Reactive psychosis is a temporary and reversible mental disorder, psychotic level, resulting from exposure to severe mental trauma. It is similar to other psychoses, but has more pronounced lability, variability and affective intensity.
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.
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.
Complex of therapeutic measures
In the process of treating psychogenics, it is important to establish the cause of the disorder and take measures to eliminate circumstances that are traumatic to the psyche.
Patients are most often hospitalized because they exhibit unpredictable behavior and can be dangerous to others. In addition, people with mental disorders are often suicidal. For this reason, medical supervision is necessary.
In some cases, just a change of environment has a beneficial effect on a person, but this is not enough for recovery. During the treatment, medications are used, such as:
- tranquilizers;
- antidepressants;
- neuroleptics;
- sedatives.
If the patient is overly excited, it is advisable to use the following drugs for intramuscular administration:
- Phenazepam;
- Tizercin;
- Aminazine;
- Diazepam.
The drugs should be administered 2-3 times a day, and drug therapy should be continued until the patient’s adequate condition is restored.
In addition, patients need psychotherapeutic influence. This is necessary for the psychological, social and labor adaptation of the victim.
The duration of treatment depends on the severity of the condition and the individual characteristics of the patient. In some cases, 10 days of hospital treatment is enough for a person, but in other situations, recovery takes 2 or more months.
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.
The role of psychogenics in the clinical presentation of endogenous delusional disorders
The lack of nosological unity of the group of so-called psychoses of the schizophrenia spectrum is due to the significant polymorphism of their clinical picture. The variety of diagnostic interpretations of these conditions is reflected in ICD-10, where endogenous psychoses are “blurred” in a large number of different headings. The most difficult qualification is the interpretation of delusional disorders, which in the vast majority of cases constitute the “core” of endogenous psychosis. Delusional disorders especially often become the subject of diagnostic discussions in cases where their occurrence is preceded by a collision with exogenous hazards, among which a significant share is occupied by psychotraumatic factors.
E. Bleuler pointed out the participation of psychogenic factors in the development of delusional disorders in schizophrenia [3]. The polymorphism of clinical manifestations of procedural delirium, according to the author, is associated with “...various combinations of physiological and psychogenic...”. By “psychogenic” the author meant the individual’s reaction to a developing disease and various psychopathological formations that arise under the influence of psychogenically traumatic factors. Subsequent studies have convincingly demonstrated that it is psychogenies that provoke delusional disorders in schizophrenia more often than other exogenous hazards [1, 6]. At the same time, most researchers have traced a certain dynamics of the development of delusional symptoms in psychogenically provoked schizophrenia from psychogenic, often neurotic, symptom complexes to delusional disorders. In some studies, analysis of differences in the dynamics of autochthonous and psychogenically provoked endogenous processes led to attempts to divide the disease into so-called nuclear (processual) and reactive schizophrenia with different outcomes [8]. The authors of this concept separately point out that the clinical picture of “reactive schizophrenia”, to a greater extent than with nuclear forms, is saturated with delusional products [7]. Investigating the clinical characteristics of delusions in schizophrenia, many authors noted the influence of psychosocial factors on the clinical presentation of delusional syndrome. A special role is given to family factors and conflicts with the immediate environment [9]. Most often, the works of domestic authors [2] emphasize that in cases of schizophrenia arising in connection with mental trauma, delusional syndrome may have a pronounced psychogenic structure. Delirium in these cases “is specific, not prone to transformation and growth, which has long been regarded as evidence of its psychogenic nature and complicates the diagnosis of schizophrenia.” The independent or comorbid coexistence of the psychogenic and endogenous in the mental status of the patient raises a large number of questions for practical psychiatry. To solve them, it is necessary to study the options for the clinical interaction of these two nosological forms. M.I. Rybalsky believes that in the case of the addition of psychogenicity to the main delusional schizophrenic process, the following combinations are possible: 1. The psychogenic factor either does not affect delusional schizophrenic symptoms in any way, or, as a result of some paralogical processing, is partially included in the psychopathological symptom complex, without affecting the content and development of delusions, but only confirming a delusional concept. 2. The content of the psychogenic factor is formally used in the plot of delirium, intertwined with other delusional statements of the patient. 3. A massive psychogenic factor is “layered”, “amalgated” onto the main schizophrenic process, acquiring most of the signs of reactive paranoid, modified by schizophrenic soil [4].
