Dysthymia is a precursor to clinical depression

What is chronic depression?

Mental disorder syndrome is always associated with a traumatic situation. The patient's mood decreases, but his background does not reach the level of melancholy.

The pathological process has the following characteristic signs:

• the presence of a psychotraumatic factor;
• lack of a person’s desire to improve his condition;
• unwillingness to fight the disease.

The lack of joy in life becomes persistent, and the following bodily disorders are present:

• decreased appetite;
• sleep disturbance.

People suffering from a long-term form of the pathology experience seasonal fluctuations in the course of the disease. The protracted form of the process is accompanied by autonomic disorders, alternating with neurosis and mental disorders.

Long-term mental disorder is manifested by the following syndromes:

• anxious-depressive;
• astheno-depressive;
• phobic;
• hypochondriacal.

Melancholy may increase due to the increased attention of staff to the patient. The patient often develops mixed forms of chronic pathology:

• hysteria with phobias;
• obsessive states.

Socio-psychological factors influence the course and prognosis of prolonged melancholia. Often the cause of the disease is intractable situations, personality traits, and ineffective forms of treatment.

Often, long-term loss of spirit is caused by hereditary factors and somatic diseases, trauma received in childhood, and characteristics of sexual intercourse.

About the consequences of dysthymia and dysthymicity

First of all, the occurrence of consequences and complications is due to the duration of the disease and the patient’s failure to recognize the presence of mental pathology.
When the duration of the disease exceeds three years and the onset of development of disorders before the age of 21, the risk of the onset of deeper forms of depression (the risk of developing major depressive disorder) actually increases along with the complication of the picture of the condition and the deepening of the patient’s social isolation.

For the limitation of the person’s own mental and physical capabilities of the person affected by the disease introduces significant restrictions into his life: he has to refuse cultural and simply public events, change jobs, break off relations with his spouse or with a loved one.

Causes and signs of chronic depression

Doctors identify a group of neurological diseases that cause the development of depression:

• Alzheimer's disease;
• vascular pathology;
• Parkinson's disease;
• cephalgia;
• multiple sclerosis;
• lack of speech after TBI;
• brain tumors;
• encephalopathy due to kidney disease or hypothyroidism.

The causes of severe disorders in old age are associated with constant anxiety-hypochondriacal and dystrophic manifestations of melancholy. Disruption of contacts in the family, dissatisfaction with education, special character traits and temperament of a person, past illnesses are the causes of long-term despondency.

Symptoms appear as the following disorders:

• sleep disorder;
• headache;
• professional coordination disorders;
• traumatic experiences.

The patient pays a lot of attention to problems at work, he is unable to cope with them, and puts off solving important issues for an indefinite period of time.

A person suffering from a protracted form of the disorder complains of memory impairment, decreased attention, mood instability, increased sensitivity to loud sounds, bright lighting, and constant noise.

Forms of pathology

Mental disorder is divided by experts into 2 main types: somatized and characterological.

1. In the first case, the patient complains of pain in the heart or gastrointestinal tract and poor health. With this type of disorder, there is a high probability of developing autonomic disorders. This is trembling in the limbs, increased blood pressure, and heart rate.
2. The characterological type of dysthymia is directly related to a depressive outlook on life. The patient becomes more irritable, suspicious, and pessimistic. Such people do not know how to enjoy life. With all their appearance they want to show others how bad they feel.

In most cases, a person with mental disorders does not recognize himself as sick, and considers all existing signs of pathology to be a short-term phenomenon. At the same time, he tries his best to avoid attempts to seek medical help.

How to get rid of chronic depression?

Therapeutic care is based on the principles of gradation, including inpatient and outpatient treatment. The patient should seek help from a specialist.

In a hospital, a depressed person is prescribed a course of reconstructive psychotherapy. Its duration depends on the patient’s condition and is aimed at eliminating the factors and mechanism of development of the disorder.

