Principles of psychodynamics

Posted on August 5, 2020  in Uncategorized

Conflict concept

In psychodynamics, the central idea is the conflict caused by the rejection of certain aspects of one’s own personality. The very expression “dynamics” was borrowed by Freud from the physics of the 19th century to convey the idea of ​​a conflict between two forces, the result of which is a third force directed in the other direction.
Since medical students study only anatomy and physiology (or their separate parts – histology and biochemistry), it is no wonder that the doctor tries to understand the patient’s complaints as symptoms of anatomical or physiological disorders and, accordingly, find a drug treatment path. It is generally accepted that about a third of patients suffer primarily from emotional problems that cannot be cured in this way. This is precisely the reason for the despair that both doctors and patients come to from fruitless attempts at such treatment. Too romantic can be called the idea that it was our time that gave rise to new phenomena in this area: in 1723 the London physician Cheyne wrote that about a third of his patients did not suffer from organic diseases.
If we take into account that (as in the case of Mrs. A.) the patient’s complaints may not be symptoms of a specific disease caused by external causes, but indicate an internal conflict, then it will be possible to fully understand the strange complaints of some patients. The discovery of microorganisms in the last century made it possible to make significant progress in understanding the nature of diseases, but at the same time led to a focus on external causes. This fully meets the need of a person to find guilty outsiders (in a way, an updated theory about devilish intrigues as the cause of disease).
The importance of internal conflict in human misery is important not only for psychiatry, but for all medicine. If a child complains of abdominal pain, this means either some real illness, for example, appendicitis, or unwillingness for some reason to go to school, which is not named because of the fear of causing a negative reaction in adults. A woman complaining about the pain of intimacy, suffers from some somatic disorders (for example, from erosion of the cervix) or simply does not want this intimacy, but for some reason does not consider it possible to say it directly. The problem may not be hidden in the state of the organism, but in the relationship. The level at which the conflict arises may be relatively conscious or deeply unconscious.
A young lonely woman complained to her family doctor about the acute disgust she got from her own nose. The doctor took all this at face value and sent the patient to the surgeon for plastic surgery. The surgeon, not seeing any special deviations in the shape of the nose, advised the woman to first consult with a psychiatrist. However, she insisted on her own: she just did not like the nose (the underlying conflict was deeply unconscious). Gradually, the woman began to realize that it was not her nose that caused her disgust, but herself (the conflict reached consciousness) and especially her homosexual feelings. You can go further and add that her disgust is caused by dissatisfaction with her own sex and, accordingly, the genitals given out by nature. But such dissatisfaction in a substituted form was expressed in claims to the nose.
The concept of conflict is not something made up by people. Ethologists recognize the usefulness of these concepts in explaining animal behavior. A bird, guarding the borders of its possessions, can very aggressively fly into another, being on the very edge of its territory, but then get scared, retreat, again depict an attack, which will be a vivid example of internal conflict. Another form of the bird’s reaction is to fly off a certain distance and begin to furiously hammer the ground with its beak, giving vent to its rage. This behavior, called redirection by ethologists, is termed bias by psychoanalysts.
What aspects of your own personality cause conflicts? We’ll explore this in more detail later when we talk about motivation. The most common distortion of Freud’s views reduces conflicts to the sphere of sex, from which it is readily concluded that psychoanalysis is not universal in nature, it only reflects the specifics of the bourgeois Vienna of the 1880s. Freud did find that the real cause of hysteria in many patients lies in sexual conflict. It is instructive to quote his true words on this matter (1894: 52): “In all the cases I have analyzed, the suppressed conflict was caused by problems of sexual relations … Theoretically, it cannot be considered impossible to manifest itself in any other area. I can only state that I have not yet met any cases caused by other problems. ” Since then, the great importance of conflicts arising “in other areas” has become clear, for example, aggressive feelings can be directed against oneself (states of depression and attempts to commit suicide) or be replaced by psychosomatic symptoms (such as migraines or hypertension).
Depression, bereavement grief, and other losses essential to a person’s self-esteem may not be recognized by the person and find a way out in physical symptoms. This often manifests itself in the aggravation of complaints precisely on the anniversary of the loss suffered (and such a connection may not be realized by the patient himself).
It should not be thought that all forms of mental illness can be explained as a result of internal conflict. There is a genetic predisposition to functional psychosis such as schizophrenia or manic-depressive psychosis. There are also quite rare forms of organic psychoses caused by brain dysfunction, such as brain tumors or vitamin deficiencies. In the context of manifestation of borderline psychoses and deep personality disorders, we are talking about the “harm caused to the personality by the surrounding external conditions and deep-rooted whims and whims, ie. about that which is beyond the control of the person himself ”(Anna Freud, 1976). All this undermines the strength of the individual and its ability to contain and control primitive reactions and impulses. Today, many types of trauma are known, including early weaning, loss (Bowlby, 1973, 1980), and child abuse (Bentovim et al., 1988). Injuries sustained at an early age influence, as has been shown in the study of miraculously surviving victims of the Holocaust and similar disasters, all further development and the emergence of new injuries later (Pines, 1986; Kestenberg and Brenner, 1986; Menzies Lyth 1989; Garland 1991 ).
The concept of conflict is even more important in the description of neurotic disorders, when it comes to the internal self-destruction of the personality through suppression and other forms of defense. Neurotic conflicts mainly arise in the field of personal relationships during the period of personality formation, when the conflict is driven inside, and later it determines the nature of relations with others. However, the outcome of the conflict here strongly depends on what is currently happening in the sphere of relations with the immediate environment, as will be shown in detail in the chapters on family therapy and therapy for married couples.

Unconscious processes

Those aspects of our “I” that contradict our conscious values ​​can be denied, suppressed, alienated – forced out into the unconscious. It is preferable to talk about different levels of awareness and use the term “unconscious” as an adjective rather than as a noun. Then it becomes possible not to imply the existence of the mysterious realm of the “Unconscious”, isolated from the rest of the brain.
Something may be unconscious simply because we have no idea about it at a certain moment (for example, the color of the front door at the time of reading these lines) or because it is easier to live by suppressing unpleasant sensations and painful memories, although we can easily recall them … Freud called these levels preconscious. On the other hand, some ideas may be unconscious, because they are actively suppressed, since thinking about them is intolerable. These are memories, fantasies, thoughts and feelings that contradict our ideas about ourselves and about what is acceptable. Thoughts that can cause too much anxiety, guilt and pain, if you are aware of them. Freud called this level the dynamic unconscious. Suppression can sometimes weaken, as a result of which the unconscious comes out, although, as a rule, in an altered form thanks to protective mechanisms. For example, in a dream in the form of a dream, during stress in the form of symptoms, or under the influence of drugs or alcohol in the form of a manifestation of seemingly alien impulses.
The concept of various psychic levels is created in parallel with the neurological levels, when higher-level centers control more primitive centers that manifest themselves in conditions of weakening of control. Freud, being a neuropathologist by training, was always influenced by the statement of the neuropathologist Hughlings Jackson (1835-1911): “Learn all about dreams – and you will learn all about madness.” In sleep and in a state of madness, the deepest layers of the psyche are most directly revealed. The winged expression “I never dreamed of this” implies several semantic layers: firstly, there is something about which you see dreams, but you will not do it in reality, and secondly (on a deeper level), there is something that we will not allow ourselves see even in a dream.
Some philosophers dispute Freud’s ideas about the unconscious on the grounds that only conscious phenomena can be considered as events of mental life. However, the concept of the unconscious was increasingly discussed throughout the 19th century. Psychologists such as Herbart (1776-1841) emphasized the conflict between the conscious and the unconscious, and the philosopher Schopenhauer (1788-1860), anticipating Freud, wrote: “Resistance of the will to penetrate into the consciousness of what is unacceptable for a person is the place through which the spirit can be struck with madness ”(Ellenberger, 1970: 209).
As the authority of the idea of ​​God declined in medieval Europe, there was a corresponding increase in the desire of people for self-knowledge, which became especially intense at the turn of the 17th century. The word “conscious” appeared in European languages ​​in the 17th century. The dualism of Descartes (1596-1650), separating mind from body and thought from feeling, testified to the close connection of this movement with the following statement: mental processes are limited to the sphere of the conscious. The emphasis on rational thinking was one of the forces that led to the Enlightenment in the 18th century and to many advances in education and political freedom. But this power devalued imagination and emotional life, a natural protest against this was the Romantic movement that began in the early 19th century, typified by such poets as Wordsworth, Keats and Shelley. The idea of ​​“unconscious” mental processes, “hidden at the turn of the 18th century, became essential at the turn of the 19th century and became effective at the turn of the 20th century” (Whyte, 1962: 63). By 1870, “Europe was ready to abandon the Cartesian view of reason as awareness” (ibid: 165). Freud’s doctrine of the unconscious only temporarily lost popularity due to the fact that it was initially focused only on sexuality.
Perhaps this idea has taken root in our thinking so much that there is no room for argument. Evidence for the truth of the concept of unconscious mental activity can be gleaned from the following sources.


Freud always considered dreams to be “the main road to the unconscious.” Of his greatest work, The Interpretation of Dreams (1900), Freud wrote: “This kind of deep insight falls to the lot of a person only once in a lifetime” (Freud, 1900: xxxii). He drew a distinction between the often seemingly absurd external content of the dream and the latent content hidden under the outer shell by censorship, but this censorship can be circumvented by the use of free association. Dreams are “disguised forms of the realization of repressed desires.” This function of fulfilling desires in a dream is a banal evidence. Children dream of holidays, adults dream of forbidden pleasures or those people and places with which attracted memories are associated, to which they would like to return again. Dreams can be an attempt to cope with unpleasant situations or solve problems. Rycroft (1979) emphasized the creative and imaginative aspect of dreams, contrasting them with simple reflections of conflicts and neurotic reactions, and viewing dreams as a non-destructive form of communication in the non-dominant hemisphere of the brain.

Artistic and scientific creativity

Many writers, artists and composers, describing the process of creativity, say that they are seized by some kind of inner force that is not completely subject to conscious control. Often the creative process takes place in a dream. Kekule, investigating the problem of the structure of benzene, saw in a dream a snake devouring its tail, which immediately prompted him to think about the ring structure of the benzene molecule (Findley, 1948). Coleridge is said to have composed the Kubla Khan poem while under the influence of opium (Koester, 1964). Playwright Eugene O’Neill claimed that in his dream he dreamed of several completed scenes and even two whole plays. When he went to bed, he tuned himself in, repeating: “My little subconscious, bring me a tidbit” (Hamilton, 1976). In a letter, Mozart described a living manifestation of his creative genius, when ideas rush upon him: “I do not know when and how they come, and I can’t cause them to appear … In my imagination I hear parts that do not follow one after another, but all all at once … All this invention, creation takes place in a pleasant living dream ”(Vernon, 1970: 55).
Unlike the flashes of inspiration that enlightened Mozart, Bertrand Russell felt a slow process of “subconscious bearing” before the final insight came:
“It turned out that after the appearance of the preliminary design of a book on some issue and a serious preparatory stage, I needed a period of unconscious bearing, which cannot be accelerated and which proceeds as if something interferes with intentional reflections … Having endured the problem at the unconscious level through intense concentration, I expect it to mature in depth and unexpectedly appear in the form of a dazzlingly clear solution, so that all that remains is to write down what has appeared at the moment of insight ”(Storr, 1976: 65).
In addition to describing the creative process taking place in a dream, many playwrights and writers reported that their characters live their own lives as if in reality. Pirandello showed this process in the play Six Characters in Search of an Author. In his diary, he wrote: “Someone lives my life. And I do not know anything about him ”(preface to Pirandello, 1954).

Hysterical symptoms

We have already seen how, after a trip to Paris, Freud developed the theory according to which hysterical states – paralysis, anesthesia, ataxia – can be caused by a patient’s perception of which he is not aware. A similar state can occur as a result of external influence (hypnosis) or from within (self-hypnosis). These hysterical symptoms, according to Freud’s assumption, are constructed, like dreams, in the form of a compromise between the demands of repressed impulses and the resistance to censorship by one’s own self (Freud, 1925: 45).
One young woman went to the hospital with complaints of her left arm. It turned out that she had just received a course of psychotherapy in a group where she was very annoyed by the male psychotherapist sitting to her left, but she did not dare to say this directly. The complaints about her arm arose as a compromise between the desire to hit him and the fear that kept him from doing this, although she found the courage to tell the doctor about everything. In order to fully understand what happened to the patient, it is necessary to know her history. The woman became angry with the therapist for his intention to leave the group. As a child, she herself was abandoned, and she was taken up by elderly spouses who did not allow “bad behavior” and threatened to abandon the girl if she did not behave well.
Post-hypnotic phenomena

A person can be hypnotized and given the instruction to completely forget what the hypnotist will suggest to him, but after a certain time interval at the snap of the fingers, which the hypnotist will produce, the person will cross the room and open the window. A person brought out of hypnosis opens a window on a signal. If you ask him why he did it, he will be slightly embarrassed and answer that the room is too hot.
This example shows how an unconscious idea (suggested under hypnosis) generates a complex sequence of actions and, moreover, rational explanations for these actions in response to a question about the reasons.

Erroneous actions

If we make a slip of the tongue or forget about something, it can be viewed as a slight malfunction of the brain, but more often than not (and this was the first to suggest Freud in Psychopathology of Everyday Life (1901)), there is an emotional motivation for what happened. For example, we forget about the appointment or the name of the one who causes our irritation, but this happens unintentionally, apart from our consciousness.
A certain young woman didn’t show up for the meeting. Later, she met the chairman and began to apologize to him: “Dr. H. made me surrender, or rather, give time to another occupation.” Was it just a slip of the tongue, or an expression of a hidden desire, or (most likely) an expression of internal protest against the fact that she was forcibly forced to do something?
Behind the “psychopathology of everyday life” one can often see the simultaneous coexistence of many levels of consciousness. Drivers often catch themselves thinking “far, far”, but at the same time continue to adequately react to the traffic situation. Often people notice that a popular melody has become attached to them, as it were, for no reason, although through associations one can always find a connection with some flashing mood, word or semi-conscious idea.

Subthreshold Perception, Selective Attention, and Perceptual Defense

Sound and light stimuli that arise below a certain threshold cause psychophysiological reactions that are not noticed by consciousness. About 30 years ago, there was a huge buzz in the United States about the use of subthreshold advertising: the message “Eat cornflakes” flashed on the movie screen for a split second, such exposure was not enough for viewers to consciously perceive the message, but enough for a sharp increase in sales of cornflakes. A host of experimental results (Dixon, 1971) indicate that the threshold of perception depends on motivation (for example, we see what we want to see, but are blind to what we do not want). It seems that there is some kind of filtering mechanism functioning at a subthreshold, unconscious level, which is very similar to Freud’s assumptions about the mechanism of sleep censorship.
Sometimes beginners who begin to assimilate the image of psychodynamic thinking wonder how these distant events remain unconscious and stay dormant for a long time until (for good or for evil) they cause some reactions, like underground currents that suddenly burst to the surface. This seems more natural to writers. Thomas Hardy wrote: “I can bury a feeling in my heart and thoughts and after 40 years exhume it, and it does not lose its freshness and sharpness in the least” (Gittings, 1975: 5).

Anxiety and mental distress

Some traits of our own personality or some facts from our experiences are unacceptable for our consciousness because they cause anxiety and mental suffering. The concept of mental suffering may seem strange at first glance to those who are used to considering suffering as physical. They believe that pain can be real (physical) or imaginary (psychological). However, all pain and suffering are phenomena highly related to psychic experience, be it somatic or psychological pain. Moreover, physical pain depends on the mood and state of the moment – in the heat of battle, severe wounds can go unnoticed. The old English expression “sore” unites the two kingdoms – psyche and soma, as we say “feeling sore” in both senses. We say that trauma is inflicted both bodily and mental. No wonder they say “headache” about a tormenting problem, “bald head eaten” – about a person. All of these expressions highlight how physical pain reflects the relationship between mental and physical pain.
For a short time, the person is able to endure significant anxiety, for example, in extreme circumstances, or significant mental distress and depression (after suffering bereavement). But this emotional discomfort can be combated through a number of defense mechanisms. If the stress is too strong, the defense mechanism may not be able to cope with it. Then the state of decompensation sets in and mental or somatic illness begins.
The state of anxiety, of course, is far from always unnatural for a person. Anxiety is associated with arousal, which is a normal response to a threatening situation, and prepares a person for a fight or flight. In ancient times, this feeling had an initial value in terms of survival. And now we experience anxiety in situations of competition and competition, which helps to raise the creative forces of the individual and inspire him for optimal activities. If anxiety is excessive or disproportionate, it can be considered maladaptive and unnatural. The anxiety that comes with having to speak in public can be annoying because you can’t defuse that anxiety.
The problem of anxiety and its overcoming is central to most descriptions of the nature of neuroses. Freud formulated the nature of anxiety differently in his early and later works. Initially, he believed that anxiety is generated by defense mechanisms, later he argued that defense mechanisms are excited as a result of anxiety.
In an early model (1894), there was a more physiological approach: it was assumed that anxiety is an expression of undischarged sexual energy, or libido. The classic example of such a statement is interruption of intercourse, which generates symptoms of anxiety due to failure to achieve discharge. Although this model has now been largely abandoned, there are situations in which it is applicable. For example, in a dangerous situation, a person does not feel anxiety as long as he is completely absorbed in salvation from impending danger. The feeling of anxiety arises when everything is over. Freud (1926) revised his ideas about anxiety as an uncharged libido and began to interpret it as a response of the individual to the threat of internal sexual or aggressive urges. Nevertheless, although the early model of anxiety in relation to sexual urges has largely been abandoned, the idea of ​​”actual neuroses” as the result of undischarged aggressive urges remains useful in explaining psychosomatic disorders (McDougall, 1974).
Bowlby made some interesting comments on the relationship between worry, discouragement, and protection. A small child attached to his mother, when separated from her, expresses his despair in three distinct phases: protest, despair and rejection. Bowlby (1973: 27) writes: “The phase of protest reflects the problem of separation anxiety, the phase of despair reflects grief and discouragement, and the phase of rejection reflects defense.” The essence of the remark is that the three types of reactions are phases of one process, and only by considering them in this way, one can understand their true meaning. Freud viewed these three stages of the separation response in reverse order. First of all, he realized the importance of protection (Freud, 1894); somewhat later – despondency (Freud, 1917) and, finally, he approached the revision of his ideas about the meaning of anxiety (Freud, 1926).
Initially, Freud dealt with the problem of anxiety and defense mechanisms against it, observing neurotic states: hysteria, obsessive states and phobias. Only later did he turn his attention to depression, the clinic of which seems to be a much larger problem: in psychiatry, more than half of patients suffer from depression. The simplest way to determine the link between anxiety and depression is to say that, as much as anxiety is a response to the threat of loss, depression is a consequence of actual loss.
Freud in his work “Sadness and Melancholy” (1917) sees a similarity between loss and depression in the manifestations of sadness, despair, loss of interest in the outside world, inhibition of activity.
“Sadness is usually a reaction to the loss of a loved one or to some abstract loss that is significant for a person: the loss of homeland, freedom, ideals, etc.…. In melancholy, the painful condition is caused in most cases by situations not associated with death, and extends to feelings of disrespect, neglect and disappointment, which include the opposite feelings of love and hate.
In other words, in melancholy or depression, the loss is not necessarily external, but rather internal in nature, associated with a person’s self-esteem. Depression, for example, can result from a failed attempt to achieve some desired goal that is vital to self-esteem (Pedder, 1982).
Otherwise, this thought can be expressed as follows: painful contradictions arise between the subjective ideal representation of myself (I am what I would like to be) and the real “I” (I am what I really am). These contradictions can cause physical distress (Joffe and Sandler, 1965), resulting in the following reactions. The normal reaction is protest, when a fight is preferred to flight, directing their aggression against the source of pain. A person may try to cope with pain through adaptation, and a mature strong personality can endure pain and overcome the frustration and damage done to self-esteem. There are several other (though less healthy) ways of responding to unbearable mental suffering. Failure to recover the desired state often results in a state of helplessness, which, according to Ioffe and Sandler (1965: 395), “is a fundamental psychobiological response, referring to the most basic responses, such as anxiety. Its roots are in the primary psychophysiological state, which manifests itself in helplessness in the face of any physical and mental suffering. “
One of the reactions to the state of helplessness is complete surrender and transition to physical illness, described by Engel (1967) as a “defeat complex”, often preceding physical illness. Another response is the transformation of mental pain into psychogenic bodily suffering (Merskey and Spear, 1967). The third is falling into depression.
On the other hand, a defense mechanism such as loss denial may be sufficient to cope with pain, at least temporarily. Let’s give an example.
The middle-aged woman had severe depression. She knew that her father died when she was only ten years old. The girl was told that he was missing, most likely died during the war. But the hope of her father’s return did not leave her all these 30 years, forcing her to shudder in anticipation at any knock on the door. During psychotherapeutic treatment, the woman recalled with horror the episode when her brother, a ten-year-old girl, who entered the room, told her about a man in the garage, covered in blood. At that moment, she instantly realized that her father had committed suicide, but immediately rejected this guess from herself. Only through the painful process of recognizing the fact of her father’s death and the terrible circumstances of his death, she was able to begin the struggle to overcome her despondency and depression.
The following sections will take a closer look at protection mechanisms.

