Stress and adjustment disorders. Severe stress response and adjustment disorders (F43) F40.8 Other phobic anxiety disorders

In the third issue of the journal World Psychiatry for 2013 (currently available only in English, translation into Russian is in preparation), the working group on the preparation of the ICD-11 diagnostic criteria for stress disorders presented their draft of a new section of the international classification.

PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. However, approaches to diagnosing these conditions have long been the subject of serious controversy due to the non-specificity of many clinical manifestations, difficulties in distinguishing disease states with normal reactions to stressful events, the presence of significant cultural characteristics in response to stress, etc.

Many criticisms have been made of the criteria for these disorders in DSM-IV and DSM-5. Thus, for example, according to the members of the working group, adjustment disorder is one of the most poorly defined mental disorders, which is why this diagnosis is often described as a kind of "wastebasket" in the psychiatric classification scheme. D The diagnosis of PTSD is criticized for the wide combination of different clusters of symptoms, low diagnostic threshold, high level of comorbidity, and in relation to the DSM-IV criteria for the fact that more than 10,000 different combinations of 17 symptoms can lead to this diagnosis.

All this was the reason for a fairly serious revision of the criteria for this group of disorders in the draft ICD-11.

The first innovation concerns the name for a group of disorders caused by stress. In the ICD-10 there is a heading F43 "Reaction to severe stress and adjustment disorders", related to section F40 - F48 "Neurotic, stress-related and somatoform disorders". The Working Group recommends avoiding the widely used but confusing term " stress-related disorders”, due to the fact that numerous disorders can be associated with stress (for example, depression, disorders associated with the use of alcohol and other psychoactive substances, etc.), but most of them can also occur in the absence of stressful or traumatic life events. In this case, we are talking only about disorders, stress for which is an obligatory and specific cause of their development. An attempt to emphasize this point in the draft ICD-11 was the introduction of the term “disorders specifically associated with stress”, which, probably, can most accurately be translated into Russian as “ disorders, directly stress related". It is planned to give this title to the section where the disorders discussed below will be placed.

The working group's proposals for individual disorders include:

more narrow concept of PTSD, which does not allow a diagnosis to be made on the basis of only non-specific symptoms;
new category " complex PTSD” (“complex PTSD”), which, in addition to the core symptoms of PTSD, additionally includes three groups of symptoms;
new diagnosis prolonged grief reaction used to characterize patients who experience an intense, painful, disabling, and abnormally persistent bereavement reaction;
a significant revision of the diagnosis " adjustment disorders”, including specification of symptoms;
revision concepts« acute reaction to stress» in line with the concept of this condition as a normal phenomenon, which, however, may require clinical intervention.

In a generalized form, the proposals of the working group can be presented as follows:

	Previous ICD-10 codes	The main diagnostic signs in the new edition
Post Traumatic Stress Disorder (PTSD))		A disorder that develops following exposure to an extreme threatening or horrifying event or series of events and is characterized by three "core" manifestations: re-experiencing a traumatic event(s) in the present tense in the form of vivid intrusive memories accompanied by fear or horror, flashbacks or nightmares; avoidance of thoughts and memories about the event(s), or avoidance of activities or situations resembling the event(s); state of subjective sense of continued threat in the form of hyperalertness or increased fear reactions. Symptoms must last at least several weeks and cause significant deterioration in performance. The introduction of a criterion of dysfunction is necessary to increase the diagnostic threshold. In addition, the authors of the project are also trying to improve the ease of diagnosis and reduce comorbidity by identifying bar elements PTSD, and not lists of equivalent "typical signs" of the disorder, which, apparently, is a kind of deviation from the operational approach in diagnostics that is customary for the ICD to ideas that are closer to domestic psychiatry about the syndrome.
Complex post-traumatic stress disorder		A disorder that occurs after exposure to an extreme or long-term stressor that is difficult or impossible to recover from. The disorder is characterized main (core) symptoms of PTSD(see above), as well as (in addition to them) the development of persistent, pervasive impairments in the affective sphere, self-relationship and social functioning, including: difficulty regulating emotions feeling like a humiliated, defeated and worthless person, difficulties in maintaining relationships Complex PTSD is a new diagnostic category replaces the overlapping ICD-10 category F62.0 "Persistent Personality Change After a Disaster Experience", which failed to attract scientific interest and did not include disorders arising from long-term stress in early childhood. These symptoms may occur after exposure to a single traumatic stressor, but are more likely to occur following severe prolonged stress or multiple or recurring adverse events that cannot be avoided (eg, exposure to genocide, child sexual abuse, children in war, severe domestic violence). , torture or slavery).
Prolonged grief reaction		A disorder in which, after the death of a loved one, persistent and all-encompassing sadness and longing for the deceased or constant immersion in thoughts about the deceased persist. Experience data: continue for an abnormally long period compared to the expected social and cultural norm (for example, at least 6 months or more depending on cultural and contextual factors), they are severe enough to cause significant deterioration in human functioning. These experiences can also be characterized as difficulty accepting death, a sense of losing a part of oneself, anger at the loss, guilt, or difficulty engaging in social and other activities. Several sources of evidence at once point to the need for the introduction of prolonged grief reaction: The existence of this diagnostic unit has been confirmed in a wide range of cultures. Factor analysis has repeatedly demonstrated that the central component of prolonged grief reaction (longing for the deceased) is independent of nonspecific symptoms of anxiety and depression. However, these experiences do not respond to antidepressant treatment (whereas bereavement depressive syndromes do), and psychotherapy that strategically targets the symptoms of prolonged grief disorder appears to be more effective in alleviating its manifestations than treatment directed at depression. People with prolonged grief disorder have serious psychosocial and health problems, including other mental health problems such as suicidal behavior, substance abuse, self-destructive behavior, or physical disorders such as high blood pressure and an increased incidence of cardiovascular disease There are specific brain dysfunctions and cognitive patterns associated with prolonged grief disorder
Adjustment disorder		A maladjustment response to a stressful event, to ongoing psychosocial difficulties, or to a combination of stressful life events that typically occurs within a month of exposure to the stressor and tends to resolve within 6 months if the stressor is not sustained for longer. The response to the stressor is characterized by symptoms of preoccupation with the problem, such as excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its consequences. There is an inability to adapt, ie. symptoms interfere with daily functioning, there are difficulties with concentration or sleep disturbances, leading to impaired performance. Symptoms can also be associated with loss of interest in work, social life, caring for others, leisure activities, leading to disruption in social or professional functioning (limitation of social circle, conflicts in the family, absenteeism from work, etc.). If the diagnostic criteria are appropriate for another disorder, then that disorder should be diagnosed instead of adjustment disorder. According to the authors of the project, there is no evidence for the validity of the subtypes of adjustment disorder described in ICD-10, and therefore they will be removed from ICD-11. Such subtypes can be misleading by focusing on the dominant content of distress, obscuring the underlying commonality of these disorders. Subtypes are not relevant to treatment choice and are not associated with a specific prognosis
reactive attachment disorder
Attachment disorder of the disinhibited type		See Rutter M, Uher R. Classification issues and challenges in childhood and adolescent psychopathology. Int Rev Psychiatry 2012; 24:514-29
Conditions that are not disorders and are included in the section “Factors influencing the health status of the population and visits to healthcare facilities” (chapter Z in ICD-10)
Acute reaction to stress		Refers to the development of transient emotional, cognitive, and behavioral symptoms in response to exceptional stress, such as an extreme traumatic experience, that causes serious harm or threat to the safety or physical integrity of the person or those close to them (e.g., natural disasters, accidents, military acts, assault, rape), or sudden and threatening changes in the individual's social position and/or environment, such as the loss of one's family in a natural disaster. Symptoms are treated like a normal reaction spectrum caused by the extreme severity of the stressor. Symptoms are usually found over a period of several hours to several days from exposure to stressful stimuli or events, and usually begin to subside within a week of the event or after the threatening situation has been removed. According to the authors of the project, the description of the acute reaction to stress proposed for the ICD-11 " does not meet the definition of mental disorder, and the duration of symptoms will help distinguish acute stress reactions from pathological reactions associated with more severe disorders. However, if we recall, for example, the classical descriptions of these states by E. Kretschmer (which the authors of the project, apparently, have not read and the latest edition of his "Hysteria" in English dates from 1926), then nevertheless, their removal from the boundaries of pathological states causes some doubt. Probably, following this analogy, hypertensive crisis or hypoglycemic states should be removed from the list of pathological conditions and headings of the ICD. They, too, are only transient states, not "disorders." In this case, the medically fuzzy term disorder (disorder) is interpreted by the authors closer to the concept of a disease than a syndrome, although according to the general (for all specialties) conceptual model used to prepare the ICD-11, the term "disorder" can include, as diseases and syndromes.

