Somatic syndromes as a manifestation of mental illness. Changes in mental activity in chronic somatic diseases. Mental disorders in traumatic brain injuries

Any illness is always accompanied by unpleasant emotions, because somatic (physical) illnesses are difficult to separate from worries about the severity of the health condition and concerns about possible complications. But it happens that diseases cause serious changes in the functioning of the nervous system, disrupting the interaction between neurons and the very structure of nerve cells. In this case, a mental disorder develops against the background of a somatic illness.

The nature of mental changes largely depends on the physical illness on the basis of which they arose. For example:

• oncology provokes depression;
• a sharp exacerbation of an infectious disease - psychosis with delusions and hallucinations;
• severe prolonged fever - seizures;
• severe infectious lesions of the brain - states of loss of consciousness: stupor, stupor and coma.

Moreover, most diseases also have common mental manifestations. Thus, the development of many diseases is accompanied by asthenia: weakness, weakness and low mood. An improvement in the condition corresponds to an increase in mood - euphoria.

The mechanism of development of mental disorders. A person's mental health is ensured by a healthy brain. For normal operation, its nerve cells must receive enough glucose and oxygen, not be affected by toxins and interact correctly with each other, transmitting nerve impulses from one neuron to another. Under such conditions, the processes of excitation and inhibition are balanced, which ensures the proper functioning of the brain.

Diseases interfere with the functioning of the entire body and affect the nervous system through various mechanisms. Some diseases impair blood circulation, depriving brain cells of a significant portion of nutrients and oxygen. In this case, neurons atrophy and may die. Such changes can occur in specific areas of the brain or throughout its tissue.

In other diseases, there is a failure in the system of transmission of nerve impulses between the brain and spinal cord. In this case, the normal functioning of the cerebral cortex and its deeper structures is impossible. And during infectious diseases, the brain suffers from poisoning by toxins released by viruses and bacteria.

Below we will look in detail at what physical diseases cause mental disorders and what their manifestations are.

Mental disorders in vascular diseases

Vascular diseases of the brain in most cases affect mental health. Atherosclerosis, hypertension and hypotension, cerebral thromboangiitis obliterans have a common complex of mental symptoms. Their development is associated with a chronic deficiency of glucose and oxygen, which nerve cells in all parts of the brain experience.

With vascular diseases, mental disorders develop slowly and imperceptibly. The first signs are headaches, flashing spots before the eyes, sleep disturbances. Then signs of organic brain damage appear. Absent-mindedness occurs, it becomes difficult for a person to quickly navigate the situation, he begins to forget dates, names, and the sequence of events.

Mental disorders associated with vascular diseases of the brain are characterized by a wave-like course. This means that the patient’s condition periodically improves. But this should not be a reason to refuse treatment, otherwise the processes of brain destruction will continue and new symptoms will appear.

If the brain suffers from insufficient blood circulation for a long time, it develops encephalopathy(diffuse or focal damage to brain tissue associated with neuronal death). It can have various manifestations. For example, visual disturbances, severe headaches, nystagmus (involuntary oscillatory eye movements), instability and lack of coordination.

Over time, encephalopathy becomes more complicated dementia(acquired dementia). In the patient’s psyche, changes occur that resemble age-related ones: criticality of what is happening and of one’s condition decreases. General activity decreases, memory deteriorates. Judgments may be delusional. A person is unable to restrain his emotions, which is manifested by tearfulness, anger, a tendency to emotion, helplessness, and fussiness. His self-care skills are reduced and his thinking is impaired. If the subcortical centers suffer, then incontinence develops. Illogical judgments and delusional ideas may be accompanied by hallucinations that occur at night.

Mental disorders caused by cerebrovascular accidents require special attention and long-term treatment.

Mental disorders in infectious diseases

Despite the fact that infectious diseases are caused by different pathogens and have different symptoms, they affect the brain in approximately the same way. Infections disrupt the functioning of the cerebral hemispheres, making it difficult for nerve impulses to pass through the reticular formation and diencephalon. The cause of the damage is viral and bacterial toxins released by infectious agents. Metabolic disorders in the brain caused by toxins play a certain role in the development of mental disorders.

In most patients, mental changes are limited asthenia(apathy, weakness, powerlessness, reluctance to move). Although for some, on the contrary, motor agitation occurs. In severe cases of the disease, more severe disorders are possible.

Mental disorders in acute infectious diseases represented by infectious psychoses. They can appear at the peak of a rise in temperature, but more often against the background of the attenuation of the disease.

Infectious psychosis can take different forms:

• Delirium. The patient is excited, overly sensitive to all stimuli (he is disturbed by light, loud sounds, strong odors). Irritation and anger are poured out on others for the most insignificant reasons. Sleep is disturbed. The patient finds it difficult to sleep and is haunted by nightmares. While awake, illusions arise. For example, the play of light and shadow creates pictures on wallpaper that can move or change. When the lighting changes, the illusions disappear.
• Rave. Feverish delirium occurs at the peak of infection, when there is the greatest amount of toxins in the blood and high temperature. The patient perks up and looks alarmed. The nature of delusions can be very different, from unfinished business or adultery to delusions of grandeur.
• Hallucinations Infections can be tactile, auditory or visual. Unlike illusions, they are perceived by the patient as real. Hallucinations can be frightening or "entertaining" in nature. If during the first one a person looks depressed, then when the second one appears he perks up and laughs.
• Oneiroid. Hallucinations have the nature of a holistic picture, when a person may feel that he is in a different place, in a different situation. The patient appears distant and repeats the same movements or words spoken by other people. Periods of inhibition alternate with periods of motor excitation.

Mental disorders in chronic infectious diseases take on a protracted nature, but their symptoms are less pronounced. For example, prolonged psychoses pass without disturbance of consciousness. They are manifested by a feeling of melancholy, fear, anxiety, depression, which is based on delusional thoughts about condemnation from others, persecution. The condition worsens in the evening hours. Confusion is rare with chronic infections. Acute psychoses are usually associated with the use of anti-tuberculosis drugs, especially in combination with alcohol. And convulsive seizures can be a sign of tuberculoma in the brain.

During the recovery period, many patients experience euphoria. It manifests itself as a feeling of lightness, satisfaction, uplifting mood, and joy.

Infectious psychoses and other mental disorders due to infections do not require treatment and go away on their own with improvement.

Mental disorders in endocrine diseases

Disruption of the endocrine glands significantly affects mental health. Hormones can disrupt the balance of the nervous system, having an excitatory or inhibitory effect. Hormonal changes impair blood circulation in the brain, which over time causes cell death in the cortex and other structures.

At the initial stage many endocrine diseases cause similar mental changes. Patients experience desire disorders and affective disorders. These changes may resemble symptoms of schizophrenia or manic depression. For example, there is a perversion of taste, a tendency to eat inedible substances, refusal to eat, increased or decreased sexual desire, a tendency to sexual perversion, etc. Among mood disorders, depression or alternating periods of depression and increased mood and performance are more common.

Significant deviation in hormone levels from the norm causes the appearance of characteristic mental disorders.

• Hypothyroidism. A decrease in the level of thyroid hormones is accompanied by lethargy, depression, deterioration of memory, intelligence and other mental functions. Stereotypic behavior may appear (repetition of the same action - washing hands, “flicking a switch”).
• Hyperthyroidism and high levels of thyroid hormones have the opposite symptoms: fussiness, mood swings with a rapid transition from laughter to crying, there is a feeling that life has become fast and hectic.
• Addison's disease. When the level of adrenal hormones decreases, lethargy and resentment increase, and libido decreases. In case of acute insufficiency of the adrenal cortex, a person may experience erotic delirium, confusion, and neurosis-like states are characteristic during the waxing period. They suffer from loss of strength and decreased mood, which can develop into depression. For some, hormonal changes provoke hysterical states with excessively violent expression of emotions, loss of voice, muscle twitching (tics), partial paralysis, and fainting.

