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

Any disease is always accompanied by unpleasant emotions, because somatic (bodily) diseases are difficult to separate from worries about the severity of the state of health and fears 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, against the background of a somatic illness, a mental disorder develops.

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

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

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

The mechanism of development of mental disorders. Mental health of a person provides a healthy brain. For normal operation, its nerve cells must receive enough glucose and oxygen, not succumb to the effects of 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 work of the whole organism and affect the nervous system through various mechanisms. Some diseases disrupt blood circulation, depriving brain cells of a significant part of the nutrients and oxygen. In this case, neurons atrophy and may die. Such changes can occur in certain areas of the brain or throughout its tissue.

In other diseases, there is a failure in the 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 with toxins that viruses and bacteria secrete.

Below we will consider in detail which somatic diseases cause mental disorders, and what are their manifestations.

Mental disorders in vascular diseases

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

In vascular diseases, mental disorders develop slowly and imperceptibly. The first signs are headaches, flashing "flies" before the eyes, sleep disturbances. Then there are signs of organic brain damage. Absent-mindedness arises, it becomes difficult for a person to quickly orient himself in a situation, he begins to forget dates, names, sequence of events.

For mental disorders associated with vascular diseases of the brain, a wave-like course is characteristic. 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 the death of neurons). It can have various manifestations. For example, visual disturbances, severe headaches, nystagmus (involuntary oscillatory eye movements), unsteadiness and incoordination.

Encephalopathy worsens over time dementia(acquired dementia). In the patient's psyche, changes occur that resemble age-related changes: the criticality to what is happening and to one's condition decreases. The general activity decreases, memory worsens. Judgments may be delusional. A person is not able to restrain emotions, which is manifested by tearfulness, anger, a tendency to tenderness, helplessness, fussiness. His self-service skills are reduced, and his thinking is disturbed. If the subcortical centers suffer, then incontinence develops. Hallucinations that occur at night can join illogical judgments and delusional ideas.

Mental disorders caused by impaired cerebral circulation 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 much the same way. Infections disrupt the work of the cerebral hemispheres, making it difficult for nerve impulses to pass through the reticular formation and diencephalon. The cause of the lesion is the viral and bacterial toxins secreted by the infectious agents. A certain role in the development of mental disorders is played by metabolic disorders in the brain caused by toxins.

In most patients, mental changes are limited asthenia(apathy, weakness, impotence, unwillingness to move). Although some, on the contrary, there is a motor excitation. With a severe course of the disease, more severe violations are possible.

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

infectious psychosis can take various forms:

• Delirium. The patient is agitated, overly sensitive to all stimuli (he is disturbed by light, loud sound, strong odors). Irritation and anger pours out on others for the most insignificant reason. Sleep is disturbed. It is difficult for the patient to fall asleep, he is haunted by nightmares. While awake, illusions arise. For example, the play of light and shadow creates pictures on the wallpaper that can move or change. When the lighting changes, the illusions disappear.
• Rave. Feverish delirium manifests itself at the peak of infection, when the blood contains the greatest amount of toxins and high temperature. The patient perks up, looks alarmed. The nature of delirium can be very different, from unfinished business or adultery to megalomania.
• hallucinations infections are 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 a person looks depressed, then when the second appears, he revives and laughs.
• Oneiroid. Hallucinations are in the nature of a holistic picture, when it may seem to a person that he is in a different place, in a different situation. The patient looks distant, 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 a protracted character, but their symptoms are less pronounced. For example, prolonged psychoses pass without disturbance of consciousness. They are manifested by a feeling of longing, fear, anxiety, depression based on delusional thoughts about condemnation from others, persecution. The condition worsens in the evening. Confusion in chronic infections is rare. Acute psychosis is usually associated with the use of anti-tuberculosis drugs, especially in combination with alcohol. And convulsive seizures can be a sign of a tuberculoma in the brain.

During the recovery period, many patients experience euphoria. It is manifested by a feeling of lightness, satisfaction, a rise in mood, joy.

Infectious psychoses and other mental disorders in 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 disturb the balance of the nervous system, exerting an excitatory or inhibitory effect. Hormonal shifts worsen the blood circulation of the brain, which eventually causes cell death in the cortex and other structures.

At the initial stage many endocrine diseases cause similar mental changes. Patients have disorders of attraction and affective disorders. These changes may resemble symptoms of schizophrenia or manic depressive illness. For example, there is a perversion of taste, a tendency to eat inedible substances, refusal of food, 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. Stereotypical behavior may appear (repetition of the same action - washing hands, “flicking the 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. With a decrease in the level of adrenal hormones, lethargy and resentment increase, and libido decreases. In acute insufficiency of the adrenal cortex, a person may experience erotic delirium, confusion, and the wax period is characterized by neurosis-like states. They suffer from a breakdown and a decrease in mood, which can develop into depression. For some, hormonal changes provoke hysterical states with excessive expression of emotions, loss of voice, muscle twitches (tics), partial paralysis, fainting.

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

In 70% of patients with severe diabetes mellitus for more than 15 years, anxiety and depressive disorders, adaptation disorders, personality and behavioral disorders, and neurosis occur.

