Treatment of bipolar affective disorder (BD)

Bipolar disorder refers to a type of mental disorder characterized by frequent and unreasonable changes in emotional status. Affective disorders are characterized by mood swings from a state of severe depression to unreasonable euphoria. to begin treatment for bipolar disorder in the early stages of pathology development.

What is bipolar disorder in simple terms?

Mood swings are common to every person. Often the patient himself, his friends and relatives associate changes in states with increased emotionality, enthusiasm, and a hysterical character.

The danger of the permissible norm for significant mood swings is associated with the development of the diagnosis. Both the patient himself and his immediate family too often do not suspect the presence of a serious illness, attributing it to a strange upbringing or eccentric character. Frequent changes in mood can be taken as normal. Patients with bipolar disorder themselves try to cope with unpleasant manifestations, mistaking them for fatigue or mood swings.

As symptoms increase, patients experience a significant deterioration in quality of life, patients lose the opportunity to continue professional activities, and children’s school performance decreases. A common outcome is the development of suicidal tendencies.

It is possible to assume the presence of this affective disorder based on the level of changes in the emotional state, often reaching extreme levels. The manic (euphoric) stage is characterized by a state close to agitation. The period of depression brings the patient to a complete loss of vitality. He is literally unable to simply get up in bed and carry out any daily activities. There is no strength or desire to maintain family ties, visit the workplace or go to school. Depressive disorder leads to a loss of interest in life itself, which often leads patients to commit suicide or cause physical harm to themselves.

The success of therapy depends on the correct diagnosis and choice of the type of treatment for bipolar disorder for each patient. The decisive factor for success is the acceptance of the presence of the disease by the patient himself and his relatives. Often, it is close people who are the first to contact a medical institution to determine the reasons for frequent mood swings and to exclude the connection between increased emotionality and severe mental pathology, which, as it develops, can destroy the patient’s personal and social life.

Manic depressive psychosis treatment

The leading role in successful therapy is given to the patient’s immediate environment. Monitoring mood changes comes to the fore in order to determine the transition of a mild disorder to a serious pathology. It is the relatives who can consult a doctor in a timely manner. In most cases, patients are unable to independently recognize the presence of the disease.

In therapy, necessary antidepressants are used at the stage of predominance of a negative attitude towards life. Additionally, sedatives are used; occupational therapy, massage courses and physiotherapy have a positive effect.

Psychotherapy sessions are conducted. An integrated approach using drug treatment, traditional methods of therapy, physiotherapy, consultations with a psychotherapist, and group classes allows the patient to be transferred to a period of long-term remission.

Causes of bipolar affective disorder

The onset of the disease is most often diagnosed between the ages of 30 and 50 years. The pathology can equally affect women and men. In some situations, the disorder is detected in elderly patients and children.

As a rule, confirmation of the diagnosis occurs during a personal conversation with a psychologist or psychotherapist. Doctors have not yet identified the exact reasons for the onset. But there are factors characteristic of the majority of patients. Experts distinguish two types of reasons: psycho-emotional and biological.

Bipolar disorder, which has biological causes, is associated with a genetic predisposition. When conducting a family history of the patient, a congenital gene disorder of neurotransmitters is revealed. Such as serotonin, dopamine, norepinephrine. Studies have shown that if there is a predisposition during the period of emotional disorder, there is also a disruption in the interaction of the systems connecting the adrenal glands-thyroid gland-pituitary gland-hypothalamus.

The presence of bipolar disorder in relatives does not become a basis for the entire family to assume the onset of the disease in any of the blood relatives. Doctors have identified a possible cause of a genetic factor as a provocateur of the onset of the disease, but such “unfavorable” heredity is not a death sentence.

The onset of the disease can be caused by taking certain medications prescribed for the treatment of psychiatric diagnoses, antidepressants.

Prolonged or major psycho-emotional trauma becomes a serious provocateur of the start. In this case, increased activity is associated with the need to distance yourself from a depressive situation, and the transition to the stage of depression is associated with the need to give the body rest. It is recommended to consult a specialist in the early stages, which allows you to develop effective treatment options for bipolar disorder.

Treatment of manic psychosis

Treatment for the diagnosis directly depends on the type of disease. Correct determination of the type allows you to avoid erroneous prescription of drugs. Thus, some types of mood stabilizers or a violation of the dosage in taking medications can transfer a patient with the bipolar type from a state of mania to a state of severe depression.

An important part of therapy is communication with a psychologist and psychotherapist. During such classes, the mental state is normalized. Additionally, traditional medicine is used. The use of sedatives and teas is indicated.

Physiotherapy courses and physical therapy exercises have a positive effect. All appointments must be comprehensive. A favorable environment is created. An important part of treatment is the removal of negative factors. Primarily stress, alcohol and drug use.