Similar results were obtained when considering this issue from the standpoint of nosological and syndromic comorbidity [5].
An analysis of most studies devoted to the study of psychogenically provoked delusional disorders gives reason to talk about the inconsistency of their results. In particular, a number of issues fundamental to clinical practice remain unresolved. Can a true reactive state, including a delusional state, develop in schizophrenia? Is it possible to transform the psychogenic into the endogenous? What are the clinical interactions between neurotic disorders and procedural delusions? What diagnostic category should include “atypical” delusional disorders that develop according to psychogenic mechanisms in patients with schizophrenia? The lack of unambiguous answers to these questions is the cause of controversy regarding therapeutic tactics and supervision of patients with this pathology. In this regard, it becomes relevant to conduct clinical and psychopathological studies aimed at studying the role of the psychogenic factor in the clinical development, dynamics and prognosis of psychogenically provoked procedural delirium.
The purpose of this study was to identify the prerequisites for psychogenically provoked delusional formation within the framework of psychoses of the schizophrenia spectrum that developed under conditions of psychotraumatic influence, as well as to determine the clinical, psychopathological and pathokinetic specificity of psychogenically provoked endogenous delusional disorders.
Clinical and psychopathological examination of 320 patients (234 women and 86 men) who were undergoing inpatient treatment in the local territorial departments of the Moscow City Clinical Psychiatric Hospital No. 1 named after. ON THE. Alekseeva (chief physician - Prof. V.N. Kozyrev) in the period from 2001 to 2008. In accordance with the diagnostic criteria of ICD-10, the study included patients whose condition met the criteria of headings F.25 “Schizoaffective disorder” (56.3% of the total sample) and F.20.0 “Paranoid schizophrenia” (43.7% of the total sample). The main criterion for selecting patients into the general group (213 patients) was reliable anamnestic information that psychotic symptoms developed under conditions of chronic or acute psychotraumatic influence. Separately, patients were recruited into the control group. In patients in the control group (107 patients), the same psychotic states (F.25 and F.20.0) manifested or recurred spontaneously without prior psychogenic provocation. Despite the syndromic heterogeneity of patients in the general sample, delusional disorders occupied a significant place in the clinical picture of psychotic states.
Distribution of patients in the main and control groups according to socio-demographic indicators (gender, age, education, socio-professional status, marital status, material income), as well as according to such clinical and dynamic characteristics as age of manifestation of the process, duration of the disease, number of previous exacerbations, frequency of exacerbations and degree of compliance turned out to be statistically comparable, which determined sufficient randomization to conduct reliable correlation studies.
The psychotraumas that the patients of the main group encountered on the eve of psychosis were conditionally divided into 4 large groups: 1) psychotrauma of extreme force, 2) emotional deprivation, 3) conflict, 4) material damage.
Psychological trauma of extreme strength occurred when exposed to situations in which there was an immediate threat to life or personal freedom: terrorist acts, crimes, criminal prosecution, disasters, being under investigation, trials. This group also included psychological traumas that arose as a result of severe moral damage: rape, public humiliation, desecration of the graves of relatives, etc. Emotional deprivation was understood as situations that led to a severance of ties with an emotionally significant person: the death of close relatives or the breakdown of a desired relationship (divorce, imprisonment of a loved one, deprivation of the patient's parental rights, etc.). Psychotraumas of conflict content were taken into account only if the conflict situation became the direct cause of a decrease in the socio-professional or family adaptation of patients. As a rule, we were talking about intractable conflicts at work and in the family, which would result in dismissal, demotion, property losses, family breakup, etc. This also included conflicts with the immediate environment, leading to humiliation of honor and dignity personality. The group of psychotraumas caused by material damage included unexpected situations that led to significant property deprivations for patients. In most cases, this occurred as a result of accidents, fraudulent actions, unscrupulous lending, financial shortages at work, dismissal, loss of the sole breadwinner, etc. Often, traumatic events carried a multifactorial impact, for example, emotional deprivation, conflict and material damage at the same time. In these cases, only the psychogeny that turned out to be the most severe for the patient was taken into account (“key experience” according to E. Kretchmer).
