Perseverations

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

However, this problem is typical not only for psychiatry, but also for other medical fields – in particular, speech therapy and neuropsychology.

Epidemiology

There are no special statistics on the occurrence of perseverations. Presumably, the frequency of occurrence 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 somewhat more often than in men. The risk of such disorders increases after 50 years, and the peak incidence occurs in old and senile age (after 65 years).

The overwhelming majority of perseverations are idiopathic (the cause remains unclear). Only in 10-30% of cases can predisposing factors for the development of pathology be detected: craniocerebral trauma, neuroses, dementia, etc.

Causes perseverations

The main cause of perseverations is the loss of the ability to "switch" the brain between individual processes or actions, according to the priority principle. The disorder may be associated with a functional failure of brain activity - for example, due to a stressful situation, overwork, the development of the nervous system, neurotic pathologies. Persistent and severe disorders 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, the causes can be divided into three categories of factors, including physiology, psychopathology and neurology. [ 3 ]

Many people, depending on a particular period of life, are subject to the appearance of perseverations. Such a disorder 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 mild. They are expressed mainly by mental disorders, emotional manifestations, and much less often - changes in motor skills. [ 4 ]

More common causes of the disorder are obvious organic lesions of the brain. Thus, perseverations of movements appear with a disorder in the anterior parts of the cerebral hemispheres. If the problem affects the premotor areas and underlying subcortical structures, then elementary motor perseveration develops, which is accompanied by multiple repeated programmed actions. With damage to the lower zones of the premotor areas of the cortex of the left hemisphere, perseverations of speech are noted.

Disturbances in mental activity arise against the background of damage to the frontal lobes of the cerebral cortex: the pathology is accompanied by a deterioration in the control of intellectual functions, incorrect planning of actions. Sensitive changes are caused by organic damage to the cortical analyzer zones - that is, areas of information processing of data received from the sense organs. [ 5 ]

Psychiatrists consider perseverations as a sign of weak 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 the "straight A student syndrome".

It should also be remembered that perseverative episodes can also be observed in cases of extreme fatigue, prolonged lack of sleep, and in people who are intoxicated. In such situations, the disturbances are always episodic, transient, and short-term. [ 6 ]

Risk factors

Factors that can influence the development of perseverations may be the following:

• Inert processes in the nervous system. Some patients experience inhibition of switching processes in the brain, which is explained by physiological characteristics. Such people find it difficult to switch from one task to another, they adapt slowly to circumstances and have a tendency 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 mentally exhausted, then he experiences a disruption of the brain processes of inhibition and excitation, 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 irritant has ceased to act. The child's reaction may be accompanied by the emergence of repetitive movements or exclamations.
• Atherosclerotic processes. In 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 most often manifest themselves as speech disorders.
• Senile dementia, Parkinson's disease and other dementias. Diseases that are accompanied by atrophic processes occurring in the cortex of the frontal-temporal and frontal brain regions and subcortical structures lead to severe intellectual disorders, speech perseverations, praxis. [ 7 ]
• Head injuries, TBI. Perseverations are observed after brain injuries, especially with damage to the lateral orbitofrontal areas, prefrontal cortex. The patient has involuntary repetitions of phrases or individual words, but effective repetitions are more often found in the form of remote consequences.
• Cerebral circulatory disorders. A stroke often leads to various neurological disorders: patients lose sensitivity and active motor skills, speech and breathing are impaired, swallowing becomes difficult. There may be problems with speech selection, and control over what is said is lost.
• Tumor processes in the brain. In brain oncologies affecting the frontal lobes, basal sections, subcortical motor nodes, changes in goal behavior, comprehension of actions, and active selectivity are often observed. Motor or motor-speech perseverations are often noted.
• Autism. Patients with autism show changes in sensory functionality, inhibition of motor and mental reactions, and behavioral stereotypy. Perseverations in patients are manifested by repeated phrases and actions devoid of any meaning, as well as a target obsessive behavioral disorder.
• Obsessive-compulsive neuroses. Obsessive-compulsive disorders are manifested by obsessive thoughts and actions. Repetitive involuntary motor acts are noted, accompanied by obsessive ideas, images, and ideas.
• Schizophrenia and mental retardation. When the processes of redirection and excitation do not work properly, patients become inert, and the formation of a conditioned reflex connection becomes more difficult. Patients with schizophrenia experience ideological unification, attempts to fill in gaps with outdated ideas, and automation of speech and mental activity. In particular, against the background of catatonia, repetitions of words and phrases and incoherence of speech are observed.

