Borderline neuropsychiatric disorders. Borderline mental states. Borderline personality disorder - symptoms and treatment of the psyche Borderline mental disorders in psychology classification

Borderline mental disorders

A group of mental disorders, united by non-specific psychopathological manifestations of a neurotic level.

In their occurrence and decompensation, the main place is occupied by psychogenic factors. The concept of borderline mental disorders is largely conditional and not generally recognized. However, it has entered the professional vocabulary of doctors and is quite common in scientific publications. This concept is used mainly to group mild disorders and separate them from psychotic disorders. Borderline states are generally not initial or intermediate ("buffer") phases or stages of major psychoses, but a special group of pathological manifestations with a characteristic onset, dynamics and outcome, depending on the form or type of the disease process. The most common signs: ■ the predominance of psychopathological manifestations of the neurotic level throughout the disease; ■ relationship between mental disorders proper and vegetative dysfunctions, night sleep disturbances and somatic diseases; ■ the leading role of psychogenic factors in the occurrence and decompensation of painful disorders; ■ "organic predisposition" of the development and decompensation of painful disorders; ■ the relationship of painful disorders with the personality and typological characteristics of the patient; ■ maintaining a critical attitude to the patient's condition and the main pathological manifestations. In borderline states, there are no psychotic symptoms, progressive dementia, and personality changes characteristic of endogenous mental illnesses (schizophrenia, epilepsy).

The borderline condition implies a pathology of mental health. It is difficult to diagnose the disease, the symptoms of psychosis and neurosis are similar to the disorder. Pathology leads to suicidal tendencies, which complicates treatment.

What is a borderline state of mind in psychiatry?

Borderline psychiatry believes that the pathology of the psyche is a complex disease that provokes disturbances in the perception of reality. The patient's behavior changes greatly, there is anxiety, distrust of the environment, emotional behavior, mood changes.

Important! Symptoms begin to appear at school age!

Borderline causes personality disorder. Psychiatrists consider such a phenomenon in the middle of normal and disorder. Pathology can be identified by a number of signs:

• depressive state;
• high anxiety;
• behavioral changes;
• isolation from the environment;
• distorted perception of reality;
• panic attacks;
• promiscuity in the choice of partners;
• bulimia and anorexia.

All symptoms require specialist research.

Reasons for the borderline state

If we talk about what a borderline condition is, then often doctors note the instability of the patient's mood. He can be overly sociable or abruptly become withdrawn and seek solitude. It is also theoretically possible to assume that the reasons are:

• imbalance of brain chemicals;
• genetic predisposition;
• low self-esteem can also provoke illness;
• childhood is of great importance, if there was sexual abuse or emotional suppression of the personality, then this can cause a serious disorder.

Important! Mental disorder causes high demands on the child in early childhood and the inability to express emotions.

Symptoms

Borderline mental state symptoms in patients may be similar. They cannot recognize their own problems and refuse to listen to common sense. Such individuals often get hung up on failures, do not try to correct mistakes due to fear of loneliness and misunderstanding, change. These fears are often completely unjustified. Sometimes a person breaks up with a partner so that he is not subsequently rejected, he finds himself in a vicious circle. Symptoms of a mental disorder can be as follows:

• increased anxiety and depression for unknown and incomprehensible reasons;
• ambiguous perception of one's own personality, high self-esteem or too low;
• unstable relationships with others, first the patient idealizes a specific person, and then feels disgust and hatred for her for no reason.

Borderline people often endanger their own lives, drive in inappropriate conditions, change sexual partners, overeat, and spend all their money. After a surge of emotions comes emptiness and depression, anger and rage.

Important! Borderline disorder is demonstrated by real or apparent suicidal tendencies.

signs

Borderline states in psychiatry are important to distinguish from neurosis or mental disorder. Patients cannot independently process information, unlike neuroses.

A person with a personality disorder does not understand that he is ill. He shows strange reactions and considers them the only correct and possible ones. During the disorder, deep mental disorders occur, rapid deterioration of the condition. They appear in connection with childhood memories or negative events of the past.

Important! A borderline condition cannot be cured completely; it is possible to calm the patient, “heal” him, and cause a prolonged remission.

Diagnostics

The borderline state of the psyche can be confused with neurotic disorders. It is necessary to conduct an examination to identify the disease. The disorder shows disturbances in emotional perception.

Psychosis is a pathology of the psyche that provokes inappropriate behavior due to problems of misperception of reality. External factors and stimuli can provoke a non-standard and inadequate reaction. The disease causes delusions, sometimes hallucinations, strange behavior and obsession.

Borderline Treatment Methods

Not everyone can diagnose mental illness, patients cannot find help, but they understand the essence of the problems. Mental decapitation occurs due to social conditions of life.

The borderline state of the psyche reduces the quality of life of patients. He needs serious intervention from a specialist, he needs social assistance and an environment.

Violations can occur due to a difficult childhood, an accident, severe stress or conflicts with the outside world.

When analyzing the factors that provoked mental disorders, some actions are distinguished, they help to bring the patient to a normal and calm state. The need for preventive measures depends on certain conditions:

• sometimes it is enough to report professionally about a problem that worries a person, then you can reduce the level of mental decapitation;
• specialists often practice group sessions and involve patients in discussing the most important life issues, extreme incidents and disasters, problems of the past;
• sometimes, to block the disorder, you need to pull the person out of the usual stressful environment.

Borderline disorder can cause social decapitation, therefore, it needs timely identification and treatment. You should consult a doctor, conduct a gentle treatment or therapy with special preparations. The patient does not need to be in a medical facility all the time, he does not pose a danger to others. With timely detection of the disorder, it is possible to quickly stabilize the patient and improve the quality of life.

Psychotherapists advise not to delay visiting a doctor when symptoms of a person's borderline condition are detected. The doctor will identify the factors that provoke the disease.

It is important that the patient trusts the psychotherapist, tells about his own experiences and feelings, sensations. A competent doctor will turn the patient in the right direction, suggest ways to search for true values ​​and one's own "I". A person will go into the most difficult situations of the past, will be able to properly survive unpleasant events and find balance.

Important! The right choice of a psychotherapist is the key to effective treatment.

The consequences of borderline disorder and untimely treatment of the patient are alcoholism, drug addiction, obesity, anorexia and bulimia, and other problems. The patient begins to hide from the outside world, prefers loneliness. There is a possibility of committing suicide.

Borderline disorder is not a cause for despair. A person will achieve a stable remission, make friends, start living happily.

This group of diseases includes neurosis, psychopathy and mental disorders in somatic pathology. They are united by an intermediate position that they occupy, on the one hand, between the norm and mental pathology, or, on the other hand, between mental and somatic pathology, the boundaries between which are often difficult to draw. Yu. A. Alexandrovsky believes that the mechanisms that determine the boundaries of normal and pathological in mental activity have a wide range of functional capabilities. It is this mobility of the borders that N. I. Felinskaya considers as the main criterion for distinguishing borderline disorders. In particular, the author speaks about the mobility of transitions between the norm and pathology, between painful states within the very forms of "minor psychiatry" and about the mobility of the relationship between the personality and psychogenic situational circumstances. With the mobility of the borders, a significant variety of manifestations of neuropsychic pathology is also associated. P. B. Gannushkin not only showed a greater dynamism of borderline disorders, but also revealed a relationship between the significance of the range of mental disorders attributed to " small» psychiatry, and the individual characteristics of the persons in whom they are observed; he also established the fact of the level formation of borderline mental pathology.

In the ICD-10, borderline neuropsychiatric disorders are included under headings F4 - "Neurotic, stress-related and somatoform disorders", F5 - "Behavioral syndromes associated with physiological disorders and physical factors", F6 - "Disorders of mature personality and behavior in adults ".

The variety of forms of borderline mental pathology testifies to the importance of pathopsychological diagnostics for “minor” psychiatry. To no lesser extent, the participation of a psychologist is also required for neuropsychic borderline disorders. To successfully conduct psychotherapy, the doctor must have an in-depth individual and personal characteristics of the patient, know his premorbid features, how his personality was formed, what his relationship with the environment is, what is the mode of the patient's reaction to a stressful situation (not only now, but also in past life periods). In this regard, S. S. Liebig (1974) highly appreciates the importance of medical psychology for psychotherapy - both purely pathopsychological studies and using the methods of social psychology. The latter have successfully proven themselves in the selection of groups of patients according to the relationships that develop between them, in the choice of the most suitable psychotherapist for a particular group of patients, etc.

Pathopsychological diagnosis in borderline disorders is primarily a diagnosis of personality. However, the role of the study of singularities should not be ignored. cognitive activity. Diagnosis of neuroses and psychopathy always proceeds by differentiation with neurosis- and psychopath-like states arising in connection with process, organic or somatic diseases. Thus, the asthenic state may be due to a psychogenic situation, exogenous organic brain damage due to traumatic brain injury, asthenic somatic (infectious) disease. Outwardly resembling asthenic symptoms can be significantly represented in the clinic of neurosis-like schizophrenia. Finally, asthenia is the leading symptom of cerebral atherosclerosis, and in its initial stages it is absolutely necessary to make a differential diagnosis between neurotic asthenia in an elderly person and atherosclerotic cerebral asthenia. The same applies to psychopathic syndromes - they may be the result of congenital abnormal personality traits or pathological development, or they may be a clinical manifestation of schizophrenia or an organic process. All this requires at the first stage of the examination of the patient to resolve the issues of nosological diagnosis. Pathopsychological diagnostics here is of a “negative” or “positive” nature, that is, it helps to resolve the issue of the absence or presence of cognitive impairment and personality traits characteristic of a mental illness that can occur with neurosis- or psychopath-like symptoms.

B. D. Karvasarsky points out that, although the clinical method of examining neurotic patients includes what, in its development, finds a more complete expression in the main methodological approaches currently existing to the experimental study of personality, it still cannot completely replace them. At the same time, the author emphasizes the following main advantages of experimental psychological methods: the study of the personality's reaction is carried out under controlled conditions, which allows, in the formal classification of decisions, to single out reproducible facts and compare data obtained under different conditions and on different subjects (the principle of measurement); the conclusion about the personality is objectified, since the experimental technique includes not only the rules for obtaining data about the personality, but also the rules for their interpretation for the purpose of reliable reproducibility; the results obtained in such a study may not depend much on the experience, qualifications, personal characteristics of the researcher; the experiment allows the most complete, versatile characterization of the personality of the subject.

The use of any one experimental method is not enough for a complete study of personality. The art of a pathopsychologist lies in the successful selection of research methods in each specific case and the constant correlation of the data obtained with the clinic.

The pathopsychologist must avoid fetishizing any method of personality research. At the present time, unfortunately, we do not yet have completely irreproachable methods in this field. Nevertheless, any method, if it is ethically acceptable, can be used to study personality, provided that the data obtained with its help are methodologically correct. In this regard, for the study of personality in borderline psychiatry, methods and techniques related to different groups can be used, that is, based on observation, on the analysis of biographical material, studying personality in activity, based on assessment and self-assessment, projective. All of them in the conditions of a pathopsychological experiment complement each other.

Personality questionnaires in borderline pathology are widely used, sometimes psychologists and clinicians place unjustified hopes on their use. The fact is that not a single personality questionnaire in itself gives results that are significant for nosological diagnosis. As a rule, most questionnaires allow the researcher to determine the level of neuroticism and make syndromological assumptions. This applies to the simplest questionnaires (Eysenck), screening questionnaires and the most complex (MMPI). However, these data also have significant diagnostic value. Neuroticism, according to N. J. Eysenck, indicates a predisposition of the individual to borderline pathology. This, to a certain extent, coincides with the concept of G.K. Ushakov (1978), who believed that the clinical quality of borderline disorders is due to the characterological radical, typical for the premorbid of a given personality, which is especially demonstrative in accentuated personalities. Psychic trauma, according to G.K. Ushakov, only overstrains the activity of deficient systems, revealing the qualities of a clinical radical of disorders. Ushakov explains the dependence of certain types of disorders on certain properties of mental trauma not by the qualities of the psychotraumatic factor itself, but by its psychological proximity to one or another characterological radical inherent in the patient.