Bipolar affective personality disorder symptoms and signs

Regardless of the age and gender of the patient, in most cases the onset of the disease is associated with the manifestation of depression. Such an episode is noted as a trigger in 70% of patients. The remaining 30% of patients call the starting point of the onset of the disease an episode of mania. Moreover, in both starting situations, in a personal conversation with a doctor, patients recall cases of frequent mood swings.

This pathology is characterized by the presence of three phases:

• Manic, the period of which a person suffers from actions and thoughts replacing each other at a fast pace. There is simultaneously a combination of logical and confused thoughts, logical and inexplicable actions. Such leapfrog leads to feelings of anxiety and dissatisfaction, irritability and anger.
• During a depressive period, the patient feels a complete loss of strength, loses faith in himself and his future.
• With hypomania, the presence of manic symptoms is detected, but at a lesser stage than directly during the manic period.

The listed stages replace each other. A feature of the course may be a long period of remission, during which the manifestations of the disease may be invisible even to a specialist who has not previously worked with this patient. Each period can last from several days to several years.

Signs of bipolar disorder in women

Statistics show that women suffer from this disease more often than men. The course of the disease in women is associated with hormonal status. To develop a competent therapy program, specialists develop prescriptions during puberty, the period of bearing a child, and the onset of menopause.

Also among the features of the development of pathology in women are:

• the prevalence of prolonged depressive disorders, occurring more often than in men;
• type II BD with rapid cycling and mixed type develops more often;
• episodes of mania and hypomania are often triggered by taking antidepressants;
• the course of the disease is accompanied by physiological disorders;
• weight gain occurs and the menstrual cycle is affected.

Negative factors include long-term diagnosis, often associated with the assumption of a connection between mood changes and the characteristics of female psychology.

Signs of bipolar disorder in men

Traditionally, men are recognized as less emotional than women. The initial period of the disease is characterized by shallow sleep and a sharp change in emotional status. Unlike women, representatives of the stronger half more often suffer from a manic episode at the onset of the disease. In some cases, there is a decrease in libido and sexual function is impaired.

On average, men develop bipolar disorder one and a half times less often than women. Their disease is more complicated.

Signs of Bipolar Disorder in Teens

Bipolar disorder can be diagnosed not only in adults. Minors may be susceptible to this disorder. The high-risk group for developing bipolar disorder in childhood and adolescence includes those who have already been diagnosed with this disorder in their family. If parents, grandparents, or other close relatives have bipolar disorder, the disease manifests itself in 50% of patients who complain of frequent mood swings.

Among the provoking factors:

• consumption of alcohol and psychotropic drugs;
• difficult emotional situation in the family or at school;
• physical head injuries leading to brain damage.

The first signs of pathology may appear in preschool age, the first months of life. Children may exhibit sexually suggestive behavior and begin to repeat words and phrases they hear. Sexual arousal in bipolar disorder is especially active at the age of puberty.

Manic psychosis in men

If in women the pathology is most often diagnosed in the stage of protracted and deep depression, in men a manic manifestation becomes a bright start in most situations. Men are characterized by a transition to an aggressive state, which develops against the background of an increased level of excitability. Patients are capable of causing injury to themselves and those around them. The most active pathology in the manic stage manifests itself against the background of drug or alcohol intoxication. In this condition, patients also move from one stage to another in a short time, plunging into a deep and often prolonged depression.

Types of Bipolar Affective Disorder

In medical practice, there are several types of bipolar disorder:

• Type I with the manifestation of manic symptoms or mixed symptoms;
• Type II, which is characterized by depressive symptoms;
• cyclotomy;
• nonspecific disorder.

Each type has individual specifics, which influence the choice of therapy and prognosis for the development of the disease.

Bipolar manic disorder

At this stage, patients feel increased activity and are agitated. The patient exhibits activity and sociability, which are normally unusual for him. Sexual desire increases, the need for sleep sharply decreases. Patients feel their own greatness, experience ideas of their superiority.

Dysphoric mania may occur. Patients, instead of a feeling of superiority and increased activity, combined with a very good mood, experience constant irritability and dissatisfaction.

Bipolar depressive disorder

Characterized by decreased mood and activity. Patients lose interest in those things that previously seemed attractive and interesting. It is accompanied by disturbances in appetite and sleep, and with the development of pathology, suicidal thoughts arise.

Bipolar affective disorder

It differs in its course, in which frequent mood swings occur with a transition from mania or hypomania to a state of deep depression. With this type, mixed states are often observed, which are often indistinguishable from agitated depression, characteristic of people with neurological disorders and an exalted character. This may prevent timely contact with a specialist.