In patients of the main group, additional (in addition to the procedural “ground”) constitutional and biological prerequisites for the formation of delusions under conditions of psychotraumatic influence were identified.
CONSTITUTIONAL PREREQUISITES
A comparison with the control group showed a significant predominance of epileptoid, psychasthenic, paranoid, hysterical and cycloid character traits in the premorbid patients of the main group (Table 1). All patients with the noted constitution had a tendency to form stable, difficult-to-correct conclusions (usually persecutory content) when they found themselves in frustrating situations.
Rigidity, viscosity, thoroughness, straightforwardness, getting stuck on trifles, suspicion, stubbornness, vindictiveness and many other traits of epileptoid characters were the basis for a paranoid reaction to conflict situations. These patients, when their ambitions and interests collided with others, often formed stable ideas of relationship, developed a thirst for “just” revenge, and developed a strategy to combat ill-wishers. With their characteristic rancor and rigidity, they scrupulously and pedantically made plans to expose the “terrible crimes happening around them.” In the overwhelming majority of cases, delusional disorders in these patients developed according to the mechanisms of primary delusional formation, on the basis of detailed, labyrinthine thinking and “crooked logic.”
When psychasthenics find themselves in situations of emotional deprivation, their typical anxious suspiciousness, sensitivity and anankasty become the basis for the development of groundless remorse, long-term and persistent feelings of guilt and inferiority. In this state, ideational obsessions, phobias, and panic attacks easily formed. These psychogenically caused experiences became the basis of delusional disorders in subsequent endogenous (usually schizoaffective) psychosis.
For paranoid individuals, any traumatic situation became the cause of decompensation of their innate suspicion. In these patients, the plot of delusional ideas was to the greatest extent “tied” to the content of the psychotrauma that provoked them. Thus, delusional ideas of jealousy arose against the background of severe conflicts in the family, litigious ideas and delusions of reformism developed when traumatic circumstances arose at work. Particularly severe was the decompensation of characterological paranoia when caught in criminal situations, in which persecutory alertness and detective behavior became the main adaptation mechanisms for patients.
Patients with schizophrenia with hysterical premorbid, when confronted with psychotrauma, most often reacted to it with massive affective and dissociative disorders with severe somatoform and conversion disorders (hypo- and paresthesia, senestopathies, paresis, aphonia, stupor, hyperkinesis, seizures, etc.). In addition, the increased suggestibility of these patients and their tendency to pseudology created the prerequisites for the formation of stable induced fantasies, the content of which, under conditions of prolonged psychotraumatic influence, acquired a delusional character. Dream-like fantasies that arose within the framework of hysterical psychosis were transformed into figurative delusions of representation (imagination), which became the “core” of schizoaffective psychosis.
In the case of affectively labile (cycloid) premorbid, the “ground” for the formation of delusions was the excessiveness of affective reactions characteristic of these patients in stressful situations. At the height of affect of any polarity, according to the mechanisms of disturbance of sensory cognition, they developed overvalued, and then delusional ideas congruent with affect. This is how the delirium of self-blame and sinfulness, special significance and greatness, invention and erotomanic content was formed.
