Perseveration

Mental perseveration consists in multiple repetitions of the same actions, phrases, etc. Such repetitions reflect a kind of "hook" inside the consciousness of certain thoughts or active segments that continue to exist beyond the present time, do not depend on the direction of activity and continue their activity in the human mind. Pathological perseveration is often observed in patients with organic brain lesions, cerebral atherosclerosis, schizophrenia, senile dementia, Alzheimer's disease, and Pick's disease. [1], [2]

However, a similar problem is typical not only for psychiatry, but also for other medical areas - in particular, speech therapy and neuropsychology.

Epidemiology

There are no special statistics on the occurrence of perseverations. Presumably, the incidence of the disorder varies from 11 to 65 cases per hundred thousand of the population.

Perseverations are predominantly found in childhood and old age, in women a little more often than in men. The risk of occurrence of such disorders increases after 50 years, and the peak of the incidence occurs in old and senile age (after 65 years).

The vast majority of perseverations are idiopathic (the cause remains unclear). Only in 10-30% of cases it is possible to detect the predisposing factors for the development of pathology: craniocerebral trauma, neurosis, dementia, etc. [3]

Causes of the perseverations

The main reason for perseverations is the loss of the ability to "switch" the brain between separate processes or actions, according to the principle of priority. The disorder may be associated with a functional failure of brain activity - for example, due to a stressful situation, overwork, the formation of the nervous system, neurotic pathologies. Stable and gross violations are noted against the background of organic brain damage, especially if the subcortical structures, tertiary cortical zones, premotor and prefrontal cortex are damaged. In general, causes can be categorized into three categories of factors, including physiology, psychopathology, and neurology. [4]

Many people, depending on a particular life period, are prone to the appearance of perseverations. Such a violation can manifest itself with a reduced control function, in the absence of a clear scheme of activity, which can be caused by emotional and physical overwork, prolonged stress, general fatigue and "burnout". Such perseverations are characterized by inconstancy, their course is easy. They are expressed mainly by mental disorders, emotional manifestations, and much less often by changes in motor skills. [5]

Obvious organic brain lesions are becoming more common causes of the disorder. So, perseveration of movements appears with a disorder in the anterior sections of the cerebral hemispheres. If the problem affects the premotor sites and the underlying subcortical structures, then elementary motor perseveration develops, which is accompanied by multiple repeated programmed actions. With the defeat of the lower zones of the premotor areas of the cortex of the left hemisphere, speech perseverations are noted. 

Disturbances from mental activity occur against the background of damage to the frontal lobes of the cerebral cortex: pathology is accompanied by a deterioration in the control of intelligence functions, improper planning of actions. Sensitive changes are caused by organic damage to the cortical analytic zones - that is, areas of information processing of data received from the sense organs. [6]

Psychiatrists consider perseveration as a sign of poor adaptation of mental acts or emotional-volitional activity. The disorder is typical for people with inert personality traits - for example, perseverations are often found in people with  excellent student syndrome . 

We must not forget that perseverative episodes can also occur with excessive fatigue, prolonged lack of sleep, as well as in persons under the influence of alcohol. In such situations, violations are always episodic, transient, short-term. [7]

Risk factors

Factors that can influence the development of perseverations can be as follows:

• Inert processes in the nervous system. In some patients, inhibition of the switching of processes in the brain is noted, which is explained by physiological characteristics. Such people find it difficult to move from one task to another, they slowly adapt to circumstances and tend to develop mild forms of perseveration - for example, their thoughts seem to "get stuck" in the process of communication.
• Excessive fatigue. If a person is physically or morally exhausted, then he has a violation of the cerebral processes of inhibition and excitement, and the moment of completion of a certain action is delayed. It is for these reasons that, against the background of severe fatigue, it is much easier to maintain monotony of actions than to switch to other tasks.
• Immature nervous system. In childhood, due to physiological characteristics, the excitation process dominates and remains active even after the end of the irritating factor. The child's reaction may be accompanied by repetitive movements or exclamations.
• Atherosclerotic processes. With cerebral atherosclerosis, cholesterol plaques are deposited in the vessels, which narrows the arterial lumen, disrupts blood circulation, and prevents the nutrition of brain cells. In this situation, perseverations are most often manifested by speech disorders.
• Senile dementia, Parkinson's disease and other dementia. Diseases that are accompanied by atrophic processes occurring in the cortex of the frontotemporal and frontal cerebral regions and subcortical structures lead to gross intellectual disorders, speech perseverations, and praxis. [8]
• Head trauma, TBI. Perseverations are noted after brain injury, especially with damage to the lateral orbitofrontal regions, prefrontal cortical bulge. The patient has involuntary repetitions of phrases or individual words, but effective repetitions are found more often in the form of long-term consequences.
• Cerebral circulation disorders. A stroke often leads to all sorts of neurological disorders: patients lose sensitivity and active motor skills, speech, breathing is impaired, and swallowing is difficult. Problems with speech selection are possible, control over what is said is lost.
• Tumor processes in the brain. In cerebral oncologies affecting the frontal lobes, basal regions, subcortical motor nodes, changes in target behavior, understanding of actions, and active selectivity are often observed. Motor or motor-speech perseverations are often noted.
• Autism. In patients with autism, there is a change in sensitive functionality, inhibition of motor and mental reactions, and behavioral stereotypes. Perseverations in patients are manifested by repeated phrases and actions devoid of any meaning, as well as targeted obsessive-compulsive disorder.
• Obsessive-compulsive disorder. Obsessive-compulsive disorders are manifested by obsessive thoughts and actions. Repetitive involuntary motor acts are noted, accompanied by obsessions, images, representations.
• Schizophrenia and mental retardation. If the processes of redirection and arousal do not work properly, inertia appears in patients, the formation of conditioned reflex communication becomes more complicated. In patients with schizophrenia, ideological unification, attempts to fill in the gaps with outdated ideas, and automation of speech and mental activity are noted. In particular, against the background of catatonia, there are repetitions of words and phrases, incoherence of speech.