Pathogenesis

Neurological origin is the 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 causes 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 level over mental activity and objective position.

Perseverations in neuropsychology are most often a consequence of traumatic brain injury, aphasia (after tumor and inflammatory processes, injuries), and past local diseases with damage to the frontal lobes of the cerebral cortex.

Perseveration in psychology and psychiatry is a pathological psychological characteristic of the type of cyclical reproduction of motor actions, persistent associations, speech repetitions. Pathology reflects the consequence of psychological dysfunctional states and most often acts as an additional characteristic and component of complex syndromes and phobic disorders. [ 8 ]

The appearance of perseverations in a patient without previous traumatic brain injury or profound stress may indicate the presence of both psychological and mental problems.

The basic pathogenetic factors for the development of the disorder are most often the following:

• typical 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 emergence of perseverations as a type of defensive reaction aimed at attracting attention to oneself;
• excessive persistent desire to learn, the presence of additional abilities can lead to a person becoming fixated on some activity;
• Features of obsessive-compulsive disorder may coexist with perseverative disorders.

If a person is obsessed with an idea, it can make him perform certain actions completely unconsciously. A striking example is obsessive-compulsive disorders, in particular, obsessive hand washing, constant medication intake supposedly for preventive purposes, etc. In this situation, it is very important to differentiate perseverations from other pathologies, regardless of the etiology of the disease. [ 9 ]

Physiological reasons for the problem:

• functional disorder of the cerebral cortex in the frontal lobe area;
• head injuries in the prefrontal convexity area;
• increasing aphasia.

Psychological factors for the emergence of the problem:

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

Verbal perseverations often occur in scientific specialists who have been studying the same issue for a long time. In severe cases, the disorder can worsen to the point of developing an obsessive-compulsive disorder, such as an obsessive pursuit of one idea.

Symptoms perseverations

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

In case of cerebral hemorrhage, cerebrovascular accident, a person may experience dizziness, weakness, speech impairment, and loss of muscle sensitivity. Motor coordination is impaired, and vision deteriorates.

Neuroses may cause mood swings, loss of orientation, and headaches.

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

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

Autism is characterized by a lack of emotional contact (including with parents), difficulties with socialization, and a weak interest in games. Hysterical fits and aggression are possible.

With schizophrenia, patients experience delusional states and hallucinations.

Obsessive-compulsive disorder is characterized by obsessive thoughts, phobias, and compulsions. The first signs of the disorder are as follows: a person loses self-confidence, constantly doubts his or her own actions and deeds. Many patients have inadequate perfectionism: such people tend to hang laundry by color and at the same level, place pots with their handles facing one way, arrange socks by color, etc. At the same time, we are not talking about the usual desire for order: the patient experiences “excessive” discomfort from the imaginary “disorder” and may try to fix the “disturbed” even when visiting.

Perseveration in a child

Perseverations often appear in childhood, which is due to the peculiarities of 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. [ 10 ]

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

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

It is important to distinguish pathological disorders from play activities and normal childhood habits. It is imperative to speak to the child unobtrusively and calmly, and if necessary, to consult specialists. [ 11 ]

Forms

Depending on the manifestations of perseverations, doctors distinguish between motor and mental (intellectual) types of disorder. [ 12 ]

Motor perseverations are a constant repetition of the same movement or a whole chain of repeated movements. Such actions have a certain algorithm that remains unchanged for a long time. For example, in vain attempts to turn on the TV, a person begins to pound on it with his fist. Such an action does not lead to anything, but, realizing this, the person repeats it again and again. Another manifestation may occur in children: the child purposefully looks for a toy where it cannot be.

