DEPRESSIVE SYNDROMES (Latin depressio depression, oppression; syndrome; synonym: depression, melancholy) — mental disorders which main symptom is the suppressed, oppressed, sad mood which is combined with a row ideatorny (disorder of thinking), motor, and also somatovegetativny disturbances. Of page, as well as maniacal (see. Maniacal syndromes ), treat group of affective syndromes — the states which are characterized by various painful changes of mood.
Of page — one of the most widespread patol. the frustration which are found almost at all mental diseases, features K-rykh affect displays of depressions. There is no standard classification of D. of page.
Of page tend to numerous repeated development therefore considerably break social adaptation of a part of patients, change their vital rhythm and in some cases promote an early invalidism; it concerns as to patients with the expressed forms of a disease, and to numerous group of patients with erased a wedge, displays of a disease. Besides, D. villages constitute danger concerning suicide, create possibilities of development drug addiction (see).
Of page can exhaust all a wedge, a picture of a disease or to be combined with other displays of mental disorders.
The clinical picture
the Clinical picture D. of page is heterogeneous. It is connected not only with various intensity of manifestations of all D. of page or its separate components, but also with accession of other signs joining in D.'s structure of page.
To the most widespread, typiforms of D. of page so-called simple depressions with a characteristic triad of symptoms in the form of reduced, sad mood, psychomotor and intellectual braking belong. In mild cases or in an initial stage of development of D. of page patients quite often have feeling physical. fatigue, slackness, fatigue. Decrease in creative activity, burdensome feeling of disappointment by, the general decrease mental and physical is noted. tone. Patients often complain of «laziness», lack of will, that they cannot «get it together». The reduced mood can have the most various shades — with feeling of boredom, grief, easy fatigue, depression to feeling of depression with uneasiness or gloomy gloom. There is a pessimism in assessment of, the abilities, social value. Joyful events do not find a response. Patients aim at a privacy, feel not such as earlier. Already at the beginning of D.'s development by page persistent sleep disorders, appetite are noted, went. - kish. frustration, headaches, unpleasant burdensome feelings in a body. It is the so-called cyclotymic type of depressions which is characterized by superficial extent of frustration.
During the deepening of weight of a depression psychomotor and intellectual block increases; the melancholy becomes the leading background of mood. In a serious condition patients look suppressed, a mimicry the mournful, slowed-down (gipomimiya) or completely stiffened (amimia). Eyes are sad, upper eyelids of a poluopushchena with a characteristic fold of Veragut (the eyelid is bent by a corner up in its internal third). The voice is silent, deaf, monotonous, low-modulated; buying up the speech, answers are terse. The thinking is slowed down, with poverty of associations, with a pessimistic orientation on the past, real, future. Thoughts of the inferiority, an otioseness, the ideas of fault or a sin are characteristic (D. of page with the ideas of self-accusation and self-abasement). At dominance of psychomotor block of the movement of patients are slowed down, a look extinct, lifeless, it is directed in space, tears are absent (a «dry» depression); in hard cases the full obezdvizhennost, catalepsy (a depressive stupor) — a struporous depression is noted. These conditions of deep block can suddenly be interrupted sometimes by conditions of melancholic fury (raptus melancholicus) — explosion of feeling of despair, a hopelessness with plaints, aspiration to a self-mutilation. Quite often during such periods patients commit suicide. Feature of melancholy is physical. her feeling in a breast, in heart (anxietas praecordialis), in the head in the form of «mental anguish», burning, in the form of «a heavy stone» (so-called vital feeling of melancholy).
As well as in an initial stage, during full development of D. of page remain expressed somatovegetativny frustration as a sleep disorder, appetite, existence of locks; patients lose flesh, turgor of skin, extremity cold, cyanochroic decreases, the ABP decreases or raises, endocrine functions fall apart, the sex instinct decreases, at women monthly quite often stop. Existence of a day-night rhythm in fluctuation of a state is characteristic, is more often with improvement by the evening. At very severe forms of D. of page daily fluctuations of a state can be absent.
In addition to typiforms above described most, there is some other kinds of D. of the page connected with modification of the main depressive frustration. Allocate the smiling depression, for a cut the smile with bitter irony over by itself in combination with extremely depression of spirit, with feeling of full hopelessness and senselessness of the further existence is characteristic.
