Affective period is called. affective disorder

Affective syndromes are symptom complexes of mental disorders determined by mood disorders.

Affective syndromes are divided into two main groups - with a predominance of elevated (manic) and low (depressive) mood. Patients with are many times more common than with and should be addressed Special attention, as approximately 50% of persons who attempt suicide suffer from depression.

Affective syndromes are observed in all mental illnesses. In some cases, they are the only manifestations of the disease (circular psychosis,), in others - its initial manifestations (, brain tumors, vascular psychoses). The last circumstance, as well as a very high frequency of suicides among patients with depressive syndromes, determines the tactics of behavior medical workers. These patients should be placed under close medical supervision around the clock and should be referred to a psychiatrist as soon as possible. It must be remembered that not only rude, but simply careless treatment of manic patients always entails an increase in their excitation. On the contrary, attention, sympathy for them allow, even if a short time, to achieve their relative calm, which is very important when transporting these patients.

Affective syndromes - syndromes, in clinical picture which the leading place is occupied by violations of the emotional sphere - from mood swings to its pronounced disorders (affects). By nature, affects are divided into sthenic, flowing with a predominance of excitation (joy, delight), and asthenic - with a predominance of inhibition (fear, longing, sadness, despair). Affective syndromes include dysphoria, euphoria, depression, mania.

Dysphoria- a mood disorder characterized by a tense, maliciously dreary affect with marked irritability, reaching outbursts of anger with aggressiveness. Most often, dysphoria occurs in epilepsy; with this disease, they begin suddenly, without an external cause, last for several days and also end abruptly. Dysphoria is also observed in organic diseases of the central nervous system, in psychopaths of the excitable type. Sometimes dysphorias are combined with binge drinking.

Euphoria- elevated mood with a touch of contentment, carelessness, serenity, without accelerating associative processes and increasing productivity. Signs of passivity and inactivity predominate. Euphoria is found in the clinic of progressive paralysis, atherosclerosis, brain injury.

Pathological affect- a short-term psychotic state that occurs in connection with mental trauma in people who do not suffer from mental illness, but are characterized by instability of mood and asthenia. The tension of affect, anger and rage in this state is immeasurably greater than those characteristic of physiological affects.

The dynamics of the pathological affect is characterized by three phases: a) asthenic affect of resentment, fear, which is accompanied by thinking disorders (incompleteness of individual thoughts, their slight incoherence) and autonomic disorders (pallor of the face, trembling of the hands, dry mouth, decreased muscle tone); b) the affect becomes sthenic, rage and anger prevail; consciousness sharply narrows, its content is dominated by psychic trauma; disorders of consciousness deepen, accompanied by excitement and aggression; the nature of vegetative changes becomes different: the face turns red, the pulse quickens, muscle tone increases; c) a way out of a pathological affect, which is realized by prostration or sleep, followed by complete or partial amnesia.

Treatment of affective conditions. The presence of one or another affective syndrome in patients requires emergency measures from the doctor: establishing supervision of the patient, referring him to a psychiatrist. Depressed patients who may make a suicide attempt are hospitalized in a unit with enhanced supervision. It is necessary to transport them to the hospital under the constant supervision of the medical staff. On an outpatient basis (before hospitalization), patients in a state of agitated depression or depression with persistent suicidal attempts are prescribed an injection of 5 ml of a 2.5% solution of chlorpromazine.

When prescribing therapy, the nosological diagnosis and the characteristics of the patient's condition are taken into account. If depression is a phase of circular psychosis, then the treatment is carried out with psychotropic drugs - antidepressants. If there is agitation, anxiety in the structure of this depression, combined therapy with antidepressants (in the first half of the day) and antipsychotics (in the afternoon) is prescribed, or treatment with nosinane, amitriptyline is carried out.

With psychogenic depressions, if they are shallow, hospitalization is not necessary, since their course is regressive. Treatment is carried out with sedative and antidepressant drugs.

Patients in a manic state are usually hospitalized, since it is necessary to protect both those around them and the patients themselves from their wrong and often unethical actions. For the treatment of manic states, neuroleptics are used - chlorpromazine, propazin, etc. Patients with euphoria are subject to hospitalization, since this condition indicates either intoxication (which requires rapid recognition for emergency measures) or an organic brain disease, the essence of which must be clarified . The euphoria of convalescents who have had an infectious or general somatic disease at home or in a somatic (infectious) hospital does not serve as an indication for hospitalization in a psychiatric hospital. Such patients should be under the constant supervision of a doctor and staff. For their treatment, along with restorative agents, sedatives can be used. Patients in a state of epileptic dysphoria are also hospitalized due to the possibility of aggression.

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affective disorder

What is Mood Disorder -

Mood Disorder (Mood Disorder)- a mental disorder associated with disorders in the emotional sphere. Combines several diagnoses in the DSM IV TR classification, when the main symptom is a violation of the emotional state.

Two types of disorders are most widely recognized, the distinction between which is based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, among which the best known and studied is major depressive disorder, which is also called clinical depression, and previously known as manic-depressive psychosis and described by intermittent periods of manic (lasting from 2 weeks to 4-5 months .) and depressive ( average duration 6 months) episodes.

What provokes / Causes of Mood Disorders:

Causes of Mood Disorders unknown, but biological and psychosocial hypotheses have been proposed.

biological aspects. Norepinephrine and serotonin are the two neurotransmitters that are most responsible for the pathophysiological manifestations of mood disorders. In animal models, it has been shown that effective biological treatment with antidepressants (AD) is always associated with inhibition of the sensitivity of postsynaptic β-adrenergic and 5HT2 receptors after a long course of therapy. This probably corresponds to a decrease in the functions of serotonin receptors after chronic exposure to AD, which reduces the number of serotonin reuptake zones and an increase in serotonin concentration found in the brain of patients who have committed suicide. There is evidence that dopaminergic activity is reduced in depression and increased in mania. Recent studies have shown an increase in the number of muscarinic receptors on tissue culture of fibrinogens, urine, blood, and cerebrospinal fluid in patients with mood disorders. Apparently, mood disorders are associated with heterogeneous dysregulation of the biogenic amine system.