Intellectual perseverations reveal themselves as abnormal "stuckness" of ideas, statements, conclusions. They manifest themselves in constant repetition of words or phrases. Such pathology is relatively easy to detect: the doctor asks a series of questions, and the person answers them all using the very first answer. There are also mild forms of the disorder, in which the patient regularly tries to discuss a long-resolved issue or topic of conversation.

Motor perseverations

Types of motor perseverations are divided according to the following principle:

• elementary perseverations consist of repeating a single action;
• Systemic perseverations involve a person repeating a whole complex of actions.

A separate category is given to speech perseverative disorder, which manifests itself in the reproduction of the same word (phrase), both oral and written.

In general, motor, or motor perseverations, are caused by damage to the motor areas of the brain. Patients experience multiple repetitions of elements of any movement or action.

Perseveration of thinking

This type of disorder is characterized by the "jamming" of a certain thought or some idea in the human consciousness, often manifested in the process of verbal communication. The patient can respond to almost any request or question, even unrelated ones, with the same word or phrase. It is possible to pronounce certain words out loud 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, talks about issues that are no longer relevant. The second name for mental perseverations is intellectual.

Paraphasias and perseverations

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

Perseverations in aphasia

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

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

Within the aphasia syndrome, perseverations act as a kind of structural element, therefore they persist for a long time, even when the basic aphasic signs disappear. Disturbances are also observed against the background of non-focal organic brain pathologies - for example, in patients with cerebral atherosclerosis, oligophrenia.

Perseverations of letters or words

Perseverations in writing or speaking are the reproduction of a letter or syllable that has just been written or spoken instead of the next necessary one. Example: занок – instead of заука; жожотные – instead of животные. [ 13 ]

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

Perseveration of syllables or letters is one of the variants of motor perseverative disorders, since it consists of reproducing physical activity - for example, writing words. [ 14 ]

But perseveration in speech therapy is a persistent letter confusion that reduces the overall quality of speech. The child experiences a kind of “stuckness” of letters – more often consonants, like their replacement in a word. Examples of speech therapy perseverative symptoms:

• in one word or phrase: “dodoga” instead of “road”, “pod postom” instead of “pod mostom”, etc.;
• against the background of weakened differential inhibition: “we played”, “we told stories”, “we will be rich”, rich people.

It is possible that contaminations can be recorded at the same time – mixing of syllables and parts of words – for example, “dogazin” is a combination of house + store.

Like contamination, perseveration is a common disorder of syllabic structure in childhood. [ 15 ]

Perseveration and verbigeration

The term perseveration originates from the Latin word perseverа tio, meaning persistence, persistence. In the speech process, the symptom manifests itself in the form of repeated reproduction of the same sounds, words, and phrases.

The patient's consciousness is "slowed down" on one word or thought, which leads to their repeated and monotonous repetition. Usually, the repetitions are not connected with the topic of the conversation or the situation. Such a disorder can also manifest itself in written form, as it is a consequence of the association of activity. It cannot be compared with obsessive phenomena, since the latter include an element of obsession, and the person himself consciously perceives the incorrectness of his actions. [ 16 ]

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

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

The peculiarity of verbigerations is that a person repeats interjections and sounds without signs of affect. Usually pronunciation is accompanied by active facial expressions and motor disorders. In most cases, the problem occurs in patients with dementia and catatonic schizophrenia.

Perseverations and situational behavior

As a child grows up, he or she inevitably encounters a fact that plays an important role in the development of his or her thinking. Observing the world around him or her, he or she notices the regularity of the sequence of individual phenomena: for example, if a mother takes shoes out of the closet, then there will be a walk, and if she puts plates on the table, then a meal will follow. Children do not immediately realize this or that connection between phenomena: at first, they emphasize the usual chain of sequences. The occurrence of one event entails the expectation of the next. Such a sequence does not always indicate the interdependence of phenomena, but it gives rise to the practical experience of the child, who begins to observe changes occurring in his or her own and surrounding environment.

