Objective cerebellar signs in schizophrenia: motor and balance coordination deficits

Abstract

In contrast with the other fields of clinical medicine, an objective evaluation of the illness pathology is still lacking in psychiatry, due to the emphasis put on the patients' subjective experience. However, nowadays it is widely accepted that deficits in the cognitive coordination (“cognitive dysmetria”), which underlies schizophrenic symptoms are determined by subtle brain lesions (within the cortico-cerebello-thalamo-cortical circuit). At the same time it was revealed that pathologic processes within cerebellum and its connections with other brain structures lead to cognitive-affective deficits and clinical manifestations, which are indiscernible from the negative and positive symptoms of schizophrenia (“cognitive-affective cerebellar syndrome”). At a clinical level, subtle motor and balance coordination deficits (MBCDs) have been noticed as early as the first descriptions of the illness and later on included in the “neurological soft signs”, which are regularly detected in schizophrenic patients and their relatives. Recently, these coordination deficits have been viewed as objective neuromotor signs of cerebellar dysfunction (“cerebellar signs”). Analogous MBCDs have been regarded as basic signs of the genetically inherited neurointegrative defect in “schizotaxia” (conceptualized as neurological phenotype of genetic predisposition to schizophrenic psychosis). In principle, the same (but more expressed) neuromotor deficits have been revealed in children who later on develop schizophrenic psychosis, as well as in high-risk subjects. Prospective clinical neurological examinations show that the objectively detectable MBCDs (although present at the pre-psychotic phase of the schizophrenic illness process) are additionally intensified during the first episode psychosis. Our own experimental studies by means of a computerized motion analysis system for objective recording of equilibriometric movement patterns (cranio-corpo-graphy) have led to the inference that these deficits in schizophrenic patients and their relatives reflect schizotaxic cerebellar dysfunction. Their dynamic follow-up up during the transition from remission toward psychotic relapse suggests that the illness process signs of mental (cognitive-affective, psychopathological, and psychomotor) deficits are intensified during the psychotic exacerbation. In contrast with the subjective mental deficits, the intensification of the objective MBCDs is not covered (masked) by the psychotic production. This fact permits objective evaluation and monitoring of the underlying cerebellar dysfunctions and their dynamics during schizophrenic psychosis. From the viewpoint of the clinical practice, the objective recording and quantification of the MBCDs allows for the introduction of a new objective (neurological) approach for revealing the vulnerability to psychosis in high-risk subjects, as well as for early detection of impending first episode schizophrenia or psychotic relapse, in order to take timely preventive and therapeutical measures as well as for prophylaxis of further complications.

Full text

EbATAPCKA
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5po0 4, 2OOZ e., eoguHa IV tssN 1312-3866
BULGARIAN neurologic and psychiatric practice
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OPt/TNHAAHIA CTATIALA
A. UJkogpo8r', E. Xrpar,Eo8a-, C. Xspe rxo8-
'npozpaMa "UJu3oopeHur", O6^acmeH gucnaHcep 3a ncuxuqHu 3a6o^r8aHUi clc cmauuoHap - Coolt;
" Kamegpa no He8poncuxuampur Ha neHcu^BaHckus yHUBepcumem BbB Ou^age^our. CAUI u Kamegpa no ncuxuampufl u ncuxomepanuc Ha
TexHu,reckur yHugepcumem I AaxeH. TepMaHUr:
"' Kamegpa no ncuxuampu, Ha MeguuuHckur yHuBepcumem - CoOuf,; Bmopa ncuxuampu,rHa k^uHuka kbM yCEA Hn "CB. HayM".
DEIIOIE
B ncuxuampuFma,3a pa3^Uka om ocmaHa ume o6^acmu Ha MeguuuHa-
ma, AuncBa o6ekmu0Ba oqeHka Ha namo^ozuFma, z^aBHo nopaqu ookycu-
paHemo fupry cy6ekmuBHume npe)ku8FBaHun ra naquermume. .qrec o6a
qe e U3BecmHo, qe I ocHoBama Ha k UHUqHume cuMnmoMu Ha uru3oope-
HUFma ^e)ku Hapyu.reHa koopguHaqu8 Ha ko?HumuBHume npouecu ("koeHU-
muBHa gwMempuf,"), o6yc^o8eHa om MUkpocmpykmypHa namo^oauF (B
paMkume Ha kopmuko-uepe6e^o'ma^aMekopmuka^HuF OyHkuuoHa^eH
kpb?) B Mo3bka. B ctqomo BpeMe ce kofcmamupa, qe namo^oeuqHu npo
qecu I o6^acmma Ha Ma^kuf, Mo3bk u Heeooume Bpb3ku c gpyau Mo3bqHu
cmpykmypu eogFm go ko?Humu8HcleMouuoHa^BU geouuumu u kAUHUqHU
npo8Bu, Hepa3^uquMu om He?amuBHume u no3umuBHume cuMnmoMu Ha
L!u3oopeHuema ("MalkoMo3bqeH kozHumuBHGaOekmu8eH cuHgpoM'). Ha
k^uHUr.rHo HUBo guckpemHu geouuumu B koopguHauuflma Ha gBu)kehuFma
u paBHo8ecuemo {IlKIlP) ca sa6e,lcsaHu oue npu nbp8ume onucaHufl Ha
3a6o^FBaHemo, a nckbcHo ca Bk^loqeHU B "Mekume Be8po^o?uqHu npu3Ha
uu', pego8Ho ycmaHoBsBaHU npu Llu3oopeHHo 6o^Hu u mexHu pogHuHu.
Hanoc^eglk me3u geouuumu ce pa3z^er(gam kamo o6ekmuBHU HeBpoMG
mopHu npofl8u ra MalkoMo3bqHa namo^oeuF ("MalkoMo3b\rHU npu38auu").