Diabetes more often than other endocrine diseases causes mental disorders, since hormonal disorders are aggravated by vascular pathology and insufficient blood circulation to the brain. An early sign is asthenia (weakness and significant decrease in performance). People deny the disease, experience anger directed at themselves and others, they have breakdowns in taking glucose-lowering medications, diet, insulin administration, and may develop bulimia and anorexia.

70% of patients suffering from severe diabetes mellitus for more than 15 years experience anxiety and depressive disorders, adaptation disorders, personality and behavioral disorders, and neuroses.

• Adjustment disorders make patients very sensitive to any stress and conflict. This factor can cause failures in family life and at work.
• Personality disorders a painful strengthening of personality traits that interferes with both the person himself and his environment. In patients with diabetes mellitus, grumpiness, resentment, stubbornness, etc. may increase. These traits prevent them from adequately responding to situations and finding solutions to problems.
• Neurosis-like disorders manifested by fear, fears for one’s life and stereotypical movements.

Mental disorders in cardiovascular diseases

Heart failure, coronary disease, compensated heart defects and other chronic diseases of the cardiovascular system are accompanied by asthenia: chronic fatigue, impotence, mood instability and increased fatigue, weakening of attention and memory.

Almost everything chronic heart disease accompanied by hypochondria. Increased attention to one’s health, interpretation of new sensations as symptoms of a disease, and fears about the deterioration of the condition are typical for many “heart patients”.

For acute heart failure, myocardial infarction and 2-3 days after heart surgery, psychosis may occur. Their development is associated with stress, which provoked disruption of the functioning of cortical neurons and subcortical structures. Nerve cells suffer from oxygen deficiency and metabolic disorders.

Manifestations of psychosis may vary depending on the nature and condition of the patient. Some experience severe anxiety and mental activity, while others experience lethargy and apathy as the main symptoms. With psychosis, patients find it difficult to concentrate on a conversation; their orientation in time and place is disturbed. Delusions and hallucinations may occur. At night, the patients' condition worsens.

Mental disorders in systemic and autoimmune diseases

With autoimmune diseases, 60% of patients suffer from various mental disorders, most of which are anxiety and depressive disorders. Their development is associated with the impact of circulating immune complexes on the nervous system, with chronic stress that a person experiences in connection with his illness and the use of glucocorticoid drugs.

Systemic lupus erythematosus and rheumatism accompanied by asthenia (weakness, impotence, weakening of attention and memory). It is common for patients to show increased attention to their health and interpret new sensations in the body as a sign of deterioration. There is also a high risk of adjustment disorder, when people react atypically to stress, most of the time they experience fear, hopelessness, and are overcome by depressive thoughts.

During exacerbation of systemic lupus erythematosus, against the background of high temperature, psychosis with complex manifestations may develop. Orientation in space is impaired as the person experiences hallucinations. This is accompanied by delirium, agitation, lethargy, or stupor (stupor).

Mental disorders due to intoxication

Intoxication– damage to the body by toxins. Substances that are toxic to the brain disrupt blood circulation and cause degenerative changes in its tissue. Nerve cells die throughout the brain or in individual foci - encephalopathy develops. This condition is accompanied by mental dysfunction.

Toxic encephalopathy cause harmful substances that have a toxic effect on the brain. These include: mercury vapor, manganese, lead, toxic substances used in everyday life and in agriculture, alcohol and drugs, as well as some medications in case of overdose (anti-tuberculosis drugs, steroid hormones, psychostimulants). In children under 3 years of age, toxic brain damage can be caused by toxins released by viruses and bacteria during influenza, measles, adenovirus infection, etc.

Mental disorders in acute poisoning, when a large amount of a toxic substance enters the body, they have serious consequences for the psyche. Toxic brain damage is accompanied by confusion. The person loses clarity of consciousness and feels detached. He experiences bouts of fear or rage. Poisoning of the nervous system is often accompanied by euphoria, delirium, hallucinations, mental and motor agitation. There have been cases of memory loss. Depression during intoxication is dangerous due to thoughts of suicide. The patient's condition may be complicated by convulsions, significant depression of consciousness - stupor, and in severe cases - coma.

Mental disorders due to chronic intoxication, when the body is exposed to small doses of toxins for a long time, they develop unnoticed and have no pronounced manifestations. Asthenia comes first. People feel weakness, irritability, decreased attention and mental productivity.

Mental disorders in kidney diseases

When kidney function is disrupted, toxic substances accumulate in the blood, metabolic disorders occur, the functioning of brain vessels deteriorates, edema and organic disorders develop in the brain tissue.

Chronic renal failure. The condition of patients is complicated by constant muscle pain and itching. This increases anxiety and depression and causes mood disorders. Most often, patients exhibit asthenic phenomena: weakness, decreased mood and performance, apathy, sleep disturbances. As kidney function deteriorates, motor activity decreases, some patients develop stupor, and others may experience psychosis with hallucinations.

For acute renal failure Asthenia may be accompanied by disorders of consciousness: stupor, stupor, and with cerebral edema, coma, when consciousness completely turns off and basic reflexes disappear. During mild stages of stunning, periods of clear consciousness alternate with periods when the patient’s consciousness becomes clouded. He does not make contact, his speech becomes sluggish, and his movements are very slow. When intoxicated, patients experience hallucinations with a variety of fantastic or “cosmic” images.

Mental disorders in inflammatory diseases of the brain

Neuroinfections (encephalitis, meningitis, meningoencephalitis)- This is damage to brain tissue or its membranes by viruses and bacteria. During the disease, nerve cells are damaged by pathogens, suffer from toxins and inflammation, attack by the immune system and nutritional deficiencies. These changes cause mental disorders in the acute period or some time after recovery.

1. Encephalitis(tick-borne, epidemic, rabies) – inflammatory diseases of the brain. They occur with symptoms of acute psychosis, convulsions, delusions, and hallucinations. Affective disorders (mood disorders) also appear: the patient suffers from negative emotions, his thinking is slow, and his movements are inhibited.

Sometimes depressive periods can be replaced by periods of mania, when the mood becomes elevated, motor excitement appears, and mental activity increases. Against this background, outbursts of anger occasionally arise, which quickly fade away.

Majority encephalitis in the acute stage have general symptoms. Against the background of high fever and headaches occur syndromes confusion.

• Stun when the patient reacts poorly to his surroundings, becomes indifferent and inhibited. As the condition worsens, stupor progresses to stupor and coma. In a comatose state, a person does not react to stimuli in any way.
• Delirium. Difficulties arise in orienting to the situation, place and time, but the patient remembers who he is. He experiences hallucinations and believes they are real.
• Twilight stupefaction when the patient loses orientation in his surroundings and experiences hallucinations. His behavior is completely consistent with the plot of the hallucinations. During this period, the patient loses memory and cannot remember what happened to him.
• Amentive clouding of consciousness– the patient loses orientation in the environment and his own “I”. He doesn’t understand who he is, where he is and what’s happening.

Encephalitis due to rabies differs from other forms of the disease. Rabies is characterized by a strong fear of death and hydrophobia, speech impairment and drooling. As the disease progresses, other symptoms appear: paralysis of the limbs, stupor. Death occurs from paralysis of the respiratory muscles and heart.

For chronic encephalitis symptoms reminiscent of epilepsy develop - seizures of one half of the body. Usually they are combined with twilight stupefaction.

1. Meningitis– inflammation of the membranes of the brain and spinal cord. The disease most often develops in children. Mental disorders at an early stage are manifested by weakness, lethargy, and slow thinking.

In the acute period, asthenia is accompanied by various forms of clouding of consciousness described above. In severe cases, stupor develops when inhibition processes predominate in the cerebral cortex. The person looks asleep; only a sharp loud sound can force him to open his eyes. When exposed to pain, he can withdraw his hand, but any reaction quickly fades away. With further deterioration of the patient's condition, the patient falls into a coma.