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

If the usual sequence is violated, then this attracts the child's attention, causes misunderstanding, and creates the need for an explanation. What 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 child 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 are a tendency to repeat the same actions. Stereotypes may include repetition of individual words or stereotypical thinking (looping).

Stereotypic processes also differ in the degree of automation. For example, verbigerations – stereotypical manifestations in the colloquial speech of patients with schizophrenia – are characterized by meaningless, automated, unconscious repetition of identical words or phrases. Motor or hallucinatory stereotypes are considered equally automatic. Hallucinations often appear against the 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 is completely or partially included in the next action, in a new task, completely unrelated to the previous one. Stereotypes are characterized by the loss of the meaning of activity (mental, motor, speech), without connection with the solution of any task. The ability to capture the relationship of stereotypical turns of phrase (mental or speech) is lost.

Stereotypes are long-term in nature, not changing under the influence of a change in activity. Perseverations depend on the degree of complexity of the subsequent task, they are easier to manifest, have in common with the previous activity. Unlike stereotypes, the patient tries to counteract perseverations.

Stereotypes are characteristic not only of schizophrenia. They are also diagnosed in organic psychoses.

Perseverations and anticipations

Some speech disorders are considered phonological, or those that relate to the sound structure of the language. The most common phonological disorders are perseverations and anticipations.

With perseverations, sounds from the first word end up in subsequent words - for example, "snezhny suzhnob" instead of "snezhny suguro", "bolit bolova" instead of "bolit golova".

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

• the sun shines on itself (instead of “in the sky”);
• I'm going to watch a TV series (instead of "watch a TV series").

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

Echopraxia and perseveration

Echopraxia, echokinesia or echokinesia is the so-called echo-symptom, which is characterized by involuntary repetition or imitation of any motor acts, gestures, body positions, etc. Most cases of echopraxia are characterized by repetitions of relatively simple movements performed in front of a person. This can be applause, squinting or waving hands. Damage to the convexital prefrontal cortex in front of the premotor zones is accompanied by prefrontal apraxia with echopraxic symptoms.

Such symptoms are usually attributed to tic disorders. They are observed in autism, Tourette syndrome, schizophrenia (mainly catatonic type), phenylpyruvic oligophrenia, Pick's disease, clinical depressive state and other neuropathologies. The catatonic type of schizophrenia, in addition to echopraxia, may be accompanied by echolalia (speech repetitions of others) and echomimia (facial repetitions of others). [ 17 ]

Behavioural perseveration

Experts call perseverations behavioral disorders, and repetitions can concern almost any actions, phrases, movements, questions, requests, etc. Perseverations in behavior are a manifestation of dysfunction of the anterior motor cortex, when the transition from an already completed action to the next action is difficult: as a result, the first action does not switch to the next, but is repeated, 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 different levels of dysfunction of the frontal cortex. Competent use of such a tendency helps to effectively consolidate relationships in childhood. Thus, behavioral perseverations in some cases can act not as a pathological obstacle, but also as an ally in correctional work. [ 18 ]

Oculomotor perseverations

Oculomotor perseverations are said to occur when a person's gaze "fixates" on a previous object. It is not always possible to immediately answer the question about the pathological origin of such a symptom, but in many patients mental and cognitive disorders may precede motor disorders.

To make a diagnosis it is recommended:

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

Cognitive impairments are assessed using specific neuropsychological tests. Mental disorders most often manifest as anxiety and/or depression. In addition, patients may experience irritability, mood instability, apathy, aggression, thought and/or motor perseverations, obsessive-compulsive disorders, and, less commonly, psychosis. The final diagnosis is established based on diagnostic testing data.

Perseverations in schizophrenia

Quite often we have to observe perseverations in patients with schizophrenia. Such disorders cover a wide range of speech manifestations. In this case, perseverations in speech can be individual sounds and words, fragments of phrases, complete speech turns. Many specialists associate the occurrence of perseverations in schizophrenics with the impoverishment of ideas and the tendency to fill the resulting mental gaps with previous ideas. In the pathogenetic aspect, an important role is played by the strengthening of the automation of intellectual and speech activity.

