Psychogenic disorders (reactive) - human reactions to difficult life circumstances

The general concept of “psychoses” (psychotic disorders) is understood as manifestations of mental illnesses in which a person’s mental activity distorts the surrounding reality in consciousness, which can manifest itself in various disorders of behavior, consciousness, and the presence of pathological syndromes and symptoms.

Reactive psychosis can be characterized by the Jaspers triad, the signs of which are as follows:

• Clinical symptoms reflect a traumatic event; • Mental disorders arise under the influence of a traumatic event; • Mental disorders disappear after the end of the event.

But Jaspers' triad is not a universal remedy. Mental disorders do not always occur immediately after a traumatic event (delayed reactions) and tend to persist for a long time after the cessation of the psychic trauma.

However, not all mental disorders that arise under the influence of mental trauma can be classified as reactive psychoses. Schizophrenia, bipolar disorder, presenile psychosis and many other diseases can be triggered by mental trauma.

Classification of reactive psychoses

In accordance with ICD-10, reactive psychosis can be observed in the following conditions: • acute and transient disorders (F23);
• depressive episode (F32); • acute reaction to stress (F43); • post-traumatic stress disorder (F43.1); • adaptation disorders (F43.2); • dissociative (conversion) disorders (F44). There are many forms of reactive psychoses. Various psychopathological syndromes alternate or predominate. The course of the disease is wavy, the duration varies depending on the initial state of a particular person and the form of psychosis.

The group of reactive psychoses can also be replenished with psychotic states, which represent one of the stages in the development of post-traumatic stress disorder

There is no generally accepted classification of reactive states, but from the point of view of clinical manifestations, several forms can be distinguished:

1. acute reaction to stress (affective-shock reaction) 2. hysterical psychoses 3. psychogenic depression 4. psychogenic mania 5. psychogenic paranoids

You can also classify according to the duration of exposure to the traumatic event:

Protracted reactive psychoses. Develops in a person with prolonged exposure to a traumatic situation (delusions, obsessive states, depression). Subacute. Occurs after exposure to psychological trauma (reactive depression, hysterical psychosis, paranoid states) Acute. Appears immediately after a traumatic event.

Data from modern epidemiological studies confirm the traditional view that psychogenic reactions are most often clinically expressed as depression. Depressive states make up about 40% of the total number of reactive psychoses, and psychogenic depressions of the subsyndromal and neurotic level are even more common - in 74.8% of all depressions identified during a non-sample survey of a healthy working population [1].

In the monograph N.V. Kantorovich [2] provides indicators comparable to the above - 42% of depression from the number of reactive psychoses studied by the author. In this study (as in the later work of O.P. Vertogradova et al. [1]), reactive psychoses were classified according to ICD-9.

The fact of the high prevalence of psychogenic disorders associated with depression is also recorded in the DSM-V [3]. However, since in this diagnostic system, as in ICD-10, reactive depression is not identified as a separate category, their prevalence can be judged by the indicators for each individual group of psychogenic disorders: the prevalence of an acute reaction to stress is 20%; adaptation reactions - 50%; post-traumatic stress disorder (PTSD) - 3.5% (within a year) and 8% (within a lifetime); “persistent complex disorder due to loss” - 2.4-4.8%.

The above makes it necessary to analyze publications reflecting the development of the doctrine of psychogenies, including reactive depression, and to discuss the position of this category of disorders in modern classification systems.

Reactive depression in modern classifications

In ICD-8 (1965, 1967) and ICD-9 (1975, 1977), the diagnostic class “Reactive depression” (300.4) was divided into neurotic and actually reactive forms. The assessment of the condition in favor of the diagnosis of reactive depression was carried out when distinguishing it from “adaptation reaction with depressive symptoms” (309.0), as well as “reactive depressive psychosis” (298.0) and “manic-depressive psychosis of the depressive type” (296.1).

Revision of the nosological paradigm with the introduction of operational diagnostic methods based on the canons of evidence-based medicine (informativeness, reproducibility, reliability, relevance of assessments), culminating in the development of DSM-III-R (1987), DSM-IV (1994) and ICD-10 (1994), was accompanied by a “transfer” of stress-induced depression to new categories. At the same time, neurotic depression was identified with “dysthymia” (F34.1), diagnosed without taking into account the connection with traumatic events, and other non-psychotic options were classified as a cluster of poorly differentiated “adaptation disorders” (F43.2). In this case, it is envisaged to distinguish only subsyndromal forms - a short-term reaction (F43.20) in the form of a transient (no more than 1 month) “mild depressive state” and “prolonged depressive reaction” (F43.21) or mild (no more than 2 years) depression, developed in response to prolonged exposure to a stressful situation.

As a result, the position of reactive depression in modern classifications turned out to be so uncertain that, as M. Stroebe et al. [4], difficult to understand.

Let us recall that in DSM-IV (1994) adaptation disorders were classified as stress-mediated, but developing outside of extreme life-threatening events. Changes in lifestyle, increased mental and physical stress, unexpectedly revealed serious illness, deprivation, loss, and separation from loved ones are considered as provoking factors. It is indicated that we are talking about both relatively short-term and delayed phenomena, previously attributed to situational psychogenic neurotic reactions and states. The phenomenological boundaries of adaptation disorders cover both extreme manifestations of distress and anxiety-depressive and behavioral disorders that require differentiation from depression.

