Border Mental Disorders
The problem of phobias and obsessions attracted the attention of clinicians in the prenosological period of psychiatry. Obsessive fear of death was described in the early seventeenth century. [Burton E., 1621]. Mentions of obsessions are found in the writings of Ph. Pinel (1829). I. Balinsky proposed the term "obsessive perceptions", ingrained in Russian psychiatric literature. In 1871, C. Westphal coined the term "agoraphobia," meaning the fear of being in public places. However, only at the turn of the XIX - XX centuries. (1895-1903) thanks to the research of students J. Charcot - Z. Freud and P. Janet, who came from different theoretical principles, attempts were made to unite anxiety-phobic disorders into an independent disease - anxious neurosis (Z. Freud), psychasthenia (P. Janet). At present, the term P. Janet "psychasthenia" is used primarily to refer to one of the types of constitutional psychopathies. Somewhat later, P. Janet (1911) combined agoraphobia, claustrophobia, transport phobias with the term "position phobias". The author put forward an idea about the binary structure of phobias, including, along with the fear of certain situations, symptom complexes reflecting the patient's response to this phenomenon.
The concept of P. Janet served as the basis for some modern systematics of obsessive-phobic disorders. In particular, A. B. Smulevich, E. V. Kolyutskaya, S. V. Ivanov (1998) distinguish two types of obsessions. The first type - obsessions with avoidance reaction (a system of mer-rituals that prevent possible contact with the object of phobias) correlate with events that may occur in the future (anxiety "forward" - agoraphobia, fear of the possibility of penetration into the body of foreign objects, the emergence of a serious illness). The second type - obsessions with the reaction of repeated control (re-checking of committed actions, re-washing hands) presents doubts about the reality of the events that have already occurred (anxiety "back" - insanity of doubts, mizofobiya - doubts about the purity of the body, clothes, fear of an incurable disease).
In accordance with ICD-10, the psychopathological manifestations of anxiety disorders include the following symptom complexes: panic disorder without agoraphobia, panic disorder with agoraphobia, hypochondriacal phobias (in ICD-10 relate to hypochondriacal disorders (F45.2).), Social and isolated phobias, obsessive - compulsive disorder.
Anxiety and phobic disorders are one of the most common forms of mental pathology.
Prevalence. According to R. Noyes et al. (1980), anxiety-phobic disorders occur in 5% of cases. However, the majority of patients are observed in the general medical network, where their prevalence rate reaches 11.9% [Sherburne C. D. et al., 1996].
Clinical manifestations. Among the psychopathological manifestations of anxiety-phobic disorders, it is first necessary to consider panic attacks, agoraphobia and hypochondria phobias, since it is in the dynamics of these symptom complexes that the greatest comorbidic associations are found.
Panic attacks - a sudden symptom of vegetative disorders arising quickly (within a few minutes) (vegetative crisis - heartbeat, chest tightness, feeling of suffocation, lack of air, sweating, dizziness), combined with a feeling of impending death, fear of loss of consciousness or loss of control above yourself, madness. The duration of manifest panic attacks varies widely, although it usually does not exceed 20-30 minutes.
Agoraphobia contrary to the original meaning of the term [Westphal S., 1871] includes not only the fear of open spaces, but also a number of similar phobias (claustrophobia, transport phobia, crowds, etc.) defined by P. Janet (1918) as phobias of position (the author unites this concept is agora-, claustrophobia and transport phobias). Agoraphobia, as a rule, manifests itself in connection with (or after) panic attacks and essentially represents the fear of being in a situation fraught with the danger of panic attack. As a typical situation, provoking the occurrence of agoraphobia, become a trip to the subway, stay in the store, among a large crowd of people, etc.
Hypochondriacal phobias (nosophobia) are an obsessive fear of a serious illness. Cardio, cancer and stroke, as well as syphilus and AIDS, are most commonly observed. At the height of anxiety (phobic raptuses), patients sometimes lose their critical attitude to their condition - they turn to doctors of the appropriate profile and require examination.
Panic disorder (episodic paroxysmal anxiety) occupies the central place among anxiety-phobic disorders. Panic disorder most often determines the debut of the disease. In this case, three variants of the dynamics of psychopathological disorders of the anxiety series, manifesting panic attacks, can be distinguished.
