MENTAL DISEASES (Greek psychikos sincere; synonym: sincere diseases, psychoses) — the diseases of a brain which are shown various disorders of mental activity — productive (nonsense, hallucinations, affective disturbances) and negative (loss or easing loonies - chesky activity), and also the general changes of the personality. Item. — specific diseases of the person.
Till 80th 19 century diseases at which disturbances of mental activity owing to damage of a brain deprived of the person of ability to realize the actions and to direct the behavior were considered as mental diseases, i.e. the profound change of the personality took place.
At P. all organism suffers, but functions of a brain are preferential broken that is shown, first of all, by frustration mental activity.
The concept «mental diseases» is not strictly certain. Starting with S. S. Korsakov this term is used in a broader sense: to P., except psychoses, carry neurosises, psychopathies, alcoholism, various toxicomanias, acute affective reactions, etc., and also the oligophrenias which are not followed by psychosis. At such understanding in number P. include all disturbances of mental activity; they make a subject of studying of psychiatry; help given corresponding-nym is called psychiatric. Due to the preventive orientation of the Soviet medicine allowing to reveal patients with initial disturbances of mental activity, a circle of the frustration entering P., more and more extends. Sometimes use even less certain term «psychoneurological diseases». In Anglo-American psychiatric literature the term «sincere disease» as a synonym of the concept «psychosis» and wider — «mental disorders», or «mental disturbances» is accepted. In fr. it is also mute. psychiatry the terms «mental diseases» and «psychoses» are more often used as synonyms.
the Various classifications of P. of the lake existing before emergence of scientific psychiatry in 19 century have only historical value. Most in detail in domestic literature they are presented in V. P. Osipov's guide «A course of the general doctrine about sincere diseases» (1923) and in «Stories of psychiatry» To). V. Kannabikh (1929). In classifications of 19 century the syndromologic direction dominated, i.e. in a basis external displays of a disease (a mania, melancholy, an amentia, etc.) undertook. Attempts to create classifications by an etiological sign, but because of a lack of knowledge of the reasons and mechanisms of development of P. were made. similar classifications differed in extreme imperfection. With emergence and development of the nosological direction in psychiatry (S. S. Korsakov, E. Krepelin) P.'s systematics began to be created., based on cumulative assessment a wedge, pictures, a current and reference, defective states of mentality and where it is possible, an etiology and a pathogeny. The allocated forms P. also development differ in special origins. In nosological classification of P. two subclasses — endogenous and exogenous psychoses were allocated. Psychoses in which development the importance is given to a hereditary factor are carried to endogenous though its nature, ways of transfer by inheritance remain unknown. This hereditary factor owing to mechanisms of development inherent in it or under the influence of external provocative influences can be implemented in a disease («pathos» turns into «nosos», according to A. V. Snezhnevsky), and can and remain not put in action and be transferred to the next generation. Since the time of E. Krepelin carried schizophrenia to endogenous psychoses (see), or «early weak-mindedness» (according to E. Krepelin), and maniac-depressive psychosis (see). However knowledge of P. would be accumulated further., on a wedge, to a picture and a current being intermediate between schizophrenia and maniac-depressive psychosis. One researchers considered them as a kind of schizophrenia, others — as atypical maniac-depressive psychosis, and a number of researchers preferred to speak about special the third, intermediate, psychosis. These psychoses most often designate as schizoaffective; their place in nosological system remains not quite certain.
In 50 — the 80th there are 20 century achievements in a research of a current and a pathogeny of endogenous psychoses awakened doubts in nosological unity of schizophrenia and maniac-depressive psychosis. Some researchers, e.g. Leongard (K. Leonhard, 1957), Angst (J. Angst, 1966), Yu. L. Nuller (1973), divide maniac-depressive psychosis into two independent diseases — monopolar depressive psychosis and bipolar affective (maniac-depressive) psychosis. Data, e.g. A. E. Lichko (1979), A collected. B. Smulevich (1980), that the slow (low-progreduated) form of schizophrenia develops on other patterns, than progreduated. P.
would carry to exogenous psychoses (infectious and intoksikatsionny psychoses, somatopsychoses, psychoses owing to craniocereberal injuries, reactive psychoses)., arising under the influence of environmental factors. Infectious and intoksikatsionny psychoses (see. Infectious psychoses, Intoksikatsionny psychoses) are divided into the psychoses developing owing to a direct injury of a brain (encephalitis, meningitis, neurointoxication) and the so-called symptomatic psychoses (see) which are only one of manifestations of the general inf. process or general intoxication of an organism. The somatopsychoses arising at diseases of internals (heart, a liver, kidneys), endocrinopathies, etc., belong to exogenous since the somatogenic source of psychosis is external for a brain — an ekstratserebralny factor. Reactive (psychogenic) psychoses allocate in special subgroup. Acute mental injuries or hron, mental traumatization are the reason of these psychoses (among them situational depressions are most frequent).
There are also such types of psychoses which cannot be carried neither to group endogenous, nor to group of exogenous. So, at the heart of some senile psychoses (see) the close interlacing endogenous and exogenous (e.g., psychogenic) factors lies, and between endogenous and exogenous factors connection as a vicious circle can be established; at an endoreactive dysthymia of Vaytbrekht (see. Maniac-depressive psychosis), on the one hand, a psychogenic factor provokes an endogenous depression, edges are done by the personality vulnerable for usual vital difficulties; on the other hand, these difficulties gain value of mental injuries, aggravating and tightening a depression. A specific place is held also by psychoses at epilepsy (see) and at an oligophrenia (see). On genesis they usually approach endogenous psychoses, and on a wedge, a picture quite often correspond to exogenous.
The described classification scheme would form a basis for various nosological systematics of P. As a matter of fact, all guides and textbooks to psychiatry published in the USSR in the 80th with nek-ry options follow this scheme.