Defense mechanisms

The inclusion of various defense mechanisms is one of the ways to approach those aspects of oneself that, if conscious, can cause intolerable anxiety and mental suffering.
Each of us applies protection in certain situations. The question is to what extent and when. Sometimes overly carried away psychiatrists speak out in the sense that no protection should ever be used, denouncing it as a kind of modern form of sin. The opposite of this point of view is an unprovoked attack on someone’s defense, which is just as unjustified as any form of aggression. Another parallel with religion is the belief in the neurotic’s ideas that sinning in thoughts is just as bad as in deed, so there is no choice: either completely suppress sexual urges and the urge to kill, or obey them and act in accordance with these urges. … The peculiarity of a mature personality lies in the ability to recognize and tolerate such inclinations, preventing them from manifesting outside acceptable situations.
Freud (1894) was the first to use the term “defense” when studying the behavior of patients with hysteria. Later, he called this form of defense repression and described some other forms. In 1936, his daughter Anna listed nine forms of defense mechanisms (regression, repression, reactive formation, alienation, inaction, projection, introjection, turning against oneself, turning into the opposite). She also added the tenth normal mechanism – sublimation, as well as two additional ones (idealization and identification with the aggressor). Melanie Klein emphasized that protection, which takes place in the form of splitting and projective identification (Segal, 1964), occurs in both normal and painful development. Below is given and considered a list of mechanisms, although not exhaustive all possible, but includes the most common forms.

crowding out

As it was shown at the beginning of the previous section, we all at certain moments suppress our unpleasant or uncomfortable inner urges, or even completely supplant something that is not acceptable to our consciousness. This is completely natural, unless it is taken to extremes. Before the advent of effective anesthesia, a surgeon with a sensitive soul had to suppress his reaction to the patient’s screams in order to provide him with the necessary help. In extreme cases, when, for example, people claim that they do not have anger or sexual arousal, they simply supplant these feelings in themselves in the most merciless way.


We may deny or cast out unpleasant events in our outer life, such as a bad deal or failure on an exam. There is evidence that up to 40% of widowed people retain the illusion of the presence of a deceased spouse and 14% actually believe they see and hear the deceased (Parkes, 1972). This is a form of denial of painful loss, quite normal in exceptional circumstances. Feelings of phantom pain in amputated limbs can also be understood as some form of loss denial. Interestingly, phantom pain occurs more often with unexpected amputations (for example, as a result of an accident) than with amputations that were preceded by a long illness, i.e. appropriate mental preparation. A sharper form of denial is hysterical flight or amnesia. During the war, the soldiers resorted in a hysterical state from the front line, where, in front of them, a shell covered all their comrades, and were forced to somehow reject this intolerable memory from themselves. In peacetime, patients sometimes appear who do not remember their name, the place where they live, and who have forgotten any details of their past life. As a rule, such phenomena are a consequence of committing some absolutely unbearable actions for consciousness (for example, the accidental murder of his wife during a violent quarrel).


We often alienate unacceptable feelings from ourselves and even attribute them to others. “The pot calls the kettle smoked.” Jesus Christ spoke about this: “Why do you notice a speck in your neighbor’s eye, but you don’t see a beam in your own?” The accusation of one’s own shortcomings on neighbors, neighbors, residents of another area, foreigners, foreigners is as old as the world. This is a natural, albeit tragic, dangerous human trait. In extreme manifestations, it reaches paranoia, when its own hostile and sexual manifestations are declared alien and even directed against the individual himself.
Sometimes people behave in such a way as if not only their feelings, but also important aspects of their personality are transferred to others (for example, a mother, unconsciously transferring feelings of her own deprivation in childhood to her child, spoils him and interferes with his independent development, but this behavior helps the mother to cope with the pain of the desire for intimacy and dependence, which she did not realize in childhood. The child’s needs are not taken into account, the mother sees in him a part of her “I”, forcing him to play this imposed role). In the professional language of the Klein psychoanalysts, such a phenomenon is called projective identification (Segal, 1964; Ogden, 1982).
In the same aspect, one can also consider the splitting, consisting in the complete separation of good and bad in oneself and in others, which is reflected in the constant interest of children in heroes and villains, good fairies and evil witches (Bettelheim, 1975). Clinically, the phenomenon of splitting can be observed in the separation of good and bad feelings, idealization and contempt both in relation to oneself and in relation to others.

Reactive education

When hiding unacceptable feelings, you can go to the opposite extreme. For example, such is the excessive stiffness observed when trying to hide the temptation to behave at ease. Excessive cleanliness can be helpful. But it can take unhealthy forms with neuroses, when many hours of ablution ritual is observed daily. The psychodynamic explanation for such neurotic states is an attempt to hide hostile feelings. A person who carefully checks three or seven times (magic numbers!), Whether he turned off the gas, might be horrified, realizing that he is suppressing his unconscious desire to harm others. Instead, he explains his behavior by the fact that he seeks to save gas – an example of the rational justification of unconscious processes.


Another example of the rational foundation of the unconscious is the case of post-hypnotic behavior already described above. The expression “the grapes are green” is an excellent illustration of this phenomenon: the fox, desperate to reach the grapes, consoles herself that the grapes are not yet ripe.

Conversion and psychosomatic reactions

The unacceptable feelings often turn into physical symptoms. Such are, for example, hysterical conversions and psychosomatic disorders. An unreleased rage can, for example, lead to migraines or high blood pressure.
A very experienced and accustomed to restraining herself, the nurse-nurse did not allow herself to show the irritation that boiled in her at the sight of stupid mistakes made by young colleagues, believing that this would harm them. Each time she held back her rage, which that same evening led to violent migraines. After completing a course of psychotherapy, the woman learned to better cope with her irritation and express it in an adequate form. Once, with surprise and joy, she said that she was able to point out the mistake in the correct form and in the evening she really managed to avoid a migraine attack.
In hysterical conditions, the symptoms may have elements of symbolism reflecting the underlying fantasy of the patient, as in the example described earlier with the supposedly poorly functioning hand, which was caused by a defensive reaction to the desire to hit his therapist. Nowadays, psychosomatic disorders are less often interpreted in such a symbolic way, but such situations happen, especially when it comes to people with limited imagination, whose feelings are expressed physically, whose speech is specific and who are not used to talking beyond necessity. The term “alexithymic” is used to describe people who do not express their feelings in words (Nemiah and Sifneos, 1970). This happens in post-traumatic and sexually perverse patients and patients with psychosomatic disorders (Taylor, 1987).

Phobic avoidance

We all, to a greater or lesser extent, try to avoid situations that cause unpleasant sensations – the spectacle of an accident, the need to speak in public, etc. Some phobias – fear of spiders or thunderstorms – often go back to early childhood, easily explained by the traumatic events that once happened to a small child. The so-called “agoraphobia” (fear of open spaces) is also easily explained. It usually arises in adolescence and testifies not so much to a fear of open space as to a fear of collision with people in places overwhelmed with people. This is a social phobia.
A certain young woman, professing the lofty ideals of marital and premarital purity, married a man who had several premarital relationships. A few years later, the husband’s job required him to be absent in the evenings, and the wife had free time to attend evening classes. But she developed agoraphobia to such an extent that the woman was generally unable to go out without being accompanied by her husband. During the psychotherapy sessions, it was possible to reveal that agoraphobia was based on the fear that her suppressed impulses to flirt with men could break through and in this way try to “level the score” with her husband, whose premarital relationship she knew. One day, a woman was treating their married friend to dinner, who, leaving, kissed her in gratitude for the dinner, which was quite acceptable from the point of view of social norms. But, having slapped him in the face, she cursed him as a “dirty beast”, projecting her own unconscious unclean thoughts on him.


If we dare not express our feelings directly in front of the one who caused them, then we usually transfer them to someone. A classic feuilleton plot: the boss pours out his anger on the deputy, he – on the next in the hierarchy, and so on to the very bottom, when the messenger kicks the cat in their hearts. A similar phenomenon is observed among animals. This is called a redirect. A common form of substitution is directing unspent anger towards oneself, which leads to self-destructive behavior and even masochism. This is especially noticeable in states of depression and suicidal moods.


It is absolutely normal and even highly desirable on a day off to drop your usual adult duties and return (regress) to childhood to swim, play, etc. In the face of adversity that we cannot cope with – a serious illness, an accident – we often behave like children, refusing to make independent decisions.
Sleep can turn out to be a normal day-to-day regression where we try to escape the problems we face in reality. For a child who has already learned to ask and does not wet the bed, the appearance of a newborn brother or sister often causes regression, manifested in the fact that the bed will be wet again. In adolescent girls with anorexia nervosa due to a ludicrous diet, the disorder may be a manifestation of regression caused by the horror of repressed adolescent sexuality (Crisp, 1967).

Depersonalization and confusion of consciousness

Both of these terms are well known from the general course of psychiatry. Depersonalization is a state in which the patient considers himself to be some kind of unreal being, separated from his own feelings and from everyone around him like a glass wall. Confusion is a state of disorientation in time and space, usually resulting from somatic brain dysfunction.
However, complaints of confusion are not always organic. Sometimes confusion becomes a protective veil under which a person tries to hide, torn apart by intolerable conflict between irreconcilable contradictions of feelings, for example, love and hate. The same defense mechanism can manifest itself in depersonalization (Lader, 1975).


Anna Freud (1936) defined the state of sublimation as “the substitution of an instinctive goal in accordance with higher social values.” This is the most developed and mature defense mechanism that allows one to partially express unconscious motives in a modified, socially acceptable and even desirable form. For example, murderous lust may find a partial outlet in slaughterhouse work or in violent sports. The impulses break away from their primitive and obvious roots and are redirected in a different direction, manifesting themselves as phenomena of a higher order.

One very intelligent young man of 18, from a family that did not encourage the expression of feelings, grew up very secretive and insecure. He was very insecure, avoided girls, and even at 16, reading about the biological aspects of reproduction shocked him. From early childhood, the young man was fond of playing with tin soldiers and collected a huge collection. This collection gave an outlet in a sublimated form to his need for competition, in the desire to show himself, etc.
In addition to the well-known neurotic manifestations, sublimation contributes to the enrichment of both the individual and society. Freud viewed culture as a sublimation of deeply hidden and dark needs and at the same time the embodiment of the highest impulses. Franz Kafka (1920) expressed something similar in the form of the following aphorism: “All virtues are individual, all vices are social, what passes for social virtues (love, lack of self-interest, justice, self-sacrifice) are just surprisingly weakened social vices.” …
Vital parts of the personality can only be expressed in dreams and fantasies. Culture makes it possible to indirectly express what is simply impossible to express otherwise. One of the prime examples is the carnival. Culture provides an outlet for the life of society at all levels – from primitive instincts to the highest ethical ideals. Unconscious strivings require their expression.


Any attempt to understand the origins of both healthy and painful human behavior in all their complexity, sooner or later, will certainly come to the problem of motivation. Playwrights, novelists and poets, exploring the realm of human passions – love and hate, heroism and self-destruction – long before scientific specialists came to a solution to this problem.
Of course, there are several types of innate behavior – from primitive reflexes to complex ones that are highly dependent on learning, for example, the behavior of a mother caring for a child. There are physiological needs for air, food and water, which, when unmet, generate powerful motivations for behavior. But in modern Western society, as a rule, there are no obstacles to meeting these basic needs. Areas that generate conflicts require more attention.
Instincts are defined as “innate, biologically determined impulses to act” (Rycroft, 1972). This term has been used since the 16th century and comes from the Latin designation for impulse. In the 19th century, the concept of instinct received a special coloring in the light of the development of the physical sciences and began to simplify the following idea: the instinctive behavior of animals is just as primitive as the reactive motion of a liquid. Today biologists prefer to talk about innate patterns of possible behavior, recognizing their much greater complexity. Such patterns or “motivational systems” (Rosenblatt and Thickstun, 1977) require a certain external triggering mechanism in order to be activated. However, at times we subjectively feel that our own impulses seem to arise within us against our will. We prefer to use the term “motivational drive” to convey both mental and bodily biological aspects.
It was already mentioned in the introduction that different schools of psychodynamics define motivational drives in different ways and highlight the most important of them in different ways. However, they all emphasize the conflict of motivational urges, with a significant proportion of schools focusing on sexual and aggressive urges. Other important motivations are related to food, attachments, parenting and social behavior. This is best illustrated with a brief historical background.
As has already been shown, Freud, in the early stages of his research, was confronted with strikingly frequent sexual conflicts, especially in hysterical women. Jung (1875-1961), opposing an excessive emphasis on sexuality, coined the term “libido”, by which he understood the existence of broader general vital forces. Adler (1870-1937) attached even greater importance to aggressiveness and the desire for power. Initially, Freud, taking on faith the stories of his patients about sexual abuse that they experienced in childhood by adults, saw the cause of neurotic conflicts in the suppression of these traumatic memories. Later, through introspection, and also feeling that child abuse could not happen as often as his theory suggested, Freud realized that he was wrong. He decided that the stories of his patients were mostly based not on actual facts, but on children’s fantasies about their own desires. He came to the conclusion that very often psychic reality is much more important than physical. Recently, however, there has been renewed talk of recognizing the reality and prevalence of the problem of child sexual abuse (Bentovim et. Al., 1988).
Freud’s discovery of the importance of infantile sexuality is reflected in his book Three Essays on the Theory of Sexuality (1905). Prior to this publication, it was generally accepted that the development of a normal heterosexual orientation was considered to re-emerge during puberty (a myth that illustrates Botticelli’s painting of the birth of Venus rising from the waves as a fully formed woman). Freud noted that this view ignores the phenomena of homosexuality, sexual perversion, child masturbation, and sexual curiosity. He came to consider sexual urges as phenomena that appear from birth and go through various stages as they develop (oral, anal, phallic, etc.), depending on which erogenous zones give pleasure at one stage or another. The most famous is the Oedipus phase (about 3-5 years), named after the hero of the Oedipus myth, who unknowingly killed his father and married his own mother, and then blinded himself (symbolic castration) upon learning of his terrible crime.
In recent years, perhaps under the influence of Adler and the destructiveness of World War I, Freud began to pay more attention to the manifestations of human aggressiveness.
The debate about whether aggressiveness is an innate or acquired property in response to frustration and deprivation is far from over. Both views are valid.
The topic of aggression between representatives of the same biological species was developed by zoologists (Lorenz, 1966). One example of such aggression is the division of territory. Another example is the struggle of males, which helps to select the best individuals for procreation. This phenomenon is especially common among animals leading a herd-nomadic lifestyle (antelopes, bison, etc.), for which the presence of strong males capable of protecting the herd is especially important. In higher primates, aggression is manifested when establishing status in the hierarchy. Social stability is promoted by such a situation in which each member of the group “knows his place”. As for the importance of a strict hierarchy in human society, it is very ambiguous. While undoubtedly a useful phenomenon in an army conducting hostilities, or in an operating team of surgeons, hierarchy can constrain the growth and initiative of an individual where it is not determined by obvious necessity.
The early-stage view of sexuality as a pursuit of pleasure, present from birth, has been very useful in explaining motivation, although some scholars have criticized it for over-focusing on the individual and his satisfaction. Object relations theorists (Fairbairn, 1952; Guntrip, 1961; Winnicott, 1965; Balint, 1968; Greenberg and Mitchell, 1983) have proclaimed the basic human need for the desire to establish relationships (in a broad sense) with other people. In contrast to the theory of seeking satisfaction, for each age, represented by different stages, they believed that different stages at different ages express a different need – different ways of establishing relationships with people (starting with the mother). This method corresponds to different developmental stages of a growing organism and begins with feeding. Instead of an infant seeking satisfaction in an oral impulse, this theory sees an explanation in a couple — mother and child — who find satisfaction in establishing a feeding relationship.
Harlow’s (1958) famous work on baby chimpanzees contains dramatic examples of such object attachments. Taken from their real mothers, little monkeys were attached to dolls and dummies, demonstrating an example of object attachment over hunger (they were fed from bottles – separately).
Bowlby (1969), continuing to develop the problem of weaning from the mother, which he began to investigate back in 1952, came to the conclusion that attachment is an important initial aspiration in humans as well. He argued that “attachment behavior is a form of behavior that is distinct from eating behavior and from sexual behavior, although it is no less significant in human life” (Bowlby, 1975). Attachment behavior peaks between nine months and three years of age. Perhaps the roots of this behavior are related to “adaptation to the environment during evolution” to protect the helpless infant from predators.
However, these biological urges and relationship-building behaviors do not exhaust human activity. Human babies are characterized by curiosity and thirst for knowledge, which Piaget writes about (1953). Should they be viewed simply as a derivative of sexual curiosity, later “sublimated” into the form of scientific and creative research? Or do they represent an independent urge leading to one of human’s most unique creative achievements? Storr (1976) argues that the preservation of children’s ability to play in adults is the basis of human creativity.
Exploratory behavior and attachment behavior are inversely related to each other. The child on the beach, carried away by exploring the surroundings, moves further and further from the mother, and then, frightened, runs back. He returns to her to calm down, gain confidence, how to “recharge the batteries”, and then again embarks on his research.
We need such a base throughout our lives: man is a social animal. About another social animal, the bee, Maeterlinck (1901: 31) wrote: “It is worth isolating it and, no matter how good the food and comfortable environment, it will die in a few days from loneliness. Overcrowding, a common settlement give her an invisible medicine, no less necessary for her than honey. There is no doubt that a person also experiences a natural need to communicate with his own kind, when he can find and realize himself. It remains debatable whether this behavior is a primary social instinct. In more advanced societies, social behavior outgrows biological needs, responding to the satisfaction of psychological needs. Social connections create a structure in which an individual struggles to gain self-worth through relationships with other people. The first social connection is the mother-child structure, then the family, then school, work, sexual partners, a new family and wider social ties. A person’s sense of self and awareness of his own worth depends on the presence and his interaction with other people throughout his life.
The school of American psychologists who made their mark in the 1930s – Fromm, Horney, Sullivan and Erickson – were called neo-Freudians. Representatives of the new school attached particular importance to the interpersonal aspect as opposed to the intrapsychic one. The conflicts and breakdowns seen in these relationships of support and self-determination lead to despair and illness. We are coming to an ever clearer awareness of the need to overcome loneliness and find a replacement for collapsing family and group ties, in other words, to support and correct the need of individuals and communities for cooperation and close ties.
Whatever definition of motivation we have to stop at, the basic concept of psychodynamics remains the conflict of primitive impulses. Freud revised his own theories of instincts several times, but dual conflicting ideas were always present in his writings. At first, he saw a conflict in the contradiction between the instinct of self-preservation and the instinct of procreation, later – between love for oneself (narcissism) and love for others; Finally, Freud poeticly formulated the conflict between the life instinct and the death instinct, echoing with Schiller, who said that until the spirit begins to rule the world, power will be divided between “hunger and love.”
Science and literature continue to understand the complexities of human motivation. Perhaps the current stage of development of knowledge is not yet mature enough for a clearer classification of motivation, in any case, this task lies outside the scope of this book. Psychotherapy is more concerned with impulses, urgent needs, and fantasies that lead to despair and conflict. Behind them are forces that emerge from the depths of the personality and are aptly named by Sandler (1974) “unconscious indisputable needs.” If we fail to get along with such a vital part of our nature, then this leads to obvious mental illness or, at least, to neurotic suffering and inhibitions.

