Diagnosis of vegetative crises

Diagnosis and differential diagnosis of vegetative crises

Diagnosis of vegetative crises is based on three criteria:

1. paroxysmal occurrence and time limitation;
2. polysystemic autonomic disorders;
3. the presence of emotional and affective syndromes.

As a variant of vegetative crisis, attacks should be considered in which the expression of emotional-affective syndromes is minimal or there are separate functional-neurological disorders. It is necessary to differentiate vegetative crises from phenomenologically close paroxysmal states of epileptic and non-epileptic nature.

Exclusion from the diagnostic range of paroxysms that outwardly resemble a vegetative crisis is the first stage of differential diagnostics. At the second stage, it is necessary to determine in the structure of which clinical (nosological) unit the vegetative crisis arose. The range of nosological units includes mental, neurological, somatic, endocrine diseases and intoxications.

Most often, a vegetative crisis occurs in the clinical picture of neurotic disorders (up to 70%), and they can occur in almost all forms of neuroses.

Vegetative crises in endogenous depressions

According to statistics, vegetative crises occur in 28% of patients with endogenous depressions, and in a third of them the onset of a vegetative crisis is preceded by depressive episodes. The vital nature of depressive disorders, suicidal tendencies, distinct daily mood swings, and the presence of depressive episodes in the anamnesis suggest a connection between a vegetative crisis and major depression.

Currently, the pathogenetic connection between vegetative crisis and depression is being hotly debated, the reason for which is:

1. frequent combination of vegetative crisis and depression;
2. the obvious effectiveness of antidepressant drugs in both cases.

However, a number of facts testify against the point of view of a single disease: first of all, these are different effects under the influence of biological factors. Thus, sleep deprivation improves the condition of patients with endogenous depression and worsens it with vegetative crisis; the dexamethasone test is positive in the first case and negative in the second; the introduction of lactic acid naturally causes crises in patients with vegetative crisis or patients with depression with vegetative crisis, but does not cause - in patients with pure endogenous depression.

Thus, discussing the frequent combination of vegetative crisis and endogenous depression, it can be assumed that the presence of endogenous depression is probably a factor contributing to the emergence of vegetative crisis, although the mechanisms of this interaction remain unclear.

Vegetative crisis in schizophrenia

In schizophrenia, vegetative crises are described as clinical rarities, and their peculiarity is the inclusion of hallucinatory and delusional disorders in the structure of the vegetative crisis.

Vegetative crisis in hypothalamic disorders

In the structure of neurological diseases, vegetative crisis is most often found in patients with hypothalamic disorders. Clinically, hypothalamic disorders are represented by neurometabolic-endocrine and motivational disorders, usually of a constitutional-exogenous nature. Vegetative crisis is added to the structure of psychovegetative syndrome of neurotic genesis or within the framework of psychophysiological disorders. Although the picture of vegetative crisis in these cases does not differ significantly from other forms, nevertheless, it is necessary to note individual clinical features of this group of patients.

First of all, hypothalamic-pituitary regulation disorders are detected long before the onset of the vegetative crisis. The anamnesis of these patients may include oligoopsomenorrhea, primary infertility, galactorrhea (primary or secondary), central polycystic ovary syndrome, pronounced fluctuations in body weight, etc. Stress factors, along with hormonal changes (puberty, pregnancy, lactation, etc.), are often provoking factors; the onset often occurs against the background of hormonal dysregulation (galactorrhea, dysmenorrhea). The onset of the vegetative crisis is sometimes accompanied by significant fluctuations in body weight (up to ±12-14 kg), and, as a rule, a decrease in body weight is observed in the first six months to a year after the onset of the disease, and an increase is more often due to treatment with psychotropic drugs. During the course of the disease, this category of patients may experience bulimic attacks, which some researchers assess as analogs of a vegetative crisis, based on the fact that in patients with bulimia, the introduction of lactic acid naturally provokes a vegetative crisis. Treatment of these patients with psychotropic drugs is often complicated by secondary galactorrhea along with a significant increase in body weight. Paraclinical studies in these cases show a normal prolactin level or transient hyperprolactinemia.

Vegetative crisis in temporal lobe epilepsy

Temporal epilepsy is an organic neurological disease! It can be combined with a vegetative crisis. It is necessary to distinguish between two situations:

• when the structure of a temporal lobe epilepsy attack (partial seizures) includes elements of a vegetative crisis and differential diagnosis must be carried out between a vegetative crisis and an epileptic seizure;
• when, along with temporal lobe epileptic seizures, patients experience vegetative crises.

When discussing the relationship between the two forms of paroxysms, three possible relationships can be assumed:

1. Temporal seizures and vegetative crises are “triggered” by pathology of the same deep temporal structures;
2. Vegetative crises are a clinical manifestation of behavioral disorders in patients with temporal lobe epilepsy;
3. Temporal lobe attacks and autonomic crises are two independent clinical phenomena observed in the same patient.

