The pathogenesis of neuroses represents the history of the formation of the pathophysiological mechanism and the clinical picture of the disease (Myasishchev V.N., 1965). Consider the pathogenesis in the dynamics of the action of such factors as: 1) constitution and neuro-somatic weakness of the body; 2) premorbid features and age; 3) unfavorable life situation; 4) mental trauma and internal conflict; 5) neuropsychic tension; 6) pathophysiology; 7) personality change. When considering the pathogenesis, both previously obtained and new data are generalized.
constitutional factor
Attention is drawn to the great similarity of children and mothers to their fathers, which creates a certain contradiction between the insufficient psychological influence of the father in the ancestral and parental families and the one-sided, substitutive female influence in both families. This is one of the variants of the constitutional-environmental conflict. It should be added that the mother herself suffered from it in childhood, when, despite the commonality with her father, she could not find emotional contact with him, including because of the unilaterally dominant position of the mother (grandmother) in the family. But even in the parental family, children are in the same situation: with a greater resemblance to their father, they are often deprived of contact with him, in contrast to the prevailing influence of the mother in the family. History, as we see, repeats itself, which is not indifferent to the formation of such personal categories as a sense of affection, love in girls of younger age and gender-role identification in boys of older preschool age.
If we consider clinical (abnormal) combinations of character traits, then along the entire female line, especially in the mother and grandmother, sensitivity and anxiety stand out in the form of affectively sharpened emotional sensitivity and anxiety. Constitutionally common will also be suspiciousness and inflexibility of thinking (rigidity) prevailing in the female line. On both lines, the hypersocial orientation of the personality will be common, which, on the one hand, reflects the positive social orientation in the families under study (sense of duty, duty, adherence to principles), and on the other hand, predetermination and maximalism, the difficulty of compromises.
Mothers are more characterologically burdened than fathers; in turn, maternal grandmothers are burdened more than grandfathers. In general, the burden in parental and grandparental families is more pronounced along the female line, which is emphasized by the presence of frequent nervousness in the mother in childhood and a neurotic state in the present. Consequently, one can speak not only of greater psychological influence along the female line in grandparental and parental families, but also of greater burden along this line. If in the female line, affective-characterological disorders are more likely to be common, then in the male line - psychomotor disorders: tics, stuttering, enuresis. On both lines there is a neuropsychic weakness in the form of neuropathy.
Temperament, an innate type of neuropsychic response, mainly from the side of the pace of mental processes, must also be attributed to constitutional manifestations. It has already been noted that the differences in the severity of temperament types in neuroses and in the norm (at primary school age) are not as significant as might be expected. Nevertheless, with neuroses, there are relatively more children with a phlegmatic temperament, in which case their neurotic retardation cannot be ruled out. The more the natural temperament “changes” under the influence of improper upbringing, the greater the severity of the neurosis caused by excessive restrictions or excessive stimulation of the psychophysiological capabilities of children. To a greater extent, this applies to boys, who, compared with girls, are more likely to have a choleric temperament, which is most easily damaged by excessive environmental restrictions. Boys are more vulnerable to restrictions in choleric temperaments, and girls to stimulation in phlegmatic temperaments.
Children with a choleric temperament are more prone to neurotic reactions of an anxious and excitable circle, with a phlegmatic temperament - to neurotic fears and reactions of an inhibited circle.
Neuro-somatic weakness
Most often we are talking about general somatic weakness, susceptibility to frequent colds, spasms in the respiratory tract, gastrointestinal tract, and cardiovascular system. More often this is observed in the foyer of neuropathy and is one of the expressions of the general altered neuropsychic reactivity of the body.
Less frequent than neuropathy, the source of neuropsychic weakness of the body will be residual cerebral organic failure. Both types of pathology contribute to the emergence of asthenic disorders, against which neurotic symptoms are more easily fixed, primarily fears, obsessive thoughts and fears.
Often we are talking about selective weakness or deficiency of certain body systems that are most susceptible to stress. It can be excessively accelerated or slow speech with elements of dysarthria in stuttering; increased muscle excitability with general motor failure and high growth with tics; violations of the biorhythm of sleep with enuresis; permeability and excitability of the mucous membranes, respiratory tract and gastrointestinal tract in stress-mediated bronchial asthma, habitual vomiting, gastritis and angiocholecystitis; vegetovascular lability in the form of headaches, instability of the pulse and blood pressure; allergic hypersensitivity of the skin and mucous membranes in the form of exudative-catarrhal diathesis, false croup, Quincke's edema and neurodermatitis.
Prolonged mental stress itself leads to certain functional disorders in the activity of the diencephalic part of the brain. This is expressed by the chronic course of somatic diseases, the first appeared vegetovascular dystonia and hormonal instability in adolescence.
A mixed variant is also possible, when chronic stress, acting through central regulatory mechanisms, sharpens the already weakened somatic spheres of the body and leads to the appearance of new, psychosomatically conditioned disorders.
When the body is weakened, the number of problems in education increases, since it is not easy to find an approach to a frequently ill child. In this case, the mother and grandmother often show hyperprotection and protection in communicating with their peers.
Dysontogenesis also has a certain significance in the pathogenesis of neuroses, both in terms of physical development (for example, high growth in children, especially girls with tics), and in terms of mental development, in the form of uneven pace in the first years of life. Usually this is an advance or delay in certain aspects of mental development as an expression of age-related instability of temperament in children with neuroses. So, with stuttering, we often see some primary delay in speech development, followed by its “breakthrough” - acceleration. Such unevenness reflects the difficulties, typical for neuroses in general, of combining contrasting features of the temperament of the parents, with stuttering - the predominance of the phlegmatic temperament of one of them at the beginning of the life of the children, and then the choleric temperament of the other, followed by a relative equalization of temperament according to the sanguine type.
Premorbid features of children
The peculiarity of the formation of character and personality is one of the central concepts of the pathogenesis of neuroses. As already noted, premorbid features are not so pronounced and abnormal as to speak of their leading role in the origin of neuroses, in contrast to psychopathic development with an initially pathological spectrum of characterological disorders. In case of neurosis, it would be more correct to single out the interaction between the emerging personality and the life traumatic situation, with the latter being the leading value. Moreover, neurosis can also occur against a premorbidly unchanged background, but to a greater extent this applies to neurotic reactions.
Of the premorbid features, attention is primarily drawn to emotional sensitivity and the severity of the feeling of "I". Emotional sensitivity is manifested by an increased need for emotional contact, recognition, love and affection from loved ones and significant persons, as well as a noticeable sensitivity to the shades of their relationship. In turn, the dissatisfaction of these needs gives rise to the fear of loneliness, which is so inherent in children with neuroses, or the fear of inseparable feelings, emotional rejection and isolation.
The expressiveness of "I" is an early manifestation of self-esteem, the desire for one's own opinion, independence in studies and actions. These children, who are whole and spontaneous in their feelings, strive to be themselves, they cannot stand fawning, feigned politeness and falseness, duality in feelings and relationships. Already in the first years of life, they vulnerablely perceive the infringement of their sense of "I", suppression, dictatorship, activity restrictions, excessive control and excessive care, showing incompatibility with such an attitude in the form of stubbornness (from the point of view of parents).
Excessive restrictions on activity and independence create the affect of blocking the needs for self-expression, self-realization and assertion of one's "I".
The inconsistency of upbringing with the originality of the innate temperament, the emerging character and the emerging personality leads to the deprivation of the fundamental needs for emotional contact, affection and love, recognition, self-expression, self-realization and the assertion of "I". In addition, the sense of “I” emphasized in these children also reflects a pronounced instinct for self-preservation, which, together with emotional sensitivity, impressionability and an unfavorable life situation, facilitates the emergence of neurotic fears and mental trauma. The latter, in turn, sharpen the need for security in the form of an increase in defenselessness, timidity and anxiety. It is in the affectively experienced deprivation and the sharpening of the leading needs that the psychogenic aspects in the formation of the personality of children with neurosis are contained.
age factor
The age factor in the pathogenesis of neuroses is important in terms of finding the most sensitive age for the appearance of neurotic disorders. In 325 children with neurosis (191 boys and 134 girls), the average age of onset of neurosis is 6 years: in boys, 5; girls - 6.5 years. In boys, this precedes the age-related activation of the left hemisphere. Thus, in most cases, neurosis begins at the senior preschool age, when children are still quite emotional and at the same time they have an intensive development of thinking (cognitive level of the psyche).
At this age, they deeply understand and deeply experience traumatic life circumstances, being still unable to resolve them in the most accessible way for themselves. If we recall the previously given data on the severity of nervous manifestations (wider than neurosis) in children of preschool age, then it is at the age of 5 and 6 that they occur most often, indicating a special, sensitive stage in the development of the psyche and the formation of personality. At the same age, age-related fears are most common, including the fear of death and related fears, clinically sharpened by strong feelings, fears and illnesses. There is a great need at this age and in communication with peers, which is also manifested by the need for role identification with a parent of the same sex while maintaining a sense of love and affection for a parent of the opposite sex. The blocking of these needs, the lack of a sense of security and self-confidence, as well as the affectively experienced experience of life failures, combined with an overstrain of psychophysiological capabilities, clearly make themselves felt in the form of a long-acting and insoluble mental stress, subsequently manifested by the clinical picture of neurosis. The earlier occurrence of neurotic disorders in boys indicates, among other factors, their greater sensitivity to the emotional problems of relationships with their mother, as the closest and at the same time traumatic person due to their inadequate attitude.
When analyzing the occurrence of neuroses for each year of life (outside the sex of children), the most vulnerable are the ages of 2,3,5 and 7 years. At 2 and 3 years, neuroticism is a consequence, on the one hand, of the traumatic experience of separation from parents when placed in a nursery and kindergarten and problems of adaptation to them; on the other hand, the confrontation of parents with the stubbornness of children, in fact, with their natural temperament, will and the emerging sense of "I". We have just talked about the sources of neuroticization at the age of 5. At the age of 7, the neurotic factor is a neuropsychic overload due to schooling (often two at a time), increased requirements for grades and excessive control over the preparation of lessons by parents, as well as problems of psychological adaptation to school.
In 64%, neurosis occurs at preschool age and in 36% at school age (significant differences). The greatest severity of neurosis is observed in boys at primary school age. It should be noted that the severity of neurosis in boys is significantly higher than the severity of neurosis in girls.
In both boys and girls, neurasthenia most often begins at 2, 3, and 7 years of age; hysterical neurosis - at the age of 3; anxiety neurosis - at the age of 5; obsessional neurosis - at school, mainly in adolescence, age. Thus, the earliest clinical forms of neurotic response (in preschool and early preschool age) will be neurasthenia and hysterical neurosis, anxiety neurosis in older preschool age, repeated neurasthenia in primary school age, and obsessional neurosis in adolescence. Accordingly, the age aspects of the origin of neuroses will be: neurasthenia at 2 and 3 years old - the struggle of parents with the stubbornness of children; hysterical neurosis at 3 years old - a violation of emotional contact on the part of the mother and the lack of recognition of children in the family; anxiety neurosis at the age of 5 - affective, situationally determined sharpening of age-related fears; neurasthenia at the age of 7 - neuropsychic overload in children under the influence of excessive demands from parents; obsessive neurosis in school, often adolescence, age - moral and ethical, affectively pointed and insoluble conflicts. It is not difficult to see in such age dynamics a transition from externally determined pathogenetic conflicts in neuroses in the first years of children's lives to internal conflicts in adolescents.
The concept of "life situation"
It means the negative effect of environmental factors on the formation of the character and personality of children. Here there will be deviations in upbringing and conflicts, life's difficulties and hardships, the difficulty of adapting to certain aspects of reality, etc. Often we are talking about an unfavorable combination of life circumstances, often playing the role of a key psycho-traumatic factor. In the first years of life, such simultaneously or closely occurring psycho-traumatic events, such as admission to a hospital without a mother, the beginning of attending a nursery and kindergarten, the birth of a brother or sister with a switch in the attention of the mother, have an adverse effect. All this can occur against the backdrop of family conflicts and divorce, fright and shock experiences, including accidents and operations. Here are such traumatic circumstances as the merciless struggle of parents with the stubbornness of children and their unwillingness to eat a lot, forcible putting to sleep during the day, inconsistent and contrasting attitudes in the family, frequent illnesses and isolation from communication with peers, emotional isolation of one of the children in the family, non-participation of the father in upbringing or his absence, lack of love from the mother when she is irritated and worried, excessive demands from a large number of adults, excessive guardianship, etc.
Here are two life situations that are common in our practice, but dramatic for children. In the first of them, a 5-year-old boy was distinguished by excitability and anxiety, did not let his mother and other adults go away from him, slept anxiously, sometimes waking up in a state of fear. He was afraid of everything new, unknown, as a possible effect of adverse events. Fear began to manifest itself from 11 months. his life, when he spent a month in the hospital with his mother for otitis media. He underwent a large number of painful procedures, including paracentesis. It is at this age that children are afraid of the appearance of unfamiliar older females. Screaming, he was taken away from his mother for procedures, and the absence of his mother was now a signal of the presence of danger. The new environment also had an effect, where he did not feel safe and protected by his mother. A busy mother early entrusted his upbringing to her parents, who, like her, have increased anxiety and hypersociality. An overprotective boy had to listen to endless moralizing from four adults about what they thought was not fast enough intellectual progress. At the same time, he was often scolded for his spontaneity in expressing feelings and activity in his movements. It should be taken into account that the domineering grandmother completely ousted the mother from her role, replacing the boy's peers as well. With unshakable, paranoid persistence, she believed that the father had a harmful effect on his son, arousing him with his unnecessary "fuss" and indulging "whims", and in essence - realizing his natural activity and emotionality. The grandmother was especially unhappy with the violation of the punctually prescribed daily routine, since the grandson had to sleep during the day, “as expected”, despite the fact that he could not fall asleep at that time. When he was 5 years old, at the insistence of his grandmother, his father was removed from the family, as he competed with her and grandfather for the right to have a decisive vote in the family. Outwardly and in temperament, the son resembled his father, which aggravated his position in the family. In addition, divorce occurred just at the age of maximum need for identification with the role of a parent of the same sex in the family. At this time, they decided to send the boy to kindergarten. But due to the large number of developed fears, self-doubt and lack of experience in communicating with peers, he could not adapt, was inhibited, tearful, experienced the absence of his mother, despite the complexity and inconsistency of relations with her. Against this background of constant and insoluble stresses, tics appeared, and at the consultation a diagnosis of anxiety neurosis was made.
As we can see, this boy had too many unfavorable events in his short life, which, of course, exceeded the threshold of adaptive capabilities and caused an overstrain of neuropsychic forces in the form of a clinical picture of neurosis.
In the second case, we will talk about a 9-year-old boy, irritable, with an unstable mood, easily tired and unsure of himself. According to the general opinion, he studies below his abilities, is easily distracted and, according to adults, cannot prepare his own lessons. If we add to this headaches in the evening, difficulty falling asleep, then there will be a clinical picture of neurasthenia. In the first years of his life, he grew up quite calm. In the meantime, conflicts between the parents were growing, mainly because of the harsh nature of the father, who was irritated by the son’s emotionality, his “inadequacy” and whims, in fact, manifestations of emotions normal for the age (the father himself was not in the role of a son, since he lost his father early and was brought up by an aunt - a woman, "correct in all respects", but devoid of a sense of tenderness and compassion). When the boy in question was 5 years old, his parents separated, and he became even more attached to his mother, not letting go of himself, because he saw in her the only source of security and reciprocal feelings. When he began to attend school, the mother remarried, and the child that appeared from the new marriage completely diverted her attention from her son. About the latter, however, "care" was manifested by the simultaneous placement in a language and music school.
In subsequent years, the mother unrecognizably changed in relations with him, began to check every step, often get annoyed and scream, and physically punish him for low grades. At the same time, she could not help her son, instill confidence in him and understand his feelings. So the boy became an emotional orphan with existing parents, having lost not only his father, but also the warmth of his mother, her spiritual help. His increased fatigue is a consequence of long-term stress, caused not so much by overwork from increased loads, but by feelings of inability, worthlessness, uselessness and loneliness in the family.
As a result of an unfavorable combination of life circumstances and a large number of affectively charged experiences, a reactive sharpening of emotional sensitivity occurs in the form of sensitivity. It is seen as a combination of emotional instability, anxiety, vulnerability and vulnerability of the self.
These children are often worried, offended and crying. There is a noticeable poor tolerance of any grief, expectations, a tendency to lower mood and sadness. They experience an increased need for security, love and empathy, but cannot fulfill it due to the attitude of their parents and the prevailing circumstances. The state of prolonged emotional dissatisfaction and mental tension as a whole indicates, therefore, the presence of a chronic psychotraumatic life situation.
mental trauma
This is a more specific concept than an unfavorable life situation or a combination of circumstances, which, unlike psychic trauma, are not always recognized and experienced, but, like psychic trauma, act as a psychogenic factor in neuroses. Psychic trauma is an affective reflection in the consciousness of individually significant events in life that have a depressing, disturbing and generally negative effect. In this sense, psychic trauma is personally unique for each person. At the same time, there is much in common that can cause an affectively sharpened experience, if we consider it from the ethical and moral positions of an emotional response to fears and threats, sudden shocks, blockade of significant needs, irreparable losses and losses. Psychic trauma is both an objective and subjective phenomenon. It is objective insofar as it reflects the universal register of human experiences; its subjectivity is in the individually different, personal nature of experiences, when what hurts painfully, sometimes for a long time, one person, affects another only in passing, for a short time.
Psychic trauma as a psychological concept includes the conscious perception of some individually significant, unpleasant events, their processing in the form of experiences and the development of a more or less prolonged state of affect or a mental state with a negative emotional sign. The statement of psychic trauma means not only the presence of negative emotions, but also the absence of their reaction. Psychic trauma is not always "visible", that is, it manifests itself in behavior, especially in children with an impressive, internal nature of processing emotions.
A lot of value for the analysis of psychic trauma comes from the disclosure of the content of dreams. So, a 13-year-old boy still recalls with horror what he dreamed of at the age of 4: “I ask - mom, what is it, and in response - roar-roar-roar.” The hypersocial, hard-nosed, and uncompromising mother often yelled, got angry, scolded, and punished her preschool son for the slightest deviation from her predetermined ideas of proper behavior. Being often in an irritated and dissatisfied state, she was "deaf" to his emotional demands, did not show tenderness and warmth, just at the time when the need for this in children is especially great. Such, albeit selective, retention of traumatic experiences in memory is an indication of their high significance in the system of leading value orientations and needs. In another case, a 4-year-old girl repeatedly has a dream: "Wolves walk along the street." Why, instead of passers-by, people, does she see animals? Her parents constantly quarrel over their upbringing, which, however, does not prevent them both from resorting to physical punishment. Traumatic experiences for the girl are forced into sleep, filling it with the horror of the transformation of parents into wolves.
It is far from always that a mental trauma, like an emotional shock, a fright, remains in the memory in subsequent years. Here, a protective mechanism of repression or amnesia of psycho-traumatic events is activated, as happened in a 9-year-old boy with stuttering that began at the age of 5, when he was frightened by a rooster chasing him. Now he does not remember this episode. Why was he so afraid of the rooster? Because it coincided with the age of increased sensitivity to the fears of animals. And the boy was afraid not only of the rooster in those years, but also of cats and dogs. In addition, he is emotionally sensitive, impressionable and defenseless in defending his rights, which was supported for the purpose of obedience by constant threats from impatient and overly strict parents.
The role of psychic trauma in the presence of expressed experiences can also be played by the events discussed in the section “Unfavorable life situation”. Of particular importance are the mental traumas associated with being in hospitals without a mother in the first years of life, a large number of painful procedures and the wrong behavior of the personnel of these institutions, ignoring the increased emotional sensitivity and impressionability of children, attachment to their mother. The same can be said about placement in somatic sanatoriums, if the staff is not up to the mark and often, as in other children's institutions (primarily this applies to random persons working as nannies), resorts to punishments, threats and condemnations in in relation to "obstinate" children who are not able to quickly fall asleep during the day, there is "as much as it should be", and all the time striving to go home to their mother. In our practice, cases are typical when children of primary preschool age are locked up in the toilet as punishment, put in a dark room, scared that their mother will not come and leave them, etc. All this. “By the way”, falls at the age of maximum sensitivity to fears of closed space, darkness and loneliness, being a source of mental traumatization of children.
The dominant role in neurosis belongs to chronic mental trauma, often supplemented by acute mental trauma. However, the latter can also play a relatively independent significance, as can be seen from the following observations. A 5-year-old boy with anxiety neurosis and stuttering was sent to a nursery at the beginning of his second year, where he was punished by a nanny for slowness on the potty. And the atmosphere in the manger left much to be desired. Having come for her son ahead of time, the mother saw the following picture: the son walks around wet, all the windows are open (in winter), and the young “educators-trainees are sitting in the kitchen and smoking. At the same time, he went to the hospital, where, while in boxing, he missed his mother very much, was afraid of injections due to intolerance to pain at this age. Until now, she is afraid of new unknown situations and stutters at the same time. He has many fears, is unsure of himself and indecisive in his actions. Another 6-year-old boy with a similar diagnosis at 1.5 years old was admitted to the hospital for asthmatic bronchitis. Due to low nutrition, it was difficult to find veins, and when the mother took him away after 1.5 months. did not recognize her and her father, as if they were strangers. Subsequently, he continued to be afraid of doctors, as well as of all strangers and new situations. Until we removed these fears, the boy continued to stutter. It should also be said about a 14-year-old girl who experienced an incomprehensible fear for others when she left the house. Let us note that children with neuroses do not run away from home, as is often the case with psychopathic developments, but, on the contrary, "run into the house", i.e., remain in it. And the girl in question used every excuse not to go to school. It all started at the age of 1.5, when her mother sent her to a nursery and could not take her out of them one day in time.
Psychic trauma is not always determined by external adverse circumstances or events. At school age, especially in adolescence, it is consonant with painful, insoluble experiences, alteration and inferiority of the “I”, unsuitability and defenselessness, rejection by peers and difference from them by the type “I am not like everyone else”. Such a transcription of psychic trauma is primarily characteristic of obsessive neurosis, in particular for dysmorphophobia with a leading obsessive fear of changing the "I". But even in these cases, one can find certain shortcomings in education, deviations in the personality of parents and relationships in the family, which, like mental trauma, affect the origin of the internal conflict in neuroses.
Internal conflict
We will consider it both in relation to pathogenic, often unconscious (in children), contradictions, and in relation to experiences - the psychological content of the conflict.
According to Freud (1912), the basic internal contradiction in neurosis is the confrontation between the conscious (environmental) and unconscious (instinctive) aspects of the psyche. With obsessive-compulsive neurotic developments, the contradiction will be mainly between the sense of duty (morality) and the desires (inclinations) of a person.
S. Jung (year not specified) finds the following basic pathogenic contradiction in neuroses: their individual predisposition, which might have chosen a different type if abnormal external conditions had not prevented this. Where there is such an externally influenced perversion of the type, the individual subsequently becomes for the most part neurotic and his cure is possible only through the identification of an attitude naturally corresponding to the individual ”(p. 13).
In the concept of neurosis in children V. I. Garbuzov (1977), the main pathogenic contradiction is the inconsistency of environmental influence with the innate type of response - temperament. According to our data (1972), the fundamental contradiction in neurosis will be in the discrepancy between the requirements of parents and upbringing in general, the psychophysiological capabilities of children, the features of character and personality formation.
According to V. A. Gilyarovsky (1938), the very essence of neurosis implies a discrepancy between the possibilities at the disposal of the individual and those duties that arise from the presence of certain social relations. R. A. Zachepitsky (1975) sees the pathogenic source of neurosis in the collision of significant personal relationships with an incompatible life situation, which leads to an overstrain of the GNA processes and its disorders.
The neurotic conflict in various neuroses is presented, according to V. N. Myasishchev (1960), as follows. With neurasthenia, it consists in a contradiction between the capabilities of the individual and excessive demands on oneself. In hysterical neurosis, the conflict is caused by overestimated claims, combined with an underestimation or complete disregard for objective, real conditions. In obsessive neurosis, the conflict is due to conflicting tendencies, the struggle between desire and duty, between moral principles and personal attachments.
The typology of pathogenic contradictions in neurosis in children in general terms repeats that described. However, a number of clarifications and additions are needed, taking into account the specifics of childhood.
With neurasthenia, there is an initial contradiction between the requirements of parents and the capabilities of children who cannot assert themselves in some significant aspects of life. This contradiction can be regarded as a conflict of self-affirmation or social conformity, expressed by fear or basic anxiety "to be not the one" who is accepted, approved, respected (authority) in the family and peer group.
In hysterical neurosis, the leading one is the contradiction between the acute need for emotional recognition and the possibility of its satisfaction on the part of parents, manifested by the fear of "being nobody", i.e., not to mean, not to be of value, to be forgotten and unloved.
With fear neurosis, the contradiction is between the impossibility or weakness of self-defense with a pronounced self-preservation instinct. Such a contradiction is manifested by the fear of "being nothing", that is, not to exist, not to be, to be lifeless and dead.
