Каплан Г.И. Клиническая психиатрия

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9

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kh[kl\_ggh]hl_eZ

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hsmiu\Zgbb

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; GZjmr_gby k\yaZggu_ k dhg\_jkb_c b ^bkkhpbZlb\gufb n_ghf_gZfb



khfZlbaZpby ih ^Z\e_gguo i_j_`b\Zgbc beb jZa\blb_ khfZlbq_kdbo kbfilhfh\ b

gZjmr_gbc

khklhjhguijhba\hevghcfmkdmeZlmjub hj]Zgh\qm\kl\gZjmr_gbyg_dhgljhebjmxlky

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 Bkl_jbq_kdZyZg_kl_abygZjmr_gb_k_gkhjghcqm\kl\bl_evghklb\ dZdhceb[h

fh^ZevghklbjZa\b\r__ky\ j_amevlZl_wfhpbhgZevgh]hdhgnebdlZ

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hgb_klvgZkZfhf^_e_

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gZijbf_jy\eyxlkykhklZ\ghcqZklvxkeh`guoijbiZ^dh\

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kh[kl\_ggh]h©Yª

 >_j_ZebaZpby km[t_dlb\gh_ hsms_gb_ g_j_Zevghklb hdjm`Zxs_]h fbjZ

[he_ag_ggh_hsms_gb_lh]hqlhfbjdZdlhbaf_gbeky

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`bl_evkl\Z

 JZks_ie_gb_ebqghklbh^ghblh`_ebph\ jZagh_\j_fyhlh`^_kl\ey_lk_[yk

kh\_jr_gghjZaebqgufbi_jkhgZfb

< =ZeexpbgZpbb

eh`gh_ \hkijbylb_ g_kms_kl\mxsbo k_gkhjguo klbfmeh\

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i_j_`b\Zgbc=ZeexpbgZpbbmdZau\ZxlgZgZebqb_ikbohlbq_kdbojZkkljhckl\lhevdh

\lhfkemqZ__kebhgbk\yaZguk gZjmr_gb_fhp_gdbj_Zevghc^_ckl\bl_evghklb

 =bigZ]h]bq_kdb_ ]ZeexpbgZpbb eh`gu_ k_gkhjgu_ \hkijbylby k\yaZggu_ k

ijhkhghqgufkhklhygb_fi_j_oh^hfhl[h^jkl\h\Zgbydhkgm

 =bighihfibq_kdb_ ]ZeexpbgZpbb eh`gu_ \hkijbylby ijhy\eyxsb_ky \

i_j_oh^guci_jbh^hlkgZd [h^jkl\h\Zgbx

 Kemoh\u_]ZeexpbgZpbbeh`gh_\hkijbylb_a\mdh\h[uqguo]hehkh\brmfh\

fmaudbblhfmih^h[gh_

 Ajbl_evgu_]ZeexpbgZpbbeh`gh_\hkijbylb_\\b^_dZd\iheg_hij_^_e_gguo

h[jZah\gZijbf_jex^_clZdb [_knhjf_gguoh[t_dlh\gZijbf_j\kiur_dk\_lZ

 H[hgyl_evgu_]ZeexpbgZpbbeh`gh_hsms_gb_aZiZoZ

 <dmkh\u_ ]ZeexpbgZpbb eh`gh_ \dmkh\h_ hsms_gb_ h[mkeh\e_ggh_

ihjZ`_gb_fdjxqdZiZjZ]biihdZfiZevghcba\bebgu

 LZdlbevgu_ ]Zilbq_kdb_ ]ZeexpbgZpbb eh`gh_ hsms_gb_ ijbdhkgh\_gby

beb ih\_joghklb Zfimlbjh\Zgghc dhg_qghklb nZglhfguc kbg^jhf hsms_gb_

iheaZgbyfmjZr_dgZdh`_bebih^g_cnhjfbdZpby

 KhfZlbq_kdb_ ]ZeexpbgZpbb eh`gh_ hsms_gb_ dZdbolh kh[ulbc

ijhbkoh^ysbo \gmljb k\h_]h l_eZ beb k gbf qZs_ \k_]h k\yaZggh_ k \gmlj_ggbfb

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 Ebebimlh\u_ ]ZeexpbgZpbb eh`gh_ \hkijbylb_ ijb dhlhjhf \k_ h[t_dlu

dZ`mlkyf_gvr_q_f\ ^_ckl\bl_evghklb

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_]h]hehkZhlhfqlhhg^hklhcgucagZxsbckbevgucq_eh\_dbl^

