The first published descriptions of depersonalization, but without the terminological definition of this syndrome, were given by French psychiatrists J. Esquirol in 1838 and J. Moreau de Tours in 1840, who paid attention to the symptoms of a split personality, as well as the alienation of sensations of one’s own body [cit. by: L.Dugas , F.Moutier ].
The first monograph, almost entirely devoted to depersonalization disorders, was the work of “ Cerebrocardiac neuropathy” by R. Krishaber , based on the description of 38 clinical observations of patients with phenomena of alienation of their own mental processes and somatic sensations. At the end of the XIX century. the French philologist and philosopher L. Dyuga proposed the term “depersonalization” 1 to refer to the disintegration of “I” ( Dugas L.).
At the beginning of the XX century. in Paris, he published a monograph L. Dugas and F. Moutier «depersonalization» (Dugas L., Moutier F.) . This paper summarizes the experience of studying depersonalization for all previous years, but there is no mention of depersonalization disorders in children and adolescents. In the Russian literature, the results of studies on depersonalization syndrome are summarized in the works of a number of authors.
C. Wernicke , using his own classification of the division of psychosis, divided the depersonalization into somatopsychic , autopsychic and allopsychic forms depending on the sense of alienation of bodily sensations, mental processes and the surrounding world, respectively; Subsequently, this classification was finalized and implemented in the practice of K. Haug . It seems that the most accurate would be to call this subdivision of depersonisation disorders into three forms by the Wernicke- Haug classification .
Autopsy depersonalization is a condition in which patients lose their ability to perceive fully or partially their own mental processes, as a rule, experiencing their "absence" or "dulling." One of the most common types of autopsy depersonalization is anesthesia. psychica dolorosa (“sorrowful insensitivity”, “painful insensitivity”), that is, the feeling of losing your own emotional experiences.
In this case, patients say that they can no longer experience suffering, feelings of fun and joy, they can not empathize with others. Thus, a patient of 15 years began to feel that she “could no longer worry about the mother’s illness”, “no matter how she tries, she is not able to shed a single tear”, although she always loved her mother and was especially attached to her. She also said that the funny and funny movies do not bring her that “previous joy”, “as if there are no emotional accompaniments at all.”
It should be noted that the true loss of emotions does not occur, such a patient, unlike a patient with apathetic disorders, always suffers, trying to understand and analyze his condition, may cry, saying that he had "gone forever feelings of joy and grief." In other cases of the autopsy of depersonalization, there is a feeling of loss of memory, attention, thinking, when the patient begins to say that he is “stupid”, “has become dull”, “has lost the ability to think”, etc. However, the patient is not found objective loss of memory, attention or thinking disorders.
Somatopsychiatric depersonalization is characterized by a decrease in the patient's perception of their own bodily (somatic) sensations and physiological processes. At the same time, complaints may appear that the parts of the body “have become somehow different,” “hands like wooden, wadded, as if not mine” 1. Food seems to them tasteless, "like tow or grass", "as if I eat straw."
So, a 16-year-old girl complained that she “did not understand” the taste of food, poured salt salt and a jar of pepper in a bowl of soup, and ate it without feeling any changes in taste; the same patient drank sugarless chicory instead of coffee without catching bitterness. One of the most frequent manifestations of the somatotopic form is the loss of the sense of sleep, when such a child or teenager, waking up in the morning, cannot say for sure whether he was asleep, and in severe cases it says that he did not sleep at all, but only lay in bed .
Allopsychic depersonalization ( derealization ) is a subjective decrease in the brightness, clarity or reality of the perception of the surrounding world. When talking about their condition, patients often use metaphors, analogies and figurative comparisons: “I see everything as through muddy glass”, “sounds reach as if there were vata in my ears”, “I perceive the world as if through a water column”, “as as if looking through a translucent film ”,“ as if I’m in a fog ”, etc. Sometimes a patient with an allopsychic form of depersonalization has a feeling of“ some kind of fabulousness ”of the surroundings, loss of volume of perception, colors appear faded, and in the most severe cases all perceived only in black and b Scrap color.
Characteristic of depersonalization experiences is increased reflection, which leads to painful attempts by the patient to understand what is happening to him, to choose the most appropriate terms that determine his condition. Most patients say that they themselves have changed, and not the world around them, that it is in them themselves. Such an understanding of the "subjectivity" of symptoms does not alleviate the burden of the experience. Using figurative comparisons and metaphors allows patients with depersonalization to most accurately characterize their experiences, comparing them with the previously experienced and experienced.
In many cases, we can speak about the presence in patients with depersonalization of a comparative version of speech, which is one of the semiological signs of this syndrome. At the grammatical level, a comparative version of speech is manifested in the constant use of various conjunctions of comparison.
