Functional visceral pathology (etiopathogenetic formation). Nonspecific approach in psychosomatics The theory of cortico-visceral pathology in psychosomatics

Cortico-visceral theory of the formation of internal diseases Konstantin Mikhailovich Bykova, Ivan Terentyevich Kurtsin, which served as a development of the previous theory of Ivan Petrovich Pavlov, and more modern models:
1) imprinting of Konrad Lorenz,
2) learned helplessness M. Seligman.

Physiological model of intrapsychological conflict was created by Ivan Petrovich Pavlov and his students in the 20-30s of the 20th century. Conducting experiments on animals, they discovered that the cause of somatic disorders is a “collision” of reflex processes. In other words, activation, using the same conditioned stimulus, of two contradictory unconditioned reflexes, for example, such as food and defensive.

According to this theory, the basis of psychosomatic disorders is a “clash” of conditioned reflexes, which contains logically insoluble contradictions.

Another physiological mechanism of psychological breakdowns- formation of “pathological” conditioned reflexes. For example, bronchospasm in a patient with bronchial asthma, which occurs only when seeing an image of an object that causes an allergy, and not when inhaling an allergen.

Practical implementation of the cortico-visceral theory conditioned reflex therapy became, that is, the correction of pathological conditioned reflexes by combining them with unconditioned reflexes. Back in the 30s, one of the first areas where conditioned reflex therapy was used was the treatment of alcoholism through the formation of a conditioned reflex vomiting reaction, according to Izmail Fedorovich Sluchevsky.

The cortico-visceral theory explains the origin of internal (psychosomatic) diseases as follows: the cerebral cortex, using the mechanisms of conditioned reflexes, directly affects the state of the internal organs, which causes an imbalance of excitation and inhibition at the level of the brain cortex. A nonspecific method of treating internal diseases using long-term artificial sleep was proposed.

From the position of body-oriented psychocorrection, awareness of bodily sensations associated with a particular internal organ and their elaboration contributes to the normalization of the functions of this organ. This effect is based on the coordination of the activity of the somato- and viscerosensory zones of the cortex and its frontal areas.

In humans, conditioned reflexes can be formed both at a conscious and unconscious level. The most important practical consequence of this theoretical model is that at the subcortical, subconscious level, a reflex act can be carried out independently of the cortical, conscious level, and much faster, since fewer “instances” are involved.

In a multi-level, hierarchical management system, the “tops” are inert, and are the last to learn about what happened and only then pretend that all positive processes occur thanks to their management, and negative ones - despite their disapproval. Usually, a habitual, conditioned reflex act occurs first, and only then does awareness arise.

Emotions are also conditioned reflexes that operate on an unconscious level and become conscious at a later stage. Recall on the theory of the origin of emotions according to James Lange: First, a reaction occurs at the level of the cortex of the right hemisphere of the brain and the limbic-reticular system, then vegetative accompaniment begins, that is, muscle tension caused by emotions, heartbeat and breathing increase, which is significant for the awareness of emotions emphasized. When these physiological changes are recognized by the “conscious” part of the brain, a properly human emotion arises.

Initially, we react to the situation around us subconsciously, the reaction can occur in tenths of a second, or, extended over time, when the emotion matures latently. Initially, emotionally-induced changes in the state of internal organs and muscles occur, and only by directing attention to them do we become aware of our feelings. But, if attention is not focused on this, then emotions create a background that manifests itself in well-being and mood.

Stereotypes of emotional response in standard situations- these are conditioned reflex reactions that are formed, as a rule, in early childhood, switched to a subconscious mode of functioning, and became automatic. For example, in an experiment on retraining motor skills: the subject, in response to a conditioned signal, continues to repeat the same automatic movement - a defensive reflex, despite attempts to stop it by force of will. The motor reaction does not have time to submit to conscious control, since subconscious control mechanisms work faster. To retrain a person, it is necessary to make a mostly subconscious reaction more conscious. To do this, a person needs to be helped to return to the “right hemisphere” state, associated with childhood, when the reflex reaction was just being formed. This is a return to the “primary” perception of the situation, when a person encounters significant information for the first time.

CORTIC-VISCERAL THEORY

Thanks to the fundamental research of I.M. Sechenov, I.P. Pavlov, N.E. Vvedensky, the corticovisceral theory was developed, the basic principles of which were developed by K.M. Bykov and I.T. Kurtsin in the 1960s. This theory made its own adjustments to the theory of the pathogenesis of internal diseases and changed the attitude towards psychosomatics in general.