The use of a personality questionnaire makes it possible to determine the type of neurotic or neurosis-like syndrome and, to a certain extent, the severity of the pathology.

So, in a number of guidelines for the use of MMPI (cited by A. Kokoshkarova, 1983), it is indicated that mild neuroses are said to be when the indicators of the neurotic triad are between 70 and 80 T-points, severe neuroses are characterized by an excess of neurotic scales of the level of 80 T- points and the addition of a rise on a scale of 7.

Rising on scale 3 with an increase on scale 1 and a decrease on scale 2 (“conversion prong”) is characteristic of hysterical syndromes. The peak on scale 7 is typical for patients with anxiety-phobic syndrome, while the score on scale 2 is also increased, however, in contrast to patients with anxiety-depressive states, in patients with phobic syndromes, the rise on scale 7 prevails over the rise on scale 2. -phobic states, in which fears for one's health predominate, and the personality profile also shows an increase in scale 1.

The MMPI technique can significantly supplement and objectify the data of clinical observation in the study of psychopathic personalities, especially those with antisocial tendencies (Fig. 39). Such research turns out to be useful in expert work. An isolated peak on a scale of 4 is regarded as a manifestation of psychopathy with antisocial tendencies. Such subjects are characterized by disregard for generally accepted norms of behavior, moral and ethical values, ignoring the forms of behavior that have developed in this environment. An even greater social maladaptation is evidenced by the addition of a high rise to the peak on scale 4 on scale 6 (Fig. 40).


The study of the level of claims in neurosis was carried out by employees of V. N. Myasishchev (1960). So, with neurasthenia, a disproportion between the level of claims and the internal resources of the individual was noted. In patients with hysteria, both an overestimated level of claims and their absence were noted. The first variant was typical for patients with aggressive-sthenic personality components, the second - for patients with relaxed hysteria, asthenic-abulic type.

V. I. Bezhanishvili (1967), B. V. Zeigarnik wrote about the fragility and instability of the level of claims in psychopathic personalities. This floor feature is also noted by us. Psychopathic personalities in the process of research, after several failures, sharply reduce their level of claims, and only after successfully solving the simplest tasks again increase it exorbitantly. The explanation of this phenomenon was proposed by B. S. Bratus (1976). Distinguishing the ideal and real goals in the process of activity, B. S. Bratus believes that the fragility of the level of claims in psychopathic personalities is due not to high self-esteem, as is commonly thought, but to the inability to separate these goals in time. The ideal goal is one that goes beyond the performance of individual tasks, the real one is achievable in given specific conditions. Psychopathic personalities, little differentiating these goals, see in each situation as if a direct test of their "I".

Projective methods provide interesting data for assessing the personality of patients with borderline mental pathology.

The data on the use of the Rorschach method in neuroses are rather contradictory, and difficulties in measuring the degree of depression, anxiety, the absence of clear boundaries between the norm and pathology, often observed "mixed" types of neuroses play a significant role in this. Nevertheless, interesting responses are noted that characterize a certain syndromic form, for example, a high frequency of responses containing "death", "sleep", etc. in conversion hysteria, criticism by patients of their own responses in obsessional syndrome. L. F. Burlachuk points out the expediency of studying the characteristics of individual forms of neuroses and their pathogenesis in the aspect of apperceptive changes, rather than searching for a “general neurotic syndrome”. Only then, the author believes, will the value of the results obtained increase significantly, since the specificity of one or another neurotic manifestation will be taken into account.

Interesting data characterizing the system of relations of patients with neuroses were obtained using the technique of unfinished sentences by G. S. Sokolova (1971). These data were compared with the results of clinical and psychological studies assessed by the attending physicians, and a high percentage of coincidence of indicators was noted. The authors identified systems of relationships that were distinguished by the greatest degree of violations (self-esteem, life goals, attitude towards relatives), which made it possible to clarify the purposefulness of psychotherapeutic work. This technique was used to form groups of patients for the purpose of collective psychotherapy by L. I. Zavilyanskaya (1977), who distributed patients not according to nosological or syndromological affiliation, but according to systems of relations that differed in the most pronounced form.

The characterization of the patient's reaction to stress is given by the drawing technique of Rosenzweig, which makes it possible to judge the frustration tolerance of patients with neuroses and neurosis-like states. L. I. Zavilyanskaya and G. S. Grigorova (1976), using this technique, conducted a study in patients with neurosis-like conditions. It was found that these patients have a low rate of group conformity. This indicates insufficient adaptation of the patient's personality to the social environment and the high frequency of conflict relations with the environment. Extrapunitive reactions predominated, bearing the character of condemnation of the external cause of frustration, demands on others to resolve it. The number of extrapunitive reactions was especially great in asthenoneurotic disorders. Intrapunitive reactions were observed with a predominance of symptoms of anxious suspiciousness, obsessions, and a decrease in the sense of reality in the clinical picture. These patients took responsibility for correcting the frustration situation in the experiment.

Impulsive reactions prevailed in psychopathic individuals with neurosis-like syndromes. The frustrating situation was considered by them as insignificant, accessible to correction, not related to anyone's fault. This was seen as an attempt by the subjects to get away from resolving the frustrating situation. In such patients, the self-protective type of reactions prevailed, in which the main role is played by the protection of one's "I", which indicates a weakness of the personality and is consistent with the data of clinical observation.

Reactions of the obstructive-dominant type were characteristic of patients with obsessive-phobic symptoms. They rarely had a persistent type of reaction.

The data obtained using the Rosenzweig technique were supplemented by the results of the analysis of autobiographical data and clinical questioning. Using the characteristics of frustration tolerance disorders in patients with neurotic syndromes allowed L. I. Zavilyanskaya (1975) to develop a psychotherapeutic technique based on autogenic training techniques and consists in modeling frustration situations using the method " successive approximation».

Frustration tolerance training can also be used as a method of psychoprophylaxis in borderline psychiatry.

The pathopsychological experiment in the somatic clinic differs in its tasks, although some of them are equivalent to the general tasks in pathopsychology.

Tentatively, we can talk about the following main tasks of the pathopsychological study of somatic patients.

1. Identification of mental (personal) predisposition to the occurrence of certain somatic, primarily psychosomatic, diseases. Here we can talk about both the peculiar personality traits inherent in a given individual in general and contributing to the emergence of a somatic disease, and a temporary state against which stress factors become pathogenic, overcoming the mechanisms of psychological defense. In both cases, we are talking about identifying factors that lead to violations of somatopsychic and psychosomatic correlation. These circumstances have long been known to clinicians - the role of personality traits in the origin of peptic ulcer, bronchial asthma, coronary disease heart, etc., the role of psychogenics in the occurrence of myocardial infarction is described. It should be noted that personality traits often observed in somatic patients reflect not only their premorbid properties, but also include elements of personality deformation under the influence of the disease. So, personal premorbid features can contribute to the emergence of hypochondriacal (" key”, in understanding) of experiences, under the influence of the disease, these experiences become dominant, as we often see in somatogenic hypochondriacal states. The differentiation of these two types of personality traits - congenital and acquired under the influence of the disease - is not always possible.

2. Study " internal picture of the disease"(R. A. Luria, 1935), reflecting the subjective side of the disease. Under " internal picture of the disease"R. A. Luria understood everything that the patient experiences and experiences, the whole mass of his sensations, not only local painful ones, but also general well-being, self-observation, his idea of ​​\u200b\u200bhis illness, about its causes, everything that is connected for the patient with the visit to the doctor. At the same time, in the “internal picture of the disease”, the author distinguished between a sensitive level, characterized by a change in self-perception, and an intellectual level, determined by the patient’s rational-logical attitude to his illness. I. A. Kassirsky (1970) considered the sensitive part of the picture of the disease as a set of subjective sensations caused by a specific painful process, while the intellectual part of the picture of the disease acts as a “superstructure” over these sensations, associated with the degree of perception of these sensations, depending on the mental state of the patient . 3. With the help of pathopsychological methods, it seems possible to obtain an objective picture of changes in some aspects of mental activity in connection with somatic pathology. This may be useful in solving a number of issues. Thus, the detection of somatogenic asthenia in the experiment allows the researcher to monitor the dynamics of the disease as drug therapy is carried out. At the same time, the lack of data in the experiment on increased exhaustion in the presence of polymorphic hypochondriacal complaints allows the doctor to suspect the need to change the initial diagnosis of somatogenic pathology and assume that the patient has a hypochondriacal form of schizophrenia, as is often the case. Such patients at the onset of the disease are often observed by somatic doctors (therapists, surgeons, dermatologists, etc.).

Improvement in some indicators of psychological research reflects a change in the general condition of the patient. For example, in the process of treating patients suffering from chronic renal failure using an artificial kidney, an improvement in their condition and a decrease in the level of azotemia are indicated by an increase in the results of a correction test and a decrease in the manifestations of exhaustion.

In some cases, somatic pathology leads to the emergence of mental disorders, which should be taken into account when addressing issues of medical and social (labor) expertise, social readaptation of these patients and their professional orientation. In this case, we can talk about recommendations for a long time or for a certain period, if the changes in mental processes are temporary, reversible. An example of the latter is a study of the restoration of the activity of mental processes after outpatient sombrevin anesthesia, which gives the doctor criteria for deciding the length of the patient's stay after surgery in a medical institution and his ability to navigate in traffic conditions (G. Yu. Ingerman, 1975).

4. Psychological research plays an important role in the construction of rehabilitation work with somatic patients. Rehabilitation of a patient who has had a myocardial infarction, based on medication alone, cannot be complete. In the complex of rehabilitation measures, psychological factors should always be taken into account - the pessimistic or optimistic attitude of the patient, changes in self-esteem caused by the disease, revision of the meaning of a number of life circumstances, changes in the entire system of relations inherent in the patient.

The importance of psychological research for the psychotherapy of somatic patients is especially great. A number of researchers emphasize the role of a psychological experiment for psychotherapeutic practice (V. M. Bleikher, L. I. Zavilyanskaya, 1966, 1970, 1976; M. S. Lebedinsky, 1971; S. S. Liebikh, 1974).

Foreign psychosomatics of the classical psychoanalytic school consider psychosomatic diseases as the result of unconscious drives, instincts, and aggressive impulses. Their suppression, inhibition in a civilized society sharpens them even more and creates a chain of negative effects on the body. Foreign researchers created a peculiar concept of organ symbolism.

Psychosomaticians greatly expand the range of psychosomatic diseases, for example, some of them consider it a delusion to isolate psychosomatic diseases - all human diseases are considered as psychosomatic.

M. Bleuler identified three groups of psychosomatic diseases.

• I. Psychosomatosis in the narrow sense of the word - hypertension, peptic ulcer, bronchial asthma, coronary disease.
• II. Psychosomatic functional disorders - borderline, functional, neurotic. These include cardiovascular reactions to psychogenia, sweating, stuttering, tics, bowel disturbances, and psychogenic impotence.
• III. Psychosomatic disorders in a broader, indirect sense of the word, such as a tendency to injury, associated with individual personality traits.

One of the main factors in the occurrence of psychosomatic diseases is the presence of a peculiar soil (constitutional predisposition and changes in the bodily constitution under the influence of certain periodic changes in ontogenesis, diseases, etc.).

