Depression, schizophrenia and dementia. What mental illnesses can begin after 45? Psychiatrist Ruslan Vorobyov: After 45 years, an early form of dementia can begin 08:01

— Some websites of psychiatric clinics contain articles about pre-senile psychoses and their treatment methods. What kind of diseases are these?

— Let me start by saying that the term you are asking about is very specific and is rarely used in the daily practice of a modern psychiatrist. Presenile is presenile; most often this period includes the age of 45-60 years. Psychosis is a pronounced form of mental disorder, in which the patient’s mental activity is characterized by a sharp inconsistency with the surrounding reality. This is manifested in behavioral disorders and the appearance of pathological symptoms and syndromes that are unusual for the norm (disorders of perception, memory, thinking, emotionality, etc.).

It is unlikely that we will find serious modern scientific studies devoted to pre-senile psychosis as an independent form of the disease. This term refers to a syndrome as a set of symptoms rather than a specific disease.

– But in ICD-10 (The International Classification of Diseases, 10th Revision, which doctors use to code diagnoses) There is a section called “Presenile psychosis, unspecified.” So this is not an illness?

— This expression is mentioned in the section devoted to dementia, or rather in the unspecified subsection of dementia. It is important to explain what dementia is here. It is an acquired dementia syndrome caused by brain damage that impairs many higher cortical functions, including memory, thinking, orientation, comprehension, arithmetic, learning, language and reasoning. Consciousness is not obscured, but it becomes difficult for the person to control their emotions and behave in accordance with social norms.

Usually we try to find the exact cause of this condition. However, in some cases it is not possible to accurately determine the nature of dementia, either because the appropriate investigations have not yet been performed or because the symptoms found during the examination do not meet the criteria for certain diseases. The diagnosis can then be formulated by adding the characteristic “unspecified”, for example “unspecified dementia”.

The category of “presenile psychosis” is used when general criteria are met for a diagnosis of dementia, but we cannot determine with certainty whether this is due to trauma, vascular damage to the brain, or Alzheimer’s disease.

At the same time, for reasons not yet clear, the presenile patient simultaneously has some obvious mental disorders, mental disorganization phenomena, delusions and hallucinations. Then we can make the diagnosis of “presenile psychosis”. Often this is a preliminary diagnosis, which later develops into a more specific diagnosis.

— Why might a patient experience these mental disorders?

— All the disorders I mentioned belong to the group of “organic mental disorders.” This means that in all these diseases, damage and changes in brain tissue can be detected. For example, in anxiety disorders, they are usually absent.

Organic changes may be caused by injury, infection, tumor, cerebral circulation problems, neuronal atrophy or other causes. They may present themselves with a wide variety of psychiatric symptoms that we can divide into two main groups.

On the one hand, these are various dementias. On the other hand, there are organic syndromes in which the most striking symptoms are disorders of perception (hallucinations), content of thoughts (delusions), mood and emotions (depression, anxiety), and behavior. Such symptoms are associated with psychosis and do not always occur simultaneously with cognitive and intelligence impairments, i.e., are not always present with dementia syndrome. Therefore, the inclusion of presenile psychoses in the category of dementia in the ICD-10 classification may be controversial.

— It turns out that the term “presenile psychosis” exists but is not used that widely. Why?

— This term has a more historical meaning. When looking at the history of psychiatry, descriptions of pre-senile psychoses date back to the end of the 19th century and the first half of the 20th century. One of the first to define this term was the German psychiatrist Emil Kraepelin. He used the word “psychosis” in a broader sense as a description of mental illness and also defined “involutionary melancholia.” Some famous psychiatrists whose works we know from that period classified melancholia (depression) as psychosis.

This term is also found in the works of leading Russian scientists of that time, such as TA Geyer and PB Gannushkin. Researchers of that time were making generalizations, hypothesizing, trying to create classifications based on their observations. It should be understood that at that time scientists did not have the opportunity to conduct neuroimaging studies such as MRI or CT, which we have today, and did not have the opportunity to determine biological markers in the blood of patients. There were no large databases that could be subjected to statistical analysis.

— And with the development of evidence-based medicine, has this term gradually disappeared?

— Since then, due to the accumulation of scientific knowledge about the functioning of the brain, its neurophysiology, biological mechanisms, various neurological and psychiatric disorders, the ideas about diseases have been significantly revised, expanded, and classifications have changed.

