In infections associated with direct damage to the brain tissue and its membranes (neurotropic infections: rabies, epidemic tick-borne, Japanese mosquito encephalitis, meningitis), the following clinical picture of the acute period is observed: against the background of severe headaches, often vomiting, stiff neck muscles and other neurological symptoms (Kernig's symptom, diplopia, ptosis, speech disorder, paresis, signs of diencephalic syndrome, etc.) develop stupor, oneiroid (dream-like) confusion, motor excitation with delusional and hallucinatory disorders.

With encephalitis, symptoms of a psychoorganic syndrome are revealed. There is a decrease in memory and intellectual productivity, inertia of mental processes, especially intellectual ones, difficulty in switching active attention and its narrowness, as well as emotional-volitional disorders with their excessive lability, incontinence. The psychoorganic syndrome in most cases has a chronic regressive course. Mental disorders with encephalitis, they are combined with neurological disorders. As a rule, persistent and intense headaches, central and peripheral paralysis and paresis of the extremities, hyperkinetic disorders, speech disorders and cranial nerve function, epileptiform seizures. Body temperature often rises to high readings (39-40 ° C). Vasovegetative disorders (fluctuations blood pressure, hyperhidrosis).

epidemic encephalitis(according to ICD-10, the rubric is specified by the code from another section G 04) was described by the Austrian scientist K. Ekonomo in 1917 and almost at the same time independently by Ukrainian neuropathologists Ya.M. Raymist and A.M. Geimanovitch. The disease was studied during the epidemic encephalitis pandemic in 1916-1922. Currently, only sporadic cases of encephalitis are noted in our country. In his clinical picture There are two stages, acute and chronic.

At acute stage against the background of a feverish state, pathological drowsiness (lethargy) appears. Hence the name sleeping sickness. Patients sleep day and night, they can hardly be awakened for eating. In addition, delirious disorders and oneiroid can be observed. Delirium is manifested by visual and auditory hallucinations, more often in the form of photopsies and acoasms; sometimes there are verbal illusions, which may be joined by fragmentary delusions of persecution. In a severe course of the disease with severe neurological symptoms, when ptosis, paresis of the oculomotor and abducens nerves, diplopia, impaired coordination of movements, convulsions, myoclonic twitches, etc. develop, there are moussifying and occupational deliriums.

During the development of the acute stage, many patients (about a third) die, some recover completely as a result of treatment. But most often the acute period of the disease passes into the chronic stage, which is called parkinsonian.

In the chronic stage, along with mental changes in the form of an apatoabulic state, postencephalic parkinsonism develops. It is the leading symptom of the disease. In addition, depressive disorders with suicidal tendencies, occasionally euphoria, importunity, petty pedantry, occasional hallucinatory-paranoid inclusions, sometimes with elements of the Kandinsky-Clerambault syndrome, are possible. Oculogyric seizures often occur: forced abductions eyeballs up, less often to the sides for a few seconds, minutes or even hours. Oculogyric crises are accompanied by a oneiroid disorder of consciousness with fantastic experiences: patients see another planet, space, underground, etc. It is assumed that epidemic encephalitis is caused by a virus that has not yet been identified.

Psychiatric disorders often occur in acute infections(sample, typhoid, scarlet fever, paratyphoid, influenza). They can proceed, as already mentioned, in the form of: 1) acute transient psychoses; 2) protracted protracted psychoses; 3) severe irreversible organic lesions of the central nervous system with signs of encephalopathy (psycho-organic and Korsakov's syndromes). In acute transient psychoses, the so-called febrile delirium most often occurs. It is manifested by delirious disorders. At the same time, patients have disorientation in place and time, psychomotor agitation, visual hallucinations. Delirious state occurs against a background of high temperature, usually rising in the evening, and disappears with the end of the fever. It may also occur at the onset of an infectious disease (initial delirium) or before the end of a fever (residual delirium).

Mental disorders in flu differ from those described above and are manifested mainly by an asthenic symptom complex - lethargy, indifference, irritability, insomnia. These symptoms are usually unstable and disappear after 1-2 weeks. In some cases, a depressive state with unmotivated anxiety, anxiety, and suicidal tendencies join asthenic disorders. Sometimes possible manic disorders. If influenza is complicated by a severe somatic illness, amental states may occur, hallucinatory-paranoid symptoms may develop.

Psychoses, the main cause of the occurrence and development of which are infections, and the psychopathological picture is determined by typical reactions exogenous type are called infectious.

The reactions of the exogenous type include the following syndromes: asthenic, delirious, Korsakovsky, epileptiform excitation (twilight state), catatonia, hallucinosis. Such psychopathological symptoms may accompany common infections (typhus, malaria, tuberculosis, etc.) or be a clinical expression of an infection with cerebral localization. With meningitis, predominantly the membranes of the brain are affected, with encephalitis, the substance of the brain itself, with meningoencephalitis, a combined lesion is observed. Some common infections may be complicated by encephalitis

261 Chapter 20 infectious diseases

(For example, purulent infection, influenza, malaria) or meningitis (eg tuberculosis).

At the beginning of the XX century. the concept of exogenous types of reactions of K. Bongeffer appeared, the essence of which was to recognize the response of similar mental forms of disorders to various exogenous hazards.

Statistical data on the frequency of infectious psychoses in certain regions of the country, cited by various authors, differ in sharp fluctuations (from 0.1 to 20% of patients admitted to psychiatric hospitals), which is associated with differences in the diagnosis of infectious psychoses and an unequal assessment of the role infectious factor in the occurrence of mental illness. To a lesser extent, the ratio of the number of infectious psychoses and other mental illnesses depends on the epidemiological characteristics of a particular area in a certain period.

Clinical manifestations

Of the non-psychotic disorders during the period of an infectious disease and during the period of convalescence, asthenic ones are most often observed. Patients quickly and easily get tired, complain of headaches, weakness, lethargy. Sleep becomes shallow with nightmares. Mood instability is noted (often the background of mood is reduced, patients are prone to melancholy, irritable, quick-tempered). The movements of patients are slow, sluggish.