• Adjustment Disorders make patients very sensitive to any stresses and conflicts. 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, grumpiness, resentment, stubbornness, etc. may increase. These traits prevent them from adequately responding to the situation and finding solutions to problems.
• neurosis-like disorders are manifested by fear, fear for one's life and stereotyped 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 all chronic heart disease accompanied by hypochondria. Increased attention to one's health, interpretation of new sensations as symptoms of the disease, and fears about the deterioration of the condition are characteristic of many "cores".

With acute heart failure, myocardial infarction and 2-3 days after heart surgery, psychosis may occur. Their development is associated with stress, which provoked a disruption in the functioning of the neurons of the cortex 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 have marked anxiety and mental activity, while others have lethargy and apathy become the main signs. With psychosis, it is difficult for patients to concentrate on a conversation, their orientation in time and place is disturbed. Delusions and hallucinations may occur. At night, the patient's condition worsens.

Mental disorders in systemic and autoimmune diseases

In 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 taking 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, they are overcome by depressive thoughts.

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

Mental disorders in intoxication

Intoxication- damage to the body by toxins. Poisonous substances for the brain disrupt blood circulation and cause dystrophic changes in its tissue. Nerve cells die throughout the brain or in separate foci - encephalopathy develops. This condition is accompanied by a violation of mental functions.

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 drugs in case of overdose (anti-tuberculosis drugs, steroid hormones, psychostimulants). In children under 3 years of age, toxic damage to the brain 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 poisonous substance enters the body, they have serious consequences for the psyche. Toxic damage to the brain is accompanied by clouding of consciousness. A person loses clarity of consciousness, feels detached. He experiences fits of fear or rage. Poisoning of the nervous system is often accompanied by euphoria, delirium, hallucinations, mental and motor excitement. There have been cases of memory loss. Depression in intoxication is dangerous with thoughts of suicide. The patient's condition may be complicated by convulsions, significant depression of consciousness - stupor, in severe cases - coma.

Mental disorders in chronic intoxication, when the body is exposed to small doses of toxins for a long time, they develop imperceptibly and do not have pronounced manifestations. Asthenia comes first. People feel weak, irritable, reduced attention and mental productivity.

Mental disorders in kidney disease

In case of violation of the kidneys, toxic substances accumulate in the blood, metabolic disorders occur, the work of the cerebral vessels worsens, edema and organic disorders develop in the brain tissue.

Chronic renal failure. The condition of patients is complicated by constant pain in the muscles and itching. It increases anxiety and depression, causes mood disorders. Most often, patients manifest asthenic phenomena: weakness, decreased mood and performance, apathy, sleep disturbances. With a deterioration in kidney function, motor activity decreases, some patients develop stupor, others may have psychoses with hallucinations.

For acute renal failure Disorders of consciousness can be added to asthenia: stunning, stupor, and with cerebral edema - coma, when consciousness is completely turned off and the main reflexes disappear. In 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" pictures.

Mental disorders in inflammatory diseases of the brain

Neuroinfections (encephalitis, meningitis, meningoencephalitis)- This is a defeat of the brain tissue or its membranes by viruses and bacteria. During 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, 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, occasionally there are outbursts of anger, which quickly fade away.

Majority encephalitis in the acute stage have general symptoms. Against the backdrop of high fever and headache syndromes obscuration of consciousness.

• Stun when the patient reacts poorly to the environment, becomes indifferent and inhibited. As the condition worsens, the stun turns into stupor and coma. In a coma, a person does not react to stimuli in any way.
• Delirium. There are difficulties in orienting in the situation, place and time, but the patient remembers who he is. He experiences hallucinations and believes they are real.
• Twilight clouding of consciousness when the patient loses orientation in the environment and experiences hallucinations. His behavior is fully consistent with the plot of hallucinations. During this period, the patient loses his memory and cannot remember what happened to him.
• Amentative clouding of consciousness- the patient loses orientation in the surrounding and his own "I". He does not understand who he is, where he is and what is happening.

Encephalitis with rabies is different from other forms of the disease. Rabies is characterized by a strong fear of death and rabies, speech disorder and salivation. With the development of the disease, other symptoms join: paralysis of the limbs, stupor. Death occurs from paralysis of the respiratory muscles and heart.

For chronic encephalitis symptoms resembling epilepsy develop - seizures of convulsions of one half of the body. Usually they are combined with twilight clouding of consciousness.

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

In the acute period, various forms of clouding of consciousness, described above, join asthenia. In severe cases, stupor develops when inhibition processes predominate in the cerebral cortex. The person looks asleep, only a sharp loud sound can make him 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, he falls into a coma.

Mental disorders in traumatic brain injury

The organic basis for mental disorders is the loss of electrical potential by neurons, trauma to the brain tissue, its swelling, hemorrhage, and the subsequent attack of the immune system 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 in brain injuries may appear immediately after the injury or in a long-term period (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 injury. At the initial stage from (several 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;
• Sopor- 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 the normalization of consciousness, amnesia may appear - loss of memory. As a rule, events that occurred shortly before the injury and immediately after it are erased from memory. Also, patients complain of slowness and difficulty in thinking, high fatigue from mental stress, mood instability.