Another prerequisite for the formation of delusions under conditions of psychotraumatic influence in patients with schizophrenia was a relatively low level of conceptual abilities associated with intellectual deficit. In more than a third of cases (Table 2), patients in the main group had mental development delays in childhood. 2.3% of patients in the main group were diagnosed with schizophrenia. Indicators of cognitive deficit associated with both congenital factors and organic exogenies were more often detected according to the experimental psychological examination in the main group. Difficulties in analytical activity, difficulties in generalization and abstraction, a visual-figurative, concrete, template level of thinking, “affective” logic, increased suggestibility and a low level of criticism created the appropriate “soil” for the formation of difficult-to-correct judgments when caught in a traumatic situation.
BIOLOGICAL BACKGROUND
Exogenous factors that occurred in anticipation of both manifest and recurrent schizophrenic psychoses were also found with a significant predominance in the main group compared to the control group (Table 3). In the overwhelming majority of cases, we were talking about asthenizing hazards, which were represented by viral infections (23.0%), alcohol abuse (13.1%), objective physical overload (long working hours, no days off, long-term care for a seriously ill relative, etc. .) (21.1%), forced lack of sleep (baby, daily work schedule, etc.) (24.9%). The psychogenic effect in these cases was the “last straw” that disrupted adaptation mechanisms. The biologically altered “soil” created the necessary background for a delusional interpretation of stressful events. In these patients, delusional disorders at the manifest stage resembled “paranoid background reactions” by K. Schneider or “paranoid external conditions” by S.G. Zhislina.
Further progression of psychosis after the cessation of exogenous influence made it possible to definitively diagnose the procedural nature of delusional production.
A thorough analysis of the initial stage of development of psychotic disorders during psychogenic provocation made it possible to identify several stages in the formation of delusional products under conditions of psychotraumatic influence: 1) the stage of psychogenically provoked precursors of delirium (prodrome); 2) stage of endoreactive delirium (transitional syndromes); 3) stage of clinically completed delusional syndrome.
At the stage of psychogenically provoked precursors of delirium, mental disorders of a psychogenic nature took place, which subsequently became the “soil” for the formation of delusions. Among them, the following were identified: 1) situational overvalued fear of persecution; 2) psychogenic affective alertness; 3) reactive confusion with deceptions of perception; 4) neurotic asthenic mentism; 5) hysterical delusional fantasy; 6) induced delusions (induced “delusions”); 7) psychogenic sensitive ideas of relationship.
Psychotraumatic circumstances that implied a real threat to life or personal freedom formed a psychologically conditioned and adequate fear of criminal or legal persecution. Patients who were victims of fraudulent activities, violence, or who came under the suspicion of investigative authorities experienced constant persecutory fear, dictated by real facts that objectively confirmed surveillance. The noted disorders were qualified at this stage as situational paranoid reactions.
In some cases, psychogenic anxiety-depressive symptoms, which provoked states of affective alertness, acted as a harbinger of delusional disorders. Affective alertness meant fear of a possible repetition of the traumatic impact. Being in a state of psychogenic depression, patients, manipulating depressive logic, proceeded from the well-known postulate that “trouble does not come alone.” Often such wariness arose in situations of repeated psychotraumatization in a short period of time (for example, two or more deaths of close relatives in a row). This was accompanied by a wary attitude towards current events with a constant expectation of the next misfortune, threat, etc.
Another precursor of psychogenically provoked endogenous delusional disorders was reactive confusion with perceptual deceptions. These disorders were transient in nature, arising directly from exposure to sudden and unexpected psychotrauma of extreme force. The psychotic level of disturbances, psychomotor symptoms, and disorders of consciousness of the “affectively narrowed twilight stupor” type made them diagnostically similar to affective-shock reactions. Affective selectivity of perception, individual psychogenic illusory-hallucinatory disorders and the partial nature of mnestic disorders created a sufficient prerequisite for subsequent delusional formation in these patients.
