Acute polymorphic psychotic disorder

This state of the human psyche is characterized by a sharp onset and changeable symptoms - the symptoms of different types of known mental states of different intensity change quickly enough, not allowing to diagnose any of them. Such polymorphism made this psychosis separate into a separate nosological unit. Polymorphic psychotic disorder develops as an acute psychosis in people who have not previously fallen into the field of vision of psychiatrists. It is impossible not to notice it, the abnormality of the patient's behavior strikes everyone's eye - the mechanism of perception, associative thinking is violated, emotional instability is present.

With a preliminary diagnosis: "Acute polymorphic psychotic disorder" is the first time most patients are hospitalized in a psychiatric hospital. The term "psychotic" itself indicates that a person has a severe mental disorder that makes it impossible for him to perform his professional duties and to ensure his personal vital activity and that calls for a doctor and treatment. In addition to the acute onset and severe course for this mental pathology is characterized by short-term and complete cure.

[1], [2], [3], [4], [5], [6]

Causes of the polymorphic psychotic disorder

French psychiatrists called such states delusional outbreaks, Japanese - atypical psychoses, the Soviets attributed them to some types of reactive psychoses, as it has long been noticed that such a state arises as a reaction to a recent acute psychotraumatic situation that occurred no more than two weeks before the demonstration acute psychosis. A prolonged sluggish stress, a long struggle with problems on the everyday front of acute psychotic reactions do not cause.

Risk factors for the occurrence of this rather serious mental disorder may be related to unexpected loss of a loved one, his death or severance of relations with him, a financial collapse, a recent episode of violence, other significant losses for the individual, material and spiritual. Psychotraumatic factors may be triggers that promote the realization of individual personality traits formed under the influence of genotype or pathological intrafamily relationships in early childhood. Often, the causes of transient acute polymorphic disorder of the psyche remain unknown.

At present, there is not enough clarity in understanding the pathogenesis of even the main diseases of the psyche, especially polymorphic disorders. There are many hypotheses that try to explain the mechanisms and conditions for the formation of acute psychoses. The most modern connect the pathogenesis of their development with a violation of the exchange of the main neurotransmitters of the nervous system (serotonin, dopamine, norepinephrine), which carry out transmission of nerve impulses in various instances of the cortex of the brain.

World Medical Statistics estimates the proportion of acute polymorphic psychotic disorders in 4% of cases of all psychoses that have an inorganic origin (including affective). Female patients with this final diagnosis are approximately four times more likely than males. The age of most patients is in the range of 30 to 50 years. As already mentioned, an acute polymorphic psychotic disorder is diagnosed during primary hospitalization most often, however, this diagnosis is not always confirmed. If the remission does not occur within three months, it is reconsidered without fail.

[7], [8], [9], [10], [11], [12], [13], [14], [15]

Symptoms of the polymorphic psychotic disorder

The first signs are noted by others as a noticeable and significant violation of normal behavior. Symptoms grow very fast, literally every day behavioral anomalies become more pronounced: unstable mood - changing very quickly, sometimes several times during the day, the patient's speech becomes meaningless, there is an intermittent versatile delirium, different kinds of hallucinations - the patient feels touches and smells, hears sounds and voices. The productive symptomatology of the disorder is polymorphic and resembles at the same time schizoaffective or delusional disorder, paranoid psychosis, manic and depressive episodes, schizophrenia, but in general does not meet their symptomatic criteria.

The patient does not have a pronounced temporal and spatial disorientation, self-identification is practically preserved. The patient is often confused, his attention is reduced, other symptoms of partially darkened consciousness appear, however, not as severe as in organic brain diseases, there is no symptomatology on them. Also, psychosis can not be directly related to the use of psychoactive substances, it is not caused by intoxication or withdrawal syndrome.

The types of polymorphic psychotic disorder identified in the latest disease classifier (ICD-10) are mainly differentiated on the basis of the presence or absence of schizophrenic manifestations, since this group of mental disorders is very heterogeneous in structure and can not be combined on another basis.

There are the following types:

• acute polymorphic psychotic disorder without symptoms of schizophrenia - the symptomatology is as described above, the types of delirium and hallucinations do not correspond to schizophrenic, violent manifestations of ecstasy reaching ecstasy are replaced by depression and apathy, polymorphism and emotional instability are very expressive (when the symptoms are stable and long-term, interpret them It is necessary as a manifestation of acute delusional disorder or cycloid psychosis);
• acute polymorphic psychotic disorder with symptoms of schizophrenia - along with the symptoms described above, there are signs of schizophrenic delirium - harassment, exposure (for example, by force fields), exaltation or the presence of a serious illness, forms of delusion are constantly changing; auditory hallucinations - the patient hears voices that order him to do something, reproach him, threaten, condemn, notice the paralogical reasoning, symbolism and discontinuity of thinking, pseudo-hallucinations and a symptom of openness of thoughts are possible; anxiety and fear prevail in the emotional sphere, but emotional-volitional negative pathologies are absent, the excitation is expressed by irritability, motor activity (when the symptoms are stable and long-term, they need to be interpreted as a manifestation of acute delusional disorder or cycloid psychosis, but with symptoms of schizophrenia);
• acute schizophreniform psychotic disorder - against the background of all the same manifestations the productive symptoms of schizophrenia prevail, if they do not pass within a month - the diagnosis is changed to schizophrenia;
• the remaining types of transient disorders are much less common, differ in some specific psychiatric symptoms, and predominantly belong to delusional and paranoid species.