Mental disorders in traumatic brain injuries

The organic basis for mental disorders is the loss of electrical potential by neurons, injury to brain tissue, swelling, hemorrhage, and subsequent immune attack on damaged cells. These changes, regardless of the nature of the injury, lead to the death of a certain number of brain cells, which is manifested by neurological and mental disorders.

Mental disorders due to brain injuries can appear immediately after the injury or in the long term (after several months or years). They have many manifestations, since the nature of the disorder depends on which part of the brain is affected and how much time has passed since the injury.

Early consequences of traumatic brain injuries. At the initial stage (from a few minutes to 2 weeks), the injury, depending on the severity, manifests itself:

• Stunned– slowing down of all mental processes, when a person becomes drowsy, inactive, indifferent;
• Stupor– a precomatose state, when the victim loses the ability to act voluntarily and does not react to the environment, but reacts to pain and sharp sounds;
• Coma– complete loss of consciousness, respiratory and circulatory disorders and loss of reflexes.

After normalization of consciousness, amnesia - loss of memory - may appear. As a rule, events that occurred shortly before and immediately after the injury are erased from memory. Patients also complain of slowness and difficulty in thinking, high fatigue from mental stress, and mood instability.

Acute psychoses may occur immediately after injury or within 3 weeks after it. The risk is especially high in people who have suffered a concussion (brain contusion) and open head injury. During psychosis, various signs of impaired consciousness may appear: delirium (usually persecution or grandeur), hallucinations, periods of unreasonably elevated mood or lethargy, attacks of complacency and tenderness, followed by depression or outbursts of anger. The duration of post-traumatic psychosis depends on its form and can last from 1 day to 3 weeks.

Long-term consequences of traumatic brain injury may become: decreased memory, attention, perception and learning ability, difficulties in thought processes, inability to control emotions. The formation of pathological personality traits such as hysteroidal, asthenic, hypochondriacal or epileptoid character accentuation is also likely.

Mental disorders in cancer and benign tumors

Malignant tumors, regardless of their location, are accompanied by pre-depressive states and severe depression caused by patients’ fears for their health and the fate of loved ones, and suicidal thoughts. The mental state noticeably worsens during chemotherapy, in preparation for surgery and in the postoperative period, as well as intoxication and pain in the later stages of the disease.

If the tumor is localized in the brain, then patients may experience disturbances in speech, memory, perception, difficulty coordinating movements and seizures, delusions and hallucinations.

Psychoses in cancer patients develop at stage IV of the disease. The degree of their manifestation depends on the strength of intoxication and the physical condition of the patient.

Treatment of mental disorders caused by somatic diseases

When treating mental disorders caused by somatic diseases, attention is first paid to the physical illness. It is important to eliminate the cause of the negative impact on the brain: remove toxins, normalize body temperature and vascular function, improve blood circulation in the brain and restore the acid-base balance of the body.

Consulting a psychologist or psychotherapist will help ease your mental state during treatment of a somatic illness. For severe mental disorders (psychosis, depression), the psychiatrist prescribes appropriate medications:

• Nootropic drugs– Encephabol, Aminalon, Piracetam. They are indicated for most patients with brain disorders due to somatic diseases. Nootropics improve the condition of neurons, making them less sensitive to negative influences. These drugs promote the transmission of nerve impulses through the synapses of neurons, which ensures coherent brain function.
• Neuroleptics used to treat psychosis. Haloperidol, Chlorprothixene, Droperidol, Tizercin - reduce the transmission of nerve impulses by blocking the work of dopamine at the synapses of nerve cells. This has a calming effect and eliminates delusions and hallucinations.
• Tranquilizers Buspirone, Mebicar, Tofisopam reduce the level of anxiety, nervous tension and restlessness. They are also effective for asthenia, as they eliminate apathy and increase activity.
• Antidepressants are prescribed to combat depression in cancer and endocrine diseases, as well as injuries that lead to serious cosmetic defects. When treating, preference is given to drugs with the fewest side effects: Pyrazidol, Fluoxetine, Befol, Heptral.

In the vast majority of cases, after treatment of the underlying disease, a person’s mental health is restored. Rarely, if the disease has caused damage to brain tissue, signs of mental illness may persist after recovery.

As a result of studying this chapter, the student should:

know

• the most common psychopathological syndromes in acute and chronic diseases of the heart, liver, kidneys, lungs, gastrointestinal tract and endocrine system;
• mental disorders in cerebral atherosclerosis and hypertension;

be able to

• identify psychopathological symptoms characteristic of somatogenic psychoses in general, and specific symptoms characteristic of individual somatic diseases;
• use the results of somatic examination and laboratory data for diagnosis;

own

• methods of conducting a clinical conversation when working with patients, obtaining anamnestic data about life and especially about past and current somatic diseases and the patient’s mental reactions when they occur;
• psychodiagnostic methods to assess the patient’s attitude to the current illness, his mood, and the state of gnostic processes.

Since the end of the 19th century. descriptions of mental disorders appeared, the occurrence of which was associated with somatic diseases, both acute and chronic (W. Griesinger, S. S. Korsakov, E. Kraepelin). Such psychoses began to be called somatogenic. At the same time, K. Bonhoeffer believed that the brain’s ability to respond to the effects of various external harms is limited, therefore there is a general, unified type of mental response - the “exogenous type of reactions”, which is reduced to several psychopathological syndromes. According to another point of view, in addition to the general type of exogenous response, there are psychopathological syndromes specific to certain somatic disorders and variants of their course over time (A. V. Snezhnevsky, V. A. Gilyarovsky, K. Conrad), E. K. Krasnushkin). In addition, the role of a person’s mental reaction to the presence of a severe somatic disorder was emphasized (R. A. Luria, E. A. Shevalev, V. N. Myasishchev).

With severe pathology of the activity of internal organs in people due to metabolic disorders, chronic intoxication, the activity of neurons in the brain changes, so mental disorders are possible.

General, most characteristic psychopathological syndromes in diseases of internal organs are the following: asthenic syndrome, emotional disorders, delusional syndromes, syndromes of impaired consciousness, behavioral disorders of a psychopathic nature.

Asthenic syndrome manifests itself in high fatigue even with minor intellectual and physical efforts, exhaustion of voluntary attention, and functional weakening of memory. In patients, productivity in activities sharply decreases. Neurosis-like symptoms appear: emotional lability, irritability, tearfulness, intolerance to strong irritants (sharp sounds, bright light), sleep disorders in the form of difficulties falling asleep, superficial, anxious sleep.

Emotional disorders predominantly manifest themselves in the form of depression, integrating with asthenia into astheno-depressive syndrome. At the onset of mental disorders of somatogenic origin, depression resembles neurotic depression, but as somatic pathology worsens, depression changes: grumpiness, capriciousness, pickiness towards others, and episodes of dysphoria appear. In children and adolescents, depression is usually short-lived, accompanied by irritability, negativism, and violations of the hospital regime; in the involutionary period of life, the anxious nature of depression is more clearly manifested. With a significant increase in somatic disorders, in critical conditions, anxiety, fear may suddenly increase sharply, or a complacent-euphoric state may appear with sudden episodes of irritability.

Delusional syndromes usually in somatically ill people they are combined with depression and asthenia. Depressive-delusional symptoms most often contain delusions of attitude, damage, often nihilistic delirium up to Cotard’s nihilistic delirium with statements from patients about the destruction and disappearance of their internal organs, about their transformation into dead people, etc. Sometimes delirium is accompanied by senstopathies.

From syndromes of impaired consciousness Most often, patients experience stupor and short-term oneiric states. Quite typical for patients are flickering clarity of consciousness of the type of asthenic confusion and transitions from one type of disorder of consciousness to another.

Psychopathic-like manifestations of somatogenic conditioning manifest themselves in the form of a person’s growing selfishness, a wary and even suspicious attitude towards others, a tendency to exaggerate the severity of his somatic condition, and a desire to attract attention to himself with elements of attitudinal behavior.