Pathogenesis

Neurological origin is most common among perseverations. It is characterized by a wide range of atypical human behavior, which is associated with damage to the cerebral hemispheres. This is what determines the impaired function of transition from one action to another, a change in the direction of thoughts and the sequence of actions: the perseverative component occupies a dominant step over mental activity and objective position.

Perseveration in neuropsychology is, most often, a consequence of craniocerebral trauma, aphasia (after tumor and inflammatory processes, trauma), and local diseases with damage to the frontal lobes of the cerebral cortex.

Perseveration in psychology and psychiatry is pathological psychological signs by the type of cyclical reproduction of motor actions, perseverating associations, speech repetitions. Pathology reflects a consequence of psychological dysfunctional states and most often acts as an additional sign and component of multi-component syndromes and phobic disorders. [9]

The appearance of perseverations in a patient without previous craniocerebral trauma or deep stressful influences can indicate the presence of both psychological and mental problems.

The basic pathogenetic factors for the development of a disorder are most often as follows:

• the typicality of selectivity and obsession with interests, which is most often found in patients with a tendency to autism;
• a feeling of attention deficit combined with hyperactivity, which stimulates the appearance of perseverations by the type of a protective reaction aimed at attracting attention to oneself;
• excessive stubborn desire for learning, the presence of additional abilities can lead to a person's fixation on any activity;
• signs of obsessive-compulsive disorder can coexist with perseverative disorders.

If a person is obsessed with an idea, this can cause him to perform certain actions completely unconsciously. A striking example is obsessive-compulsive disorders, in particular, obsessive hand washing, constant medication supposedly for prophylaxis, etc. In this situation, it is very important to differentiate perseveration from other pathologies, regardless of the etiology of the disease. [10]

Physiological causes of the problem:

• functional disorder of the cerebral cortex in the area of the frontal lobes;
• head trauma in the area of the prefrontal bulge;
• growing aphasia.

Psychological factors in the appearance of the problem:

• prolonged stress;
• phobic conditions;
• autism;
• acute hyperactivity.

Verbal perseverations often arise among scientific specialists who have been studying any one and the same issue for a long time. In difficult cases, the disorder can worsen up to the appearance of obsessive-compulsive disorder, in the form of obsessive adherence to one idea.

Symptoms of the perseverations

If the perseverations are caused by any disease, then the patient will have the corresponding symptoms of this disease. Next, we will consider the signs typical of some pathologies accompanied by perseverations.

With cerebral hemorrhage, impaired cerebral circulation, a person may experience dizziness, weakness, speech impairment, and notice a loss of muscle sensitivity. Motor coordination is impaired, vision deteriorates.

With neuroses, mood swings, loss of orientation, pain in the head are possible.

Such a dangerous source of perseverations as a tumor process in the brain is characterized by a gradual increase in paroxysmal dizziness, severe pain in the head, the development of one-sided blindness or deafness, and general exhaustion of the body.

Traumatic brain injuries can be characterized by general weakness, nausea, headache, visual and hearing impairments, and vestibular disorders.

In autism, there is a lack of emotional contact (including with parents), there are difficulties with socialization, and a weak interest in games. Attacks of hysterics and aggression are possible.

With schizophrenia, patients experience delusional states, hallucinations.

Obsessive-compulsive thoughts, phobias, and compulsions are characteristic of obsessive-compulsive disorder. The first signs of a violation are manifested as follows: a person loses self-confidence, constantly doubts his own actions and deeds. Many patients have inadequate perfectionism: such people tend to hang clothes according to colors and at the same level, arrange pots with handles in one direction, lay out socks according to color, etc. This is not about the usual desire for order: the patient experiences "outrageous" discomfort from the imaginary "disorder" and may try to correct the "violated" even at a party.