The most characteristic for acute infectious psychoses are states of disturbed consciousness and, in particular, its clouding: delirious or amental syndrome, less often - twilight darkness consciousness. Disturbances of consciousness often develop at the height of the temperature reaction, in their structure acute sensory delirium is found in combination with vivid visual and auditory hallucinations. These phenomena after the passage of the febrile period pass.

Infectious psychosis can also develop after normalization of body temperature. After the acute period of severe infection has passed, an amental syndrome can be observed with a transition to deep asthenia with hyperesthesia and emotional weakness.

Protracted and chronic infectious psychoses are characterized by: amnestic Korsakoff syndrome (with a tendency to

262 Section III. Separate forms mental illness

gradual recovery of memory disorders), hallucinatory-paranoid, catatonic-gebephrenic syndromes against the background of a formally clear consciousness. The last two syndromes are sometimes difficult to distinguish from the symptoms of schizophrenia. Great importance in the differential diagnostic plan, there is a statement of personality changes characteristic of schizophrenia (autism, emotional impoverishment of the personality, etc.) or infectious psychoses (emotional lability, memory impairment, etc.). In this case, it is necessary to take into account the complex of all symptoms, as well as serological and other laboratory data important for diagnosis.

With encephalitis, symptoms of a psychoorganic syndrome are revealed. There is a decrease in memory and intellectual productivity, inertia of mental processes, especially intellectual ones, difficulty in switching active attention and its narrowness, as well as emotional-volitional disorders with their excessive lability, incontinence. The psychoorganic syndrome in most cases has a chronic regressive course. Mental disorders in encephalitis are combined with neurological disorders. As a rule, there are persistent and intense headaches, central and peripheral paralysis and paresis of the extremities, hyperkinetic disorders, speech disorders and cranial nerve function, epileptiform seizures. Body temperature often rises to high readings (39-40 ° C). Vasovegetative disorders (fluctuations in blood pressure, hyperhidrosis) are noted.

In the chronic course, infectious psychoses, with all the variety of mental disorders, often lead to personality changes according to the type of organic syndrome.

263 Chapter 20. Disorders in infectious diseases Etiology and pathogenesis

In infectious psychosis clinical manifestations conditioned individual features sick person to respond to exogenous harmfulness.

The pathogenesis of mental disorders in various infectious diseases is not the same. It is believed that in acute infections there is a picture toxic encephalopathy with degenerative changes in neurons; at chronic infections highest value has vascular pathology and hemo- and liquorodynamic disorders.

Treatment

In the presence of an infectious disease, the underlying disease is treated with the addition of detoxification therapy (polyglucin, rheopolyglucin), vitamin therapy. In the presence of acute psychosis with excitation or clouding of consciousness, the use of tranquilizers is recommended (seduxen intramuscularly at 0.01-0.015 g 3-4 times a day), with an increase in excitation - haloperidol (0.005-0.01 g intramuscularly 2-3 times a day) .

With amnestic syndrome and other psychoorganic disorders, it is advisable to prescribe nootropil (piracetam) (from 0.4 to 2-4 g per day), aminalon (up to 2-3 g per day), seduxen, grandaxin (up to 0.02-0.025 g per day). days), vitamins.

Mental disorders in infectious diseases quite often ascertain in the most severe clinical forms. The depth of these disorders largely depends on the intensity and duration of exposure to the pathological onset of the underlying disease. In addition, the age and general condition of the patient's body undoubtedly have a certain value, other things being equal. In most cases, mental disorders, under the influence of intensive treatment of the underlying disease, pass without a trace. But it is possible, especially in their chronic and long-term course, residual effects in the form of organic changes in the brain and the corresponding psychopathological symptoms. It is the latter that determine the deviations in the behavior of such patients, becoming the object of a forensic psychiatric examination.

In acute infections, all kinds of neurotic and other moderately pronounced psychopathological manifestations, and sometimes psychosis, can be observed.

Common features for almost all of these diseases are disturbance of consciousness, disorientation in the environment, the appearance of anxiety, fears, abundant, mainly visual hallucinations, a delusional interpretation of what is happening around, the appearance of a sharp motor excitement, often leading to aggression and the commission of unlawful acts.

At a forensic psychiatric evaluation Usually, only those who show deep dementia with a decrease in criticism and a violation of judgment processes, accompanied by phenomena of disinhibition, impulsivity, motor restlessness, increased fussiness, malice, annoyance, aggressiveness, are usually recognized as insane from among such persons.

The resolution of forensic psychiatric issues in infectious psychoses is associated with significant difficulties. The presence of pronounced psychosis during the commission of the offense is the basis for recognizing the state of insanity. However, in practice, there may be less pronounced mental manifestations, in which patients do not lose the ability to realize the actual nature and social danger of their actions and control their behavior. Then the accused should be considered sane.

35. Mental disorders in AIDS. Forensic psychiatric evaluation.

AIDS- a disease transmitted by a slow retrovirus that has lymphotropic and neurotropic properties and, therefore, can directly affect the nervous system, causing a variety of neurological and mental disorders (affective and psychopathic disorders, dementia, psychosis).

Among the mental disorders that develop with AIDS, there are disorders associated with the reaction of the individual to the fact of AIDS, and mental disorders as a result of organic damage to the brain. The first psychological problem that AIDS patients face is their social isolation. Their families break up, they are abandoned by relatives and friends, they are often unreasonably fired from work, expelled from school. All this causes a negative reaction in AIDS patients, leads to the development of reactive mental disorders and can cause them to commit various antisocial acts.

Mental disorders associated with the reaction of the individual to the disease are atypical due to the simultaneously developing organic brain damage. These include reactive states. wide range: from psychological disorganization and affective and personality disorders to hysterical, hypochondriacal and paranoid psychoses.

The progression of the disease in about half of the patients causes the development of organic brain lesions, which are manifested by memory loss, difficulty concentrating, apathy, physical and mental asthenia. In patients, the social circle narrows, constant drowsiness (lethargy), progressive headaches appear. These manifestations of the psychoorganic syndrome often appear long before the development of the overt signs of HIV infection - fever, profuse night sweats, diarrhea, lymphadenopathy, pneumonia, etc. The first sign of AIDS in 40% of cases is depression. Often it is precisely because of depressive disorders that patients turn to psychiatric institutions, where they show signs of AIDS.

