History of psychiatry. Main directions of psychiatry

Psychiatry in Russia was based on the ideas of a humane attitude towards the mentally ill, requiring pity, but not punishment. 11 General psychopathology. Historical sketch of the development of psychiatry. Development of the doctrine of mental illness in ancient times // http//formen.narod.ru/psihiatria_history True, in some cases witchcraft and “apostasy” were attributed to patients, and they, unfortunately, sometimes became victims of popular anger. Thus, in 1411, Pskov residents burned 12 mentally ill women accused of witchcraft, which allegedly led to a massive death of livestock. In most cases, the sick were looked after in monasteries so that they would not be “a hindrance to the healthy... they would receive admonition and guidance to the truth.” Many, “devoid of reason,” were called “fools” and “blessed.”

In 1776 - 1779 The first psychiatric hospitals were created, where patients received medical care and were involved in learning crafts, agriculture, and literacy. The first scientific work of Russian psychiatry is considered to be M. K. Pequin’s monograph “On the Preservation of Health and Life,” published in 1812. Beijing believed that existing life situations play a major role in the occurrence of mental illnesses, and recommended the use of psychotherapy as a method of eliminating the causes of mental disorders .

It should be noted that until the end of the 19th century. Most psychiatrists adhered to the concept of a single psychosis. Until this time, mental illnesses were not differentiated according to the nosological principle, and only the works of S. S. Korsakov, V. Kh. Kandinsky, E. Kraepelin (on the clinic of psychoses), F. Morel (on the etiology of psychoses), I. E. Dyadkovsky and T. Meinert (on the anatomophysiology of psychoses) contributed to the differentiation of complex plexuses of psychopathological symptoms.

In Russia, the revolutionary democrats had a great influence on the development of psychiatry, which determined the predominance of natural scientific trends both in this and other areas of medicine in our country.

Among the world's leading psychiatrists is Sergei Sergeevich Korsakov (1854-1900), one of the founders of the nosological trend in psychiatry, founded at the end of the 19th century. German psychiatrist Emil Kraepelin (Kraepelin, Emil, 1856-1926), as opposed to the previously existing symptomatic direction.

S. S. Korsakov was the first to describe a new disease - alcoholic polyneuritis with severe memory disorders (1887, doctoral dissertation “On alcoholic paralysis”), which was already called “Korsakov psychosis” during the author’s lifetime. He was a supporter of freedom for the mentally ill, developed and put into practice a system of keeping them in bed and monitoring them at home, and paid great attention to the issues of preventing mental illness and organizing psychiatric care. His “course on psychiatry” (1893) is considered a classic and has been reprinted many times.

In general, we can say that the end of the 19th - beginning of the 20th centuries. were marked by the rapid accumulation and generalization of a huge amount of scientific facts in the field of psychiatry. psychiatry treatment of corsacs

After the October Revolution of 1917, psychiatry further developed in Russia. Treatment and prevention institutions and pharmacies were nationalized, women's and children's clinics were established, and a psychiatric service began to function. The Council of Medical Colleges in April 1918 created a special psychiatric commission.

Particular attention was paid to helping children suffering from various mental illnesses. In September 1918, the People's Commissariat of Health organized a department of child psychiatry and an institute for the defective child. Psychiatric care for war invalids was also provided. Gradually, the deployment of public health care began throughout the country, including the provision of assistance to mental patients. Medical examination of the population was carried out as the best method of identifying the disease and providing assistance to those in need. 11 General psychopathology. Historical sketch of the development of psychiatry. Development of the doctrine of mental illness in ancient times // http//formen.narod.ru/psihiatria_history

In 1924, the first neuropsychiatric dispensary was opened in Moscow. Then such dispensaries were created in other cities. Inpatient mental health care has changed significantly. Hospital bed capacity increased, paraclinical research methods and modern treatment methods were introduced. The technical and material support of psychiatric institutions and patient care have improved. A number of research institutes were organized (in Moscow, Leningrad, Kharkov, Tbilisi).

In 1927, the first All-Union Congress of Psychiatrists and Neuropathologists took place, which demonstrated the widespread development of scientific thought at all levels of the country's psychoneurological service. Reports on exogenous psychoses, epilepsy and other problems were deserved. In 1936, the Second All-Russian Congress of Psychiatrists and Neuropathologists took place, where issues of treatment of schizophrenia and traumatic damage to the nervous system were considered.

During the Great Patriotic War, the main task of organizing psychiatric services was to provide assistance to persons who had received a traumatic head injury, often causing unconsciousness in the victims, and speech and hearing disorders (surdomutism). The leading principle of treatment and evacuation support was the principle of staged treatment with evacuation as directed. During the war, it was important to resolve the issue of the need to bring psychiatric care closer to the front and treat shell-shocked patients, as well as people with borderline conditions, in field conditions.

In recent years, a number of congresses of neurologists and psychiatrists, symposia, and conferences have been held, at which the problems of organizing psychiatric care and ways of its further development, as well as a number of clinical problems relating to vascular pathology of the nervous system, schizophrenia, borderline neuropsychiatric disorders, organic lesions of the nervous system. Scientific societies of neuropathologists and psychiatrists had a great influence on the solution of scientific and organizational problems in providing psychiatric and drug addiction care to the population.

In the development of scientific and practical psychiatry in Russia in the second half of the 19th century, the opening of departments of psychiatry played an important role, the first of which was organized in 1857 at the St. Petersburg Medical-Surgical Academy. The department was headed by Professor I.M. Balinsky. He developed a curriculum in psychiatry, and on his initiative a new clinic for the mentally ill was built. In 1857 - 1859 I.M. Balinsky wrote lectures on psychiatry. He had priority in creating the doctrine of psychopathy; he proposed the term “obsessive ideas.” The prominent scientist was the first chairman of the first society of psychiatrists in Russia. The professor managed in a fairly short period of time to prepare qualified scientific and pedagogical personnel for teaching psychiatry in other newly organized departments, as well as a large number of psychiatrists to work in practical psychiatry. In 1877 I.M. Balinsky was replaced by his student I.P. Merzheevsky, who paid great attention to the study of mental disorders in somatic diseases. The work of Merzheevsky and his students contributed to the rapprochement of psychiatry with somatic medicine. In 1882, the scientist developed separate programs for teaching psychiatry and nervous diseases. He described the pathological and anatomical features of oligophrenia. In addition, Mergeevsky took the first steps to study mental illness in children. Balinsky and Mergeevsky are the founders of the St. Petersburg Psychiatric School. In 1893, the leadership of this department was entrusted to V.M. Bekhterev - psychiatrist-neurologist. In 1908 he organized a psychoneurological institute. In 1905, under the name “delirium of hypnotic fascination,” Bekhterev gave a vivid description of the psychopathological phenomena of the syndrome of mental automatism. He made a great contribution to the development of neurology, leaving more than 600 scientific papers. Among psychiatrists of the second half of the 19th century, a prominent representative of the St. Petersburg Psychiatric School, V.Kh., occupies a special place. Kandinsky. Being a subtle psychopathologist, with the ability to clearly distinguish between similarities and differences between various psychopathological phenomena, he scientifically substantiated the division of hallucinations into true and false; first described all psychopathological phenomena of mental automatism syndrome; made an attempt to physically interpret the essence of hallucinations; identified ideophrenia as an independent form of mental illness; developed a classification of mental illnesses adopted by the first congress of Russian psychiatrists. In Moscow, teaching psychiatry as an independent course began much later than in St. Petersburg. In 1887, the first psychiatric clinic was organized at Moscow University, the management of which was entrusted to S.S. Korsakov. He created a truly original national psychiatric school, being one of the pioneers of the nosological trend in psychiatry. Korsakov, with his clinical observations and descriptions, enriched the nosological taxonomy of psychoses. In 1889, he gave a report on alcoholic polyneuritic psychosis at the International Medical Congress in Vienna, and in 1897, at the XII International Medical Congress in Moscow, this psychosis was named after him. Korsakov created a classification of mental illnesses that differed from others in its clear transition from symptomology to nosology. Under the name “dysnoia,” the scientist described a group of acute mental disorders, some of which can be classified as acute schizophrenia. Korsakov substantiated the need to create a nationwide system of psychiatric care for patients, which he understood not only as an obligation to provide treatment, but also as the patient’s organization in life, in everyday life, and in professional activities.

P.B. Gannushkin, a student of Korsakov, developed his ideas and left a great legacy in various areas of psychiatry. According to one of the talented students O.V. Kerbikov, Gannushkin entered the history of Russian psychiatry mainly as the founder of “small” or “borderline” psychiatry. “Small” - in the sense of unexpressed mental disorders, but very “large” - in the sense of the frequency and complexity of the observed phenomena. His monograph “Clinic of Psychopathy, Their Statics, Dynamics, Systematics” (1933) has not lost its significance to this day. Gannushkin trained a large galaxy of talented students (O.V. Kerbikov, V.M. Morozov, S.G. Zhislin, N.I. Ozeretsky, F.F. Detengov, A.Ya. Levinson, etc.).

In the history of psychiatry, an important place belongs to V.A. Gilyarovsky, who for many years headed the Department of Psychiatry at the 2nd Moscow Medical Institute. He was the organizer of the Institute of Psychiatry; now it is the All-Russian Scientific Center for Mental Health of the Russian Academy of Medical Sciences. Gilyarovsky owns scientific works devoted to the study of mental disorders in typhus. Problems of borderline states, head trauma, and schizophrenia occupied a large place in his research. Gilyarovsky's work in the field of hallucinations has become widely known. He is the author of a number of textbooks on psychiatry.

A significant contribution to the development of psychiatry in subsequent years was made by A.V. Snezhnevsky, O.V. Kerbikov, G.V. Morozov. Snezhnevsky was one of the first to study protracted somatogenic psychoses and study the dynamics of senile diseases. He is the founder of an original direction, the essence of which is to identify patterns in the dynamics of psychopathological phenomena and reveal their interchangeability in the course of psychosis. These studies allowed Snezhnevsky to shed new light on questions about the forms and characteristics of the course of schizophrenia, the patterns of changing syndromes during the development of the disease, and the nosological specificity of psychopathological syndromes. Published in 1983 on the initiative and under the leadership of Snezhnevsky, the two-volume “Manual of Psychiatry” is currently a reference book for psychiatrists. O.V. Kerbikov covered in detail the problem of acute schizophrenia. He was the first to show the formation of various forms of so-called “marginal” psychopathies, and substantiated the ways and conditions of their formation. The deep erudition of the clinical psychiatrist was reflected in his lectures on psychiatry, published in 1955 by G.V. Morozov made a great contribution to the development of problems of psychogenic stupor, insanity and incapacity, and the prevention of socially dangerous actions of mentally ill people. With the participation of G.V. Morozov and under his editorship, manuals on forensic psychiatry and alcoholism, a textbook of forensic psychiatry were published. On the initiative of the scientist and under his editorship, in 1988, a very popular two-volume “Manual of Psychiatry” was published, compiled with the participation of foreign psychiatrists. The most important event of the early and mid-20th century in psychiatry should be considered the creation of out-of-hospital psychiatric services, represented by psychoneurological dispensaries and psychiatric offices. They played a big role in monitoring patients and providing them with medical and social assistance. Since the 1920s, biological therapy for mental illness began to develop, aimed at the disease as a biological process and at the patient’s body as a biological object. The initial types of biological therapy were malaria therapy for progressive paralysis, insulin shock therapy for schizophrenia and electroconvulsive therapy for manic-depressive psychosis. The development of psychiatry was greatly influenced by the introduction of psychopharmacological agents into psychiatric practice, starting in the fifties. Their positive impact on the clinical characteristics and course of mental illness is manifested not only in the reverse development up to the complete disappearance of productive psychopathological disorders, but also often in the weakening of negative disorders that were previously considered irreversible. In addition, as a result of the widespread use of psychopharmacological drugs in recent years, severe mental disorders such as catatonic and paraphrenic states have ceased to occur and appear only in rudimentary form, with a simultaneous increase in the proportion of mental illnesses with neurosis-like, psychopathic-like and erased affective disorders.