On the issue of adequate therapy for protracted reactive depression

Posted on August 1, 2020  in Uncategorized

Among the psychogenic factors involved in the determination of reactive depressions, the leading role is assigned to bereavement, which damages the sphere of individual personal values. The sudden loss of the object of attachment (“significant other” in the terminology of psychologists) – love drama, tragic death or suicide are considered in the literature as a catastrophic stressful effect. The latter is equated in importance with events of an extreme nature with a universal property – the ability to cause distress1. Only 800,000 people experience marital loss in the modern world every year, and at least a third of them need treatment for an acute psychogenic reaction. At the same time, in half of the patients, after acute affective-shock disorders have passed, clinically outlined reactive depressions are formed, the duration of which exceeds 12 months.
Such protracted depression, denoted in psychologically oriented publications by the concept of “pathological grief reactions” (PRG), not only worsen the quality of life, but increase the suicidal risk, lower the threshold of susceptibility to recurrent affective disorders, contribute to the development of comorbid pathology (anxiety, pathocharacterological disorders, dependence on psychoactive substances).
The data obtained allowed modern researchers to come to the conclusion that protracted psychogenic depressions occurring with the picture of PRG, in contrast to the psychologically deduced phenomenon of “normal work of grief”, cannot be regarded as an “acceptable process” and should be the subject of special attention of clinicians.
However, the psychological clarity of the tragic life situation in the minds of patients (and even, unfortunately, in the judgment of some specialists) often shifts the real idea of ​​a depressive reaction as a mental disorder to its understanding exclusively in the context of a natural, inevitable and irreversible, and thus not in need of treatment for the consequence of the loss suffered.
Meanwhile, in the absence of adequate therapy, psychogenic depression with features of PRH is not only not reduced, but becomes chronic. At the same time, mental trauma becomes a maladaptive “focus” that determines, over a long period of time, violations of behavior, social functioning and the entire life structure of patients. Accordingly, the timeliness of adequate therapeutic measures in such cases is a factor of key importance.
As evidenced by the clinical experience, which is consistent with the literature data, accumulated in the department for the study of borderline mental pathology and psychosomatic disorders of the NCPZ RAMS, in a wide range of therapeutic influences (biological, psychotherapeutic, social rehabilitation) used for protracted psychogenic depressions occurring in the form of PRG , the main component is pharmacotherapy with the predominant use of antidepressants.
This position is based on a revision of the traditional concept of psychotherapy as the only effective method of treating such conditions2. With the accumulation of the results of special comparative studies, which provide statistically reasoned evidence, it became obvious that psychotherapeutic interventions in combination with placebo (i.e., the appropriate monotherapy) can achieve a positive effect in only 29% of patients with PRH [Reynolds Ch.F. et al., 1999]. At the same time, the effectiveness of antidepressant treatment is at least twice as high and can exceed 70%.
The approaches to the choice of therapeutic tactics are carried out in accordance with the concept of psychogenies, consistently developed in a series of works by A.B. Smulevich, devoted to the problem of the contribution of personality disorders to psychogenic response to stress (see, in particular, the publication in the “Journal of Neurology and Psychiatry named after SS Korsakov”, No. 6, 2000, as well as the article in this issue).

Psychopharmacotherapy of prolonged depression with a picture of PRH is carried out taking into account the general principles of treatment of affective disorders: the volume and power of the drug effect are consistent with the severity of the condition. Accordingly, in the treatment of deep depression, the use of a high activity of psychotropic drugs of a wide spectrum is shown, while mild hypothymic disorders require the prescription of drugs with a differentiated effect on psychopathological manifestations (a narrow spectrum of psychotropic activity). However, these provisions are applicable to the conditions under discussion only in part, as evidenced by the already well-known fact that, despite the dominance of hypothetical manifestations in the picture of depressive reactions with features of PRH, the set of drugs used in the treatment, as a rule, is not limited to antidepressants.
The need for complex therapy, as follows from the results of a number of studies, correlates with a special characteristic of psychogenic depression – their clinical manifestations depend on the structure of comorbid relationships of affective disorders with personality disorders. In cases of the formation of protracted depressions with a picture of PRG (this will be shown below), we are talking about a mandatory complicity in the structure and dynamics of the depressive reaction of personality disorders (PD) or even disorders of an endogenous procedural nature3.
The ultimate goal of treatment is the most timely impact not only on the pathologically altered affect, but also on the pathocharacterological manifestations.
Initially, the choice of the psychopharmacotherapy technique depends on the belonging of the clinical manifestations of psychogenia to one of the following levels of personal response to stress, reflecting the stages of the dynamics of the disorder:
1 – the level of “deep personality” with polymorphic undifferentiated affective disorders (acute period);
2 – constitutional characterological / pathocharacterological level with differentiation and modification of affective disorders according to the patterns of post-traumatic comorbidity (subacute period, stabilization period).
For disorders of the first level, as shown in the figure, urgent intensive psychopharmacotherapy is shown, which in severe cases is advisable to be carried out in a hospital setting. Therapeutic tactics are determined by the peculiarities of the clinical picture of affective-shock reactions with abrupt (like rapid hysterical states of raptoid) changes in affect (from confusion, anxiety with a feeling of unacceptability of the catastrophe, despair with demonstration of suicidal intentions to ecstatic “fascination” with visions of a happy past) and dissociative disorders (psychogenically narrowed consciousness, fugiform agitation or stupor, seizures, hallucinations of the imagination).
The primary task of therapy is the timely relief of all components of the syndrome: affective imbalance, signs of hysterically clouded consciousness and psychomotor agitation. This problem is solved using parenteral (intramuscular, intravenous jet or drip) administration of tranquilizers prescribed in high daily doses (30-50 mg of diazepam) from the moment of admission to the hospital. (It should be borne in mind that “classic” affective-shock reactions are not always observed – the state at first may correspond not to an acute reaction to stress, but to an adaptation reaction, i.e., shallow psychogenic depression. This does not exclude the possibility of the formation of prolonged depression with features of the PRG, although there is no need for hospitalization immediately after the loss). It should be noted that stationing not only provides the possibility of intensive medication, but also has a psychotherapeutic meaning. Placing the patient in a hospital setting at least partially shifts attention and alleviates the burden of traumatic memories.
As clinically delineated depression forms, which indicates the possibility of the development of protracted psychogenia with a picture of PRH, antidepressants of the 1st generation in adequate daily doses (250-300 mg of tricyclic antidepressants – TCAs) are added to tranquilizers. The latter, if necessary, are also used parenterally, including intravenous drip. In complex therapy, the antidepressant properties of TCAs can be enhanced by the addition of medium and high (3-6 mg) daily doses of alprazolam (Xanax), a triazolebenzodiazepine derivative, the tricyclic structure of which is not directly related to antidepressants, but radically distinguishes this tranquilizer from other benzodiazepine derivatives. If signs of behavioral toxicity characteristic of benzodiazepines are identified, it is advisable to use non-benzodiazepine tranquilizers (hydroxyzine-atarax – 50-100 mg / day, buspar-buspirone – 20-30 mg / day). Less often (with the predominance of psychogenic deceptions of perception or arousal phenomena), neuroleptics of a wide spectrum of action in low doses are prescribed (aminazine – 100-150 mg / day, haloperidol – 5-10 mg / day, azaleptin-leponex – 50-100 mg / day). Such tactics in a significant part of cases allows achieving a complete reduction of psychogenic disorders.
In the part of cases when the desired therapeutic effect cannot be achieved, i.e. when the transition to the second level of psychogenic response with the formation of subacute affective disorders is registered, the issues of constructing optimal treatment programs acquire special significance.
It should be immediately emphasized that in case of second-level disorders, adequate therapy requires not only the differentiated use of medications, taking into account the spectrum of their psychotropic activity, but also the choice of various methods in which these drugs (antidepressants and drugs of other classes), as well as other biological effects included in very different proportions. The rationale for this strategy is its compliance with clinical reality – the therapy technique is consistent with the nature of comorbid connections between psychopathological formations and PD, which determine the characteristics of the observed manifestations of psychogenia. Differentiation of approaches to the choice of one method or another is carried out on the basis of the typology of protracted psychogenic depression with a picture of the PRG, subdivided, according to A.B. Smulevich (2000), into two options.
The first option is protracted psychogenic depression of the type of characterological dysthymia. As the severity of the condition decreases, clear signs of post-traumatic personality development are revealed. As a result of the interaction of affective disorders with personality patterns by the amalgamation mechanism (literally merger), a gradual transformation of affective disorders into pathocharacterological ones occurs. The persistently lowered mood takes on the character of a gloomy “basic tone” inseparable from the pessimistic outlook of the victim of an unhappy fate. Catatimically charged, mastering representations of the acute period are transformed into persistent overvalued formations with idealization and embellishment of the lifetime virtues of the object of loss and the cultic activity of perpetuating his memory (obsession with grief), less often – with the struggle (up to litigation and even paranoid tendencies) for “just punishment »Perpetrators of misfortune (often imaginary).
Treatment with this variant of comorbid relationships pursues two goals: it is aimed at the fullest possible elimination of depressive symptoms with minimization of the risk of exacerbations in the form of “double depression” and at the same time – at compensation for pathocharacterological manifestations – a decrease in the “emotional charge” of overvalued formations and associated abnormalities. behavior. The amount of drug exposure in this variant of comorbid ratios is rather limited due to the shallow level of affective disorders proper. At the same time, despite the blurring of dysthymic phenomena inseparable from PD, they are distinguished by the pathological resistance inherent in residual states. It is not necessary to expect rapid success from the use of drugs, which would manifest itself as a complete reduction of symptoms; it makes no sense to intensify therapy for this purpose. It should be borne in mind that the regression of psychopathological formations occurs very slowly, and their disappearance is possible after many years. This implies the need for long-term treatment with the prescription of new generation antidepressants (atypical TCAs – selective serotonin reuptake stimulants – SSOZS – tianeptine-coaxil at doses of 25-37.5 mg / day; selective serotonin reuptake inhibitors (SSRIs) bicyclic – citalopram-cypramypram-cypramine -40 mg / day, paroxetine-paxil 20-40 mg / day, sertralin-zoloft 50-100 mg / day; monocyclic SSRIs – fluoxetine-Prozac 20-40 mg / day, fluvoxamine-fevarin 20-40 mg / day; selective serotonin and norepinephrine reuptake inhibitor – SNRIs – milnacipran-ixel 50-100 mg / day, etc.).
An equally important prerequisite for the success of therapy is the use of modern atypical antipsychotics (risperidone-rispolept 2-4 mg / day, olanzapine-zyprexa 5-15 mg / day, flupentixol-fluanksol 1-3 mg / day, sulpiride-eglonil 200-400 mg / days). The preference for such a choice is quite justified, since psychotropic drugs of the latest generations, along with the main effect, have a high safety and tolerability index, are convenient to use, and do not require careful dose titration.
In conditions of the reverse development of hypothymia, a transition to monotherapy with atypical antipsychotics in doses sufficient for the correction of pathocharacterological disorders is shown.
This technique helps to level the signs of exacerbation in the structure of pathologically altered affect (dysphoric outbursts, “anniversary reactions”) and to gradually deactualize litigious and paranoid tendencies.
Of particular importance in conditions of long-term treatment, in which patients often do not see the need, are informational strategies that make it possible to create the necessary and effective medical alliance between the doctor and the patient, to achieve his interested participation in the therapy process, which minimizes violations of the prescribed recommendations. This interaction, according to the concept of completeness of adherence to the treatment regimen (compliance), is greatly facilitated by the expansion of knowledge of medical personnel at all levels, coverage of the current state of the problem. The
second option is protracted PRGs of the type of endogenomorphic depression. Affective disorders interacting with pathocharacterological formations by the integration mechanism (literally unification) reveal features of constitutional reactive lability (“dynamics of susceptibility”). In contrast to the manifestations of characterological dysthymia (option 1), in which each of the components (hypothymia, PD) in the picture of depression loses its independence, with this option their connection is expressed by the generalization of the elements forming the depressive syndrome and the worsening of the clinical picture. Vital disorders (insomnia, anorexia, circadian rhythm) dominate, ideas of self-accusation are strengthened, true suicidal thoughts are formed. This worsening of depression can reach the level of PD-associated quasi-psychosis (signs of dissociative alienation and / or sensitive paranoia and / or basic anxiety with fear of new loss transferred to the substitute).
The clinically substantiated amount of necessary medical care in accordance with the nature and severity of psychopathological manifestations includes active complex effects that reduce the level of generalization of the disorder and thereby – the therapeutic effect.
Treatment begins with the use of newer generation antidepressants; in the absence of an effect, antidepressants of a wide spectrum of action are prescribed with universal psychotropic activity (TCAs – imipramine-melipramine, amitriptyline, clomipramine-anafranil 250-300 mg / day in combination with high-potential tranquilizers of the benzodiazepine series and, less often – traditional neuroleptics / butyrophenerazines – haloperidol 10-20 mg / day, trifluoperazine-stelazine 10-15 mg / day).
When signs of aggravation of the condition or resistance are identified, strategies of intravenous drip of psychotropic drugs are used.
In the absence of a positive response to psychopharmacotherapy, it is advisable to conduct a course of electroconvulsive therapy. The main indication for prescribing ECT is the severity of the affective component of PRH, when the manifestations of hypothymia approach the picture of a severe depressive episode without psychotic symptoms (psychomotor retardation or agitation, consciousness of worthlessness, guilt, high suicidal risk, sleep and appetite disorders) or with psychotic symptoms (delusional ideas of sinfulness, signs of sensitive paranoia). It is clear that intravenous infusions of psychotropic drugs, as well as shock methods, are possible only in a specialized hospital.

1This term (English distress – grief, suffering, severe malaise, exhaustion) denotes stress (“stress stress” in Russian literature), which has a negative, disorganizing effect on the body, activity and behavior; the result of this influence may be psychopathological disorders.

2In modern balanced strategies with the exclusion of alternative approaches opposing pharmaco and psychotherapy, the latter remains an important part of the treatment process. It is assumed that the community of psychiatrists and psychotherapists provides the possibility of active use of targeted psychotherapeutic influences (rational, cognitive-behavioral, suggestive, family psychotherapy, the tactics of “therapeutic crisis intervention” – an intensive individual psychocorrectional intervention that helps to prevent suicidal intentions). Treatment is differentiated depending on the stage of development of the disorder (see article by A.V. Andryushchenko in this issue). If in the acute period of the psychogenic reaction psychotherapy in the form of adequate support is needed, then in the subsequent treatment techniques include an increasingly subtle study of the traumatic experience aimed at reducing the psychogenic complex, a realistic, distant reassessment by the patient of the loss suffered instead of its pathological denial, building adequate relationships with the environment and modeling of adaptive behavior in general.

3 This aspect of the problem, which requires coverage of the issues of psychogenic provocation of affective diseases (“depressive illness” by modern French authors) and / or “true psychogenies” in schizophrenia, is beyond the scope of this report.

Non-drug treatments for depression

Posted on July 28, 2020  in Uncategorized

Depression is a disease that is quite common in medical practice. It manifests itself primarily in the affective sphere and is accompanied by severe somatic, motivational, autonomic disorders. In the treatment of depression, two directions are developing: pharmacological and non-pharmacological.

The widespread and well-founded pharmacotherapy of depression is still insufficiently effective in 25% of cases due to poor tolerance to drugs and the resistance of the disease itself (S. Dilsaver et al., 1983, S.P. Oskolova, 1985).

In this regard, non-pharmacological methods of treatment, which also have their own pathogenetic rationale, play a significant role.

These include:

– psychotherapy;

– breathing and relaxation training;

– light therapy (phototherapy);

– sleep deprivation (sleep deprivation);

– electroconvulsive therapy.

Psychotherapeutic treatments are divided into psychodynamic, non-directive, rational, and interpersonal psychotherapy.

The basic principles of psychodynamic therapy were developed by Bullack. There are ten most important mental manifestations that are subject to research and correction (self-esteem, self-flagellation, anger, disappointment, feelings of loss, narcissism, denial of latent anger, etc.). Classical psychoanalysis is not indicated for severe depression.