The development of an organic brain lesion over several weeks or months ends with the development of dementia with psychomotor retardation, convulsive seizures, mugasm, impaired consciousness, urinary and fecal incontinence, and coma.

AIDS is considered incurable and ends with the death of the patient. The cause of death is severe organic brain damage, developing sarcomas or other malignant tumors, as well as various somatic diseases, in particular bilateral pneumonia as the most common cause of death in AIDS patients.

Forensic psychiatric assessment should be based primarily on the establishment of the nosological nature of the disease (in this case HIV infection), determining its clinical form, type of course and severity of existing mental disorders. So, clinically expressed dementia usually does not cause doubts in case of its clinical qualification and recognition of this person as insane. However, it should be borne in mind that patients often retain habitual stereotypical forms of behavior, and therefore they can outwardly give the impression of being quite intact.

When burdening the underlying disease with various additional hazards, HIV-infected people often experience decompensation states that are different in their clinical structure and depth, up to psychotic ones. When ascertaining psychotic states during the commission of the acts incriminated to them, these persons must also be recognized as insane.

However, more often HIV-infected persons do not lose the ability to realize the actual nature of their actions and manage them, in connection with which they are recognized as sane.

Infectious psychoses are a group of mental illnesses caused by a variety of infections.
Violations of the mental status of a patient with an infectious disease depend on its nature, the characteristics of the reactivity of the central nervous system and on the localization of the pathological process. Mental disorders occur not only in general infections, but also in infectious lesion central nervous system. The division of mental disorders in an infectious disease into symptomatic - with general infections and organic - with intracranial, directly affecting the brain infections, is very relative. This fact is due to the fact that common infections with their unfavorable course at a certain stage can affect the brain and thus acquire the clinical picture of intracranial infections.

Clinical picture in common infectious diseases
Infectious psychoses are based primarily on psychopathological disorders, which, according to K. Bongeffer, belong to the so-called exogenous types of reaction. These include: delirium, amentia, twilight state of consciousness, epileptiform excitation and hallucinosis. These states can proceed as follows:
1) transient psychoses. In this case, they are exhausted by syndromes of stupefaction, such as delirium, stunning, amentia, twilight stupefaction (epileptiform excitation) and oneiroid;
2) protracted (protracted or prolonged) psychoses. In this case, the above states occur without impaired consciousness, but only with transient, intermediate syndromes, which include hallucinosis, hallucinatory-paranoid state, apathetic stupor, and confabulosis; 3) irreversible mental disorders with signs of organic damage to the central nervous system. Such mental disorders include Korsakov's and psychoorganic syndromes.
Transient psychoses are transient and do not leave any consequences.
Delirium is one of the syndromes of impaired consciousness, which is the most common type of response of the central nervous system to infection, which is especially pronounced in childhood and young age. Delirium can proceed with its own characteristics, the nature of which depends on the type of infection, the age of the patient, and also on the state of his central nervous system.
With the development of infectious delirium, the patient's consciousness is disturbed, he cannot navigate in the surrounding space. However, in some cases it is possible to attract the attention of the patient for a short time. Against the background of infectious delirium, numerous visual experiences are born in the form of illusions and hallucinations, fears, ideas of persecution. Manifestations of delirium intensify towards evening. At this time, patients "see" scenes of fire, death a large number people, widespread destruction. It begins to seem to them that they are traveling, getting into terrible accidents. At such moments, their speech and behavior are due to hallucinatory-delusional experiences, in the formation of which, in infectious delirium, painful sensations in the various bodies, namely: it seems to the patient that he is being quartered, his leg is amputated, his side is shot through. During the development of infectious psychosis, the patient may experience a symptom of a double. At the same time, it seems to him that his double is nearby. Often, patients develop professional delirium, in which they perform actions familiar to their professional activities.
Infectious delirium in unequal types infectious process has its own characteristics of the clinic and course.
Amentia is manifested by a deep stupefaction of consciousness, while orientation in the surrounding space is disturbed, the loss of one's own personality, being a direct reaction of the higher nervous system to an infectious disease, develops in connection with a severe somatic condition. The clinical picture of amentia is characterized by: impaired consciousness, severe psychomotor agitation, hallucinatory experiences. Also, amentia is characterized by incoherence of thinking (incoherence), speech and confusion. Excitation is rather monotonous, limited to the limits of the bed. The patient randomly rushes from side to side (actation), shudders, stretches, but sometimes he wants to run somewhere, feels fear. Such patients need strict supervision and care.
The state of oneiroid is characterized by the detachment of patients from the environment, the dramatization of fantastic events that arise in their own imagination. Patients are either in a stupor, or motor restless, excited, fussy, anxious, fearful. The affective state is extremely unstable. Sometimes, while maintaining the correct orientation, patients experience involuntary fantasizing. A similar state with detachment, lethargy, and spontaneity is defined as oneiroid-like. Delirious-oneiric (dream) states contain dream disorders, often with fairy-tale and fantastic themes. Patients at the same time are active participants in the events, experience anxiety, fear, horror.
Much less often, transient psychoses include amnestic disorders in the form of short-term retrograde or anterograde amnesia: events that preceded the disease or occurred after the acute period of the disease disappear from memory for some time. Infectious psychosis is replaced by asthenia, which is defined as emotional-hyperesthetic weakness. This variant of asthenia is characterized by irritability, tearfulness, severe weakness, intolerance to sounds and light.

Prolonged (protracted, prolonged) psychoses
A number of common infectious diseases under adverse circumstances can acquire a protracted and even chronic course. Mental disorders often proceed from the very beginning without clouding of consciousness in the form of so-called transient symptoms. Protracted psychoses usually end with prolonged asthenia, and in some cases with Korsakov's or psychoorganic syndrome.
The clinical picture of protracted infectious psychoses is quite variable. A depressive-delusional state can be replaced by a manic-euphoric one with an elevated mood, talkativeness. The following mental disorders are mainly formed: hypochondriacal delusions, ideas of persecution, hallucinatory experiences. Confabulations in transient psychoses are less common. Psychopathological disorders are accompanied by a pronounced asthenic syndrome with symptoms of irritable weakness, as well as often depressive-hypochondriacal disorders.