It is assumed that secondary regulation systems, such as adenylate cyclase, calcium, phosphatidyl inositol, may also be etiological factors.

It is believed that neuroendocrine disorders reflect dysregulation of the entry of biogenic amines into the hypothalamus. Deviations along the limbic-hypothalamic-pituitary-adrenal axis are described. Some patients have hypersecretion of cortisol, thyroxine, a decrease in nocturnal secretion of melatonin, a decrease in the main level of FSH and LH.

Sleep disturbances are one of the strongest markers of depression. The main disorders consist in a decrease in the latent period of REM sleep, an increase in the duration of the first period of REM sleep and an increase in the amount of REM sleep in the first phase. It has been suggested that depression is a violation of chronobiological regulation.
Decreases in cerebral blood flow, especially in the basal ganglia, decreased metabolism, and disturbances in the late components of the visual evoked potential were found.
It is assumed that the basis of sleep disorders, gait, mood, appetite, sexual behavior - is a violation of the functions of the limbic-hypothalamic system and basal ganglia.

Genetic aspects. Approximately 50% of bipolar patients have at least one parent with a mood disorder. The concrodance rate is 0.67 for bipolar disorder in monozygotic twins and 0.2 for bipolar disorder in dizygotic twins. A dominant gene located on the short arm of chromosome 11 has been found to confer a strong predisposition to bipolar disorder in the same family. This gene may be involved in the regulation of tyrosine hydroxylase, an enzyme required for the synthesis of catecholamines.

Psychosocial aspects. Life events and stresses, premorbid personality factors (suggestible personalities), psychoanalytic factors, cognitive theories (depression due to a misunderstanding of life events).

Symptoms of Mood Disorders:

Depressive disorders
Major depressive disorder, often referred to as clinical depression, is when the person has experienced at least one depressive episode. Depression without periods of mania is often referred to as unipolar depression because the mood remains at one emotional state or "pole". When diagnosing, several subtypes or specifications for the course of treatment are distinguished:

- atypical depression characterized by reactivity and positive mood ( paradoxical anhedonia), significant weight gain or increased appetite(“eating to relieve anxiety”), excessive sleep or drowsiness (hypersomnia), a feeling of heaviness in the limbs, and a significant lack of socialization as a consequence of hypersensitivity to perceived social rejection. Difficulties in assessing this subtype have led to questions about its validity and distribution.

- melancholic depression(acute depression) is characterized by a loss of pleasure (anhedonia) in most or all activities, an inability to respond to pleasurable stimuli, a feeling of lowered mood more pronounced than a feeling of regret or loss, worsening of symptoms in the morning hours, waking up early in the morning, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or intense guilt.

- Psychotic depression- a term for a long depressive period, in particular in a melancholy nature, when the patient experiences psychotic symptoms such as delusions, or less often hallucinations. These symptoms almost always match the mood (the content matches the depressive themes).

- Depression congealing - involutional- a rare and severe form of clinical depression, including a disorder of motor functions and other symptoms. In this case, the person is silent and almost in a state of stupor, and is either immobile or makes aimless or even anomalous movements. Similar catatonic symptoms also appear in schizophrenia, manic episodes, or are a consequence of neuroleptic malignant syndrome.

- postpartum depression marked as qualifying term in DSM-IV-TR; it refers to the excessive, persistent and sometimes disabling depression experienced by women after childbirth. Postpartum depression, estimated at 10-15%, usually appears within three working months and lasts no longer than three months.

- seasonal affective disorder is a qualifying term. Depression in some people is seasonal, with an episode of depression in the fall or winter, and a return to normal in the spring. The diagnosis is made if depression occurs at least twice during the cold months and never at any other time of the year for two years or more.

- Dysthymia- chronic, moderate mood disorder, when a person complains of an almost daily bad mood for at least two years. Symptoms are not as severe as in clinical depression, although people with dysthymia are also subject to periodic episodes of clinical depression (sometimes called "double depression").

- Other depressive disorders(DD-NOS) are coded 311 and include depressive disorders that are detrimental but do not fit into formally defined diagnoses. According to the DSM-IV, DD-NOS encompasses "all depressive disorders that do not meet the criteria for any specified disorder." They include diagnostic testing

Recurrent fulminant depression, and Minor depression, as listed below:
- Recurrent transient disorder(RBD) is distinguished from major depressive disorder mainly because of the difference in duration. People with RBD experience depressive episodes once a month, with individual episodes lasting less than two weeks and usually less than 2-3 days. For RBD to be diagnosed, episodes must have been present for at least one year and, if the patient is female, regardless of menstrual cycle. People with clinical depression can develop RBD, and vice versa.

- minor depression who does not meet all the criteria for clinical depression, but in which at least two symptoms are present within two weeks.

Bipolar Disorders
- bipolar affective disorder, formerly known as "manic-depressive psychosis", is described as alternating periods of manic and depressive states (sometimes very quickly replacing each other or mixing into one state, in which the patient has symptoms of depression and mania at the same time).

Subtypes include:
- Bipolar disorder I defined as having or having experienced one or more manic episodes with or without episodes of clinical depression. For a DSM-IV-TR diagnosis, at least one manic or mixed episode is required. For the diagnosis of Bipolar I disorder, depressive episodes, although not required, appear quite often.

- Bipolar disorder II consists of repetitive alternating hypomanic and depressive episodes.

- Cyclothymia is a milder form of bipolar disorder that presents with intermittent hypomanic and dysthymic episodes without any more severe forms mania or depression.

The main violation is a change in affect or mood, the level of motor activity, the activity of social functioning. Other symptoms, such as a change in the pace of thinking, psychosensory disturbances, statements of self-blame or overestimation, are secondary to these changes. The clinic manifests itself in the form of episodes (manic, depressive) of bipolar (two-phase) and recurrent disorders, as well as in the form of chronic mood disorders. Intermissions without psychopathological symptoms are noted between psychoses. Affective disorders are almost always reflected in the somatic sphere (physiological functions, weight, skin turgor, etc.).