Acute psychoses may occur immediately after injury or within 3 weeks after it. The risk is especially high in people who have had a concussion (brain injury) and an open craniocerebral injury. During psychosis, various signs of impaired consciousness may appear: delirium (often persecution or grandeur), hallucinations, periods of unreasonably elevated mood or lethargy, bouts 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 can become: a decrease in memory, attention, perception and learning ability, difficulty in thought processes, inability to control emotions. It is also likely that pathological personality traits will form in the form of hysteroid, asthenic, hypochondriacal or epileptoid character accentuation.

Mental disorders in oncological diseases and benign tumors

Malignant tumors, regardless of their location, are accompanied by predepressive states and severe depression caused by patients' fears for their health and the fate of loved ones, 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.

In the event that the tumor is localized in the brain, then patients may experience speech, memory, perception disorders, difficulty in coordinating movements and convulsions, delusions and hallucinations.

Psychosis 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

In the treatment of mental disorders caused by somatic diseases, first of all, attention is paid to bodily disease. 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 to alleviate the mental state during the treatment of a somatic disease. In severe mental disorders (psychosis, depression), the psychiatrist prescribes the appropriate drugs:

• Nootropic drugs- Encephabol, Aminalon, Piracetam. They are indicated for the majority of patients with impaired brain function in 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 the coherence of the brain.
• Antipsychotics used to treat psychosis. Haloperidol, Chlorprothixene, Droperidol, Tizercin - reduce the transmission of nerve impulses by blocking the work of dopamine in the synapses of nerve cells. It has a calming effect and eliminates delusions and hallucinations.
• tranquilizers Buspirone, Mebikar, Tofisopam reduce the level of anxiety, nervous tension and anxiety. They are also effective in asthenia, as they eliminate apathy and increase activity.
• Antidepressants are prescribed to combat depression in oncological and endocrine diseases, as well as injuries that led to serious cosmetic defects. During treatment, preference is given to drugs with the least number of side effects: Pyrazidol, Fluoxetine, Befol, Heptral.

In the vast majority of cases, after the treatment of the underlying disease, the mental health of a person is also restored. Rarely, if the disease has caused damage to the brain tissue, signs of a mental disorder 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 a somatic examination and laboratory data for diagnosis;

own

• the method 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 for assessing the patient's attitude to the current disease, his mood, the state of gnostic processes.

From 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 became known as somatogenic. At the same time, K. Bongeffer (K. Bonhoeffer) believed that the brain's ability to respond to the action of various external hazards is limited, therefore there is a common, single type of mental response - an "exogenous type of reactions", which boils down to several psychopathological syndromes. According to another point of view, in addition to the general type of exogenous response, there are psychopathological syndromes specific for certain somatic disorders and variants of their course in time (A. V. Snezhnevsky, V. A. Gilyarovskiy, K. Conrad, E. K. Krasnushkin). In addition, the role of a person's mental response to the presence of a severe somatic disorder was emphasized (R. A. Luria, E. A. Shevalev, V. N. Myasishchev).

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

common, 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 insignificant intellectual and physical efforts, in the exhaustion of voluntary attention, in functional impairment of memory. Patients have a sharp decrease in productivity in activities. Neurosis-like symptoms appear: emotional lability, irritability, tearfulness, intolerance to strong stimuli (sharp sounds, bright light), sleep disorders in the form of difficulty falling asleep, superficial, anxious sleep.

Emotional disorders predominantly manifest as depression, integrating with asthenia into astheno-depressive syndrome. At the beginning of mental disorders of somatogenic origin, depression resembles neurotic depression, but with the aggravation of somatic pathology, depression changes: grouchiness, capriciousness, pickiness towards others, and episodes of dysphoria appear. In children and adolescents, depression is usually not prolonged, accompanied by irritability, negativism, violations of the hospital regime, in the involutionary period of life, the anxious nature of depression is more clearly manifested. With a significant aggravation of 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 are combined with depression and asthenia. Depressive-delusional symptoms most often contain delusions of relationship, damage, often nihilistic delirium up to Kotard's nihilistic delirium with the patients' statements about the destruction and disappearance of their internal organs, about their transformation into dead people, etc. Sometimes delirium is accompanied by sensopathies.

From syndromes of disturbed consciousness most often, patients have stupor, short-term oneiroid states. Quite typical for patients are flickering clarity of consciousness in the form of asthenic confusion and transitions from one type of consciousness disorder to another.

Psychopathic manifestations of somatogenic conditioning manifested in the form of growing selfishness of a person, in a wary and even suspicious attitude towards others, a tendency to exaggerate the severity of one's somatic state, the desire to attract attention to oneself with elements of attitudinal behavior.

Diseases of certain systems and organs of a person can also be reflected in some features of mental disorders.

At diseases of the gastrointestinal tract(gastritis, colitis, gastric and duodenal ulcers), neurosis-like and psychonaton-like symptoms may appear. Patients become capricious, irritable, 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 somatic pathology is cured, they usually stop.