In the absence of considerable motor and intellectual braking depressions with dominance of tears — the «tearful» depression «grumbling» a depression, with constant complaints — the «aching» depression are observed. In cases of an adynamic depression into the forefront decrease in motives with existence of elements of apathy, feeling physical acts. powerlessness, without true motor block. At some patients the feeling of mental insolvency with impossibility of any intellectual tension, in the absence of block and melancholy can prevail. In other cases the «gloomy» depression with feeling of hostility, the spiteful relation to all surrounding develops, it is frequent with a dysphoric shade or with burdensome feeling of internal discontent with, with irritability and gloom.
Also D. are allocated to page with navyazchivost (see. Persuasive states ). At superficial psychomotor block D. of page with «feeling of loss of consciousness», the loss of an affective resonance consisting in decrease in an opportunity to react to a situation and the external phenomena can develop. Patients become as if emotionally «stone», «wooden», not capable of empathy. Nothing pleases them, concerns (neither the family, nor children). The similar state usually is followed by complaints of patients to loss of emotions, feelings (anesthesia psychica dolorosa) — D. page with depressive depersonalization, or an anestetichesky depression. In some cases depersonalizatsionny frustration can be deeper — with feeling of a considerable izmenennost spiritual «I», all warehouse of the personality (D. page with depersonalization); some patients complain of the changed perception of the outside world: the world as if loses paints, everything surrounding objects become gray, faded, dim, everything is perceived as through «a muddy cap» or «through a partition», sometimes surrounding objects become as if unreal, lifeless as though drawn (D. of page with a derealization). Depersonalizatsionny and derealizatsionny frustration are usually combined (see. Depersonalization , Derealization ). Among D. of page
the alarming agitated or agitated depressions figure prominently alarming. At such states psychomotor block is replaced with the general motive concern (agitation) in combination with alarm and fear. Degree of manifestation of agitation can be various — from unsharp motive concern in the form of a stereotypic potiraniye of hands, pulling of clothes or circulation up and down before sharp motive excitement with expressional and pathetic forms of behavior in the form of hand-wringing, the aspiration to be up against a blank wall, to break off on itself clothes with groans, sobbings, lamentations or the same monotonous repetitions of any phrase, word (alarming verbigeration).
At heavy depressions development of a depressive and paranoid syndrome is characteristic (see. Paranoid syndrome ), differing sharpness, sharply expressed affect of alarm, fear, the ideas of fault, condemnation, nonsense of a performance, false recognitions, the ideas of the special importance. The syndrome of hugeness can develop (see. Kotara syndrome ) with the ideas of eternal torment and immortality or hypochiondrial nonsense of fantastic contents (nigilistic nonsense of Kotar, a melancholic paraphrenia). At height of a disease development of oneiric disorder of consciousness is possible (see. Oneiric syndrome) .
The depression can be combined with catatonic frustration (see. Catatonic syndrome ). At further complication of clinic of D. of page there can be ideas of prosecution, poisoning, influence or to join acoustical both true, and pseudohallucinations within Kandinsky's syndrome (see. Kandinsky-Klerambo syndrome ).
Zattes (H. Sattes, 1955), Petrilovich (N. Petrilowitsch, 1956), Leon-gard (To. Leonhard, 1957), Yantsarik (W. Janzaric, 1957) described D. of page with dominance of somatopsychic, somatovegetativny frustration. For these forms are not inherent deep motor and mental block. Character and localization of senestopathetic frustration can be the most various — from simple elementary burning sensation, an itch, tickling, passing of cold or heat with narrow and their permanent localization to senesthopathias with the broad, constantly changing localization.
Along with the above described forms D. of page a number of authors allocate extensive group so-called hidden (erased, larvirovanny, masked, latent) depressions. According to Yakobovsky (V. of Jacobowsky, 1961), the latent depressions meet considerably more often than expressed, and are observed preferential in out-patient practice.
Understand such depressions which are shown first of all by somatovegetativiy frustration whereas typically depressive symptoms are erased as the latent depressions, being almost completely blocked by vegetative. To depressive it is possible to speak about accessory of these states only on the basis of frequency of these frustration, existence of daily fluctuations, positive therapeutic effect from use of antidepressants or existence in the anamnesis of affective phases or hereditary burdeness affective psychoses.