Manic depressive psychosis in women

It occurs with long periods of stable remission. At the same time, representatives of the fair sex may suffer from prolonged depression, during which there is a loss of interest in life. A high degree of manifestation of pathology is the loss of related feelings, including the maternal instinct.

During the manic period, women may display aggression towards others. They can disrupt social contacts due to lack of control over friendships and increased sexual activity. At the same time, the woman perceives herself admiringly, refuses to listen and accept criticism.

Bipolar disorder phase

In medical practice, there are two phases of this pathology:

• Depressive, characterized by a depressed mood, a feeling of hopelessness, decreased interest in everyday activities; patients develop self-rejection and a desire to commit suicide.
• Manic is accompanied by an increase in motor arousal, increased mood, and idiomatic mental arousal.

A significant proportion of patients are faced with a mixed version of the phases. When conducting an oral conversation with a doctor, manifestations of phases are revealed that are present simultaneously or appear with a short time interval.

Manic depressive psychosis in men

In the manic stage, in the first stages it is often perceived positively by the patient himself and his environment. Business activity and self-confidence increase, and ideas on the verge of genius arise. This behavior, in the minds of the masses, is typical of business and successful people and is perceived not as a disease, but as success. As the diagnosis progresses, activity turns into increased irritability, aggression occurs, and the man may attack others.

A severe course is also distinguished by a depressive state in men. They often begin to try to rethink their actions throughout life, to negatively perceive what only a few hours ago seemed to be an outstanding success. Apparently, in approximately the same state, Gogol decided to burn the second volume of Dead Souls.

As the depressive state progresses, the desire to completely isolate oneself from the world develops, the patient tries to move minimally, refuses food, sexual desire disappears, and family ties disappear. Many patients talk about ending their lives or attempt suicide.

Manic psychosis in a person has every right to be called a silent killer. Diagnosis of pathology is complicated by frequent refusals by patients of any gender to seek help from a psychiatrist, citing a changeable character or slight natural hysteria. For this reason, pathology is often detected already at the stage of a serious attack, which requires immediate hospitalization.

Treatment of affective bipolar disorder

The development of a course of treatment for bipolar disorder is carried out by a psychologist or psychotherapist. An individual program is drawn up for each patient, which takes into account:

• patient's age, gender;
• frequency of attacks, duration of remissions;
• present concomitant diseases;
• type and phase.

Like other affective disorders, the prognosis for the development of the disease is initially difficult to predict. The doctor develops a treatment option, checking which medications and psychological practices help the patient.

Bipolar disorder in adolescents

Bipolar disorder in adolescents is difficult to diagnose. Its manifestations may be similar to teenage whims associated with hormonal changes. Some experts suggest the presence of symptoms of bipolar disorder at the initial stage in almost half of young men and adolescent girls. About 1.5% of young people are formally diagnosed.

Therapy is based on correcting the disorder primarily through psychological training and sedative medications. It is recommended to take B vitamins that strengthen the nervous system.

According to indications, it is recommended to prescribe antipsychotics, mood stabilizers, antidepressants, and sedatives. The use of medications in the treatment of adolescents is used in situations of recovery from an acute condition.

Bipolar disorder in women

In the fair sex, the manifestation of bipolar disorder is characterized by starting with a depressive episode. A peculiarity of diagnosing bipolar disorder in the fairer sex is the frequent failure to identify the diagnosis, the manifestation of which is associated with a naturally elevated emotional status. In an attempt to independently overcome mood swings, women often bring the disease to the stage of frequent alternation between a depressive state and manic states.

When developing a course of therapy, the need to adjust the course depending on the hormonal status of the patient is taken into account. Puberty, any termination of pregnancy (abortion, miscarriage or childbirth), menopause can provoke an exacerbation of bipolar disorder and change the symptoms of the disease. An exacerbation can provoke the simple onset of monthly menstrual bleeding.

Treatment uses a combination of atypical psychotics and mood stabilizers. The disease is often accompanied by physical pain and increased body temperature. Antipyretic and analgesic drugs are used in treatment.

Each patient undergoes a course of individual and group psychotherapy. This allows you to relieve a high degree of tension, anxiety, and reduce the level of depression.

Bipolar affective disorder in men

Considering that men more often suffer from the onset of a manic phase, preference in therapy is given to sedatives and sedatives. It is not recommended to stop using medications at the stage of relapse or first manifestation. The use of medications ensures rapid relief of an active condition that is dangerous for the patient. Further, it is recommended to prescribe medications that ensure long-term, ideally lifelong, remission.

A feature of therapy for men is the frequent refusal of patients to accept the presence of a diagnosis. Starting with a manic episode, accompanied by increased activity and performance, allows patients to simply assume that they have a colossal amount of vital energy. Most men positively accept their unexpected increased sexuality, from their point of view, additionally confirming success and strength. The lack of therapy leads to a change from a manic stage to a depressive stage with severe symptoms.

