- Symptoms of Affective psychosis
- Reasons of Affective psychosis
- Treatment of Affective psychosis
Affective psychosis — the mental disease which is characterized by frequency of emergence of autokhtonny affective disturbances in the form of the maniacal, depressive or mixed states (attacks, phases, episodes), their full reversibility and development of intermissiya with recovery of mental functions and personal properties; not leading to weak-mindedness.
This definition of affective psychosis corresponds to criteria of the endogenous diseases which are traditionally carried to maniac-depressive psychosis which is known also under names circular insanity, a tsiklofreniya, the circular psychosis, a maniac-depressive disease fazno proceeding mono - or bipolar psychosis. In relation to affective psychosis as nosologically to independent unit this definition is rather conditional as today it is represented clinically, pathogenetic and even nosologically a heterogeneous disease [Angst J. et al., 1970].
Affective psychosis is characterized only affektivna ми by phases which can be the different depth and duration. Maniacal phases are usually shorter than depressive. The average duration of the last 4 — 9 months, maniacal — 5 — 6 months. According to MKB-10, diagnostic criterion of affective phases is their duration not less than 1 — 2 week with the "full disturbance of usual working capacity and social activity" the patient causing need of the address to the doctor and treatments. The maximum duration of an affective phase can make several months and even several years (the depressive phases lasting 18 years are described).
The period of one affective phase and the intermissiya following it is designated by the concept "cycle of affective psychosis".
Symptoms of Affective psychosis:
Depending on dominance in structure of a syndrome of these or those psychopathological phenomena manifest depressions on the clinical picture approach in one cases depressions with hysterical, alarming and phobic or senestoipokhondrichesky frustration, in others — astenoadinamichesky, anestetichesky depressions, in the third — "classical" sad depressions. In most cases (43,9%) the picture of a depression includes polymorphic neurosis-like symptomatology with dominance of alarming and phobic or senestoipokhondrichesky manifestations.
The Atipichnost of depressive syndromes at affective psychosis is shown as well that they, being a symptom of an endogenous disease, on the structure not completely correspond to a concept of a typical endogenous depression, approaching structure of a situational or endoreak-tivny depression. Only in 36,5% of cases manifest depressions can be defined as clearly endogenous.
Depressions, reactive on structure, arise generally in connection with the difficult psychoinjuring situations. It often leads "reactive depressive psychosis" to statement of the initial diagnosis. The clinical picture of such situational depression is characterized by bystry increase of affective frustration, preservation throughout disease state of psychologically clear communication of clinical displays of a depression with the maintenance of a psychoinjury. Prevailing here is not vitalizirovanny affect of despondency, depression, and feeling of indifference, a hopelessness. Patients in these cases are usually concentrated on circumstances of the mental injury which is not able to distract with burdensome experiences, misfortune which comprehended them. In behavior prevail passivity, in statements — claims to people around. The ideas of self-accusation are also connected with the psychoinjuring experiences. The day-night rhythm of changes of mood not only is not expressed, but often perverted. Considerable vegetative disturbances in the form of attacks of tachycardia, perspiration, fluctuations of the ABP are noted. Complaints to a superficial dream with dreadful dreams are frequent. Duration of such depression, reactive on structure, about 3 months.
It should be noted that the described situational depressions at affective psychosis can arise at a combination of psychogenic and somatogenic factors when the psychoinjury works against the background of somatopathies, pregnancy, childbirth, etc.
Manifest endosituational depressions as well as reactive, develop after influence of exogenous harm, but at the same time accurate correlation with sharpness and force of a psychogenia is not observed here. Initial manifestations of endosituational depression are characterized by development of a depression which main content is defined by the psycho-injuring situation. Patients accuse combination of circumstances, the destiny of the incident, aim to dramatize them excessively. Into the forefront in these cases concern in the feeling sick acts. Further, however, the vitalization of affective frustration amplifies and in a depression endogenous lines with physical feeling of "mental anguish" more and more are found, elements of motive and ideatorny block appear. Patients note at themselves disappearance of ease, plasticity in the movements, difficulties in performance of calculating operations (though patients sometimes try to explain it with forgetfulness). After a while finally the subject of the psychoinjuring experiences loses the relevance. In statements of patients the depressive ideas of self-accusation and sinfulness begin to prevail, more outlined there are daily changes of health, typical for an endogenous depression, with improvement of mood in the evening and clear somatovegetativny symptoms of a depression. Endoreaktiv-naya the depression usually happens longer in comparison with reactive, proceeding on average about 6 months.