In obsessive neurosis, the contradiction is between feeling and duty, the emotional and rational sides of the psyche, with a central fear of change or the fear of "not being yourself."
The conflict of self-affirmation in neurasthenia often occurs in the pre-school age as a manifestation of the emerging "I", as well as in primary school age, during the formation of a sense of duty, responsibility and duty (united by the concept of "conscience") and the need to be the one who finds acceptance and understanding in the group. The conflict of recognition in hysterical neurosis is typical in the younger preschool age, when the need for emotional recognition, affection and love is expressed. With fear neurosis, a conflict based on the inability to protect oneself or more broadly - a conflict of self-determination - is characteristic of older preschool age with an emphasized need for communication and understanding of the abstract categories of time and space, life and death. Finally, the conflict of the unity of the “I” in obsessional neurosis is characteristic of the adolescent stage of the development of self-consciousness and is expressed by the problem of “being oneself among others”.
Of course, this is a scheme that does not exclude other age-related variants of pathogenic contradictions or the presence of several at once. The main thing in the considered pathogenic contradictions is the affectively experienced impossibility of realizing the vital needs of self-affirmation, recognition (love), protection (security) and the unity of the “I”. As a result, obstacles are created on the way to the implementation of the leading personal need - self-realization as the main plot of the internal conflict in neuroses.
Consider the psychological content of the internal conflict. The merit of 3. Freud is that he was the first to understand neurosis as the suffering of the contradictory development of the personality (I. E. Volpert, 1972). According to K. Norneu (1946), a neurotic conflict occurs when a person's desire for security contradicts the desire for satisfaction of desires, and then a certain strategy of behavior is developed in order to resolve the conflict. According to E. Fromm (1947), the duality or inconsistency of a person's motivation, which contributes to internal conflict, is also emphasized by the fact that, on the one hand, he strives for independence; on the other hand, he wants to avoid independence, as it will lead to alienation. Close to this is the later point of view of K. Norney on neuroses as the alienation of the personality from the “self”, the predominance of the idealized “I” in it, which is the product of the irrational imagination of the individual (Horney K., 1950).
Experiences during an internal conflict become painful if they occupy a central or at least significant place in the system of relations between the individual and reality. Their significance is the condition of affective tension and affective reaction.
The psychological conflict in neurosis is an incompatibility, a clash of contradictory and insoluble personality relationships (Myasishchev VN, I960). The greater the degree of inconsistency, inconsistency and inadequacy in relation to the child in the family, the more tense and unstable is his internal position, which is a significant factor contributing to the overstrain of nervous processes and neurotic "breakdown" under the influence of even minor psychotraumas and somatic weakness (Zakharov A. I., 1972).
Conventionally, internal conflict can be divided into a conflict of interests (preferences), needs, opportunities and drives. A conflict of interest is often represented by a situation where parents do not take into account the sexual preferences of children, raising them as "asexual beings", or a girl as an expected boy, and a boy as an emotionally preferred girl. The situation that has developed in a 10-year-old girl, both of whose parents are engineers and are dissatisfied with her low success in mathematics, will also be typical. The daughter shows interest in the humanities, which does not suit her parents.
A conflict of interest is often supplemented in neuroses by a conflict of possibilities, in which, in turn, abilities for a certain type of activity are involved. So, a high school girl, at the insistence of her father, an engineer, studies at a mathematical school. Her mother, a musician, makes her study at a music school as well. Parents compete with each other; in addition, they do not have mutual understanding, and each strives to attract his daughter to his side. In this situation, she became more and more tired, headaches appeared, her sleep was disturbed, her mood dropped, and her neurasthenia was a response to the demands of her parents that were excessive and disproportionate to her abilities. In the future, she chose not a technical university or a conservatory, but a medical university, which, however, she could not enter because of her morbid condition. We have already spoken about the leading conflict of needs, noting the conflicts of self-affirmation, recognition, protection and unity of the “I”.
Characteristic in neurosis is a conflict of desires, which consists in a collision in adolescents of a developing sexual feeling, sexual desire with moral norms and restrictions.
The dynamics of the internal conflict in expanded form can be represented as follows: 1) the presence of psycho-traumatic, i.e. causing experiences, life circumstances or events; 2) difficulty, the impossibility of resolving them by the child, which leads to a chronic feeling of fatigue and tension; 3) clash of oppositely directed motives, desires, aspirations, generating the effect of frustration, internal unrest; 4) the appearance of a feeling of dissatisfaction with oneself, increased anxiety and affective tension; 5) instability of self-esteem, mainly its lowering, pessimistic assessment of the prospects; 6) decrease in internal consistency in assessments and judgments, fluctuations in decision-making, self-doubt; 7) increased sensitivity in the form of intolerance to certain life circumstances and events or an idiosyncratic, affectively sharpened type of response.
If the first and second points of the considered dynamics of the internal conflict mean stress, then, starting from the third point - frustration - it turns into distress - a more or less stable, negatively perceived emotional disorder. The child himself cannot get out of this state, since the psycho-traumatic conditions of life are not eliminated, and he does not have sufficient life experience. At the same time, the growing affect, as a derivative of experiences, increasingly blocks decisions and the ability to endure similar experiences in the future.
The insolubility of experiences in the form of a sense of hopelessness emphasizes the insecurity of the “I”, the lack of adequate psychological protection and self-confidence, which is reflected in dreams, like an 8-year-old girl: “I fell from a mountain into the sea and there monsters surrounded me on all sides.” She is surrounded by four demanding and at the same time conflicting adults who expect her to excel in both regular and music school.
The dream of a 9-year-old boy also attracts attention: “The car drives along the street and takes everyone in its vise. I want to say something, but I don’t have time and I almost hit her.” The machine is the principled and inflexible demands of exemplary behavior and high achievements in two schools, set once and for all by numerous adults. But these same adults forget to warm the boy with tenderness and love, unable to feel the depth of his experiences, the fear of not being in time and doing something wrong. He does not have his own word in the family, he cannot express his desires, even be sad and upset, as he is completely and completely programmed for the ideal type of behavior and continuous success in all areas.
On the one hand, children with neuroses are socially oriented, that is, they want to be like everyone else, and on the other hand, they do not want to be what their parents want to see them, because this is incompatible with their interests, needs and capabilities. The duality of such a situation would not be so traumatic and would not lead to a pronounced sense of guilt in the presence of conformity in children with neuroses, then they would outwardly correspond to the requirements of their parents, while remaining themselves at the same time. But due to their characterological features, they cannot be dual, deliberately play a role, as well as pretend, cunning. Trying to assert their "I", these children cannot reject the image of "I" imposed by their parents, become themselves. This is accompanied by a growing sense of inner restlessness, tension and self-doubt. There is a compensatory need to be even more socially accepted and approved in order to reduce feelings of anxiety and guilt about not wanting to become what parents want children to see. But social recognition (outside the family) is difficult due to neurotic sharpened character traits, affectively high expectations, and growing painful changes. Failures in communication with peers, the difficulty of social adaptation, a chronic feeling of dissatisfaction give rise to abstract formations that replace reality, an idealized construction or superstructure of the “I”. Basically, these are dreams of selfless friendship, for which nothing needs to be done, eternal love, undivided happiness and the belief that everything will work out by itself, it will be resolved if you perform certain actions and take less risks. In relation to one's own "I", the development of uncertainty, distrust of oneself and dissatisfaction, supplemented by a diffusely growing feeling of anxiety and anxiety, is noticeable. As a result, the contours of the "I" become indefinite, blurred, and its ability to withstand danger is reduced. Together, this increases the permeability of the self for the perception of traumatic events and the accumulation of experience of life's failures. Moreover, the constant feeling of dissatisfaction and anxiety, due to the impossibility of being oneself, that is, feeling natural and at ease, active and confident, sooner or later creates a state of psychological breakdown with a feeling of helplessness and impotence, hopelessness and hopelessness, pessimism and despair, disbelief. in their strength, in their ability to withstand danger. Feelings of helplessness and impotence can be represented by weakness, intolerance, defenselessness and fears; feelings of hopelessness and hopelessness - fatigue, loss of strength, a feeling of insurmountable obstacles, loss of interest, satiety; feelings of pessimism and despair - anxious-depressive mood background, outbursts of irritation and discontent. Self-doubt means lack of internal unity, low consistency in assessments, hesitation in decision-making and anxiety in new situations.
The described process of the psychogenic change of the "I" in neuroses differs from the disintegration of the "I" and even more so the depersonalization in psychoses and reactive states. In case of neurosis, it is more correct to speak not about the alienation of one's own "I", but about the inconsistency of its psychological structure in the form of hypertrophy of some sides to the detriment of others, which is accompanied by a violation of the sense of wholeness, unity of the "I", anxiety and self-doubt. Painful, occurring against the will, mental changes in neuroses such as affective instability, internal tension, increased fatigue and fears, and in themselves are perceived as something alien, alien, incompatible with the “I”, interfering with it, preventing further development. It is also impossible to get rid of these painful changes on your own, although at first they are able to some extent activate the “I”, its functions of resistance and protection. However, the involuntary nature of neurotic changes, with the failure of previous attempts to defend and affirm the “I”, make it less and less active, psychogenically altered, incapable of perceiving reality.
Neuropsychic stress
In neurosis, this is a broader concept than internal conflict, since it arises from more numerous sources and is not always psychologically motivated. At the initial level, it can be represented by constitutionally and antenatal altered neuropsychic reactivity in neuropathy, perinatal and postnatal organic cerebral pathology, and a genetically difficult combination of contrasting temperament of parents.
The tension resulting from improper upbringing and conflicts, unlike previous sources, tends to increase with the age of children. First of all, blocking of activity, lack of emotional response, excessive stimulation of opportunities and education in general, which do not correspond to the characteristics of temperament, character and personality formation, are pathogenic. Pathogenic situations of upbringing and relationships in the family are not necessarily recognized as traumatic, but nevertheless contribute to the development of mental stress. In addition, it can also arise as a result of psychological infection or induction - involuntary assimilation of the nervous state of adults and peers with whom the child has been in direct and close communication for a long time - contact. This is typical for emotionally sensitive, spontaneous and impressionable children who, as it were, transfer to themselves, absorb the emotional state of close and significant persons, empathizing, sympathizing or imitating, identifying with them. The psychological mechanisms of high emotional imprintability, selective suggestibility, affection and love also work here.
A chronic psycho-traumatic situation as a source of tension should be discussed in the presence of experiences that are insoluble for children, which make up the content of an internal conflict. Against this background, additionally acting mental traumas - emotional upheavals - increase the pathogenicity of the life situation, since the child cannot cope with them, survive them. Together with an internal conflict, communication problems and an unfavorable combination of life circumstances, this allows us to speak about the appearance of an unsuccessful, traumatic life experience or a state of chronic distress, as the main source of pathogenic tension in neuroses. The situation is complicated by the fact that, due to their limited and already psychogenically deformed life experience, the conditions of upbringing and family relationships, children with neuroses cannot emotionally respond to the accumulating neuropsychic stress. They are forced to suppress it, which exceeds the limit of adaptive capabilities and changes the neuropsychic reactivity of the body even more. In this case, an unproductive expenditure of psychophysiological resources and capabilities occurs, their further overstrain and painful weakening in general. The consequence of chronic mental stress will be an increase in cerebral asthenic disorders that fix experiences and make it difficult to further restore neuropsychic forces. At the same time, mental tolerance to the continued impact of stress factors decreases, anxiety and emotional instability increase, vegetovascular and somatic disorders appear or increase, and overall endurance and body resistance decrease. Together, this allows us to speak about the appearance of a detailed clinical picture of neurosis.
The development of long-acting mental stress into neurotic, pathogenic-causal stress can be judged by the following psychogenic changes, taken in the dynamics of their development: 1) overstrain of the psychophysiological capabilities and systems of the body; 2) affective processing of life experience (in the form of fixation of experiences, emotional instability and anxiety); 3) increased sensitivity to the action of further threats to the "I" (the effect of emotional idiosyncrasy or sensitization); 4) reactive, psychogenically conditioned change in attitude towards oneself and others (formation of self-doubt, affective-anxious and egocentrically protective type of perception); 5) the emergence of defensive-avoidant motivation of behavior (when the child “does not hear”, does not respond to traumatic stimuli from the external environment - the phenomenon of “selective inattention”, when he avoids difficulties and dangers that can further lower the sense of “I”, when fears and feels insecure in new, unusual situations of communication); 6) a decrease in vital activity, energy, biotonus in general, a change in reactivity and the development of central pathophysiological changes in a functional nature; 7) a clinically defined violation of the regulatory and adaptive (adaptive) neuropsychic mechanisms, including the vegetosomatic activity of the body in places of its least resistance.
We have already touched on the question of why mental stress in neurosis does not decrease, but increases, reaching a critical level. This is partly due to the specifics of the manifestation of protective psychological mechanisms. In the traditional sense, S. Freud (1926) and A. Freud (1936) regard them as involuntary forms of mental response, having as their motive (goal) the elimination of anxiety as an awareness of a conflict, unpleasant situation for the individual. The starting points for the development of this view were the following: 1) the perception of a threat is accompanied by the mobilization of defense in order to support the "I"; 2) experiences that are incompatible with a person's self-image tend to be excluded from awareness; 3) unconscious transfer of one's own feelings, desires, inclinations to another person, if a person does not want to admit to them, realizing their social unacceptability; 4) rationalization of feelings and inclinations as a means of their social control.
In the present, the main defense mechanisms are: repression, projection, denial (refusal), rationalization, sublimation, isolation and regression. Subsequently, a number of researchers contributed to the development of the theory of defense mechanisms. In this regard, mention should be made of hypercompensatory psychological mechanisms (Adler A., 1928); defensive-passive and protective-aggressive behavior (Sukhareva G. E., 1959); three stages of development of the adaptation syndrome: anxiety, protection and exhaustion (Selye H., 1974); the protective significance of the neurotic symptoms themselves and reactive character shifts (Ivanov N.V., 1974); transformation of negative attitudes and their replacement in the system of motives in the form of substitutions (F. E. Bassin, V. E. Rozhnov, M. A. Rozhnova, 1974). In patients with neurasthenia, the leading types of psychological defense are denial and rationalization; with obsessive-compulsive disorder - isolation of affect; with hysteria - displacement (Tashlykov V.A., 1981).
For children with neuroses, such a type of protection as projection is not typical, but it is often found in psychopathic development. In children with neuroses, responsibility for the events that take place is attributed to oneself with the appearance of feelings of guilt and rudimentary ideas of self-abasement. Characterized by silence, confusion, frustration, when the child is lost and cannot say anything, giving the impression of "guilty without guilt." Normally, there is an average type of reaction, when children do not let themselves be offended, revealing a flexible, situational type of reaction. Sublimation occurs in adolescents with dysmorphophobia and psychogenic aporexia within the framework of obsessive neurosis, when the emerging sexual desire and secondary sexual characteristics are rejected as something dirty and shameful, as opposed to high academic achievements. Children with obsessive neurosis are also characterized by excessive rationalization of feelings and desires, hypertrophy of mental activity, moral prohibitions to the detriment of emotional perception and immediacy in expressing feelings. In hysterical neurosis, the leading types of psychological defense will be repression (often in the form of amnesia of unpleasant experiences) and regression - a psychogenic, reactively conditioned transformation of the “I” by the type of return to earlier, emotionally acceptable stages of mental development. Regression and rationalization are also observed in neurasthenia, while anxiety neurosis is more characterized by isolation and fixation of affect, its germination by anxiety and fear.
In the event of a neurosis, an increase in the activity of inhibitory processes has a certain protective value, creating pathophysiological zones of transcendental inhibition and protecting nerve cells from further overstrain and exhaustion. Such a child becomes more and more sluggish, “slow” in class, eating, dressing, preparing homework. This prevents further accumulation of neuropsychic tension, the child gets less tired, getting a temporary respite. Selective inattention also serves the same purpose, when children ill with neurosis stubbornly “do not hear” the demands of adults, endless prodding and coercion, are often distracted while preparing lessons, and begin to engage in other, more pleasant and emotionally rich activities. It is also difficult for children with neuroses to start any obligatory, responsible and strictly regulated activity, since it requires a high concentration of attention and efficiency, already weakened as a result of neurosis. At the same time, parents, not understanding and often ignoring the painful nature of the existing disorders, sharply increase the psychological pressure on children, overly control the lessons, force them to rewrite everything anew at the slightest mistake, and constantly read morality to children that they cannot assimilate. Typical in this case is the repression of experiences in dreams, their affective processing, which we have repeatedly spoken about. However, sleep itself loses many of its natural functions, becoming a source of danger rather than a source of security and recuperation due to night terrors.
Pathophysiology of neuroses
In the classical version, it is represented by the works of I. P. Pavlov (1951) and N. I. Krasnogorsky (1939). The functional nature of neurodynamic disturbances in neuroses as a result of overstrain of the processes of excitation and inhibition, their mobility and collision has been proved. The pathophysiological mechanisms of the functional weakening of the cortex, the development of hypnotic (phase) states, isolated "sick points", foci of pathologically inert excitation with inductive inhibition around, as well as disturbed relationships between the cortex and subcortex were revealed. The subsequent revision of the pathophysiological mechanisms in neuroses was as follows: the revival of ideas about the dominant of A. A. Ukhtomsky; revealing the role of subcortical formations and giving them greater pathogenic significance, in particular, disorders of the limbic-reticular complex; criticism of the artificiality of "weak" and "strong" types of higher nervous activity with great attention to temperament; understanding the one-sidedness of views on the first and second signaling systems and drawing attention to the problem of interhemispheric asymmetry.
In a generalized form, the pathophysiological mechanism of neuroses, BD Karvasarsky sees in the disorder of the functions of the integrative systems of the brain, among which, along with the cerebral cortex, a significant role belongs to the limbic-reticular complex. A. M. Vein, A. D. Solovieva, O. A. Kolosova (1981) emphasize the softness and reversibility of its lesions in neuroses that resist gross local lesions of the brain.
VK Myager (1976) disclosed the specific nature of changes in the mesodiencephalic region in neuroses that affect vegetative-trophic and somatic functions.
We can comment on the pathophysiological disorders in neurosis by the dynamics of the following concepts, connecting them mainly with the clinic: 1) overstrain of the excitation process; 2) overvoltage of the braking process; 3) "collision" of the processes of excitation and inhibition; 4) violation of bilateral regulation; 5) development of phase states; 6) changes in neuropsychic reactivity and adaptive functions of the organism; 7) the formation of pathodynamic and, at the same time, relatively stable cerebral disorders, manifested by the clinical picture of neurosis.
Excitability - the earliest response in ontogenesis under the action of restrictions and intense stimuli in sthenic, active by nature children. Excitability also indicates an increased constitutional sensitivity of the nervous system with a simultaneous large number of interference or distortions in its work, which is manifested by neuropathy. Subsequently, excitability is a consequence of the accumulation of experience of affects, especially in conditions of physical inactivity and blocking of emotional discharge in children with a choleric temperament, extroverted and prone to expressive expression of feelings. Excitability can also be acquired through the mechanisms of psychological infection on the part of nervously excitable, impatient and conflicting persons surrounding the child. The inconsistent address of one of the adults and the contrasting attitude of several of them also have an exciting effect.
Excitability in neurosis is most often represented by irritable weakness or inert excitement, when the child, according to the parents, often grumbles, gets angry, being dissatisfied, capricious and unstable in mood or cannot stop quickly, slowly comes to his senses, cries for a long time and inconsolably and gets upset. The latter is illustrated by a case at school with an 11-year-old boy who was being treated by us for neurasthenia. One day the music teacher left the classroom; everyone began to dance merrily to the beat of the music, and the boy too. When the teacher suddenly entered the classroom, everyone immediately fell silent, but he could not stop, and he got hit for everyone. Excitability is often manifested by a pronounced feeling of restlessness and anxiety, as well as general restlessness, rapid speech, and increased distractibility. Excitability in neurosis is selective, manifesting itself mainly in the family as the greatest source of mental trauma.
Braking often is a reaction to the action of transcendent stimuli, which the child is not able to endure. Another source will be the increased sensitivity of the nervous system, but, unlike excitability, with a greater shade of vulnerability and vulnerability, both constitutional and neuropathic, as well as a mixed nature. Inhibition also acts as a consequence of mental shocks and traumatic experience in the face of endless threats and excessive stimulation of psychophysiological capabilities in children with a phlegmatic temperament, introverted, prone to impressive expression of feelings. Inhibition can also be acquired through the mechanisms of psychological infection on the part of anxious, suspicious and indecisive adults. Excessive moral demands, which the child is not able to justify, will have an inhibitory effect. Inhibition occurs when you need to do quickly what a child with a phlegmatic temperament is not able to do without overstraining his strength. The feeling of guilt cultivated by parents, the children's feeling of their helplessness and impotence, mental asthenia as a result of an overstrain of available opportunities and resources enhances inhibition.
Inhibition is manifested by slowness, torpidity of reactions, a pronounced latent period of response, pauses in conversation, as well as a large number of fears, self-doubt, indecision in actions and deeds, and avoidance of difficult situations. Increasingly, the child gives the impression of being lethargic, uncollected, indifferent and indifferent to the demands of the parents, often "does not hear", that is, does not react immediately, "digs", that is, inert; at times it “freezes” and “looks at one point”, that is, it involuntarily gives itself a temporary respite.
Inhibition, like excitability, is more characteristic of certain situations. The selectivity of excitability and inhibition shows that. despite the participation of the reticular formation (excitability) and limbic formations (inhibition) in their appearance, a significant role belongs to the change in the neurodynamics of the frontal cortex with its functions of control and comparison of various behavioral strategies. As already noted, excitability is influenced by choleric temperament, and inhibition by phlegmatic temperament. In turn, excitability and inhibition themselves sharpen these extreme types of temperament, giving the impression of hyperactivity or hypoactivity.
The next pathophysiological mechanism in neurosis will be "collision" of the processes of excitation and inhibition, more broadly - constitutional-environmental contradictions. On the intrapsychic level, a “collision” is the result of multidirectional motivations, for example, the desire to rest when fatigue has already arisen and the need to perform, let alone complete, some kind of routine and unpleasant work; the need to act and fear, etc. Such contrasting experiences colored by affect form dominants of increased excitability and inhibition, often at different levels of the functional organization of the mental activity of the brain.
The discrepancy between the requirements of the parents and the psychophysiological capabilities of the children, i.e., constitutional and environmental contradictions, will also be a kind of "collision".
In this regard, the pathogenic role of excessive restrictions on increased psychomotor activity in children with choleric and excessive stimulation in children with phlegmatic temperament has been repeatedly noted. The most unfavorable situation is observed in those cases when a mother with a contrasting, phlegmatic temperament and a preliminary set for the appearance of a girl has a boy with a choleric temperament similar to her father. We can also talk about a pronounced constitutional-environmental conflict when a mother with a choleric temperament and a preliminary set for the appearance of a boy has a girl similar to her father with a phlegmatic temperament.
In children with a sanguine temperament, the effect of "collision" is created by the contrasting attitude of the parents, when one of them, usually with a faster temperament, overstimulates, and the other, with a less rapid temperament, on the contrary, excessively limits the child's activity. Then we see the effect of the “disappearance” of the natural temperament, represented as if by pseudo-poles of the extreme types of temperament in the form of increased excitability and inhibition at the same time. Some adults consider these restless, with unstable attention of children, choleric, others - phlegmatic because of slowness in classes, general intolerance and inhibition. The truth is somewhere in the middle - these children have a sanguine, but not sufficiently stable and, most importantly, pathologically altered temperament. In this regard, a typical situation is when the mother of a 3-year-old boy with tics and stuttering against the background of a general neurotic disease has a choleric temperament, endlessly hurries and spurs (stimulates) her son, his already quite pronounced activity and speed of movements. A father with a phlegmatic temperament, on the contrary, is prone to excessive restrictions on his son's activity, immediacy in expressing feelings. As a result, a boy with a natural sanguine, but still unstable temperament, on the one hand, is excitable, restless and impatient, and on the other hand, he is slow in his movements, "slow" and inertly stubborn. This creates the impression that at the same time, but in different situations, he is both a choleric and a phlegmatic. Elements of both temperaments are really present in him, creating the effect of marginality or instability in the development of his inherent sanguine temperament. But the age-related instability of temperament would not have been so long and pronounced if there had not been a contrast and extremes in relation to parents that conflict with the natural activity of children. With stuttering, we often see a similar picture, expressed both by clonic (associated with choleric temperament) and tonic (influence of phlegmatic temperament) speech convulsions. We also note that in the “war” of temperaments under consideration, a mother with a choleric temperament, in essence, fights in the person of her son with the phlegmatic temperament of the father, and the latter with the choleric temperament of the mother, demonstrating low psychological and psychophysiological compatibility with each other.
