Obsession

• 1614 - Felix Plater made the first clinical description of an obsessive-state neurosis (OCD) , in the structure of which, in fact, obsessions were described ^[1] .
• 1834 - J.-E. D. Escirol , describing a patient with OCD , vividly described obsessions along with compulsions and phobias ^[2] .
• 1858 - I. M. Balinsky noted that all obsessions have a common feature - alien to consciousness, and proposed the term " obsessive state " ^[3] .
• 1860 - B.O. Morel suggests that the cause of obsessive states is a violation of emotions . The individual symptoms of obsessive syndrome are described.
• 1866 - J.P. Falre-father first obsessive doubts are described.
• 1868 - V. Grisinger described another separate version of the obsessions - sterile philosophizing ^[4] .
• 1877 - K.-F.-O. Westphal pointed out that obsessions surfaced with intellect unaffected in other respects and cannot be expelled from consciousness. He suggests that the basis of obsessive states is a disorder of thought, which coincides with the currently accepted view of obsession ^[5] .
• 1885 - J.M.Sharko (and in 1892 - J.-J.-V. Manyan ) onomatomania was described.
• 1890 - 1892 - V. M. Bekhterev first applied successful psychotherapy for obsessions ^[6] .

It is rather difficult to systematize obsessions ^[7] . V.P. Osipov , E.S. Averbukh , V.A. Gilyarovsky and E.A. Popov were opposed to their classification because of the presence in one patient most often of different types of obsessions, often together with compulsions and phobias. However, an attempt to classify them was still generally accepted ^[7] .

Obsessive symptoms (from the point of view of the physiological principle of classification of psychiatric syndromes based on a reflex arc ) relate to disorders of intrapsychic activity ^[8] (that is, to disorders in the central part of mental activity). In turn, among disorders of intrapsychic activity, obsessions, together with supervaluable ideas and delirium , fall into a subgroup of thinking disorders (associative process) ^[9] .

Obsessive syndrome refers to productive (positive) syndromes . E. Kraepelin , like the French school of psychiatry , referred him to the first, easiest group. In domestic psychiatry, according to A. V. Snezhnevsky , this syndrome belongs to the 3rd of nine productive circles of defeat ^[10] .

According to K. T. Jaspers ^[11] (1913), the obsessions are divided into:

1. Distracted (not accompanied by altered affect ):
   1. Barren philosophies;
   2. Intrusive account - arithmomania ;
   3. Obsessive memories (some cases);
   4. Decomposition of words into syllables.
2. Figurative (accompanied by the painful affect of anxiety or fear ):
   1. Obsessive doubts;
   2. Obsessive drives
   3. Obsessive memories
   4. Possessing views.

According to Lee Baer, obsessions can be divided into three main groups:

1. Inappropriate aggressive thoughts;
2. Inappropriate thoughts about sex drive ;
3. Blasphemous religious thoughts ^[12] .

A.M.Svyadoshch , in addition to his classification of Jaspers in the modification of Snezhnevsky, developed his classification of obsessions according to pathogenesis (1959):

1. Elementary - appear immediately after an extremely strong stimulus and their etiology is obvious to the patient; this may include, for example, the fear of a train after a railway accident, iatrogenic ;
2. Cryptogenic - the etiology, and therefore the mechanism of occurrence, is unknown; however, unlike dissociative disorders , the cause is not forgotten, but not taken into account by the patient and can be identified with causal psychotherapy ^[13] .

According to A. G. Ivanov-Smolensky , obsessions are divided into two groups that are not very distinct:

1. Obsessive phenomena of arousal: in the intellectual sphere - obsessions, ideas, memories, desires, associations, in the emotional sphere - most often obsessive fears;
2. Obsessive delays, painful inhibitions that interfere with arbitrary movements or under certain conditions ^[14] . For the first time, such phenomena were described back in 1905 by S. A. Sukhanov ^[15] .

According to Lee Baer, obsessions are most characteristic of obsessive-compulsive disorder . If people with obsessions from the United States came together, they could create the fourth largest city in the country after New York , Los Angeles and Chicago ^[16] . A 2007 study claimed that 78% of patients with clinically established OCD suffer from obsessions ^[17] . Of 50 adult patients with OCD, 10-20% have obscene obsessive sex drive ^[18] . According to other sources, 25% of 293 patients with established first time OCD have such attractions in the history of the disease ^[19] . With neurosis, obsessions are the third most common after depressive and hypochondriacal syndromes ^[20] .

At the moment, the specific etiological factor of the obsessions is unknown. Complicating his search is the fact that they are found in various mental disorders, whose etiology is also not exactly known. There are several valid hypotheses . There are 3 main groups of etiological factors ^[21] :

1. Biological ^[22] :
   1. Diseases and functional and anatomical features of the brain ^[22] ; features of the functioning of the autonomic nervous system ^[23] ;
   2. Violations in the exchange of neurotransmitters - primarily serotonin and dopamine , as well as norepinephrine and GABA ;
   3. Genetic - increased genetic concordance ^{[24] [22]} ;
   4. Infectious factor ( PANDAS Syndrome theory).
2. Psychological :
   1. Psychoanalytic theory;
   2. Theory of I.P. Pavlov and his followers;
   3. Constitutional-typological - various accentuations of personality or character ;
   4. Exogenously traumatic - family, genital or industrial.
3. Sociological (micro- and macro-social) and cognitive theories (strict religious education, modeling of the environment, inadequate response to specific situations) ^[22] .