The next steps in the development of the ICD-11 project on disorders directly related to stress will be its public discussion and testing in the "field" conditions.

Acquaintance with the project and discussion of proposals will be carried out using the ICD-11 beta platform ( http://apps.who.int/classifications/icd11/browse/f/en). Field studies will assess clinical acceptability, clinical utility (eg ease of use), reliability and, to the extent possible, validity of draft definitions and diagnostic guidelines, in particular against ICD-10.

WHO will use two main approaches to pilot the draft sections of ICD-11: Internet research and clinical research. Internet research will be carried out primarily within the framework, which currently consists of more than 7,000 psychiatrists and primary care physicians. Research into disorders directly related to stress is already planned. Clinical research will be carried out through the international network of WHO Collaborating Clinical Research Centres.

The Working Group looks forward to working with colleagues around the world to test and further refine the proposals for diagnostic guidelines for disorders directly related to stress in ICD-11.

Liked: 3

myalgia;

polyarthralgia without redness or swelling of the joints;

headache (other in nature or intensity than before the disease);

lack of rest after sleep

lasting more than 24 hours after physical exertion.

When a patient with chronic fatigue syndrome is treated: firstly, the patient must be aware of his illness, and secondly, the patient must be periodically examined comprehensively in order to exclude other diseases. Thirdly, non-steroidal anti-inflammatory drugs reduce headache, myalgia, arthralgia, and fever.

Antidepressants improve mood and sleep, reduce fatigue syndrome.

Fourth, patients should receive lifestyle advice. Overeating, drinking coffee and alcoholic beverages should be avoided. Requires dosed physical activity, behavioral psychotherapy; struggle with memory impairment, with apathy and despair.

LITERATURE

1 Acneson ED. The clinical syndrome variously called beningn myolgie, enapnalomielitis. Jseland disease and epidemic neuromyasenenta. Am. J/Kud 26:589, 1959

2. Bock J.H. Whelan J (eds) Ciba Joufnsymp 173, 1993

3. With Strauss. Chronic Fatigue Syndrome. Practice 2005 7 pp 3014-3017

4. Fukuda k et al: fatigue syudrome: A comprenensive approach to its definition and sudy: Ann Intern Med 121.953,1994

CLINIC, DIAGNOSIS OF STRESS DISORDERS AND DISTURBANCES OF ADAPTATION. (F 43.1. ICD - 10)

V.A. Sapphirova, O.M. Shtang, A.A. Zusman

Epidemiological studies of recent years show that from 10 to 30% of the population seek help from general practitioners. At the same time, only 3% of patients complain of purely mental problems, 68.8% present only somatic complaints, and 27.6% present both somatic and psychological complaints. In the majority of these patients (75%), these disorders become chronic and require specific therapy.

Stress disorders and adaptation disorders are united by the fact that a psychogenic (stress) factor plays a significant role in their pathogenesis, i.e. the impact of a traumatic situation, of varying severity and duration. Severe anxiety can be caused by extreme mental trauma, with an affective-shock reaction. They lead to significant changes in the way of life, which contribute to a violation of adaptation (injury or death of loved ones, a threat to the patient himself).

This disorder occurs as a result of being in extreme situations, catastrophes with experiences of fear and horror. Although an important role in the development of these disorders is played by individual predisposition and vulnerability, that is, hereditary, constitutional and personal factors, the main cause of these disorders is the direct impact of stress or a prolonged psychotraumatic situation, without which the disorder could not have arisen.

An anxiety reaction can occur immediately after injury (acute stress disorder), and delayed, with relapses (post-traumatic stress disorder) F-43.1.MKB-10.

Both syndromes are accompanied by a decrease in mental response, emotional dullness, and sometimes depersonalization. In some cases, the patient cannot remember individual details of the traumatic event, although in other cases he can endure it many times - in dreams and thoughts, especially if the real situation is somewhat reminiscent of what happened. Therefore, patients actively avoid any stimuli that evoke memories of the experience. Such memories evoke

alertness, anxiety, fear. Patients with stress disorders have an increased risk of anxiety disorders with adjustment disorder, affective disorders, alcohol abuse, and drugs.

Conditions that meet the criteria for post-traumatic stress disorder are observed in 5-10% of the population at one time or another in life; in the general population, women are more likely to suffer.