Nondirective psychotherapy is based on the concepts of Rogers, Maslow, and Perls. The patient expresses his thoughts and feelings, and the therapist, without imposing his interpretations, helps to understand himself. An important condition for treatment is empathy – the ability of the psychotherapist to put himself in the patient’s place, to look at the world through his eyes. The focus is on the current situation.

Rational psychotherapy is aimed at eliminating irrational ideas expressed by patients with depression. It is more effective in patients with depression compared to the psychodynamic method. There are indications that it is comparable to or even more effective than drug therapy, especially for mild to moderate depression.

Interpersonal psychotherapy was developed by Klerman, Weisman, and others. It improves the social adaptation of patients and interpersonal contacts, reduces the secrecy of patients, makes it possible to express their thoughts and feelings. It has been shown that interpersonal therapy for some manifestations of depression, for example, in relation to social maladjustment, can effectively reduce it, which is comparable to drug therapy.

Thus, it should be noted that psychotherapy is especially effective for mild or minor depression, characterized by decreased mood and some somatic complaints. In general, it should be noted that psychotherapy should be performed by an experienced specialist. However, the treatment of autonomic disorders and sleep disorders is better corrected by combination with drug therapy.
Respiratory relaxation training (DRT)

Depressive disorders are often combined with anxiety, according to A.F. Schatzberg (1995), at 31 – 62%. Therefore, in these cases, it is advisable to use DRT, which combines elements of mental and muscle relaxation with chest excursions in the inhalation – exhalation rhythm. When performing DRT, it is necessary to observe several principles: the gradual inclusion of the diaphragm in breathing, the formation of a certain ratio between the duration of inhalation and exhalation – a ratio of 1: 2. The transition to the abdominal type of breathing causes the Hering-Breuer reflex, which helps to reduce the activity of the reticular formation of the brainstem, reduce mental stress, reduce hyperventilation syndrome and anxiety. Reduced and deeper breathing optimizes the processes of pulmonary ventilation and diffusion, improves microcirculation.
Light therapy (phototherapy)

Among the recently used non-drug treatments for depression and various somatovegetative disorders associated with it, bright white light therapy has begun to be used. Interest in this method has increased in recent decades in connection with the treatment of seasonal affective disorders (W. Rosental, A. Levy; 1982-1984.) , selective hyperphagia of carbohydrates. Body weight increases. Blood levels of melatonin increase in patients with SBP. With an increase in the light phase of the day, the severity of symptoms decreases. In 1980, A. Levy reported on the blockade of melatonin by bright white light. After that, light therapy began to be used in the treatment of various disorders: seasonal and non-seasonal affective disorders, insomnia, etc. Treatment with bright white light is based on its effect through the retina, hypothalamus, b-adrenergic receptors of the pineal gland membrane. Light helps to reduce melatonin, increase serotonin and dopamine. Our experience (Ya.I. Levin, A.R. Artemenko, 1996, A.D.Solovieva, E.Ya. Fishman, 1997) showed that bright white light reduces the level of depression, improves sleep, and vegetative manifestations accompanying depression.

Phototherapy is carried out according to the technique, which consists in the fact that the patient takes light sessions every day (preferably in the morning). The lamp cover is installed at an angle of 45 degrees in relation to a straight line drawn mentally from the center of the eyeball to the horizontal axis of the lamp. The patient is at a distance of 60 cm from the lamp; the session lasts 60 minutes, during the session the patient receives about 3500 – 4000 lux.
Sleep deprivation (sleep deprivation)

In 1966 W. Schulte introduced the treatment of depression by sleep deprivation into psychiatric practice. He showed that deprivation improves the condition of patients with psychogenic and organic depression. Later, other researchers noted its pronounced effect in depressive disorders. It is known that sleep disorders occur in 83 – 99% of patients with depression. Sleep disturbances along with other symptoms are a criterion for diagnosing depression. A study of sleep in patients with depression showed a decrease in its depth and an increase in motor activity during sleep. In the works of A.M. Wayne, R.G. Airapetova, 1983, 1984 it was shown that with various forms of depression, the latent periods of the first, second and third phases of sleep increase, there is a pronounced reduction of the fourth, most profound stage, the phase of slow sleep, a decrease in the latent period of the phase of REM sleep (REM) was revealed, which is associated with the pressure of REM sleep, characteristic for depression. Thus, subjective complaints of patients about sleep disorders are combined with objective changes during the night on the EEG.

Treatment is with total sleep deprivation. Patients do not sleep from the morning of the day preceding the sleepless night until the evening of the next day, i.e. sleep deprivation is 36 – 38 hours. Then there are two restorative nights, during which patients sleep naturally. After which the deprivation is repeated, if the condition improves, then a third sleep deprivation is performed. Sleep deprivation stops if the patient’s condition does not change or worsens after two sessions. When the condition improves, it is recommended to carry out two sleep deprivations per month. Sleep deprivation provides an improvement in mental state in 90% of patients. According to R.G. Ayrapetova (1984), the positive effect of sleep deprivation is especially noted in melancholy depression, where it is not inferior in effectiveness to antidepressants, adynamic depression. It is less effective in asthenic and anxious depression and has not been shown to have a beneficial effect in masked depression. Deprivation actually has a thymoleptic and disinhibitory effect that stimulates activity, while improving mood and physical activity. There is an activation of the REM sleep phase and synchronization in the EEG of wakefulness, which is of a compensatory nature and provides emotional stabilization.

Sleep deprivation therapy is indicated for any depression that is not accompanied by psychomotor agitation. It itself has a positive effect by reducing depression and significantly enhances the effect of antidepressant treatment, which can significantly reduce the dose of pharmacological drugs. The best results, as a rule, can be achieved with combination therapy: sleep deprivation in combination with antidepressants.
Electroconvulsive therapy (ECT)

This type of therapy for depressive disorders was especially widely used in psychiatry in the 30s and 50s, then a period of rejection began. In recent years, there has been renewed interest in this therapy. ECT is used mainly in patients with severe depressive disorders in specialized psychiatric hospitals, as well as in patients with contraindications to pharmacotherapy and in cases where other methods of treatment are ineffective. ECT is the treatment of choice in cases of extraordinary suicide attempts or persistent refusal to eat, where ineffective antidepressant therapy can lead to wasted time. ECT is considered to be the most effective treatment for depressive attacks and is a treatment for depression that prevents manic attacks. Therefore, it is effective in TIR, in which antidepressants increase the frequency of seizure changes, in psychotic depression, in which antidepressants help little or no help.

There are no absolute contraindications to ECT, but a number of factors and the existence of relative contraindications must be taken into account when prescribing. The patient is examined in the same way as during an operation performed under general anesthesia. ECT is considered a minor surgery. For its implementation, special instructions have been developed.

The mechanism of action of ECT has not been definitively established. There is evidence that ECT enhances dopaminergic transmission, affects opiate and peptide receptors. ECT is thought to improve mood and exercise. ECT in comparison with antidepressants faster eliminates vegetative manifestations of depression.

Neurologists, as a rule, deal with depression of mild or moderate severity, which is more often hidden, under the guise of chronic pain syndromes, autonomic disorders, metabolic endocrine disorders, etc. In these cases, psychotherapy, respiratory relaxation and light therapy have been successfully used.

New possibilities for treating mentally ill patients (review of foreign literature)

Posted on July 24, 2020  in Uncategorized

Clopixol (zuclopentixol), which has rightfully become a classic first-line neuroleptic for foreign specialists, is one of the newest and least studied drugs for the majority of domestic psychiatrists. At the same time, both a kind of spectrum of psychotropic activity of Clopixol, which combines a pronounced antipsychotic effect with a transient sedative and specific inhibitory effect, is of great interest, as well as the existence of various dosage forms of the drug, among which, along with the already familiar tablets and depot injections, there is a unique one that does not have analogs injectable form with three-day action (Klopiksol-Akufaz).

Zuclopenthixol is a powerful antipsychotic agent from the thioxanthene group containing a piperazine side chain. Zuclopenthixol is the cis isomer of clopixol and, as an active molecule, is included in all dosage forms of Clopixol.

The primary antipsychotic activity of zuclopenthixol, like most antipsychotics, may be due to its high affinity for dopamine D2 receptors. In addition, a relatively high degree of affinity of zuclopenthixol to dopamine D1 receptors was revealed, which probably determines the low severity of extrapyramidal disorders. Found also the affinity of zuclopenthixol for serotonin 5-HT2 receptors and a1 – adrenergic receptors.

In our opinion, the availability of a wide range of different dosage forms of the antipsychotic zuclopenthixol is an important advantage, since it opens up new therapeutic possibilities, allowing you to combine different doses, intervals and methods of drug administration in the same patient. In addition to this, the monotherapy method significantly increases the efficacy and safety of treatment by eliminating the possibility of mutual inhibition or potentiation of medicinal substances and their metabolites.

It is well known that at various stages of mental illness, the requirements for the selection of therapy are determined by the characteristics of a particular condition. As clinical experience shows, the optimal method of therapy for acute psychotic conditions may be the appointment of intramuscular injections of aqueous solutions of highly potent antipsychotics. This method provides a rapid therapeutic effect by eliminating the phase of hepatic metabolism, and also creates an optimal dosage control regimen. Unfortunately, the appointment of frequent intramuscular injections in the first days of a patient’s stay in a psychiatric clinic often leads to serious difficulties in the patient’s relationship with medical personnel, and also causes the formation of painful infiltrates at the injection site. In this situation, the advantages of the dosage form of the drug (Klopixol – Akufaz) with a fairly rapid development of sedative and antipsychotic action, but allowing for less frequent prescription, are undoubted.

Studies show that about 50% of people with schizophrenia do not take the prescribed treatment, which leads to a decrease in its effectiveness and an increase in the risk of relapse. In one of the latest works on this problem, more pessimistic figures are given: about 80% of patients with schizophrenia do not really take drugs. In this regard, the advantage of using depot neuroleptics, in particular Klopiksol Depo, is obvious and is associated with the convenience of administration (once every 2-4 weeks), the guaranteed intake of the neuroleptic into the patient’s body, a decrease in the risk of overdose of the drug when it is used independently by patients, as well as a decrease in the total dose of the drug, since when using depot neuroleptics there is no phase of hepatic metabolism. The last circumstance, i.e. a decrease in the total dose of the drug leads to less severity of side effects.

The use of depot preparations provides the most stable serum level of the active agent and a more predictable antipsychotic effect. In addition, the use of depot neuroleptics contributes to better socialization of patients, because eliminates the need for regular medication during business hours, which may be undesirable or inconvenient for patients.

It seems quite logical to present the literature data on the use of various dosage forms of Clopixol in the distribution according to the “longitudinal” disease, ranging from the most acute and severe conditions (manifestation, exacerbation of psychosis), requiring active therapeutic intervention, to lighter ones (the formation of remission, remission, mild processes), where supportive therapy is needed.
Clopixol Akufaz (zuclopenthixol acetate) is an injection with a duration of 48-72 hours for intramuscular administration.

This dosage form of Clopixol was specially developed at the request of Scandinavian psychiatrists for the relief of acute psychoses. The acetate, which is the ester of zuclopenthixol, is dissolved in coconut oil. After intramuscular administration, the acetate undergoes hydrolysis with a gradual release of the active molecule zuclopenthixol. The concentration of zuclopenthixol in plasma increases rather quickly, its maximum falls on a period of 24 to 48 hours (on average 36 hours) after injection, followed by a gradual decrease by 3 to 4 days.

Biological studies have shown that the maximum concentration of the drug in serum was observed in the range from 28 to 56 hours. The authors came to the conclusion that the introduction of clinical doses (50-150 mg) of Clopixol Akufaz should lead to an even faster introduction of the drug into dopamine structures, persistent preservation of the required parameters in the established dose interval and, possibly, an extension of this period.

The experience of using Klopixol Akufaz in a clinical setting has confirmed the above theoretical and preclinical data on the features of its therapeutic action in acute psychotic conditions with a fairly good tolerance. According to the majority of researchers, Clopixol Akufaz provides reliable control over the mental state at the earliest stages of the development of acute mental disorders, including their manifestation or exacerbation of chronic mental illness. The dynamics of the clinical state after the first intramuscular injection of Klopixol Akufaz was very pronounced and consisted in a rapid and stable reduction in acute manifestations of mental disorder.

The efficacy and safety of Clopixol Akufaz have been established in a number of multicenter studies. In most of them, the drug was used to treat 3 types of acute psychotic disorders (according to DSM III criteria):
for the first time in life, an acute psychotic episode developed (assessed in the framework of schizophrenia)
exacerbation of a chronic schizophrenic disorder
manic phase of TIR

Doses of the drug ranged from 25 mg to 250 mg of zuclopenthixol acetate per injection and varied depending on the therapeutic need and individual patient tolerance of the drug. It should be noted that in most cases, doses were used that did not exceed 150 mg of zuclopenthixol per injection, with the most often recommended dose of 100 mg. Most studies used 1 to 3 injections with an injection interval of 24 to 96 hours. Most often, 2-3 injections were prescribed, although in some studies, significant improvement was achieved with a single injection. The expediency of using more injections of Klopixol Akufaz is questionable due to the decrease in its nonspecific sedative effect over time (see below). Concomitant therapy in all studies was limited to the use of antiparkinsonian drugs (only in cases where such a need arose), hypnotics, tranquilizers, and in some patients – lithium preparations.
Sedative action

It should be noted that the first reaction to Klopixol Akufaz is associated with the presence of a powerful nonspecific transient sedative effect that develops in the first hours after injection in the absence of a hypnotic effect. The sedative effect of Clopixol Akufaz was clearly manifested already 2 hours after injection, reached a maximum by 8 hours, and then gradually decreased. By the power of sedative action, Clopixol Akufaz is superior to haloperidol. After the second injection, the severity of sedation is usually less than after the first.
Antipsychotic action

In most studies, a clear antipsychotic effect of the drug was recorded by 24 hours, with a subsequent increase by 72 hours after injection. In some studies, a statistically significant antipsychotic effect of Clopixol Akufaz was determined as early as 8 hours after the start of treatment. In most patients, the observed therapeutic effect, assessed using the BPRS (Brief Psychiatric Rating Scale) and CGI (Clinical General Impression Scale), was classified as significant or pronounced. So, 72 hours after the first injection of Klopixol Akufaz (50-200 mg), a significant improvement was determined in 88% of patients with acute psychoses. In terms of the strength of the antipsychotic effect and the rapidity of the development of the therapeutic effect, this dosage form of Clopixol is comparable to injectable haloperidol.

Noteworthy is the fact that the use of Clopixol Akufaz led to significant changes not only in the total average BPRS scale, but also in individual indicators characterizing the severity of independent psychopathological symptoms. At the same time, according to some indicators, such as “fencing off”, “tension”, “suspicion”, “hallucinatory behavior”, “unusual content of thoughts”, “reduced affect” and “agitation” – a statistically significant effect appeared already by 8 hours after the injection … In a number of studies, a distinct effect was found not only on productive, but also on negative schizophrenic symptoms.

The features of changes in BPRS indicators described above during therapy with Klopixol Akufaz are of great importance, since they indicate the so-called. The “uniform” nature of the antipsychotic action of the drug, which covers both traditional “productive” (hallucinations, delusions, agitation) and “negative” (emotional and social isolation, mannerisms, etc.), and affective disorders.

This feature of the drug’s action, as well as the significant severity of the therapeutic effect, undoubtedly allow it to be classified as one of the most active antipsychotics.
Anti-manic action

The action of Klopixol Akufaz has been studied in patients with acute manic conditions. The mental state of patients was assessed using the BRMS (Beck-Raphaelsen scale for assessing manic disorders) and CGI scales. On the BRMS scale, there was a statistically significant (p <0.01) decrease in the overall score (reflecting the severity of mania) already 24 hours after injection. In general, responders (i.e. patients with marked improvement) make up about 80%.

In a multicenter, randomized trial, the effect of Clopixol Akufaz and injectable haloperidol on acute psychotic conditions, including mania, was compared. It was found that the anti-manic effect of Clopixol Akufaz appears faster than that of haloperidol. The reduction in mania (according to BRMS) 24 hours after the start of treatment was more significant in the group receiving Clopixol Akufaz than among those receiving haloperidol. A more pronounced antimanic effect of Clopixol Akufaz compared with haloperidol was also recorded 3 days after the first injection.
Anti-aggressive action

In a number of works it was noted that such a symptom as “aggressiveness” was subjected to a particularly pronounced reduction. Thus, the results of counting the number of acts of aggression by patients in a psychiatric hospital over several years are presented. It was found that the number of cases of aggression within a year after the start of the use of Klopixol Akufaz in this clinic has decreased by about half, compared with the previous year.

The use of Clopixol Akufaz, on the one hand, leads to a decrease in the aggressiveness of patients due to the general antipsychotic effect of the drug. On the other hand, one should not underestimate the fact that the use of a drug prescribed in the form of an injection only 1 time within 2 to 3 days, in comparison with water-soluble injections of traditional antipsychotics prescribed 3 to 4 times a day, reduces the very possibility of provoking aggression from the patient and improves compliance (ie, patient consent to treatment). The authors conclude that Clopixol Akufaz is “a unique first-line antipsychotic drug for the treatment of patients with a high potential risk of aggressive and hostile behavior”.

Several authors have studied the effect of Clopixol Akufaz on “psychotic anxiety.” An open-label study was conducted using a special Psychotic Anxiety Scale (PAS, O. Blin et al, 1988). Forty-six patients with schizophrenia and “short psychotic disorder” were prescribed Clopixol Akufaz. In most cases, the course of treatment consisted of three injections, which were given once every three days. The average dosage of the drug was 126 – 138 mg per injection. A statistically significant decrease in anxiety was noted as early as 24 hours after the first injection. By the end of the course of treatment, i.e. by day 9, anxiety had disappeared completely, which correlated with a significant overall reduction in psychotic symptoms.
Side effects

The frequency of side effects when using Klopixol Akufaz, according to most authors, was small with a low and medium degree of their severity, which is probably due to the pharmacokinetic characteristics of the drug, which determines a relatively gradual increase in its plasma level. In 43% – 80% of patients in the studied groups, side effects were not observed or, being mild, did not disrupt the general life of the patients. One study [18] found that 52% of patients had no side effects at all. At the same time, there is evidence that when using Clopixol Akufaz (up to 200 mg per injection) with a high therapeutic effect (79% of responders), acute dystonic reactions of significant severity were observed in 12% of cases, requiring the appointment of antiparkinsonian drugs.