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

kidney failure often accompanied by complaints of headaches, low mood, high fatigue. With an increase in decompensation of kidney 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 relation, special significance, with auditory hallucinations can be observed. Such psychotic pictures can last up to several weeks, but there are also short-term mental disorders with pronounced fear and disorders of consciousness for several hours or days.

A variety of psychiatric disorders are diseases of the heart and cardiovascular system. So, in heart diseases with angina attacks, 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 have affective reactions to others, cardiophobic manifestations.

In anticipation of myocardial infarction and in its acute period, patients with and without angina pectoris usually develop anxiety, fear of death, and hyperesthesia. Patients are extremely irritable, restless on the move, or, conversely, silent, inactive, lying in bed, afraid to move. There may be stupefaction of different depths (from mild stupor to coma). In the acute period of myocardial infarction, especially with the disappearance of angina pectoris, an anxious depressive state can be replaced by euphoria, in which patients no longer adequately perceive their somatic state, despite the protests of medical personnel, they tend to leave the intensive care unit, remove the electrodes from the cardiograph and declare their desire to go home because they feel great. After an acute period of infarction, a depressive background of mood is often observed with severe asthenia, with fear of a second heart attack, with a dreary experience of the end of life and suicidal thoughts, especially in elderly patients. Often, patients become hypochondriacal, afraid of any physical exertion 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 pronounced 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 manifestations of mental disorders often occur: irritable weakness, general anxiety, exhaustion, signs of somato-vegetative dysfunctions, sleep disorders and frequent headaches. The speed of memorization of current information and the amount of short-term memory are reduced. There are senestopathies, hypochondria, fear of progression of hypertensive manifestations and death. Anxious suspiciousness, irascibility, capriciousness are growing. During the period of pronounced signs of hypertension, organic changes in the 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 on others. Memory defects worsen. Egocentricity and conflict are growing. The range of interests narrows, initiative and activity decrease, 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 without gross changes. Gradually, with an increase in hypertensive crises, patients may experience periods of acute psychotic states with anxiety-depressive manifestations, aggravated in the evening, with the emergence of delusional ideas of attitude, special significance, and persecution. Against the background of a hypertensive crisis, disorders of consciousness appear in the form of stupor, twilight states, and sometimes a delirious syndrome. At the late stage of the course of hypertension, dementia gradually develops, often of a lacunar nature, when certain aspects of the intellect, knowledge and skills are completely preserved, while others show severe insufficiency, perhaps total dementia with a gross decrease in the capabilities of memory, attention, mental operations and reproduction of past knowledge and skills.

After heavy brain strokes dementia can be accompanied by gross memory disorders up to Korsakov's syndrome, loss of acquired skills, airacto-agnostic disorders and apato-abulic manifestations.

Mental disorders in endocrine diseases have both signs common to all of them, and associated with disorders of individual endocrine glands.

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

At dysfunction of the anterior pituitary gland(Simmonds' disease) in patients the leading is apato-Abulichssky syndrome with hypodynamia, asthenia, tearfulness. Perhaps the occurrence of non-durable episodes of hallucinatory-delusional nature.

At hyperfunction of the thyroid gland in patients, there is pronounced tearfulness, a quick change in mood, a decrease in working capacity with exhaustion of attention, fussiness, irritability and hyperesthesia. Often there is depression with hypochondria, anxiety, much less often there is apathy, indifference to what is happening.

At hypothyroidism patients are drowsy, lethargic, lack of initiative, fatigued, with a sharp slowdown in the rate of mental processes and a 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 in patients on an asthenic background, high fatigue, lethargy, decreased mood, and emotional instability are observed. A long course of the disease with frequent hypoglycemia can lead to encephalopathy with intellectual-mnestic insufficiency. Perhaps the emergence of short-term psychotic states with disorders of consciousness of the delirious, amental type or with illusory-hallucinatory confusion, affective tension. There are epileptiform seizures and twilight disturbances of consciousness.

In cases of chronic insufficiency of the functions of the adrenal cortex, 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, memory loss. Often apathy or low mood prevails, or unmotivated anxiety, anxiety, suspicion, and resentment arise. There may be short-term psychotic states with anxiety-delusional and anxiety-depressive symptoms, with a kind of tactile protozoal hallucinosis (feeling of various insects and small worms crawling under the skin). Hallucinosis is more common in elderly patients.

Control questions and tasks

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

In patients with somatic diseases, a wide range of mental disorders can be observed, both neurotic and psychotic or subpsychotic levels.
K. Schneider proposed to consider the presence of the following signs as the conditions for the appearance of somatically conditioned mental disorders: 1) the presence of a pronounced clinical picture of a somatic disease; 2) the presence of a noticeable connection in 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 probability of occurrence of somatogenic disorders depends on the nature of the underlying disease, 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 organism, 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 that are not associated with the disease may be involved in the process of somatogenic disorders.