Schizophrenic disorders are generally accompanied by disturbances of thinking and perception, inadequate or decreased affect. In most cases, patients retain clear consciousness and mental abilities, although certain cognitive problems may appear over the years.

In schizophrenia, fundamental functions that give normal people a sense of their own individuality and purposefulness are impaired. Auditory hallucinations, explanatory delirium, and the perception of colors or sounds are often noted. Thinking becomes unclear, vague, and intermittent, and speech becomes incomprehensible. Catatonic disorders are possible. [ 19 ]

Complications and consequences

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

For example, if perseverative states are not corrected or are not amenable to correction for a long time, 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;
• a feeling of inferiority, lack of self-confidence;
• condemnation from relatives, friends, etc.

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

But it is important to note that in all cases it is necessary to conduct a clear and deep differential diagnosis with various mental disorders, systemic diseases, intoxications, etc. It is impossible to exclude the appearance of perseverations only episodically, without any motivation: in such situations, people often get scared, they have difficulty with self-realization, as they experience active pressure, misunderstanding and opposition from loved ones.

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

Diagnostics perseverations

Before diagnostic procedures, the doctor conducts a conversation with the patient, his parents or relatives. [ 20 ] The following questions are clarified:

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

The mental and neurological state of a person is assessed by questioning and collecting anamnesis, both from the person himself and from his close people. Complaints are collected, motor function, facial reactions, viscero-vegetative disorders are visually examined. [ 21 ] The level of perseverance, anxiety, muscle tension of the patient is externally assessed. The presence of fatigue, weakness, fussiness, irritability, sleep disorders is necessarily ascertained. Among the vegetative changes, attention is paid to increased heart rate, tremors in the fingers and limbs, increased sweating, nausea, urination and digestion disorders. [ 22 ]

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

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

Additional diagnostics include:

• Clinical and biochemical blood tests (including glucose levels, ALT, AST, alkaline phosphatase), thymol test.
• Wasserman reaction, blood test for HIV.
• Clinical urine analysis.
• Electrocardiogram.
• If necessary: bacterial analysis, swab from the nose and throat.

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

• electroencephalography;
• magnetic resonance imaging;
• computed tomography.

A common procedure, electroencephalography, helps detect epileptic tendencies and also assess the maturity and functional activity of the brain. [ 23 ]

Differential diagnosis

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

• obsessive-compulsive disorders;
• common human habits;
• sclerotic memory disorders.

It is very common to see people (especially older people) tend to repeat the same phrases, words or actions simply because of poor memory or impaired concentration.

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

Obsessive thoughts are painful ideas, representations that arise regardless of a person's will. They look like stereotypes, and a person actively tries to resist them. Episodic obsessive images are unfinished, with a whole set of alternatives: they are caused by the patient's loss of ability to make even a simple decision, like ordinary everyday affairs.

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

Treatment perseverations

The basis for eliminating perseverations is the use of a comprehensive and step-by-step 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 is diagnosed with neurological diseases of the brain, then medications are necessarily included in the treatment regimen. In particular, it is appropriate to use sedatives of central action, as well as multivitamins and nootropics.

Psychological assistance may include the following key strategic points:

• The expectant strategy consists of observing and waiting for certain changes as a result of any medical prescriptions (medications or procedures). Such a measure allows us to establish the degree of persistence of pathological symptoms.
• The preventive strategy involves preventing the transition of mental perseverations into motor disorders, as well as their combination. The method usually consists of eliminating the most painful physical activity for the patient.
• The redirected strategy consists of changing the direction of a person's physical or emotional activity. With a sharp change in the topic of 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 volume: for example, some provocative actions are allowed to be performed only during a strictly defined period of time.
• The abruptly excluding strategy is aimed at the immediate cessation of perseverations by putting the patient into a state of shock. For example, such an effect can be expected from sudden loud screams, or from visualizing direct harm from pathological manifestations.
• The ignoring strategy involves completely ignoring perseverations. Such a measure is ideal if the provoking factor was attention deficit. When the patient does not receive the expected effect, the meaning of his actions disappears.
• The strategy of mutual understanding consists of finding an approach to the patient, establishing a trusting contact with him, which helps the person to organize his own thoughts and actions.