Irreversible mental disorders
This pathology is based on an organic lesion of the brain, the clinical manifestations of which can be psycho-organic and Korsakov's syndromes. They are irreversible, most often occurring with intracranial infections or with general infections accompanied by cerebral damage.
IN recent decades along with infectious diseases, mental disorders also underwent significant pathomorphism. Psychotic forms have given way to the symptoms of the borderline circle of mental disorders. Being a core, asthenic syndrome is accompanied by pronounced autonomic disorders, senestopathic-hypochondriacal, obsessive phenomena, sensory synthesis disorders. Affective pathology manifests itself in the form of a predominance depressive disorders, often with a dysphoric tinge - with melancholy, spitefulness, irritability. With a protracted course of the disease, personality shifts are formed, character changes, excitability or features of self-doubt, anxiety, suspiciousness appear. These symptoms can be quite persistent.
In a number of infections, mental disorders have some features that can be diagnostic.
The nature of mental disorders in scarlet fever depends on the form of the disease and its course. At mild form disease already on the second day after a short-term excitation develops asthenic symptoms. In moderate and severe forms of scarlet fever, asthenia in children in the first 3–4 days is combined with mild stupor. At severe forms ah scarlet fever, the development of psychoses is possible mainly in the form of delirium and oneiroid with periodically increasing hallucinations with a fantastic content. At the same time, psychosis has an undulating course with a rapid change in mood. In weakened, often ill children with erased atypical forms scarlet fever psychosis can develop on the 4-5th week.
Asthenic disorders after scarlet fever are the basis for the formation of neurotic reactions in children. Toxic and septic form scarlet fever can get worse organic lesion brain in the form of encephalitis, meningitis. In these cases, in the long term, the development of an epileptiform syndrome, a decrease in memory, intelligence, personality changes with an increase in explosiveness are possible. With the toxic form of scarlet fever, accompanied by cerebral edema, coma is possible. The septic form of scarlet fever at the 3-5th week of the disease can be complicated by embolism cerebral vessels with symptoms of hemiplegia.
Erysipelas is relatively rarely accompanied by the development of mental disorders. At acute course illness at the height of fever against the background of asthenic symptoms, transient psychosis may develop in the form of abortive, usually hypnagogic, delirium. With a sluggish or protracted course erysipelas an amental state may develop. This syndrome occurs following a short-term hypomanic state with euphoria. In the case of a long course of the disease, the development of psychosis without impaired consciousness is possible.
Among the intermediate or transitional syndromes with erysipelas, asthenodepressive, asthenohypochondriac, and hypomanic are more common.
With a severe course of infection, the development of phlegmon, a catatonic state is possible.
The prognosis of transient and prolonged psychoses with erysipelas is favorable.
At intestinal infections mental disorders include asthenic disorders with tearfulness, melancholy, anxiety.
Typhoid fever is accompanied by asthenia, weakness, insomnia, frightening hypnagogic hallucinations, often anxiety, fear.
Tropical malaria is the most severe form of malaria. Plasmodium falciparum infection is accompanied by symptoms that indicate brain damage. Such cases of the disease belong to the cerebral form of malaria. When even mild mental disorders appear without any neurological symptoms, it is customary to speak of a cerebral form. Malignant coma and apoplexy varieties of cerebral malaria are dangerous.
The disorder of consciousness develops gradually or very quickly: outwardly completely healthy man suddenly loses consciousness, sometimes at normal temperature, which can result in death after a few hours. Often a coma is preceded by various symptoms an infectious disease or only an increase in headache. Coma may occur after delirium or twilight confusion, less often after epileptiform seizures.
Convulsive syndrome is an essential manifestation of cerebral malaria. Important signs for the diagnosis of this form of the disease are stiff neck muscles, sometimes paralysis eye muscles, other forms of damage to the cranial nerves, monoplegia, hemiplegia, impaired coordination of movements and hyperkinesis.
The prognosis for comatose form is very serious. In addition to stunning and delirium, in the cerebral form of malaria, twilight confusion and amentia can occur. Malarial psychoses last for days or even weeks.
With influenza, mental disorders are observed during epidemics.
Psychosis develops at the height of the infection after 2-7 days, less often - 2 weeks after the drop in body temperature. With the development of psychosis in the acute period, there is a violation of consciousness with visual hallucinations. With post-influenza psychosis, affective disorders and fears develop. Children develop headaches, anorexia, bradycardia, deep asthenia with sleep disorders, psychosensory disturbances, fears, pain in the heart, depression. Sometimes there is dreary excitement, delusions of self-accusation. Asthenia may be accompanied by severe vegetative disorders.
With measles, nocturnal delirious excitation (feverish delirium) often develops. Sometimes delirium develops during the day, motor restlessness appears with sudden crying, screaming. In measles, as in scarlet fever, delirium often develops in adults. When measles is complicated by encephalitis, convulsions, paralysis appear, stunning and hibernation often develop. The emerging psychoorganic syndrome is accompanied by the development of psychopathic changes.
The clinic of mental disorders in mumps differs little from the mental pathology in scarlet fever and measles. A complication of mumps can be meningoencephalitis, accompanied by severe stunning, stupor, and even coma. At the same time, seizures, hyperkinesis, paralysis are also possible.
With pneumonia, delirious episodes are possible in the evening and at night, drowsiness during the day may be accompanied by paraidolic illusions.
In patients chronic alcoholism pneumonia can contribute to the development of delirium tremens.
Mental disorders in rheumatism have attracted attention for more than 100 years. W. Griesinger described melancholy and stupor in this disease.
Leading in the clinical picture of mental disorders in rheumatism is asthenic syndrome, which is more correctly called cerebrosthenia (G. A. Sukhareva). The triad of motor, sensory and emotional disorders belongs to the features of rheumatic cerebral palsy.
Along with the slowness of movements, there is a tendency to hyperkinesis - violent movements.
Among sensory disorders, optical perception disorders are more often observed: bifurcation of objects, a change in their size and shape, the appearance of fog, multi-colored balls and stripes. Objects seem very far away or, conversely, very close, large or small. There are vestibular disorders. Sometimes the perception of one's own body is disturbed.
Emotional disorders include depression, mood swings, anxiety, fears, often there are sleep disorders. A number of patients have behavioral disturbances in the form of disinhibition, motor restlessness. Often with rheumatism develop persistent phobias, hysterical reactions.
In the case of a long course of the disease, twilight disorders of consciousness, epileptiform syndromes develop. to heavy neuropsychiatric disorders rheumatism includes rheumatic cerebropathy with a more severe impairment of intellectual performance. Rheumatic psychoses are characterized by oneiroid disorders, depression with bouts of melancholy, anxiety, fear.
Chronic psychoses are characterized by delirious states. At earlier stages of the disease, affective instability, increased exhaustion, lethargy, weakness are noted. Occasionally, the development of an anxiety-depressive or manic state is possible.