AHa o?uqHu IKIP ce npueMam 3a 6a3ucHu (6^u3ku go cy6cmpama) npoF-
Bu Ha aeHemuqHo yHac^egeHuF HeBpouHme?pamuBeH geoekm npu "L!u3G
makcuB' (koHuenmya u3upaHa kamo HeBpo^o?uqeB OeHomun Ha eeHemuq-
Hama npegpa3no^o)keHocm klM uu3oopeNNa ncuxo3ai. npufltunHo cbulu-
me (Ho ncu3pa3eHu) He8poMomopHU HapyureHUr ca pa3kpuBa8u npu geua,
koumo nqkbcHo ca pa38u^u u.ru3oopeHHa ncuxo3a a cbu.lo u npu uHguBtr
gu c oucok puck 3a pa3Eumue Ha ncuxomuqHa cuMnmoMamuka. npocnek-
muBHu k UHUqHU npoyqBaHUF noka3Bam, qe o6ekmuBHo ycmaHo8uMUme
lKlP (Makap ga ca Ha^uue u B npeg-ncuxomuqHama Oa3a Ha uru3o$peH-
HUF npouec), gonb^HUme^Ho ce 3acu^Bam no BpeMe Ha nbp8up ncuxomu'
qen enu3og. Co6cmBeHume HU mc^egBaHun c noMouma Ha cucmeMa 3a
peeucmpauuF Ha ekBu^u6puoMempuqHU gBuaame^HU namepHU (kpaHuG
kopncapaoufl) c noc^eg8aul o6ekmuBeH koMnbmbpeH aHa^u3 Ha gaHHU-
me Bogem go 3ak^loqeHuemo, qe BbnpocHume !K!P npu uJu3oopeBHo
6oanu u mexnu pogHuru ompasnBam uJU3omakcuqHa Ma^koMo3bqHa guc
Qynkuus. !urauuqromo uM npoc^egFBaHe npu npexoga om peMucuq ktM
ncuxomuqeH peuuguB no3Bo^FBa ga ce Hanpa8u u3Boq, qe u me kamo npe
qecHume nposBu Ha ncuxuqe8 (ko?H!muBHo€tvouuoHa eH, ncuxonamo^o-
?uqeH u ncuxoMomopeH) geouuum ce uHme83uouqupam no BpeNte Ha ncu-
xomuqHa gekoitne8caquF. 3a om6e^F38aHe e o6aqe, qe 3a pa3^uka om
ncuxu'.iHume npoqecHu geouq!rnu, uHmeB3uouuupa8emo Ha !K!p He ce
Mackupa om ncuxomuqHama npogykuuR. Taka ce cEga8am npegnocma&
ku 3a o6ekmuBHa oqeHka Ha Ha uq8ume Ma koMo3bqHu gucoyHkquu u
mFxHama guHaMUka no EpeMe Ha ulu3oopeHHa ncuxo3a. Om ?AegHa moq,
ka Ha k^uHuqHama npakmuka, o6ekmuBHama peaucmpaqus u u3MepBaHe
Ha.qK.qP no38o^-q8am BbBe>kgaHemo Ha npuHuunHo HoB o6ekmuBeH (He&
po^oeuqeH) nogxog kakmo 3a ycmaHoBFBaHe Ha 6uo^o?u,]Ha yrcBuMocm
npu BucokGpucko8u uHguBugu, maka u 3a paHHo pa3kpuBaHe Ha 3anoqBau-l
nrp8u Lr.ru3oopeHeH enu3og u^u ncuxomuqeH peuuguB, c o?Aeg npegnpue-
MaHe Ha c8oeBpeMeHHu npe8aHmuoHU u mepaneBmu,tHu Mepku u npoou,
Aakmuka Ha noc^egcrnBuFma u yc^o>kHeHufma.
OBJECTm CEiEBELIIR SIGXS lX 3CHIZOPHREXIrI IOTOn
XD BALAXCE COORDIIAT|oX DEFICIT3
D. Shkodrov.r E, H.rrlrnoya, S. Hlrdrmy
TUIITNY
ln contrasi with lhe olher lields of clinical medicine, an objeclive evaluaiion
o, the illness palhology is stilJ lackrng in psychiatry, due lo lhe emphasis put
on the patients' subjeclive experience. However, nowadays il is widely
accepted thal delicits in the cognitive coordination ('cognilive dysmetria"),
which underlies schizophrenic symploms are determined by subtle brain
lesions (within the cortico{erebellcthalamqcorlical circuil) At lhe same
time. lt was revealed that palhologic processes within cerebellum and its con-
nections with other brain struclures lead to cognitive-ailective delicils and
clinical manilestations. which are indiscernible kom the negative and posilive
symptoms of schizophrenia ('cognitive€tieclive cerebellar syndrome'). Al a
cllnical level, subtle motor and balance coordination deficits (MBCDS) have
been noliced as early as the ftrst descriptions 01 the illness and later on
ncluded in the "neurological soll signs'. which are regularly detected in
schizophrenic patienls and lheir relaiives. Recenlly, these coordinalion
dellcils have been viewed as objective neuromotor s gns ol cerebellar dys-
funclion ("cerebellar signs"). Analogous t\,4BCDs have been regarded as
basrc signs of the genetically inherited neurointegrative delect in ,,schizotax-
ia" (conceplualized as neurological phenotype of genetic predisposition lo
schizophrenic psychosis). ln principle, lhe same (bul more expressed) neu,
romotor deficits have been revealed in ch ldren who later on develop schi-
zophrenic psychosis, as well as in high,risk subjects. prospective clinical neu-
rological examinations show thal the obteclively detectab e MBCDs (although
present al1he pre-psychoiic phase ol the schizophrenic illness process) are
additionally inlensified during the lirst episode psychosis. Our own experi-
f,Alo{Olll IYUllr
lllrro+p3l r, ruulomalcur, xaek xoeL, iSuafriartrl
looDgulrltllr't pd ooacra, to.lumrol. gurxamput
20 ounrepcxn HEBponoTt4qHA u ncuxr4ATprlLtHA npAKTrlKA

llClAXt/1Ar P VA
mental sludies by means ol a computerized moiion analysis syslem lor objec-
lve record ng ol equilibriometric movemenl patlerns (craniqcorpGgraphy)
have led lo the rnlerence thal lhese delicils in schizophrenic patients and
lheir relatives retlect schizotaxic cerebellar dysfunction. Their dynamic lollow-
up during the transition lrom remission toward psycholic relapse suggests
lhal the rllness process signs ol menlal (cognitive€lfective, psychopathologr-
cal, and psychomotor) deiicits are inlensified during lhe psychotic exacerba-
tion. ln contrast wilh the subjeclive mental deficits, the intensilication ol the
objective [,4BCDs is not covered (masked) by the psychotic produclion. This
fact permrts the objective evaluation and monitoring ol the underlying cere
bellar dyslunctions and therr dynamics during schizophrenic psychosis. From
the viewpoint oi the clinical practice, the objeclive recording and quantilica-
lion of the MBCDs allows lor the introduction of a new objective (neurologr-
cal) approach lor revealing the vulnerability to psychosis in high'risk subjects,
as well as lor early detection of rmpending lrrst episode schizophrenia or psy-
chotic relapse, rn order to take limely prevenlMe and therapeutrcal measures
as well as lor prophylaxis ol fu(her comDlicalions.