Often there is a need to use antidepressant therapy. In particular, in case of obsessive-compulsive disorder, monotherapy with antidepressants is prescribed at the initial therapeutic stage. If such an approach does not bring the desired effect, then the treatment regimen is expanded with drugs of other groups and directions. In all cases, the patient must be carefully monitored by a doctor. In complex cases, the patient is hospitalized, and in case of a mild course of pathology, outpatient management is preferable.

One of the effective methods is psychotherapy. To date, the positive effect of cognitive behavioral therapy in various directions has been proven, 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.

Individual treatment plans, group work, and family psychotherapy are both acceptable. In most cases, medical supervision should be long-term, at least 12 months. Even if pathological signs can be stopped within a few weeks, stopping medical supervision is unacceptable.

Non-drug methods are appropriate as psychosocial interventions, cognitive behavioral therapy.

Medicines

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

In involutional processes in the brain, balanced action antidepressants with increased thymoleptic potential and anxiolytic properties are used. The choice of medications should be made taking into account their side effects: it is preferable to prescribe medications with less orthostatic action (Nortriptyline, Doxepin) and a small anticholinergic effect (Trazodone, Desipramine). [ 24 ]

In case of Alzheimer's disease the following is carried out:

• replacement therapy to compensate for cholinergic deficiency in neuronal systems;
• neuroprotective therapy to enhance neural survival and adaptation;
• vasoactive and anti-inflammatory therapy.
• Replacement therapy is carried out using acetylcholinesterase inhibitors:
• Exelon (Rivastigmine) – taken twice daily, morning and evening, starting with 1.5 mg. Further maintenance effective dose – from 3 to 6 mg twice daily. Possible side effects: confusion, agitation, dizziness, loss of appetite, increased sweating.
• Aricept (Donepezil) is prescribed to 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.

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

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

Neuroprotective therapy is aimed at improving the viability of nerve cells. Nootropic drugs, antioxidants and neurotrophic agents are recommended for this purpose – for example, Cerebrolysin, which contains bioactive neuropeptides with a small 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 neuroprotectors is represented by calcium channel blockers, NMDA receptor antagonists, antioxidants, lazaroids, and enzyme blockers. At present, the study of analogs of such drugs is ongoing – in particular, growth factors obtained by the recombinant DNA method.

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

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

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

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

In case of periodic confusion of consciousness, small doses of Haloperidol and Risperidone are used. In case of depressive disorders, antidepressants are indicated, and in case of hallucinations, neuroleptics.

Physiotherapy treatment

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

Non-drug methods help:

• slowing down the progression of pathology, improving the quality of life;
• correction of motor activity;
• improving cerebral blood supply.

The positive effect of physical factors is noted by the improvement of blood circulation in the brain, increased production of dopamine, increased receptor sensitivity to dopamine, activation of dopamine release processes from the presynaptic space, and increased functional activity. In some cases, the use of physiotherapy allows for a reduction in the dosage of medications, which is important in progressive pathologies prone to complications.

Electrophoresis of medicinal substances is often prescribed to activate cerebral circulation and reduce pathological symptoms. The following are often used as medications: 0.5-1% nicotinic acid, 2-5% ascorbic acid, 2-5% sodium and potassium iodide, 1-2% drotaverine, etc. Electrophoresis is carried out using the collar or orbital-occipital method. Heparin electrophoresis is appropriate when it is necessary to reduce blood clotting and cholesterol levels, as well as for antisclerotic and antihypoxic action.

Sinusoidal modulated currents are used to influence the neuromotor cerebrospinal apparatus. After completing the amplipulse therapy course, hydrogen sulphide or radon baths are prescribed, according to indications.