Study history of psychiatry insufficient attention is paid in our country. Many consider this topic to be secondary and not significant for a practicing physician. In fact, the history of psychiatry includes a complete body of theoretical and practical knowledge; the history of psychiatry is psychiatry as a whole, with its categorical apparatus, methodology of psychopathological diagnosis and treatment of mental illness. Naturally, a well-trained doctor must have a wide range of knowledge in his professional field, this is what allows him to think clinically, which is very important for accurate diagnosis.

History of psychiatry examines and analyzes a number of the most important aspects of the development of science, first of all, of course, the chronological aspect, which includes knowledge of the most important historical dates that determine the stages of the development of science. Thus, it is known that J. Reil introduced into circulation in 1803 term "psychiatry", since then, for 200 years, there has been a continuous accumulation and systematization of data in the field of psychopathology. There are many other important historical milestones that mark the advances of psychiatry. In 1822, A. Bayle clinically substantiated the identification of progressive paralysis as an independent disease, which served as a stimulus for the development of the nosological direction. The same can be said about the “dementia praecox” described in 1896 by E. Kraepelin, the identification of the “schizophrenia group” by E. Bleuler in 1911, etc. No less important is the personological aspect, which implies a thorough knowledge of the historical role played in psychiatry outstanding doctors and scientists who determined the formation of the most important directions in the development of psychiatry as a science. The name of F. Pinel is associated with the creation of the foundations of scientific psychiatry. He freed the mentally ill from their shackles, destroying the so-called chain syndrome, which made it possible to study the manifestations of psychosis in natural conditions. It was Pinel who developed a simple and convenient classification of psychoses, first identifying “mania without delusions” (psychopathy) and determining the forensic psychiatric assessment of these patients. In his declining years, he became an academician and consultant to Napoleon's imperial court.

The students and followers of F. Pinel, J. Esquirol, A. Fauville, J. Falret, J. Baillarger, E. Lace, and others developed the nosological approach.

The contribution to science of B. Morel (works of 1857), the founder of the concept of endogenous psychoses and the leading principles of mental hygiene, is invaluable.

Already in the 20th century, in 1957, G. Deley and P. Deniker became “pioneers” of psychopharmacology.

The German scientist W. Griesinger introduced the concept of “symptom complex” (“syndrome”), described “obsessive philosophizing”, developed the concept of “single psychosis”, revealing the general pattern of stage-by-stage changes in psychopathological syndromes during the development of psychoses (works of 1845).

A huge contribution to psychiatric science was made by K. -L. Kahlbaum, the founder of “current psychiatry,” described catatonia (known as Kahlbaum’s disease) in 1874 and identified hebephrenia in 1871, together with his student E. Hecker.

Russian scientists S.S. Korsakov and V.M. Bekhterev became the founders of leading directions in the study of mental pathology, the creators of the Moscow and St. Petersburg schools of psychiatry. The amnestic symptom complex () described by S. S. Korsakov in 1887 is the first scientific definition of organic psychosyndrome, and his concept of “dysnoia” is the prototype of the future teaching about. V. H. Kandinsky, in his unique work “O” (1890), revealed the scientific essence of this most important psychopathological phenomenon. Subsequently, at the suggestion of A. Epstein and A. Perelman, the concept of “Kandinsky-Clerambault syndrome” was introduced into clinical practice. It is still used to designate the syndrome of mental automatism.

Naturally, the study of books and publications by major scientists is an integral part of the professional training of any psychiatrist.

The third, perhaps the most significant section of the history of psychiatry can be considered the conceptual aspect - the “conceptual direction”, which studies the formation of the most important theories that explain the essence of mental illness. These include the concept of endogenous and exogenous diseases (identified by P. Yu. Moebius in 1893), the concept of contrasting “organic” and “functional” psychoses, the concept of “single psychosis” and “nosological approach”. As psychiatry developed, the directions of conceptual research changed, approaches to their resolution were transformed, but the “eternal” fundamental problems remained unchanged and fundamental. These include, first of all, the problem of systematics and taxonomy.

It is the issues of classification in psychiatry that are currently not only the most relevant, but also extremely acute, since they determine its theoretical foundation, practical orientation, social significance, immediate and long-term prospects for development as a medical and social science. This is the reason for our special interest in presenting the history of psychiatry in this section, which is the most important at the present time.

It is appropriate to note here, as E. Ya. Sternberg wrote, referring to the famous therapist L. Krel, that “our present taxonomy bears traces and scars of its historical development.” That is why the historical and clinical analysis of the problem fully contributes to its disclosure and allows us to gain an understanding of the deep processes underlying it.

Systematics as such is a field of knowledge within which the problems of designating and describing the entire set of objects that form a certain sphere of the real are solved in a certain way. Systematics is necessary in all sciences that deal with complex, internally branched and differentiated systems of objects: in chemistry, biology, linguistics, in medicine as a biological science, including psychiatry.

Systematics of diseases, or nomenclature of diseases, is closely related to nosology, which has traditionally been understood as a section of pathology, including the general study of disease (general nosology), as well as the study of causes (etiology), development mechanisms (pathogenesis) and clinical features of individual diseases (special nosology ), classification and nomenclature of diseases. However, nosology in this understanding does not have clearly defined boundaries with the concept of “pathology”. In modern medical literature, the concept of “nosological approach” is usually used, interpreted as the desire of clinicians and representatives of theoretical medicine to identify a nosological form, which is characterized by a specific cause, unambiguous pathogenesis, typical external clinical manifestations and specific structural disorders in organs and tissues.

In 1761 G. Morgagni identified fevers, surgical (external) diseases and diseases of individual organs, laying the foundation for scientific nosology.

The successes of pathological anatomy, inextricably linked with the works of R. Virchow, and bacteriology (L. Pasteur) made it possible to develop the morphological and etiological directions of diagnosis and carry out an organ-localistic classification of diseases, for example, for clinical therapy. However, the “linear” principle (one cause gives the same diseases), as I.V. Davydovsky showed, is not justified in all cases.

Bacilli carriers were discovered who remained (paradoxically) healthy throughout their lives; different symptoms, course and outcome of the disease in different individuals infected with the same pathogen, and vice versa, the same manifestation of pathology caused by completely different reasons - the so-called equifinality.

Such complex relationships between etiological factors, pathogenetic mechanisms and clinical manifestations are quite typical for mental disorders, which creates special difficulties in solving problems of taxonomy, classification and diagnosis.

Difficulties classification of diseases in general (and in psychiatry in particular) notes R. E. Kendell: “... Migraine and most mental illnesses are clinical syndromes, constellations of symptoms, according to T. Sydenham. Mitral stenosis and cholecystitis are distinguished based on pathophysiological characteristics. Tumors of all types are systematized, guided by histological data. Tuberculosis and syphilis - based on bacteriological data. Porphyria - based on biochemical studies. Myasthenia gravis - based on physiological dysfunction; Down's disease - characteristics of chromosomes. The disease classification is similar to an old house furnished with new plastic furniture, glass, while retaining Tudor chests of drawers and Victorian armchairs.”

History of the development of psychiatry shows that with the accumulation of knowledge about the clinic and the course of various types of pathology, the clarification of the causes of the emergence of the main psychopathological symptom complexes, and the definition of their clinical boundaries, the idea of ​​the essence of diseases changed, the approaches to their taxonomy became different, which transformed the nomenclature of psychoses.

Progress in resolving the problem of systematics and nosology in psychiatry reflects the general progress of biology and medicine, which is associated both with the deepening of clinical-psychopathological research and with modern achievements of related sciences - psychology, biology, genetics - primarily molecular. This indicates that when analyzing the problem considered in our study, the historical-clinical approach is implemented in the key of epistemology, in line with scientific methods (V.M. Morozov, S.A. Ovsyannikov, 1995).

Indeed, deciphering the mechanisms of formation of many clinical pictures requires more accurate paraclinical research methods that allow visualization of brain activity, complex family genetic studies, and molecular genetic diagnostics. The task of deciphering the human genome has now been successfully solved. The last decade of the 20th century, declared by WHO as the “decade of the brain,” became the final stage in this regard - now everything related to the “anatomy” of the genome has been studied in full

Nevertheless, a comprehensive understanding of the dynamics and current state of systematics, its prospects cannot be obtained without a historical and epistemological analysis, without a detailed consideration of how at different stages of the development of psychiatry (starting from antiquity, and then in the Middle Ages, in the brilliant periods of the Renaissance and Enlightenment ) the formation and development of views on issues of psychopathology, systematics and nosology took place; how the main paradigms of scientific psychiatry changed, the focus of which invariably remained on the issues of clarifying individual diseases and dividing nosological units; how the nosological direction developed in parallel with the symptomological one, how problems of the general (nosology) and the particular (symptomatology) were solved in science.

CONCEPTS ABOUT MENTAL ILLNESSES IN ANTIQUE. TERMINOLOGY. ATTEMPTS AT SYSTEMATIZATION

In medicine of antiquity - a period that covers the period from the 5th century. BC. up to the 5th century. AD, - psychiatry as an independent science did not yet exist, but the manifestations of mental illness were already known at that time. These disorders were studied with interest by doctors of that time, many of whom were also famous philosophers of their era (Empedocles, Aristotle, Theophrastus, Democritus, etc.).

As for the issues of systematization in the psychiatry of antiquity, it must be said that already at that time, that is, in ancient times, a heated debate began between two directions in the study of diseases regarding their classification, between two different schools.

One of these directions was formed in the works of scientists of the Cnidus school, which continued the tradition of Babylonian and Egyptian doctors (Euryphon, Ctesias, etc.). Euryphon and Ctesias were contemporaries of Hippocrates. Euryphon was captured by the Persians for seven years, later became the favorite of Artaxerxes Mnemon and was sent by him as an ambassador to the Greeks. Ctesias, a relative of Hippocrates, also lived at the Persian court and was known to his contemporaries for his historical descriptions of Persia and India, excerpts of which were quoted by Photius. Little is known about the main principles of the Knidos school, but it was the representatives of this school who identified complexes of painful symptoms and described them as separate diseases, and too carefully separated individual painful forms of organs. They advocated the need to name diseases, and achieved certain results in this regard. As G. Gezer notes, the followers of the Knidos school described, for example, seven types of bile diseases, twelve types of bladder diseases, three types of consumption, four types of kidney diseases, etc. Thus, the diagnosis of the disease was put in the foreground here, and great importance was attached to independence diseases.

The history of the Kos school is connected primarily with the name of Hippocrates, who was a contemporary of Euryphon (5th century BC) and worked during the time of Pericles in Athens. Hippocrates is rightly considered the “father” of clinical medicine, since he was the first to argue that diseases are not the product of “evil”, but arise from specific natural causes. Unlike representatives of the Cnidus school, Hippocrates focused not on the diagnosis of the disease, but on its prognosis. He fiercely criticized the Knidos school, its desire to divide diseases and make a variety of diagnoses. For Hippocrates, more important than the name of the disease was the general condition of each patient, which he considered necessary to study in all details; This, according to him, is the key to a correct prognosis of the disease.

High degree of development in writings of Hippocrates psychiatry discovers. In his opinion, mental illnesses are explained exclusively by physical causes and diseases of the brain. In any case, physical illnesses associated with insanity, for example, phrenitis, hysteria, often differ from mental illnesses in the general sense. Hippocrates and his followers distinguished mainly between two main forms of insanity: “melancholia” and “mania.” These names, as many medical historians believe, were known even before Hippocrates and have survived to the present day. “Melancholy” (translated from Greek as black bile) was understood as all forms of insanity resulting from an excess of black bile, including madness in the most literal sense. “Mania” (translated from Greek - to rage, predict, predict) meant madness in general. The term “phrenitis” denoted acute diseases that occur when brain activity is disrupted, occurring against the background of fever, often “with catching flies and a small rapid pulse.”

In the case histories given in the Hippocratic collection, descriptions are given of patients suffering from mania and melancholy; Hippocrates' clinical observation did not allow him to ignore this fact. Hippocrates noted that the same patient alternately experienced states of mania and attacks of melancholy. However, he did not conclude that these attacks are the same disease, in which polar opposite mood disorders occur. At the same time, Hippocrates began to use various designations to define insanity with delusions. In this regard, one of the authoritative researchers of Hippocrates’ work, the French historian Demar, believes that the founder of medicine was the first to develop a nomenclature for delusional states. Hippocrates distinguished among them such as “paraphronane” (delusion in general), “paracronein” (hallucination, a strong degree of delirium), “paralerein” (delirium, incoherent speech), “paralegane” (conspiracy, a lesser degree of delirium); these types are mentioned in the Hippocratic collection Epidemics.