Mental disorders due to acute brain infections Clinical Options neuroinfections are diverse. Such diversity depends not only on the characteristics of the nosological nature of infections, but also on the site of action. pathological factors- in the meninges or in the substance of the brain (meningitis, encephalitis, meningoencephalitis), the method of penetration into the brain (primary and secondary forms), the nature of the pathological process (meningitis - purulent and serous, encephalitis - alternative and proliferative).

Encephalitis
Encephalitis includes inflammatory diseases of the brain of various etiologies.
There are primary encephalitis, which are independent diseases(tick-borne, mosquito, equine encephalitis, Economo lethargic encephalitis), and secondary encephalitis developing against the background of any general infection.
Encephalitis is subdivided into encephalitis with a primary lesion white matter of the brain - leukoencephalitis, with a predominant lesion of the gray matter - polyencephalitis, encephalitis, in which both the white and gray matter of the brain is affected - panencephalitis.
The clinical picture of mental disorders in encephalitis includes acute psychoses with clouding of consciousness. These psychoses proceed according to the type of "exogenous type of reactions" (the so-called transitional syndromes) in combination with affective, hallucinatory, delusional and catatonic-like manifestations. In addition, psychosis in encephalitis can be combined with psycho-organic and Korsakov's syndrome.
Epidemic encephalitis (lethargic encephalitis, Economo's encephalitis) refers to viral infections.
Epidemic encephalitis occurs in two stages: acute and chronic. There are cases in which the acute stage of the disease is asymptomatic, and the pathology itself manifests itself only with symptoms characteristic of the chronic stage. The acute stage of epidemic encephalitis is characterized by a sudden manifestation or develops after short-term prodromal events with irregular fever. In this period, sleep disturbance is noted, in most cases drowsiness is observed, as a result of which epidemic encephalitis is called sleepy or lethargic. For the most part, drowsiness predominates from the start, although more often it follows delirious or hyperkinetic disturbances. Drowsiness must be distinguished from stupor resulting from increased intracranial pressure.
Sometimes, on the contrary, persistent insomnia can be noted. The acute stage of epidemic encephalitis lasts from 3-5 weeks to several months and is often accompanied by psychotic disorders in delirious, amental-delirious and manic forms.
In the delirious form of psychotic disorder, impaired consciousness may be preceded by neurological disorders which at this stage of the disease include paresis of the oculomotor and abducens nerves, diplopia and ptosis. The features of the course of delirium in this pathology include hallucinations. The hallucinations may be dreamlike or terrifying, or they may be elementary (such as lightning or light). In addition to visual, elementary auditory hallucinations sometimes develop, in the event of which the patient can say that he hears music or ringing. In more rare cases, verbal and tactile deceptions (eg, burning) occur.
Hallucinations reflect past events. Often develops professional delirium. Perhaps the development of delusional ideas. The delirious form of the disease quite often develops against the background of other rather pronounced toxic manifestations, such as fever body, sharp hyperkinesis, autonomic symptoms. In severe cases of encephalitis, mushing delirium is possible. In some cases, the delirious form of the disease can take malignant character with acute delirium syndrome. With this development of events, the excitement reaches its maximum severity, speech becomes completely confused, and the patients die in a state of advancing coma.
The amental-delirious form of epidemic encephalitis is characterized by the initial appearance of a picture of delirium, which after a few days is replaced by an amental syndrome. This form lasts up to 3-4 weeks and ends with the disappearance of psychopathological symptoms, followed by more or less prolonged asthenia. Rarely, patients develop a oneiroid state.
The manic form of pathology is manifested by signs of a manic syndrome.
The outcome of the acute stage may be different. During the epidemic, about a third of patients die at this stage of encephalitis. However, there is also a complete recovery, but more often it is apparent, since after several months or years, symptoms of the chronic stage of the disease are revealed.
Between the acute and chronic stages, residual disorders are most often observed.
The most characteristic of the chronic stage are various manifestations of parkinsonism. Muscle rigidity appears, which is expressed in a peculiar posture of the patient with arms brought to the body and knees slightly bent. The appearance of constant trembling, especially of the hands, is also very characteristic. All movements are slow, which is especially evident when performing arbitrary acts. When trying to move, the patient falls back or forward and to the sides - retropulsion, anteropulsion and lateropulsion. At this stage of the disease, personality changes become more and more pronounced, the manifestations of which are described in the literature under the name "bradyphrenia". This term refers to a syndrome that includes different combinations significant weakness of motives, decrease in initiative and spontaneity, indifference and indifference. Parkinsonian akinesia can be interrupted suddenly by short, very fast movements. There are also paroxysmal disorders
(convulsions of gaze, violent attacks of screaming - klasomania, episodes of dream-like clouding of consciousness with oneiric experiences). Relatively rare cases of hallucinatory-paranoid psychoses, occasionally even with the Kandinsky-Clerambault syndrome, as well as protracted catatonic forms, have also been described.
The acute stage is based on vascular-inflammatory and infiltrative processes in the gray matter of the brain. chronic stage accompanied by degenerative changes in nerve cells and secondary growth of glia.
Tick-borne (spring-summer) encephalitis caused by a neurotropic filterable virus and transmitted ixodid ticks, and mosquito (summer-autumn) encephalitis, also caused by a neurotropic filterable virus, but carried by mosquitoes, like epidemic encephalitis, occur with acute and chronic stages. Clinical manifestations differ little from those in epidemic encephalitis. So, in the acute stage, manifestations of syndromes of clouded consciousness are observed.
In the chronic stage tick-borne encephalitis the most characteristic is the syndrome of Kozhevnikov's epilepsy, as well as other paroxysmal disorders (psychosensory disorders, twilight disorders of consciousness, cases resembling V. M. Bekhterev's "choreic epilepsy").
Rabies is the most severe encephalitis, also related to primary, always proceeding with mental disorders. The clinical picture of rabies is typical. There are three stages.
The first (prodromal) stage is expressed in the feeling general malaise, depression. Often already at this stage, sensitivity to various irritations, to the slightest breath of air (aerophobia) is increased.
The beginning of the second stage is accompanied by an increase in body temperature, as well as the appearance of headaches. Increased restlessness and agitation. Patients become depressive, experience fear of death, are sure of imminent death. Characterized by hydrophobia (hydrophobia). Even the idea of water causes convulsive spasms in the larynx in the patient, a state of suffocation develops, sometimes accompanied by motor excitation. At this stage, patients often have delirious and amental states. They often have convulsions, speech disorders, increased salivation, tremor.
In the third stage (paralytic), paresis and paralysis of the limbs occur. Increasing speech disorders. A state of stupor grows, turning into a stupor. Death occurs with the development of respiratory paralysis. The course of the disease in children is more rapid and catastrophic, prodromal stage shorter.
Leukoencephalitis (described by P. Schilder in 1912) is “diffuse periaxial sclerosis”. The disease begins gradually with asthenic symptoms, memory impairment, speech disorders (aphasia, dysarthria), motor awkwardness.
In the future, self-service skills, neatness disappear, dementia increases. In the remote stage, hyperkinesis, decerebrate rigidity appear, and cachexia develops.
Secondary encephalitis, which develops on the basis of common infections, proceeds approximately according to the same laws as the primary ones, but each of the infections has its own characteristic clinic of the preencephalitic period.
With regard to psychiatric disorders secondary encephalitis, then they differ little from those in primary encephalitis.
Meningitis - inflammatory disease membranes of the brain and spinal cord. The most common leptomeningitis is an inflammation of the pia and arachnoid meninges. Meningitis develops in young children.
Meningitis can be caused by a variety of pathogenic microorganisms, various viruses, bacteria and protozoa.
In the prodromal period of meningitis, asthenic symptoms are noted. At the height of the disease, states of clouding of consciousness are mainly observed.
Mental disorders in meningitis can be different depending on what kind of meningitis we are talking about - purulent or serous. So, in epidemic cerebrospinal meningococcal purulent meningitis in the acute period, stunning prevails with episodes of delirious and amental stupefaction, in the most severe cases development of soporous and coma is possible.
In Group serous meningitis(meningoencephalitis), the most pronounced mental disorders can be observed with tuberculous meningitis. In the acute period, stunning may alternate with short-term delirious-oneiric episodes, figurative fantastic experiences, visual and auditory hallucinations, depersonalization-derealization disorders, and false recognition of loved ones.
In follow-up (after complex treatment) asthenia, emotional excitability, lability, resentment, mood swings persist, less often psychomotor disinhibition, tactlessness, rudeness, pathology of drives, reduced criticism with a formal preservation of intelligence, less often - an intellectual defect, gross violations of the emotional-volitional sphere (loss of attachment to loved ones , lack of shame).
In some patients, after a few years at puberty, depressive-dysthymic and manic episodes also draws attention paroxysmal course psychoses.
Serous meningitis in mumps often accompanied by severe drowsiness, lethargy, psychosensory disorders without pronounced phenomena of clouding of consciousness.
When the acute period of meningitis subsides, transient syndromes can develop, lasting from 1 week to 3 months.