The range of affective disorders includes seasonal weight changes (usually weight gain in winter and weight loss in summer within 10%), evening cravings for carbohydrates, in particular sweet before bed, premenstrual syndromes, expressed in a decrease in mood and anxiety before menstruation, as well as " northern depression”, which migrants to northern latitudes are subject to, it is observed more often during the polar night and is due to a lack of photons.

Diagnosis of Mood Disorders:

Changes in affect or mood are the main signs, the rest of the symptoms are derived from these changes and are secondary.

Affective disorders are observed in many endocrine diseases (thyrotoxicosis and hypothyroidism), Parkinson's disease, vascular pathology brain. In organic affective disorders, there are symptoms of a cognitive deficit or a disorder of consciousness, which is not typical for endogenous affective disorders. They should also be differentiated in schizophrenia, however, with this disease, other characteristic productive or negative symptoms are present, in addition, manic and depressive states are usually atypical and closer to manic-hebephrenic or apathetic depressions. The greatest difficulties and disputes arise when differential diagnosis with schizoaffective disorder, if secondary ideas of overestimation or self-blame arise in the structure of affective disorders. However, with true affective disorders, they disappear as soon as the affect is normalized, and do not determine the clinical picture.

Treatment of Mood Disorders:

Therapy of affective disorders consists of the treatment of depression and mania itself, as well as preventive therapy. Therapy for depression includes, depending on the depth, a wide range of drugs from fluoxetine, lerivon, zoloft, mianserin to tricyclic antidepressants and ECT. Sleep deprivation therapy and photon therapy are also used. Therapy for mania consists of therapy with increasing doses of lithium while monitoring them in the blood, the use of neuroleptics or carbamazepine, sometimes beta-blockers. Maintenance treatment is with lithium carbonate, carbamazepine, or sodium valprate.

Treatment of psychogenic depression start with the appointment of antidepressants. Depression, as mentioned above, may be accompanied by an anxiety component or, conversely, asthenic syndrome may be leading. Depending on this, treatment will be built. Doses are titrated as needed.

In the presence of asthenic syndrome, SSRIs are prescribed such as: fluoxetine, fevarin, paxil.

In the presence of anxiety, SSRIs are prescribed such as: cipramil, zoloft. Additionally, alprazolam (Xanax) or mild antipsychotics - chlorprothixen, sonapax are prescribed.
The patient, as the cure progresses, can go into a hypomanic state, in which case it is necessary to prescribe normotimics, for example, finlepsin from 200 mg and above. Psychotherapy (cognitive therapy, behavioral, interpersonal therapy, group and family therapy) is also prescribed.

From the moment of improvement, continue treatment with antidepressants for at least 6 weeks, then reduce the dose of the drug, if necessary, prescribe maintenance therapy.

Treatment of endogenous depression start with the appointment of antidepressants. Selective and non-selective serotonin and norepinephrine reuptake inhibitors are most effective.

In the presence of anxiety, amitriptyline and other sedative antidepressants are prescribed. Of the selective inhibitors - ludiomil, desipramine, as well as remeron (central alpha-2-blocker), moclobemide, an additional appointment of anxiolytics or neuroleptics is possible. With inefficiency, non-selective MAOIs, but always in combination with anxiolytics, or antipsychotics, because MAOIs have a pronounced only activating effect.

With the prevalence of melancholy, lack of anxiety, anafranil, protriptyline, nortriptyline are prescribed - activating antidepressants. In case of inefficiency, you can also prescribe an MAOI - tranylcypramil (non-hydrozated) - a positive effect after 2-3 days. When using hydrozed - nialamide - after 2-3 weeks.
From the moment of improvement, treatment is continued for 6 months (as recommended by WHO). For 2-3 weeks before the dose reduction, normotimics are prescribed (Finlepsin from 1000 mg). Reduce by 25 mg of amitriptyline per week, and after withdrawal, continue treatment with mood stabilizers for 1-2 weeks. If necessary, supportive therapy.

If the patient gives allergic reaction all antidepressants or treatment is ineffective - prescribe ECT (electroconvulsive therapy). It is possible to conduct up to 15 sessions in elderly patients with endogenous depression.

Treatment of mania is reduced to the appointment of neuroleptics of the buterophenone or phenothiazine series, mood stabilizers, psychotherapy. ECT - 10-15 sessions.

Treatment of cyclothymia comes down to the appointment of antidepressants (from small doses, due to the possibility of phase reversal), mood stabilizers, psychotherapy - see endogenous depression.

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Other diseases from the group Mental and behavioral disorders:

Mood disorder is a group of emotional disorders that occur in children and adults. This variety has a psychogenic or hereditary nature of occurrence. There are a large number of types of affective disorders, each of which differs in symptoms and severity. in children's and adolescence there are features of the course of the disease that must be taken into account when making a diagnosis. Diagnosis of the disease is carried out with the help of a psychiatrist and psychologist, it is often necessary to examine other narrow specialists.

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Description of the disease

An affective disorder in psychiatry is a mental disorder that is characterized by disturbances in the emotional sphere. According to statistics, this group of diseases is observed in every fourth adult inhabitant of our planet. The exact nature of the occurrence of this disease has not been established. This pathology has various degrees: mild to severe.

Mild severity is characterized by the presence of mild symptoms. At this stage, it is difficult to diagnose an affective disorder according to any criteria. This degree of severity is characterized by a small number of manifestations that relate to certain diseases. In the middle and severe stages, a diagnosis can be made, because the symptoms are vivid and diversified.

According to the results of the studies, affective disorders occur against the background of impaired functioning of brain structures (pineal gland, pituitary gland, hypothalamus, limbic system). This disease develops due to aggravated heredity (in 50% of cases) or due to a mutation of a gene that is located on the 11th chromosome. Common causes development of affective disorders are:

• stressful situations (psychogenic occurrence);
• overstrain of the nervous system;
• death of loved ones;
• the end of the relationship;
• conflicts in the family and at work;
• individual psychological characteristics of the personality (high suggestibility, sensitivity, suspiciousness).