In Anglo-American classifications of P. are divided into two basic groups: diseases at which by modern methods damage of a brain is found i.e. material substrate patol, process (they are designated as acute and chronic brain psychotic frustration), and on diseases at which it is not possible to find any damages of a brain clearly comes to light, even the possibility of their existence is called into question or in general is rejected. These P. are considered as frustration of the personality (reaction, development, etc.). Similar division of P. representatives of neofreudian psychoanalytic schools adhere. In their opinion, patients with P. the first group need in biol, treatment, patients with P. the second group — in psychotherapy, in particular in psychoanalysis (see). Example of similar division of P. Howells's classification (J. Howells, 1971) who divides all psychoses into entsefaloza and psikhonoza serves. Fr. classifications of P. keep influence of the old syndromologic direction, including in the headings chronic crazy psychosis, melancholy, etc. It is mute. classifications in the majority follow the nosological principle.
Attempt of WHO to develop and extend uniform international classification of P. represented very difficult task. Interfered with it a variety of national systematics, distinction of views of P. in the different countries, and most of all — a lack of knowledge of their etiology and a pathogeny. The international classification was exposed to numerous changes and additions. It supports three groups of diseases: psychoses (codes 290 — 299), neurosises, psychopathies and other mental disorders of not psychotic character (codes 300 — 309) and mental retardation (codes 310 — 315) which are combined by the concept «mental disorders» (class V). The international classification of diseases of the eighth review was generally constructed by the nosological principle (it concerns taxons — units of classification — the first order): 290 — senile and presenile dementia, 291 — alcoholic psychosis, 292 — psychoses as a result of an intracranial infection, 293 — the psychoses resulting from other brain disturbances, 294 — the psychoses which resulted from other somatic disturbances, 295 — schizophrenia, 296 — affective psychoses. But at the same time 297 — paranoid states — a tribute to the syndromologic direction, 298 — other psychoses, 299 — not specified psychoses — in a certain measure reflection of a lack of knowledge of an etiology and a pathogeny, however the code 298 means generally reactive psychoses. The international classification of diseases of the ninth review in this respect significantly does not differ from former. In taxons of the second and third order still big derogations from the nosological principle are allowed. Eclecticism especially affects at classification of neurosises, psychopathies and other not psychotic frustration where as taxons not only syndromes, but also separate symptoms are included. The international classification of diseases of the ninth review differs from previous in the fact that in it psychoses are divided into two groups: organic psychotic states (codes 290 — 294) and other psychoses (codes 295 — 299). In practice (examination, the dispensary accounting, the organization of mental health services) of the concept «mental diseases» and «psychoses» usually are synonyms.
P.'s Epidemiology. sets as the purpose studying both prevalence of these diseases in general, and separate nozol. forms, and also the factors influencing their prevalence. During the studying of prevalence of P. distinguish two main indicators — the relation of number of patients to the total number of the population (morbidity) and the relation of number of new cases of P., arisen for a certain time term, usually in a year, to the total number of the population (incidence). Distinction of sizes of morbidity and P.'s incidence. reflects first of all completeness of their identification. These data are processed statistically.
P.'s epidemiology. uses two types of sources — primary, to the Crimea direct inspection of the population at the place of residence (e.g., household bypasses belongs at censuses of the insane in some provinces of pre-revolutionary Russia), and secondary — data of psychiatric BCs, psikhonevrol. clinics and other institutions keeping account of mentally sick. During the use of primary sources it is impossible to achieve the sufficient depth of inspection of the population. The lack of the second source consists that it does not cover all contingent of patients. E.g., according to N. M. Zharikov (see t. 10, additional materials), not less than 17% of patients with schizophrenia would never be hospitalized in psychiatric. However in the USSR thanks to creation of wide network psikhonevrol. clinics indicators of identification of mentally sick approach primary.
Interest in P.'s statistics. arose in 19 century. So, on 100 thousand population in Germany in 1867 it was registered 160, in England in 1871 — 250, in the USA in 1891 — 310 mentally sick. In pre-revolutionary Russia the census of the insane was conducted only in some provinces (St. Petersburg, Moscow, Nizhny Novgorod); according to V. P. Osipov (1923), 200 — 250 patients on 100 thousand population were on average registered.
Epidemiol. data of different researchers are difficult comparable because of heterogeneity of a used dressing material. In the general epidemiology it is connected first of all with whether join in number P. neurosises, hron, alcoholism, easy degree of an oligophrenia, etc. In the USSR since the end of the 70th the network of specialized narcological BCs and clinics began to be developed (the special accounting of patients hron, is entered by alcoholism). It is supposed to enter in psikhonevrol. clinics special accounting of patients with neurosises and nek-ry other borderline cases.
Number of the considered P.'s cases. depends also on that, how fully they come to light, and their identification — from the level of the organization psikhonevrol. help. E.g., according to Yu. A. Dobrovolsky (1968), for years of World War II in a number of the Western European countries (Austria, Belgium, Italy, the Netherlands, France) the number considered mentally sick considerably decreased (in France in 1940 — 251, in 1945 — 160 by 100 thousand population) that was obviously connected with deterioration in medical aid, and in the countries which underwent fascist occupation, perhaps and with death of patients. At the same time in not being at war countries or in the countries which population directly did not feel horrors of war (Sweden, the USA, Canada) the number of patients did not change or even increased (in the USA in 1940 — 368, in 1945 — 409 on 100 thousand population).
Studying of incidence of P. even less, than morbidities is developed. In the capitalist countries primary receipts in psychiatric would be almost only source of these data. Therefore indicators of incidence of P. most of all depend on availability of the stationary help and significantly differ in the different countries (in 1960 in England — 127, and in Norway — 61 on 100 thousand population). Almost in all Western European countries incidence of men is higher, than incidence of women, in the USA — on the contrary.
System psikhonevrol. clinics in the USSR created optimum conditions for epidemiol. researches. However in the cities the network of clinics more branched and brought closer to the population, than in rural areas therefore according to S. V. Kurashov (1953), in the cities of RSFSR on average was registered apprx. 500 patients on 100 thousand inhabitants, and in rural areas — is much less.