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dhlhjuo g_ khhl\_lkl\m_l ^_ij_kkb\ghfm khklhygbx beb g_ khhl\_lkl\m_l

fZgbZdZevghfm khklhygbx gZijbf_j m [hevgh]h k ^_ij_kkb\guf gZkljh_gb_f

]ZeexpbgZpbb g_ hij_^_eyxlky qm\kl\hf \bgu gZdZaZgby beb kh[kl\_gghc

g_iheghp_gghklb Zm [hevgh]h k fZgbZdZevguf gZkljh_gb_f g_ k\yaZgu k _]h

\Z`ghklvxagZqbfhklvxbebkbehc

 =Zeexpbgha ]ZeexpbgZpbb gZb[he__ qZklh kemoh\u_ dhlhju_ k\yaZgu k

ojhgbq_kdbf aehmihlj_[e_gb_f Zedh]hey b ihy\eyxlky [_a dZdboeb[h ijbagZdh\

gZjmr_gbykhklhjhguk_gkhjghckbkl_fu\ ijhlb\hiheh`ghklv[_ehc]hjyqd_

 Kbg_kl_aby hsms_gby beb ]ZeexpbgZpbb h[mkeh\e_ggu_ ^jm]bfb

hsms_gbyfb gZijbf_j kemoh\h_ hsms_gb_ Fhijh\h`^Z_lky beb \hagbdZ_l \

j_amevlZl_\ha^_ckl\bygZajbl_evgucZgZebaZlhja\md\hkijbgbfZ_lkydZdajbl_evguc

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deZkkbnbdZpbx '60,,,5 < gZklhys__ \j_fy \_^_lky jZ[hlZ ih ih^]hlh\d_

deZkkbnbdZpbbFD;