It is believed that affective disorders occur against the background of the release of a deficient amount of neurotransmitters (norepinephrine and serotonin), which affect a person's mood. In some patients, this disease develops due to the excretion a large number cortisol and thyroxine. A decrease in the production of melatonin contributes to the development of affective disorders.

This group of diseases develops against the background of diseases endocrine system, which include diabetes, hypothyroidism, thyrotoxicosis. Epilepsy, multiple sclerosis, trauma and brain tumors can also affect the development of affective disorders. Mental illnesses such as schizophrenia and personality disorders are the cause of depression or other emotional disturbances. Neurodegenerative diseases can influence the formation of these disorders.

Main clinical manifestations and types

Currently, there are three groups of affective disorders, each of which differs in symptoms and their severity: depressive disorders, manic and bipolar spectrum disorders. Depressive disorders include the following types:

View	Characteristic
Clinical	There is a decrease in mood, increased fatigue and a decrease in energy. Patients complain of decreased appetite and sleep disturbances. They lose interest in events and hobbies. There are suicidal thoughts and attempts, as well as pessimism about the present and the future. Presents without psychotic symptoms
Malaya	Two or more signs of clinical depression within two weeks
Atypical	Increased appetite, weight gain and drowsiness. Patients have emotional reactivity - a rapid emotional response to events. There is a high level of anxiety, emotional lability (mood swings), hallucinations. Patients complain of increased fatigue
psychotic	There are hallucinations (auditory and visual) and delusional ideas against the background of reduced mood. There is a lack of libido, apathy, slow thinking and inability to cry
Melancholic (acute)	Patients experience guilt and loss of interest and energy. Worsening of symptoms in the morning, sleep disturbances and weight loss
involutionary	Movement disorders are noted. The patient is always silent and immobile
Postnatal (postpartum)	An affective disorder accompanied by a decrease in mood after childbirth. Duration - up to three months
recurrent	Symptoms appear once a month and persist for several days
Dysthymia	Daily bad mood for two years
Seasonal	A condition that occurs in autumn and winter. Manifestations of this disease disappear in the spring. Diagnosis requires two episodes of symptoms during the cold months and none at other times of the year for two or more years.

There are two types of manic disorders:

• hypomania (elevated mood, high motor activity and psychomotor agitation);
• mania ( mild form mania, characterized by less pronounced severity).

Bipolar disorder (manic-depressive psychosis) is a disease characterized by periods of manic and depression and alternates with the normal state of the patient's psyche (remissions, light intervals). This disease occurs in 1.5% of cases of affective disorders. Bipolar disorder is divided into three types:

• bipolar disorder I (presence of one or more manic episodes without manifestations of a depressive state);
• bipolar disorder II (alternating manic and depressive episode);
• cyclothymia (the presence of hypomania and dysthymia).

Features of affective disorders in children and adolescents

Symptoms of this disease have certain characteristics in children and adolescents. In these patients, there is a predominance of somatic and autonomic symptoms. Depressive psychoses in patients are characterized by the presence of night terrors, sleep disturbances (difficulty falling asleep).

Pallor of the skin is noted, complaints of pain in the chest or abdomen. There is increased fatigue, loss of appetite and capriciousness. Children refuse to play with peers. There are learning difficulties and slowness.

Manic states proceed with certain features. There is an increased mood and disinhibition of mental processes. They are out of control and laugh all the time. There is a gleam in the eyes, redness of the skin and accelerated speech.



Diagnostics

Affective disorders are diagnosed by a psychiatrist. Diagnostic value is the collection of anamnestic information. The anamnesis includes establishing the cause of the onset of the disease (heredity or other factors), the patient's complaints, how long ago they appeared.

In addition, the patient must undergo an examination by a psychologist, endocrinologist and neurologist, if the patient has other concomitant somatic diseases in order to prescribe a course of treatment. An examination by a psychologist allows you to determine the level of anxiety, to identify the absence or presence of suicidal thoughts, impaired thinking, memory, attention and intelligence, which are characteristic of other mental illnesses. For this, the following psychodiagnostic methods are used:

• pictograms;
• exclusion of the 4th superfluous;
• classification of objects;
• "ten words";
• comparison of concepts;
• Spielberg test;
• the Beck Depression Scale;
• Schulte tables;
• correction test;
• understanding the figurative meaning of metaphors and proverbs;
• progressive matrices of Raven (Raven);
• Kos cubes;
• Wexler test.

Treatment

Treatment of affective disorders is carried out with the help of medications (mainly antidepressants) and psychotherapy. Therapy is carried out in outpatient and stationary conditions. Hospitalization is prescribed by a doctor if the patient has hallucinations, suicidal attempts and thoughts. Such patients are treated in psychiatric clinics under the constant supervision of medical personnel.

The effectiveness of the therapy becomes noticeable one to two weeks after the start of the course of treatment. The doctor should inform the patient and his relatives that self-treatment and non-compliance with the dosage, duration and frequency of taking the drug is not recommended, because the patient's mental state may worsen, an overdose of drugs is also possible.

Cancellation of drugs is carried out by the doctor gradually, taking into account the improvement in dynamics. The dosage and duration of treatment depends on the severity and type of affective disorder, as well as individual characteristics patient (weight, age and tolerance of individual medicinal components). Treatment of depressive disorders is the use of fluoxetine, sertraline, amitriptyline, nortriptyline and others. medicines. If antidepressants are not suitable for the patient, then electroconvulsive therapy (ECT) is prescribed.




In the presence of anxiety, the patient is prescribed Cipramil or Sonapax. The course of treatment is six weeks, after which the dosage of drugs is reduced and maintenance therapy is prescribed (treatment with drugs in small doses to prevent exacerbation). If the patient has hallucinations, then neuroleptics and sleeping pills are prescribed (Persen, Novo-Passit). The groups of neuroleptics include haloperidol, Aminazin, Azaleptin.