Diagnostic criteria for post-traumatic stress disorder:

A. The patient has undergone psychotraumatic extreme effects, in which he:

1. Was a participant or witness of events accompanied by severe injuries, death or threat of death of people, or a threat to himself.

2. Experienced intense fear, anxiety, or helplessness.

B. The traumatic event is repeatedly relived in one of the following ways:

recurring obsessive depressing memories (images, thoughts, sensations).

recurring heavy dreams, including dreams from recent events.

vivid re-experiences of experienced events (when waking up or when intoxicated).

expressed anxiety and discomfort from reminders or allusions to experienced events.

B. Decreased mental response, the desire to avoid reminders of past events:

Avoiding thoughts, feelings, or conversations related to the experience;

Avoidance of people of places or activities that evoke memories of the experience;

Inability to remember important details of the experience;

A significant decrease in interest in previously important activities, non-participation

Detachment, isolation;

Emotional dullness (for example, inability to love);

Feeling no future (no thoughts of promotion, marriage, children, normal life expectancy)

D. Two or more of the following symptoms of persistent hyperexcitability not present before the injury are present:

Difficulty falling or staying asleep.

Irritability, outbursts of anger.

Violation of concentration.

Increased alertness.

Startling in response to common stimuli.

E. The symptoms indicated in points B, C, D last more than one month.

E. Symptoms cause severe discomfort, disruption of life and social adaptation.

Risk factors for PTSD are a history of mental illness, high levels of neuroticism, and extraversion.

Recent studies have shown that genetic factors play a significant role in the development of symptoms of post-traumatic stress disorder.

Etiology and pathogenesis.

It is assumed that in post-traumatic stress disorder, an excessive release of norepinephrine during stress plays a role and a gradual generalization of reactions to any stimuli, even remotely reminiscent of a psycho-traumatic situation, persistent fixation of psycho-traumatic impressions in place of the neurons of the hipcampus and amygdala occurs.

Reduced serotonergic effects, cortisol secretion, increased inhibitory effect on this secretion of dexamethasone. In patients with post-traumatic stress disorder, during situations resembling stress, the release of norepinephrine increases, as well as a decrease in the activity of platelet adenylate cyclase.

Acute stress disorders resolve on their own: their treatment includes only a short course of benzodiazepines and psychotherapy. However, when

PTSD, with its chronic relapsing course, is more difficult to treat. Anxiety, intrusion symptoms (painful memories, dreams) and avoidance are treatable with tricyclic antidepressants (amitriptyline), serotonin reuptake inhibitors (paxil, zoloft, cipralex). For insomnia, tranquilizers are prescribed.

In some patients, many manifestations of post-traumatic stress disorder are relieved by carbamazepine, valproic acid preparations, and alprazolam.

The tasks of psychotherapy in post-traumatic stress disorder are to help the patient overcome depression, cope with avoidance reactions and with the fear of a repetition of the trauma.

The most effective methods of mental desensitization, in which the patient gradually learns to calmly recall the events that accompany the trauma.

LITERATURE

1. Stress disorders and adaptation disorder. S.N. Mosolov. Clinical use of modern antidepressants. Medical information agency. St. Petersburg 1995 pp. 411-415.

2. Hyman E.E. Nester E.J. Initiation and adaptation: A paradigm for under standing psychotropic drug action. Aur. J. Psychiatry 153 154 1996

3. Marshall R.D. Klein D.F. Pharmacotherapy in the treatment of posttraumatic stress disorder. Phsychiatr.Amr.25:588

4. Vein A.M., Golubev V.P., Kolosova O.A. Anticonvulsants (carbamazepine) and atypical benzodiazepines (kponazepam and alprazolam) in the clinic of nervous diseases. Edited by A.M. Wayne and S.N. Mosolova 1994, 266-316

NEUROLOGICAL MANIFESTATIONS OF HEREDITARY CONNECTIVE TISSUE DISEASES

E.N. Popova, E.A. Selivanova, O.P. Sidorova.

Moscow Regional Research Clinical Institute. M.F.Vladimirsky

Hereditary connective tissue diseases include Marfan syndrome, Ehlers-Danlos syndrome, undifferentiated connective tissue dysplasia, etc. collagen.

As you know, the connective tissue is generalized in the body and is the basis for the osteoarticular, cardiovascular systems, skin and fascia, ligamentous apparatus, and the organ of vision. This explains the polysystemic lesion in Marfan's syndrome - one of the most important characteristics of hereditary diseases in general, and Marfan's syndrome in particular.

For Marfan's syndrome, the following symptoms are characteristic of these body systems.

Osteoarticular system: deformities of the chest and spine, dolichostenomelia, positive finger tests, hypermobility in small joints, limited extension of the elbow joints, craniofacial features (hypoplasia of the zygomatic arches, retrognathia, malocclusion, high palate, etc.).

Organ of vision: more often - visual impairment, less often - ectopia of the lens.

Cardiovascular system: more often - valve prolapse with or without regurgitation, expansion of the pulmonary artery, mitral valve calcification; less often (pathognomonic signs) - expansion of the ascending aorta with or without aortic regurgitation and involvement of at least the sinus of Waalsawa, dissection of the wall of the ascending aorta.

Respiratory system: spontaneous pneumothorax, apical blebs (detected by X-ray).

Please upload images/files only to our website.
Button "Upload File" located below the text input window.

Compliance with medical secrecy is an integral rule of the site.
Don't forget to delete the patient's personal data before publishing the material.