In conditions of prolonged mental trauma, combined with significant physical overload, conditions often developed that fit into the diagnostic framework of neurasthenia. Asthenic or cerebrasthenic symptoms in these patients were accompanied by symptoms of mentism. In addition to the unproductive acceleration of ideation activity, patients noted a confusion of thoughts, a “whirlwind of ideas,” a chaotic flow of associations, etc. The noted thinking disorders had a clear connection with the intensity of stress and asthenizing factors (forced lack of sleep, malnutrition, heavy physical labor). Subsequently, the noted associative disorders became the “soil” for the formation of delusions.
Hysterical delusional fantasies were observed on the eve of schizophrenic psychosis in only 5 patients of the total sample. However, despite the small number of these observations (which corresponds to general population epidemiological data), it was also decided to include the noted disorders in the group of precursors of delusional disorders during psychogenic provocation of endogenous psychoses. Fantastic delusional judgments, accompanied by fragmentary illusory-hallucinatory experiences, were built around acute and extreme psychotraumatic circumstances. They were characterized by transient and paroxysmal nature, accompanied by phenomena of affective narrowing of consciousness, demonstrative and grotesque excitement with blackmailing auto-aggression and various sensorimotor disorders, including a hysterical attack. Diagnosis of the psychogenic nature of the noted psychotic disorders was difficult due to the schizophreniform nature of the fantasy plot, on the one hand, and the presence of exogenous-organic and epileptiform coloring of the disorders, on the other. In all these patients, schizophrenic psychosis developed after a relatively long (from 3 days to 2 weeks) “bright” interval. Despite this, the non-amnesic part of delusional fantasies formed the “core” of the delusional system in subsequent endogenous psychosis.
In some patients at the prodromal stage, psychogenic induced delirium was formed under conditions of psychotraumatic influence. The inductors in such cases were either mentally ill relatives or representatives of so-called paranormal or metaphysical practices (psychics, sorcerers, magicians, fortune tellers, etc.). The induction was facilitated by high suggestibility, which was one of the frequent clinical manifestations of psychogenic disorders, for which patients sought help from various parapsychological “healers.” The persistent belief in the presence of the “evil eye” and “damage”, “negative influence of space”, etc., being at first a difficult-to-correct induced delusion, later, at the stage of formation of endogenous psychotic disorders, was transformed into acute sensory or figurative delusion.
Another precursor of delusional disorders during psychogenic provocation of schizophrenic psychoses were sensitive ideas of attitude. These disorders predominantly developed in sensitive-schizoid individuals in response to so-called “ethical conflicts” (work, family, sexual). They did not reach the level of delirium, being unstable and closely related to the actualization of the conflict. One of the sources of the development of sensitive ideas of attitude (especially in women) was a significant and obvious external defect. Patients noticed “disdainful” glances and “ridicule” directed at them in public places. Social phobia and avoidance of crowded places often developed. The noted disorders were included in the group of precursors of delusions, since the subsequent transformation of obsessive-overvalued ideas of relationship into a paranoid syndrome occurred.
The stage of endoreactive delirium was represented by complex polymorphic symptom complexes that combined in their structure psychogenic disorders described above as the prodrome of delusional disorders and delusional symptoms of a schizophrenic nature. Assessment of these conditions from a clinical and dynamic point of view allows us to qualify them as transitional syndromes. Four groups of transitional endoreactive syndromes have been identified: 1) depressive-delusional, 2) obsessive-delusional, 3) hysterical-delusional, 4) endoreactive paranoia.
Depressive-delusional syndrome (51.2%)
Both its affective and delusional parts were distinguished by endoreactivity - a combination of psychogenic and procedural diagnostic signs. Depressive symptoms were represented by massive anxious affect, expectation of repetition or worsening of the traumatic event. The patients associated their condition with stress factors and, when they were mentioned, reacted by increasing the severity of depressive symptoms. At the same time, endogenous clinical signs took place: regular daily fluctuations in affect, vitality, caesthetic pain in the chest area, suicidal intentions, a feeling of hopelessness, painful mental insensibility.
