In everyday speech, this word often sounds abusive or sarcastic, it is also readily used by journalists and political scientists ( “mass psychosis” ), but in psychiatry and pathopsychology the term “psychosis” has a purely special meaning and clearly defined diagnostic criteria.
Many are interested in the question of the differences between concepts such as psychosis and neurosis; often these concepts are mixed or mistakenly interpreted as synonyms.
The author of the term “psychosis” is considered to be the German physician Karl Friedrich Kanshtatt , who used it in one of his works ( 1841 ) to refer to the “psychological manifestation of brain disease” . According to another version, the author should be considered the Austrian encyclopedist – surgeon, psychiatrist, philosopher, writer, Ernst Maria von Feuchtersleben , who a little later ( 1845 ) introduced the concept of “psychosis” into the scientific vocabulary to replace the terms “madness” that were clearly outdated at that time and “madness . “
With all the variety of psychoses known today (only a general overview is given here ), a certain clinical similarity with subpsychotic and borderline conditions, the special nature of psychoses as a pathology of a qualitatively different level is emphasized in the specialized literature. The fundamental difference is that in psychosis one or, more often, several mental functions are grossly distorted, providing an adequate perception of reality and, accordingly, an adequate response to external stimuli, including attempts at verbal correction.
Despite the severity and, in most cases, the danger of psychotic conditions for the patient and / or for others, psychoses are relatively common . For example, in the United States of America, the proportion of people who have undergone a psychotic episode at least once during their lifetime is estimated at 3%. According to other sources, in terms of the global population, this share increases to 4-6%.
Causes
The dichotomous division of psychoses into endogenous (caused by internal changes and disturbances in the body) and exogenous (caused or provoked by external factors) is traditional .
With regard to endogenous psychoses , primarily schizophrenia and bipolar affective disorder (manic-depressive psychosis in outdated terminology), a number of key issues remain unclear from ancient times to this day. A variety of hypotheses regarding their etiopathogenesis are expressed, actively investigated and discussed – i.e. causes and developmental mechanisms – and none of these hypotheses, to paraphrase Niels Bohr , seems crazy enough to be rejected a priori. So, the spectrum of assumptions extends from biochemical, endocrine, genetic, viral versions to the interpretation of endogenous psychoses as diseases of civilization , due to the very fact of the presence of reason and purely human consciousness – evolutionary phenomena, we note, are absolutely social in nature. Interesting psycholinguistic hypotheses are also being made, according to which, for example, speech disorders characteristic of schizophrenia ( schizophasia ) are actually not a consequence of the endogenous schizophrenic process, but its cause. Human thinking and speech are closely connected, one can even conditionally call them a single whole, and this hypothesis would explain at least the fact that the equivalent of schizophrenia does not occur in the animal kingdom, even among the closest biological relatives of a person (and very few such diseases so that only and exclusively a person is sick of them). The concept of “single psychosis” of Grisinger ( Neumann-Zeller-Grisinger ), according to which in general all mental disorders should be considered different phases or stages of the same pathological process, gained wide popularity at the time .
With the accumulation of new data and the development of psychiatry, the classification of psychoses into endogenous and exogenous became more and more insufficient. So, in some cases it is difficult to qualify the immediate cause as external or internal. Therefore, organic psychoses (caused by pathological changes in brain tissues), somatogenic (developing against the background and as a result of severe somatic illness), psychogenic (reactive, caused by experiencing an extreme situation), intoxication (developing under the influence of toxic substances on the central nervous system) are distinguished into separate subgroups. , withdrawal (withdrawal syndrome occurs as a narcotic potions, most of the alcohol, but also amphetamines, LSD, barbiturates, etc.).
Symptomatology
The clinical picture of psychoses can vary to a large extent: in some cases , psychomotor agitation dominates, in others, stuporous inhibition of mental activity; some patients fall into euphoria, foolishness, powerliness (“childishness”), others behave aggressively or, with panic fear, seek to save themselves, people, the whole world or the whole Universe; some talk extremely much, not always at the same time needing a material interlocutor, speech contact is impossible with others . However, the common, most universal sign of psychosis is a grossly distorted, completely irrational reflection of reality (or some part of it), as well as one’s own role in this reality , which manifests itself in behavioral and affective reactions, judgments, emotions, etc. Typical disturbances in perception include hallucinations of various modality, content and orientation : visual, tactile, taste, olfactory, auditory; extra- or intraprojective (ie, localized somewhere in the outer space or “going from the inside”, respectively); menacing, majestic, neutral, disgusting, comic, plot, abstract, absurd, etc. In most cases, the logical-semantic system of thinking is violated , which is manifested by fragmentary delusional ideas or the formation of a generalized delusional system, the subject of which can be practically any; the most common options include delusions of persecution, special treatment, domestic damage, invention, high origin, greatness or self-abasement, social rearrangement, “rigging” and predetermination of events, openness of thoughts and the presence of controlling someone else’s will, the struggle of higher powers and many others .
It should be repeated that psychotic symptoms are unusually varied , and the mechanisms for the development of disorders in a particular mental sphere are very complex. To date, many syndromes have been identified and described in psychiatry (hallucinatory-paranoid, senesto-hypochondriac, pseudo -dementia, etc.), a detailed description of which is beyond the scope of this material. Presenile and senile (age-related) psychoses have significant etiopathogenetic, clinical, prognostic differences from, say, postoperative and postpartum psychoses; confusion or “twilight” of consciousness in epileptic psychosis – from hysterical “twilight”, etc.
