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Keywords: the abstract on psychiatry, acclimatization, distress, somatoform distress, ìêá-10, the international classification of illnesses, psychosomatic diseases, treatment, a dysmorphophobia, a hypochondria, a somatization, an asthenia, conversion distresses, the abstract on psychology
THE ABSTRACT
DISTRESSES OF ACCLIMATIZATION. SOMATOFORM DISTRESSES
INTRODUCTION
All history of psychiatry is the witness of that practically always object of studying of psychiatrists were psychotic forms of a mental pathology and an organic pathology, as most clinically expressed diseases adducting in the most rasping forms of a disadaptation and demanding urgent measures on treatment and an avoidance of complications. It is natural, that frequently were not noticed, ignored, and, probably, and many were not interpreted as such clinically not expressed, amorphous, not typical developments having completely to other stereotype not psychotic forms of a mental pathology. Today they can be designated as boundary (small) alienations - neurosises, neurotic reactions and states, personal distresses, behavioural exhibitings, distresses of acclimatization, somatoform distresses, psychosomatic distresses.
DISTRESSES OF ACCLIMATIZATION
Definition of distresses of acclimatization, an etiology.
Distresses of acclimatization (F43.2) on ÌÊÁ-10 are characterized by a state subjective distressa and the emotional infringements arising in the season of acclimatization to appreciable change in life or stressful event and building difficulty for vital activity. Stressful event can break integrity of social relateds of the individual or system of social support and values (migration, the status of the refugee) or to make changes to life (entering in an educational institution, the beginning or the terminal of professional work, failure in achievement of the desirable purpose and so forth) . Individual predisposition, vulnerability matter, however distress of acclimatization arises in reply to traumatizing factor. So distresses of acclimatization, for example, are more often meet at persons with the highest personal uneasiness, with serious somatopathies, invalids, the persons lost parents in the early childhood or testing a disadvantage of a maternal care. Distresses of acclimatization are most typical for teenage age, that, however, does not exclude an opportunity of their originating at any age. The majority of signs weakens in due course without treatment, is especial after the terminal of action of a stress factor; at variant with possible chronic flow there is a risk of secondary depression, alarm and abuse by the psychotropic materials.
Diagnostics of distresses of acclimatization.
Distresses of acclimatization are diagnosticated at conformity of a state to the following criteria:
1) the identified psychosocial stress which is not reaching extreme or catastrophic scope, signs appear within a month; 2) separate signs (except for crazy and hallucinative), conforming to criteria affective (F3), neurotic, stressful and somatoform (F4) distresses and infringements of a social behavior (F91), not conforming completely to any of them; 3) signs do not exceed on duration of 6 months from the moment of cancellation of a stress or its consequences except for lingering depressive reactions (F43.21.)
Signs can vary on frame and gravity. Distresses of acclimatization in dependence on exhibitings predominant in a clinical picture are differentiated as follows:
F43.20 short-term depressive reaction a transient state of the mild depression continuing not over month;
F43.21 prolonged depressive reaction - a mild depression as reaction to the lingering stressful situation, continuing not over two years;
F43.22 blended alarming and depressive reaction - is submitted both alarming, and a depressive symptomatology, on intensity not exceeding blended alarming and depressive distress (F41.2) or other blended alarming distresses (F41.3);
F43.23 with predominance of infringement of other emotions - the symptomatology has various frame of an affect, the alarm, depression, disturbing, intensity and anger are submitted. Signs of alarm and depression can correspond to criteria of blended alarming and depressive distress (F41.2) or other blended alarming distresses (F41.3), but their expressiveness is insufficient for diagnostics of more specific alarming or depressive distresses. This category should be used and for reactions of children's age where in addition there are such attributes of regressive behaviour as a uracrasia or a suction of a dactyl;
F43.24 with predominance of a behavior disorder - distress affects mainly a social behavior, for example, aggressive or dissotsialnye its forms in frame of reaction burning in teenage age;
F43.25 blended distress of emotions and behaviour - determining are both emotional exhibitings, and infringements of a social behavior;
F43.28 other specific prevailing signs.
the Differential diagnosis.
