CLINICAL MANIFESTATIONS Initial syndromes Usually, the initial manifestations of mental disorders of vascular genesis are defined as "p...
CLINICAL MANIFESTATIONS
Initial syndromes
Usually, the initial manifestations of mental disorders of vascular genesis are defined as "pseudo-neurasthenic syndrome", meaning the non-psychotic nature of symptoms and a significant proportion of asthenic inclusions associated with organic (vascular) pathology.At the same time, the actual psychopathological symptoms are closely intertwined with neurological stigmas, which are also not pronounced.
Such patients express very characteristic complaints of tinnitus, which arises suddenly, often rhythmically repeating a pulse wave ("I hear the heart beating in my ears and in my head"), or also a sudden "ringing" in the head, rapidly growing and just as fast passing. Often there are pains in the head, especially in the back of the head, which are in the nature of compression (spasm of the occipital, vertebral artery), in many patients such pains occur right after waking up in the morning.
Usually sleep is short, superficial, waking up after 2-3 hours, then patients cannot fall asleep, the next day they experience a state of "weakness", feel weak, tired. They have a heightened sensitivity to all stimuli (sounds, light); phenomena of hyperpathy (hyperacusis) are very characteristic of the clinical manifestations picture of the disease.
Occasionally there are attacks of dizziness, imbalance when walking. Forgetfulness, emotional instability, tearfulness, sentimentality are noted. It becomes more difficult to work due to rapid fatigue, instability of attention, you need to rest more often. As a rule, the awareness of one's own change, morbidity remains.
From the description of the characteristic initial symptoms, it can be seen that, along with the symptoms of irritable weakness, albeit indistinct, but still evidential signs of an organic decrease in mental activity are expressed. It is almost always possible to register a decrease in the volume of perception; patients very often do not notice or do not perceive all objects in the field of vision.
This explains the rather typical searches for glasses, keys, and other small items. The slowdowns of motor reactions and speech are quite obvious, which leads to difficulties in everyday life. In some cases, thinking becomes circumstantial, and a tendency toward edifying reasoning may be found.
Memorizing and fixing new events, new information weakens, chronological orientation may be violated, especially the ability to accurately date events. Many patients notice that at the right moment they cannot quickly recall what is needed (some name, date of an event, a fragment of what they have just read, a number, etc.).
The instability of the emotional-affective sphere is constantly noted, irritability, moodiness, resentment easily arise; tearfulness for minor reasons is a fairly constant sign of this pathology (affect incontinence). Many patients have a tendency to anxious fears for their health, for those close to them; rather persistent hypochondriasis, a decrease in mood can develop.
In cases where patients have transient somatic disorders, and this happens quite often, reactive states and neurosis-like disorders develop easily. At the same time, depressive reactions, hypochondriac symptoms, fears of death, the development of paralysis with helplessness, dependence are constant, especially in people who do not have relatives living alone.
In the presence of such symptoms in the clinical picture of the initial stage of cerebral vascular pathology, personality changes with peculiar psychopathic manifestations begin to appear. The sharpening of character traits characteristic of patients becomes noticeable.
The basis of personality transformation is the appearance of a kind of rigidity of the entire mental sphere, but at the same time, the dependence of "psychopathization" on the age factor is an absolutely obvious fact.
With the development of the vascular process in the involutionary period, one can note, first of all, an increase in asthenic structural components of character - such as indecision, self-doubt, a tendency to anxious suspiciousness, anxiety-depressive, hypochondriacal reactions.
If the vascular process begins in old age, the "psychopathic" manifestations are largely similar to those which are noted in the initial period of senile dementia, when, indeed, mental rigidity, egocentrism, general coarseness of the personality, a general gloomy-displeased, gloomy mood with hostile attitude towards others are most pronounced.
Undoubtedly, premorbid personality traits play a major role in the clinical picture of personality anomalies in the early stages of the development of the vascular process. At the same time, such features as anxious suspiciousness, capriciousness, hysterical demonstrativeness, explosiveness become grotesquely exaggerated.
The characteristics of personality changes are also influenced by the characteristics of the vascular process itself, such as the degree of progression, localization of vascular lesions, the presence of arterial hypertension, various somatic, i.e. extracerebral manifestations.
In clinical manifestations practice, the presence of pseudo-neurasthenic disorders of vascular origin does not exclude their combination with various signs of weakening, decreased mental activity of varying severity. In such patients, various dysmnestic disorders are constantly present, a decrease in the pace and productivity of mental activity, criticism, and the level of judgments can be noted.
The totality of these manifestations corresponds to the concept of "organic psychosyndrome" or "psychoorganic syndrome". With an increase in the progression of vascular lesions, the development of cerebral infarctions, micro-strokes, a picture of vascular dementia is revealed.
Vascular dementia
Vascular dementia is the main syndrome in the development of severe atherosclerosis and hypertension (these types of vascular pathology are often combined). Dementia often develops in people who have had a stroke. According to Yu. E. Rakhal'skiy, the incidence of stroke in the history of patients with atherosclerotic dementia is 70.1%.