Delusional disorders were represented by a combination of psychologically determined delusional ideas of relationship and blame, ruin and impoverishment, jealousy and erotic contempt, on the one hand, and holothymic delusions of self-abasement and self-blame, influence and staging, special meaning and doubles, on the other.
Obsessive delusional syndrome (7.5%)
The clinical picture of these symptom complexes was represented by a combination of neurotic obsessions and endogenous delusional syndromes. There was a combination of psychogenic nosophobia with paranoid hypochondriacal delusions, panic attacks and agoraphobia with acute delusional depersonalization, senestopathosis and sensory mental automatisms, social phobia and dysmorphomania with delusions of relation, transport phobias with phenomena of mentism, ideational and sensory automatisms, derealization and acute sensory delusions of staging.
Hysterical delusional syndrome (20.2%)
Somatoform hystero-conversion symptoms (gloves and socks anesthesia, paresthesia, algia, pseudoparesis, pseudoparalysis, etc.) were accompanied by a delusional interpretation, combined with visceral hallucinosis, delusions of obsession, or Cotard's syndrome. Psychogenic hysterical psychosis of a polymorphic structure with a combination of stupor, affectively narrowed consciousness, pseudodementia, astasia-abasia coexisted with affective-delusional and catatonic-hebephrenic disorders of a procedural nature. Moreover, the endogenous and psychogenic parts of psychosis were in close intersyndromal interactions, transforming into each other from time to time. The syndrome of delusional fantasy combined the features of psychogenic hysterical psychosis (transitivity and paroxysmalness, affective narrowing of consciousness, demonstrativeness and grotesqueness of mythomanic constructions and their meaningful connection with a traumatic event) and acute delirium of the imagination, delusional erotomania, religious, archaic, Manichaean and apocalyptic delirium.
Endoreactive paranoia (21.1%)
In 21.1% of patients, so-called endoreactive paranoia was diagnosed as a transition syndrome. In this group, a combination of psychogenic overvalued ideas and procedural interpretive delusions was observed. It should be noted that in these patients the traumatic circumstances were represented by an immediate threat of violent death or imprisonment (investigative actions). These patients were subjected to criminal persecution, suspected of committing crimes, etc. The content of situationally determined, highly valuable persecutory experiences was fully consistent with psychotrauma. Paranoid delusions of a schizophrenic nature did not simply coexist with reactive interpretive formations, but were the result of their further psychogenic-process dynamics. For quite a long time, delusional disorders in these patients showed a close relationship with psychotraumatic circumstances and were not regarded by the immediate environment (largely induced by these ideas) as pathological. Nevertheless, the persistence and uncorrectability of these judgments, their tendency to generalize and expand the plot, and their continued high coverage even with the distance in time or the complete disappearance of a real threat to life or personal freedom, gave reason to talk about their pathological transformation. These conditions presented the greatest difficulties for differential diagnosis, since, on the one hand, they were typical procedural symptoms, and on the other, they were psychologically determined and logically derived from traumatic circumstances.
At the stage of clinically completed delusional syndrome, delusional symptoms were formed into a syndromicly defined psychopathological formation of a procedural nature. In the framework of this study, it was decided to classify all delusional syndromes, both in the main and control groups, according to two key characteristics, such as the severity of occurrence (acute and chronic delusions) and the psychopathological “soil” for delusion formation - disorder of ideas (figurative delusions) , perception (sensual, hallucinatory delusions), affect (depressive, manic delusions), thinking (interpretive paranoid, paranoid and paraphrenic delusions). Delusional production in most cases was not stable and static, often transforming within one attack or relapse. Taking into account the plasticity and variability of delusional disorders, they were built into a dynamic continuum: figurative delusions of imagination (acute fantastic paraphrenia) – sensory delusions of perception (acute hallucinatory-paranoid syndrome) – affective delusions (ideas of self-deprecation, expansive paraphrenia, affective-delusional syndrome) – hallucinatory delusion (delusional interpretation of “voices”) – acute interpretative delusion (delusional insight) – chronic paranoid delusion (delusion of interpretation) – chronic paranoid delusion (Kandinsky syndrome) – chronic paraphrenic delusion (systematic paraphrenia).