An important condition for the successful treatment of bipolar disorder in men is the joint work of relatives and doctors. This helps to seek medical help in a timely manner.

Bipolar disorder in patients of any gender is currently not completely curable. The condition must be monitored for life by a specialist. In most situations, a preventive examination, prescribed once every few months, is sufficient.

When life factors occur that can provoke a relapse, patients are advised to seek advice on their own. Provocateurs are individual for everyone. This could be a long-term stressful situation, a sad or joyful event. Patients with bipolar disorder and their relatives are advised to remember the need to promptly stop a potential exacerbation.

Manic psychosis in women

Women suffer from this mental state disorder approximately three to four times more often than men. Representatives of the fair sex are characterized by the prevalence of depressive states. The manic stage in the early stages is often mistaken for hysteria.

A feature of the course is the ability to plunge into a prolonged depressive state, which can often last for years. During this period, all life activities are disrupted. It is also possible that menstruation may stop due to depression.

How to live with bipolar disorder

People who have been diagnosed with bipolar disorder need to self-manage their health. Contacting a doctor is required at the first manifestation of symptoms. In this list:

• unexpected mood swings from unbridled joy to deep sadness over the course of several hours;
• loss of interest in life, leading to physical weakness and apathy;
• excessive excitement, in many cases accompanied by loud laughter and unmotivated joy;
• loss of appetite, weight can either begin to increase or decrease, the usual order of eating and taste preferences change.

Patients themselves may pay attention to other unusual factors caused by changes in their psycho-emotional state.

In the case of the presence of attacks in the past, patients with bipolar disorder know what symptoms may accompany the completion of remission. If there is a suspicion of a new attack, the patient is recommended to contact the treating psychologist or therapist.

At the same time, the diagnosis should not be perceived as a sentence that forces you to give up your usual way of life. With properly selected therapy and timely consultation with a doctor, bipolar disorder can go into a state of long-term, even lifelong, remission. Monitoring the patient’s condition by doctors and relatives, including the patient himself, is required for life. The lack of accurate data on the causes of this disease excludes the possibility of developing preventive measures.

Compliance with the rules for monitoring well-being and psycho-emotional state will help patients with bipolar disorder of any type maintain the quality of life of an almost completely healthy person. Attending psychotherapy courses and starting to take medications maintains emotional balance within normal limits in a large number of patients for many years. As a rule, others have no idea that a patient who constantly monitors himself has a complex and life-threatening pathology.

What to do if you suspect you or your loved ones have bipolar disorder?

If you notice sudden mood swings for no apparent reason, this is a reason to seriously think about it. Ten or more of the symptoms we have listed may indicate the presence of a disorder. Especially if thoughts of suicide appear from time to time.

1. The first step is to see a therapist. Get tested and undergo the examination that he prescribes. Some hormonal disorders are similar to bipolar disorder - for example, diabetes, hyper- and hypothyroidism. It is important to exclude them or detect them and begin treatment.
2. The second step is an appointment with a psychotherapist or consultation with a psychologist. Be prepared that the specialist will ask about your lifestyle, bad habits, relationships with people, hereditary diseases, childhood injuries and many other details.

Based on this data, you will be prescribed treatment. This could be depth psychotherapy, medication, or all three.

Do not self-medicate under any circumstances, so as not to aggravate the condition. At the moment of exacerbation, do not be alone - let one of your relatives be with you. Call a licensed psychologist, your primary care physician, call an ambulance, or go to the hospital immediately.

If your loved one is depressed, do not leave him alone. Remove all objects that can cause harm to health - from piercing and cutting objects to tablets. Persuade him to call a doctor.

In the domestic literature, the concept of atypical depression does not have clear diagnostic boundaries, and the understanding of the very atypicality of the clinical picture of depression most often reflects the presence of symptoms (somatovegetative, obsessive, etc.) that are not characteristic of manifestations of classic melancholic affect [4, 6, 8, 9]. At the same time, in foreign publications this term has its own syndromological meaning in the structure of a major depressive episode (DSM-IV). The origins of the term “atypical depression” are the English psychopathologists E. West and P. Dally [43], who, in their work studying the effectiveness of a drug from the group of monoamine oxidase inhibitors (MAOIs) - ipronioside, identified a group of patients with a hysterical personality type, secondary depression and anxiety. The result of a systematic study of this disorder by J. Rabkin et al. [34] atypical depression was included in the DSM-IV in 1994 as a specifier for major depressive episode. Despite the high prevalence of atypical depression, reaching 15.3–29% [7, 10, 15–18, 38], there is currently no common understanding of its place in the structure of affective pathology. Some authors [14, 24, 40] identify atypical depression as an independent nosological entity, confirming their conclusions with the biological features of its pathogenesis, while others [11] consider this condition as a “transitional” syndrome, a kind of bridge from unipolar depression to bipolar II disorder type, and still others [15, 28, 32, 42] consider atypical depression to be a syndrome that develops according to compensatory mechanisms in response to stress factors. This is largely explained by the heterogeneity of the results of works directly devoted to the analysis of the clinical features of conditions, in the structure of which either inversion of vegetative symptoms, or reactive lability, or sensitivity to rejection is identified as an obligate feature.