Diseases of certain human systems and organs may also be reflected in some features of mental disorders.

At diseases of the gastrointestinal tract(gastritis, colitis, gastric and duodenal ulcers), neurosis-like and psychonate-like symptoms may appear. Patients become moody, irritable, and express hypochondriacal complaints. All this is observed against the background of astheno-depressive syndrome. Auditory pseudohallucinations and senestopathies may occur. Psychopathological symptoms are more often associated in time with an exacerbation of a somatic disease, but not necessarily. The duration of mental disorders reaches several weeks; When cured from somatic pathology, they usually stop.

At liver diseases Depression, sleep disorders, adynamism of the patient are often observed, and when acute liver failure There may be delirious type disorders of consciousness or coma.

Kidney failure often accompanied by complaints of headaches, low mood, and high fatigue. With increasing decompensation of renal function, disorders of consciousness occur in the form of delirium, twilight and coma.

In patients bronchial asthma Irritability, affective explosiveness, depressive-delusional syndrome with ideas of relationship, special meaning, and auditory hallucinations may be observed. Such psychotic pictures can last up to several weeks, but there are also short-term mental disorders with pronounced fear and disturbances of consciousness for several hours or days.

A variety of mental disorders occur with diseases of the heart and cardiovascular system. Thus, in heart diseases with attacks of angina pectoris, emotional instability of patients, asthenia, increased anxiety, sleep disorders with frequent sudden awakenings and unpleasant disturbing dreams are characteristic. Against the background of dysthymic conditions, patients often experience affective reactions to others and cardiophobic manifestations.

On the eve of myocardial infarction and in its acute period, patients with and without angina pain usually experience increased anxiety, fear of death, and hyperesthesia. Patients are extremely irritable, restless motorly, or, conversely, silent, inactive, lying in bed, afraid to move. Stupefactions of varying depths may occur (from mild stupor to coma). In the acute period of myocardial infarction, especially with the disappearance of anginal pain, an anxious depressive state can be replaced by euphoria, in which patients cease to adequately perceive their somatic state, despite the protests of the medical staff, they strive to leave the intensive care ward, remove the electrodes from the cardiograph and declare their desire to go home because they feel great. After an acute period of a heart attack, a depressive mood background with severe asthenia, with fear of a second heart attack, with a sad experience of the end of life and suicidal thoughts is often observed, especially in elderly patients. Patients often become hypochondriacal and are afraid of any physical activity and the expansion of hospital regime restrictions. In the future, hypochondriacal and phobic manifestations can become quite persistent.

In patients with severe heart defects with severe decompensation of cardiac activity, states of sharp expressed fear, dysthymia, anxiety, or, conversely, euphoria are observed.

At hypertension mental disorders can manifest themselves at different stages of its course. In the early stages, neurosis-like and psychopathic-like manifestations of mental disorders often occur: irritable weakness, general anxiety, exhaustion, signs of somato-autonomic dysfunction, sleep disorders and frequent headaches. The speed of memorizing current information and the volume of short-term memory decreases. Senestopathies, hypochondriasis, and fear of progression of hypertensive manifestations and death appear. Anxious suspiciousness, hot temper, and capriciousness increase. During the period of pronounced signs of hypertension, organic changes in the blood vessels of the brain increasingly lead to signs of encephalopathy. At the same time, headaches become almost constant, constant irritability turns into frequent affects of anger towards others. Memory defects worsen. Self-centeredness and conflict grow. The range of interests narrows, initiative and activity decrease, and the pace of intellectual operations slows down. However, the professional capabilities and basic personal qualities of a person, despite the weakening of intellectual data, remain generally unchanged. Gradually, with the increase in hypertensive crises, patients may experience periods of acute psychotic states with anxiety-depressive manifestations, intensifying in the evening, with the emergence of delusional ideas of relationship, special meaning, persecution. Against the background of a hypertensive crisis, disorders of consciousness appear in the form of stupor, twilight states, and sometimes delirious syndrome. At a late stage in the course of hypertension, dementia gradually develops, often of a lacunar nature, when certain aspects of intelligence, knowledge and skills are completely preserved, while others show pronounced insufficiency, and perhaps total dementia with a gross decrease in the capabilities of memory, attention, mental operations and reproduction of past knowledge and skills.

After heavy cerebral strokes dementia can be accompanied by severe memory disorders up to Korsakov's syndrome, loss of acquired skills, air-agnostic disorders and apatho-abulic manifestations.

Mental disorders with endocrine diseases have both common symptoms for all of them, and those associated with disorders of individual endocrine glands.

Among the common mental disorders in endocrinopathies, one can distinguish “endocrine psychosyndrome” (M. Bleuler) - an increase or decrease in the intensity of the influence of instincts and drives on the patient’s behavior, intellectual deficiency, especially with congenital pathology of the endocrine system, the presence of asthenic syndrome and affective violations.

At insufficiency of the functions of the anterior pituitary gland(Simmonds disease) in patients, the leading one is the Apato-Abulich syndrome with physical inactivity, asthenicity, and tearfulness. Short-term episodes of hallucinatory-delusional nature may occur.

At hyperthyroidism Patients experience severe tearfulness, rapid mood swings, decreased performance with exhaustion of attention, fussiness, irritability and hyperesthesia. Depression with hypochondriasis and anxiety is often observed; apathy and indifference to what is happening is much less common.

At hypothyroidism patients are drowsy, lethargic, lack initiative, tired, with a sharp slowdown in the rate of mental processes and weakening of memory. With congenital insufficiency of the thyroid gland (myxedema), a severe degree of mental underdevelopment develops in the form of cretinism.

At pancreatic insufficiency in the form of diabetes mellitus, patients with an asthenic background experience high fatigue, lethargy, decreased mood, and emotional instability. A long course of the disease with frequent hypoglycemia can lead to encephalopathy with intellectual and mental deficiency. The occurrence of short-term psychotic states with disorders of consciousness of a delirious, amentive type or with illusory-hallucinatory confusion, affective tension is possible. There are epileptiform seizures and twilight disturbances of consciousness.

In cases of chronic insufficiency of adrenal cortex functions, accompanied by excessive pigmentation of the skin and mucous membranes (Addison’s disease, “bronze disease”), patients often experience a state of chronic fatigue, lethargy, drowsiness, difficulty concentrating, and weakened memory. Apathy or low mood often predominates, or unmotivated anxiety, anxiety, suspicion, or resentment arise. There may be short-term psychotic states with anxiety-delusional and anxiety-depressive symptoms, with a kind of tactile protozoan hallucinosis (the feeling of various insects and small worms crawling under the skin). Hallucinosis is more common in elderly patients.

Test questions and assignments

• 1. What are the characteristic psychopathological symptoms in the initial period of somatogenic psychoses?
• 2. Describe perception disorders in somatogenic psychoses.
• 3. Specify the thinking disorders characteristic of somatogenic psychoses.
• 4. List the syndromes of emotional disorders in somatogenic psychoses.
• 5. Name the psychopathological syndromes associated with hypertension.
• 6. Name the psychopathological syndromes associated with cerebral atherosclerosis.
• 7. List mental disorders in diseases of the thyroid gland.
• 8. List mental disorders in diseases of the pancreas.
• 9. What are the mental disorders during myocardial infarction?

Patients with somatic diseases may experience a wide range of mental disorders, both neurotic and psychotic or subpsychotic levels.
K. Schneider proposed to consider the presence of the following signs as conditions for the appearance of somatically caused mental disorders: 1) the presence of a pronounced clinical picture of a somatic disease; 2) the presence of a noticeable connection over time between somatic and mental disorders; 3) a certain parallelism in the course of mental and somatic disorders; 4) possible, but not obligatory, appearance of organic symptoms
The likelihood of the occurrence of somatogenic disorders depends on the nature of the underlying disease, the degree of its severity, the stage of the course, the level of effectiveness of therapeutic interventions, as well as on such properties as heredity, constitution, premorbid personality, age, sometimes gender, reactivity of the body, the presence of previous hazards.