The qualification of delusional disorders was made in accordance with the main syndrome that predominated in the clinical picture of the attack (exacerbation). With psychogenic provocation of delusional psychotic disorders, a certain pattern of changes in syndromes was discovered from psychogenic precursors to endoreactive states and then to clinically completed delusional disorder (see figure).
The figurative delirium of the imagination was preceded by the hysterical-delusional states described above, which in turn developed on the basis of the primary psychogenies of the hysterical pole (delusional fantasies or induced delusional judgments). Acute sensory and affective delusions were formed as a result of the endogenization of psychogenic depression with affective alertness. The transition syndrome in this variant of pathokinesis was an endoreactive depressive-delusional state. Reactive confusion with deceptions of perception during affective-shock reactions became the “soil” for the development of hallucinatory or sensory delusions. The prerequisite for psychogenically provoked manifestations or exacerbations of interpretative delusions of a paranoid, paranoid or paraphrenic structure was endoreactive paranoia, which in turn “flowed” from situational overvalued persecutory fear within the framework of paranoid reactions, neurasthenic mentism or sensitive ideas of relation, socio- and agoraphobia in obsessive-compulsive neurosis states. Psychogenic obsessive-compulsive disorders sometimes transformed into endoreactive obsessive-delusional disorder, on the “base” of which procedural paranoid, paranoid or paraphrenic symptoms developed or sharpened. Thus, psychogeny played a significant role not only in shaping the plot of endogenous delirium, but also determined in most cases its pathokinesis and psychopathological structure. Additional confirmation of this thesis can be provided by examples of the development of delusional symptoms that are “atypical” for one or another form of procedural disease during their psychogenic provocation (Table 4). The appearance of secondary delusions in continuously ongoing paranoid schizophrenia was observed only in the main group in 21.4% of cases. Primary, interpretative, systematized delusions were observed in the main group of schizoaffective psychoses almost twice as often as in the control group. In all variants of such “atypia,” it was possible to trace the pathodynamic patterns described above in the clinical development of delusional disorders under conditions of psychotraumatic influence.
In conclusion, it should be noted that the majority of patients in both the main and control groups, in addition to subjectively significant psychotrauma, encountered a number of different nonspecific psychotraumatic influences. Such psychogenies, first of all, must include stigmatization, the consequences of which were experienced to a greater or lesser extent by virtually all patients in the total sample. It is extremely difficult to assess the degree of its influence on the clinical picture of delusional states. At the same time, it should be noted that patients who were more subject to “social rejection” showed a greater degree of systematization of delusional ideas both in schizoaffective psychosis and in paranoid schizophrenia. This served as a relative predictor of poor prognosis of the disease.
Thus, the results of the study indicate the clinical and pathogenetic heterogeneity of delusional disorders in psychoses of the schizophrenia spectrum that developed under conditions of psychotraumatic influence. The fundamental possibility of transforming psychogenic disorders into endogenous ones confirms the hypothesis of the multifactorial pathogenesis of psychoses of the schizophrenia spectrum. The degree of so-called “clinical atypia” of endoreactive psychoses is so high that it is incorrect to correlate them with diagnostic criteria for schizophrenia or psychogenic diseases. In this regard, there are sufficient grounds for identifying nosologically independent groups of endoreactive diseases. For practical psychiatry, the diagnostic criteria for precursors of psychogenically provoked delusional psychoses, as well as “transitional” endoreactive states, should be especially significant. Timely diagnosis and treatment of these disorders will significantly improve the prevention of psychoses of the schizophrenia spectrum.