Electrosleep in the form of direct current pulses on the subcortical-stem brain formations improves blood circulation, changes the functional state of these structures, and increases the synthesis of beta-endorphins. The procedures are carried out using 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 and 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 received by patients, has a positive effect on the psycho-emotional sphere, reduces the intensity of symptoms of anxiety, depression, cognitive disorders.

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

Herbal treatment

Fans of alternative treatments and folk remedies offer their own recipes for eliminating perseverations. In some cases, they can really be effective:

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

Tea is brewed on the basis of 1 teaspoon of plant material per 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 attacks, as such, do not pose any threat to human life. However, in some cases they may indicate the development of serious pathologies. Therefore, you cannot rely entirely on traditional medicine: it is important to consult with doctors in a timely manner and, if necessary, undergo qualified treatment.

If perseverations have appeared in a person who abuses alcohol, then to get rid of the disorder, you can use an infusion of rowan bark. Take 50 g of rhizome, brew 200 ml of boiling water, insist in a thermos for five to six hours. Then filter the infusion and take 80 ml up to five times a day.

For disorders caused by senile dementia, prepare an elecampane tincture. Take 500 ml of vodka and 50 g of raw material, insist in a bottle for a month, periodically stirring the remedy. After a month, filter the tincture and take 1 tbsp. between meals, several times a day.

For anxiety, it is recommended to prepare a medicine from the zamaniha. Mix 10 g of the plant's rhizome and 100 g of vodka, leave for two weeks, filter. Take the tincture 20 drops three times a day.

If perseverations are caused by chronic lack of sleep or dementia, then treatment with mint is carried out. Brew 1 teaspoon of mint in 200 ml of boiling water, leave for 15-20 minutes. Drink one glass three times a day, instead of tea.

In case of excessive excitability, use a decoction of valerian root and fennel (a mixture of equal proportions). Take 2 tablespoons of raw materials, pour 0.5 liters of boiling water, boil over low heat for 10 minutes. Cover with a lid, leave for an hour, then filter. Take twice a day - morning and evening - 150-200 ml.

Surgical treatment

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

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

The most commonly used method of performing surgeries is the endoscopic method, which is due to the low trauma and effectiveness of such intervention.

Prevention

There are no specific preventive measures to prevent perseverations, as many reasons for their occurrence are known. Therefore, recommendations for prevention are mainly general in nature.

Preventive measures can be primary and secondary.

Primary measures include those aimed at preventing the development of any psychopathological and neurological symptoms. Experts recommend preventing the occurrence of psychotraumatic situations in everyday life and at work/school, and devoting sufficient time and attention to children.

Secondary preventive measures are aimed directly at preventing the recurrence of perseverative traits. For this purpose, it is recommended to use several methods at once:

• with the help of psychotherapy and other similar procedures and sessions, an adequate human response to all sorts of psychotraumatic and stressful situations is formed;
• the need to comply with all appointments and recommendations of specialists is determined;
• General strengthening treatment is prescribed, sufficient and complete rest and sleep are ensured;
• the consumption of alcohol, stimulants 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) is increased, and the consumption of dark chocolate and coffee is limited.

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

• hard cheeses (Swiss, Roquefort, Cheddar, Poshekhonsky);
• chicken and quail eggs;
• soybeans;
• 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;
• oatmeal;
• cottage cheese (not low-fat);
• greens, cauliflower;
• dried fruits;
• mushrooms.

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

Forecast

The prognosis depends entirely on the underlying cause of the perseverative disorders. The most unfavorable outcome is the acquisition of a chronic course of the pathology. It should be noted that many patients with diagnosed pathological perseverations may experience a long-term stable condition, which is especially typical for people suffering from any form of obsessions. In such a situation, clinical manifestations are alleviated and social adaptation is optimal.

Mild perseverations are treated on an outpatient basis. Most patients show improvement within the first year of therapy. Severe cases of the disorder, which have multiple obsessions, phobic states, and rituals in their structure, tend to be stable, resistant to treatment, and to frequent relapses. Relapses can be provoked by repeated or new psychotraumatic episodes, overfatigue (both physical and mental or emotional), general cachexia, and lack of rest (including nighttime rest).

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