The changes made to the latest edition of the American classification system, DSM-V (2013), do not reflect a fundamental revision of the concept of psychogenic disorders. The modification of the taxonomy consists in introducing a category designated as “disorders associated with exposure to trauma and stressors” and separated from anxiety-phobic, hysterical and somatoform disorders into an independent diagnostic class. Psychogenic reactions of childhood (violation of attachments and interactions with the social environment) are included in this category for the first time. As for the taxonomy of psychogenies in adults, they are coded within the traditional taxa - “post-traumatic stress disorder”, “acute stress disorder” and “adjustment disorders, including reactions with depressive mood”. In addition, a category was created for “other specified disorders associated with exposure to trauma and stressors.” This category includes the following conditions “similar to adaptation disorders”: 1) with a delayed onset (not earlier than 3 months after stress exposure); 2) prolonged (lasting more than 6 months, despite the cessation of stress) disorders; 3) cultural forms that do not change the official status of pathological reactions to loss.

Some of the stress-induced reactions (in clinical assessment we are talking about psychogenic depression associated with the irreversible loss of the object of attachment) turned out to be a “bone of contention” when constructing the classification under discussion). The term “persistent complex bereavement disorder” could only be included in the “Future Research Directions” section of Section III “New Dimensions and Models” as a taxonomic category complementing the nomenclature of psychogenic (PTSD, adjustment disorders) and depressive disorders. The fact is that when trying to add a corresponding category to the main section of the classification, consensus was not reached. Discussion of this problem was accompanied by a debate, during which some experts expressed fears that the proposed changes would lead to the establishment of many “false positive” diagnoses, as a result of which “normal distress” could be mistakenly assessed as a mental disorder. This position, laid down by S. Freud, of taking “normal grief” beyond the scope of mental pathology is shared by a number of foreign authors [5-10]​1​᠎. However, deciding whether there is a causal relationship between an event and a response and the “proportionality” of the response remains a matter of subjective judgment by the clinician [11, 12]. According to H. Helmchen et al. [13], “normal types of negative emotions (sadness and despair) should not be mistaken for depressive affect, characterized by holothymic deficiency and a special emotional feeling familiar only to persons with depression.” However, in the works of P. Clayton [14] and Ph. Bornstein and R. Clayton [15] argue that the grief reaction is realized in the form of depression, its symptoms are typical for a depressive disorder and therefore “chronic grief” can be defined as “continuous depressive syndrome.” R. Pies [16] emphasizes that bereavement-related depression has similarities with episodes of major depression at the level of genetic predisposition, premorbid personality characteristics, comorbidity patterns and the risk of chronicity and/or recurrent course, and M. Shear et al. [17] note that the presence of loss determines a more severe course of depression with a high risk of suicide. A number of researchers [18–20] believe that the traumatic grief reaction deserves the status of an independent diagnostic category. An important argument put forward [16, 21, 22] is the need to alleviate mental suffering with the active use of clinically oriented (including medications) means.

Let us now turn to publications covering the problem of reactive depression both in the historical aspect and at the present stage of the evolution of scientific views.

History of the development of ideas about reactive depression

The foundations of the doctrine of reactive states (including depression) as one of the forms of pathological response of the individual to mental trauma2​᠎ were laid in the late 19th - early 20th centuries. It was at the turn of the century that the unambiguous understanding of psychopathological disorders accepted by the school of “somatics”, according to which they are based on a neuroanatomical process, was replaced, as P.B. emphasizes. Gannushkin in the preface to the 1st edition of “History of Psychiatry” by Yu.V. Kannabikh (1928), “the transformation of psychiatry from a science of brain diseases into a science of understanding and knowing people.” This happened thanks to progress in the field of individual psychology and the development of “minor” psychiatry.

We emphasize that the problem of psychogenic depression is considered in the literature within the framework of two main, parallel developing directions - clinical and psychoanalytic (psychological, psychosocial).

Clinical direction

This direction is opened by the priority research of R. Sommer [24], who introduced the concept of “psychogeny”, “psychogenic” (from the German “erlebnisbedingt” - caused by experiences). R. Sommer's point of view on reactive states as a group of psychogenies induced by hysterical mechanisms, interpreted in accordance with the research of the school of J. Charcot [25] on the psychogenic nature of hysteria, was shared by R. Gaupp [26]. In the author's interpretation, hysterical disorders represent an abnormal type of reaction to the demands of life; the corresponding mechanisms are embedded in the human psyche, and reactions are detected in cases where reality makes exorbitant demands on a person.

These works (taking into account the experience of the First World War)3​᠎ attracted special attention of researchers to assessing the role of psychotraumatic influences and the contribution of constitutional, as well as individual psychological mechanisms in the genesis and clinic of psychogenic disorders, which are not exhausted, as clinical practice has shown [29], hysterical reactions.

The study of reactive states was initially accompanied by significant difficulties, to which K. Birnbaum (1917) [30] specifically devoted one of his works. Problems associated with their study include the lack of a final definition, the need to assess the relationship between the pathological effect of mental trauma and emotional, “thymogenic” and constitutional factors, as well as pathoplastic psychogenic effects in diseases of a different nature (including schizophrenia). In the author’s definition, psychogenics should be understood as the pathological effect of exposure to trauma not only in cases where a previously painful state was not observed, but also when psychogenically caused changes occur in an already existing pathological phenomenon. All disorders of psychogenic origin, in his opinion, must be functional, that is, they must be a pathological distortion of normal reactions. A disease can be considered psychogenic only if its occurrence and clinical manifestations are adequate to the cause that caused it.

One of the first clinical studies directly devoted to psychogenic depression was published by E. Reiss in 1910 [31], who highlighted them in a separate chapter “Constitutional affective disorders and manic-depressive insanity” in his monograph ​4​᠎. In this publication, reactive depression was considered for the first time as an independent disorder with a specific etiology. It provides the following signs reflecting the psychogenic nature of suffering: the manifestation of the disorder must be preceded by circumstances that can be considered as provoking (the reason can be not only severe trauma, but also an objectively neutral event that has subjective significance). An affective disorder must develop in direct temporal connection with psychotraumatic influence. The severity and pace of onset, as well as the reverse development of psychogenic depression, must correspond to the individual characteristics of the patient. The content of pathological ideas must be in a semantic connection with the experience that provoked depression.

