Diagnosis of vegetative crises

Diagnosis and differential diagnosis of autonomic crises

Diagnosis of vegetative crises is based on three criteria:

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

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

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

The most common 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 depression

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

At the present time, the pathogenetic connection between the vegetative crisis and depression is vigorously debated, the reason for which is:

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

However, a number of facts testify against the point of view about a single disease: these are primarily different effects when exposed to biological factors. So, deprivation of sleep improves the condition of patients with endogenous depression and worsens in a 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 a vegetative crisis, but does not cause - in patients with pure endogenous depression.

Thus, when discussing the frequent combination of a vegetative crisis and endogenous depression, it can be assumed that the presence of endogenous depression is probably a factor contributing to the emergence of a 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 feature 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, the vegetative crisis is most often found in patients with hypothalamic disorders. Clinically, hypothalamic disorders are represented by neuro-exchange-endocrine and motivational disorders, usually of a constitutionally exogenous nature. Vegetative crisis join the structure of psycho-vegetative syndrome of neurotic genesis or within the framework of psychophysiological disorders. Although the pattern of vegetative crisis in these cases does not differ significantly from other forms, nevertheless it is worth noting the separate clinical features of this group of patients.

First of all, violations of hypothalamic-pituitary regulation are detected long before the debut of the vegetative crisis. In the anamnesis of these patients may be oligoopmenorrhea, primary infertility, galactorrhea (primary or secondary), polycystic ovary of the central genesis, pronounced body mass fluctuations, etc. Provocative factors, along with hormonal changes (puberty, pregnancy, lactation, etc.) are often stressors, often the debut occurs on the background of hormonal disregulation (galactorrhea, dysmenorrhea). The appearance of a vegetative crisis is sometimes accompanied by significant fluctuations in body weight (up to ± 12-14 kg), and, as a rule, a drop in body weight is observed in the first six months or a year after the debut of the disease, and an increase - more often with psychotropic drugs. During the disease in this category of patients, there may be bulimic attacks that some researchers estimate as analogues of a vegetative crisis, based on the fact that in patients with bulimia, the introduction of lactic acid naturally triggers a vegetative crisis. Treatment of these patients with psychotropic drugs is often complicated along with a significant increase in the body weight of the secondary galactorrhea. Paraclinic studies in these cases show a normal level of prolactin or transient hyperprolactinemia.

Vegetative crisis with temporal epilepsy

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

• when the structure of an attack of temporal epilepsy (partial seizures) includes elements of a vegetative crisis and differential diagnosis should be carried out between a vegetative crisis and an epileptic fit;
• when along with temporal epileptic seizures, vegetative crises are noted in patients.

Discussing the relationship between the two forms of paroxysms, we can assume three variants of possible relationships:

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

Vegetative crises in endocrine diseases

With endocrine diseases, vegetative crises occur and require differential diagnosis most often in the pathology of the thyroid gland and pheochromocytoma. In patients with vegetative crises, a special study of the thyroid function (plasma content of T3, T4 and thyroid-stimulating hormone) did not show a significant deviation from the norm, while 11.2% of women with vegetative crises had a history of thyroid gland hypertension - and hypothyroidism (in the population thyroid pathology in the anamnesis occurs in 1%). Thus, in patients during the period of vegetative crisis the probability of revealing thyroid pathology is very small. At the same time, patients with thyroid pathology (hyper- and hypothyroidism) often have symptoms resembling vegetative crises, and therefore differential diagnosis of autonomic crisis and thyroid pathology is undoubtedly relevant.

Contrary to popular belief about a 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. In the clinical picture of pheochromocytoma, permanent hypertension prevails: it occurs in 60% of cases, while paroxysmal - in 40%. Often pheochromocytoma is clinically "mute"; in 10% of cases, pheochromocytoma has an extra-adrenal localization.

It must be remembered that tricyclic antidepressants inhibit the reuptake and metabolism of catecholamines, therefore, when suspicion of pheochromocytoma should be refrained from prescribing antidepressants.

Vegetative crises in somatic diseases

Differential diagnosis of psychogenic forms of vegetative crisis and hypertensive disease presents significant difficulties for clinicians, which are connected with the fact that in both cases the disease develops against the background of increased tone and reactivity of the sympathetic adrenal system. This, perhaps, explains the clinical and pathogenetic proximity of the vegetative crisis and hypertensive crisis, especially in the early stages of the course of hypertensive disease.

The relationship between the vegetative crisis and hypertension can be very diverse. As the most typical, two options should be noted.

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

In the second variant of the vegetative crisis appear against the background of the traditional course of hypertension; as a rule, in these cases, patients themselves clearly differentiate between hypertensive crises and vegetative crises, the latter being subjectively transferred much more heavily 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 of the heart).

In the first and second variant, in terms of a differential diagnosis, hereditary predisposition to hypertensive disease is of definite help.

Vegetative crises during mitral valve prolapse (PMC)

The ratio of vegetative crisis and prolapse of the mitral valve is a question about which the discussion continues at the present time. The range of PMC representation in patients with autonomic crisis ranges from 0 to 50%. The most likely is the view that the frequency of PMC 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 PMD, most of the symptoms (tachycardia, pulsation, dyspnoea, dizziness, presyncopal conditions, etc.) are identical to those observed in a vegetative crisis, so the questions of differential diagnosis in this form of somatic pathology are relevant.

When diagnosing PMC, echocardiography is of absolute importance in two dimensions.

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

In conclusion, it is advisable to present in a generalized form a number of diseases and conditions in which vegetative crises or crise-like conditions can arise.

1. The cardiovascular system
   • Arrhythmias
   • Angina pectoris
   • Hyperkinetic heart syndrome
   • Mitral valve prolapse syndrome
2. Respiratory system
   • Exacerbation of chronic pulmonary diseases
   • Acute asthmatic attack
   • Pulmonary embolism (repeated)
3. Endocrine system
   • Hyperthyroidism
   • Hypoparathyroidism
   • Hyperparathyroidism
   • Hypoglycaemia
   • Cushing's Syndrome
   • Pheochromacytoma
4. Neurological diseases
   • Temporal epilepsy
   • Ménière's disease
   • Hypothalamic syndrome
5. Associated with medicinal products
   • Abuse of stimulant drugs (amphetamine, caffeine, cocaine, anorexants)
   • The withdrawal syndrome (including alcohol)

[1], [2], [3]