It is also necessary to note the dysontogenetic type of contradiction, due to oppositely directed tendencies of the constitutionally determined development of temperament. There is no doubt that temperament is not something fixed, once and for all unchanged. Even in adults, in the course of life, in a number of cases, certain changes in temperament occur, when some become more slow in movements over the years, unhurried and thorough in judgments, while others, on the contrary, become more active and fast. In some children and adolescents, such dynamics are more noticeable, especially in cases where parents have contrasting temperamental traits. Then we see great instability, a kind of marginality of temperament in children in connection with the incompatible combination in the process of development of opposite temperaments of parents. Moreover, in the first years of life, the child may be less active, somewhat slower in the development of walking and speech skills, then more and more fast, impetuous, rapidly speaking (the effect of "speech breakthrough", which is often found in stuttering), reminding all of this, respectively, of the phlegmatic temperament of one and the choleric temperament of the other parent. Or the reverse dynamics takes place, when the relatively accelerated maturation of individual mental and psychomotor functions in the first years of life is replaced by a slowdown in the rate of their subsequent development, thus resembling the choleric temperament of one and the phlegmatic temperament of the other parent. Similar dynamics of the formation of temperament, characteristic of neuroses, quite often explains the unevenness of psychomotor development, its dysontogenesis. Thus, one can speak of a certain instability of temperament in those cases when a child simultaneously resembles and does not resemble each of the parents in temperament and is not able to temporarily stabilize in the process of growth on one of his types. It should be emphasized that the instability of temperament is sharpened to a greater extent under the influence of an attitude that does not correspond to the psychophysiological capabilities of children and the oppositely directed attitude of parents. Of no small importance in this variant is the fact that the children are similar to one of the parents. Then “over the years” they more and more resemble the temperament of this parent, which may conflict with his attitude, being again one of the expressions of the constitutional-environmental conflict.
Let us illustrate this with two observations. In one of them we will talk about a 10-year-old boy with a diagnosis of neurasthenia. At first, he slowly developed speech and began to walk later than most of his peers, despite the absence of rickets and diseases. He was also distinguished by calmness, slowness in movements and activities. Gradually, even at preschool age, against the background of constant stimulation from the mother, he became faster in movements, talkative, and by now gives the impression of being excessively fast, restless and impatient. Such dynamics can be regarded as a weakening of the features of his phlegmatic temperament, common with his father, and strengthening of the features of his choleric temperament, common with his mother. In fact, we can talk about the presence of a sanguine, but still unstable, marginal temperament, which could be judged by the end of preschool age, when he was not slow or fast, combining these qualities. At school, the psychological pressure of the father, whom the boy resembles, has sharply increased. Limitation of activity, physical punishment, punctuality and pedantry in the requirements led to an increase in the boy's excitability, he became even more restless and mobile, inattentive and scattered, as if hyperactive. All these manifestations also increased as a result of the excited, restless state of the mother, who was in a neurotic state. In addition, both parents quarreled all the time about raising their son, that is, there was a tense situation in the family. The more the father “pressed” on the son and conflicted with the mother, the more the latter “fixed” in her neurotic state, involuntarily passing on her excited, painful state to her son. As a result, the boy could not yet stabilize any of the types of temperament. This case allows us to take a fresh look at some aspects of dysontogenesis due to the uneven development of temperament.
In another case, a 12-year-old boy with neurasthenia drew attention to himself by his lethargy and slowness in his studies, general awkwardness, and difficulties in drawing. Like his father, he keeps all experiences to himself, is not frank with loved ones, is not as sociable as most of his peers. Simultaneously with the slowdown in activity, academic performance worsened, he did not have time to complete assignments at school, he was inattentive, scattered in movements, he spent a long time “digging” at home with lessons, without having time to finish all of them. With his appearance and increasing slowness, impressiveness and introversion, the son is more and more like his father with a phlegmatic temperament. In the first years of his life, on the contrary, he developed rapidly: he began to speak, walk early, was mobile, direct in expressing feelings. With his activity and speed of reactions, he then resembled a mother with choleric temperamental traits. Shortly after he "got on his feet", continuous restrictions followed by his father's parents, who lived in the family until his 5 years of age. It was not allowed to run, make noise, openly express their feelings. He had to do everything quietly, walk on tiptoe and not express his "I" in anything. Being stingy in expressing positive feelings, compassion and love, grandparents constantly scolded their grandson that he was doing everything wrong, “bad”, “naughty”, “stubborn”. At the age of 4, he began to attend a kindergarten, where he was “unlucky” with a teacher who emphatically shamed everyone in front of everyone and made remarks that he did not sculpt as well and was generally not like everyone else. And if in the first years of his life everything was fine with the boy’s motor skills, he did not fall, he dressed himself, built complex structures from cubes and auxiliary objects, then he gradually became less and less confident in himself, in his ability to do what was needed, as required . At the same time, stiffness, tension, and mistakes in preparing assignments grew, unanimously condemned by all adults except the mother. She believes that it was from this age that the son could hate classes, which manifested itself in school, where his father, an engineer by profession, intolerantly perceived any mistakes his son made in drawing and exact disciplines. But the more dry in character, tough, pedantic and hypersocial-minded father was strict and demanding of his son, considering him lazy, the more the latter slowed down and studied worse, unable to resist the father’s inadequate attitude, as well as excessive stimulation, fitting from an impatient mother. As a result of a chronic psycho-traumatic situation and the inability to justify the increased demands of adults to become “who you should be”, there was a “crash” between the boy’s primary high activity and the need to constantly restrain himself, inhibit his feelings and desires, be thorough and punctual in everything. It was during the period of attending school that a painful overstrain of his neuropsychic forces and capabilities appeared, as well as a neurotic illness in the form of neurasthenia. He was never able to become “other”, as the family demanded, falling ill with neurosis and eventually turning into, as it were, his antipode - inhibited, lethargic, slow and unable to assimilate further demands of adults. His "pseudo-phlegmatism" was thus a manifestation of a neurotic illness. At the same time, it emphasized and painfully sharpened the inner instability of temperament. "By itself" he would most likely become sanguine, which was noticeable towards the end of preschool age. But even then he was in unfavorable conditions of development, experiencing the growing negative influence of adults. His family drama was set off by the presence of a younger brother who was prosperous in all respects, to whom his parents treated more carefully, realizing mistakes in some ways, but not being able to rebuild their stereotype of perceiving the first-born, who is a kind of "outcast" in the family. In addition, the younger one looked like a mother, unlike the older one, and, like her, did everything without delay, quickly and with initiative.
Common in the cases considered will be the internal instability of temperament, constitutionally conditioned by the process of growth, as a reflection of the contrasting features of the temperament of the parents. The instability of temperament increases in conditions of adult attitudes that do not correspond to the psychophysiological capabilities of children, causing an overstrain of the processes of excitation and inhibition, the effect of their “collision”. The latter is also indicated by the multidirectional clinical picture. So, in the first case, along with the predominance of excessive mobility, restlessness and excitability, there are also elements of lethargy, slowness in classes. In the second case, on the contrary, with the dominant general lethargy, lethargy and slowness, restlessness, impulsiveness and dispersion in classes occur.
In both cases, there is a violation of the most vulnerable property of the nervous system - the mobility of the processes of excitation and inhibition, their relationship, with the appearance of a painful disorder or a clinical picture of neurosis.
Violation of bilateral regulation - another pathophysiological mechanism in neuroses deserving special consideration. From literature reviews by N. N. Bragina. T. A. Dobrokhotova (1981), V. Rotenberg (1984), E. G. Simernitskaya (1985), Yu. Chirkov (1985) it follows that the concept of dominance of one hemisphere that existed for a long time is now being replaced by the concept of functional specialization of the hemispheres . The left hemisphere provides discrete, analytical, verbal-logical thinking, the right - spatial-figurative, concrete. Sensory perception, intuitive orientation in the surrounding world, perceptual insight take place in the right hemisphere. It is dominated by unconscious, spontaneous processes, non-verbal analysis of information, negative emotions such as sadness and fear. Conscious and speech processes, positive emotions dominate in the left hemisphere. If the left hemisphere is the language center, then the right hemisphere is the center of the feeling of music. The dominance of the left hemisphere may be associated with the predominance of the second, and the dominance of the right - with the predominance of the first signal system (Suvorova V.V., 1975; Rusalov V.M., 1979).
Greater activity of the right hemisphere is noticeable in the presence of neurotic personality traits: insecurity, anxiety, stress intolerance (Horkovic G., 1977). Early and excessive stimulation of the left hemisphere functions to the detriment of the right hemisphere in the conditions of hypersocial education in neuroses in children was noted by V. I. Garbuzov (1986). Outside of neurosis, a connection was found between the clinical symptoms of childhood autism and the mechanisms of hypoactivation of the right hemisphere (Kagan V. E., 1978). In the right hemisphere, defense mechanisms are activated in the form of repression and dreams. The repressed motive passes into the subconscious and causes unconscious anxiety. Then a person cannot concentrate and his ability to solve current problems weakens (Rotenberg V., 1985).
A child is born with both "right" hemispheres. Up to 2 years, any of them can become left - speech. Boys in terms of brain asymmetry develop faster than girls. By the age of 6 in boys, a distinct functional specialization of the hemispheres is already noticeable; girls up to 13 years old retain a certain plasticity of the brain, the equivalence of its halves (Chirkov Yu., 1985). In general, it is believed that in the first years of life, the right hemisphere is more active, including in relation to speech, compared to the left (Simernitskaya E. G. 1985). But even in the subsequent increase in the activity of the left hemisphere does not exclude fluctuations in the activity of the right. Thus, according to the Moscow Research Institute for Problems of Higher Education, right-handed (left-hemispheric) students with increased nervous sensitivity by the end of the examination session under the influence of stress increased the activity of the right hemisphere. With regard to left-handedness, not always, but quite often, associated with right-hemispheric activity, the genetic factor matters, as well as, according to the literature, neuropsychic weakness and, in particular, early diffuse brain disorders (Simernitskaya E. G., 1985) . Noteworthy are also indications of a greater severity in left-handers and ambidexters of anxious and suspicious character traits (Hicks R., Pellegrini R., 1978).
An analysis of premorbid features in children with neuroses shows the predominance of right hemispheric activity, which persists for a relatively longer time than normal. This is evidenced by the integrity of perception, naivety, spontaneity, suggestibility (which, in our opinion, like hypnotizability, is a function of the right hemisphere), susceptibility to anxiety and fears, impressionability, imagery of thinking, increased sensitivity to music, fixation of past experience and a tendency to repress unpleasant experiences, including during sleep. The predominant role of the right hemisphere is also indicated by the relative frequency of left-handedness (ambidexterity), which will be discussed below.
Children suffering from neurosis are characterized by a contradiction between the predominant activity of the right hemisphere and the predominantly “left hemisphere” type of education. The latter is facilitated by excessively early socialization, excessive rationality in dealing with children, a large number of moral restrictions, verbal instructions, threats and advice. At the same time, there is no immediacy in the expression of feelings on the part of parents, they do not play with children, they prevent the spontaneous expression of feelings, but they constantly teach how to behave, restrain, control each step. They also sharply react to insufficient, from their point of view, intellectual achievements in children. This is especially pronounced when they are placed in specialized speech schools, where children who become ill with neuroses often do not show much success and where, according to our data, the greatest number of neuroses. In addition, children with leading right-hemispheric activity in the first grades and ordinary schools often have difficulties in the Russian language (partly in mathematics) and deterioration in speech such as stuttering.
The "left-sided" aspect of education is more clearly expressed in parents in the professional group of engineers, which prevails, as we remember, in children with neuroses. With anxious and suspicious character traits, parents show excessive control, doubts and fears about the capabilities of children, their intellectual achievements.
Taking into account the one-sided rational, “second-signal” attitude of parents, we can talk about a certain overload or excessively early stimulation of the functions of the left hemisphere, which are not yet characteristic of children with neuroses, with a known “blocking” or inhibition of the first-signal, spontaneously expressive (expressive) activity associated with the functioning of the right hemisphere. To a greater extent, this affects left-handers with emphasized activity of the right hemisphere. At the same time, anxiety and anxiety on the part of parents, as well as mental shocks, fears and painful experiences in children, create an additional burden on the functioning of the right hemisphere, which generates fears and anxiety to an increasing extent.
Rational-sign pressure on the left hemisphere often does not decrease, but increases with neurotic disorders that have arisen, which parents and teachers regard as a lack of volitional (conscious) regulation of behavior and strengthen moral requirements instead of weakening them and rebuilding relationships with children. It is then that the child ceases to assimilate, i.e., process as acceptable, the demands of the parents, "does not hear", does everything emphatically slowly, "digs", experiencing fatigue and low mood, which often occurs with neurasthenia. Experiences incompatible with the attitude of parents in children are manifested by unpleasant dreams with bouts of night anxiety and morning amnesia with anxiety neurosis. This indicates the protective function of the right hemisphere, which does not allow awareness of experiences that are unacceptable to it. But the less awareness, the more diffuse, free-floating anxiety or restlessness, acting more and more as an irrational or neurotic aspect of mental activity. It is the impossibility of understanding the internal conflict, its irrational processing in the right hemisphere that creates the effect of its insolubility. In addition, insight is impossible due to the inhibition of the right hemisphere, and the anxiety coming from it inductively changes the logical thinking inherent in the left hemisphere, making it even more difficult to constructively solve problems that arise.
Let us clarify the above provisions. If the left hemisphere experiences chronic overload from excessive information and at the same time there is no emotional reaction of unpleasant feelings and experiences on the part of the right hemisphere, then the irrational “product” of the latter distorts the logical thinking of the left. In it, centers or dominants of obsessive fears, apprehensions and thoughts appear, which are perceived by consciousness as “not their own”, going against the will, involuntary. But the “overloaded” left hemisphere cannot get rid of them due to the developing phenomena of cerebral asthenia or “moral intoxication”. In addition, obsessions reduce the pressure of fear and anxiety from the right hemisphere, which is expressed by the well-known clinical phenomenon of “crystallization of fears” in the form of phobias in obsessive-compulsive disorder. The next stage of clinical dynamics will be the transition of obsessive fears into obsessive doubts (thoughts) with age (usually not earlier than 5 years for boys and 12 years for girls) and constitutionally determined activity of the left hemisphere. This is a situation where one-sidedly intellectually developed, but often motorally awkward and emotionally shackled children give the impression of little old people speaking memorized phrases and using adult, often ornate, turns of speech. They clearly lack emotionality, expression, the whole gamut of human, especially childish, feelings. Obsessive doubts in the conditions of family predisposition and the corresponding attitude of parents become the basis for the development of anxious and suspicious character traits in adolescence.
When considering the dynamics of interhemispheric asymmetry in neuroses as a whole, it is necessary to take into account the initial activity of the hemispheres in various clinical forms of neuroses, unless we are talking about the first years of life. In obsessional neurosis and partly neurasthenia, the left hemisphere is relatively more active than in anxiety neurosis and especially hysterical neurosis, in which the functional activity of the right hemisphere is more pronounced.
In all cases, the main aspect of the problem of interhemispheric asymmetry in neuroses will be that the activity of the right hemisphere is inhibited too early and the activity of the left hemisphere is excited, or there is a unilateral substitution of right hemisphere activity for left hemisphere functional activity.
The dynamics of interhemispheric ratios in neurosis is considered in Table 5. The functional specialization of the hemispheres in the clinic of neurosis is considered in Table 6.
Table 5. Dynamics of interhemispheric relationships in neuroses
|
Stage of dynamics of neuroses |
Left hemisphere |
Right hemisphere |
|
|
Elementary |
Common to all neuroses |
Excitation - overexertion (in conditions of excessive moral stimulation or restrictions) |
Inhibition - repression (suppression of the possibility of emotional reaction of negative, unpleasant feelings and experiences) |
|
Development |
Neurasthenia; anxiety neurosis and hysterical neurosis |
Inhibition - fatigue (mental asthenia) with increasing anxiety |
Excitation - generation (in conditions of emotional stress and shock experiences) of states of affect, anxiety and unrest. Their amnesia, repression into dreams, or diffusion into the left hemisphere |
|
Obsessional neurosis |
Dominants of congestive arousal (obsessive fears, thoughts of fear) |
Inhibition - depression with elements of emotional impoverishment, leveling of feelings |
Table 6. Functional specialization of the hemispheres in the clinic of neurosis
|
Left hemisphere |
Right hemisphere |
|
Anxiety such as fears (to be nobody, not that, not yourself, to be late, not to be in time) |
Anxiety, a diffuse feeling of anxiety (“what if” something happens) |
|
Anxiety transforms into obsession |
Anxiety transforms into fear |
|
Obsessive doubts (self-reflection) - to the extent of ideas of self-abasement |
Suggestibility as an involuntary, in addition to consciousness, assimilation of information given from outside |
|
Neurotic depression (moral aspect) |
Neurotic depression (vital connotation) |
|
The manifestation of protective mechanisms such as rationalization |
The manifestation of protective mechanisms such as repression and amnesia (forgetfulness) |
|
Anxious and suspicious type of response |
Affectively excitable type of response |
|
Model of subsequent clinical germination in the form of psychasthenia |
Clinical model of hysterical neurosis |
Note. A common (integrative) characteristic for both hemispheres will be anxiety, inner dissatisfaction.
In connection with the considered interhemispheric relationships in neurosis, we will touch upon the problem of left-handedness. The predominance of the left hand is revealed in the “mosquito squeak” and “hand” samples.
The "mosquito squeak" test is used to determine suggestibility. The subject stands with his back to the doctor, who announces the "turning on" of the device (toy), which makes a sound similar to the squeak of a mosquito. Children not only determine the sound if they "hear", but also localize it at the request of the doctor, mainly to the left or right of the ear. The test was carried out in 74 children with neuroses. Most children (64% of boys and 63% of girls) find the sound source on the left, i.e., they find left-sided localization in the perception of an unpleasant sound (the differences are significant in boys). The predominance of right-hemispheric activity is also noticeable on the EEG, when the right hemisphere significantly predominates among the "interested" hemispheres.
The "hand" test consists in the fact that after the end of the conversation or the game, the doctor suddenly gives his hand to the child, saying: "Goodbye." Of 112 children with neuroses, 36%, i.e. every third, gave their left hand as a more comfortable hand, without differences in boys (34%) and girls (37%). The “hand” test is more sensitive than the visual determination of the preference for the left hand, according to parents, which is 24% of the total number of children with neuroses. In addition, all left-handers (which include ambidexters) are "right-handed" at the time of the examination, i.e. retrained to manipulate the right hand. The average age of boys during the examination is 7 for left-handers, 9 years for right-handers; in girls, respectively, 8 and 9 years. Consequently, with left-handedness, neurotic symptoms are expressed at an earlier age. When children are divided by age up to 10 years and older, in boys and girls, left-handedness significantly prevails in preschool and primary school age compared to adolescence. In boys, the ratio is 59 and 7% (p<0,001), у девочек - 48 и 20% (р<0,05), т. е. у мальчиков левшество проходит раньше, а у девочек - позже, что подтверждают данные литературы о более раннем возрастании активности левого полушария у мальчиков.
A high percentage of left-handedness is observed in boys with anxiety neurosis (52%), a low percentage in boys with obsessive neurosis (0), which emphasizes the unequal leading activity of the right (fear neurosis) and left (obsessive neurosis) hemispheres.
Outside the clinical form of neurosis, the index of fears was calculated separately for left-handedness and right-handedness. For boys, it is significant, and for girls, as a tendency, it is higher with left-handedness. It is interesting that the fears denied by the children, but recognized by the parents (i.e. repressed), are greater in left-handedness (trend). These data confirm the "interest" of the right hemisphere in the displacement of unpleasant feelings and experiences.
Neuropathy, residual cerebral organic insufficiency and stubbornness (from the point of view of parents) do not have a significant effect on the leftism of boys. Girls tend to increase left-handedness with residual cerebral organic insufficiency. But even then it is necessary to keep in mind the leading clinical symptoms of neurosis.
The predominant functional aspect of left-handedness is also evidenced by the fact that the hand was changed to the right hand after successful therapy of fears and an increase in the general emotional tone of children.
Here are some extracts from the case histories of children with neurosis, both left-handed and right-handed, with an emphasis on the clinical symptoms of neurosis. The unifying points in all observations will be the inconsistency of the attitude of parents with the psychophysiological capabilities of children, including the type of temperament, an excessively intense amount of intellectual stress, including verbal stimulation, moral prohibitions and prescriptions, excessively early socialization and rationalization of children's feelings, blocking the possibilities of reacting to unpleasant feelings and experiences, lack of expressively rich games, immediacy in relations with children.
In one observation, a 7-year-old girl from an incomplete family reveals anxiety and fears before sleep, which, however, are not fully realized and are denied in a conversation with a doctor. From the very beginning, she gave preference to the left hand, being highly emotionally sensitive and impressionable, ahead of her peers in mental and physical development. The mother is an engineer, anxious and suspicious, replaces feelings with words, controls every step of her daughter and demands high intellectual achievements from her. Even before school, the girl experienced overload due to coercion in music lessons, impeccable mastery of musical notation. In the 1st grade she began to get tired, headaches, irritability and excitability appeared. The grandmother on her mother's side, with authoritarian personality traits, constantly made sure that her granddaughter used that hand "as it should be", constantly making comments and hitting her left hand when she made a mistake. At the reception, the patient is constrained and tense, afraid to express feelings and desires, to do something wrong, as it should, "as expected." She does not know how to play like children, her speech is colorless and sluggish, interrupted from time to time by a nervous cough. The impression of her is that she is emotionally devastated, programmed to perform only a certain range of actions, devoid of spontaneity and immediacy in expressing feelings. The diagnosis is neurasthenia. In its origin, the “left-sided” type of upbringing in the absence of opportunities for emotional response matters. Clinically, this is expressed by an increase in both asthenic disorders (mainly the left hemisphere) and fears (the right hemisphere) with the appearance of left-sided self-doubt and fears. In another observation, a 12-year-old boy from an incomplete family studies at an English school with a technical bias. His father and parents are constantly working with him - both professors: a linguist and a philosopher. Everyone together makes them repeatedly rewrite the lessons, looking for the slightest mistakes and demanding excellent achievements, but the son “doesn’t pull”, he gets more and more tired, complains of a headache, falls asleep with difficulty, sometimes wets himself at night. Lessons take up to 4 hours or more; the father sits nearby and makes him endlessly repeat the material aloud, memorize it. For example, the son repeatedly repeats where England is located, and in the morning he says that she is in Africa or who knows where. Simultaneously with fatigue, he becomes more and more distracted and forgetful, cannot concentrate for a long time, is easily distracted. Adults consider this laziness and only increase the demands and moral pressure. Mother - an engineer by profession, lives separately, with her youngest son, thus dividing the children with her husband. Before the divorce, the parents constantly quarreled over the elder, engaging in verbal squabbles and unsuccessfully figuring out who was right and who was wrong. The mother often took out her irritation on her son, hit him on the head with "excessive" activity. His father, trying to forget himself and distract himself from family troubles, abused alcohol at that time, completely entrusting his upbringing to his wife (at one time his parents also sent him to a specialized school with English and forced him to study “excellently” by any means. By the end of the school, noticeably tired, worried about headaches, diagnosed with gastric ulcer.Despite the lack of interest, parents persuaded, promised and threatened to enter a technical university where his father taught.The son took academic leave several times until he transferred, already of his own free will, to the humanitarian university). His story repeats itself, as we see, with his son, but the father does not want to admit this, subconsciously hoping that the son can make up for what he himself once turned out to be insolvent and uninterested. Here we can clearly see the psychological defense mechanism of projection, characteristic of fathers in our observations, according to the type: “It was hard for me, it’s hard, so let it be hard, it’s hard for him, let him know, “how much is the pound.” As for the boy, in the background of his clinical picture of neurasthenia, there is an inhibition of the right hemisphere, which is more actively functioning in him, with a simultaneous ever-increasing verbal-sign load on the left. This is manifested, on the one hand, by “right-sided” outbursts of irritation and arousal, i.e., negative emotions, their involuntary response, and on the other hand, by the development of cerebrosthenic disorders, forgetfulness and absent-mindedness, which perform a certain protective function - protecting the left hemisphere from excessive, transcendent and not characteristic of him informative load.
In the following observation, a 7-year-old boy with anxiety neurosis and stuttering, while still with an unstable, marginal temperament, experiences constant stimulation, adjustment from his mother with a choleric temperament and excessive restrictions from his father with a phlegmatic temperament. In the family, as is often the case with children with stuttering, there are many adults, in this case, the verbal-informative load on the left hemisphere is especially high. In addition, he attends a “full-day school,” where many children get tired of the noise, complaining of headaches at home. At night, he often wakes up in a state of fear, screams, in the morning he does not remember anything from what he experienced. Night fears are, therefore, a peculiar way of reacting to the negative emotions accumulated during the day in the right hemisphere. The protective inhibition that occurs after terrible dreams prevents them from being realized in the morning. At the same time, the relevance of daytime fears weakens somewhat until they again accumulate within critical limits and another attack of nighttime fear occurs. Here we see a certain mechanism of mental homeostasis - an involuntary regulation of neuropsychic tension. The sharpness of night fears would be less if the boy could express his disagreement, protest, or at least react to it in the game. But he was deprived of his word in the family, instead of games there were constant classes, reading, memorization, recitation, that is, his left "unusual" hemisphere was overloaded, and his right hemisphere was "underloaded." But that is not all. The family had a so-called "healing-protective" regime, which was understood as the unquestioning fulfillment of countless orders of adults in the absence of active emotions and games, communication with peers. In addition, adults constantly forced to repeat every incorrectly pronounced word, to speak only on the exhale, slowly and in a singsong voice, which created an unbearable burden for the boy, who was still fast enough in temperament, and only fixed his speech disorders in the form of clonic stuttering. His emotions were represented mainly by fears, reaching their clinical climax during sleep.