The purpose of this work is to study the clinical features of atypical symptoms in the structure of a depressive episode and determine their role in the formation of a stereotype of the course of an affective disorder.

Material and methods

The study was conducted in the Department of New Means and Methods of Therapy, Department of Borderline Psychiatry, State Scientific Center for Social and Forensic Psychiatry named after. V.P. Serbsky on the basis of the Moscow Psychiatric Clinical Hospital No. 12.

The sample consisted of 46 people aged 18 to 65 years with a diagnosis of atypical depression in the structure of a major depressive episode (according to DSM-IV). Of those examined, the majority (87%) were women. The average age of the patients was 37.6±13.5 years. Analysis of the educational level of the study group showed a predominance (47.8%) of people with higher education; a significant proportion were people with incomplete higher (26%) and secondary specialized (19.5%) education; the percentage of those surveyed who received only primary education was 6.5. An assessment of work activity showed that 45.6% of patients had a permanent job and stable income, 54.3% did not work, of which 26% were due to mental illness.

The criterion for including patients in the study was that their mental state met the criteria for atypical depression according to the DSM-IV classification: the mandatory presence in the clinical picture of criterion A (mood reactivity) and two of the four criteria B (hypersomnia, hyperphagia, lead paralysis, sensitivity to rejection). Patients with acute and chronic somatic diseases in the stage of decompensation, severe neurological pathology, organic pathology of the brain, epilepsy, schizophrenia and delusional disorders, as well as substance abusers were excluded from the study.

During the study, psychopathological and psychometric research methods were used, including the 17-item Hamilton Depression Scale (HAMD-17), the Atypical Depression Scale (ADDS), and the Mini-Mult scale (an abbreviated version of the MMPI) was used to assess personality characteristics.

Results and discussion

During a clinical assessment of the patients' condition, the psychopathological heterogeneity of atypical depression was revealed, which made it possible to distinguish three of its variants: with a predominance of 1) mood reactivity; 2) inverted vegetative symptoms (hyperphagia, hypersomnia), including “lead paralysis”; 3) sensitivity to rejection.

A variant of atypical depression with a predominance of mood reactivity

occurred in 30.4% of patients, mainly in women (92.3%). Their mean age was 42.3±12.6 years. Patients in this group were characterized by a predominance (61.5%) of people with higher and incomplete higher education. Persons with permanent jobs and stable earnings accounted for 38.4%, 61.5% were unemployed, of which 37.5% were due to mental health.

Mood reactivity came to the fore in the clinical picture of the condition of such patients, i.e. the ability to improve it in response to current or potentially positive life events [35, 39, 42]. This readiness of emotional reactions to change (increase) mood in response to events or situations that have a positive meaning for patients was observed with general complaints of anhedonia, apathy and other symptoms of a depressive state [41]. Patients with a predominance of mood reactivity, when mentioning their loved ones or friends, memories, for example, of a recent vacation or visiting the theater, became significantly more animated, their facial expressions and movements became expressive, and their mood improved. From their face one could easily guess their attitude towards an object, event or person. At the same time, completely different factors were subjectively significant and positive, improving the mood of patients. Some people, or “to escape depression, throw themselves into work”; for others, potentially significant events were thoughts about a future vacation - “only thoughts about it lift my mood,” “during periods of strong apathy, I begin to plan it in great detail and then the melancholy subsides for a while”; the third brought pleasure from the thought of planned purchases - “instead of working, I again look at advertisements for apartments for sale, although I know them by heart”; for the fourth, a simple compliment or encouragement from loved ones or a doctor was a positive event. Such positive events were long-awaited for them, and they often “mentally pressed for time” in impatience to escape from the “pending problems.” The ability of patients to respond to subjectively significant positive life situations differed in the degree of reversibility of hypothymia, manifested in an improvement in mood - from an insignificant level to its complete normalization [19]. Thus, one patient o, while another indicated that during periods of depression she likes to meet with friends, although “the feeling is not the same.” Some patients were characterized by long periods of normothymia under favorable circumstances [5, 17], others noted long periods of low mood with short-term “enlightenments” in response to positive, emotionally significant events in their lives [37].