The patient is given a special daily regimen. In a hospital setting, the patient engages in self-care and occupational therapy. Some patients receive disability because... the protracted course of the disease is caused by organic brain pathology, concomitant diseases, difficult to resolve situations, and the lack of effective and timely treatment.

To eliminate long-term melancholy, 3 factors are taken into account:

• personal;
• interpersonal;
• situational.

Treatment with medications

Many patients do not know what to do; chronic depression does not allow them to fully work and rest. Antidepressants are used for severe melancholia.

The patient is prescribed tricyclic drugs, selective norepinephrine reuptake blockers - SBOZK: Ludiomil, Lerivon.

In order to eliminate the symptoms of despondency, a person takes the following medications:

• Fluoxetine;
• Fluvoxamine;
• Sertraline;
• Paroxetine;
• Citalopram;
• Coaxil;
• Moclobemide;
• Pyrazidol.

After taking antidepressants such as Mirtazapine Remeron or Milnacipran, the patient's symptoms of anxious depression are completely eliminated. In the case of the development of a protracted form of the disease, the first-line drugs are tricyclic antidepressants.

Treatment begins with a small dose of medication, and the therapeutic effect appears after 2-3 weeks of the course.

Dejection in patients over 65 years of age is treated with medications such as:

• Pyrazidol;
• Moclobemide;
• Sertraline;
• Paroxetine.

A patient suffering from epilepsy often feels depressed. People who have suffered a stroke are prescribed medications in case of blues development:

• Pyrazidol;
• Minirin;
• Azafen.

Treatment with psychotherapy

Melancholy is a mental illness. It is difficult to get rid of it on your own; only a psychotherapist knows how to help a patient in a difficult situation.

Rational treatment of the patient includes:

• influence on the partner’s opinion;
• teaching correct thinking.

The doctor uses several techniques:

• worldview;
• encouragement;
• abstraction.

The psychotherapist establishes close contact with the patient and explains to him the mechanism of the appearance of symptoms of depression. For chronic pathology, psychotherapy is ineffective. In some cases, the doctor uses suggestion, persuasion, and explanation.

The patient is put into a state of narcotic sleep, suggestion is carried out at each stage of anesthesia. In this case, the doctor can:

• eliminate hysteria;
• rid the patient of phobias;
• cure neurotic disorders.

The course of therapy consists of 20 procedures. Indirect suggestion and self-hypnosis are the basis of many methods of psychotherapy.

The doctor uses the following technique:

• self-hypnosis using the Coue method;
• autogenic training;
• behavioral psychotherapy.

KOLYUTSKAYA Elena Vladimirovia

DISTHYMIC DEPRESSIONS (psychopathology, typological differentiation, therapy)

Abstract of the dissertation for the scientific degree of Candidate of Medical Sciences

GENERAL CHARACTERISTICS OF THE STUDY

The relevance of research

The creation of a new category of “dysthymic disorder” in modern classifications of mental illnesses has made it possible to combine within the framework of a general concept many forms of prolonged non-psychotic depression, previously attributed to various diagnostic groups.

With the development of the concept of dysthymia, the prerequisites were created for studying one of the important aspects of the problem of erased depression, namely, to clarify the role of factors that determine their protracted course. However, in existing taxonomies of dysthymic conditions (McCullough J., 1988, Akiskal H., 1990; Rihmer Z., 1990), this aspect is usually not considered.

This situation is due to the fact that the construction of a typology of dysthymia is carried out without taking into account the dynamics. Even in follow-up studies involving the study of the stereotype of the development of this disorder, the main attention is paid to the statistical indicators of “recovery”, “relapse” or “chronification” (Rounsavlle B et al, 1980; Barret J., 1984, Kovacs M. et al, 1984, Gonzales L. et al, 1985; Spitzer R. et al, 1988), which allows us to obtain data on the average duration of dysthymia, while clinical characteristics are not specified. As a result, there is a contradiction between the idea of ​​dysthymia as a disorder, one of the distinguishing features of which is its chronic course, and the small number of studies aimed at studying the clinical structure of dysthymic conditions in dynamics