Psychological Theory

Deep Psychology

Psychoanalytic Theory

Sigmund Freud's ( 1907 , published in 1909 ), Notes on a Case of Obsession Neurosis, is the first case of psychoanalysis of a patient with a neurosis of obsessive states that he described. According to Freud, many associations associated with sexual experiences remain unconscious . Mental trauma or strong feelings associated with these associations with sexuality may be crowded out , but continue to affect the behavior and mental life of a person. Neurosis and their symptoms (in particular obsession) are considered in psychoanalysis as the result of such an effect. Trying to return to consciousness, repressed psychosexual material is replaced by obsessive symptoms. According to Freud, for any neurosis (including with obsessive symptoms), childhood with its sexual complexes (for example, the " Oedipus complex ") is of primary etiological importance. If, through psychoanalysis, the association of obsessive symptoms with these complexes is returned to consciousness, then the symptoms will disappear ^[25] .

Individual Psychology

The student of Z. Freud A. Adler , who founded the school of individual psychology , denied the role of sex drive, arguing that the basis of all neuroses is the conflict between the desire for power and a sense of inferiority, that is, the “ I ” conflict according to Freud ^[26] . According to the domestic scientist V.N. Myasishchev , the basis is unresolved contradictions between personality and reality.

Analytical Psychology

According to C. G. Jung, groups of associations associated with a common affect are called complexes ^[25] . They can affect mental processes. A separate view of the complex, which has penetrated the consciousness, can become an obsession. Associated with the complex, it will not come into contact with other ideas and will not disappear from them from consciousness, remaining deeper than its threshold ^[25] .

Critique of the approach

Given the full value of these hypotheses, it is worth noting that they describe the appearance of obsessions in neurotic stress-related and somatoform disorders - psychogenic processes , while they only partially reveal the essence of endogenous processes, for example, schizophrenia, as well as epilepsy and encephalitis.

Theory of I.P. Pavlov and His Followers

According to IP Pavlov , an obsessive-state neurosis occurs in people with different types of higher nervous activity ^[27] , but more often, in a mental “truly human type” ^[28] .

Pavlov believed that in obsessions, the mechanism is common with delirium ^[27] . Both are based on pathological inertness of excitation , the formation of isolated "large points" of foci of unusual inertness , increased concentration , extreme tonicity of excitation with the development of negative induction . An inert focus of excitement with obsession does not suppress the excitation of competing foci, as with delirium. Inertness is associated with the impossibility of volitional elimination of obsessions, as well as the inability to suppress them with a new stimulus, which turns out to be too weak for this ^[29] .

Further , I.P. Pavlov suggested that the essence of the pathophysiology of the disorder is not inert excitation, but in the lability of inhibition . The basis of obsessive blasphemous thoughts in religious people and an obsessive attraction to contrast action is the ultra-paradoxical phase of inhibition in the focus of pathologically inert excitation ^[30] . His disciples M.K. Petrova and F.P. Mayorov also considered it, somewhat supplementing these provisions ^[31] . The safety of criticism of obsessions is preserved due to the low intensity of pathological arousal compared to delirium and, consequently, the lower force and prevalence of negative induction.

A. G. Ivanov-Smolensky , a student of V. M. Bekhterev and an employee of I. P. Pavlova , argued that obsessions are obsessive ideas of arousal ^[31] .

S. N. Davidenkov explained obsessive doubts about the inertness of both inhibition and excitement. According to his theory, there are several competing points of excitement at the same time, that is, impulses to action disputing each other ^[31] . Developed this theory by José de Castro ^[32] . S. N. Dotsenko established the inertness of excitation in patients and only in an insignificant part the inertness of both processes. M. I. Seredina , argues that the focus of pathologically inert excitation in the patient’s cerebral cortex causes both negative induction and transcendent inhibition ^[14] .

E.A. Popov , a pupil of I.P. Pavlov , linked blasphemous obsessive thoughts, contrasting drives with ultra-paradoxical inhibition, when centers that are responsible for opposite concepts are excited. He believed that obsessive doubts about successfully completed actions are connected with the presence of 2 points of arousal, and the point of doubt, being “large”, suppresses the “smaller” point, which is responsible for confidence ^[33] .

M. M. Georgievsky , M. B. Umarov and A. P. Lapite explained character changes that are prone to obsessions, the weakening of processes in the cerebral cortex and deep asthenization of the central nervous system of patients ^[34] . The basis of asthenia during obsessions occurring in neuroses in the structure of which they arise are additional “breakdowns” of higher nervous activity . These disruptions occur during the overstrain of the strength and mobility of nervous processes. This occurs not so much with an exogenous reaction as with the endogenous struggle of the dynamic structure of the personality and the pathodynamic structure of obsession ^[35] . This process of constant struggle with obsessions leads to asthenia in the higher parts of the brain. Such phenomena occur with neurosis other than psychasthenia and are temporary, passing with a cure. With psychasthenia, these processes are not dynamic, they are a kind of “state”, “constitution” ^[35] .