Thus, the etiopathogenesis of mental disorders in somatic diseases is determined by the interaction of three groups of factors:
1. Somatogenic factors
2. Psychogenic factors
3. Individual characteristics of the patient
In addition, additional psychotraumatic factors not related to the disease may be involved in the development of somatogenic disorders.

Accordingly, the influence of a somatic illness on the patient’s mental state can lead to the development of predominantly somatogenic or predominantly psychogenic mental disorders. In the structure of the latter, nosogenies and iatrogenies are of greatest importance.
Determining the role of somatogenic and psychogenic factors in the pathogenesis of mental disorders in each individual patient with somatic pathology is a necessary condition for choosing an adequate treatment strategy and tactics. At the same time, correct qualification of a mental disorder and its pathogenetic mechanisms is possible only by taking into account the somatic and mental status of the patient, somatic and psychiatric history, features of treatment and its possible side effects, data on hereditary burden and other predisposition factors.
Mental disorders in a patient with a somatic illness necessitate joint management by an internist and a psychiatrist (psychotherapist), which can be carried out within the framework of different models. The most widely used model is the consultation-interaction model, which involves the direct and indirect (through counseling and training of somatologists) participation of a psychiatrist in the therapeutic management of somatic patients with mental disorders: the psychiatrist acts as an expert consultant and, interacting with the patient and internists, participates in the development and adjustment of treatment tactics.
The priority for the consultant psychiatrist is the task of recognizing and differential diagnosis of mental disorders associated and not associated with the patient’s physical illness, as well as prescribing adequate treatment taking into account his mental and somatic status.
1. Somatogenic mental disorders
Somatogenic mental disorders develop as a result of the direct influence of the disease on the activity of the central nervous system and manifest themselves mainly in the form of neurosis-like symptoms, however, in some cases, against the background of severe organic pathology, the development of psychotic states, as well as significant impairment of higher mental functions up to dementia, is possible.
ICD-10 specifies the following general criteria for somatogenic (including organic) disorders:
1. Objective data (results of physical and neurological examinations and laboratory tests) and/or anamnestic information about CNS lesions or disease that may cause cerebral dysfunction, including hormonal disorders (not associated with alcohol or other psychoactive substances) and the effects of non-psychoactive drugs.
2. Time dependence between the development (exacerbation) of the disease and the onset of a mental disorder.
3. Recovery or significant improvement in mental state after eliminating or weakening the action of presumably somatogenic (organic) factors.
4. Absence of other plausible explanations for the mental disorder (for example, a high family history of clinically similar or related disorders).
If the clinical picture of the disease meets criteria 1, 2 and 4, a temporary diagnosis is justified, and if all criteria are met, the diagnosis of a somatogenic (organic, symptomatic) mental disorder can be considered definite.
In ICD-10, somatogenic disorders are presented mainly in Section F00-F09 (Organic, including symptomatic mental disorders) -
Dementia
F00 Dementia due to Alzheimer's disease
F01 Vascular dementia
F02 Dementia in other diseases (Pick's disease, epilepsy, traumatic brain injury, etc.)
F03 Dementia, unspecified
F04 Organic amnestic syndrome (severe memory impairment - anterograde and retrograde amnesia - against the background of organic dysfunction)
F05 Delirium not caused by alcohol or other psychoactive substances (confusion due to severe medical illness or cerebral dysfunction)
Other mental disorders caused by brain damage or dysfunction or physical illness:
F06.0. Organic hallucinosis
F06.1. Organic catatonic state
F06.2 Organic delusional (schizophrenia-like) disorder.
F06.3 Organic mood disorders: manic, depressive, bipolar disorders of the psychotic level, as well as hypomanic, depressive, bipolar disorders of the non-psychotic level
F06.4 Organic anxiety disorder
F06.5 Organic dissociative disorder
F06. Organic emotionally labile (asthenic) disorder
F06.7 Mild cognitive impairment due to cerebral dysfunction or physical illness

1.1. Syndromes of confusion.
Most often, in somatic pathology, delirious stupefactions occur, characterized by disorientation in time and place, influxes of vivid true visual and auditory hallucinations, and psychomotor agitation.
In somatic pathology, delirium can be both wavy and episodic in nature, manifesting itself in the form of abortive delirium, often combined with stunning or oneiric (dreaming) states.
Severe somatic diseases are characterized by such variants of delirium as excruciating and occupational with frequent transition to coma
In the presence of organic brain damage of various origins, various variants of twilight disorders are also possible.

1.2. Syndromes of switching off consciousness.
When consciousness is turned off to varying degrees of depth, there is an increase in the threshold of excitability, a slowdown in mental processes in general, psychomotor retardation, impaired perception and contact with the outside world (up to complete loss in a coma).
Loss of consciousness occurs in terminal conditions, with severe intoxication, traumatic brain injuries, brain tumors, etc.
Degrees of switching off consciousness:
1. somnolence,
2. stun,
3. stupor,
4. coma.

1.3 Psychoorganic syndrome and dementia.
Psychoorganic syndrome is a syndrome of impaired intellectual activity and emotional-volitional sphere due to brain damage. It can develop against the background of vascular diseases, as a consequence of traumatic brain injuries, neuroinfections, chronic metabolic disorders, epilepsy, atrophic senile processes, etc.
Disorders of intellectual activity are manifested by a decrease in its overall productivity and impairment of certain cognitive functions - memory, attention, thinking. A decrease in tempo, inertia and viscosity of cognitive processes, impoverishment of speech, and a tendency to perseveration are clearly evident.
Violations of the emotional-volitional sphere are manifested by emotional instability, viscosity and incontinence of affect, dysphoria, difficulties in self-control of behavior, changes in the structure and hierarchy of motives, impoverishment of the motivational-value sphere of the individual.
With the progression of the psychoorganic syndrome (for example, against the background of neurodegenerative diseases), dementia may develop.
A characteristic sign of dementia is a significant impairment of cognitive activity and learning ability, loss of acquired skills and knowledge. In some cases, disturbances of consciousness, disturbances of perception (hallucinations), phenomena of catatonia, and delirium are observed.
With dementia, there are also pronounced emotional and volitional disorders (depression, euphoric states, anxiety disorders) and distinct personality changes with a primary sharpening of individual traits and subsequent leveling of personal characteristics (up to general personal disintegration).

1.4. Asthenic syndrome in somatic diseases.
Asthenic phenomena are observed in most patients with somatic diseases, especially with decompensation, unfavorable course of the disease, the presence of complications, and polymorbidity.
Asthenic syndrome is manifested by the following symptoms:
1. increased physical/mental fatigue and exhaustion of mental processes, irritability, hyperesthesia (increased sensitivity to sensory, proprio- and interoceptive stimuli)
2. somato-vegetative symptoms;
3. sleep disorders.
There are three forms of asthenic syndrome:
1. hypersthenic form;
2. irritable weakness;
3. hyposthenic form.
Characteristic signs of the hypersthenic variant of asthenia are increased irritability, short temper, emotional lability, inability to complete an energetically started task due to instability of attention and rapid fatigue, impatience, tearfulness, predominance of anxious affect, etc.
The hyposthenic form of asthenia is more characterized by persistent fatigue, decreased mental and physical performance, general weakness, lethargy, sometimes drowsiness, loss of initiative, etc.
Irritable weakness is a mixed form, combining signs of both hyper- and hyposthenic variants of asthenia.
Somatogenic and cerebrogenic asthenic disorders are characterized by (Odinak M.M. et al., 2003):
1. Gradual development, often against a background of decreasing severity of the disease.
2. Clear, persistent, monotonous symptoms (as opposed to dynamic symptoms in psychogenic asthenia with the typical addition of other neurotic symptoms).
3. Decreased working capacity, especially physical, independent of the emotional state (as opposed to a decrease in predominantly mental working capacity in psychogenic asthenia with a clear dependence on emotional factors).
4. Dependence of the dynamics of asthenic symptoms on the course of the underlying disease.