Perseveration in a child

Perseverations often appear precisely in childhood, which is due to the peculiarities of the psychology, physiology of children, as well as active transformations of life priorities in different periods of growing up. It is sometimes quite difficult for specialists to distinguish true perseverative signs from intentional ones, as well as from those that indicate the presence of more complex psychopathologies. [11]

Parents play an important role in identifying pathologies in children: they are advised to carefully observe the child, to record any manifestations of perseveration - for example, such:

• periodic repetitions of the same phrases, regardless of the circumstances and the questions posed, as well as the perseveration of words;
• regular repetitions of certain actions - for example, touching a place on the body, tapping, etc.;
• reproduction of identical objects (images, phrases, questions, etc.);
• repetitions of requests that are not suitable for specific situations.

It is important to distinguish pathological disturbances from play activities and normal childhood habits. It is imperative that you talk to your child unobtrusively and calmly, and, if necessary, consult a specialist. [12]

Forms

Depending on the manifestations of perseverations, doctors distinguish motor and mental (intellectual) types of disorders. [13]

Motor perseverations are a constant repetition of the same movement, or a whole bunch of repetitive movements. Such actions have a certain algorithm that remains unchanged for a long time. For example, with vain attempts to turn on the TV, a person begins to bang on it with his fist. Such an action does not lead to anything, but, realizing this, a person repeats it over and over again. Children may have another manifestation: the child is purposefully looking for a toy where it cannot be.

Intellectual perseverations reveal themselves to be abnormal "getting stuck" of ideas, statements, and conclusions. They are manifested by the constant repetition of words or phrases. Such a pathology is relatively easy to detect: the doctor asks a series of questions, and the person answers everything using the very first answer. Mild forms of disorder also occur, in which the patient regularly tries to discuss a long-decided issue or topic of conversation.

Motor perseverations

The types of motor perseverations are subdivided according to the following principle:

• elementary perseverations consist in the repetition of any one action;
• systemic perseverations involve the repetition of a whole complex of actions by a person.

Speech perseverative violation, which is manifested by the reproduction of the same word (phrase), both oral and written, is placed in a separate category.

In general, motor, they are also motor perseverations, are caused by damage to the motor brain regions. Patients have multiple repetitions of elements of any movement or action.

Perseveration of thinking

This type of violation is characterized by "jamming" in the human mind of a certain thought or any idea, often manifested in the process of verbal communication. With the same word or phrase, the patient can answer almost any request or question, even not related to each other. It is possible to pronounce certain words aloud without any direction (talking to oneself). One of the characteristic features of mental perseverations: a person constantly tries to return to a long-closed conversational topic, speaks about issues that are no longer relevant. The second name for mental perseverations is intellectual.

Paraphasia and perseveration

Paraphasia is a speech disorder when the correct words or letters are replaced by others, inappropriate and incomprehensible for a particular moment. A person suffering from paraphasia speaks unnaturally, his speech is incorrect, often contains non-existent words. In addition, speech can not only be distorted, but also speed up or slow down, which makes it even more difficult to understand from the outside. Violation is often accompanied by the fusion of words, their incorrect use and confusion, perseverations. The main causes of pathology are head injuries, circulatory disorders in the brain, severe infections with cerebral complications, thromboembolism, tumor and cystic processes of the brain, aneurysm opening. The pathology treatment strategy is individual.

Perseveration in aphasia

Perseverations are also characteristic of amnestic  aphasia . The patient names the first object shown to him, after which he calls all other objects in the same terms. For example, at the sight of a teapot, a patient may say: "This is for water, for boiling, so that you can drink later." After that, he is shown scissors, and he says: "This is a teapot to cut, I had one."

It is noteworthy that the patients themselves do not notice perseverations in themselves, if the analyzer of speech perception is simultaneously affected, which happens with sensory-motor aphasia.

Within the limits of aphasia syndrome, perseverations act as a kind of structural element, therefore they persist for a long time, even with the disappearance of basic aphatic signs. Violations are also noted against the background of non-focal organic cerebral pathologies - for example, in patients with cerebral atherosclerosis,  oligophrenia .

Perseverate letters or words

Perseverations in writing or oral represent the reproduction of the letter or syllable just written or said instead of the following necessary. Example:  behind the knot  - instead of  around the corner; oily  - instead of  animals. [14]

A specific distortion of the phonetic composition of words can appear in both oral and written speech, and bears the character of progressive and regressive assisillation.

Perseveration of syllables or letters is one of the variants of motor perseverative disorders, since it consists in reproducing physical activity - for example, writing words. [15]

But perseveration in speech therapy is a persistent letter confusion that reduces the overall quality of speech. The child has a kind of "stuck" letters - more often consonants, by the type of replacement in a word. Examples of speech therapy perceptual symptoms:

• in one word or phrase: "dodoga" instead of "road", "under the post" instead of "under the bridge", etc.;
• against the background of weakened differentiation inhibition: "played" played, "told" said, "rich budi" rich people.

It is possible that contamination can also be recorded at the same time - mixing of syllables and parts of words - for example, "dogazin" combining a  house + a store.

Like contamination, perseveration refers to frequent violations of the syllabic structure in childhood. [16]

Perseveration and verbigeration

The term perseveration takes its origin from the Latin word  persever tio, meaning  perseverance, perseverance. In the speech process, the symptom manifests itself in the form of repeated reproduction of the same sounds, words, phrases.

