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3STRATEGY FOR EARLY DIAGNOSIS WITH CARDIOVASCULAR DISEASEISOMATIZED MENTAL
DISORDERS
1Prostyakova Natalia Turchaninova, 2Shamilov Vladimir Malakhonovich, 3Sharapova Dilfuza Nematillayevna, 4Shernazarov Farrukh
1Novosibirsk State Medical University, Russian Federation city of Novosibirsk 2Siberian State Medical University, Russian Federation city of Tomsk 3 Samarkand State Medical University Clinical ordenator in the direction of psychiatry 4608 group students of Samarkand State Medical University Faculty of Medicine https://doi.org/10.5281/zenodo.10335770
Abstract. According to the WHO (2014) definition, public mental health is an important medico-social resource, the potential of society, helping to ensure an optimal level of the quality of life of the population and national security. In recent years, the chances of preventing mental and behavioral disorders among the population have expanded significantly. In addition, the fact of the need to identify a limited mental pathology in the early stages of the disease for timely effective treatment is recognized by many researchers, since it has the potential for self-prevention and rehabilitation, reduces stigma.
Keywords: diagnosis, somatized mental disorders, cardiovascular manifestations.
Introduction. In everyday clinical practice, general practitioners, cardiologists often face various manifestations of neurotic, affective, and other psychopathological disorders observed in patients with cardiovascular disease (KVH) [1-3]. The greatest difficulties arise in the recognition of depressive disorders, the symptoms of which are masked by somatic symptoms. Various somato-vegetative symptom complexes, characteristic of both affective pathology and somatic disease, characterized by polymorphism of symptoms, have independent dynamics or are layered with a CVD course, which, in particular, makes it difficult to diagnose coronary artery disease (CAD) early, its clinical picture "coincides" with the symptoms of mental disorders. The difficulty of determining the initial, deleted, masked, subclinical forms of psychopathology for general practitioners in the special literature of recent years is characteristic of half of patients who resort to primary care [4-10] the latter often have no experience in differential diagnosis, treatment and rehabilitation of such maternity hospitals. The problem of detecting mental disorders is inherent not only to Internist doctors, but also to specialists in the field of mental health. This is due to the lack of opinions of specialists specializing in clinical manifestations of Mental Disorders at the initial stage of the development of the disease. Of particular importance are issues related to the secondary prevention of prescribed conditions, since borderline mental disorders, including somatized mental disorders, the imperfection of the organization of psychiatric care for such patients, stigmatization in psychiatry are common among the population. [11-16] secondary prophylaxis should be understood to mean a decrease in cases of a known disorder or disease in the population through early detection and treatment [17-22] Pletnev first described the common somatic symptoms of cyclothymia in his paper "somatic to the question of cyclothymia", in which "somatic "and mental symptoms are related and complementary, due to the common etiological moment... and the simultaneous expression of the pathological dynamics of the organism", which called the phase manifestations "diagnostic contours of psychogenic disorders." in the clinic of internal diseases [23-27]. A lot in the field of the clinical direction of Psychosomatic Medicine, completely forgotten, remains relevant even now. After 50 years (in the 70s and 80s of the 20th
century), psychiatrists introduced the concept of "somatic cyclothymia" as "masked depression" (Kielholz P.,1973) or "latent", "larval", "alexithymic" depression, or "thymopathic (depressive) equivalents" (J. J. Lopez Ibor), 1973). The leading place in the clinical picture is occupied by symptom complexes that go beyond affective register disorders. Patients with symptoms of masked depression may be unaware of depressive disorder, make sure that there is a rare, difficult-to-diagnose somatic disease, and require numerous examinations in non-psychiatric medical facilities. But with active interrogation, the pathological effect, which is often subjected to daily fluctuations, can be detected in the form of unusual morning sadness, depression, anxiety or apathy, environmental protection with excessive fixation in body sensations [28-32]. In the conditions of the primary branch of medical care, problems of the differential diagnostic procedure often arise when contacting the therapist or cardiologist of the clinic, since somatic symptoms, which are part of a mental illness, lead to an overdiagnosis of somatic disease or misinterpretation of existing diseases. Despite the huge achievements in the field of Cardiology and the large volume of accumulated scientific practical materials, the issues of comorbidity (bowing) of cardiovascular pathology of psychic diseases are a multifaceted, ambiguous problem in methodological and practical aspects. Currently, the role of psychological factors in the increase in mortality in coronary artery disease has been identified, the relationship between stressful events and the prevalence of anxiety and depressive disorders in patients with CVD has been proven. Thus, the published data of a generalized meta-analysis for many years, the effect of depression on cardiovascular diseases [33-37], as well as the results of multicenter clinical and epidemiological studies of the well-known Russian software for the study of depression, high risk of fatal and nonfatal cardiovascular complications and high prevalence of anxiety and depressive disorders in KVH in acute or chronic conditions psycho-emotional stress [38-41]. The vnok1 expert committee focuses on the importance of studying psychosocial stress in recent Russian recommendations (2008) as one of the risk factors for CAD development and its complications. Because of the high prevalence in the population of anxiety-prone depressive disorders, it is revealed that community mental health problems are inextricably linked with cardiovascular disease [42-46].