Side effects in the studies were assessed using the CGI, ESRS (Extrapyramidal Symptom Scale) and UKU (Scandinavian Side Effect Scale) rating scales. In most cases, side effects developed 24 to 72 hours after the first injection. Tremor was one of the most common side effects. Along with it, sweating, restlessness, dizziness, drowsiness, and dry mouth were noted. The most pronounced and influencing the level of adaptation are neurological side effects in the form of dystonia, rigidity, akinesia, tremor and akathisia. Of autonomic disorders, accommodation disorder and increased salivation were most often noted. At the same time, there is evidence that side effects had a certain dynamics during the 3-day period after the first injection. So, it is indicated that such side effects as tremors, sweating and restlessness tended to weaken, and such as dizziness, drowsiness, dry mouth, increased sleep duration and nasal congestion, to increase. At the same time, the percentage of patients with severe side effects that disrupted daily functioning decreased from 22.2% to 7.4%. Comparison of Clopixol Akuphaz and injectable haloperidol revealed a greater severity of extrapyramidal side effects in the latter, while the difference was statistically significant.

Concomitant treatment associated with the need to correct the side effects of therapy according to various data, was used in 14 – 54% of patients.

When analyzing the use of injectable forms of antipsychotics, the problem of tissue damage at the injection site deserves a separate consideration. Specially conducted comparative studies on animals have shown that water-soluble antipsychotics cause necrotic tissue damage at the injection site, while injections based on Viscoleo oil used in Clopixol Akufaz do not lead to local damage. In clinical practice, this property of the drug leads to the absence of local irritating effects.
Laboratory research

The results of laboratory studies carried out in the course of therapy with Klopixol Akufaz showed that only a small number of laboratory parameters in all examined groups of patients went beyond the normal range both at the beginning and at the end of therapy, while the frequency of cases was not higher than expected for the corresponding group [3 ]. No significant changes in laboratory parameters during the course of therapy were identified.
Clopixol Tablets (Zuclopenthixol Hydrochloride) – Oral Form

This form of the drug has a much longer history of use than Clopixol Akufaz and is widely used worldwide for the treatment of schizophrenia and other mental illnesses.

To date, a large amount of information has been accumulated about the experience of using zuclopenthixol in tablets in the treatment of acute psychoses, exacerbations of chronic psychosis and acute manic states. Many direct and comparative, including double-blind, trials of this drug have been carried out, confirming its high therapeutic efficacy, comparable to the efficacy of haloperidol and chlorpromazine.

In the UK, a multicenter study compared, using a double-blind method, the effect of tablets of Clopixol and chlorpromazine in acute psychoses (schizophrenia and schizoaffective psychosis). The study included patients aged 18 to 65 years who began to receive Clopixol 25-150 mg / day (average 75 mg / day) or chlorpromazine 100-600 mg / day. Starting from the second week of treatment, in most patients, without prejudice to the therapeutic effect, the daily dose of Clopixol was reduced to 50 mg. Chlorpromazine was used throughout the study (10 weeks) mainly at a dose of 600 mg / day. Both drugs have shown high antipsychotic activity. According to this indicator, there was a tendency towards the advantage of Clopixol, however, it did not reach the degree of statistical reliability.

Another multicenter, double-blind study compared the effects of clopixol and haloperidol tablets on acute psychoses. The average daily dose of Clopixol was 33.5 mg, and that of haloperidol was 10.3 mg. Both drugs showed equally high therapeutic activity, however, patients taking Clopixol were discharged from the psychiatric hospital earlier, which reflected the faster development of the antipsychotic effect of Clopixol compared to haloperidol. Clopixol caused a significantly more pronounced reduction in the anxiety-depressive component of psychosis than haloperidol. In addition, the extrapyramidal symptoms in those taking Clopixol were, as a rule, transient, while in patients receiving haloperidol, they were almost constant.

Significant improvement while taking Clopixol tablets was observed in 69 – 87% of patients with acute and subacute manic conditions. A significant mitigation of acute manifestations of manic disorder was observed according to various data during the first 1 to 4 weeks of therapy. In some studies in some of the most severe cases, the treatment of an acute condition began with the use of Clopixol Akufaz during the first 3 to 6 days of treatment, and then continued with Clopixol tablets. It is important to pay attention to the fact that the use of high doses (up to 130 – 150 mg / day) was not more effective than the use of average therapeutic doses for manias (20 – 50 mg / day). About 80% of patients received the drug at a dose of 20-30 mg / day, and an increase in dosages above 50 mg / day did not increase the effectiveness of therapy, but only led to an increase in the severity of side effects. Most researchers have come to the conclusion that with a good therapeutic effect, it is possible to start reducing doses on average 2 weeks after starting treatment without the risk of exacerbation. It has been argued that slightly lower doses are needed to treat manias than to treat schizophrenia.

Of particular interest is the use of Clopixol for agitation and aggressiveness in the elderly. Clopixol was compared using a double-blind method with thioridazine and a combination of haloperidol and levomepromazine. Both studies were conducted in Scandinavia and were multicenter. The first of them included dementia patients (mainly with Alzheimer’s disease) at the age of 64–97 years who were in the hospital. Their mental state was characterized by “the presence of anxiety, hostility, as well as accompanying anxiety, confusion, irritability, insomnia, delirium, hallucinations, hypochondria, and screaming.” A higher efficacy of Clopixol on insomnia was found (the difference between the drugs is statistically significant). Side effects of Clopixol were rare, their severity was insignificant, and there was no serious undesirable effect on the cardiovascular system associated with the drug.

A population of patients similar in demographic and clinical characteristics was used when comparing Clopixol tablets with a combination of haloperidol and levomepromazine (tizercin, nosinan). The study lasted 4 weeks. The starting dose for Clopixol was 4 mg (one 2 mg tablet twice a day). In another group of patients, 1 mg of haloperidol was administered in the morning and 5 mg of levomepromazine in the evening. Average daily doses of drugs at the end of the study were slightly higher: 4.8 mg of clopixol; 1.6 mg haloperidol + 7.6 mg levomepromazine. The authors concluded that for the treatment of aggressiveness and agitation in the elderly, it is preferable to use Clopixol tablets, since it acts faster and allows monotherapy.

It should be noted that, in accordance with the average dosages used in a particular mental pathology, tablets of different dosages are produced: 2, 10 and 25 mg, which makes the use of the drug more convenient.

Thus, literature data indicate that Klopixol tablets can be successfully used both in the treatment of acute and subacute psychoses, including acute manic states, and in agitation and aggression in the elderly, as well as for the correction of behavioral disorders in persons with intellectual disabilities. …
Clopixol Depot is an oily solution of zuclopenthixol decanoate for intramuscular administration with a duration of action of one injection from 2 to 4 weeks.

Clopixol Depo is widely used in psychiatric practice, primarily as a means of supporting outpatient therapy for patients with schizophrenia. In some research, it has been used for active treatment of schizophrenia in a hospital. Finally, depot injections of zuclopenthixol have been used to treat psychotic disorders associated with behavioral disorders in the elderly and conduct disorders in intellectually impaired individuals.

When switching from the tablet form of Clopixol to taking Clopixol Depot, the general rule applies: the dose of the depot injection is calculated by multiplying the daily oral dose by 8. Subsequently, a 2-week interval between injections is usually maintained. When switching from Klopixol Akufaz to treatment with Klopixol Depo, 200-400 mg of Klopixol Depo should be administered intramuscularly simultaneously with the last injection of Klopixol Akufaz. Further, repeated injections of Klopiksol Depot are carried out once every 2 weeks.

There have been several studies of zuclopenthixol decanoate in which it was compared with other depot neuroleptics using a double-blind method and showed high therapeutic activity. One of these studies, which examined Clopixol Depot and haloperidol decanoate, was conducted as a multicenter study in Finland and Sweden. The study included middle-aged patients (25-60 years old) diagnosed with chronic schizophrenia (according to DSM-III) in the stage of stabilization. During the study, patients received injections of both depot antipsychotics every 4 weeks during the 9-month treatment period. The authors considered a dose of 200 mg of zuclopenthixol decanoate to be equivalent to 50 mg of haloperidol decanoate. The patient’s condition and its dynamics were assessed using the CGI, BPRS, UKU and SAS (Simpson-Angus Scale for Evaluation of Extrapyramidal Disorders) scales. The average doses used were 284 mg (100 to 600) Clopixol Depot and 92 mg (38 to 200) haloperidol decanoate. Both drugs in the course of the study showed equally high therapeutic activity; the total scores of the rating scales reflecting the severity of psychopathological disorders progressively decreased throughout the study, despite the fact that they were not initially high, because the patients were already in the stabilization phase.

In “chronic schizophrenia,” the systematic use of Klopixol Depo contributed to the reduction of both the overall BPRS score, which reflects the severity of the condition, and indicators for individual symptoms (hallucinations, delirium, depression, aggressive behavior). The effect of Clopixol Depo on negative schizophrenic symptoms was also noted.

Of undoubted interest are the results of the use of zuclopenthixol decanoate in the treatment of patients with schizophrenia in a hospital. If two foreign works dealt with “chronic paranoid schizophrenia”, then in one of the few domestic studies (G. Ya. Avrutskiy), Klopixol Depo influenced acute schizophrenic psychoses. Inpatient doses (up to 1000-1200 mg) were generally higher than those used in outpatient practice (200-400 mg), and the interval between injections was shorter (up to 1 week). In all these studies, Clopixol Depot showed high antipsychotic activity with a low severity of side effects. In one of the works, paranoid schizophrenia was recognized as the “best indication” for the drug. In a domestic study, Clopixol Depot surpassed haloperidol decanoate, moditen depot, and piportil L4 in terms of therapeutic efficacy [1].

Despite the long history of the use of deposited antipsychotic drugs, only a relatively small part of the research is devoted to the targeted study of the characteristics of their use in later life. The problem of treating elderly patients with symptoms of excitement (late paraphrenia, organic psychosis in dementia) with Clopixol Depo has been studied in the UK. The study, 24 weeks long, was carried out in an open way, it included 30 patients aged 65 years and older. To assess their condition, the following scales were used: BPRS, CGI, etc. Most of the patients received injections of zuclopenthixol decanoate at a dose of 50 mg (maximum 200 mg) every 2 to 4 weeks, which corresponded to 4 to 6 mg / day with daily oral administration. The results of the study showed that an improvement in the mental state was noted already after 3 weeks of treatment, which was expressed in a statistically significant (p <0.01) decrease in the total BPRS score, as well as indicators: “anxiety”, “thought disorder”, “agitation” and ” suspicion”. Side effects were rated in 4 categories: behavioral, extrapyramidal, autonomic, and allergic. The initial level of side effects in most patients was determined by the fact that before the appointment of depot – injections of Clopixol, they took other antipsychotics. Compared to baseline, there was a clear decrease in behavioral side effects during treatment with Clopixol Depo, other side effects did not undergo significant changes. Insomnia, stiffness and tremors were the most common. In 25% of patients, there were no side effects, while in the rest, the violations did not have any significant effect on the quality of life and adaptation. In 30% of cases, patients did not require concomitant treatment at all. Antiparkinsonian medications were used in 50% of patients and the researchers consider this to be acceptable, provided that such prescriptions should not be routine practice. In the future, the dosage of antiparkinsonian drugs was reduced by adjusting the dose of the neuroleptic.

Clopixol Depo has also shown itself to be effective in the treatment of behavioral disorders in persons with intellectual disabilities, while the side effects of the drug did not cause serious problems and did not interfere with treatment.
Selection of the optimal dose of Clopixol Depot

One of the most important tasks of psychopharmacotherapy is the choice of the optimal dose of the drug, i.e. dose that provides the maximum therapeutic effect with a minimum of side effects. In the chronic phase of the disease, this is achieved by using the minimum effective dose (MED), which is necessary to prevent the development of a relapse of the disease.

In Denmark, a study was conducted to determine the MED of zuclopenthixol decanoate and blood levels of the drug in the maintenance treatment of chronic schizophrenia. The MED averaged 200 mg zuclopenthixol decanoate every two weeks (60 to 400 mg) in the study. A statistically significant positive correlation was found between MED and corresponding serum drug levels. Achieving MED by gradually decreasing the dosage, according to the authors, can be not only a research task, but also be one of the aspects of the work of a practitioner, provided the minimum effective dose is correctly and carefully selected.
Co-injection of Clopixol Akufaz and Clopixol Depot

A significant part of patients with exacerbation of chronic psychosis (most often schizophrenia), which is stopped by Clopixol Akufaz, then needs long-term supportive treatment. Taking into account the pharmacokinetic characteristics and features of the clinical action of Clopixol Akufaz and Clopixol Depo, their joint administration in one syringe seems logical. The relief of acute manifestations of psychosis is carried out by Klopixol Akufaz, and by the time its effect is exhausted (4-5 days), Klopiksol Depot begins to act.

The theoretical prerequisites for the use of co-injection have been verified in clinical trials. In total, these studies involved 22 patients with exacerbation of psychosis (of which 18 patients with schizophrenia). In most cases, the first co-injection consisted of 100 mg of Clopixol Akufaz and 200 mg of Clopixol Depot. The duration of the first study was limited to 2 weeks; all patients received only one co-injection. A significant reduction in psychopathological disorders was observed, which was reflected in a decrease in the scores of the rating scales 1 and 2 weeks after co-injection, i.e. it was about a continuous 2-week therapeutic effect on psychosis. The protocol of the second study (10 patients with schizophrenia participated) was more complicated, it was allowed to use additional injections of Clopixol Akufaz (50-150 mg each) on days 3 or 7 after co-injection, 14 and 28 days after co-injection, repeated injections of Clopixol Depot were made (200 – 350 mg). A pronounced improvement in the condition was recorded as early as 3 days after the start of treatment (25% decrease in the total BPRS score, p <0.001). In the future, the condition continued to improve, by the end of 4 weeks, the reduction in the total BPRS score was more than 50%. Data on the side effects of such neuroleptic treatment are of considerable interest. The authors of the work concluded that, in general, side effects were quite rare, their severity, as a rule, was not significant. In one of the patients, on the second day after co-injection, acute dystonic reactions were observed, which required parenteral administration of antiparkinsonian drugs. In another case, dystonia, rigidity, hypokinesia, orthostatic dizziness were noted. One of the patients developed mild orthostatic dizziness on the 14th day after the start of treatment. Against the background of the use of correctors, the side effects disappeared completely, in none of the cases did they lead to the cancellation of Clopixol therapy. After the studies carried out, the method of treating psychosis by co-injection has become routinely used in a number of foreign psychiatric clinics.

Analysis of this literature review devoted to the experience of using various dosage forms of zuclopenthixol allows us to draw the following main conclusions:
The availability of a wide range of dosage forms of zuclopenthixol provides an optimal approach to the treatment of various forms of mental disorders at various stages of the disease.
Zuclopenthixol, especially in the form of Clopixol Akufaz, effectively relieves acute psychoses, including manic states and exacerbations of chronic psychosis, has high therapeutic activity against the most severe psychotic disorders, such as delusions, hallucinations, thought disorders, psychomotor agitation, aggressiveness, etc.
High therapeutic the effect of zuclopenthixol is combined with the safety of its use, associated with a low frequency and low severity of side effects.
The use of Clopixol Akufaz and co-injections of Clopixol Akufaz and Clopixol Depot, in fact, is a new approach to the treatment of acute psychoses.
The possibility of a relatively rare appointment of Klopiksol Akufaz (1 time in 2-3 days) provides a more humane and comfortable treatment of acute psychoses, reduces the risk of developing conflicts between the patient and the medical staff.
The presence of various dosage forms of zuclopenthixol makes it possible to carry out monotherapy – from the use of Clopixol Akuphaz in the acute period of the disease, to continuing treatment of the patient at the stage of convalescence, and then maintenance therapy with tablets or depot injections of Clopixol containing the same active substance (zuclopentixol). Monotherapy throughout the course of the disease provides the best therapeutic effect with a minimum of adverse events.

Mental cold

Posted on July 20, 2020  in Uncategorized

There are days, weeks and even months when there is a desperate lack of light, warmth, participation, when we are constantly out of sorts and no more sense from us than from a burned out light bulb. Seasonal depression, which experts figuratively call a mental cold, begins with a feeling of inner coldness and unrest – as if the electricity was cut off in the shower.

The anguish virus

Almost all people experience emotional recession in the cold season. “Erased forms of seasonal depression are found in two out of five Russians,” warns Nina Ivanovna Andrienko, a neuropsychiatrist at the Medical Diagnostic Center of the Western District of Moscow. – And 6% of the population show such obvious symptoms of “mental cold” that they need the help of a specialist. The reason for the blues is a long winter with a typical vitamin deficiency and a short daylight hours, aggravated by eternal bad weather. Under conditions of light starvation, the brain does not have time to produce a sufficient amount of the hormone melatonin, which regulates the emotional tone and biorhythms of the body. But work capacity, endurance, sleep, mood and health of a person depend on this.

According to the Meteorological Observatory of the Moscow State University, in recent years, due to abnormally warm and rainy winters, sunlight in the capital region has become 4 times less than the seasonal norm. At the same time, the snow cover does not set for a long time, which reflects 70-90% of the rays, compensating for short days of light. So even mentally healthy people are depressed by the lack of sun and lack of snow.


“Control your mood, – called on contemporaries Horace, – for it, if it does not obey, then commands you.” The English proverb says the same: “The events of your life directly depend on your mood.” Therefore, do not miss the first symptoms of mental bad weather!

The hallmark of seasonal depression is unreasonable sadness, depression, apathy, irritability, fatigue, drowsiness, and also “refrigerator syndrome” – constant hunger with all the ensuing consequences for the figure. True, only those who are already inclined to be overweight, accustomed to seizing troubles with sandwiches and cheering up with sweets, get fat from melancholy. But for thin victims of seasonal despondency, appetite can be lost.

A signal of the onset of depression often becomes pain – in the neck, back, abdomen, chest, arms, legs, but more often headache. Remember in Pushkin – “I don’t like spring – I’m sick in spring”? Quite a strange confession in the mouth of a poet who, according to the recollections of his contemporaries, was distinguished by enviable optimism! Yes, just in the spring, mental discomfort is easily transformed into physical: if the nerves are not put in order, the pathological condition will be fixed and the body will begin to fall apart. The test will help you distinguish depression from bad mood.


In front of each statement, put a letter corresponding to your feelings: A – no or very rarely, B – periodically, C – often, D – yes or constantly recently. Following the table, select the appropriate number of points for each letter and calculate them.

1st group of statements:
You are sad, sad, sad.
Sometimes you want to cry for no reason.
Sleep poorly.
Losing or, on the contrary, gaining weight.
Complain of constipation.
Disturbed by attacks of rapid heartbeat.
You get tired quickly.
Due to anxiety, you cannot sit still.
The nerves are strained to the limit.
We are convinced that if you suddenly disappear, no one will notice it.

2nd group of statements: You
feel good in the morning.
Eat the same amount as usual.
You will not deny yourself the pleasure of flirting with an attractive man.
Provide fresh ideas on demand.
Everyday life and office routine do not irritate you.
Look to the future with hope.
Easy to make decisions.
You feel that your family needs you, that you are irreplaceable at work.
The feeling of fullness of life does not leave you.
Everything that was pleasing before is enjoyable now.