In terms of temperament, a 9-year-old boy with a diagnosis of "obsessive neurosis" has a similar situation. He is also the only one in the family and has 4 adults with technical backgrounds. He developed early, read at the age of 5, studied a foreign language and music even before school. As the intellectual pressure of adults increased, he became more and more constrained and awkward, slow, at times excitable and impatient, that is, there was a clinical sharpening of the extreme sides of his constitutionally unstable, marginal temperament. But all this is a prerequisite for what happened to him at school, where the domineering teacher, who does not tolerate any deviations from her methodology, began to demand a clear, according to all the rules, reading, emphasizing for all the shortcomings of the boy's sound pronunciation. At home, on the advice of the teacher, all adults began to force them to read and learn lessons aloud. At the same time, as "unpromising", he was expelled from the sports section, where he went with desire. Such stresses, as well as increased workload due to the continued attendance of two schools, did not go unnoticed. He became unnaturally slow for himself, painfully, like a stutterer, choosing his words, obviously afraid of saying something wrong, not in the right way. In addition to growing anxiety and mental asthenia, increased neurodermatitis, he often began to complain of abdominal pain after school (the examination did not reveal any pathology), he felt sick in the morning, put in lethargic, irritable. If before he had never laughed, now he became sad, depressed, at times whiny, i.e., there were signs of latent, in this case, psychogenically conditioned, depression. At the same time, he becomes more and more suspicious, doubting the correctness of his decisions, unsure of himself, “lost”, as we see, not only “his” temperament, but also his sense of “I”. His painfully overstrained, albeit quite active, left and inhibited, “unpowered” right hemisphere created a clinical picture of the development of anxious and suspicious character traits and astheno-depressive layers.
In adolescent girls, depressive neurotic layers are more common than in boys, but also with emotional retardation of the right hemisphere and intellectual-rational overload of the left. Typical in this case is the clinical picture of neurasthenia with depressive and hysterical inclusions, especially in girls with a phlegmatic temperament, taciturn, prone to impressive expression of feelings. Such traits under the influence of prolonged stress associated with one-sided intellectual stimulation, excessive demands of adults, excessive moral pressure, clinically sharpen, creating the effect of a melancholic-inhibited, sluggish and lack of initiative, and essentially a neurasthenic (hyposthenic) type of response.
A similar situation was observed in 2 girls 13 years old. Both are "right hemisphere", emotionally sensitive and impressionable, but already inhibited, overly tired, unable to emotionally express themselves not so much because of a phlegmatic temperament, but because of intellectual dictate and emotional restrictions on the part of mothers with hypersocial and paranoid character traits. Both study in a special language and music school at the same time, experiencing difficulties in writing, graphics, and, as is the case with "right-brained" and which is generally typical for children with neurosis, they often cannot freely, naturally express in words what they think, all the more they feel and guess. It is not surprising that after another viral acute respiratory disease with laryngotracheitis, which is usual for it, their voice “did not recover”. This made it possible not to go to school for a long time, thus eliminating the continuation of the race for success, which did not bring feelings of satisfaction and pleasure, and to avoid further overstrain of neuropsychic forces. Psychogenic, hysterically fixed, aphonia also made it possible to exclude the forced communication at school, which they were to a large extent burdened with, as well as increased, not characteristic of them, left hemisphere requirements for speech.
It should be noted that such a form of psychotherapy as a game, carried out in an emotionally rich, expressive way, is able to restore the activity of the right hemisphere. At the same time, there is often a general revival of emotional activity, as one of our patients with neurotic depression and anxious and suspicious development writes in her diary: “Recently I notice that I have changed significantly. How to mature. The fourth dimension has opened up. The world became brighter, deeper, filled with sounds and ceased to be one-sided, gray. Sadness and causeless longing gradually receded. Everything fell into place." At the same time, she felt that mathematics became more difficult, although she still had good grades. Everything was set up later. We are talking about a kind of balance - the alignment of the unnaturally altered functional activity of the hemispheres, which, by the way, made it possible to get rid of the obsessive fears and doubts that had haunted her before.
In another case, a 9-year-old left-handed girl with a diagnosis of “neurasthenia, stuttering” wrote after a series of play activities: “For the first time in many years (and she is only 9 years old) I wanted to jump, run, scream. And when I jumped, I wanted to lie down, fall asleep and not pay attention to anything. At the same time, speech worsened in terms of stuttering and the painfully sharpened attitude to grades at school weakened (she studies with "excellent"). There was a restoration of the natural functional balance of the hemispheres, accompanied by an increase in the activity of the “blocked” right hemisphere and a decrease in the hypertrophied activity of the left hemisphere, while emphasizing its still largely physiological (left-handedness) and age-related “uncommonness” in the form of a temporary increase in speech disorders - stuttering. Then we successfully used hypnotherapy to eliminate the consequences of cerebrasthenic (left hemisphere) disorders and restore speech function.
Such examples show the need to take into account in psychotherapy the considered features of the dynamics of interhemispheric relationships and the subsequent strengthening of the tone of the "I" through hypnotherapy.
Sometimes a timely consultation is quite sufficient, which allows the parents themselves to correct some of the aspects of relations with children. In this regard, it should be said about the “right hemispheric” boy of 7 years old, who attended a crowded “zero class” a year ago, where the race for grades was already cultivated; instead of “additional” games, there were edifications, and daytime sleep was only on paper, since none of the children slept, getting even more tired of doing nothing and being forced to restrain themselves. In a family of 4 adults with a higher technical education, the boy’s grades are painfully perceived, they force him to read aloud a lot, because he has “not the right diction”. We note that the father with a choleric temperament has a fast and tensely confused speech; in a mother with a phlegmatic temperament, speech, on the contrary, is slow, viscous, detailed, which sets off her anxious and suspicious character. In addition to school, the boy attends English classes with reluctance, and his mother is going to transfer him to a language school. In the meantime, everyone is forcing him to repeatedly rewrite the lessons, often interrupting his speech, fixing hesitation and taking him to a speech therapist, who teaches him to speak slowly, in a singsong voice, naturally fast, with the boy's choleric temperament. The deterioration of his condition (increased fatigue, distractibility, headaches) and the persistence of stuttering at the same level forced his parents to seek advice. The recommendations were as follows: 1) to provide greater motor and emotional relaxation; 2) do not limit the conversation; let him speak as he pleases; do not interrupt the speech; 3) not to force to read aloud, as well as to force to read a large number of books; 4) stop learning English, leave at the same school; 5) do not patronize on trifles; 6) change attitudes towards grades received at school; respond more calmly to them; 7) do not require rewriting lessons; 8) father to speak without haste; 9) exclude classes with a speech therapist.
Parents followed these tips, along with which the boy's general condition gradually improved and stuttering stopped.
Development of phase states in neurosis, we will consider in connection with the dynamics of the processes of excitation and inhibition. In contrast to their unilateral sharpening, the appearance of an equalizing phase means a decrease in excitability and an increase in inhibition. The leveling phase is a consequence of mental asthenia, fatigue of nerve cells. Moreover, on the one hand, the child, being inert, cannot quickly turn on, get excited, clearly express his feelings, including resentment, annoyance and anger, and on the other hand, he cannot slow down, restrain his feelings, which are becoming more and more involuntary. character. Characteristic signs of the leveling phase are fatigue, satiety, loss of interest, lack of vivid feelings and experiences, response to the usual and at the same time transcendent demands of adults, when the child “does not hear”, shows stubbornness from the point of view of others. The leveling phase is primarily characteristic of the clinical picture of neurasthenia.
In the next, paradoxical, phase, a weak reaction to strong, mostly real, stimuli is found, and, conversely, weak, mostly imaginary, stimuli or stimuli cause a strong, inadequate reaction. This is explained by the action of both protective inhibition under conditions of excessive stimulation and overexcitation, and sharpening of sensitivity, mainly due to the development of mental sensitization or idiosyncrasy - conditioned reflex pathological response stereotypes. A similar situation is typical for fear neurosis, when real stimuli, danger have a lesser effect than the fears caused by the imagination. In a broader sense, the paradoxical phase is characterized by an affectively sharpened sound of internal sensations or experiences of anxiety, anxiety, fear, irritation, resentment and dissatisfaction, which acquire a certain self-development and clinical significance under conditions of ongoing stress, the impossibility of emotional response and constructive solution to emerging problems. Instead of their rational processing in the waking state, an irrational processing takes place during dreams, which, due to their affective workload, increasingly lose their adaptive, protective function, being an additional source of mental traumatization.
The severity of the ultraparadoxical phase depends on the development of painful functional foci or dominants of congestive excitation, mainly in the left hemisphere, with an increase in the process of inhibition in the right. More broadly, this is the process of dissociation or disintegration of interhemispheric interaction, accompanied by the appearance of obsessive, primarily contrasting, ideas. One 13-year-old girl with obsessional neurosis was disturbed by obsessive thoughts about bad people as good people and vice versa. The beginning of this was laid in the family, when the anxious, suspicious and hypersocial-minded mother was in constant conflict with her grandmother, who suppressed her will, which, however, did not prevent them from having a negative attitude towards the father whom the daughter loved and who was eventually forced to leave families. It is not difficult to guess that the mother and grandmother exert strong psychological pressure on the girl, mostly moral and intellectual, and the grandmother's authoritarianism finds expression in countless prohibitions on her spontaneous, emotionally direct activity. In addition, the believing grandmother does not allow any expression of negative feelings in the girl, especially in the first years of her life, considering them "from the devil, the evil one." Under these conditions, the spontaneity and emotional activity of the girl gradually decrease; she becomes more and more inhibited, at times excited, i.e., a reactive process of inhibition of her right, leading hemisphere takes place (she draws well, studying in the art studio, has developed imaginative thinking, emotional sensitivity and impressionability). There is also a clash (clash) of a sense of duty towards her mother and grandmother and a feeling of love for her father as the basis, the motivation for her insoluble internal conflict, since she cannot abandon her parents or experience persistent unfriendly and aggressive feelings towards them. Inhibited right and overloaded, excited left hemisphere create the effect of dissociation in interhemispheric relationships with the formation of dominant obsessive thoughts in the left hemisphere due to the displacement of negatively directed feelings, anxiety and restlessness from the right hemisphere. Along with the left hemisphere developed sense of duty, obligation, responsibility, which is united by the concept of "conscience", this creates a collision effect, since the left hemisphere "does not let through" unacceptable, negatively focused feelings from the right and at the same time cannot, due to its congestion (asthenia), provide necessary conscious, rational control over them. As a result, the girl thinks badly about good people (estimated from a social point of view by left-brain thinking), that is, she perceives, feels them like that (right-brain, sensual type of assessment).
The presence of an ultra-paradoxical phase can also be seen in cases where anxiety replaces joy, tears replace anger, the new frightens, but sadness excites, or when the child cries and laughs at the same time. The ultraparadoxical phase is not always only a clinical phenomenon. Often it takes place at 2 years old - in the period of the so-called "stubbornness", when the child fulfills the requirements of adults "on the contrary": instead of lifting, he throws, dresses, when he is told that he is not needed, that is, he does everything emphasized in its own way, the way you want. Here there is a clear clash (conflict) between the negative perception of excessive, somewhat transcendent, demands of adults, which limit the spontaneous expression of feelings and do not allow to respond to those emotions that the child does not yet consider negative (the effect of blocking or inhibition of the right hemisphere), and the emerging feeling " I, self-awareness (which can be regarded as a predominantly left-hemispheric phenomenon). Negativism is not expressed in cases where parents take into account the natural emotional activity of children, give them the opportunity to express feelings of excitement, anger and crying in spontaneous play or independent pastime, and at the same time do not interfere with their desire to be themselves.
A change in the neuropsychic reactivity and adaptive functions of the body occurs in conditions of functional disorders of the cortical tone and violations of cortical-subcortical relationships, including influences from the thalamus (sensitivity), hypothalamus (vegetative-vascular regulation) and the reticular formation (energy potential). The analysis of these relations is not included in our task. The main thing is that all these changes are mediated by prolonged stress, which creates neuropsychic tension with functional disorders of cortical-subcortical relationships and interhemispheric interaction in general. Here, much depends on the constitutional features and premorbid characteristics of the individual, which facilitate or hinder the emergence of psychogenically caused neurotic disorders, as well as the initial deficiency of certain body systems, which, as places of its least resistance, are primarily exposed to stressful influences, more precisely, their neuro-somatic and endocrine indirect consequences.
The final stage of the considered pathophysiological changes will be the appearance of a detailed clinical picture of a neurotic disease. From a systemic point of view, the clinic of neuroses is a reactive process of changing the constancy of the mental and neuro-somatic environment of the body, the emergence of relatively stable pathodynamic structures, violations of voluntary regulation of behavior and the development of neurotic symptoms. The clinic of neurosis is closely related to the weakening of the body's defenses, a decrease in its tone, reactivity, the lack of effective mental self-regulation along with a change in well-being and self-perception. The ongoing neurotic, mostly involuntary, not controlled by will, conscious control, changes disrupt adaptation to the environment, which together serves as a source of additional and, again, insoluble experiences for children, who are increasingly different in their behavior from their peers. Growing difficulties in realizing one's capabilities, asserting oneself, and revealing one's creative potential are the basis of specific personality changes in neuroses, the more pronounced the longer the course of the neurosis and the severity of the unfavorable life situation as a whole.
In a generalized form, the pathogenesis of neuroses in children and adolescents can be represented as follows (Fig. 1).
Rice. 1. Pathogenesis of neuroses in children and adolescents
Personality changes
As a result of a long course of neuroses, they can be grouped as follows: 1) a decrease in overall productivity and activity due to an increase in asthenic disorders and defeatist moods; 2) an increase in anxiety and anxiety, the appearance of affective alertness and a defensive-avoiding egocentric type of behavior; 3) emotionally depressed mood background; 4) development of self-doubt and difficulties in predicting events; 5) dependence on others in communication due to an affectively pointed expectation of increased attention to oneself, sympathy and support; 6) subjectivism in assessments with reactive inflexibility of thinking and its irrational processing; 7) inconsistency and inconsistency in actions.
If it is impossible to resolve a traumatic life situation and there is no timely, pathogenetically substantiated psychotherapeutic intervention, children with neuroses can no longer withstand, decompensating at the same time on: 1) waiting; 2) uncertainty, uncertainty; 3) prolonged neuropsychic stress, especially in a situation of increased responsibility; 4) remarks, censures and threats against oneself (the effect of sensitization in the form of touchiness and vulnerability); 5) failures in communication and performance of significant activities; 6) loss or reduction of love, recognition and support; 7) feeling of loneliness as a threat of socio-psychological isolation due to increasing violations in the field of interpersonal relations.
It is not only difficult for children with neuroses to be themselves, but also to establish smooth, direct relationships when they become either overly dependent, submissive, suggestible, or try to play leading roles, which conflicts with their already largely altered abilities and abilities. It is difficult to start any, especially responsible activity, stability and consistency in its implementation, as well as perseverance, patience, attentiveness. A large number of compensatory or reactive desires come into conflict with an increasingly deteriorating adaptability to the demands of life, its difficulties and problems, which creates the phenomenon of neurotic idealism. In turn, the difficulty of adaptation, the inability to make friends, the egocentric fixation on experiences form the phenomenon of neurotic "withdrawal into oneself" or individualism. All this allows us to talk about the growing gap between high ideals, life goals and the inability to put them into practice, as well as to protect oneself, to defend one's opinion, especially in the presence of any threat from the outside. A reflection of neurotic personality changes will be a constant feeling of dissatisfaction and dissatisfaction with oneself, a kind of crisis of self-consciousness, which transforms in adolescence into a feeling of worthlessness and loss of the meaning of life, the collapse of its values.
CONCLUSION
In the methodological aspect, the problem of neuroses includes such sections as: etiology, anamnesis, consisting of an anamnesis of life and the history of the disease, pathogenesis, clinic, differential diagnosis, treatment and prevention. This monograph deals with the first three, less fully covered in the literature, sections, a kind of propaedeutics of neuroses. Data on etiology have been significantly expanded due to the specification of the role of the family factor in the origin of neuroses; the anamnesis is supplemented by the dynamics of personality formation, and the pathogenesis is studied from the standpoint of the unity of psychological, clinical and physiological factors. In turn, the etiology and anamnesis, considered in their inextricable relationship, is the genesis of neuroses, which makes it possible to more meaningfully illuminate the most complex section of their pathogenesis. The latter is structured like a presentation of other data, primarily in terms of revealing the general patterns characteristic of the development of neuroses in general. The systematic approach made it possible to single out a number of specific features of the premorbid personality of parents and family relations, which form a single conceptual model of neuroses in children and adolescents.
Neurosis in childhood is a reflection of clinical, personal and socio-psychological problems that arise in adults who become parents in a difficult period of life too early or late, being unprepared for this role, infantile-immature or overly ambitious, pressing the mental development of children into Procrustean bed of his ambitious plans and hopes. It is impossible to discount the reflection in the development of children of the personal problems of parents, due to the acceleration of the pace of modern life, its urbanization and technocratization, along with the ever-increasing responsibility and rigidity of social role prescriptions, the complication and impersonality of interpersonal relations, unfavorable trends in the socio-psychological dynamics of family development: a decrease in its stability, fertility with the unilateral dominance of the mother, her excessive workload and neuroticism. The lack of moral and ethical principles in the relations of surrounding adults, the psychopathic germination of personality in some modern women, the low socio-psychological culture of communication, the lack of accessible, effective and timely psychological and psychotherapeutic assistance are not indifferent to the mental development of children.
The origins of many parental problems in the present are in the ancestral family, in those features of relationships and upbringing that had an adverse effect on the formation of the character and personality of the parents and complicated their subsequent relationships in marriage. Of the personal characteristics, authoritarian traits are distinguished in the maternal grandmother, along with a hypersocial orientation of the personality and high anxiety. One-sided upbringing on her part and dictate in the family come into contrast with the daughters' greater similarity to their father, whose role in the family is clearly insufficient, as well as emotional contact with children. The future spouse emphasized neurotic dependence on the mother in childhood and in subsequent years with insufficient influence or absence of the father in the family. As a result, we see the excess of female influence as opposed to the insufficiency of male, as well as neurotic complementarity in marriage, when the spouse projects his attachment to the mother onto the spouse, and the latter fulfills unrealized love for the father in relations with him. Such neurotic pointed expectations come into conflict with the real contrast of temperament and character of the spouses, creating the initial disposition in their relationship. It begins to sound more clearly after the birth of a child, whose upbringing becomes the main source of family disagreements. And, in addition to them, the psychological stress experienced by parents means crises of their personal self-awareness, attempts to find themselves and assert their place in life, which are especially pronounced in the age range of 35-40 years. Conflicts in the family and psychological crises are significant sources of increased mental stress in parents, sharpening of unfavorable character traits and neuroticism, at least one of them, usually the mother, who is experiencing a high load from combining family and professional roles. Thus, we are dealing with the initial psychological and clinical burden in the family in the form of unfavorable personal characteristics of the parents, the conflict structure of relationships and a neurotic illness in one of them. To a greater extent, this applies to mothers who suffer from neuroses, who are more personally changed and who consider family relationships to be conflict. In all cases, the parents are psychopathologically changed more than the children, which, together with unfavorable relationships in the family, negatively affects the upbringing and formation of their personality. Persistent disagreements between parents mean the inability to stabilize the emotional state of each other, which contributes to the emergence, first of all in the mother, first of all of the feeling, and then the fear of loneliness. Along with her neurotic state, this creates three characteristic phenomena in her relations with children: constant anxiety, like a protopathic, instinctively sharpened anxiety or premonition that something is bound to happen to them; excessive, passing age needs of guardianship; the desire to form with children an emotionally isolated dyad in the family. In turn, the greater the anxiety and guardianship on the part of the mother, the more pronounced the opposition on the part of the father, who often uses contrastingly different, tough tactics in relations with children or deliberately does not take part in upbringing. If parents spend most of their energy on sorting things out with each other, then the extremes of direct treatment of children may not be so great and not be accompanied by conflict with them. In the opposite situation of the transition of the conflict to relations with children, their mental development is even more in danger, since they cannot protect themselves, and besides, parents irreconcilably perceive in children negative, from their point of view, character traits of each other. Then the affective focus of the low psychological (characterological) compatibility of the parents is the child, whose position is especially unfavorable given his previous undesirability, the mismatch of the sex expected by the parents and the presence in the family of a brother or sister who is more prosperous in many respects. The situation of inversion of parental roles, typical for the families studied, will also be unfavorable for the formation of the personality of children, when the grandmother replaces the mother, who, in turn, plays the role of the father, and the latter turns out to be “superfluous” in the family, often leaving it. A more traumatic situation like this affects boys who are left without the protection of their father, who are deprived of adequate sex models of behavior and experience both excessive guardianship and rejection in the family of traits of temperament and character common with their fathers. Then they are especially prone to fear and self-doubt, as happened with one 3-year-old boy who wakes up at night with a chilling cry: “Flies, flies.” Our assumption that he sees Baba Yaga in a dream was confirmed by being reflected in the corresponding drawing. This fairy-tale image is involuntarily associated with the threat of separation from his mother, since the boy attends a round-the-clock group from toddler age, does not remain alone, is terribly afraid of the dark, that is, he discovers age-related fears, but strengthened by the family situation. At the same time, an imperious, excitable mother with a “loud voice” treats her son rudely and “pullingly”, physically punishing him for his stubbornness, but in essence - for his common mobility with his father and the desire to be himself. The whole problem is that he does not have a “protector who would cope with Baba Yaga”, just as there is no father who was expelled from the family at the insistence of his grandmother. As in other cases, the mother would hardly have decided on a divorce if it were not for the blind support of her parents, who rather proceed from their one-sided attitudes than from disinterested love and care for their grandson. We reproduced the horror of the night in a game where the son bluntly made his mother Baba Yaga, and he himself became a "protector" of himself. When, after the game, we gave the recommendation to the mother, among other things, to avoid physical punishment, she took it negatively, saying: “How could it be otherwise, because a criminal can grow out of him!” This emphasizes how the mother’s anxiety can coexist with her paranoid attitudes - suspicion and prejudice regarding the mental development of her son, who is for her something like a “scapegoat”, “a thing always at hand”, on which you can constantly take out your mood and aggressive, unfriendly feelings for your ex-husband. These women are able to educate not future men, but timid, fearful and insecure beings who do not have their own opinions, are overly dependent and internally unstable, conflicted.
It is not always possible to speak of the upbringing of children with neuroses as "wrong"; Quite often it is "overly correct" in nature. These are cases of a hypersocial orientation of the personality in parents, primarily in mothers, accompanied by excessive exactingness and adherence to principles in relations with children, rejection of their immediacy and emotionality, that is, everything that we designate as the complex of Princess Nesmeyana. The same "left-brain oriented parents" are inflexible in dealing with children, overly intensify and accelerate their intellectual capabilities, simultaneously manifesting many prohibitions and moral prescriptions. Such an attitude is often found in parents from the ITR group, who are overly rational and rational, thinking more with schemes and clichés than with feelings and images. These mothers attach less importance to emotional aspects in relationships with children, the protection of their internal, mental environment, but exorbitantly great importance to issues of prestige and career, success at any cost. Comparing not always the best way with men in mastering the engineering profession, these mothers lost many of their inherent qualities, not finding in return what could be a sincere, warm, direct and responsive beginning in relations with children, without which their development cannot be complete and harmonious. As a result, we can say that in children with neurosis, “childhood disappears”, taken away by adults who in childhood did not have a chance to experience the happiness of being children themselves.
An unfavorable life situation in which the formation of the personality of children takes place, the discrepancy between the attitude of parents to psychophysiological capabilities and personal characteristics, as well as the combination of psycho-traumatic life circumstances in general, is a source of constant mental stress, experiences of an insoluble conflict, a stress factor in mental development. Moreover, the latter in itself is distinguished by a certain originality, age-related instability of temperament, right hemispheric differentiation, constitutionally due to the weakening of some body systems.
Mental traumatization and blocking of emotions are two factors that pathologically excite and at the same time inhibit the activity of the leading, right, hemisphere, which is complemented by “left-sided”, rationally overloading the left hemisphere of education. Then negative emotions, including anxiety and fears, produced by the right hemisphere, in the absence of the possibility of their reaction, are processed in the left into anxiety, obsessive fears and doubts, i.e., into an anxious and suspicious type of response. The subsequent depressive mood shift in children with neuroses is the result of increasing inhibition of the right hemisphere with hypertrophied, altered activity of the left, which explains the development of painfully sharpened conscientiousness, adherence to principles, a sense of duty, duty and difficulty in compromise, along with the appearance of anxious suspiciousness and inhibited traits in character.