The theory of I.P. Pavlov and his followers is consistent with the neurotransmitter, but the first describes brain damage on an organismic level, while the second describes subcellular and molecular damage. This is natural, given that in the first half of the 20th century, data on neurotransmitters were very scarce and related mainly to adrenaline and acetylcholine ^[31] . In addition, she explains the occurrence of obsessions at the initial stage of schizophrenia, complicated by delirium. IP Pavlov regarded this symptom as evidence of the ultraparadoxical phase of inhibition of the cerebral cortex . According to Pavlov, the basis of the pathogenesis of schizophrenia is beyond protective inhibition:

“... a chronic hypnotic state” ^[36] .

И. П. Павлов расценивал это как свидетельство ультрапарадоксальной фазы торможения коры головного мозга , присутствующее и при обсессиях с той разницей, что при бредовых состояниях большая, по сравнению с навязчивостями, интенсивность патологического возбуждения и, следовательно, меньшая сила и распространённость отрицательной индукции.

Однако, теория И. П. Павлова , разработав патогенез навязчивостей, не указывает этиологию процесса обсессий, а встречаются они при заболеваниях как эндогенной, так и экзогенной природы, то есть совершенно разного происхождения.

Конституционно-типологические факторы

В основе личности людей с ОКР часто выступают ананкастные черты ^[37] .

Нейромедиаторная теория

Механизм, связанный с серотонином

В рамках нейрофизиологического подхода, исследователи выдвигают теорию о связи ОКР, а, следовательно и обсессий, с нарушениями коммуникации между глазнично-лобной корой мозга и базальными ганглиями . Эти структуры мозга используют нейротрансмиттер серотонин для взаимодействия. Считается, что между ОКР и недостаточным уровнем серотонина есть связь ^[38] . Процесс передачи информации между нейронами регулируется, в частности, обратным захватом нейротрансмиттеров в нейроны — нейромедиатор частично возвращается в испускающий нейрон, где ликвидируется моноаминоксидазой , что контролирует его уровень в синапсе . Предполагается, что у больных ОКР происходит повышенный обратный захват серотонина ^[39] , и импульс не доходит до следующего нейрона. В пользу этой теории выступает то, что больные чувствуют пользу от приёма антидепрессантов класса селективных ингибиторов обратного захвата серотонина .

Данная теория согласована с генетической теорией возникновения обсессий о патологии гена hSERT и возникновении их при других невротических, связанных со стрессом и соматоформных расстройствах, кроме того, она частично объясняет возникновение обсессий при БАР и шизофрении ^[40] . Однако все механизмы обсессий она всё же не раскрывает.

Механизм, связанный с дофамином

Многие пациенты с ОКР и шизофренией имеют повышенную концентрацию дофамина в базальных ганглиях (левом хвостатом ядре и левой скорлупе ) ^{[41] [42] [43] [44] [45] [46]} . Эти нейромедиаторы являются частью так называемой « системы поощрения » и вырабатываются в больших количествах во время позитивного по представлению пациента опыта типа секса , приёма наркотиков , алкоголя , вкусной еды, а также стимуляторов, ассоциированных с ними ^[47] . Нейробиологические опыты также показали, что даже воспоминания о позитивном поощрении может увеличить уровень дофамина ^{[48] [49]} . Например, мозг пациентов, которым было дано плацебо , вырабатывал дофамин так же, как и при приёме настоящего препарата ^[50] . Однако некоторые пациенты умышленно перенапрягают эту систему поощрения, искусственно вызывая приятные для них воспоминания и мысли снова и снова, поскольку таким образом естественно производятся нейромедиаторы хорошего настроения . Это похоже на наркотическую зависимость , ведь практически все наркотики прямо или косвенно нацелены на «систему поощрения» мозга и насыщают его структуры дофамином ^[51] .

Если пациент продолжает перестимулировать свою «систему поощрения», то постепенно мозг адаптируется к чрезмерному потоку дофамина , производя меньше гормона и уменьшая количество рецепторов в «системе поощрения» . В результате, химическое воздействие на мозг уменьшается, снижая способность пациента наслаждаться вещами, от которых он раньше получал удовольствие ^[51] . Это снижение заставляет пациента, зависимого от дофамина , усиливать свою «мыслительную деятельность» , пытаясь привести уровень нейромедиаторов в нормальное для него состояние — этот эффект известен в фармакологии как толерантность . Дальнейшее развитие толерантности может постепенно привести к очень тяжёлым изменениям в нейронах и других структурах мозга и потенциально может, в долговременной перспективе, нанести серьёзный ущерб здоровью мозга ^[52] . Современные антипсихотические препараты нацелены на блокировку функций дофамина . Но, к сожалению, эта блокировка иногда также вызывает и приступы депрессии, что может усилить зависимое поведение пациента ^[53] . Когнитивно-поведенческая психотерапия (КПТ), проводимая профессиональным психологом, также может помочь пациентам эффективно контролировать свои навязчивые мысли, поднять самооценку, понять причины депрессии и объяснить им долговременные негативные последствия дофаминовой зависимости.

Как видно из этой теории, она, в отличие от серотониновой, описывает частные случаи возникновения обсессий и не раскрывает их этиологию и патогенез полностью.

Теория PANDAS-синдрома

Существует также теория, которая объясняет появление или резкое значительное ухудшение симптомов ОКР (в том числе и обсессий ^[54] ) при стрептококковой инфекции. Эти бактерии вызывают, к примеру, ангину . Согласно этой теории, в процессе борьбы с бактериями антитела в организме пациента «случайно» разрушают другие ткани тела, а не бактерий (происходит аутоимунный процесс ). Это может вызвать ОРЛ , гломерулонефрит , а также ОКР, если разрушается, к примеру, ткань базальных ганглиев . Хотя эта причина ОКР является довольно редкой, она тем не менее объясняет некоторые случаи флуктуации симптомов, независимых от внешних воздействий (стресса). Однако эта теория не объясняет возникновение обсессий при множестве других заболеваний, как психогенных, так и эндогенных, поэтому является частным случаем их появления.

