Kharkiv National Medical University Department of Psychiatry, Narсology and Medical Psychology WORKBOOK MANUAL FOR INDIVIDUAL WORK OF STUDENTS PSYCHIATRY Part 1 Student _________________________________________________________ Faculty _________________________________________________________ Curs _________________ Group ____________________________________ Копіювання для розповсюдження в будь-якому вигляді частин або повністю можливо тільки з дозволу авторів навчального посібника. Психіатрія та наркологія (частина 1): робочий зошит для самостійної роботи студентів // Г.М. Кожина, В.М. Сінайко, І.М. Стрельнікова, І.В. Лещина, К.О. Зеленська, І.Д. Вашкіте – Харків, 2018. – 186 с. CLASS №1 THE SUBJECT AND TASKS OF PSYCHIATRY AND NARKOLOGY. ORGANIZATION OF PSYCHIATRIC AID. METHODS OF EXAMINATION OF MENTAL DISEASE. CLASSIFICATION OF MENTAL DISEASE. REGISTER MENTAL DISEASE. DISTURBANCES OF SENSATIONS AND PERCEPTIONS. Psychiatry is the medical science dealing with the study of diagnosis, etiology, pathogenesis and rate of mental diseases, as well as organization of the psychiatric aid. Psychiatry (Greek psyche – soul, iatreia – treatment) = treatment of the soul. Tasks of psychiatry: 1. Study of the rate, conditions of origination, nosological structure and clinical peculiarities of mental diseases. 2. Study of the etiology and pathogenesis of mental diseases. 3. Treatment and prevention of mental diseases. 4. Social-labour rehabilitation of patients. 5. Labour, forensic and military psychiatric examination. 6. Carrying out of sanitary-educational and psychohygienic measures among the population. Main sections of modern psychiatry: 1. General (study and treatment of mental illness) 2. Pediatric, juvenile 3. Geriatric 4. Narcology 5. Forensic psychiatry 6. Social psychiatry 7. Psychotherapy 8. Psychopharmacotherapy 9. Sexual pathology 10. Suicidology 11. Penitentiary psychiatry (It examines the characteristics of mental disorders in people who are in prison, risk factors for committing illegal actions). 12. Transcultural psychiatry (especially comparative studies of psychiatric disorders in people of different nations, cultures and social systems) HISTORY OF DEVELOPMENT. A brief overview of the history of psychiatry Mental illness exists as long as humanity exists. In the pre-scientific period of the history of medicine prevalent primitive theological understanding of the anomalous behavior of the patients, which is reflected in myths and legends. For example, the Bible describes cases of mental disorders in the Babylonian king Nebuchadnezzar, in the Jewish King Saul (melancholy and epilepsy). The origins of the birth of psychiatry associated with the great physician and philosopher of ancient Greece - Hippocrates, which is rightly considered the founder of scientific medicine. Hippocrates first claimed that the mentally ill suffer from the brain, and so they should be treated by the doctor. Hippocrates believed that the mental characteristics of man are determined by mixing 4 main juices of a living organism (blood, phlegm, yellow and black bile), depending on the predominance of one of them he distinguished between 4 types of temperaments: sanguine, phlegmatic, choleric, melancholic. Hippocrates looked at mental illness as treatable and recommended sick body rest, diet, baths, cold douche, light exercise and light gymnastics, emetic and purgative. Heavily influenced by Hippocrates, was Aristotle - a philosopher, and pay attention to the study of mental illness. He noted the tendency to violence epileptics and melancholic considered gifted others. Aretha, the ancient physician, described epilepsy, melancholia, mania, their clinic, course and outcomes, as well as acute psychosis in somatic diseases. Claudius Galen studied the brain, the seat of his mind thought, thoughts localized in the heart, the desire - in the liver. Mental illness Galen differentiated between on acute and chronic, related to the first feverish delirium, to the second - melancholy. The advent of a new era, the Middle Ages, slowed down the development of science. During this period was dominated by the influence of the church on the diabolical obsession of apostasy, of holiness and possessed with a devil, so any violation of the psyche is not assessed as a disease but as a result of voluntary intercourse with the devil. In the early Middle Ages began to emerge and progressive views on the nature of mental illness. So, the famous Arab scholar Avicenna considered disease infringement of mental activity, and called for their treatment. These views Avicenna implemented in the construction of hospitals for the mentally ill. At the end of XVII - beginning of XVIII century in connection with the expansion of cities and crowded public authorities ordered the relatives of patients to protect the peace living nearby. Patients were tied, chained, locked in rooms. In Europe, there are shelters for the mentally ill. However, although these institutions patients have not executed and burned, the attitude towards him was harsh and cruel. An example of this is organized in England psychiatric institution - Bedlam, whose name became a household word in the future. The Bedlam patients were kept in small rooms with stone floors and no furniture, chained to the walls. In the era of the rise of capitalism in Europe, there is a gradual liberation of science from the influence of theology. Creates prerequisites for the formation of psychiatry as a science. In the XVIII century there have been major changes in the organization of mental health care. This reflected the social changes that have occurred in France during the period of the bourgeois revolution. French philosophers (Lammert, Diderot, Cabanis, Holbach, Helvetius) had a great influence on medicine. According to the Treaty of Cabanis, mental illnesses are brain diseases. Now you can transform the legislative provisions of the mentally ill. French psychiatrist Philippe Pinel (1745-1826), the chief doctor psychiatric hospital Bicetre achieved at the National Convention of the right to withdrawal of chains with the mentally ill and went down in history as the "father of modern psychiatry." F. Pinel - founder of psychiatry in France, its main merit is that he was "elevated to the rank of a crazy person of unsound mind". The closest disciple Pinel, Zh.Eskerol, laid the foundation for the scientific and clinical psychiatry, legalized the mandatory medical examination of persons placed in psychiatric institutions. Eskerol initiated the study of progressive paralysis, set of somatic symptoms in the clinic of psychosis, delusions and hallucinations differentiated. Reforms initiated by Pinel, continued in England Connolly. He was the professor of University of London, which declared the principle of "unconstrained" mentally ill. In the middle and second half of the XIX century, psychiatry has made significant progress. The Viennese psychiatrist T. Meinert described amentia, German psychiatrist Karl Wernicke first described alcoholic hallucinosis, introduced the concept of overvalued ideas, pseudohallucinations, hallucinosis, hallucinatory confusion. At the end of the XIX century, wider development receives symptomatic psychiatry: a systematic delusional psychosis (C. Magnan), circular insanity, catatonia (K. Kahlbaum) hebephrenia (E. Hecker) geboidofreniya (K. Kahlbaum) diznoyya (S.S. Korsakov). Simptomatologicheskoe direction limited to the description of symptoms, symptom, in which mental illnesses manifest themselves, without taking into account the causes and mechanisms of development. This period of world psychiatry is defined as the development of preclinical but two disease entities have been described already in this period: progressive paralysis (AG Bell), alcoholic psychosis polinevrichesky (S.S. Korsakov). A major role in shaping the views of nosology in psychiatry have played the works of the German scientist E. Kraepelin. Kraepelin stated that mental illness - a natural biological process, having a specific etiology of specific mental and physical symptoms, postmortem basis, and for the typical pre-ordained outcome. He singled out two endogenous mental illness - dementia praecox (demence precose) and manic- depressive psychosis. In XX century, has spread the teachings of Karl Bonhoeffer exogenous types of reactions in the form of disturbance of consciousness of the effect of exogenous harmful factors (infection, intoxication). In 1911, Swiss psychiatrist E. Bleuler suggested the name schizophrenia disease described Kraepelin. A.Altsgeymer described the histopathology of progressive paralysis, he has allocated a special form of early dementia, named after him. Great influence on the development of mental health in Europe and especially in the United States had the teachings of Freud. The main point of this trend is the recognition of the prevalence of psychiatric unconscious over the conscious. The unconscious, according to Freud, is instinct, primarily sexual, which cause all the psychic activity of man. According to Freud's theory, the conflict that arises between the subconscious and the unconscious, if it is not disclosed, and not react, can cause neurosis. History of Ukrainian psychiatry. In Slavic countries related to the mentally ill it was more humane. Some patients have proclaimed "holy fools", "holy", and tried to talk to them to perceive the various predictions and advice. Already in Kievan Rus were established organizational forms of care for the mentally ill. Since 1775 began to open psychiatric units in hospitals. Ukraine's first psychiatric hospital was opened in 1796 in Kharkov ("Saburov's Dacha"). In 1834, Professor of the Department of Kharkov University Surgery PA Butkovskiy wrote the first textbook on psychiatry for the Slavic peoples "Mental illness". The official teaching of psychiatry at the medical faculties was proclaimed in 1835, but this rate continued reading teachers of other specialties. Korsakov created the original classification of mental diseases where individual nosological forms are described (dystonia, psychoneurotic alcoholic psychosis). KH Kandinsky, who wrote the classic work "On pseudohallucinations", which has become a kind of guide to the psychopathology of delusions, hallucinations and pseudohallucinations. The first independent chair of psychiatry and neurology was established in 1877 in Kharkov University, led by her professor PI Kovalevsky, known for his work in psychology, anatomy, psychographics, who proposed his own classification of mental disorders. Since 1883, PI Kovalevsky publishes first domestic journal "Archives of Psychiatry, Neurology and Forensic psychopathology." An important role played by such scholars in the development of Ukrainian psychiatry as A.J. Anfimov, K.I. Platonov, V.P. Protopit, EA Popov working in Kharkov. ORGANIZATION OF PSYCHIATRIC AID. "The good of the patient - the supreme law" (Salus aergoti suprema lex) - a basic principle which must use all doctors, especially psychiatrists. The significant role of ethics in professional work of the psychiatrist as the nature of his relationship with the patient special, creating a specific moral issues. These issues are determined by the fact that psychiatry has the means of human exposure. One of the tasks of psychiatry - enhance the social acceptance of the mentally ill, overcoming barriers of bias, exclusion and regulation of social sanctions against the mentally ill. Unlike other medical disciplines, psychiatry applies in respect of certain categories of patients coercion, creating a frightening aura about psychiatry, causing