Larvirovanny D.'s clinic of page is very various. In 1917 Mr. Devo and Logr (A. Devaux, J. Century of Logre) and in 1938 Montassyu (M. of Montassut) described the monosimptomny forms of melancholy which are shown in the form of periodic sleeplessness, periodic impotence, periodic pains. The Fonseg (A. F. Fonsega, 1963) was described by the remittiruyushchy psychosomatic syndrome which is shown a lumbago, neuralgia, attacks of asthma, periodic feeling of compression in a breast, gastric spasms, periodic eczema, psoriasis etc.
Lopez Ibor (J. Lopez Ibor, 1968) and Lopez Ibor Alinyo (J. Lopez Ibor Alino, 1972) allocate the depressive equivalents arising instead of depressions: the states which are followed by pains and paresthesias — headaches, a dentagra, a back pain and other parts of a body, neuralgic paresthesias (somatic equivalents); periodic mental anorexia (periodic lack of appetite of the central origin); psychosomatic states — fears, persistence (mental equivalents). Pisho (P. Pichot, 1973) allocates still toxicomaniac equivalents, napr, hard drinkings.
Duration of larvirovanny depressions is various. The tendency to their long current is noted. Kreytman (N. Kreitman, 1965), Serri and Serri (D. Serry, M. of Serry, 1969) note duration them to 34 months and above.
Recognition of larvirovanny forms allows to apply to them the most adequate therapeutic tactics. Vegetative depressions of Lemke are close on a wedge, to a picture to the latent depressions of «a depression without depressions», described by Priori (R. Priori, 1962), and (R. Lemke,
1949). Distinguish the following forms from «depressions without depressions»: pure vital, psychoaesthetic, difficult hypochiondrial, algichesky, neurovegetative. Periodic sleeplessness, a periodic adynamy, periodically coming headaches, pains is characteristic of vegetative depressions of Lemke or senesthopathias (see) in various parts of a body, periodic hypochiondrial states, phobias.
Above and above the described D.'s kinds of page meet at various mental diseases, without differing in strict specificity. It is only possible to speak about preference of some types of D. of page for a certain type of psychosis. So, superficial D. the pages proceeding or in the form of a simple tsiklotimopodobny depression, a depression with tearfulness, an adynamy, or with dominance of somatovegetativny frustration, navyazchivost, phobias or unsharply expressed the person of lizatsionno-derealizatsionny frustration are characteristic of neurosises, psychopathies, cyclotymias, some types of somatopsychoses.
At MDP — maniac-depressive psychosis (see) — D. of page with a clear depressive triad, anestetichesky depressions or depressions with dominance of the ideas of self-accusation, the alarming or alarming agitated depressions are most typical.
At schizophrenia (see) range of kinds of D. of page is widest — from lungs to the most severe and irregular shapes atypical forms when into the forefront the adynamia with the general decrease in all motives acts, as a rule, meet or the feeling of hostility, gloomy and spiteful mood prevails. In other cases into the forefront the depression with catatonic frustration acts. Difficult D. by page with a persecution complex, poisonings, influences, hallucinations, a syndrome of mental automatism is often noted. Considerably features of depressions depend on character and extent of change of the personality, on features of all clinic of schizophrenic process, depth of its frustration.
At late involutional depressions note a number of the general of lines, characteristic of them — less expressed affect of melancholy with dominance of gloom and or irritability, peevishness, or alarm and agitation. Quite often there is a shift towards crazy symptomatology (the idea of damage, an impoverishment, hypochiondrial nonsense, nonsense of the ordinary relations) thanks to what the wedge, sides in the description of an involutional depression, depression is noted deleting at MDP, schizophrenia or organic diseases. Also small dynamics, sometimes a protragirovanny current with the «stiffened», monotonous affect and nonsense is characteristic.
Situational (psychogenic) depressions result from mental injuries. Unlike D. of page, at MDP here the main maintenance of a depression is filled with a psychoreactive situation, with elimination a cut usually there passes also the depression; there are no ideas of primary fault; the ideas of prosecution, hysterical frustration are possible. At a long reactive situation of D. of page can be protragirovanny with a tendency to its vitalization, to weakening of reactive experiences. It is necessary to distinguish situational depressions from psikhogenno the provoked depressions at MDP or schizophrenia when the reactive factor or does not find reflection in the content of experiences of patients at all, or meets at the beginning of an attack the subsequent dominance of symptoms of a basic disease.