Today we use the word “psychosis” in a narrower sense. For example, previously a depressive state without delusional and hallucinatory phenomena was called psychosis. Today we clearly know that it is characterized by thought disorder, delusions, hallucinations, the patient loses his criticism of his condition, his behavior becomes incomprehensible to his relatives, illogical, unrelated to his past experiences and personality traits.

Based on modern concepts, psychotic states can occur not only in the context of organic disorders, but also with various mental pathologies, for example, schizophrenia, schizoaffective disorder, bipolar disorder, and also against the background of various toxic effects of alcohol, drugs or psychoactive substances. In some cases, the emergence or exacerbation of a mental illness can occur precisely in the period of 45-60 years, which we are discussing.

— What other symptoms of psychosis can occur in pre-senile age?

— As I have said, this may be a delusional disorder, characterized by the development of delusions which in some cases become chronic. The content of the delirium is varied; it is often a persecutory delusion, fear of poisoning, theft, some everyday ideas, so-called everyday delusions or “petty delusions.”

Hypochondriacal delusions become more common with age. The content and onset of delirium are often related to life circumstances; other symptoms may be absent; (such situations are called evolutionary paranoia). However, in some cases, hallucinations may be present as well as delusions. Often, such conditions are accompanied by depressed mood, anxiety and other symptoms of depression.

— Can dementia occur at this age?

– Yes, it can manifest itself at the age of 45-60. We have already understood that dementia is not psychosis and develops gradually. There is such a thing as early-onset dementia, that is, the pre-senile variant.

The most common cause of dementia is Alzheimer’s disease. This is a disease that develops due to impaired metabolism of the amyloid protein and the formation of deposits of this protein in brain tissue (amyloid plaques). This triggers a series of processes that lead to the death of neurons (neurodegeneration), as a result of which less functional brain tissue is formed and mental functions begin to suffer.

A certain role in the development of dementia is also played by disorders of blood flow to the brain due to vascular pathology: hypertension, atherosclerosis, stroke. Neurologists often treat dementia. But sometimes patients first turn to psychiatrists, because in neurological diseases associated with the development of dementia, depression, anxiety, and sleep disorders often also occur.

— Are the symptoms of early-onset dementia different from regular dementia?

— Clinical symptoms of Alzheimer’s disease that begin at an earlier age are similar to those that begin at an older age. The first symptoms of Alzheimer’s disease include short-term memory impairment, absent-mindedness, difficulty planning activities, and decreased performance.

In the future, memory deterioration progresses, the ability to understand new information, assimilate instructions is damaged, practical skills are impaired. At the beginning of the disease, memory disorders, mostly short-term, are not severe in nature, but further progression leads to forgetting the names of loved ones, the names of objects, words.

The rate of development of the disease may vary over the years from the onset of the first symptoms of the disease, with memory disorders accompanied by visual-spatial functions and counting disorders. The circle of interests, mood swings, anxiety and suspicion gradually narrow.

— How can a psychiatrist understand what type of illness a patient has, since the symptoms are often similar?

— The symptoms are similar, but all diseases have their own specifics. When making a diagnosis, anamnesis and characteristic symptoms are taken into account, various studies are performed, including MRI, CT, PET CT of the brain, EEG, Dopplerography of cerebral vessels, various blood tests, neuropsychological tests, and in some cases more complex additional studies. In addition, monitoring the patient over time brings a lot of useful information. All this together allows for diagnosis.

— How should these patients be treated when a definitive diagnosis cannot be made?

– In any case, we treat the patient, but symptomatically, in this case we are fighting the symptoms, not the disease, because we do not yet know the disease itself. There are many strategies, the choice of which depends on the situation, concomitant diseases, medical history, the presence of contraindications, compliance. (the patient’s conscious implementation of the doctor’s recommendations during treatment – editor’s note) patient.

In the most general case, if the patient is predominantly delusional and hallucinatory, antipsychotics will be chosen. These are drugs that are specifically aimed at alleviating the productive symptoms of delusional and hallucinatory disorders. If he is depressed, antidepressants will be prescribed. If there is anxiety, tranquilizers. And when additional examinations are carried out, which make it possible to recognize the nature of this condition and to clarify the diagnosis, then therapy can be adjusted and specific agents, drugs against a specific disease, can be added.