CLINICAL AND PSYCHOPATOLOGICAL CHARACTERISTICS OF VASCULAR DISEASES OF BRAIN
IN PATIENTS WITH PARANOID SCHIZOPHRENIA
Temur B. IRMUHAMEDOV, Vasila K. ABDULLAEVA, Aleksey V. ROGOV, Anastasiya A. MATVEYEVA, Kamola B. SULTONOVA, Dilorom S. ABBASOVA
Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
ABSTRACT
Mental disorders in vascular diseases of the brain are a group of pathological conditions that develop as a result of cerebral circulation disorders of various etiology and pathogenesis. Today, the diagnostic base of vascular diseases of the brain has significantly expanded due to the introduction into practice of such methods of instrumental diagnostics as neuroimaging of vascular diseases of the brain, which makes it possible to qualitatively and quantitatively assess the clinical picture of vascular diseases of the brain, as well as structural, hemodynamic and metabolic disorders in the brain. , which contributed to the development of more stringent and clear criteria for the diagnosis of the vascular cerebral process, as well as a significant revision of the approaches, principles of classification of mental disorders in vascular diseases of the brain.
KEY WORDS: hemodynamic disorders, mental disorders, vascular diseases of the brain, endoform, exogenous organic mental disorders
INTRODUCTION
Mental disorders in vascular diseases of the brain are a group of pathological conditions developing as a result of cerebral circulation disorders of various etiology and pathogenesis.
Today, there are ample opportunities in the diagnosis of vascular diseases of the brain due to the introduction of methods of intravital neuroimaging into practice of vascular diseases of the brain (computer, magnetic resonance imaging of the brain), taking into account the staging of their development [1, 2], which makes it possible to qualitatively and quantitatively assess not only the clinical picture of vascular diseases of the brain, but also structural (genetic- pathomorphological), hemodynamic (ultrasound) [3] and metabolic (biochemical) disorders in the brain. This led, on the one hand, to the development of more stringent and clear criteria for the diagnosis of the cerebral vascular process, and on the other, to a significant revision of the approaches, principles of typology and classification of mental disorders in vascular diseases of the brain [4]. In turn, mental illness and anxiety disorders are risk factors for cardiovascular disease in general. These circumstances determine the relevance of studying mental disorders of vascular genesis, especially since at the present stage there is an increase in the stress load of unfavorable socio-economic conditions and the breaking of ideological stereotypes [5], especially in the population of elderly and senile people.
Causal relationships between vascular diseases of the brain and disorders in the mental sphere appear to be complex and ambiguous. Even in the presence of obvious symptoms of vascular damage to the brain, mental disorders are not always present [6]. In addition, the correlation of mental disorders with vascular pathology can have varying degrees of evidence:
from indisputable (exogenous organic mental disorders) to doubtful (endoform mental disorders) [7, 8]. These facts are explained mainly by the nature of the vascular lesion of the brain (its localization, severity, severity) [9] and the possibility of the presence in patients of the so-called
vascular risk factors (arterial hypertension, atherosclerosis), degenerative brain diseases (Parkinson's disease, Alzheimer's disease, etc.) [10].
CLASSIFICATION
There are 3 groups of mental disorders of vascular genesis: exogenous organic mental disorders (transient and persistent), vascular dementia and endoform mental disorders [11]. It is advisable to distinguish mental disorders in the syndrome of vascular parkinsonism (mixed cortical-subcortical vascular dementia) [12].
CLINICAL SIGNS
Clinically, exogenous organic mental disorders are polymorphic. So, pathognomonic criteria of vascular confusion of consciousness are: anxiety and motor restlessness, mainly at night; short duration, recurrence, rudimentarity, atypicality - during, observed in 33-50% of cases of ischemic and 53-88% of cases of hemorrhagic stroke, as well as in 29% of cases of transient ischemic attacks. In a state of confusion, along with obubilation, are noted: pronounced exhaustion and instability of attention, fragmented thinking, disorientation in time and place, sometimes with a false orientation, weakening of memory [13]. Delirious and oniric elements are often observed. Confusion can occur both against a sluggishly apathetic or complacent-euphoric emotional background, and it can be accompanied by fear, anxiety with pronounced motor restlessness. The state of confusion of consciousness can be (especially in old age) the main clinical manifestation of acute cerebrovascular accident, more often minor stroke or lacunar infarction with rudimentary neurological symptoms, and is an unfavorable prognostic sign indicating a high probability of subsequent dementia or death in clinical significant stroke [10].
In the genesis of acute confusion arising in acute cerebrovascular accident, inhibition of the function of the cholinergic system, as well as an increase in the level of cortisol associated with cerebral ischemia, are important [14].