Vascular dementia as a special qualitative pathological condition is formed as a result of a gradual (or rapid) increase in mnestic disorders, stiffness, rigidity of thinking, and incontinence of affect. In the presence of strokes, the course of the vascular process becomes jerky.
The classic type of vascular dementia is "lacunar",partial dementia, which is characterized by uneven damage to various aspects of the psyche and intellect with an increase in memorization and selective reproduction disorders, a violation of chronological orientation (while there is a relative preservation of allopsychic and autopsychic orientation).
Difficulty and slowdown of all mental processes progresses. Asthenia and a decrease in mental activity, difficulty in verbal communication, difficulty in finding the right words, a decrease in the level of judgments and criticism are observed with a certain preservation of the consciousness of one's own inconsistency and basic personal attitudes (preservation of the "core of the personality").
At the same time, a tearful mood, faintheartedness are almost constant symptoms. This type of dementia develops in atherosclerotic processes manifesting at the age of 50 to 65 years.
In some cases, it can form gradually due to the intensification of psychoorganic disorders that arose in the early stages of the disease. In some patients, the syndrome of lacunar dementia occurs more acutely (postapoplectiform dementia). In such cases, the onset of dementia is preceded by a transient (in the understanding of H. Vick) amnestic, Korsakov-like syndrome.
After an acute disturbance of cerebral circulation (strokes, severe hypertensive crises, subarachnoid hemorrhages), and sometimes after acute vascular psychosis, the onset of amnestic dementia syndrome with severe memory impairments such as fixation amnesia, gross disorientation and confabulations is possible. The picture of such amnestic dementia in some cases is reversible and represents the pictures of "acute dementia" described by H. Weitbrecht.
Alzheimer'stype of vascular dementia (asemic dementia) is characterized by manifestations of focal cortical cerebral disorders, which is associated with a special localization of the vascular process. Similar types of dementia were previously designated as diseases of V.M. Gakkebush, T.A.Geyer, A.I.Geymanovich (1912).
These researchers believed that with such a clinical picture, locally small vessels of the brain are affected (atherosclerosis of the smallest capillaries), an imitation of conditions characteristic of Alzheimer's disease occurs. Later, such cases were described in the works of A. B.
Snezhnevsky (1948), E. Ya. Sternberg (1968) with an indication of the secondary developing phenomena of senile atrophy of the brain. For such patients, a more acute onset is characteristic, as well as the subsequent "flickering" of symptoms (described by G. Shterz). Possible nighttime, observed for several hours,
The pseudo-paralytic type of vascular dementia is characterized by symptoms that outwardly resemble a picture of progressive paralysis. In such patients, there is a combination of dementia with euphoria or an expansive-manic state with a predominance of general carelessness, talkativeness, disinhibition of drives and loss of criticism, a sharp decrease in the level of judgment, memory, and orientation.
The pseudoparalytic type of vascular dementia is more often found in patients of a younger age (up to 65 years) with severe hypertensive encephalopathy or with frontal localization of the focus of softening of the brain.
In severe hypertensive encephalopathy, a rare form of vascular dementia is sometimes encountered with stunned patients, adynamia and decreased motor and speech activity, expressed difficulty in fixing attention, perception and understanding what is happening. Because of the similarity of such symptoms with the pictures developing in brain tumors, these conditions are defined as "pseudotumorous".
Senile-like type of vascular dementia develops with the manifestation of the vascular process in old age (after 70 years). As in cases of senile dementia, the initial stage of this type of vascular dementia is characterized by pronounced personality changes with distrust, discontent, grumbling, irritability, and hostility towards others.
The clinical manifestations picture of dementia is characterized by deeper and more diffuse memory impairments than is expressed in dysminestic dementia. Patients have more pronounced disorientation and signs of a "shift in the situation to the past", there is a deeper decrease in all types of mental activity. This indicates that dementia is more reminiscent of "total dementia", but at the same time it is not as catastrophic as in senile dementia.
Binswanger encephalopathy refers to microangiopathic dementia and is associated with damage to the white matter of the subcortical brain structures (leukoencephalopathy, Binswanger's disease). It was first described by the author in 1894 as a form of vascular dementia with a predominant lesion of the white subcortical substance of the brain.
The vascular nature of the disease was proved by A. Alzheimer after histological examination of the brain. He suggested calling this type of pathology Binswanger's disease (BD). Brain pathology includes diffuse or spotty demyelination of the semioval center with the exception of Y-fibers, as well as astrocytic gliosis, microcysts in the subcortical white and gray matter. Isolated cortical infarctions are observed.
Computed tomography and especially nuclear resonance imaging with visualization of the white subcortical substance and its pathology make it possible to diagnose BB in vivo.leukoariosis , often in combination with lacunar infarctions. It turned out that BB is quite common.