Among other atypical symptoms, patients in this group were characterized by complaints of a feeling of heaviness, fatigue throughout the body, including in the limbs (53.8%), as well as increased sensitivity to rejection (46.1%), which has been characteristic of them since childhood and not increasing in the current state. At the same time, other symptoms of atypical depression, such as hyperphagia and hypersomnia, were minimally expressed (23% each, respectively).

The severity of the current depressive episode on the HAMD scale was 20±3 points. The personality profile of patients with mood reactivity was characterized by pronounced psychasthenic, schizoid and hysterical traits with minimal manifestations of hyperthymic and paranoid traits. Using the ADDS scale, a spectrum of atypical symptoms was identified that are most characteristic of the described variant of atypical depression. It is shown in Fig. 1.

A variant of atypical depression with a predominance of inverse vegetative symptoms

was the most numerous (39.1%). The average age of patients in this group was 30.1±9.4 years. This group, like the previous one, was characterized by a predominance of women (73%) and persons with higher and incomplete higher education (83.3%). However, there were more patients with permanent work - 55.5% (44.4% were unemployed, of which 28.5% were due to a current mental disorder).

The psychopathological picture of this variant of atypical depression was primarily determined by the symptoms of hypersomnia, hyperphagia and lead paralysis. The high correlation between these symptoms, noted by many authors [10, 13, 25, 26], was the basis for the reconstruction of the diagnostic criteria for atypical depression proposed by F. Benazzi [12], according to which the presence of only two symptoms (overeating and drowsiness) is sufficient to make an appropriate diagnosis.

A symptom observed in almost all patients (89%) of this group was hypersomnia, which was manifested either by increased sleepiness during the day, or by sleep attacks (which were not explained by insufficient duration of sleep at night), or by a prolonged transition to a state of full wakefulness after awakening. [19]. The total number of hours of sleep per day in patients with hypersomnia ranged from 10 to 16. Most often (61%), hypersomnia was manifested by a feeling of daytime sleepiness of varying severity, in which patients could “lie down for several hours” several times during the day, or, with more severe drowsiness, they fell asleep wherever possible - “I sleep at home, in the subway, at the institute.” Less often (28%) it manifested itself as a prolonged transition to full wakefulness after awakening. In such patients, despite the duration of sleep significantly exceeding the norm, there was a lack of feeling of rest after waking up; it was difficult for them to wake up, force themselves to get out of bed - “in the evening I fall into a deep sleep without awakening, and in the morning it’s as if I hadn’t slept.” Sometimes (11%) manifestations of hypersomnia resembled the clinical picture of Kleine-Levin syndrome [27] and were so pronounced that patients described these states with the words “hibernation”, “I sleep like a bear and don’t want to wake up”, “I wake up for short periods of time and again I'm falling asleep." Periods of such “hibernation” lasting several days could be repeated, alternating with minor phenomena of daytime sleepiness.

Hypersomnia in 78% of cases was accompanied by another symptom characteristic of this variant of atypical depression—hyperphagia [7, 10]. Patients complained of increased appetite; their behavior could manifest itself either in the frequent consumption of small amounts of food, “I’m always chewing something,” or in episodes of simultaneous consumption of large quantities of food—“dinner turns into a feast.” Some patients were characterized by an increased craving for food rich in carbohydrates (“carbohydrate thirst”): flour and confectionery products, in particular chocolate [5, 29, 31]. Often, patients did not see a problem with increased appetite, believing that they successfully compensated for the calories received, for example, with physical activity. In other cases, increased appetite and “craving for food” were masked by the internal prohibitions of the patients themselves, who refused to eat by force of will: “I always want to chew something, but I don’t allow myself to relax.” Sometimes, according to patients, the tendency to hyperphagia was a way of coping with stressful life situations characteristic of them since childhood [32] - “when I’m worried, I definitely need to eat something tasty”, and with depression it only intensified - “a ravenous appetite awakens " In a number of patients, the increase in appetite reached the level of an uncontrollable desire to absorb food, which corresponded to the clinical picture of eating disorders in bulimia nervosa of a compulsive nature [36]. At the same time, the patients did not feel the taste of food and did not think about its quantity - “I eat everything that comes to hand,” “I open the refrigerator and want to eat everything at the same time.” Highlighting the craving for overeating as a symptom reflecting the common pathogenetic mechanisms of atypical depression and bulimia nervosa, J. Wildes and M. Marcus [44] classify both syndromes as “mild bipolar spectrum” disorders [32]. Patients who complained of hyperphagia often (78%) reported a weight gain of 3–6 kg; In 22% of patients, the weight gained reached significant values, increasing by 7-12 kg over several months.