The basic principles of the cortico-visceral theory can be presented as follows:

1. Participation of the mechanisms of the cerebral cortex in the reproduction of pathological reactions of the body according to the type of conditioned reflex.

2. The role of a neurotic state in the pathogenesis of corticovisceral diseases. The neurotic state is caused by the processes of excitation, inhibition and mobility of the processes of the cerebral cortex.

I.P. Pavlov discovered the functional interaction between internal organs and the cerebral cortex. In general, the basic principles of the cortico-visceral theory have significantly changed the view of psychogenics and their influence on the etiology and pathogenesis of a number of diseases. The intermediaries between the cerebral cortex and the internal organs are the limbic-reticular, autonomic and endocrine systems. And the main transmitters are cortisol, thyroxine and adrenaline. It follows that the emotional background of a person, influencing the nervous and hormonal systems, triggers biochemical processes that are reflected at the bodily level.

Developments in the field of reflexology by I.M. Sechenov, which were developed in the teachings of I.P. Pavlov on higher nervous activity, allow us to assert that through conditioned reflex mechanisms any of the autonomic functions can arise and be changed, incl. and in the department of endocrine glands, in the activity of the blood system, metabolism, etc. Thus, thanks to the cortico-visceral theory, today we can talk about the somatoform nature of the following diseases: secretory disorders of the gastrointestinal tract, stomach, liver, intestines, pancreas, endocrine disorders such as diabetes mellitus, thyrotoxicosis, impotence, etc. Diseases with organic manifestations: duodenal ulcer, atherosclerosis, hypertension and hypotension, angina pectoris, bronchial asthma, myocardial infarction.

From the point of view of symptom formation, the following should be noted - the formation of conditioned reflexes in a person can be formed at two levels, on the conscious and unconscious. Moreover, the reflex process at the unconscious (subcortical) level can be formed independently of the conscious (cortical) one. And since the formation of a reflex at the unconscious level requires fewer “instances,” it is formed faster than at the conscious level. Here (in the unconscious) a mechanism for the formation of emotions is formed, which are recognized by a person as the final authority of this mechanism. According to the theory of James Lange: initially a reaction occurs at the level of the cortex of the right hemisphere of the brain and the limbic-reticular system, then the autonomic system is activated, which manifests itself in muscle reactions, as a rule, the heartbeat and breathing become more frequent, which leads to awareness of emotions. Once physiological changes are recognized by the cerebral cortex, emotion arises.

The corticovisceral theory has been repeatedly criticized due to its lack of specificity. The main doubt was that this theory substantiated the etiopathogenesis of diseases of different nature and organs of different functionality within the same mental mechanisms. Another stumbling block is ignoring complex biochemical and hormonal processes.

Basic principles of corticovisceral pathology. The cortico-visceral theory of disease pathogenesis was developed by Soviet researchers (K. M. Bykov, I. T. Kurtsin, etc.) and is based on the reflex theory of I. M. Sechenov, I. P. Pavlov and N. E. Vvedensky.

The basic principles of corticovisceral pathology (K. M. Bykov and I. T. Kurtsin, 1960) are as follows.

1. The possibility of reproducing some pathological reactions through the mechanism of a conditioned reflex, which shows the undoubted participation of the cerebral cortex in their pathogenesis. Indeed, after repeated injections of bulbokapkin into animals in a certain experimental setting, A. O. Dolin observed, under the influence only of the experimental setting, the emergence of a cataleptic state characteristic of the action of this poison. In the laboratory of A.D. Speransky, the possibility of conditioned reflex reproduction of anaphylactic shock was proven. There are many facts in the literature indicating the possibility of conditioned reflex reproduction of relapses of other pathological processes.
2. A major role in the pathogenesis of corticovisceral diseases belongs to the neurotic state.

As is known, the occurrence of a neurotic state is associated with overstrain of the excitatory or inhibitory processes of the cerebral cortex, as well as their mobility. Overstrain of the irritative process occurs in animals under the influence of agents of great strength or when using conditioned stimuli that are too complex for the animal’s nervous system. Overstrain of the inhibitory process occurs when the period of action of negative conditioned stimuli is prolonged. Finally, impaired mobility is observed with a continuous change from an inhibitory state to an irritable one or, conversely, with a change in the dynamic stereotype.