Features of the course of infectious psychoses in children
In children with rough influences infectious pathology often develops a state of stunning, then stupor and coma. To features childhood the frequency of pre-delirious states also applies: irritability, capriciousness, anxiety, restlessness, hypersensitivity, weakness, superficiality of perception, attention, memorization, hypnagogic illusions and hallucinations often occur.
The most important role belongs to age reactivity. Children under 5 years of age are more sensitive to toxic effects. They often develop convulsive conditions, hyperkinesis. Productive symptoms in this age group very rare and manifests itself in motor excitation, lethargy, rudimentary delirious states, illusions.
In children in a post-infectious state, along with asthenia, fears, psychopathic disorders, puerile forms of behavior, and memory loss for current events may occur. In children of preschool age, under the influence of severe intoxication, there may be a delay in physical and mental development. Asthenic disorders are the basis for the formation of neurotic reactions.
With epidemic encephalitis in children and adolescents, psychopathic disorders, impulsive motor restlessness, drive disorders, foolishness, antisocial behavior, inability to systematic mental activity in the absence of dementia are formed. Encephalitis transferred in childhood entails the development of psychopathic symptoms with importunity, adynamic disorders, sometimes increased attraction to food, hypersexuality. Mental retardation sets in, although severe dementia does not occur. Similar disorders are present in other encephalitis. For meningitis in children younger age lethargy, adynamia, drowsiness, stunning with periods of motor restlessness predominate. Convulsive paroxysms are possible.

Classification of mental disorders according to the International Classification of Diseases-10
In the International Classification of Diseases of the 10th revision, mental disorders in general and brain infections are classified in the section "Organic, including symptomatic, mental disorders" B 00-B 09 and are coded depending on the leading syndrome (delirium, amnestic syndrome, hallucinosis, delusional, affective, anxiety disorder and behavioral disorders).