It should be emphasized that the criteria of E. Reiss correlate with the triad identified on the basis of the phenomenological idea of ​​psychologically understandable cause-and-effect relationships between the content of psychogeny and the nature of trauma, “forming an integral understandable context” according to K. Jaspers [37]. trauma, connection between the content and stressful effects, reduction after the cessation of such effects).

Analyzing the dynamics of psychogenic depression, E. Reiss puts forward a priority hypothesis that was ahead of its time about the possibility of constructing an imaginary trajectory starting from reactive depression, including intermediate forms and ending with endogenous depressions. This assumption is based on clinical experience, which allows, according to the author, “to observe how depressions increasingly differ from each other in the type of triggering - from completely provoked to endogenous, quite independent of external influences without it being possible to draw a clear line between them dividing line."

Note that almost 30 years later, A. Lewis [38] will propose a model according to which all depressive states represent a single continuum, leveling out the differences (both pathogenetic and clinical) between psychogenic and endogenous depression. The hypothesis formulated by E. Reiss was developed in the model of psychogenically provoked melancholia by J. Lange [39]. Supporting the idea of ​​psychogenic influence as a trigger mechanism of endogenous depression, the author in the chapter of the “Manual of Psychiatry”, published in 1928, ed. O. Bumke [40], along with reactive ones, distinguishes psychogenic depressions (the principle of such differentiation is outlined below).

The Dutch psychiatrist A. Wimmer [41], the founder of the Scandinavian concept of psychogenic psychoses, used this term to define “various clinically independent conditions, the main feature of which is the occurrence on a characteristic basis.” (“They are caused by mental factors - “mental traumata”, which determine the onset and course of the disease - remission, intermission, exacerbation and very often its cessation.”) The form and content of reactive psychoses are determined by triggering stress factors. The predominant tendency is towards recovery, although “more specific” is towards the absence of deterioration. A constitutional predisposition is often identified, but unlike an obligate trait (connection with mental trauma), this condition is not necessary. The stated concept, according to E. Strömgren [42], also shared by Japanese and Russian researchers, retains its significance in Scandinavia to this day [43]. Along with affective (depression, mania), hysterical (twilight stupefaction, pseudodementia, puerilism, hysterical stupor, syndromes of delusional fantasies and personality regression) forms, as well as psychogenic paranoids, are distinguished. In addition, reactive psychoses include schizophrenic reactions, discussed in detail in the review by N.A. Ilina (2006) [44].

Psychoanalytic direction

This direction in the study of reactive depression is opened by the work of S. Freud “Sadness and Melancholia” [45]. The author distinguished between two types of reactions: “sadness” and “melancholy”, which reveal a similar clinical picture and arise under the influence of similar reasons - unfavorable life events (or real loss - the loss of a loved one: “separation by death” [46] / “case of an abandoned bride” (S. Freud), or replacing it with such “abstract equivalents as fatherland, freedom, ideal”). Melancholy, which occurs with “deep suffering dejection, disappearance of interest in the outside world, loss of the ability to love, delay in all activities, ... reproaches and insults addressed to oneself, reaching the delirium of expectation of punishment,” differs from normal sadness in “a huge impoverishment of the Self (Ichverarmung).” With sadness, the world became impoverished and empty; with melancholy, the Self itself; Another psychologically remarkable feature is the alienation of the drive that “forces all living things to cling to life.” Being a reaction to the loss of a love object, melancholy in origin is associated with an ambivalent libidinal conflict, which explains the pathological nature of the reaction, which distinguishes melancholy from normal sadness.

The author is the first to put forward a thesis about the manifestations of grief as a natural reaction to the death of an attachment figure. In the process of such a reaction, the possibility of adaptation to a loss is realized, which is initially subjectively unacceptable, “overwhelming,” irreversibly disrupting the “intimate balance” of the individual [47]. It is believed that an individual may be deeply attached to the object of loss, but is able to endure the loss “and then recover to become attached again” [48].

In fact (if we approach the assessment of the concept under consideration from a clinical position), we are talking about one of the first attempts to isolate mild depressive reactions by taking them beyond the boundaries of clinical pathology (which was further developed in the research of modern psychoanalysts and psychologists who share the concept of “normal” grief) [ 49, 50]. The ideas of modern psychoanalysts are reflected in the study of T. Rando [51], who clarifies the initial interpretation of the dynamics of the grief reaction. If, according to S. Freud, for the reverse development of such a reaction it is necessary to completely overcome the memories of an irreparable loss, then T. Rando and other researchers working in the direction under discussion [52, 53] emphasize that the reduction of grief is a process that occurs in certain stages (see table). T. Rando identifies the following “phases of grief”: 1st - denial, 2nd - confrontation (reaction to loss - acute grief, rethinking the relationship with the deceased, rejection of the deceased and the previous worldview), 3rd - accommodation (adaptation to the new world, the formation of new relationships). The author points out that if adaptive coping mechanisms are not activated from the second stage of the confrontation phase, the grief process “takes a lifetime” and never reaches the level of completed or experienced grief. In psychologically/psychoanalytically oriented studies, such an outcome is considered as one of the signs of pathological grief reactions. The latter will be discussed below, but here we note that, from a clinical point of view, we are talking about the formation of post-reactive personality development.