An equally pressing aspect of the problem is the issue of comorbidity of dysthymia with other disorders. The fact that affective disorders in such cases are usually combined with psychopathological formations of the non-affective circle (Weissman M. et al, 1988; Sanderson S. et al, 1990; Keller M., Sessa F.. 1990; Angst J. et al. al, 1991), is interpreted ambiguously. During the discussion, directly opposite points of view are expressed - some researchers (Keller M., Shapiro R., 1982; Klein D. et al, 1988; Selvewright N., Tyrer R., 1990) interpret the heterogeneous clinical manifestations observed with dysthymia as independent, others (Aklskal N., 1983; Weissman M. et al. 1988) believe that dysthymia is “secondary” to disorders that “overlap” its symptoms. Such discrepancies in assessments are primarily associated with different approaches to the issue of the unity and independence of dysthymic disorder.

Thus, many fundamentally important aspects of the problem of dysthymia have not yet been resolved and require further study.

In connection with the above, the relevance of the research undertaken is of particular importance. The work carried out allows us not only to come closer to understanding the clinical essence of the disorders being studied, but also to outline new approaches to overcoming differences in approaches to the problem of dysthymia.

Purpose and objectives of the study. The purpose of this study is a clinical (using follow-up data) study of dysthymic conditions, aimed at analyzing the problem of dysthymia in terms of typology, course, therapy and rehabilitation. Accordingly, the following tasks were solved in the work:

— typological differentiation of dysthymic states, taking into account the stereotype of their development;

— clarification of the correlations between the actual affective and comorbid psychopathological manifestations in the structure of dysthymic disorder;

— optimization of treatment and rehabilitation programs in accordance with the typology of dysthymic conditions.

Scientific novelty. The study of the psychopathological structure of dysthymic states in dynamics allowed us to obtain a number of data that have not been covered so far in the literature devoted to this problem.

It has been established that dysthymic states, regardless of their typological affiliation, have a biaxial structure, which, along with the hypothymic one, includes a comorbid “axis” represented by persistent psychopathological formations of the somatopsychic. catathymic and pathocharacterological series. The latter play the role of differentiating characteristics, according to which a typological model of dysthymic states, divided into types of the same name, can be proposed. The adequacy of this differentiation was also confirmed when analyzing the characteristics of the symptoms of the hypothymic “axis” - the actual affective disorders in somatized dysthymia are represented by manifestations of asthenic depression, in catathymic - endoreactive and in characterological - dysphoric depression.

The prognostic significance of the structure of dysthymic states is considered. It has been shown that despite the reduction of affective symptoms at distant stages of the course of dysthymia, disorders comorbid with hypothymia remain stable and determine the prognosis (the least favorable for somatized dysthymia).

It has been suggested that there are factors contributing to the chronification of dysthymic conditions. As a working hypothesis, stable comorbid connections between intermittent and reversible affective disorders and symptoms of “continuous” series (somatopsychic, catathymic, pathocharacterological) are interpreted as one of the factors ensuring the protracted course of dysthymic disorder as a whole.

Practical significance of the study. The typological differentiation of dysthymic conditions presented in the work is informative regarding the assessment of the studied pathology and allows optimizing the effects aimed at reducing painful manifestations and compensating for the condition. The scope and tactics of therapeutic and rehabilitation measures have been determined; Appropriate techniques have been developed, differentiated depending on the type of dysthymia.

Publication of research results. The results of the study are reflected in... scientific publications, a list of which is given at the end of the abstract. The main provisions of the dissertation work were presented (in the form of posters) at the Ninth World Congress on Psychiatry (Brazil, Rio de Janeiro, June 6-12, 1993), the Second International Conference “Biological basis of individual sensitivity to psychotropic substances” (Moscow, 22- May 26, 1993) and the Sixth Congress of the European College of Neuropsychopharmacology (Hungary, Budapest, October 10-14, 1993).