Persistent mental conditions in chronic forms of vascular diseases of the brain include asthenic conditions and psychoorganic disorders. Asthenia is a polymorphic psychopathological condition characterized by weakness, increased fatigue, fatigue, emotional lability, decreased appetite, memory, attention, physical endurance, as well as sleep and sexual function disorders [15]. In the pathogenesis of asthenic disorders, the leading role is played by a change in the activity of the reticular formation (more often a decrease in activating influences) and dysfunction of the limbic-reticular complex. Allocate hypersthenic and hyposthenic forms of asthenia [16]. With a hypersthenic form of asthenia (lighter), the clinical picture of the disease is dominated by symptoms of irritation (irascibility, explosiveness, impatience, a feeling of inner tension, inability to restrain himself). In the case of a hyposthenic form of asthenia (more severe), among the asthenic symptoms, fatigue and a feeling of powerlessness dominate - an astheno-dynamic state. Asthenic conditions develop either at the initial stages of vascular diseases of the brain [17], or after suffering acute cerebrovascular accident. Asthenia is manifested by polymorphic mental, somatic and autonomic dysfunction and, as a state of psychosomatic maladjustment, reduces the body's resistance to pathological exogenous factors, underlies the formation of various diseases, and later enters the structure of complex syndromes as a "cross-cutting" symptom that worsens the quality life of patients and prognosis of the course of the disease [18]. The share of psychoorganic syndrome (not reaching the degree of dementia) of vascular genesis accounts for 25% of cases of mental pathology in persons over 60 years of age in outpatient practice. A variety of mechanisms of occurrence, clinical manifestations,
dynamics of the course and, as a consequence, diverging ideas about the typology and systematization of the psychoorganic syndrome have been established. psychoorganic syndrome is characterized by a triad of signs (Walter-Buel): a weakening of memory (mainly of the type of hypomnesia, confabulations and amnesia are possible), a decrease in understanding, and incontinence of affect. There is also a decrease in the volume and concentration of attention; the quality of perception suffers, orientation in one's own personality and in space deteriorates;
concepts and ideas are depleted, the assessment of the situation and one's capabilities is impaired when the rate of thought processes is slowed down, there is a tendency to perseveration, getting stuck on details (torpid thinking), and asthenia is not uncommon [19]. There are asthenic, explosive, euphoric, apathetic variants of the psychoorganic syndrome, which are often stages in the development of the syndrome, reflecting the different depth and extent of the damage to mental activity [20].
The diagnosis of not pronounced organic changes in the psyche of vascular genesis is made in the presence of complaints (general cerebral syndrome), clinical (neurological) signs of chronic cerebrovascular accident (chronic cerebral ischemia, disseminated focal neurological symptoms, impaired higher cerebral functions), a history of indications of acute cerebral insufficiency circulation (cerebral hypertensive crisis, transient ischemic attack, stroke) and on the basis of data from computer and / or magnetic resonance imaging of the brain: leukoaraiosis foci (up to 10 mm wide (grade I), 10–20 mm (grade II), more than 20 mm (III stage of chronic cerebral ischemia); the number of lacunae (1–2; 3–5; more than 5 - according to the stages of chronic cerebral ischemia) A history of hypertension, heart disease, diabetes mellitus is often accompanied by subthreshold (diagnosis experimentally -psychological methods) signs of mnestic-cognitive deficiency, which can be partially reduced during their correction [21].
Vascular dementia is a persistent syndrome of deficiency of cognitive functions, leading to social and household maladjustment, caused by destructive damage to the brain as a result of a violation of its blood supply. Vascular dementia is determined by the presence of diagnostic criteria [22]: 1) memory impairment (weakening of the ability to memorize new information or recall previously learned); 2) one or more of the following cognitive disorders: aphasia, apraxia, agnosia; 3) violation of executive functions (planning, organization of activities, sequential actions, abstraction). Patients with vascular dementia are characterized by uneven severity of impairments in certain cognitive functions. Cognitive deficits lead to significant impairments in social or labor functioning, manifested by a significant decrease in the level of functioning. In patients with vascular dementia, a syndrome of focal neurological symptoms (pseudobulbar disorders, ataxia, spastic hemiparesis), changes characteristic of vascular diseases of the brain, in terms of laboratory and instrumental research methods, is revealed. There are several types of vascular dementia: lacunar (subcortical), multi-infarction with an acute onset (due to strategically localized cerebral infarction).
A high frequency of mental disorders is recorded in vascular parkinsonism, the frequency of which is 9.3% of the total number of patients with parkinsonism, increasing in the elderly (54.2%). Among the population of persons with vascular diseases of the brain (multi-infarction brain damage (75%). The course of vascular parkinsonism is predominantly subacute (80.3%), in the neurological status akinetic-rigid syndrome prevails (92.9%) in combination with signs lesions of other parts of the nervous system (pyramidal, cerebellum, cerebral cortex, etc.). The main disorders of higher mental functions are detected in the blocks of expressive speech, speech understanding, visual gnosis, praxis (dynamic), counting, body scheme; a significant decrease in memory and The psychopathological status of patients with vascular parkinsonism is
characterized by melancholy, adynamic and anxious depression (64.5%), a high level of personal anxiety (53.8%), the presence of mild and moderate cognitive disorders (43%).