Differentiation of reactions to loss by stages according to literature data

As a result of research carried out in the framework of the considered areas, by the end of the 20s of the last century, two approaches to the study of psychogenics had emerged. The first approach is based on the concept of psychogenesis of reactive states, according to which the leading role of traumatic events in their occurrence is postulated; the second - from the idea of ​​a constitutionally inherent susceptibility to a psychogenic reaction.

In studies of stress-induced depression, carried out on the basis of the first approach, the emphasis is placed on the nature of external harmfulness and the congruence of the manifestation of mental disorders with the influence that caused them. Trauma is considered as a decisive (predictor of the manifestation of psychogenic depression) and sensitizing (increases readiness for repeated psychogenic) factor [56-62].

Let us note that K. Jaspers [63] emphasized the need to distinguish between psychogenies caused by unexpected events (for example, sexual assault, earthquake and other disasters), the picture of which is dominated by fear, horror, rage, from deep mental upheavals associated with long-term negative life situation (breakup of a love relationship, imprisonment in adolescence and adulthood, “pension bankruptcy”, friction with the younger generation in the elderly).

Modern research on reactive states

In accordance with the first of the above approaches, stressful life events are currently divided into traumatic stress associated with natural or man-made disasters (earthquakes, tsunamis, radiation incidents, etc.), acts of mass violence (victims of torture, being held hostage, violence against family members, etc.) [64-68], and shocks within ordinary circumstances (bereavement, divorce, incurable physical illness, financial collapse, etc.) [69].

A standardized tool has been created that allows for differentiated assessment of the impact of injury (severity rating, subjective significance, etc.). We are talking about the stress scale T. Holmes and R. Rahe [70] - The Social Readjustment Rating Scale), containing 43 items that list social and life events, ranked depending on the severity of stress. The most severe traumas include the death of a spouse, divorce, judgment; to the mild ones - changes in the usual sleep patterns, eating, minor offenses. The taxonomy, based on the subjective significance of stress [71], ranks traumatic events on the ALE (Appraisal of Life Events Sale) scale [72] into three categories: “loss” (loss of an object of affection and love, social status, etc.); “threat” (the expected probability of physical harm, illness, death, etc.); “challenge” (violation of personal autonomy, restriction of freedom, rejection, etc.). More modern instruments are also used, such as the IES-R, the Impact of Traumatic Event Scale [73]; CAPS - Clinical Diagnostic Scale for PTSD (2002) (cited: P. Arndt, N. Klingen, 2011 [74]). Recognizing the need to use an operational approach to assessing the pathology being studied, the authors of modern analytical reviews [4, 75] point out that excessive focus on statistics carries the risk of neglecting the clinic and its flattening.

Based on the principle of a simple/linear connection between affective disorders and a psychotraumatic—“etiological” in the authors’ understanding—factor, variants such as, for example, depression of widowers [15], displaced persons [76], divorce cases [77], etc. are identified.

The second approach is aimed at analyzing vulnerability factors (primarily constitutionally determined) to the development of stress-induced depression. Let us turn to the works carried out using this approach, which provides not only for the verification of psychogenic/situational triggers, but also for the analysis of the “soil” on which psychogenies are formed.

As evidenced by the data of domestic [78-83] and foreign [84] authors, somatic (asthenizing) and endogenous-process diseases (negative changes of a psychopathic type within the framework of current/residual schizophrenia) [87–90]. We also note the contribution of domestic researchers to the systematic study of psychogenies observed in forensic psychiatric practice, the development of their classification and principles of expert assessment [91-97]. Depression associated with the threat of criminal liability (such events account for 12% of the total number of mental traumas in peacetime [2]) are represented by depressive-paranoid, asthenodepressive, and depressive-hysterical types.

The connection between personality anomalies and the manifestation of psychogenic disorders (primarily reactive depression) is interpreted on the basis of a number of concepts. Of these, the model of constitutional readiness for psychogenic reactions is the most adequate to clinical reality [98]. The author identifies a special mode of constitutional vulnerability to the effects of stress - reactive lability. In carriers of this constitution, “transient personality collapses” are revealed, in particular in the form of transient psychogenically provoked disorders that occur with symptoms of clouding of consciousness (acute shock reactions, designated by the author with the term “psychoses of horror” - Schrackpsychosen). The latter (like affective and psychogenic depressions) represent “natural phases of the entire life curve.”

In the domestic literature, reactive lability is defined by synonymous terms: “remitting reactivity” [99]; “excessive reactivity” [91]; “reactions within the limits of the individual’s resources” [94]; “characterological psychopathic reactions” [97, 100]. Modern foreign researchers, in development of the teachings of K. Kleist, put forward the concept of diathesis-stress interaction [101, 102].

It must be emphasized that such a conceptualization of the genesis of reactive depression is traditional for Russian psychiatry. So, also S.S. Korsakov, in his “Course of Psychiatry” [103], published in 1913, identified among the causes of psychogenics “producing” (moral shocks) and predisposing (personal predisposition) and emphasized the leading role of an abnormal constitutional make-up. The author pointed out that even in cases where the connection between depression and psychotraumatic effects is beyond doubt, the contribution of a constitutional predisposition cannot be excluded. E.A. Shevalev [99], with reference to K. Jaspers [37], emphasized the ambiguity of the connection between psychogeny and mental constitution. Such an association can be not only psychopathic (i.e. innate: persistent or subject to phase fluctuations), but also acquired (both “temporary”, reversible - exhaustion, and progressive - schizophrenia). This point of view is fully shared by modern authors [69, 104-106], who argue that only by taking into account the “pre-traumatic” personality characteristics involved in the breakdown of individual adaptation mechanisms and predisposing the experience of stress to result in psychopathological disorders, it is possible to obtain relevant information about psychogenics.