Scope and structure of work. The dissertation is presented on ___ pages of typewritten text (main text ___ literature index ___ and consists of an introduction, 4 chapters (Literature review; Characteristics of materials and research methods; Typology of dysthymic conditions; Therapy and rehabilitation of dysthymic conditions) conclusions and conclusions. The bibliographic index contains ___ sources (__ works of domestic and ___ foreign authors). __ tables are provided.

Materials and methods of research.

75 patients with dysthymic conditions were examined (68 women and 7 men aged from 22 to 59 years; average age 45.3 + -4.8 years).

When selecting patients, we used diagnostic criteria for dysthymic disorder, developed during the preparation of the International Classification of Diseases, Tenth Revision (ICD-10, 1990), which, along with reliable verification of the diagnosis, ensures comparability of results with data from other researchers.

Accordingly, the studied sample was formed on the basis of the identification at the time of examination of signs of dysthymic disorder that met the ICD-10 criteria (non-psychotic level of depressive disorders, duration of at least 2 years).

Exclusion criteria: 1. leafing is combined with schizophrenic or affective psychosis, organic damage to the central nervous system or severe somatic pathology, chronic alcoholism or substance abuse; 2. adolescent or late age of patients.

When examining patients included in the sample, in addition to the main clinical method (using follow-up data lasting 1-3 years), a number of auxiliary research methods were used: genealogical (study of the structure of affective pathology burden in families of patients with dysthymia using a combined approach using “family survey” methods "(family study) and "family history" (family history); formal statistical (use of standard diagnostic scales - the 24-point Hamilton Depression Scale and the SCL-90 scale with subsequent mathematical processing of the results); psychophysiological (method for recognizing facial expressions with taking into account interhemispheric asymmetry).

RESEARCH RESULTS

Analysis of psychopathological manifestations within the framework of dysthymic states, taking into account their modification in the process of dynamics, allowed us to identify the following dependencies.

In its clinical structure, dysthymia is a disorder formed by two components. Actually hypothymic is comorbid with persistent formations of other psychopathological series (somatopsychic, catathymic, pathocharacterological). The latter can be considered as an obligate sign of dysthymia, reflecting its clinical unity. Such unity is, in particular, confirmed at the pathogenetic level.

Genealogical characteristics in dysthymia differ significantly from the corresponding indicators not only in affective psychoses, but also in major depression, and the frequency of affective pathology in families of patients with dysthymic disorder (7.7% versus 18-25% in major depression) is comparable to indicators whose values ​​are considered as one of the pathogenetic confirmations of the independence of this disorder.

Psychophysiological data also indirectly testify to the unity of dysthymic disorder. Statistically significant differences between samples of patients with dysthymia and with major depression in terms of changes in the recognition function of facial expressions, obtained in the experiment, can be interpreted as a reflection of a different level of disorders of the psychophysiological mechanisms of facial gnosis compared to major depression.

The idea of ​​the unity of dysthymia does not contradict the possibility of its typological differentiation.

The construction of a typology of dysthymic states in this study is based on the analysis of psychopathological manifestations observed in the process of evolution (debut - dysthymia itself - outcome). Along with the clinical characteristics of depressive disorders, special attention is paid to the qualification of concomitant (comorbid) non-affective symptoms, and comorbid connections are considered not only from a clinical point of view, but also on the basis of formalized (statistical) approaches.

As a result of clinical differentiation, taking into account both the hypothymic and non-affective components of dysthymic disorder, three types were identified.

The first type is somatized dysthymia (26 observations; 23 women and 3 men).

The clinical picture at the initial stage consists of the interaction of affective and anxiety disorders with the dominance of the latter. A depressed mood is inseparable from sudden (often in a series) panic attacks that occur with massive vegetative symptoms (dyspnea, nausea, dizziness, tremor, sweating, abdominal discomfort) and are accompanied by internal tension and anxiety. Moreover, pathological bodily sensations attributed to somatic anxiety, as well as multiple polymorphic algopathies, along with somatic manifestations of depression, are mediated as physical suffering.