Discharge summary from the medical history
Full name, female, 52 years old
FROM ANAMNESIS Heredity is not pathologically burdened. Early development without features. Higher economic education. A specialist works in OAO "...energo". Lives in the second marriage, from the first marriage has two adult children who live separately. Previously, she did not turn to psychiatrists for help. The condition changed a few months ago due to everyday psychotrauma (the husband had another woman). Against this background, her sleep was disturbed, her appetite decreased, she became whiny, anxious, irritable, she stopped coping with work, ordinary daily activities.
She turned on her own for help to a GPD psychotherapist, was hospitalized in the department in his direction.
TBI, TVS, hepatitis, injuries, operations - denies.
Allergy denied.
EPID ANAMNESIS: Over the past 3 weeks, fever, skin rash, respiratory infections were not observed. There was no contact with infectious patients. Intestinal dysfunction denies.
STATUS AT ADMISSION The general condition is satisfactory. Complains of unstable mood, tearfulness, difficulty concentrating,
"Confusion" of thoughts, memory loss, irritability, anxiety, superficial - "leaky" sleep, poor appetite.
Available to voice contact. Oriented in every way correctly. The mood is unstable, closer to reduced. Hypochondria. Fixed on somatic sensations, conflict situation - conflict at work. Absent-minded. Emotionally labile, weak-hearted. Does not produce active psychosymptomatics. Suicidal thoughts and aggressive tendencies are not updated. Looking for help and support. The state is critical.
IN THE DEPARTMENT Available to voice contact. Oriented in all forms correctly. Outwardly, she became a little calmer, more orderly in behavior. Notes some improvement in sleep when taking medication, improved appetite. Tearful at times, especially when remembering a traumatic situation. Worried about memory impairment. In the department, he spends time within the ward, but notes "that there was a desire to communicate with someone." Immersed in my feelings. Thinking is consistent. Productive psychosymptomatics in the form of delirium, hallucinations does not reveal. Aggressive actions and suicidal tendencies are not detected. Sleep is disturbed, appetite is reduced.
SURVEYS-
THERAPIST: IRR of the hypotonic type.
NEUROLOGIST: Polysegmental osteochondrosis with a predominant lesion of the cervical and thoracic regions, remission.
ECG: Sinus rhythm 68 per minute. Normal gender EOS.
ECHO-ES: No M-ECHO offset. There were no signs of intracranial hypertension.
PSYCHOLOGIST: social disadaptation of the subject, fixation on negatively colored experiences, loss of neutrality of background stimuli, reduced ability to self-guidance, immaturity of emotional and volitional manifestations. Some decrease in cognitive functions is noted.
GYNECOLOGIST: 03/19/13 - healthy (GP No. 3).
TREATED- Glucose 5%, potassium chloride, insulin, vitamin C, B1, B6, sibazon, eglonil, reamberin, phenazepam, sertraline, ketilept.
STATUS AT DISCHARGE Complaints at the time of inspection does not show. Behavior is orderly. Does not produce active psychosymptomatics. Decreased fixation on psychotrauma.
Discharged from department
Issued b/l from 20.05.13 to 03.06.13. To work - 04.06.13.
DIAGNOSIS
Concomitant diseases - M42.9, I95.9: IRR of the hypotonic type.
Polysegmental osteochondrosis in the predominant lesion of the cervical and thoracic regions, remission.
Discharge summary from the medical history
psychiatric patient,
hospitalized with a diagnosis
F43.22 Mixed anxiety and depressive reaction due to adjustment disorder
frg dated 12/20/2014 - norm
Woman, 43
Address
passport: series - , number - , issued
Insurance policy -
SNILS -
Disability - no
Sent to hospital for the first time
Purpose of hospitalization: treatment
Carried out - 47 bed-days
FROM ANAMNESIS Heredity is not psychopathologically burdened. Early development without features. Secondary education (seller). Hasn't worked for about a year. Married with 2 adult children. In 1996, an operation on the left ovary. Previously to a psychiatrist and other honey. did not contact the experts. She considers herself ill for about a year, when for the first time after stress at work, tic-like blinking movements appeared, “could not open her eyes”, felt that she “could lose her sight”. She was in the neurology department for several days, underwent magnetic resonance imaging (MRI) of the brain, according to the words, no pathology was found. She was examined by an ophthalmologist, a neurologist - no pathology was found, she was at the DS of the polyclinic, treatment was recommended in the neurosis department of the Specialized Psychiatric Hospital No. 1. Traumatic brain injuries (TBI), tuberculosis, venereal diseases, hepatitis - denies.
ALLERGIC HISTORY - not burdened
EPID ANAMNESIS: during the last 3 weeks of fever, skin rash, respiratory infections are not noted. There was no contact with infectious patients. Intestinal dysfunction denies.
STATUS AT ADMISSION
Attitude to the conversation: available to the contact
Orientation: true in all views
St.pr.psychicus: Motor retarded. Depressed, weepy. The mood background is reduced, anxious. Complains of tearfulness, bad mood, insomnia, anxiety. He connects his condition with a traumatic situation in the family, a conflict with her husband. In a conversation, she cries a lot, is emotionally labile. Critical, looking for help. Thinking is consistent. Productive psychosymptomatics in the form of delirium, hallucinations does not reveal. Sleep is disturbed, appetite is reduced.

IN THE DEPARTMENT Orientation: true in all views
St.pr.psychicus: Depressed, tearful. The mood background is reduced, anxious. Complaints of tearfulness, bad mood, anxiety persist. Fixed on a traumatic situation. Critical, looking for help. In the department, he spends time within the ward. Immersed in my feelings. Thinking is consistent. Productive psychosymptomatics in the form of delirium, hallucinations does not reveal. Sleep is disturbed, appetite is reduced.
SURVEYS -
NEUROLOGIST: Transient motor tics
THERAPIST: Hypertension 2 st risk 3.
OCULIST: no pathology
PSYCHOLOGIST: in this study, violations characteristic of the exogenous organic register syndrome were manifested: maladjustment of the mental activity of the subject, emotional tension of the state, instability of emotional and volitional manifestations, easy exhaustion of mental processes, slight decrease in voluntary attention, moderate decrease in mnestic activity, decrease in the dynamic component of thinking , rigidity of affect. The relevance of negatively colored experiences is noted.
GYNECOLOGIST: from 10.6.2015 - no pathology.
ECG: syn rhythm 61 min. Normal gender EOS. Changes in the LV myocardium.
ECHO-ES: No M-ECHO offset. There were no signs of cranial hypertension
EEG: Low amplitude EEG. Perhaps the predominance of activating ascending nonspecific systems. Reactivity of nervous processes is satisfactory. Typical epi-activity and interhemispheric asymmetry were not revealed.
Blood test from 06/19/2015: Leukocytes (WBC): 5.6; Erythrocytes (RBC): 4.31; Hemoglobin (HGB): 13.4; Hematocrit (HCT): 39.1; Platelets (PLT): 254; LYM%: 35; MXD%: 11.2; NEUT%: 53.8; ESR: 5; MCH: 31.1; MCHC: 34.3; MCV: 90.7; Mean platelet volume (MPV): 11.4;
Urinalysis from 06/19/2015 10:30:34 am: Color (COL): s\f; Specific gravity (S.G): 1015; p.H: 5.5;
Examination for pathogenic microbes of the intestinal family dated 06/22/2015 10:41:55 AM: Result: not detected;
Examination of a smear for diphtheria bacillus dated 06/22/2015 11:11:53 AM: Result: not detected;
Cala analysis for I/worm from 06/30/2015 12:48:54 pm: microscopic worm eggs and intestinal protozoosis: not detected;
TREATED- eglonil, glucose 5%, potassium chloride, insulin, fevarin, ketilept.
STATUS AT DISCHARGE Discharged from the department in a satisfactory condition: the mood is even, without active psychotic symptoms, there are no suicidal tendencies, the behavior is ordered.
weight at admission: 54 kg, at discharge: 54 kg.
DIAGNOSIS- F43.22 Mixed anxiety and depressive reaction due to adjustment disorder.
Concomitant diseases - F95.1, I11.0: Hypertension 2 st risk 3. Transient motor tics