Approximately in V3 of cases manifest depressions arise hey-tokhtonno, i.e. without any external influences. On structure such depressions from the very beginning are endogenous.
The clinical picture of typically endogenous depressions is characterized by existence of vital affect of melancholy with the changes in ideatorny and motive spheres corresponding to it. Patients note difficulties in assimilation of new information, difficulty of concentration, feeling of "emptiness" in the head. Their movements differ in sluggishness. The ideas of self-abasement and self-accusation stated by them have supervaluable character. There are also somatic displays of a depression in the form of deterioration in appetite, decrease in body weight, locks. Existence of a day-night rhythm, typical for an endogenous depression, with noticeable improvement of a mental state in the second half of day is characteristic of such depressions. Duration of endogenous depressions on average about 5 months.
It should be noted that approximately with an equal frequency occur among depressions, reactive on structure, alarming and phobic, astenoadina-michesky and isterodepressivny. In 50% of cases of endosituational depressions in a clinical picture alarming and phobic frustration prevail. At endogenous depressions the "classical" melancholic depression was most often observed.
Depressive phases in dynamics of affective psychosis in general meet more often, making 80% of all affective phases. Besides, affective psychosis demonstrates more often (90%) a depressive phase, in other cases — maniacal. At 30% of patients during a disease the mixed states are noted.
The majority of maniacal states at affective psychoses, as well as a depression, are atypical. One of options of atypical manias are the maniacal states designated as "a mania without mania" (by analogy with the term "depression without depression", on R.Priori, 1969), which are observed approximately in 10% of cases. For the first time they were described by M. A. Morozova (1989). The leading symptom in a mental condition of patients in these cases is motive excitement which is not followed by increase in speed of ideatorny reactions. At safe ability to concentration of attention productivity of thinking, on the contrary, decreases. Patients in the presence of such mania are mobile, talkative, gesticulate much, easily come into contacts. The characteristic of maniacal patients increased activity differs in monotony and small productivity, but with the supervaluable relation to activity. In these cases actually maniacal affect is atypical. It differs in fadedness. The feeling of completeness of physical wellbeing inherent to a mania and comfort is not combined with feeling of joy and fun, and, on the contrary, is followed by irritability or irascibility. Tendency to revaluation of opportunities of own personality in these cases is not beyond exaggeration of the valid events. Disturbances-matovegetativnykh from functions are insignificant and are expressed generally in a sleep disorder and appetite. Duration of such maniacal state can reach 1 years.
Most often at affective psychoses manifest phases with a picture of a psychopatholike mania develop (more than in half of observations). Their development happens quickly, within 4 — 5 days. The average duration of such manifest mania is 4 — 5 months.
Manifest maniacal states as a classical cheerful mania are noted at 20% of patients. They develop also quickly — during 1 week and last on average 3 — 4 months. In certain cases maniacal states develop with special sharpness within 1 — 2 days, at height of affect the maniacal nonsense and (or) ideatorny confusion appear.
The mixed states. At bipolar kinds of affective psychosis the mixed states can develop [Sosyukalo O. O., 1989]. One of them can be considered as the typical and mixed states forming as substitution of separate components of an affective triad of one pole psychopathological frustration relating to an affective triad of an opposite affective pole — slowed down and associative slowed down manias, hyperactive and associative accelerated depressions; others treat the atypical mixed states forming as a result of accession to a typical affective triad of one pole of separate frustration, phenomenologically related to separate components of an affective triad of an opposite pole — disforiyepodobny, hypochiondrial and asthenic manias.