BbBETEHXE
3a pa3AUka om ocmaHa ume o6^acmu Ha MeguuuBama, B ncuxuampuF-
ma UfcBa o6ekmuBHa oueHka Ha namo^ozuflma. O6ncfexuemo xa mosu
Oakm o6ukHoBeHo ce mbpcu B cy6ekmuBHuF xapakmep Ha ncuxonamo^c
euqHUme cuMnrnoMu. HaucmuHa, uFAo fanpaB^eHUe Bt'B Ou^ocoounma'
0eHoMeHoAoeuFma o6ocHo8aBa npuHuunHama HeBb3Mo)kNocm 3a o6ek'
muBHo u3c^eg8aHe Ha ncuxuqHume (DeHoMeHU u npenopbqBa ga ce pa3,ru
ma Ha cy6ekmuBHu nogxogu kamo uHmpocnekuurma. Om maka8a a^egHa
moqka oueHkama Ha ncuxuqHama namo^oeuF 6u c^egBalo ga ce 6a3upa
u3u-q^o Ha cy6ekmuBHUF omqem Ha nauueHmume. B cbuomo BpeMe egHo
om HauSAUqmeAHume HanpaBAeHUn B ncuxorozunma - 6uxe8uopusMt'm'
BbBe)kga moqHo o6pamHUF nogxog, kamo ce koNueNmpupa Bbpxy gocmbn-
HUme 3a o6ekmuBHo Ha6^logeHUe no8egeHqecku npoF8u,6e3 ga ce uHme
pecy8a om cy6ekmuBHuF omqem Ha u3c^egBaHume AUua (cqumaH 3a Be-
gocmo8epeh). Cnopeg Hac u gBama nogxoga uMam c8oume ocHoBaHuF u
3amo8a He mpfl68a ga ce npomu8onocmaBnm. a ga ce koM6uHupam nc
Me)kgy cu. Tlamo^oeuqHUme npoMeHu B no8egeHuemo u ncuxoMomopuka-
ma NaucmuHa ca gocmbnHu 3a o6ekmuBHo Ha6^logeHUe u pe?ucmpauufl
(1 3. 13), Ho no cBoFma cbutHocm cu ocma8am c^egcmBue om ko?Humu&
Ho€MouuoHa^HUme gucOyHkuuu u a6HopMHUme npe)kuBFBaHUfl fa nauu
eHmume, m.e. BbHLUHa npor8a (ompakeHUe) Ha cy6ekmuBHarna ncuxona'
mo^oeuF.
Om a^egHa moqka Ha o6ekmuBHocmma B ncuxuarnpusma 3a Hac e nc
BakHo gpy?o. Kakmo kameeopu!rHo ce goka3a qpe3 cbBpeMeHHUme Meme
gu 3a u3c^egBaBe, uJu3oopeHuBma go ?o^FMa cmeneH e pe3y^mam om
guckpemHa (Mukpocmpykmypna), Ho Bce nak o6ekmuBHo ycmaHoBuMa na
mo^o?ufl, 3acs?au]a onpege^eBu oyHkuuohalHu kpbeo8e B Mo3rrka (7-9).
CAegoBameAHo, u3c^egBaHemo Ha ma3u Mo3bqfa namoroaun 6u no3Eoru-
^o ga ce nogxogu o6ekmuBHo kbM MexaBwMume Ha 3a6o^FBaHemo B noc
AegHUme ?oguHU oco6eBo BHUMaHUe ce omge^F Ha Ma koMo3bqHama na,
mo^o?uF kamo ocHoBeH oakmop 3a gucoyHkuuFma Ha kopmukcuepe6e^e
ma aMGkopmuka^HU, kpbz (Ou?ypu 1 u 2), ocbutecmBBBaul Ba*HU uHme?-
pamuBHU u koopquHupautu OyHkuuu Ha Mo3brrHo u ncuxuqHo HuBo (7I 12.
15. 19 2A 22.23) Cnopeq Hflkou aBmopu uMeHHo namo^o?u8rna B mo3u
OyHkuuoHa^eH kpbz o6yc^a8e HapyuleHama koopguHauuF Ha koeHumuBFtu
me npouecu ( gu3MempuF Ha MUc^eHemo" u^u 'ko?HumuBHa g!3MempuF")
kosmo ^e)ku B ocHoBama Ha uJU3oOpeHHUme cuMnmoMu (8 9. 19 20 23)
Cueao uo>ke ga ce kai(e, qe kohuenuuFma 3a "kozHumuBHama gu3Mem-
Ouz. 1 CmpykmypHu u OyHfuuoHa,lh! HapyueHuB np{r uru@peHus
np@poHma,rHa kopa,
(n^ahupa e, koopouHauun.
uHmeapauun) \
(ceH30p8a uHmezpaquF) (kozHumuBHa u gBuzameAHa
koopguiaqur)
ouz. 2 llucoyHkqusma I kopmuko-uepe6e^o-ma&Mo-kopmuka^sus kphz ioku I ocHoBama Ba
cuMnmoMume u npof,Sume ra uw@peHuma
(0J!umuBHa u q8u?ame^Br q u3r,re rn p u,r
'.: h
--s --t *"'
pufl' (9), nocmaBFuta akueHma Bbpxy po^xma Ha Ma^ku, Mo3bk, noBacmoF
uleM e Hao-BAurme^Hama meopuF 3a o6FcHeHUe Ha pa3Hoo6pa3HUme He&
po^o?uqHu, koerumuBnu. eMouuoHalBU u ncuxonamo^o?uqHu npofl8u Ha
LUU3oopeHUflma (8, 23).