According to R. Liu and L. Alloy [107], already the first reactive depression is not only an informative harbinger of the occurrence of depressive reactions in the future, but also the “selection of stress” anticipates the occurrence of a response to a similar stress. According to S. Hammen [108, 109], the formation of stress is largely the result of stable personal characteristics (personality characteristics and behavior of those susceptible to depression - “depression-prone individuals' personality and behavior” in the terminology of T. Joiner et al. [110] ) and the corresponding events arising from these characteristics (“dependent”). Accordingly, from a conceptual point of view, reactive depression cannot be considered as a purely etiological diagnosis [111, 112]. The apparatus of diagnostic criteria, in addition to psychotraumatic influences, should include a number of other indicators, united by the concept of “soil”: constitutional properties, family history of affective and other mental illnesses, age, cultural characteristics of patients, the influence of suffered somatic and exogenous-organic hazards, etc.

For the first time, the connection between stress-induced affective disorders and constitutional make-up as a distinctive characteristic was noted by J. Lange [39]. The author divided the psychogenies of the affective circle into two types. The first includes depression, designated by the term “psychogenic”. The condition develops in schizoid, sensitive, anxious, hysterical individuals. Accordingly, we are talking about a heterogeneous predisposition, devoid of signs preferred for affective pathology, including family aggravation. Such depressions “lack vital foundations.” The second type is represented by “reactive depressions”. J. Lange considered this group of disorders as attacks of circular melancholia provoked by mental trauma. The latter manifest themselves on a constitutionally homogeneous basis - with anomalies of the affective circle (cycloid constitution).

M.O. Gurevich and M.Ya. Sereisky [113] also classify psychogenic depression as a manifestation of psychopathic predisposition. At the same time, the authors considered personality disorders of the affective circle (cycloids, constitutional depressives) as the most typical characteristic of vulnerability in the manifestation of reactive depressions occurring with endoform symptoms. I.N. Vvedensky [91] noted that affective disorders in depression with such a constitutional predisposition occur with vital melancholy .

According to P.B. Gannushkina [114], reactive depression “most readily and deeply” affects persons with a cycloid predisposition. ON THE. Kornetov [115], when analyzing the premorbid makeup of patients with psychogenic depression (217 observations), recorded a predominance of personality anomalies of the affective (31.8%) and hysterical (22.6%) types. The contribution of psychopathic “soil” (personality disorders) in persons who have suffered reactive depression, N.K. Kharitonov [116] estimated 86.2%.

The idea of ​​the importance of constitutional predisposition in psychogenic depression is also being developed by modern foreign authors [117-120]. According to C. Brewin [121], based on an analysis of the results of comparative prospective studies (it was established that the individual significance of a traumatic event increases in the presence of personality disorders), constitutional factors are included in vulnerability to the perception/experience of stress. This constellation increases the “resolution of grief” [122]. At the same time, in the publication of S. Safford et al., dating back to 2007 [118], as well as in some earlier studies [108, 123], negative cognitive style (perception of events of everyday life and, accordingly, stress in “black” colors [108, 109, 124]). In other works [125-130], a special role among depressogenic personality traits is given to neuroticism [131, 132], negative self-esteem (negative evalution of self [133]), low assessment of the environment [134-136], as well as attitude towards the presence of social support as an external locus of control [137].

Different ideas about the nature of reactive depression are reflected in the construction of a typology of psychogenies. Some of them are eclectic - they combine syndromic and transsyndromal characteristics of depression that arise in premorbidly unburdened, “normal” individuals, with forms of psychogenic disorders identified on the basis of the severity/chronicity of the condition or on the basis of a constitutional predisposition.

So, in the proposed D.Yu. Veltishchev [104] model of stress-induced depression, analysis of the structure of psychogenicity is based on the characteristics of the syndrome-forming pattern - “leading affect”, divided into anxious, melancholy and apathetic types (this corresponds to the concept of modality of affect by O.P. Vertogradova [138]), and “core affect” as a basic personality characteristic.

Among the syndromic variants of stress-induced depression, simple depression is distinguished: melancholic, hysterical, asthenic, and hypochondriacal depression [94, 95, 139]. According to the observations of N.V. Kantorovich [2], reactive depression, as a rule, manifests itself in the form of asthenodepressive or anxiety-depressive states. The author identifies the following differences between such states and circular melancholia. Their structure includes symptoms of stupor and psychogenically narrowed consciousness; a common phenomenon is perceptual deceptions, including verbal hallucinations; ideas of self-accusation (in cases where they can be identified) are “intertwined” with ideas of blaming others. A significant characteristic of psychogenic depression is the undulation of the course, as well as the relative short duration. In ½ patients the duration of depression does not exceed 3 months). At the same time, in the second half of cases, a protracted course of psychogenia is possible with the formation of a psychogenic type of pathological personality development (acquired psychopathy. V.N. Krasnov [140], when describing psychogenic depression with a protracted course, identified a single syndrome - anxiety-depressive. Along with melancholy and anxiety in the clinical picture of depression are dysphoric and asthenic inclusions, phenomena of irritable weakness and sensory hyperesthesia. According to N.I. Felinskaya [94], the hysterical type is more common, including signs of psychogenically narrowed consciousness with the phenomena of pseudodementia, puerilism, delusional fantasies. Expressiveness is characteristic , mobility of symptoms; dramatic demonstration of despair, absence of ideas of self-blame with a tendency to blame others.Hysterical depression is characterized by an intermittent type of course with pronounced fluctuations in the mental state (transitions from psychomotor retardation up to psychogenic stupor to excitement, bringing the clinical picture closer to agitated melancholia). The asthenodepressive reaction is manifested by mental and physical weakness, accompanied by profound somatic changes, severe physical exhaustion; behind the monotony and indifference of patients there is preserved emotionality, concern about the current situation; ideas of self-accusation alternate with attempts to “rehabilitate” in the eyes of others, to “atone for guilt.” Asthenic depression has a progressive type of course, lasts a long time and often ends with the formation of a residual (post-reactive) asthenic state. I.N. Bobrov [95] along with the options considered by N.I. Felinskaya, identifies simple reactive depression with a tendency to relapse, when in the picture of repeated reactive formations depressive disorders acquire a more developed and pronounced character - depressive affect is vitalized, signs of melancholic depersonalization and derealization are revealed. The author pays special attention to the characteristics of flaccid-asthenic reactive depression, in which the severity of metabolic and autonomic disorders allows the author to state “the presence of a single psychogenically caused psychosomatic syndrome.” The progressive nature of the course inherent in this type of psychogenic depression contradicts the main criterion of the reactive state - its reversibility. Throughout the entire period, the condition is characterized by monotony and stability; there are almost no fluctuations in the psychomotor background characteristic of other clinical forms of psychogenia. In dynamics, along with the aggravation of clinical manifestations up to the point of flaccid apathetic stupor, the disease completely separates from the psychotraumatic cause that caused it, and the clinical picture becomes similar to asthenic psychopathy, and in more severe cases - a psychoorganic defect.