The role of the personality factor in the occurrence of human diseases was also recognized by supporters of nervism when they spoke of the significance of types of higher nervous activity, but they understood by this the general mental characteristic of a person. Personality as a special construct of the psyche, the highest level in the mental hierarchy of a person, they did not attach any importance.

American psychosomatics developed the concept of a personal profile of the personality of patients predisposed to psychosomatic diseases. So, they differed:

• overreacting individuals predisposed to peptic ulcer and ischemic coronary disorders;
• insufficiently responsive - ulcerative colitis, dermatitis, rheumatoid arthritis;
• Restrained reactions - hypertension, bronchial asthma, migraines, thyroid disorders.

These statements were not always confirmed by practice, and the term personality profile was replaced by the term personality constellation.

All this shows the need for further development of the problem of premorbid personality traits in psychosomatic patients. To a large extent, it will be possible if the study of personality is carried out not purely empirically, but on the basis of a certain concept. As such a basic concept, we have chosen the theory of personal accentuation proposed by Leohard. The discovery of a significantly higher degree of personality accentuation in the premorbidity of psychosomatic patients would indicate the role of personal predisposition to these diseases, would make it possible to identify a zone of increased risk, and would be important in the treatment of psychosomatic diseases.

A critical attitude to the theoretical concepts of modern psychosomatic medicine, which is based on either orthodox Freudian theoretical schemes or modernized psychoanalytic ideas, up to attempts to synthesize Freudianism with the teachings of I.P. Pavlov, does not contradict the recognition of the legitimacy of distinguishing psychosomatic diseases. This group includes diseases in the etiopathogenesis of which the importance of mental factors is especially great. For domestic researchers, the position of psychosomatics, based on the Freudian understanding of the unconscious, in which somatic diseases are considered as a manifestation of conversion, regression, repression, and their symptoms as a kind of symbolism of organs, remains completely unacceptable. However, without accepting the theoretical constructions of a psychoanalytically oriented psychosomatic medicine, our researchers show great interest in developing questions of the clinic of psychosomatic diseases and studying their characteristic features of the psyche in the personal aspect, since it is the personality that is the highest step in the hierarchy of the activity of the central nervous system. V. N. Myasishchev (1971) wrote about personalized somatic diseases, and in their origin he assigned a greater role to the characteristics of the patient's personality and the presence of a long-term pathogenic situation, often associated with these characteristics, than to acute psychogenies.

In connection with the foregoing, the question arises about the possibilities of approach to the study of personality. FV Bassin (1970) rightly points out that we do not yet have not only specially developed methods for studying psychosomatic correlations, but even a special conceptual apparatus necessary for conducting such research. According to F. V. Bassin, the methods of psychological and clinical examination of patients suffering from psychosomatic diseases should be based on the development of such concepts as “psychological protection”, “psychological attitude” in the understanding of the school of D. N. Uznadze, “I power” . Currently, clinical psychologists in the study of psychosomatic relationships resort to traditionally used and yet often debatable methods of personality research.

On the basis of Leonhard's concept of accentuated personalities, a comparative study of the personality characteristics of patients suffering from psychosomatic diseases, both true psychosomatosis and functional psychosomatic disorders, was undertaken. The study was conducted with the Shmishek and Littman-Shmishek questionnaires. The features of accentuation were studied both in the period of a pronounced psychosomatic illness and in premorbid.

In all forms of psychosomatic pathology, a significant increase in the average accentuation index was found compared to healthy subjects in the control group.

Comparing the indicators for individual types of accentuation in various diseases, we noted predominantly accentuation of the traits of affective lability, anxiety, cyclothymia (dysthymicity), and increased reactivity. The relative similarity of the determined personality traits in patients with peptic ulcer, chronic coronary insufficiency and bronchial asthma was noted. The curves reflecting the average levels of accentuation in patients approximately repeat the similar dynamics of indicators in healthy subjects with the difference that the curve of the control group is much lower.

A group of mental disorders, united by non-specific psychopathological manifestations of a neurotic level.

In their occurrence and decompensation, the main place is occupied by psychogenic factors. The concept of borderline mental disorders is largely conditional and not generally recognized. However, it has entered the professional vocabulary of doctors and is quite common in scientific publications. This concept is used mainly to group mild disorders and separate them from psychotic disorders. Borderline states are generally not initial or intermediate ("buffer") phases or stages of major psychoses, but a special group of pathological manifestations with a characteristic onset, dynamics and outcome, depending on the form or type of the disease process.
The most common signs of borderline conditions:
■ the predominance of psychopathological manifestations of the neurotic level throughout the course of the disease;
■ relationship between mental disorders proper and vegetative dysfunctions, night sleep disturbances and somatic diseases;
■ the leading role of psychogenic factors in the occurrence and decompensation of painful disorders;
■ "organic predisposition" of the development and decompensation of painful disorders;
■ the relationship of painful disorders with the personality and typological characteristics of the patient;
■ maintaining a critical attitude to the patient's condition and the main pathological manifestations.
In borderline states, there are no psychotic symptoms, progressive dementia, and personality changes characteristic of endogenous mental illnesses (schizophrenia, epilepsy).
Borderline mental disorders can occur acutely or develop gradually, be limited to a short-term reaction, a relatively long-term state, or take a chronic course. Taking into account the causes of occurrence in clinical practice, various forms and variants of borderline disorders are distinguished. At the same time, there are different principles and approaches (nosological, syndromal, symptomatic assessment). Pay attention to their stabilization. Taking into account the non-specificity of many symptoms (asthenic, vegetative dysfunctions, dyssomnic, depressive, etc.) that determine the psychopathological structure of various forms and variants of borderline conditions, their external ("formal") differences are insignificant. Considered separately, they do not provide grounds for reasonable differentiation of existing disorders and their delimitation from reactions healthy people under stressful conditions. The diagnostic key in these cases can be a dynamic assessment of painful manifestations, the discovery of the causes of their occurrence and the analysis of the relationship with the individual typological psychological characteristics of the patient and with other somatic and mental disorders.
The variety of etiological and pathogenetic factors can be attributed to the borderline forms of mental disorders:
■ neurotic reactions;
■ reactive states (not psychoses);
■ neuroses;
■ pathological personality development;
■ psychopathy;
■ a wide range of neurosis- and psychopath-like manifestations in somatic, neurological and other diseases.
In the ICD-10, these disorders are mainly represented by:
■ various types of neurotic, stress-related, and somatoform disorders (section F4);
■ behavioral syndromes due to physiological disorders and physical factors (section F5);
■ “disorders of adult personality and behavior” (section F6);
■ depressive episodes (section F32), etc.
Borderline conditions usually do not include endogenous mental illnesses (including sluggish schizophrenia), at certain stages of development of which neurosis- and psychopath-like disorders predominate and even determine their clinical course, largely imitating the main forms and variants of borderline states proper.
In both neurotic and neurosis-like disorders, there are sufficiently pronounced and well-formed clinical manifestations that make it possible to differentiate them within the framework of certain painful (nosological) conditions. This takes into account:
■ firstly, the onset of the disease (when a neurosis or a neurosis-like state arose), the presence or absence of its connection with psychogeny or somatogeny;
■ secondly, the stability of psychopathological manifestations, their relationship with personality-typological features.
Among the main manifestations (symptoms, syndromes, conditions) considered within the framework of borderline mental disorders are the following violations, which are mostly non-specific for one or another nosological form.
■ Character accentuations.
■ Apathy.
■ Asthenia.
■ Dystonia neurocirculatory.
■ Ideas are overvalued.
■ Hysteria.
■ Sleep disorders
■ Neurasthenia.
■ Obsessional neurosis.
■ Manifestations are pre-neurotic (pre-painful).
■ Psychasthenia.
■ Increased irritability.
■ Confusion.
■ Hypochondriacal disorders.
■ Mental disorders in somatic diseases.
■ Mental disorders in emergency situations.
■ Senestopathic disorders.
■ Social stress disorders.
■ Panic disorder.
■ Post-traumatic stress disorder.
■ Generalized anxiety disorder.
■ Chronic pain syndrome.
■ Postencephalic syndrome.
■ Chronic fatigue syndrome.
■ Burnout syndrome.
If these disorders are identified, a psychiatrist's consultation is necessary, however, treatment and rehabilitation measures can be carried out by doctors of general medical institutions in outpatient and inpatient practice.

ACCENTUATIONS OF CHARACTER
Features of originality in the character of a person that do not go beyond the mental norm, but under certain conditions can significantly complicate his relationship with others. Accentuated personalities occupy an intermediate position between mentally healthy and patients with psychopathic disorders. A variety of character traits are intertwined, but there are leading, "predominant" features. They are sharpened, first of all, in adverse situations. The most common types of accentuations include:
■ hysterical (demonstrative);
■ hyperthymic;
■ sensitive;
■ psychasthenic;
■ schizoid;
■ epileptoid;
■ emotionally labile.

APATHY
Indifference, at the initial stages - some weakening of inclinations, desires, aspirations. As the condition worsens, the patient ceases to be interested in events that do not concern him personally, does not participate in entertainment. With an emotional decline, for example, in schizophrenia, he calmly reacts to exciting, unpleasant events, although in general the patient is not indifferent to external events. Some patients are little touched by their own situation and family affairs. Sometimes there are complaints of emotional "stupidity", "indifference". The extreme degree of apathy is complete indifference. The facial expression of the patient is indifferent, he is indifferent to everything, including his own appearance and cleanliness of the body, to stay in the hospital, to visit relatives.

ASTHENIA
Increased fatigue is one of the least specific mental disorders. With minor phenomena, fatigue occurs more often with increased load, usually in the afternoon. In more pronounced cases, even with relatively simple activities, a feeling of fatigue, weakness, an objective deterioration in the quality and pace of work quickly appear, rest helps little. Among vegetative disorders, excessive sweating and pallor of the face predominate. Asthenia of extreme severity is accompanied by a sharp weakness, any activity, movement, short-term conversation is tiring. Rest doesn't help. Asthenic disorders are often combined with irritability, impatience, fussy activity (“fatigue that does not seek rest”).

DYSTONIA NEUROCIRCULATORY
Manifested in polymorphic clinical disorders including various functional neurotic and neurosis-like symptoms.
In clinical psychiatry, the manifestations of neurocirculatory dystonia are described within the framework of predominantly borderline disorders. As an independent diagnostic category, neurocirculatory dystonia in the ICD-10 in the section "Mental disorders and behavioral disorders" is interpreted as somatoform autonomic dysfunction of the heart and CVS (cardiac neurosis, neurocircular asthenia).
Currently, there are certain preferences in understanding this clinical phenomenon. Internists generally consider neurocirculatory dystonia a nosologically independent diagnostic category; in psychiatry and neurology, it is most often assessed as a syndrome.

IDEAS SUPERVALUABLE
Pathological judgments that arise as a result of real circumstances and on the basis of real facts, acquiring a dominant meaning in the mind of the patient. They are monothematic, one-sided, emotionally rich, lacking the ability to critically analyze.