This group of disorders differs from other groups in that it includes disorders that are identifiable not only on the basis of symptoms and course, but also on the basis of evidence of the influence of one or even both causes: an exceptionally adverse life event that caused an acute stress reaction, or a significant changes in life leading to prolonged unpleasant circumstances and causing adaptation disorders. Although less severe psychosocial stress (life circumstances) may hasten the onset or contribute to the manifestation of a wide range of disorders present in this class of diseases, its etiological significance is not always clear, and dependence on the individual, often on his hypersensitivity and vulnerability (t i.e. life events are not necessary or sufficient to explain the occurrence and form of the disorder). The disorders collected under this rubric, on the other hand, are always considered as the direct consequence of acute severe stress or prolonged trauma. Stressful events or prolonged unpleasant circumstances are the primary or predominant causative factor and the disorder could not have arisen without their influence. Thus, the disorders classified under this rubric can be seen as perverted adaptive responses to severe or prolonged stress that interfere with successful coping and therefore lead to social functioning problems.

Acute reaction to stress

A transient disorder that develops in a person without any other psychiatric manifestations in response to unusual physical or mental stress and usually subsides after a few hours or days. In the prevalence and severity of stress reactions, individual vulnerability and the ability to control oneself matter. Symptoms show a typical mixed and variable picture and include an initial state of "dazedness" with some narrowing of the field of consciousness and attention, inability to fully recognize stimuli, and disorientation. This state may be accompanied by a subsequent "withdrawal" from the surrounding situation (up to a state of dissociative stupor - F44.2) or agitation and hyperactivity (flight or fugue reaction). Some features of panic disorder (tachycardia, excessive sweating, flushing) are usually present. Symptoms usually appear a few minutes after exposure to a stressful stimulus or event and disappear after 2-3 days (often after several hours). There may be partial or complete amnesia (F44.0) for the stressful event. If the above symptoms persist, the diagnosis should be changed.

crisis response
response to stress

Nervous demobilization

Crisis state

mental shock

Post Traumatic Stress Disorder

Occurs as a delayed or prolonged response to a stressful event (brief or prolonged) of an exceptionally threatening or catastrophic nature that can cause profound distress to almost anyone. Predisposing factors, such as personality traits (compulsivity, asthenicity) or a history of neurological disease, may lower the threshold for the development of the syndrome or exacerbate its course, but they are never necessary or sufficient to explain its occurrence. Typical signs include episodes of repetitive experiences of the traumatic event in intrusive flashbacks, thoughts, or nightmares that appear against a persistent background of feelings of numbness, emotional retardation, alienation from other people, unresponsiveness to the environment, and avoidance of actions and situations reminiscent of the trauma. Hyperarousal and marked hypervigilance, increased startle response, and insomnia are common. Anxiety and depression are often associated with the above symptoms, and suicidal ideation is not uncommon. The appearance of symptoms of the disorder is preceded by a latent period after injury, ranging from several weeks to several months. The course of the disorder varies, but in most cases recovery can be expected. In some cases, the condition may take a chronic course for many years with a possible transition to a permanent change in personality (F62.0).

Traumatic neurosis

Disorder of adaptive reactions

A state of subjective distress and emotional distress that creates difficulties for social activities and actions that occurs during the period of adaptation to a significant change in life or a stressful event. A stressful event may disrupt the integrity of an individual's social relationships (bereavement, separation) or broad social support and value systems (migration, refugee status) or represent a wide range of life changes and upheavals (going to school, becoming parents, failure to achieve a cherished personal goals, retirement). Individual predisposition or vulnerability play an important role in the risk of occurrence and the form of manifestation of disorders of adaptive reactions, however, the possibility of such disorders without a traumatic factor is not allowed. Manifestations are highly variable and include depressed mood, alertness or anxiety (or a combination of these conditions), a feeling of inability to cope with the situation, plan ahead or decide to stay in the present situation, and also include some degree of decrease in the ability to function in daily life. At the same time, behavioral disorders can join, especially in adolescence. A characteristic feature may be a brief or prolonged depressive reaction or disturbance of other emotions and behaviors.

Send your good work in the knowledge base is simple. Use the form below

Students, graduate students, young scientists who use the knowledge base in their studies and work will be very grateful to you.

ST. PETERSBURG MEDICAL ACADEMY OF POSTGRADUATE EDUCATION

DEPARTMENT OF CHILD PSYCHIATRY, PSYCHOPATHY AND MEDICAL PSYCHOLOGY

SUMMARY TOPIC:

DISORDERS OF ADAPTATION. SOMATOFORM DISORDERS

CONTRACTOR: STOLNIKOVA YU.N.

PLACE OF WORK: GUZ

"REGIONAL PSYCHONEUROLOGICAL

HOSPITAL No. 5

MAGNITOGORSK, 2008

INTRODUCTION

The entire history of psychiatry is evidence that psychotic forms of mental pathology and organic pathology have almost always been studied by psychiatrists as the most clinically pronounced diseases, leading to the most severe forms of maladjustment and requiring urgent measures to treat and prevent complications. Naturally, many clinically unexpressed, amorphous, non-typical, non-psychotic forms of mental pathology, which have a completely different stereotype of development, were often not noticed, ignored, and, perhaps, not interpreted as such. Today they are commonly referred to as borderline (minor) mental disorders - neuroses, neurotic reactions and conditions, personality disorders, behavioral manifestations, adjustment disorders, somatoform disorders, psychosomatic disorders.