The patient's consciousness is, as it were, "inhibited" by one word or thought, which leads to their repeated and monotonous repetition. At the same time, repetitions usually have nothing to do with the topic of the conversation or with the situation. A similar violation can manifest itself in writing, as it is a consequence of the association of activities. It cannot be compared with obsessive phenomena, since such include an element of obsession, and the person himself consciously perceives the incorrectness of his actions. [17]

Along with perseverations, verbigerations are often found in schizophrenia. We are talking about mental problems, in which the patient resoundingly and monotonously repeats the same syllables, words, phrases. But such repetitions are automatic, devoid of content, and can last for several hours or even days.

The patient, with a certain rhythm, and sometimes in rhyme, pronounces sound combinations or words that are completely devoid of meaning. It is important to distinguish verbigeration from perseverative manifestations, since in the last episodes of repetitions are associated with the neuropsychic state of a person and are eliminated with the normalization of this state.

A feature of verbigeration is that a person repeats interjections and sounds without signs of affect. Pronunciation is usually accompanied by active mimicry and motor disorders. In most cases, the problem occurs in patients with dementia and catatonic schizophrenia. [18]

Perseveration and situational behavior

In the course of growing up, a child is necessarily faced with a fact that plays an important role in the development of his mental activity. Observing the world around him, he notices the regularity of certain phenomena: for example, if mom takes shoes out of the closet, then there will be a walk, and if she puts the plates on the table, then a meal follows. Children do not immediately realize this or that connection between phenomena: at first, they emphasize the usual chain of consequences. The onset of one event entails the expectation of the next. This sequence does not always indicate the interdependence of phenomena, but gives rise to the practical experience of the baby, who begins to observe the changes taking place in his own and in the environment.

It is important to understand that we are not talking about automatic repetitions of the same events in the same sequence, but about the changes that take place in the child's environment as a result of any actions.

If the usual sequence is violated, then it attracts the child's attention, causes misunderstanding, gives rise to the need for clarification. How should children feel in such a situation? This is a feeling of surprise, curiosity, incomprehensibility. If the violation of the usual order is perceived by the child painfully (the baby constantly returns everything to its place, despite the explanations of adults), then one should think about the presence of certain perseverative problems.

Perseverations and stereotypes

Stereotypes mean the tendency to repeat the same actions. Possible stereotypical repetition of individual words, or stereotypical thinking (looping).

Stereotyping processes also differ in the degree of automation. For example, verbigeration - stereotypical manifestations in the colloquial speech of patients with schizophrenia - are characterized by meaningless, automated, unconscious repetition of the same words or phrases. Motor or hallucinatory stereotypes are also considered automatic. Hallucinations often appear against a background of insufficiently clear consciousness - for example, in acute poisoning or infections. Mental stereotypes are more arbitrary, but in this situation, the leading role belongs to states of mental automatism.

Stereotypes are not perseverations. With perseverations, an already completed action, in whole or in part, falls into the next action, into a new task that is completely unrelated to the previous one. For stereotypes, the loss of the meaning of activity (mental, motor, speech) is characteristic, without connection with the solution of any problem. The ability to capture the relationship of stereotypical turns (mental or speech) is lost.

Stereotypes are of a long-term nature, without changing under the influence of a change in activity. Perseverations, on the other hand, depend on the degree of complexity of the subsequent task, they manifest themselves more easily, they have in common with the previous activity. Unlike stereotypes, the patient tries to counteract perseverations.

Stereotypes are not unique to schizophrenia. They are also diagnosed with organic psychosis.

Perseveration and anticipation

Some speech disorders are considered phonological, or those that relate to the sound linguistic structure. The most common phonological disorders are perseveration and anticipation (anticipation).

During perseverations, sounds from the first word fall into subsequent words - for example, “snowy suzhnob” instead of “snowdrift”, “bolova hurts” instead of “headache”.

If we talk about anticipations, then we are talking about the processes opposite to perseverations. For example, a person mistakenly names a sound from any subsequent word:

• the sun is shining on itself (instead of "in the sky");
• I will erase the series (instead of "watch the series").

In the perseverative version, it can be assumed that the person was simply confused and accidentally uttered a sound from the previous word, although this is not so.

Echopraxia and perseveration

Echopraxia, echokinesia or echokinesis is the so-called echo symptom, in which there is an involuntary repetition or imitation of any motor acts, gestures, body positions, etc. For most cases of echopraxia, repetitions of relatively simple movements performed in front of a person are characteristic. This can be applause, squinting your eyes, or waving your hands. The defeat of the convexital prefrontal cortex in front of the premotor zones is accompanied by prefrontal apraxia with echopraxic symptoms.

These symptoms are usually referred to as tic disorders. These are observed in autism,  Tourette's syndrome , schizophrenia (mainly of the catatonic type), with phenylpyruvic oligophrenia,  Pick's disease , clinical depression and other neuropathologies. The catatonic type of schizophrenia, in addition to echopraxia, can be accompanied by  echolalia  (speech repetitions for others) and echo (mimic repetitions for others). [19]

Behavioral Perseveration

Experts call perseverations behavioral disorders, while repetitions can relate to almost any actions, phrases, movements, questions, requests, etc. Does not switch to the next, but repeats, which does not allow achieving the original goal.