Endoform mental disorders include vascular psychoses and vascular depression [23].
Acute and subacute vascular (post-stroke) delusional psychoses develop immediately after a stroke and last from several hours to several days, are similar to acute paranoids. The clinical state in acute and subacute vascular delusional psychoses is labile, characterized by a pronounced affect of fear, illusory delusional perception of the environment as a threat to the patient, elements of confusion are noted, intensified or provoked by the patient entering an unfamiliar environment.
Vascular depression is a subtype of depressive disorder, which is characterized by: debut at a later age (more often after 65 years against the background of a symptom complex characteristic of vascular diseases of the brain), psychomotor retardation, apathy, depressive thinking with guilt and ideas of self-deprecation, poor executive activity, cognitive dysfunction due to a decrease in the speed of thought processes. A predictor of PD development is a severe neurological deficit and a history of mental disorders. After a single acute cerebrovascular accident within a year, PD develops in 34% of patients (on the first day (50%), in acute (12%), early recovery (29%) and late recovery (9%) periods of acute cerebrovascular accident) ). There are 3 clinical types of PD: anxious, apathetic, melancholy [24]. The duration of PD depends on the size of the lesion in the brain. The presence of PD doubles the mortality of patients in the post-stroke period. The cause of the development of vascular depression in chronic cerebral ischemia is microvascular lesion of the subcortical layer of the prefrontal cortex [16], which is manifested by the hyperintensity of the white matter of the deep hemispheres and subcortical gray matter in the T2-mode with magnetic resonance imaging, leading to dysfunction of the cortical neural-subcortical circles that regulate mood. The presence of depression in elderly patients with chronic cerebral ischemia is associated with an increased risk of subsequent development of vascular dementia [25].
Psychopathological manifestations change depending on the predictor of vascular diseases of the brain (somatoform autonomic dysfunction; arterial hypertension; cerebral atherosclerosis; atherosclerotic carotid stenosis; pathological tortuosity of the main arteries of the head; extravasal compression of the arteries in osteochondrosis and cranial spine.
Syndromological forms of vascular diseases of the brain have certain features of pathopsychological manifestations. In stroke, the localization of the lesion focus in the brain determines the degree of depression of consciousness and the variety of mental disorders in patients. Patients with acute cerebrovascular accident poorly control their emotions (pathological tearfulness, emotional lability or incontinence, pathological giggle and pseudobulbar affect). The initial manifestations of cerebral circulation insufficiency (the initial stage of chronic cerebral ischemia) are characterized by labile cerebrasthenic syndrome (general cerebral complaints; in the neurological status - signs of lability of the autonomic nervous system; mild neuropsychological and emotional disorders of the non-psychotic level).
In patients with discirculatory encephalopathy (a clinically outlined stage of chronic cerebral ischemia), asthenic phenomena are primary in the structure of the psychoorganic syndrome. discirculatory encephalopathy is associated in ICD-10 with the concept of “vascular dementia” [20]. There are three degrees of severity of discirculatory encephalopathy: 1st degree - the presence of focal diffuse neurological symptoms, which is combined with mild cognitive impairments of a neurodynamic nature; 2nd degree - the presence of a pronounced neurological syndrome, which is combined with clinically obvious cognitive impairment, usually of a
moderate degree; 3rd degree - a combination of several neurological and neuropsychological syndromes, indicating multifocal brain damage, cognitive impairment reaches the degree of dementia. As dyscirculatory encephalopathy progresses, the number of patient complaints decreases significantly, which is due to a decrease in patients' criticism of their condition (they complain mainly of instability when walking, noise and heaviness in the head, sleep disturbance). The severity of social maladjustment is increasing.
CONCLUSIONS
The growing interest in the problem of the relationship between psychopathological disorders and vascular diseases of the brain is associated with their widespread prevalence, social significance, adverse effects on work ability and a high degree of comorbidity. Regardless of whether the patient suffered from psychopathological disorders before the development of vascular diseases of the brain or they developed secondarily as a reaction of the individual to a somatic illness, mental disorders significantly aggravate the course of the disease.
Currently, the possibilities of diagnosing vascular diseases of the brain have improved thanks to modern methods of neuroimaging. This allows us to take a fresh look at the important problem of cognitive and emotional disorders in vascular diseases of the brain in terms of correcting mental disorders in complex programs of medical and psychological rehabilitation and treatment. Active promotion of knowledge about the causes of the development of vascular diseases of the brain (schools, public lectures, appearances in the media, etc.), planned dispensary observation and timely preventive treatment reliably improve the condition of patients and prevent the progression of the disease.
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