If we compare the ancient ancient term of Hippocrates “paralegane” with the modern term “paralogical thinking”, we can see that Hippocrates, apparently, described the same disorders of thinking and speech characteristic of delusional patients that we observe today in our practice.

Special merit Hippocrates is deciphering the essence of the “sacred disease”, or . He wrote: “Concerning the disease called sacred, the situation is this way: as far as it seems to me, it is not more divine, not more sacred than others, but has the same nature of origin as other diseases.”

In the same works, he noted certain “mental abnormalities” in epilepsy, which are similar to madness in other patients, namely that “these patients sometimes cry and scream in their sleep, others choke, others jump out of bed and run out and wander around, until they are awakened, and then they are healthy, as before, in their minds, but pale and weak; and this doesn’t happen to them just once, but often.” Hippocrates makes very valuable comments regarding the origin of epilepsy, believing that the disease, like all others, is hereditary: “for if a phlegmatic person is born from a phlegmatic person, a bilious person from a bilious person, a consumptive person from a consumptive person... then what prevents this disease, if her father and mother were possessed by her, will she appear in any of her descendants?” In fact, the author reflects, since birth occurs from all parts of the body, it will be healthy from healthy ones, and painful from painful ones. In addition, according to Hippocrates, there is another great proof that this disease is no more divine than other diseases - this disease “appears in phlegmatic people by nature, but does not happen at all in those who are bilious. Meanwhile, if it were more divine than others, it would have to happen equally to everyone and would not make a difference between the bilious and the phlegmatic.” The cause of this disease, as Hippocrates wrote, is the brain. More often, the disease, the “father of medicine” believes, begins in childhood, then its prognosis is worse, many of these children die; those who fall ill after 20 years of age have a better prognosis, they anticipate an attack and therefore run away from human gaze and rush home if it is close, otherwise to a secluded place. And they do this out of shame for their illness, and not out of fear of God, as most people think. But at first, out of habit, children fall where they have to; when they are more often struck by the disease, then, anticipating it, they run to their mothers out of fear and fear of the disease, because they do not yet feel shame. Hippocrates’ opinion about excessive “wetness” of the brain in epilepsy and excessive “dryness” in other psychoses was based on the teaching of that time about the juices of the body, their correct (“crasia”) or incorrect (“dyscrasia”) mixing. The doctrine of “kraz” is the basis of the doctrine of temperaments, and Hippocrates already mentions not only the disease of melancholy, but also the melancholic temperament. Melancholic people are characterized by a predominance of timidity, sadness, and silence. Illness often arises from this temperament: “If the feeling of fear or cowardice continues for too long, then this indicates the appearance of melancholy. Fear and sadness, if they last a long time and are not caused by everyday reasons, come from black bile.” “Silent” insanity was also known to Hippocrates. V.P. Osipov emphasizes that the “father of medicine” paid attention not only to “violent” mental disorders with delirium, excitement (mania), but also for the first time used the term “hypominomena” to designate “calm” insanity, in which the desire for solitude, taciturnity, fears, sadness. Such diseases subsequently formed the field of minor, “borderline” psychiatry, and we find its origins in medicine and philosophy of antiquity.

In the same way, Socrates, as his student Xenophon wrote about it, separated the states that he called “megalo” from the states he terminologically designated “microndiamartanein”. Paranoia was more often considered as one of the types of “quiet” insanity; even Pythagoras (6th century BC) opposed dianoia as a painful state as a state of a healthy mind.

But, of course, doctors, philosophers, and historians of antiquity first of all paid close attention to acute manifestations of madness. In this sense, especially interesting are the statements of Herodotus, a contemporary of Hippocrates, the founder of historical science, who described cases of mental illness (it was the word “disease” that he used in his book) among the Spartan king Cleomenes: “The Spartan king Cleomenes, after a tiring journey, returned to Sparta and fell ill with insanity . However, he was not entirely sane before - every time he met one of the Spartans, he threw a stick in their face. Due to this behavior, the relatives put Cleomenes in the stocks as if he were crazy. While in prison, he once noticed that the guard was left alone with him and demanded a sword from him: he at first refused, but Cleomenes began to threaten him with punishment later, and under pain of threats, the guard gave him the sword. Taking the sword in his hands, the king began to cut himself into strips, starting from the thighs, and it was he who cut his skin lengthwise from the thighs to the stomach and lower back, until he reached the stomach, which he also cut into narrow strips, and so he died.” The reason for this insanity, according to Herodotus, was stated by the Spartans themselves, who knew perfectly well all the circumstances of the king’s life: at every reception of foreign ambassadors and on every occasion in general, he drank immoderately undiluted wine, so that Cleomenes fell ill from drunkenness. This shows that the ancient Hellenes noted the power of external (exogenous), in particular alcoholic, factors that could cause insanity.

In Herodotus we find information about another patient who suffered and was characterized by extreme cruelty. We are talking about the Persian king Cambyses, who, without any reason, killed the son of one of his courtiers with an arrow. At the same time, Herodotus emphasized that the spirit cannot be healthy if the body is sick.

Not only the effect of alcohol, but the effect of narcotic substances, as it is currently defined, was also noted by Herodotus: “Hemp grows in the Scythian land - a plant very similar to flax, but much thicker and larger. In this way, hemp is significantly superior to flax. It is bred there, but wild hemp is also found. The Thracians even make clothes from hemp that are so similar to linen that a person who is not particularly knowledgeable cannot even tell whether they are linen or hemp. Having taken this hemp seed, the Scythians crawl under a felt yurt and then throw it onto the hot stones. From this, such strong smoke and steam rises that no Hellenic bath (steam) can compare with such a bath. Enjoying it, the Scythians scream loudly with pleasure.” It should be noted that the undiluted wine that Cleomenes drank, as Herodotus wrote, was also used by the Scythians; the Greeks called it “drinking in the Scythian way,” since the Hellenes usually drank wine diluted.

An analysis of the writings of Hippocrates, one of the founders of the Kos school, shows that observations of patients suffering from psychoses were made without an obvious desire to systematize them, but still the main types of psychoses - mania, melancholy, phrenitis - were designated by various terms, even types of delusional disorders were described insanity In this regard, G. Schule wrote: “He (Hippocrates) already knew melancholy and mania, madness after acute febrile illnesses, after epileptic and labor processes, he also knew drunken delirium and hysteria, and from individual symptoms - precordial melancholy and auditory . The significance of the psychopathic temperament, which is not real insanity, did not escape his gaze.”

Indeed, Hippocrates not only described acute psychoses, but, following Empedocles (6th century BC), became a syncretist, continuing the formation of the concept of eukrasia (norm) and dyscrasia (pathology). V. M. Morozov believes that Empedocles influenced the Hippocratics, and the four liquids of Hippocrates (mucus, blood, black and yellow bile) are a further development of the concept of Empedocles, the basis of humoral pathology and the foundation of the doctrine of temperaments as manifestations of special personality traits, not related to psychosis, insanity. In his book “Epidemics,” Hippocrates cites clinical cases that, of course, can be interpreted as modern “neurotic” disorders. For example, he describes Nicanor’s illness as follows: “... going to a feast, he (Nicanor) experienced fear of the sounds of the flute; Having heard its first sounds at the feast, he experienced horror; he told everyone that he could hardly control himself if it was at night; during the day, listening to this instrument, he did not experience any excitement. This went on for a long time."

L. Meunier, in a guide to the history of medicine, also draws attention to the fact that Hippocrates, being a keen observer of life, identified special mental disorders among residents of large cities and explained the origin of such diseases as the influence of civilization - these are fears, melancholy, i.e. such conditions which are currently classified as neuroses, or personality disorders.

Yu. Belitsky wrote that Hippocrates described clinical cases of “hysteria”, adhering to the “uterine” theory, which was borrowed by the Greeks from the ancient Egyptians: “If the uterus goes to the liver, the woman immediately loses her voice; she clenches her teeth and turns black. The disease occurs especially often in old maids and young widows who, having children, do not remarry.”

All this proves that Hippocrates and the adherents of his school considered a number of painful mental states as special diseases, and among them they noted not only “violent” manifestations of psychoses (mania, melancholy), but also those that were designated as hypopsychotic (hypominomena) and were actually classified as to borderline mental disorders.

Ancient philosophers also paid attention to various deviations in mental illness. Here we can mention, first of all, Pythagoras and representatives of the Pythagorean school, who formed the basic principles of encyclopedic knowledge about normal mental activity and some deviations from it in the form of various reactions; At the same time, various systems of training, education of the spirit were used, as well as treatment methods in which “catharsis” (purification) was possible, in particular music, music therapy (VI century BC). Alcmaeon of Croton, a student of Pythagoras (500 BC), considered “democratic equality” (“isonomy”) in relation to elementary forces to be the main condition and foundation of health; at the same time, according to Alcmaeon, “monarchy”, or the predominance of one thing in the body, causes disease, since the “monarchy” of one of the two opposites is detrimental to the other. Such “monarchy,” or disharmony in the mental sphere, can lead to mental disorder localized in the lateral ventricles of the brain, which Alcmaeon already knew about. Socrates, following Pythagoras, taught that philosophy as the love of wisdom appears as the love of divine wisdom. In his speeches, he repeatedly turned to the concept of reason and madness, analyzing the normal activity of the soul, psyche and deviations from the norm.

The psychiatric views of Socrates are reflected quite clearly in the work of his student Xenophon, dedicated to the memory of his unforgettable teacher. Madness, according to Socrates, is the opposite of wisdom. Here he argued how Pythagoras, who distinguished between two concepts: “dianoia”, a normal state of the psyche, was contrasted with “paranoia” - madness. Socrates did not consider ignorance to be madness. But if someone does not know himself (the old Greek wisdom is “know yourself”) or forms an opinion about what he does not understand, then this, as Socrates believed, borders on madness. Such a judgment by the philosopher indicates his recognition of states bordering on madness or psychosis. According to Socrates, madness is a complete deviation from generally accepted concepts, or “megaloparanoia,” and a slight deviation from the concepts of “crowd” is “microndiamartanein” - a disorder closely related to madness, bordering on it.

The conclusion that can be drawn from the “psychiatric” views of Socrates is this: ignorance, or “anepistemosyne,” is qualitatively different from mania, or madness, but there are states bordering on it, they cannot be identified with complete health.

Democritus, a contemporary of Hippocrates and Socrates (5th century BC), the founder of ancient atomism, also considered a number of “psychiatric” problems in his “Ethics”. He defined the state of mental balance and peace (the norm) as “euthymia,” or complacency. He noted that people who meet this requirement “always strive for just and good deeds,” therefore such people “both in reality and in their dreams are joyful, healthy and carefree.” He contrasted “euthymia” with states of mental incontinence, such as the desire to “insult others, envy them, or follow sterile and empty opinions.” In the reflections of Democritus one can also find his understanding of the relationship between the mental and the physical, the influence of the soul on the body. Considering the soul to be the cause of the body’s misfortunes, he explained: “If the body were to blame the soul for all the suffering that it has endured, and I myself (Democritus), by the will of fate, had to take part in this lawsuit, then I would willingly condemn the soul for what it ruined the body partly by her careless attitude towards it and weakened it through drunkenness, and partly spoiled it and led to its death through her excessive love of pleasure, just as if any instrument or vessel were in poor condition, he would blame one who, while using it, treats it carelessly.” These lengthy statements by the philosopher indicate initial attempts to establish psychosomatic disorders, which are currently included in the study of borderline psychiatry. In “Ethics,” Democritus directly defined those signs of mental properties, features of the psyche that deviate from the usual and are now interpreted as characterological stigmas, psychopathy, personality disorders: “And those souls whose movements oscillate between great opposites are neither calm nor joyful." And here he summed it up: “... if you go too far, then the most pleasant things will become unpleasant.” As a way to get rid of the wrong movements of the soul, Democritus proposed philosophical contemplation of the world; he believed that if the art of medicine heals diseases of the body, then it is philosophy that frees the soul from passions.