distrust of society and the natural tendency to protect itself from undue interference in their lives. The object of psychiatric ethics is to limit the scope of coercion in the provision of mental health care to the limits determined by medical necessity that ensures respect for human rights. Do not use coercive measures in relation to patients who do not pose a threat to themselves or others. patient burdensome to others should not be a prerequisite for the use of coercion. The duration of stay of the patient in the hospital should be determined only by his mental state. Do not delay in hospital patients, as it can cause hospitalism syndrome. It is important that patients are as long as possible socially adapted as continuing to work patients arrive at the hospital less often, and the time spent in hospital is shorter than that of patients who left work. When the patient returns from the hospital is necessary to consider the conditions in which they live at home. During the patient stays in the hospital doctor should monitor the ratio of staff to the patient, to avoid the possibility of being subjected to inappropriate or disciplinary action. Do not use the restriction of patients unless absolutely necessary. Studies in different countries have shown that while decreasing of disciplinary measures in psychiatric departments, unlimited visits of relatives, provide home vacation, they reduce the number of aggressive and auto-aggressive acts of mental sick patients. In the relationship doctor - patient is the most attractive model, when the doctor is not a dispassionate functionary and counselor, a friend, a teacher, which helps the patient to choose the only correct decision. However, as an alternative with respect to the individual patient, paternalism ( "parent" model), and the partnership is not alternative to psychiatry in general. Specificity and complexity psychiatry is that even with respect to one and the same patient can change these models to each other at different stages of the disease. Therefore, one of the tasks of psychiatric ethics is to establish the optimum relationship between doctor and patient, promoting implementation of the interests of the patient, taking into account the specific clinical situation. World public care about issues prevent possible abuse in the provision of mental health care. Inhuman attitude towards the mentally ill, unfortunately, there are also today in many countries and cultural regions and political systems. Misuse of psychiatry - is the intentional infliction of moral, physical or other damage to the person by applying to it the medical measures that are not shown and necessary, or by non-use of medical measures that are shown and necessary, based on the state of his mental health. The main regulations on misuse of psychiatry are Hawaiian Declaration, adopted by the World Psychiatric Association in 1977, and "Principles for the protection of persons suffering from mental illness and improving health in the field of psychiatry", adopted by the UN General Assembly in 1991. Any abuse of psychiatry your knowledge incompatible with professional ethics. The psychiatrist can not use his abilities against the health interests, without justification and the need to use medical measures. You can not put a psychiatric diagnosis only based on the divergence of views and opinions. In his work, the psychiatrist should consider only his medical conditions, medical debt and the law. Doctor should be independent in his decisions. The Law of Psychiatric Aid. In Ukraine, the Law on Psychiatric Aid was adopted; it regulates the rights of mental patients, the rules for giving them aid, as well as clearly determines indications for hospitalizing patients to psychiatric establishments. The basic clauses of the Law on Psychiatric Aid proceed from the statement that mental patients who are citizens of our country enjoy all the rights declared in the Constitution of Ukraine. The Law on Psychiatric Aid is based on 10 main principles worked out by the Mental Health Department of the World Health Organization. These principles are as follows: 1. Development of mental health and prevention of mental disorders. Every person should look after his mental well-being and take measures for eliminating causes of mental disorders. 2. Availability of the basic psychiatric aid. The psychiatric aid must preserve dignity of the patient, it must be materially accessible, just, be at an accessible distance from the patient’s place of living, as well as be given on the voluntary basis. 3. Assessment of the mental health in compliance with the generally accepted international principles.д 4. Provision of the psychiatric aid in the least restrictive form. If it is necessary to use various measures of restriction, one should periodically revise this decision (e.g., every 30 minutes in case of a physical restriction and not more than 4 hours). 5. Self-determination, i.e. receiving of the patient’s consent before using any type of interference. 6. The right to receive help in self-determination. 7. Availability of the reassessment procedure. The decision must satisfy all the legal rules in force at this particular moment. The laws must be open, easily understood and in a clear form. The patient should be informed about his rights. The control over the actual application of the Law on Mental Health must be exercised by a body which does not depend upon the health care authorities. 8. Mechanism of automatic periodic review. 9. Qualification of the people taking a decision. The people who take a decision concerning the patient must be: a. competent; b. informed; c. independent; d. impassive. Ideally, the body taking a decision should consist of at least 3 persons. 10. Respect of law. The decision must satisfy all the legal rules in force at this particular moment. The laws must be open, easily understood and in a clear form. The patient should be informed about his rights. The control over the actual application of the Law on Mental Health must be exercised by a body which does not depend upon the health care authorities. Psychiatric treatment organization are divided into 3 main groups: outpatient, inpatient and social rehabilitationщ. Outpatient care is mentally ill in psychiatric (neuropsychiatric) dispensaries. Psychiatric clinics serve 9municipal and regional residents. In addition, at district health centers, district hospitals (in places where there areщ щno clinics) organized psychiatric treatments. Indications for hospitalization in a psychiatric hospital. 1. The presence of severe mental illness, which can not be treated on an outpatient basis 2. The necessity for permanent dynamic medical supervision for the differential diagnosis and diagnostics. 3. Indications for emergency hospitalization (without the patient's consent) will be regulated by the law on psychiatric care. Finally, the issue of psychiatric hospitalization only solves a psychiatrist after a personal examination of the patient. If you have doubts about the mental health of the patient's doctor of any specialty is obliged to advise the patient consultation psychiatrist, if there are indications for immediate hospitalization organize challenge teams of specialized mental health care. Specificity of the organization of psychiatric hospitals. The optimal location of the place of psychiatric hospitals should be considered as a green area, distant from saturated transport routes and industrial plants. It is essential that the hospital area was planted, each department should be allocated places for walking patients (exercise yards). Departments of psychiatric hospitals is differentiated by gender (male and female) and age (children, teenagers, gerontology) principles. In addition, there are specialized departments: for neurotic patients, forensic psychiatric examination, tuberculosis, infectious disease, emergency department, department for emergency treatment. In psychiatric hospital also work therapists, dentists, neurologists, gynecologists, surgeons, ophthalmologists, otolaryngologists. Organized diagnostic services: radiological, electrophysiological, laboratory (clinical and biochemical studies), as well as the psychological laboratory. The work organized by administrative - economic staff. The organization of psychiatric department has a such features. It is necessary to exclude the possibility of leaving the department by patients with aggressive and auto-aggressive tendencies. This explains the specific of closed doors. Every psychiatric department is divided into 2 types of parts: the sanatorium and observation. Children's department of mixed gender. In such department organized classrooms, where children learn, play. Department of neuroses do not a lot of differents from typical neurological departments. In the departments of forensic psychiatry more stricter regime, than in psychiatric, it is provide by the halp of police. Since 1975, in our country Narcologikal Service is a separate unit. For outpatient, treatment is provided in narcological dispensary and district narcologikal departments and for inpatient - in narcological hospitals. METHODS OF EXAMINATION FOR MENTAL PATIENTS. The main method in examination of mental patients is the clinical- psychopathological one, which is based on a conversation with a patient, observation of his expression and behaviour. The first acquaintance of the physician with the patient and establishment of an adequate psychological contact between them are of paramount importance. During the conversation the physician is also a subject of study from the patient’s side. Mental patients, and patients in general, are very sensitive to manifestations of inattention, rudeness, tactlessness, superiority, falsity, they finely respond to kindness, sympathy, a merciful attitude to themselves from the side of the physician and medical staff. In case of an inadequate emotional contact of the physician with the patient the latter develops watchfulness, distrust, a wish to hide his feelings with a resultant incorrect interpretation of the diagnostic value of the signs of mental and somatic disorders. Often the patients whose attitude to their state is not critical dissimulate, i.e. deliberately hide their mental disorders. The physician should be able to listen to the patient, giving him an opportunity to tell about himself as independently as possible. Nevertheless, the conversation can be directed; the physician should skillfully ask questions trying not to induce the patients with them, more frequently ask to describe some or other symptoms with more details rather than to confine himself only to statement of the terms used by the patients, as they often put their own meaning to known terminological designations instead of the generally accepted one. Therefore the physician should ask the patient, “What is it?”, “Describe with more details what really you feel.” The physician should put questions in the form understandable for the patient, use only the terms that the patient knows or, if something is not clear for the patient, patiently explain, be an active participant in the dialogue, listen to the patient attentively, not to be distracted for outside matters in the patient’s presence. The physician must not emotionally respond to any absurdities heard from the mental patient or seen in his behaviour. In the end of the conversation it is necessary to tell the patient your preliminary opinion about his state in a delicate form. The scheme of a case report 1. Passport data (information) 2. The patient’s complaints 3. The life history (according to the patient) 4. The case history (according to the patient) 5. The objective history (according to the people who know the patient) 6. The patient’s state at the moment of examination: a) somatic; b) neurological; c) mental. 