According to clinical computed tomography studies, it accounts for about a third of all cases of vascular dementia (A. B. Medvedev and others). Persistent arterial hypertension is a risk factor.
The picture of dementia has varying degrees of severity with variable symptoms. With the exception of asemic, almost all types of dementia are observed, as with ordinary vascular dementia.
The predominance of signs of subcortical and frontal dysfunction is noted, there may be epileptic seizures. The course is progressive, with periods of stabilization of varying duration. The causes of dementia are considered to be the separation of the cortical-subcortical connections.
Multi- infarction dementia is caused by large or medium-sized multiple infarctions, mainly cortical, which occur as a result of thromboembolism of large vessels. According to clinical computed tomography studies, it accounts for about a third of all cases of vascular dementia.
Vascular Psychosis
Psychopathological manifestations in the form of acute psychosis can occur at any stage of the vascular process, even in a state of dementia. F. Stern (1930) described "arteriosclerotic states of confusion". Such psychosis are characterized by a number of common clinical manifestations properties.
Manifestations of acutevascular psychosis do not always correspond to the most typical pictures of delirium, amentia, twilight state, oneyroid and others, which allows us to reasonably qualify them as states of "confusion" (M. Bleiler, 1966).
Another property of vascular psychosis is that acute psychotic episodes are quite often short-lived, occur sporadically, last no more than several hours. As a rule, such an episode unfolds at night, and during the day, patients can be in a clear consciousness, without psychotic disorders.
A common property of vascular psychosis is also their recurrence, sometimes repeated. This applies primarily to nighttime states of confusion. The course of acute vascular psychosis differs from the course of symptomatic psychosis of a different etiology, such as alcoholic delirium, acute traumatic psychosis.
So, in the dynamics of delirium tremens, the increase in the severity of the disease is most often expressed by the deepening of the delirious syndrome itself (the transition of "professional delirium" to the exaggerating one), and in acute vascular psychosis, various syndromes of altered consciousness can replace each other (after the delirious syndrome, amentive, etc.) .).
In the subacute course of vascular psychosis with a more protracted course, in addition to confusion syndromes, there may be not accompanied by a disorder of consciousness, but also reversible syndromes, which H. Wick called "transitional" or "intermediate".
Compared with symptomatic psychosis, such protracted and more complex forms of the course of vascular psychosis are much more common. E. Ya. (adynamic, apathetic-abulic, euphoric, expansive-confabulatory, amnestic, Korsak-like).
Depressive states occur, taking into account different data, in 5 - 20% of all cases. At the same time, along with the phenomena of melancholy, grumpiness, pronounced tearfulness, hypochondriasis ("tearful depression", "aching depression") are almost constantly observed.
With each new recurring episode of depression, an organic defect with the formation of dementia becomes more and more obvious. Depressive episodes are just as often accompanied by anxiety, unaccountable fear, they often precede an acute disorder of cerebral circulation.
Paranoid (schizoform) psychosis are characterized by acute sensual delirium with ideas of attitude, persecution, poisoning, exposure. Such psychosis are usually short-lived and usually occur in the initial stages of cerebral atherosclerosis with signs of hypertension.
For the later stages of cerebral atherosclerosis, acute hallucinatory-paranoid states are characteristic. Hallucinations in such cases are of a stage nature, visual deceptions (both illusions and hallucinations) often occur.
The most difficult to recognize are protracted endoform psychosis of vascular origin. In addition to constitutional genetic predisposition, special properties of the organic process play an important role in the development of protracted vascular psychosis.
As a rule, protracted endoform psychosis develop in vascular processes that manifest late enough (at the age of 60 - 70 years), proceeding with a slow progression and without gross focal disorders.
Such patients with a picture of delusional psychosis are not characterized by the usual initial asthenic manifestations of the vascular process, more often there is an exacerbation of personal characteristics.
The most clinically justified isolation of protracted paranoid psychosis in men, mainly in the form of delirium of jealousy. It is characterized by a small development of the topic, poorly systematized.
At the same time, the predominance of sexual details with a large nudity of this plot can be considered a distinctive feature. Typical topics in the descriptions of patients are the wife's betrayal with young people, young members of the patient's family, including his son, son-in-law.
Delirium of jealousy is usually combined with ideas of harm (the wife feeds rival lovers better, gives them the patient's favorite things, etc.). A tearful-suppressed mood with outbursts of irritability, malice and aggression. Such organic stigmatization is more pronounced with profound psychoorganic changes.
Chronic verbal hallucinosis in the framework of vascular psychosis is also diagnosed quite often. It manifests itself as a polyvocal (many "voices") true verbal hallucinosis, flows in waves, sometimes at the height of development it becomes stage, usually intensifies in the evening and at night, its content is predominantly threatening.
The intensity of hallucinosis is subject to fluctuations. Its vascular nature is often proved by a parallel recorded increase in blood pressure, an increase in other vascular stigmata (headache, increased tinnitus, dizziness, etc.)