R.R. Girgenson [141] traced the relationship between reactive depression and personal deviations. He identified two options: the first - with a predominance of angry affect (the clinical picture is dominated by dysphoria, overvalued ideas of the guilt of others) and the second - with a predominance of asthenic affect (ideas of self-accusation and self-abasement are dominant), which are respectively associated with personality anomalies of the excitable and inhibited circle. T.N. La

Causes of reactive psychoses

This is a traumatic situation that has a strong stressful effect on a person.
The situation may pose a threat to life or well-being and is associated with character traits, environmental conditions, and beliefs. Reactive psychoses can occur during accidents, catastrophes, natural disasters, losses, imprisonment or the threat of legal liability, etc. In the appearance of reactive psychoses, an important role is played by the initial functional state of the central nervous system (CNS), the personal characteristics of the patient before the onset of the disease, the typological properties of his nervous system. All factors combined make a given person more (prone) vulnerable to the occurrence of mental trauma.

Pathogenesis

As a result of psychotrauma, inhibition occurs in the cerebral cortex and its subcortical structures.
The specific clinical form of psychosis depends on the spread of inhibition. In acute and prolonged psychoses, the main pathogenetic factor is the pathodynamic structures responsible for the extent of inhibition in the cerebral cortex. In this case, the main neuroassociative stream is involved in a given point of the cortex and remains fixed there. This is the mechanism of one of the main symptoms of reactive states - the pathological fixation of patients’ attention on traumatic thoughts. In psychogenic stupor, inhibition from the pathodynamic structure is concentrated in the motor (cortical and subcortical) parts of the brain, when, for example, in hysterical psychoses (with impaired consciousness) pathological excitation appears in them.

The experiences of patients with reactive psychoses depend on the functional ability of the pathodynamic structure itself. When it is fixed in pathological arousal, patients are reliably fixed on psychotraumatic circumstances; and vice versa, in the presence of phase states, patients experience psychotrauma in a positive way for themselves, as is observed in some psychogenic twilight states and delusional fantasies.

When the pathodynamic structure transitions into an inhibitory state, patients “forget” everything that is directly or indirectly associated with psychotrauma and even the fact of its presence (the mechanism of affectogenic amnesia in delusional fantasies, pseudodementia, puerilism, etc.).

Reactive paranoid syndrome, in the cerebral cortex, causes a number of isolated from each other, but associated with the pathodynamic structure of the diseased points in the cerebral cortex, which determines the psychogenic content of their specific delusional ideas in these patients. In subacute paranoid reactive psychoses and in cases of psychogenic delusional psychosis, in the cerebral cortex there is a functionally isolated single powerful pathodynamic neuroassociative structure in a state of inert excitation, switching over the main neuroassociative flow.

The differences in the clinical picture and further course of the disease are determined by the fact that the paranoid reaction is formed under the influence of acute psychotrauma on the basis of any phenotype of the nervous system, while in psychogenic paranoid delusions the pathodynamic structure is formed under conditions of chronic psychotraumatization on the basis of an initially inert phenotype of the nervous system - paranoid psychopathy.

Symptoms of reactive psychosis

1. Shock psychogenic reactions (shock neuroses, affective-shock reactions, emotional neuroses)

Psychosis occurs due to a sudden strong emotional shock or a life-threatening situation (accident, catastrophe, etc.), all of which can be associated with situations of a negative nature. Affective shock psychoses can manifest themselves in two forms: psychomotor retardation and psychogenic motor agitation. Psychomotor retardation with mutism. The disease manifests itself as complete immobilization and the inability to establish speech contact. The patient is unable to move or call for help, even in a potentially dangerous situation. In this condition, the patient is in clear consciousness, perceives events around him, but does not react to what is happening. Psychogenic motor agitation begins acutely, in the presence of psychotrauma. General psychomotor agitation occurs, the patient is restless, makes aimless movements, speech is usually slurred, and a grimace of horror or fear may be expressed on the face. Impaired consciousness is present.