HYSTERIA
It is characterized by extreme brightness of ideas about the environment, the emotional coloring of experiences prevails over rationality, violating the proportionality of a person's reaction to life events.
Figurative-emotional thinking, the so-called artistic type, in itself is not a pathology, but such people easily develop painful features. Too emotionally, violently reacting to the environment, they emphasize their likes and dislikes, self-centered, capricious, noisy, abrupt in their movements; if such a person laughs, then for a long time, if he cries, then sobbing. Usually a patient with hysterical traits seeks to attract the attention of others and, for this purpose, depicts himself as unhappy, offended, or, conversely, extols his own merits. One can note artificiality, theatricality, and often falseness in behavior, a person, as it were, constantly plays a role invented by himself.
People with such a temperament work successfully, can be disciplined, often evoke the sympathy of others and often become the “soul of society”. In the case of a neurotic breakdown, the already weakened control over one's emotional state is reduced, resulting in increased one-sidedness in the perception of the environment. All hysterical traits are aggravated, the theatricality and deliberateness of actions are especially intensified.
Hysteria used to be called the "great pretender", "the great simulator", meaning not a deliberate simulation, but an involuntary, unconscious imitation. A person with hysterical traits is easily suggestible, in fact, he is not able to perceive the difference between fantasy and reality. Under the influence of strong impressions, some mental images, taking on pathological brightness, turn into sensations, sometimes displacing the surrounding reality from consciousness.
■ Manifestations of hysteria are many-sided and are most clearly expressed in movement disorders (paralysis).
■ From excitement, patients with hysteria may temporarily lose their speech.
■ Their various functions are upset: the temperature rises, the heartbeat intensifies, appetite disappears, vomiting appears (without indigestion), skin diseases occur.
■ Among the hysterical disorders may include loss or weakening of hearing, vision, touch and smell, cramps of the limbs, lethargic sleep, and finally, hysterical seizures after some kind of trouble or exciting event.
The seizure, as a rule, begins with loud crying, screaming, laughter, followed by motor excitement and individual convulsive twitches. Sometimes the patient falls during a seizure, his muscles are sharply tense, in rare cases he lies on his back, bending his body in an arc. Such an attack lasts from several minutes to tens.
Hysterical paralysis also usually becomes a response to some kind of experience. The patient cannot move one or both (very rarely all) limbs. Significantly more often, contractures of the arms or legs develop: individual fingers freeze motionlessly in an unnatural, "strange" position. Hysteria is characterized by a peculiar violation of the ability to stand and walk: in bed, the patient actively performs all movements, but standing on his feet, falls, "like a knocked down one." This clearly shows the tendency of patients, characteristic of hysteria, not to overcome the violation that has arisen in them, but to emphasize it.
Movement disorders in patients with hysteria are fundamentally different from movement disorders characteristic of organic diseases of the nervous system:
■ First of all, disturbances in hysteria are not permanent, as in organic diseases, but disappear during sleep and become aggravated under the influence of psychogenic circumstances;
■ but most importantly - with hysterical paralysis, there are no violations of tendon reflexes and pathological reflexes.
At the height of a hysterical attack in patients, consciousness narrows and attention sharply decreases, which in some cases leads to short-term memory loss.
Hysteria can begin in childhood, but is more common between the ages of 16 and 25. It proceeds differently depending on individual features a person: in some patients, all symptoms disappear with the onset of a period of maturity, in others they persist for many years. Under the influence of adverse life situations, hysterical manifestations usually increase, outside of traumatic circumstances, and also under the influence of treatment, the disease is significantly weakened and practically does not prevent a person from living and working.
The term "hysteria" is excluded from the American national classification and from the ICD-10 as "compromising" and replaced by the concepts:
■ dissociation;
■ conversion;
■ histrionic (in the form of theatricality, demonstrativeness) personality disorder.
The main pathogenetic mechanism of various hysterical syndromes is dissociation (splitting), i.e. violation of the integrity of the personality, expressed primarily by the loss of the ability to synthesize mental functions and consciousness. The narrowing of consciousness allows the dissociation of some mental functions, which largely determines both dissociative and conversion disorders.
The study of the pathomorphism of hysteria indicates a decrease in recent years in the frequency, simplification of the structure of hysterical seizures, stupor, pseudodementia, puerilism, Ganser's syndrome, as well as hysterical paresis, paralysis, contractures. Along with this, the frequency of hysterical disorders of a somatized structure increases, which can be classified as conversion (dissociative), since they are, in essence, disorders of the sensory, motor and autonomic spheres.
In ICD-10, the concepts of "dissociative" and "conversion" disorders (F44) are identical and include different variants of conversion hysteria. In addition to dissociative amnesia (F44.0), dissociative fugue (F44.1) and dissociative disorder, unspecified (F44.9), ICD-10 includes dissociative (conversion) stupor (F44.2), trance and possession (F44.3) , dissociative movement disorders (F44.4), dissociative convulsions (F44.5), dissociative anesthesia or sensory loss (F44.6), mixed dissociative (conversion) disorders (F44.7) and other dissociative (conversion) disorders (syndrome Ganzer, psychogenic twilight state; F44.8).

SLEEP DISORDERS
Sleep disorders, disturbances in the depth and duration of sleep, awakening disorders, drowsiness during the day.
Sleep disorders. At first, occasionally, especially when tired, falling asleep is delayed by no more than 1 hour. At the same time, paradoxical doubts are sometimes noted (drowsiness dissipates when trying to fall asleep), prosonic hyperesthesia of hearing, and sense of smell that do not cause anxiety. With difficulty falling asleep, the patient remains in bed, usually does not pay attention to violations, noting them only during a special questioning.
With more pronounced disorders, falling asleep disorders are almost constant, they disturb the patient. Falling asleep is delayed by 2 hours, while, along with paradoxical somnesia and drowsy hyperesthesia, a feeling of internal tension, anxiety, and various autonomic disorders can be observed. The patient with difficulty falling asleep sometimes gets out of bed.
Severe sleep disturbances are manifested by a painful, exhausting inability to fall asleep for several hours. Sometimes drowsiness is completely absent. The patient lies in bed with open eyes, in tension. There may be anxiety, phobias, pronounced vegetative disorders, often hyperesthesia, hypnagogic hallucinations. The patient is anxious, waiting for the night with fear, if it is impossible to fall asleep, he tries to change the daily rhythm of sleep, actively seeks help.
Violations of the depth and duration of night sleep. Occasionally, more often with fatigue, there are sudden nocturnal awakenings, after which sleep quickly reappears. In some cases, intrasomnic disorders are expressed in the appearance of periods of superficial sleep with abundant and vivid dreams. The total duration of night sleep is usually not changed. The patient remains in bed, not attaching serious importance to these violations.
In more severe cases, awakenings almost constantly occur. Dissociated, fragmented night sleep is usually accompanied by senestopathies, phobias, autonomic disorders. Awakenings are painful for the patient, after which he cannot fall asleep again for a long time. In a number of cases, intrasomnic disorders are expressed in a superficial, dream-filled state of drowsiness, which does not bring a feeling of cheerfulness and freshness in the morning. The total duration of a night's sleep, as a rule, is reduced by 2-3 hours (sleep duration is 4-5 hours).
These disorders are difficult for patients to endure, they seek help, they strive to comply with medical recommendations.
With extreme degrees of sleep disturbance, there is painful, almost daily insomnia, when sleep does not occur throughout the night or short periods of superficial sleep are replaced by awakenings. Sometimes intrasomnic disorders are accompanied by sleepwalking, somnambulism, pronounced night terrors. The patient often has a fear of insomnia (hypnophobia), he is anxious, irritable, actively seeking medical help. The duration of night sleep is reduced by 4-5 hours (sleep duration is sometimes only 2-3 hours).
Awakening disorders. In mild cases, occasionally with fatigue, after somato- and psychogenic awakening is delayed, the patient cannot gain a feeling of cheerfulness and clarity for several minutes. During this period, there is marked drowsiness. Another type of disturbed awakening is extremely rapid, sudden awakening in the morning with autonomic disorders. Awakening disorders do not cause concern to the patient, they can only be found out with a special questioning.
With the complication of symptoms, disturbances in awakening are almost constant, in the morning there is no feeling of freshness and cheerfulness characteristic of a rested person. With difficulty waking up, along with severe drowsiness, prosonic disorientation is sometimes noted. Awakening disorders can be expressed as instantaneous awakening with significant autonomic reactions (palpitations, fear, tremor, etc.). The patient is concerned about disturbances in awakening, with delayed awakening in the morning, he is usually lethargic, drowsy.
The most pronounced awakening disorders are accompanied by painful, almost constant disturbances in the form of a long-term impossibility after sleep to engage in vigorous activity, feelings of fatigue, a complete lack of vigor and freshness. In prosonic states, illusory and hypnosomnic hallucinatory disorders, disorientation, and dysphagia are noted. In the first half of the day, the patient feels constant lethargy, drowsiness. Along with the difficulty of awakening, sudden awakening with a feeling of lack of sleep (denial of the former dream) is possible. A pronounced feeling of weakness, lethargy, lack of vigor and freshness are extremely disturbing to the patient.
Increased sleepiness. The first manifestations of increased drowsiness are found only during questioning, the number of hours of sleep per day is slightly increased (by no more than 1 hour). Drowsiness is easily overcome by the patient and is not relevant for him. In more pronounced cases, in the morning the patient sleeps for a long time, wakes up with difficulty, complains of drowsiness during the day, which he cannot overcome. Noticeably "sleepy" facial expression (relaxed facial expressions, slightly lowered eyelids). In addition to night sleep, the patient, as a rule, sleeps or naps during the day for 3-4 hours.
With the most pronounced drowsiness, the patient sleeps or dozes almost all day, vigorous activity is extremely difficult. When contacting the patient, it is difficult to answer simple questions. The face is sleepy, somewhat edematous, the eyelids are lowered, the muscles of the face and the whole body are relaxed.

NEURASTHENIA
Causes increased excitability and rapid depletion of active mental activity. Literally, this term means "nervous weakness."
■ The patient begins to notice increased fatigue that was not characteristic of him before, difficulties in work that requires concentration and perseverance, loss of calmness and inner balance. There is increased irritability.
■ The patient may be rude because of a trifle, and then, having calmed down, regret that he "lost his temper." In such patients, the correspondence between the strength of the stimulus (minor nuisance) and the intensity of the reaction and affect (pronounced "nervous" outbreak) has been lost.
■ Fatigue and simultaneous excitement deprive a person of the clarity and freshness of thought necessary for productive and purposeful activity. He is vulnerable, extremely sensitive to insults, does not withstand any heated debate, does not tolerate bright light and noise.
■ Patients with neurasthenia usually avoid prolonged stress. They are characterized by a successful and intensive start to work and a rapid decline in its productivity.
■ Against the background of such manifestations of "nervous weakness", especially when tired, there are outbursts of anger, which serve as the most striking and most noticeable expression of neurasthenia for others. Affective outbursts are usually short-lived, but their intensity and frequency may gradually increase. It is very difficult to stop an attack of excitement, but, as a rule, it quickly ends with impotence (both physical and psychological).
■ As with other neuroses, sleep is disturbed with neurasthenia. It is not deep enough, the patient is disturbed by disturbing dreams, he does not want to get up, he is lethargic, feels unwell, drowsiness prevents him from working during the day. However, by the evening the condition evens out, even cheerfulness appears, and again until late at night a person cannot fall asleep.
■ An almost constant companion of neurasthenia is a headache.
■ Along with this, the patient notes discomfort in the internal organs, especially in the heart, stomach, intestines, liver.
The main psychogenic cause of neurasthenia is overwork as a result of overwork, prolonged mental stress, unhealthy, "unspoken" relationships. All this constantly "presses" on a person and causes neurotic disorders.
It has been established that forced inactivity, in particular during experimental and training sessions, also causes neurotic reactions. This confirms the view that neurasthenic disorders can cause both too strong a stimulus and its absence. The disease proceeds in waves, remission or deterioration occurs periodically, depending on external conditions or somatic diseases.