7. Conclusions on the basis of the primary examination, the initial syndromological diagnosis. 8. Data of the follow-up and examination of the patient. 9. Differential diagnosis. 10. Making of the final diagnosis. 11. Administration of the treatment. 12. Making of the prognosis and social-labour recommendations. Laboratory examinations: a) clinical analyses of the blood, urine, liquor, etc.; b) X-ray examinations; c) electrocardiography, electroencephalography, rheoencephalography; d) experimental-pathological ones. A conclusion made on the materials of the primary examination: determination of the psychopathological syndrome, making of the initial diagnosis, administration of urgent medical measures. Data of the subsequent observation and examination of the patient (laboratory examinations, results of examinations made by other specialists, records from diaries of everyday observation of the patients, etc.). Making of the differential diagnosis, making of the final nosological and syndromological diagnosis and administration of the treatment. In order to reveal and specify disorders of mental processes, an experimental- psychological examination is made. The methods of the experimental- psychological examination were studied in the course of the fundamentals of general psychology and medical psychology. The investigation of attention, fatiguability and memorization is carried on using the proof-reading test, Crepelin’s count, counting, finding numbers in Schulte’s tables, learning 10 words by heart. Peculiarities of thinking and intellect are investigated with help of the following tests: repetition of stories, explanation of subjects of pictures, classification of objects, definition of concepts, explanation of the figurative meaning of proverbs and sayings, Wechsler’s test. Peculiarities of personality are assessed using the Minnesota Multitype Personality Inventory (MMPI), Schmyschek’s Inventory, Pathocharacterological Inventory. The factors traumatizing the psyche and morbid feelings can be revealed by the method of unfinished sentences, with help of the topical aperceptive test (TAT). Luscher’s colour test and Taylor’s alarm scale help in revealing latent depression. The medical psychologist gives interpretation of the study results which are only auxiliary material for the physician. In diagnosing exogenous-organic psychoses, neurophysiological (electroencephalography – EEG, rheoencephalography – REG, echoencephalography – Echo-EG), as well as neurovisualizing (X-ray examination of the skull, computed tomography of the brain) methods of examination are used. For diagnosis and therapy of many mental diseases, analyses of blood, urine and cerebrospinal fluid are used. Studies of brain structure. Computed tomography (CT) is increasingly being used for diagnosis in recent years. They helps to diagnose large tumors, cysts, destruction, to determine the size of the ventricles, hydrocephalus, cerebral cortex. Small tumors can not be detected if by CT. Magnetic resonance imaging (MRI) makes it possible to analyze without special staining brain structure in different modes with high quality. Positron emission tomography (PET) allows you to explore not only the structure but also the peculiarities of the different parts of the brain, and with great quality. The method is based on a study of the distribution of natural brain metabolites (glucose, neurotransmitters, drugs and other substances), labeled with specific short-lived radioisotopes, and requires a special laboratory for the production of these isotopes, so now it is used for research purposes only. The bones of the skull does not allow us to study the structure of the brain using ultrasound, but ultrasound clinic utilizes a method that determines the position of median brain structures (M-echo). In a normal shift of midline structures is less than 2 mm from the center. Volumetric processes (tumors, cysts, abscesses) cause M-echo shift in the direction opposite lesions. Psychological methods. There is a huge amount of experimental psychological techniques used in various fields of psychology. The most common psychological analysis was performed to assess the extent and nature of memory disorders and intelligence, identifying pathological characteristics of the patient thinking, personality characteristics. For the diagnosis of organic brain lesions, the degree of mental retardation using a technique of studying memory, attention and intelligence. In most cases used such characteristic, as the IQ endex to determine intelligence. Raven's Matrices, using non-verbal character sets and figures, in the location where the person has to detect patterns. The test has small connection with the education of the person. Previous training is also can masked the results. In clinical practice, physicians often use simplified test problem about estimating the degree of disorder of memory and intelligence. In particular, the sample is used to memorize 10 words (normally stored after the test 3-4 verbal repetitions) or meaningless phrases (memorized after 5-7 reps). Countig by Kraepelin involves subtracting from 100 or 200 of the same number (7 or 17). Violations occur when a memory disorders, as well as the weakening of the intellect. The deterioration of the results, as evidenced by the task about exhaustion. the classification of the objectives of the division of a large number of objects in less than the number of groups. In violation of the capacity for abstraction turns out a large number of small groups. On the damage and intelligence indicating specific interpretation of the content of proverbs and sayings. Of great importance are methods for estimating harmony and focus thinking in diseases such as schizophrenia, epilepsy and others. Some abnormalities may be detected already when using the samples described above on memory and intelligence. In particular, patients with schizophrenia are often used during the classification unimportant, minor signs. This is particularly evident in the application of methodology "fourth extra" (the subjects were asked to make a group of 3 pieces and explain what 4th object is not included in it). When interpretation of metaphorical meaning of proverbs and sayings with schizophrenia often use non-standard abstract symbolic explanation. Patients with epilepsy usually, on the contrary, there are simple, close to the everyday explanations with greater attention to detail. At times, patients simply can not exclude any subject ( "What superfluous So nothing is too much is not: after all, a chair, and a table and a bed, and a cup - all you need As without them can not be ?!?!") Pictograms Method (LS Vygotsky) is trying to memorize 10-15 words and abstract concepts with the help of their image in the picture without the use of letters. Subjects are chosen in ascending order of the degree of abstraction, such a happy holiday, hard work, illness, happiness, love, development, deceit, heroism, hatred, justice, friendship, and others. The relationship that the patient explains, between drawing and depicts the concept. Identify the level of abstraction, naturopathic associations, support to secondary symptoms, emotional attitude to the portrayed subject's concept. Personality questionnaires suggest multiple choice answers to a number of questions. The subject in this case may deliberately distort the results, simulating the pathology or hiding the existing negative personality traits. Therefore, an important requirement to create tests - the presence of special evaluation scales that exhibit conscious attitude. Influence of the installation of the test the more than obvious purpose of the study, so monothematic questionnaires are considered less reliable (eg, range of reactive and personal anxiety Spielberg). The most commonly used clinical psychologist Eysenck questionnaire, MMPI. Eysenck test is based on the individual characteristics of the parameters "extraversion-introversion" and the severity of the factor "neuroticism", it consists of 57 questions (24 for each factor and 9 issues of "lie" scale). Each question allows only two possible answers: "Yes" and "No". It is assumed that there are introverts dysthymic symptoms extroverts - hysterical and psychopathic, the degree of manifestation of neuroticism points to the severity of the suffering (neurosis). In patients with schizophrenia, neuroticism lowest level in depressed patients - high. With age, the severity of neuroticism and extraversion decreases. The test is not considered ideal because of the significant impact on the result of the intellectual level of the subject, the proposed scale of lies is imperfect and does not rule out such an effect. Test MMPI (Minnesota Multiphasic Personality Inventory) in the original version contains 550 statements and suggests an answer in the form of assessments 'true' or 'false'. The result is an estimate of 8 clinical parameters (hypochondriasis, depression, hysteria, psychopathic, paranoid psychasthenia, schizophrenia, hypomania), 2 psychological characteristics (masculinity-femininity and social introversion) and 3 rating scales (false, reliability, correction). Projective techniques allow us to investigate the identity of the most free, untrammeled imagination and activity of the patient's what some pre-prepared answers. Pictures and questions in these tests differ incompleteness and uncertainty, which allows you to explore the deep, often unwitting psychological processes. Because these techniques do not suggest answers are ready, possible a greater range of reactions, more "subjective". In this sense, talk to your doctor, who asks the question in the infinitive form, which does not contain the answers foreseen, is endowed with a maximum degree of projective and can provide a wealth of material for the analysis of the patient's personality. The main problems of the use of projective techniques is the difficulty of unambiguous interpretation of the results of different investigators and the complexity of their standardization. In the method the patient is invited to Rorschach associations that arise from it when looking at the 10 tables with symmetrical polychrome and monochrome images (spots). A detailed formal list of the most common responses. A large number of vivid associations, the perception of motion show high intelligence and activity, attention to detail - about the disorganization of thought (for example, mental illness), related to the colors - an emotional experience, the presence of repetition - a sign of passivity, perseverative thinking. Thematic Apperception Test (TAT) is based on the stories, compiled by the subject when looking at the cards, which depict people and objects in uncertain proportions and conditions. In total there are 30 cards with pictures and one without images intended for their own fantasies of the subject. Allowed presentation directed questions. Dear, the test shows the basic aspirations, needs, existing conflicts and ways of resolving them. The test Rosenzweig uses 24 figures, images which require more specific and explicit limitation subject of interest (frustration) - thus possible to evaluate human behavior under stress. Luscher test does not use any images of anything, but only the human tendency to interpret certain colors. In a simplified version of a technique using a set of 8 colors (gray, blue, green, red, yellow, purple, brown, black). Application projective techniques in clinical practice is limited due to their complexity or (Rorschach, TAT) or an insufficient degree of validity (Lusher test). The main provisions of the ICD-10 International Classification of Diseases (ICD) developed by the World Health Organization (WHO) in order to unify the diagnostic approach in statistical, scientific and social research. Section of mental illness is entered in the International Classification after the Second World War, the development of its 6 th revision. Currently, there are 10 th revision - ICD-10 (ICD-10), where mental disorders and behavioral disorders account for chapter V (F). CLASSIFICATION OF MENTAL AND BEHAVIORAL DISORDERS F0 Organic, including symptomatic, mental disorders F00 Dementia in Alzheimer’s disease F01 Vascular dementia F02 Dementia in the diseases qualified in other sections (in Pick’s, Creutzfeldt-Jacob, Gentington’s, Parkinson’s diseases caused by the human immunodeficiency virus (HIV) F04 Organic amnestic syndrome, not caused by alcohol or other psychoactive substances F05 Delirium, not caused by alcohol or other psychoactive substances F06 Other mental disorders resulting from an injury or dysfunction of the brain, or caused by a physical disease (hallucinosis, catatonic disturbance, delirious disturbance, affective disturbances, anxious disturbance, dissociative disturbances, asthenic disturbances) F07 Disorders of the personality and behaviour caused by a disease, injury and dysfunction of the brain F1 Psychic and behavioural disorders caused by taking of psychoactive substances (alcohol, opioids, cannabioids, sedative or soporific substances, cocaine, other stimulants, including caffeine, hallucinogens, tobacco, volatile solvents) F2 Schizophrenia, schizotypical and delirious disorders F20 Schizophrenia (paranoid, hebephrenic, catatonic, postschizophrenic depression, residual, simple) F21 Schizotypical disorder F23 Acute and transitory delirious disorders F24 Induced delirious disorder F25 Schizoaffective disorders F3 Affective disorders of mood F30 Maniacal episode F31 Bipolar affective disorder F32 Depressive episode F33 Recurrent depressive derangement F34 Chronic (affective) disorders of mood (cyclothymia, dysthymia) F4 Neurotic, stress-related and somatoformic disorders F40 Anxious-phobic disorders (agoraphobia, social phobiae, specific [isolated] phobiae) F41 Other anxious disorders (episodic paroxysmal anxiety, generalized anxious disorder, mixed anxious and depressive disorder) F42 Obsessive-compulsive disorder (annoying thoughts, obsessive rituals) F43 Response to severe stress and disorders of adaptation (acute response to stress, posttraumatic stress disorder, disorders of adaptation) F44 Dissociative (conversive) disorders (amnesia, fugue, stupor, trances and states of seizures, disorders of motility, spasms, anaesthesia, Ganser’s syndrome, disorders of the multiple personality) F45 Somatoformic disorders (somatized disorder, undifferentiated somatoformic, hypochondriac disorder, somatoformic vegetative dysfunction of the heart and cardiovascular system, gastrointestinal tract, respiratory system, urogenital system, chronic somatoformic pain disorder) F48 Other neurotic disorders (neurasthenia, the syndrome of depersonalization and derealization, etc.) F5 Behavioural syndromes connected with physiological disorders and physical factors F50 Disorders in food taking (anorexia nervosa, bulimia nervosa, vomiting combined with other psychological disturbances) F51 Sleep disorders of inorganic nature (insomnia, hypersomnia, failure to keep to the sleep-wakefulness regimen, sleep walking – somnambulism, horrors during sleep, nightmares) F52 Sexual dysfunction not caused by any organic disorder or disease (sexual anhedonia, disturbed orgasm, premature ejaculation, vaginismus, dyspareunia) F53 Mental and behavioural disorders connected with childbirth and puerperal period F55 Abuse of substances which do not cause addiction (antidepressants, purgatives, analgetics, antacids, vitamins, steroids and hormones, specific herbs and folk medicine means, etc.) F6 Disorders of mature personality and behaviour in adults (paranoid, schizoid, dissocial, emotionally unstable, hysteric, anancastic, anxious, dependent, etc.) F62 Chronic personality changes not connected with any injury or disease of the brain (after suffering an accident, after a mental disease, etc.) F63 Disorders in habits and drives (pathological disposition to games of chance, pyromania, kleptomania, trichotillomania, etc.) F64 Disorders in sex identification (transsexualism, transvestism of the double role, etc.) F65 Disorders in sex preference (fetishism, fetishistic transvestism, exhibitionism, voyeurism, pedophilia, sadomasochism, multiple sex preference disorders, etc. F66 Psychological and behavioural disorders connected with sexual development and orientation (disturbance of sexual maturation, egodystonic sexual orientation by sex, disturbance of sex relations, etc.) F68 Other disorders of mature personality and behaviour in adults (exaggeration of physical symptoms for psychological reasons, deliberate causing or simulation of somatic or psychic symptoms or disability – simulatory disorder) F8 Disorders in psychological development F80 Specific disturbance of speech development (articulation, expressive speech, receptive speech, aphasia) F81 Specific disorders in the development of school skills (reading, spelling, counting) F82 Specific disorder in the development of motor functions F83 General developmental defects (infantile autism, atypical autism, Rett’s syndrome, hyperactive disturbance, Asperger’s syndrome) F9 Behavioural and emotional disorders that usually develop in children and juveniles F90 Hyperkinetic disturbances (disturbance of attention activity, hyperkinetic behavioural disorder) F91 Behavioural disorders (limited by family conditions, unsocialized, socialized, oppositionally provocative, depressive) F93 Emotional disorders specific for childhood (anxious disturbance owing to parting, phobic, social anxious disturbance, disturbance of sibling rivalry, etc.) F94 Disorders of social functioning with the beginning specific for childhood (elective mutism, reactive disturbance of attachment in childhood, disinhibited disturbance of attachment in childhood, etc.) F95 Tic disorders F98 Other behavioural and emotional disorders which usually develop in children and juveniles (inorganic enuresis, inorganic encopresis, digestive disturbance in infancy, eating of the inedible in infancy and childhood, stereotyped dyskinesiae, stammering, breathless speech, etc.) The concepts of the registers of mental disorders Non-psychotic register of syndromes is mainly characterized by impairment in the emotional and motor-volitional sphere with the fact of criticism (understending) of the disease. Psychotic register of syndromes are characterized by following symptoms: hallucinations, delusions, disorders of consciousness in the absence of a criticism (understending) the disease. Syndromes of defect-organical register characterized by cognitive impairment (memory disorders, attention, thinking and intelligence), with a partial fact of a criticism (understending) the disease. DISTURBANCES OF SENSATIONS AND PERCEPTIONS Sensations and perception are the initial stage in the cognitive activity of man, the sensual cognition of the surrounding reality. Sensation is the primary psychic act, a mental process of reflection of separate properties and qualities of objects or events in the human consciousness, these objects or events producing a direct effect on the sense organs. The reflection of the outer world is not limited by sensations, but is manifested in a more complex process – the process of perception. Perception is a mental process of reflection of objects or events in the totality of their properties in the human consciousness, these objects or events producing a direct effect on the sense organs. This is a synthesis of a complex of available sensations and representations, rather than a mechanical unification of all sensations. Representation is a trace of a former sensation or a former perception. This is an imagery recollection, a mental (subjective) image of the reality which appears in the human consciousness in the absence of the corresponding object or event that produced an effect on the sense organs before. Representations are particularly important in children and juveniles. Representations are the main component of the children’s imagination, the basis of creation, children’s fantasies. Children at the age of 3-7 years have an extreme brightness and picturesqueness of visual representations; therefore it is difficult for a child to distinguish the images of representations from those of a direct perception. This ability to reproduce bright representations is termed eidetism. Eidetism is a physiological phenomenon. It is peculiar to artists (visual), musicians (auditory). Imagination is creation of new images on the basis of the existing representations. It is a sensual (imagery) basis for abstract (conceptual) thinking. In the act of imagination there is formation of not only new images, but later, in juveniles, of new ideas. In order to better understand disturbances in the processes of sensation and perception it is necessary to know what distinguishes perception from representation, what properties the perception has. They are as follows: 1. Perception possesses a sensual verve. 2. Perception possesses extraprojection. 3. Perception does not possess any arbitrary changeability. 4. Perception possesses the sense of reality. 5. Perception possesses non-belonging to “me”. The representation has the following properties: 1. It does not have any sensual verve. 2. It is projected in the inner world of a human being. 3. It can be arbitrarily changed. 4. It does not possess the sense of reality. 5. It belongs to the subject. Classification of disturbances of sensations and perceptions I. Hypoesthesia and anesthesia II. Hyperesthesia III. Paraesthesiae, synaesthesiae, senesthopathies IV. Psychosensory disorders 1. Visual psychosensory disorders: a) micropsiae b) macropsiae c) dysmorphopsiae 2. Intero-and proprioreceptive disturbances: an improper body scheme V. Illusions 1. By analyzers: visual, auditory, olfactory, gustatory, tactile, of general feeling (visceral and proprioreceptive). 2. By the mechanism of appearance: a) physical b) physiological c) psychic (affective, verbal, pareudolic) VI. Hallucinations 1. By analyzers: visual, auditory, olfactory, gustatory, tactile, of general feeling (visceral and proprioreceptive). 2. By complexity: simple (photopsiae, acoasm), compound (having some contents). 3. By the completeness of development: complete (true) and incomplete (false, pseudohallucinations, hallucinoids). 4. By the attitude to the patient’s personality: neutral, commenting, imperative. 