The differential diagnosis of distresses of acclimatization should be carried out with posttraumatic stressful distress, acute reaction to a stress, short-term psychotic distress, uncomplicated serious loss. Posttraumatic stressful distress and acute reaction to a stress are characterized by that these diagnoses defines singularity of a stress which war is beyond normal human experiences, for example, mass accident, act of nature, rape, a capture in hostages. Short-term psychotic distress is characterized by hallucinations and delirium. Uncomplicated serious loss arises before expected mors of the close person or soon after it; professional or social activity worsens in limens of the expected season, then is spontaneously normalized.
Treatment.
For treatment of distresses of acclimatization a preferable psychotherapy which includes research of value of a stress factor for the patient, maintenance of support, drive to search of alternative paths of the decision of a problem, exhibiting of sympathy. If the alarm use of procedures of a biological feedback is expedient, relaxations and hypnosis prevails. Intervention during crisis is directed on assistance to the patient in the fast decision of a problem by means of use of methods of support, a suggestion, belief, paravariation of environment. Hospitalization is in case of need possible. Medicamental therapy is shown at serious distresses. It is possible to apply anxiolytic agents or antidepressants to treatment in dependence on type of distress, but thus it is necessary to be careful to not admit originating of dependence on a preparation (especially at use benzodiazepinov).
SOMATOFORM DISTRESSES
the Urgency of a problem of somatoform distresses.
The problem of psychosomatic interrelations is a subject of discussions not only for psychiatry, but also for the general pathology of the person. The question of influence of corporal sensations in norm and to a pathology on mental sphere and development of the various psychopathologic phenomena is not subject to doubt. Presence of somatopsychic distresses is the authentic proof of existence of communication between a body and psychics.
However more and more enriched clinical data testify, as changes in mental sphere can invoke corporal (including pathological) changes, thus causing development of so-called psychosomatic diseases.
The problem of a somatopsychic pathology is in detail enough covered in the medical literature. As to psychosomatic infringements they are investigated insufficiently and many questions concerning the given problem, till now are far from the sanction. Among them especially disputable and undeveloped medical and psychiatric problem there is a problem of somatoform distresses. Views of clinicians on the given problem the extremely discordant, and it is frequent even opposite and mutually exclusive.
Well-timed diagnostics and adequate treatment of these states is put forward as priorities of system of public public health services. Alterations which take place in modern psychiatry, dictate a urgency and necessity of conceptual research of somatoform distresses. These alterations are defined, on the one hand, by shift of accent with "big" on "small" psychiatry, steady body height of a boundary mental pathology; on the other hand, necessity of judgement of the collected data and data for the attitude of masked depressions, conversion infringements, hypochondrias, the vegetative distresses being actually the maintenance of somatized mental infringements has appeared. At last, necessity of research of somatoform distresses is caused by economic interests - expediency additional, at times unjustified material - financial charges.
Definition.
Somatoform distresses - bunch of the distresses described by constant complaints of the patient on infringement of the state, a reminding somatopathy; thus do not find out any pathological process explaining their originating. Distresses are not caused by other mental disease or abuse of the psychotropic materials. If the patient has a somatopathy, the given case histories, somatic inspection and laboratory analysises cannot explain the cause and an expressiveness of complaints. Signs do not think out intentionally, as against is artificial shown distresses and a simulation. In spite of the fact that originating and conservation of a symptomatology is frequently closely connected to unpleasant events, difficulties or conflicts, patients usually against attempts of discussion of an opportunity of its psychologic conditionality; it can take place even at presence of distinct depressive and alarming signs. The achievable degree of comprehension of the causes of a symptomatology frequently is disappointing and frustrirujushchej both for the patient, and for the doctor.
Some explorers are convinced that somatoform signs are actually exhibitings of the hidden depression, and on this establishment treat their antidepressants, others consider, that they are special conversion, that is dyssociative distresses and consequently should be treated by psychotherapeutic methods.
Frequency of somatoform distresses - 0,1-0,5 % of the population. More often somatoform distresses are observed at women.
Classification of somatoform distresses (on ÌÊÁ-10).
F45.0 Somatized distress.
F45.1 Undifferentiated somatoform distress.
F45.2 Hypochiondrial distress.
F45.3 the Somatoform dysfunction of vegetative nervous system.
F45.4 Steady somatoform pain distress.
F45.8 Other somatoform distresses.
F45.9 Somatoform distress not specified.
the Separate sets of symptoms meeting at somatoform distresses.