NEUROSIS OF OBSESSIVE CONDITIONS
It can occur both in neurasthenia and in psychasthenia, but in some cases it is an independent symptom complex. Thoughts, memories, fear, desires, absurdity and unreality of which the patients understand, but they cannot get rid of, “get rid of” them, appear. Human behavior is gradually changing.
The most common obsessive fear (phobias): patients are afraid of death from any specific cause, they experience fear of darkness, closed spaces (for example, a theater hall, which is why they do not attend the theater), sharp objects (with which they supposedly can inflict themselves cuts), shaking hands or touching doors (so as not to get infected), facial redness, etc.
Fears leave a certain imprint on the entire behavior of patients. Patients perform actions that protect against obsessions - rituals. Fear of getting sick, such as cancer, encourages patients to go from doctor to doctor; such patients do not believe that they are healthy, begging for an operation. A special type of phobias are obsessive fears associated with the profession. So, for example, actors sometimes develop a fear that on stage they will forget the text of the role, fall into the orchestra pit. Attempts to overcome these conditions are usually accompanied by shortness of breath, sweating, dilated pupils, pallor of the face, and other autonomic disorders.
In many patients, obsessions develop on the basis of real, slightly exaggerated fears. For example, after the death of a close relative from cancer, a person begins to look for signs of the disease in himself. There is concern about the imaginary symptoms of a serious illness, which causes the formation of senestopathic and hypochondriacal disorders.

MANIFESTATIONS OF PRE-NEUROTIC (PAINLESS)
They refer to the clinical expression of the intense functional activity of the adaptive barrier. They reflect the subthreshold activity of the system of mechanisms that ensure mental adaptation within the limits of functional stability, and the compensatory interaction of various biological and socio-psychological factors that form mental adaptation under stressful conditions. The intense activity of the mental adaptation barrier is not a pathological process, it proceeds within the framework of adaptive mechanisms and reflects (is a marker), especially at the first stages, the occurrence of physiological (rather than pathophysiological) reactions aimed at maintaining "mental homeostasis" and forming the most appropriate programs of behavior and activity in complicated conditions. Preneurotic reactions are not the initial manifestations of neurosis, not its mild forms. They express a protective and adaptive function during an overstrain of the system of mental adaptation. Clinical manifestations of preneurotic reactions are polymorphic short-term disorders of the neurotic level, personality decompensation, autonomic dysfunctions.

PSYCHASTHENIA
Translated from Greek means "mental weakness." Psychasthenia develops predominantly in people with a mental type of mental activity and is, as it were, the opposite of hysteria. Patients complain that the environment is perceived by them "as in a dream", their own actions, decisions, actions seem not clear enough and accurate. Hence the constant tendency to doubt, indecision, uncertainty, anxious and suspicious mood, timidity, increased shyness. Previously, psychasthenia was called "the insanity of doubt." Due to constant doubts about the correctness of what has been done, a person tends to redo the work that has just been completed. All this creates in the patient a painful feeling of his own inferiority. A fictitious nuisance is no less, and perhaps more terrible, than an existing one.
Patients with psychasthenia often indulge in all sorts of abstract thoughts; in dreams they are able to experience a lot, but they try in every possible way to evade participation in reality. The so-called professional lack of will (aboulia) of patients with psychasthenia is described, which manifests itself primarily at work, in the performance of immediate duties, when a person with psychasthenic disorders begins to have doubts and show indecision. With psychasthenia, various hypochondriacal and obsessive states often develop.
Psychasthenic character traits, like many other neurotic disorders, can be observed already at a young age. However, individual and vaguely expressed manifestations do not yet give grounds to consider psychasthenia as a disease. If, under the influence of psychogenic traumatic circumstances, they grow, become more complicated, and become dominant in a person’s mental activity, one can speak not about the originality of character, but about a painful neurotic state that prevents a person from living and working.
Psychasthenic disorders during illness usually exist constantly, but at first the patient copes with them himself. If traumatic circumstances persist and intensify, without systematic treatment, the manifestations of the disease may increase.

IRRITABILITY INCREASED
The tendency to react disproportionately strongly to everyday stimuli, expressing in words and deeds discontent and hostility towards others. At the first stages, various painful conditions rarely occur, usually in connection with a specific emotionally significant situation. Sometimes the patient looks irritated and gloomy, but more often irritability is revealed only during questioning, there is no fixation on it, a critical attitude and the ability to cooperate with others remain.
However, gradually increased irritability can become almost permanent. It occurs under the action of not only emotionally significant, but also indifferent stimuli (bright light, loud conversation).
The patient looks tense, with difficulty restraining anger, threats can break through the tension. He assesses the external situation as "outrageous", it is difficult to attract him to cooperation.
The most pronounced forms of increased irritability have vivid manifestations: fragmentary screams, abuse at the slightest pretext. Direct attacks on the object of anger are possible, and the excitement can be generalized, chaotic. Sometimes the patient scratches himself or damages surrounding objects, clothes; at extreme severity, narrowing of consciousness occurs, consistent self-esteem and self-control are absent.

CONFUSION
Nonspecific mental disorder. With the development of confusion, the patient develops uncertainty, facial expression becomes puzzled. Sometimes the patient reports that he is confused, confused, believes that the external situation or internal state is generally understandable, but still strange, unclear, baffling, requiring clarification. With the development of confusion, the patient looks with interest and listens to the situation or becomes thoughtful, immersed in himself. Speech loses consistency, becomes inconsistent, the patient does not finish the phrase, which, however, does not exclude the establishment of a productive contact. There is an expression of surprise on the face, the patient wrinkles his forehead, his eyebrows are raised, his gaze is wandering, searching, movements and gestures are uncertain, incomplete, contradictory, he often throws up his hands, shrugs his shoulders, asks "to clarify the incomprehensible."
Expressed confusion is accompanied by facial expressions of bewilderment or (in autopsychic confusion) "enchantment" with a frozen face, "attention turned inward." Often the patient has wide open, shiny eyes. Speech is chaotic, broken to incoherence, interrupted by silence.

HYPOCHONDRIC DISORDERS
unjustifiably increased attention to one's health, extreme preoccupation with even a minor ailment, conviction in the presence of a serious illness in the absence of its objective signs. Hypochondria is usually a component of a more complex senestopathic-hypochondriac, anxiety-hypochondriac and other syndromes, and is also combined with obsessions, depression, and paranoid delusions.

MENTAL DISORDERS IN SOMATIC DISEASES
Psychopathological manifestations, primarily of a neurotic level, due to various somatic diseases. Asthenic disorders, vegetative dysfunctions and night sleep disorders usually predominate. They can be observed at the initial stages of a somatic disease, during the period of the greatest development of the disease process, and for a long time determine the state after the reduction of the main disorders. Closely merging with the symptoms of a somatic disease, neurotic manifestations play an unequal role at its various stages. Often they cannot be isolated from the overall picture of the disease.
For a differential diagnostic understanding of neurotic disorders in these cases, it is necessary to answer at least three basic questions:
■ what is the role of somatogeny in the development and stabilization of the existing neurotic symptom complex (is there a direct or indirect causal relationship);
■ there is or is not an individually significant psychogeny for the patient, whether it arose as a result of a somatic disease or only aggravated against the background of somatogeny;
■ what is the patient's personal reaction to the somatic disease.
Answering these questions, one can be convinced of the unity of biological and socio-psychological mechanisms in the origin of both psychopathological and somatic disorders proper. This explains the need for an integrated approach to building an individual therapeutic plan for each patient. The integration of the biological and socio-psychological mechanisms by a sick person indicates the conventionality of the differences between “somatopsychic” and “psychosomatic”. From a practical point of view, in the first case, mental disorders (mainly of a neurotic structure) are understood that have formed on the basis of (sometimes as a result of) somatogeny, in the second - predominantly somatic disorders that have arisen, as it were, secondarily, following mental (mainly psychogenic) disorders.
In ICD-10, the terms "psychosomatic" and "somatopsychic" are not used because of the position of the compilers of qualifications regarding the fact that "mental" (psychological) factors affect the occurrence, course and outcome of not only "selected" diseases that make up the group of "psychosomatic ', but of all disease states. Instead of these concepts, the term "somatoform disorders" is used.

DISORDERS SENESTOPATIC
The appearance in various parts of the body of unpleasant and painful sensations, sometimes unusual and pretentious. When examining a patient, they do not reveal a “diseased” organ or part of the body and do not find an explanation for unpleasant sensations. With the stabilization of senestopathic disorders, they largely determine the behavior of the patient, lead him to meaningless examinations. Senestopathic sensations as psychopathological manifestations should be carefully differentiated from the initial symptoms of various somatic and neurological diseases. Senestopathies in mental illness are usually combined with other mental disorders characteristic of sluggish schizophrenia, the depressive phase of manic-depressive psychosis, etc. Most often, senestopathies are part of a more complex senestopathic-hypochondriac syndrome.

SOCIAL STRESS DISORDERS
The group of social stress disorders is not included in the ICD-10 diagnostic list. It was identified at the end of the 20th century on the basis of an analysis of the mental health of large groups of the population of Russia and other countries in the context of fundamental changes in the socio-economic and political situation and is not directly related to an acute reaction to stress.

DIAGNOSIS CRITERIA FOR SOCIAL STRESS DISORDERS
■ a radical change in social relations that goes beyond ordinary experience;
■ change in the system of cultural, ideological, moral, religious ideas, norms and values ​​that remained unchanged throughout the life of previous generations;
■ change in social connections and life plans;
■ instability and uncertainty of life situation.

FEATURES OF BEHAVIOR AND CLINICAL MANIFESTATIONS
■ sharpening of personality-typological character traits;
■ development of hypersthenia (up to self-destructive inexpediency), hyposthenia, panic reactions, depressive, hysterical and other disorders;
■ loss of "plasticity of communication" and the ability to adapt to what is happening while maintaining perspectives in purposeful actions;
■ the appearance of cynicism, a tendency to antisocial actions.
Regardless of the nature of neurotic manifestations, personality and somatic disorders within the framework of pre-morbid conditions or those that are part of the structure of a clinically formed borderline state, many people with social stress disorders develop a certain indifference to situations that have recently disturbed them, pessimism, cynicism, the circle of social contacts narrows, they become "fleeting", "hurrying". Often real examples of "social injustice" and malevolence are sought out or thought out, which explains the corresponding reaction. The created conditions of life and relationships make it extremely difficult for creative work and the competent use of one's knowledge. A feeling of dissatisfaction, devastation, constant fatigue, a painful feeling that "something is wrong" develops. It is difficult to realize the growing deterioration of one's health, as a result of which active visits to doctors are extremely rare.

PANIC DISORDER
Panic disorder is a mental disorder characterized by recurrent attacks of severe anxiety with marked autonomic disturbances.

ICD-10
F41.0 Panic disorder (episodic paroxysmal anxiety)
EPIDEMIOLOGY
The prevalence is up to 1.5% of the adult population. It usually starts in middle age. Women make up 75% of patients.
CLASSIFICATION
Given the significant range of individual variations in both the frequency of seizures and their severity, the ICD-10 proposes to distinguish two degrees of disorder:
■ moderate (at least 4 panic attacks in a 4-week period);
■ severe (at least 4 panic attacks per week during 4 weeks of follow-up).
DIAGNOSTICS
SURVEY PLAN
Diagnosis is based on recurrent panic attacks with autonomic manifestations.