Etiology and pathogenesis
Psychosis during common infectious diseases and intracerebral infections do not always occur. The development of psychosis is determined by the characteristics of the infection. For example, in diseases such as typhus, rabies, psychoses develop always. Other infectious diseases (diphtheria, tetanus) are much less often accompanied by mental disorders. There is a point of view that acute psychoses with clouding of consciousness develop under the influence of intense and short-term harmful factors, while protracted psychoses, similar in clinical picture to endoform ones, occur with prolonged exposure to these factors (E. Kraepelin). Important role in the development of psychosis plays the age of the patient. In the elderly, infectious psychoses are abortive, while in children they are very acute. Women are more susceptible to infectious psychosis. Persistent irreversible mental disorders in infectious diseases are determined morphological changes in the brain.
The clinical picture of mental disorders reflects the degree of intensity and progression of brain damage. Epidemic encephalitis is based on vascular-inflammatory and infiltrative processes in the gray matter of the brain. The chronic stage is accompanied by degenerative changes in nerve cells and secondary growth of glia. At the heart of leukoencephalitis is atrophy of the white matter of the cerebral hemispheres.
The causative agents of encephalitis are various viruses, bacteria, rickettsia, fungi, protozoa, helminths.

Diagnostics
The diagnosis of infectious psychosis can be established only in the presence of an infectious disease, and the clinical picture of psychosis corresponds to the endogenous type of reactions - acute and prolonged.
Acute psychoses with impaired consciousness syndromes develop against the background of acute infectious diseases. Protracted psychoses are characteristic of a subacute course.
differential diagnosis. Infectious mental disorders must be distinguished from other mental illnesses. First of all, infectious diseases can become a condition for the development or exacerbation of endogenous psychoses (schizophrenia, manic-depressive psychosis). In addition, a number of psychopathological disorders in infectious diseases can cause great diagnostic difficulties.
The greatest attention in this regard deserves the amental state in a severe infectious disease, which must be differentiated from the catatonic syndrome in schizophrenia. Catatonia is characterized by mobility, sharp impulsiveness, negativity, grandiloquence of the content of the statements of patients, whimsical speech, allegoricalness. When calming down in the case of catatonia, a negative inaccessibility and an increase in impulsivity appear with the aggravation of painful manifestations.
Excitation in amentia is limited to the bed. The appearance and behavior of patients indicate helplessness. Speech during amentia is incoherent. Patients speak now animatedly, then the tone of their speech becomes weeping. Temporary sedation of amentia is replaced by the so-called adynamic depression (E. Stransky).
No less difficult is the differentiation of transitional, intermediate syndromes, very close to endogenous psychoses.
Asthenic syndrome, against the background of which psychosis occurs, the development of the latter after one of the syndromes of disturbed consciousness, or the change of psychosis in the evening by delirium, give grounds to diagnose a transient syndrome of infectious origin.
The aggravation of a mental disorder with an improvement in the somatic state, as well as the development of a mental pathology after the end of a somatic disease or the preservation of mental disorders for a long period after the end of an infectious disease give reason to doubt the presence of an infectious psychosis.
The pathomorphosis of both the infectious diseases themselves and the mental disorders developing with them requires the differentiation of neurosis- and psychopath-like disorders in infections from psychogenies and psychopathy. From neuroses, borderline mental symptoms in infections can be differentiated on the basis of the absence of direct mental trauma and the presence of clinical manifestations of an infectious disease. For a diagnosis of psychopathy, there must be evidence of the presence of psychopathy prior to the onset of an infectious disease.

Prevalence of infectious psychoses
Data on the frequency of infectious psychoses over the past 40-60 years fluctuate depending on the periods in which statistical studies were carried out, and on views on the diagnosis of this pathology. In recent decades, as a result of a significant decrease in the frequency of infectious diseases, there has been a further decrease in psychiatric hospitals patients with infectious psychoses.

Forecast
Acute infectious psychoses usually pass without a trace. However, after infectious diseases accompanied by acute symptomatic psychoses, there is a state of emotional-hyperesthetic weakness with severe asthenia, lability of affect, intolerance to loud sounds, bright light. In unfavorable cases, infectious delirium proceeds with deep clouding of consciousness, pronounced excitation, which takes on the character of erratic throwing (mushing delirium), and ends lethally. Prognostically unfavorable is the preservation of such a state with a drop in body temperature. Protracted psychoses lead to personality changes according to organic type. So, toxic and septic forms of scarlet fever can be complicated by encephalitis or meningitis. Features of the course of psychosis and its outcome depend on the age of the patient and the state of the organism's reactivity.
The prognosis of encephalitis is often unfavorable. Ability to work decreases, psychopathization with asocial forms of behavior appears. Sometimes schizophrenia-like symptoms are noted.
With meningitis, often along with the development of psychopathic disorders with disinhibition, pathology of drives, there are intellectual-mnestic disorders, convulsive paroxysms.

Treatment and rehabilitation of patients with infectious psychoses
Rehabilitation of patients with infectious mental disorders includes timely diagnosis and adequate treatment.
Treatment of acute and protracted infectious psychoses should be carried out in psychiatric hospitals or infectious diseases hospitals under the constant supervision of a psychiatrist and staff supervision. Along with active treatment of the underlying disease, patients should be given massive detoxification therapy. Treatment of psychosis is determined by the psychopathological picture of the disease.
Acute infectious psychoses with confusion, acute hallucinosis are treated with chlorpromazine, it is also possible to use Seduxen or Relanium intramuscularly.
Treatment of protracted psychoses is carried out with neuroleptics, taking into account psychopathological symptoms. Along with chlorpromazine, other antipsychotics with a sedative effect are used: frenolon, chlorprothixene. Some sources recommend avoiding the use of drugs such as haloperidol, triftazin (stelazin), ma-zheptil, tizercin due to their hyperthermic properties.
In depressive states, amitriptyline, azafen are most widely used. With agitation, they should be combined with chlorpromazine. In case of impaired liver function, the doses of frenolon and seduxen are significantly reduced.
With irreversible mental disorders in the form of Korsakovsky and psychoorganic syndromes nootropic drugs are widely used.
Currently, atypical antipsychotics can be used to treat productive symptoms: rispolept, seroquel (quetiapine).
In therapy depressive states it is more rational to use: coaxil, selective serotonin reuptake inhibitors, such as zoloft, lerivon, remeron.
Rehabilitation measures in patients with long-term protracted psychoses, as well as irreversible mental disorders, include an adequate solution of social and labor issues.