It is especially possible to secure conversion sets of symptoms, asthenic states, depressive sets of symptoms, a set of symptoms of a nervous anorexia, a set of symptoms of a dysmorphophobia which are included into frame of various somatoform distresses.
Conversion sets of symptoms.It is characterized by change or loss of any function of a body (an anaesthesia and a paraesthesia of extremities, deafness, blindness, anosmija, psevdotsejzis, parezy, choreiform habit spasms, ataksija, etc.) as a result of the psychologic conflict or need, thus patients do not realize, what psychologic cause causes distress, therefore cannot control him voluntary. Conversion - transformation of emotional infringements in motorial, sensory and vegetative equivalents; these signs in domestic psychiatry usually survey within the framework of a hysterical neurosis.
Asthenic statesconcern to most frequently meeting in practice of the doctor of a wide structure. The fast emaciation acts in these cases on a background of the raised psychological excitability. To number of complaints of somatic character with which the patient addresses, changeable and diverse headaches, sometimes such as " a neurasthenic helmet ", but also a pricking in ranges of a forehead and a nucha, sensation " a stale head concern first of all. Pains strengthen at a mental load and usually become more serious after midday. Asthenic states can imitate the signs inherent to this or that somatopathy. It, as a rule, palpitation, a lability of arterial pressure, often desires to an emiction, a dysmenorrhea, downstroke libido, potencies, etc.
Depressive sets of symptomsalso meet enough frequently (approximately in half of cases the state of somatoform patients is qualified as depressive). The special interest is invoked with so-called somatized (masked) depression.
the Set of symptoms of a nervous anorexia- progressing self-restriction in meal at safety of appetite with the purpose of growing thin in connection with conviction in excessive completeness or from fear to be thick. This state meets mainly at persons of a female at podrostkovo-youthful age. Characteristic for a set of symptoms expressed in all completeness, the triad is considered: abandoning of meal, appreciable growing thin (about 25 % of premorbidal mass), an amenorrhea.
the Set of symptoms of a dysmorphophobia.It is the type of hypochiondrial sets of symptoms mainly meeting at teenage age (up to 80 %). At a dysmorphophobia pathological conviction or available any disfiguration, or in diffusion by the patient of unpleasant odours takes place. Thus patients are afraid, that associates notice these disadvantages, discuss them and laugh at them. For expressed dismorfomanicheskogo a set of symptoms the triad of attributes is typical: ideas of a disfiguration, idea of the attitude, the suppressed mood.
In connection with conviction in existence of imaginary defect or at presence of any insignificant disfiguration at its excessive exaggeration patients persistently address for the help to doctors of various specialities - to cosmeticians, stomatologists, endocrinologists, plastic surgeons.
For patients with a dysmorphophobia predilection to a dissimulation of the state is characteristic. In this connection it is important to note presence of two characteristic signs which can be revealed at inquiry of patients and their relatives: these are signs of "mirror" (steadfast survey of in a mirror with the purpose to be convinced available a disfiguration and to try to find a look, masking this "defect") and "photos" (last is surveyed as documentary acknowledgement of disadvantages of the appearance in this connection photographing is avoided).
Clinic of somatoform distresses.
We shall consider the most often variants of flow of somatoform distresses.
Somatized distress.the Basic attribute is presence plural, repeatedly arising and frequently changing somatic signs which usually take place during lines of the years previous to the reference of the patient to the psychiatrist. The majority of patients have passed a long and complex path, including initial and special medical service during which negative results of inspections have been received and useless operations could be executed. Signs can concern to any part of a body or system, but most frequently there are gastrointestinal sensations (a pain, an eructation, a regurgitation, a vomiting, a nausea, etc.), and also abnormal dermal sensations (an itch, a burning sensation, a pricking, a numbness, morbidity, etc.). Sex and menstrual complaints are frequent.
Distinct depression and alarms is frequently found out. It can justify specific treatment. Flow of distress chronic and fljuktuirujushchee, is frequently combined with long infringement of social, interpersonal and family behaviour. Distress much more often meets at women, than at men, and frequently begins at young age.