Bb3XO)|(HOCTX 3 OSEXTXBHO X3C EIE ItE H rA rG
o3bqH^ra naTo^orxf, nPll uIx3ooPEHx,
no?uqHo e ga ce gonycHe. qe uloM k UHUqHUme cuMnmoMLr Ha uru3oope-
Hunma ce o6yc^aBFm om onpege^eHa Mo3bqHa namo^ozuB (Bk^loqBau{a
Ma kufl Mo3bk kamo ocfoBeN koMnoHeHm). ma3u namo^o?LrF 6! 6!^a
gocrnbnHa 3a o6ekmuBHo u3c^egBaHe - npqko (,-rpe3 Bucoko,ryBomBumeAH!
u3o6pa3FBauiu u oyHkquoHa Hu Memogu) u^u kocBeHo (qpes o6ekmuBHu-
me il HeBpo^o?uqHU npoF8u). !oka3ame^cmBo 3a nbp8ama Bb3Mo)kHocm
e Oakmbm, qe cmpykmypHa u OyHkLluoHa^Ha rva^koNio3brrHa namo^o?u8
MHo?okpamHo e ycmaHoBrBaHa npu uru3o$peHHo 6o^Hu (8,9, 12, 15, 22).
B cbqomo BpeMe e u3BecmHo, qe namo^o?uqHU npoqecu B o6^acmrna Ha
Ma^kuF Mo3rk u Bpb3kume My c gpyau Mo3bqHU cmpykmypu ce npugpy-
)kaBam om koeHUmu8Ho€MouuoHaAHU geOuu!mu u ncuxomuqHU npofl8u,
Hepa3^uquMU om He?amuBHurne u no3umuBHume uJU3oopeBHu cuMnmo-
Mu (8, 19,20,22). nogo6Hu Haxogku ca ocHoBaHue 3a o6oco6FBaHemo Ha
Ma^koMo3bqef ko?HUmuBHGaoekmuBeH curigpoM (20),3a koomo ce npu-
eMa, qe e ncuxuqHa npoFBa Ha Ma^koMo3!qHa gucoyHkuus. Bk^lo\tume^-
Ho u npu Luu3oopeHuf, \8, 19, 20, 22, 23l. Iloko^komo o6aqe nprkomo u3
c^egBaHe Ha Ma^koMo3bqHama namo^o?uq e c^o)kHo. mpyqoeMko u ckb
no (9. 12, 15.22) sHaqume,^Ho no-agekBameH om z^egHa moqka Ha kAU
HUqHama npakmuka e uHgupekmHUflm nogxog qpe3 o6ekmuBHume u
nporBu (gBueame^HU koopguHauuoNHU geOuuumu) npu ulu3oopeNHo 60^-
hu ! mexHu pogHuru c Bucok puck 3a pa3g!mlre Ba 3a6o^F8aHemo (2€.
1A 12 1+26)
IGY UOIDCT
raftLcDiil*r, *ttltcida, c.raDalum, motoa coorffioll,
bdanc., coenlllu. drrn.th
21 sunrnpcxe HEBpolorugHA u ncuxt4ATpt4LlHA npAKTtlKA
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HAP'ruEHA IFXTATEAHA I(oOPTIH^IUN NP rIt]l3OOPEHXf
l,ftBecmHo e, qe ocHoBHama OyHkuur Ha Ma^kuF Mo3bk e koopguHauuF-
ma Hag8u)keHuFma noxogkama u pa8Ho8ecuemo (7-9 12 1+16 19.20.22
23) 3amoBa He e yqygBauo. qe makuBa (Makap ! guckpemHu) koopguHa-
uuoHHU HapyL!eBU9 npu uru3oopeHHo 6oAHu ca om6e^F3asu oute om Kpe
neAUH u E^oa^ep npu nbpBume uM k^uHu,+iu onucaHuF Ha 3a6olF8aHemo
(8, 9, 15) nckbcBo me3! Hapyu.reHu! (Hapeg c geouuumume B ceH3opBa-
ma uHmeepauuF u a mepHupautume noc^ego8ame^HU g8u>keHUf) ca Bk^lG
qeHU B "Mekume He8po^oeuqHU npu3Hauu" pegoBHo ycmaHoBFBaHu npu
uru3oopeHHo 6o^HU u mexHu pogHUHU (1Gl2, 15. I6. 21. 23). B egBa om Hao
3HaquMUme ?eHemuqHU meopuu Ha uJU3oopeHUFma - ma3u 3a L!u3omak'
cuema (4,5 17) Mekume HeBpo^oeulrHu npu3Bauu ce pa3?^e)kgam kamo
Ha0SakBama (6^Bka go cy6cmpama) nporBa Ha yHac^egeHUF HeBpouH
me?pamuBeH geoekm ("xunokpu3uF") 3a pa3^uka om ncuxomuqHume
cuMnmoMu, 3a koumo ce npueMa, lre Mo?am ga 6bgam npegu3BukaHu u om
enu?eHemu'tHu l6uo^o?uqHu u/u^u ncuxocouua Nu) 0akmopu. om ma3u
?AegHa moqka ct,u.tHocmma Ha urBoopeHuFma kamo eHgo?eHHo Mo3bqHo
3a6o^s8aHe ce nposBr8a ncnpBko \rpe3 o6ekmu8Hama Be8po^o?uqHa (Lr.ru
3omakcuqHa) namo^oeuF, omko^komo qpe3 cy6ekrnuBHUme ncuxornuqHU
npe>kuBBBaHU, Ha nauueHmume Cnopeg Bac 3Haqume^Ha qacm om uu3G
makcuqHume NapyLl.reNuq ca npoFBa Ha i,ra^koi,ro3bqHa gucoyHkUUF u Ha
HapyuJeHU B3auMogeucmBuF Me)kgy Ma^kuF Mo3bk, ma^aMyca u npeopoH-
ma^Hama kopa (4, 7, 8).