Each age is sensitive in its own way to certain aspects of parental attitudes. Thus, in the pre-school age, separation from the mother has a special psycho-traumatic significance, which prevents the formation of an adequate sense of attachment and is associated primarily with placement in a nursery. At the same age, the fight against the temperament and stubbornness of children, which is formed by the feeling of "I", is pathogenically significant. At a younger preschool age, the feeling of love and emotional development in general are especially vulnerable, easily damaged in a situation of family conflict, the appearance of a sibling, excessive strictness and integrity in dealing with children. The peak of the need for love in 4-year-old children often does not coincide with the reciprocal feeling of love in the mother, who is late with its manifestation.
If up to 5 years the most damaged mental structures are emotions and temperament actively developing at this age, then later on the personality comes to the fore while maintaining the possibility of an adverse effect on the character.
In older preschool age (5-7 years), the father's departure from the family is traumatic (for boys); the lack of an adequate model of identification with a parent of the same sex, again more often in boys, which complicates their interaction with peers; isolation from communication with them through imposed contact with adults; excessive guardianship and anxiety of parents, increasing age-related fears in children, undermining their self-confidence.
At primary school age, there will be increased sensitivity in relation to school success, intellectual workload, a sense of responsibility that a child cannot justify. In adolescence, sensitive areas will be such personal characteristics as self-awareness and self-respect, mental integration, interests and hobbies.
As a result, the prevailing pathogenic aspects of the attitude of parents in preschool children are insufficient emotional responsiveness, blocking of emotions, feelings of "I" and temperament, excessively early socialization and an excessive level of moral restrictions and prohibitions. At school age, distrust in the abilities of children, an excess of control over lessons, intellectual pressure and bias in grades become more important.
The appearance in these conditions of traumatic life experience and neuropsychic stress becomes especially noticeable in the absence of the possibility of a timely response by children to negative emotions and the presence of unlimited similar opportunities for parents. Here, the effect of a “steam boiler” is triggered, exploding sooner or later with a steady increase in pressure and the absence of a valve to reduce it. A similar critical meaning of the “last drop”, “push”, “breakdown of the GNI” in the classical sense is possessed by an acute psychic trauma that decompensates the already weakened forces of the body, further changing its reactivity. Together with the previous high level of neuropsychic stress, this leads to a psychogenic disease of the emerging personality - neurosis. The duration of its course is facilitated by an inadequate reaction on the part of parents who are unable to understand the origins of the disease and rebuild their rigidly frozen relationships, as well as a sharpened personal reaction of children in response to progressive difficulties in achieving significant goals. Then life for children with neurosis can be a continuous drama with an increasingly tragic ending, where there are no intermissions and where the only "sensitive" spectators are themselves. Affectively pointed personality problems in neurosis are problems of finding one's "I", one's face and place in life. The insolubility of these attempts gives rise with age to a constant feeling of dissatisfaction with oneself and anxiety, often turning into pessimism, despair, a state of hopelessness and psychological breakdown, disbelief in one's own strength. We see the reflection of this in adults who cannot withstand life's difficulties and get tired easily, who are not adapted in marriage and are often disappointed, who remain in their souls a capricious, self-willed, vulnerable, touchy, timid and unable to fend for themselves child.
To date, the diagnosis of neurosis in children is clearly imperfect and needs to be improved if we want to put into practice, not in words, but in deeds, the slogan: "Human health is laid down in childhood." Some experts attribute to neuroses all clinical forms of psychomotor disorders: tics, stuttering, enuresis, which is fundamentally wrong. Others enroll them in neurosis-like disorders, which also does not always correspond to reality. The truth is somewhere in the middle, but in order to establish it and correctly diagnose neuroses in general, including those complicated by psychomotor disorders, special, psychoneurological qualifications of doctors and special reception conditions are required. Psychoneurological qualification includes psychiatric, neurological, psychological and psychotherapeutic training, as well as a one-year internship in one of the practical institutions. Special conditions are the directed admission of patients with neuroses who are screened out from the general admission or directed by other specialists. Accordingly, more time should be allocated to these patients on one of the days, since it is necessary to interview the parents in sufficient detail and use psychological diagnostic methods. Accordingly, the specialty of a pediatric psychoneurologist should be added to the existing medical specialties, with the right to work in polyclinics, hospitals and sanatoriums at the rate of at least 1 doctor in the outpatient clinic and 1 doctor in the hospital network per 300 thousand children and adults. We should also go for the creation of specialized psychotherapeutic centers for the treatment of neurosis in children in large cities at the rate of at least 3-4 doctors and 1 psychologist per million inhabitants. The creation of a directed psycho-neurological service and specialized treatment and diagnostic centers will make it possible to obtain more reliable statistical information about neuroses, organize timely treatment and unload the appointments of neuropathologists and psychiatrists, ensuring their adequate focus. Relatively small costs will be reimbursed, since psychotherapy, as the leading method of treating neuroses, makes it possible to stop their long, many-year course and prevent both adverse changes in character and personality in adolescents and neuroticization in adults. Timely psychotherapy also makes it possible to reduce the disproportionately high costs of paying sick leave to parents and missing work on certificates - caring for children with neuroses who often suffer from somatic diseases. Thus, our data show a significant (2-3 times) decrease in the incidence of children with neuroses after undergoing a course of psychotherapy (complemented with drug therapy). Through family-oriented psychotherapy, it is possible to prevent crisis situations in marital and parental relationships and thereby avoid divorce, the threat of which is quite common in the families under consideration. We should not forget that the appearance of a second child in the family, if the first one has been suffering from neurosis for a long time, is unlikely, since parents are afraid of a repetition of neuropsychiatric pathology. On the contrary, with timely and effective treatment of the first child, the probability, as our observations show, of the birth of second children increases.
The development of an all-Union program for the mental health of children, which would outline a specific series of measures for the early prevention, diagnosis and treatment of neuroses, is topical and urgent. It is necessary to strengthen at the present stage both the patronage of dysfunctional families, assistance to families with children under 3 years of age due to a sharp reduction in the number of nurseries, as well as psycho-prophylactic work with future parents. It should be started at school as part of the Ethics and Psychology of Family Life course. The creation of a psycho-neurological service must be supported by an increase in the activity of sanitary and educational work with the involvement of the media, the release of a specialized journal and more books on this topic.
Application. NEUROTISATION SCALE
Can you say that you...
1) get tired easily;
2) easily irritated;
3) (you) often change your mood;
4) are often in a state of anxiety;
5) (you) often have a headache as a result of tension and fatigue;
6) (for you) during tensions and unrest there are spasms, sore throats, redness, chills, increased pressure;
7) do not fall asleep well, sleep, wake up at night, do not feel well in the morning;
8) (you) have a perceptible decrease in sexual desire or ability;
9) (you have) mostly unimportant physical health;
10) are not satisfied with the relationship with the child;
11) are not satisfied with the relationship with the husband (wife);
12) dissatisfied with relationships at work;
13) (Your) energy often does not find an outlet;
14) could be much more active than you are;
15) (You) often have to restrain yourself;
16) have difficulty expressing your feelings;
17) (You) find it difficult to gather your thoughts and get lost easily;
18) (You) find it difficult to stand your ground;
19) often doubt the correctness of your decisions;
20) not self-confident enough;
21) It is extremely difficult (for you) to wait;
22) (you) have fears or obsessive, persistent and unpleasant thoughts that you would like to, but cannot get rid of.
23) (with you) in the present there is more bad than good;
24) (you) often have a bad, low mood;
25) you often feel internally lonely(s);
26) It is more difficult for you than others to establish contacts with people;
27) dissatisfied with themselves;
28) that there is something inside you that constantly haunts you;
29) you experience a state of internal tension from which you cannot completely get rid of;
30) faced with a choice that you cannot make;
31) that there is something inside you that hinders the realization of your plans;
32) suffer from the fact that you cannot come to terms with some of your desires;
33) (You) are oppressed by the state of uncertainty in which you are;
34) that in your childhood and adolescence, not everything was safe with your nervous system;
35) find your state in the present not quite natural, to some extent painful and would like to get rid of it.
USED METHODS
Examination of children
Bowling
Interview
Drawing as a method of psychological diagnostics
Eysenck questionnaire (adolescent version)
Questionnaire Cattel (adolescent version)
Rosenzweig technique (children's version)
Methodology for measuring intelligence - WISK
Thematic Apperception Test - TAT
Questionnaire of magical mood
Questionnaire of the neurotic type of response
Mosquito squeak test
Methodology for determining suggestibility
Questionnaire of problematic situations in relationships with children
Examination of parents
Eysenck questionnaire
Minnesota Multidimensional Personality List - MMPI
Questionnaire Cattel (forms A and C)
Rosenzweig technique
Luscher's technique
Incomplete Sentence Technique
Leary Questionnaire
Questionnaire PARI
Intelligence measurement methodology - WAIS
Early Childhood Development Questionnaire
Neuroticization Scale
Questionnaire of magical mood
Questionnaire "Proverbs"
Questionnaire for Parental Evaluation of Children's Character and Behavior
Homeostat
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PSYCHOTHERAPY OF NEUROSIS IN CHILDREN AND ADOLESCENTS
Chapter 5 ETIOLOGY AND PATHOGENESIS OF MENTAL DISORDERS IN CHILDHOOD
THE MECHANISM OF ACTION OF EMOTIONAL STRESS AND FACTORS CONTRIBUTING TO THE APPEARANCE OF MENTAL AND PSYCHOSOMATIC DISORDERS
STRESS AND EMOTIONAL STRESS. MECHANISMS OF THEIR DEVELOPMENT
The most characteristic feature of a child is his emotionality. He responds very vividly to negative and positive changes in his environment. These experiences are mostly positive. They are very important in the adaptation of the child to a changing life. However, under certain conditions, feelings can also play a negative role, leading to neuropsychiatric or somatic disorders. This happens when the strength of the emotion reaches such a degree that it becomes the cause of the development of stress.
Emotional stress is a state of pronounced psycho-emotional experience by a person of conflict life situations that acutely or for a long time limit the satisfaction of his social or biological needs [Sudakov K. V., 1986].
The concept of stress was introduced into the medical literature by N. Selye (1936) and described the adaptation syndrome observed in this case. This syndrome can go through three stages in its development:
1) the stage of anxiety, during which the body's resources are mobilized;
2) the stage of resistance, in which the body resists the stressor if its action is compatible with the possibilities of adaptation;
3) the stage of exhaustion, during which the reserves of adaptive energy are depleted when exposed to an intense stimulus or prolonged exposure to a weak stimulus, as well as when the adaptive mechanisms of the body are insufficient.
N. Selye described eustress, a syndrome that promotes health, and distress, a harmful or unpleasant syndrome. This syndrome is considered as an adaptation disease that occurs due to a violation of homeostasis (the constancy of the internal environment of the body).
The biological significance of stress is the mobilization of the body's defenses. Stress, according to T. Cox (1981), is a phenomenon of awareness that arises from a comparison between the requirement placed on a person and her ability to cope with this requirement. The imbalance in this mechanism causes the occurrence of stress and the response to it.
The specificity of emotional stress is that it develops in conditions when it is not possible to achieve a result that is vital for meeting biological or social needs, and is accompanied by a complex of somatovegetative reactions, and the activation of the neuroendocrine system mobilizes the body to fight.
Emotions, which are the first to be included in the stress reaction, are the most sensitive to the action of damaging factors, which is associated with their involvement in the apparatus of the acceptor of the results of action in any purposeful behavioral acts [Anokhin P.K., 1973]. As a result, the autonomic system and endocrine provision, which regulates behavioral responses, is activated. A stressful state in this case can be caused by a mismatch in the possibility of achieving vital results that satisfy the leading needs of the body in the external environment.
Instead of mobilizing the resources of the body to overcome difficulties, stress can cause serious disorders. With repeated repetition or with a long duration of affective reactions due to protracted life difficulties, emotional arousal can take a stagnant stationary form.
In these cases, even when the situation is normalized, emotional arousal activates the centers of the autonomic nervous system, and through them upsets the activity of internal organs and disrupts behavior.
The most important role in the development of emotional stress is played by disorders in the ventromedial hypothalamus, the basal-lateral area of the amygdala, the septum, and the reticular formation.
The frequency of emotional stress increases with the development of scientific and technological progress, the acceleration of the pace of life, information overload, increasing urbanization, and environmental problems. Resilience to emotional stress varies from person to person. Some are more predisposed, others are very stable. However, the development of neuropsychiatric or somatic diseases in a child due to the occurrence of life difficulties depends on the mental and biological characteristics of the individual, the social environment and the stressor (the event that caused the emotional reaction).
SOCIAL ENVIRONMENT
Repeatedly transferred in the past difficult situations in the family and outside it adversely affect the consequences of emotional stress. In this case, the frequency and severity of the experienced events matter. For mental and somatic health, not only one tragic incident, similar to the death of close relatives, is dangerous, but also several less dramatic ones that occurred in a short period of time, as this also reduces the ability to adapt. However, it should be borne in mind that the child is not alone in the world, that other people can facilitate adaptation to the situation. Along with previous life experience, current life circumstances are also of significant importance. With the disproportion of personal reactions to the changing world, there is a danger to health. This approach involves a comprehensive consideration of man and his environment.
The development of the disease after emotional stress is facilitated by a state of helplessness, when the environment is perceived as unsafe, not enjoyable, and the person feels abandoned. At the same time, if the individual's environment shares his assessments and opinions, and he can always find emotional support from him, then the probability of the morbid effect of emotional stress decreases. For a person (especially in childhood), the presence of social ties is so important that even their insufficiency can cause stress.
The attachment that arises between children and their parents in the most sensitive period for this - soon after birth, is of tremendous importance not only as a cementing mechanism that unites groups of people, but also as a mechanism that ensures their safety.
The formation of this social mechanism is based on innate patterns of behavior, which determines not only the strength of attachments, but also their great protective power. In those cases where parental care was insufficient, and social relations were violated or absent, children in the future lack the necessary social qualities in life. The feeling of defenselessness and inability to protect oneself from danger leads to frequent anxiety reactions and almost permanent neuroendocrine changes. This condition increases the risk of adverse effects of emotional stress.
STRESSOR
Emotional stress can be caused by both positive and negative events. Due to the fact that only adverse factors are considered harmful, only negative events are systematized as potential stressors.
S. A. Razumov (1976) divided the stressors involved in the organization of the emotional stress response in humans into four groups:
1) active activity stressors: a) extreme stressors (combat actions); b) production stressors (associated with great responsibility, lack of time); c) stressors of psychosocial motivation (exams);
2) assessment stressors (performance assessment): a) "start" - stressors and memory stressors (upcoming competitions, memories of grief, expectation of a threat); b) victories and defeats (victory, love, defeat, death of a loved one); c) spectacle;
3) stressors of mismatch of activity: a) separation (conflicts in the family, at school, threat or unexpected news); b) psychosocial and physiological limitations (sensory deprivation, muscle deprivation, diseases that limit communication and activity, parental discomfort, hunger);
4) physical and natural stressors: muscle loads, surgical interventions, trauma, darkness, loud sound, pitching, heat, earthquake.
The mere fact of exposure does not necessarily imply the presence of stress. Moreover, the stimulus acts, as P. K. Anokhin (1973) pointed out, at the stage of afferent synthesis of summing stimuli that are very diverse in quantity and quality, so it is extremely difficult to assess the role of one of the factors. At the same time, susceptibility to some stressors can be very different in people. New impressions are unbearable for some, while others are necessary.
ADVERSE PSYCHOSOCIAL FACTORS
Psychosocial adverse factors.
Among the global psychosocial factors, children's fears of war appear partly as a reflection of the anxieties of parents and grandparents, partly as their own impressions received through the media about ongoing armed clashes. At the same time, children, unlike adults, incorrectly assessing the degree of real danger, believe that the war is already on the threshold of their home. Due to soil, water and air pollution, the expectation of an environmental catastrophe is becoming a new global fear that affects not only adults, but also children. Interethnic confrontations, which have become so aggravated in recent times, can be attributed to the number of harmful ethnic factors. Under the influence of such regional psychosocial factors as natural disasters - earthquakes, floods or industrial disasters, along with physical factors leading to injuries, burns and radiation sickness, a panic arises that covers not only adults, but also children. In this case, the psychogenic effect may be delayed in time and manifest itself after the disappearance of the immediate danger to life.
In some settlements there are vital local difficulties. For example, voluntary or forced departure from habitual habitats. At the same time, refugee children, both under the influence of their own difficulties and under the influence of the anxieties of loved ones, turn out to be severely mentally traumatized. These difficulties are greatly exacerbated when migration takes place in areas where people interact differently, raise children differently or speak a different language. A great risk of mental disorder arises if the relocation of the family entails the loss of the social status of the child. This happens in a new school, where he may not be accepted and is rejected.
In the area in which the child lives, he may be attacked, bullied or sexually abused outside the home. Not less, but more dangerous to the child are episodic or constant threats that have to endure from peers or older children from the same educational institution or nearby area. A heavy imprint in the soul of a child is left by persecution or discrimination in the children's team for belonging to a certain ethnic, linguistic, religious or some other group.
Adverse factors associated with children's institutions. The school, which constitutes the social environment in which children spend much of their time, is often the cause of four sets of problems. The first of these is associated with entering school, due to the transition from play to work, from family to team, from unrestricted activity to discipline. At the same time, the degree of difficulty of adaptation depends on how the child was prepared for school.
Secondly, the student has to adapt to the pressure exerted on him by the requirements of the educational process. The pressure of parents, teachers, classmates is the stronger, the more developed the society and the consciousness of the need for education.
Thirdly, the "technization" of society, which requires the complication of curricula, its computerization dramatically increases the difficulties in mastering school knowledge. The situation of the student is even more complicated if he suffers from developmental delay, dyslexia, impaired perceptor-motor functions, or was brought up in conditions of social deprivation, in an unfavorable socio-cultural environment. The situation of the child is worsened by “sticking a label on him as a patient”, since the attitude towards him in accordance with the diagnosis changes, and the responsibility for his successful studies is shifted from teachers to doctors.
Fourthly, due to the presence in the school of an element of competition associated with a focus on high performance, lagging behind students are inevitably condemned, in the future they are treated with hostility. These children easily develop a self-defeat reaction and a negative self-image: they resign themselves to the role of losers, underachievers and even unloved, which hinders their further development and increases the risk of mental disorders.
To school stressful situations, one can add rejection by the children's team, manifested in insults, bullying, threats, or coercion to one or another unsightly activity. The consequence of the child's inability to conform to the desires and activities of peers is almost unceasing tension in the relationship. A serious mental trauma can be a change in the school team. The reason for this lies, on the one hand, in the loss of old friends, and on the other hand, in the need to adapt to the new team and new teachers.
A big problem for the student can be the negative (hostile, dismissive, skeptical) attitude of the teacher or the unrestrained, rude, overly affective behavior of an ill-mannered or neurotic teacher who tries to cope with children only from a position of strength.
Staying in closed children's institutions - nurseries, orphanages, orphanages, boarding schools, hospitals or sanatoriums - is a great test for the child's psyche and his body. In these institutions, a constantly changing group of people brings up, and not one or two relatives. A small child cannot become attached to such a kaleidoscope of faces, feel protected, which leads to constant anxiety, fear, anxiety.
Family adverse factors. Parental upbringing can be unfavorable when a child is brought up by foster parents, stepfather or stepmother, strangers, as well as parents with intermittent living with them. Growing up in an incomplete family, in particular, becomes unfavorable when the parent feels unhappy and, locking himself in the family, is not able to create the necessary conditions for his son or daughter to form positive feelings and satisfaction from life.
Children themselves get a lot from communication outside the family. At the same time, the social isolation of the family can become a risk factor for the child, as it counteracts his contacts with the environment. The isolation of the family usually arises as a result of changes in the personality of the parents or their rigid preferences, which differ sharply from those accepted in the environment. The overprotective parent makes decisions for the child, protecting him from even minor or imaginary difficulties instead of helping him overcome them. This leads to the dependence of the child and prevents the formation of his responsibility, the acquisition of social experience outside the family, isolates him from other sources of social influences. Such children have difficulties in communicating with others, they have a high risk of neurotic breakdowns and mental disorders.
The family provides the child with life experiences. Insufficient communication of the child with parents, the lack of joint games and activities not only limits the possibilities of his development, but also puts him on the brink of psychological risk.
Constant parental pressure that does not meet the needs and needs of the child is usually aimed at making him become not who he really is or who he can be. Requirements may not match gender, age, or personality traits. Such violence against a child, attempts to change his nature or force him to do the impossible, are extremely dangerous for his psyche. Distorted relationships in the family due to insufficient frankness, fruitless disputes, inability to agree among themselves to solve family problems, hiding family secrets from the child - all this makes it extremely difficult for him to adapt to life. Such an uncertain and usually stressful environment in which a child is brought up is fraught with risk to his mental health.
Mental disorders, personality disorders or disability of one of the family members represent a potential risk for a child with a mental disorder. This may be due, firstly, to the genetic transmission of increased vulnerability to the child and, secondly, to the impact of parental mental disorders on family life. Their irritability deprives the child of peace, a sense of confidence. Their fears can become a reason for limiting children's activity. Their delusional and hallucinatory experiences can frighten children and even cause sick parents to encroach on the health and life of children. Neuropsychiatric disorders can deprive parents of the ability to care for a child. Thirdly, because of the identification with the parents, the child, like them, may experience anxiety or fears. Fourthly, the harmony of family relations may be disturbed.
A mental or physical disability, a sensory defect (deafness, blindness), severe epilepsy, a chronic somatic disease, a life-threatening illness of the parent make him unable to serve and educate the child. He is also unable to manage the household, which certainly interferes with the well-being of the child and poses a risk to his mental health.
These states of mental or physical inferiority of the parents have an impact on the child due to a clear social stigmatization; due to insufficient care and supervision of the child; due to changes in parental feelings of affection and reduced responsibility caused by an inability to understand children's needs and difficulties; due to family disagreements and tensions; due to socially unacceptable behavior; due to the child's limitations in activity and contact. Antagonistic interactions and relationships between family members also lead to adverse consequences for the social and emotional development of the child.
A child may be affected by one, several or all of these factors at the same time. All bilateral relationships between people depend on the behavior of each of them. Accordingly, varying in degrees, disturbed intra-family relations may arise in part as a result of the reactions, attitudes or actions of the child himself. In each individual case, it is difficult to judge his actual participation in intra-family processes. Common cases of disturbed family relationships include lack of warmth in the relationship between parents and child, disharmony between parents, hostility towards or abuse of the child.
Disharmonious relationships between adult family members, manifested by quarrels or an atmosphere of emotional tension, lead to uncontrollable and hostile behavior of individual family members, which stubbornly maintains cruel relationships with each other. After serious conflicts, family members do not communicate with each other for a long time or tend to leave the house.
The hostility of some parents is manifested in the constant imposition of responsibility on the child for other people's misdeeds, which actually turns into mental torture. Others subject the child to systematic humiliation and insults that suppress his personality. They reward the child with negative characteristics, provoke conflicts, aggression, undeservedly punish.
Cruel treatment of a child or physical torture by his parents is dangerous not only for somatic, but also for mental health. The combination of pain, somatic suffering with feelings of resentment, fear, despair and helplessness due to the fact that the closest person is unfair and cruel can lead to mental disorders.
Coercion to sexual life, depraved actions, seducing behavior of parents, stepfather, other relatives, as a rule, are combined with serious trouble in family relations. In this situation, the child is defenseless against sexual abuse, his feelings of fear and resentment are exacerbated by the inevitability of what is happening, the impunity of the offender and the conflicting feelings of the offended towards him.
The ability of an event to cause distress is determined by how the individual perceives it. When assessing the difficulties experienced by the degree of adaptation or by the level of distress, it turned out that the subjective and objective significance of events for an adult and a child is different. For young children, the most significant experience can be even a temporary separation from their parents. Older children are hard pressed by their inability to meet parental aspirations for high academic performance or exemplary behavior. In a teenager, the development of stress is often associated with rejection or rejection by the peer group to which he wants to belong.
The fact that not everyone who is exposed to stress gets sick is due to the resilience of some individuals. At the same time, some people are more sensitive to stress.
Among the individual personality traits that contribute to the emergence of diseases as a result of external influences, temperament stands out. Its aspects, such as a low threshold of sensitivity to stimuli, the intensity of reactions, difficulties in adapting to new impressions with a predominance of negative emotions, and others, make the child very sensitive to stress. At the same time, the activity of the child, the rhythm of physiological functions, accessibility and good adaptability to the new, along with the prevailing even mood and low intensity of reactions to changes in the environment, prevent the development of diseases in the presence of potentially stressful events.