For the 1st group: A – 1 point, B – 2 points, C – 3 points, D – 4 points.

For the 2nd group: A – 4 points, B – 3 points, C – 2 points, D – 1 point.

Evaluation of the results

Add up the numbers obtained for both groups and estimate the level of depression.

From 20 to 49 points is the norm. You do not have depression, and that your mood periodically spoils – it’s not surprising. It’s natural to be sad, sad, and upset when difficulties arise.

From 50 to 60 points – borderline state. You try not to become limp because of troubles,
do not attach importance to them. But experiences driven into the subconscious lead to depression. You need to react to negative emotions! Do not hesitate to shed tears, consult a psychologist.

From 61 to 80 points – you have depression. This serious illness must be treated by a specialist. Such a state weakens and depletes, deprives one of working capacity, destroys relationships with others and ultimately breaks life. Seek help from a psychotherapist, neurologist or psychiatrist!

EAT FRUIT OF JOY. Prolonged bad weather depletes mental energy, and the fruits of sunny shades – yellow, red, bright orange – replenish it, feeding the brain with glucose, vitamins, magnesium (dark chocolate is also rich in them) and other essential substances. Just before you eat an orange, mango, banana or apple, admire them: this also lifts the mood!
LET’S ADD BRIGHT COLORS. And not only in the details of clothing, but also in the interior. Don’t skimp on electricity by choosing the right lighting. Lamps that spread a deathly white, bluish and greenish glow cause subconscious irritation. Artificial light should be soft, warm shades – in a yellowish range.
LOAD MUSCLES. Start your day jogging or exercising and end up in the pool or gym.
RELAX! Go to the movies, theaters, travel. Scientists explain the tendency to seasonal depression by the excessive activation of brain areas that receive information from the outside at this time of the year. But the zones responsible for making decisions and actions are inhibited. Because of this bias, the normal cycle “perception – activity” is disrupted, and emotions that do not find a way out begin to put pressure on the psyche, leading to depression.
RESTORE CONTACTS! “Companionship is one of the most effective drugs for depression,” says London-based physician Tyril Harris. He suggested that patients replace tranquilizers with communication with a friend. Her role was played by a female volunteer. She regularly visited her wards, drank tea with them, went to the cinema and to concerts. Within a year, 72% of women felt better, in contrast to the control group, where only 45% were cured with antidepressants. Thanks to communication, many patients were able to make peace with their lovers, relatives and friends, and found interesting jobs. “The recognition and respect made these women change their attitude to the world, to themselves and get rid of depression,
” says Dr. Harris.
NO – LOW CALORIE DIET! A lack of carbohydrates and the need for restriction make depression worse. Given the special seasonal circumstances, do not deny yourself the pleasures. When you really feel like it, eat a slice of cake. Just 150-200 grams of carbohydrate-rich food is enough to invigorate.
YES – TO PRODUCTS INCREASING MENTAL IMMUNITY. These are feijoa, irgi fruits, seaweed and fish, oysters, mussels, hazelnuts and almonds. Prepare a natural antidepressant by rubbing walnuts with honey (1: 1). Take the mixture in a teaspoon one hour before meals 3 times a day for 3 weeks.
LESS COFFEE AND BLACK TEA. They contain caffeine and theobromine – substances that sharpen emotions (including negative ones!). They displace adenosine from receptors in the brain, which the nervous system produces to calm down and get rid of depression.
SOOTHING NERVES. Drink green or herbal tea. To prepare the latter, take an equal amount of St. John’s wort, hawthorn flowers and chamomile. Pour a teaspoon of the collection with a glass of boiling water and leave under the lid for 15-20 minutes.
FRAGRANCES OF GOOD MOOD. To increase the body’s energy reserves, take a teaspoon of fragrant violet flowers and poplar buds, 2 teaspoons of rowan and strawberry leaves, 3 teaspoons of currant leaves. Brew 3 tablespoons of the mixture with 1 liter of boiling water overnight in a thermos. In the morning, spray a fragrant rain from a flower spray. Do this throughout the day.


Have you ever wondered why birds in early spring rush to our winter homeless lands from the fertile southern latitudes? Why can’t they stay warm? And they return to the first drop to drink melt water, without which the reproduction of birds is impossible. Having become interested in this problem, scientists have found that it is a universal antidepressant, given to us by nature.

In the streams spreading out from under the sagging snowdrifts, unlike tap water, there is no deuterium – a special isotope of hydrogen. The molecules of ordinary water weighted with it hardly pass into the openings of cell membranes and hinder metabolic processes, including in the cells of the brain. Considering that our body is 65% liquid, it becomes clear that by freeing the body from deuterium, you can increase the production of hormones of joy and adapt more easily to spring. Research shows that melt water effectively fights the manifestations of spring depression. And it is not necessary to substitute the cup under the March drops. You can prepare melt water at home.

METHOD FIRST. Fill a wide bowl with filtered raw water and place in the freezer. When it starts to freeze, remove the newly formed crust of ice from the surface – it is in it that harmful deuterium accumulates. After the bulk of the water has solidified, rinse a piece of ice under a cold tap from the tap to remove impurities that have floated to the surface – the ice will become completely transparent. Now melt without heating, and drink a glass of melt water 2-3 times a day, and also prepare meals and drinks on it.

METHOD SECOND. Heat 2-3 cups of filtered raw water in a saucepan over low heat to 94-96 °. In this state, the water does not boil yet, but it is already in full swing (bubbles rise from the bottom in streams). Remove the pan from heat and chill quickly on the balcony or outside the window. When the water has cooled, pour it into a wide bowl and place in the freezer. And then do everything in the same way as in the first recipe.

This method is more complicated, but its advantage is that water sequentially goes through all the phases of the usual cycle in nature: it evaporates, cools, freezes and melts. Experts believe that such water is especially useful – it has enormous internal energy, which is so necessary in case of a decline in mental strength.


Massage them clockwise with the tip of your index finger several times a day. Knead paired points (they are marked with asterisks) at the same time, the rest – in turn.
YIN-TAN (“LBA LINE”) – above the bridge of the nose in the middle between the eyebrows.
SHEN-TING (“THE BODY OF THE SOUL”) – along the midline of the forehead 1 cm above the front border of hair growth.
TOU-WEI (“HEAD KEEPER”) – 1 cm above the angle of the front hairline (where the forehead passes into the temple).
TAI-YAN (“SUN”). Press the upper phalanx of the thumb to the outer edge of the eye socket – its pad will be on the “sunny” point.
Bai-huei (“superior connection”). Look for this point at the top of your head.
TSZU-SAN-LI (“POINT FROM A HUNDRED DISEASES”). Sit on a chair, place your palm on your knee, fingers relaxed and slightly apart. The nameless pad will indicate the desired point.

The heptral phenomenon: Depression, withdrawal symptoms, cholestasis, arthralgia: a pharmacologist’s view

Posted on July 16, 2020  in Uncategorized

In the etiology of mental disorders, biological methylation processes play a key role. The main source and effective donor of methyl groups in the central and peripheral nervous system is ademethionine (heptral “) – an active sulfur-containing metabolite of methionine, a natural antioxidant and antidepressant that is formed in the liver in an amount of up to 8 g / day and is present in all tissues and body fluids, and most of all – in places of education and consumption, i.e. in the liver and brain.
In this regard, two particularly important biochemical processes in the liver are the synthesis of methionine and S-adenosyl-L-methionine by methylation of homocysteine. The enzymes S-adenosyl-methionine-synthetase and methionine-adenosyl-transferase (MAT) are involved in the formation and functioning of ademetionine. The latter is encoded on two genes – MAT1A and MAT2A, catalyzing the formation of SAM, and only MAT2A expression is associated with faster cell proliferation.
The circular DNA of human SAM synthetase includes 3217 nucleotides encoding a protein of 395 amino acid residues with a molecular weight of 43 647 daltons. In the messenger RNA of the human genome, a single region is responsible for the coding of this protein, and the structural features of the liver-specific S-adenosylmethionine synthetase gene in humans and rats turned out to be quite similar.
The idea of ​​using SAM as an independent drug (MP) is based on qualitative and quantitative correlations of the severity of mental and somatic disease states in humans and animals with the doses and content of SAM in normal or pathologically altered target tissues of the body.
The purpose of this information and analytical review is more pragmatic and consists in generalizing and comparing the observed clinical efficacy and safety of Heptral with existing drugs prescribed for the same indications. The most important and recognized of these indications are exogenous and endogenous depression, alcohol withdrawal, liver disease and arthralgia.
Sources of information
1. Medical and biological data of the Internet (Medline, Pubmed, etc.).
2. Thematic abstract journals of VINITI RAS.
3. Systematic reviews of the Cochran library (Oxford, UK) for 1984-2000.

Heptral – an antidepressant The
relative harmlessness of Heptral made it possible to assess its effect on the vital signs of healthy people. In particular, the heart rate and the concentration of adrenaline in the plasma of healthy subjects moderately decreased against the background of daily administration of 400 mg of heptral for a week as well as under the influence of MAO inhibitors, but the plasma MHPG level did not depend on the intake of heptral. An increase in the level of adrenaline when changing the position of the body from horizontal to vertical was easily stopped by taking Heptral, which indirectly confirms that it has antidepressant properties.
A statistical generalization (meta-analysis) of the results of 19 comparative clinical trials involving 498 depressed patients of varying severity made it possible to establish a reliable, 38-60%, increase in the antidepressant activity of heptral over placebo activity and the coincidence of its intensity with the antidepressant effects of standard tri- and heterocyclic drugs – imipramine, desipramine, amitriptyline and others with almost complete absence of their inherent side effects.
In standard clinical trials, Heptral was statistically significantly superior in efficacy to placebo and tricyclic antidepressants in recurrent endogenous and neurotic depression resistant to amitriptyline, differing from them in the ability to interrupt relapses and in the absence of side effects.
Almost all researchers note a more rapid development and stabilization of the antidepressant action of heptral (weeks 1 and 2, respectively) compared to standard drugs, especially with parenteral administration. In particular, in an open multicenter clinical study of 195 depressed patients, remission occurred after 7-15 days of parenteral administration of heptral at 400 mg / day, and when combined with tricyclic antidepressants, the effects were much faster and more pronounced than when combined with placebo. It should be noted that with an exacerbation of depressive symptoms, the level of ademetionine in the blood and tissues decreases, which requires an increase in dosages.

Heptral with withdrawal symptoms
The experience of testing and using heptral for alcohol withdrawal and opium addiction is apparently quite limited, since there are no English-language publications on this topic in available Internet databases. The following are the main results of two domestic clinical trials of Heptral, conducted in the Department of Clinical Psychopharmacology of the Research Institute of Narcology of the Ministry of Health of the Russian Federation (Director of the Research Institute, Corresponding Member of the Russian Academy of Medical Sciences, Prof. N. N. Ivanets) and at the Central Research Institute of Gastroenterology and the 17th Narcological Hospital in Moscow .
1. Heptral for alcohol withdrawal
Stopping the habitual consumption of alcohol is fraught with fatal complications. Clinically, alcohol withdrawal is manifested by tremors, hallucinations, seizures and delirium, infectious and somatic diseases and injuries. Symptoms appear after a few hours and gradually disappear within 2-3 days. Alcoholic delirium usually develops in 5-10% of cases after 3-4 days and also includes trembling, agitation, confusion, loss of orientation and a sharp increase in autonomic activity – fever, tachycardia and profuse sweating; lethality is about 5%. Convulsive seizures are quite rare, occur 12-48 hours after alcohol withdrawal and are usually generalized; their number is small and they are stopped by conventional drugs.
The aim of the study was to study the hepatotropic effect and effectiveness of Heptral in the treatment of depressive disorders and pathological craving for alcohol (with alcohol withdrawal syndrome) in an open-label study.
Examined 20 alcoholic men 30-60 years old with a disease duration of 6-25 years, 12 of them – with hereditary burden. All patients were diagnosed with stage II alcoholism: with a predominance of the pseudo-bore form – in 14, a constant form against a background of high tolerance – in 6 patients.
All of them had diagnostic criteria for stage II alcoholism: primary pathological craving for alcohol, a pronounced symptom of “loss of control”, maximum alcohol tolerance, fully formed alcohol withdrawal syndrome (AAS) – morning intoxication, altered patterns of intoxication combined with amnesia during the period of intoxication, aggravation premorbid character traits, adverse social and somatic consequences of the disease.
AAS was accompanied by the usual somatovegetative and psychopathological disorders. The severity of AAS was regarded as mild in 6 and moderate in 14 patients, with a Hamilton score of at least 14 points, which was a criterion for inclusion in the study along with a pathological attraction to alcohol and liver pathology. All patients had an enlarged liver, 17 were diagnosed with alcoholic fatty hepatosis, and 3 had chronic alcoholic hepatitis.
Heptral was prescribed in 2 parenteral bottles (800 mg) for 2 weeks. and then 1 tablet (200 mg) 4 times a day for the next 2 weeks. Along with Heptral, vitamins of groups B and C were prescribed and, if necessary, antihypertensive drugs (magnesium sulfate) and benzodiazepines (only at night) in the first 2 days.
Results. The therapeutic effect was noted on days 2-4 of treatment. Fear and anxiety disappeared, irritability decreased, asthenia decreased and physical condition improved, blood pressure returned to normal, appetite appeared, tremor and hyperhidrosis disappeared. By the end of the week, mood was leveled, sleep was restored, depressive symptoms decreased by 60-70%, and after 4 weeks depressive disorders were completely stopped. Craving for alcohol decreased on average by the 10th day. On the scale of general impression, the results were assessed as significant improvement within the framework of depression and as moderate – in relation to craving for alcohol and hepatotropic action (a trend towards positive dynamics of liver function and a decrease in its size). The drug was well tolerated and there were no side effects, complications or addiction to it.
In the instructions for the use of heptral, it is recommended to prescribe it for intrahepatic cholestasis induced by liver lesions of various origins, cirrhotic and precirrhotic conditions, encephalopathies of secondary genesis, depressive syndromes (including secondary) and with withdrawal syndrome.
Heptral is contraindicated in case of individual hypersensitivity to it, in the first two trimesters of pregnancy and lactation. In cirrhotic and precirrotic conditions associated with hyperazotemia, heptral oral administration should be carried out under medical supervision and nitrogen level control. Heptral is not recommended for children without strict indications. No interactions of heptral with other drugs were observed and no clinical cases of overdose were noted.
2. Heptral for opiate withdrawal
Under the observation were 20 male patients 17-38 years old with a diagnosis of “opium addiction of the 2nd degree, withdrawal symptoms” and with a disease duration of 1-22 years; in 50% of cases, the course of drug addiction was aggravated by taking diphenhydramine (1-2 tablets per drug injection). Treatment consisted of administering Heptral intravenously, 800 or 1600 mg / day in the first 14 days and 1600 mg / day in tablets for the next 14 days. We observed an improvement in the functional state of the liver and stimulation of microsomal oxidation processes, expressed in increased clearance and accelerated elimination of the marker preparation of antipyrine. The reverse development of clinical manifestations of abstinence and a distinct antidepressant effect was also noted.

Heptral is a hepatoprotector
Most of the etiological factors of intrahepatic cholestasis inhibit the activity of S-adenosylmethyl synthetase and reduce the production of S-ademethionine, which is accompanied by a violation of biochemical processes in hepatocytes – transmethylation and trans sulfidation. As a result, they decrease: the content of phospholipids, the activity of Na + K + -ATPase and other carrier proteins, membrane fluidity, capture and excretion of bile components, cellular reserves of thiols and sulfates (glutathione, taurine, etc.), which have a pronounced antioxidant effect and are the main substances in detoxification of endogenous and exogenous xenobiotics. Deficiency of these products leads to cytolysis of hepatocytes in cholestasis of any genesis.
The clinical manifestations of cholestasis are quite the same, these are:
1. excessive intake of bile elements in the blood;
2. a decrease in the amount or absence of bile in the intestine;
3. The effect of bile components on liver cells and tubules.
Regurgitation of bile into the blood induces pruritus, jaundice, xanthomas, xanthelasmas, darkening of urine, and systemic lesions:
acute renal failure;
the development of ulcers, erosions and bleeding in the stomach;
increased risk of endotoxemia and septic complications.

At the same time, a deficiency of bile in the intestine is fraught with steatorrhea and malabsorption syndrome, a deficiency of fat-soluble vitamins, and impaired bone mineralization. An excess of bile components leads to necrosis of hepatocytes and tubules and to liver cell failure, and with prolonged cholestasis cirrhosis forms with the development of ascites, edema, and hepatic encephalopathy. Often cholestasis (for example, drug) is asymptomatic and its only manifestation is the results of biochemical liver tests.
The etiological effect on cholestasis is problematic, and most patients are prescribed pathogenetic and symptomatic treatment. Heptral is the drug of choice in most cases for the following mechanisms and causes of cholestasis:
Decreased fluidity (permeability) of the basolateral and / or canalicular membrane of hepatocytes during pregnancy, alcoholic and medicinal liver damage.
Inhibition of Na + K + -ATPase and other membrane carrier proteins in drug and / or bacterial liver damage.
Destruction of the cytoskeleton of hepatocytes, impaired vesicular transport in viral, alcoholic and drug hepatitis, cirrhosis, endotoxemia, sepsis, benign recurrent cholestasis.
Violation of the integrity of the tubules (membranes, microfilaments, cellular compounds) under the influence of drugs, oral contraceptives, bacterial infections, Beiler’s disease.

Clinical trials:
1. In an open clinical trial, heptral treatment of alcoholic liver diseases (34 people) for 14 days with an intravenous drip of 800 mg / day, and in the next 14 days, 400 mg / day 2 times inside (tablets) led to the disappearance of signs depression, improvement of biochemical and physical (liver density) indicators.
2. Treatment of 23 patients with chronic hepatitis C with interferon a2 was accompanied by the development of cholestatic and depressive syndromes. Signs of cholestasis were manifested in the first 3 months of treatment and especially clearly in patients with cirrhotic transformation of the liver. The inclusion of Heptral in the complex of therapy helped to timely stop depressive and cholestatic phenomena and to conduct a full course of antiviral therapy with interferon a2.
3. In the treatment of 8 patients with medicinal lesions of the liver, an improvement in the general condition and normalization of liver tests were observed.
4. Heptral was prescribed to 32 patients with chronic diffuse liver diseases and intrahepatic cholestasis, 16 of whom had primary biliary cirrhosis. During the first 16 days of phase I of treatment, Heptral was injected intravenously at 800 mg / day, and in the next 16 days – 1600 mg / day. Most patients showed a pronounced positive effect – the symptoms of asthenia, skin itching, jaundice, as well as a statistically significant normalization of biochemical parameters disappeared. In patients with primary biliary cirrhosis, there is a tendency to lower cholesterol and bilirubin in the blood. With repeated courses, heptral tolerance and a lack of resistance to its positive effect were noted.