Mechanisms of development of depersonalization.
In the second half of the XIX century. It was hypothesized that the phenomenon of alienation is a defensive process in which the “neutralization” of emotions occurs due to the painful experience of longing ( Ireland W.). It was also assumed that apathy is the basis of depersonalization ( Dugas L., Moutier R.); attempts to explain this phenomenon as a phase in the development process gipnoidnogo states of consciousness (Pilot LA), pointed out the proximity of depersonalization schizophrenic consciousness hypotension (Mehrabian AA), offered to consider one particular aspect of depersonalization agnosia.
According to some data ( Megrabian AA), the main feature of the affective sphere of the majority of patients is the presence of a vital protopathic affect of anxiety, tension and fear. It is pointed out that the depersonalization "triggered" anxiety affect (and possibly vital anguish), but in the future may acquire an autonomous existence, and not depend on the affective background.
There is an opinion ( Nuller Yu.L., Mikhalenko I.N.) that the basis of psychic anesthesia is increased secretion of endorphins (endogenous opiates) or altered sensitivity of opiate receptors. O. G.Kenunen and VL Kozlovsky noted that the increase in the activity of endogenous antinociceptive system observed both in depersonalization, and under stress; in the latter case, in experimental animals, this leads to hypoalgesia , similar to mental anesthesia in humans.
The authors note that it would be interesting to study the system of stimulating amino-acidic transmission, controlling the development of both naloxone-sensitive and naloxone- insensitive analgesia, as well as the role of serotonin and histaminergic structures. EV Snedkov binds appearance depersonalizatsionnye experiences with hyperactivation medial temporal structures increase striatal dopamine in areas of the hippocampus cells by inhibiting serotonin and GABA-ergic decrease in the number of binding receptor.
There are also studies that show the important role of the reflexive structures and speech behavior of patients with depersonalization disorders, and it is noted that the clinical manifestations of depersonalization reflect pathological neurophysiological processes in an indirect form through the subjective structures of reflection and speech acts; reflexive structures and speech behavior are considered to be the leading subjective factors of pathogenesis and at the same time the main semiological signs of depersonalization.
Depersonalization as a syndrome.
In general, depersonalization disorders are a nosological nonspecific syndrome, which is observed both in psychogenic, exogenous-organic and organic psychopathological disorders, and in endogenous mental diseases. There is a neurotic as well as psychotic level of depersonalization symptomatology.
The author of the term “depersonalization” L. Dyuga considered this syndrome in the framework of emotional pathology ( Dugas L.). In the same years, other researchers attributed depersonalization to sense disorders ( Griesinger V., Kraft- Ebing R., Serbian V. P.), disorders of self-consciousness.
In the future, opinions are also divided. Some attribute depersonalization to the pathology of perception (Kaplan G., Sadok B., Lehman LS), others, agreeing with this opinion, note that self-consciousness is also violated (Gurevich M.O., Sereysky M.Ya., Ursova L.G. .). V.M. Banshchikov et al . They include depersonalization as a disorder of perception, but they indicate that the sphere of emotions and thinking can change simultaneously.
VV Kovalev notes that depersonalization is not a disorder of perception in the true sense of the word, but a violation of subjective experience and awareness of perceptions and sensations. Some authors define derealization as a violation of perception, and depersonalization is considered within the framework of self-consciousness disorders. Many researchers attribute the entire depersonalization-derealization syndrome to the pathology of self-consciousness. It is noted that depersonalization is a dystontogenetic disorder of self-consciousness (change of its ontogenesis with pathological diontogenesis ), and in many patients manifestations of depersonalization combine the features of both productive and negative disorders.
Some researchers ( Ursova L.) have a depersonalization-derealization syndrome on the border between intrapsychic and receptor disorders, others ( Snezhnevsky A.V.) believe that only derealization lies on the border between these disorders, and depersonalization refers to intrapsychic pathology. Often, the opinion of the authors on the distinction between depersonalization and psychosensory disorders is often different.
In one case, these phenomena are considered as a whole (Gurevich, M.O., Sereysky, M.Ya., Kharitonov, R.A., Megrabyan , A.A., Lichko, A.E.), in the other, the depersonalization and such pathological phenomena as metamorphoses and violations of the “body pattern”.
The most fair is the opinion of S.S. Mnukhina et al ., Who considered it necessary to strictly distinguish between syndromes of depersonalization and psychosensory disorders (opto-vestibular disorders, disorders of the “body schema”, etc.). Despite the frequent comorbidity of these syndromes, according to the authors, they are by no means a single entity. From the point of view of the school of S. S. Mnukhin, such phenomena as deja do not apply to depersonalization disorders. vu and jamais vu . Consider the latest psychopathological phenomena appropriate in the section dysmnestic violations.