Expertise
Forensic psychiatric examination. Patients with acute and protracted psychoses are recognized as insane. In the presence of residual disorders, the expert assessment is determined by the severity of changes in mental activity.
Labor expertise. Patients with severe irreversible mental disorders are recognized as disabled. The degree of disability is determined by the severity of the mental state. After the disease with encephalitis (and often meningitis), the ability to work decreases.

MENTAL DISORDERS IN INFECTIOUS DISEASES. NEUROSYPHILIS. TRANSMISSIVE (PRION) SPONGIOFORM ENCEPHALOPATHY

Mental disorders in common infectious diseases

Mental disorders in infectious diseases have been known for a long time. Even in the writings of ancient doctors there are references to psychotic disorders in patients in a feverish state.

Etiology and pathogenesis

The scientific approach to the study of mental disorders in infectious diseases was started by the German scientist E. Kraepelin, who in 1881 proposed to divide them into febrile ones that appear at the beginning of the disease, during the peak of fever and postfebrile, or asthenic. He explained febrile mental disorders by the action of an infectious agent, and postfebrile disorders by the presence of asthenia. Taking into account scientific achievements in microbiology (L. Pasteur, R. Koch), E. Kraepelin suggested that the clinical manifestations of infectious psychoses depend only on the infectious factor.

An alternative opinion was expressed by K. Bonhoeffer. Based on the concept of A. Hoche about the presence in the brain of certain mechanisms of response to internal and external harmful factors, he put forward a hypothesis about exogenous response types. K. Bonhoeffer argued that the development of infectious psychoses is not associated with an infectious agent, but with the reaction of the brain. Thus, he denied the possibility of a connection between infectious diseases and a specific clinic of infectious psychoses.

In the process of monitoring the course of infectious diseases during epidemics, it was established that in infectious psychoses there are both general violations caused by the reaction of the brain, and specific, characteristic of a particular infectious disease.

G. Stertz (1927) argued that the symptoms and syndromes observed in exogenous, in particular infectious psychoses, can be divided into obligate (mandatory in the clinical picture of the disease) and optional (non-permanent), appearing periodically. He considered obligate syndromes of confusion and dementia as a possible consequence of severe forms of these diseases. Facultative manifestations of infectious psychoses are characterized by affective disorders, schizoform symptoms, convulsive states. N. Wieck (1961) divided exogenous psychoses into functional, or reverse, and those that contribute to the development of psycho-organic changes, that is, a defect syndrome. In his opinion, between acute exogenous reactions, which are manifested by syndromes of clouding of consciousness, and an organic defect-syndrome, there is a group of transitional syndromes. To them, N. Wieck counted conditions accompanied by changes in motives, affective and schizoform disorders, amnestic (Korsakov's) syndrome. He argued that in the presence of one or another transitional syndrome, it is possible to determine the prognosis of the disease. He considered affective states to be favorable, and organic register syndromes to be unfavorable. The appearance of the latter testified to the development of dementia.

Except psychotic disorders infectious genesis, mental disorders of a non-psychotic nature can develop, primarily asthenic conditions, manifested by prodrome and in the final stages of the disease. Asthenic conditions are accompanied by mood changes, more often depression with hypochondriacal feelings. Hypochondria indicates a dysfunction of the autonomic nervous system, preceding the appearance of specific manifestations of an infectious disease. Hypochondriacal symptoms can complete the course of such a disease, when recovery for various reasons is "unprofitable" for the patient. During this period, he complains of deterioration physical condition, although there are no objective signs of somatic pathology. Sometimes infectious diseases provoke (start-up reaction, according to A. Kempinski, 1975) the development of non-psychotic manifestations behind the neurotic type.

It has not yet been clarified what contributes to the development of infectious psychoses and why often their clinical picture and course do not differ, although the cause is various infectious diseases. At the same time, we can talk about specific symptoms in various neuroinfections.

Think that feverish conditions, organic changes in the brain caused by an infectious process cause a special tendency of the nervous system to respond appropriately to infectious agent.

The development, clinical picture, course of infectious psychoses depend on the interaction between the macro- and microorganism, according to the state of the organism's reactivity, on the one hand, and the virulence of the infectious agent, on the other.

I.F. Sluchevsky (1957) distinguishes four types of the course of infectious psychoses.

First type- infectious psychosis develops with sufficient reactivity of the body. In this case, the disease begins acutely, violently, often with symptoms of a delirious, or amental, syndrome.

Second type- an infectious agent acts on an organism with a weakened reactivity, which does not contribute to the mobilization of protective forces, so psychosis becomes protracted. The disease lasts for several months.

Third type- immunoreactive forces are gradually weakened, and degenerative changes occur in nerve cells, contributing to the development of a stable organic defect.

Fourth type the course of infectious psychosis is associated with an inflammatory process in the brain - the development of encephalitis. In this case, the patient either recovers, or persistent and residual psychopathological neurological symptoms appear.

Therefore, the concept of K. Vonjoe on the exogenous type of response and the associated ideas about the absence specific features psychoses caused by infectious diseases remains the main one in understanding this mental pathology. Most authors apply the etiological principle of classification of infectious psychoses, as it indicates the connection between the infectious process and psychotic disorders. This principle helps to recognize the disease and promotes adequate comprehensive treatment.

Infectious psychosis is preceded by various conditions: weakening of the body's defenses, overwork, negative experiences, hypothermia, intoxication, somatic diseases non-infectious origin etc.

Infectious psychoses are characterized by common features that do not depend on etiological factor, namely:

1) acute onset of psychosis;

2) the presence of manifestations of an infectious disease, caused psychopathological disorders;

3) somatic signs of an infectious disease;

4) the presence of amentality (misunderstanding) in the clinic of the psychopathological syndrome;

5) the presence of physical and mental asthenia in the clinical picture of infectious psychosis (even after the symptoms of psychosis have been eliminated).

Mental disorders in infectious diseases. Mental disorders in infectious diseases

35. Mental disorders in AIDS. Forensic psychiatric evaluation.

MENTAL DISORDERS IN INFECTIOUS DISEASES. NEUROSYPHILIS. TRANSMISSIVE (PRION) SPONGIOFORM ENCEPHALOPATHY

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