ADAPTATION DISORDERS

Definition of adjustment disorders, etiology

Adjustment disorders (F43.2) according to ICD-10 are characterized by a state of subjective distress and emotional disturbances that occur during the period of adaptation to a significant change in life or a stressful event and create difficulties for life. A stressful event can disrupt the integrity of an individual's social ties or the system of social support and values (migration, refugee status) or make changes in life (enrolling in an educational institution, starting or ending a professional activity, failure to achieve a desired goal, etc.). Individual predisposition, vulnerability matter, but adjustment disorder occurs precisely in response to a traumatic factor. So, for example, adaptation disorders are more often found in people with extremely high personal anxiety, with serious somatic diseases, people with disabilities, people who lost their parents in early childhood or experienced a lack of maternal care. Adjustment disorders are most typical for adolescence, which, however, does not exclude the possibility of their occurrence at any age. Most symptoms improve over time without treatment, especially after the stressor wears off; in the variant with a possible chronic course, there is a risk of secondary depression, anxiety and substance abuse.

Diagnosis of adjustment disorders

Adjustment disorders are diagnosed when the condition meets the following criteria:

1) identified psychosocial stress that does not reach extreme or catastrophic proportions, symptoms appear within a month;

2) individual symptoms (with the exception of delusional and hallucinatory ones) that meet the criteria for affective (F3), neurotic, stressful and somatoform (F4) disorders and social behavior disorders (F91) that do not fully correspond to any of them;

3) the symptoms do not last more than 6 months from the moment of cessation of the stress or its consequences, with the exception of protracted depressive reactions (F43.21).

Symptoms may vary in structure and severity. Adaptation disorders, depending on the manifestations dominant in the clinical picture, are differentiated as follows:

F43.20 short-term depressive reaction a transient state of mild depression lasting no more than a month;

F43.21 prolonged depressive reaction - a mild depressive state as a reaction to a protracted stressful situation, lasting no more than two years;

F43.22 Mixed anxiety and depressive reaction - both anxiety and depressive symptoms are present, the intensity of which does not exceed mixed anxiety and depressive disorder (F41.2) or other mixed anxiety disorders (F41.3);

F43.23 with a predominance of disturbances of other emotions - the symptomatology has a diverse structure of affect, anxiety, depression, anxiety, tension and anger are represented. Symptoms of anxiety and depression may meet the criteria for mixed anxiety and depressive disorder (F41.2) or other mixed anxiety disorders (F41.3), but are not sufficient to diagnose more specific anxiety or depressive disorders. This category should also be used for reactions in childhood, where additional signs of regressive behavior such as enuresis or thumb sucking are present;

F43.24 with a predominance of behavioral disorders - the disorder affects predominantly social behavior, for example, its aggressive or dissocial forms in the structure of grief in adolescence;

F43.25 mixed disorder of emotions and behavior - both emotional manifestations and violations of social behavior are decisive;

F43.28 other specific predominant symptoms

Differential Diagnosis

The differential diagnosis of adjustment disorders should be made with post-traumatic stress disorder, acute stress reaction, short-term psychotic disorder, uncomplicated bereavement. Post-traumatic stress disorder and acute stress reaction are characterized by the fact that these diagnoses define the unusual stress that goes beyond normal human experiences, for example, war, mass disaster, natural disaster, rape, hostage taking. Brief psychotic disorder is characterized by hallucinations and delusions. Uncomplicated bereavement occurs before or shortly after the expected death of a loved one; occupational or social performance worsens within the expected period, then spontaneously normalizes.

Treatment

For the treatment of adjustment disorders, psychotherapy is preferred, which includes exploring the meaning of the stressor for the patient, providing support, encouraging them to find alternative ways to solve the problem, and showing empathy. If anxiety prevails, then it is advisable to use biofeedback, relaxation and hypnosis techniques. Intervention during a crisis is aimed at helping the patient to quickly solve the problem through the use of support methods, suggestion, persuasion, and environmental modification. If necessary, hospitalization is possible. Medical therapy is indicated for severe disorders. Anxiolytics or antidepressants may be used for treatment, depending on the type of disorder, but care must be taken to avoid dependence on the drug (especially when using benzodiazepines).

SOMATOFORM DISORDERS

The relevance of the problem of somatoform disorders

The problem of psychosomatic relationships is a subject of discussion not only for psychiatry, but also for general human pathology. The question of the influence of bodily sensations in normal and pathological conditions on the mental sphere and the development of various psychopathological phenomena is beyond doubt. The presence of somatopsychic disorders is a reliable proof of the existence of a connection between the body and the psyche.

However, increasingly enriched clinical data indicate that changes in the mental sphere can also cause bodily (including pathological) changes, thereby causing the development of so-called psychosomatic diseases.

The problem of somatopsychic pathology is covered in sufficient detail in the medical literature. As for psychosomatic disorders, they have not been studied enough and many issues related to this problem are still far from being resolved. Among them, the problem of somatoform disorders remains a particularly controversial and underdeveloped general medical and psychiatric problem. The views of clinicians on this problem are extremely contradictory, and often even diametrically opposed and mutually exclusive.

Timely diagnosis and adequate treatment of these conditions is put forward as a priority for the public health system. The shifts that are taking place in modern psychiatry dictate the relevance and necessity of a conceptual study of somatoform disorders. These shifts are determined, on the one hand, by a shift in emphasis from "large" to "small" psychiatry, the steady growth of borderline mental pathology; on the other hand, there was a need to comprehend the accumulated data and information regarding masked depressions, conversion disorders, hypochondria, psychovegetative disorders, which are actually the content of somatized mental disorders. Finally, the need to study somatoform disorders is determined by economic interests - the expediency of additional, sometimes unjustified material and financial expenses.

Definition

Somatoform disorders - a group of disorders characterized by the patient's constant complaints about a violation of his condition, resembling a somatic disease; at the same time, they do not reveal any pathological process that explains their occurrence. The disorder is not due to another mental illness or substance abuse. If the patient has a physical illness, the data of the medical history, physical examination and laboratory tests cannot explain the cause and severity of the complaints. Symptoms are not intentionally invented, unlike artificially demonstrated disorders and simulations. Despite the fact that the onset and persistence of symptoms are often closely related to unpleasant events, difficulties or conflicts, patients usually resist attempts to discuss the possibility of their psychological conditioning; this may occur even in the presence of distinct depressive and anxiety symptoms. The degree of understanding of the causes of symptoms achievable is often disappointing and frustrating for both patient and clinician.

Some researchers are convinced that somatoform symptoms are actually manifestations of latent depression, and on this basis they are treated with antidepressants, others believe that they are special conversion disorders, that is, dissociative disorders, and therefore should be treated with psychotherapeutic methods.

The frequency of somatoform disorders is 0.1-0.5% of the population. More often somatoform disorders are observed in women.