More and more attention is paid to the depressions which are intermediate between the so-called endogenous, main forms which are found at MDP and schizophrenia and situational depressions. Here endoreactive dysthymias of Vaytbrekht, a depression of exhaustion of Kilkholts, a depression of a background and a depression of the soil of Schneider join. Though the common features caused by a combination of endogenous and reactive lines are inherent to all this group of depressions distinguish a separate wedge, forms.
The interlacing of endogenous and reaction torques, dominance in clinic of senesthopathias from an astenoipokhondricheskma frustration, gloomy, irritable and dissatisfied or tearful and dysphoric mood is characteristic of endoreactive dysthymias of Vaytbrekht, is frequent with vital character, but with lack of primary ideas of fault. Insignificant reflection in clinic of psychoreaction torques distinguishes endoreactive dysthymias from situational depressions; unlike MDP, at endoreactive dysthymias there is no maniacal and truly depressive phase, in a sort weak hereditary Burdeness is noted by affective psychoses. In a premorbida persons sensitive, emotionally labile, irritable, a little gloomy prevail.
Dominance of psychoreaction torques is characteristic of depressions of exhaustion of Kilkholts; the disease in general is regarded as psikhogenno caused patol, development.
For depressions of a background and Schneider's soil, as well as for Vaytbrekht's dysthymias, emergence of affective phases in connection with provocative somatoreaktivny factors, however without their reflection in D.'s clinic of page is peculiar. Unlike D. of page, at MDP there is no vital component as there is no psychomotor block or agitation, and also the depressive crazy ideas.
At the symptomatic depressions caused by various somatogenic or cerebral and organic factors, the clinic is various — from superficial astheno-depressive states to the expressed depressions with dominance of fear and alarm, e.g., at cardial psychoses, with dominance of slackness, block or an adynamia with apathy at long somatogenic, endocrine diseases or organic diseases of a brain, mrachnozlobny, «dysphoric» depressions at some types of tserebralnoorganichesky pathology.
The etiology and a pathogeny
In D.'s etiopathogenesis of page great value is attached to pathology of talamogipotalamichesky area of a brain with involvement of a cerebral cortex and endocrine system. DeLay (J. Delay, 1953) at a pneumoencephalography observed changes of affect. Ya. A. Ratner (1931), V. P. Osipov (1933), R. Ya. Golant (1945), and also E. K. Krasnushkin connected a pathogeny with defeat of diencephalic and pituitary area and endocrine and vegetative disturbances. V. P. Protopopov (1955) attached significance in D.'s pathogeny of page to increase in a tone of a sympathetic part of century of N of page I. P. Pavlov considered that decrease in activity of a brain due to development of ultraboundary braking with extreme exhaustion of a subcortex and oppression of all instincts is the cornerstone of a depression.
A. G. Ivanov-Smolensk (1922) and V. I. Fadeyeva (1947) at a research of patients with depressions obtained data on quickly coming exhaustion of nervous cells and on dominance of brake process over irritable, especially in the second alarm system.
The Japanese authors Suva, Yamasita (N. Suwa, J. Jamashita, 1972) connect tendency to frequency in emergence of affective frustration, daily fluctuations of their intensity with frequency in the functional activity of a bast layer of adrenal glands reflecting the corresponding rhythms of a hypothalamus, limbic system and a mesencephalon. X. Megun (1958) gives great value in D.'s pathogeny of page to disorder of activity of a reticular formation.
In the mechanism of affective frustration the important part is assigned also to disturbances of exchange of monoamines (catecholamines and indolamines). Believe that functional insufficiency of a brain is characteristic of D. of page.
D.'s Diagnosis of page is made on the basis of identification of characteristic signs in the form of reduced mood, psychomotor and intellectual block. The last two signs are less steady and find considerable variability depending on that nozol, forms, within a cut the depression, and also from premorbidal features, age of the patient, character and extent of change of the personality develops.