Accordingly, the influence of a somatic disease 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 the 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 strategy and tactics of treatment. At the same time, the correct qualification of a mental disorder and its pathogenetic mechanisms is possible only when taking into account the somatic and mental status of the patient, somatic and psychiatric anamnesis, treatment features and its possible side effects, data on hereditary burden and other predisposition factors.
Mental disorders in a patient with a somatic disease makes it necessary to manage it jointly by an internist and a psychiatrist (psychotherapist), which can be carried out within the framework of different models. The most widely used is the consultation-interaction model, which involves the direct and indirect (through consultation 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 a consultant psychiatrist is the task of recognizing and differential diagnosis of mental disorders associated and not associated with the patient's somatic disease, 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 conditions is possible, as well as significant violations of higher mental functions up to dementia.
The ICD-10 specifies the following general criteria for somatogenic (including organic) disorders:
1. Objective evidence (results of physical and neurological examinations and laboratory tests) and/or history of 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 the mental state after the elimination or weakening of the supposedly somatogenic (organic) factors.
4. Absence of other plausible explanations for the mental disorder (for example, a high hereditary burden 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 the criteria are met, the diagnosis of a somatogenic (organic, symptomatic) mental disorder can be considered definite.
In the ICD-10, somatogenic disorders are presented predominantly in Section F00-F09 (Organic, including symptomatic mental disorders) -
dementia
F00 Dementia in Alzheimer's disease
F01 Vascular dementia
F02 Dementia in other diseases (Pick's disease, epilepsy, brain injury, etc.)
F03 Dementia, unspecified
F04 Organic amnesic syndrome (severe memory impairment - anterograde and retrograde amnesia - against the background of organic dysfunction)
F05 Delirium not caused by alcohol or other psychoactive substances (clouding of consciousness against a background of severe physical illness or brain dysfunction)
Other mental disorders due to damage or dysfunction of the brain or physical illness:
F06.0. organic hallucinosis
F06.1. Organic catatonic state
F06.2 Organic delusional (schizophrenia-like) disorder
F06.3 Organic mood disorders: psychotic-level manic, depressive, bipolar and non-psychotic-level hypomanic, depressive, bipolar disorders
F06.4 Organic anxiety disorder
F06.5 Organic dissociative disorder
F06. Organic emotionally labile (asthenic) disorder
F06.7 Mild cognitive impairment due to brain dysfunction or physical illness

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

1.2. Syndromes of turning off consciousness.
When the consciousness of varying degrees of depth is turned off, 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 coma).
Switching off consciousness occurs in terminal states, with severe intoxication, craniocerebral trauma, brain tumors, etc.
Degrees of turning off consciousness:
1. doubt,
2. stun,
3. sopor,
4. coma.

1.3 Psychoorganic syndrome and dementia.
Psychoorganic syndrome is a syndrome of impaired intellectual activity and emotional-volitional sphere in case of brain damage. It can develop against the background of vascular diseases, as a consequence of craniocerebral trauma, neuroinfections, chronic metabolic disorders, epilepsy, atrophic senile processes, etc.
Disorders of intellectual activity are manifested by a decrease in its overall productivity and a violation of individual cognitive functions - memory, attention, thinking. Decrease in pace, inertia and viscosity of cognitive processes, impoverishment of speech, and a tendency to perseverations are clearly visible.
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 feature of dementia is a significant impairment of cognitive activity and learning, the loss of acquired skills and knowledge. In some cases, there are disturbances of consciousness, perception disorders (hallucinations), catatonia, delirium.
In dementia, there are also pronounced emotional and volitional disorders (depressions, euphoric states, anxiety disorders) and distinct personality changes with a primary sharpening of individual features and subsequent leveling of personality traits (up to a general personality breakdown).

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, 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.
The characteristic signs of the hypersthenic variant of asthenia are increased irritability, irascibility, emotional lability, inability to complete an energetically started business due to instability of attention and rapid fatigue, impatience, tearfulness, the predominance of anxious affect, etc.
For the hyposthenic form of asthenia, persistent fatigue, a decrease in mental and physical performance, general weakness, lethargy, sometimes drowsiness, loss of initiative, etc. are more characteristic.
Irritable weakness is a mixed form that combines signs of both hyper- and hyposthenic variants of asthenia.
For somatogenic and cerebrogenic asthenic disorders are characteristic (Odinak M.M. et al., 2003):
1. Gradual development, often against the background of a decrease in the severity of the disease.
2. Clear, persistent, monotonous symptoms (as opposed to dynamic symptoms in psychogenic asthenia with typical addition of other neurotic symptoms).
3. Decreased ability to work, especially physical, independent of the emotional state (as opposed to a decrease in predominantly mental performance 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 disturbances due to somatogenic influences are depressions.
Organic depressions (depressions in organic disorders of the central nervous system) are 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 can also be noted. With brain dysfunctions, dysphoric depressions often develop with a predominance of a melancholy-evil mood, irritability, and excrement.
Depression against the background of somatic pathology is characterized by a significant severity of the asthenic component. Typical phenomena of increased mental and physical exhaustion, hyperesthesia, irritable weakness, weakness, 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 mimic 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 that develop in patients against the background of a general increased mental exhaustion and insufficiency of personal resources to overcome the stress of the disease.