In some cases, psychosis is in the nature of a single acute episode – such, for example, reactive psychoses that are reduced after the termination or elimination of a traumatic situation. In others, psychosis acts as a residual , residual consequence of the prolonged action of the pathogenetic factor, even if it is no longer relevant (e.g., alcoholic Korsakov psychosis ). The paroxysmal course of schizophrenia is characterized by the fact that after each new psychotic episode (the so-called fur coat), irreversible specific emotional-volitional and personal changes remain; with a progressive course, such changes increase more or less gradually.
In general, distinguish between productive and negative symptoms (in professional jargon, respectively, “plus symptoms” and “minus symptoms”). Productive , in particular, include hallucinatory and delusional phenomena , negative ones – weakening (up to a complete absence) of drives and motives, will, purposefulness, motivation (apathetic-abulic syndrome), personality degradation, impaired emotions, progressive cognitive decline (weakening of memory) , attention, intelligence) .
Diagnostics
In most cases, when a patient in a psychotic state is taken to a hospital by a specialized ambulance team (which, in turn, often has to be called to police officers), the diagnosis is not difficult – especially if reliable anamnestic information and archival data about previous hospitalizations are available etc. However, the doctor always carries out a clinical and psychopathological study both in the acute period (as far as possible) and after the relief of acute psychotic symptoms. The speech, level and logic of judgments, facial expressions, emotional background, attitude to the situation and many other aspects of the patient’s mental state are evaluated . A conversation with relatives, colleagues or close friends sometimes clarifies key, crucial points that are significant for diagnosis (for example, the nature of the patient’s behavior and statements in the previous period, the use of certain psychoactive substances, especially the dynamics of the development of psychosis, etc.).
It should be noted that in psychiatric practice (especially when it comes to labor, military, judicial examination, but not only), one constantly has to deal with various variants of the so-called installation behavior: the patient can consciously exaggerate the real violations (aggravation), imitate them ( simulation) or, on the contrary, hide, deny, not mention (dissimulation); Anosognosia is a special option – a complete lack of consciousness of the disease, often combined with a delusional belief that family members, neighbors, doctors, etc. are mentally ill. Contrary to the existing misconception, which is largely fueled by cinema and literary works, such distortions are detected by specialists quite easily, and the more the patient “prepares” for psychiatric textbooks, online resources, stories of other patients, those – oddly enough! – absurd looks and easier to identify installation behavior.
However, the following should be noted . Our psyche is perhaps the most complex of all objects and phenomena known to man (at least one of the most complex). Therefore, the identification, qualification, objective assessment of mental disorders and disorders, including the psychotic level, often requires considerable effort, a certain amount of time and high professionalism. The latter implies not only knowledge, experience, erudition and constant self-development, but also the ability to recognize the difficulties that have arisen – which are resolved by a collegial discussion of the case in the department, hospital-wide clinical analysis, and cathedral consultation. In some cases, instrumental diagnostics (e.g., signs of atrophy on MRI, paroxysmal readiness on EEG , etc.) and laboratory tests (e.g., in the case of infectious, somatogenic, toxic psychoses ) provide the necessary or missing information .
A very important and informative tool is a psychodiagnostic study carried out by a medical psychologist using special verbal and non-verbal techniques, samples, questionnaires, etc. Note that the word “tests” that is being asked in this context is not used intentionally: it is completely discredited and refers more to salon games, magazine entertainments and online amusements at the level of horoscopes (like “Know Yourself” or “Check Compatibility”), which is not it has absolutely nothing to do with professional psychodiagnostics – a complex, strict, cold science, strictly regulated at the international level and by no means as romantic as it is most often seen from the outside.
Treatment
Equally stringent requirements and regulatory standards are currently applied to the field of medical ethics, deontology and the patient’s bioethical rights. With regard to the treatment of psychotic patients and, in general, persons with mental disorders all over the world, there are a number of intractable problems, which, however, are gradually overcome in the process of searching for optimal forms of medical care. So, at the legislative level , situations of forced hospitalization, norms for determining the degree of sanity (this is generally a judicial procedure, not a medical one), establishing disability and guardianship, transfer to a boarding school, terms, conditions and regimen of inpatient treatment, rules for maintaining medical documentation, etc. .d .
It should be emphasized that no “compartments for riotous madness” (a favorite place for the action of numerous anecdotes of this subject) has long existed. As a rule, the modern psychiatric ward is divided into the sanatorium and the observation half (in some cases, it is necessary to stop psychosis in the intensive care unit). Round-the-clock observation by junior and secondary medical personnel is carried out in the presence of severe psychomotor agitation, suicidal tendencies and other psychotic disorders, when there is a real risk of physical harm to the patient and others. However, in this case, psychosis, as a rule, is interrupted rather quickly by medication.
Not to mention medieval chains or prison casemates, but even straitjackets are practically not used at present – at least for a quarter century of work in a large psychiatric clinic, the author of the article has never been able to at least see this means of restraint (in the case of extreme If necessary, resort to the so-called viscous loose fixation on the bed).
In general, the situation in psychiatric hospitals has changed radically since the mid-twentieth century , when they were in the clinical practice of the first neuroleptics (antipsychotic) introduced – chlorpromazine , haloperidol , triftazin and others . The current generation of antipsychotic drugs is significantly milder in terms of side effects (in particular, the infamous extrapyramidal syndrome), although absolutely safe drugs, as you know, have never been and never are now. As necessary, antidepressants, anxiolytics (drugs that reduce the intensity of anxiety and fear), sedatives, or, conversely, stimulants, neuroprotectors, and, according to indications, other types of treatment , are also prescribed .