The tendency to perseverative acts is used at different stages of socialization of children suffering from efferent motor alalia and autism - pathologies with multilevel dysfunctions of the frontal cortex. The competent application of this trend helps to effectively consolidate relationships in childhood. Thus, in some cases, behavioral perseverations can act not as a pathological obstacle, but also as an ally in corrective work. [20]

Oculomotor perseverations

They say about oculomotor perseverations when a person has a "looping" gaze on a previous subject. It is not always possible to immediately answer the question of the pathological origin of such a symptom, however, in many patients, mental and cognitive disorders may precede movement disorders.

To make a diagnosis, it is recommended:

• assess whether a person has possible cognitive impairments;
• assess the presence of mental disorders;
• will clarify information about the stability of the nervous system, about the absence of neurological and systemic diseases.

Cognitive impairment is assessed using specific neuropsychological tests. Mental disorders are most often manifested by anxiety and / or depression. In addition, patients may experience irritability, mood instability, apathy, aggression, mental and / or motor perseverations, obsessive-compulsive disorders, less often psychoses. The final diagnosis is established based on the data of diagnostic studies.

Perseveration in schizophrenia

It is quite common to observe perseveration in patients with  schizophrenia . Such violations cover a wide range of speech manifestations. In this case, perseverations in speech can be individual sounds and words, fragments of phrases, full speech turns. Many experts associate the occurrence of perseverations in schizophrenics with a depletion of ideas and a tendency to fill the formed mental gaps with previous ideas. In the pathogenetic aspect, an important role is played by the strengthening of the automation of intellectual-speech activity.

Schizophrenic disorders in general are accompanied by disorders of thinking and perception, inadequate or decreased affect. In most cases, patients remain clear and mentally alert, although certain cognitive problems may develop over the years.

In schizophrenia, fundamental functions are affected that give normal people a sense of their own individuality, purposefulness. Auditory hallucinations, explanatory delusions, and impaired perception of colors or sounds are often noted. Thinking becomes indistinct, indistinct and discontinuous, and speech becomes incomprehensible. Catatonic disturbances are possible. [21]

Complications and consequences

The appearance of complications of perseverations can be associated with the development of the underlying disease or with the addition of mental or other disorders.

For example, if perseverative states do not undergo or can not be corrected for a long time, then the patient may develop depressive disorders, anxiety pathologies, and even suicidal thoughts. This is due to many reasons:

• the inability to independently get rid of perseverations;
• feeling of own inferiority, self-doubt;
• condemnation from loved ones, friends, etc.

In addition, often we are talking about cases of abuse of sedatives, tranquilizers, psychotropic substances, alcoholic beverages, which has an extremely negative effect on the results of treatment and on the mental state of the patient. With pronounced obsessive states, tumor processes, dementia, the quality of life of people suffers noticeably. Normal social function deteriorates, working capacity decreases, communicative qualities are impaired. 

But it is important to note that in all cases, a clear and deep differential diagnosis is required with various mental disorders, systemic diseases, intoxications, etc. Difficulty with self-realization, as they experience active pressure, misunderstanding and opposition from close people.

With the sudden development of such violations, other motives are likely to appear, including acts of self-harm, aggression, etc.

Diagnostics of the perseverations

On the eve of diagnostic measures, the doctor conducts a conversation with the patient, his parents or relatives. [22] The following questions are clarified:

• hereditary cases of pathologies, including mental ones;
• the age at which the first signs of violations appeared;
• quality of social function;
• accompanying symptoms and diseases, adverse factors;
• features of the patient's behavior at the time of examination and conversation, orientation in place, in time, etc.;
• somatic and neurological condition.

An assessment of the mental and neurological state of a person is carried out by questioning and collecting anamnesis, both from himself and from his loved ones. Complaints are collected, motor function, mimic reactions, viscero-vegetative disorders are visually examined. [23]Externally, the level of perseverance, anxiety, muscle tension of the patient is assessed. The presence of fatigue, weakness, fussiness, irritability, sleep disturbances must be found out. Among vegetative changes, attention is drawn to rapid heartbeat, tremors in the fingers and limbs, increased sweating, nausea, urinary and digestive disorders. [24]

For physical examination, it is possible to involve a therapist or pediatrician, psychiatrist, neuropathologist. During a neurological examination, the following is determined:

• disruption of the cranial nerves;
• the presence and change of reflexes, the presence of voluntary movements;
• extrapyramidal disorders (hypokinesis, hyperkinesis, myoclonus);
• violations of motor coordination and sensitivity;
• functional disorders of the autonomic nervous system.

Additional diagnostics include:

• Clinical and biochemical blood tests (including the level of glucose, ALT, AST, alkaline phosphatase), thymol test.
• Wasserman reaction, blood test for HIV.
• Clinical analysis of urine.
• Electrocardiogram.
• If necessary: bacterial analysis, nasal and pharyngeal swabs.