The anamnesis notes recurrent panic attacks that occur spontaneously and are not associated with specific situations.
A panic attack is characterized by the following main features (in accordance with the ICD-10 criteria).
■ A discrete episode of intense fear or discomfort.
■ Sudden onset.
■ Rapid achievement of the most pronounced manifestations that last for several minutes.
■ At least 4 of the symptoms listed below, with one of them from 1-4.
1. Strengthened or rapid heartbeat.
2. Sweating.
3. Trembling or tremor.
4. Dry mouth (not due to medication or dehydration).
5. Difficulty in breathing.
6. Feeling of suffocation.
7. Pain or discomfort in the chest.
8. Nausea or abdominal distress (such as burning in the stomach).
9. Feeling of dizziness, unsteadiness, fainting.
10. Feeling that objects are not real (derealization) or that one's own "I" has moved away or is "not here" (depersonalization).
11. Fear of losing control of oneself, insanity.
12. Fear of dying.
13. Hot flashes or chills.
14. Numbness or tingling sensation.
Panic attacks often lead to a constant fear of the next attack.
LABORATORY AND INSTRUMENTAL STUDIES
There are no special laboratory or instrumental signs of panic disorder.
Laboratory and instrumental studies can be carried out with a differential diagnostic purpose to exclude other causes of anxiety (endocrine diseases, organic brain diseases, mitral valve prolapse, etc.).
DIFFERENTIAL DIAGNOSIS
Panic disorder must be distinguished from panic episodes in the structure of another pathology:
■ mental: other anxiety-phobic disorders, depressive states;
■ somatic and neurological: hyper- and hypothyroidism, hyperparathyroidism, ischemic heart disease, pheochromocytoma, pathology of the vestibular nerve.

Psychiatrist: with a newly diagnosed disorder, with a decompensated condition.
TREATMENT
GOALS OF THERAPY
The disappearance or drastic reduction in the number of panic attacks and the reduction of comorbid disorders and avoidance behavior.
INDICATIONS FOR HOSPITALIZATION
Same as for generalized anxiety disorder.
NON-DRUG TREATMENT
Psychotherapy: short-term psychodynamic cognitive-behavioral.
DRUG THERAPY
■ Tranquilizers, preferably parenteral.
■ Outside of attacks at the beginning of treatment, to overcome the fear of waiting, it may be appropriate to prescribe a short course of tranquilizers.
■ Antidepressants of different groups. The cessation of panic attacks, as a rule, occurs after 2-4 weeks from the start of treatment. To achieve stable remission, patients need a long-term (6–12 months) intake of the selected drug.

Determined individually.
MANAGEMENT
It is carried out by the attending psychiatrist.
EDUCATION OF THE PATIENT
Aimed at explaining the causes of a panic attack and mastering fear.
FORECAST
In a long-term follow-up, about 20% of patients remain symptomatic. Depression occurs in 70%, alcohol and substance abuse - in 20% of cases.

Post-traumatic stress disorder
Is modern definition known in the past mental disorders in people who survived an emergency, and described in the framework of neurotic (psychogenic) reactions, conditions, personal development. From these positions, post-traumatic stress disorder is a part of borderline mental disorders, in the development of which non-specific disorders of the neurotic level occupy a fundamental place. Post-traumatic stress disorder does not include the main forms of neurotic and psychopathic disorders, but is not absorbed by them either. Syndromogenesis of the disorder is characterized by a general stereotype that goes in the direction from a reaction to a particular event to a chronic disease state and the presence (as in other psychogenic disorders) of the so-called K. Jaspers triad. It includes:
■ the established fact of the occurrence of the disorder in connection with mental trauma;
■ the relationship between the duration of mental disorders and the continuing relevance for the patient of a traumatic situation;
■ reflection in the patient's painful experiences of mental trauma (criteria for psychologically understandable connections).
Currently, the diagnosis of post-traumatic stress disorder occupies one of the central places among the so-called new borderline mental disorders that have been specially identified in recent decades. This is due, primarily from the point of view of clinical psychiatry, with the dynamic analysis of the impact of emergencies on mental health. The “model” of post-traumatic stress disorder shows that a person’s life is filled not only with fairly ordinary mental situations, but also with atypical stressful conditions of activity during natural disasters, catastrophes, and military operations. In these cases, a large number of people can simultaneously find themselves in a life-threatening situation, who subsequently, at relatively distant stages of "neurosis", develop mental and related somatic disorders.
The frequency of acute psychogenic reactions (acute stress disorders) in emergency situations is relatively low. However, the experiences of people who were in areas of natural disasters, catastrophes, wars, even if they did not receive bodily injuries, do not pass without a trace. To understand the dynamics of possible distant mental disorders in these cases, it is necessary to analyze the individual, group, family and social perspectives of the development of a post-traumatic situation. It indicates that sometimes, even several years after the experienced life-threatening situation, various neurotic and pathocharacterological stigmas associated with it develop, against the background of which pronounced pathological conditions often form. The accumulation of neurotic manifestations and their remote activation under the influence of a significant psychogenic event are a reflection of the general patterns of the formation of functional disorders of the individual barrier of mental adaptation. Often, at the same time, factors that are insignificant at first glance serve as a trigger mechanism that “unwinds” a conglomerate of biological and socio-psychological interactions prepared by previous individual history. As a result, certain remote (delayed) forms and variants of mental maladjustment appear at the clinical level, which accompanies any borderline mental disorder. The difference between post-traumatic stress disorder is that it occurs in a large number of people after they have experienced a common, unifying, usually suddenly developed life-threatening situation, the consequences of which, despite sometimes significant temporal prescription, continue to persist as an individually significant psychogeny.
Post-traumatic stress disorder was first described in the United States based on a long-term study of the mental state of US Army soldiers who returned from the Vietnam War. At the same time, the main criteria were identified that combine post-traumatic stress disorder and separate it from other borderline mental disorders. Currently, these include: establishing the fact of a stressful state suffered during a natural disaster, catastrophe, war; influxes of obsessive memories (reminiscences) about life-threatening situations that have taken place; tormenting dreams with nightmarish scenes of the experience; the desire to avoid emotional stress; uncertainty due to the fear of the appearance of tormenting memories (“playing out the tragedy”), resulting in postponing decision-making, non-contact with others; a complex of neurasthenic disorders with a predominance of increased irritability, decreased concentration of attention and “functioning tone”, stigmatization of individual pathocharacterological symptoms and a tendency to the formation of psychopathic disorders with episodes of antisocial behavior (alcoholism, drug addiction, cynicism, lack of respect for officials, especially those who allowed the experienced tragedy , and etc.).
Each of these criteria is not specific to post-traumatic stress disorder, but combined together, they make up a fairly typical picture. From a clinical point of view, post-traumatic stress disorder may include the entire "phenomenological set" of the main psychopathological non-psychotic manifestations. The identification of post-traumatic stress disorder as a special type of borderline mental disorders is important for predicting its development after a particular event and for developing special preventive and rehabilitation programs necessary in these cases. At the same time, it should be taken into account that the occurrence of post-traumatic stress disorder in each individual person is determined by the mutual influence of factors called “personal vulnerability predictors”. These include unpreparedness for the impact of trauma, previous negative experience, passivity of coping strategies developed throughout life, mental and somatic diseases. Understanding the role of these factors, as well as the observed dependence of the severity of post-traumatic stress disorder on exposure and the individual severity of traumatic impact, underlies the scientific rationale for all treatment and preventive measures.
Depending on the onset and duration of symptoms typical of post-traumatic stress disorder, three of its variants are distinguished - acute post-traumatic stress disorder (duration from one to three months; if the disorder develops immediately after a life-threatening event and lasts less than one month, there are more grounds for their assessment in as part of an acute stress response); chronic post-traumatic stress disorder (lasting more than three months); and delayed-onset post-traumatic stress disorder (onset of characteristic symptoms at least six months after exposure to the traumatic event).

GENERALIZED ANXIETY DISORDER
Anxiety is a feeling of indefinite danger, an impending catastrophe, which is directed to the future and contains a mobilizing component.
Unlike anxiety, fear is the experience of an immediate, concrete threat.
Generalized anxiety disorder is a mental illness, the main manifestations of which are primary persistent, not limited by any situation, anxiety and associated somatovegetative disorders.
ICD-10
F41.1 Generalized anxiety disorder
EPIDEMIOLOGY
The disease affects 2-5% of the population. It usually starts in middle age. Outpatient practice is dominated by women (ratio to men 2:1).
DIAGNOSTICS
SURVEY PLAN
The diagnosis is made on the basis of the prolonged and persistent (for most days for a long time - weeks and months) the presence of anxiety and its associated symptoms.
HISTORY AND PHYSICAL EXAMINATION
■ Anxiety, increased anxiety.
■ The alarm is constant; is not limited, not called, and does not even arise with a clear preference in connection with any specific life circumstances.
■ Frequent fears (feeling of upcoming troubles and failures, fear for loved ones, etc.).
■ Constant tension, inability to relax, difficulty falling asleep due to anxiety.
■ Difficulty concentrating or "head blankness" due to anxiety or restlessness.
■ Vegetative symptoms:
✧ increased or rapid heartbeat;
✧ sweating, dry mouth (but not from drugs or dehydration);
✧ tremor or shivering;
✧ difficulty in breathing, feeling of suffocation;
✧ chest pain or discomfort;
✧ nausea or abdominal distress (such as burning in the stomach);
✧ hot flashes or chills;
✧ numbness or tingling sensation in various muscle groups; muscle tension or pain.
Manifestations of anxiety are present on most days for a long time (weeks and months).
LABORATORY EXAMINATION
There are no specific laboratory or instrumental markers for generalized anxiety disorder.
Laboratory and instrumental studies can be carried out with a differential diagnostic purpose to exclude other causes of anxiety (endocrine disorders, organic brain disease, use or a sharp break in the use of psychoactive substances, etc.).
DIFFERENTIAL DIAGNOSIS
Differential diagnosis is carried out with anxiety states of a different nature.
■ Endocrine disorders (such as hyperthyroidism).
■ Anxiety in the framework of affective and hallucinatory-delusional psychoses.
■ Other anxiety disorders (organic anxiety disorder, panic disorder, phobias, etc.).
■ Substance use disorders (use of amphetamine-like substances or withdrawal of benzodiazepines).
INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS
Psychiatrist:
■ when the disorder is first diagnosed;
■ decompensated condition.
TREATMENT
GOALS OF THERAPY
Complete or significant regression of symptoms, achieving stable remission.
INDICATIONS FOR HOSPITALIZATION
■ The severity of disorders.
■ The need to remove the patient from the traumatic environment.
■ Resistance to outpatient therapy.
As a rule, the patient is hospitalized in the border psychiatry department of a psychiatric or somatic hospital.
NON-DRUG TREATMENT
Psychotherapy:
■ relaxation methods (autogenic training, self-regulation with feedback);
■ short-term psychodynamic;
■ cognitive-behavioral.
DRUG THERAPY
■ Benzodiazepine tranquilizers at the beginning of therapy as an emergency for severe anxiety and fear in a short course to avoid the formation of dependence.
■ Antidepressants of different groups. The anxiolytic effect builds up slowly over several weeks. To achieve stable remission, patients need long-term (up to six months or more) taking the selected drug.
APPROXIMATE TERMS OF TEMPORARY INABILITY TO WORK
Determined individually.
MANAGEMENT
It is carried out by the attending psychiatrist or general practitioner with the advice of a psychiatrist.
EDUCATION OF THE PATIENT
Coping behavior training on a conscious level.
FORECAST
The disease is chronic and can last a lifetime.