In 67% of cases, inverse vegetative symptoms (hyperphagia and hypersomnia) were accompanied by asthenic complaints in the form of a feeling of unusual heaviness in the limbs - “lead paralysis” [39]. Patients described their condition with the words “I feel as if I had been poured with lead”, “my legs feel like they’re made of cast iron”, “I can’t move in a chair, I’m so tired”, “I feel like I was carrying two heavy bags." In some patients, sensations of heaviness were accompanied by symptoms of paresthesia in the extremities: “numbness,” “stiffness.” The symptom of lead paralysis was observed both short-term - for 20-30 minutes, and long-term - several hours, arising in situations of psycho-emotional stress or spontaneously, without external provocation [5], in various situations (at home, at work, in transport).

The presence of other atypical symptoms in this group of patients was insignificant, confirming the high degree of conjugation of inverse autonomic symptoms. For example, mood reactivity occurred in 27.2% of cases, while sensitivity to rejection occurred only in 36.3%, reflecting more a character trait than manifestations of atypical depression. The average severity of depressive disorder was more pronounced than in the previous version (22.8±4.1 according to HAMD). The structure of the constitutional anomaly that predisposes to the development of atypical depression with a predominance of inversion of vegetative symptoms is represented by hysterical, psychasthenic, schizoid, and also, in contrast to the previous type of atypical depression, cycloid and hyperthymic features. Clinical features of this variant of atypical depression are shown in Fig. 2.

The third variant of atypical depression with a predominance of increased sensitivity to rejection

was detected in 32.6% of patients who were at a later age (42.5±14.4 years). Most of them (87%) were women. Compared to the socio-demographic characteristics of patients in previous groups, in this group there were 73% of people with higher and incomplete higher education, and the percentage of unemployed people reached 60%, of which 56% were due to a mental state.

Persistent hypothymic affect was combined in these patients with increased sensitivity and constant anxiety about the attitude of others towards them; expectation, as a rule, of imaginary criticism addressed to oneself, an unfavorable opinion about oneself, a tendency to take personally any neutral or insignificant change in the behavior of people, often close to them, interpreted by them as rejection, reproach, or a dirty trick [1, 16, 17, 25 ]. Patients said that they “take everything to heart,” “my friends didn’t invite me to the movies and I don’t want to talk to them anymore,” “he called later than he should have and we quarreled,” “colleagues didn’t invite me to lunch, and I was offended by them.” The behavioral component of the syndrome in the patients studied is represented by patterned hysterical reactions, refusal reactions [3, 22], dysphoric outbursts with accusations of loved ones for lack of understanding and indifference. Individualism combined with increased vulnerability (the so-called nuanced sensitivity) led to selectivity in contacts, accompanied by emotional rejection similar to that noted in childhood [23] - obvious (aggression, avoidance) or hidden (emotional hostility and coldness). Reacting with excessive vulnerability, touchiness with the formation of avoidant behavior or severe irritability, short temper, aggression directed at anyone who came into contact with them (“ready to attack if they reprimand me”) [5, 18], patients stopped going to work, study, tried not to enter into contact with relatives unnecessarily. Thus, one patient did not go to a meeting of classmates for fear of becoming an object of ridicule, another was unable to pay the rent because of a long line at the bank - “someone will definitely scold me.” The consequence of such inadequate reactions was frequent difficulties in interpersonal relationships, which further strengthened patients’ thoughts that they were being rejected [25], leading in severe cases to ideas of their own low value, phobic experiences and social maladjustment [39]. Often, in the clinical picture of the condition, a significant place was occupied by symptoms of persistent asthenia with complaints of lack of strength: “I didn’t do anything, and I was tired like after a whole day at work.”

The severity of behavioral disorders in this group of patients was noted by many authors, who identified in such cases a special vulnerable personality type with idealization and romanticization of the surrounding reality against the background of emotional immaturity, excessive enthusiasm and hypersensitivity to interpersonal relationships, rejection of situations that hurt their pride and frustrate their need for attention , approval and recognition, an expressed feeling of internal protest against current circumstances (fate), the need for liberation from “injustice” combined with inflated, unrealistic demands on oneself and especially others [1, 21, 28, 30]. This personality type, characterized by an amalgamation of pathocharacterological and hypothymic disorders, was designated as hysterical dysphoria [2, 20-22]. Among other atypical symptoms, this group of patients was characterized by the presence of lead paralysis (73%) and mood reactivity (60%), while the severity of such signs of atypical depression as hypersomnia and hyperphagia was minimal - 13 and 20%, respectively ( Fig. 3).

The personality structure characteristic of this variant of atypical depression was represented by psychasthenic, hysterical, paranoid and schizoid traits, and the severity of the first three exceeded those in patients with other variants. A peculiarity of patients in this group was the virtual absence of persons with hyper- and cyclothymic features.

The selected variants of atypical depression reflect a different stereotype of the dynamics of affective pathology (see table).