Vegetative crises in endocrine diseases

In endocrine diseases, vegetative crises occur and require differential diagnostics most often in thyroid pathology and pheochromocytoma. In patients with vegetative crises, a special study of thyroid function (the content of T3, T4 and thyroid-stimulating hormone in plasma) did not show significant deviations from the norm, while 11.2% of women suffering from vegetative crises have a history of thyroid pathology - hyper- and hypothyroidism (in the population, thyroid pathology in the history occurs in 1%). Thus, in patients during the period of vegetative crisis, the probability of detecting thyroid pathology is very small. At the same time, patients with thyroid pathology (hyper- and hypothyroidism) often experience symptoms reminiscent of vegetative crises, in connection with which differential diagnostics of vegetative crisis and thyroid pathology is undoubtedly relevant.

Contrary to the widespread opinion about the significant representation of vegetative crisis with high arterial hypertension in pheochromocytoma, it should be noted that pheochromocytoma is a rare disease and occurs in 0.1% of all patients with arterial hypertension. At the same time, permanent hypertension prevails in the clinical picture of pheochromocytoma: it occurs in 60% of cases, while paroxysmal hypertension occurs in 40%. Pheochromocytoma is often clinically "silent"; in 10% of cases, pheochromocytoma has an extra-adrenal localization.

It is important to remember that tricyclic antidepressants inhibit the reuptake and metabolism of catecholamines, so if pheochromocytoma is suspected, antidepressants should be avoided.

Vegetative crises in somatic diseases

Differential diagnosis of psychogenic forms of vegetative crisis and hypertension presents significant difficulties for clinicians, which are related to the fact that in both cases the disease develops against the background of increased tone and reactivity of the sympathoadrenal system. This, perhaps, explains the clinical and pathogenetic closeness of vegetative crisis and hypertensive crisis, especially in the early stages of hypertension.

The relationship between vegetative crisis and hypertension can be very diverse. Two variants should be highlighted as the most typical.

In the first variant, the disease debuts with a vegetative crisis, the peculiarity of which is a significant increase in arterial pressure, and regardless of the dynamics of the affective component, arterial hypertension continues to remain in the picture of the crisis. In the further course of the disease, episodes of arterial hypertension are noted outside of crises, but the leading ones are vegetative crises with arterial hypertension. The peculiarity of the course of such a "crisis" form of hypertension is the absence or late detection of somatic complications of hypertension (retinal angiopathy and left ventricular hypertrophy). Sometimes it is possible to trace the familial (hereditary) nature of such a variant of hypertension.

In the second variant, vegetative crises appear against the background of the traditional course of hypertension; as a rule, in these cases, patients themselves clearly differentiate hypertensive crises and vegetative crises, and the latter are subjectively tolerated much more severely than the former. The diagnosis of hypertension in this case is based on clinical signs (permanent and paroxysmal arterial hypertension) and paraclinical data (retinal angiopathy and left ventricular hypertrophy).

In the first and second variants, in terms of differential diagnosis, a hereditary predisposition to hypertension provides some assistance.

Vegetative crises in mitral valve prolapse (MVP)

The relationship between vegetative crisis and mitral valve prolapse is an issue that is still being debated. The range of MVP representation in patients with vegetative crisis fluctuates from 0 to 50%. The most probable point of view seems to be that the frequency of MVP in patients with crises approaches its frequency in the population (from 6 to 18%). At the same time, in the clinical picture of patients with MVP, most symptoms (tachycardia, pulsation, dyspnea, dizziness, presyncopal states, etc.) are identical to those observed in vegetative crisis, therefore, issues of differential diagnostics in this form of somatic pathology are relevant.

In diagnosing mitral valve prolapse, two-dimensional echocardiographic examination is of absolute importance.

According to the literature, it is the presence of mitral valve prolapse in patients with vegetative crisis that determines the prognostically unfavorable course of the disease with fatal outcomes (cerebral and cardiac catastrophes). There is a point of view that the basis for increased mortality in vegetative crisis is the asymptomatic course of mitral valve prolapse.

In conclusion, it is appropriate to present in general terms a number of diseases and conditions in which vegetative crises or crisis-like conditions may occur.

1. Cardiovascular system
   • Arrhythmias
   • Angina pectoris
   • Hyperkinetic cardiac syndrome
   • Mitral valve prolapse syndrome
2. Respiratory system
   • Exacerbation of chronic lung diseases
   • Acute asthma attack
   • Pulmonary embolism (repeated)
3. Endocrine system
   • Hyperthyroidism
   • Hypoparathyroidism
   • Hyperparathyroidism
   • Hypoglycemia
   • Cushing's syndrome
   • Pheochromocytoma
4. Neurological diseases
   • Temporal lobe epilepsy
   • Meniere's disease
   • Hypothalamic syndrome
5. Drug related
   • Abuse of stimulant drugs (amphetamine, caffeine, cocaine, anorexics)
   • Withdrawal syndrome (including alcohol)

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