The predisposition to the occurrence of stress is also associated with the presence of a discrepancy between the requirements of the environment and the individual's ability to adequately respond to them. The stress reaction is understood as an imbalance in the relationship of the individual with the environment and as a manifestation of the discrepancy between his expectations and the possibilities for their implementation. However, the end result of this realization depends on the activities of others who can increase the stress or reduce its pathogenic effect through the support of the experiencer. This explains, for example, why one child, finding himself in the same difficult conditions of an educational institution, successfully adapts, while another, who does not have the support of parents or friends, cannot resolve his difficulties except through a neuropsychiatric disorder.
Among those who fell ill after suffering stress, those individuals who are distinguished by great nihilism, a sense of powerlessness, alienation, and lack of enterprise predominate. The pathogenic impact of stressors is reduced by the presence of high self-esteem, an energetic position in relation to the environment, the ability to make obligations, confidence in the ability to control events. Activity increases the chance of a favorable outcome of stress transfer, while the refusal to look for a way out of the situation makes the body vulnerable to the occurrence of diseases.
Catastrophic events are often followed by a state of “refusal”, “surrender” in a person who has survived them, less often - a premonition of this state. The individual reacts with the affect of helplessness or hopelessness, realizing his inability to act, to overcome the difficulties that have arisen without the help of others, or sometimes even with the help. Such people become preoccupied with experienced sad events. They perceive these memories as if everything unpleasant from the past has returned, overflowing and threatening. At this time, it is difficult for them to imagine the future or try to look for ways out. They turn away from the environment, plunge into their past experiences. This condition puts individuals on the brink of disease risk, makes them extremely vulnerable.
The appearance of mental disorders is also associated with the content of personality experiences. Such an experience can be an actual, threatening, or imagined "loss of the object." At the same time, the “object” is understood as both animate beings and inanimate objects, which, due to their attachment, the individual cannot refuse. An example would be a short-term or - especially - long-term loss of contact with relatives or with habitual activities (playing with peers).
Celebrate the significance of a particular life situation and the corresponding cultural influence. Moreover, social development and technological revolution in recent years are changing all norms in society. In this regard, tension arises between the individual and the environment, which is one of the main factors in the development of neuropsychiatric diseases.
During the action of a stressor on ligence, its primary assessment takes place, on the basis of which a threatening or favorable type of the situation is determined. From this moment, mechanisms of personal protection ("processes of co-ownership") are formed, that is, the means of the individual exercising control over situations that threaten or upset her. Coping processes, being part of an affective reaction, are aimed at reducing or eliminating the current stressor.
The result of the secondary assessment is one of three possible types of coping strategies:
1) direct active actions of the individual in order to reduce or eliminate the danger (attack or flight);
2) mental form - repression ("this does not concern me"), reassessment ("this is not so dangerous"), suppression, switching to another form of activity;
3) coping without affect, when a real threat to the person is not expected (contact with means of transport, household appliances).
The third evaluation occurs in the process of changing the judgment as a result of the received feedback or their own reactions. However, the origin of emotional reactions cannot be understood without considering physiological mechanisms. Mental and physiological processes should be considered in their mutual dependence.
PSYCHOLOGICAL PROTECTION AND BIOLOGICAL PROCESSES
Psychological protection is important to prevent the disorganization of mental activity and behavior and thus to create an individual's resistance to the possible development of the disease. It arises in the form of an interaction of conscious and unconscious psychological attitudes. If, as a result of mental trauma, it is impossible to implement a previously formed attitude in behavior, then the created pathogenic tension can be neutralized by creating another attitude, within which the contradictions between the initial desire and the obstacle are eliminated. An example would be the grief of a child who has lost his beloved dog. In connection with the impossibility of returning the pet, it is possible to console the child only by giving him another living creature, developing in him a new attitude to caring for a newly made friend. Instead of the described transformation of a negatively influencing attitude, one can observe the substitution of an unrealizable attitude by some other one that does not encounter obstacles when expressed in action. It is with the disintegration of psychological defense that favorable conditions are created for the pathogenic effects of psycho-emotional stress - the development of not only functional, but also organic disorders.
Biological processes that occur during the period of stress and have pathogenic significance arise the more easily, the more pronounced the hereditary predisposition to neuropsychiatric disorders. The particular sensitivity of some people to emotional stress, which was explained by a general hereditary-constitutional weakness or a type of higher nervous activity, is currently specified by pointing to the mechanism of the body's vulnerability - an increase in the activity of the hypothalamic-pituitary-adrenal system, a violation of the transformation of blood monoproteins and immunological characteristics of the body. The absence of stimuli or their excessive flow, acting on the hypothalamus, disrupts the hypothalamic-cortical relationship and changes the individual's reactivity to stress. The occurrence of physiological changes under the influence of stress depends on the level of emotional arousal, the quality and sign of emotions, the types of physiological responses of individuals and the differences in responses in the same person at different times, as well as the state of the autonomic nervous system.
The stress-limiting systems existing in the individual's body through the adrenergic and pituitary-adrenal systems create mechanisms that facilitate adaptation to the environment. These systems not only protect the body from direct damage, but also shape emotional behavior.
One of the mechanisms of resistance to emotional stress is the activation of the opioidergic system in the brain, which is able to eliminate negative emotional arousal. The accumulation of serotonin in the brain during adaptation to difficult situations also suppresses the stress response. Activation of the GABAergic system suppresses aggressiveness and regulates behavior.
SOMATIC CHANGES DURING STRESS
Stress, being an interaction between a person and the environment, is a complex process based on the integration of almost all parts of the brain. In this case, the brain plays a decisive role: the cerebral cortex, the limbic system, the reticular formation, the hypothalamus, and peripheral organs.
The stress reaction in response to a psychosocial stimulus begins with the perception of the stressor by the receptors of the peripheral nervous system. Information is received by the cerebral cortex and the reticular formation, and through it the hypothalamus and the limbic system. Each stimulus can reach one or another brain structure only through activation, which depends on the subjective significance of this stimulus and the situation that preceded its impact, as well as on previous experience of transferring similar stimuli. Thanks to this, events get an emotional coloring. The received signals and their emotional accompaniment are analyzed in the cortex of the frontal and parietal lobes. Information accompanied by emotional evaluation from the cerebral cortex enters the limbic system. If the psychosocial stressor is interpreted as dangerous or unpleasant, then intense emotional arousal can occur. When the satisfaction of biological, psychological or social needs is blocked, emotional stress occurs; it is expressed, in particular, by somatovegetative reactions. In the process of development of stress, excitation of the autonomic nervous system occurs. If a useful adaptive reaction is not formed in response to changes in the environment, then a conflict situation arises, and emotional tension increases. An increase in excitation in the limbic system and the hypothalamus, which regulates and coordinates the activity of the autonomic-endocrine system, leads to the activation of the autonomic nervous system and endocrine organs. And this leads to an increase in blood pressure, an increase in heart rate, the release of hormones into the blood, etc. Thus, stress reactions to psychosocial difficulties are not so much a consequence of the latter, but an integrative response to their cognitive assessment and emotional arousal.
The first somatic manifestations of stress arise due to the rapid reaction of the autonomic nervous system. After the psychosocial stimulus has been assessed as threatening, the nervous excitation passes to the somatic organs. Stimulation of autonomic centers leads to a short-term increase in the concentration of norepinephrine and acetylcholine at the nerve endings, normalizing and activating the activity of organs (heart, blood vessels, lungs, etc.). To maintain stressful activity for a longer time, the neuroendocrine mechanism is activated, which implements the stress response through adrenocortical, somatotropic, thyroid and other hormones, as a result, for example, an increase in blood pressure, shortness of breath, palpitations, etc. persist for a long time.
The control center of the neuroendocrine mechanism is the septal-hypothalamic complex. From here, impulses are sent to the median tubercle of the hypothalamus. Here, hormones are released that enter the pituitary gland, the latter secretes adrenocorticotropic hormone, growth hormone, which enter the adrenal cortex, as well as thyroidotropic hormone, which stimulates the thyroid gland. These factors stimulate the release of hormones that act on the bodily organs. The pituitary gland, having received nerve signals from the hypothalamus, releases vasopressin, which acts on kidney function, and oxytocin, which, together with melanocyte-stimulating hormone, affects learning and memory. During the stress response, the pituitary gland also produces three gonadotropic hormones that act on the sex and mammary glands. Under stress, under the influence of an appropriate concentration of testosterone, sex-appropriate behavior is determined.
Thus, during a period of stress, due to the interaction of the cortex, the limbic system, the reticular formation and the hypothalamus, the external requirements of the environment and the internal state of the individual are integrated. Behavioral or somatic changes are the result of the interaction of these brain structures. If these structures are damaged, this leads to the impossibility or disorder of adaptation and disruption of relationships with the environment.
In a stress reaction, brain structures, interacting with each other, manifest themselves differently. When basic biological needs are in danger, the hypothalamus and the limbic system play a major role. Difficulties in fulfilling social needs require the greatest activity of the cerebral cortex and limbic system.
PATHOGENICITY OF STRESS
The state of stress leads to an increase in the interaction of the hypothalamus and the reticular formation, a deterioration in the connection between the cortex and subcortical structures. In case of violation of the cortical-subcortical relations, both in acute and chronic stress, typical motor disorders, rhythm of sleep and wakefulness, disturbance of drives, and mood occur.
Along with this, the activity of nerve transmitters is disturbed, the sensitivity of neurons to transmitters and neuropeptides changes.
The pathogenicity of stress (the ability to cause somatic and neuropsychiatric disorders) depends on its intensity or duration, or both. The fact of the occurrence of a psychosomatic illness, neurosis or psychosis is explained by the fact that the individual tends to form similar psychophysiological reactions to various stressors.
Stress does not develop according to the all-or-nothing law, but has different levels of manifestation. It proceeds as a compensatory process in relationships with the outside world, as a somatic regulation. With a constant increase in the activity of functional systems, their wear and tear can be depreciated.
M. Poppel, K. Hecht (1980) described three phases of chronic stress tegenia.
phase of inhibition - with an increase in the concentration of adrenaline in the blood, inhibition of protein synthesis in the brain, a decrease in the ability to learn and a strong inhibition of energy metabolism, which is interpreted as a decrease in protection from stressors.
The mobilization phase is an adaptive process with a strong increase in protein synthesis, an increase in the blood supply to the brain, and an expansion in the types of metabolism in the brain.
Premorbid phase - with the formation of energy, which is associated with dysregulation in many systems, with a limitation in the development of new conditioned reflexes, an increase in blood pressure, a change in blood sugar under the influence of insulin, the elimination of the action of catecholamines, with a violation of the sleep phase, the rhythm of physiological functions and weight loss body.
Ways of implementation of the stress reaction are different. The variety of stress reactions is associated with implementation through various "initial links" of the nervous system and further pathways for the distribution of stimuli.
Somatic stress (impact of physical or chemical factors) is carried out through the subcortical structures (anterior tuberal region), from where the corticotropin-releasing factor through the hypothalamus enters the anterior pituitary gland.
Psychic stress is realized through the cerebral cortex-limbic-caudal subtubercular region-spinal cord-abdominal nerves-adrenal medulla-adrenaline-neurogi-pituitary-ACTH-adrenal cortex.
Stress can be a mechanism for the development of neurotic, mental and psychosomatic (cardiovascular, endocrine and other disorders, joint diseases, metabolic disorders). The basis for the development of the disease during prolonged stress is the prolonged influence of hormones involved in the formation of the stress response and causing disturbances in the metabolism of lipids, carbohydrates, and electrolytes.
Short-term acute exposure to stress leads to an increase in adaptive abilities. However, if the prepared “fight-flight” reaction (fighting with difficulties) is not carried out, then stress has a negative effect on the body and can cause an acute affective reaction.
SOMATIC ETIOLOGICAL FACTORS
Bodily diseases, injuries, poisoning cause neuropsychic disorders. However, traditionally, the study of somatogenic neuropsychiatric disorders, i.e., those associated with physical injuries and diseases, in children, as well as in adults, was carried out in psychiatric clinics. In this regard, as a rule, expressed mental disorders with a protracted or periodic course were subjected to analysis. It seemed that the only reason for their occurrence are physical hazards acting on the human body. It was believed that the clinical manifestations of mental illness could depend only on the severity, pace and strength of their impact. Cases of short-term disorders that did not require hospitalization in a psychiatric hospital were described much less frequently. Recently, pronounced and especially severe forms of somatogenic mental disorders in children have become a rarity. At the same time, cases of mild forms of psychosis, neurosis-like (similar in clinical manifestations to neurosis), endoform (reminiscent of endogenous diseases) disorders became more frequent. The need to prevent and treat mental disorders and related complications required the study of this fairly common somatogenic psychopathology observed outside of psychiatric hospitals.
In patients who applied to a children's clinic or were treated in children's somatic hospitals and sanatoriums, the entire spectrum of neuropsychic symptoms was revealed: from initial manifestations to severe psychoses. To understand the origin and characteristics of the symptoms, they studied hereditary burden, biological hazards, premorbid state (mental and somatic health before illness), personality changes during the course of the disease and its response to the mental somatic state, the influence of micro- and macrosocial conditions.
As a result of the study of these shallow mental disorders, it was found that the symptoms of neuropsychiatric disorders in the vast majority of cases are combined with personal reactions to both somatic and mental illness. These reactions depend on the characteristics of the personality of the child or adolescent, his age, gender, and the more pronounced, the less severe the psychopathological symptoms.
In order to better understand the personal response, an analysis of the internal picture of the disease (IDP) was carried out. Special methodological techniques made it possible to assess the role of the intellectual level of children, knowledge about health and illness, the experience of suffering, the prevailing emotional attitudes of parents to the child's illness and the patient's perception of it in the formation of ICD.
Bearing in mind the complexity of the pathogenesis (mechanism of development) of neuropsychiatric diseases, it is nevertheless necessary to separately consider the features of the factors acting on the body and causing mental disorders. These "somatogenic" factors include exogenous (external) factors: somatic and general infectious diseases, brain infectious diseases, intoxication (poisoning), traumatic brain damage. It is assumed that exogenous (for example, somatogenic) disorders arise due to the action of external causes, and endogenous (for example, schizophrenia) - due to the deployment of internal mechanisms, the implementation of a hereditary predisposition. In fact, between "pure" endogenous and exogenous disorders there are transitions from those in which there is a very pronounced genetic predisposition, easily provoked by a minor external influence, to those in which a noticeable predisposition cannot be noted, and a powerful external harmfulness turns out to be the etiological factor.
The prevalence of exogenous hazards can be judged from the data of V. I. Gorokhov (1982). Among the patients observed by him who fell ill in childhood, 10% were exogenous organic diseases. They were caused in 24% of cases by head injuries, in 11% - by meningitis, encephalitis, in 8% - by somatic and infectious diseases. However, most often - in 45% of cases - combinations of the listed factors were found, which confirms the predominance in real life of the complex effect on the body and psyche of various hazards.
Among the etiological factors of infectious psychoses, we note, for example, such diseases as influenza, measles, scarlet fever, hepatitis, tonsillitis, chicken pox, otitis media, rubella, herpes, poliomyelitis, whooping cough. Neuroinfections (infectious diseases of the brain) cause mental disorders during the development of meningitis, encephalitis (meningococcal, tuberculosis, tick-borne, etc.), rabies. It is also possible the appearance of complications (secondary encephalitis) with influenza, pneumonia, measles, dysentery, chicken pox and after vaccinations. Rheumatism and lupus erythematosus can also lead to acute and chronic mental disorders. Diseases of the kidneys, liver, endocrine glands, blood, heart defects can be complicated by neuropsychiatric disorders. Mental disorders can be caused by poisoning with tricyclic antidepressants, barbiturates, anticholinergics, hormonal drugs, as well as gasoline, solvents, alcohol and other chemicals. The cause of mental disorders may be traumatic brain damage (concussions, bruises, and less often open head injuries).
It is very difficult to associate the occurrence of the disorders under discussion with one single cause. “It is impossible to single out one main factor, and even more so the only one, and reduce the etiology of the phenomenon to it” [Davydovsky I.V., 1962]. The complex of exogenous hazards that cause mental disorders is usually preceded by factors that weaken the body, reducing its reactivity, i.e., the ability to protect itself from disease. These include features of the somatic development of the child, immune reactivity, as well as increased vulnerability of some parts of the brain, endocrine-vegetative, cardiovascular disorders that are involved in resistance to harmful influences. In the weakening of the body's defenses, inflammatory or traumatic brain damage, repeated somatic diseases, severe moral shocks, physical overstrain, intoxication, and surgical operations can also play a role.
Features of the impact of an exogenous "causal factor" are determined by its strength, the rate of impact, the quality and characteristics of the interaction of predisposing and producing causes.
Consider the impact of exogenous factors on the example of infections. According to B. Ya. Pervomaisky (1977), three types of interaction between the organism and infection can occur. With the first of them, due to the great severity (virulence) of the infection and the high reactivity of the organism, as a rule, there are no conditions for the occurrence of mental disorders. With a prolonged infectious disease (type 2), the possibility of developing mental disorders will depend on additional (debilitating) factors. In this case, the right diet and treatment are decisive. The third type is characterized by both low reactivity of the organism and insufficiency of the thermoregulatory system. The protective inhibition that occurs in the brain plays the role of protecting the body, and mental disorders in which it manifests itself play a positive role.
To understand the pathogenesis of exogenous neuropsychiatric disorders, it is necessary to take into account the importance of the developing lack of oxygen supply to the brain, allergies, disorders of brain metabolism, water and electrolyte balance, acid-base composition of cerebrospinal fluid and blood, increased permeability of the barrier that protects the brain, vascular changes, and edema. brain, damage to nerve cells.
Acute psychoses with stupefaction occur when exposed to intense, but short-acting hazards, while protracted psychoses, approaching endogenous in clinical manifestations, develop with prolonged exposure to hazards of a weaker intensity [Tiganov A.S., 1978].
HEREDITARY FACTORS UNDERLYING CERTAIN DISEASES OR DEVELOPMENTAL DEFECTS
Hereditary causes are involved in the origin of a number of diseases and disorders of mental development. In diseases of genetic origin, genes produce abnormal enzymes, proteins, intracellular formations, etc., due to which metabolism is disturbed in the body and, as a result, one or another mental disorder may occur. The mere presence of deviations in the hereditary information transmitted by parents to children is usually not enough for the onset of a disease or developmental deviation. The danger of the appearance of a disease associated with a hereditary predisposition, as a rule, depends on adverse social influences that can “trigger” a predisposing factor, realizing its pathogenic effect. Knowledge of this fact by special psychologists and educators will allow them, for example, to better assess the likelihood of mental disorders in children with parents suffering from mental disorders or mental retardation. Creating favorable living conditions for such children can either prevent or mitigate the clinical manifestations of mental disorders.
Here are some hereditary syndromes of mental disorders that develop under certain chromosomal or genetic, and sometimes under conditions unknown to us.
Fragile X syndrome (Martin-Bell syndrome). In this syndrome, one of the long branches of the X chromosome narrows towards the end, it has a gap and individual fragments, or small protrusions are found. All this is revealed by culturing cells with specific additives, in which there is a lack of folates. The frequency of the syndrome among the mentally retarded is 1.9-5.9%, among the mentally retarded boys - 8-10%. One third of heterozygous female carriers also have an intellectual defect. 7% of mentally retarded girls have a fragile X chromosome. The frequency of this disease in the entire population is 0.01% (1:1000).
Klinefelter syndrome (XXY). In this syndrome, males have an extra X chromosome. The frequency of the syndrome is 1 in 850 male newborns and 1-2.5% in patients with mild mental retardation. With this syndrome, there may be several X chromosomes, and the more there are, the deeper the mental retardation. A combination of Klinefelter's syndrome with the presence of a fragile X chromosome in a patient is described.
Shereshevsky-Turner syndrome (monosomy X). The condition is determined by a single X chromosome. This syndrome occurs in 1 out of 2200 girls born. Among the mentally retarded, 1 out of 1500 females.
Syndrome of trisomy of chromosome 21 (Down's disease). This syndrome is the most common human chromosomal pathology. It has an extra 21st chromosome. The frequency among newborns is 1:650, in the population - 1:4000. Among patients with mental retardation, this is the most common form, it is about 10%.
Phenylketonuria. The syndrome is associated with a hereditary, genetically transmitted lack of an enzyme that controls the conversion of phenylalanine to tyrosine. The accumulation of phenylalanine in the blood causes mental retardation in 1 in 10,000 newborns. The number of patients in the population is 1:5000-6000. Patients with phenylketonuria make up 5.7% of the mentally retarded who seek help from genetic counseling.
Syndrome * face of an elf * - hereditarily genetically transmitted hypercalcemia. In the population, it occurs with a frequency of 1:25,000, and at a genetic consultation appointment, it is the most common form after Down's disease and phenylketonuria (almost 1% of children who apply).
tuberous sclerosis. This is a hereditary systemic (tumor-like lesion of the skin and nervous system) disease associated with a mutant gene. In the population, this syndrome occurs with a frequency of 1:20,000. At the reception at the genetic consultation, such patients make up 1% of all patients who apply. It often occurs in severely mentally retarded patients.
Alcoholic encephalopathy. Fetal alcohol syndrome, caused by parental alcoholism, accounts for 8% of all cases of mental retardation. With the abuse of alcohol and smoking during pregnancy, the frequency of intrauterine and perinatal deaths, prematurity, asphyxia in childbirth increases, and the incidence and mortality of children in the early years of life increases. Alcohol intensively acts on cell membranes, on the processes of cell division and DNA synthesis of nerve cells. In the first weeks after conception, it leads to gross malformations of the central nervous system and to mental retardation. After the 10th week of pregnancy, alcohol causes cellular disorganization and disrupts the further development of the central nervous system.
Later, alcohol disrupts brain metabolism in the fetus and neurogenic effects on the endocrine system, which causes endocrine disorders, in particular growth disorders. The severity of the syndrome depends on the severity of maternal alcoholism and the duration of alcohol exposure to the fetus.
What is "neurosis"?
Neurotic disorders are the subject of minor psychiatry and neurosology. The concept of neurosis is not strictly defined. To date, there is no generally accepted definition of neurosis. In traditional psychiatry, neuroses are understood as functional diseases characterized by a psychogenic origin, a variety of somatovegetative and psychoemotional disorders. With neurosis, unlike other mental illnesses, the consciousness of the disease is not disturbed in the individual. Neuroses proceed without psychotic disorders and severe behavioral disorders. Since these diseases are functional in nature, in most cases, with the right treatment started in a timely manner and a favorable situation, they are reversible.
Classification of neurotic disorders in children and adolescents
The questions of the grouping of neuroses are among the unresolved, since childhood neuroses are distinguished by their clinical originality. According to the position of the child psychiatrist V.V. Kovalev, the incompleteness, rudimentary nature of symptoms, the predominance of somatovegetative and movement disorders, the lack of personal experience of the disease, deep internal processing, explain the predominance of monosymptomatic neuroses in children and the relative rarity of general neuroses observed only from 10-12 -years of age. Monosymptomatic (systemic) childhood neuroses include neurotic stuttering, tics, sleep and appetite disorders, neurotic enuresis and encopresis, pathological habitual actions (thumb sucking, nail biting, onanism) [V.V. Kovalev, 1995].
At the same time, in adolescence, general neurosis becomes the predominant form of psychogenic illness, often acquiring a tendency to a protracted course and to a transition to neurotic personality development. With all the variety of allocation of various forms of neurotic syndromes, the recognition of three classical forms of general neuroses in adolescents remains generally recognized:
At present, in the ICD-10, some general neuroses are divided into various categories according to the syndromological principle. Thus, obsessive compulsive disorder is divided into two diagnostic categories - anxiety and phobic disorders and obsessive-compulsive disorder. Hysterical neurosis is presented in a wide group of dissociative conversion disorders and, according to some authors, refers to somatization disorder (Bricke's syndrome) (F45.0 according to ICD-10) [A. Yakubik, 1982].
What causes teenage anxiety?
In traditional child-adolescent and adult psychiatry, it is generally accepted that the cause of neurosis is complex, multidimensional. The leading cause of neurosis is a traumatic effect, which is associated with internal and external conditions. The internal conditions that contribute to the emergence of a neurotic way of responding in adolescents include accentuated and pathological character traits, residual cerebro-organic insufficiency, burdened by childhood neuropathy, somatic weakness due to the transfer of a "chain" of infections or the manifestation of a somatic disease, an age factor contributing to a general nonspecific increase in vulnerability of the neuropsychic sphere in transitional age periods. The factors of external conditions include an unfavorable family climate, unsettled relationships in the peer group with the position of a teenager in the role of a loner, and the discrepancy between the type of school and the level of the child's abilities. These factors facilitate the emergence of neurosis under the influence of the outlined psychotraumas. Psychogenies leading to neurosis are classified into shock psychotraumas, situational factors of a relatively short-term effect, chronically acting psychotraumatic situations and factors of emotional deprivation [V.V. Kovalev, 1995].
According to V. V. Kovalev, in child psychiatry, age-related features of the pathogenesis of neuroses in children and adolescents have not been studied at all [V.V. Kovalev, 1995].
A look at the problem of different schools of psychotherapy
The orthodox psychoanalytic interpretation of the emergence of neuroses differs significantly from that adopted in traditional psychiatry. According to the views of Sigmund Freud, it is assumed that neurosis arises as a result of the suppression of libidinal sexual impulses during fixations at certain stages of psychosexual development.