5. Particular kinds of hallucinations: hypnagogic, hypnopompic, extracampic, reflex, functional. Hypoesthesia is a decrease of the subjective vividness and intensity of sensations and perceptions; it is manifested in such subjects through their loss of sensual verve, vividness and concreteness up to appearance of the feeling of their alienation (it is in the structure of the syndrome of depersonalization and derealization). For example, a patient with schizophrenia could look at the bright sun with unprotected eyes. Anesthesia is disengagement of sensations and perceptions owing to disturbances along the projection system or a lesion of the cortical nucleus of an analyzer (optic, auditory, tactile and other anesthesia). It is observed in hysteria. Hyperesthesia is intensification, increase of sensations of previously neutral stimuli, accompanied by hyperpathic emotional coloring. The stimuli are perceived as excessively bright or loud. The usual light dazzles, the sound of voice deafens, a touch is perceived as painful. Synaesthesiae are intensification of receptivity of stimuli with radiation of sensations and perceptions to another analyzer; as a result, they acquire some colorings unusual for them, a character of dual sensation. That is, a sound stimulus gives rise to visual sensations, e.g., a color (colored music), an olfactory stimulus excites visual, coloured sensations (roses smell blue), a sound stimulus causes painful sensations. Hyperesthesia and synaesthesiae develop in the state of intoxication with hallucinogens. Senesthopathies are various, extremely unpleasant, painful and unusual sensations originating from some internal organs and different areas of the body and having no causes for their origination in this particular organ. These are vague sensations in the form of burning, swelling, bursting open, pouring, twisting, pain in different parts of the body or in the organs where there is no pathological process (inflammation, degeneration, etc.). Senesthopathies may be localized or migrating, isolated or multiple. Typical for schizophrenia are senesthopathies which are fanciful, “florid” in character. For example, a patient complains of “a sensation of fear in the frontal area”, a sensation of the lungs “sticking together”. Metamorphopsiae (visual psychosensory disorders) are a distorted perception of really existing objects with preservation of understanding of their meaning and essence, as well as a critical attitude of the patient to them (dysmorphopsiae are a distortion of the form of objects, macropsiae mean enlargement of objects, micropsiae are reduction of their size). Spatial relations are disturbed, there are changes in the time sense, assessment of distances, etc. Psychosensory intero- and proprioreceptive disorders mean distortions or disturbances of perception of the corporal “ego”, they are manifested in the sense of changes in the proportions and dimensions of the body, its parts. Usually they are in the structure of such syndromes as depersonalization, an improper body scheme, dysmorphophobia and the hypochondriac one. Examples: “the head is enormous”, the arms are too long, the teeth are loose. Illusions are a distorted perception of a really existing object with a change of its contents, meaning. Depending upon a disturbance in the activity of some or another analyzer, there are auditory (a distorted perception of the meaning of the real speech, hearing of voices in some noise, etc.), visual and other illusions. For instance, in the noise of a wind the patient hears voices: “we will kill you”. Instead of the cactus, the boy sees a porcupine on the window-sill. Illusions of the general feeling (intero- and proprioreceptive) include sensations of compressing, pressing, spasm, tension, pulsation in the internal organs and other parts of the body, i.e. those various and peculiar sensations which can ground on real stimulations of corresponding receptors too. By the mechanism of appearance, illusions are subdivided into: Physical – they appear as a result of peculiarities in physical properties of objects and substances (refraction of objects on the border of two media, mirages). Physiological – they are connected with physiological peculiarities in the functioning of analyzers (e.g., the sensation of movement after the train stops; the horizon, where the land meets the sky; parallel lines at a distance are perceived as meeting together, etc.). They are caused by imperfection of the sense organs. Illusions can be caused by the fact that attention is concentrated on one stimulus, therefore others may be perceived in a distorted way. Jaspers called these illusions as “illusions of inattention”. Psychic illusions are connected with a change in the mental activity. They are: affective, verbal and pareudolic. Strong emotions, fear, expectation, stress give birth to affective illusions. Their appearance is facilitated by difficult conditions for perception (bad illumination, audibility). Audible verbal, or interpretative, illusions develop when in different sounds (the noise of a wind, squeak, gritting of wheels of a train, etc.) or talks of the surrounding people the patient hears reproofs, orders at his address. These illusions are often accompanied by delusion of reference. Pareudolic illusions appear owing to a disturbance of consciousness (in intoxication, hyperthermia, taking of hallucinogens). In pictures of wallpaper, shadows of objects the patient with pareudolic illusions sees whimsical, fantastic monsters, dreadful images. Pareudoliae are compound sensual, imagery illusions. What was read and seen before acquires excessive strength and is superimposed on the real image which does not correspond by its contents. For example: in a verse “The Forest Vampire” by Goethe a sick boy in a feverish state perceives the surrounding wood and sky as frightening, branches of the trees were seen as stretched pawns of a wood vampire. Hallucinations are an imaginary perception without any real stimulus (image, phenomenon) at this time. For instance, the patient states that he sees a devil “making faces, dancing” before him and is excessively surprised that the physician does not respond to the devil and says that “he is not here”. According to the phase-inhibition theory by Ye.A. Popov, hallucinations are pathomorphologically based on the equalizing and paradoxical phases of an incomplete protective inhibition. Visual hallucinations are an imaginary perception of visual images without any real stimulus (image, phenomenon) at this time. For example, the patient states that he sees snakes crawling under the bed. As a rule, visual hallucinations reflect acute states, while auditory (verbal) and tactile hallucinations reflect chronic ones. Visual hallucinations are more typical for the exogenous-organic pathology. Auditory hallucinations: the patient hears calls, talks, music, singing, etc., which do not exist at this moment. Verbal hallucinations in the form of a human speech are particularly distinguished. With respect to the patient’s personality, they can be neutral, commenting (hostile, threatening, benevolent, antagonistic – some voices are kind, others are malicious), imperative, i.e. ordering the patient to do something. Imperative hallucinations represent a grave danger for the patient himself and surrounding people because “the voices” may order to kill somebody, set a flat on fire, throw out valuable things, etc. Olfactory hallucinations: the patient perceives some smells which are absent at present. They may be pleasant, but oftener they are foul, e.g., strong smells of burning, petrol, “the smell of flatus”. Strong smells are observed in the olfactory aura in epileptics. Gustatory hallucinations are manifested by the fact that the patient perceives some gustatory stimuli which do not exist at this moment; often it is a smack of a poison, “bane” (mercury, lead, strychnine). Tactile hallucinations: temperature ones, a perception of some moisture on the body, in the form of touches, compression, strokes, pinches, thrashes, stretching of the skin, etc. Visceral hallucinations (senesthopathic hallucinosis): there is a perception of an object or image in some organ or part of the body. For example, the patient saw that “some snake crawled into my mouth and settled in my oesophagus”. Simple hallucinations (photopsiae, acoasm) do not have any contents. They are perceived in calls, light effects, luminous points, etc. Compound hallucinations have some contents, may be in the form of images, scenes, panoramas, dialogues, talks, smells, touches, etc. True, complete hallucinations are those ones that possess all the properties of perception, namely sensual verve, extraprojection, absence of an arbitrary changeability with a resultant sense of reality. For instance, the patient saw a witch. He vividly and lively described details in the appearance of the “witch”, her deathly pale body, “claws” (it was the reason to regard this image as a witch). She sat at the room, made faces, scared, but he could not do anything, the witch was real, “true”. This patient suffered from a complete, true hallucination. Incomplete hallucinations (pseudohallucinations) are those ones that do not have some of the properties of perception. If there is no extraprojection, then it is a pseudohallucination, described by V.Kh. Kandinsky and manifested in the fact that the patient hears inside his head some voices, sounds, etc., or sees with “his inner eye” “some little fellows on the gyri” or other images. Pseudohallucinations lose such a property of perception as the sense of reality and differ from real stimuli. Particular kinds of hallucinations Hypnagogic are the hallucinations which appear during a transition from wakefulness to sleep (when falling asleep). These hallucinations develop with closed eyes, they may be isolated or multiple, scene-like or kaleidoscopic. Significantly less frequent are hypnopompic hallucinations which appear when waking up, i.e. during a transition from sleep to wakefulness. These hallucinations disappear when the patient falls asleep or wakes up completely. Extracampic are the hallucinations localized outside the visual field. For instance, a patient looking straight forward “sees” a devil behind him. Functional hallucinations: a hallucinatory stimulus is perceived side by side, simultaneously with a real one. An example: in the noise of water one also hears the noise of water and “voices”. The difference between illusions and functional hallucinations lies in the fact that in illusions, instead of some stimulus, there is perception of another one by contents (not the noise of water when a tap is turned on, but a whisper speech), while in functional hallucinations, as it was said before, both the noise of water (real) and a hallucinatory speech in it are perceived. Reflex hallucinations: these are reflected when a real stimulus (e.g., a turn of a key in a lock) is hallucinatorily perceived in another place (a turn of a key in the heart). Or, for instance, a spindle in a hand is perceived as a spindle spinning and buzzing in the heart. Suggested hallucinations are called forth during a session of hypnotherapy. Negative hallucinations: absence of perception of really existing objects. Episodical hallucinations: they appear periodically, e.g., ecstatic ones in epileptics. Hallucinations of Charley Bonnet’s type: mentally healthy people who lost their sight or hearing develop visual or auditory hallucinations (with a critical assessment). For example: a female patient (who had become blind) saw “a blonde girl in a beautiful blue dress going along a fence painted green”. Phantom phenomena in people with amputations: they are hallucinations in mentally healthy subjects (with a critical attitude to them), when a person perceives presence of an amputated extremity, may feel a pain in it, etc. Children and juveniles most frequently have visual hallucinations (animals, monsters from the tales they have read, etc.), auditory ones being in the form of simple or elementary hallucinations (ringing, noises, shots, calls by name, etc.). Hallucinations are revealed in a conversation with the patient, questioning him, observing his behaviour, facial expression, etc. Patients with auditory hallucinations would lend their ears to something, talk with “voices”. In case of visual hallucinations, patients would look attentively to something; patients with tactile hallucinations would whisk off something from themselves, etc. In patients with delirium tremens, it is possible to call forth hallucinations (if they disappeared) or cause their intensification (if they are present) with help of a slight pressing on the eyeballs (Liepman’s symptom). The physician may show a patient a clean sheet of paper and suggest to read a text written there (suggested hallucinations), and the patient will read a non-existent hallucinatory text (Rieger- Reichardt symptom). Auditory hallucinations intensify or appear in acute or chronic alcoholic hallucinosis after the physician suggests the patient to listen attentively to a monotonous sound of a metronome, clock (Bekhterev’s symptom). It is possible to suggest a patient to speak on the telephone whose receiver is disconnected from the set, and the patient will “hear” a voice in the receiver (Aschaffenburg’s symptom). THE SYNDROMES ON THE TOPIC OF “DISTURBANCES OF SENSATIONS AND PERCEPTION” SEE CLASS № 3. Control questions: 1. Describe the structure of mental health care. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. List the indications for hospitalization in a psychiatric hospital. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3. Describe the basic method of examination of mental patients. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. Give the characteristic of psychotic, non-psychotic and defect-organic syndrome? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ 5. Give the definitions of hyperesthesia, hypoesthesia, anesthesia, senestopathia: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 6. Give the definition of psychosensory disorders: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 7. Fill the empty cells: 8. Fill the table The distinctive features of true hallucinations from pseudohallucinations True hallucinations Pseudohallucinations 9. Particular kinds of hallucinations. Give definitions: Hypnagogic are the hallucinations, which appear __________________________ __________________________________________________________________ Hypnopompic hallucinations, which appear _______________________________ __________________________________________________________________ Extracampine are the hallucinations _____________________________________ __________________________________________________________________ Functional hallucinations ______________________________________________ __________________________________________________________________ Reflex hallucinations_________________________________________________ __________________________________________________________________ Suggested hallucinations ______________________________________________ __________________________________________________________________ Negative hallucinations _______________________________________________ __________________________________________________________________ Episodical hallucinations ______________________________________________ Varieties of illusions (Give an example_______ _____________________ ____________________) _____________________ _ (Give an example_______ _____________________ ____________________) (Give an example_______ _____________________ ____________________) __________________________________________________________________ Hallucinations of Charley Bonnet’s type _________________________________ __________________________________________________________________ Tests 1. Who is the first identified 4 types of temperaments and connected them with a predominance in the body of one of the 4 main juices of a living organism (blood, phlegm, yellow bile and black)? А. Pinel В. Freud С. Hippocrates D. Esquirol Е. Kraepelin 2. Who is the first fined the name "schizophrenia" for the disease, described by Kraepelin? А. Kandinsky В. Freud С. Hippocrates D. Protopopov Е. Bleuler 3. Finally, the issue of hospitalization in a psychiatric hospital decides: А. Patient's сolleagues В. Patient's relatives С. Family doctor D. Doctor - psychiatrist Е. Policemen 4. In the emergency department of a psychiatric hospital comes a 30 years old man, he said that " aliens introduced in his spine the sensors that govern his actions, thoughts ...". Man is brightly gesturing, looks bad condition, speaks with a loud voice, he thinks that he is mental healthy. Determine the register of this mental disorders. А. Non-psychotic B. Psychotic C. Psychopatic D. Mental healthy E. Defect-organical 5. 25 year-old woman went to the doctor with the complains of anxiety, depressed mood, increased irritability which came after the sudden tragic death of her parents. Determine the register of this mental disorders: A. Non-psychotic B. Psychotic C. Psychopatic D. Mental healthy E. Defect-organical 6. A 23 years-old patient said that she hears «a voice of God from the backbone». What disorder of perception does she have? A. True hallucinations B. Pseudohallucination C. Illusion D. Psychosensoric disorder E. Senestopathy 7. The child aged 6 is afraid of the dark. In the evening when falling asleep he saw “an animal” in the room, but when he wakes up, he understood that it was an armchair. What disorder of perception did the child have? A. Illusion B. Hallucinations С. Psychosensoric disorder D. Hyperesthesia E. Synesthesia 8. A 30 y.o. man was always reserved by nature. He never consulted psychiatrists. He complains of headache, sensation "as if something bursts, moves, bubbles under his skin". Objectively: no pathology was revealed. What is the most probable psychopathologic symptom in this case? A. Senestopathy B. Paresthesia C. Hallucination D. Hypersthesia E. Dysmorphopsia Tasks 1.A 78 years old patient vas taken by ambulance from the street. He cannot tell his passport data, does not know the date and place of his location. He is emotionally adequate, quiet, answer to the questions, he is worry, that he cannot recall the home address. Who can decide what to do with the patient. What kind of documents they need to use for help to this patient? Determine register of this mental disorder. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2.The mother says, that her 6-year-old child has mental development retardation of the children of his age: late began to speak and walk, can’t read, has bad memory to the letters. She asked for help to the local pediatrician. In which institution doctor should send this patient? In what way should examination of the child to be made? What kind of documents they need to use for help to this patient? Determine register of this mental disorder. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ CLASS №2 DISTURBANCES OF THINKING. DISTURBANCES OF INTELLECT. DISTURBANCES OF MEMORY AND ATTENTION. DISTURBANCES OF EMOTIONS AND EFFECTOR-VOLITIONAL SPHERE. DISTURBANCES OF THINKING Thinking is the higher form of reflection of the objective reality, a process of a generalized and mediated reflection of objects and events of the material world in their natural connections and relations. In pathological states, there may be a disturbance of the associative process or disappearance of connections between isolated thoughts, it demonstrating a disturbance of thinking by form. In other cases there is a disturbance in the process of formation of conclusions, the logic suffers, there is a disturbance of thinking by contents. Classification of disturbances of thinking 1. A disturbance in the formation of concepts: a) pseudoconcepts b) condensation of concepts c) neologisms 2. A disturbance in the rate of thinking: a) rapidity of thought, “galloping ideas” b) retarded thinking c) delay, arrest (Sperrung) d) mentism 3. A disturbance in the form of thinking: a) pathologically circumstantial thinking b) philosophizing c) non-continuous thinking – schizophasia d) incoherent thinking e) amorphous thinking f) paralogical thinking g) autistic thinking h) symbolic thinking i) verbigerations j) perseverations k) affective thinking 4. A disturbance in the contents of thinking a) fixed ideas b) dominant ideas c) overvalued ideas d) delusion-like fantasies e) forced thoughts f) delusions Forms in the formation of delusion: 1. Primary delusion (interpretative). 2. Secondary delusion (sensual, imagery). The contents of delusions: a) persecution, b) influence, c) reference, d) pretence, e) damage, f) self-condemnation, self-humiliation, g) negation (nihilism), h) hypochondria, i) jealousy, j) love, k) invention, l) reforming, m) high origin, n) litigiousness, o) expansive delusions, p) induced delusions. Pseudoconcepts are false concepts formed on the basis of casual, insignificant signs. For example, a female patient asks to give her green and feels hurt that she is not understood. Condensation of concepts (agglutination) is manifested in a fusion of several concepts which are rather remote from one another. It is observed in schizophrenia and some organic lesions of the brain. For instance: when a female patient was asked how she felt she answered “shockolately” and explained it in the following way: “after insulin shocks my health is beginning to return to normal”. Neologisms are new, unusual concepts created by patients. For example, complaining of her destiny a female patient says: “It is not life, but apheides and poltoraniae”. Pseudoconcepts, condensed concepts and neologisms are usually produced by patients with schizophrenia. But one should remember that sometimes neologisms are used as a literary device by writers and poets (Khlebnikov, Mayakovsky). Rapidity of thought is observed in maniac and hypomaniac states of various origin: in the manic-depressive psychosis, exogenous psychoses, at the initial stage of alcoholic intoxication. Usually rapidity of thought passes against a background of high spirits and increased distraction of attention, it is characterized by a rapid, easier development of associations, most frequently of superficial ones. The mental productivity of such patients is sharply decreased, they are characterized by an easy loss of the object of discourse. A significant rapidity of thought is termed “galloping ideas”. In galloping ideas the relation between thoughts is not lost, but the patient can say only some part of them, the speech lags behind the thought, having begun some phrase the patient passes to the second one without completing the first phrase, he skips words, hurries to say another thought, etc. In case of rapidity of thought often there is a decrease of reasonableness, the sense of tact, confusion, the patients may say to a person’s face such things which a healthy person would prefer to keep to himself. An example of the patient’s speech: “Doctor, I love you ... the love is not a vice, but a considerable swinishness... look at her, there is her grandson’s shirt under her gown... Friday from under Saturday... tomorrow will be Saturday and my husband will come... ha-ha... a husband is not a jazz band... ha-ha”. Retarded thinking is observed in asthenic states and the depressive syndrome; it is characterized by a decreased number of ideas accompanied by a subjective sensation of stiff thinking, the feeling of the patient’s own intellectual indigence. The thoughts pass slowly, the patients complain that they have “few thoughts”, it is possible to observe appearance of the sensation of emptiness in the head. The speech is slow and has scanty words, the patients answer questions in one syllable and after a long pause. Delay of thinking (Sperrung) is manifested by a sudden