P.'s epidemiology. studies also social, geographical, demographic and other factors influencing spread of these diseases. The most frequent way — comparison of the data obtained at inspection of different regions and different groups of the population. E.g., it is established that in rural areas more high level of morbidity an oligophrenia, in a number of the developed capitalist countries and in some countries of the East — the level of drug addiction. In the USA among smokers of marijuana incidence of schizophrenia is at least 10 times higher, than in the general population. Similar epidemiol. researches allow to reveal groups of the increased risk of development of P. Are undertaken also epidemiol. the researches directed to definition of efficiency of methods of treatment, different forms of the help to patients. Usually for this purpose in a certain region homogeneous patients, treated by any method and uncured are compared.
Etiology and pathogeny
P.'s Reasons. are very difficult. Even in those cases where they seem obvious, napr, at some symptomatic infectious and intoksikatsionny psychoses, the cause and effect relations are not so rectilinear and simple as can seem. At one patient inf. the disease proceeding in the most severe form would not involve P.'s development., and the same disease at smaller weight of somatic manifestations causes development of psychosis in another. Hron, alcoholism at one persons early begins to be followed by alcoholic psychoses (see), and at others — does not take to them, despite long-term heavy intoxication and explicit degradation of the personality.
In understanding of the reasons of P. two extreme tendencies come to light. One researchers aim to establish rigid connection of each nosological form with strictly certain reason (e.g., all P. irrespective of a wedge, pictures and currents „if they developed after acute or against the background of any hron, infections consider infectious psychoses, after an injury — traumatic, in the presence of symptoms of organic lesion of a brain — organic, etc.). Others would consider P. as polyetiological, and the reasons they are considered by pathogenic factors as acting during antecedents of the patient, and estimated, and the role of each of them and the main reasons remain undetected. Supporters of that and other tendency make unjustified hypotheses and recommendations, napr, to treat antibiotics all P., developed after an infection in spite of the fact that infectious process passed long ago.
At clarification of an etiology of P. reveal a role of each factor participating in development of disease process. The same harmful agent in different cases plays an unequal role. Distinguish several types etiol, factors — the main and additional (provocative, precipitant, contributing, patoplastichesky). The basic is the factor playing a key role in a pathogeny; without it this P.'s development. it is impossible. So, hron, intoxication alcohol plays a similar role at alcoholic psychoses. The provocative factor is a releaser of a disease, edges further can develop without its participation. This factor is often not specific, at the same P. different harmful agents can act in such role. E.g., the massive acute drunkenness, especially at teenagers, can provoke an acute debut of schizophrenia, edges at the same subject can be provoked by other vrednost (a mental injury, an infection, etc.).
The precipitant factor accelerates, the course of a disease, before proceeding inertly, hardly noticeably or having more favorable current pushes. So the chronic drunkenness would affect P.'s current., caused by a craniocereberal injury.
The contributing (predisponiruyushchy) factor creates the selective increased vulnerability in the relation of certain harmful influences. So, at persons with hron, a drunkenness at some acute infections with fever or after craniocereberal injuries the infectious or traumatic delirium easily develops.
The Patoplastichesky factor leaves a peculiar mark on a wedge, a picture P., caused by other reason. So, if sick schizophrenia begins to abuse alcohol, then in a wedge, a picture of a disease the separate symptoms inherent to alcoholic psychoses can appear. Value of a patoplastichesky factor should not be underestimated since it becomes frequent it one of important components of a pathogeny. Some pathogenic agents in certain conditions can make the sanifying impact (e.g., malaria can be the cause of infectious psychosis, at the same time the inoculation of malaria is method of treatment of a general paralysis).
The hereditary factor can be the basic (e.g., at some types of an oligophrenia) or the contributing factor causing selective weakness of certain systems of a brain. Participation of a hereditary factor in a pathogeny of endogenous psychoses is undoubted, but its role is still insufficiently clear; its role in genesis of one of forms of maniac-depressive psychosis — bipolar affective psychosis is established. Obshchebiol. factors (age, sex, the constitution, etc.) play a role of contributing more often. However the critical age periods with their rough neuroendocrinal shifts can play a role of factors, provoking, endogenous psychoses. Not accidentally considerable part of debuts of progreduated schizophrenia fall on the pubertal period. The climax, perhaps, plays the main role in developing of some psychoses (see. Menopausal syndrome). Floor would also matter in emergence of a row P. So, at women maniac-depressive psychosis and presenile melancholy meet more often (see. Presenile psychoses); at men the big frequency of alcoholic psychoses is noted.
Among exogenous factors in an etiology there is P. first place is won by a drunkenness, the second — craniocereberal injuries, the third — infections and somatogenias, and also other intoxications. In the past infections possessed considerably a big role. Successful fight against typhus, a lung fever, malaria and other heavy infections sharply reduced the frequency of infectious psychoses. Among infections the most psychotogenic are rheumatism and flu; among intoxications, except alcoholic, it is important to note some not alcoholic toxicomanias (see). At action of hallucinogens (the substances causing «model psychoses»), napr, holiiolitichesky central acting agents, and some stimulators (like Phenaminum) there are acute psychotic episodes. Item., caused by professional intoxications, in the USSR meet seldom. Mental injuries only at reactive psychoses serve as a major factor. However their role as accessory factors (provocative, precipitant, contributing) is extremely big.
P.'s pathogeny. represents a difficult chain of mechanisms: on the one hand, it changes in all organism (somatogenez), napr, disturbances of constancy of internal environment, change of metabolism with formation of toxic products (endointoxication), penetration into internal environment of an organism of exogenous toxicants, an impulsation from the struck bodies and fabrics; on the other hand — defeats of tissues of brain or disturbance of its function (tserebrogenez) which can be both primary, and caused somatogenezy. The most important part of a pathogeny of P. makes a psychogenesis, under the Crimea mean the disturbances of mental activity caused by mental factors which, on the one hand, would lead to P.'s development. (see Psychogenias), and with another — would participate in formation of a picture P. also influence its current (firmness of remissions, a recurrence).