If it is necessary to exclude the organic pathology of the central nervous system, then instrumental diagnostics are carried out:

• electroencephalography;
• Magnetic resonance imaging;
• CT scan.

A common procedure for electroencephalography helps to detect an epileptic tendency, as well as assess the degree of maturity and functional activity of the brain. [25]

Differential diagnosis

Regardless of the etiological origin of perseverations, they must be distinguished from such pathologies and conditions:

• obsessive-compulsive disorder ;
• ordinary human habits;
• sclerotic memory impairment.

Very often you can observe when a person (especially an elderly person) tends to repeat the same phrases, words or actions just because of poor memory or impaired concentration.

It is important to notice when the patient has symptoms such as obsessive thoughts and compulsive actions. Such obsessions are perceived by the patients themselves as something psychologically incomprehensible, alien.

Abscessive thoughts mean painful ideas, ideas that arise regardless of the will of a person. They look like stereotypes, and a person actively tries to resist them. Episodic obsessive images are incomplete, with a whole range of alternatives: they are due to the loss of the patient's ability to make any even simple decision, like ordinary everyday affairs.

Compulsive actions require compulsory differential diagnostics - stereotypes in the form of repeated actions, sometimes ritual actions that play the role of a kind of protection and a way to relieve excessive anxiety. The overwhelming majority of compulsions are related to repeated checks - ostensibly to obtain a guarantee of further exclusion of a potentially dangerous moment or situation. Often the basis for such a violation is the phobia of danger - an imaginary expectation of an unforeseen negative program, both for the patient himself and for his environment.

Treatment of the perseverations

The basis for eliminating perseverations is the application of an integrated and phased approach. It should be noted right away that there is no standard proven treatment regimen for perseverative deviations: therapy is selected individually. If a patient has neurological diseases of the brain, then drugs must be included in the treatment regimen. In particular, the use of centrally acting sedatives, as well as multivitamins and nootropics, is appropriate.

Psychological assistance can include the following key strategic points:

• The expectant strategy is to observe and anticipate certain changes as a result of any medical prescriptions (drugs or procedures). This measure allows you to establish the degree of persistence of pathological symptoms.
• A preventive strategy involves the prevention of the transition of mental perseverations to motor disorders, as well as their combination. The method usually consists of eliminating the most painful physical activity for the patient.
• A redirected strategy is to change the focus of a person's physical or emotional activity. With a sharp change in the subject of the conversation, a change in the nature of the activity, the patient is distracted from obsessive states.
• The limited strategy helps to reduce the degree of perseverative attachment by limiting the patient's actions. Obsessive activity is minimized to a certain amount: for example, it is allowed to perform some provocative actions only in a strictly defined period of time.
• A sharply excluding strategy is aimed at the immediate termination of perseverations by introducing the patient into a state of shock. For example, a similar effect can be expected from sudden loud screams, or from visualization of direct harm from pathological manifestations.
• Ignoring strategy involves completely ignoring perseverations. Such a measure is ideal if attention deficit is the provoking factor. When the patient does not receive the expected effect, the meaning of his actions disappears.
• The strategy of mutual understanding consists in finding an approach to the patient, in establishing trusting contact with him, which helps the person to organize his own thoughts and actions.

There is often a need for antidepressant therapy. In particular, with obsessive-compulsive disorder, antidepressant monotherapy is prescribed at the initial therapeutic stage. If this approach does not bring the desired effect, then the treatment regimen is expanded with drugs from other groups and directions. In all cases, the patient should be closely monitored by a physician. In difficult cases, the patient is admitted to a hospital, and in case of a mild course of pathology, outpatient management is preferable.

One of the most effective methods is psychotherapy. To date, the positive effect of cognitive-behavioral therapy has been proven in different directions, which sometimes turns out to be more effective than taking medications. In addition, psychotherapy is often used to enhance the effect of medications, which is especially important for patients with severe disorders.

Both an individual treatment regimen and group work, as well as family psychotherapy, are allowed. In most cases, medical supervision should be long-term, not less than 12 months. Even if pathological signs can be stopped within several weeks, it is unacceptable to stop medical supervision.

The non-drug technique is appropriate as psychosocial interventions, cognitive-behavioral therapy.

Medicines

The use of certain drugs for perseverations is due to the course of the underlying disease or condition. Thus, medications are prescribed strictly individually: there is no general algorithm for conservative treatment.

In involutive processes in the brain, antidepressants of balanced action with increased thymoleptic potential and anxiolytic properties are used. The choice of medicines should be carried out taking into account their side effects: it is preferable to prescribe medicines with a lower orthostatic effect (Nortriptyline, Doxepin) and a low anticholinergic effect (Trazodone, Desipramine). [26]

With Alzheimer's disease, carry out:

• replacement therapy to replenish cholinergic deficiencies in neuronal systems;
• neuroprotective therapy to enhance neuronal survival and adaptation;
• vasoactive and anti-inflammatory therapy.
• Replacement therapy is carried out using acetylcholinesterase inhibitors:
• Exelon (Rivastigmine) - taken twice a day, morning and evening, starting at 1.5 mg. Further maintenance effective dose is 3 to 6 mg twice a day. Possible side effects: confusion, agitation, dizziness, loss of appetite, increased sweating.
• Aricept (Donepezil) is prescribed for adults at 5 mg daily at night. The duration of therapy is determined by the doctor. Possible side effects: diarrhea, nausea, agitation, headache, increased fatigue.

