporary mental disorders that develop after emotional upheavals. Violations are reversible and disappear after treatment. Such a pathology can occur in any person after difficult experiences, for example, after the death or serious illness of a loved one, family breakup and other sad events. However, an unfavorable and protracted course of these disorders is observed in people suffering from psychopathy or vascular diseases.

Reactive states are the body's response to mental trauma. Two main subtypes of such disorders can be distinguished:

• reactive neuroses;
• reactive psychoses.

Neurosis usually occurs during a long traumatic situation. Psychoses appear as a reaction to acute emotional experiences and stress.

The following forms of reactive states of a neurotic nature can be distinguished:

• neurasthenia;
• obsessive-compulsive disorder;
• hysteria.

There are also several types of reactive psychoses:

• depression of psychogenic etiology;
• paranoid disorders;
• psychogenic hallucinosis;
• puerilism;
• delusional fantasies;
• stupor;
• syndrome of "running wild";
• imaginary dementia.

The symptoms of such disorders are always pronounced. The duration of the flow of jet mental disorders depends on the presence of concomitant vascular pathologies and the type of personality of the patient. At vulnerable people with and also in patients with atherosclerosis, such disorders can continue for a long time.

Symptoms of reactive mental disorders

The clinical picture of reactive disorders is extremely diverse. Symptoms of the disease depend on the form of the disorder.

The main symptoms observed in various forms of psychogenic neurotic states should be considered:

1. Neurasthenia. The patient is mentally and physically exhausted. The patient gets tired easily constant fatigue, headaches, sleep is sharply disturbed. Decreased performance. The person becomes excitable, irritable, anxious. At the same time, the mood is constantly lowered.
2. Obsessional neurosis. Such a deviation after a psychotrauma is observed infrequently. The patient constantly performs the same actions, for example, counting objects or touching them. Sometimes a person makes different movements. For the patient, this takes on the character of protective rituals. Disturbed by obsessive thoughts, memories, fears that arise against the will of the patient.
3. Hysteria. There is a strong crying with screams and motor excitation. In some cases, a person cannot stand and walk with a completely healthy musculoskeletal system. These phenomena are accompanied by vegetative disorders: sensation of a lump in the throat, suffocation, nausea.

In reactive psychoses, more severe disorders are noted:

1. Psychogenic depression. Patients experience a persistent decrease in mood. The severity of this symptom can vary from mild depression to severe depression. Often patients blame themselves, for example, for the death and illness of a loved one. Movement and facial expressions are sharply inhibited.
2. paranoid disorders. Against the background of a dreary mood and increased anxiety, delusions of persecution or external influence arise. Patients become fearful, restless or aggressive. The content of delusional ideas is usually associated with psychotrauma.
3. psychogenic hallucinosis. The patient has auditory hallucinations. He hears voices discussing him. At the same time, the patient feels intense fear. Optical deceptions are possible when the patient takes the surrounding objects for people. The content of hallucinations is associated with experienced stress.
4. Puerilism. The patient imitates the behavior of a small child. Patients talk in a childish voice, act up, cry.
5. Delusional fantasies. The patient periodically has ideas of greatness or imaginary wealth. Unlike paranoid delusions, these disturbances are not persistent and permanent. One idea quickly replaces another. With treatment, fantasies disappear.
6. Stupor. The patient becomes extremely lethargic, stops moving, eating and talking.
7. Syndrome "wildness". This type of reactive mental state is extremely rare. In the behavior of the patient, features characteristic of the habits of animals are noted. Patients moo, bark, crawl on all fours, become aggressive.
8. Imaginary dementia. There are signs of dementia. Patients have impaired memory, they cannot give the correct answer to simple questions or perform habitual actions. However, unlike true dementia, this condition is easily cured and has a good prognosis.

Diagnosis of reactive psychoses is often difficult. These conditions must be distinguished from schizophrenia and bipolar disorder. The psychiatrist should conduct a conversation with the patient and his relatives to identify the presence of a stressful situation. Chronic mental illnesses develop independently of psychotrauma, and reactive disorders are always the result of moral upheavals.

Reactive mental disorders in childhood

A reactive state in children occurs after transferred fright and other traumatic factors. It is most often observed in infancy and preschool age. There are two types of reactions of the child's psyche to trauma. The child either becomes restless (rushing about, crying, screaming), or freezes in place and stops talking. This is accompanied by vegetative disorders: sweating, redness of the skin, tremors, involuntary urination and defecation.

Then the child becomes lethargic, whiny, he is worried about fears. Behavioral patterns may appear that are characteristic of younger children. For example, a child of 5 - 6 years old begins to behave like a baby of 1.5 years old. Reactive mental states in children require immediate treatment. All changes are reversible.

Therapy of reactive mental disorders

In the treatment of neurotic disorders, sedatives are used. If the symptoms are mild, then you can prescribe herbal remedies (valerian, motherwort) or the medicine "Afobazol". For more severe disorders, tranquilizers are indicated. Not only medicines are used, but also psychotherapeutic methods.

Treatment of reactive psychoses is more challenging. In a dreary mood with ideas of self-blame, antidepressants are used. If the patient has delusions and hallucinations of psychogenic origin, then neuroleptics and sedative drugs are used.

Forensic medical examination for reactive mental disorders

In the forensic psychiatric assessment of reactive states, the form of the disorder should be taken into account. With neuroses, patients are usually recognized as sane. They may be held responsible for the offenses committed.

As for reactive psychoses, it is necessary to take into account the degree of their severity. With mild violations, a person usually gives an account of his actions. In severe delusional disorders and hallucinations, the patient may be declared insane. It is also important to remember that depressed patients with ideas of self-blame often slander themselves and sometimes confess to offenses they did not commit.

Acute reactive states with delusions and hallucinations are considered as mental pathologies that are temporary. During the period of painful manifestations, a person may be recognized as incapacitated. In this case, all civil acts (transactions, wills, etc.) committed by him during a mental disorder are recognized as invalid.