• cognitive behavioral;
• interpersonal;
• group;
• family;
• art therapy.

With the help of cognitive-behavioral therapy methods, a psychotherapist can change the patient's attitudes from negative to positive, identify and eliminate the causes of the disease. With the help of this type of psychotherapy, you can get rid of fears and anxiety through the constant implementation of certain techniques. The course of treatment is 3-4 months. After the treatment, a persistent state of remission is noted. Through this method, patients change their behavior in the social environment.

Interpersonal psychotherapy consists of 12-16 sessions. The duration of one session is 50-60 minutes. This method of treatment is used if the patient has difficulties in interpersonal communication against the background of the disease. With the help of interpersonal psychotherapy, one can work out such a reason for the appearance of affective disorders as the death of a loved one.

Group psychotherapy is a form of treatment of diseases, the purpose of which is to resolve internal and interpersonal conflicts, relieve emotional stress and change the patient's behavior in society. This type of psychotherapy is carried out with a small group of people (5-10 people). Group psychotherapy has several advantages over individual therapy:

• the patient receives support from other members of the group, which is a necessary element in the treatment of affective disorders;
• there is personal growth;
• the patient's ability not only to be an active participant in the therapy process, but also a spectator, i.e. the patient can observe the interaction of other members of the group and try on their roles.

Family psychotherapy is a type of treatment that is aimed at correcting relationships in the family. The purpose of this psychotherapy is to change attitudes in the family, to correct the patients' views on the problem in relationships, to create ways to solve problems. If the patient's relationships in the family change, then the emotional state returns to normal.

A method such as art therapy is also used, which consists in fine art aimed at changing the psycho-emotional state of the patient.

Prevention and prognosis

As a preventive measure for the onset of the disease, one should try to avoid conflict and stressful situations. It is recommended to observe the sleep and rest regimen (sleep should last at least eight hours a day). In order to get rid of negative thoughts, you need to master the skills of meditation and relaxation, walks in the fresh air and exercises in the morning will be useful.

At proper treatment the prognosis of the disease is favorable. With regular maintenance therapy, the recurrence of the disease can be prevented. Affective disorders reduce the level of the patient's ability to work and prevent the establishment of friendships and family relationships, thereby having a negative impact on the life and actions of the patient. If a person has a long-term decrease in mood, then it is necessary to immediately contact a specialist in order to identify the disease at an early stage.

Mood Disorder Criteria:

• autochthonous appearance of emotions (i.e., not associated with external causes, somatic, endocrine pathology and other physiological disorders);
• lack of emotional reactions to personal significant situations and objects;
• disproportion of the intensity and duration of emotional reactions to the reasons that cause them;
• discrepancy between the quality of the emotional reaction and the reason that causes it;
• violations of adaptation and behavior in connection with emotion;
• the unusual nature of emotional experiences, different from what was previously characteristic of a healthy individual;
• the emergence of emotional reactions in response to virtual, surreal, meaningless stimuli.

These criteria do not have an absolute value, they are rather relative, so that the emotional reactions of the individual can be assessed ambiguously.

In fact, situations often arise when it is rather difficult and even impossible to distinguish between the norm and the pathology of emotions without further observation of the individual.

1. Violations of affect

The above affect criteria are not clinically delimited, although various and numerous deviations have been pointed out. In forensic psychiatry, pathological, physiological variants of affect, as well as physiological affect on pathological grounds, are distinguished.

The preparatory phase is characterized by the interpretation of psychogeny, the appearance and growth of emotional stress. Acute psychogenia can reduce the duration of the phase to a few seconds. A long-term psychotraumatic situation lengthens the preparatory phase for months, years: during this period, for some reason, the patient delays with an adequate response to the challenge, and his “spinelessness” can significantly aggravate the situation. The permissive occasion (“the last straw”) may be quite ordinary, banal, but it is in connection with it that terrible consequences come. In the preparatory phase, the individual may simply not know, not see a worthy way out of the situation; if a psychologist or an experienced psychotherapist happened at the same time, the tragedy might not happen. Consciousness in this phase is not darkened, however, its narrowing is observed in the form of an increasing concentration of attention on the psychotraumatic situation.

Pathological affect- an acute, short-term painful state of a psychogenic nature that occurs in a practically healthy individual (Shostakovich, 1997). Pathological affect proceeds in three phases.

The explosion phase comes suddenly, absolutely unexpectedly both for the individual himself and for those around him. The main thing that characterizes her is an affective twilight clouding of consciousness. This is a psychophysiological process, and not just the dynamics of involuntary attention. During this period, there may be various affective disorders (anger, despair, confusion, other manifestations hidden under the main affect), the phenomena of sensory hypo- and hyperesthesia, illusions, perceptual deceptions, unstable delusions, violations of the body scheme and other manifestations of a violation of self-perception. Typically, an acute psychomotor agitation that has no connection with the patient's conscious self, but, as it were, stems from the depths of his unconscious.

Arousal can be chaotic, aimless, or appear to be well-ordered with targeted aggression. Actions are performed at the same time "with the cruelty of an automaton or a machine" (Korsakov, 1901). Sometimes they are performed in the form of motor iterations: for example, an already lifeless victim continues to inflict countless wounds, blows or shots. It is aggression that reigns supreme, it does not switch over to oneself, apparently there are no suicidal acts. States of pathological affect with rage and auto-aggression do not occur, probably at all, or they cannot be identified. Patients are disoriented in place, time, circumstances; it cannot be ruled out that the autopsychic orientation is disturbed. Patients can vocalize loudly, clearly pronounce individual words, repeating them, but usually the speech becomes incoherent.

Apparently, they either do not pay attention to the speech of others, or do not understand it. Non-verbal speech, on the contrary, is lively, it is like instinctive speech, and it can be quite understandable (grimace of rage, grinning of teeth, narrowing palpebral fissures or, on the contrary, their expansion, a continuous look at the object of anger, etc.). The intellect suffers deeply - an individual performs certain actions without understanding the real situation, without realizing their consequences. The nature of the actions - their special cruelty, the totality of the destruction produced do not correspond or even contradict the personal qualities of the individual. There are, for example, patients who are not self-confident, defenseless, devoid of any aggressive tendencies. Violent and extremely aggressive individuals usually commit offenses outside the state of pathological affect.