HKGH<GU?HKH;?GGHKLB

'60,,,5

HibkZl_evguc ih^oh^

 Ih^oh^ ijbf_gy_fuc \ '60,,,5 g_ y\ey_lky

l_hj_lbq_kdbf\ kfuke_k\yab^bZ]ghaZk wlbheh]b_cLZdbfh[jZahf '60,,,5 ²wlh

ihiuldZih gylghhibkZlvqlhij_^klZ\eyxlkh[hcijh y\e_gbyikbobq_kdbogZjmr_gbc

b lhevdh bgh]^Z h[tykgblv bo ijbqbgm H[sbc ih^oh^ y\ey_lky hibkZl_evguf \lhf

kfuke_ qlh hij_^_e_gb_ wlbo gZjmr_gbc h]jZgbqb\Z_lky \ hkgh\ghf hibkZgb_f bo

debgbq_kdbohkh[_gghkl_c

>bZ]ghklbq_kdb_ djbl_jbb

 >ey dZ`^h]h ki_pbnbq_kdh]h ikbobq_kdh]h

gZjmr_gbykms_kl\mxlki_pbnbq_kdb_djbl_jbb^bZ]ghklbdbWlbdjbl_jbb\dexqZxl

hibkZgb_ kms_kl\_gguo oZjZdl_jbklbd gZebqb_ dhlhjuo g_h[oh^bfh ^ey ihklZgh\db

^bZ]ghaZ>hdZaZgh qlh lZdb_ djbl_jbb ih\urZxl gZ^_`ghklv ijhp_kkZ \ j_amevlZl_

dhlhjh]hjZagufbdebgbpbklZfbklZ\blkyh^bgblhl`_^bZ]gha

Kbkl_fZ hibkZgby

< '60,,,5 ih^jh[gh hibku\Zxlky \k_ gZjmr_gby

hlf_q_gu bo kms_kl\_ggu_ oZjZdl_jbklbdb b khimlkl\mxsb_ hkh[_gghklb Z lZd`_

ijb\_^_gu djZldb_ ^Zggu_ h \hajZkl_ gZqZeZ aZ[he_\Zgby ^bgZfbd_ h[hklj_gbyo

hkeh`g_gbyo b ij_^jZkiheh`_gghklb jZkijhkljZg_gghklb k_dkmZevghc kn_j_

gZke_^kl\_gghklbb ^bnn_j_gpbZevghf^bZ]gha_ '60,,,5g_ij_l_g^m_lgZlhqlh[u

hgZ kqblZeZkv jmdh\h^kl\hf <g_c g_ kh^_j`blky l_hjbc dZkZxsboky wlbheh]bb

l_q_gby beb l_jZibb hlkmlkl\m_l lZd`_ h[km`^_gb_ ijhlb\hj_qb\uo fhf_glh\

kms_kl\mxsboijbihklZgh\d_dZ`^h]hhij_^_e_ggh]h^bZ]ghaZ

Fgh]hhk_\Zy hp_gdZ

 '60,,,5 ²fgh]hhk_\Zy kbkl_fZ iha\heyxsZy hp_gblv

khklhygb_[hevgh]hihg_kdhevdbfi_j_f_ggufhgZkh^_j`bliylvhk_c

Hkv

, Debgbq_kdb_ kbg^jhfu b khklhygby g_ k\yaZggu_ k ikbobq_kdbf

aZ[he_\Zgb_f

Hkv

,, Hldehg_gby \ jZa\blbb ebqghklb \dexqZxl mfkl\_ggmx j_lZj^Zpbx

ki_pbnbq_kdb_ gZjmr_gby jZa\blby hkh[_ggh l_ dhlhju_ \_^ml d ^_nhjfZpbb

ebqghklbb ebqghklgu_gZjmr_gby

Hkb

,, kh^_j`Zl dhfie_dkgmx deZkkbnbdZpbx ikbobq_kdbo gZjmr_gbc

dhlhjZy\dexqZ_l  hkgh\guodeZkkbnbdZpbcb [he__  ki_pbnbq_kdbogZjmr_gbc

Gb`_ijb\_^_gudeZkkubeb]jmiiukhklhygbc\dexq_gguo\hkb, b ,, '60,,,

5

 GZjmr_gbydhlhju_h[uqgh\i_j\u_ijhy\eyxlky\ ^_lkdhfbebih^jhkldh\hf

\hajZkl_hlghkblkyd dZl_]hjbbgZjmr_gbcjZa\blbyih '60,,,5

 Hj]Zgbq_kdb_ikbohkbg^jhfub gZjmr_gby

 G_\jheh]bq_kdb_ gZjmr_gby hj]Zgbq_kdh]h oZjZdl_jZ \ua\Zggu_ ijb_fhf

ikbohljhiguokj_^kl\

 >jm]b_gZjmr_gby\ua\Zggu_ijb_fhfikbohljhiguokj_^kl\

 Rbahnj_gby

 ;j_^h\hiZjZghb^gu_jZkkljhckl\Z

 Ikbohlbq_kdb_jZkkljhckl\ZjZg__g_\dexqZ\rb_ky\ deZkkbnbdZpbx

 GZjmr_gby gZkljh_gby dhlhju_ ij_`^_ \ '60,,,5 gZau\Zebkv

Znn_dlb\gufbjZkkljhckl\Zfb

 JZkkljhckl\Z\ujZ`Zxsb_ky\ ih\ur_gghclj_\h`ghklbbebg_\jha

KhfZlhnhjfgu_gZjmr_gby

>bkkhpbZlb\gu_ gZjmr_gbygZijbf_j bkl_jbq_kdbc g_\jha ^bkkhpbZlb\gZy

nhjfZ

K_dkmZevgu_gZjmr_gby

JZkkljhckl\ZkgZ

GZjmr_gby\hagbdrb_bkdmkkl\_ggh

GZjmr_gby dhgljhey gZ^ k\hbfb ih[m`^_gbyfb jZg__ g_ \dexqZ\rb_ky \

deZkkbnbdZpbx

GZjmr_gb_j_]meypbb

Ikboheh]bq_kdb_nZdlhju\ebyxsb_gZnbabq_kdh_khklhygb_

JZkkljhckl\Zebqghklb