All philosophers and doctors of the “Hippocratic era” described various mental deviations in general terms; these were the first timid attempts to subdivide them and decipher them, which outlined further paths for a more detailed and thorough description.

After the “Hippocrates,” extensive data from the field of psychiatry was accumulated by Asclepiades, whose opposition to Hippocrates makes itself felt in this area. He put mental treatment, music, and cold baths in the foreground, while he rejected bloodletting and similar “energetic” means. Celsus' notes on mental illness are distinguished by great independence. He adds to the previously known forms of mania melancholy, hallucinations (he did not introduce the term himself, designating the phenomenon as “deceptive imagination”), absurd ideas and idiocy (“moria”).

However, the most important of the heritage of ancient doctors on mental illness can be considered that preserved by Caelius Aurelian (undoubtedly from the writings of Soranus). Here the point of view of the methods was manifested, which was expressed in the division of diseases into exalted and depressed states. This classification dichotomy “exaltation - depression” is apparently one of the first in the history of medicine; it dates back to a period when psychiatry as a science did not yet exist.

It is impossible not to note the contribution to the study of the problem under consideration by another giant of the philosophical thought of antiquity, a contemporary of Hippocrates and Democritus, a student of Socrates - Plato. True, he mainly considered only those conditions that later began to relate to the field of psychology and borderline psychiatry. A.F. Lazursky believes that Plato was the first to approach the problem of character, and although he himself did not introduce this term (theophrastus, a student of Aristotle, did this a little later), he made the first attempt to classify the types of mental makeup. The philosopher's views on this issue were closely related to his teaching about the relationship of the soul to the body. According to Plato, two sides must be distinguished in the human soul: the more sublime, coming from the world of ideas, where it existed before joining the body, and the more base, which is the result of the incarnation of the ideal part of the soul and dies with the body. The second half of the soul is divided into two parts. Thus, Plato divides the soul into three parts. Of these, the first (supersensible) is pure knowledge and is located in the head. The second, more noble half of the base soul, represents the source of courage or ambition and is localized in the chest. Finally, the third, the lowest part of the soul, is located in the liver and is the source of all kinds of base desires. All human properties (later Theophrastus defined them with the term “characters”), according to Plato, are composed of these three aspects of mental life, and individual characteristics depend on the predominance of one or another part of the soul.

In the direction of deciphering personality traits, Plato’s student Aristotle (384 - 322 BC) went further than all his colleagues. He tried to study ethical problems to define the concept of “norm” (metriopathy - the median sense of proportion) and pathology in behavior, but a special classification of “characters” was first made by his student Theophrastus (371 - 287 BC), who described 30 types of human personality. Among them are identified such as irony, flattery, idle talk, uncouthness, fussiness, stupidity, etc. In this list we see the characteristics that Aristotle gives to the “shortcomings” of human character (irony, obsequiousness), but Theophrastus outlines a qualitatively different approach to this topic - each character in him is the sum of certain properties that form the basis of personality. Theophrastus groups and classifies human qualities according to their main property (vice), and each of them corresponds to a specific carrier (type), a specific character. Theophrastus’s character is already the sum of mental properties, manifested in the actions and worldview of the individual.

Claudius Galen(II century AD), Roman physician and naturalist, known for summing up the ideas of ancient medicine in the form of a single doctrine, canonized by the church and dominant in medicine until the 15th - 16th centuries, continued the development of Hippocrates’ ideas on the importance of the humoral factor in the origin of diseases and temperament. He distinguished among the causes of a painful state the immediate (spoilage of juices, dyscrasia), the suffering caused by these causes (pathos) and the abnormal educational processes caused by the latter (nosema, nosos); further he highlighted the symptoms. Thus, K. Galen considered it expedient to identify various “nososes”, diseases, while he tried to decipher their anatomical lining, i.e., he sought to understand the causal relationships in the disease (etiology). K. Galen accepted the four temperaments of Hippocrates as the main ones (melancholic, choleric, sanguine, phlegmatic), but also believed that mixed types were possible. With regard to brain diseases, K. Galen believed that it was necessary to distinguish between forms dependent on anemia and plethora. Anemia causes convulsions, paralysis, and plethora promotes apoplexy. Like Hippocrates, he identified “phrenitis,” febrile psychoses, melancholy, and mania. He first designated one type of melancholy as “hypochondria,” believing that this disease begins in the stomach. He described such symptoms of “hypochondria” as belching, passing wind, a feeling of heat in the right hypochondrium, swaying, and sometimes pain. According to Galen, attacks of hypochondria are a consequence of inflammation of the stomach and retention of thick black bile. Melancholic people are always obsessed with fear, which, like sadness, is a constant companion of this disease. K. Galen saw the clinical difference between melancholia and hypochondria in the presence of “stomach” attacks in hypochondria.

If we generalize what has been said regarding the medicine of antiquity, we can conclude that there was a gradual clarification of the signs of various mental illnesses, terminology was approved, which subsequently defined psychiatric vocabulary (mania, melancholy, phrenitis, paranoia, hysteria, epilepsy, hypochondria, characters), despite the fact that There has not yet been a special identification of mental illness in the nosological sense. This was a pre-paradigmatic, pre-nosological period, a pre-systematic stage in the formation of psychiatry.

VIEW OF MENTAL DISEASES IN MEDICINE IN THE RENAISSANCE AND ENLIGHTENMENT ERAS

With the further development of medicine during the Renaissance and Enlightenment in Europe, the most significant thing was the creation of the first classification systems. In this regard, the 18th century began to be defined in science as the “age of systems.” Still in work Jean Francois Fernel's "General Medicine", first published in 1554, along with the general sections "Physiology" and "Pathology", there is a special chapter "Diseases of the Brain".

The author was the first to attempt to correlate psychoses with brain pathology. In accordance with the concept of temperaments, he distinguished mania, melancholia, phrenitis, delirium (delirium), hypochondria, stulticio, or morositas (dementia). In his book “General Medicine” J. Fernel sought a more complete description of these diseases, to subdivide their main types into different options (for example, “complete melancholy”, “primary”, as well as the mildest “melancholia”), to differentiate such conditions (diseases) such as mania and apoplexy. This indicates an increase in knowledge about mental illnesses. According to I. Pelissier, J. Fernel gave the prototype for the contrast between delusional psychoses with fever (phrenitis) and non-febrile psychoses (mania, melancholia, catalepsy, delirium). This position of J. Fernel outlines, accordingly, as I. Pelissier believed, a three-member division of mental pathology (future exogenous, endogenous disorders, “initial” states).

However, J. Fernel, like C. Galen, did not classify epilepsy and hysteria as brain diseases in the taxonomy. Of particular interest to researchers is that the author uses the term “hallucination” to refer to eye disease.

In the officially considered the first classification of mental illnesses - the taxonomy of F. Plater(XVII century) - there are 23 types of mental illnesses, placed in four classes. For us, the third class is of greatest interest - “mentis alienatio” (the term “alienatio”, or alienation, will long define patients with mental illness as people alienated from society), it describes in detail the symptoms of mania, melancholy, hypochondria as a disease, and phrenitis. According to Yu. Kannabikh, F. Plater was the first to point out the external and internal causes of psychosis. From external causes, as the author believed, diseases such as commotio animi (mental shock) occur, which, for example, are the cause of fears, jealousy, etc. Obviously, F. Plater’s classification outlines not only the diagnosis of “mental” disorders, but also pathology “borderline” register, and he provided relevant clinical descriptions. It is important that in F. Plater “mania” and “melancholy” are already quite clearly separated, despite the general signs of existing excitement.

It is noteworthy that 17th-century protopsychiatry preserved connections with philosophy, general medicine, and biology. This is reflected in the problem of systematics and diagnosis of diseases. A number of psychiatrists believe that F. Plater applied the inductive method proposed by the philosopher to medicine F. Bacon, who devoted his whole life to developing a plan for the “great restoration of the sciences” and continued the traditions of scientists of antiquity. According to F. Bacon, images of objects, entering consciousness through the senses, do not disappear without a trace; they are preserved by the soul, which can relate to them in three ways: simply collect them into concepts, imitate them with the imagination, or process them into concepts with the mind. On these three abilities of the soul, according to F. Bacon, the division of all sciences is based, so that history corresponds to memory, poetry to imagination, and philosophy to reason, which includes the doctrine of nature, God and man.

Cause of delusion of mind F. Bacon considered false ideas that come in four types: “ghosts of the race”, rooted in human nature itself (in the future endogenous diseases), “ghosts of the cave” arising due to the individual characteristics of a person (hereinafter referred to as “characteropathy”), “ghosts of the market” generated by an uncritical attitude towards popular opinions, as well as “ghosts of the theater” - a false perception of reality based on blind faith in authorities and traditional dogmatic systems. The teachings of F. Bacon had a huge influence on all natural sciences, including medicine, which was reflected, for example, in the compilation of classifications and diagnosis of mental illnesses, especially in the works of scientists of the 18th century (F. Boissier de Sauvage, C. Linnaeus, J. B. Sagar, W. Cullen, F. Pinel, etc.).

E. Fischer-Homburger notes that T. Sydenham, who was called the English Hippocrates, back in the 17th century proposed “to classify diseases with the same care that botanists show in their phytologies.” The tendency towards systematization in medicine of the 18th century was significantly influenced by the philosophical concepts of T. Sydenham's friend, the great English philosopher J. Locke. He distinguished three types of knowledge: intuitive, demonstrative (the prototype of which is mathematics) and sensory, or sensitive. The latter is limited to the perception of individual objects of the external world. In terms of its reliability, it is at the lowest level. Through it we understand and cognize the existence of separate individual things. From this we can conclude that medicine is primarily an area of ​​application of sensitive cognition. It is in this sense that we can talk about the influence of the philosophical views of J. Locke on the development of the concept of classification of diseases (including mental ones) in the 18th century.

The philosopher used the terms “genus” and “species”. It can be considered that the issues of classification and diagnosis of diseases at this stage of the development of medicine, raised by T. Sydenham in accordance with the principles of botany, or “botanical principles of classification,” became the forerunner of nosological constructs in the 18th and 19th centuries. K. Faber cites a statement characteristic in this sense from a letter from K. Linnaeus: “My weak brain... can only understand what can be generalized systematically.”

First edition of the book K. Linnaeus “System of Nature” published in 1735 and brought him wide fame as a natural scientist, but his activities as a doctor and taxonomist in the field of psychiatry deserve special consideration in the aspect that interests us.

Carl Linnaeus in his book “Kinds of Diseases” he divided all diseases into eleven classes, placing mental illnesses in class V. He further divided mental disorders into three orders: diseases of the mind, diseases of the imagination, diseases of affects and drives. K. Linnaeus described hysteria and epilepsy outside the rubric of mental pathology, placing them in class VII (impaired motor functions). In class V, K. Linnaeus counted 25 genera of diseases. In the first order, he described (acute and chronic variants). In the second order, the terms “siringmos” and “Phantasma” were used by C. Linnaeus to designate auditory and visual hallucinations (he did not use the term “hallucinations” itself, but clinically separated these disorders from delusions). Finally, in the third order, K. Linnaeus includes “fears,” “impulsions,” and “anxiety states.” In fact, K. Linnaeus's classification represents one of the first variants of general psychopathology, a prototype of future syndromology, which already entered the arena in the 19th century and was subsequently opposed to nosology. The progress of clinical psychiatry found its further expression in new taxonomies, the task of which, as J. P. Frank believed (1745), was to create a medical language accessible to a wide variety of nations from pole to pole.