arrest in the flow of thoughts. It is observed in patients with schizophrenia and easily revealed in a conversation. The patient would unexpectedly stop talking and then explains his silence by the fact that he had a delay of thoughts, for some time he had a sensation of absence of thoughts. Sperrung can be detected during an experimental- psychological examination when the patient’s activity is characterized by stops of various duration explained by the patient as “disappearance of thoughts”. Sperrung may last from a few seconds to several days. Sometimes it is accompanied by signs of psychic automatism; in this case the patient explains absence of thoughts as their “taking away”. Sperrung does not affect the speed in the course of associative processes, after the delay the thoughts pass again as usual. Flow of thoughts (mentism) is an obsessional automatic flow of thoughts which is painfully felt by the patient; the thoughts incoherently appear and continuously flow in the consciousness irrespective of the patient’s wish. The flow of thoughts is in the structure of Kandinski-Clerambault psychic automatism syndrome. It is observed in schizophrenia, encephalitis, traumatic injuries of the brain, in the state of extreme asthenia, in intoxications with some drug preparations (diphenylhydramine hydrochloride). Pathologically circumstantial thinking (stiff thinking) is observed in epileptic dementia, at the remote period of epidemic encephalitis, in other organic diseases of the CNS. The disorder is characterized by thoroughness, an increased detailing, an inability to separate the main from the minor, a difficulty in switching over from some subject to another one. The speech includes words-parasites (“you see”, “so to say”, “so”, etc.). Repetitions, pauses, diminutive words and terms of endearment are typical. The patient would deviate from the main subject of the story, then some time later return to it and again turn to side details, his reaction to the questions with which his interlocutor interrupts his speech is little, even if these questions are to help him. An example of the patient’s speech: Question: “Did a person who got stuck in a bog act correctly when he tried to pull himself out by his hair?” Answer: “It is difficult to say exactly what hair, probably a dark-haired man, if it was very boggy, would not pull out himself unaided, or maybe nothing more remained for him to do. Let him have a nice time. I regret his hair, if it is good, like in a tale, they would pull and pull, but will they draw out the turnip? But it was difficult too.” Philosophizing means idle futile discourses deprived of a cognitive sense. It is observed in schizophrenia, other diseases. In philosophizing, the patient uses formal casual associations, where the purpose of a task is moved back to a background, while the patient’s desire to philosophize is moved forward to a foreground. Philosophizing is particularly striking in those cases where fulfilment of a task requires wordy definitions, wordings, comparison of concepts. In such cases it is possible to observe an increased pretentiousness in contrast with an insignificance of the object of the judgement, commonplace discourses, a pathetic tone of the speech, often against a background of an increase in the self-estimation and level of claims. In schizophrenia, philosophizing reveals actualization of “weak” signs, disruption of associative processes, destruction of mental stereotypes formed during the life. In patients with epilepsy, philosophizing is of a compensatory character which reflects overestimation of the personality and is manifested by an instructive tone of speech, trite judgements with poor contents, as well as by inertness, a difficulty in distraction from the situation, a narrow range of thinking, egocentric tendencies with a poor stock of words. In oligophrenia at the degree of debility, philosophizing is of a compensatory character too, where loquacity of judgements hides poverty in the contents of speech. Below is an example of philosophizing. A patient’s treatise on subject “Why there is appearance of love”. In the organism of a human being there is appearance of hormones. In a man they are male, in a woman they are female. These hormones are of a protein origin. But when did they originate? In what conditions? Every human being from the very moment of conception has an ability to excitement. Between an excited tissue and an unexcited one appears a biocurrent which externally is expressed by a magnetic flow. The force of this magnetic excitation changes depending upon the environment and the latter, therefore, can produce some effect on excitability of the organism. Hence the force of this magnetic field of one person (we suppose a man and a woman) begins to interact with another one. An internal excitation of the man creates one potential. The externally applied potential may contribute to the internal excitation. The human being perceives the externally applied potential by his olfactory, visual, sensual and auditory organs and the surrounding magnetic field which is not possible to see, hear and even feel. Paralogical thinking is observed mostly in schizophrenia and is characterized by a disturbance of logical relations in judgements, conclusions, arguments, cause- effect correlations. Here it is often possible to observe preservation of memory, ability to count, understanding and reasonableness with respect to many everyday occurrences. In case of paralogical thinking, the patient may use expressions with an inappropriate meaning, not caring whether some or another expression has any definite contents and meaning, there is no reasonableness and criticism with respect to logical mistakes; these mental disorders are difficult to correct. In paralogical thinking, the patient would ignore real true prerequisites and arguments, using instead of them conclusions which do not have any logical relation with the initial judgements. Slide-down, amorphous thinking: it is a deviation from the main thought to some side-thoughts which substitute for the main one. A loss of logical relations may be complete or partial. Non-continuous thinking is typical for schizophrenia and is manifested by absence of any semantic relations between concepts with preservation of the grammatical system of the speech. The patient’s speech is deprived of contents and logical relation, though externally it seems regular because of preservation of grammatical relations. Only in case of a sharply expressed lack of continuity there is a disturbance in grammatical relations and then the speech consists of an irregular mere verbiage (“a wordy jumble”). In non-continuous thinking it is possible to observe slide-downs of the thought expressed in passing from some notion to another one without any natural logical relations, there is appearance of associations by a “weak” or “latent” sign. It is not in rare cases that the patient’s speech does not depend upon presence of an interlocutor (a symptom of monologue), the speech does not fulfill its function of communication any more, it becomes incomprehensible for the surrounding people. Here are some examples of speech of patients with non-continuous thinking: “A cake of imperialism – it is forty chickens – having become sad, they were drawing her eyes on Whatman paper of the Moon, but a millionaire was whistling.” “Show... I will eat it... Would bake pies... I don’t know...I’ll cut off the same one... pies... About neither Ivan nor Darego... Show... will be done by me... plastics... I’ll eat... give a disk for pies.” “I’ll take all in my fist, carry... maybe rotated. Well, here you are... Ivan-pie... to press a button... to turn round... a small study... to walk on a platform.” “And I am rolling a cigarette; but why a cigarette, maybe a single rat? Or maybe not a cigarette but a cake-dad. If a cake is dad, then cream will be mum.” “Thank you, my dear fellow, that I am not Kate. Aunties and uncles, be so kind, look at my amiable finger.” Here is an example of “a wordy jumble”: “Khiumala, riumala, piumala, zhiumala, mex, regis, pan, pan, pan, yarbin, dirbin, palamida, bruda plet, yatka, purus, lakkhid, elivator, acquirated, maniloid, tiuligen, thirty three, twenty five and two, twelve, twenty two, have mercy upon me, O Lord, let this soul repose with the saints, sands, cents, dollars mine, yours, Robert Burns, come, become, vemala, pemala, so, though, oh, low, no, go.” Incoherent thinking is characterized by inability to form associations; separate perceptions, images, concepts are not connected among themselves. There are no, even primitive, mechanical associations by likeness, by contiguity in time and space. The patient is disorientated in time and place, does not understand what is taking place around him, he is confused. The patients’ speech is incoherent, it consists of separate, casual words, not connected either by meaning or grammatically, the phrases are constructed in wrong ways. Incoherent thinking is observed in acute exogenous psychoses, accompanied by a disturbance of consciousness in the form of amentia, and is indicative of a severe state of the patient. Below is an example of the speech of a patient with incoherent thinking: “Sewed... got cold... bang... roar... never... yes, yes, to nobody... spun... cornfields... oh-oh-oh. But the mother is so young, very young, pyoung... tibol and nif... an utter rout.” Autistic thinking rests upon the patient’s inner feelings, his subjective aims, wishes, fantasies, rather than on real facts. The patient does not pay any attention to the fact that his thoughts contradict the reality. Rather often it appears as “a dawn” and is expressed in realization of the patient’s “innermost wishes”. Symbolic thinking: the patient supplies various concepts with some allegorical meaning which is absolutely unclear for other people, but for the patient himself has a certain sense. The patient may symbolically understand the speech of the surrounding people, the meaning of colours. For instance, having seen a nursery maid wearing a yellow jacket a female patient declared: “She is a traitor, because yellow is the colour of treachery”. Verbigeration is a senseless repetition of the same words or scraps of phrases or a simultaneous appearance of two contrary thoughts. It is typical for schizophrenia. Perseverations and stereotypies of thinking: sticking to some representations. They are manifested by repetitions of the same words or sentences many times, and for this reason the patient’s answers sometimes become senseless. It is not in rare cases that perseverations and stereotypies accompany aphasia in patients with apoplectic or senile dementia, they are also observed in other organic lesions of the brain. Here is an example of the speech of a patient with perservation: Question: “What are your first and second names?” Answer: “Piotr Ivanovich.” Question: “In what year were you born?” Answer: “Ivanovich.” Question: “Where do you live?” Answer: “Ivanovich.” Affective thinking: the patient constructs his judgements and conclusions on the emotions and wishes prevailing at the moment, rather than basing on logic. Fixed ideas are representations and thoughts which appear involuntarily (irrespective of the patient’s will) and are alien to the contents of consciousness at this moment; they are characterized by a critical attitude of the patient to them, understanding of their morbid character, as well as by an active aspiration for getting rid of them. Unlike delirium, patients with fixed ideas preserve their critical attitude to them, the course of