Somato classificationform disorders (according to ICD-10)

F45.0 Somatization disorder

F45.1 Undifferentiated somatoform disorder

F45.2 Hypochondriacal disorder

F45.3 Somatoform dysfunction of the autonomic nervous system.

F45.4 Persistent somatoform pain disorder

F45.8 Other somatoform disorders

F45.9 Somatoform disorder, unspecified

Selected syndromes occurring in somatoform disorders

Of particular note are conversion syndromes, asthenic conditions, depressive syndromes, anorexia nervosa syndrome, dysmorphophobia (dysmorphomania) syndrome, which are part of the structure of various somatoform disorders.

conversion syndromes. It is characterized by a change or loss of any body function (anesthesia and paresthesia of the limbs, deafness, blindness, anosmia, pseudoceisis, paresis, choreiform tics, ataxia, etc.) as a result of a psychological conflict or need, while patients do not realize what kind of psychological the cause causes the disorder, therefore they cannot control it arbitrarily. Conversion - the transformation of emotional disturbances into motor, sensory and vegetative equivalents; these symptoms in domestic psychiatry are usually considered within the framework of hysterical neurosis.

Asthenic conditions are among the most frequently encountered in the practice of a generalist. Rapid exhaustion appears in these cases against the background of increased neuropsychic excitability. Among the complaints of a somatic nature with which the patient addresses are, first of all, variable and varied headaches, sometimes of the "neurasthenic helmet" type, but also tingling in the forehead and occiput, a feeling of "stale head. Pains increase with mental stress and usually become more severe in the afternoon.Asthenic conditions can mimic the symptoms characteristic of a particular somatic disease.This is, as a rule, palpitations, lability of blood pressure, frequent urge to urinate, dysmenorrhea, decreased libido, potency, etc.

Depressive syndromes are also quite common (in about half of the cases, the condition of somatoform patients is classified as depressive). Of particular interest is the so-called somatized (masked) depression.

anorexia nervosa syndrome- progressive self-restriction in food with the preservation of appetite in order to lose weight due to the belief in excessive fullness or for fear of becoming fat. This condition occurs predominantly in females during adolescence and adolescence. The triad is considered characteristic of the syndrome, expressed in its entirety: refusal to eat, significant weight loss (about 25% of the premorbid mass), amenorrhea.

Syndrome of dysmorphophobia (dysmorphomania). This is a kind of hypochondriacal syndromes, predominantly occurring in adolescence (up to 80%). With dysmorphophobia, there is a pathological belief either in the presence of any physical defect, or in the spread of unpleasant odors to patients. At the same time, patients are afraid that others notice these shortcomings, discuss them and laugh at them. For a pronounced dysmorphophobic syndrome, a triad of signs is typical: ideas of physical deficiency, ideas of attitude, depressed mood.

In connection with the belief in the existence of an imaginary defect or in the presence of any minor physical defect with its excessive exaggeration, patients persistently seek help from doctors of various specialties - cosmetologists, dentists, endocrinologists, plastic surgeons.

Patients with dysmorphophobia are characterized by a tendency to dissimulate their condition. In this regard, it is important to note the presence of two characteristic symptoms that can be identified when questioning patients and their relatives: these are the symptoms of a "mirror" (gazing at yourself in a mirror in order to make sure that there is a physical defect and try to find a facial expression that hides this "defect"). ") and "photographs" (the latter is considered as documentary evidence of the inferiority of one's appearance, and therefore photography is avoided).

Clinic of somatoform disorders

Consider the most common variants of the course of somatoform disorders.

somatic disorder. The main feature is the presence of multiple, recurring and often changing somatic symptoms, which usually occur over a number of years preceding the patient's visit to a psychiatrist. Most of the patients went through a long and difficult path, including primary and special medical services, during which negative examination results were obtained and useless operations could be performed. Symptoms may refer to any part of the body or system, but the most common are gastrointestinal sensations (pain, belching, regurgitation, vomiting, nausea, etc.) and abnormal skin sensations (itching, burning, tingling, numbness, soreness etc.). Frequent sexual and menstrual complaints.

There is often marked depression and anxiety. This may justify specific treatment. The course of the disorder is chronic and fluctuating, often associated with long-term disruption of social, interpersonal, and family behavior. The disorder is significantly more common in women than in men and often begins at a young age.

It is not uncommon to find dependence or abuse of drugs (usually sedatives or analgesics) as a consequence of frequent drug courses.

Somatoform dysfunction of the autonomic nervous system. Complaints are presented to patients in such a way that they are due to a physical disorder of that system or organ that is mainly or completely under the influence of the autonomic nervous system, that is, the cardiovascular, gastrointestinal or respiratory systems. (This also includes the genitourinary system.) The most frequent and striking examples relate to the cardiovascular system ("cardiac neurosis"), the respiratory system (psychogenic dyspnoea and hiccups), and the gastrointestinal system ("gastric neurosis" and "nervous diarrhea"). Symptoms are usually of two types, neither of which indicates a physical disorder of the affected organ or system. The first type of symptoms, on which diagnosis is largely based, is characterized by complaints reflecting objective signs of autonomic arousal, such as palpitations, sweating, redness, and tremors. The second type is characterized by more idiosyncratic, subjective, and non-specific symptoms, such as sensations of fleeting pain, burning, heaviness, tension, bloating, or stretching. These complaints are related to a specific organ or system (which may include autonomic symptoms). The characteristic clinical picture consists of a distinct involvement of the autonomic nervous system, additional non-specific subjective complaints, and the patient's constant references to a particular organ or system as the cause of his disorder.

Many patients with this disorder have indications of the presence of psychological stress or difficulties and problems that appear to be associated with the disorder. However, in a significant proportion of patients who meet the criteria for this disorder, aggravating psychological factors are not detected. In some cases, minor physiological disturbances such as hiccups, flatulence and dyspnoea may also be present, but they do not in themselves interfere with the basic physiological functioning of the organ or system concerned.

Chronic somatoform pain disorder. Among the causes of chronic somatoform pain disorder, psychodynamic ones are distinguished - pain manifests itself as a way to achieve love, avoid punishment and atone for guilt, a way to manipulate loved ones. What matters is therefore the secondary benefit of this symptom. The presentation of pain can also be a way of keeping a loved one close to you or a kind of reflex after a long period of somatic or neurological pain. In the etiology of pain, the central mechanisms associated with the level of endorphins are important.