Against the background of treatment with these drugs, the elimination of perseverations occurs within the first 3-4 weeks of therapy.

Gliatilin, a choline derivative, plays a special role in the enhancement of central cholinergic activity. Akatinol memantine is a modulator of the glutamatergic system - an important element that provides memory and learning processes. There is a good effect of the use of this drug in mild to moderate manifestations of dementia. In addition, the medication has a beneficial effect on the emotional background and motor functions of patients. 

Neuroprotective therapy is aimed at improving the vitality of nerve cells. For this purpose, nootropic drugs, antioxidants and neurotrophic agents are recommended - for example, Cerebrolysin, which contains bioactive neuropeptides with low molecular weight. This drug has a multispectral organ-specific effect on the brain: it stabilizes metabolic processes in the brain and provides a neuroprotective effect. Cerebrolysin is administered intravenously or intramuscularly, in individually selected dosages. Possible side effects: loss of appetite, headache, drowsiness, tachycardia.

The new generation of neuroprotective agents is represented by calcium channel blockers, NMDA receptor antagonists, antioxidants, lazaroids, and enzyme blockers. At the moment, the study of analogues of such drugs continues - in particular, growth factors obtained by the method of recombinant DNA.

In some cases, non-hormonal anti-inflammatory therapy is effective.

In case of vascular disorders, therapy is directed at improving blood circulation in the brain, optimizing trophic processes, which helps to eliminate perseverations. In order to improve cerebral circulation, Cinnarizin, Actovegin, Cerebrolysin, Nomodipin, medicines based on the Ginkgo biloba plant are used. Cinnarizine is taken 1 tablet three times in 

Sometimes the use of drugs that affect the neurotransmitter systems is indicated:

• cholinomimetics (Rivastigmine, Galantamine, Donepezil);
• stabilizers of the function of the glutamatergic system (Memantyl).

With periodic confusion of consciousness, small doses of Haloperidol, Risperidone are used. Antidepressants are indicated for depressive disorders, and antipsychotics for hallucinations.

Physiotherapy treatment

In the initial period, with mild and moderate pathologies, with progressive perseverations, physiotherapy is used as part of a comprehensive treatment, including diet, taking certain medications (for example, antidepressants, drugs to improve cerebral circulation, etc.).

Non-drug methods contribute to:

• inhibition of the progression of pathology, improving the quality of life;
• correction of physical activity;
• improving cerebral blood supply.

The positive effect of physical factors is noted for improving blood circulation in the brain, increasing dopamine production, increasing receptor sensitivity to dopamine, activating the processes of dopamine release from the presynaptic space, and increasing functional activity. In some cases, the use of physiotherapy allows you to reduce the dosage of medications, which is important in progressive pathologies that are prone to complications.

Often, electrophoresis of medicinal substances is prescribed to activate cerebral circulation and reduce pathological symptoms. As medications, 0.5-1% nicotinic acid, 2-5% ascorbic acid, 2-5% sodium and potassium iodide, 1-2% drotaverine, etc. Are often used. Electrophoresis is performed using the collar or orbital-occipital method. Heparin electrophoresis is appropriate when it is necessary to lower blood clotting and cholesterol levels, as well as for anti-sclerotic and antihypoxic action.

Sinusoidal modulated currents are used to influence the neuromotor cerebrospinal apparatus. Upon completion of the amplipulse therapy course, hydrogen sulfide or radon baths are prescribed, according to indications.

Electric sleep in the form of direct current impulses on the subcortical-brainstem formations improves blood circulation, changes the functional state of these structures, and increases the synthesis of beta-endorphins. The procedures are carried out according to the orbital-occipital method, with a course of 12 sessions. Electrosleep is especially recommended for patients with depressive symptoms.

Darsonvalization is used to stimulate brain centers, improve trophism. The impact is carried out locally, daily or every other day, up to 15 procedures per course.

The UHF electric field has a thermal effect, increases the excretion of dopamine and norepinephrine. A combination of UHF therapy and electrosleep is often practiced. This approach is well accepted by patients, has a positive effect on the psycho-emotional sphere, reduces the intensity of symptoms of anxiety, depression, and cognitive disorders.

To achieve a vasodilator, anti-inflammatory, desensitizing effect, ultra-high frequency electromagnetic waves are used, and if necessary, dopamimetic effects are prescribed phototherapy.

Herbal treatment

Fans of unconventional therapies and alternative remedies offer their own recipes for eliminating perseverations. In some cases, it really can be effective:

• ginger root tea;
• a mixture of carrot, beetroot and pomegranate juice;
• parsley seed tea.