The first and, perhaps, the only classification of diseases in England (Scotland), which received worldwide recognition, belonged to W. Cullen (1710-1790). He made an attempt to classify diseases according to the principle of K. Linnaeus: classes, orders, orders, genera, species. V. Cullen first introduced the term “neurosis” into medicine as a general name for all mental disorders. He classified neuroses in the second class, which included 4 orders, 27 genera and more than 100 species and, in addition, a large group of paranoid diseases. According to the data given in O. Bumke's manual, already in the 18th century, V. Cullen's nosology was criticized by another classic of English medicine, T. Arnold, who argued that insanity can be divided into only two types. In one of them, perception is upset, in the second, perception is normal, but the mind develops false concepts. Such polemics are regarded by many historians of psychiatry as the initial stage in the formation of the future dichotomy “nosology - a single psychosis.” Finally, the classification of F. Pinel, the founder of scientific psychiatry, seems to sum up in favor of nosological taxonomy; it approves the term “neuroses” to designate mental illnesses following Cullen, which is explained by the understanding of the leading role of the nervous system in the origin of not only psychoses, but also various according to their clinical manifestations of “neuroses of nutritional functions”, or “systemic” neuroses in a later understanding, which were first identified by this brilliant scientist, psychiatrist-humanist.

F. Pinel's taxonomy is distinguished by deliberate simplicity; it is not as symptomatic as that of V. Cullen; the principle of pathogenesis has already been introduced into it. This is evidenced by the identification of “neuroses of cerebral functions”, which include luck. F. Pinel believed that they constitute five genera: mania, “mania without delirium,” melancholy, dementia and idiocy. “Mania without delusions” became the prototype of those clinical types that later made up the “psychopathy” group, and F. Pinel was also the first to note the forensic psychiatric rationale for identifying such a group, believing that these individuals should not be brought to justice, but require placement to a special (psychiatric) hospital.

In Russia, one of the first works devoted to the taxonomy of psychoses can be considered the works of I.E. Dyadkovsky. In his lectures, he urged domestic scientists to follow an original path in the description and division of mental pathology and compiled an original taxonomy of this pathology. I.E. Dyadkovsky identified diseases of the senses (anaesthesia), diseases of impulses (epithymia), diseases of the mind (synesia), diseases of movement (kinesia) and diseases of the forces (dynamia), believing that there is no disease without “material changes” in some system or some some organ.

K.V. Lebedev, student of I.E. Dyadkovsky, subjected to critical analysis the nosological systems of Linnaeus, Sauvage, Vogel, Cullen, Pinel, Mudrov, Schönlein. However, while criticizing some particulars, he did not dispute the validity of nosological principles in psychiatry in the 17th century, believing this approach to be promising for the development of psychiatry. Historical and epistemological analysis shows that even at this stage of development, psychiatry, enriched with clinical material, developed in fairly close connection with other shops. This period, from the point of view of scientific studies, can be designated as clinical-nosological, which formed a new clinical-systematic paradigm for understanding mental, or mental, diseases.

According to V.M. Morozov (1961), the founder of scientific psychiatry was F. Pinel, who approached the understanding of mental pathology as a nosologist-clinician, a critic of various speculative constructs, relying on clear clinical criteria for dividing individual types of illness. His position is reflected quite clearly in the change in the title of the main works on psychiatry. If F. Pinel called the first manual “Treatise on Insanity, or Mania” (1801), then the re-edition was called “Medical and Philosophical Treatise on Insanity” (1809). As you can see, F. Pinel deliberately omitted the term “mania”, since he began to use it to designate not “insanity in general”, but a separate type (genus) of mental illness - with excitement, a separate “nosos” in the taxonomy of diseases.

The next, 19th century became a new stage in the discussion, reflecting the long-standing controversy between the Knidos and Kos schools.

NEW TIME. XIX-XX CENTURIES

In the 19th century, after F. Pinel substantiated the clinical-psychopathological foundation of psychiatry as a science, it was in France, his homeland, that the origins of the clinical-nosological approach - the main method of diagnosis and systematics - began to take shape. Among the students and followers of F. Pinel, the largest were J. Esquirol, A. Bayle, J. P. Falre (father), E. -C. Laceg, B. Morel, V. Magnan and others, who founded the conceptual direction of the French clinical school.

For example, J. Esquirol identified five main forms of insanity: lipemania (or melancholia), monomania, mania, dementia and imbecility. In his opinion, they express the generic nature of insanity. J. Esquirol, like his teacher F. Pinel, paid special attention to the concept, which later became known as “trend psychiatry”; at the same time, he objected to the future theory of a “single psychosis.” But nevertheless, the psychoses he identified and their forms alternately replace each other: J. Esquirol moved towards an understanding of nosological taxonomy, using the concepts of syndromes, disease states and (to a greater extent than F. Pinel) types of course of psychoses. According to V.M. Morozov, the works of J. Esquirol correspond to the initial clinical-nosological stage of development. It cannot be emphasized enough that J. Esquirol, for the first time in the history of psychiatry, formulated the scientific concept of hallucinations: “A person who has a deep conviction that he has a perception at the moment, while there is no external object within the reach of his senses, is in a state hallucinations are a visionary.”

J. Esquirol, like F. Pinel, in his theoretical views firmly stood on the positions of the sensualistic materialist philosophy of Condillac, who continued the traditions of J. Locke, a convinced supporter of classification systems. A significant contribution to the establishment of the nosological principle was the identification by A. Bayle in 1822 of progressive paralysis as an independent disease with a characteristic clinical picture and outcome in dementia. The triumph of clinical diagnosis here was obvious - the specific pathogen Treponema pallidum, which is the cause of the disease, was discovered in the blood by S. Wasserman in 1833, and in the brain it was discovered by H. Nogushi only in 1913. French clinicians subsequently, continuing the traditions of F. Pinel and J. Esquirol, successfully used clinical observations to clarify the boundaries of individual diseases.

J. -P. Falre (father), perhaps more accurately than other medical colleagues, expressed the conceptual idea about the significance of clinical types of illness for psychiatric taxonomy: “What especially needs to be studied in mentally ill patients is the course and development of the disease; Usually the patient is examined and studied more or less carefully once or twice, soon after his admission to the hospital, and meanwhile observation must be carried out for years. Then we will discover the various diseases and their phases into which they enter. Knowing the course and nature of various diseases, we will be able to construct a new natural classification of psychoses.” This clinical and dynamic approach allowed J. -P. Falret, simultaneously with J. Baillarge, describe and highlight circular insanity, or insanity with “two forms,” reports of which appeared in the “Bulletin of the Medical Academy” for 1853-1854. Then E. -Sh. Lace described the chronic type, the most common type in practice, with a continuous course, drawing attention to the typicality of the clinical picture. His research was significantly supplemented by J. -P. Falre, noting the progressively developing systematization of delusions and identifying three stages in the development of a delusional symptom complex - incubation, systematization and stereotypy. But along with the development of the nosological division of diseases in the 19th century, a completely different direction began to take shape, which later began to be called the concept of “single psychosis.” The term “single psychosis” in the scientific sense began to be used primarily in German psychiatry in the 40-60s of the 19th century, although the origins of this concept first appeared in the works of J. Ghislain - the “Belgian Esquirol”, as his contemporaries called him. He believed that all psychoses follow approximately the same path of development, and in this regard, melancholy is a “fundamental form” - all psychoses, according to J. Ghislain, begin with melancholy. From the initial stage - melancholia - psychosis subsequently develops into mania, after which delirium with confusion develops, and then systematic delirium. The final stage of psychosis is dementia.

Thus, there is no point in talking about various mental illnesses, identifying various nosological forms, as was done by French scientists, followers of F. Pinel and J. Esquirol. The ideas of J. Ghislain began to be established in Germany in the works of E. Zeller, G. Neumann, and W. Griesinger. The essence of such a concept is expressed especially categorically in the manual of G. Neumann: “We consider any classification of mental disorders to be completely artificial, and therefore a hopeless undertaking; and we do not believe in the possibility of real progress in psychiatry until a unanimous decision triumphs - to abandon all classifications and declare with us: there is only one type of mental disorder, we call it insanity. E. Zeller, in whose hospital V. Griesinger worked, also identified four stages of a single psychosis and believed that they reflected the general pathological patterns of any psychosis.

V. M. Morozov believed that V. Griesinger, who had already mentioned the term “symptom complex,” developed the idea of ​​“single psychosis” at a higher level, using new data from anatomy and physiology. He argued that the various forms of insanity are only separate stages of one disease process, which can stop at any stage of its development, but, as a rule, progresses from melancholia to dementia. V. Griesinger made a distinction between hallucinatory-delusional disorders with the presence of affective pathology and truly delusional disorders in the dynamics of psychosis. Clinically accurately, V. Griesinger pointed out that the manifestations of a single psychosis are reversible only at the stages of affective and affective. As he himself noted, he was characterized by a desire for a “physiological” characterization of the various stages of a “single” psychosis: the disease began with a disturbance in the affective sphere, then disorders of thinking and will appeared, and everything ended in organic decay. In the last years of his life, V. Griesinger expanded the scope of the concept of a “single” psychosis and, following L. Snell, recognized the existence of a “primary” delusion, the occurrence of which is never preceded by states of melancholia or mania.

In Russia, two years after the publication of V. Griesinger’s manual, Russian psychiatrist P. P. Malinovsky wrote that foreign psychiatrists encountered many subdivisions of insanity. He pointed out the need to distinguish between diseases and their symptoms. Of course, there is no doubt that the doctrine of a “single” psychosis was historically necessary. It put an end to the purely symptomatic and speculative interpretation of mental disorders in previous periods and placed the doctrine of psychosis on a general pathological and pathogenetic basis. This teaching made it possible to prove that all manifestations of psychosis are a typical expression of a progressive disease process, and this contributed to the establishment of the principle of “flow psychiatry”, laid down by F. Pinel and J. Esquirol. Just like W. Griesinger in his work of 1845, G. Modeli focused on the general patterns of development of mental disorder and its course in specific patients. G. Models wrote about this: “Features of mental organization or temperament are more important for determining the form of insanity than the producing causes of the disease. Only as a result of far-reaching insanity, when productive creative activity as the highest function of a high and healthy mind is leveled out, then general signs of insanity appear for all ages and different countries.”

A contemporary of P. P. Malinovsky, Russian therapist I. E. Dyadkovsky, emphasized that the best system for classifying diseases is symptomatic, and the similarities and dissimilarities between diseases can be determined by their internal essence. All this once again reminds us that in the 19th century, a kind of centuries-old scientific discussion continued, leading from the Knidos and Kos schools of antiquity on the issue of the advisability of identifying individual diseases and their classification.

It is significant in this sense that the outstanding researcher of the 19th century K. -L. Kahlbaum, the predecessor of E. Kraepelin, in his first monograph on the classification of psycho-things, did not completely break with the doctrine of a “single psychosis” and created his own “typical luck”, like W. Griesinger and G. Neumann, with four characteristic successive stages; Later, he took a new step in strengthening the position of nosography in psychiatry, publishing his findings regarding a new disease he identified - catatonia. He gave a deep and detailed substantiation of the theory and practice of clinical nosology. His position is so precisely argued that it retains its significance to this day.

K. -L. Kahlbaum distinguished between the disease process and the picture of the disease state, psychosis; He considered it necessary, using the clinical method, to study the entire course of the disease in order to substantively prove the difference between symptom complexes and “painful units.” The term “painful unit” was introduced by K. -L. Kalbaum to designate the nosological form based on taking into account psychopathological disorders, physical symptomatology, the course and outcome of the disease, including all stages of its development with various symptom complexes. K. -L. Kahlbaum finally formulated the “trend psychiatry” outlined by French researchers.

In Russia, a supporter of the nosological trend at that time was V. H. Kandinsky, who highly appreciated the work of K.-L. Kalbaum “On catatonia...” V. H. Kandinsky wrote: “The present time, i.e. the 70-80s of the 19th century, is in psychiatry the time of replacing previous, one-sided, symptomatological views, which turned out to be unsatisfactory, with clinical views based on patient, comprehensive observation of mental disorder in its various specific or clinical forms, that is, in those natural forms that exist in reality, and not in artificial theoretical constructs taking into account one, arbitrarily chosen symptom.”

K. -L. Kahlbaum suggested to his student E. Hecker the idea of ​​describing another independent disease - hebephrenia, which also has a characteristic clinical picture with onset at a young age and outcome in dementia. Nel b It’s also worth noting the contribution of K. -L. Kahlbaum into general psychopathology - his description of functional hallucinations, verbigerations, . Another clinical unit described by K. -L. Kalbaum in 1882, -, or a lightweight version of circular luck. His description is thorough and complete, indicating a favorable outcome in recovery.