In P.'s development. mechanisms of a somatogenez, tserebrogenez and psychogenesis closely intertwine. At the same time emergence of dependences like a vicious circle is characteristic; e.g., the mental injury, an emotional stress cause receipt in a blood stream of a large amount of biogenic amines, as a result of action on certain systems of a brain the alarm, mental tension, and it develop, in turn, increases readiness for emotional stresses.
the Term «experimental psychoses» or «models of psychoses» designate experimentally caused reversible disturbances of a mental state which on the wedge, remind a picture the corresponding psychoses of the person. They usually are called by administration of specific chemical substances or other influences. The term «psychosis» in relation to artificially caused behavior disorders at animals is used conditionally as «psychosis» — the concept applicable only to pathology of the person. The disturbances arising at animals under the influence of various substances of an exogenous or endogenous origin represent only model, i.e. the simplified reflection of the reproduced phenomenon. However it allows to isolate the separate parties and links patol, process that is important for studying of mechanisms of its development, but is not always feasible at a research of the person. Therefore experimental psychoses represent the important tool in hands of researchers and are widely used in psychiatry.
The mental disorders caused by vegetable poisons are known since the most ancient times. But actually experimental psychiatry appeared at the end of 19 century when in psychiatry organic and toxic theories of psychoses dominated and the researches sent to search for the poisons causing endogenous psychoses were conducted. Pioneers in the field of experimental psychiatry were Prentiss and Morgan (D. W. Prentiss,
F. P. Morgan, 1895), and also Mitchell (W. Mitchell, 1896), described action of a mescaline (see) which caused mental disturbances in healthy faces (disorders of perception, thinking, etc.). In the USSR these phenomena were studied in experiences of introspection by A. B. Aleksandrovsky (1934), in more detail and widely — S. P. Ronchevsky (1941).
De Jong and Baryuk's works (N. of de Jong, N. of Baruk, 1930) on an experimental catatonia at animals were an important stage in development of a problem of modeling of psychoses. It was shown that the catatonia caused by various influences (chemical substances, disturbances of exchange, neurosurgical methods, electric current, etc.), is the universal reaction arising in connection with a hypoxia of cells of a brain. The stereotype of development of an experimental catatonia, separate phases was described to-rogo reminded the corresponding manifestations (negativism, stereotypies, a katalepsy, a stupor) of a catatonic syndrome at the person. Further development of experimental psychiatry is connected with opening in 1943 by Shtollem and Goffmann (A. Stoll, A. Hoffmann) abilities of diethyl amide lysergic to - you (DLK, or LSD) in small doses (0,001 mg/kg) to cause the mental disturbances reminding on a wedge, a picture psychoses in healthy faces: disturbance of mood (euphoria), bright hallucinations, aggravation of perception surrounding, disturbance of perception of own body, disorder of consciousness.
The substances capable to cause models of psychoses received the name of psychotomimetics or hallucinogens. Their number is rather big. Basic groups of psychotomimetics are derivatives of a feniletilamin (a mescaline, 3,4 ditags si-feniletilamin, amphetamines, etc.), derivatives of a triptamin (bufotenin, psilotsin and its phosphoric ether — a psilocybin, dietiltriptamin, etc.), derivatives lysergic to - you (DLK, etc.), a kannabinola (tetrahydrocannabinol, etc.), derivatives glycolic to - you (ditran, phencyclidine, etc.). They are adjoined by some other substances, including used in the corresponding doses how to lay down. means, napr, quinacrine, tofranil, etc. In animal experiments they cause changes of behavior, reproduce some the psychopath of l. syndromes (catatonic) and the symptoms (fear, etc.) which are observed at the person. Also atropine belongs to such substances. Changes of behavior of animals cause also such antipsychotic means as Reserpinum (model of a depression) and aminazine (an experimental catatonia). A peculiar shizofrenopodobny reaction (with stereotypies, vigilance, a stupor or a hyperactivity, «strange» behavior) is caused by amphetamines.
Some researchers were originally inclined in the states caused by psychotomimetics (a mescaline, DLK, amphetamines, etc.), to see the lines characteristic of endogenous psychoses, especially at the observations made on the person and highest animal (monkeys). However further most of researchers began to hold the opinion that during the use of psychotomimetics and other entered substances intoksikatsionny psychoses, i.e. exogenous (symptomatic) mental disorders develop. At the same time the dozozavisimy effect — from insignificant deviations in behavior to the expressed conditions of the changed consciousness with the delirious phenomena, confusion, and also to a deep coma and the convulsive phenomena is characteristic of such substances. Psychotomimetics are capable to provoke endogenous P. (schizophrenia, maniac-depressive psychosis), especially at relatives of patients, revealing the corresponding predisposition to psychosis. The majority of the listed psychotomimetics belongs to the means prohibited to use in medical practice though in a number of the countries there were attempts to use even DLK in treatment of some groups of patients.
Despite impossibility to draw a direct analogy between experimental psychoses and endogenous P. as in clinical (psychopathological), and etiological aspects, modeling of mental disturbances is widely used in scientific psychiatry in several directions. One of them is connected with establishment of neurophysiological, neurochemical and anatomic correlates of separate phenomena of disturbance of mental activity (experimentally reproduced symptoms and syndromes), the second — with searches of endogenous substances, including structurally similar to nek-ry psychotomimetics which could cause the disorder of mental activity reminding frustration at schizophrenia and other endogenous psychoses. In 1954 Hoffer, Osmond, Smitiz (A. Hoffer, N. of Osmond, J. Smythies) paid attention to structural similarity of some products of exchange of adrenaline (adrenokhry, adrenolyutin) with a mescaline and on this basis put forward the katekholaminovy theory of schizophrenia. Other aspect of pathogenetic researches of endogenous psychoses based on modeling of mental disorders (an experimental catatonia, in particular), is connected with studying of a so-called toxic factor of not brain origin. Various model experiences of Fromen (Ch. Frohman, 1970), etc. are devoted to searches of the protein fractions responsible for a special biol, effect of blood serum of patients with schizophrenia. R. G. Heath's works with sotr are known. (1957), concerning disturbances of protein metabolism at patients with schizophrenia. The active fraction capable to cause «models» of psychoses, he called tarakseiny. As a result of long-term works with broad use of experiments these researchers changed the initial representations to animals. So, a combination of methods of modeling of psychosis on animals with biochemical, and immunol. experiments, and also simultaneous record EEG, allowed R. G. Heath to approach integration biochemical, and immunol. concepts of a pathogeny of schizophrenia. He began to consider taraksein as the anti-brain antibody possessing high biol, activity and ability to change a functional condition of structures of a brain. The Katekholaminovy hypothesis was transformed to such hypotheses of a pathogeny of schizophrenia as dopamine, O-transmethylations of adrenaline and the hypothesis connected with the assumption of change of activity of MAO. Essential feature of these representations is that action of a possible endogenous toxic product on nervous cells is considered through its interaction with the receptor device of nervous cells. In studying of these interactions the large role is played by model experiments with psikhofarmakol. means (e.g., a haloperidol) which change sensitivity of receptors of nervous cells. The similar model experiments developed in the 80th are connected with studying of the opiate receptors and their endogenous ligands (endorphines) opened in a brain. This direction of researches can be of great importance not only for studying of a pathogeny of endogenous psychoses, but also for experimental psychopharmacology where modeling of mental disorders figures prominently.