CHRONIC PAIN SYNDROME
Clinical reality shows the association of chronic pain syndromes with psychopathological disorders. Somatogenic pain is often accompanied by the development of borderline mental disorders, primarily depression, asthenia, hypochondria. In such cases, pain is usually considered as a causative factor, in relation to which mental disorders become secondary. However, a number of pain disorders are predominantly psychopathological in origin. With algia, the source of pain may be completely absent or play the role of only a triggering factor. The clinical assessment of chronic pain often depends on views on the phenomenon of "psychopathological pain" itself. Currently, the most common multifactorial model of pain, which takes into account the personal and emotional components of pain experience, as well as comorbid symptoms. There are two aspects in understanding the pain syndrome:
■ direct tissue damage and associated sensations;
■ emotional state due to various reasons.
Unlike acute pain, in which tissue damage is of paramount importance, the emotional component is closely related to the nociceptive reaction, and personality factors are practically not involved, chronic or pathological pain is distinguished as an independent disease with a primary process in the somatic sphere and secondary dysfunction of the peripheral nervous system and CNS with the participation of personality-psychological mechanisms. Chronic pain is characterized by duration (according to DSM-IV, more than 6 months), resistance to ongoing therapy and the absence of direct dependence on the cause that caused it. Such pain is continuous, depressing, characterized by high comorbidity with mental and somatic pathology, which, in turn, exacerbates the pain syndrome.

SYNDROME POSTENCEPHALIC
Residual effects after suffering encephalitis, expressed in cerebrasthenic disorders, combined with various residual-organic and neurosis-like disorders. Against the background of postencephalic disorders, personal accentuations are sharpened and pathocharacterological development can be formed.

CHRONIC FATIGUE SYNDROME
The combination of nonspecific polymorphic asthenic, subdepressive, neurasthenic, neurocirculatory disorders. As a separate mental disorder, most researchers do not distinguish. It often occurs after an infection (some researchers attach importance to the development of chronic fatigue syndrome to lymphotropic herpesviruses, retroviruses, enteroviruses), accompanied by slightly pronounced changes in immunity (a moderate nonspecific increase in antinuclear antibodies titer, a decrease in the content of immunoglobulins and NK-lymphocyte activity, an increase in the proportion of T-lymphocytes and etc.). Disorders occur after a flu-like condition and tend to linger. The somatic or psychogenic basis of the presented complaints is not detected. Treatment with restorative agents, psychotherapy, antidepressants with an activating component give a fairly pronounced effect.
The identification of chronic fatigue syndrome indicates the search for a somatic ("biological") basis for many non-specific non-psychotic (neurotic, borderline) disorders. On this path, the emergence of pathogenetically substantiated methods of therapy is possible, primarily the use of immunotropic drugs in conjunction with antidepressants and other psychotropic drugs.

BURNOUT SYNDROME
A relatively new designation for a pronounced deformation of emotional experiences in professional activity associated with the constant presence in the usual conditions of emotional stress (for example, the work of a resuscitator, surgeon, psychiatrist, the activities of rescuers, military personnel, etc.).

Borderline psychiatry is one of the fastest growing areas of clinical and social medicine in recent years. This is due not only to the trend towards the integration of psychiatry into general medicine and psychology, but also to a number of objective realities modern life, leading to psycho-emotional overstrain of people, which requires further improvement in the assessment of psychopathological manifestations. The plasticity of the psyche is often insufficient for quick and adequate adaptation to changing environmental conditions.

The fact that the increase in the number of people with neurotic and psychosomatic disorders is observed primarily in developed countries is probably due not only to an improvement in the detection of mental disorders, but also to a complex of factors contributing to their true growth. Diseases of the neurotic circle, as a rule, affect people of working age and often turn out to be the causes of a significant decrease in the quality of life of patients, as well as prolonged and recurrent disability.

Introduction

The concept of borderline mental disorders is used to refer to mild disorders that border on a state of health and separate it from the actual pathological mental manifestations, accompanied by significant deviations from the norm. Disorders of this group violate only certain areas of mental activity. In their occurrence and course, social factors play a significant role, which, with a certain degree of conventionality, allows us to characterize them as a breakdown in mental adaptation. The group of borderline mental disorders does not include neurotic and neurosis-like symptom complexes associated with psychotic (schizophrenia, etc.), somatic and neurological diseases.

More and more clearly there is a tendency for the psychopathology of the neurotic circle to go beyond the psychiatric field. In this regard, mutually complementary cooperation between psychiatrists and internists, convergence of positions of specialists of various profiles, constructive exchange of scientific and practical information, increase in the level of literacy of doctors of various specialties in mental health issues, as well as psychiatrists in the clinic of internal diseases, are important.

Diagnostics

The most characteristic features of borderline psychopathology include:

Neurotic level, functional nature and reversibility of existing disorders;

Vegetative "accompaniment", the presence of comorbid asthenic, dyssomnic and somatoform disorders;

The relationship of the occurrence of diseases with psychotraumatic circumstances and personality-typological characteristics;

Egodystonism (unacceptability for the "I" of the patient) of painful manifestations and the preservation of a critical attitude towards the disease.

With borderline psychopathology, the following are excluded:

Psychotic disorders (delusions, hallucinations);

progressive dementia;

Severe personality changes, disturbances in thinking and behavior, ego syntony (harmony, consonance for the "I" of the patient) symptoms characteristic of endogenous mental disorders

Classification

With the introduction into practice of the International Classification of Diseases of the 10th revision (ICD-X), the nomenclature of borderline mental disorders has undergone significant changes. Perhaps the most difficult to understand and debatable was the removal from the classification of the concept of "neurosis", which had existed in psychiatry for over 200 years, while maintaining the definitions of "neurotic" and "neurosis-like". Nevertheless, the absence of the traditional division into neuroses and psychoses, the focus on behavioral disorders, and the presentation of most disorders in the form of syndromic rubrics contributed to a significant expansion of the diagnostic capabilities of borderline psychiatry, to the clarification and delimitation of its concepts. At the same time, this made the borders between “big” and “small” psychiatry, already difficult to distinguish, even less defined, and caused difficulties in designating the endogenous and the psychogenic. In particular, when diagnosing a depressive episode, the ICD-X suggests fixing the so-called somatic symptom by those who would like it, allowing for the possibility of ignoring it without losing other information. It is also very difficult in practice to delimit schizotypal personality disorder from both schizoid personality disorder and various forms of sluggish schizophrenia.

The foregoing predetermined the emergence of numerous and sometimes tough discussions both in various scientific forums and on the pages of the professional press, including in the "MG", about the imperfection and "Americanization" of the ICD-X and the need to develop a domestic psychiatric classification. Nevertheless, given the fact that the ICD-X is valid, and there is no domestic classification, we present our vision of borderline mental pathology in accordance with the first. Based on the foregoing, borderline mental disorders can be classified as:

1. Organic, including symptomatic, mental disorders (F-06):

Non-psychotic depressive disorder of an organic nature (F06.36);

organic anxiety disorder (F06.4);

Organic dissociative disorder (F06.5);

Organic emotionally labile (asthenic) disorder (F06.6);

Mild cognitive impairment (F06.7);

Other non-psychotic disorders due to damage and dysfunction of the brain or physical illness (F06.82);

Unspecified non-psychotic disorders due to damage and dysfunction of the brain or physical illness (F06.92);

Disorders of personality and behavior due to disease, damage or dysfunction of the brain (F07).

2. Mood disorders (affective disorders) (F-3):

mild depressive episode (F32.0);

Depressive episode of moderate degree (F32.1);

Severe depressive episode without psychotic symptoms (F32.2);

Recurrent depressive disorder, current mild episode (F33.0);

Recurrent depressive disorder, moderate current episode (F33.1);

Recurrent depressive disorder, current severe episode without psychotic symptoms (F33.2);

Cyclothymia (F34.0);

Dysthymia (F34.1).

3. Neurotic stress-related and somatoform disorders (F-4):

Phobic anxiety disorders (F40);

Other anxiety disorders (F41);

Obsessive Compulsive Disorder (F42);

Response to severe stress and adjustment disorders (F43);

Dissociative (conversion) disorders (F44);

Somatoform disorders (F45);

Neurasthenia (48.0).

4. Behavioral syndromes associated with physiological disorders and physical factors (F-5):

Eating disorders (F50);

Sleep disorders of non-organic etiology (F51);

Sexual disorders (dysfunctions) not due to organic disorders or diseases (F52).

5. Personality and behavior disorders in adulthood (F-6).

Flow

Borderline psychiatric disorders may occur acutely or develop gradually, their duration may be limited to a short-term reaction, a prolonged state, or a chronic course. Most patients recover with treatment or, in cases of reactions, even without it. However, in 20-40% of patients, the course of the disease can take on a relapsing, recurrent nature, significantly reducing the level of social functioning of patients, but never leading to disability.

Epidemiology

It is difficult to judge the true prevalence of mental disorders of the neurotic circle with accuracy (the indicators are usually underestimated), since these patients often fall out of the field of view of psychiatrists (they turn to healers, psychics, or, at best, to general practitioners). Nevertheless, in recent years there has been a clear trend towards an increase in the share of borderline mental disorders in the structure of morbidity in the population. According to various authors, the prevalence rates of neurotic disorders among men range from 2 to 76 per 1000 of the population, among women - from 4 to 167 per 1000.

The ratio of men and women in the incidence of borderline mental disorders is approximately 1:4. This is a consequence not only of the relatively low prevalence of morbidity among men, but also of the latter's low demand for psychiatric help. Feeling shame for such absurd, from their point of view, thoughts or for fear of being classified as mentally ill, some patients for a number of years, with the help of developed individual systems of "protective measures", usually continue their usual social functioning and, despite a significant complication of life, stubbornly avoid psychiatrists.

A special place is occupied by the problem of neurotic disorders in the elderly. Age-related changes in the mental sphere are characterized by a deterioration in imaginative thinking, a decrease in strength, balance, concentration and mobility of the main nervous processes, a change in the rate of psychomotor reactions. The generally accepted opinion is about the sharpening of character traits, the conservatism of the elderly, their unmotivated resentment, egocentrism, hypochondria, depriving them of the brilliance and brightness of new impressions and constituting the main mechanism for violations of psychological adaptation.

The result of the epidemiological work carried out by domestic and foreign gerontopsychiatrists was a stable idea of ​​the significant prevalence of mental disorders of a non-psychotic level among the population of older age groups. It should be noted that late age is considered in the psychogeriatric literature as an increased risk factor for the development of stress-related mental disorders.

Etiology and pathogenesis

There is no clear understanding of the phenomenology of borderline mental disorders, and the symptoms characteristic of them can often seem vague, bizarre, indefinite and almost impossible to objectify. In this regard, coherent conceptions of the origin of neurotic experiences were proposed only by psychoanalysts. Freud had three theories of anxiety. According to the first, anxiety is a manifestation of repressed libido; the second viewed it as a re-experience of birth; the third, which can be considered as the final psychoanalytic theory of anxiety, asserts the presence of two types of anxiety - primary and signal. At the same time, signal anxiety is a watchdog defense mechanism that warns the ego of an impending threat to its balance, and primary anxiety is an emotion that accompanies the disintegration of the ego. Primary anxiety indicates the failure of the defense and manifests itself in nightmares.

Biological theories of the etiopathogenesis of neurotic disorders are based on the discovery of biological markers of brain mechanisms that correlate with the corresponding symptoms. Despite the division of anxiety and depressive disorders into different diagnostic categories in modern classifications, the high prevalence of cases of combined manifestation of symptoms of anxiety and depression served as the basis for the revival of the concept of a single symptomatic continuum of these disorders. Genetic and neurobiological evidence has been obtained that the relationship between anxiety and depressive disorders is realized not only at the clinical, but also at the pathophysiological level. The so-called neurotic factor has been identified, which includes feelings of inferiority and rejection, demoralization, shyness, and general affective distress.