The purpose of the study: was to develop algorithms for the early diagnosis of somatized mental disorders with cardiovascular manifestations in patients of the city Polyclinic.
Materials and methods. In the process of work, the following tasks were formed: the designation of types of somatized mental disorders with cardiovascular manifestations in the Polyclinic; analysis of clinical features at the initial stage of the disease; description of algorithms for the early diagnosis of these conditions for specialists of the city Polyclinic (local therapist, cardiologist, neurologist, medical psychologist, psychotherapist, etc.). From 2019 to 2022 patients with mental disorders somatized by cardiovascular symptoms were examined with different severity of the disease. Taking into account the diagnostic criteria of ICD-10, as well as the peculiarities of the clinical picture of the disease, such groups of somatized mental disorders were identified in patients of the city Polyclinic: polysimptomatic hysteria (somatized disorder), somatized depression and panic disorder. The distribution of patients to the main and control groups occurred taking into account the severity of the clinical manifestations of the disease. The core group (100 people) consisted of patients with mental disorders whose initial clinical manifestations of the disease, incomplete clinical presentation, did not comply with the guidelines of modern taxonomists, somatized by cardiovascular manifestations with a duration of the disease of up to 1 year. These patients turned to Polyclinic doctors for medical care (therapist, neurologist, cardiologist, endocrinologist). They were identified in city polyclinics No. 1, No. 5. Initially, the sample also included 11 patients with hypochondria with cardiovascular manifestations and 6 patients with somatoform autonomic dysfunction of the heart, but due to their low number, they
did not form the final group. The control group (118 people) consisted of patients with an extended clinical picture of the disease, the duration of which was from 1 to 5 years. These patients were in the psychosomatic Department of the regional Narcological hospital, in the 1st day hospitals, in the clinical psychoneurological dispensary, in inpatient treatment by a psychiatrist. To fully objectively assess the condition of patients, it was subjected to a somatic and neurological examination with the participation of specialists (therapist, cardiologist, neurologist, endocrinologist). Patients in both groups were dominated by functional signs of the cardiovascular system, which allowed us to identify somatized mental disorders with cardiovascular manifestations. To solve the assigned tasks, clinical-psychopathological (assessment of symptoms and syndromes), clinical-dynamic (assessment of the dynamics of clinical manifestations of the disease), experimental psychological (qualitative and quantitative assessment of emotional and personal characteristics) were used as the main methods of research., statistical method. As an initial manifestation of the disease, a number of clinical and psychological parameters were considered, which reflect the state of the emotional, personal sphere, the stressful load option, the level of stress resistance, which can be checked not only by psychotherapists and medico-psychological doctors, but also in the clinic. Internist doctors. This position is a. Y. Related to the problems of patomorphosis of the psychopathology of the body sphere, considered by Berezantsev (2001). We used a complex of psychodiagnostic methods: 1) personal and reactive anxiety scale. Spielberger-yu. L. Hanina (the questionnaire is designed to measure anxiety as an individual trait of an individual and as a state in response to a stressful situation); 2) T. I. in adapting to V. Method of differential diagnosis of depressive states of the Tsung. Balashova (questionnaire for screening diagnostics of depressive states for the purpose of initial, initial medical diagnosis); 3) differentiated self - assessment test of functional State-san (aimed at studying the three main components of emotional state - well-being, activity and mood); 4) Holmes and Rae's method of determining stress resistance and social adaptation (for independent assessment using a measure of stress levels and stress resistance)., in which each important life event corresponds to a certain number of points, depending on the level of stress).