The general features of this disorder are: 1) duration of algopathic states for at least 6 months; 2) the absence of somatic pathology confirmed as a result of special examinations, which could cause the onset of pain; 3) the severity of complaints of pain and the associated decrease in adaptation significantly exceed the expected consequences of somatic symptoms in cases of concomitant somatic pathology. Additional common signs of algopathies are: 1) the absence of symptoms of an endogenous disease (schizophrenia, MDP) and organic damage to the central nervous system; 2) comparability with pain sensations observed in somatic pathology.

Pain often appears in combination with emotional conflict or psychosocial problems, regarded as the main cause. As a rule, there are headaches, pain in the back, sternum, neck.

Hypochondriacal disorder. Despite the fact that hypochondria is one of the most frequent psychopathological phenomena, the issues of nosological assessment and the choice of adequate therapeutic measures have not been sufficiently developed.

What is hypochondria? This is an excessive, unreasonable attention to one's health, a preoccupation with even a minor ailment or a belief in the presence of a serious illness, bodily disorders or deformity.

With hypochondria, we are talking not just about anxious suspiciousness as such, but about the corresponding mental, intellectualized processing of certain painful sensations from the somatic sphere. Often the case ends with the construction of the concept of a certain disease, followed by a struggle for its recognition and treatment. The psychopathological nature of hypochondria is confirmed by the fact that when combined with a real somatic disease, the patient does not pay the latter even a fraction of the attention that he pays to an imaginary disorder.

Hypochondriacal conditions often develop in adulthood or old age, equally often in men and women.

The leading structural elements of the hypochondriacal syndrome primarily include paresthesia - sensations of numbness, tingling, crawling, etc., not caused by external stimuli. This is followed by psychalgia, which is not caused by any specific lesion, but is the result of a physiological increase in the pain threshold. These are ordinary pains without real grounds, often multiple. Another such element is senestoalgia, which are distinguished by a more bizarre and peculiar character. For example, the headaches here are already burning, shooting, piercing, stabbing. This is followed by senestopathies - also occurring spontaneously and extremely painful sensations that do not correspond in localization to specific anatomical structures. Senestopathies are characterized by novelty and a variety of sensations; patients find it difficult to accurately describe them. And, finally, synesthesia - sensations of vague total physical distress or malaise with peculiar, difficult to describe violations of the motor sphere (unexpected physical weakness, swaying and uncertainty when walking, heaviness or emptiness in the body).

Differential Diagnosis

The differential diagnosis of somatoform disorders is carried out with a whole group of diseases in which patients present with somatic complaints. So the differential diagnosis from hypochondriacal delusions is usually based on careful consideration of the case. Although the patient's ideas persist for a long time and seem contrary to common sense, the degree of conviction usually decreases to some extent and for a short time under the influence of argumentation, reassurance and new examinations. In addition, the presence of unpleasant and frightening physical sensations can be seen as a culturally acceptable explanation for the development and persistence of a belief in a physical illness.

A differential diagnosis with somatic disorders is mandatory, although usually patients get to a psychiatrist after doctors of a somatic profile. But still, the probability of the appearance of an independent somatic disorder in such patients is not lower than in ordinary people at the same age.

Affective (depressive) and anxiety disorders. Depression and anxiety of varying degrees often accompany somatic disorders, but they should not be described separately unless they are sufficiently pronounced and stable to warrant a self-diagnosis. The appearance of multiple somatic symptoms after the age of 40 may indicate the manifestation of a primary depressive disorder.

It is also necessary to exclude dissociative (conversion) disorders, speech disorders, nail biting, psychological and/or behavioral factors associated with disorders or diseases classified elsewhere, sexual dysfunction not due to organic disorders or diseases, tics, Gilles de la Tourette syndrome , trichotillomania.

Treatment

Therapy of somatoform disorders includes a wide range of therapeutic and preventive measures that require the participation of both an internist and a psychiatrist and psychotherapist.

Of great practical importance is the fact that the corresponding mental disorders may not be recognized by the patient himself or may be dissimulated. Patients usually resist attempts to discuss the possibility of a psychological condition of symptoms, even in the presence of distinct depressive or anxiety manifestations. As a result, the basic direction in the treatment of patients with somatoform disorders is currently psychotherapy. Almost the entire spectrum of modern forms and methods of psychotherapy is used. Rational therapy, autogenic training, hypnotherapy, group, analytical, behavioral, positive, client-centered therapy, etc. are widely used. However, despite the priority of psychotherapeutic correction, the prevalence of somatovegetative components in the clinical picture does not make it possible to do without drug therapy. In the initial period, even strictly directive methods do not allow you to get a quick desired result, which ultimately compromises psychotherapy as a method.

Pharmacotherapy of somatoform disorders involves the use of a wide range of psychotropic drugs - primarily anxiolytics, as well as antidepressants, nootropics and antipsychotics. However, the use of psychotropic drugs in the clinic of somatoform disorders has its own characteristics. When prescribing psychotropic drugs, it is advisable to confine oneself to monotherapy with the use of easy-to-use drugs. Given the possibility of hypersensitivity, as well as the possibility of side effects, psychotropic drugs are prescribed in small (compared to those used in "large" psychiatry) doses. The requirements also include a minimal effect on somatic functions, body weight, minimal behavioral toxicity and teratogenic effect, the possibility of use during lactation, a low probability of interaction with somatotropic drugs.

CONCLUSION

The pronounced clinical pathomorphosis of somatoform disorders themselves, a significant expansion of their classification and an increase in the proportion of somatic pathology that occurs with borderline mental disorders requires a revision and refinement of the criteria for differential diagnosis and creates prerequisites for the development of new diagnostic and therapeutic approaches. Timely detection and adequate diagnosis of somatoform disorders is crucial for successful therapy and a favorable prognosis of the disease.

In this regard, it seems appropriate to integrate the system of psychotherapeutic care into general somatic treatment and prophylactic structures, the opening of psychosomatic departments in the structure of general somatic hospitals. It is also necessary to emphasize the important role of increasing the knowledge of doctors in the general medical network. For general practitioners, teaching the basics of medical ethics, deontology and psychotherapy should be provided, for psychotherapists - in-depth professional training. The development of special training programs on specific problems of psychosomatic pathology (clinic, diagnostics, therapy), the holding of thematic conferences and seminars, and the organization of advanced training courses are very relevant.

BIBLIOGRAPHY

1. T.B. Dmitriev. “Clinical Psychiatry. A guide for doctors and students, 1998.

2. G.I. Kaplan. B.J. Sadok. “Clinical Psychiatry. From a synopsis on psychiatry in 2 volumes, 1994.

3. Journal of Neurology and Psychiatry named after S.S. Korsakov.

4. ICD-10. Clinical classification.