2. Hysterical psychoses (psychogenic twilight states)

Hysterical psychoses are a common type of reactive states.
They are characterized by symptoms of any type of clouding of consciousness (disorientation, no reaction to events occurring around them, disruption of object contact, etc.). Clouding of consciousness can be traced to a connection with mental trauma. Hysterical psychoses are often divided into three types: pseudodementia, puerism, and hysterical twilight stupefaction. Pseudo-dementia
- the patient suddenly becomes “stupid”, cannot solve the simplest problems, gives ridiculous answers, and is disoriented.
Ganser syndrome is a type of pseudodementia that affects people in prison. Puerilism
is characterized by regression of the psyche to the level of a child.
The form of speech, behavior, emotional reactions become similar to children's. This clinical picture may include elements of adult behavior. Hysterical twilight states
occur in persons with hysterical psychopathy. Patients are demonstrative and can act out scenes in which there is a connection with psychotrauma. There is a perception disorder (true hallucinations), the statements are delusional, they also reflect the traumatic situation suffered.

3. Psychogenic depression (reactive depression)

Psychogenic depression is the most common form of reactive states. It is characterized by: decline in mood, feeling of depression, the patient is careless, stops taking care of himself. As depression deepens, depressive delusions (constant feelings of guilt) and often suicidal thoughts appear. The main cause of anxiety is the psychological trauma that caused the disease. The course is wavy, relative to the severity of symptoms. In clinical practice, there are three more variants of reactive depression: asthenic, depressive-delusional, hysterical psychogenic.

4. Psychogenic manias

Psychogenic manias are much less common than other reactive states. The cause of occurrence is sudden severe psychotrauma that causes a state of passion. A predisposing factor to psychogenic mania may be the presence of psychopathy of the affective and hysterical type, or schizotypal personality disorder. The clinical picture is characterized by irritability, fussiness, increased activity, and unreasonable joy. There is often a combination of opposing emotions present. A sleep disorder occurs (insomnia, restless sleep, difficulty falling asleep, shortened sleep time) associated with replaying memories of traumatic events. The patient is energetic and strives to do everything possible to improve his traumatic situation. At the peak of affect, productivity is lost, hyperactivity, importunity, and conflict come to the fore. The delirium of litigiousness and the desire to punish those “culpable” in the event may join.

5. Psychogenic paranoids

(reactive paranoid, psychogenic paranoid delusional formation, induced delusion) Reactive paranoid develops as a result of an unfavorable situation for the patient, there is a delusional belief that he is being watched, everyone around him is an enemy, treats him badly and wishes harm, etc. Auditory hallucinations often appear, which confirm the patient's beliefs. The development of an acute condition occurs after a short preceding period, with a feeling of anxiety, fear that something bad is about to happen. Psychotraumatization occurs after a new, unusual situation for the patient, combined with external impressions that create an atmosphere of anxiety, uncertainty, and anxiety.

Psychogenic paranoid delusional formation

- a type of reactive psychosis, does not have an acute onset, develops over a long period of time and gradually develops (sometimes several years). The disease is more common in individuals with paranoid psychopathy. Development occurs in conditions of chronic psychotraumatization. The delusion is systematized, based on the interpretation of real events and the situation surrounding the patient. With a prolonged course, delirium becomes persistent and persists for many years.

The patient loses the ability to work and care for himself. Memory, intelligence, adequacy and expression of emotions are not affected.

Induced delusion manifests itself in the “transition” of mental disorders from one person to another. Such a transition is observed in conditions of close communication between several individuals, while one of the individuals suffers from psychosis and is the source of induction - the inducer. A person who perceives these disorders is called inducible.

There are a number of conditions that promote psychic induction:

• close communication (cohabitation, common work or personal relationships) of the inducer and the inducible • the initial mental superiority of the inducer over the inducible (intellectual, social or characterological) • mental weakness, suggestibility of the inducible Themes of induced psychoses are most often associated with delusions of persecution, jealousy, and litigiousness.

Nature of acute psychotic disorder

Acute psychosis is a mental disorder, the main manifestations of which are disturbances in the perception of the surrounding world and depersonalization, that is, an incorrect perception of one’s personality. In this condition, the patient loses control over his thoughts, emotions and behavior.

All psychoses, according to their origin, are divided into exogenous and endogenous forms.

• Endogenous psychoses arise as a consequence of exacerbation of other mental illnesses. Very often this leads to schizophrenia, as well as schizoaffective disorders.
• Exogenous psychoses are provoked by external factors. These can be any traumatic situations: loss of a loved one, violence, racial discrimination, isolation from society. It has been established that poverty is one of the most powerful provocateurs of psychosis. It is a known fact that people who have suffered various forms of violence in childhood, especially sexual violence, loss of loved ones and lack of attention from those raising them in adulthood are susceptible to developing a psychotic disorder.

Another reason for such a violation is various diseases .

Brain injuries and lesions . Syphilis is one of the many diseases that destroys brain cells in the later stages. As a result, the personality degrades so much that I characterize its behavior as the dirty old man syndrome.

Intoxication . Many chemical compounds, when in contact with them, cause agitation and inadequate mental functioning. These include mercury and lead. The latter is found everywhere: dilapidated buildings, drinking fountains with lead lining, pipes, dishes, automobile gases. It tastes sweetish, which can attract children. Those of them who have undergone such intoxication become excitable and lag behind their peers in development.

Other harmful compounds are also known. Thus, two brothers living in Nevada acquired carbon disulfide. They needed the substance to bait gophers. Interaction with this drug caused a psychotic disorder in both brothers. As a result, one of them shot a man. Another fell into depression, his consciousness darkened. This ultimately led to suicide. The story dates back to 1989.

Another group of toxic compounds are psychoactive substances: alcohol, drugs, some medications. They actively influence a person’s mental state, causing pathological changes and inadequate reactions.