The differential diagnosis
In some cases D. pages can have looking alike a dysphoria, an asthenic state, apathetic or catatonic syndromes. Unlike dysphorias (see), at D. page there is no so expressed spiteful intense affect with a tendency to affective explosions and destructive actions; at D. the page with a dysphoric shade notes more expressed decrease in mood with melancholy, existence of a day-night rhythm in intensity of frustration, improvement or full escaping of this state after therapy by antidepressants. At asthenic states (see. Asthenic syndrome ) into the forefront increased fatigue in combination with a hyperesthesia, irritable weakness, with considerable deterioration by the evening acts, and at D. the asthenic component is more expressed to page since morning, the state in the second half of day improves, there are no phenomena of giperestetichesky emotional weakness.
Unlike apathetic syndrome (see) against the background of deep somatic exhaustion, at an anestetichesky depression there is no absolute indifference, indifference to themselves and to people around, the patient takes indifference hard. At D. of page with abulichesky frustration, unlike apathetic states at schizophrenia (see), these frustration are not so expressed. Developing within D. page, they have no constant, irreversible character, and are subject to daily fluctuations and recurrence in development; at a depressive stupor, unlike a lyutsidny (pure) catatonia (see. Catatonic syndrome ), patients have heavy experiences of depressive character, sharp psychomotor block is noted, and the catatonic stupor is characterized by substantial increase of a muscle tone.
Therapy by antidepressants gradually forces out other methods of treatment. The choice of antidepressive means in many respects depends on a form D. of page. Allocate three groups of antidepressive drugs: 1) preferential with psychogogic effect — Nialamidum (nuredal, Niamidum); 2) with a broad spectrum of activity with dominance of timoleptichesky effect — an imipramine (Imipraminum, Melipraminum, tofranil), etc.; 3) preferential with a sedative timolepticheskim or sedation — amitriptyline (Triptizolum), chlorprothixene, melleril (sonapaks), levomepromazinum (Tisercinum, Nozinanum), etc.
At depressions with dominance of psychomotor block without the expressed affect of melancholy, and also at adynamic depressions with decrease in strong-willed and mental activity drugs with the stimulating effect (drugs of the first group) are shown; at depressions with dominance of feeling of melancholy, vital components, with motor and intellectual block drugs of the second (sometimes the first) groups are shown; at alarming depressions, depressions with irritability, tearfulness and peevishness without the expressed psychomotor block therapy by drugs with a sedative timolepticheskim or sedative tranquilizing effect (drugs of the third group) is shown. Antidepressants with psychogogic action to appoint dangerous by the alarming patient — they cause not only strengthening of alarm, emergence of depressive excitement with suicide tendencies, but also an exacerbation of all psychosis in general, strengthening or emergence of nonsense and hallucinations. At difficult D. the page (depressive and paranoid, at depressions with nonsense, hallucinations, Kandinsky's syndrome) needs a combination of antidepressants to neuroleptics. Almost all antidepressants possess side effect (a tremor, dryness in a mouth, tachycardia, dizziness, disturbance of an urination, orthostatic hypotonia, sometimes hypertensive crises, transition of a depression to manias, an aggravation of schizophrenic symptomatology etc.). At increase in intraocular pressure it is dangerous to appoint amitriptyline.
Despite broad use psikhofarmakol, means, treatment by electroconvulsive therapy, especially in the presence of long long forms of depressions, resistant to medicinal influences still matters.
As in a wedge., and in out-patient conditions the increasing value is gained by therapy by salts of lithium which have ability not only to influence affective frustration during a phase of a depression, but also to prevent or remove emergence of a new attack in time and to reduce its intensity.
concerning life is favorable, except for some somatogenic pathopsyhosis where it is defined by a basic disease. Concerning recovery, i.e. escaping of a depression, the forecast is also favorable, but it is necessary to consider some cases of the lingering, protragirovanny depressions lasting for years. After escaping of depressions at MDP patients are in most cases almost healthy, with a complete recovery of working capacity and social adaptation, at some patients the residual frustration close to asthenic are possible. At schizophrenia as a result of an attack increase of changes of the personality with decrease in working capacity and social adaptation is possible.
The forecast concerning frequency of development of D. of page is less favorable — first of all it belongs to MDP and pristupoobrazno the proceeding schizophrenia where attacks can repeat several times in a year. At symptomatic psychoses the possibility of repetition of D. of page is very rare. In general the forecast is defined by that disease, within to-rogo D. of page develops.
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V. M. Shamanina.