Однако нельзя отрицать, что инфекции имеют астенизирующее влияние на ЦНС ^[55] . Так, ещё гораздо раньше других авторов, в 1905 году С. А. Суханов отмечал ухудшение состояния при неврозе навязчивых состояний у взрослых в зависимости от экзогенных условий:

«При истощении навязчивые состояния усиливаются. Обострение их вы встретите после инфлуэнцы ( гриппа ), после родов , при кормлении, после какой-нибудь физической болезни» ^[56] .

Генетическая теория

Возможно, способствуют ОКР, а значит и обсессиям, генетические мутации . Они были обнаружены в человеческом гене переносчика серотонина hSERT (ген SLC6A4), у неродственных семей с ОКР ^[57] . Он локализирован в 17 хромосоме , плечо q11.1—q12. В ней происходила транслокация аллеля L и соответственно генотип LL.

Данные про однояйцовых близнецов также подтверждают существование «наследственных факторов невротической тревоги» ^[58] . Кроме того, лица с ОКР более вероятно имеют членов семьи первой степени родства с этим же расстройством, чем здоровые представители контрольной группы. В случаях, когда ОКР развивается в детстве, наследственный фактор гораздо сильнее, чем тогда, когда ОКР развивается позже во взрослом возрасте.

На генетические факторы может приходиться 45-65 % ОКР у детей с этим диагнозом ^[59] . Однако очевидно, что на экспрессивность генов влияют факторы внешней среды. Сейчас активно ведутся исследования в этом направлении. Кроме того, мутации переносчика серотонина hSERT могут быть связаны с социофобией, большой депрессией и ПТСР ^[60] , но их наличие не объясняет обсессии при других заболеваниях.

Manifestations

Обсессии могут проявляться в виде навязчивых образов, мыслей, страхов , желаний. Например, может присутствовать навязчивая мысль о собственной нечистоте. Обсессии часто ведут за собой компульсии — специальные «ритуалы», выполнение которых позволяет избавиться на некоторое время от навязчивой мысли.

Поначалу достаточно было их просто-напросто помыть, чтобы на несколько дней почувствовать себя намного лучше. Но, по мере того, как шло время, чувство загрязнённости возвращалось к девочке всё чаще, а избавление от грязи требовало всё более долгого мытья рук. В конце концов, она мыла их по несколько раз в день; оттирала их щёткой из рисовой соломы, пока те не начинали кровоточить. Только лишь когда боль становилась совсем уж невыносимой, Цинь-цзяо наконец-то чувствовала себя чистой, но и то — всего лишь на пару часов.

— Орсон Скотт Кард . «Ксеноцид» ( 1991 )

Discussions can be in one patient, either of the same species or of several at the same time. They can appear both suddenly - paroxysmally and be short-lived, and gradually and continue chronically ^[61] .

Distinctive Features of Obsessive Thoughts

Distinctive features of the obsessions were distinguished by S. A. Sukhanov ^[62] ( 1912 ) and V. P. Osipov ( 1923 ) and formulated by V. M. Bleicher :

1. The discussions are reproduced by the consciousness against the will of the individual, however, the consciousness remains clear ^[63] . At the same time, the volume of consciousness can be narrowed, but during obsessions this is very weakly expressed ^[64] . The patient cannot eliminate the obsession with volitional effort ^[63] . However, he still tries to fight them. There is an active and passive type of struggle ^[64] . With a rarer active patient, he deliberately does everything contrary to the obsession (with obsessive attraction, rushing under the train specially goes to the station and stands at the edge of the platform ). With a passive type, the patient can: switch attention to other activities; try to avoid situations associated with obsessions, including preventing obsessions - if someone obsessively drives someone to kill, do not approach sharp objects; perform compulsions ^[65] . Active struggle is less preferable, as it causes undesirable vegetative reactions ^[66] .
2. Discussions have no visible connection with the content of thinking , and are alien to it ^[63] .
3. Discussions are closely related to emotions , especially depressive ones and anxiety ^[63] .
4. Discussions do not affect the patient’s intellect , including logical constructions ^[63] .
5. Criticism has been maintained for the obsessions. By this we mean that a painful attitude has been maintained towards obsessive thoughts, and the patient is aware of their unnaturalness ^[63] . At the same time, there is no sense of imposition on the outside , which creates the basis for building a critical attitude towards them ^[67] . With the intensification of obsessions, especially with their paroxysms, criticism weakens.

Distracted Obsessions

Infertile painful philosophies - one of the types of obsessions, characterized by empty, fruitless verbosity, reasoning with the absence of specific ideas and purposeful thinking process with the presence of a critical attitude to this condition. That is what it fundamentally differs from the phenomenon of resonance . More often, issues of the relationship of the concepts of metaphysical , moral, religious and other characters are solved ^[4] . An example of the patient’s train of thought, described by the author of the study, Henri Legrand du Soleil :

A young ... woman ... being alone on the street, begins to ask herself the following questions: “Will someone now fall from my window under my feet? Will it be a woman or a man? Will this face be smashed to death or only be wounded? Will it fall on your head or feet? Will there be blood on the sidewalk? If this face is beaten to death, what should I do? Should I call for help or run away? Will they accuse me of this incident? Will my disciples leave me because of this? Will my innocence be recognized? ”

- Henri Legrand du Saulle . Mental disorder of doubt (with delusions of touch) = La folie du doute (avec delire du toucher). - Paris : Adrien Delahaye , 1875 . - S. 12.