In the first variant of anxiety-phobic disorders, which is relatively rare (6.7% of the total number of patients), their clinical picture is presented only by panic attacks. Panic attacks manifest as an isolated symptom complex with a harmonious combination of signs of cognitive and somatic anxiety (hypertypical panic attacks) with a minimum of comorbidic connections and are not accompanied by the formation of persistent mental disorders. The clinical picture of panic attacks is expanding only due to transient hypochondria phobias and the effects of agoraphobia, which are secondary in nature. By passing the acute period and reducing panic attacks, the reverse development of concomitant psychopathological disorders also occurs.
Under the second option (33.3% of all patients with anxiety and phobic disorders), anxiety disorders include panic attacks and persistent agoraphobia. Panic attacks in these cases develop as an existential crisis. Their distinctive features are the absence of previous psychopathological disorders (spontaneous panic attacks, according to M. Kyrios, 1997); the prevalence of cognitive anxiety with a feeling of sudden bodily catastrophe developing among full health (life with a minimum severity of autonomic disorders); quick joining of agoraphobia.
Panic attacks occur suddenly, without any precursors, are characterized by vital fear, generalized anxiety and rapid (sometimes after the first attack) the formation of phobophobias and avoidant behavior. As the panic attacks develop backward, the full reduction of psychopathological disorders does not occur. In the foreground in the clinical picture are the phenomena of agoraphobia, which not only does not reduce, but becomes resistant and independent of panic attacks. These features of the dynamics of anxiety-phobic disorders (persistence of agoraphobia and its independence from other manifestations) are closely related to comorbid mental disorders, among which hypochondriacal phenomena dominate.
It must be emphasized that in these cases we are not talking about the danger of an imaginary disease (neurotic hypochondria), not about developing methods of treatment and methods of healing (hypochondria of health), but about a special variant of overvalued hypochondria. The dominant idea, which submits the whole way of life of patients, here is the elimination of the conditions for the occurrence of painful manifestations, ie, panic attacks. Measures to prevent panic attacks are taken from the onset of the fear of re-attack and, gradually becoming more complex, are transformed into a complex hypochondriacal system. A complex of protective and adaptive measures is being developed, including changing jobs (up to dismissal), moving to an "ecologically clean" area, etc. Formed hypochondriacal attitudes (a gentle way of life, limiting contacts, avoiding certain forms of activity, including professional ones) support and exacerbate manifestations of a phobic series, such as the fear of movement in transport, the fear of the crowd, and being in public places. Accordingly, agoraphobia is not only not reduced, but acquires a persistent character.
The third option (60% of the total number of patients) includes anxiety-phobic disorders with panic attacks, developing according to the type of vegetative crisis (Da Costa syndrome) and ending with hypochondriacal phobias. Distinctive features of panic attacks: long prodromal stage - subclinical manifestations of anxiety, combined with algii and conversion symptoms; psychogenic provocation of attacks (in 50% of cases provoked - "attributable panic attacks", according to M. Kyrios, 1997); the prevalence of somatic anxiety with dominance of symptoms in the cardiovascular and respiratory systems without vital fear ("alexithymic panic", according to M. Kushner, B. Beitman, 1990); expansion of the picture due to hypochondriacal phobias with minimal severity of phobic avoidance and agoraphobia.
After the passage of the unfolded panic attacks (acute period), the full reduction of the psychopathological disorders of the anxiety series, as in the second variant, the dynamics of anxiety-phobic disorders does not occur. Hypochondrial phobias (cardio, stroke, thanatophobia) that define the clinical picture for months and even years are highlighted. It is necessary to emphasize that the formation of such persistent fears is closely related to the phenomena of hypochondria that are growing from the moment of the manifestation of panic attacks - heightened introspection and constant hypochondriacal concern for their health (neurotic hypochondria). With the presence of hypochondriac sensitization, even minor deviations in the activity of the organism can become a reason for the aggravation of fears and anxious fears - vegetative, algic and conversion manifestations that would normally pass unnoticed.
Update of hypochondriacal phobias occurs both in connection with psychogenic (iatrogenic) and somatogenic (intercurrent diseases) provocations, and spontaneously and, as a rule, is accompanied by frequent visits to doctors and the resumption of medication (hypochondriac neurosis).