Dementia or senile dementia . This is an age-related process, expressed in disruption of the structure of blood vessels and the entire blood circulation in general. Impaired blood circulation in the brain leads to persistent destructive transformations of the personality that are irreversible.

Other provoking diseases include:

• oncological processes;
• epilepsy;
• infections: tuberculosis, influenza, tularemia, malaria, AIDS, etc.;
• atherosclerosis;
• deficiency or excess of certain vitamins and minerals;
• hormonal disorders;
• kidney and liver diseases.

Diagnosis of reactive psychoses

It is important to carry out a differential diagnosis; the symptoms of reactive psychoses are similar to the symptoms of diseases such as schizophrenia, manic-depressive psychosis, delusional disorders, endogenous and psychogenic depression, drug or alcohol intoxication, etc. The diagnosis is made based on the medical history, anamnesis, clinical picture, presence traumatic event and the connection of symptoms with psychotrauma. For example, reactive depression differs from the first depressive phase of circular psychosis (which has a psychogenic onset) in that patients are fixated on traumatic thoughts rather than on their own personality, while the patient justifies melancholy and suicidal thoughts with traumatic events.

Psychogenic disorders

Psychogenic (reactive) disorders are disorders of a neurotic or psychotic level that arise as a result of exposure to shocks that are very significant for a person, negative life situations, and the loss of loved ones.

This is a whole group of disorders, including reactive psychoses, depression, hysterical psychosis, etc. In the International Classification of Diseases ICD 10, psychogenic disorders are included in the heading “Reaction to severe stress and adaptation disorders,” which does not fully reflect the picture of reactive (psychogenic) psychoses.

Causes and factors contributing to the development of psychogenic disorder

The main and, in fact, the only reason for the appearance of a reactive state is the impact of mental trauma, which acts as a trigger. Many troubles happen in a person’s life: natural disasters, wars, man-made accidents, death of loved ones, difficult unforeseen circumstances. It is not always possible to withstand the pressure of negativity that surrounds us. Therefore, many cannot withstand the load, lose self-control, and do inappropriate actions.

A distinctive feature from mental illnesses such as schizophrenia or bipolar disorder is that psychogenic disorders are not associated with heredity. The presence of reactive psychosis in relatives is not the reason for its manifestation in a particular person. In addition, after leaving the psychogenic state, behavioral disorders (adaptation) do not progress; they completely disappear, leaving residual changes in the form of asthenia (exhaustion).

Despite the lack of a clear connection with genetic predisposition, different people react individually to a traumatic situation. This is due to constitutional characteristics, concomitant diseases, duration of exposure to the trigger and the level of mental exhaustion of the person.

Course of the disease, prognosis

Psychosis usually develops within a few hours of psychological trauma.
The duration of psychosis ranges from several hours to several months, but this time may vary. Psychogenic motor excitation has a short course, the output is acute with restoration of orientation, but with amnesia for the period of psychosis. Psychomotor retardation with mutism also has an acute outcome and is accompanied by brief asthenia. The way out of reactive depression is initially lytic, but from the moment the condition improves, there is a tendency to wave-like changes in the severity of symptoms. In general, the duration of the disease ranges from several weeks to 2-3 months. Reactive paranoid can last from several days to several months and depends on how much the traumatic situation has disappeared.

With effective therapy, the prognosis of the disease is favorable. Treatment and its duration are determined by the mobility of symptoms, the good initial (before the disease) condition of the patient, the duration of symptoms, as well as the presence of cases of mental disorders in heredity. It should be remembered that reactive psychoses can also occur in patients with a history of chronic mental illnesses. In this case, the symptoms may be influenced by the underlying psychopathological condition.

Acute mental disorder - treatment

Reactive psychoses require immediate isolation from a traumatic environment and hospitalization. Neurotic spectrum disorders in mild cases are treated on an outpatient basis.

For reactive (psychogenic) paranoid, antipsychotic therapy is preferably not recommended. It is necessary to prescribe sedatives, although they are not etiotropic therapy. It is necessary for the patient to get a good night's sleep.

For psychogenic depression, antidepressants are prescribed if the severity of the depressive state is significant and psychotherapy does not help the patient feel comfortable. For severe anxiety, anxiolytics and tranquilizers are used, and sleeping pills are used to normalize sleep.

The most important place in the treatment of psychogenic disorders is occupied by psychotherapeutic work with the patient at different stages of treatment.

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Treatment of psychosis at the Alter Clinic

Treatment of reactive psychoses in patients is currently carried out by a large system of medication, psychotherapeutic and social techniques.
To be effective, all treatment methods must be in balance with each other, taking into account the clinical form of the reactive state and the type of its treatment. In the presence of an acute condition, treatment is carried out inpatiently. At the clinic of Dr. Shmilovich “Alter” it is possible to undergo a course of individual pharmacotherapy, psychotherapy, incl. cognitive-behavioral, which will help you get rid of attitudes that have arisen against the background of the disease and receive the necessary recommendations. Only highly qualified specialists work. Each psychologist and psychiatrist has extensive experience in this field and constantly improves their qualifications.

Our specialists use the most modern techniques with proven effectiveness to achieve the desired result. The specialist finds an individual approach to each patient. Also, any of your calls to our clinic will remain anonymous.

Fixed price for each individual service. You can find prices and a list of services on our website Convenient location. Our clinic is located in the center of Moscow, near the Cathedral of Christ the Savior, on Vsevolozhsky Lane, next to the Kropotkinskaya metro station.

If you find yourself in a difficult situation, we will provide you with qualified assistance, high quality and at an affordable price. Finding a solution to the problem is much easier if you contact a specialist as early as possible. Our goal is your recovery.