In Russia, the nosological position, as we noted, was held by V.Kh. Kandinsky, who identified a new nosological unit - ideophrenia. The author argued his understanding of the independence of this disease by the fact that it is based on a violation of the ideational, mental function. He divided ideophrenia into simple, catatonic, periodic forms; later he also included acute and chronic hallucinatory forms here. He emphasized the state of weakness at the final stage of the disease. The description of V.Kh. is of great interest. Kandinsky attacks a special kind of dizziness with a change in the sense of the ground, a feeling of weightlessness of one’s body and a change in its position in space, which is accompanied by a stop in thinking. This is typical, according to V.Kh. Kandinsky, for initial (acute) ideophrenia. Among chronic cases of ideophrenia, he described schizophasic states. The thinking of such patients, as V.Kh. believed. Kandinsky, is characterized by a number of “words or phrases without a shadow of a common meaning... such people have completely lost the ability to establish connections between their ideas.”

The monograph “About x” is devoted to the study of the psychopathology of ideophrenia as a whole, which indicates the priority of Russian psychiatry in covering this extremely important problem and the unsurpassedness of this research, which retains its significance to this day. It is quite obvious that V. H. Kandinsky’s ideophrenia became the prototype of the future concept of schizophrenia in German psychiatry in the 20th century.

V. Kh. Kandinsky reflected his ideas about the importance of nosological understanding of the essence of mental illnesses in the classification he compiled. This classification, with some changes, was adopted by the first congress of domestic psychiatrists and neuropathologists, according to the author’s report.

An analysis of the historical development of Russian psychiatry convincingly shows that it consistently defended the principles of nosological taxonomy. The founder of the Moscow school, S. S. Korsakov, like V. Kh. Kandinsky, believed that the identification of certain forms of diseases in psychiatry should be based on the same principles as in somatic medicine. This line represents a continuation of the development of the ideas of I. E. Dyadkovsky, it brings together the mental and somatic, and this is its progressive nature as an integral concept of pathology.

V.S. Korsakov believed that “just as in somatic diseases a known, constantly recurring set of symptoms, their sequence, change and anatomical changes underlying the disease, make it possible to identify individual painful forms, in the same way in mental illnesses based on what symptoms are observed and in what order they appear, we determine the individual clinical forms of mental illness.” According to S.S. Korsakov, in most cases we observe not just one symptom of mental illness, but a set of symptoms that are to one degree or another connected with each other; they develop into a more or less definite picture of a psychopathic state, different in different cases. According to S.S. Korsakov, such examples of a psychopathic state can be a melancholic, manic state. The picture of the disease process consists of a sequential change of psychopathic states. An excellent confirmation of the validity of such statements can be considered the identification by S. S. Korsakov of another new disease, which was later named after him. This form of the disease is a variant of acute alcoholic encephalopathy, usually developing after atypical alcoholic delirium (delirium tremens), and is characterized by a combination of polyneuritis with atrophy of the muscles of the limbs of varying severity, as well as mental changes in the field of memory - amnesia, confabulation, pseudo-reminescence.

On XII International Medical Congress in 1897 professor F. Jolly, who made a report on memory disorders in polyneuritis, proposed calling polyneuritic psychosis Korsakoff's disease. Korsakov's original observations were soon recognized by psychiatrists in all countries, which is also explained by the fact that the old symptomatic direction no longer satisfied scientists. S. S. Korsakov, before E. Kraepelin (in any case, independently of him), created a nosological concept with his definition of polyneuritic psychosis, which was a brilliant example of a new understanding of psychosis with certain pathogenesis, symptoms, course, prognosis and pathological anatomy.

In addition to the teaching on memory disorders, S. S. Korsakov’s teaching on acutely developing psychoses was of great importance, which allowed him to establish a completely new painful unit - dysnoia. S. S. Korsakov argued with V. Griesinger, believing that the latter’s idea that all psychoses are preceded by affective disorders has lost its universal meaning. He cited the history of the doctrine of such acute psychoses that begin without previous emotional disorders. Paranoia, divided into acute and chronic, hallucinatory insanity (acute) and primary curable dementia, were consistently distinguished. S.S. Korsakov himself believed that among non-affective psychoses there are three main forms - Meynert's amentia, paranoia and premature dementia. From Meynert, S.S. Korsakov identified dysnoia, which should be considered as the main precursor of acute schizophrenia. He divided the new disease into subgroups, but also gave a general description of the entire form as a whole. S.S. Korsakov included disturbances in intellectual activity with a disorder in the combination of ideas, a defect in the associative apparatus, a disorder in the emotional sense and a disorder in the sphere of will as the main symptoms.

It is quite obvious that in 1891, when E. Kraepelin had not yet announced his concept of dementia praecox, S. S. Korsakov, creating the doctrine of dysnoea and striving to isolate “natural painful units” similar to progressive paralysis, designated acute diseases as autointoxication , in his opinion, psychoses with the correct formal perception of the external world, but with an incorrect combination of these perceptions. S.S. Korsakov did not base his identification of the disease on specific final conditions - on the contrary, he studied the dynamics of acute conditions and saw the main thing in pathogenesis, understanding the possibility of various outcomes - from death, dementia to recovery.

A natural expression of the views of the outstanding scientist was his classification of psychoses, while he believed that taxonomy should:

• allow any observable form, even a purely symptomatic one, to be designated by a specific name;
• satisfy mainly clinical needs, that is, help divide diseases into forms according to the characteristics of their symptoms and course;
• do not force one or another case that does not fit into a precise definition into the narrow framework of established forms, and thus provide the opportunity for further development of knowledge regarding individual forms of mental illness.

Having identified three classes of diseases, S. S. Korsakov especially fully substantiated the differentiation of psychoses and psychopathic constitutions, contrasting them with transient mental disorders - symptomatic and independent, as well as states of mental underdevelopment. In the second class, those diseases that later formed the group of “endogenous pathology”, including dysnoia, and “organic pathology” are convincingly differentiated. S. S. Korsakov’s classification became for its time the only complete and original classification of mental illnesses based on the principle of nosology.

V.M. Bekhterev, the largest Russian neurologist-psychiatrist, also made a significant contribution to the development of nosological understanding of mental illnesses. He became a pioneer in identifying psychopathy, giving a detailed report on this problem in 1885 in Kazan; Subsequently, he published a work on the forensic psychiatric significance of psychopathy for resolving the issue of sanity.

A study of the works of leading Russian psychiatrists in the 80s and 90s of the 19th century confirms that domestic psychiatry at that time accumulated a sufficiently large amount of clinical material to create a solid foundation for clinical nosological systematics. These studies were distinguished by their depth and content, based on scientifically based approaches to understanding the etiopathogenesis of individual nosological units (autointoxication as the basis of dysnoia, according to S.S. Korsakov, “objective psychology” according to V.M. Bekhterev). All this became the forerunner of the appearance on the arena of European psychiatry E. Kraepelina, who, having synthesized the experience accumulated by his predecessors, at the very end of the 19th century, made a revolutionary attempt to establish the nosological direction in psychiatry as the basis for understanding all mental pathology.

The main idea of ​​E. Kraepelin was the following hypothesis: “ The course and outcome of the disease strictly correspond to its biological essence". Following K.-L. Kahlbaum, he chose progressive paralysis as a kind of standard and set himself the task of identifying the same sharply defined nosological forms from the amorphous mass of all other clinical material. These ideas were expressed by him in the fourth edition of the textbook “Psychiatry,” published in 1893, although they had not yet been finally formulated by him at that time. However, already in this book, E. Kraepelin argued that periodic mania and circular psychosis are related to each other. E. Kraepelin showed that the course of catatonia has a fatal outcome for patients, and, despite the possibility of a practical cure in some cases, close observation by an experienced psychiatrist always makes it possible to detect the indelible features of the destructive process, which he designated by the term “Verblodung” (“stupidity” ). Among the same processes he included Hecker’s hebephrenia, Dim’s simple dementia, and delusional psychoses with the systematic evolution of Magnan. E. Kraepelin united all this pathology as an independent nosological form of progressive mental illness, which he designated as “dementia praecox.” In terms of course and prognosis, the author contrasted dementia praecox as a disease in which phases of mania and depression alternate, but the “stupidity” characteristic of dementia praecox does not develop.

On November 27, 1898, E. Kraepelin gave a report on the topic: “On the diagnosis and prognosis of dementia precox,” and in 1899, in the VI edition of his "Textbook of Psychiatry" introduced a new name for the circular illness - manic-depressive psychosis. Thus, a dichotomy of two main endogenous diseases was created, differing in prognosis - unfavorable for early dementia and favorable for manic-depressive psychosis. E. Kraepelin identified paranoia as an independent form of the disease, since with it he did not find signs of terminal dementia.

What E. Kraepelin accomplished in the last years of the 19th century produced a radical revolution in clinical psychiatry, as his ideas began to spread in different countries, including Russia, where they were accepted by the majority of psychiatrists (except V.P. Serbsky). Psychiatric nosology has entered the first stage of its development, which determined the prospects for studying scientific problems in the 20th century.

The exceptional scientific erudition of E. Kraepelin allowed him to fully develop very harmonious concepts and create a classification that has retained its significance as an example of logically consistent methodological development. E. Kraepelin's abbreviated classification, the so-called small scheme, formed the basis of the nomenclature adopted for reports in Russian psychiatric hospitals. S.S. When creating the Russian national classification, Korsakov included the main positions in it Kraepelinian taxonomy, which E. Kraepelin looked like this:

• Mental disorders in traumatic brain injury.
• Mental disorders in other organic brain diseases.
• Mental disorders in case of poisoning.
• A. Alcoholism.
• B. Morphinism and others.
• B. Poisoning with poisons due to metabolic disorders (uremia, diabetes, etc.).
• D. Disorders of the functions of the endocrine glands (cretinism, myxedema, etc.)
• Mental disorders in infectious diseases (typhoid, etc.).
• Syphilis of the brain, including tabes. Progressive paralysis of the insane.
• Arteriosclerosis. Presenile and senile mental disorders.
• Genuine epilepsy.
• Schizophrenia (forms of dementia praecox).
• Affective insanity.
• Psychopathy (obsessive states, psychoneuroses, pathological characters).
• Psychogenic reactions, including hysterical reactions (traumatic and war neuroses, fear neuroses, expectations, etc.).
• Paranoia.
• Oligophrenia (idiocy, imbecility, etc.).
• Unclear cases.
• Mentally healthy.

CLASSIFICATION OF MENTAL ILLNESSES IN NEW TIMES

New times (XIX - XX centuries) outlined ways to strengthen nosological positions, which were increasingly improved in competition with the ideas of the concept of “single psychosis”.

The literature on this issue that appeared in the 20th century was extremely extensive, but, as in previous times, ambiguous. It is significant that after E. Kraepelin identified the dichotomy “manic-depressive psychosis - dementia praecox” in 1896 (which in 1911 was designated by E. Bleuler with the term “”), the debate between “nosologists” and supporters of the priority of the concept “symptom complex” intensified again "Taking into account the well-known works of A. Gohe, K. Jaspers, K. Schneider and others. As is known, A. Gohe ironically compared the search for “diseases” in psychiatry, which he called a phantom, with the transfusion of turbid liquid from one vessel to another; E. Kretschmer was equally skeptical about the nosological position. E. Kraepelin repeatedly revised his initial views and in 1920 began to talk about “registers”.

By the middle of the 20th century, “antinosological” attitudes began to be postulated quite clearly again. Thus, M. Bleuler in the reissues of the manual on psychiatry preferred to talk not about diseases, but about axial symptom complexes, identifying “the main forms of mental disorders,” meaning “an organic psychosyndrome that developed as a result of diffuse brain damage”; “endocrine psychosyndrome” caused by diseases of the endocrine system; “acute exogenous reactions” such as the Bongeffer reaction that occur in general somatic diseases; “psychoreactive and psychogenic disorders” caused by mental experiences; “personality variants” (psychopathy and oligophrenia), as well as “endogenous psychoses”.