In existential-phenomenological psychiatry, “neurotic existence is an attempt to avoid the consciousness of existential fear and guilt by evading responsibility for one’s life and fleeing from self-realization, i.e., “true” life. A person chooses psychopathological symptoms as a method of solving existential problems. Neurosis, according to some existentialists, is a way to avoid non-existence by evading being, i.e., in neurosis, the potentialities of the individual cease to be embodied, because “to be” means to be aware of “non-existence” with its inherent existential fear. According to Rollo May, the cause of neurosis is, first of all, the belief in the absence of one's meaning in the world, a radical doubt about the meaning of one's existence, a feeling of loneliness and despair. Neurosis is the result of the denial of the basic relationship of “being-with-others”, as it were, the rejection of “meeting another person” as an equal partner. In neurosis, a person is overly focused on the external world and too little on his own inner world. Yakubik, 1982, p. 121].
Proponents of behavioral psychotherapy, holding the position that human behavior, in general, is the result of learning, consider the behavior of neurotic adolescents as the result of incorrectly learned ways of behavior. They suggest that, along with the classical one, operant conditioning is involved in symptom formation and the course of neurotic disorders, especially such as fears and obsessions [R. Telle, 2002].
Gestalt therapy also has its own view of neurotic disorders. Fritz Perls, in his early work Ego, Hunger and Aggression, states that the meaning of neurosis is found in the disruption of developmental and adjustment processes. Neuroses are the consequences of the conflict between the organism and the environment [F.Perls, 2000]. Later, developing the ideas of understanding neuroses, Fritz Perls argues that “neurosis is the avoidance and limitation of spontaneous arousal. This is the preservation of sensory and motor attitudes in situations that do not justify them, or even outside the contact situation: like an uncomfortable posture maintained during sleep. These habits interfere with physiological self-regulation and cause pain, exhaustion, hypersensitivity, and eventually disease. There is no total relaxation, no ultimate satisfaction. A neurotic who is troubled by unsatisfied needs and unconsciously continues to pinch himself cannot be carried away by his own external interests or successfully embody them. In awareness, for the most part, his own personality is present: embarrassed, alternately offended and guilty, conceited and humiliated, impudent and shy, and so on. Perls, 2010, p. 274].
The French Gestalt therapist Serge Ginger, drawing on the work of the humanistic psychoanalyst Karen Horney, considers neurosis as one of the defense mechanisms against the basic existential anxiety that is present throughout a person’s life and is associated with the need to make choices. Disturbances in the mental functioning of a person are initially adaptation mechanisms that help to survive at a given moment of existence, however, then they are established and continue to work anachronistically inflexibly, preventing the satisfaction of needs, transforming into resistance in the Gestalt sense of the word [S. Ginger, 2010].
As a psychologist who specializes in Gestalt therapy, I will also add a few personal notes on the subject of teenage neuroses. Adolescence is a period of a person's life during which a reorganization of mental activity takes place, ensuring the coordination of psychophysiological changes and the social development of the personality, is quite problematic for the adolescent himself and his environment. At this age, the need to find one's own uniqueness is actualized, attempts to overcome conformism arise, there is a hard clash with existential compulsions - loneliness, sexuality, freedom, imperfection, responsibility. The Gestalt approach has proven itself in the psychotherapeutic space as an effective approach with the whole spectrum of these problems, and with its help it is possible to help the teenager realize how he comes into contact with himself, how he comes into interaction with other people and how he positions himself in the surrounding society, how he builds contact with him.
Gestalt therapy, with its view of the integrity of the biological, psychological and social in human existence, with its emphasis on phenomenology, on the recognition of the uniqueness and originality of each individual, seems to be a fairly promising psychotherapeutic direction for the treatment of various neurotic disorders, organically fitting into the ideas of the new general medical paradigm . Adherence to the idea of holism markedly distinguishes Gestalt therapy from other psychotherapeutic approaches that emphasize either expanding the behavioral repertoire to improve the adaptive interaction of a person with society (behavioral psychotherapy), or rationally rethinking fragments of old life experience, believing that this will change existence. person in the future (psychoanalysis).
List of used literature
Ginger S. Gestalt: the art of contact / Per. from English. T. A. Rebeko. – Ed. 2nd. - M .: Academic project; Culture, 2010. - 191 p. – (Psychotherapeutic technologies).
Kovalev VV Psychiatry of childhood: a guide for doctors. Ed. 2nd, revised and expanded. – M.: Medicine, 1995. – 560 p.
Perls F. Theory of Gestalt therapy / Per. from English. A. Korneva, V. Petrenko. - M.: Institute for General Humanitarian Research, 2010. - 320 p. Series: ("Modern psychology: theory and practice").
Perls F. Ego, hunger and aggression / Per. from English. N. B. Kedrova, A. N. Kostrikova. – M.: Meaning, 2000. – 358 p.
Telle R. Psychiatry with elements of psychotherapy / Per. with him. G.A. Obukhova. - Minsk: Interpressservis, 2002. - 496 p.
Yakubik A. Hysteria / transl. from Polish M. G. Lepilina. - M.: Medicine, 1982. - 344 p.
Neurotic disorders in children and adolescents: symptoms, causes, therapy
symptoms, causes, therapy
We live in a strange era. Every day there are more and more different educational games and techniques for children, and parents have less and less time to play with their children. The number of incomplete families has increased, children experience the stress of parental divorce, and in the future - life with a step-dad, etc.
The workload for children has also increased significantly. A child begins to be led in developing circles almost from birth, and by school he should already be able to read and solve examples. All this together creates excessive psycho-emotional stress for the child, which not every organism is able to survive without harming itself.
Every year the number of children who have various kinds of neurotic disorders increases. According to statistics, by the end of the junior school level, almost half of neurologically healthy children remain. Often there are neuroses in children, and a number of other neurogenic disorders.
Childhood neurosis is a shallow (under favorable conditions - completely removable) mental illness in a child, the symptoms of which are already often diagnosed in a teenager, and in a child of primary school, and even preschool age. What are the causes of neurosis in children? Are all children susceptible to it?
The origin of the disease: why my child?
Neurosis in young children (up to 2-3 years old) is usually associated with physiological causes. Later, when the character of the child is formed, psychological reasons also come into force. But for babies aged 0-3 years, the leading stress factor is the state of health, in this case, the child's nervous system. Symptoms (signs) of a neurotic disorder in children of this age group may be due to such reasons:
- severe pregnancy, mother's illness during pregnancy and other factors that led to intrauterine fetal hypoxia, and varying degrees of damage to the child's nervous system;
- birth trauma, unfavorable course of childbirth, which also resulted in perinatal damage to the child's central nervous system;
- frequent illnesses of the child at an early age, severe course of the disease (complications).
- Increased sensitivity, emotionality. Such children react very strongly to separation from their mother, they may burst into tears of pity, etc.
- Inability to protect their interests, defenselessness.
- Anxiety, a tendency to worry and fear.
- Impressionability (for a long time they remember an insult, an unpleasant situation).
- Inconsistency, instability (usually between rationalism and the emotional component).
- Introversion (the whole mass of emotional sensations and contradictions is rarely voiced, the child “digests” them inside himself).
- The child's high need for self-assertion.
- physiological causes (that is, the type of nervous system on the basis of which neuroses are easily formed in children and adolescents);
- psychological reasons.
- sleep disturbances (insomnia, interrupted sleep, there may be nightmares, especially in children 3 years old - 6 years old);
- appetite disorders (neurosis in young children is expressed more often by a decrease in appetite or vomiting symptoms, adolescents may experience bulimia nervosa or anorexia);
- headaches, dizziness, spasms of cerebral vessels;
- muscle weakness, weakness, fatigue;
- nervous cough, urinary and fecal incontinence (most often this is how neurosis manifests itself in young children, occasionally in primary school age);
- spasmodic pain in the heart or stomach;
- nervous tics, convulsions, impaired motor functions.
- irritability, mood swings (most pronounced in adolescents);
- sensitivity, vulnerability, vulnerability (more often observed in children aged 3-6 years, school-age children begin to hide these signs, introversion occurs);
- oppressed, depressive state (maximum manifested in adolescents);
- fears, phobias;
- tantrums, falling to the floor with sobs (most pronounced in the preschool period, teenagers also occur, but look different).
Neurosis in preschool children (3-6 years old) has already 2 sets of causes: psychological and physiological.
Psychological reasons include stress, excessive workload, unfavorable relationships in the family, problems in kindergarten. Physiological causes are more extensive, it is worth dwelling on them in more detail.
Children's neuroses most often manifest themselves on "favorable" soil for this, that is, in a child with certain features of the nervous system and psyche:
Neurosis in schoolchildren is also formed in a similar way:
The physiological prerequisites have already been described above, it is on the basis of such a psychotype that children's neuroses are formed in any age category. But the psychological reasons vary depending on age. Both neurosis in children and other neurotic disorders are more often manifested during an age-related crisis in a child's life.
For the period of primary school age (7-12 years) there is another age crisis, which the child goes through in the seventh year of life. The child enters the era of schooling, the most significant adult becomes the first teacher. And the assertion of one's social significance now takes place in the conditions of study, and depends on school achievements. The information load increases significantly. In a neurologically weak child, on this basis, childhood neurosis may occur.
Neurosis in children in adolescence (12-16 years old) is reinforced by the adolescent age crisis. Hormonal storm, mood swings, frequent depression are constant companions of this age.
Thus, both neuroses in children and adolescents are based on the weakness of the nervous system, on the one hand, and increased psycho-emotional stress, on the other.
Symptoms and types
Neurosis in children and adolescents have signs (symptoms) of both physiological and psychological nature. Physiological symptoms include:
Both neuroses in children and adolescent neuroses also have psychological signs (symptoms):
In accordance with a certain set of symptoms, neuroses in children and adolescent neuroses are divided into several types:
- Hysterical neurosis (tantrums, falling to the floor, screaming, sobbing).
- Asthenic neurosis (weakness, fatigue, sleep disturbance, tearfulness). VSD often accompanies both asthenic neuroses in children and adults.
- Obsessional neurosis. Some authors also refer to it obsessional neurosis (it is characterized by various tics, convulsions, muscle spasms), and phobic neurosis (fears of darkness, loneliness, separation from loved ones, death).
- depressive neurosis- desire to retire, depression, depressed mood. Most manifested in adolescence.
- Hypochondriacal neurosis- Fear of getting sick is also more common in adolescents.
Both neuroses in children and adolescent neuroses must be treated in a complex manner, taking into account both psychological and physiological symptoms.
Methods of rehabilitation and prevention
Treatment of neurosis in children is carried out with the help of such specialists:
- a neurologist (will help to treat directly neurological disorders, if necessary prescribe sedatives, conduct diagnostics);
- child and family psychologist (helps restore a psychologically favorable microclimate in the family, choose the optimal model of education);
- a psychotherapist (will help treat obsessive-compulsive disorders, can conduct hypnosis sessions, working with this specialist is most important for adolescents and adults);
- other specialists of a narrow profile (consultation of a psychiatrist and an endocrinologist may be required, and a reflexologist, acupuncturist, masseur also helps to treat neurotic conditions).
Comprehensive and timely treatment of neurosis in children helps to completely eliminate the symptoms of the disease. But remember that the special vulnerability of your child's nervous system is the qualities given to him by nature for life.
That is why the prevention of neurosis in children is of such importance. And the main role here is given to parents.
To ensure the mental health of your baby, follow these simple rules:
- Create a clear daily routine for your child. This helps to stabilize the work of his unbalanced nervous system.
- Pay close attention to the stress in your child's life. At the first signs of neurological trouble, consult a neurologist (supporting the course of treatment) and teachers (reduce the load).
- Be sure to provide your child with feasible physical activity, it reduces mental stress.
- With psychological problems in the family, do not delay the visit to a family psychologist.
- If possible, provide your child with a visit to a child psychologist and methods of dealing with stress (game therapy, fairy tale therapy, art therapy).
- If necessary, use relaxation means available at home (pine bath, aroma lamp with soothing oils, breathing exercises and muscle relaxation methods, taking soothing herbs and fees). Older children can be taught meditation. Yoga is good for all ages, now there is even baby yoga for toddlers.
- opposition reaction;
- reaction of nihilism;
- hypercompensation reaction;
- imitation response.
- Kirpichenko A. A. Psychiatry: Proc. for honey. in-comrade. - 2nd ed., revised. and additional — Mn.: Vysh. school, 1989.
- Bortnikova S. M., Zubakhina T. V. Nervous and mental diseases. Series ‘Medicine for you’. Rostov n/a: Phoenix, 2000.
- hysterical neurosis.
- Asthenic neurosis.
- Obsessional neurosis.
- logoneurosis (stuttering), tics, enuresis, encopresis.
- 1. Psychological - includes the individual characteristics of a person, the conditions for his upbringing and formation as a person, the development of his relationship with the social environment, the level of ambition.
- 2. Biological - associated with functional insufficiency of certain parts of the neurotransmitter or neurophysiological system, which significantly reduces psychological resistance to negative psychogenic influences.
- F40. Phobic Anxiety Disorders: This includes agoraphobia, all social phobias, and other similar disorders.
- F41. Panic disorders (panic attacks).
- F42. Obsessions, thoughts and rituals.
- F43. Reactions to severe stress and adjustment disorders.
- F44. dissociative disorders.
- F45. somatoform disorders.
- F48. Other neurotic disorders.
- a person is dizzy;
- he lacks air;
- he is shivering or, conversely, throws him into a fever;
- there is a rapid heartbeat;
- the patient's hands tremble;
- makes him sweat;
- there is a feeling of nausea.
- anxiety;
- anxiety;
- tension;
- a feeling of unreality of what is happening;
- memory impairment;
- fatigue;
- sleep disturbance;
- difficulty concentrating;
- fears;
- feeling excited;
- stiffness.
- 1. Agoraphobia - manifested by fear of a place or situation from which it is impossible to leave unnoticed or immediately get help when immersed in an extremely anxious state. Patients subject to such phobias are forced to avoid encountering specific provoking factors: large open urban spaces (squares, avenues), crowded places (shopping centers, train stations, concert and lecture halls, public transport, etc.). The intensity of the pathology varies greatly, and the patient may lead an almost normal life, or may not even be able to leave the house.
- 2. Sociophobia - anxiety and fear are caused by fear of public humiliation, demonstration of one's weakness, inconsistency with other people's expectations. The disorder manifests itself in the inability to express one's opinion to a large number of listeners, as well as to use public baths, swimming pools, beaches, gyms for fear of being ridiculed.
- 3. Simple phobias are the most extensive and diverse type of disorders, since any specific objects or situations can cause pathological fear: natural phenomena, representatives of the animal and plant world, substances, conditions, diseases, objects, people, actions, the body and its parts, colors , numbers, specific places, etc.
- strong fear of the object of the phobia;
- avoidance of such an object;
- anxiety in anticipation of meeting him;
- increased sweating;
- increased heart rate and breathing;
- dizziness;
- chills or fever;
- shortness of breath, shortness of breath;
- nausea;
- loss of consciousness or fainting;
- numbness.
- uncontrollable fear;
- dyspnea;
- tremor;
- sweating;
- fainting;
- tachycardia.
- 1. Cleansing (expressed mainly in washing hands and wiping surrounding objects).
- 2. Prevention of potential danger (multiple checks of electrical appliances, locks).
- 3. Actions in relation to clothes (a special sequence of dressing, endless pulling, smoothing clothes, checking buttons, zippers).
- 4. Repetition of words, counting (often with a list of items aloud).
- 1. Acute stress reaction - a rapidly passing disorder (several hours or days) that arose in response to an unusual strong physical or mental stimulus. Symptoms include: a state of "stupefaction", disorientation, narrowing of consciousness and attention.
- 2. Post-traumatic stress disorder - is a delayed or protracted response to a stressful factor of exceptional strength (various catastrophes). Symptoms include: recurring intrusive memories of the traumatic episode in thoughts or nightmares, emotional retardation, sleep disturbances (insomnia), alienation, hypervigilance, overexcitation, depression, suicidal thoughts.
- 3. Disorder of adaptive reactions - characterized by a state of subjective distress that occurs during the adaptation period after exposure to a stress factor or significant changes in the patient's life (loss of a loved one or separation from him, forced migration to an alien cultural environment, going to school, retirement, etc. d.). This type of disorder creates difficulties for normal social life and natural actions, and the following manifestations are characteristic of it: depression, alertness, a feeling of helplessness and hopelessness, depression, culture shock, hospitalism in children in the context of deviant development (lack of communication of a child of the first year of life with adults ).
- 1. Dissociative amnesia. A characteristic feature is partial or selective memory loss, directed specifically at traumatic or stress-related events.
- 2. Dissociative fugue - manifested by the sudden relocation of the patient to an unfamiliar place with a complete loss of personal information up to the name, but with the preservation of universal knowledge (languages, cooking, etc.).
- 3. Dissociative stupor. Symptoms: reduction or complete disappearance of voluntary movements and normal reactions to external stimuli (light, noise, touch) in the absence of physical pathology.
- 4. Trance and possession. It is characterized by an involuntary temporary loss of personality and a lack of awareness of the world around the patient.
- 5. Dissociative movement disorders. Manifested in the form of a complete or partial loss of the ability to move the limbs, up to a seizure or paralysis.
- somatization disorder - patient complaints of numerous, often changing physical symptoms in any organ or system, recurring for at least two years;
- hypochondriacal disorder - the patient is constantly concerned about the possible presence of a serious illness or its appearance in the future; while normal physiological processes and sensations are perceived by him as unnatural, disturbing signs of a progressive disease;
- somatoform dysfunction of the autonomic nervous system manifests itself in two types of symptoms characteristic of normal ANS dysfunction: the first contains the patient's objective complaints of sweating, tremor, redness, palpitations, the second includes subjective complaints of a non-specific nature of pain throughout the body, sensations of fever, bloating of the intestine ;
- persistent somatoform pain disorder - characterized by persistent, sharp, sometimes excruciating pain in a patient that occurs under the influence of a psychogenic factor and is not confirmed by a diagnosed physical disorder.
- 1. Psychotherapy is the main method in the treatment of neuroses. It has the main pathogenetic methods (psychodynamic, existential, interpersonal, cognitive, systemic, integrative, gestalt therapy, psychoanalysis) that affect the causes that provoke the development of the disorder; as well as auxiliary symptomatic methods (hypnotherapy, body-oriented, exposure, behavioral therapy, various breathing exercises techniques, art therapy, music therapy, etc.), which alleviate the patient's condition.
- 2. Drug therapy is used as an auxiliary method of treatment. The appointment of drugs can only be done by a qualified specialist - a psychiatrist or neurologist. Serotonergic antidepressants (trazodone, nefazodone) are used to treat obsessive-compulsive disorders. Patients with mild forms of conversion neurosis are often prescribed tranquilizers (Relanium, Elenium, Mezapam, Nozepam, etc.) in small doses in short courses. Acute conversion states (gross seizures), combined with dissociative disorders, are stopped by intravenous or drip administration of tranquilizers. In the case of a protracted course of the disease, therapy is supplemented with neuroleptics (Sonapax, Eglonil). For patients with somatoform neuroses, general tonic nootropics (phenibut, piracetam, etc.) are added to psychotropic drugs.
- 3. Relaxation treatment. It combines a whole range of auxiliary methods to achieve relaxation and improve the patient's condition: massage, acupuncture, yoga.
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Both neuroses in children and adolescent neuroses are easier to prevent than to treat. But, although the treatment of neurosis in children is not an easy task, a full recovery is possible provided that you contact specialists as soon as possible.
Medvedev D.F.
neurotic disorders in childhood
In childhood, neurotic manifestations have a number of features. So, for example, psychotraumas in children lead to neurosis faster during periods of age-related crises. In children of early, preschool and primary school age, neuroses most often have the character of monosymptomatic neurotic reactions, manifested by a violation of the activity of any one system of the body (tic, stuttering, lack of appetite, nocturnal enuresis). Such neurotic reactions can also occur in adults (the so-called "systemic neuroses").
Neuroses in childhood acquire a deeper and more protracted character against the background of somatic diseases, accentuated and psychopathic personality traits, mild organic brain lesions, with dysfunctional intra-family relationships and unsuccessful relationships in the collectives of children's institutions.
neurotic fears — arise as a result of unexpected, frightening circumstances for the child, or due to the fact that adults deliberately intimidate the baby with an “educational” purpose.
Often, children have a fear of visiting a children's institution after a frightening or conflict situation has arisen there.
After trying to forcefully teach a child to swim, a fear of water space may appear.
Neurotic tics . Tiki — these are involuntary, episodically repeated and aggravated by excitement contractions of individual muscle groups, which, as a rule, occur after acute psychotrauma. At the same time, the decisive role belongs not so much to the most frightening situation as to the violent reaction of the surrounding adults to it.
Neurotic sleep disorders (night terrors) — they are manifested by sudden awakenings of the child under the influence of a nightmare, reflecting to some extent a real psycho-traumatic situation. At the same time, the baby screams, cries, calls his parents, is afraid to sleep alone. With violations of the depth of sleep in neurotic children, sleep-talking, sleepwalking, and bedwetting may appear. Psychotrauma of a protracted nature often leads to a violation of falling asleep or a perversion of the sleep formula, when the patient falls asleep during the day and stays awake at night.
Neurotic speech disorders — often children have a fear of speaking in the presence of a large number of people or certain persons. In the case of acute psychotrauma, stuttering may develop; it can also appear in a protracted psycho-traumatic situation, especially with constant corrections and criticism of the child’s speech, as well as prohibitions to say anything in his defense.
Neurotic disorders of appetite — neurotic refusals to eat are most often formed in children as a result of traumatic experiences while eating. In adolescence, food refusal is often associated with a fear of fullness, which leads to anorexia nervosa with a catastrophic drop in body weight.
In situations of gross infringement of the interests of the child, insult or deceit, it often arises pathocharacterological reactions. These are short-term states of maladaptive behavior lasting from several hours to several days. They show inappropriate behavior. Distinguish:
In cases where the psycho-traumatic situation is of a protracted, insoluble nature, neurotic development of the personality may be noted.
For the treatment of neurosis, it is very important to improve the microsocial environment and, if possible, eliminate the psychotraumatic situation. The main method that gives a stable therapeutic effect is psychotherapy. Moreover, not only the patient himself, but also his family often needs psychotherapeutic correction. Psychotherapy can be individual or group. The most effective methods are aimed at correcting the structure of the personality and its system of relations (personality-oriented). They include psychodrama, transactional analysis, gestalt therapy.
Good results come from rational psychotherapy. It allows, through logical arguments, to change the patient's attitude to a traumatic situation.
Widely used for the treatment and prevention of neurosis autogenic training- a method of therapeutic self-hypnosis. Various meditation techniques with concentration and breathing exercises can be helpful.
Suggestion methods include hypnosuggestive therapy with immersion of the patient in a hypnotic sleep, and drug psychotherapy when the suggestion is carried out against the background of a narcotic sleep caused by medication - barbamil, hexenal, pentonal.
Along with psychotherapy for the treatment of neurosis is widely used pharmacotherapy. The most commonly used tranquilizers are phenazepam, tazepam, eunoctin, elenium, seduxen, trioxazine.
They allow you to reduce the severity of the emotional reaction to a traumatic situation. In addition, stimulant psychotropic drugs are used - sidnocarb, sidnofen; antidepressants - amitriptyline, lerivon, pyrazidol; neuroleptics - Azaleptin, Neuleptyl. The combination of drugs from different groups can significantly reduce their dosage. Only a doctor can prescribe medication. It is better to carry it out in a hospital. However, patients with neurosis are critical of their condition, do not need constant monitoring and are more often treated on an outpatient basis. When taking psychotropic drugs at home, it must be remembered that most of them reduce the speed of reaction and attention.
In mild forms of neurasthenia, sedative herbal preparations can have a good effect: tincture or decoction of valerian root, tincture of motherwort, peony, novo passit(hypersthenic form); eleutherococcus, Chinese magnolia vine, ginseng root (hyposthenic form). Vitamin therapy and nootropics are shown.
In neurosis, it is of particular importance mode, a reasonable alternation of work and rest, sufficient exposure to fresh air, good sleep. Moderate physical activity, physiotherapy exercises, coniferous and herbal baths are useful.
Neurosis in children and adolescents
neuroses- these are relatively shallow, in most cases, reversible mental disorders due to the impact on the personality of various mental traumas. Neurosis affects from 3 to 20% of the total population. In girls, neurosis occurs 3 times more often than in boys.
With neurosis, a disorder of the system of relations occurs, and the violation of the attitude towards oneself, manifested in low or contradictory self-esteem, acquires the main significance. Personal conflicts play a role in the development of neuroses.
In childhood, intrapersonal conflicts are unstable and rudimentary, interpersonal conflicts in the family are of greater importance. Adolescents brought up in dysfunctional families can have both intrapersonal and interpersonal conflicts, which causes neurosis in some, behavioral and impulse disorders in others.