Some foreign critics of I.P. Pavlov, questioning his research, pointed out that the animals in the pen were to a certain extent fixed. Therefore, in their opinion, the data obtained cannot be transferred to normal conditions. However, back in 1924 in the laboratory of I. II. Pavlov, dogs that were outside the experimental setting developed a neurotic state as a result of flooding. Later, the students of I. P. Pavlov (P. S. Kupalov and others) proved the possibility of studying higher nervous activity and thereby obtaining neuroses in conditions of free behavior of animals.

"Guide to Pathological Physiology",
I.R.Petrov, A.M.Chernukh

The history of mankind is inextricably linked with the history of wars. In parallel with the improvement of destructive weapons and the aggravation of wounds, experience in treating the wounded was accumulated. The presence of visceral pathology in injuries was noted by surgeons back in the 17th-18th centuries. They described the general reaction of the body to severe mechanical damage, the development of a cardiac aneurysm after a chest contusion, pneumonia, pleurisy, pyothorax, and lung abscess as complications of chest wounds.
In the middle of the 19th century, N.I. Pirogov, summarizing his own observations and the experience gained by surgeons in treating the wounded, laid the foundations for the doctrine of the pathology of internal organs during trauma. In “The Beginnings of General Military Field Surgery” (1865), he wrote that “... after traumatic injuries, local suffering of internal organs is often noticed, accompanied by fever or without it. The most common of these include blenorrhea of ​​the intestinal canal and albuminorrhea.” He was the first to draw doctors' attention to the fact that the outcome of a wound depends not only on the result of the interaction between the wounding projectile and the macroorganism, but also on the general reactions and complications that accompany the injury and turn the local wound process into a general disease, and the wounded into a patient. In development of the stated points, he described the clinical picture of pulmonary hemorrhages, pointed out the uniqueness of the course of “acute tuberculosis” in the wounded, described the clinical picture of “traumatic consumption”, and developed practical recommendations for the diagnosis and treatment of pathology of internal organs during trauma in the conditions of the evacuation system of that time.

During the Russian-Turkish War (1877-1878), S.P. Botkin, being the chief physician of the headquarters, actually acted as a non-staff chief therapist for the army. Taking direct part in the diagnostic and treatment process, he emphasized the need for constant contact between surgeons and therapists in everyday work, drawing attention to the fact that, regardless of the location of the injury, each of the wounded should be considered as a patient, with his own “clinical and physiological characteristics.”
The increase in military conflicts in the first half of the 20th century led to a significant increase in the relevance of the problem of visceral pathology in the wounded. Thus, during the fighting at Lake Khasan, M.P. Akhutin discovered pneumonia in 7.5% of those wounded in the chest, and during the war with the White Finns (winter period) - in 18%.
During the Great Patriotic War, more than 400 works were published on the clinical manifestations and treatment of visceral pathology in the wounded. Based on the analysis of these materials, N. S. Molchanov for the first time formulated the main provisions of a new chapter of internal medicine - the doctrine of the pathology of internal organs during trauma.
The intensive development of resuscitation in the post-war years made it possible to significantly increase the survival rate of victims with severe injuries and wounds, in whom various changes in the body that were not directly related to the injury began to be recorded in the early stages. In this regard, the theory of hypovolemic shock was put forward, which for a long time served as a conceptual model explaining the variety of organ pathologies at different times after injury.
However, the experience of the Korean and Vietnam Wars has shown that not all changes in internal organs after injury can be explained from the perspective of this theory. In 1973, Tiney formulated the concept of multiple organ failure, the mechanism of which can be broadly represented as follows. Severe injuries are accompanied by blood loss and the release of cell destruction products, microthrombi, and fat droplets from tissues suffering from hypoxia, which acquire the properties of microemboli. Embolization occurs first of the pulmonary capillaries, and after emboli pass through the pulmonary circulation - the capillaries of the kidneys, liver, heart and brain. Massive blood loss with disseminated intravascular coagulation aggravates microembolic processes and contributes to disruption of capillary circulation, increasing blood shunting in vital organs. If there is a discrepancy between pathological and protective-adaptive processes, the functions of organs are disrupted. Mono-organ failure develops first, and then multi-organ failure.
Further study of the visceral consequences of both combat trauma and peacetime trauma is associated with the names of M. M. Kirillov, E. V. Gembitsky, F. I. Komarov, A. A. Novitsky, etc. The influence of previous and concomitant internal diseases was studied organs (chronic bronchitis, coronary heart disease, hypertension, etc.) on the course of the wound process. A fundamentally new direction was the study of the impact on the body of unfavorable factors of military labor and environmentally caused visceral pathology. Such conditions include personality neuroticism, fatigue, dehydration syndrome, overheating, hypothermia, trophic insufficiency, development of secondary immunodeficiency, etc. Much attention was paid to the study of intercurrent pathology - infectious diseases, consequences of surgical treatment, drug diseases.
The determinism and cause-and-effect relationship between the processes developing in the body at different periods after injury and injury were the theoretical prerequisites for changing the concept of traumatic shock to the concept of traumatic disease. According to the definition of I. I. Deryabin and S. A. Seleznev, a traumatic disease is a set of effects of damage and compensatory reactions of the body that determine its life activity from the moment of injury to recovery or death.
The main reason for the development of visceral complications in the wounded is the injury itself, its nature, location and severity. The general reactions of the body during injury are largely determined by reflex influences from the area of ​​the affected tissues, mediated through the endocrine and central nervous systems. In addition, blood loss and associated disorders of central hemodynamics and microcirculation are of great importance.
tions. In the future, wound infection plays a significant role in the pathogenesis of diseases of internal organs, which in some cases causes the development of complications (endocarditis, nephritis, pneumonia, etc.).
The hypoxia often observed in the wounded is of significant importance. Dystrophic changes in parenchymal organs are largely associated with anemia and hypoxia.
Currently, the course of a traumatic disease is divided into four periods:

1. Acute (shock) - first hours (day).
2. The period of unstable adaptation and early complications is up to 7 days. Its duration is determined by the degree and duration of violations of specific functions of damaged organs and deviations of the leading parameters of homeostasis, which creates conditions for the development of early (infectious) complications.
3. The period of stable adaptation lasts several days or weeks.
4. The period of recovery (rehabilitation) - its duration depends on the severity of the injury and the course of the traumatic illness and lasts weeks and months.

Primary Secondary

Along with this, numerous studies in peacetime injuries (wounds), conducted in clinical settings using more subtle methods, have shown that even with mild injuries, significant changes in the functions of the most reactive systems of the body (neuroendocrine, external respiration, blood circulation) are recorded, requiring special corrections.
All this dictates the need for a more in-depth study of the mechanisms of occurrence of pathological processes at different degrees of severity of the lesion, the active participation of therapists from the early stages of treatment of the wounded and especially during the period of recovery and rehabilitation of the victims.
The existing classification of pathological changes in internal organs in the wounded [Klyachkin L.M., Kirillov M.M., 1972] systematizes the changes they have at different stages of the disease, identifies pathogenetically caused changes and diseases that do not have a direct connection with injury, and also contributes to optimization of therapeutic care and individualization of the approach to treating the wounded.
The basis of the proposed classification is the consistent division of pathological conditions and processes observed in the wounded, firstly, according to the principle of their pathogenetic connection with injury, and secondly, according to the involvement of individual organs or systems and the occurrence of general disease syndromes.
The main general pathological syndromes - traumatic shock, purulent-resorptive fever, wound sepsis, wound exhaustion are described in sufficient detail in the course of military field surgery. This section will discuss in detail organopathological changes in the wounded.
Primary changes arise as a consequence of direct damage to one or another organ during injury (contusion of the heart, kidneys, barotrauma of the lungs; pulmonitis from a gunshot wound to the lung, etc.). Subsequently, primary changes can be transformed into the development of inflammatory, purulent-septic, dystrophic, sclerotic processes.
As firearms improve, local (primary) changes in organs and systems become significantly more severe, and the range of so-called secondary changes, that is, damage to organs and systems outside the wound zone, becomes much wider.
These changes have a definite, albeit indirect, connection with trauma. Changes in intact organs are caused by disturbances in the systems of neuro-endocrine regulation, external respiration and blood circulation, the development of secondary hypoxia and endotoxemia, wound infection, thromboembolism, metabolic disorders, etc.
Diseases that are not pathogenetically related to trauma include previous and intercurrent diseases. The former, in turn, are divided into background diseases and environmentally caused types of pathology. Any chronic diseases (peptic ulcer of the stomach and duodenum, bronchial asthma, chronic ischemic heart disease, etc.) can be a background to injury. It is necessary to take into account the possible features of their pathogenetic interaction with the wound process (mutual burden syndrome). In practice, two subgroups of background diseases can be distinguished - with exacerbation and without exacerbation after injury.
A group of pathological conditions that are based on changes in the body’s reactivity caused by exposure to unfavorable environmental factors and everyday activities is of independent importance. Extreme environmental influences, sharp fluctuations in air temperature, atmospheric pressure, oxygen content, dust, humidity, and others can lead to pronounced disturbances in homeostasis, overstrain of the adaptation process and its disruption, which creates an extremely unfavorable background for the course of the wound process and causes changes in clinical manifestations. The development of such pathological conditions as overheating or hypothermia, body weight deficiency, nutritional dystrophy, dehydration, desalination, mountain sickness, etc. is possible.
Intercurrent diseases are mainly acute infectious diseases (epidemic, sporadic, in-hospital) that aggravate the course of a traumatic illness in a wounded person. The most typical among them are acute respiratory viral infections and viral hepatitis. Intercurrent diseases also include allergic
diseases, including drug-induced diseases. The absence of their pathogenetic connection with the wound process should be understood conditionally: without being causally determined by the latter, intercurrent diseases can nevertheless significantly aggravate its course and outcome.
Thus, a complex of secondary pathology syndromes occurring against the background of mechanical trauma in conditions of disruption of regulatory and trophic processes is the essence of a traumatic disease.