Heptral – an analgesic
Osteoarthrosis is a degenerative joint disease characterized by progressive catabolic loss (“wear”) of articular cartilage due to an imbalance between the synthesis and degradation of cartilaginous proteoglycans, followed by bone growths along the edges of the articular surfaces. It mainly develops in the elderly, but can occur at any age, especially as a result of trauma, chronic inflammatory diseases, and congenital joint defects. Most often, the distal and proximal interphalangeal joints of the hands, the hip and knee joints, the cervical and lumbar spine are affected. Spondyloarthrosis sometimes leads to narrowing of the spinal canal (caudogenic intermittent claudication), pain in the legs and buttocks when standing or walking. It is accompanied by severe bone and muscle pain.
The goal of therapy is to relieve pain and prevent disability. The use of non-steroidal anti-inflammatory drugs (NSAIDs) can provide short-term pain relief, but with prolonged use, harmful side effects (eg, gastric bleeding) develop and cartilage loss increases. The empirical use of Heptral in osteoarthritis has led to analgesia comparable to NSAIDs with no side effects, as well as to stimulation of proteoglycan synthesis and partial regeneration of cartilage tissue.

Conclusion The
possibilities of heptral, alone and in combination with other drugs, in the treatment of depressive disorders are far from exhausted. As already noted, in the available Internet databases there are no English-language publications on the treatment of heptral withdrawal symptoms, and in a random sample of 18 domestic articles, only non-steroidal anti-inflammatory drugs were used in the treatment of arthralgia. There is a further study of the effectiveness of Heptral in the treatment of affective disorders, inhibition of prolactin secretion, etc. Pharmacokinetics has not been studied at all, although the relationship of the antidepressant efficacy of ademetionine with its concentration in blood and tissues appears explicitly or implicitly in many studies, which suggests the possibility of searching for optimal treatment regimens among existing … So far, it has been possible to find out that its transport through the villi of preparations of the human placenta proceeded rather slowly, like passive diffusion of L-glucose, and was accompanied by non-enzymatic conversion to a metabolite of an unknown structure. The transport of melatonin and its antipyrine marker drug proceeded most rapidly, while vitamin E diffused 10 times slower than L-glucose and ademethionine, but its non-racemic free forms were much faster. Measurable concentrations of ademetionine after parenteral administration were found in CSF in patients with senile dementia, which gives hope for new possibilities in the treatment of this and other neurodegenerative diseases with heptral.

Paroxetine in the treatment of anxiety and depressive disorders in somatic patients

Posted on July 12, 2020  in Uncategorized

Anxiety is an integral part of the clinical picture of mental, neurological and somatic disorders. Being a clinical phenomenon of psychopathological manifestations, it is closely related to other symptoms and, as a rule, to the greatest degree determines the level of psychosocial maladaptation.

Central to a series of anxiety-phobic disorders is panic disorder. Over the course of a lifetime, 10-20% of the population will experience one or more panic attacks. Panic attacks – an unexpectedly arising and quickly, within a few minutes, growing symptom complex of vegetative disorders (vegetative crisis – palpitations, chest tightness, a feeling of suffocation, lack of air, sweating, dizziness), combined with a feeling of impending death, fear of loss of consciousness, loss of control above oneself. The duration of panic attacks is variable, with an average of about 30 minutes. In 2.7% of the population, panic attacks are combined with agoraphobia. Social phobias (fear of shame and confusion in the presence of other people) affect 3-5% of the population. Specific phobias (fear of certain diseases, specific objects, situations, actions) are more common than social ones; patients, according to various sources, comprise 5-12% of the population. Generalized anxiety disorder occurs in 2-5% of the population. These people become disabled very quickly, and in most cases they do not immediately fall into the field of vision of psychiatrists, moving from a local doctor to a neuropathologist and other specialists. In the beginning, the diagnosis of vegetative-vascular dystonia is most often made, then diencephalic crises.

According to our data, the incidence of clinically significant depression among inpatient therapeutic patients is 31.5%, depressive disorders are divided into three groups: psychogenic – 46.1%, somatogenic – 36.4%, endogenous – 17.5%. At the same time, about 35% of patients in outpatient practice with unclear somatic diagnoses also suffer from larvae (somatized) depression.

Somatized depression, disguised as somatovegetative disorders, often lead to errors in diagnosis. Deterioration of the patient’s mental state, markedly reducing stress tolerance, leads to deterioration of the somatic state and, accordingly, improper treatment of the patient.

The adaptive role of anxiety is characterized by a number of physiological shifts that prepare the body for a quick response to danger: the release of adrenaline increases, the sympathetic system is activated, resulting in an increase in blood pressure, an increase in blood flow in the muscles and brain, and blood glucose levels increase in order to create the most favorable for these systems. conditions for activity.

These and other physiological changes are clearly adaptive in nature, but they, with excessive strength and duration, can be the cause of somatic disasters and diseases: heart attack, stroke, hypertensive crisis.

Given the nature of neuroendocrine reactions, anxiety can be defined as a mental component of stress. An inadequately severe anxious reaction to a traumatic situation can occur if the person has a low threshold for anxious response. A possible reason for this may be the insufficient activity of the GABA-ergic system and, in particular, the GABA-benzodiazepine receptor complex. In another type of anxiety disorder, panic attacks, patients have a reduced GABA content in the occipital lobe of the cerebral cortex (A. Goddard et al., 2001) and there is a genetically determined change in benzodiazepine receptors. This is why benzodiazepine tranquilizers are not effective enough in treating panic disorder.

The drugs of choice in these cases are selective serotonin reuptake inhibitors (SSRIs). SSRIs – a group of drugs that are heterogeneous in chemical structure. These are one-, two- and multicyclic drugs with a common mechanism of action: they selectively block the reuptake of serotonin only, without affecting the uptake of norepinephrine and dopamine,
and do not affect the cholinergic and histaminergic systems. The true “champion” in serotonin-positive effect is paroxetine, which has the most balanced effect. The advantage of paroxetine, compared with tricyclic antidepressants, which are most often used by general practitioners, is its safety for patients with somatic and neurological pathology, the elderly. Paroxetine can also be used on an outpatient basis.

An increasing amount of data shows that paroxetine, as a dual-action drug (anxiety and depression), has inherited high efficacy and good tolerance (minimum side effects) from previous generations of antidepressants, it acts against a wider range of symptoms of anxiety and depression.

The mechanism of action of paroxetine is based on its ability to selectively block the reuptake of serotonin (5HT) by the presynaptic membrane, which is associated with an increase in the free content of this neurotransmitter in the synaptic cleft and an increase in the serotonergic effect in the central nervous system, which is responsible for the development of the thymoanaleptic (antidepressant) effect. Paroxetine has low affinity for m-cholinergic receptors, a- and b-adrenergic receptors, as well as for dopamine, 5HT1-like, 5HT2-like and histamine H1 receptors.
The main components of the profile of the psychotropic activity of paroxetine are antidepressant and anti-anxiety effects with a moderate stimulating (activating) effect. In the series of serotonergic drugs, paroxetine is the most powerful and one of the most specific serotonin reuptake blockers.

Paroxetine has therapeutic efficacy even in those patients who did not respond adequately to previous standard therapy. The patient’s condition improves within 1 week after the start of treatment. Taking paroxetine in the morning does not adversely affect the quality and duration of sleep. Moreover, with effective therapy, sleep should improve. During the first few weeks of taking paroxetine, it improves the condition of patients with anxiety or depressive disorders of various origins. Paroxetine has minimal side effects. Treatment with paroxetine is characterized by low severity and rarity of unwanted symptoms, which determines the good tolerance of the drug and the willingness of patients to take paroxetine for a long time as maintenance therapy.

Thus, we can say that, having a pronounced thymoanaleptic effect, paroxetine is a balanced antidepressant and equally reduces both symptoms of anxiety and lethargy.

Therapy for schizophrenic (schizoid) reactions

Posted on July 8, 2020  in Uncategorized

Despite the numerous studies and the diversity of the concepts of schizophrenic reactions (SR), there is still no unity of views on the clinical boundaries of this concept, and the research criteria for reactive states, the atypia of which is due to the inclusion of procedural manifestations, are still a subject of discussion. The existing disagreements to a certain extent reflect the position of the SR in ICD-10, in which psychogenias of this circle can be classified in the diagnostic sections “Schizotypal disorder” – F21 and “Acute and transient psychotic disorders” – F23. At the same time, in order to classify non-psychotic level SRs to the first of these diagnostic categories, it is not necessary to have a connection with traumatic influences (only in the domestic version of the classification, SRs in this understanding are distinguished by a separate heading – F21.2). At the same time, section F23, which includes, as a priority, the association of psychopathological disorders with stress, does not include disorders whose severity does not reach the degree of acute psychosis (within this category, “Acute polymorphic psychotic disorder” – F23.1; “Acute schizophrenic-like psychotic disorder “- F23.2).
The concepts of the development of psychogenias in schizophrenia, the origin of which dates back to the beginning of the 20th century, were based on the assumption of the existence of a special type of reactive lability, which is formed under the influence of an endogenous process. There was even a separate type – “reactive schizophrenia” [Berze J., 1929], in which, as a result of the impact of mental trauma, a latent schizophrenic process manifests itself as “schizophrenic-psychotic processing of experiences”. Further studies of psychogenias in procedural diseases are based on the idea of ​​the existence of prerequisites in the form of increased readiness for reactions depending on the stage of schizophrenia. It was established that the greatest vulnerability to stressful effects is observed mainly in the initial and post-process periods. In the acute phase of the process, the condition of patients is less affected by psycho-traumatic events [Kantorovich N.V., 1967], while special sensitivity to stress during stabilization can be due to a pathologically altered “soil” with the formation of pseudopsychopathy [Melekhov D.E., 1934] …
As a result of a targeted study of psychogenias in low-grade schizophrenia, A.B. Smulevich (1987), along with SRs that occur simultaneously with the manifestation or entail an exacerbation of the endogenous process, highlighted a variant in which SRs, preferred for patients with residual pseudopsychopathic conditions, are not associated with exacerbation of schizophrenia. According to the author’s observations, this type of SR develops in patients with residual pseudopsychopathic conditions.
It should be emphasized that if the idea of ​​schizophrenia (or schizoidia) as a necessary condition for the formation of SR, which has developed since the time of E. Bleuler [1920], does not cause any particular controversy, then the one put forward in the few works of domestic authors [Melekhov DE, Chernoruk V. G., 1933], not all researchers share the point of view about the possibility of such reactions “on the basis” of personality disorders, not only schizoid, but also of other types.
At the same time, this possibility can be considered in the analysis of modern concepts of schizotypal and borderline personality disorders (PD). Although schizotypal PD largely corresponds to the characteristic of latent schizophrenia in the traditional sense, and borderline one combines deviations, the main features of which are impulsivity with inconstancy of interpersonal relationships, inability to adequately assess reality, affective instability with episodes of dysphoria, irritability, anxiety, tendency to auto-aggressive behavior and disorders drives, their common characteristic is increased vulnerability to psychogenic influences, which is realized by atypical depressive states, obsessive, dissociative disorders and “brief psychotic episodes” or “mini-psychoses” [Kernberg OF, 1967; Gunderson JG, 1975; Paris J., 1999].
This interpretation of SR as clinical structures identified not only by signs of psychogenic provocation and the presence of schizophreniform symptoms contributes to the development of optimal approaches to the treatment of such conditions.
Some of these approaches were developed on the basis of data obtained in the course of a study devoted to the analysis of therapy in patients hospitalized for SR in the clinic of borderline mental pathology and psychosomatic disorders (headed by Academician A.B.Smulevich) of the National Center of the Russian Academy of Medical Sciences.
In the studied patients, a reactive state was verified, which arose against the background of a diagnosis of schizophrenia established in accordance with ICD-10 (“residual” – F20.5, “latent” – F21.1) or PD (“schizotypal personality disorder” – F21.8, ” paranoid personality disorder ”- F60.0,“ borderline type of emotionally unstable personality disorder ”- F60.31). Acute or prolonged mental trauma preceded psychogenesis in the studied sample, in response to which a depression of moderate or mild severity was formed, the content of which was determined by the psychogenic (catatomic) complex. Along with hypotension, other psychopathological disorders (anxiety-obsessive, dissociative, hallucinatory-paranoid) that were heterogeneous with respect to affective ones were also recorded in the clinical picture.
The results of the study allow us to assert that when choosing a method of therapy for SR, it is necessary to take into account, on the one hand, the level of psychopathological disorders (neurotic-psychotic, and on the other hand, interaction with personality (ontogenetically or procedurally determined – psychopathy / pseudopsychopathy) pathology.

Two types of reactions schizophrenic
Depending on the level of psychopathological disorders and comorbid structure constitutional or acquired (residual schizophrenia) personal pathology are two main types of shunt reactor distinguished:
1. SR arising in patients with borderline, schizotypal (including latent schizophrenia) or paranoid RL occurring with the formation of transient psychotic episodes (mini-psychoses) of the type of “outbreaks of hereditary deviants” and are closely interrelated with the psychopathic structure that was formed in the period preceding mental trauma.
2. SRs arising in patients with residual schizophrenia within the framework of a persistent pseudopsychopathic state, proceeding with the formation of psychopathologically homogeneous disorders of a predominantly neurotic level, which are realized within the resources of a personality altered by a progressive endogenous process without the addition of symptoms of more severe registers.

The first type of SR
In the first type of SR, reactive states, although they have the basic signs of true psychogeny, i.e. arise in connection with objectively significant stressful influences (death of loved ones, betrayal, divorce, loss of work), and the psychogenic complex remains relevant throughout the reactive state, differ in a number of significant features.
The clinical picture of reactive states of this type is determined by the combination of a shallow (hysterically dysphoric or anxious) depression of psychogenic content with patho-characteristic (impulsiveness, demonstrativeness, explosiveness) and polymorphic subpsychotic disorders. A characteristic feature of the latter part of the cases is the coexistence of dissociative disorders (pseudodementia, magical thinking, delusional fantasizing), catatimically charged imagery and hallucinations of the imagination, reflecting a traumatic situation, and psychologically irreducible deceptions of perception (calls, haptic, olfactory hallucinations). In other cases (in individuals of a paranoid warehouse with an unshakable conviction of their own rightness, perseverance, determination to achieve a goal, uncompromisingness), in the process of developing psychogeny, the homonymous to obligate properties of the RL are unstable, unsystematized delusions overlap with the anxiety-obsessive form polar with respect to the structure of the RL “Madness of doubt.”
Such reactions are reversible, do not show a tendency to a protracted course (their duration does not exceed several months) and are not accompanied by an exacerbation of the endogenous process with an increase in negative changes in the schizophrenic type.

Therapeutic approaches for type I SR The
therapeutic approaches for this type of SR correspond to the characteristics of both psychopathological disorders that determine the structure of the reaction as a whole (affective – reactive depression), and optional subpsychotic formations.
As a rule, combined therapy is carried out (antidepressants in combination with antipsychotics), and due to the fact that in the clinical picture throughout the pathological reaction the most stable component is hypotension, the main place in the treatment regimen is given to antidepressants, which is consistent with data from other authors. Preferred drugs of the group of selective serotonin reuptake inhibitors (SSRIs), prescribed in high doses (fluoxetine 60-80 mg / day; fluvoxamine 300 mg / day). The appropriateness of using SSRIs is explained in the literature [Coccaro EF, 1996; Paris J., 1999] not only with a favorable tolerance profile and a wide therapeutic range of doses for this group, but also with high lethal doses, which ensures their safety in patients with a risk of impulsive suicidal behavior.
Given the affective instability, the propensity of patients with this type of reaction to repeated depressive conditions, the use of normotimics (carbamazepine, lithium carbonate) is justified.
Subpsychotic manifestations in the picture of psychogenicity are stopped by neuroleptics. At the same time, the corrective effect of the agent of this class on pathocharacterological disorders is also used. Traditional antipsychotics are prescribed taking into account the transient nature of the hallucinatory-paranoid register disorders and the flotating nature of anxiety-obsessive manifestations in low doses (a series of controlled studies have shown the effectiveness of non-injection forms of chlorpromazine [Leon NF, 1982] and haloperidol [Sebran G., Siegel S., 1984]). However, our own observations confirm that given in the modern literature [Khousam HR, Donnely NJ, 1997; Szygethy EM, Schulz SC, 1997] information on the preference of atypical antipsychotics (risperidone 4-6 mg, quetiapine 150-400 mg).
In a number of cases (with the predominance of psychopathic and / or paranoid symptoms over affective ones), monotherapy with neuroleptics of a new generation, which is not inferior in effectiveness to combined treatment, can be carried out.

The second type of SR
With SR of the second type (as opposed to the first), the acquired reactive lability inherent in patients ensures the pathogenicity of even objectively insignificant traumatic events. A pathological reaction is characterized by a dissociation between the minimum force of stress (minor office conflict, family troubles, problems with passing exams or paperwork) and the severity of the response to it. The reactive formations formed at the same time are characterized by relative simplicity, stereotype and a small range of psychopathological manifestations, limited mainly by disorders of the affective and neurotic levels.
Corresponding in the psychological understanding to “refusal reactions” or avoidance, SR according to clinical manifestations can be classified as hysterical, hypochondriacal, asthenic and anxious, which are based on doubts about the ability to cope with habitual activities, associated with real failure.
Shallow psychogenically caused psychopathological disorders are accompanied by the actualization of litigious tendencies, diffuse ideas of attitudes aimed at the “offenders”, “troublemakers”. In some cases, such conditions can persist for months, while in others they can be transient and undergo reduction within a few days even without medication.

Psychopharmacotherapy in type 2 SR
The role of psychopharmacotherapy in this type of SR is relatively small in comparison with type 1 psychogenias. Therapeutic tactics are based on the clinical picture of the reactive state, taking into account the comorbid manifestations of the schizophrenic defect. The main means of stopping psychogenic formations, accompanied, as is typical of “refusal reactions”, confusion in front of everyday difficulties, fear of being left unattended and unsupervised, painful fears and anxiety symptoms, are tranquilizers. At the same time, the treatment adapts to the clinical features of SR: to influence asthenic symptoms, it is necessary to add nootropics and / or small doses of neuroleptics with activating properties (trifluoperazine 3-5 mg, sulpiride 100-200 mg); in cases where the clinical picture of psychogenia is characterized by hysterical or hypochondriacal (neurotic hypochondria) disorders, the effect of tranquilizers can be enhanced with neuleptil in daily doses of 5-10 mg.
Social measures aimed at changing or resolving the situation that contributed to the emergence of a reactive state also have a healing effect. The psychotherapeutic effect of this type of SR is achieved even by the fact of hospitalization, which helps isolate the patient from the traumatic situation.