The most often atypical affective syndromes develop at the monopolar course of affective psychosis, they are also considerable also in cases of a bipolar course of a disease with dominance any one of poles of affective frustration (depressive or maniacal).
Features of depressive and maniacal manifest states at different types of affective psychosis. Monopolar depressive affective psychosis in most cases begins reactive and an endoreactant-nymi depressions in which clinical picture atypical syndromes of a depression with alarming and phobic, astenoadinamichesky and senestoipokhondrichesky manifestations prevail. When psychosis develops as a monopolar mania, the disease demonstrates a clinical picture of the atypical maniacal state designated as "a mania without mania". Manifestation of a disease of endoreak-tivny phases with a clinical picture of the alarming and phobic depression or depression coming to classical option of an endogenous depression is characteristic of bipolar affective psychosis with dominance of depressive frustration. Specific weight of endogenous frustration increases in these cases.
Manifest maniacal phases in which clinical picture affective frustration as a psychopatholike mania dominate are most of all inherent to bipolar type of affective psychosis with dominance of maniacal frustration. In cases with clearly bipolar type of a course of endogenous affective psychosis depressions which demonstrates a disease on the structure belong to a classical endogenous depression with a picture of typical sad melancholy or classical cheerful mania.
At patients irrespective of a pole of phase and affective frustration (depressive or maniacal) development of a manifest affective syndrome more often happens to monopolar endogenous affective psychosis gradual, within several weeks and if depressive frustration irrespective of structure of a depression (reactive, an endoreactant - ache, endogenous) accrue lytically during 2 — 5 weeks, then development of a maniacal manifest phase happens slower, sometimes drags on about one month. The return dynamics of an affective syndrome at monopolar kinds of affective psychosis also gradual. An exit from an affective phase proceeds during 3 — 4 weeks. During this period it is, as a rule, long astenovegetativny frustration in the form of increased fatigue, tearfulness, irritability or the passing alarming fears connected with the forthcoming extract from a hospital remain.
At all kinds of bipolar endogenous affective psychosis, irrespective of a ratio of different poles of affect in a disease picture, the manifest phase is characterized by acute development of an affective syndrome with bystry, within 3 — 4 days, increase of depressive or maniacal symptomatology and same critical, within several days, completion of affective frustration with a full exit from a state and recovery of former working capacity (patients "as if wake up from a disease").
Manifest affective phases at separate kinds of a course of affective psychosis differ also on duration. The most long (4 — 12 months) are affective states which demonstrates monopolar affective psychosis, both depressive, and maniacal (78 and 83,3% respectively). On the contrary, the smallest duration of phase and affective frustration at disease manifestation (up to 3 months) is observed at bipolar kinds of a current, especially at clearly bipolar — in 78,6%.
Reasons of Affective psychosis:
The reasons and the mechanism of development of affective psychoses so far are completely not established though in the last decades new essential data are obtained in this area. They concern first of all the nature of inheritance of a disease and a neurochemistry of affective pathology, and also effect of antidepressants and other remedies at the level of receptors of nervous cells. Such data allow to look in a new way at a role in a pathogeny of a disease of earlier established disturbances of exchange of biogenic amines, endocrine shifts, changes of a water salt metabolism, pathology of circadian rhythms, influences of gender and age, constitutional features. Various hypotheses of an etiology and a pathogeny of affective psychoses based on these data reflect not only the general ideas of biological essence of a disease, but also idea of a role of separate factors in formation of clinical features of a disease.
Now are laid great hopes on a molecular ge-neticheskiye of a research which at affective psychoses as well as at other endogenous diseases, are conducted rather intensively, though are in the beginning of the development. The data of clinical genetics testimonial of the significant contribution of hereditary factors to development of a disease are the cornerstone of these researches.
Accumulation of sekundarny cases of affective pathology in families of patients, dependence of risk of development of a disease on degree of related proximity of the family member and proband incomplete concordance of monozygotic twins (if one of them is sick) put researchers before need to address quantitative assessment of a contribution of genetic and environmental factors to development of a disease.