2. Nosogenic mental disorders
Nosogenic disorders are based on a maladaptive reaction of the individual to the disease and its consequences.
In somatopsychology, the features of a person’s response to a disease are considered within the framework of the problem of “internal picture of the disease”, attitudes towards the disease, “personal meaning of the disease”, “experiencing the disease”, “somatognosia”, etc.
In the psychiatric approach, those maladaptive personal reactions to the disease that, in their manifestations, meet the criteria of psychopathology and qualify as nosogenic mental disorders are of the greatest importance.

2.1. Attitude towards illness
The concept of attitude to the disease is associated with a wide range of psychological phenomena considered in the study of the problem of relationships in the personality-illness system.
Formed under the influence of objective and subjective factors, the system of values ​​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 a more or less successful adaptation of the patient to the disease.
The development of a patient's attitude to the disease, structural and functional changes in the entire system of his relations in connection with the fact of the disease naturally affect not only the course of the disease and medical prognosis, but also the entire course of personality development. In relation to the patient to the disease, the uniqueness of his personality, experience, current life situation (including the characteristics of the disease itself) is expressed.
The concept of attitude to the disease is meaningfully close to the concept of "internal picture of the disease" (IKB), introduced by R.A. Luria (1944), who contrasted it with the "external picture of the disease" available for an impartial examination of a doctor. R.A. Luria defined WKB as the totality of the patient's feelings and experiences in connection with the disease and treatment.
Currently, VKB 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 following levels are distinguished in the structure of the WKB:
1. sensual - 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, nature, 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; nature of changes in behavior and lifestyle due to illness.
It should be emphasized that attitudes towards the disease and WKB are not reducible to ideas about the disease, an emotional reaction to the disease, or a behavioral strategy in connection with the disease, although they include all these three components and are manifested in them.
Among the factors influencing the nature of the attitude towards the disease, the following are distinguished:
1. Clinical characteristics: the degree of threat of the disease to life, the nature of the symptoms, the course of the disease (chronic, acute, paroxysmal) and the current phase of the course 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-consciousness (self-perception, self-esteem, self-attitude), etc.
3. Socio-psychological factors: age at the onset of the disease, the patient's social status and the nature of the impact of the disease on him, the adequacy / insufficiency of social support, the likelihood of stigmatization, ideas about the disease characteristic of the patient's microsocial environment, ideas about the disease and norms of the patient's behavior, characteristic of society as a whole, etc.
Conventionally, the following types of attitudes 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 "withdrawal to work from the disease", the desire to compensate for the feeling of personal inferiority due to the disease with achievements in professional, educational activities and, in general, a high level of activity. The selective attitude to treatment, the preference of social values ​​for the value of health are characteristic.
3) Anosognosic type - manifested by partial or complete disregard for the fact of the disease and medical recommendations, the desire to maintain the old way of life and the old image of the Self, despite the disease. Often this attitude towards the disease is protective and compensatory in nature and is a way to overcome anxiety in connection with the disease.
4) Anxious type - characterized by a constant feeling of concern about the somatic condition, medical prognosis, real and imaginary symptoms of the disease and complications, the degree of treatment effectiveness, etc. Anxiety in connection with the disease forces the patient to try new methods of treatment, to turn to many specialists, without finding, however, reassurance and the opportunity to get rid of fears and fears.
5) Obsessive-phobic type - manifested by obsessive thoughts about the unlikely adverse effects 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 - manifested in focusing on subjective painful, unpleasant sensations, exaggeration of suffering in connection with the disease, the desire to report one's illness to others. A combination of a desire to be treated and disbelief in the success of treatment is typical.
7) Neurasthenic type - characterized by phenomena of irritable weakness, increased fatigue, intolerance to pain, outbursts of irritation and impatience due to illness, followed by repentance for one's own incontinence.
8) Melancholic type - is determined by low mood due to illness, despondency, depression, disbelief in the success of treatment and the possibility of improving the somatic condition, 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, narrowing the range of interests and social contacts.
10) Sensitive type - manifested by increased sensitivity to the opinions of others regarding the fact of the disease, the fear of becoming a burden for 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 - is characterized by the use of the disease in order to manipulate others and attract their attention, the requirement of exceptional care for themselves and the subordination of their interests to their own.
12) Paranoid type - associated with the belief that the disease is the result of malicious intent, suspicion of drugs 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 maliciousness of the medical staff.
13) Dysphoric type - manifested by an angry-dreary mood in connection with illness, envy, hostility towards healthy people, irritability, outbursts of anger, the requirement to subordinate others to personal interests, including those associated with illness and treatment.