Tea is brewed on the basis of 1 tsp. Vegetable raw materials for 200-250 ml of boiling water, infused for 6-8 hours. In addition, mint and lemon balm leaves, linden blossom can be successfully used for treatment.

Perseverative seizures, as such, do not pose any threat to human life. However, in some cases, they may indicate the development of serious pathologies. Therefore, one cannot fully rely on alternative medicine: it is important to consult with doctors in a timely manner and, if necessary, undergo qualified treatment.

If perseverations appear in a person who abuses alcohol, then an infusion of mountain ash bark can be used to get rid of the disorder. Take 50 g of rhizomes, brew 200 ml of boiling water, insist in a thermos for five to six hours. Next, filter the infusion and take 80 ml up to five times a day.

For disorders due to senile dementia, tincture of elecampane is prepared. Take 500 ml of vodka and 50 g of raw materials, insist in a bottle for a month, periodically stirring the product. After a month, the tincture is filtered and taken orally in 1 tbsp. L. Between meals, several times a day.

In case of anxiety, it is recommended to prepare a medicine from the bait. Mix 10 g of plant rhizomes and 100 g of vodka, infuse for two weeks, filter. Take a tincture of 20 drops three times a day.

If the perseverations are due to chronic sleep deprivation or dementia, then mint is treated. Brew 1 tsp. Mint in 200 ml of boiling water, insist for 15-20 minutes. They drink one glass three times a day, instead of tea.

With excessive excitability, use a decoction of valerian root and fennel (a mixture of equal proportions). Take 2 tbsp. Spoons of raw materials, pour 0.5 liters of boiling water, boil over low heat for 10 minutes. Close with a lid, infuse for an hour, and then filter. It is taken twice a day - in the morning and in the evening - 150-200 ml.

Surgery

Surgical treatment is not essential for the appearance of perseverations. However, surgery can be prescribed for some pathologies that could cause perseverative disorders. For example, the help of a surgeon may be required:

• with venous-arterial malformations of the cerebral vessels;
• with saccular aneurysms of the cerebral arteries;
• with tumor processes in the brain, meningioma, metastatic tumors;
• with some ischemic disorders of cerebral circulation (angioplastic surgery);
• with intracerebral hematomas of traumatic and non-traumatic origin, etc.

The most commonly practiced endoscopic method of operations is due to the low trauma and effectiveness of such an intervention.

Prevention

There are no specific preventive measures to prevent perseverations, since many reasons for their occurrence are known. Therefore, recommendations for prevention are predominantly generalized.

Preventive measures can be primary and secondary.

The primary measures include those that are aimed at preventing the development of any psychopathological and neurological symptoms. Experts recommend to prevent the emergence of traumatic situations in the domestic environment and at the workplace / study place, to devote enough time and attention to children.

Secondary preventive measures are aimed directly at avoiding the re-development of perseverative signs. For this, it is recommended to apply several techniques at once:

• with the help of psychotherapy and other similar procedures and sessions, an adequate response of a person to all kinds of traumatic and stressful situations is formed;
• the need to comply with all appointments and recommendations of specialists is determined;
• restorative treatment is prescribed, sufficient and proper rest and sleep is provided;
• the intake of alcohol, stimulating drinks and drugs is completely excluded;
• some changes are made to the diet: the diet is enriched with vitamins and microelements, the proportion of foods rich in tryptophan (a precursor of serotonin) increases, and the use of dark chocolate and coffee is limited.

To prevent recurrence of perseverations, patients are advised not to limit themselves to a nutritious diet and add the following foods to the diet:

• hard cheeses (Swiss, Roquefort, Cheddar, Poshekhonsky);
• chicken and quail eggs;
• soy;
• feta cheese, feta cheese;
• red caviar;
• dairy products;
• sunflower seeds;
• turkey meat;
• sesame;
• cashews, pistachios, hazelnuts, peanuts;
• legumes (beans, peas, lentils, chickpeas);
• pink salmon, squid, herring, cod, pollock, horse mackerel;
• cereals;
• cottage cheese (not fat-free);
• greens, cauliflower;
• dried fruits;
• mushrooms.

Among cereals, grain products and legumes, preference should be given to peas, buckwheat, corn grits, oatmeal.

Forecast

The prognosis depends entirely on the root cause of the appearance of perseverative disorders. In this case, the acquisition of the chronic course of pathology becomes the most unfavorable. It should be noted that in many patients diagnosed with pathological perseverations, a long-term stable state is possible, which is especially typical in relation to persons suffering from any form of obsession. In such a situation, there is a mitigation of clinical manifestations and optimal social adaptation.

The mild type of perseveration is treated on an outpatient basis. In most patients, improvement is noted during the first year of therapy. Severe cases of disorder, which have multiple obsessions, phobic states, rituals in their own structure, tend to be resistant, resistant to therapeutic measures, as well as to frequent repeated exacerbations. Relapses can be provoked by repeated or new traumatic episodes, overwork (both physical and mental or emotional), general cachexia, lack of rest (including night).

Perseveration in childhood has a more optimistic prognosis than in elderly patients and the elderly.