Thus, already at the onset of dysthymia of the type under consideration, somatopsychic disorders that violate the “natural mechanism of invisibility of the body” (Ruffin H., 1959) come to the fore.

Moreover, despite the rapid de-actualization of anxiety disorders, it is the symptoms of the somatopsychic series that acquire a persistent character in this type of dysthymia, although they change as the syndrome evolves.

At the stage of dysthymia itself, asthenia occupies an increasingly important place in the clinical picture, which is attributed by some authors (Smulevich A.B., Dubnitskaya E.B., Sokolovskaya L.V., 1991) to somatopsychic disorders.

Unreasonable anxiety is replaced by indifference, psychomotor agitation (at the initial stage reaching agitation) by a decrease in motor activity with a feeling of physical impotence, tension by lethargy.

Accordingly, the depressive triad is disharmonious in nature. Depressive affect is manifested by a slowdown and difficulty in all mental acts, a decrease in drives, and sleep and appetite disturbances. Indifference, inability to experience joy, interest, and compassion prevail (“depressive refusal” according to N. Weltbrecht, 1973). Characteristic is the formation of a stable relationship between apathetic and increasing asthenic symptoms (“vital asthenia” - A.K. Anufriev, 1979). Objectively recorded signs of depressed mood: low self-esteem, pessimism, insolvency are subjectively assessed as a consequence of constant physical illness. A painful feeling of bodily ill-being is associated with hypochondriacal fears.

Further dynamics of the syndrome is manifested by a gradual reduction of depressive disorders, while somatized (asthenic) disorders, accompanied by a decrease in activity and performance extended over years, actually completely determine the outcome of dysthymia of this type.

The high level of social maladaptation (in more than 1/3 of cases) identified in this type of dysthymia reflects a worsening of the mental state in the long-term stages.

Rare exacerbations (on average once a year) in their clinical structure are comparable to initial depressive manifestations, although they are significantly less intense.

The second type is catathymic dysthymia (13 observations, all women).

The picture of dysthymia of this type includes not only the dysthymic ones themselves, but also the disorders associated with them - manifestations of a protracted reactive symptom complex.

Dysthymia debuts as an acute psychogenia, developing in response to an individually intolerable situation, perceived as a catastrophe, the collapse of all life plans (the “key experience” is the loss of an object of ecstatic attachment - the death of a child, spouse). Psychopathological symptoms are determined by the affect of despair, focused on a narrow range of ideas reflecting the content of mental trauma, and accompanied by ideas of self-blame and suicidal tendencies. The formation of reactive depression is preceded by a shock reaction with a predominance of the phenomena of psychogenically darkened consciousness. Already at the initial stage of catathymic dysthymia, retention of the psychogenic complex is observed, associated with pathologically persistent (“catathymic” according to H. Maler, 1912) affect, aimed at a subjectively significant area of ​​mental life.

It is characteristic that in conditions of this type, not only initial, but also dysthymic disorders themselves are realized with the participation of catathymic affect.

The formation of dysthymic disorder after passing the initial stage is accompanied by a change in the nature of affective manifestations. In the clinical picture, complaints of melancholy are “petrification”, external manifestations of suffering and grief are replaced by passivity, isolation from the environment, while at the same time signs of vital depression are added (formation of a circadian rhythm, elements of the vital symptom complex). In other words, the dynamics of affective disorders at the stage of dysthymia itself are in many ways comparable to the picture of endoreactive dysthymia (Weitbrecht H. 1952). However, a typical sign of the latter—a reduction of psychogenic disorders associated with an increase in hypochondriacal symptoms—is not observed in catathymic dysthymia. On the contrary, despite the undoubted vitalization of depressive manifestations, the psychogenic symptom complex does not lose its relevance. At the same time, painful memories of a tragic event that arise against one’s will become similar to obsessive ones.