Dependence or abuse by medicinal preparations (it is usual sedatikami or analgethics) as consequence of often medicamental courses is quite often found out.
the Somatoform dysfunction of vegetative nervous system.Complaints are showed to patients thus as if they are caused by physical distress of that system or a member which basically or completely are under influence of vegetative nervous system, that is cardiovascular, gastrointestinal or respiratory system. (Here also the genitourinary system) in part concerns. The most often and vivid examples concern to cardiovascular system (" a neurosis of heart "), respiratory system (a psychogenic short wind and a hiccup) and gastrointestinal system (" a neurosis of a stomach " è " nervous diarrhea "). Signs usually are two phylums, any of which does not specify physical distress of an affected member or system. The first phylum of signs on which in many respects diagnostics is based, is characterized by the complaints reflecting objective attributes of vegetative exaltation, such as palpitation, a reddening and a tremor. The second phylum is characterized more idiosinkrazicheskimi, subjective and nonspecific signs, such as sensations of fleeting pains, burning sensations, gravities, strains, sensations of inflating or a distention. These complaints concern the patient to the certain member or system (to which can concern and a vegetative symptomatology). The characteristic clinical picture develops of distinct recruitment phenomenon of vegetative nervous system, additional nonspecific subjective complaints and constant references of the patient to the certain member or system as the cause of the distress.
Many patients with this distress have indicatings on presence of a psychologic stress or difficulty and a problem which are represented connected with distress. Nevertheless, at an appreciable part of the patients adequate to criteria of the given distress, burdening psychologic factors are not taped. At some cases there can be also insignificant infringements of physiological functions, such as a hiccup, a meteorism and a short wind, but in themselves they do not break the basic physiological functioning of the conforming member or system.
Chronic somatoform pain distress.Among the causes of chronic somatoform pain distress excrete psychodynamic - the pain shows, as the mean to achieve love, to avoid punishment and to expiate fault, a mean of a manipulation relatives. Secondary benefit from the given sign matters therefore. The presentation of a pain can be also a mean of deduction near to itself of object of love or original jerk after the long season of a somatic or neurologic pain. In an etiology of a pain the central mechanisms connected to a level of endorfinses matter.
The general attributes of this distress are: 1) duration algopaticheskih states not less than 6 months; 2) absence of a somatic pathology confirmed as a result of special inspections which could cause originating of pains; 3) the expressiveness of complaints to pains and downstroke of acclimatization connected to them considerably exceed expected consequences of somatic signs in case of a concomitant somatic pathology. Additional general attributes algopaty are: 1) absence of signs of endogenic disease (a schizophrenia, a maniacal - depressive psychosis) and an organic lesion of a central nervous system; 2) comparability to pain sensations observable at a somatic pathology.
The pain frequently appears in a combination to the emotional conflict or the psychosocial problems regarded as the main cause. As a rule there are headaches, dorsodynias, a breast bone, a neck.
Hypochiondrial distress.In spite of the fact that a hypochondria - one of the most private psychopathologic phenomena, questions of a nosological assessment and a choice of adequate medical measures are developed insufficiently.
What is the hypochondria? This excessive attention not having the real establishments to the health, concern even an insignificant malaise or conviction available serious illness, infringements in corporal sphere or teratisms.
At a hypochondria the question is not simply alarming suspiciousness as such, and about the conforming mental, intellectual processing those or other morbid sensations on the part of somatic sphere. Quite often put comes to an end designing of the concept of the certain disease with the subsequent struggle for its recognition and treatment. Psychopathologic character of a hypochondria proves to be true that at its combination to a real somatopathy of the patient does not pay on the last and lobes of that attention which gives imaginary distress.
Hypochiondrial states educe in mature more often or advanced age, is identical frequently at men and women.
Paraesthesia first of all concern to leading structural elements of a hypochiondrial set of symptoms - sensations of a numbness, a pricking, crawling murashek, etc., not caused by choronomic irritants. Further follow psihalgii, caused not any concrete lesion, and being consequence of physiological rising of a pain threshold. These are usual pains without the real establishments, quite often plural. Other such element are senestoalgii which differ more bizarre and original character. For example, headaches here already stinging, shooting, penetrating, koljushchie. Senesthopathias - too the arising spontaneously and burdensomest sensations arising spontaneously which is not conforming on localization to concrete anatomic formations further follow. For senesthopathias novelty and a diversification of sensations are characteristic; patients are at a loss precisely to describe them. And, at last, synesthesias - sensations of obscure total physical trouble or a malaise with original, hardly giving in to the description of infringement of motor sphere (unexpected physical delicacy, rocking and uncertainty at walking, gravity or emptiness in a body).
the Differential diagnosis.