In the complex hierarchy of a vertically organized regulatory system, each “floor” has an important place. However, it was the central nervous system that subordinated other links, heading the entire regulatory apparatus. Its effect on internal organs, including the heart and blood vessels, is mediated in two ways (Fig. 1).

Functional visceral pathology (etiopathogenetic formation).

The first path is transpituitary, first through the releasing (realizing) factors of the hypothalamus, then the tropic hormones of the pituitary gland and, finally, the corresponding hormones of the peripheral endocrine glands. The second path is parapituitary: through the channels of neuro-vegetative connections between the center and the periphery.

If the mechanisms of humoral hormonal regulation, in the words of A.F. Samoilov (1960), act in accordance with the slogan “everyone - everyone - everyone!”, then the influence of the autonomic nervous system is carried out according to the principle of “a letter with an address”, i.e. more substantively, and therefore clearly.

G. Bergman (1936), the most prominent representative of the functional trend in medicine of the 30s, wrote about this: “... a functional disorder covers the humoral and neural together,” but “the neural is clinically more visible.”

The formation of visceral functional disorders is mostly caused by a defect in the neurovegetative regulatory pathway and is topographically associated with dysfunction of suprasegmental (subcortical-cortical) autonomic formations.

As emphasized by A.M.Vein et al. (1981), “a feature of the modern stage is the approach to vegetative-visceral disorders as psycho-vegetative ones. We are talking about a combination of emotional and vegetative disorders that arise either simultaneously or in a certain sequence” (our discharge - A.M.).

Accordingly, the formation of functional visceral pathology can be expressed by the following structure: psychogenic (emotional) disorders - "autonomic dysfunction -> somatic disorders. Thus, functional diseases of internal organs in general and the heart in particular are a consequence and an integral part of neurosis, i.e. represent his “somatic response”.

According to the ideas of I.P. Pavlov, neurosis or a breakdown of higher nervous activity develops as a result of a collision (“mistake”) and overstrain of the cortical processes of excitation and inhibition. This interpretation of neurosis has become textbook, although, as I.P. Pavlov himself admitted, it had a significant gap. If all the paths of the process of excitation as one of the “fighting” parties were accurately traced, it remained unclear how it arises and what constitutes inhibition.

On this occasion, I.P. Pavlov wrote: “No matter how significant our experimental material is, it is clearly insufficient to form a general definite idea of ​​​​inhibition and its relationship to irritation.” At the end of 1934, i.e. shortly before his death, at one of his famous clinical meetings, he spoke even more categorically: “... it is significant that at present we do not know at all what internal inhibition is.”