The general patterns of a clinical picture
the Leading place in a wedge, a picture P. occupy symptoms of disturbance of mental activity, P.'s most. is followed by also neurologic and somatic disturbances. Symptoms of mental disturbances develop in a picture of psychotic syndromes. Studying of symptoms and syndromes of mental disturbances, their classification, clarification of their value for the diagnosis, the forecast and as a reference point for the choice of therapy make a subject of psychopathology (see). There is a set of systematics of symptoms and P.'s syndromes. The vast majority of classifications of the end 19 — the beginnings of 20 century was psychological and proceeded from the idea of mental functions dominating in psychology (feeling, perception, emotions, thinking, intelligence, will, attention, inclinations, memory, consciousness) as rather independent components of mentality. Symptoms and syndromes of disorder of perception (illusion, a hallucination, etc.) were respectively allocated, to memory (e.g., amnesia, dysmnesias), thinking (disruptiveness, nonsense, persistence, etc.), emotions etc. These classifications were artificial since the same symptom and furthermore the syndrome usually happens a consequence of disorder of mental activity in general, but not one any mental function (e.g., nonsense not simply disturbance of thinking, but also the emotional sphere, perception, consciousness, etc.).
A. V. Snezhnevsky offered essentially new systematics of symptoms and syndromes, the cut was depth of mental disorders the basis. The least deep are asthenic rasstroystva, then affective (easier — depressive, heavier — maniacal), for to-rymi neurotic frustration follow (hysterical, obsessivny, etc.). The listed symptoms and syndromes are characteristic as of P., and for borderline cases. They can be both psychotic, and neurotic (e.g., the depression can be both neurotic, and psychotic). Further on the increasing depth there are only psychotic disturbances — paranoiac frustration (see. Paranoiac syndrome), hallucinosis (see. Hallucinations ), paranoid (see. Paranoid syndrome ), parafrenichesky (see. Paraphrenic syndrome ), catatonic (see. Catatonic syndrome ), oneiric (see. Oneiric syndrome ), delirious (see. Delirious syndrome ), amental (see. Amental syndrome ), twilight, convulsive frustration and, at last, psychoorganic (see. Psychoorganic syndrome ). Though distribution of some frustration in this scheme on depth is debatable and not all a wedge, symptoms of mental disorders found in it the place, its advantage that it gives the chance to consider to the loudspeaker P.
Each P.'s current. occurs on a stereotype, the forecast is based on knowledge to-rogo. The deviation from a stereotype can be caused by treatment, complications and other factors. Item. can proceed sharply and chronically. At an acute current observe obshchepatol. patterns: period of harbingers; initial (initial, or domanifestny) period; beginning, or debut; manifest period; period of recovery (reconvalescence); period of the residual phenomena. The same frequency is quite often noted at aggravations and chronic P.' recurrence.
The period of harbingers is often imperceptible for people around and is forgotten by the patient therefore it comes to light considerably less than happens actually. As harbingers psychotic episodes in the form of ridiculous acts, incidental hallucinations, short flashes of nonsense, inadequate affective categories can serve short (the proceeding hours, even minutes). The similar episodes preceding endogenous psychoses are called sometimes «summer lightnings». Harbingers can take place long before (months, years) prior to the beginning of P.
Initial (initial, or domanifestny) the period differs from harbingers in what directly precedes expansion of a disease. In this period the nonspecific picture of a disease in the form of syndromes of rather superficial level of defeat is usually observed (asthenic, neurotic, etc.). Sometimes in this period there are pictures of mental disorders, as if contrast to those which would will develop at P.'s height., napr, the subdepression before a maniacal state raised, though chaotic, activity before an apatoabulichesky syndrome (see. Apathetic syndrome), persuasive fears and sensitivity of paranoiac nonsense, etc.
Beginning, or debut, P. can be acute (within several hours, days), subacute (within a week) or gradual (months and even years).
The manifest period is characterized a wedge, a picture of one of the psychotic syndromes inherent in this P. Throughout this period the same syndrome can keep or occur the change of syndromes usually inherent to this nosological form.
The period of reconvalescence is shown just as the initial period, syndromes of superficial level of defeat, but the residual phenomena from the manifest period can take place (e.g., the so-called residual nonsense which already significantly is not affecting behavior of the patient).
After P. the period of the residual phenomena or development so-called initial, defective is possible, states — permanent changes of the identity of the patient as a result of which it decreases or working capacity and capacity of the patient and his opportunity to adapt to an environment and to exist without assistance is completely lost.
Mental defect is not identical to defect organic. It, though resistant, but, apparently, functional disturbance; in many cases (under the influence of treatment, sometimes at action of unusual stressful situations) the similar state is reversible. Reference states differ in it from dementia — the irreversible acquired weak-mindedness (see).
Chronic P., napr, endogenous psychoses, can variously proceed. Allocate the following types of their current: progreduated, pristupoobrazno-progreduated, recurrent (periodic), phase. A progreduated current — continuous development of P., speed to-rogo, however, can be various (a low-progreduated, sredneprogrediyentny, malignant current). Pristupoobrazno-progrediyentnoye, or peremezhayushche-forward, the current is that separate attacks of different duration (from several days to many months) alternate with remissions which quality variously — from practical recovery before temporary suspension of development of P. with a picture of the expressed defect. The recurrent (periodic) current is also characterized by separate attacks, however with full-fledged light intervals, especially after the first attacks, and unsharply expressed signs of mental defect even after several attacks. A phase current — affective phases, polar on a wedge, a picture (depressive, maniacal phases), with practical recovery (intermissiya) between them; P.'s current would occasionally be observed. in the form of one attack, for the Crimea many years there is no recurrence.