The final phase comes as swiftly, with lightning speed, as the second. There is a sharp exhaustion, prostration, sleep or somnolence. Psychomotor retardation sometimes reaches the degree of stupor. This phase lasts for tens of minutes. Upon restoration of clarity of consciousness and activity, extensive congrade amnesia for impressions, experiences and actions of the second phase of affect is revealed. Amnesia can be delayed, and usually after minutes, tens of minutes everything is completely forgotten. Separate memories of the final and, to a greater extent, preparatory phase may be preserved. An individual often relates to what he has done in a state of pathological affect as if it had nothing to do with him, he does not appropriate, does not appropriate the stories of other people about what happened.

Cases of pathological affect arising in connection with a protracted psychic trauma differ from those described in several essential features. This is a long latent or preparatory stage, development on an outwardly insignificant occasion, of which there were plenty before, the awareness and apparition of what was done upon leaving the affect, the polarity of experiences and actions in the affect to the personal qualities of the individual, as well as the fact that immediately or somewhat later can develop acute depressive reaction to the incident with suicidal actions. Such patients do not try to hide something, lie, they willingly cooperate with the investigating authorities, forensic doctors. Previously, E. Kretschmer designated such variants of pathological affect as short-circuit reactions. Persons falling into states of such an affect are referred to in modern literature as "aggressors who overly control themselves." The exclusion of short-circuit reactions as a special variant of pathological affect is associated, we believe, with ignoring important essential distinctive features between them.

Physiological affect on a pathological basis(Serbsky, 1912) - a transitional form between physiological and pathological affects. The pathological basis of such an affect more often, apparently, is psychopathy, alcohol dependence, and possibly other forms of chemical and non-chemical dependence, PTSD. VP Serbsky believes that the degree of impairment of consciousness is insignificant.

Typically, there is a discrepancy between the strength of affect and the real significance of the cause that caused it. The affect can be intense to such an extent as to become, as it were, the main cause of a serious offense. A common example of such an affect is the frequent cases of alcoholic (other) intoxication, when at some point the patient’s self-control is turned off, the affects of anger come to the fore, hostility, jealousy, a sense of revenge, a tendency to destructive actions, violent fights, etc. In another observation with OA, aged 39 (“schizotypal personality disorder”), after a quarrel with her husband, the patient with her daughter locked herself in the room with the thought of killing her and herself.

When asked to open the door, she responded with the threat of killing her daughter and herself. Then, according to her, she "lost consciousness." Relatives, having entered the room, with difficulty tore the sick knife out of their hands. “They said that at that time I was crying, laughing.” Then she "felt the hands, the knife, began to come to her senses." She says that she seriously intended to kill herself and her daughter, but “something inside prevented me from doing this.” Due to the high frequency of such things, questions of sanity are initiated very rarely. Nevertheless, very difficult situations can arise here, so that the usual forms of their assessment can give rise to justified doubts in a forensic psychiatrist. Nowhere is the possibility excluded that a pathological or physiological affect may arise on the alienated part of one's self.

Physiological affect is a state of very pronounced affect without clear signs of a twilight state of consciousness. Usually, different, including significant, degrees of affective narrowing of consciousness in relation to external, as well as internal impressions, are noted. Physiological affect also proceeds in three stages, although it is quite difficult to clearly distinguish between them. Clinically obvious signs of narrowing of consciousness are believed to be observed only in the second phase of affect. The painful episode does not end with marked prostration, sleep, and somnolence; the amnesia is partial. In a state of physiological affect, patients can commit illegal acts - affectdelict. Illustration (Shostakovich, 1997):

K., 42 years old, specialized secondary education (accountant). By nature, vulnerable, touchy, impressionable. At the age of 17, she suffered a spinal fracture. She divorced her first husband because of his drunkenness. The second husband drinks heavily, is jealous, and beats her. Has a 7 year old son from him. During the next conflict, she killed him.

Reports that last years lived in constant fear, "experienced panic fear and horror." I didn’t want to live, I didn’t see any other way out of the situation, how to commit suicide. On the day of the offense, her husband came home drunk and immediately began scolding her, beating her, hitting her body. She tried to hide in the bathroom, but he pulled her out and began to choke her in the kitchen. She says that she experienced "terrible fear", there was a thought that he would kill her. She notes that she saw everything as if in a fog, only clearly saw his eyes. She remembers how she ran out of the room, hid, thought that he would not chase her. She does not remember how she beat him with a knife, where she got him, and how such a thought came to her. How many times it took to kill her husband and how it all happened, he does not remember. When I came to, I felt weak, tired, my hands were shaking. Entering the kitchen, she saw her dead husband, realized that it was she who had killed him.

Called out " ambulance' and the police. Psychological research has established that the subject is impressionable, vulnerable, prone to “accumulation of negatively colored experiences”, avoidance of conflicts; it is difficult to find constructive ways out of conflicts (which are not indicated), has a type of intraputative response to difficult situations (for example, suicidal tendencies). Psychologists do not mention the presence of signs of increased aggressiveness. On a comprehensive examination, it was recognized as healthy. The conclusion of the commission of experts indicated that the subject was in a state of physiological affect. It probably was. But this case does not provide evidence that there are no transitional states between the indisputable cases of pathological affect and the much more frequent states of proper physiological affect.

This situation, not without serious comparisons, could also be regarded as a short circuit reaction. Psychiatry does not fit well under the Euclidean paradigms based on the priority of visual behavioral impressions, which ignore the fact that internal psychological factors can radically change the sensations, perceptions, interpretations, emotional reactions and behavior of a person, including the researcher himself.

There are a number of morbid affects that are not pathological solely because they do not involve violence, although they are sometimes capable of it. Let's name some of them.