These basic syndromes indeed form the core of all international classifications adopted in recent decades. For example, ICD-9 was built on the dichotomy “neurosis - psychosis”, approved after the work of V. Cullen (neurosis) and E. Feichtersleben (psychosis). According to E. Feuchtersleben, “every psychosis is at the same time a neurosis,” this was confirmed later by a careful study of the clinical course of diseases such as schizophrenia (endogeny) and organic lesions of the central nervous system (CNS), since neurosis-like ( non-psychotic) pictures are found in almost any disease determined nosologically.

Despite the fact that over the past 100 years, scientists have repeatedly revised the international classification of mental illnesses, this process has been most active in the last 20 years. This is due to the general progress of biomedical research, the development of genetics, psychoimmunology, epidemiology and psychopharmacology, with the help of which it was possible not only to achieve significant advances in the field of treatment of mental illnesses, but also to significantly change the “face of the disease”, and with it the contingent of inpatients and outpatients.

Changes in the forms of the course and symptoms of mental illness associated with the phenomena of pathomorphosis, a significant increase in erased, subclinical manifestations of the disease do not fully explain the need for constant attention of psychiatrists to problems of classification. An ever-increasing number of various psychosocial factors in the context of industrialization and urbanization also has an undoubted influence on the development of mental illness. Often, problems of classification go beyond the scope of our discipline due to the close attention of society to the very concept of “mental illness” and with the development of the so-called anti-psychiatric movement.

CREATION OF AN INTERNATIONAL CLASSIFICATION

Progress in the development of classification, although obvious - the evolution from ICD-6 to ICD-10 (ICD - International Classification of Diseases) - is, in our opinion, not progressive enough. This is largely due to the inconsistency of approaches to a given problem, the eternal dispute between nosological and syndromic principles of classification, as well as a number of little-studied subjective and objective factors. Meanwhile, the first international classification of mental illnesses was proposed by a commission chaired by Auguste Morel (Auguste Benedict Morel, 1809-1873) to the International Congress of Psychiatric Sciences in 1889 in Paris and consisted of 11 categories: mania, melancholia, periodic insanity, progressive periodic insanity, dementia , organic and senile dementia, progressive paralysis, neuroses, toxic insanity, moral and impulsive insanity, idiocy. The prototype of the International Classification of Diseases was the International Classification of Causes of Death, which was approved by the International Statistical Institute in 1893. Since 1900, this classification has been steadily revised every subsequent 10 years, served primarily for statistical purposes and did not include any taxonomy related to mental illness. Between the First and Second World Wars, the Hygiene Service of the League of Nations participated in the creation of the classification by periodically revising the List of Causes of Death and Injury. In 1938, the heading “Disorders of the nervous system and sensory organs” first appeared in this classification (5th revision).

In 1948, responsibility for this procedure was assumed by the World Health Organization (WHO), which carried out the next, sixth revision of the “List of Causes of Death and Injury” and gave it a new name - “Manual for the International Classification of Diseases, Injuries and Causes of Death” (ICD -6). In this manual, a section “Mental, psychoneurological and personality disorders” appeared, which included ten categories of psychoses, nine categories of psychoneuroses and seven categories to designate disorders of character, behavior and mental development. This classification was unanimously accepted by WHO member countries, but for some reason it did not include such concepts as dementia (dementia), some common personality disorders and a number of other disorders. All this led to the fact that, despite the urgent recommendations of the WHO, the classification section for mental illnesses was officially used only in five countries: Great Britain, New Zealand, Finland, Peru and Thailand.

The situation did not immediately cause serious concern, so the corresponding section of ICD-7 (1955) appeared practically without any changes. Meanwhile, the lack of a common language among psychiatrists in the era of the “psychopharmacological revolution” of the 1950s already served as a serious brake on the progress of international scientific research in the fields of psychopharmacology and epidemiological psychiatry. In 1959, WHO commissioned Erwin Stengel, who emigrated from Austria to England, to study the situation surrounding ICD-7, especially since in Great Britain itself, despite the official recognition of ICD-7 by the government, psychiatrists practically ignored it. In his voluminous report, E. Stengel characterized the attitude of psychiatrists in different countries to ICD-7 as “ambivalent, if not cynical,” while emphasizing “almost universal dissatisfaction with the state of psychiatric classification, both national and international.” E. Shtengel came to the conclusion that the impossibility (or unwillingness) to use a unified nomenclature of terms is due to the etiological origin of diagnostic definitions. And it was precisely the different approaches to the problem of etiology among different psychiatric schools that made this problem so intractable. At the same time, Shtengel made a proposal to exclude the etiological principle from the international classification and use diagnostic terms only as functional names characterizing deviations from the norm. The same report recommended creating a glossary of terms in as many languages ​​as possible for use in the ICD.

After the publication and discussion of Stengel's report, WHO began work on ICD-8, and one of the main directions of this project was the creation of a glossary of psychiatric terms. It turned out that due to existing disagreements between various psychiatric schools, this work would require too much time and money, and therefore it was decided to invite each country to first prepare its own version.

The experience of working on national glossaries was certainly very useful in preparing the International Glossary of Terms. ICD-8 was adopted by the WHO General Assembly in 1966 and began to function at the national level in 1968, but the glossary was prepared only in 1974.

Despite the fact that the path to creating the first international classification of mental illnesses was thorny and complicated, the very fact of its appearance and widespread distribution speaks volumes. It certainly reflected the progress made by scientists in the fields of biological psychiatry, psychopharmacology, social psychiatry, as well as in epidemiological research.

In 1975, ICD-9 was adopted, which did not contain radical changes compared to its predecessor, but was supplemented by a glossary, which was the result of six years of work by psychiatrists from 62 countries. Despite its cumbersome and eclectic nature, ICD-9 was an important step forward in classification and was of great practical importance for developing international research and the development of a unified diagnosis. Scientists were not embarrassed that the classification was based on different principles, that it used indicators that were very diverse in nature (etiological, symptomatological, age-related, behavioral, etc.). It was believed that this approach would further contribute to the transition to multi-axial classification, and this would allow diagnostics to be carried out as individually as possible.

The adoption of the American classifications DSM-III and DSM-III-R served as the basis for the development of the latest International Classification ICD-10. It should be noted that this classification was adopted during the Cold War and was not without a certain authoritarianism, since it was introduced under the motto of eliminating “sluggish schizophrenia” from the classification, allegedly artificially constructed in the USSR for political purposes. At the same time, historical realities were not taken into account at all - E. Bleuler’s identification of “latent schizophrenia” back in 1911, the presence of a number of American works on “pseudo-neurotic schizophrenia”, C. Pascal’s description of schizophrenia with psychasthenic-like and hysterical-like symptoms in France, etc.

The taxonomy within ICD-10 differs, firstly, in that compared to ICD-9 it contains three times more descriptors. This circumstance gives it a kind of “inventory” character. In addition, like DSM-III, it is eclectic and does not strictly follow the nosological principle, although it does not exclude such nosological forms as schizophrenia and epilepsy. However, along with the heading “schizophrenia”, it also contains the heading “schizotypal disorders”, the designation of which is very vague, and it is sometimes difficult to draw the line between “schizotypal disorders” and “typical” schizophrenic diseases. In addition, ICD-10 no longer contains such historically established categories of “borderline” psychiatry as neuroses and psychopathy, replaced by the rather amorphous term “personality disorders.”

The originality of this taxonomy objectively reflects a new, pre-paradigmatic period in the development of psychiatry, formed against the background of the historical development of the dichotomy “nosology - symptomatology”, which can be traced since antiquity as an echo of the unspoken polemics of the Kos and Knidos schools, which have survived to this day.

The rubric “somatoform disorders” is quite vague and blurred, which is evident from the vagueness of the very definition of this diagnostic “unit” and the fact that it includes completely heterogeneous pictures in the etiopathogenetic sense. “Dissociative disorders” are usually identified in a clinical sense with schizis, since in the classic work of E. Bleuler (1911) splitting, dissociation, and schizis are considered, along with autism and dimming of emotions, to be the main symptoms of schizophrenia. In ICD-10, “dissociated disorders” mainly describe various variants of hysterical symptoms. Today's practice shows that diagnosis, for example, of a “mild depressive episode” is completely arbitrary and often far-fetched; moreover, such a formulation does not give an idea of ​​the cause of the depressive state (psychogeny? cyclothymia? schizophrenia?). The lack of clarity of the concepts and definitions of ICD-10, its cumbersomeness, the inclusion of various behavioral conditions in the sphere of mental pathology allowed anti-psychiatrists and the anti-psychiatric movement to actively appeal to the world community with a protest against psychiatry, referring primarily, paradoxically, to ICD-10, supposedly legitimizing the assessment of the entire society as “abnormal.”

In our opinion, the foundations of the national psychiatric classification were nevertheless formed taking into account the historical transformation of views on the main mental disorders, which, depending on the etiology and type of course, were considered as relatively independent types of diseases. In general, these “painful units”, which are formed symptom complexes, are quite clearly described in the classifications of S.S. Korsakova (1893), F.E. Rybakova (1914), V.A. Gilyarovsky (1938), A.B. Snezhnevsky, P.A. Najarova (1983).

In the most general form, they can be presented as follows:

1. Exogenous-organic mental diseases:

a) mental disorders due to brain injuries;

b) mental disorders due to infectious diseases;

c) mental disorders due to intoxication of the central nervous system;

d) mental disorders due to brain tumors;

e) mental disorders due to alcoholism and x;

f) symptomatic psychoses associated with somatic non-infectious diseases.

1. Endogenous mental illnesses:

a) schizophrenia (with continuous, paroxysmal and periodic course)

b) cyclophrenia (phasophrenia, affectophrenia); circular and unipolar psychoses; cyclothymia;

c) mixed endogenous psychoses ();

d) paranoia;

e) functional psychoses of late age; involutional melancholia; involutional paranoid.

1. Endogenous-organic mental diseases:

a) epilepsy;

b) degenerative (atrophic) processes of the brain; ; ;

b) mental retardation;

c) distortions of mental development.

It should be noted that the principles of nosological and symptomatological approaches constantly coexist throughout the historical development and formation of basic concepts. According to A. Kronfeld (1940), they will continue to be in unity, which should help improve diagnostics and, most importantly, increase the effectiveness of therapy.

Modern studies devoted to the classification of mental illnesses with an analysis of the approaches of various national schools especially emphasize the importance of biological criteria for distinguishing psychoses, and note the special role of biochemical factors and genetic markers, in particular the dexamethasone test for depression.

Work by P.V. Morozova in this regard became the first and important milestone in the search in this direction, the first multinational work on the topic under consideration, which asserted the priority of the psychopathological-biological systems approach for the classification of psychoses and the use of multicenter international WHO collaboration programs.

The complexity of the problem is largely explained by a change in the basic paradigm, which forces many researchers (F. Roberts, 1997; N. Andreachen, 1997, etc.) to again talk about the crisis in psychiatry. In connection with the successes of biology and molecular genetics, the possibility of using modern methods of molecular genetics and the genetics of quantitative traits for systematic analysis of individual nosological forms of the role of genetic factors in the development of mental illnesses is being considered.

Such a systematic study will make it possible, according to a number of scientists, to study the involvement of genes in the pathogenesis of mental illnesses and, on this basis, to develop new methods for diagnosing and treating mental illnesses. N. Andersen believes that the psychiatry of the future will develop as a biological science, based on neurobiological research data, and the main emphasis will be on a symptomatological approach. In Russia, the works of V.I. Trubnikova, G.P. Panteleeva, E.I. Rogaeva et al. focus on the fact that existing classifications of clinical forms of mental illness do not take into account their genetic heterogeneity. The formation of a DNA collection from patients with endogenous psychoses and the prospects for such studies provide grounds for the successful development of a new field of psychiatry - molecular psychiatry. Unfortunately, most of the work in this area is not carried out in our country. The expansion of molecular genetic research and biological research is aimed at searching for specific mutations in genes that may be involved in the main biochemical metabolic pathways and lead to the discovery of single mutations that cause impairment of certain mental functions.