3a 6a3ucHama po^r Ha Ma^koMo3b!rHama namo^o?un npu Luu3oopeHUn
nogckagBa u oakmbm, qe npu qacm om nauueHmume ce ycmaHoBFBam
He8poMomophu koopguHauuoHHu geouuumu oute npegu noflBama Na
ncuxomuqHa cuMnmoMamuka (7, 8, 18, 2+26)- OcBeH moBa, npu npoc^e
gflBaHe Ha BucokGpuckoBu uHguBugu (geua na uusoQpenno 6orsu) ce
oka38a, qe Ha.^uquemo Ha makuBa geouqumu B paHHa gemcka Bb3pacm
npu mflx e npegukmop 3a pa3Bumue Ha uJU3oopeHHa ncuxo:a B 6ugeue
\7, 18, 24. 25],. Cnequa^Ho npoBegeHU pempocnekmuBHU npoyqBaHUe Ha
goMaL!Hu BugeoouAMU noka3Bam, qe geua, kourno Bnoc^egcm6ue ce pa3
6o^sBam om uru3oopeHuF, ou-le Ha 2- go laoguura Bt:pacm uoaam ga
6bgam pa3nmHamu om cneuua^ucmu B o6^acmma Ha HeBpopa3Bumue-
mo u pa3epaHUqeHU om cBoume EpbcmHuqu no Hecpl,]HUme u 3Ae koop
guHUpaHU gBu)keHUB (24,25). N.4akap npocnekmuBHUme u3c^egBaHUF ga
koHcmamupam qe c^eg teoguurHa Eb3pacrn qBHume HapyureBuF B gBu-
?ame^Hama koopguHauue 6u8am koMneHcupaHu u om3ByqaBam (18). ^a'
meHmHama ?omo8Hocm Bce nak ocmaBa.3automo aHa^o?uqHa koopgu-
HaquoHHa namo^ozur (kamo cbutecmBeHa qacm om Mekume HeBpo^o-
?uqBU npu3Hauu) Mo)ke ga 6bge pa3kpuma u I no-kbcHa Bb3pacm c ne
MOUma Ha gemal^Bo u cmaBgapmu3upaHo FteBpo^o?uqHo u3c^egBaHe
1 1Gl2, 15 l6 21 , 23). Cl,BceM fackopo 6eL!e ycmaHo8eHo. ,re noHe qacm
om ma3u namo^o?uF ce 3acu^Ba no EpeMe Ha ncuxo3a u c^eg moBa ce
Bptua kbM u3xogHomo paBBuute npu 06pamHuB npexog om ncuxo3a kbM
nb^BoueHHa mepane8muqHa peMucuF (10, 12. 16) B Hao ?o^FMa cmeneFr
onucaHama guBaMUka ce omHacfl 3a HapyuleHUFma B noxogkama u pa&
HoBecuemo (AokoMomopfa u cmamuqHa amakcul). koumo ce pa3? e)t(,
gam kamo ocHoBHU npoFBu Ha Ma^koMo3bq8a gucoyHkuuf, (8, 12. 15. 16.
20,22).
Ka3aHo Bakpamko, Beqe uMa gocmambqHo gaHHU 3a o6ekmuBHo ycma
roBuuu rapyuexun B gBuzame^Hama koopguHauun Ha noxogkama u pa&
HoBecuemo, ompa3F8auu namo^o?uF Ha MaAkuF Mo3t,k (u Bpb3kume My c
gpy?u Mo3tqHU cmpykmypu) koFmo o6yc^aBn u koaHumuBHoeMouuo|aA
Hume gucoyHkuuu, ^e)kauu B ocfoBama Ha cy6ekmuBHume cur\,4nmoMu
npu urwoopeHUfl (8, 9,15,20,22,23) Heuto noBeqe, npoyqBaHuflma noka3
Bam, ue gBueamemama koopguHauuoNHa namo^o?ur npeguJecmBa no8Ba-
ma Ha ncuxomuqHU cuMnmoMu u no makbB Hairuh ce f,BFBa npegukmop Na
uru3oopeHHama ncuxo3a (ffi 1G]2, 16, 18, 21 22 2+26])npu Ba^uque Ha
uru3oopeHeN npouec B Mebka (4S)
H pyurEHA llrr rE H KOOPAI|H qf,n X UX3OoPEI|H
ItGlflo3l
LtloM cy6ekmuBHume ncuxomuqHu cuMnmoMu npu u.lu3oopeHuF ce
npegLUecm8am u/u^u cbnbmcmBam om o6ekmuBNo ycma|oBuMU (Makap
u guckpemHu) HeBpoMomopHU npoflBu Ha Ma^koMmbqHa gucoyHkuuF (2 4
7-9.11 12.1+16,1V23). Bb3NukBa Bbnpocbm kakBu ca B3auMoomHoLUeHUr'
ma Me*(gy Hapyu.reHama gBu?ame^Ha koopguHauuF u uru3oopeHHama ncu-
xo3a. To3u Bbnpoc e npou38ogeH om no-o6utama npo6^eMamuka 3a B3au
Mo8pb3kurne Me)kgy o6ekmuBHume Be8po^o?u,rNU npoFBu u cy6ekmuBru-
rne ncuxomuqHu cuMnmoMu Ha uJU3oOpeHUFma 11 ,2, +9 I 1 , 1422) Hackc
po HauuFm ekun pa3pa6omu meopemuqHa koHuenuuF 3a pa3luqHomo
oy8kuuoHalHo 3HaqeHUe u guHaMuka Ha uu3oopeHHus npoqec B Mo3bka
kamo cbulHocm Ha 3a6o^r8a8emo u Ha uJU3o0peHHama ncuxo3a kamo cBe
eo6pa3Ha Mo3bqHlncuxuqHa peakuus Ha gekoMneHcau!F Bc^egcmBue Ha
uJu3oopeHHUfl npouec (6) B koHmekcma Ha ma3u koHuenuui ncuxo3ama e
caMo Hau Fpkama u kiuHuqHo Hai{neuuouqHa (Makap u uHgupekmHa)