On the basis of obsessive philosophies, the so-called “obsessive world outlook (worldview)” ^[62] , which contradicts moral and other principles of a person, is alien to his consciousness, but which he cannot get rid of. Sometimes obsessions prevent the patient from focusing on a specific object of thought.

Obsessive memories - a phenomenon in which there is a desire to reproduce in memory various minor events ^[68] . Close to this is onomatomania - obsessive reproduction of words.

Differentiate obsessional rituals with rituals that belong to compulsions ^{[68] [69]} .

Shaped Obsessions

Obsessive doubts are a variant of obsessions, in which the individual is not sure either of the correctness or completeness of the actually completed actions, and, accordingly, the actions ^[68] . If it is possible to check the action, the patient will do it repeatedly ( compulsion ), if not, for a long time with a pronounced affect remember the algorithm of action, whether he was mistaken at a certain stage of its execution.

Obsessive fears are the phenomena of anxiety about the inability to do something familiar, professional and automated ^[68] . So, for example, a notary was described who had a strong sense of anxiety about whether he had written something that could “bring him to trial” and asked to close his office and hide the keys to it, since he he didn’t trust himself ^[70] . They must be distinguished from phobias, although the affect of anxiety can turn into fear .

Obsessive drives - an obsession in which the patient wants to make a meaningless, dangerous and obscene act ^[68] . So, back in the 17th century, F. Plater described a innkeeper who passionately loves her newborn child with the urge to kill him ^[1] . They must be distinguished from impulsive actions . They differ in that they are never enforced.

Possessing ideas are implausible or incredible thoughts about a real event significant for the patient.

A patient died of tuberculous meningitis ; he was buried. After some time, the father of the child had the idea that his son was buried alive. The patient vividly imagined ( hallucinatory obsessions ) how the child woke up in a coffin, screaming and finally suffocated. This thought and the corresponding notions were so strong and painful that the patient repeatedly went to the cemetery, put his ear to the grave and listened for a long time to see if there would be screams from the grave. This was not the end of the matter. The father turned to the cemetery administration with a request to open the grave and check if the position of the body had changed in the coffin.

- ^[71]

Contrasting ideas and blasphemous thoughts are ideas that contradict the worldview and ethical principles of the individual. F. Plater described the “faithful son of the church”, which, in thoughts on religious topics, represents indecent things ^[1] . But they can be connected not only with religion, but also with persons authoritative for a given person or moral values.

Emotional Disorders

Symptoms from the sphere of emotional disturbances are almost always found in the structure of obsessive syndrome ^[61] . This is especially characteristic of figurative obsessions. Then, even with moderate obsessions, there is a subdepressive background with the phenomena of depression, a sense of inferiority and insecurity. Asthenia is also possible, including with phenomena similar to neurasthenia : irritability or irritable weakness. At the height of the obsessions, agitation and anxiety-depressive affect are possible.

Emotional disorders are a criterion for regression of obsessional treatment. So, in the opinion of E. Regi ^[72] ( 1902 ), obsessions do not decrease, “until the accompanying and conditioning affective background decreases and disappears ^[73] ”. Patients themselves during treatment note that with a decrease in the emotional component, the obsessions do not disappear, but the patient is much less concerned ^[73] .

Perceptual Disorders

Different perceptual disorders occur during obsessions with a varying frequency. Thus, elements of depersonalization are an integral symptom in an obsessive syndrome ^[61] . The depersonalization phenomenon is characterized by the “mirror symptom” described by N. K. Lipgart . Such patients avoid looking in the mirror so as not to see what they think is a “crazy look." Sometimes, for the same reason, they do not look into the interlocutor’s eyes ^[74] .

However, hallucinations can occur at the height of the obsessions ^[61] . Although they are more common with severe phobias, according to modern concepts, they are not included in obsessive syndrome, they can occur with obsessions in the form of blasphemous thoughts in the form of pictures of cynical content and with obsessive drives in the form of pictures of the action and its consequences ^[61] . They are called hallucinatory obsessions and are classified as Kandinsky pseudo-hallucinations . They were described by J. Segl in 1892 and 1895 ; A. Pitre and E. Regi ^[72] in 1897 and S. A. Sukhanov in 1904 . In patients, according to A. M. Svyadoshch , tactile pseudo-hallucinations are possible ^[75] . Disorders of taste and smell may appear. In addition, sometimes with severe obsessive syndrome with a component of depression, illusions are possible ^[76] .

Vegetative Disorders

Paroxysmal obsessions may be accompanied by blanching or reddening of the skin, tachycardia , bradycardia , cold sweat, shortness of breath , increased peristalsis , polyuria , dizziness, and fainting . Severe autonomic disorders can even distort the basic characteristics of obsessions, such as alienness, clarity of consciousness, criticism and the fight against them ^[77] . It can be argued that disorders of the autonomic nervous system are the only objective symptoms of obsessions. Obsessions themselves, unlike, for example, compulsions, are not manifested by motor impairments, but are mainly subjectively experienced by patients ^[78] .