Literature
1. Ambrumova A.G. On the clinical and pathophysiological characteristics of schizophrenia that arose after mental trauma / Proceedings of the All-Union Scientific Practical Conference dedicated to the 100th anniversary of the birth of S.S. Korsakov. M., 1955. 2. Ambrumova A.G., Ordyanskaya A.B. Types of psychogenic reactions in patients with schizophrenia with a favorable course (clinical follow-up study) // Current issues of social psychiatry and borderline neuropsychiatric disorders. M., 1975. 3. Bleuler E. Guide to psychiatry / trans. with him. A.S. Rosenthal. Berlin: Doctor, 1920. Reprint edition: Publishing House of the Independent Psychiatric Association, 1993. 4. Rybalsky M.I. Rave. M.: Medicine, 1993. 5. Smulevich A.B., Kolyutskaya E.V., Almaev A.A., Ilyina N.A., Tukhvatulina L.Sh. Post-traumatic stress disorder in endogenous diseases // Psychiatry. 2003. No. 3. 6. Frumkin Ya.P. Psychogenic factors in the pathogenesis and course of schizophrenia // Collection of abstracts of scientific works of employees of the Kyiv Medical Institute. Kyiv, 1957. 7. Berze E. Psychologie der schizophrenic // Springer, Berlin. 1929. 8. Langfeldt G. The reactive psychoses // Wein Zeitshrift fur Nerven-heilkunde. 1967. Vol. 25. P. 278-285. 9. Myin-Germeys PA, Nicolson NA, Delespaul EG The context of delusional experiences in the everyday life of patients with schizophrenia // Psychological Medicine. 2001. No. 31.
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.
General nature of causes and etiology
The causes of psychogenicity lie in psychological trauma of varying severity. An individual’s experiences can be acute or chronic, characterized by a state of shock, depression or anxiety.
In many ways, the course of the disease and the patient’s condition are determined by the severity of the injury and the degree of mental instability. A person who is sensitive by nature to emotional shocks experiences this condition much more difficult than someone whose psyche is more stable.
More often, psychogenic disorders occur in vulnerable and infantile people who react sharply to what is happening, as well as in people with mental retardation.
In addition, unfavorable life circumstances, the death of loved ones and long-term family troubles, a humiliating position of a person or awareness of physical deformity and inferiority can give impetus to the development of mental disorders. In this case, the disease develops slowly, gradually reducing vitality and leading the individual to a state of apathy.
It is not possible to find out how widespread such a disorder is, since many people do not assess their condition as painful, considering what is happening as a “everyday situation” and a “dark streak.”
However, it is safe to say that cases of the development of psychogenicity become significantly more frequent during mass upheavals in the form of wars and natural disasters.
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.
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.
Features of psychogenic disorders in children and adolescents
Any of the listed types of mental disorders may occur in childhood and adolescence. The difference is that a fragile child’s psyche can react to traumatic situations more acutely, but recovery in children with proper treatment is faster.
Factors that indicate a child or adolescent’s predisposition to the development of psychogenics include the following features:
- anxiety and suspiciousness;
- increased excitability;
- impressionability and sensitivity;
- infantilism;
- tendency to worry and unreasonable fears.
The personality characteristics of a child largely determine the type of disorder that may arise in a stressful situation.
For example, children suffering from increased anxiety are more prone to neurotic disorders of overvalued content, and an easily excitable child reacts to mental trauma with manifestations of the hysterical type.
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.
Implications for general health
Our psyche is sometimes unpredictable, and the same applies to prognoses for various disorders. The chances of recovery and possible consequences directly depend on the situation that caused the mental disorder, as well as on the individual characteristics of the body.
In addition, one should not miss such a moment as the timeliness of assistance - the earlier treatment is started, the higher the chance of a favorable outcome.
In some cases, the patient fully recovers from the shock, but it also happens that what happened leaves a mark for life.
In addition, psychogenic and reactive mental states can cause somatic diseases, for example:
- disruption of the gastrointestinal tract;
- problems with the respiratory system;
- heart and vascular diseases;
- enuresis and difficulty urinating;
- hormonal imbalances.
Also, as a result of mental disorders, frigidity occurs in women, and impotence in men.