Social phobias [Marks J. M., 1966] - the fear of being in the center of attention, accompanied by fears of a negative assessment of others and the avoidance of social situations. Data on the prevalence of social phobias in the population range from 3-5% [Kaplan GI, Sadok B.J., 1994] to 13.3% [Magee R. Jr. et al., 1996]. In the field of view of psychiatrists, these patients are relatively rare. According to E. Weiller et al. (1996), only 5% of patients with "uncomplicated" social phobias use specialized care. Persons with subliminal social phobias [Katsching H., 1996], who do not significantly affect daily activities, predominate among those not covered by therapeutic measures. When referring to a doctor, most often those suffering from this disorder focus on comorbid (mainly affective) psychopathological symptom complexes. Social phobias usually manifest in adolescence and adolescence. Often the appearance of phobias coincides with adverse psychogenic or social influences. At the same time, only special situations (the answer at the blackboard, exams - school phobias, appearance on the scene) or contact with a certain group of people (teachers, educators, representatives of the opposite sex) act as provoking. Communication with family and close friends, as a rule, does not cause fear. Social phobias can occur transiently or have a tendency to chronic development. Patients suffering from social phobias, more often than healthy, live alone, have a lower level of education.
Social phobias are characterized by a high level of comorbidity with other mental disorders (in 70% of cases, according to R. Tyrer, 1996). In most cases, there is a combination of them with manifestations of anxious-phobic series (simple phobias, agoraphobia, panic disorder), affective pathology, alcoholism, medication, eating disorders. Comorbid combinations of any other mental disorder and social phobia worsen the prognosis of the disease and increase the risk of suicidal attempts.
There are two groups of states - isolated and generalized social phobias [Katsching H., 1996]. The first of these includes monophobia, accompanied by relative restrictions in the sphere of professional or public activity (fear of public speaking, communication with higher persons, working in the presence of others, eating in public places). In essence, isolated social phobias represent a fear of not performing usual actions in people associated with anxious expectations of failure (expectation neurosis in E. Kraepelin, 1915), and as a result, avoidance of specific life situations. At the same time, there are no difficulties in communicating outside such key situations. This group of phobias includes ereytofobiya [Casper G. L., 1846] - the fear of blushing, show awkwardness or confusion in society. Eritophobia may be accompanied by fears that others will notice a change in complexion. Accordingly, shyness, embarrassment, accompanied by internal stiffness, muscle tension, trembling, palpitations, sweating, and dry mouth appear in humans. Generalized social phobia is a more complex psychopathological phenomenon, which includes along with phobias ideas of low value and sensitive ideas of attitude. Disorders of this group most often act as part of scoptophobia syndrome [Ivanov S.V., 1994; Dosuzkov F. N., 1963]. Scoptophobia (from the Greek. Scopto - to joke, scoff; phobos - fear) - fear to seem ridiculous, to detect in people signs of imaginary inferiority. In these cases, the foreground is the affect of shame, not corresponding to reality, but defining behavior (avoiding communication, contact with people). Fear of confrontation can be associated with ideas about the hostile assessment of people of the "flaw" attributed to the patient, and the corresponding interpretations of the behavior of others (dismissive smiles, ridicule, etc.).
Specific (isolated) phobias are phobias, limited to a strictly defined situation - fear of heights, nausea, thunderstorms, pets, and treatment by a dentist. Since contact with objects of fear is accompanied by intense anxiety, in these cases the tendency to avoid them is characteristic.
Obsessive-compulsive disorders, (obsessio, compulsio (lat.) - obsession) as well as anxiety-phobic, are quite widespread in the population.
Their prevalence in the population is determined by an indicator of 1.5–1.6% [Nestadt G., Samuels J. F. et al., 1994; Black D. W., 1996] (meaning those suffering from this disorder during the last month or 6 months, respectively) or 2-3% (if those suffering during their lifetime are counted) [Black D. W., 1996]. Patients with obsessive-compulsive disorders constitute 1% of all patients receiving treatment in psychiatric institutions [Kaplan GI, Sadok B.J., 1994]. Such patients are most often observed in PND or in psychiatric hospitals. Their share in the offices of neuroses of the general polyclinic is relatively low [Smulevich A. B., Rotshtein V. G., et al., 1998].
Clinical manifestations. The onset of the disease occurs in adolescence and early adulthood. The manifestation of clinically defined manifestations of obsessive-compulsive disorders falls on the age range of 10 years - 24 years [Rasmussen S., Eisen J. L., 1991].
Obsessions are expressed in the form of obsessive thoughts and compulsive actions perceived by the patient as something psychologically alien to him, absurd and irrational. Obsessional thoughts are ideas, images or desires that arise against the will, which in a stereotypical form again and again come to the patient's mind and which he is trying to resist. Compulsive actions are repetitive stereotypical actions that sometimes take on the character of protective rituals. The latter are intended to prevent any objectively unlikely events dangerous to the patient or his relatives. Despite the diversity of clinical manifestations, the series of obsessive-compulsive disorders includes delineated symptom complexes and among them are obsessive doubts, contrasting obsessions, an obsessive fear of pollution (infection).