The simultaneous presence of pronounced hallucinatory-delusional symptoms and depersonalization ( Megrabyan A.A., Anufriev A.K.) was also noted , and Yu.L. Nuller suggests that depersonalization can in this case block productive symptoms and stabilize the process. It is noted (N. Ivanov) that depersonalization, as a rule, gives atypicality to the main picture of the disease.
The combination of depersonalization phenomena with such affective disorders as anxiety or depression during depressions is highlighted ( Megrabyan A.A. , Nuller Yu.L.), indicates the possibility of a combination of depersonalization and manic syndrome ( Nuller Yu.L., Mikhalenko I.N.) . G. Kaplan and B. Sadoc notice that depersonalization as an independent syndrome is rare. In contrast to this opinion, it is possible to point out numerous observations ( Nuller, Yu.L., Mikhalenko, I.N.), when depersonalization was almost the only violation, and conditionally these patients were diagnosed with “ depersonalization disease”.
At what age does depersonalization begin?
According to G. Kaplan and B. Sadok , depersonalization most often begins between the ages of 15 and 30 years. In the domestic literature pubertalism is considered the most frequent age for the onset of depersonalization disorders.
This circumstance is explained by the fact that, like any emerging system, the function of self-consciousness in the transitional phase of development becomes the most fragile, and the clinical manifestations of the “I” disorders are most pronounced (G. Sukhareva). Unlike adults, in depressions in adolescents, depersonalization occurs rarely ( A. Lichko ), and more often appears in the framework of schizophrenia with a low-progreduated course or in the use of psychoactive substances.
According to a number of authors, in its typical form, depersonalization appears only from adolescence. Vorobiev noted the predominance of the autopsychic form of depersonalization in puberty and adolescence. Disproving this point of view, GK Ushakov believes that autopsy depersonalization is less characteristic of adolescents than its other forms.
V.V. Kovalev notes that up to 10-11 years of age, the phenomena of depersonalization are rudimentary, they appear mainly in somatopsychic form and do not add up to the developed syndrome. A. A. Mehrabian points out that till 7-8 years depersonalization does not occur at all. According to V. M. Bashina , depersonalization can be recorded in children from the age of 3 in the structure of early childhood schizophrenia, as a manifestation of shallow affective and neurosis-like levels of response, and in Kanner syndrome .
The author noted that children of 3-7 years of age have not yet established categories of self-consciousness are easily violated, but their diagnosis is difficult because of the difficulty of reflection in the child’s verbal report.
A. Mehrabian notes that he did not reveal the difference in the frequency of occurrence of depersonalization syndrome between men and women, but refers to the data of German authors, indicating a significant predominance of women (4: 1). G. Kaplan and B. Sadoc indicate that depersonalization occurs in women twice as often, but short-term depersonalization disorders can occur in 70% of the population without any difference between men and women. According to our observations, children have no significant difference in the frequency of occurrence of depersonalization between boys and girls.
The course of depersonalization in children
Depersonalization states can be either short-term (a few minutes) or protracted for many months and years (Smirnov V.K., Nuller Yu.L.). It should be noted that in healthy individuals transient depersonalization disorders may occur, often developing under the influence of overwork, undernutrition, or lack of sleep.
Possible and psychogenically caused the occurrence of depersonalization for a relatively short period of time. As an example, we give a vivid description of depersonalization experiences that have appeared in an adult young man after suffering stress.
There are observations of patients in whom depersonalization lasted for fifteen years or more, and in the case of a long-term course, an autopsychic form without a sense of emotional pain came to the fore. In general, depersonalization tends to a long, chronic course (Kaplan G., Sadok B.). So, depressive states in the case of depersonalization joining occur, as a rule, for a long time.
K. Haug notes that depersonalization often occurs as a highly volatile and not fully formed syndrome, further displaced by productive schizophrenic symptoms. A.K. Anufriev believes that autopsy depersonalization is transformed into delirium , rarely derealization , and the delirium of grandeur results from the initial “ hyperthymic ” depersonalization (the color of the surrounding world in iridescent tones with a tinge of self-importance).
According to B. D. Friedman, depersonalization is a relaxed psychotic state that proceeds in the form of only detached, alienated, but not imposed from the outside. This syndrome is an intermediate stage in the development of certain psychopathological states. The author identifies three possible ways of the dynamics of depersonalization:
1. Obsessive ideas - depersonalization - catatonia;
2. Hypochondria - depersonalization - nihilistic nonsense;
3. Depersonalization — impact ideas — ideas of obsession.
There is an opinion (Efremov V.S.) that if depersonalization is transformed into a state of “I am lost” or patients begin to tell about themselves in the third person, then this “removes” the diagnosis of depersonalization. The author in this case proposes to use the term “ apersonalization ”, considering it also as an obligatory element of the late stages of the development of the syndrome of mental automatism.