1.5. Somatogenic emotional disorders.
The most typical emotional disorders due to somatogenic influences are depression.
Organic depression (depression in organic disorders of the central nervous system) is characterized by a combination of affective symptoms with phenomena of intellectual decline, the predominance of negative affectivity in the clinical picture (adynamia, aspontaneity, anhedonia, etc.), and the severity of asthenic syndrome. With vascular depression, multiple persistent somatic and hypochondriacal complaints may also be noted. With brain dysfunctions, dysphoric depression often develops with a predominance of a melancholy-angry mood, irritability, and expulsiveness.
Depression against the background of somatic pathology is characterized by a significant severity of the asthenic component. Typical symptoms are increased mental and physical exhaustion, hyperesthesia, irritable weakness, weakness, and tearfulness. The vital component of depression in somatic disorders often prevails over the actual affective one. Somatic symptoms in the structure of a depressive disorder can imitate the symptoms of the underlying disease and, accordingly, significantly complicate the diagnosis of a mental disorder.
It should be emphasized that the pathogenesis of depressive states in somatic disorders, as a rule, includes the interaction and mutual reinforcement of somatogenic and psychogenic factors. Depressive experiences often appear in the structure of maladaptive personal reactions to the disease, which develop in patients against the background of a general increased mental exhaustion and insufficient personal resources to overcome the stress of the disease.

2. Nosogenic mental disorders
Nosogenic disorders are based on a maladaptive personality reaction to the disease and its consequences.
In somatopsychology, the peculiarities of a person’s response to illness are considered within the framework of the problem of “internal picture of illness,” attitude to illness, “personal meaning of illness,” “experience of illness,” “somatonosognosia,” etc.
In the psychiatric approach, the most important are those maladaptive personal reactions to illness, which in their manifestations correspond to the criteria of psychopathology and qualify as nosogenic mental disorders.

2.1. Attitude to illness
The concept of attitude towards illness is associated with a wide range of psychological phenomena considered when studying the problem of relationships in the personality-illness system.
Formed under the influence of objective and subjective factors, a value system and, first of all, the value of health, the attitude towards the disease reflects the personal meaning of a particular disease, which determines the external manifestations of the patient’s more or less successful adaptation to the disease.
The patient’s development of an attitude towards the disease, structural and functional changes in the entire system of his relationships in connection with the fact of the disease naturally influence not only the course of the disease and medical prognosis, but also the entire course of personality development. The patient’s attitude to the disease expresses the uniqueness of his personality, experience, and current life situation (including the characteristics of the disease itself).
The concept of attitude towards illness is substantively close to the concept of “internal picture of illness” (IPI), introduced by R.A. Luria (1944), who contrasted it with the “external picture of the disease”, accessible to the impartial examination of the doctor. R.A. Luria defined VKB as the entire set of sensations and experiences of the patient in connection with the disease and treatment.
Currently, VCD is understood as “a complex of secondary, psychological in nature, symptoms of the disease” (V.V. Nikolaeva), reflecting the subjective meaning of the disease for the patient. The structure of the VKB includes the following levels:
1. sensory – sensations and states in connection with the disease;
2. emotional – experiences and emotional states in connection with the disease and treatment, emotional reaction to the disease and its consequences;
3. intellectual – the patient’s ideas about the causes, essence, danger of the disease, its impact on various areas of life, treatment and its effectiveness, etc.
4. motivational – a change in the motivational structure (hierarchy, leading motives) in connection with the disease; the nature of changes in behavior and lifestyle due to illness.
It should be emphasized that the attitude towards illness and VCB cannot be reduced to ideas about the illness, an emotional reaction to the illness or a behavioral strategy in connection with the illness, although they include all these three components and are manifested in them.
Among the factors influencing the nature of attitude towards the disease are the following:
1. Clinical characteristics: the degree of threat of the disease to life, the nature of the symptoms, the characteristics of the course (chronic, acute, paroxysmal) and the current phase of the disease (exacerbation, remission), the degree and nature of functional limitations, the specifics of treatment and its side effects, etc.
2. Premorbid features of the patient’s personality: characterological features, features of the system of significant relationships and values, features of self-awareness (self-perception, self-esteem, self-attitude), etc.
3. Socio-psychological factors: age at the onset of the disease, the social status of the patient and the nature of the impact of the disease on him, adequacy/inadequacy of social support, the likelihood of stigmatization, ideas about the disease characteristic of the patient’s microsocial environment, ideas about the disease and the patient’s norms of behavior, characteristic of society as a whole, etc.
Conventionally, the following types of attitude towards the disease are distinguished (Lichko A.E., Ivanov N.Ya., 1980; Wasserman L.I. et al., 2002):
1) Harmonious type – characterized by a sober assessment of one’s condition and the desire to contribute to the success of treatment.
2) Ergopathic type - manifested by “going to work from illness”, the desire to compensate for the feeling of personal inferiority due to illness with achievements in professional, educational activities and a generally high level of activity. Characteristic is a selective attitude to treatment, a preference for social values ​​over the value of health.
3) Anosognosic type - manifested by partial or complete ignoring of the fact of illness and medical recommendations, the desire to maintain the same lifestyle and the same image of the self, despite the illness. Often this attitude towards the disease is protective and compensatory in nature and is a way of overcoming anxiety in connection with the disease.
4) Anxious type - characterized by a constant feeling of concern about the physical condition, medical prognosis, real and imaginary symptoms of the disease and complications, the degree of effectiveness of treatment, etc. Anxiety in connection with the disease forces the patient to try new methods of treatment, contact many specialists, but without finding reassurance and the opportunity to get rid of concerns and fears.
5) Obsessive-phobic type - manifested by obsessive thoughts about the unlikely adverse consequences of the disease and treatment, constant thoughts about the possible impact of the disease on everyday life, the risk of disability, death, etc.
6) Hypochondriacal type - manifests itself in a focus on subjective painful, unpleasant sensations, exaggeration of suffering due to illness, and the desire to communicate about one’s illness to others. A typical combination of desire to be treated and disbelief in the success of treatment.
7) Neurasthenic type - characterized by symptoms of irritable weakness, increased fatigue, intolerance to pain, outbursts of irritation and impatience due to illness, followed by remorse for one’s own incontinence.
8) Melancholic type - determined by low mood due to illness, despondency, depression, disbelief in the success of treatment and the possibility of improving the physical condition, feelings of guilt due to illness/infirmity, suicidal ideas.
9) Apathetic type - characterized by indifference to one’s fate, the outcome of the disease, the results of treatment, passivity in treatment, a narrowing of the circle of interests and social contacts.
10) Sensitive type - manifested by increased sensitivity to the opinions of others regarding the fact of the disease, fear of becoming a burden to loved ones, the desire to hide the fact of the disease, expecting an unfavorable reaction, offensive pity or suspicion of using the disease for personal gain.
11) Egocentric type - characterized by the use of a disease for the purpose of manipulating others and attracting their attention, demanding exclusive care of oneself and subordinating their interests to one’s own.
12) Paranoid type - associated with the belief that the disease is the result of malicious intent, suspicion of medications and procedures, the behavior of the doctor and loved ones. Side effects and the occurrence of complications are considered as a consequence of dishonesty or malicious intent of medical personnel.
13) Dysphoric type - manifested by an angry and melancholy mood in connection with illness, envy, hostility towards healthy people, irritability, outbursts of anger, demand for the subordination of others to personal interests, including those related to illness and treatment.