Obsessional Character Change

Long-term obsessions affect the behavior of patients and their personality as a whole ^[79] . So, previously uncharacteristic or already present features are aggravated by the character of patients with obsessions. Secondary character changes did not occur during obsessions lasting less than 2 years ^[79] . According to N. K. Lipgart , patients began:

“... extremely suspicious, impressionable, anxious, insecure, indecisive, timid, shy, fearful” ^[80] .

That is, patients showed alarmingly suspicious character traits. A preliminary diagnosis of severe obsessive changes in character was more often “ psychasthenia ” ^[80] . During the onset of new symptoms, patients were given different diagnoses, depending on the situation.

Psychometry

For conducting psychometry , in addition to standard tools used for various diseases, tests specific to obsessions are used. First of all, it is recommended to use the Yale – Brown obsessive-compulsive scale ^[81] . If the scale is not used, consider the time that the patient spends on obsessive thoughts and other types of obsessions ^[81] . Situations actively avoided by the patient are also recorded, and after a certain time, new data are compared with the initial ones ^[81] .

Differential Diagnosis

Discussions differentiate with overvalued ideas and nonsense . Principal differences:

1. Overvalued ideas and nonsense are not alien to the patient’s consciousness, the patient’s “ I ” always protects them ^[61] . The patient continues to struggle with obsessions to a greater or lesser extent.
2. Obsessions, unlike overvalued ideas and nonsense, retained the ability to approach critically. It is worthwhile to be careful in the prognostic plan, since with overvalued ideas and delirium, criticism may also be partially present in the initial stage.

Obsessions also differentiate with mental automatisms . During obsessions there is no feeling of imposition from the outside, done. They are alien to thinking, but perceived as their own thoughts, and not "made" by someone. With paroxysmal obsessions, it is necessary to conduct an EEG and to collect a very detailed history of the disease ^[82] . In addition, obsessions are differentiated from accusations of depression and anxiety during anxiety neurosis ^[81] .

Diseases characterized by the syndrome

Obsessive symptoms are characteristic of obsessive-compulsive disorder (OCD) and anancastic personality disorder , and can also occur in post-traumatic stress disorder (PTSD), anxiety neurosis , eating disorders and psychotic phenomena ^[17] .

With different neuroses, the obsessions are somewhat different. So, with OCD they are especially pronounced ^[35] . Moreover, the volume of consciousness is almost unchanged, the criticism is high, and the elements of the struggle are most active. Patients even with strong paroxysms of obsessions try to remain active, and obsessions and their depressive background hide. With neurasthenia, the level of criticism and struggle is lower, in general behavior there are changes against the background of complaints of somatic and neurotic symptoms. Psychasthenia is characterized by a gradual development of symptoms, partial criticism, and a passive struggle. Patients hardly hide emotions.

More often obsessions are found in neurotic, associated with stress and somatoform disorders. However, they can be included in the group of affective disorders, more often depression ^[83] . Moreover, they can either be part of its structure, or be its equivalent. Patients with clinical depression may experience more intense obsessions, and consider them as a well-deserved punishment for their sins. They should be differentiated from suicidal thoughts, since the latter can be life threatening ^[84] .

Often, unwanted thoughts about harming your child occur in postnatal depression ^[85] . A study of 65 women with major postnatal depression, conducted in 1999 by Catherine Wisner et al., Found that the most common obsessive aggressive drive was to harm newborns ^[86] .

Obsessions can also occur with cyclothymia and mild bipolar affective disorder . A. M. Svyadoshch described cyclotymia in which in the depressive phase the key was not depressive mood, which was the background, but an obsessive fear of contracting tuberculosis and cancer ^[87] .

Often, obsessive syndrome manifests itself in the debut of psychoses ^[88] , including schizophrenia . With schizophrenia, obsessions occur in less than 1% of cases. Their distinctive features: suddenness, unmotivated, completely incomprehensible to others content ( A. M. Svyadoshch described a patient whose obsession caused pollen of butterflies), persistence, monotony, and resistance to psychotherapeutic effects ^[89] . With schizophrenia, the obsessive syndrome can gradually become more complicated, for example, with supervaluable ideas , and then - delirium with ideational mental automatisms . Obsessive doubts can complicate the appearance of delirium of a depressive nature. However, R. A. Nadzharov in 1955 indicates that obsessions may not be replaced for a long time by psychic automatisms, coexisting with them ^[88] . It is noteworthy that patients often treat such obsessive conditions passively, that is, they do not fight them, but strive for their rigorous execution. With obsessions, a neurosis-like form of schizophrenia and its paranoid subtype more often begin.

Obsession has its own characteristics in personality disorders (psychopathies), namely, in case of anancaste personality disorder . Firstly, they occur with low-intensity stimuli. Secondly, more often they are multiple. Thirdly, with obsessions, anxious-suspicious character traits of patients are aggravated ^[90] .

With epilepsy, obsessions are manifested in the form of phenomena of impaired consciousness . They are short-lived, paroxysmal, elementary, not associated with psychological trauma, and sharply affectively saturated (for example, the obsessive drive to kill a loved one). В импульсивные действия они не переходят ^[91] . Исследование М. Мулы в 2008 установило, что при височной эпилепсии (ВЭ) обсессии часто связаны с половой сферой ^[92] . Ф. Монако в 2005 сравнил обсессии при (ВЭ) и идиопатической генерализированной эпилепсии. У 15 % пациентов с ВЭ присутствовали обсессии ^[92] .