Acute polymorphic psychotic disorder can be treated in any case, the symptoms are quickly stopped by medication. Rapid development, quite severe course and short duration (sometimes regression occurs after a few days) are also signs that the patient has polymorphic personality disorder, rather than the manifestation of another more serious progredient mental illness.

Complications and consequences

The greatest danger of this condition is that it can be a manifestation of a mental illness, in particular - schizophrenia, for this development of events indicates the stability of the symptomatology and its presence for more than three months. The sooner the therapy begins, the more favorable will be its prognosis.

Acute polymorphic psychotic disorder is completely curable, goes without complications, consequences and is considered a one-time episode. But in a period of acute illness the patient is socially maladjusted, can be dangerous to himself and others, requires protection and care.

[16], [17], [18], [19], [20], [21], [22], [23], [24]

Diagnostics of the polymorphic psychotic disorder

The doctor makes a preliminary diagnosis, after listening to complaints of the patient or his relatives, according to the description of the symptoms, the speed of development of psychosis (the interval from the appearance of the first symptoms to the development of the full picture should not exceed two weeks). The diagnostic message about a traumatic event that occurred in the recent past (up to two weeks) has diagnostic significance.

With the help of special techniques, an experimental psychological examination is conducted to identify violations of the processes of higher nervous activity.

General diagnostic studies that give an idea of the state of the patient's body - blood and urine tests, the biochemical composition of the blood can be normal, deviations from the norm speak, rather, about the presence of concomitant diseases. Consultation of the therapist, neurologist and other specialists may be prescribed.

Instrumental diagnosis usually does not show significant abnormalities and is assigned for differentiation in order to exclude similar in clinical course diseases.

Tomography, computer or magnetic resonance, allows you to exclude current organic pathologies, electroencephalography is prescribed in convulsive seizures, echoencephalography - the presence of darkened consciousness, electrocardiography is used to control the reaction of the body to drug treatment.

[25], [26], [27], [28]

Differential diagnosis

Differential diagnosis is carried out with psychoses of organic origin, schizoaffective disorder and manifestation of schizophrenia, delirious states due to the syndrome of poisoning or withdrawal of psychoactive substances.

The main diagnostic marker is the length of the period of clinical symptoms. If pathological symptoms were observed not more than one month and resulted in recovery, the diagnosis of polymorphic psychotic disorder is fully confirmed. In the presence of clinical symptoms in the time interval from month to three, the diagnosis is already considered doubtful, however, it can still be confirmed. A longer course of the disease requires a revision of the diagnosis.

[29], [30], [31], [32]

Treatment of the polymorphic psychotic disorder

Acute polymorphic psychotic disorder has a short, but severe course. After the examination and diagnosis the patient can leave the house if the symptomatology of the disorder is not threatening and the relatives can provide the patient with proper care, timely medication and support to control the treatment.

In most cases, patients are hospitalized in a psychiatric hospital. The criteria for hospitalization for polymorphic disorder, which are voluntary, include the antisocial behavior of a patient whose manifestations are not amenable to docking in outpatient care. The second variant of voluntary hospitalization is carried out if there is a need for constant monitoring to submit the materials to the expert commissions for determining the patient's capacity for work.

In the presence of psychopathological actions of the patient, which are dangerous for others or for himself, he is forced to be placed in a psychiatric hospital. Also, if it is necessary to provide permanent psychiatric medical assistance in order to prevent worsening of the symptoms, the patient's disorder is hospitalized without his consent. If the patient is in a helpless state, and there is no one to ensure proper care, the patient's consent to hospitalization is not required.

In cases where the patient has already committed an unlawful act, he may be placed in a psychiatric hospital by a court decision.

To stop the symptoms of acute polymorphic psychotic disorder, a standard treatment protocol is used. The main drugs that are used to eliminate productive manifestations of psychosis are neuroleptics. Currently, the drugs of choice are atypical neuroleptics, which have a more favorable safety profile than typical ones. Their effectiveness is approximately equivalent, so the choice of the drug is carried out for reasons of the best tolerability of the patient (allergic reactions, concomitant diseases, possible resistance). Also, the choice of a medicament is influenced by the structure of the most pronounced syndrome, the presence of pathological prerequisites (hereditary predisposition, stress, somato-neurological diseases).

Acute psychosis with primary productive schizophreniform symptoms can be stopped with Amisulpride. Atypical neuroleptic of the new generation has the ability to have antipsychotic effects - reduces the severity of delirium and hallucinations, as well as - depression and inhibition. Has a sedative effect. Side effects are noted, mainly, with high-dose long-term use. Epileptic seizures, sleep disorders, sexual disorders, weight gain and other side effects may develop. Potentiates the effect of drugs that depress the central nervous system. It is not compatible with alcohol and levodopa.