With the predominance of the symptom complex of obsessive doubts of patients pursue obsessive thoughts about the correctness of the actions or decisions made. The content of doubts is different: intrusive household fears (whether the door is locked, whether the windows or water taps are tightly closed, gas and electricity turned off), doubts related to business activities (if the addresses on business papers are not mixed up, if the numbers are not accurate, correct whether orders are formulated or executed). Patients use different strategies to reduce the time for rechecking. In this regard, the rituals of counting, the system of "good" and "bad" numbers often develop. The phenomenon of sudden introspective sensations can be used as a ritual. Compulsions in these cases cease only after the restoration of the inner feeling of completeness of the fullness of the motor act. Such a sensation arises more often suddenly, like an insight of the type of gaining, as it were, a body sensation lost earlier.
Rarely, at the height of the development of the disease, obsessions reach the level of "mania of doubt" - folie du doute [Legrand du Saulle, 1875]. The condition of patients is determined by the presence of generalized anxious doubts related to the completeness of any ideatory or motor act, accompanied by a complete immersion in the "test" rituals.
Contrast obsessions ("aggressive obsessions," according to S. Rasmussen, J. L. Eisen, 1991) are blasphemous, blasphemous thoughts, fear of causing harm to themselves and others. Psychopathological formations of this group relate mainly to imaginative obsessions with a pronounced affective saturation and seizing ideas [Snezhnevsky AV, 1983; Jaspers, K., 1923]. They are distinguished by a sense of alienness, absolute non-motivated content, as well as a close combination with obsessive drives and actions, which are a complex system of protective rituals and magical actions.
Patients with contrasting obsessions and complain about the irresistible desire to add to the just heard remarks certain endings that give said unpleasant or threatening meaning, repeat behind others, but with a touch of irony or anger, religious phrases, shout out cynical, contrary to their own attitudes and generally accepted morality ; may be afraid of losing control over themselves and the possible commission of dangerous or absurd actions, auto-aggression, and injury to their own children. In the latter cases, obsessions are often combined with phobias of objects (fear of sharp objects - knives, forks, axes, etc.). The group of contrasting partially includes obsessions of sexual content (obsessions of the type of forbidden ideas about perverse sexual acts, the object of which are children, representatives of the same sex, animals).
Obsessive pollution ideas (misophobia). This group of obsession includes not only the fear of pollution (earth, dust, urine, feces and other impurities), but also phobias of harmful and toxic substances (asbestos, toxic waste) entering the body, small objects (glass fragments, needles, specific types of dust ), microorganisms, i.e., phobias of extracorporeal threat [Andryushchenko A.V., 1994; Efremova, MD, 1998]. In some cases, the fear of pollution can be limited, remain for many years at a subclinical level, manifesting itself only in certain personal hygiene features (frequent change of linen, repeated hand washing) or in the order of housekeeping (thorough food processing, daily floor washing). , "Taboo" on pets). This kind of monophobia does not significantly affect the quality of life and is assessed by others as habits (exaggerated cleanliness, excessive fastidiousness).
Clinically completed variants of mizophobia belong to the group of severe obsessions, in which the tendency to complication and even generalization is often found [Zavidovskaya GI, 1971]. In the clinical picture in the foreground, the gradually becoming more complex protective rituals come to the forefront: avoiding sources of contamination, touching "unclean" objects, processing things that could get dirt, a certain sequence in the use of detergents and towels, allowing to keep "sterility" in the bathroom. Staying outside the apartment is also being arranged with a series of protective measures: going outside in special clothes that cover the body as much as possible, and special handling of personal items on returning home. In the later stages of the disease, patients, avoiding contact with dirt or any harmful substances, not only do not go outside, but do not even leave their own room. In order to avoid contacts that are dangerous in terms of contamination and contact, patients do not allow even their close relatives.
Fear of infection with a disease that does not belong to the categories of hypochondriacal phobias is also adjacent to the misophobia, since it is not determined by fears of the presence of a particular disease. In the foreground - the fear of threat from the outside - the fear of penetration of pathogenic bacteria into the body. Fear of infection in these cases sometimes occurs in an unusual way: for example, due to fleeting contact with old things that once belonged to a sick person or his letters. Sometimes for the emergence of such fears, a single glance at a person with a physical deformity or similar to a resident of the area where the endemic center of the disease is located is sufficient.