Research on the neurobiology of borderline mental disorders is predominantly focused on the study of the noradrenergic, GABAergic, and serotonergic neurotransmitter systems. The latter plays a special role as a common substrate in the pathophysiology of neurotic manifestations. 5-HT neurons, whose bodies are located in the nuclei of the midbrain raphe, form a network of branched processes throughout the brain. They act as "activators" through slow but constant pulse generation. They are assigned the role of the main modulators of the functional state of the central nervous system. Accordingly, 5-HT neurons influence a wide range of physiological (temperature, sleep, nutrition, pain sensitivity), behavioral, and other CNS functions, including affective state, anxiety, impulsivity, and aggressiveness. Hence the boom in selective serotonin reuptake inhibitors that we are seeing in the pharmaceutical market today.

Another neurotransmitter involved in the etiopathogenesis of anxiety in particular may be adenosine, since the anxiogenic effect of caffeine may be associated with it. A similar effect is revealed by sodium lactate and carbon dioxide when its concentration in the air is brought to 5%. Although the mechanism of this effect is not entirely clear, it is assumed that it is associated with hyperstimulation of the subcortical pontine nuclei.

Borderline mental disorders also have a serious genetic basis: in patients with agoraphobia, up to 20% of relatives suffer from such disorders, and in cases of generalized anxiety disorders, concordance is characteristic in 50% of identical and 15% of fraternal twins.

Clinic

When communicating with patients presenting certain complaints about disorders classified as borderline, the doctor faces many questions that require a systematic, purposeful solution. The latter are primarily associated with functional disorders that sometimes determine imperceptible transitions from normal manifestations of mental health to pathology, which requires a rigorous differential diagnosis using a multidisciplinary approach that includes data from various medical specialties (therapy, cardiology, gastroenterology, neurology, etc.) and paraclinical disciplines (psychology, physiology, hygiene, etc.). This applies primarily to diseases of the cardiovascular system, gastrointestinal tract, chronic nonspecific respiratory diseases, endocrine disorders, in which complex interactions of adverse mental and somatic factors lead to the formation of neurotic disorders that cause violations of the mechanisms of socio-psychological adaptation. A reaction to stress, a reaction of disadaptation often occurs against the background of chronic somatic diseases. In this case, the disease is a comorbid disorder, when neurotic and neurosis-like symptoms occur against the background of somatic pathology. Deterioration of the mental state of the patient, leading to a deterioration in the somatic state, significantly reduces tolerance to stress. At the same time, the so-called post-stress psychosomatic defenselessness is noted, leading to an increase in sensitivity to any environmental stimuli after the stress.

Up to 57% of patients with various mental disorders, but not registered with psychiatrists, turn to polyclinics. Among this contingent, a significant group consists of patients in whom neurosis- and psychopath-like symptoms that have existed for months, and sometimes for years, are most often expressed in the somatization of a mental disorder, that is, in this case, we are most likely talking about symptoms that largely imitate certain somatic symptoms. diseases. This is not "neuroticization" of a particular organ, but a functional mental disorder.

Characteristically, this group of patients faces the most difficult path of persistent but fruitless searches before they become the object of psychiatric examination and treatment. Episodic reception of tranquilizers does not give the expected effect and forms a belief in the incurability of the disease. All this leads to untimely and inadequate diagnosis, aggravation of the course of the disease, unjustified costs for unnecessary examinations in this case, permanent disability and subsequent social exclusion. It is important to note that, when advised to consult a psychiatrist, these patients often refuse to apply to PND, sanatorium departments of psychiatric hospitals for fear of their stigmatization and discrimination in connection with the antipsychiatry campaign that has taken place in Russia over the past decade. In this regard, for example, almost half of patients with depression do not seek medical help at all, and 80% are treated by general practitioners, presenting only somatic complaints. The lack of competence of somatologists in matters of psychopathology and the lack of a clear algorithm for referring patients to specialized medical institutions also delay the start of qualified assistance to patients suffering from borderline mental pathology.

The number of somatic diseases in one patient is 4-5. This emphasizes the multiconditionality of borderline pathology, the presence of a close relationship between somatic, mental and social processes, the psychophysiological integrity of a person. In this regard, there is a growing need for further improvement of an interdisciplinary approach based on the combined efforts of internists and psychiatrists.

Treatment

The emergence of highly specific modern pharmaceuticals, the inclusion in the context of psychiatry of such general medical concepts as risk/benefit, quality of life, individual sensitivity, informed consent, as well as the shift in emphasis in the relationship between doctor and patient from paternalism to partnership increased public confidence in the psychiatric service, contributed to the expansion her contacts with somatic medical and preventive institutions.

The steady increase in the representation of borderline mental disorders by themselves or in the structure of other diseases dictates the need to master the skills of their therapy and general practitioners, who, with a certain level of literacy, could supervise the majority of such patients. The strict rules of pathogenetic treatment in this case should be the following: selection of optimal (mostly low) doses of drugs; careful consideration of all contraindications, side effects and possible complications a mandatory combination of psychopharmacotherapy and psychotherapy. Treatment should be carried out according to an individual plan developed for each patient, taking into account the form of the disease, the leading psychopathological symptom complex and the dynamics of the somatic state.

Extremely important in the treatment of borderline mental disorders are the creation and observance of the necessary psychotherapeutic environment at all stages of treatment and the provision of social support for the patient. Just as a surgeon cannot operate in "septic" conditions, so it is pointless for a psychiatrist to treat a patient in a traumatic situation. Whatever remedy is prescribed to the patient, whatever method of therapy is used, for the most effective action, an extremely benevolent, sympathetic attitude towards the patient is necessary.

The traditional prejudice against psychotropic drugs predetermines the management of patients at minimal therapeutic doses, the active "exploitation" of the placebo effect, various forms of psychotherapeutic influence, which, of course, does not exclude the use of high therapeutic doses if there are appropriate indications.

For the treatment of neurotic disorders, drugs of almost all classes of psychotropic drugs are used, mainly tranquilizers and, increasingly, antidepressants. The use of the first allows you to achieve a quick, but short-lived anxiolytic effect, moreover, it is associated with the threat of developing dependence. The appointment of the latter ensures the achievement of a stable positive result in therapy without the occurrence of addiction, and therefore is more preferable. It is most justified to start treatment of borderline mental disorders with the latest generation of antidepressants, which include selective serotonin reuptake inhibitors (fluoxetine, paxil, zoloft, cipramil), a serotonin reuptake activator (coaxil) and noradrenergic and serotonergic selective antidepressant (remeron). Their undoubted advantages are good tolerability (lack of behavioral toxicity), the absence or slight severity of side effects, ease of use (single daily intake), the possibility of safe combination with somatotropic drugs.

In some cases, monotherapy with antidepressants is ineffective, which requires the inclusion of antipsychotics, vegetotropic and nootropic drugs in the regimens. The neuroleptics of choice may be teralen, eglonil, sonapax, fluanxol, rispolept. Finlepsin, as a drug with a wide spectrum of action, is effective against any paroxysmal manifestations, including hot flashes, vegetative-vascular crises, migraine attacks.

Establishing empathic contact between the doctor and the patient plays a key role in achieving positive treatment results. In practice, cases of treatment of patients who have undergone courses of treatment with modern, expensive drugs prescribed by psychiatrists in adequate dosages, but not having the expected effect, are not uncommon. It is not possible to measure the depth and measure of the psychotherapeutic impact of the doctor's personality on the human psyche. Nevertheless, there is every reason to believe that the degree and quality of this effect often play a decisive role in the normalization of the patient's condition. The situation in which the patient is considered as a legitimate partner in the treatment process, and his relationship with the doctor is built on mutual respect and trust, is not only an indispensable condition, but also one of the components of treatment that allows achieving positive results using minimal doses of psychotropic drugs.

Patient education is an important part of any treatment plan. It should instill confidence in the patient, contribute to the implementation of medical prescriptions and thereby improve the prognosis of the disease. Supportive counseling is recommended throughout the course of treatment. At the same time, thoughtful advice is required from the doctor on the duration of treatment, changing the level of doses, and refraining patients from drinking alcohol. In all cases of prescribing pharmacotherapy, the doctor may make a conscientious attempt at treatment with one drug, and then switch to another group of drugs, or even (if necessary) to a third, until a therapeutic effect is achieved.

In difficult differential diagnostic situations or in the absence of the expected result of pharmacotherapy (with adequate doses for an adequate period of time), the general practitioner should manage patients with the advisory participation of a psychiatrist or transfer the patient to him for full supervision. If problems go beyond the competence of a general practitioner, he needs to refer the patient to a specialized hospital. Among the most common difficulties include signs of suicidal risk; severe, disabling or atypical forms of the course of the disease; anxiety or depression, manifesting a manifestation of schizophrenia or other process-related disorder; complications of the disease due to alcoholism, personality disorders or other factors.

An indispensable guarantee of the success of the treatment of borderline mental disorders is the principle of a comprehensive approach, which includes, along with a full-fledged pharmacotherapy, a wide range of psychotherapeutic, physiotherapeutic and social rehabilitation measures. Along with a full-fledged pharmacotherapy of the main and concomitant diseases, the treatment process includes a whole set of proven psychotherapeutic, motor, physiotherapeutic and many other methods that have proven their effectiveness. Methods used in the clinic can be conditionally divided into psychotherapeutic, physiological, psychological and sociotherapeutic.

1. Psychotherapeutic methods - rational psychotherapy, multi-stage autogenic training, hypnotherapy, psychotherapeutic mediation and potentiation of therapeutic measures, etc.

2. Physiological methods carried out in accordance with the immune and neurohormonal status of patients with the determination of daily biorhythms:

Motor (breathing and relaxation therapeutic exercises, aerobics, therapeutic exercises on simulators);

Physiotherapy (therapeutic massage, hydrothermal effects, electro- and light therapy, EHF-therapy);

Acupuncture, laser therapy;

Hyperbaric oxygenation;

Unloading diet therapy.

3. Psychological - relationship analysis, psychodrama, transactional analysis, neurolinguistic programming, gestalt therapy, "Ericksonian hypnosis", mental gymnastics, etc.

4. Sociotherapeutic methods - cultural therapy, bibliotherapy, music therapy, dance therapy, art therapy, poetry evenings, etc.

A wide range of therapeutic and diagnostic measures provides a subtle interweaving of multidirectional influences, the ultimate goal of which is to break pathological stereotypes and compensate for painful manifestations. Thus, the integration of psychiatric and general somatic services is achieved and successfully developed, creating favorable conditions for the treatment of patients with neurotic disorders.

Social aspects

The disease of borderline mental disorder can have serious social consequences for the patient. For example, those suffering from panic disorder are deprived of the opportunity to use public transport or cease to cope with duties at work and leave work altogether. With decompensation of personality disorders, patients have difficulty maintaining adequate interpersonal relationships, which often leads to numerous conflicts and divorces. Depressed patients often experience suicidal thoughts, and in the absence of adequate therapy, they make suicidal attempts.

The problem of borderline mental disorders is extensive and significant. However, with a timely diagnosis and the appointment of adequate therapy, neurotic pathology lends itself well enough to reduction and allows patients to return to full activity in all spheres of life. Ecological, xenobiotic, socio-psychological reasons in our country, in essence, have changed the population norm of the socio-functional capabilities of the individual. Unfortunately, the efforts of doctors alone are often not enough for positive changes. However, the rapprochement of the positions of doctors and social workers, the creation of a preventive network, and an increase in the level of knowledge of the population in matters of psychoprophylaxis and psychohygiene could significantly improve the mental health of the nation and reduce the incidence of borderline mental disorders.

Renat AKZHIGITOV, Deputy Chief Physician of the Moscow Specialized Clinical Hospital No. Z.P. Solovyova ("Clinic of neuroses"), candidate of medical sciences.