these ideas is episodical, fit-like. They are observed in neurosis of annoying states, in psychasthenic psychopathy. Dominant ideas are right thoughts which are connected with the life, prevail in a person’s consciousness and sometimes prevent him from concentrating on the current activity. For instance, constant thoughts about a sick child during work. They are more frequently observed in depression. Overvalued ideas are judgements resulting from real circumstances but owing to their emotional saturation they take the prevailing meaning in the consciousness which is disproportional to their objective importance. Overvalued ideas are fruitless, the thinking becomes unilateral, everything that is not connected with the overvalued aim or contradicts it is ignored and suppressed. Overvalued ideas may affect the behaviour, inciting the subject to exclusive actions. Unlike delirium, overvalued ideas yield to correction, though with difficulty, under the influence of forcible logic arguments and a change of life circumstances, it contributing to a loss of their affective saturation and urgent significance. They are observed in psychopathies, schizophrenia, affective psychoses. Delusion-like fantasies are relatively short-term and most typical for juvenile psychopaths who want to appear before people of their age playing a hero, an outstanding personality, and with this purpose they exaggerate facts, invent fables and believe in them themselves. Forced thoughts are elementary, they appear in the consciousness unexpectedly, any stage of doubt and struggle is absent. The patients would ask to keep them from throwing themselves into a stair-well, spitting into somebody’s face, because they are not sure that they are able to control themselves. Such thoughts are observed in patients who suffered encephalitis, a brain injury. Delusions are wrong judgements and conclusions which appear on a morbid basis, completely seize the patient’s consciousness and do not yield to correction. They reflect reality in a distorted way, are notable for constancy and firmness; any attempts to dissuade the patient, prove him incorrectness of his delusional constructions, as a rule, result only in intensification of delirium. Typically the patient is convinced and confident in an absolute reality and reliability of delusive feelings. Development of delirium is connected with a certain dynamics in the patient’s state. At first, there are emotional disorders in the form of internal tension, unexplained anxiety, foreboding of some inevitable evil, increasing alarm. The patient tries to understand what is going on, why the surroundings have acquired a new meaning which is not clear for him, often there is appearance of a delirious perception: everything around seems unreal, artificial or threatening, ominous, having some particular meaning hidden from the patient. Delirious perception is directly connected with formation of delirious representation, on whose basis some events in the past of the patient’s life are particularly distinguished in their new meaning. Finally, there is development of delirious realization: a peculiar dawn with realization of the essence of events not understood before, delusional judgements receive some concrete contents, it is accompanied by a subjective sense of relief, emotional calming – crystallization of delirium occurs. Primary delusion is based on false interpretations originating from either real facts of the outer world or inner sensations and feelings. The patients interpret behaviour of the surrounding people and their statements in an unexpected way. The same happens with respect to inanimate objects too. This delusion is systematized, stable, expanding and complicating. Secondary (sensual, imagery) delusion appears in presence of other mental disorders: hallucinations, disorders of emotions and consciousness. Its intensity corresponds to that of these mental disorders. Most frequently, sensual delusion appears acutely, usually it is unsystematized, unstable, its plot is vivid, but unstable. Depending upon the contents of statements, the following kinds of delusion are distinguished: delusions of persecution, influence, poisoning, jealousy, self- condemnation and self-humiliation, grandeur, etc., the name usually reflecting the contents of delirious feelings. The delusion of grandeur is manifested in the patients’ statements that they are people of outstanding intellect and great strength. In the delusion of wealth the patient states that he possesses great treasures. Different clinical kinds of delusions are not specific for some definite mental disease. Thus, delusions of grandeur, high origin and wealth may be observed in the maniacal phase of the manic-depressive psychosis, in the expansive form of general paralysis of the insane, paraphrenic states of various genesis. Within the limits of each nosological form the delusions have their clinical peculiarities. In the maniac syndrome, delusions of grandeur depend upon the affective state and do not reach any significant expressiveness; in general paralysis of the insane, delusions are absurd, amorphous, unstable; in the structure of the paraphrenic syndrome, delusions are of a systematized character. In the delusion of invention, the patients tell about their invention of various apparatuses, devices and instruments which are to improve the life of the mankind. Such a kind of delusions is often observed in the paraphrenic syndrome within the framework of schizophrenia. In case of erotic delirium, the patient feels personal interest taken in him by some representatives of the opposite sex. The object of delirious feelings is usually subject to a real persecution from the side of the patient who sends her numerous love-letters, makes appointments. Often it is accompanied by the patient’s morbid overestimation of his own personality. This delirium is most frequently observed in schizophrenia. Delusions characterized by a negative emotional tint are typical for depressive states. These are delusions of self-condemnation, being sinful, impoverishment, a bodily defect, in hypochondria. The delusions of self-condemnation, self- humiliation and being sinful are observed in the expressed circular depression. In involutional melancholia there are delusions of self-condemnation and impoverishment passing against a background of the anxious-depressed affect. The delusions of reference are manifested in the fact that any event or act of the surrounding people acquires a particular significance in the patient’s eyes. The red colour of the traffic light means that there will be bloodshed. As soon as the patient takes a tram all people inside it begin exchanging glances. The patient with delusions of persecution would state that he has become an object of persecution by some people or their group who have united with the aim to kill him. It should be remembered that such patients represent a certain social danger, because often from the persecuted they become persecutors and inflict severe injuries to their imaginary offenders. In case of the delusion of influence the patients are convinced that they are subject to influence with help of various devices, rays (delusion of physical influence) or hypnosis, telepathic suggestion at a distance (delusion of psychic influence). Patients with delusions of poisoning state that somebody adds some poison to their food, fills the flat with a lethal gas, etc. The delusions of reference, influence, persecution and poisoning are most frequently observed in schizophrenia. The delusions of poisoning accompanied by those of a bodily defect are observed in involutional psychoses. In the delusion of reference supplementing the delusions of persecution, the patient takes events indifferent to him as referring to himself. What is going on around him has a double meaning, everything is of particular significance (delusion of special meaning). The delusion of jealousy is characterized by the patients’ statements about adultery of their partners in marriage. The patients spy upon their wives or husbands, constantly try to find out proofs of the adultery; all the behaviour, appearance, statements of the spouse, his/her surroundings and events are considered as “evidence” testifying to the adultery. It is not in rare cases that such patients are socially dangerous as they may make attempts to kill the unfaithful spouse and his/her imaginary lovers. The delusion of jealousy is observed in schizophrenia and alcoholism. Induced delusions originate in a mentally healthy person as a result of adoption of delusions from a mental patient with whom the induced subject contacts. Most frequently it develops in personalities with a low intellectual level, who are unable to correctly comprehend the situation in a critical way and have increased suggestibility. In these cases the induced person begins to state the same delusions and in the same form as the mental patient does. Usually they are people from the patient’s surroundings who have particularly close personal contacts with him and are his family members or relatives. Appearance of the induced delusion is facilitated by the patient’s deep conviction in the truthfulness of his thoughts as well as by the authority he had before the disease. Patients with the delusion of pretence, the delusion of intermetamorphosis state that everything around them is specially fabricated, scenes of some performance from their life are played, it is carrying out of an experiment, a double game, everything continuously changes its meaning: at one moment it is a hospital with its medical staff and patients, at another one it is some investigation establishment; the physician is not a physician, but an investigator, the case report is a file with his personal records, the patients and medical staff are disguised officers of security services. The delusion of damage: the patients believe that evil-wishers inflict them some material or moral damage, rob, spoil their belongings, defame them, infringe upon their rights. Usually it is manifested within the framework of the delusion of persecution. The delusion of litigiousness, or querulousness: the patients convinced in an inattentive, unjust or ill-disposed attitude to them provoke conflicts, devote themselves to disclosures, waste for it much strength, time and sometimes all their material resources, complain to various establishments and departments, involving still more and more new people into their delusions; the subjects of the delusions are drawn from the real situation: squabbles with their neighbours, conflicts with members of their family and colleagues. In case of the depressive delusion with hypochondriac subjects at an old age, statements easily become of a grotesque, megalomaniacal character. Here, by its contents, the delusion becomes nihilistic, or the delusion of negation. For example, at first the patient states that he has an undiagnosed severe disease of his stomach and he is dying of it; later he makes statements that he has no stomach as it has already rotted and there is some emptiness in its place; soon one may hear that the patient himself does not exist either, he is a living corpse, he has decomposed alive; still later he says that there is nothing – no world, no life, no death (Cotard’s syndrome). The hypochondriac delusion is connected with a conviction of having a severe incurable ailment. Close to it is dysmorphomania which may be defined as a delirious conviction in the presence of a bodily defect, most frequently of visible parts of the body: the form or size of the nose, ears, te