Frustration as a type of mental condition

Posted on July 4, 2020  in Uncategorized

In recent years, in psychology, much attention has been paid to the study of certain pronounced mental states: stress, anxiety or anxiety (anxiety), rigidity (tendency to perseveration) and, finally, rustration. True, foreign researchers often avoid the terms “conditions” in relation to these phenomena, but in fact it is about states that under certain conditions leave a mark on the entire mental life for a while or, if we speak the language of biology, are integral reactions of the body in his active adaptation to the environment.
The problem of frustration is posed in terms of theoretical discussion and, to an even greater extent, is the subject of experimental research conducted on animals and people (more often on children). Despite the large number of works published on the topic of frustration, there is still a lot of obscurity in this topic. It is no accident that doubts are even expressed about the need for the concept of frustration, since the phenomena it covers are diverse and can be explained without resorting to this concept. So, in particular, Reed Lawson raises the question in the book “Frustration. Development of a scientific concept ”[18; 58, 60]. ‘This book is an attempt to show the modern setting and various solutions to this problem. In the book, in addition to a large generalizing article by the specified author under the heading “Searches and Arguments”, eight articles by various authors expressing a different approach to frustration are given.
There are difficulties in understanding the very term “frustration”. If we turn to the philology of this term, then frustration means disorder (of plans), destruction (of plans), that is, it indicates some kind of traumatic situation in a certain sense of the word, in which failure is suffered. As we will see below, the philology of the term is close to the widespread, though not widely accepted, understanding of frustration. Frustration should be seen in the context of the broader problem of endurance in relation to life difficulties and reactions to these difficulties.
IP Pavlov spoke many times about the difficulties of life that cause unfavorable conditions of the cerebral cortex. In one of the clinical environments, he made a characteristic confession: “In general, life is always unpleasant, continuous difficulty, and this difficulty makes itself felt when the nervous system has already been knocked down. We must consider that life is always difficult ”[3; 213]. In another clinical environment, Pavlov said that “difficult life situations cause either extreme agitation or depression” (3; 555). But difficulties in life can be divided into two categories. There are difficulties that are quite surmountable, although tremendous efforts are often required to overcome them. As Ushinsky pointed out, every work is associated with difficulties. These are often the difficulties, the overcoming of which is one of the conditions for the mental development of a person and his mastery of professional qualifications. When they talk about perseverance, they mean that character trait that is expressed in the struggle with difficulties, in overcoming obstacles. The concept of frustration does not apply to such difficulties, and if it does, it only applies to those cases when completely surmountable difficulties are subjectively perceived as insurmountable, when a person surrenders to them.
Other difficulties in life are among the insurmountable, or, carefully speaking, almost insurmountable (some difficulties that are insurmountable at the present time, for example, in the fight against cancer, will probably be overcome in the future). Researchers of frustration study those difficulties that are truly insurmountable obstacles or barriers, barriers that stand in the way of achieving a goal, solving a problem, and meeting a need.
But can all the insurmountable difficulties in life be reduced to barriers that block the intended action? MI Kalinin, in one of his conversations with high school students, talked about life pricks, disappointments and adversities, which require firmness to endure. character [1; 197]. Indeed, there are life difficulties, often arising unexpectedly as one or another kind of adversity or misfortune, which can be called barriers or barriers only conditionally, since they impede well-being, happiness.
The phenomena of frustration are most studied in relation to the barriers to activity, and therefore in the future we will focus on precisely such situations when the activity is blocked due to insurmountable obstacles, although the scope of frustration cannot be limited to such situations. There are ambiguities as to what to attribute the term frustration to: to an external cause (situation) or to the reaction it causes (mental state or individual reactions). In the literature you can find another use of the term. It would be expedient, in the same way as distinguishing stress – a mental state from a stressor – its causative agent, similarly distinguishing between a frustrator and frustration – an external cause and its effect on the body and personality. Although the term frustration in the literature is of little use, we will use it in the following exposition, using the term frustration – mainly to indicate the state provoked by the frustration. Such use of words prevents confusion in concepts and corresponds to the essence of the matter.
Referring to the definitions of frustration available in the literature, one can proceed from its definition given by S. Rosenzweig, a prominent researcher of this problem in the United States, according to which frustration “takes place when the body encounters more or less insurmountable obstacles or obstructions on the way to the satisfaction of any – or a vital need “(24; 379-388). Apparently, here frustration is viewed as a phenomenon that occurs in the body, in its adaptation to the environment. But a person is a social being, a personality, and therefore the considered definition, which limits frustration to biological interpretation, is completely insufficient.
According to the definition given by Brown and Farber [8], frustration is the result of conditions under which the expected reaction is either prevented or inhibited. Lawson, interpreting the position of these authors, explains that frustration is a conflict between two tendencies: the one that belongs to the type of connection “goal-reaction”, and the one that arose under the influence of interfering conditions [18; 31]. Brown and Farber emphasize the contradictions that arise from the action of frustrators, and it is this contradiction that explains the emotionality, which usually distinguishes reactions in these situations. Ardently supporting these authors in an effort to distinguish between an external cause and the state caused by it, Childe and Waterhouse [9], in contrast to Brown and Farber, recommend to call frustration only the fact (Event) interference, studying its effect on the activity of the organism, but do not lead to such word usage of any developed justifications. Based on the concept of frustration as a mental state, we give it the following definition: frustration is a person’s state expressed in the characteristic features of experiences and behavior and caused by objectively insurmountable (or subjectively understood) difficulties that arise on the way to achieving a goal or solving a problem. As applied to animals, the definition is as follows: frustration is a state of an animal, expressed in characteristic reactions and caused by difficulties that arise on the way to meeting biological needs. The need for two definitions is dictated by the fact that an animal is a biological creature, and a person is a public one, and frustration has different significance and different causes in humans and animals, although there is much in common in this state, as provoked by “barriers” that block activity. There are attempts to elevate the phenomenon of frustration to the rank of completely regular phenomena that necessarily arise in the life of the organism and personality. Thus, Mayer [19] believes that the behavior of an animal or a person depends on two potentials. The first of these is the “repertoire of behavior”, determined by heredity, developmental conditions and life experience. The second potential is constituted by selective or selection processes and mechanisms. They, in turn, are subdivided into those acting with motivated activity and those arising from frustration. The former function when the activity is aimed at achieving a goal based on appropriate motives, one of which (very important) is the satisfaction of needs. In such cases, behavior is always the path to solving the problem. Quite different electoral processes and mechanisms take place during frustration: while motivated and purposeful behavior is distinguished by variability, constructiveness or maturity and “exercise in freedom of choice”, the unfocused behavior characteristic of frustration is characterized by destructiveness, rigidity, and immaturity. There is doubt as to whether frustration can be considered unjustified. If by it we understand how this is wanted, for example, by Childe and Waterhouse, an external reason (barrier or obstruction), then one of two things is possible: either this barrier is overcome, and in this case the behavior will be not only motivated, but also reasonably motivated, or the barrier causes inappropriate, and sometimes, indeed, destructive behavior. But even then it cannot be said that behavior is not motivated by anything and does not pursue any goal. The mere fact that it is attributed to selective forms of behavior indicates that it has its own motivation.
Although the concept of frustration is used in the arsenal of Freudianism, it cannot be considered necessarily associated with it. The problem of the barrier that blocks activity is posed by Kurt Lewin without the direct influence of Freudianism. Many psychologists who conduct a large experimental work on frustration are not Freudians at all. In particular, it would be ridiculous to suspect Freudian researchers of frustration conducting experiments on animals – and there are many of them.
The work on frustration carried out from the standpoint of Freudianism and neo-Freudianism should be categorically rejected. These positions are based on the fantasy of the struggle between “id” (unconscious but powerful drives), “ego” (personality with its psyche) and “superego” (principles of behavior, social norms and “values”). This struggle is full of frustration, understood as suppression by “censorship”, which is a function of the “superego,” the drives that a person has been obsessed with since childhood and which are significant (neo-Freudian) or fully (in Freud’s) sexual nature. Freudianism belittles the role of consciousness and the specific social conditions of human development. Instead of vital needs, conscious purposeful actions, Freudianism puts in the foreground some kind of “subsoil” fatal forces, which supposedly determine the behavior of a person doomed to constant frustration, since the “superego” resists the manifestations of “id”.
Particularly vicious are the attempts to use the doctrine of frustration in its Freudian interpretation to explain social phenomena, attempts to take it into the arsenal of social psychology. So, for example, in the book of Dollard, Dub, Miller, Mauer and Sears “Frustration and Aggression” [13], even such phenomena as war are reduced to the drama of infringement of personal desires, requests and hopes. L. Berkovits [7] considers the aggression arising in social relations to be nothing more than a manifestation of frustration – a conflict between a person with his violently asserting instincts and the environment, considered “in general” as something unchanging and hostile to a person. The anthropologist B. Malinovsky [21] ascribes to the natives a susceptibility to frustration in the form of aggression, as if inherent in them by nature. With this “discovery”, he tries to explain the struggle of the natives with the colonialists, leaving aside the specific conditions of enslavement and exploitation that encourage the indigenous population to rebel against colonial oppression.
Meyer in his article “The Role of Frustration in Social Movements” [20] draws on the phenomena of frustration as an explanation of the relationship between countries. He, for example, declares: “We were more afraid of Russia because we were afraid of its goals more than the frustrations of Japan and Germany.” At the same time, it would be wrong to associate all works on social psychology carried out abroad with Freudianism and, in particular, with frustration in its Freudian interpretation. So, in the large collective work “Current Problems in Social Psychology” [15], which contains articles by 51 authors, Freudianism and psychology occupy an insignificant place, and frustration is mentioned only occasionally. This, of course, does not mean that social psychology in the United States, which does not take the position of Freudianism, does not have very significant shortcomings, and, in particular, in the psychologicalization of the driving forces of social development. The influence of behaviorism is very strongly manifested in the USA in works on frustration. Lawson explicitly states: “In short, the interest in frustration as an internal state, from a behavioristic point of view, distorts the problem, makes it a pseudo-problem” [18; 7]. The existence of what is called the inner world of a person, the existence of consciousness, direction as a system of attitudes and experiences by behaviorism is either denied or recognized as something not worthy of scientific study. However, the requirement of objectivity in psychology does not mean a denial of the inner world of a person, but an incentive to cognize it by the most objective methods, which include not only experiment, but also observations, as well as a verbal report, which always includes some elements of self-observation. The behaviorist position impoverishes the study of frustration, simplifies and sometimes distorts this complex phenomenon, socially determined in humans.
Usually, frustration is studied as a reaction to those stimuli or those situations that can be called frustrators. If by reaction we mean everything that is provoked by a frustrator in an animal or a person, including a mental state, then one cannot object to this. But speaking of frustration as a reaction, foreign researchers usually mean the movements and actions performed, not taking into account the fact that the same movements and actions in the psychological sense can be ambiguous. Often a very strong and deep experience of frustration is weakly expressed externally, it seems to go deep, just as in the case of grief some people do not cry, outwardly remain calm, and yet they can feel grief. stronger than those people who in similar cases shed profuse tears.
It is characteristic that psychologists who object to the study of mental states in frustration, nevertheless, are forced to talk about them, and even the same Lawson, among the “dependent variables” allocated to him during frustration, calls “changes in imagination and emotionality”. The mental state caused by a frustrator undoubtedly depends on the type of this frustrator. S. Rosenzweig [24; I51] identified three types of such situations. He attributed privation to the first, i.e. lack of the necessary means to achieve a goal or satisfy a need. As an illustration of “external deprivation”, i.e. cases when the frustration is outside the person himself, Rosenzweig brings a situation where a person is hungry and cannot get food. An example of internal deprivation, that is, with a frustrator rooted in the person himself, is a situation when a person feels attraction to a woman and at the same time realizes that he himself is so unattractive that he cannot count on reciprocity. The second type is deprivation. Examples: death of a loved one; the house in which they lived for a long time burned down (external loss); Samson, losing his hair, which, according to legend, was all his strength (inner loss).
The third type of situation is conflict. Illustrating a case of external conflict, Rosenzweig gives an example of a man who loves a woman who remains faithful to her husband. An example of an internal conflict: a man would like to seduce his beloved woman, but this desire is blocked by the idea of ​​what would happen if someone would seduce his mother or sister.
The above typology of situations that cause frustration raises great objections: the death of a loved one and love episodes are placed in one row, conflicts that relate to the struggle of motives, to states that are often not accompanied by frustration, are unsuccessfully highlighted. It’s not at all good to call conflict cases when a person encounters an external insurmountable barrier on his way. According to this logic, one should speak, for example, about the state of conflict with a turbulent river, which turned out to be an insurmountable obstacle for a person. But leaving these remarks aside, we must say that the mental states of loss, deprivation, and conflict are very different. They are far from identical with various losses, hardships and conflicts depending on their content, strength and significance. With all this, we believe, it is still possible to single out some typical states that are often found under the action of frustrators, although they manifest themselves each time in an individual form. First of all, it is necessary to indicate those cases when frustrations do not cause frustration. In the literature, they are often referred to as tolerance, i.e. patience, endurance, the absence of heavy experiences and harsh reactions, despite the presence of frustrators.
There are different forms of tolerance.
The most “healthy” and desirable should be considered a mental state, characterized, despite the presence of frustrators, calmness, prudence, readiness to use what happened as a life lesson, but without much complaint about oneself, which would already mean not tolerance, but frustration.
Tolerance can be expressed, however, not only in a completely calm state, but also in a certain tension, effort, and containment of undesirable impulsive reactions.
Finally, there is a tolerance of the type of flaunting with accentuated indifference, which in some cases masks carefully concealed anger or despondency.
Tolerance can be nurtured. In the experiment of Keister and Epdegref [16], children practiced solving problems according to the so-called method of successive approximation, in which the difficulty of the problems gradually increases. Children trained in assessing the difficulty of tasks and as a result, they developed a “sober”, calm attitude, even to insoluble tasks.
Dewitz [12] showed by his experiment that children accustomed to behave calmly and play amicably with other children in their usual conditions showed less aggressiveness in frustration than children brought up in a less calm environment.
Tolerance regarding barriers that can be called reasonable and necessary is mandatory. The term tolerance in this case is not even adequate. It is not about “enduring” these barriers, but about recognizing all their necessity and usefulness, considering them to be good for oneself and experiencing frustration rather when these barriers are insufficient (for example, in the so-called “loose” collective or in a classroom where the teacher cannot provide discipline).
What are the mental states in those cases. ”When there is no tolerance, but there is frustration?
It should be said from the very beginning that these states are different and depend on different reasons, the significance of their action, habits to them, the individual characteristics of the subject play an important role; the same frustrator can cause completely different reactions in different people. In American literature, there is a very common tendency among the reactions to a frustrator to highlight aggression. There is an attempt to interpret any aggression as frustration. For example, Miller, Mauer, Oak, and Dollard — the workers at the Institute of Human Relations at the University of Iels, [22] stand at this position. One of the articles of these authors says: “The student of human nature should be told that when he sees aggression, he should suspect whether there is frustration here, and that when he sees interference with the habits of an individual or group, one should be wary of whether all other aggression ”[22; 337]. Although these authors reject the accusation that they reduce all frustration to aggression, they emphasize aggressive reactions to frustration so much that their theory of frustration is usually called the theory of frustration – aggression. We believe that there is no reason to consider aggression as the only reaction to frustration. But this form of reaction is observed very often.
What is meant by aggression?
According to the direct meaning of the word, it is an attack on one’s own initiative with the aim of seizing. When talking about frustration, the term aggression is given a broader meaning. We are talking about a condition that may include not only a direct attack, but also a threat, a desire to attack, hostility. The state of aggression can be outwardly pronounced, for example, in pugnaciousness, rudeness, “cockiness”, or it can be more “hidden”, having the form of latent ill will and anger. Outwardly seeming aggressive reaction may actually not be the same, for example, when the student, as they say, “gives back”. A typical state in the so-called aggression is characterized by an acute, often affective experience of anger, impulsive disorderly activity, malice, and in some cases a desire to “take evil away” on someone and even on something. Roughness is a fairly common manifestation of aggression.
IP Pavlov gives such an example of an aggressive breakdown in himself: “When the experiment did not go, but the experiment was done by the assistant, then the devil knows what words I made at his address, which I would never have allowed, I threw the tools etc.” [3; 179]. In one of the clinical environments, there is a case when a friend asked Pavlov to wake him up, and when Pavlov fulfilled this request, a friend, a quite “decent” man, threw a pillow at him [3; 365].
In both examples, loss of self-control, anger, and unnecessary aggressive actions come to the fore. Pupils who “failed” in the exam, sometimes without making any open aggressive actions, at the same time, show anger, a desire to transfer the blame to innocent people, more often to an “unfair”, “picky” teacher, and sometimes “to comrades and even parents who seemed to interfere with their proper preparation for the exam.
Attempts to link aggression with a certain level of personality development should be rejected, as G. Anderson, for example, did. [4; 13]. He proposed to distinguish six levels of personality development. The highest level – socially holistic behavior – is characterized by submission, recognition of dominance. This is followed by a level called “avoidance of dominance” and differing, apparently, in its formal recognition, if you want to find some workarounds. The third level is characterized by aggression, hostility, anger.

How to deal with spring depression

Posted on June 30, 2020  in Uncategorized

Many people are susceptible to spring depression. At first glance, spring and depression, words with the opposite meaning and can’t stand nearby. This period is closely associated with nature awakening after a long winter hibernation. It seems that the mood should only improve.

There is no consensus on the factors that cause spring depression. But doctors and other specialists have one conviction – the changes are guilty. The discrepancies are only in the details: some believe that the body’s resources have dried up after winter and it is necessary to replenish them. Others argue that the body goes into an energetic phase and requires more sun energy. Still others say that human biorhythms are to blame.

So what if you suddenly find yourself in the net of spring depression? Now they talk a lot about healthy proper nutrition – of course, you need to add more fresh vegetables and fruits to the diet, for leading a healthy lifestyle, it is important regardless of the time of year.

It is important to reverse the negative train of thought and rebuild yourself in a new way. The most effective solution is to actively engage in sports, but this requires a serious attitude and time. By the beginning of classes, spring may end.

Hiking is recommended as a good alternative. Generally speaking, this type of load is very useful and most suitable. And in the case of depression, with its help you can immediately get a lot of benefits in the form of:

• Soft workload • Positive emotions from singing birds and blooming plants. • Blue sky and bright sun. • Fresh impressions 

Fresh impressions are extremely important in any depressed and depressive states. They help distract from all the negative, and capture completely. So we are arranged – the new is more interesting, even if it is not at all different from the old.

Therefore, you can add other sources of new things to walks – a new hobby, new acquaintances, trips to nature for the weekend. A walk in new clothes and a new acquaintance at this time especially helps. With prolonged and prolonged depression, some medicinal plants that have a stimulating effect can help . 

This is enough for the spring depression to recede. And it will help to finish off a lot of fresh air and light. The room where we spend most of the time should be well lit and ventilated.

And finally, do not forget about the smile – in this case, the spring depression will recede irrevocably.