At distant stages of dysthymia, despite the gradual reduction of depression and the appearance of signs of social readaptation, the psychogenic complex remains relatively intact. Its modification is limited only by a certain decrease in the affective charge of ideas of the previous - catathymic - content (losing the “sense of vitality” according to J. Glatzel, 1972, these ideas are stereotyped).

The further dynamics of the disorder is determined by erased exacerbations, usually coinciding in time with dates reminiscent of the traumatic event (“anniversary reactions” according to J. Cavenar, 1977). Such depressive episodes do not exceed a week in duration and, as a rule, resolve spontaneously.

The third type is characterological dysthymia (36 observations; 32 women and 4 men).

Like catathymic, characterological dysthymia debuts with a picture of reactive depression. However, the mechanism of formation of initial manifestations has significant differences. Only in rare cases does severe mental trauma act as a provoking factor. It is preferable to develop a reaction in response to everyday events in the context of an already existing frustrating situation (protracted family and work conflicts, love conflicts).

The psychogenic symptom complex is characterized by instability and variability of the plot. The direction of the “vector of guilt” (according to K. Scheld, 1934) is also different from catathymic dysthymia: responsibility for events is assigned to the environment.

In the clinical picture, comorbid disorders—pathocharacterological—can also be considered no less significant than depressive ones. The latter, although they belong to different types of personality disorders (mainly histrionic and narcissistic), nevertheless exhibit those features that make it possible to combine the corresponding deviations into a single - dramatic - cluster (Svraklc D., 1989; Roningstam E., Ganderson J. 1990; Akiskal H., 1990). In the patients studied, they are expressed in exaggerated complaints of depression and demonstrative behavior.

In the process of the dynamics of conditions of this type, pathocharacterological disorders not only do not reduce, but, along with hypothymic ones, acquire a persistent character.

The dysthymic stage itself is characterized by the predominance in the structure of depression of an irritated, grouchy, grumpy mood, dissatisfaction (that is, dysphoria phenomena) in the absence of objective signs of loss of perspective, life plans, or interest in the environment. This characteristic of affect, according to a number of researchers (Liebowitz M., Klein D. 1979; Akiskal H., 1983), preferable for psychopathic states, is consistent with deviant behavior (manipulativeness, explosive outbursts, rental attitudes).

The gradual amalgamation of affective and personality disorders, which begins already at the onset, is most clearly manifested in distant stages. Depressive manifestations become “habitual” and are subjectively perceived as an acquired character trait (“personal characteristics that are part of the dysthymic disorder itself and indistinguishable from it” - R. Hirschfeld, 1990).

The exodus stage is characterized by de-actualization of psychogenic influences and a gradual change in the content of depression, now spreading to wider areas (pessimistic interpretation of indifferent life events, dissatisfaction with the current fate, negative attitude towards the environment). A special, darkly dysphoric worldview is formed. In contrast to Depressive ideas of failure, self-abasement, and guilt, the content of ideation disorders is one’s own failure, attributed to “hypersensitivity”, the inability to resist oppressive circumstances. With complaints of joylessness and loss of interests similar to depressive anhedonia, the mood is often not reduced, but rather changed, alien to the previous perception of life.

The proposed typological model of dysthymic conditions has not only theoretical, but also practical significance.

The results of the study create new opportunities for organizing optimal treatment and rehabilitation measures for dysthymic conditions. The latter are in the nature of complex effects that ensure the reduction of hypothymic and painful manifestations with them and are differentiated in accordance with the type of disorder and the stage of its dynamics.

For somatized dysthymia at the stage of manifest manifestations, DOL, INKAZAN, COAXIL) in combination with nootropics or stimulants, which allows you to relieve asthenodepressive symptoms and at the same time avoid the undesirable effects associated with the use of tricyclic antidepressants (increased anxiety, excessive sedative effect). During the period of stabilization of the condition (outcome stage), benzodiazepine derivatives, classified as narrow-spectrum tranquilizers (RUDATEL, SIGNOPAM, ALPRAZOLAM), which have minimal muscle relaxant and sedative effects and do not aggravate asthenia, are used as the main therapeutic agent.