And he continued: “This is a damned question - the relationship between excitation and inhibition... there is no solution to it.” A quarter of a century later, P.K. Anokhin tried to answer it. In 1958, his monograph “Internal inhibition as a problem of physiology” was published, which contained a number of provisions significantly different from the generally accepted ones.

Some orthodox physiologists perceived them almost as an encroachment on the teachings of I.P. Pavlov. The author himself did not think so, believing that he was following the behest of his teacher, who more than once called for a “decisive attack” on the “damned question” mentioned above.

According to P.K. Anokhin, internal inhibition never acts as an independent nervous process, but arises only as a result of a collision of two systems of excitations and is a means by which a stronger (dominant) excitation suppresses a weaker one, thereby eliminating “ activities that are unnecessary or harmful at the moment.”

Thus, he contrasted the classical formula of “the struggle of excitation and inhibition” as the main cortical processes, “having their own individuality and, to some extent, independence of course,” with another - “the struggle of two excitation systems” with the help of “a universal weapon - inhibition.”

“Excitement,” writes P.K. Anokhin, “can never fight inhibition, because the latter is the result of excitation and immediately disappears as soon as the excitation that gave rise to it has disappeared.”

P.K. Anokhin’s concept captivates with its “tangibility,” vitality, and closeness to clinical reality. It moves the question of internal inhibition from a theoretical one, relating only to physiological laboratories, to a practical one.

In fact, if you think about it, the collision of multidirectional excitations (impulses) and the conflict-free suppression of one of them by another, stronger system of motivations is a universal pattern of our everyday life. Only thanks to this, orderly human behavior and purposeful actions that meet the “relevance of the moment” become possible.

How can one disagree with A.A. Ukhtomsky, who argued that “it is generally difficult to imagine a non-dominant state of the central nervous system, since at each specific moment the body performs some kind of activity.” Overstrain of higher nervous activity, as P.K. Anokhin believes, occurs when competing excitations, for some reason, cannot inhibit each other and, alternately gaining “victories,” are mutually potentiated and stabilized at a new, higher energy level of excitability . A conflict situation arises that persists for a long time - a state of “explosiveness” or readiness for an emotional breakdown.

Although I.P. Pavlov never considered the genesis of inhibition, like neurosis, from the standpoint of the “struggle” of two excitations, he was close to this when he said: “I am interested in a strong irritable process, and circumstances urgently require me to slow it down. Then it becomes difficult for me...”

Personal conflicts leading to neurosis most often develop precisely according to this type: in one or another life collision, some human impulse comes into conflict with another system of excitations, i.e. with the very “circumstances” that for some reason do not allow its implementation.

This leads to a practical conclusion: if in a particular case of neurosis it is possible to hide the content of conflicting excitations, then by strengthening one and weakening the other, one can reduce nervous tension - the other side of the conflict. As a matter of fact, this is the essence and ultimate goal of psychotherapy or, in the words of P.K. Anokhin, “education of inhibition.”

It is no coincidence that definitions of neurosis acquired etiopathogenetic and clinical overtones. Let us present one of them (V.A. Raisky, 1982) in a slightly edited form. Neurosis is a psychogenic (usually conflict-related) functional neuropsychic disorder that occurs under the influence of traumatic stimuli and manifests itself as pathology in the sphere of emotions in the absence of psychotic disorders, i.e. a critical attitude towards the disease is maintained and the ability to manage one’s behavior is not lost.

There are three clinical forms of neuroses: neurasthenia, hysteria and obsessive-compulsive neurosis. 90% of all cases of neuroses occur due to neurasthenia (Votchal B.E., 1965; Svyadoshch A.M., 1982), which precisely serves as the pathogenetic basis of NCA. Neurasthenia was identified as an independent nosological unit by W. Beard in 1880.

Its main distinguishing feature is considered to be “irritable weakness” - easy excitability and rapid exhaustion of patients. V.N. Myasishchev Reveals the essence of the disease as follows: “With neurasthenia, the source of the disease is that the person is unable to cope with the task facing him, even with the most active desire to resolve it.

The contradiction lies in the relative discrepancy between the capabilities or means of the individual and the requirements of reality. Unable to find the right solution with maximum effort, a person stops coping with work and develops a painful condition.”

