Eating Disorders

Headache in psychiatric practice

The specific features of cephalgic syndrome are closely linked to the underlying psychopathological or organic process. Patient complaints often allow for initial differential diagnosis.

• Depressive spectrum: pain sensations are synchronized with the affective state. In mild depression, pain intensifies toward morning alongside depressed mood, but as the depressive episode deepens, it paradoxically disappears.
• Hysterical neurosis: patients describe their suffering in highly metaphorical and bizarre terms (a feeling of "drilling," "being tightened by an iron hoop," or the sensation that "the skull is splitting").
• Tension headache: typical for anxious and hypochondriacal individuals. The pain is pressing and bilateral, localized in the vertex and occiput with radiation to the shoulders. The condition worsens toward evening and after psychotraumatic events. It is often accompanied by scalp hyperesthesia (tenderness when brushing hair). Treatment involves benzodiazepine tranquilizers to reduce muscle tone, massage, thermal procedures, and distraction techniques.
• Schizophrenia: classic headache is rare. Coenesthesias come to the fore—bizarre bodily fantasies (e.g., the illusion that "the cranial bones are breathing" or "the brain is melting").

Headaches of organic and vascular genesis

Organic lesions require the exclusion of life-threatening conditions, such as mass lesions or vascular catastrophes.

1. Elevated intracranial pressure (ICP): a ominous sign of mass lesions. Pain increases in the morning hours and intensifies with head turns. A specific marker is sudden vomiting not preceded by nausea. The clinical picture also features bradycardia, altered consciousness (ranging from obnubilation to stupor), and papilledema.
2. Vascular pathologies: the pain is throbbing and directly depends on blood pressure fluctuations. The attack can be triggered by a hypertensive crisis, alcohol withdrawal, or hyperthermia. Pain subsides upon compression of the carotid arteries and is exacerbated by vasodilators (nitroglycerin).
3. Migraine: attacks of intense unilateral pain lasting several hours, caused by local dilation of cerebral vessels. The attack is often preceded by an aura (visual, auditory, or olfactory hallucinations, dizziness, aphasia). Triptans (sumatriptan, zolmitriptan), predominantly in an intranasal form, are used for relief. Analgesics do not work in this case.

Sexual dysfunctions

Sexual dysfunction is largely a subjective concept. The reason for medical intervention is a feeling of guilt, anxiety, or depression, even if the physiological process proceeds normally.

Main types of disorders:

• Arousal disorders (impotence, frigidity).
• Orgasm disorders (premature ejaculation, anorgasmia).
• Pain syndromes (vaginismus, dyspareunia, postcoital cephalalgia).

Key etiological factors:

• Psychogenic (most frequent): anticipatory anxiety, fear of first experience or age-related changes, relationship dissonance, strict religious attitudes.
• Iatrogenic: side effects of pharmacotherapy (antidepressants, antipsychotics, diuretics, antihypertensives, beta-blockers).
• Somatic and mental: severe depression, endocrine disorders, neurological diseases (epilepsy, parkinsonism).
• Toxic: substance abuse.

Approaches to correcting sexual disorders and paraphilias

Therapy for sexual disorders is comprehensive and often begins with psychoeducation. The physician must explain to patients the difference in physiology: in men, arousal builds and subsides quickly, whereas in women these processes occur more slowly, requiring due attention to foreplay.

Pharmacological support includes tranquilizers to relieve anxiety, specific phosphodiesterase inhibitors (sildenafil) to improve erection, as well as nootropics and vitamins for asthenia.

Special attention should be paid to paraphilias (fetishism, exhibitionism, pedophilia, etc.). It is important to remember the strict diagnostic criterion: non-standard sexual behavior is recognized as pathological only if it causes social maladaptation, grossly violates social norms, or brings suffering to the individual and others. Harmonious relationships by mutual consent are not classified as disorders. In ego-dystonic orientation, the patient suffers due to an internal conflict with their beliefs, but attempts to change the direction of the drive itself (conversion therapy) are usually unsuccessful.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Mechanisms of coenesthesia formation in schizophrenia.
• Differential diagnosis of aura types in migraine attacks.
• The effect of psychotropic drugs (antipsychotics and antidepressants) on the phases of the sexual cycle.
• Psychotherapeutic approaches in ego-dystonic sexual orientation.

Other topics in "Chapter 16. Somatic disorders and disturbances of physiological functions as a manifestation of mental pathology"

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