As V.P. rightly noted. Efroimson, the principles of inheritance demonstrated by the example of nervous diseases have universal significance for clinical genetics. They force the doctor to focus not on the disease as such, but on its specific forms, so it is necessary to be prepared to detect completely different pathologies under the cover of clinically similar symptoms in different families. This may bring psychiatry closer to achieving more accurate knowledge about the etiology of mental illnesses at the gene-molecular and even atomic levels for those conditions that in existing classifications are sometimes considered as independent nosological forms. Now we know that, for example, in some types of patients there is an interest in chromosomes I and XXI, that Huntington’s chorea is determined by DNA diagnostics with precise identification of damage to the short arm of chromosome IV, etc. Such research suggests that in the 21st century, a new approach to the treatment of mental illness may emerge, namely gene therapy, as modern geneticists speak quite confidently about. Of course, at the new level of development of molecular psychiatry, methods of clinical psychopathological diagnosis will also be improved. If we talk about the paradigm of psychiatry of the 21st century, then we need to keep in mind a number of studies devoted to this issue. Thus, in the works of G. Engel from 1977-1988, a biopsychosocial model of psychiatry was formulated and developed, which, according to the author, provides new thinking for the psychiatrist and defines new approaches to understanding the causes of deviations in human behavior and, accordingly, to ensuring health, normal development and success in the treatment of mental illness.

The author justifies the value of the biopsychosocial model against the background of consideration of many philosophical theories - mechanism, dualism, determinism, Newtonian views, as well as the achievements of modern physics.

A. Beigel (1995) believes that the 20th century brought many outstanding changes to psychiatry, each of which dominated for 20 years or more. Among such changes he includes the formation of classical psychiatry by E. Kraepelin and E. Bleuler, Sigmund Freud’s theory on the role of the unconscious, the introduction into practice of effective psychopharmacological agents and the associated removal of a large number of mentally ill patients from the walls of psychiatric hospitals, and at the end of the century such a new phenomenon There was a rapid evolution of psychiatry, driven by discoveries in the field of neuroscience, which revived interest in the etiology and nosology of psychoses.

On the threshold of the new century, according to the author, psychiatrists must develop a worldview that would bring them closer to representatives of other medical disciplines, because only complete mutual understanding will ensure the successful development of psychiatry in the future. A revision of the worldview is possible only with a critical attitude of professionals towards the state of modern psychiatry. In this regard, the authors consider it important to put forward the following fundamental positions for successful advancement into the future: the acceptance by all psychiatrists of the biosocial model of psychiatry, awareness of the importance of its scientific foundations for psychiatry, namely advances in the field of molecular biology, biochemistry, genetics and the development of new methods of brain research; understanding that psychiatry is a medical discipline and its main priority should be the protection of human values ​​and rights, respect for the patient and strengthening his position.

Regarding mental illness, initially in Rus' a concept similar to the European one reigned. They were understood to a large extent as the result of the influence of “supernatural forces”, as possession by an evil or good spirit. The sick were considered holy fools, blessed, and were looked after in monasteries.

Later, when the general level of development began to increase, views on the nature of diseases of the body and brain also changed.

In 1776, the first psychiatric institution in the Russian Empire was opened in Riga.

The first scientific work of Russian psychiatry is considered to be the monograph by M.K. Pequena “On the Preservation of Health and Life,” published in 1812. The author believed that existing life situations play a major role in the occurrence of mental illness, and recommended the use of psychotherapy as a method of eliminating the causes of mental disorders.

In 1835, at the medical faculties of Russian universities, professors and therapists began to teach a separate course in psychiatry, which subsequently began to be taught at special departments: in St. Petersburg (1857), Kazan (1866), Moscow (1887) and other cities of the country.

The network of comfortable psychiatric hospitals expanded significantly after the zemstvo reforms of the 1860s.

Significant influence on the development of psychiatry from the mid-19th century. The evolutionary theory of Ch. Darwin and the further development of the doctrine of reflex by Russian physiologists I.M. Sechenov and I.P. Pavlov had an impact.

Along with this, psychiatry, more than any other field of medicine, was influenced by idealistic movements in philosophy. This was most clearly manifested in Germany, since in German philosophy of the early 19th century. idealistic trends prevailed. In psychiatry, they manifested themselves in the views of the “psychic” school, which defined mental illness as the result of a person’s evil will or sinfulness. In the middle of the 19th century. Another idealistic school of “somatics” came to the fore. Believing that the soul is immortal and cannot be sick, somaticians considered mental illness as a disease of the body, i.e. the material shell of the soul. At the end of the 19th - beginning of the 20th centuries. idealistic trends in psychiatry revived and most widely manifested themselves in psychoanalytic schools.

In Russia, the development of psychiatry was dominated by natural scientific trends, as in other areas of medicine in our country.

A significant contribution to the development of psychiatric science was made by I.M. Balinsky (1824 - 1902), who organized the first department of psychiatry in Russia, the first clinic for mental illness, and the first school of Russian psychiatrists. Balinsky sought to prove the need for a close connection between psychiatry and general somatic clinical disciplines, with physiology. His student, I.P. Merzheevsky (1838 - 1908), an outstanding psychiatrist, neurologist, pathologist, also contributed a lot to the development of domestic and world psychiatry. He studied organic brain damage, alcoholism, epilepsy, and hypnosis.

One of the largest psychiatrists of this period was Sergei Sergeevich Korsakov (1854-1900), one of the founders of the nosological trend in psychiatry, founded at the end of the 19th century. German psychiatrist Emil Kraepelin ( 1856-1926) as opposed to the existing symptomatic direction. S. S. Korsakov was the first to describe a new disease - alcoholic polyneuritis with severe memory disorders (1887, doctoral dissertation “On alcoholic paralysis”), which was already called “Korsakov psychosis” during the author’s lifetime. He was a supporter of freedom for the mentally ill, developed and put into practice a system of keeping them in bed and monitoring them at home, and paid great attention to the issues of preventing mental illness and organizing psychiatric care. His Course in Psychiatry (1893) is considered a classic and has been reprinted several times.

V.Kh. Kandinsky, P.P. Kashchenko, V.P. Serbsky, P.B. Gannushkin, V.M. Bekhterev also made a great contribution to the development of psychiatry in the 20th century. Along with traditional tasks, psychiatrists have paid great attention to helping children suffering from various mental illnesses. Since the 1920s, neuropsychiatric dispensaries began to open. Hospital bed capacity increased, paraclinical research methods and modern treatment methods were introduced. The technical and material support of psychiatric institutions and patient care have improved. A number of research institutes were organized (in Moscow, Leningrad, Kharkov, Tbilisi).

The importance of psychiatrists was great during the Great Patriotic War and after its end.

In the post-war period, further study of topical issues related to the organization of psychiatry, problems of the epidemiology of mental illness, the biological basis of neuropsychiatric disorders, forensic psychiatry and narcology, treatment and rehabilitation of the mentally ill took place.

Over many years of working in psychiatry, you get used to some particularly stable stereotypes of patient behavior. One of these is the custom, whether we are talking about discharge from a hospital or the end of a course of outpatient treatment, to say goodbye forever. And this behavior is very understandable: who, tell me, wants to return again and again to these walls, always yellow, no matter what their current color? And you, of course, know that

in most cases, a person will come again sooner or later, he’s just so ardently and sincerely convinced that this time was certainly the last or even the only one that it’s a pity to dissuade him.

But in fact, our psychiatric illness is a persistent thing, and once it has clung to it, it is reluctant to let go. If he lets go at all. No, of course, there are one-time episodes - for example, a reaction to some events or circumstances. Neurotic, depressive, even with hallucinations or delusions - there is still a majority of chances for a complete recovery.

Or delirium tremens. It flows brightly and is remembered by everyone around him - and there are not so many repeated cases, apparently, a person gets scared well, tries in the future not to get drunk with little green men, devils, or whatever the heraldic animal of drug addiction specialists brings with him.

Other mental illnesses, for the most part, tend either to occur constantly, or to worsen or decompensate from time to time. Even such a group as neuroses. And it seems that, from the point of view of psychiatry, there is nothing fatal: exacerbations are not of such a formidable nature as in psychosis, and do not lead to madness, and do not make one disabled - unless the patient pays for this disability himself. And certainly no one has died from neurosis yet. But how tired it is to suffer from this very neurosis! Or, as it is now fashionable to put it, the quality of life is noticeably reduced. So a person asks, once again experiencing all the delights of a decompensated neurotic state: doctor, is neurosis really incurable?

Unfortunately, as the same long-term practice shows, and not only mine, yes, it is incurable. And he stubbornly strives to return. Why is that?

The main reason lies in the very essence of neurosis. The fact is that it was once considered a psychogenic disease, that is, one that is caused not by brain damage or a malfunction of other systems, but by psychological reasons. In particular, conflicts that are significant for a particular person and, accordingly, predetermine the development of one or another (but for a specific person - strictly defined) type of neurosis.

For example, neurasthenia was considered to be characterized by a conflict between a completely intact, but tired and exhausted personality, and the external unfavorable circumstances and adversities that befell her, and to such an extent that it is not possible to overcome them; Bolivar cannot withstand two.

For hysterical neurosis, the conflict between the childishly impatient desires of the monstrously egocentric “I” and the impossibility of getting it all right now is considered significant. For hypochondriacal neurosis... well, you remember the quote from “The Formula of Love”: hypochondria is a cruel lust that keeps the spirit in a continuous sad state. By the way, almost to the point: the conflict between secret desires, but condemned by moral norms, and the need to suppress them was considered significant for hypochondria.

Accordingly, it was once believed that it was enough to reduce the severity of neurosis with medications, and then involve psychotherapy in order to reveal the essence of the current conflict and make it irrelevant for the patient - and a cure would occur. Or at least a long remission. Until the next brewing conflict.

Only it turned out that this debriefing was not enough for restitutio ad integrum. And further searches revealed that each type of neurosis has its own special... let's say, genetic firmware. It determines the personality type, character traits, and characteristics of mental and biochemical reactions.

On the one hand, it has become clearer why, say, a neurasthenic has a deeply violet type of conflict that successfully cripples a hypochondriac: he is simply not genetically designed to react sharply to such things. What kind of lust is this - you have to plow, overcome and burden yourself with new problems!

On the other hand, genes are stable things. Find me a psychotherapist who knows how to persuade the genetic program to be ashamed and correct itself - and I will go build him a temple and become an apostle. Well, we don’t yet know how to work with genes - at least, so subtly and with such a predictable result, and without dangerous consequences - to tackle the problem from this side as well. So what to do?

There is, it turns out, one more point that both psychiatrists and their neurotic patients know or guess about, but which somehow always escapes the focus of their attention. And it concerns high spheres, the level of worldview. We are talking about the goals that a person sets for himself. Suddenly?

Meanwhile, if the doctor carefully questions, and the patient remembers it well, it turns out that (if we consider a lot of cases and compile some semblance of statistics) there are moments in life when neurosis is not remembered, even if there were episodes before. And these are precisely the moments when a person had a goal that he wanted to achieve with all his soul. Build a house there, raise a son, plant a tree. Well, or something else fundamental, strategic, from the point of view of your own life. For everyone - their own, but their own, so that there is direct light in the window, so that “I see the goal - I see no obstacles.”

And while there was movement towards this goal - albeit with all the difficulties and hassle - the person did not even remember about neurosis. What kind of neurosis is this? No time, I’m busy making dreams come true!

But when a goal is achieved or lost, and a new one is not set, when there is a lull in plans, then this vacuum begins to be filled with all sorts of ailments and worries. Like a top that lost momentum and staggered. And so, instead of resting on the laurels of what has been achieved or enjoying the pause before the next ascent, a person is forced to waste nerves, time and energy on coping with neurosis.

The conclusion seems to be simple: you need constant movement towards some next goal. But there is, as always, a nuance. Not a single psychotherapist, not a single psychiatrist can take it and say: here’s a new goal for you, dear comrade, move in the indicated direction, you have a smartphone with a navigator, you won’t get lost.

Will not work. Why? It's not enough to suggest. It is necessary for a person to make a decision himself, and not just make it, but with all his soul, including this point in his worldview, as another - his own - directive. But this cannot be done from the outside, which, on the one hand, is for the best, otherwise it would be too easy to control us all, but on the other hand, no one will do this work for a person.