The differential diagnosis of somatoform distresses is carried out with the whole bunch of diseases at which patients show somatic complaints. So the differential diagnosis from hypochiondrial delirium usually is based on close examination of a case. Though ideas of the patient are kept is long and seem contradicting to common sense, the degree of conviction is usually reduced in any measure and for short time under influence of the argument, abirritation and carrying out of new inspections. Besides presence of unpleasant and frightening physical sensations can be surveyed as cultural comprehensible explanation of development and conservation of conviction in physical disease.
The differential diagnosis with somatic distresses though usually patients get to the psychiatrist after doctors of a somatic structure is obligatory. But nevertheless the probability of appearance of independent somatic distress at such patients is not lower, than at usual people at the same age.
Affective (depressive) and alarming distresses. Depression and alarm of a various degree frequently accompany with somatized distresses, however they should not be described separately unless they are obvious enough and stable to justify own diagnosis. Appearance of plural somatic signs in the age of the ambassador of 40 years can testify to demonstration of initial depressive distress.
Also it is necessary to exclude dyssociative (conversion) distresses, alalias, the psychologic and-or behavioural factors connected to infringements or illnesses, categorized in other headings, sex the dysfunction which has been not caused by organic infringements or illnesses, habit spasms, set of symptoms ZHill de la Turetta, a trichotillomania.
Treatment.
Therapy of somatoform distresses includes the broad audience of the medical and preventive actions demanding participation as the doctor - internista, and the psychiatrist and the psychotherapist.
Huge practical value has that fact, that the conforming alienations can not be realized by the patient or dissimulirovatsja. Patients usually against attempts of discussion of an opportunity of psychologic conditionality of signs, even at presence of distinct depressive or alarming exhibitings. Thereof a basic direction in treatment of patients by somatoform distresses now is the psychotherapy. All spectrum of modern forms and methods of a psychotherapy is used practically. Rational therapy, autogenic training, a hypnotherapy, group, analytical, behiveoral, positive, the client - tsentrirovannaja therapy is widely applied, etc. However, despite of prioritetnost psychotherapeutic correction, the prevailation in a clinical picture of vegetative components does not give an opportunity to do without medicamental therapy. In the initial season even rigidly directive procedures do not allow to receive fast desirable result, that, finally, compromises a psychotherapy as a method.
The pharmacotherapy of somatoform distresses assumes use of a wide spectrum of psychotropic agents - first of all anksiolitikov, and also antidepressants, nootropov and neuroleptics. However application of psychotropic agents in clinic of somatoform distresses has the features. At purpose of psychotropic agents it is expedient to be limited to monotherapy with use of convenient medicinal preparations in the use. Taking into account an opportunity of a hypersensibility, and also an opportunity of by-effects, psychotropic agents are appointed in small (in comparison with used in the "big" psychiatry) doses. The minimal influence on somatic functions, weight of a body concern to demands, minimal a behavioural toxicity and teratogenic effect, an opportunity of application in the season of a lactemia, low probability of interaction with somatotropic preparations also.
THE CONCLUSION
The expressed clinical pathomorphism on itself of somatoform distresses, appreciable dilating of their classification and augmentation of densities of the somatic pathology proceeding with boundary alienations, demands revision and specification of criteria of differential diagnostics and frames preconditions for development of new diagnostic and therapeutic approaches. Well-timed revealing and adequate diagnostics of somatoform distresses has crucial importance for successful therapy and the congenial forecast of disease.
In this connection integration of system of the psychotherapeutic help into somatic treatment-and-prophylactic frames, discovering of psychosomatic abjointings into frame of somatic hospitals is represented expedient. It is necessary to emphasize also the important role of rising of knowledge of doctors of a medical network. For doctors of the general practice teaching of bases of medical ethics, a deontology and a psychotherapy, for doctors - psychotherapists - the profound vocational training should be stipulated. Are rather actual development of special curriculums on concrete problems of a psychosomatic pathology (clinic, diagnostics, therapy), carrying out of thematic conferences and seminars, the organization of courses of improvement of qualification.
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Keywords: the abstract on psychiatry, acclimatization, distress, somatoform distress, ìêá-10, the international classification of illnesses, psychosomatic diseases, treatment, a dysmorphophobia, a hypochondria, a somatization, an asthenia, conversion distresses, the abstract on psychology
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