Confusion(“the affect of bewilderment”, according to S.S. Korsakov). It manifests itself as an absolute misunderstanding of the current situation, which is explained by the disintegration of the intellect and the inability to synthesize different impressions, as well as to search for such or similar ones in memory. This bewilderment is usually combined with fear, anxiety, a feeling of complete helplessness and unsuccessful attempts by the patient to understand what is happening by seeking help from those present.

Disturbances of orientation in a place, situation, time, environment, sometimes in oneself are typical. Contact with the external world, whose consciousness is often preserved, is one-sided: patients usually ask peculiar questions, not addressing anyone in particular, but they do not react to the answers, do not take them into account, perhaps not always understanding their meaning. Typical fear, anxiety, the mood is mostly suppressed. There may be motor excitation with fussiness, akinesia. There is hypermetamorphosis, there are fragmentary productive disorders (deceptions of perception, delusions, episodes of confused consciousness, symptoms of mental automatism).

Patients ask one question after another like: “What is this room? Where are you taking me? Why are you wearing a white coat? Why are you writing? Who are these people? Where am I? What does all of this mean?" Or: “I don’t understand, am I alive or dead? Where am I? Is anybody here? It looks like the coffin is here. Am I conscious or unconscious? They don't give mirrors, I don't know if I have a face or not? Am I a man or not?.. It seems that I am a man. Am I in this world or not anymore? What's the matter? Cut, burn, electrify. The decor changes all the time. Are you relatives, a doctor or someone from prison? Have I done something? Where do I go now? In the first case, confusion is more about external impressions, attention is constantly moving from one object to another. In the second case, the patient is more concerned about what is happening to him, in his behavior. At the same time, violations of self-perception are revealed up to the loss of one's identity and autometamorphosis, the feeling of reincarnation into another being; delusional ideas of influence, staging. The condition of the patients in both cases approaches amentia, and thinking - to fragmentation.

Recall that when thinking is actually broken, there is no confusion and elementary orientation is most often not violated, patients seem to understand what is happening, sometimes they behave in a rather orderly manner and do not react to their lack of understanding of the essence of what is happening, as well as to a lack of coherence of thinking. Confusion often occurs in the acute onset of schizophrenia (Kerbikov, 1949). Short episodes of confusion ("stupidity") are very common when a patient first appears at the doctor's office. Entering the office, the patient seems to be lost, looks around, does not understand where to sit, or asks about it, even if only a single chair has been prepared for him to talk. Confusion is an ominous sign, especially in schizophrenia, when the role of the patient is not immediately accepted or not accepted at all due to, probably, depersonalization.

panic fear- spontaneously occurring and short-term states of "horror" with confusion, motor agitation with the desire to run somewhere, make frequent calls to the "ambulance", pronounced vegetative disorders (high rises in blood pressure, difficulty breathing, frequent urination, vomiting, profuse sweat and many others) . etc.). Often there is fear or a feeling of insanity, loss of self-control, the phenomena of mental anesthesia, painful physical sensations, such as senestopathies. Attacks of fear occur spontaneously and quite suddenly, sometimes patients anticipate their approach.

They can arise for random provocative reasons, and then patients also “wind themselves up” with ideas of an imminent catastrophe, mistaking fantasies for something that has already happened or for something that will certainly happen. At first, the attacks are single and not so often repeated. Then they can become more frequent and occur several times a day, while lengthening up to several tens of minutes (usually, patients immediately begin to take something sedative, especially tranquilizers, alprozalam), call an ambulance (up to 6-10 times a day). Usually persists obsessive fear of recurrence of seizures, their alarming expectation. Patients try to avoid visiting the places with which they associated the occurrence of seizures, they are afraid to be alone at home or on the street, some do not tolerate driving, do not risk using the elevator, etc. As a rule, they do not part with medicines. Gradually, patients seem to get used to the attacks, realizing that they are not fatal and can be stopped without much difficulty. There are patients who indicate the seasonal nature of the occurrence of seizures.

Illustrations: “In the evening after work, the thought suddenly came: what if one of the buyers put damage on me. Immediately there was fear, animal fear, to the point of horror. It seemed that I was going crazy and doing something crazy. I rushed around the house, completely confused, did not know what to do ... I was with my grandmother, she treated me with prayers. Suddenly it seemed to me that she had missed some necessary word in the prayer. It got worse than ever before. I feel my heart pounding, my blood pressure rises, there is not enough air, I feel dizzy, pain appeared in the pit of my stomach, everything floats around, sways, it seems unreal, everything is mixed up in my head like crazy. And fear, wild indescribable fear to horror. I could not sit still, jumped off and ran to another grandmother. Suddenly it becomes terrifying, everything floats, it’s unreal, it seems that I’m going crazy, I don’t recognize myself, as if it’s not me anymore.

Some authors try to differentiate panic disorder into attributive, i.e., psychogenically conditioned attacks, alexithymic - "without experiencing fear", hypertypical - without experiencing fear before and after the attack, "existential crises" - with fear of a bodily catastrophe, taking, it seems, into account not so significant or even dubious signs.

Terms "panic disorder" or " » are not quite accurate, since in a painful state there is not an objective, conscious fear, but unaccountable anxiety, autopsychic confusion and many other disorders, among which stands out acute disorder self-perception (depersonalization, derealization, the tendency to take the imaginary for reality, the phenomena of mental anesthesia). In view of what has been said, the term "acute anxiety attack with depersonalization" would be more correct.

Moreover, in a significant, if not the vast majority of patients, a distinct anxious depression with symptoms of self-perception pathology is subsequently detected. Neurologists have previously distinguished "diencephalic seizures" with very similar symptoms, although with an emphasis on somatovegetative and neuroendocrine disorders. Panic itself is a symptom of an acute reaction to a sudden and severe traumatic situation, often fraught with disaster for many people. Such panic is accompanied by confusion, psychomotor agitation or stupor. Cases of mass panic are known. Cases of mass "panic disorder" are not observed, although individual patients can induce each other, usually aggravating the severity of the disorder.