Development and use of special methods of studying of interaction of genetic and environmental factors in an etiology of psychoses by component decomposition of the total phenotypical variance [Gindilis V. M., Shakhmatova-Pavlova I.V., 1978] showed that the contribution of genetic factors to development of affective psychoses made 70%, and environmental respectively 30%. At the same time the contribution of arbitrary environmental factors makes 8%, and all-family — 22%. It turned out that on these indicators bipolar and monopolar psychoses differ: the contribution of genotypic factors is more at bipolar psychoses (76%) in comparison with monopolar (46%), and the ratio at them accidental environmental and all-family a component makes respectively 6%: 28% at bipolar psychoses and 12%: 33% — at monopolar. In later researches conducted by P .McGuffin and R.Katz (1989), the contribution of genetic factors was equal to 80%, and accidental environmental — 7%, i.e. was close to the above-stated indicators.
Recognizing possible etiological heterogeneity of affective psychoses, L.A.Meynett-Johnson and R. Mskeop (1996) assume the following models of inheritance of affective psychoses: the disease is caused by one (only) gene — model I; the disease is defined by a multifakto-rialny polygenic mode of inheritance — model II; inheritance of a disease goes as effect of a key gene — model III; transfer of a disease decides by primary influence of external factors on turning on of mechanisms of phenocopying — model IV. At affective psychoses in general or at their separate clinical options further researches, first of all molecular and genetic have to show legitimacy of existence of this or that model. But also earlier researches in this area are of a certain interest.
F.Kallmann (1956, 1957), having own data according to which maniac-depressive psychosis at sibs and dizygotic twins can develop in 20 — 25% of cases, and at cases, monozygotic in 66 — 96%, assumed dominant transfer of a disease with effect of one gene and its incomplete penetrance. Such point of view was stated earlier also by other researchers [Slater E., 1938; Stenstedt A., 1952]. There is an assumption that penetrance to a great extent is defined by a floor as the most part of cases of a disease in families is caused by sick women. In the specified hypotheses communication of coupling of the genes participating in development of affective psychoses with X-chromosome is allowed [Vartanyan M. E., 1970; Winokur G., 1972]. Inheritance on such type gains even more arranged character at division of affective psychoses according to a current into bipolar and monopolar options: the inheritance linked to X-chromosome is more peculiar to bipolar psychoses. Explain with communication with X-chromosome also cases of the linked inheritance of maniac-depressive psychosis and color-blindness. The last is considered even as a genetic marker of affective disturbances.
Except color-blindness, refer insufficiency of enzyme glyukozo-6-fosfatdegidroge-nazy (G6PO), antigenic types of leukocytes and a blood group of Xg to genetic markers of affective diseases [Meynett-Johnson L.A, McKeon P., 1966]. However the corresponding researches yielded so variable results that they allow to confirm genetic heterogeneity of the considered psychoses only. From the separate facts in this area the following deserves attention: coupling of color-blindness and affective psychoses with long shoulder H-hro-mosomy and coupling of a blood group of Xg with her short shoulder are noted; color-blindness is at the same time linked to insufficiency of G6PO enzyme. Coupling of affective psychoses with a blood group of Xg was not confirmed. In 1993 M. Baron and соавт. conducted a control research of a stseplennost of a number of signs with X-chromosome on several generations of three Israeli families and did not confirm coupling of the studied genetic markers of affective pathology with X-chromosome. Thus, this question still remains open. When studying genetic markers also the chromosome 11 drew to itself attention [with Egeland J.A. et al., 1987], but its communication with a disease was not confirmed.