2.2. Actually nosogenic mental disorders
In the presence of predisposing conditions (special personal premorbidity, history of mental disorders, hereditary burden of mental disorders, threat to life, social status, external attractiveness of the patient), a maladaptive personal reaction to the disease can take the form of a clinically pronounced mental disorder - nosogenic disorder.
Depending on the psychopathological level and clinical picture of nosogenic disorders, the following types are distinguished:
1. Reactions of a neurotic level: anxious-phobic, hysterical, somatized.
2. Reactions at the affective level: depressive, anxious-depressive, depressive-hypochondriacal reactions, “euphoric pseudodementia” syndrome.
3. Reactions of a psychopathic level (with the formation of overvalued ideas): “hypochondria of health” syndrome, litigious, sensitive reactions, syndrome of pathological denial of illness.
It is also fundamental to differentiate nosogenic disorders according to the criterion of the degree of awareness and personal involvement of the patient in the situation of the disease. Based on this criterion, the following are distinguished:
1. Anosognosia
2. Hypernosognosia
Anosognosia is a clinical and psychological phenomenon characterized by complete or partial (hyponosognosia) unawareness and distorted perception by the patient of his disease state, mental and physical symptoms of the disease.
Accordingly, hypernosognosia is characterized by the patient’s overestimation of the severity and danger of the disease, which determines his inadequate personal involvement in the problems of the disease and associated disorders of psychosocial adaptation.
One of the risk factors for the development of hypernosognosic reactions is incorrect (unethical) behavior of the doctor (medical staff), leading to the patient’s incorrect interpretation of the symptoms and severity of the disease, as well as the formation of maladaptive attitudes towards the disease. In this case, in some cases, the development of (iatrogenic) neurotic symptoms with a pronounced anxiety and somato-vegetative component is possible.

Primary prevention of somatogenic disorders is closely related to the prevention and earliest possible detection and treatment of somatic diseases. Secondary prevention is associated with timely and most adequate treatment of interrelated underlying diseases and mental disorders.
Considering that psychogenic factors (reaction to the disease and everything associated with it, reaction to a possible unfavorable environment) are of no small importance both in the formation of somatogenic mental disorders and in the possible aggravation of the course of the underlying somatic illness, it is necessary to apply preventive measures this kind of influence. Here, the most active role belongs to medical deontology, one of the main aspects of which is to determine the specifics of deontological issues in relation to the characteristics of each specialty.

3. Particular aspects of mental disorders in somatic diseases (according to N.P. Vanchakova et al., 1996)

3.1 Mental disorders in cancer
With cancer, both somatogenic and psychogenic mental disorders can develop.
Somatogenic:
a) tumors with primary localization in the brain or metastases to the brain: the clinic is determined by the affected area, represented by neurological symptoms, insufficiency or destruction of individual mental functions, as well as asthenia, psychoorganic syndromes, cerebral symptoms, convulsive syndrome and, less often, hallucinosis;
b) disorders caused by intoxication of tissue decay and narcotic analgesics: asthenia, euphoria, stupefaction syndromes (amentive, delirious, delirious-oneiroid), psychoorganic syndrome.
Psychogenic:
They represent the result of the individual’s reaction to the disease and its consequences. One of the most significant components is the reaction to the diagnosis of cancer. In this regard, it is necessary to understand that the issue of communicating a diagnosis to a cancer patient remains ambiguous. In favor of reporting the diagnosis, as a rule, indicate:
1. the opportunity to create a more trusting atmosphere in the relationship between the patient, doctors, family and friends, to reduce the patient’s social isolation;
2. more active participation of the patient in the treatment process;
3. the possibility of the patient taking responsibility for his future life.
Failure to report a diagnosis is motivated primarily by the high likelihood of severe depressive reactions, including suicide attempts.
So go the other way, regardless of the source of information about the presence of cancer, a person goes through a crisis characterized by the following stages:
1. shock and denial of the disease;
2. anger and aggression (experience of unfair fate);
3. depression;
4. acceptance of the disease.
The idea of ​​what stage of the crisis the patient is at is the basis of psychocorrectional work aimed at optimizing the treatment process and improving the quality of his life.

3.2. Mental disorders of the pre- and postoperative periods
Preoperative period
The leading factor in the pathogenesis is the individual’s reaction to the disease and the need for surgical intervention. The clinic is mainly represented by anxiety and anxiety-depressive disorders of varying severity. Essential in prevention is adequate preoperative psychological preparation, which includes an explanation of the nature and necessity of the operation, the formation of an attitude towards the operation and, if necessary, reducing the level of anxiety using both psychotherapeutic and medicinal methods. The degree of psychological preparedness of the patient as a result of psychosomatic relationships largely determines both the course of the operation itself and the postoperative period.
Postoperative period
The occurrence of mental disorders in the postoperative period is determined by the influence of all three main groups of factors. The clinic is represented by the main syndromes of mental disorders characteristic of somatic diseases (see above).

Questions for self-study

1. List the groups of factors contributing to the development of mental disorders in somatic patients
2. Objectives of psychiatric counseling for a somatic patient
3. List the general criteria for somatogenic mental disorder (according to ICD 10)
4. Clinic of asthenic syndrome
5. List the emotional disorders that are most common in somatic diseases
6. Internal picture of the disease - definition, content of the concept (components)
7. Variants of the internal picture of the disease
8. Define iatrogenics
9. List the most common mental disorders that occur in cancer patients (connection with the etiological factor)
10. List the most common mental disorders in the pre- and postoperative period.
Tasks:
1. A 78-year-old patient has been undergoing treatment for discirculatory encephalopathy at the neurological department of a somatic hospital for the second day. During the day he went into the department mode, visited his relatives, talked with the doctor, and showed a moderate intellectual-mnestic decline of the vascular type. At night, his condition changed sharply: he became restless, anxious, fussy, could not stay in place, wandered around the wards, was convinced that he was “at home,” looked for some things, and reacted aggressively to the nurse’s attempts to convince him otherwise.
Describe the patient’s altered consciousness, treatment tactics, and features of the therapy regimen.

The content of the article

General and clinical characteristics

Classification of somatogenic mental disorders

Mental disorders in certain somatic diseases

Mental disorders in heart disease

Mental disorders in patients with renal pathology

Mental disorders in diseases of the digestive tract

Mental disorders in cancer

Mental disorders of the postpartum period

Endocrine diseases

Treatment, prevention and social and labor rehabilitation of patients with somatogenic disorders

Somatic diseases, consisting of damage to internal organs (including endocrine) or entire systems, often cause various mental disorders, most often called “somatically caused psychoses” (K. Schneider).

K. Schneider proposed to consider the presence of the following signs as a condition for the appearance of somatically caused psychoses: (1) the presence of a pronounced clinical picture of a somatic disease; (2) the presence of a significant relationship over time between somatic and mental disorders; (3) a certain parallelism in the course of mental and somatic disorders; (4) possible, but not obligatory, appearance of organic symptoms.

There is no single view on the reliability of this “quadriad”. The clinical picture of somatogenic disorders depends on the nature of the underlying disease, the degree of its severity, the stage of its course, the level of effectiveness of therapeutic interventions, as well as on such individual properties as heredity, constitution, premorbid personality, age, sometimes gender, reactivity of the body, the presence of previous hazards ( the possibility of a “changed soil” reaction - S.G. Zhislin).

The section of so-called somatopsychiatry includes a number of closely interrelated, but at the same time different in clinical picture, groups of painful manifestations. First of all, this is somatogenesis itself, that is, mental disorders caused by a somatic factor, which belong to a large section of exogenous-organic mental disorders. Psychogenic disorders occupy no less place in the clinic of mental disorders in somatic diseases (a reaction to a disease not only with a limitation of a person’s life activity, but also with possible very dangerous consequences).

It should be noted that in ICD-10 mental disorders in somatic diseases are described mainly in sections F4 (“Neurotic, stress-related and somatoform disorders”) - F45 (“Somatoform disorders”), F5 (“Behavioral syndromes associated with with physiological disorders and physical factors") and F06 (Other mental disorders due to brain damage and dysfunction or physical illness).