Absolute practical recovery occurs after exogenous psychoses. At endogenous psychoses it is accepted to speak about remissions and intermissiya since the probability of a recurrence is always high. In intermissiya the complete recovery of working capacity and social adaptation usually takes place. However and remissions can be so full and long (for many years) that in the social plan it is possible to speak about practical recovery. The probability of a recurrence at long remissions considerably decreases.
Quality and the nature of remissions are various. Quality of remissions is estimated by means of scales. In the USSR Sereysky's scale (a little changed Bauer's scale) is most known, according to a cut allocate remission And (total disappearance of all psychotic symptomatology with full criticism to the postponed attack of psychosis, recovery of professional working capacity), remission In (recovery of working capacity and capacity in the presence of some residual symptoms of a disease or unsharp changes of the personality which significantly are not affecting behavior, opportunities of social adaptation), remission With (incomplete, partial remission, with noticeable mental defect and considerable decrease in working capacity), remission of B (improvement in a wedge, a picture of a disease, napr, change of a syndrome with deep disturbance for less deep, without recovery of working capacity).
Except assessment of remission on quality, distinguish also types of remissions (it belongs to incomplete remissions — In, With, In) on residual symptomatology or changes of the personality which are caused by a disease. So, G. V. Zenevich allocates psychopatholike, paranoid, autistic, apathetic, asthenic, hypochiondrial and other types of remissions.
Remissions can be spontaneous (caused by a stereotype of disease) and therapeutic (caused by successful treatment). Therapeutic remissions are possible even at a continuous and progreduated form of a current, however they are unstable if the maintenance therapy is not applied.
A pathomorphism — permanent and essential change a wedge, pictures, pathogenetic mechanisms and pathomorphologic signs of mental diseases under the influence of various influences in comparison with their classical manifestations.
Division of a pathomorphism of P. on sotsiogenny, natural (spontaneous) and induced (therapeutic) it is conditional. E.g., the so-called age pathomorphism in essence is the natural, caused change of the organism, and at the same time sotsiogenny since it is connected with demographic processes.
In P.'s development. the large role is played by social factors therefore P.'s pathomorphism. it is in many respects connected with social and demographic changes. Shifts in age structure of the population — increase in a share of elderly people — led to increase in number of elderly patients, including mental diseases. It led to a pathomorphism of mental disturbances which expressiveness and complexity depend on a maturity of a nervous system of sick and age features of reaction. Change wedge, pictures P. can depend on the organism (the constitution, a sex, age), and also on intercurrent diseases. It is exogenous the caused pathomorphism can result from interaction of a basic disease (e.g., schizophrenia) with the joined second disease (e.g., rheumatism). S. G. Zhislin (1965) designated a similar combination as P.'s development. on patholologically to the changed soil. Manifestations of the induced therapeutic pathomorphism are connected both with achievements of psychopharmacology, and with all system of the organization of mental health services. Early hospitalization of mentally sick allows to begin intensive drug treatment in an initial stage of a disease. Both of these circumstances lead to reduction of number of the developed forms P., to increase in a share of their abortal options. For P.'s pathomorphism. lines of a pathomorphism of other diseases are characteristic. P.'s pathomorphism. is a part occurred in 70 — the 80th there are 20 century of shifts in structure of morbidity, incidence and mortality of the population (wide, panoramic, a pathomorphism).
P.'s pathomorphism. (in narrow value) it is shown in change morfol. and wedge, pictures of a disease, and also social characteristics. So, change morfol, pictures of a general paralysis is revealed at treatment by its inoculations of malaria, schizophrenia — under the influence of insulinoshokovy therapy, treatment by psychotropic drugs, etc. Klin, a picture any P. undergoes a metabasis, ratios as a part of symptom complexes, the sequence and rate of development of syndromes, ratios between forms of development, etc. Increase of favorably proceeding cases with not developed options P. is typical., that connect with broad use of psychotropic drugs.
Changes in a wedge, a picture of endogenous psychoses in the course of therapy happen in three stages. The first stage is characterized by a reduction of heavy frustration (catatonic and crazy). At the second stage the tendency to a pristupoobrazny current is noted, affective, neurosis-like, psychopatholike pictures which can lose an accurate syndromal ocherchennost begin to prevail, receive, according to Petrilovich (Petrilowitsch, 1968), lines so-called transitional, or intermediary. syndromes, resistant to therapy. The third stage (at relative stabilization of process with domination of periodically repeating affective phases) is expressed by the smaller depth of affective frustration. Changes in dynamics and symptomatology, i.e. a wedge, a pathomorphism, obych but are not beyond the manifestations inherent to this nosological form. However emergence of new syndromes is possible. Decrease in rate of a progrediyentnost of mental disorders correlates with reduction of number of the patients who are in hospitals and improvement of their social and labor adaptation.
Treatment can be subdivided on biol, therapy (i.e. use of the funds allocated for a disease as on biol, process and on an organism of the patient as on a biological object) and corrective actions into the patient as on the personality, the member of the public environment (society) surrounding it. Carry psychotherapy, work therapy which could be combined under the term «social therapy» in the broadest sense to the last if behind the similar term «sociotherapy» narrower understanding did not take roots (stimulation of activity of patients by introduction of elements of self-government in-tsakh, creation of the favorable microsocial environment, etc.). Social therapy is not identical to rehabilitation, cover the purpose first of all — recovery of abilities of the patient as member of society (see. Mental health services , rehabilitation). Different methods, including some receptions biol, therapies are for this purpose used.