Очень похожие на эпилептические обсессии при эпидемическом энцефалите. Они часто исполняются в виде компульсий ^[91] . При органических заболеваниях головного мозга чаще возникают навязчивые сомнения. Их легко вызывает небольшая психотравма в связи с астенией ЦНС ^[91] .

Лечение обсессий принято проводить не как отдельный синдром , а вместе с основной нозологической единицей во всех школах нозологической направленности ( российской , немецкой ), в отличие от французской , придающей большое значение симптомам и синдромам. Лечение обсессий можно разделить на 2 группы — этиологическое и патогенетическое ^[93] . При этиологическом лечении устраняют причины, травмирующие пациента. При патогенетическом лечении воздействуют на патофизиологические звенья в головном мозге. Ведущим считается патофизиологическое лечение, так как даже если изъять пациента из неблагоприятных условий, полностью обсессии не прекратятся ^[93] . Кроме того, для эндогенных психозов и ряда других болезней этиологическое лечение не подходит, потому что их этиология точно не известна.

Психотерапия

Поскольку в рамках разных школ психологии существуют разные теории патогенеза обсессий, то и методы психотерапии обсессий каждая школа предлагает разные.

Созданное Американской психиатрической ассоциацией практическое руководство по лечению ОКР рекомендует применять методы когнитивно-поведенческой психотерапии , так как, в отличие от других направлений психотерапии, её эффективность достоверно показана ^[81] . Она даёт позитивные результаты ^{[94] [95]} , хотя необходимым является формирование концептуального представления об обсессиях ^[96] . Одним из популярных методов в рамках этого направления является экспозиционная психотерапия ^[19] . Как дополнительный приём может использоваться метод « остановки мысли » ^{[97] [98]} .

Для лечения ОКР применяется и рационально-эмоционально-поведенческая терапия ^[99] , во многом сходная с когнитивно-поведенческой психотерапией .

При обсессиях показано психотерапевтическое лечение, направленное на создание новых интересов (интересный труд, походы и экспедиции) ^[99] . Результат при этом нестойкий. Более продолжительный эффект может дать трудотерапия ^[99] .

Применяются методы внушения и самовнушения — гипноз и аутогенная тренировка ^[6] . При обсессиях обязательно необходим полноценный продолжительный отдых, однако не безделье, которое может привести к их обострению.

Совсем иначе дела с лечением ОКР обстоят в глубинной психологии (например, психоанализе ), рассматривающей обсессии как симптом, являющийся выражением более глубоких проблем, на работу с которыми и должна быть направлена терапия. Американское руководство по лечению ОКР отмечает, что эта терапия способна помочь пациенту преодолеть собственное сопротивление лечению путём устранения причин для желания оставаться таким, как он есть ^[81] .

Семейная психотерапия (она является не методом, а формой психотерапии, при которой работа идёт со всей семьёй пациента, а не только с ним одним) снижает напряжение внутри семьи, обостряющее обсессии ^[81] .

Терапия психотропными средствами

Для терапии психотропными средствами обсессий применяют транквилизаторы, антидепрессанты (причём чаще не очень сильные, так называемые «мягкие» ^[21] ) и нейролептики (антипсихотики), тоже преимущественно мягкие.

Антидепрессанты. Транквилизаторы

Так, для медикаментозного лечения обсессий при ОКР, депрессии, циклотимии, ПТСР ^[100] и синдроме Туретта ^[101] применяются антидепрессанты из группы селективных ингибиторов обратного захвата серотонина ( СИОЗС ): « Сертралин », « Пароксетин », « Флуоксетин », « Флувоксамин », « Циталопрам », « Эсциталопрам » — и трициклический антидепрессант « Кломипрамин » ^[81] . Применять антидепрессанты можно и при обсессиях при неврозоподобной шизофрении ^[102] . Очень эффективно применение антидепрессантов при аффективных расстройствах — БАР и циклотимии ^[103] и, в комбинации с психотерапией, — постнатальной депрессии ^[104] .

При наличии выраженной тревоги в первые дни фармакотерапии целесообразно назначение бензодиазепиновых транквилизаторов (« Клоназепам », « Алпразолам », « Диазепам », « Феназепам », « Гидазепам »).

Среди новых препаратов из класса СИОЗН используют атомоксетин в комбинации с СИОЗС. Так как предпочтительнее монотерапия, чаще применяют селективные ингибиторы обратного захвата серотонина и норадреналина (СИОЗСН) — венлафаксин и дулоксетин ^[105] .

Антипсихотики

При хронических формах ОКР , не поддающихся лечению антидепрессантами типа ингибиторов обратного захвата серотонина (около 40 % пациентов), всё чаще применяют типичные и атипичные антипсихотики ^[106] ( Рисперидон , Оланзапин , Кветиапин ) ^{[107] [108] [109] [110]} . Уместно также сочетать приём лекарственных препаратов с когнитивно-поведенческой психотерапией , проводимой профессиональным психологом ^[107] . При этом большие дозы антипсихотиков уменьшают эмоциональную насыщенность, а малые делают пациента более доступным для психотерапии ^[103] . В США лечение обсессий при ОКР антипсихотиками не одобрено Управлением по контролю качества продуктов и лекарств , однако их широко используют в качестве аугментации (дополнения) СИОЗС при резистентных явлениях ^[105] .