Clinical manifestations. Different stages of the disease may be accompanied by different syndromes. At the same time, there is a certain range of pathological conditions that are currently especially characteristic of somatogenic mental disorders. These are the following disorders: (1) asthenic; (2) neurosis-like; (3) affective; (4) psychopathic; (5) delusional states; (6) states of stupefaction; (7) organic psychosyndrome.

Asthenia is the most typical phenomenon in somatogenies. often the so-called core or through syndrome. It is asthenia that currently, in connection with the pathomorphosis of somatogenic mental disorders, may be the only manifestation of mental changes. In the event of a psychotic state, asthenia, as a rule, can be its debut, as well as its completion.

Asthenic conditions are expressed in various ways, but the typical ones are always increased fatigue, sometimes in the morning, difficulty concentrating, and slower perception. Emotional lability, increased vulnerability and touchiness, and easy distractibility are also characteristic. Patients cannot tolerate even minor emotional stress, get tired quickly, and get upset over any trifle. Hyperesthesia is characteristic, expressed in intolerance to sharp stimuli in the form of loud sounds, bright light, smells, touches. Sometimes hyperesthesia is so pronounced that patients are irritated even by quiet voices, ordinary light, or the touch of linen to the body. Various sleep disturbances are common.

In addition to asthenia in its pure form, its combination with depression, anxiety, obsessive fears, and hypochondriacal manifestations is quite common. The depth of asthenic disorders is usually associated with the severity of the underlying disease.

Neurosis-like disorders. These disorders are associated with the somatic status and occur when the latter becomes more severe, usually with an almost complete absence or minor role of psychogenic influences. A feature of neurosis-like disorders, in contrast to neurotic disorders, is their rudimentary nature, monotony, and are typically combined with autonomic disorders, most often of a paroxysmal nature. However, autonomic disorders can be persistent and long-lasting.

Affective disorders. Dysthymic disorders are very characteristic of somatogenic mental disorders, primarily depression in its various variants. Given the complex interweaving of somatogenic, psychogenic and personal factors in the origin of depressive symptoms, the proportion of each of them varies significantly depending on the nature and stage of the somatic disease. In general, the role of psychogenic and personal factors in the formation of depressive symptoms (with the progression of the underlying disease) initially increases, and then, with further aggravation of the somatic condition and, accordingly, deepening of asthenia, significantly decreases.

Some features of depressive disorders can be noted depending on the somatic pathology they are observed in. In case of cardiovascular diseases, the clinical picture is dominated by lethargy, fatigue, weakness, lethargy, apathy with disbelief in the possibility of recovery, thoughts about the “physical failure” that supposedly inevitably occurs with any heart disease. Patients are sad, immersed in their experiences, show a tendency to constant introspection, spend a lot of time in bed, and are reluctant to come into contact with their ward neighbors and staff. In the conversation they talk mainly about their “serious” illness, about the fact that they do not see a way out of the current situation. Typical complaints are about a sharp loss of strength, about the loss of all desires and aspirations, about the inability to concentrate on anything (difficulty reading, watching TV, even difficult speaking). Patients often make all sorts of assumptions about their poor physical condition, the possibility of an unfavorable prognosis, and express uncertainty about the correctness of the treatment.

In cases where the internal picture of the disease is dominated by ideas about disorders in the gastrointestinal tract, the patient’s condition is determined by a persistent melancholy affect, anxious doubts about their future, subordination of attention exclusively to one object - the activity of the stomach and intestines, with fixation on various unpleasant emanations. sensations. There are complaints of a “pinching” feeling localized in the epigastric region and lower abdomen, of almost persistent heaviness, squeezing, distension and other unpleasant sensations in the intestines. Patients in these cases often associate such disorders with “nervous tension”, a state of depression, despondency, interpreting them as secondary.

With the progression of a somatic disease, a long course of the disease, the gradual formation of chronic encephalopathy, melancholy depression gradually takes on the character of dysphoric depression, with grumpiness, dissatisfaction with others, pickiness, demandingness, and capriciousness. Unlike the earlier stage, anxiety is not constant, but usually occurs during periods of exacerbation of the disease, especially with a real threat of developing dangerous consequences. In the long-term stages of a severe somatic illness with severe symptoms of encephalopathy, often against the background of dystrophic phenomena, asthenic syndrome includes depression with a predominance of adynamia and apathy, indifference to the environment.

During a period of significant deterioration in the somatic condition, attacks of anxious and melancholy excitement occur, at the height of which suicidal acts can be committed.

Psychopathic-like disorders. Most often they are expressed in an increase in egoism, egocentrism, suspicion, gloominess, hostile, wary or even hostile attitude towards others, hysteriform reactions with a possible tendency to aggravate one’s state, the desire to constantly be in the center of attention, elements of attitudinal behavior. It is possible to develop a psychopath-like state with an increase in anxiety, suspiciousness, and difficulties in making any decisions.

Delusional states. In patients with chronic somatic diseases, delusional states usually occur against the background of a depressive, asthenic-depressive, anxiety-depressive state. Most often this is delirium of attitude, condemnation, material damage, less often nihilistic, damage or poisoning. Delusional ideas are unstable, episodic, often have the character of delusional doubts with noticeable exhaustion of patients, and are accompanied by verbal illusions. If a somatic illness entails some kind of disfiguring change in appearance, then a dysmorphomania syndrome (an overvalued idea of ​​a physical defect, an idea of ​​a relationship, a depressive state), which arises through the mechanisms of a reactive state, may form.

A state of darkened consciousness. The most common episodes of stunning are those that occur against an asthenic-adynamic background. The degree of stunning may fluctuate. The mildest degrees of stunning in the form of loss of consciousness when the general condition worsens can progress to stupor and even coma. Delirious disorders are often episodic in nature, sometimes manifesting themselves in the form of so-called abortive deliriums, often combined with stunning or oneiric (dreaming) states.

Severe somatic diseases are characterized by such variants of delirium as excruciating and occupational with frequent transition to coma, as well as a group of so-called silent delirium. Silent delirium and similar conditions are observed in chronic diseases of the liver, kidneys, heart, and gastrointestinal tract and can occur almost unnoticed by others. Patients are usually inactive, in a monotonous position, indifferent to their surroundings, often giving the impression of dozing, and sometimes muttering something. They seem to be present when viewing oneiric paintings. At times, these oneiroid-like states can alternate with a state of excitement, most often in the form of chaotic fussiness. Illusory-hallucinatory experiences in this state are characterized by colorfulness, brightness, and scene-likeness. Depersonalization experiences and sensory synthesis disorders are possible.

Amental clouding of consciousness in its pure form occurs infrequently, mainly with the development of a somatic disease on the so-called altered soil, in the form of a previous weakening of the body. Much more often this is an amental state with a rapidly changing depth of stupefaction, often approaching disorders such as silent delirium, with clearing of consciousness and emotional lability. A twilight state of consciousness in its pure form is rare in somatic diseases, usually with the development of organic psychosyndrome (encephalopathy). Oneiroid in its classical form is also not very typical, much more often it is a delirious-oneiric or oneiric (dreaming) state, usually without motor excitation and pronounced emotional disorders.

The main features of stupefaction syndromes in somatic diseases are their erasure, rapid transition from one syndrome to another, the presence of mixed conditions, and their occurrence, as a rule, on an asthenic background.

Typical psychoorganic syndrome. In somatic diseases, it occurs infrequently; it occurs, as a rule, in long-term diseases with a severe course, such as, in particular, chronic renal failure or long-term liver cirrhosis with symptoms of potal hypertension. In somatic diseases, the asthenic version of the psycho-organic syndrome is more common with increasing mental weakness, increased exhaustion, tearfulness, and asthenodysphoric tint of mood (see also the article “ Psychoorganic syndrome"in the "Psychiatry" section of the medical portal website).