Khklhygby dhlhju_ g_evay k\yaZlv k ikbobq_kdbf aZ[he_\Zgb_f gZ dhlhju_

ke_^m_lh[jZlblv\gbfZgb_b e_qblv

Khhl\_lkl\_ggh '60,,,5 \h fgh]bo kemqZyo ^he`gu gZ[ex^Zlvky gZjmr_gby

kjZamihh[_bfhkyfGZijbf_jm \ajhkeh]h[hevgh]hfh`_lgZ[ex^Zlvky^_ij_kkby\

\b^_ __ hkgh\gh]h ijhy\e_gby beb kbg^jhfZ hlf_qZ_fh]h ih  hkb , b gZjmr_gb_

ebqghklb \ nhjf_ dhfimevkb\ghklb hkb ,, beb `_ m j_[_gdZ fh]ml [ulv gZjmr_gby

ih\_^_gbyihhkb , b jZkkljhckl\Zj_qbihhkb ,,

Hkv

,,, Hkv ,,, kh^_j`bl i_j_q_gv nbabq_kdbo gZjmr_gbc beb khklhygbc

dhlhju_fh]m lgZ[ex^Zlvkym [hevgh]hk ikbobq_kdbfbjZkkljhckl\Zfb

< hkgh\_ gZjmr_gby ikbobq_kdh]h khklhygby fh]ml e_`Zlv bklbggh nbabq_kdb_

ijbqbgu ijbf_jhf fh]m l kem`blv kemqZb dh]^Z [he_agv ihq_d \uau\Z_l ^_ebjbc

fh]ml lZd`_ \klj_qZlvky kemqZb dh]^Z \ hkgh\_ gZjmr_gby nbabq_kdh]h khklhygby

e_`Zlikbobq_kdb_jZkkljhckl\ZgZijbf_jm [hevgh]hZedh]hebafhffh`_ljZa\blvky

\lhjbqguc Zedh]hevguc ]Zkljbl b gZdhg_p bgh]^Z khfZlbq_kdh_ aZ[he_\Zgb_

gZau\Z_lkykZfhklhyl_evghg_aZ\bkbfhhlikbobq_kdbogZjmr_gbc

Hkv ,,, kh^_j`bl dh^u aZbfkl\h\Zggu_ ba F_`^mgZjh^ghc deZkkbnbdZpbb

[he_ag_cljZ\fb ijbqbgkf_jlbFD;

Hkv

,9 Hkv ,9 kh^_j`blrdZemba  imgdlh\^eydh^bjh\ZgbyikbohkhpbZevguo

nZdlhjh\ \uau\Zxsbo klj_kk b kihkh[kl\mxsbo jZa\blbx h[hklj_gbc

gZ[ex^Zxs_]hkyaZ[he_\ZgbyGb`_ijb\h^ylkyijbf_jubeexkljbjmxsb_hkv ,9dZd

^ey \ajhkeuo lZd b^ey ^_l_c b ih^jhkldh\ Gb`_ ijb\h^blky rdZeZ ly`_klb

ikbohkhpbZevguoklj_kkh\^ey\ajhkeuo

Dh^

 Klj_kkhjgucnZdlhjhij_^_ey_lkydZdhlkmlkl\mxsbcgbdZdb_kh[ulbyg_

fh]ml jZkkfZljb\Zlvky dZd hkljuc klj_kk kihkh[guc \ua\Zlv aZ[he_\Zgb_

hlkmlkl\mxl lZd`_ mklhcqb\u_ ^ebl_evgu_ klj_kkh\u_ h[klhyl_evkl\Z dhlhju_

fh]eb[u\ua\ZlvaZ[he_\Zgb_

Dh^

 Klj_kkhjguc nZdlhj oZjZdl_jbam_lky dZd keZ[uc ijbf_jhf hkljuo

klj_kkh\kem`bljZaju\k \haex[e_gguf\haex[e_gghcgZqZeh beb hdhgqZgb_

mq_[u \rdhe_ kemqZc dh]^Z j_[_ghd jZkklZ_lky k ^hfZrgbfb ^ebl_evgu_

klj_kkh\u_ h[klhyl_evkl\Z²dhgnebdlu \k_fv_ g_m^h\e_l\hj_gghklv jZ[hlhc

ijh`b\Zgb_\ jZchg_\ukhdhcij_klmighklb

Dh^

 Klj_kkhjguc nZdlhj oZjZdl_jbam_lky dZd mf_j_gguc ijbf_jZfb hkljuo

klj_kkhjguonZdlhjh\fh]ml[ulv[jZdjZaemdZk kmijm]hfihl_jyjZ[hlumoh^

gZ i_gkbx Z[hjl ijbf_jZfb mklhcqb\uo klj_kkh]_gguo \ha^_ckl\bc ²

g_kh]eZkb_ \ [jZd_ k_jv_agu_ nbgZgkh\u_ aZljm^g_gby iehob_ hlghr_gby k

gZqZevgbdhf kemqZc dh]^Z h^bg ba jh^bl_e_c bkihegy_l \k_ jh^bl_evkdb_

h[yaZgghklbjh^bl_evh^bghqdZ

Dh^

 Klj_kkhjguc nZdlhj jZkkfZljb\Z_lky dZd ly`_euc ijbf_jhf hkljuo

nZdlhjh\kem`bljZa\h^bebjh`^_gb_j_[_gdZbebojhgbq_kdbcdh]^Zkm[t_dl

g_fh`_lgZclbjZ[hlm[_^ghklv

Dh^

 Qj_af_jgh ly`_euc klj_kkhjguc nZdlhj hkljuc²kf_jlv h^gh]h ba

kmijm]h\ dh]^Z klZ\blky ^bZ]gha k_jv_agh]h khfZlbq_kdh]h aZ[he_\Zgby dh]^Z

km[t_dl klZgh\blky `_jl\hc gZkbeby ojhgbq_kdbc²gZebqb_ k_jv_agh]h

ojhgbq_kdh]h aZ[he_\Zgby m km[t_dlZ beb _]h j_[_gdZ gZebqb_ nbabq_kdhc beb

k_dkmZevghcg_iheghp_gghklb