In case of catathymic dysthymia at the active stage of the disorder, intensive psychopharmacotherapy (intravenous drip infusions of high doses of drugs) with the simultaneous use of several polycyclic antidepressants (AMITRIPTILINE, MELIP-RAMIN, LUDIOMIL) in repeated long courses is indicated, which makes it possible to relieve drug-resistant symptoms (due to catathymic affect) depressive symptoms. Correction of disorders observed at the outcome stage is carried out by prescribing polycyclic antidepressants, but in medium doses and in combination with tranquilizers. At the same time, combination drugs (LIMBIT-ROL, AMIXID), which have both antidepressant and anxiolytic effects, create optimal conditions for maintenance therapy.

For characterological dysthymia at the active stage, it is preferable to use tricyclic antidepressants (AMITRIPTILINE, ANAFRANIL) in small doses and in combination with neuroleptics that have a behavior-correcting effect (NEULEPTIL, CHLORPRO-THIXEN, TERALEN, SONAPAX), which allows to relieve depressive-dysphoric symptoms. Along with tricyclic antidepressants, serotonergic thymoleptics (FLUOXETINE) are indicated at the stage of dysthymia itself. At the outcome stage for this type of dysthymia, antipsychotics are used in balanced doses to help correct pathocharacterological disorders.

Psychocorrectional effects are differentiated on the same basis as biological therapy. Moreover, if at the initial stages of dysthymia the possibilities of psychotherapy are limited (mainly rational psychotherapeutic influences are used, aimed at increasing the self-esteem of patients, building trust in the doctor, an adequate attitude towards treatment, and confidence in its success), then as the intensity of affective disorders decreases, its volume is significantly increases. Psychocorrectional measures (aimed at stimulating adequate adaptive mechanisms) are differentiated depending on the type of dysthymia.

— With somatized dysthymia, psychotherapeutic influences are informative and activating in nature. The main therapeutic goal is to reduce the importance of passive defense mechanisms (“withdrawing into illness”).

In case of catathymic dysthymia, the choice of psychotherapeutic techniques involves the formation of additional motivations that stimulate active compensation mechanisms (“withdrawal into activity”).

In case of characterological dysthymia, psychotherapeutic interventions are aimed at adaptive mechanisms that promote a realistic assessment of behavior and correction of communicative style.

CONCLUSIONS

Clinical (using follow-up data) study of dysthymic conditions made it possible to establish the following dependencies.

1. Dysthymia, according to its clinical structure, is a disorder formed by two components (“axes”). A common feature of dysthymia - a biaxial structure - not only unites all types of this disorder, but is also a basic characteristic throughout, reflecting its clinical unity. This unity has been confirmed at the pathogenetic level (based on significant differences in genealogical and psychophysiological indicators in dysthymic and major depressive disorder).

2. The idea of ​​unity does not contradict the typological heterogeneity of this disorder, since in its structure, the hypothymic itself is comorbid with persistent formations of different psychopathological series - somatopsychic, catathymic, patho-characterological. The latter are considered as an obligate, differentiating sign of dysthymia. When constructing a typological model of dysthymia, taking into account the modification of psychopathological manifestations in the process of evolution (debut - dysthymia itself - outcome), three types of the studied disorder were identified.

2.1. The first type - somatized dysthymia is realized by the interaction of affective and somatopsychic manifestations, not only coinciding in time, but also at all stages of the dynamics that determine the clinical characteristics of the syndrome (anxious depression with a predominance of somatic anxiety - asthenoapathic depression - asthenia with residual subdepressive manifestations).

2.2. The second type - catathymic dysthymia is characterized by a comorbid connection in the form of pathological synergism between intermittent psychogenic depression and persistent constitutional catathymic affect, which persists at all stages of the dynamics of the syndrome (acute psychogenia by the mechanism of “key experience” - vitalizing depression with retention of the psychogenic complex - obsessive memories of psychogenic content on background of “fading” affect).