npoflBa Ha 6o^ecmHuF npouec B Mo3bka Hapeg c HeF ce Ha6^logaBam u
no{uckpemHu, cqumaHu 3a gua?HocmuqHo HecneuuourrHU, Ho ncnpeku
npouecHu npoflBu (Bk^loq&utu ce B uuaoSperrun cnekmbp), c Hencuxe
muqHa ncuxuqHa (LUU3omunHa) u/uAU HeBpo^oeuqHa (ulu3ornakc!,.rHa)
cuMnmoMamuka, koumo 6u mpn6Baao ga ce uMam npegBug kakrno B ?eHe
muuuume npoyv6anun (4 6, 17,2426) maka u npu ^eqeHuemo Ha LUU3G
OpeHUrma (4 5-7 l0). AHa^u3bm Ha guHaMUqHUme BsauMogeucmBuF Me)k-
gy npouec u ncuxo3a HU y6egu. qe Mekume HeBpoAoeuqHU npu3Hauu, pa3
kpumu npu uru3oopeHno 6ouu u npu uuguBugu c Bucok puck 3a pa3Bumue
Ha ncuxo3a, Bct,ulHocm ca uru3omakcuqHU npoflBu Ha u.lu3oopeBBUF npo-
uec B Mo3bka (4). Cneuuaaso oHe3u om m8x koumo ompa3sBam Napyure-
HUF B gBuaame^Hama koopguHauuF u pa88oBecuemo Mo?am ga ce pa3?'
Aer(gam kamo o6ekmuBHa npoflBa Ha namo^oaunma B cbulufl Mo3bqeH
kpb? (Bk^loqBaut npeopoHma Hama kopa ma aMyca u Ma^k!F Mo3bk), koa'
mo o6yc^a8F u ko?HUmuBHcaoekmuBHama gucpe?y auuF, Ae)kauta B ocHG
Bama Ha cy6ekmuBHUme u.ru3oopeHHU cuMnmoMU (8, 9) 3a om6e^F3BaHe
e o6aqe. qe Makap ga ca Ha uqe oue npegu nbpBuF ncuxomuqeH enu3og
(4, 5. 7 B, ]G]2. 17.18.21 22 2426), noae Lracm om me3u HapyureBufl B
gBueame^Hama koopguHauuF u paBHo8ecuemo ce 3acu^Bam no BpeMe Ha
ncuxomuqHa gekoMneHcauuF (3, 10. 12. 16,22) O6ekmuBHomo pe?ucmpu'
paHe u u3Mep8aHe Ha BbnpocHUme HapyueHUf, cb3gaBa npegnocmaBku 3a
pa3pa6omBaHe Ha npuHuunHo HoB nogxog kbM Ma^koMo3blrHUme gucoyHk
uuu npu Llu3oOpeHU, (2.3 8. 13).
x xltl| to x TEoPErxqHo 3ll qEHxEH H PvlltEllar
IEXT TE H XOOPATH qXf nP UTXSOoPEtl,i
Cnopeg pa:pa6omerarna om HauuF ekun meopemuqHa koHuenuur (6)
uru3oopeHHuFm npouec e cBbFaN c ncuxuqfu geouuunu. koumo ce 3a
cu^Bam no BpeMe Ha ncuxo3a. Ho B cbulomo BpeMe ce Mackupam om na
pa e^Ho pa38uBauama ce ncuxornuqHa npogykuur. B kpauHa cMemka
uMeHHo ncuxomuqHama npogykuuF ga8a k UHUqHUf o6AUk Ba ncuxo3ama
a npouecHUrne geouuumu (Makap u 3acu^eHU) Mo?am ga 6irgarn ycmaHG
Benu cauo vpe: cneuua^Hu u3c^eg8aHu, u aHa u3u. ly'3k^loqeHue npaBFm
HeBpo^o?uLrHume (LUU3omakcuqHu) npoflBu Ha 6o^ecmHUF npouec B Mo3b
ka u nccnequa Ho geouuumume B koopgurauuFma Ha g8u)keHuFrfa u pa&
Ho8ecuemo. Cbuo kamo ncuxuqHume geouuumu, me c€ uNmeH3uOuqu-
pam no BpeMe Ba ncuxomuqHa gekoMneHcauuF (8, j 0, 12, 14 l6) Ho3apa3,
AUka om mFx He ce Nrackupam om napa-^e^Ha namo^o?uqHa npogykuu8 3a-
moBa uHmeH3uouuuparemo uu rr,ro>ke ga 6r4e ycmaHoBeHo qpe3 npocnek
muBHo k^uHulrHo HeBpo^oeuqHo u3c^egBaHe 110 i2 16). AHa^oeu,rHU gaH-
HU 3a 3acu^BaHe Ha HapyLueHunma B koopguHaquflma Ha gBu)keHuFma u
paBHoBecuemo no BpeMe Ha ncuxomulteH enu3og, c noc^egBaqa pegyk-
UUF kbM u3xogHume cmoaHocmu npu npexoga om npucmbn B peMucufl, yc-
nf,xMe ga pe?ucmpupaMe c noMouma Ha cnequaAHa anapamypa (kpaHuG
22 sunrnpcxn sEBponorhqHA u ncuxt4ATp14LtHA npAKTt4KA

nCilXt4ATPt4fl
kopno-epaouF) u o6ekmuBHo ga u3Mepur\,4 qpe3 opu?uHa^Ha Memoguka 3a
koMnlombpeH aHa^u3 Ha gBu?ame^Hu namepHu (8, 14). EgHa makaBa Haxog
ka x8bp^q BoBa cBem^lHa Bbpxy B3auMoge0cm8u8rna Me)kgy npouec u
ncuxo3a npu urU3oopeHuF (B)k. 6) u no3Bo^rBa ga ce BanpaBu u3Bog, qe gG
kamo Ha ncux!qHo (koeuumuBnmuouuouarHo, ncuxonamo^o?uqNo u ncu
xoMomopHo) HUBo ncuxGama Mackupa npoqecHume geouuumu, Ha He8pe
^o?uqHo (rlu3omakcuLrHo) HUEo me Bogu go ycu^BaHe Ha npo8Bume uM.