It is impossible not to notice that in this definition the same “struggle” of two systems of excitations is clearly visible: “an active desire to solve a problem”, on the one hand, and “requirements of reality”, on the other. A. Păunescu-Podeanu, deviating from dry formulations, calls neurasthenia “a disease of an exhausted, exhausted brain”, qualifies it as “a neurosis of tense people, overwhelmed with worries and anxiety, lashed by lack of time”, i.e. "time squeeze neurosis"

In this he sees its fundamental difference from hysteria - “the neurosis of prosperous people who can waste time and are not involved in the struggle with life,” i.e. “neurosis of free, empty time”2. The cause of neurasthenia in general and NCA in particular are psycho-emotional stimuli (psychogenies) that cause negative emotions.

Emotions are mental processes, the content of which is a person’s attitude to the world around him, his own health, behavior and occupation.

They are characterized by such polar states as pleasure or disgust, fear or peace, anger or joy, excitement or release, acceptance or rejection of the situation as a whole. Consequently, the emotional stimulus with its edge is directed towards consciousness. It requires comprehension and an adequate response, and therefore “emotion is an integral part of understanding.”

The phrase of J. Hassett contains a lot of meaning: “Emotions add flavor to life and serve as the source of all life’s dramas.” The scale of psychogenies leading to neurosis is extensive and unequal in value terms: from overstrain due to persistent intellectual activity, prompted by lofty thoughts, to the so-called primitive emotions.

These include everyday, family and other troubles, love troubles, various kinds of frustrations (dissatisfaction), for example sexual ones. Of great importance are the “silent conflicts” smoldering in the depths of consciousness, caused by the clash between needs and possibilities, desire and decency, motives and rules of society, etc., in a word, everything that I.P. Pavlov aptly called “the deceptions of life” .

Particularly pathogenic are situations that are characterized by relative intractability, putting a person before the need to make an alternative decision: “either-or.” From the standpoint of physiology, we are talking about the “mistake” of two highly competitive excitations, when the strengthening of one (inhibitory excitation) induces the other (inhibited excitation) - a struggle of arguments and counterarguments.

Trying unsuccessfully to slow each other down, they stabilize, maintaining a high degree of psycho-emotional tension. One cannot but agree with R. Dubos that “the need to make a choice is perhaps the most characteristic feature of conscious human life. This is its greatest advantage, but also its greatest burden.”

The source of psychogenesis can be not only external (exteroceptive), but also internal (interoceptive) stimuli. We are talking about secondary psycho-emotional disorders associated with the peculiarities of perception, experience and self-esteem of organic pathology, i.e. about the so-called somatogenic neurosis.

It is clear that a person cannot help but be depressed by the deterioration in the quality of life caused by any disease, be it a previous myocardial infarction, repeated bronchospasm attacks, skin diseases, problems with the gastrointestinal tract, etc.

Someone’s expression that “the rectum determines a person’s state of mind” is by no means a caricature. Even the outstanding French thinker Francois Voltaire (1694-1778) did not ignore this. With his characteristic brilliance, he wrote: “How blessed by nature are those people who empty their bowels every day with the same ease as they expectorate sputum in the morning.

“No” in their mouth sounds much more kind and helpful than “yes” in the mouth of a person suffering from constipation.” It is appropriate to recall the “hemorrhoidal character” described by Hippocrates and the common literary type of the “bilious man.” It is no coincidence that the term “hypochondria,” which refers to a painful fixation on one’s health, comes from the Latin word “hypochondricus” - hypochondrium.

As B.E. Votchal wrote, every person who constantly suffers from his illness “involuntarily acquires neurotic traits.” In turn, somatogenically caused psycho-emotional disorders boomerang on visceral symptoms, exacerbating old ones or giving rise to new ones.

A “vicious circle” or the well-known image of a “snake biting its own tail” is created. The formation of emotions is associated with the activity of the limbic system of the brain (limbic-reticular complex), which includes a large group of subcortical formations concentrated around the brain stem (Vein A.M. et al., 1981; Magun G., 1960; Lindsley D., 1960; Cellhorn E., 1961).

On the one hand, the limbic system has neuronal connections with the “new” cortex, in particular the “orbital cortex,” and takes an active part in organizing behavioral and other conscious acts. This is well illustrated by the words of I.P. Pavlov: “The main impulse for the activity of the cortex comes from the subcortex. If these emotions are excluded, the cortex is deprived of its main source of strength.”