2.3. The third type - characterological dysthymia is manifested by the association of affective disorders with pathocharacterological ones up to their amalgamation at distant stages of dynamics (situational depression with dramatization of symptoms - dysphoric depression - inclusion in the structure of abnormal personal properties of a special worldview with a pessimistic interpretation of indifferent events, dissatisfaction with fate, hostility).

3. Treatment and rehabilitation measures for dysthymia are complex (psychopharmacotherapy, psychocorrectional influences). Drug treatment is aimed simultaneously at the actual affective and accompanying symptoms. Accordingly, the drugs used in psychopharmacotherapy include, along with antidepressants, drugs of other classes (tranquilizers, antipsychotics, stimulants), the use of which is differentiated depending on the type of disorder.

3.1. For somatized dysthymia at the stage of manifest manifestations, narrow-spectrum antidepressants (PIRAZIDOL, INCAZAN, COAXIL), used in combination with nootropics and stimulants, are preferred. During the period of stabilization of the condition (outcome stage), benzodiazepine derivatives (RUDATEL, SIGNOPAM, ALPRAZOLAM) with minimal muscle relaxant and sedative effects are used as the main therapeutic agent.

3.2. For catathymic dysthymia at the active stage of the disorder, intensive psychopharmacotherapy is indicated to eliminate the influence of pathological synergism between the depressive and catathymic affect itself (intravenous drip infusions of high doses of drugs) with the simultaneous use of several polycyclic antidepressants (AMITRIPTILINE, MELIPRAMINE, LUDIO-MIL) in repeated long courses. Correction of disorders observed at the outcome stage is carried out by prescribing polycyclic antidepressants, but in medium doses and in combination with tranquilizers. At the same time, combination drugs (LIMBITROL, AMIXID) create optimal conditions for maintenance therapy.

3.3. For characterological dysthymia, it is preferable to use tricyclic antidepressants (AMITRIPTILINE, ANAFRANIL) in small doses and in combination with antipsychotics that have a behavior-correcting effect (NEULEPTIL, CHLORPROTHIXEN, TERALEN, SONAPAX). At the outcome stage for this type of dysthymia, antipsychotics are used in balanced doses.

4. Psychocorrectional influences in their scope increase significantly as the intensity of affective disorders decreases and at the stage of outcome of dysthymia they become of paramount importance. At the same time, the tactics of psychotherapy aimed at stimulating adequate defense mechanisms depend on the type of dysthymia.

4.1 With somatized dysthymia, psychotherapeutic influences are activating in nature. The main therapeutic goal is to reduce the importance of passive defense mechanisms (“withdrawing into illness”).

4.2. In case of catathymic dysthymia, the choice of psychotherapeutic techniques involves the formation of additional motivations that stimulate active compensation mechanisms (“withdrawal into activity”).

4.3. In case of characterological dysthymia, psychotherapeutic interventions are aimed at adaptive mechanisms that promote a realistic assessment of behavior and correction of communicative style.

LIST OF WORKS published on the topic of the dissertation

1. To the problem of dysthymic conditions. // Review of Psychiatry and Medical Psychology named after. V. M. Bekhtereva. 1993. - No. 1. - p.96-98.

2. Neuro- and psychopathological characteristics during therapy of comorbid anxiety and depressive disorders. //In: Abstracts of the 2nd International Conference “Biological Basis of Individual Sensitivity to Psychotropic Drugs”, Moscow, 22-26 May. 1993. - p.34 (with Morkovkina I., Mlchallova E., Andruschenco A.).

3. To the comparative analyzes of Hypochondriacal Euphoria and Dysthymlc Disorder. //In: Abstracts of the 9th World Congress of Psychiatry, Brazil, Rio de Janeiro, 6-12 June. 1993. - p.97 (with Dubnitskaya EB, Chudakov VM).

4. Some aspects of the clinic and rehabilitation of dysthymia of the characterological type. / In the book: Prevention of neuropsychiatric diseases. Tomsk, 1993. - p.88-89.

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