!oko^komo gBu?ameAHUme koopguHauuoBf u geOuqumu ca o6ekmuBHa
npon8a Ha Mo3bqHama (EklbqumeAHo Ma^koMo3bqHama) namo^o?ufl, Ae-
)kauta G ocHoBama Ha uJU3oopeHHUF npouec (4,5,7-9, ll, 12,14,15,19,20,
22, 23), mFXHomo uHmeH3uouuupaHe no EpeMe Ha ncuxomuqHa gekoMneH-
cauufl nomBbpr(gaBa gonyckaHemo, qe u.ru3oopeHHama ncuxo3a e c^eg'
cmBue om u3qepnBaHe Ha agek8amHume 3autumHeaganmuBHekoMnehca'
mopHU MexaHU3MU Ha Mo3bqHe6uo^o?uqHo HUBo (l ) u Bk^loqBaHe Ha namc
o?uqHu 3aulumu u xunepkoMneHcauuu Ha ncuxoguHaMuqBo HuBo (6). K U,
Hulr8omo u kpaHuokopnc?paocko npoc^egrBaHe ha guHaMukama B Hapy'
uJeHama gBuaame^Ha koopgUHaUUf no BpeMe Ha ncuxomuqeH enu3og no3-
Bo^rBa npFko ga ce Ha6^logaBa 3acu^BaHemo Ha npouecHUme geouuumu.
He3aBucuMo om cy6ekmu8Hume ncuxomuqHU nper(ugFBaHUF Ha nauuef,
mume Emo 3au.io o6ekmuBHomo u3MepBaHe Ha rna3u guBaMLrka Mo*e ga
ce pa3?^e)kga kamo BoB nogxog kbM Mo3tqHume MexaHu3Mu fa npoqeca
u ncuxo3ama (6).
@akmum ue npu Ha Uq!le Ha ulu3oopeHeH npouec koopguHauuoHBUrne
geouuumu npegulecmBam ncuxGama u npu Bucoko puckoBu uHguougu ce
sBFBam npegukrnop Ha ulu3oopeHBa ncuxo3a, HU ga8a ocHoBaHue ga cqu,
maMe qe e Bb3Mo)kHo paHHo pa3kpuBaHe Ha uJu3oopeHHUF npouec npu
nce_aoa3no^o>keHu uNguBugu qpe3 k^uHUqHo HeBpo o?uqHo U3cAegBaHe
ur u^u qpe3 kpaHUo-kopncepaocka pe?ucmpauun u o6ekmuBeH koMnlomb
peH aNa^u3 Ha gBu?arne^Hume namepHU (4-8) Taka ce cHgaBam npegnoc,
ra3,(i 3a eBeHmya^Ha npeBeHLlLrF Ha ncuxo3ama qpe3 npegnpueMaHe Ha
cEoeBpeMeHHU npoOu^akmu!lHU (ncuxomepaneBmuqHU u/u^u oapMakome
pa.e8rnuuBU) Mepku oco6eHo npu ycu BaHe Ha koopguHauuoHHUme qeou,
L.umu ha oofa Ha no8egeHqecku omkAoHeHUF u cy6ekmuBHU nclxonamo-
r'oe---- cuMnmoMU (46) Ha npakmuka ycmaHo8eHomo 3acu^BaHe Ha ge-
0uuLrmume B koopguHauuf,ma Ha gBur(eHuFma u paBHoBecuemo no BpeMe
.a noogpoMalHama 0a3a Ha 3ano\r8aut ntp8u ncuxomuqeH enu3og (uAU pe-
u!guAr 6u Mo?^o ga gage ocHo8afue 3a paHHa npeg-ncuxomuqHa uHmep
Bexuus (6.8) Te3u nepcnekmuBu ca Hanb^Ho pea^Hu, kamo ce uMa npeg,
Bug qe kakmo k UHUqHomo HeBpo^oeuqHo u3c^eg8aHe, maka u BauJUflm
Memog ca npocmu, AecHo ocbuecmBuMu, HeuHBa3uBHU, cpaBHUmeAHo
kpamkompauHU (1G20 MUH.) u eBmuHU.