Obsessive actions are relatively rarely appear in an isolated form, not being combined with verbal obsessions. Obsessive actions in the form of isolated, monosymptomatic movement disorders take a special place in this regard. Among them, tics prevail, especially often in childhood. Tics, in contrast to organically caused involuntary movements, are much more complex motor acts that have lost their original meaning. As J. M. Charcot wrote (quoted in P. Janet, 1911), tics sometimes give the impression of exaggerated physiological movements. This is a kind of caricature of certain motor acts, natural gestures. Patients suffering from tics can shake their heads (as if checking whether the hat is sitting well), make hand movements (as if throwing off disturbing hair), blink their eyes (as if getting rid of a mote). Along with obsessive tics, pathological habitual actions (lip biting, teeth grinding, spitting, etc.) are often observed, which differ from the obsessive actions themselves by the absence of a subjectively painful feeling of lack of coherence and experiencing them as alien and painful.
Neurotic states, characterized only by obsessive tics, usually have a favorable prognosis. Appearing most often in preschool and primary school age, tics usually fade by the end of puberty. However, such disorders can also be more persistent, persist for many years and only partially change in manifestations. The rapid complication of the clinical picture as a result of joining other motor obsessions, phobias and obsessions with long-existing isolated tics requires the elimination of sluggish schizophrenia.
Diagnostic difficulties can also be caused by conditions with a predominance of generalized ticks, known as tick diseases, or Gilles de la Tourette's diseases. Tics in such cases are localized in the face, neck, upper and lower extremities and are accompanied by grimaces, opening of the mouth, protruding tongue, intensive gesticulation. In these cases, coarseness of movement disorders and more complex in structure and more severe mental disorders (coprolalia, echolalia, ecopraxia, impulsive acts, psychopathic behavior with demonstrativeness and aggressiveness) help to eliminate obsessive-compulsive disorders in these cases [Shanko G. G., 1979].
The course of anxiety and phobic disorders. Turning to the patterns of the dynamics of anxiety-phobic disorders, it is necessary to indicate chronification as the most characteristic tendency. Cases of episodic manifestation and recovery are much less common [Angst J., 1994]. However, for many, especially with persisting monomorphism of manifestations (agoraphobia, intrusive counting, ritual hand washing), long-term stabilization is possible. In these cases, there is a gradual (usually in the second half of life) reduction of psychopathological symptoms and social rehabilitation. These patients adapt to daily life better than other obsessive states. For example, patients who are afraid of traveling on certain types of transport or public speaking, do not feel impaired and work along with healthy ones. In subclinical forms of manifestation, obsessional disorders, as a rule, proceed favorably on an outpatient basis. The reverse development of symptoms occurs after 1 year - 5 years from the time of diagnosis [Godwin D. W. et al., 1969].
Heavier and more complex obsessive-phobic disorders, such as phobias of contamination, pollution, sharp objects, contrasting representations, numerous rituals, on the contrary, can become resistant, resistant to treatment by psychopathological formations or detect a tendency to recurrence with persisting (even with active therapy a) residual disorders. Further dynamics of these states indicates a gradual systematization of obsessions and complication of the clinical picture of the disease as a whole. As the work of N. I. Ozeretskovsky (1950) showed, in a number of such cases, especially with a tendency to logical processing of obsessions, growth of ritual formations, rigidity, ambivalence, monotony of emotional manifestations, the development of a sluggish schizophrenic process cannot be ruled out. The same diagnostic alternative occurs in chronic anxiety states characterized by prolonged panic attacks and pan-aura phobia [Kolyutskaya Ye. V., Gushansky N. E., 1998]. Protracted obsessional states of a complex structure must be distinguished from the attacks of fur-like schizophrenia [Zavidovskaya G.I., 1971]. In contrast to neurotic obsessive states, they are usually accompanied by sharply increasing anxiety, a significant expansion and systematization of the range of obsessive associations that acquire the character of obsessiveness of "special significance" (Geltungszwang, no K. Jaspers): previously indifferent objects, events, random comments of others remind patients about the content phobias, contrasting and blasphemous thoughts and thus acquire a special, threatening value in their presentation. If paroxysmal obsessive states such as homicidal inclinations prevail in the clinical picture, they must be differentiated from the mental equivalents of epilepsy.