Modern molecular and genetic researches develop in the direction of so-called genetic mapping, i.e. search of certain areas of chromosomes which can be connected with hereditary transfer of a disease or its remote signs. They are based on scanning of a genome at members of the families having patients. The greatest attention was drawn by two researches published in 1994 in which several generations of families of patients with affective psychoses were studied [Berrettini W.H. et al., 1994; Straub R.E. et al., 1994]. The obtained data showed that loci of genes, perhaps, concerning development of a disease, are located in peritsentromerny area of a chromosome 18 (these Berrettini groups) and on a chromosome 21 — area 21q22.3 (these Straub groups). But these results are estimated as especially preliminary and needing confirmation. They received partial confirmation in 1996. So, A.De Brune and соавт. established coupling of bipolar disorders with a chromosome 18 (areas 18qll — 18q23), and N. Soop and соавт., having generalized results of inspection of families where there were 45 patients (27 with bipolar disorders, 18 — with unipolar), established that the disease can be connected with a chromosome 18 — area 18q23, but not with centromere area.
Genetic researches of affective psychoses are conducted taking into account influence on a course of a disease of gender and age of patients, and also external factors.
Influence of age and floor on development of psychosis. Most of authors recognize that affective psychosis meets at women (60 — 70%) more often — twice more often than at men. According to E.Kraepelin, for women it is diagnosed 2/z всехслучаев maniac-depressive psychosis. However according to J.Angst (1966), with bipolar forms of affective psychosis men get sick more often, and the unipolar form 3 times more often develops at women [M.M.'s Weissman, 1988; Judd L.L., 1994]. The risk of development of a recurrent depression in women makes 10 — 25%, men have 5 — 12%. In comments to DSM-IV it is specified that prevalence of bipolar forms of affective psychosis is identical to men and women and 0,4 — 1,6% equal. Affective psychosis often develops at women in the period of periods, after the delivery, in involution that confirms participation of an endocrine factor in its pathogeny.
Treatment of Affective psychosis:
Distinguish methods of the active therapy directed to stopping of displays of a disease in the period of an attack (phase), and preventive therapy which purpose are the prevention of a recurrence of a disease and lengthening of remission (intermissiya). On the nature of influence allocate medicamentous and other biological therapy and psychotherapy. The last at affective psychosis has auxiliary character.
The choice of specific therapeutic methods is connected with clinical features of each of forms of affective psychosis, and also with a stage of a course of a disease and specific features of the patient.
Biological therapy. At monopolar forms of affective psychosis when in a picture of a disease atypical affective syndromes are most of all presented, treatment of depressive and maniacal states has a number of features. At depressions, reactive and endoreactive on structure, with the alarming and phobic and senestoipokhondrichesky manifestations serving as a prerogative of monopolar depressive psychosis positive reaction to antidepressants of preferential sedative and so-called balancing action is observed. Prescription of antidepressants of the second generation (atypical antidepressants) in which psychotropic range it is combined is preferable the tranquilizing or promoting effect with timoleptichesky is distinct. Are used terfonat, Pyrazidolum, ludiomit, вивалан, or emovit, in rather high daily doses (from 150 to 250 mg), fluoxetine (20 mg a day), серталин (100 — 150 mg a day). Tricyclic antidepressants in these cases are much less effective and if they are appointed, then in moderate doses (amitriptyline to 150 mg). At emergence of a tendency to the long course of a depression for an intensification of therapy the method of intravenous drop administration of amitriptyline, a ludiomil, a combination of antidepressants to acupuncture and method of short-term acupuncture influence [Polyakov are used by Page E., 1986; Asimov M. And, 1994], intravenous laser radiation of blood [Perstnev S. V., 1995].
The desirable therapeutic effect is reached, as a rule, at a combination of antidepressants to small neuroleptics of sedative action (сонапакс — to 30 mg, chlorprothixene — to 150 mg, Theralenum — to 30 mg a day) or with tranquilizers (Phenazepamum — to 6 mg, Elenium — to 30 mg, Seduxenum — to 30 mg). At a depression involution stage preference is given to so-called atypical antidepressants, or antidepressants of the second generation (Pyrazidolum, emovit, timelit, ludiomit, инказан), the most effective at superficial depressions of neurotic level again. According to recommendations of the medical centers of WHO (1989), it is reasonable to continue antidepressive therapy within 6 months after achievement of therapeutic effect (for its fixing).