2.2. Actually nosogenic mental disorders
In the presence of predisposing conditions (a special personal premorbid, a history of mental disorders, hereditary burden of mental disorders, threats to life, social status, external attractiveness of the patient), a maladaptive personal reaction to a disease can take the form of a clinically pronounced mental disorder - a nosogenic disorder.
Depending on the psychopathological level and the clinical picture of nosogenic disorders, the following types are distinguished:
1. Reactions of the neurotic level: anxiety-phobic, hysterical, somatized.
2. Reactions of the affective level: depressive, anxiety-depressive, depressive-hypochondriac reactions, "euphoric pseudodementia" syndrome.
3. Reactions of the psychopathic level (with the formation of overvalued ideas): the “health hypochondria” syndrome, litigious, sensitive reactions, the syndrome of pathological denial of the disease.
It is also fundamental to distinguish between nosogenic disorders according to the degree of awareness and personal involvement of the patient in the situation of the disease. Based on this criterion, there are:
1. Anosognosia
2. Hypernosognosia
Anosognosia is a clinical and psychological phenomenon characterized by complete or partial (hyponosognosia) unawareness and a distorted perception by the patient of his disease state, mental and physical symptoms of the disease.
Accordingly, hypernosognosias are characterized by an overestimation by the patient of the severity and danger of the disease, which determines his inadequate personal involvement in the problems of the disease and the psychosocial adaptation disorders associated with it.
One of the risk factors for the development of hypernosognosic reactions is the incorrect (unethical) behavior of the doctor (medical staff), which leads to an incorrect interpretation of the symptoms and severity of the disease by the patient, as well as to the formation of maladaptive attitudes towards the disease. At the same time, 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 early detection and treatment of somatic diseases. Secondary prevention is associated with the timely and most adequate therapy of interrelated underlying diseases and mental disorders.
Given that psychogenic factors (reaction to a disease and everything associated with it, a reaction to a possible unfavorable environment) are of no small importance both in the formation of somatogenic mental disorders and in the event of a possible aggravation of the course of the underlying somatic disease, it is necessary to apply measures to prevent 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 Psychiatric disorders in oncological diseases
In oncological diseases, both somatogenic and psychogenic mental disorders can develop.
Somatogenic:
a) tumors with primary localization in the brain or brain metastases: the clinic is determined by the affected area, presented 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 tissue breakdown intoxication and narcotic analgesics: asthenia, euphoria, confusion syndromes (amental, delirious, delirious-oneiric), psychoorganic syndrome.
Psychogenic:
They are the result of a person's reaction to a disease and its consequences. One of the most significant components is the reaction to the diagnosis of cancer. In this regard, it should be understood that the issue of reporting a diagnosis to an oncological patient remains ambiguous. In favor of reporting a diagnosis, as a rule, indicate:
1. the ability to create a more trusting atmosphere in the relationship between the patient, doctors, relatives and friends, to reduce the social isolation of the patient;
2. more active participation of the patient in the treatment process;
3. the possibility of the patient taking responsibility for his future life.
The non-reporting of the diagnosis is motivated, first of all, by the high probability of severe depressive reactions up to suicidal attempts.
So go the other way, regardless of the source of information about the presence of an oncological disease, a person goes through a crisis characterized by the following stages:
1. shock and denial of the disease;
2. anger and aggression (experience of injustice of fate);
3. depression;
4. acceptance of illness.
The idea of ​​what stage of the crisis the patient is at is the basis of psycho-correctional 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
Leading in the pathogenesis is the reaction of the individual to the disease and the need for surgical intervention. The clinic is mainly represented by anxiety and anxiety-depressive disorders of varying severity. Adequate preoperative psychological preparation is essential in prevention, including an explanation of the nature and necessity of the operation, the formation of an attitude to the operation and, if necessary, a decrease in the level of anxiety, both by 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. Tasks of psychiatric counseling of a somatic patient
3. List the general criteria for a somatogenic mental disorder (according to ICD 10)
4. Clinic of asthenic syndrome
5. List the emotional disorders 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 iatrogenic
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 is being treated for dyscirculatory encephalopathy at the neurological department of a somatic hospital for the second day. During the day, he kept within the regimen of the department, visited his relatives, talked with the doctor, found a moderate intellectual-mnestic decrease in the vascular type. At night, the state changed sharply, became restless, anxious, fussy, did not stay still, wandered around the wards, was convinced that he was “at home”, was looking for some things, reacted aggressively to the attempts of the nurse to change his mind.
Give a description of the patient's altered consciousness, treatment tactics, 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 in the defeat of internal organs (including endocrine) or entire systems, often cause various mental disorders, most often called "somatically conditioned psychoses" (K. Schneider).

K. Schneider proposed to consider the presence of the following signs as a condition for the appearance of somatically conditioned psychoses: (1) the presence of a pronounced clinical picture of a somatic disease; (2) the presence of a marked relationship in time between somatic and mental disorders; (3) a certain parallelism in the course of mental and somatic disorders; (4) the 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, its severity, the stage of the course, the level of effectiveness of therapeutic effects, as well as on such individual properties as heredity, constitution, premorbid personality, age, sometimes gender, reactivity of the organism, the presence of previous hazards ( the possibility of the reaction of "altered soil" - S.G. Zhislin).

The section of the so-called somatopsychiatry includes a number of closely related, but at the same time, different groups of painful manifestations in their clinical picture. First of all, this is actually somatogeny, that is, mental disorders caused by a somatic factor, which belong to a large section of exogenous organic mental disorders. No less place in the clinic of mental disorders in somatic diseases is occupied by psychogenic disorders (the reaction to the disease not only with the restriction of human life, but also with possible very dangerous consequences).