Om meopemuqHa e^egHa moqka o6ekmuBHomo goka3BaHe Ha Ha^ultue-
mo Ha guckpemHu HapyuJeHuf, B koopguHauuFma Ha gBu)keBUFma u paBHc
Becuemo npu u.ru3oopeHHo 6o^HU u mexHu pognuru (2 4, 7, 8, 14) gaBa eM-
nupu,.rHa nogkpena u c8bp3Ba noMe)kgy uM maku8a oyHgaMeHma HU koH-
uenqlru 3a uru3oopeHUflma kamo me3u 3a "ko?HumuBHama gu3Mempu8'(8,
9), 3a "Ma koMo3bqHUF koeHumuBHo-aoekmuBeH cuHgpoM" (8, 19, 20) u 3a
"u.lwomakcuFma" (4,8. l7). Ommyk Mo)ke ga ce u3Bege u 3HaqeHuemo Ba
o6ekmu8ro ycmaxoBuMUme npoFBu fa Ma koM$bqHa oucoyHkuuF kakmo
3a ?ehemuqHume npoyq8aHufl Ha uJU3oopeHUSma u Llu3oOpeHHuF
cnekmbp (npu nbpBuqHo pa3kpu8aHe Ha nogo6Hu npoflBu), maka u 3a npc
Ou^akmukama Ha ulu3oopeHBUme ncuxGu (c^eg ycmaHoBf,BaHe Ha uHmeH-
3uouqupaHemo uM npu guHaMUqHo npoc^egFBaHe). B kpa0Ha cMemka ma-
ka ce no^a?am ocro8ume ra npurqunHo HoB o6ekmuBeH (HeBpo^oeuqeH)
nogxog 6 ncuxuampunma (8. 14), koomo ct3gaBa npegnocmaBku ga ce noc-
rnu?He ka,recm8eH ckok B guazHocmukama u npoou^akrnukama Ha eHgo-
?eHHUme ncuxo3u.
pa8HoBecuemo npu urGoopeHuF (gu3MempuF u amakcuF) Mo?am ga ce
pa3z^e>kgam kamo o6ekmuBHa npoFBa Ha Ma^koMo3bqHa gucoyHkuuB koe-
mo (kamo BakHa qacm om kopmukcuepe6e^o-ma aMckopmuka HUe kpb?)
o6yc^aBF u "ko?HUmuBHama gu3MempuFrr. ^e)+(aua B ocHoBarna Na cy6ek
muBHUme cuMnmoMU Ha 3a6o FBaHemo l\,4a^koMo3bqHama oucOyHkUUF e
nprko c8bp3aHa c ulu3oope8HuF npouec B Mo3bka. Ho Mo)ke BpeMeHHo (06
pamuMo) ga ce ycuABa no BpeMe Ha ncuxomuqHa gekoMneHcaquF. Makap
npouect'm u ncuxo3ama npu uru3oopeHuF no npurr.lun ga Bogrm go 6uno
AspHu omkloHeHuF om HopMama (Ha kozrumuBnoctvouuoHa^Ho, ncuxona-
mo^o?uqHo u ncuxoMomopHo HuBo), koopguHauuoHHUme g8ueame^iru Ha'
pyureHuF ca egBonocoqHu (MoHono^rpHU). Ilpexogromo sacuir8ale xa re&
poMomopHUme npofl8u Ha Ma^koMo3bqHa qucoyHkuu8 no gpeMe Ha ncuxG
3ama c!3ga8a npegnocmaBku 3a o6ekmu8Ha oueHka Ha Ha uq8ume Ma^kc
Mo3bir8u geouuumu u Ha mFxHama guHaMuka BbB BpeMemo u nog B^unHUe
Ha mepanurma. Om cBon cmpaua o6ekmu8rama peaucmpauuF u u3MepBa-
He Ha HapyureHuFma B koopguHaquema Ha gBu)keHuFma u paBHoBecuemo
c noMoqma Ha kpaHUckopncepaouF u pa3pa6omeHa om Hau.lun ekun koM-
nlombpHa cucmeMa 3a aHa u3 Ha ekBuru6puoNlempuur.tu gBu?ame^Hu na,
rnepHu no3Bo^rBa BbBe)kgaBemo Ba o6ekmuBeFt (HeBpo^ozuqeH) nogxog
kakmo 3a ycmaHo8FBaHe Ha npegpa3no^o)keBocm kbM utwoopeHHa ncuxe
3a npu Eucoko-pucko8u uHguBugu. maka u 3a paNHo pa3kpuBaHe Ha 3ano'l
Eaut nbpBu L!u3oopeHeH en6og u/u^u ncuxomuuer peuuguB.
ATIEP I'DA
1.-', ^ C r,lenog.r u )En@icntu 3a np&*u@E u ae.eg&aBe Ha xa^buu'ahauu
8*ttutuHg a$@kffru u ne@neknt8u AJcap\]at](]A. Co{.)nr lr,hguuuHcka Akag€MU, I 987
t f.r..-.4! C, }.|ri.af ,.A,rya,|,AlD. Hegphootop"u u ncuxouonoptu t apyue
rut npu uBooperso &r4u. o@(nu&ta @?ucn@uu, u kotuqetnkra oue*a qpej /r'npa31t*.,
8a kogolohbp,a kea?uo+ot.c?padt4 6\^2 !,e1aa\ 2ml 11215556
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ka\hc.r)6et .itii,|L3 aa ",rpr,.rarll nfu{ .,toptt1 \)d ap.ttt*afio,,rel,r, ps\,natc
News 2000 8 r€
f. rT..&.at C, L?..rd., 1l,frq,,,t, E ul-tora^.,ena Aa".i, r.zhrn,tjFolee
@loeoaeh der.'nt. pe u 4re.rrcrr He8oo^ .curuanD 2lO5 322:3
A lFr.xog G, UroiDo8., A XT.nt|.a., E, /trtr., r.r\ ) tane rttjtr L.-lL 6 nn t)anil
ena ha auodt\,"Lrha Negaor .rjulHr, 2005 2e9
C Xfrrd' Cr rlT r..a.. E UrqD.a.r A /,i ."i. . i ..,!.-,; .:.,,. iir.,.rce!, , ..: i
23 runrapcxe HEBpoAoTL4r.tHA r ncuxrlATpt/r.tHA npAKTI4KA
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Hunet pdbcflu 3a€a6gaHu4 HeBpo^ ncuxuamp. 2006 I 2224
&h..-.a+I'ft..i.atc-lryrdqLPo^t a'a a^kut k$bk I neopuena
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a, Iifa-r r.cr ,arlf+ ] cl,rho, "Cogtut\e dtsmeha' as an nteglattre the
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lG a..bri q laLra.f c. tafraaa., J tleu,olog:at salt eqns h ,tdegsode s.h1z.
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