Ecstasy- a state of extreme, expressed to a frenzy of delight, less often - another emotion. Here is a description of a typical ecstatic state at the onset of an epileptic seizure (sometimes a focal emotional attack): (It is) "an extraordinary inner light..., rapture..., supreme calm, full of clear, harmonious joy and hope, full of reason and ultimate reason, ( which) turns out to be in the highest degree harmony, beauty, gives an unheard-of and hitherto unexpected feeling of fullness, measure, reconciliation, enthusiastic prayerful fusion with the highest synthesis of life, self-consciousness and ... self-awareness in the highest degree direct, (which) in itself was worth throughout life” (F.M. Dostoevsky).

Orgiastic states- ecstasy that occurs during ritual actions, for example, shamans' rituals, dervishes' dances. Other participants in sacred ceremonies usually fall into ritual ecstasy, if they have completely identified themselves with other members of the group. This type of ecstasy is characterized by the possession of a spirit, good or evil. In the first case, the members of the ritual group experience a feeling of a higher ordinary life endless happiness, exultation, admiration, power, with a feeling of loss or dissolution of one's Self, as well as with a change of identity.

In the second case, violent rage, rage, senseless and chaotic prevails. Consciousness I also disappears, all feelings and actions have a source of some kind of internal demonic beginning. Some sacred rites encourage unrestricted sexual intercourse, so that the rite culminates in a wild orgy. In a number of sects, there is a practice of mass immersion of their adherents into ecstasy, during which awareness of one's Self is also lost and self-identification with charismatic leader. The memory for the experience of ecstasy is retained, although perhaps not fully. Memory for what is happening around is not preserved. In satanic sects, ecstasy is experienced as self-identification with Satan; malice, rage, and bloodthirstiness are possessed by adepts.

mystical ecstasy It is achieved through special exercises that make it possible to experience a feeling of merging with God or another higher power. It is in such states that “insights” arise, “revelations”, “signs from above” are perceived, followed by belief in them as some kind of higher, absolute, indisputable truth.

Meditative ecstasy- “waking dreams”, an uncontrollable stream of dreams, in which one experiences a sense of belonging with transcendent entities, with the essence of another, inaccessible through ordinary knowledge of the world.

Prayer ecstasy- a state of delight, bliss, a feeling of merging with God or his Divine will, a feeling of unity with him, merging with him. It is observed among deeply religious people, but it is more characteristic, apparently, of fanatical believers, who know no doubt that their faith is the only true and unshakable one. All other religious movements of the spirit are "from the evil one."

Manic ecstasy- a feeling of inexpressible admiration and delight, observed in some manic patients somewhere at the height of the morbid state. This is a special type of mania, suggesting an altered state of consciousness and a persistent focus on representations of sublime content; in typical cases of mania hypervariability of attention and personality regression are usually observed.

Hypnotic ecstasy- an ecstatic state, usually suggested in a state of deep hypnotic sleep. Not all patients have such an extraordinary feeling as ecstasy in hypnosis. Probably, there must be some internal predisposition to this. Oneiroid ecstasy is observed in a state of manic-ecstatic oneiroid, when dreams and other painful phenomena are produced with the content of "paradise", extraterrestrial, cosmic, otherworldly being generated by higher, previously unknown forces of love and infinite goodness. It is, as it were, the spiritual quest of patients carried out in a painful state.

Ecstatic dreams- a special type of dreams, in which unusually bright, colorful, enchanting images are captured with experiences of extraordinary happiness, amazing beauty that swallowed up the ordinary world and presented it as a kind of vague prototype of reality. Patients speak of an inexplicable feeling of rapture, admiration for a different, extremely attractive and the only acceptable image of the universe that has become open, tangible and real. All this is mixed with the feeling of being reincarnated as "the queen of the world, a deity, an angelic creature, a messenger of Heaven in the sinful material world."

It is difficult to explain such metamorphoses, not knowing the human essence, tearing up. Coming out of psychosis, some patients remain confident that they have seen the real world with their own eyes, and not some kind of its surrogate, in which people are doomed to exist. Sometimes such dreams retain the force of reality for a long time, and patients stop themselves from trying to discredit this dream - "reality".

Reports of ecstatic episodes from believing patients are very few, if not almost non-existent. Nevertheless, G.V. Morozov and N.V. Shumsky (1998) note a “special” frequency of states of ecstasy when pseudohallucinatory memories occur.

In a state of ecstasy, stupor, incomprehensible, as it were, symbolic psychomotor agitation, disconnection from reality, desomatization phenomena, disturbances in the sense of time are usually observed (the latter “lengthens” or stops altogether; F.M. Dostoevsky reports that Mohammed once “examined” all the details of a vast The long journey of the prophet did not last long, according to earthly time, one moment, during which not a drop spilled from the overturned cup of wine).

The memory for subjective experiences during the period of ecstasy is often preserved to the smallest detail (apparently, this is imprinted in the memory as in selective hypermnesia, as something of exceptionally great personal significance). Memories of what is happening around are incomplete, inaccurate, distorted, many are not stored in memory. The duration of ecstatic episodes ranges from a few seconds to a number of hours. Patients regard ecstatic experiences as the greatest value of their lives.

Amazement- an extreme degree of surprise with a stop in the flow of thoughts, freezing in some kind of pose, a frozen expression on the face, on which the surprise froze, and at the same time fell silent. Occurs, as mentioned, when something very unusual, improbable, directly contradicts the absolute certainty of the individual that it should happen.

frenzy- an extreme degree of arousal with a loss of self-control, most often arising from frustration and manifesting itself in the form of impotent anger (Ilyin, 2002).

Psychiatry. A guide for doctors Boris Dmitrievich Tsygankov

Chapter 21 MOOD DISORDERS (PSYCHOSIS)

MOOD DISORDERS (PSYCHOSIS)

Affective Responses Today, as specific Kleinian concepts involving direct psychic transmissions from the outside are becoming increasingly popular in psychoanalytic language, there is reason to recall the simple basic fact that all experiences