I.P. Pavlov’s idea of ​​the “bright spot of consciousness” is also associated with the function of the limbic system. Explaining this, P.V. Simonov writes: “The bright spot of consciousness,” like a spotlight, “highlights” exactly those phenomena in the surrounding world that are currently of greatest importance to the organism.” On the other hand, the higher autonomic centers are concentrated in the limbic system, mainly in the hypothalamus.

Consequently, it is closely connected with internal organs and is endowed with the functions of regulation and control over their activities. Thus, if we use the terminology of A. Clod (1960), the limbic system is a “somato-psychic crossroads”.

Its functional originality is emphasized by other names: “emotional brain (Konorsky M., 1954), “neurovegetative brain” (Fulton 1943), “visceral brain” (McLean, 1949). The formation of emotiogenic (psychogenic) visceral disorders is shown schematically in Fig. 2. In any emotional reaction, two parallel effects can be distinguished.

Functional visceral pathology (etiopathogenetic formation).

The first effect is ascending, or cortical, controlled by consciousness. It determines the sensory coloring of the stimulus and the adequacy of the mental and behavioral reaction to it, including facial expressions, gestures, and words.

It can be suppressed by an effort of will (external calm) and artificially reproduced (acting skill). The second effect is descending, or neurohumoral, escaping cortical control. It has the function of autonomic support of holistic behavior.

On this occasion, P.K. Anokhin wrote: “A person who has subordinated to cortical control all types of external expression of his emotional state, ... with fatal inevitability, “turns pale” and “blushes” due to his visceral organs, and also performs a “facial reaction” due to smooth muscles of their insides"

So, in the clinical understanding, emotion is a psycho-vegetative reaction of the body, where the autonomic nervous system acts as an intermediary between the cerebral cortex and the visceral organs (Topolyansky V.D., Strukovskaya M.V., 1986). In the language of metaphors, which E.K. Krasnushkin, one of the most famous psychiatrists of the past, resorts to, “the autonomic nervous system is the “mouthpiece of emotions,” and the “inner speech” of emotions is a function of the organs.”

This is, in a summary presentation, the physiology of emotions, which, under the circumstances discussed above, develops into their pathology. It manifests itself in the same two directions: ascending (psychoneurosis) and descending (vegetative dystonia). To understand the psychogenesis of neurosis, it is important to keep in mind that the pathogenicity of a psychotraumatic effect is determined not by the “physical strength” of the stimulus, but by its high individual significance, i.e. extreme for a given individual.

Indifferent or insignificant for one, qualitatively the same stimulus is highly relevant for another. Moreover, the main significance is not so much acute severe shocks, which at once age a person for several years, as long-term mental stress, which acquires the features of chronic emotional stress with the formation of a stagnant-dominant focus of excitation, displacing all others - idea fix.

At the same time, “in cases of prolonged and repeated release of emotional excitations onto the vegetative organs, all conditions are created for the emergence of so-called autonomic neuroses,” or otherwise, dysregulatory visceropathies. The role of unreacted emotions is especially important in their development. As P.K. Anokhin emphasized, “when the cortical component of emotion is suppressed, the body’s reaction does not cease to be holistic, but the entire force of central excitations is directed along well-defined centrifugal vegetative pathways” (Fig. 3).

Moreover, “excitements with emphasized intensity rush to the internal organs through the centers of emotional discharge” (our discharge - A.M.). The same meaning is contained in the aphorism of H. Mandsley: “sadness that does not pour out in tears makes other organs cry.”

Functional visceral pathology (etiopathogenetic formation).

Thus, autonomic disorders in neurosis are obligate (Vein A.M. et al., 1981; Svyadoshch A.M., 1982), but the form of their clinical expression is different. In some, they are limited to peripheral (nonspecific) stigmas, in others, certain viscero-organ syndromes are formed, including cardiac syndromes. This is a subject for a separate discussion (see Chapter 5).

Let’s finish with another quote from P. Kanokhin (p. 420): “Which effector path will be prevalent for reaching the periphery of emotional excitement depends on the characteristics of the emotion, the nervous constitution of a given person and the entire history of his life. As a result of these determining factors, we will have in each individual case various kinds of visceral neurotic disorders.

They can affect smooth muscles (pylorospasm, cardiospasm, spastic constipation), have a predominant expression on blood vessels (hypertensive conditions), have access to the heart, etc.” . As clinical practice shows, the heart is the main visceral target of psychoemotional disorders and associated autonomic dystonia.