In biol, therapy treatment by psychopharmacological means (see), shock methods of treatment (electroshocks and other types of convulsive therapy, insulinoshokovy therapy, treatment by atropinic and other types of a cholinolytic coma), the pyrogenic therapy (pyrogen of l), treatment by drugs of lithium, hormonal, fermental and other biologically active means, and also some methods of physical therapy enter (e.g., an electrosleep).
Biol, therapy is carried out with the different purpose, e.g. to interrupt a bad attack of P., to eliminate or soften heavy displays of mental disorders — excitement, alarm, hallucinations, fear, nonsense, etc. (the stopping therapy). During remission with the purpose to improve its quality and firmness, to avoid an aggravation of symptoms, to prevent a recurrence the maintenance therapy is carried out, edges can last many months and years. Preventive therapy is carried out to the period of intermissiya, napr, purpose of drugs of lithium at affective psychoses.
The psychotherapy is more and more widely used not only for treatment of neurosises and other borderline cases, but also for treatment of psychoses. Along with it apply other methods of social therapy — work therapy, «treatment Wednesday», i.e. creation in an environment of the patient of the favorable psychological atmosphere, methods of stimulation of social activity, etc.
During acute psychopathological states social and psychological influences have the limited purpose — to protect the patient from provocative psychogenic factors, to distract it from painful experiences (e.g., «therapy by employment», «hobby therapy», etc.). At improvement of a state (spontaneous or caused biol, therapy), its purpose — to achieve deeper critical relation of the patient to the postponed psychosis, to develop at it adequate installations on the future, to skorrigirovat the level of claims, to stimulate labor activity, communication with people around, etc. For this purpose use various methods — rational psychotherapy, group psychotherapy, «behavioural therapy», etc.
Necessary psychological correction shall be carried out also concerning the immediate environment of the patient, especially members of his family at whom it is necessary to develop the correct attitude towards the patient, adequate assessment of his opportunities. Similar psychotherapeutic influences received the name «family psychotherapy». It is more correct to consider the concepts «sick family» and «treatment of a family», «family diagnosis» used in literal sense by many psychiatrists abroad only tropes since actually it is about psychological correction of those disturbances of relationship in a family which would be brought by P. one of her members.
Surgical treatment. P.'s treatment. by neurosurgical methods usually call a psychosurgery. The first attempts of surgical impact on a brain of the person for the purpose of treatment psikhopatol. syndromes were undertaken at the end of 19 century by Burkhardt. In 1936
A. Munish offered operation of a prefrontal leucotomy (see). By means of this operation undertaken at various P., first of all at schizophrenia, interrupted frontal and thalamic ways that in some cases allowed to lay down. effect. However serious complications in the form of a resistant psychoorganic syndrome with decrease in intelligence, often adverse remote effects after operation, and also implementation highly effective psikhofarmakol. means led to failure from it.
From 70th 20 century the new stage in development of a psychosurgery connected with the fact that in a wedge, practice the stereotaxic method (was entered see began. The stereotaxic neurosurgery), allowing to make strictly local destruction (switching off) of separate structures of a brain (e.g., an amygdaloid kernel, a hippocampus, a hypothalamus), patholologically a superactivity of which causes emergence of some mental diseases and syndromes which are not giving in to treatment psikhofarmakol. means. To lay down. the effect of this method consists in disappearance of separate symptoms and syndromes. In case of full unsuccessfulness of all types of conservative treatment it is possible to resort to surgery at epilepsy (first of all, temporal epilepsy), at the sexual perversions which are not P.'s symptoms., a heretical oligophrenia, some forms of schizophrenia, a syndrome silt L and Turetta, and also in some cases at the organic lesions of a brain which are followed by aggression, asocial behavior etc.
Among numerous psychosurgeries the back gipotalamotomiya — bilateral stereotaxic destruction of back kernels of a hypothalamus is high on the list. Operation is shown, first of all, at «a syndrome of aggression» which is characteristic of patients with temporal epilepsy, and also with a heretical oligophrenia. Aggression is especially expressed at so-called heretical children with crushing organic lesions of a brain; these children constantly aim to put damages to themselves and people around. The back department of a hypothalamus has the small sizes therefore the center of destruction shall be no more than 3 — 4 mm. Nadvornik (R. Nadvornik) et al. (1973), Sano (To. Sano, 1974), etc. noted after a gipotalamotomiya permanent reduction or disappearance of aggression, concern, aspiration to self-damage. The mechanism to lay down. actions of this operation it is insufficiently clear. It is supposed that it normalizes the broken ergotropny and trofotropny balance controlled by a hypothalamus.
Destruction of other department of a hypothalamus — a ventromedialny kernel and a tuberomamillyarny complex — is effective at sexual perversions (pedophilia). Perhaps, at the same time there is a switching off of the hormonal and behavioural sexual centers of a hypothalamus. The Ventromedialny gipotalamotomiya was applied by Shramka (M. Sramka, 1977) with sotr. at hron, alcoholism; results of operation were encouraging.
Destruction of a zone crinkle (see. Tsingulotomiya ), the limbic system which is a part, it was made by a number of neurosurgeons at heavy not giving in to treatment psikhofarmakol. means neurosises, at separate forms of schizophrenia, drug addiction. Tsingulotomiya reduced or liquidated patol, excitement, aggression. According to the same indications carry out destruction of basal and medial quadrants of both frontal lobes. In 1974 Mr. L. V. Laitinen offered stereotaxic destruction of a knee of a corpus collosum — a mozoloviotomiya. Operation was made at the schizophrenia accompanied with permanent catatonic excitement, autoagressivny actions. The front capsulotomia — destruction of a front hip of the internal capsule — was made in 1973 by Bingley with sotr. at a depression, neurosises and phobias; improvement was reached.
Psychosurgical interventions are made on some kernels of a thalamus. So, there are data that destruction of the median center removes a syndrome of aggression, bilateral destruction of medial and interlaminarny kernels of a visual hillock was applied at severe forms of neurosises with obsessional neurosis. R. Poblete with sotr. in 1970 applied stereotaxic destruction of other thalamic structure — the internal brain plate which is closely connected with limbic system and orbital frontal bark. Operation was also performed at «a syndrome of aggression».