Существуют, однако, данные, что некоторые из атипичных антипсихотиков (обладающие антисеротонинергическим действием — клозапин , оланзапин ^[111] , рисперидон ^[112] ), напротив, обладают способностью вызывать и усиливать обсессивно-компульсивные симптомы ^{[111] [112]} . Выявляется прямая зависимость между выраженностью такой симптоматики и дозами/продолжительностью применения этих препаратов ^[111] .

Нейролептики применяют также при лечении неврозоподобной шизофрении (см. Вялотекущая шизофрения ), лечение которой отличается от лечения обсессий при неврозах отсутствием эффекта от психотерапии ^[102] . Такое применение этих препаратов рекомендуют преимущественно авторы на территории бывшего СССР. При лёгком течении рекомендуют сульпирид , тримепразин . При более тяжёлом течении назначают амисульприд , тиоридазин , галоперидол , трифлуоперазин и пролонгированные препараты: модитен-депо ( флуфеназин ), клопиксол-депо ( зуклопентиксол ) и флуспирилен -депо ^[113] .

Помогают атипичные антипсихотики также для лечения обсессий при депрессии , в том числе кветиапин и арипипразол ^[105] . Некоторые авторы полагают, что рисперидон и оланзапин противопоказаны при депрессии и навязчивостях ^[114] и могут сами вызывать ^[115] или усиливать ^[114] депрессию.

Экспериментальная терапия

Существуют данные о благотворном воздействии на обсессии при ОКР и аффективных расстройствах инозитола ^[116] . Другие исследования считают необходимым при обсессиях усиленно снабжать организм витаминами и минералами ^[117] .

Быстро улучшить состояние при обсессиях, вызванных ОКР, теоретически могут μ-опиоиды , такие как гидрокодон и трамадол ^[118] . Трамадол не только действует как опиоид, но и ингибирует обратный захват серотонина и норадреналина ^[119] . У больных с резистентными обсессиями экспериментально улучшил состояние приём морфина , хотя эффект этот не изучен и механизм неизвестен ^[120] . Использование данных средств крайне ограничено из-за сомнительного соотношения польза/риск (все вышеназванные опиоиды — наркотики ).

The effect of observational OCD was observed with psychedelic drugs such as LSD and psilocybin ^[121] . It is believed that hallucinogens stimulate 5-HT _2A receptors , and at least 5-HT2C receptors , inhibiting the orbitofrontal cortex , a site heavily associated with OCD and obsessions in particular ^[122] .

Regular nicotine intake can reduce obsessive syndrome in OCD, although the mechanism of this action is unknown ^[123] .

Since acetylcholine antidopaminergic effects worsen the course of OCD , anticholinesterase agents are used to treat stable obsessions ^[124] .

Hypericum perforatum is considered useful in observational cases of OCD and depression , but a double-blind study using a flexible dose schedule showed that its effect is equal to placebo ^[125] .

Biological Therapy

It is rarely used, for example, in severe OCD, with obsessions refractory to other types of treatment. In the USSR and now the CIS countries , atropinomatous therapy is used for this ^[126] .

In the West, electroconvulsive therapy is used to treat obsessions ^[127] . However, in the CIS countries, indications for her are much narrower. It is not used during obsessions. It is inappropriate during obsessions and IST ^[103] .

Physiotherapy

For the treatment of obsessions, it was recommended to use (source of the beginning of the XX century):

1. Warm baths (35 ° C ) lasting 15-20 minutes with a cool compress on the head in a well-ventilated room 2-3 times a week with gradual cooling of the water temperature in the form of rubbing and dousing ^[128] .
2. Wiping and pouring water from 31 ° C to 23-25 ​​° C ^[128] .
3. Bathing in river or sea water ^[128] .

With disorders of the autonomic vascular system, electrophoresis , darsonvalization is indicated.

Neurosurgery. Psychosurgery

As you know, A. Egash Monish first applied frontal leukotomy in 1936 with schizophrenia. We also used it in cases of OCD with drug-resistant cases with obsessions. So, in 1960 V. Mayer-Gross , E. Slater , M. Roth , and later, in 1967 G. Yu. Aizenk , P. Bernard and C. Brisset in severe cases of OCD also recommended such operations. However, the resulting “ frontal lobe syndrome ” caused this method to be abandoned and to seek safer methods of intervention ^[103] . In 1976, S. A. Shevits proposed in severe OCD, which is associated with affective disorders, such operations: transorbital lobotomy, singulectomy, gyrectomy, bimedial leukotomy, thermocoagulation, cryotherapy, ultrasound exposure and laser exposure. However, representatives of the domestic school of psychiatry, in particular, A.M.Svyadoshch, a major specialist and author of the monograph on neurosis, consider these tools to be excessive and inappropriate (obsessions are most often reversible, corrected by a modern arsenal of tools, and the consequences of brain damage are unpredictable and irreversible) and possibly with a small positive effect ^[103] .

At this stage, observational psychosurgery is performed in China ^[129] , Belgium , the Netherlands , France ^[130] , Spain ^[131] , Great Britain , and Venezuela ^[132] and, possibly, in some other countries.

Polar views on neurosurgical intervention in temporal lobe epilepsy. Barbieri et al. Argue that such treatment leads to a complete remission of obsessions ^[92] , while other authors ^[92] believe that it is the operation that leads to their exacerbation.

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