E. B. Bezzubova identified the following stages of formation (dynamics) of depersonalization syndrome in adolescence and youth:
1. Vital depersonalization: violation of the vital sense of certainty of one’s own existence, feeling of inner discord, which is the most difficult for speech expression. Affective disorders manifest vital, non-objective, protopathic fear;
2. Dominance of allopsychic phenomena. Affective symptoms become formalized . Anxiety is often combined with dysthymia;
3. Somatopsychiatric disorders, the formation of which is observed from 12-13 years old, when the formation of the self-consciousness of the physical "I" ends; 4. Gradual addition of autopsychic depersonalization itself.
In general, depersonalization-de-realization phenomena in children proceed more favorably than in adults. It can be noted that in children, even after severe stress (hostage-taking), the phenomena of derealization were already reduced one month after the traumatic situation.
E.I. Bogdanova and N.V. Shavar , after conducting comparative follow-up studies of depersonalization in adults and children, showed that in children with age, depersonalization disorders, as a rule, completely disappear, while in adult patients there is a tendency to a protracted syndrome.
Thus, the first manifestations of depersonalization disorders can be observed in children from the age of 3 years. The younger the child, the atypical depersonalization takes place, significant difficulties are observed in the verbal expression of his own experiences, and also clinical variants of the syndrome that are not typical for adults.
In a typical form, depersonalization disorders are recorded only from puberty, and adolescence and adolescence are the most frequent age at the onset of depersonalization-derealization disorders.
What is psychic atony in children?
In the works of a number of authors (Bekhterev V.M., Mnukhin S.S., Isaev D.N., Voronkov B.V.) one can find references to “ atonicity ” and a decrease in mental tone, a kind of “weakness” in mental activity. Currently, there are questions related to these concepts: what is “ atonicity ” and who should be considered “ atonic ”, what are the reasons for the decrease in mental tone, how big is the role of “ atonicity ” in the formation of mental retardation and autism? Speaking of " atonicity ", we can assume that we are talking about the absence of mental tone.
It would be more accurate to speak about its decline in different degrees of severity (that is, about hypotension), rather than about the absence. By mental tone we understand the ability of higher nervous activity to provide an adequate level of mental activity in various environmental conditions. S. S. Mnukhin in the concept of " atonicity " put not so much the absence or reduction of mental tone, how many changes in mental activity in general, manifested in the characteristics of behavior, development, life.
Undoubtedly, these features are important and necessary in the understanding of " atonicity ". Can they be considered a consequence of reduced mental tone? There is currently no reliable answer to this question.
In the view of I.V. Makarova et al ., The “ atonic ” group is fairly homogeneous, and the clinical picture is characterized primarily by the “weakness” of all mental functions. The main differences within the group are: the presence or absence of motor disinhibition, the level of intelligence, the presence or absence of schizoform symptoms (by " schizoformnost " we mean clinical signs due to organic brain damage, resembling typical symptoms of schizoid psychopathy and constitutional autism).Atonic symptom complex presents the following disorders:
1. Violations of attention: hypoprosexia ( aprosexy ), rapid depletion of attention, the impossibility of prolonged concentration.
2. Violations of the emotional sphere: poverty and coldness of emotional manifestations, lack of syntonality , affective flashes.
3. Violations of behavior and activities: aimlessness, helplessness, stereotype.
4. Contact disturbances: disinterest in communication, detachment, avoidance of contact.
5. Speech disorders: delayed speech development, echolalia .
6. Motility disorders: motor development delay, low motor activity, clumsiness.
7. Neurological disorders: decreased muscle tone, extrapyramidal insufficiency, signs of intracranial hypertension.
8. Violations of reflex activity and instincts: the weakening of unconditioned-reflex reactions, insufficiency of instinctive manifestations.
These disorders are not obligate and can be modified depending on the underlying disease.
Atonicity can be combined with motor disinhibition. This is possible if the mental tone is not evenly reduced, and violations affect only certain areas. In this case, it would be more correct to talk about dystonia, and not about atony. In addition to motor disinhibition, these children will have multiple stereotypes and echolalia . Emotional reactions are much more lively than those of " atonic ", but often poorly differentiated . The clinical picture is largely dependent on the integrity of the intellect.
So, children with an intelligence close to normal more often produce the impression of “strange”, “eccentric”. " Atoniki " reduced intelligence often diagnosed as mentally retarded. It must be assumed that there is also a connection in the development of schizoformity and atonicity , and mental atony is not only often accompanied, but also enhances schizoform traits.