Results and their discussion. Features of the clinic at the initial stage of somatized mental disorders with cardiovascular manifestations include: in patients with polysimptomatic hysteria (somatized disease)-more than 6 symptoms of four diagnostic groups (disorders of the heart and respiratory system, pseudoneurological, gastrointestinal, pain symptoms), the duration of the disease is up to 1 year; with somatized depression (within the framework of adaptation disorders) - mild severity of the disease (the set of symptoms for diagnosis is no more than three), has a senestopathic tone in the clinical picture of somatovegetative functional symptoms from the cardiovascular system, a short (up to six months) course; in patients with panic disorder - in the panic attack clinic, a small number of symptoms (no more than three), psychological symptoms recorded in individual cases, interstitial period without prior warning, obsessive hypochondria, hypochondria hypochondria, low frequency of panic attacks (less than 1 time per week),duration of the disease up to 1 year. For the first time, a simultaneous study of premorbid-personal, excitatory, clinical and psychological parameters was carried out in the hospital, which became the basis for the development of dynamic diagnostics of somatized cardiovascular diseases in patients. Syndromic and nosological aspects of somatized cardiovascular disease have been identified. For the first time, the leading symptom complexes characteristic of each of the nosological groups (cardialgic, vascular-dystonic and cardiodisrhythmic syndromes) were identified, which makes it possible to develop more specific criteria for diagnosing this pathology. Differential assessment of the effect of therapy on the rate of cessation of Affective, functional and cardiovascular diseases in patients with somatized depression, anxiety-depressive and anxiety-
phobic disorders, taking into account the features of the psychological mechanisms of protection and studying their mental state. Somatized cardiovascular diseases are a complex comorbid complex formed on the basis of primary emotional disorders, the development of which is determined by the presence of predictors of a biological and psychosocial nature; the clinical version of somatized cardiovascular diseases is largely determined by the form of nosological pathology associated with certain premorbid - personal characteristics of patients;-each variant of the somatized cardiovascular system is characterized by specific changes in the patient's mental state and features of psychological defense mechanisms that can be determined using questionnaires and scales;- treatment of diseases of the somatized cardiovascular system should be carried out taking into account their nosological type with the introduction into the treatment regimen of not only antidepressants, but also tranquilizers and antipsychotics.- programs for diagnosing somatized diseases should include an assessment of the patient's mental state, which is an important predictor of the dynamics of clinical manifestations of somatoform autonomic dysfunction of the cardiovascular system, as well as a factor affecting the choice of therapy. This method can also be used to assess the effectiveness of treatment. Strong psychotraumatic life events were more important for women: factors of the production plan, medical problems (for 50% of men and 37% of women, respectively). The main life events, family-household and negative interpersonal relationships have become relevant for 61,8% of women and 49,1% of men. The results of studies of the pathogenetic state of psychosomatic diseases associated with the lability of regulatory systems to the action of psychosressors show an important role of psychosocial factors in mechanisms that disrupt the adaptive capabilities of patients and enhance the development of somatic diseases that occur. According to the results of the study, in 40,8% of the total sample of patients, the motive for contacting cpsychiatr for hospitalization was subjective dissatisfaction with its condition, which was more important for women than for men. Regardless of the nature of the disease, patients who identified themselves as "seriously ill" initially consulted an Internist, citing General poor health, but without receiving a full explanation from the attending physician about their condition, sought help from other specialists or resorted to unconventional treatments, including psychicalar2. In more than half of the cases, these patients were given recommendations to consult a psychiatrist or psychotherapist, but patients refused the recommendations recommended by therapists, not recognizing mental health issues. High-level social stigmatization of Psychiatry in society. Patients who require constant attention have become "difficult sick" for the Attending Physician 3.Z. J. Lipowski (1986, 1988), Lyubanplozza V. and others according to their observations. (1996), after a long "marathon" in search of the "best" specialists for various medical institutions, the so-called "difficult sick" is not accepted for a long time in the field of vision. Later, patients were admitted to the border conditions Department and contacted the CPSU independently or on the advice of relatives and friends. A comparative analysis of motivational factors has shown that it is more important for women to maintain psychotraumatic situational 2) Women who found themselves seriously ill experienced fear, anxiety, depressed mood of different composition, noted anhedonia, loss of body weight and lack of appetite, suicide, mental discomfort, tears, general weakness. The most important psychostressors for women were the main life events, negative interpersonal relationships and family and family factors. These conditions are characterized by psychopathological incompleteness of depressive syndrome ("subsyndromal depressions"), weak violence, or lack of major manifestations of depression (hypothymia, psychomotor disorders, guilt ideation, etc. By identifying themselves as" nervous "or" somatic " sick, men found a greater general dissatisfaction with their condition, or they completely rejected the disease. They were characterized by emotional instability, irritability, conflict, the presence of sephalgia, fear of death, anxiety, loss of interest in
life, work (anhedonia without additional signs of depression), to a greater extent self-deprecation and a tendency to self-blame ideas. The most important psychotraumatic factors were medical problems (related to the fact of the disease) and production problems. Mental health problems became a reason to bypass the general somatic treatment facility and turn men into psychiatrists. The patient's" lack of self-identification as sick" to somatic disease causes a denial of the disease (anozognostic reaction), in particular, low adherence to the examination and treatment of Cardiological patients, which is confirmed by epidemiological studies of a specific male part of the population. In the group of women, a predominance of depressive, anxiety-depressive, hysterical, phobic syndromes was observed. Dominants thymic, irritating, hypochondriacal, asthenic symptomatology in men (p=0,001). Hysterical circle syndromes dominated 16,4 percent of dinners and dysthymic dominated 23,1 percent of men. Depressive disorders in women were found at 34,4%, in men at 25,0%. Symptoms of anxiety and phobias are more common in women, while hypochondria and asthenic conditions in men are diagnosed 3 times more often. In patients with internal organ disorders, the psychopathological picture of the current mental disorder is somatic "masks" or masked, filled with somatic, somatovegetative symptoms indicated as somatized symptoms, "decorated". In the composition of psychopathological diseases, the most frequent" masks" are 4 vegetative, somatized and endocrine diseases, in the form of Algic symptomatology, not typical of the classic clinical signs of a specific pathology of internal organs. It is likely that only 40-50% of all patients with angina know motheralicias disease and receive appropriate treatment, in 50-60% of cases the disease is not recognized.
Conclusions. The main conditions of the differential diagnostic approach to the examination of a psychosomatic patient are compliance with the requirements for careful collection of Anamnesis, proper exercise of complaints presented and active in a detailed analysis of the observed symptoms and syndromes, comprehensive clinical structural examination of the patient and close cooperation of the therapist (cardiologist) and psychiatrist. A study conducted found the presence of various somatovegetatives, Psychovegetative ipsychological manifestations in patients with comorbid heart and mental pathology. Symptoms that "block" the clinical signs of somatic disease and psychopathological syndrome, on the one hand, reflect the likelihood of their pathogenetic community with psychopathological diseases, on the other hand, with a certain somatic disease. In this case, the disease of the internal organs, against the background of an extended psychopathological picture, remains symptomatic, but the complex of objective somatic symptoms is exacerbated or altered by non-characteristic and non-specific manifestations, which are clinical equivalents that are difficult to diagnose in the early stages of KVH. Psychopathological diseases in cardiovascular diseases are the subject of debate about diagnostic and therapeutic difficulties in general medical and psychiatric practice, posing a major problem for the patient himself. A significant increase in Mental Disorders at the neurotic and affective levels among patients in general medical institutions indicates the relevance of the organization of specialized (medical counseling, rehabilitation) integrated care for these patients and the need to improve the training of Internist doctors in the field of Psychosomatic Medicine.
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