In a psychosurgery there are many unresolved and controversial issues. So, issues of indications to operations are not resolved at various the psychopath of l. syndromes, the long-term results of surgical intervention are insufficiently studied, the complex moral and ethical problems connected with a psychosurgery remain the most acute (some psychiatrists consider that brain operations at P. shall not be permitted).
the Forecast at P. concerning life it is, as a rule, favorable. Deaths from P. are quite rare. Only at a hypertoxical form of schizophrenia (see Delirium acutum) and severe forms of a tremens the high lethality is observed (see. Alcoholic psychoses). However a certain danger would be constituted by high risk of suicides at a row P., and especially at some syndromes and even symptoms. Carry depressions at endogenous psychoses to them and hron, alcoholism, situational depressions at advanced age, a syndrome azhitiro bathing melancholy, tendency to conditions of a melancholic raptus, or melancholic fury (see. Depressive syndromes); at schizophrenia imperative hallucinations, conditions of crazy tension with existence of nonsense of influence, self-accusation, ill treatment are dangerous, at epilepsy — the heavy, reaching psychotic level dysphorias. Suicide actions are possible during P.'s remissions., the patient quite often begins to understand damage caused by a disease of his personality and meets difficulties of social adaptation.
The forecast concerning P.'s current. depends on a nosological form, type of a current, quality of remissions, and also on existence in a wedge, a picture of the manifest period of the certain symptoms indicating a possibility of an adverse current (e.g., emergence of hebephrenic symptomatology at schizophrenia, bystry change of phases without light intervals at maniac-depressive psychosis).
The forecast concerning the course of a disease (a wedge, the forecast) and the forecast concerning working capacity, capacity, possibilities of social adaptation (the social forecast) are interconnected, but match not completely. On the social forecast, except P.'s current., some other factors significantly influences: premorbidal features of the personality, vocational training, marital status (the social forecast at lonely is always worse), living conditions and other social and psychological factors.
Prevention quite often mixes up with the concept «psychoprophylaxis», the wide complex of all-recreational measures (first of all, concerning psychological factors) for the prevention of mental disturbances, including borderline cases means edges (see the Psychoprophylaxis). P.'s prevention. includes the measures directed to separate P.' prevention. Along with psychoprophylactic measures, it widely joins genetic consultation, intensive treatment of somatopathies, quite often defiant or provoking psychoses, preventive medicinal treatment, etc.
In psychiatry would distinguish three types of prevention of P. (primary, secondary and tertiary). Primary it is directed to the prevention of emergence of P. (e.g., treatment of infections, intoxications, especially hron, alcoholism, craniocereberal injuries, i.e. elimination of factors, defiant exogenous and provoking endogenous psychoses, etc.). Secondary prevention is performed during remissions and intermissiya and is directed to prevention of a recurrence (the supporting and preventive antirecurrent therapy, rational employment, creation of a favorable environment, etc.). Tertiary prevention consists of a package of measures of rehabilitation, directed to reduction of mental defect, the phenomena of a hospitalism (strengthening of changes of the personality at long stay in hospital) and development of disability.
Mental diseases in wartime
Mental diseases in wartime — disorders of mental activity, in emergence and which current specific conditions of a fighting situation and the striking action of weapon have the defining value.
Characteristic forms P. in wartime among staff of troops mental disorders at the closed injuries of a brain, a psychogenia are and epilepsy. However the ratio between the specified forms in various wars changed depending on improvement of means of armed struggle. During the Russian-Japanese war of 1904 — 1905 considerable specific weight was occupied by epilepsy; during World War I of 1914 — 1918 — psychogenias, epilepsy and mental disorders at the closed injuries of a brain. At the same time psychogenias developed owing to influence of chemical weapon and against the background of the slight closed injuries of a brain, a surdomutism — at massive use of artillery. In the Great Patriotic War of 1941 — 1945 mental disorders at the closed injuries of a brain prevailed. The defeats caused by influence of an air and blast wave (an air contusion) also belonged to the closed injuries of a brain. Psychogenias during war especially often arose against the background of the remote effects of the closed injuries of a brain and extracranial wounds. Exogenous psychoses were noted at heavy somatic pathology, napr, at hypovitaminoses, and also at viral encephalitis and intoxications by technical liquids. Dynamics of frequency of mental disorders after the closed injuries of a brain was connected during the Great Patriotic War with increase of their frequency in connection with the increasing fire power of the battling armies. Frequency of psychogenias throughout war, on the contrary, decreased from year to year.
During the Great Patriotic War as a result of improvement of mental health services and its approach to the army district the vast majority of the persons who had mental disorders at the closed injuries of a brain and also after a psychogenia was returned in a system. Patients (with easy forms of mental disorders) with the term of treatment to 10 days remained in MSB, with for up to 1 month — were evacuated in therapeutic PPG and in army hospital for lightly wounded. Persons with heavier pathology went to front psikhonevrol. hospital or in specialized departments of front hospitals for lightly wounded. At the long course of mental disorders sick and struck went in psychiatric to lay down. institutions of the back of the country.
For the rendering medical aid and treatment struck psikhonevrol. a profile in field army were created specialized to lay down. institutions (neurologic field mobile hospital, nevropsikhiatrichesky evacuation hospital) and specialized departments in hospitals for lightly wounded.
Among the military personnel of armies of the capitalist states mental disorders meet more often. The prevailing form of pathology are psychogenias that was noted, in particular, in time fighting in Korea (1950 — 1953), Vietnam (1964 — 1973) and in the Middle East (1973). According to Tiffany and Allerton (1967), the frequency of mental diseases among the military personnel of army of the USA from 1951 to 1965 increased by 3 times.
In the conditions of use of nuclear weapon the probability of emergence of mental diseases increases. So, at eyewitnesses of atomic explosion in Hiroshima the large number of the mental disorders (acute psychogenic reactions, reactive psychoses, long massive neurotic frustration) which were quite often passing in was observed it is heavy and long the proceeding psychoses.
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A. E. Pm; M. E. Vartanyan (experimental psychoses), E. I. Kandel, A. Romodanov (hir.), L. I. Spivak (soldier.), L. K. Khokhlov (pathomorphism); an introductory part (redotdet).