Atypical depression with a predominance of mood reactivity was formed, as a rule, within the framework of recurrent depressive disorder. In these cases (38.4%), the disease usually began at the age of 28±11 years with a mild depressive episode that had a psychogenic provocation with the inclusion of atypical symptoms, mainly in the form of mood reactivity and asthenic complaints (similar to lead paralysis). From the time the first symptoms of the disease appeared to the age of the patients when the diagnosis was established (40.2±14 years), patients suffered an average of 2.8±0.7 depressive episodes lasting from 60 to 180 days, of varying severity and structure - with alternation more severe depression with melancholic features and suicidal ideas, often occurring in milder phases with a predominance of mood reactivity, which, although it was the main clinical characteristic of depression, over time had a clear tendency to reduce the amplitude of affect fluctuations. Less frequently (15.3%) this variant of atypical depression was observed in the structure of bipolar disorder. In this case, there was an earlier development of the disease (at the age of 25.5±9.1 years), a visit to the doctor almost at the first symptoms of the disease, a higher frequency and severity of depressive and manic/hypomanic episodes, and a high frequency of visits to a psychiatrist.

A variant of atypical depression with a predominance of inverted vegetative symptoms was characteristic of bipolar disorder (33.3%) and was practically not encountered in recurrent course (5.5%). The disease manifested itself, as a rule, at a younger age (20.1±7.1 years) with a mixed state, the structure of which included short-term episodes of increased appetite and daytime sleepiness. The further course of the disease was characterized by alternating depressive and hypomanic episodes with deepening depressive phases and vegetative manifestations characteristic of this type of atypical depression, leading to significant maladjustment (loss of work, study) and referral to a psychiatrist (average age 26.1 ± 3.7 years) . Euthymic intervals tended to shorten their duration or, less commonly, the disease immediately acquired a continuous course.

The variant of atypical depression with a predominance of sensitivity to rejection, as well as with mood reactivity, is more typical for recurrent depressive disorder (26.6%) and was almost never found in the structure of the bipolar course of the disease (6.6%). Depression, as a rule, developed at the age of involution (48.75±1.4 years) most often in connection with severe stress (death of a loved one, dismissal from work, divorce). Repeated episodes, occurring with similar clinical symptoms of the “cliché” type, were provoked by individually intolerable conflict situations, the content of which “sounded” throughout the entire depressive episode. The anamnestic revealed periods of low mood at a subclinical level associated with “loss” (romantic relationships) or “failure” in solving important life tasks (career growth, starting a family).

Thus, the clinical study of atypical depression confirmed the assumption of its heterogeneity. In the psychopathological differentiation of the disorders dominant in the clinical picture, three variants of atypical depression were identified - with a predominance of 1) mood reactivity, 2) inversion of vegetative symptoms, 3) sensitivity to rejection, which reflect the stereotype of the development of an affective disorder with a high level of bipolarity in depression with a predominance of inverted vegetative symptoms symptoms and a high level of monopolarity for the remaining options.

Hypochondriacal syndrome

The second group of disorders is the so-called “Hypochondriacal syndrome”. This is a mental disorder, manifested by an overvalued passion for one’s health and a constant search for some kind of disease.

Patients with hypochondriacal disorders find themselves regulars in medical institutions. These are patients who cannot calm down after receiving good results of examinations, neurophysiological, laboratory and others, which indicate that they do not have any pathological abnormalities. They cannot calm down, they still need to recheck, because as part of this hypochondriacal syndrome, obsessions arise in their heads, and they force them to visit diagnostic centers again and again.

In connection with the epidemic, in connection with such rich, not always correct information about viral diseases and about Covid in particular, these patients concentrate precisely on searching for new and new symptoms associated with Covid, they barricade themselves at home, categorically refusing to go out street. Even when it's not dangerous at all. They put on an excessive amount of personal protective equipment, they develop anxiety-phobia disorders, that is, a constant, obsessive need to wash their hands. These patients categorically refuse communication and face-to-face contact with loved ones and relatives with whom they have always had good relationships.

And in this hypochondriacal madness, excuse me for the term, where this hypochondriacal idea becomes a fixed idea, they lose all their social, professional and other roots with which their life was connected.

Are these disorders reversible?

I want to reassure those who, listening to me, are now getting dressed in panic to run to the nearest diagnostic center. Believe me, these disorders are mostly reversible. If you do not now have the opportunity to undergo examination and treatment, these disorders will go away on their own, it will just take additional time.

Many medical institutions have introduced proposals for the rehabilitation of patients who have suffered from covid infection.

Ours also makes this offer to its clients. We have sufficient medical resources: we have psychiatrists and psychologists, and if necessary, we will attract neurologists and other specialists. We can help with conditions related to PTSD or any other conditions that you think may be associated with an infection or related traumatic event.

Contact us, come, we are always ready to help you.