Risperidone is used to stop the productive symptoms (delusions, hallucinations) of different structures. The agonist of serotonin and dopamine receptors reduces irritability, causes suppression of abnormal motor activity. Contraindicated in patients with epilepsy and Parkinson's disease. Extrapyramidal disorders this drug causes more often than other representatives of this group. Also as side effects, negative symptoms of schizophrenia may occur. Hyperprolactinemia is often observed, so the drug, like the previous one, is contraindicated in breast cancer.

In cases of predominance of the state of psychomotor agitation, a typical neuroleptic, Aminazine, may be prescribed. It has a diverse and complex dose-dependent effect on the central and peripheral nervous system. The increase in the dose causes an increase in sedation, the musculature of the patient's body relaxes and motor activity decreases - the patient's condition approaches the normal physiological state of sleep, which differs from the narcotic in that it is devoid of side effects of anesthesia-deafness and ease of awakening. Therefore, this drug is the drug of choice for arresting the states of motor and speech excitement, anger, rage, unmotivated aggression in combination with hallucinations and delirium, especially during the stage of first aid.

All antipsychotics have a direct effect on the occurrence and conduct of nerve impulses that transmit excitation in different parts of both the central and autonomic nervous system. Under their influence, metabolic processes in the brain tissues slow down, especially in the neurons of its cortex. Therefore, the neuroplegic effects of the drug are associated with cortical activities. Drugs of this group extinguish virtually all types of psychomotor agitation, relieve hallucinatory and delusional symptoms, however, are not hypnotics. A patient who is under the influence of a drug in this group is able to respond adequately and answer questions.

Can be used alone or in combination with anxiolytics and other psychotropic drugs. Absolute contraindications to the use of antipsychotics are severe system pathologies of the brain and spinal cord, dysfunction of the liver and kidneys, hematopoietic organs, myxedema, propensity to thromboembolism, decompensated heart disease.

Used in the treatment of patients of any age, dosed individually, according to age norms and severity of the condition. Oral reception is possible, and also - parenteral (usually in a hospital).

After the use of neuroleptics, especially in the injectable form, it is possible to drop blood pressure, so the patient is recommended to lie down for several hours and take a vertical position without sudden movements. In addition, other side effects are possible - allergies, dyspepsia, neuroleptic syndrome.

Antipsychotic therapy is performed according to general principles. Oral administration of one drug is recommended for a minimum duration of ten days to two weeks. Then the effect of treatment is evaluated. The condition can already be stopped, however, with resistance to treatment, two atypical antipsychotics are assigned simultaneously. Select drugs are different in chemical structure.

Ten days later, in the absence of effect, more powerful typical antipsychotics begin treatment. Do not prescribe a parallel intake of more than two drugs of this group, and even two - the same chemical structure.

Corrective treatment is recommended to begin only after the development of side effects. For example, when manifesting extrapyramidal disorders - tremors in the limbs, numbness, dyskinesias appoint Cyclodol (triexyphenidyl). The drug has a powerful central and peripheral holinoliticheskoe effect, eliminates motor disorders, hypersalivation (until dry mouth), hyperhidrosis. As a result of taking Cyclodol, the pulse increases, the intraocular pressure rises, delusions and hallucinations can return.

The treatment regimen may include drugs for the elimination of concomitant mental pathology:

• normotimiki (finlepsin, lamotrigine) - to stabilize biorhythms, normalize the emotional background, and at the same time and arrest epileptic seizures (side effect of antipsychotics);
• anxiolytics (phenazepam, diazepam) - for relief of symptoms of anxiety, fear;
• antidepressants - preference is given to selective serotonin reuptake inhibitors (fluoxetine, sertraline), with their inefficiency, tricyclic antidepressants (amitriptyline) can be prescribed.

The treatment regimen is supplemented with drugs that favorably affect the brain - prescribe nootropics and B vitamins, as well as liver (hepatoprotectors).

After relief of acute symptoms, the patient is given a course of psychotherapeutic treatment. It is possible to stay sick in a day hospital.

Neuroleptic therapy is continued after discharge, gradually reducing their dose or replacing the drugs with prolonged action. Discontinue treatment only with the permission of the doctor.

Prevention

Preliminary prophylaxis of acute polymorphic psychotic disorder is not carried out, because it is impossible to predict it. However, recommendations regarding a healthy lifestyle, nutrition, physical activity, positive thinking are relevant in this case. They are the key to increasing stress resistance.

Preventive maintenance of relapse can become employment auto-training, yoga, in psychotherapeutic groups. Homeopathic treatment and phytotherapy also help to avoid the development of repeated acute psychosis.

[33], [34]

Forecast

Polymorphic psychotic disorder, both with symptoms of schizophrenia, and without them, can be cured before complete recovery. This statement concerns the final diagnosis. If such a medical report was preliminary, then the prognosis depends on the disease that manifested under the guise of this psychosis.