It should be noted that in the 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 damage and dysfunction of the brain 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, especially characteristic of somatogenic mental disorders at the present time. These are the following disorders: (1) asthenic; (2) neurosis-like; (3) affective; (4) psychopathic; (5) delusional states; (6) states of clouding of consciousness; (7) organic psychosyndrome.

Asthenia is the most typical phenomenon in somatogeny. often happens the so-called core or through syndrome. It is asthenia at present, due to the pathomorphosis of somatogenic mental disorders, that 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 completion.

Asthenic conditions are expressed in various ways, but fatigue is always typical, sometimes in the morning, difficulty concentrating, slowing down perception. Emotional lability, increased vulnerability and resentment, and quick distractibility are also characteristic. Patients do not tolerate even a slight emotional stress, quickly get tired, upset because of any trifle. Hyperesthesia is characteristic, expressed in intolerance to sharp stimuli in the form of loud sounds, bright lights, smells, touches. Sometimes hyperesthesia is so pronounced that patients are irritated even by low voices, ordinary light, and the touch of linen on the body. Sleep disturbances are common.

In addition to asthenia in its purest 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.

neurotic disorders. These disorders are associated with the somatic status and occur when the latter is aggravated, usually with an almost complete absence or a small role of psychogenic influences. A feature of neurosis-like disorders, in contrast to neurotic disorders, is their rudimentary nature, monotony, a combination with autonomic disorders, most often of a paroxysmal nature. However, vegetative disorders can be persistent, long-term.

affective disorders. For somatogenic mental disorders, dysthymic disorders are very characteristic, primarily depression in its various variants. In the context of a complex interweaving of somatogenic, psychogenic and personal factors in the origin of depressive symptoms, the share 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) first increases, and then, with further aggravation of the somatic condition and, accordingly, deepening of asthenia, it significantly decreases.

Some features of depressive disorders can be noted, depending on the somatic pathology in which they are observed. In cardiovascular diseases, the clinical picture is dominated by lethargy, fatigue, weakness, lethargy, apathy with disbelief in the possibility of recovery, thoughts about the supposedly inevitable “physical failure” that occurs with any heart disease. Patients are melancholy, 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 roommates and staff. In a conversation, they talk mainly about their “serious” illness, that they do not see a way out of the situation. Complaints are typical of a sharp decline in strength, the loss of all desires and aspirations, the inability to concentrate on anything (it is difficult to read, watch TV, it is even difficult to speak). Patients often make all sorts of assumptions about their poor physical condition, about the possibility of an unfavorable prognosis, and express uncertainty about the correctness of the treatment being carried out.

In those cases when the internal picture of the disease is dominated by ideas about disorders in the gastrointestinal tract, the condition of patients is determined by persistent dreary 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 things emanating from them. sensations. Complaints are noted for a "pinching" feeling localized in the epigastric region and in the lower abdomen, for almost non-passing heaviness, squeezing, bursting and other unpleasant sensations in the intestines. Patients in these cases often associate such disorders with "nervous tension", a state of depression, depression, interpreting them as secondary.

With the progression of a somatic disease, the long course of the disease, the gradual formation of chronic encephalopathy, dreary depression gradually acquires the character of a dysphoric depression, with grouchiness, dissatisfaction with others, pickiness, exactingness, capriciousness. Unlike an 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. On remote taps of a severe somatic disease with pronounced 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 state, attacks of anxious and dreary excitement occur, at the height of which suicidal acts can occur.

psychopathic disorders. Most often they are expressed in the growth of egoism, egocentrism, suspicion, gloom, 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. Perhaps the development of a psychopathic state with an increase in anxiety, suspiciousness, difficulties in making any decision.

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

A state of clouded consciousness. The episodes of stunning that occur against an asthenic-adynamic background are most often noted. The degree of stunning can be fluctuating in this case. The lightest degrees of stunning in the form of an obnubilation of consciousness, with an aggravation of the general condition, can pass stupor and even to coma. Delirious disorders are often episodic, sometimes manifesting themselves in the form of so-called abortive deliriums, often combined with stunning or with oneiric (dreaming) states.

Severe somatic diseases are characterized by such variants of delirium as mushing and professional with a 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, gastrointestinal tract and can proceed almost imperceptibly to others. Patients are usually inactive, are in a monotonous pose, indifferent to the environment, often give the impression of dozing, sometimes muttering something. They seem to be present when viewing oneiric paintings. Periodically, these oneiroid-like states may alternate with a state of excitement, most often in the form of erratic fussiness. Illusory-hallucinatory experiences in this state are characterized by brilliance, brightness, scene-like. Possible depersonalization experiences, disorders of sensory synthesis.

Amentative clouding of consciousness in its pure form is rare, mainly with the development of a somatic disease on the so-called changed 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 clarification of consciousness, emotional lability. The twilight state of consciousness in its pure form in somatic diseases is rare, usually with the development of an organic psychosyndrome (encephalopathy). Oneiroid in its classical form is also not very typical, much more often delirious-oneiric or oneiric (dreaming) states, usually without motor excitation and pronounced emotional disorders.

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

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