In the origin of neurosis in children and adolescents, organic diseases, features of the emerging personality, and pathological family education are important. All neuroses found in children are usually divided into general and systemic. According to the incidence of neurosis, they are distributed as follows:
I. General neuroses:
II. Systemic neuroses:
Hysterical neurosis more often occurs in children and adolescents with traits of personal immaturity, infantilism, demonstrativeness, a tendency to fantasies, hypercompensation reactions. Hysterical neurosis in early childhood can be manifested by a disorder of physiological functions (breathing, swallowing, urination, defecation), disorders of the speech sphere - mutism, motor sphere. At an older age, the manifestations of hysterical neurosis are more diverse, capture the emotional and cognitive spheres to a greater extent and, in fact, are not noted from hysterical neurosis in adults.
Neurasthenia (asthenic neurosis). In preschool children, in response to psychotrauma, psychogenic asthenic reactions occur. Children are cautious, afraid of risk, competition, situations like "exam", emotional and intellectual stress.
Symptoms are represented by headaches and pains in the heart area, fears, anxiety, sleep disturbances, hypochondriacal fears.
obsessive-compulsive disorder. Most often, children with obsessive-compulsive disorder grow up in conditions of "increased moral responsibility", in which the main values in life are hypertrophied adherence to duty and ignoring one's own emotional and bodily impulses. Obsessive compulsive disorder manifests itself in the form of psychogenic obsessive reactions, which clinically appear in the form of obsessive phobias, movements and actions.
Tics neurotic- are involuntary, sudden, rapid, repetitive, non-rhythmic, stereotyped movements or vocalizations.
Both genetic and psychogenic factors play a role in the development of tics. The basis of the transient tic is suppressed aggressiveness in the child. Tics are more often motor in the form of blinking or other movement of the facial muscles, tongue, lower jaw, neck muscles. More rare are tic movements of the upper extremities, even rarer are the trunk and lower extremities. In most cases, tics go away over the years, appearing only in stressful situations.
neurotic enuresis. Enuresis refers to the loss of control over urination during the night and day. Violations at any level of regulation can cause enuresis. 75% of patients have a hereditary burden of this disorder.
Non-organic enuresis may be the result of chronic psychogeny - divorce of parents, their pronounced conflict, the birth of brothers or sisters, the beginning of school, separation from the mother, emotional rejection of the child, especially intensifying with the onset of enuresis.
Neurotic encopresis- inability to control the excretion of feces, as a result of which involuntary or arbitrary fecal incontinence is found in places inappropriate for this purpose.
The delay in the formation of skills of neatness, control over defecation is associated with a violation of the socialization of the child - premature stimulation of his ability to use the potty, humiliation and punishment of the child in case of failure in defecation, an atmosphere of suppression of independence in the manifestation of one's desires. The prevalence of the disease is 1.5% under the age of 5 years. Rarely seen in adolescence.
Logoneurosis (neurotic stuttering)- a psychogenic disorder of rhythm, tempo, fluency of speech, which is associated with muscle spasms that carry out the act of speech. Chronic and acute mental traumas - conflicts in the family, emotional rejection of the child and upbringing based on it by the type of dominant hyperprotection.
The first signs are the repetition of initial sounds in words, the first or most difficult words in a sentence at moments of emotional stress in situations like "exam". Episodes of stuttering are replaced by episodes of speech without impairment. Symptoms may be absent when singing, reciting, or interacting with animals and inanimate objects.
Basic principles of therapeutic therapy of neuroses:
The etiology and pathogenesis of neurotic disorders are determined by the following factors.
Genetic are, first of all, the constitutional features of the psychological tendency to neurotic response and the features of the autonomic nervous system.
Factors influencing in childhood. Studies conducted in this area have not proven an unambiguous influence, however, neurotic traits and the presence of neurotic syndromes in childhood indicate an insufficiently stable psyche and a lag in maturation. Psychoanalytic theories pay special attention to the influence of early childhood psychotraumas on the formation of neurotic disorders.
Personality. Factors of childhood are able to form personality traits, which subsequently become the basis for the development of neuroses. In general, the significance of personality in each case is, as it were, inversely proportional to the severity of stressful events at the time of the onset of neurosis. Thus, in a normal person, a neurosis develops only after serious stressful events, such as wartime neuroses.
Predisposing personality traits are of two kinds: a general tendency to develop a neurosis and a specific predisposition to develop a certain type of neurosis.
Neurosis as a violation of learning. There are two types of theories presented here. Proponents of the theories of the first type recognize some of the etiological mechanisms proposed by Freud, and try to explain them in terms of learning mechanisms. Thus, repression is treated as the equivalent of learning to avoid; emotional conflict is equated with an approach-avoidance conflict, and displacement is equated with associative learning. Theories of the second type reject Freud's ideas and try to explain neurosis in terms of concepts borrowed from experimental psychology. At the same time, anxiety is considered as a stimulating state (impulse), while other symptoms are considered a manifestation of learned behavior, the reinforcement for which is the decrease in the intensity of this impulse caused by them.
Environmental factors (living and working conditions, unemployment, etc.). Unfavorable environment; at any age, there is a clear relationship between psychological health and indicators of social disadvantage, such as a low-profile occupation, unemployment, poverty at home, overcrowding, limited access to benefits such as transport. Possibly, unfavorable social environment increases the degree of distress, but is unlikely to be an etiological factor in the development of more severe disorders. Adverse life events (one of the reasons is the lack of protective factors in the social environment, as well as intra-family adverse factors).
Quite clearly, all these factors were summed up in the theory of the "barrier of mental resistance" (Yu.A. Aleksandrovsky) and the development of a neurotic disorder in cases where this barrier is insufficient to counteract psychotrauma. This barrier, as it were, absorbs all the features of the mental warehouse and the possibility of a person's response. Although it is based on two foundations (which can only be divided schematically), biological and social, it is essentially their single integrated functional-dynamic expression.
Morphological bases of neuroses. The dominant ideas about neuroses as functional psychogenic diseases, in which there are no morphological changes in the brain structures, have undergone a significant revision in recent years. At the submicroscopic level, cerebral changes associated with changes in GNI in neurosis were identified: disintegration and destruction of the membranous spiny apparatus, a decrease in the number of ribosomes, and expansion of the cisternae of the endoplasmic reticulum. Degeneration of individual cells of the hippocampus was noted in experimental neuroses. Common manifestations of adaptive processes in brain neurons are considered to be an increase in the mass of the nuclear apparatus, mitochondrial hyperplasia, an increase in the number of ribosomes, and membrane hyperplasia. The indicators of lipid peroxidation (LPO) in biological membranes change.
Etiology of neurotic and somatoform disorders
At present, psychodynamic and cognitive-behavioral theories of personality and the origin of neuroses are most widely used.
According to the first [Freud A., 1936; Myasishchev V.N., 1961; Zakharov A.I., 1982; Freud 3., 1990; Eidemiller E. G., 1994], neurotic disorders are the result of an unresolved neurotic conflict, both intra- and interpersonally. The conflict of needs creates emotional tension accompanied by anxiety. Needs that are linked to each other for a long time in conflict do not have the opportunity to be satisfied, but persist for a long time in the intrapersonal space. The persistence of conflicts requires a large amount of energy, which, instead of being directed to the development of the personality / organism, is spent on its energy maintenance. That is why asthenia is a universal symptom in all forms of neurosis in children, adolescents and adults.
An outstanding contribution to understanding the nature of neuroses within the framework of the psychodynamic paradigm was made by V. N. Myasishchev (1961), who is a major figure who predetermined the development of "pathogenetic psychotherapy" (personality-oriented, reconstructive psychotherapy by B. D. Karvasarsky,
G. L. Isurina and V. A. Tashlykov) and family psychotherapy in the USSR.
In modern psychoneurology, a prominent place has been occupied by the theory of the multifactorial etiology of neurotic and somatoform disorders, in which the psychological factor plays a leading role.
To the greatest extent, the content of the psychological factor is revealed in the pathogenetic concept of neuroses and the "psychology of relations" developed by V. N. Myasishchev, according to which the psychological core of the personality is an individually-holistic and organized system of subjective-evaluative, active, conscious, selective relations with the environment. It is now widely believed that relationships can be unconscious (unconscious).
V. N. Myasishchev saw in neurosis a deep personality disorder due to violations of the system of personality relations. At the same time, "attitude" was considered by him as a central system-forming factor among many mental properties. “The source of neurosis both physiologically and psychologically,” he believed, “are difficulties or disturbances in the relationship of a person with other people, with social reality and with the tasks that this reality sets before him” [Myasishchev V.N., 1960].
What is the place in history of the concept of “relationship psychology”? This concept developed in a totalitarian society. V. N. Myasishchev, having inherited the scientific methodological potential of his teachers - V. M. Bekhterev, A. F. Lazursky and his colleague M. Ya. Basov, turned to the living thing that was in the philosophy of K. Marx - to the thesis K Marx that "the essence of man is the totality of social relations." According to L. M. Wasserman and V. A. Zhuravl (1994), this circumstance helped V. N. Myasishchev to return to scientific use the theoretical constructions of A. F. Lazursky and the famous Russian philosopher S. L. Frank about the relationship of the individual to himself and to the environment.
If the concept of "relationship" for I.F. Garbart, G. Gefting and W. Wundt meant "connection", the dependence between parts within the whole - "psyche", then for V. M. Bekhterev the concept of "relationship" ("correlation") meant not so much integrity as activity, that is, the ability of the psyche not only to reflect the environment, but also to transform it.
For A.F. Lazursky, the concept of “relationship” had three meanings:
1) at the level of endopsychics - the mutual connection of the essential units of the psyche;
2) at the level of exopsychics - phenomena that appear as a result of the interaction of the psyche and the environment;
3) interaction of endo- and exopsychics.
M. Ya. Basov, until recently, a student of V. M. Bekhterev and a colleague of V. N. Myasishchev, almost unknown to a wide circle of the psychiatric community, sought to create a “new psychology” based on the approach that later became known as the system approach. He considered "the dismemberment of a single real process of life into two incompatible halves - physical and mental - one of the most amazing and fatal illusions of mankind." The relations of the organism/personality and the environment are mutual, and the environment is an objective reality in its relation to the organism/personality.
Schematically, it may look like this (Fig. 19).
Rice. 19. The relationship of the organism and the environment.
O - the possibilities of the object in the role of mother
C - the capabilities of the object in the role of a son
O1 - new features of the object in the role of mother
C1 - new features of the object as a son
In his teaching, V. N. Myasishchev not only integrated the ideas of V. M. Bekhterev, A. F. Lazursky and M. Ya. Basov, but also put forward his own. He singled out the levels (sides) of relations that are formed in ontogeny:
1) to other persons in the direction from the formation of relations to the neighbor (mother, father) to the formation of relations to the distant;
2) to the world of objects and phenomena;
The attitude of a person to himself, according to B. G. Ananiev (1968, 1980), is the latest formation, but it is this that ensures the integrity of the system of personality relations. Relationships of the individual, united among themselves through the attitude towards oneself, form a hierarchical system that plays a guiding role, determining the social functioning of a person.
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Neurotic personality disorders in children and adults
Neurotic personality disorders (neurosis, psychoneurosis) are diseases of the central nervous system, singled out in a special group. They disrupt the normal activity of only selective areas of the human psyche and do not cause serious deviations in the behavior of the individual, but they can significantly worsen the patient's quality of life.
Statistics show a constant increase in the disease over the past 20 years. Scientists attribute this to a large acceleration of the rhythm of life and a multiply increased information load. Women are more susceptible to the development of neurotic disorders: they are diagnosed with such disorders twice as often as in the male population (7.6% of men and 16.7% of women per 1000 people). With timely access to specialists, most neurotic disorders are successfully cured.
Neurotic disorders in clinical practice are called a large group of functional reversible mental disorders, occurring mainly in a protracted type. Clinical manifestations of neurosis are obsessive, asthenic and hysterical states of patients, accompanied by a reversible decrease in efficiency, both mental and physical. Psychiatry is the study and treatment of neuroses. In the history of the study of pathology, various scientists believed that its development was caused by completely different reasons.
The world famous Russian neurophysiologist IP Pavlov defined neurosis as a chronic disorder of higher nervous activity that develops as a result of extremely intense nervous tension in areas of the cerebral cortex. This scientist considered excessively strong or prolonged external influences to be the main provoking factor. The no less famous psychiatrist Z. Freud believed that the main reason was the internal conflict of the personality, consisting in the suppression of the instinctive "It" drives by morality and the generally accepted norms of the "Super-I". Psychoanalyst K. Harney based neurotic changes on the contradiction of internal methods of protection (based on the movement of the individual “towards people”, “against people”, “away from people”) from adverse social factors.
The modern scientific community agrees that neurotic disorders have two main directions of occurrence:
A provocative factor for the onset of the development of any form of the disease is always external or internal conflicts, life circumstances that cause deep psychological trauma, prolonged stress or critical emotional and intellectual overstrain.
According to the type of manifestation and symptoms, according to the ICD-10 (International Classification of Diseases), neurotic disorders are divided into the following groups:
It should be noted why neurotic disorders are singled out as a separate group of mental pathologies. Unlike other psychiatric diseases, neuroses are characterized by: the reversibility of the process and the possibility of complete recovery, the absence of dementia and increasing personality changes, the painful nature of pathological manifestations for the patient, the patient's critical attitude to his condition, the prevalence of psychogenic factors as the cause of the disease.
The symptoms characteristic of neuroses in general can be divided into two groups. So, physically this state is manifested as follows:
The psychological symptoms of neurosis are as follows:
Anxiety disorders in neurotic conditions are one of the most frequently diagnosed forms of neurotic changes. In turn, they are divided into three types:
Phobic disorders manifest themselves with a number of symptoms:
Patients with this type of disorder experience recurrent bouts of extreme anxiety, so-called panic attacks. Manifested in the patient's complete loss of control over himself and an attack of severe panic. A characteristic feature of the pathology is the absence of a specific cause of the attack (a certain situation, object), suddenness for others and the patient himself. Attacks can be rare (several times a year) and frequent (several times a month), their duration varies from 1-5 minutes to 30 minutes. In severe cases, recurrent attacks lead to self-isolation and social isolation of patients.
Such a neurotic condition is usually diagnosed in childhood and young age, in women - 2-3 times more often than in men. With timely and adequate complex therapy, in most cases, a complete recovery occurs. In the absence of treatment, the disease takes a protracted course.
Panic disorder is characterized by the following symptoms:
Obsessive states, or obsessive-compulsive disorders, are characterized by obsessive, frightening thoughts or ideas (obsessions) and (or) repetitive, also obsessive, outwardly aimless and tiresome actions in an attempt to get rid of obsessive thoughts (compulsions). The disease is more often diagnosed in adolescence and young age. Compulsions often take the form of a ritual. There are four main types of compulsions:
The performance of one's own rituals is always associated with the patient's internal feeling of incompleteness of any action. In ordinary everyday life, this manifests itself in the constant re-checking of documents drawn up by oneself, the desire to constantly freshen up makeup, the repeated packing of things in the closet, etc. Adolescents often have a combination of checking and cleaning, manifested in obsessive touches to the face and hair.
This group includes disorders identified on the basis of not only characteristic symptoms, but also an obvious cause: an extremely adverse and negative event in the patient's life that caused an extreme stress reaction. Exist:
Dissociative (conversion) disorders are changes or disturbances in the work of the main mental functions: consciousness, memory, a sense of one's own identity and a violation of control over the movements of one's own body. The etiology of occurrence is recognized as psychogenic, since the occurrence of the disorder coincides in time with the traumatic situation. They are divided into the following forms:
A distinctive feature of this type of disorder is the patient's repeated complaints of somatic (bodily) symptoms in the absence of somatic diseases and insistent demands for repeated examinations. A similar clinical picture is observed in neurosis-like states. Allocate:
There are many methods for the treatment of neurotic disorders. Therapeutic measures depend on the form and severity of the course of the disease and always provide for an integrated approach, including the following techniques and methods:
Neurotic disorders are reversible pathologies and, with adequate therapy, are mostly cured. Sometimes self-treatment of neurosis is possible (the conflict loses its relevance, the person is actively working on himself, the stress factor completely disappears from life), but this rarely happens. The bulk of cases of neuroses need qualified medical assistance and supervision, and it is preferable to carry out treatment in special specialized departments and clinics.
Neurotic disorders (neurosis), classification and statistics
A neurotic disorder, or neurosis, is a functional, that is, inorganic, violation of the human psyche that occurs under the influence of stressful events and psychotraumatic factors on the psyche, personality and human body.
Neurotic disorders can strongly influence behavior, but do not cause psychotic symptoms and severe impairment of quality of life. A separate group of neurotic disorders are those that accompany psychotic disorders. However, they are included in the classification under a separate code and will not be considered further.
According to the latest WHO data, the number of people with neurotic disorders has greatly increased over the past 20-30 years: up to 200 people per 1000 population, depending on the region, social and military living conditions. Almost doubled neurotic disorders in children and adolescents.
Classification of neurotic disorders
One of the best classifications can be found in International Classification of Diseases 10th Edition (ICD-10) based on the DSM classification system. In this classification, neurotic disorders are included under the code from F40 before F48. The following disorders of the neurotic level are meant:
neuroses – psychogenic diseases, which are based on disorders of higher nervous activity, clinically manifested by affective non-psychotic disorders (fear, anxiety, depression, mood swings, etc.), somatovegetative and motor disorders experienced as alien, painful manifestations and tending to reverse development and compensation .
Etiology. In the etiology of neuroses as psychogenic diseases, the main causal role belongs to various psycho-traumatic factors: acute shock mental effects accompanied by severe fright, subacute and chronic psycho-traumatic situations (parents' divorce, conflicts in the family, school, the situation associated with parents' drunkenness, school failure, etc.). etc.), emotional deprivation (i.e., a deficit of positive emotional influences - love, affection, encouragement, encouragement, etc.). Along with this important in the etiology of neurosis internal and external factors. Internal factors: Personality traits associated with mental infantilism (increased anxiety, fearfulness, a tendency to fear). Neuropathic conditions, i.e. a complex of manifestations of vegetative and emotional instability. Changes in the age-related reactivity of the nervous system in transitional (crisis) periods, i.e. at the age of 2-4 years, 6-8 years and in puberty.
External conditions factors: Wrong upbringing. Unfavorable microsocial and living conditions. Difficulties in school adaptation, etc.
Pathogenesis. Actually, the pathogenesis of neuroses is preceded by the stage of psychogenesis, during which the psychological processing of psycho-traumatic experiences infected with negative affect (fear, anxiety, resentment, etc.) takes place. An important place in the pathogenesis of neuroses belongs to biochemical changes.
Systemic neuroses in children are somewhat more common than general neuroses. neurotic stuttering- P sychogenically caused violation of the rhythm, tempo and fluency of speech, associated with muscle spasms that are involved in the speech act. Boys more often than girls. It develops during the formation of speech (2-3 years) or at the age of 4-5 years (phrasal speech and inner speech). Causes - acute, chronic mental trauma. Neurotic tics - automated habitual movements (blinking, wrinkling of the skin of the forehead, wings of the nose, licking of the lips, twitching of the head, shoulders, various movements of the limbs, torso), as well as "coughing", "hunting", "grunting" sounds (respiratory tics) that occur in as a result of fixing one or another defensive movement, it is initially expedient. NT (including obsessive) - are found in boys in 4.5% and in girls in 2.6% of cases. NT is most common between the ages of 5 and 12 years. Manifestations of NT: tic movements in the muscles of the face, neck, shoulder girdle, respiratory tics predominate. Neurotic sleep disorders. It is very common in children and adolescents. Reason: various psychotraumatic factors, especially acting in the evening hours. Clinic of HPC: sleep disorders, restless sleep, sleep depth disorder, night terrors, sleepwalking and sleepwalking. Neurotic disorders of appetite (anorexia).H eurotic disorders, characterized by various eating disorders due to a primary decrease in appetite. It is observed at early and preschool age. Clinic: the child’s lack of desire to eat any food or pronounced selectivity for food with the rejection of many common foods, a slow eating process with long chewing of food, frequent regurgitation and vomiting during meals. There is a lowered mood during meals. neurotic enuresis - unconscious loss of urine, mainly during nocturnal sleep. Etiology: traumatic factors, neurotic conditions, anxiety, family burden. The clinic is characterized by a pronounced dependence on the situation. NE becomes more frequent with exacerbation of a traumatic situation, after physical punishment, etc. already at the end of preschool and the beginning of school age, there is an experience of lack, low self-esteem, anxious expectation of a new urination. Neurotic encopresis - involuntary excretion of a small amount of bowel movements in the absence of lesions of the spinal cord, as well as anomalies and other diseases of the lower intestine. It occurs 10 times less often than enuresis, in boys aged 7 to 9 years. Etiology: prolonged emotional deprivation, strict requirements for the child, intra-family conflict. The pathogenesis has not been studied. Clinic: violation of the skill of neatness in the form of the appearance of a small amount of bowel movements in the absence of the urge to defecate. Often he is accompanied by low mood, irritability, tearfulness, neurotic enuresis. Pathological habitual actions - fixation of voluntary actions in young children. Finger sucking, genital manipulation, head and torso rocking at bedtime in children of the first 2 years of life.
General neuroses. Neuroses of fear. The main manifestations are objective fears associated with the content of a traumatic situation. Paroxysmal occurrence of fears is characteristic, especially when falling asleep. Attacks of fear last 10-30 minutes, accompanied by severe anxiety, often hallucinations and illusions. The content of fears depends on age. In children of preschool and preschool age, fears of darkness, loneliness, animals that frightened the child, characters from fairy tales, or those invented by parents with an “educational” purpose (“black uncle”, etc.) predominate. In children of primary school age, a variant of fear neurosis, called "school neurosis", is observed. Children who were brought up at home before school tend to develop "school neurosis". The course of anxiety neuroses can be short-term and protracted (from several months to 2-3 years). Obsessional neurosis. The predominance of obsessive phenomena that arise relentlessly against the will of the patient, who, recognizing their unreasonable painful nature, unsuccessfully seeks to overcome them. The main types of obsessions in children are obsessive movements and actions (obsessions) and obsessive fears (phobias). Depending on the predominance of one or the other, a neurosis of obsessive actions (obsessive neurosis) and a neurosis of obsessive fears (phobic neurosis) are conditionally distinguished. Often there are mixed obsessions. Obsessive neurosis is expressed by obsessive movements. In phobic neurosis, obsessive fears predominate. Obsessive-compulsive disorder tends to have a relapsing course. Depressive neurosis. Depressive mood shift. In the etiology of neurosis, the main role belongs to situations associated with illness, death, divorce of parents, prolonged separation from them, orphanhood, experiencing one's own inferiority due to a physical or mental defect. Typical manifestations of depressive neurosis are observed in puberty and prepubertal age. Characterized by somatovegetative disorders, loss of appetite, weight loss, constipation, insomnia. hysterical neurosis. A psychogenic disease characterized by a variety of (somatovegetative, motor, sensory, affective) disorders of the neurotic level. In the etiology of hysterical neurosis, an important contributing role belongs to hysteroid personality traits (demonstrativeness, "thirst for recognition", egocentrism), as well as mental infantilism. In the clinic of hysterical disorders in children, the leading place is occupied by motor and somatovegetative disorders: astasia-abasia, hysterical paresis and paralysis of the limbs, hysterical aphonia, as well as hysterical vomiting, urinary retention, headaches, fainting, pseudo-algic phenomena (i.e. complaints of pain in certain parts of the body) in the absence of organic pathology of the corresponding systems and organs, as well as in the absence of objective signs of pain. Neurasthenia (asthenic neurosis). The emergence of neurasthenia in children and adolescents is facilitated by somatic weakness and overload with various additional activities. The neurasthenia in the expressed form meets only at children of school age and teenagers. The main manifestations of neurosis are increased irritability, incontinence, anger and at the same time exhaustion of affect, easy transition to crying, fatigue, poor tolerance of any mental stress. There is vegetovascular dystonia, decreased appetite, sleep disorders. In younger children, motor disinhibition, restlessness, and a tendency to unnecessary movements are noted. Hypochondriacal neurosis. Neurotic disorders, the structure of which is dominated by excessive concern about one's health and a tendency to unreasonable fears about the possibility of a particular disease. It occurs mainly in adolescents. Prevention of neurosis in children and adolescents First of all, it is based on psychohygienic measures aimed at normalizing intra-family relations and correcting improper upbringing. Taking into account the important role in the etiology of neurosis of the characteristics of the character of the child, educational measures for the mental hardening of children with inhibited and anxious and suspicious character traits, as well as with neuropathic conditions, are appropriate. Such activities include the formation of activity, initiatives, learning to overcome difficulties, deactivation of frightening circumstances (darkness, separation from parents, meeting strangers, animals, etc.). An important role is played by education in a team with a certain individualization of the approach, the selection of comrades of a certain type of character. A certain preventive role also belongs to measures to improve physical health, primarily physical education and sports. A significant role belongs to the mental hygiene of the mental work of schoolchildren, the prevention of their intellectual and information overload.
