МИНИСТЕРСТВО ЗДРАВООХРАНЕНИЯ РФ

Государственное образовательное учреждение

высшего профессионального образования
МОСКОВСКАЯ МЕДИЦИНСКАЯ АКАДЕМИЯ им. И.М. СЕЧЕНОВА

Кафедра психиатрии и медицинской психологии

PRACTICAL MANUAL OF PSYCHIATRY

УЧЕБНО-МЕТОДИЧЕСКОЕ ПОСОБИЕ
по ПСИХИАТРИИ и НАРКОЛОГИИ
для студентов факультетов медицинских ВУЗов
с частичным преподаванием на английском языке

Под общей редакцией члена-корреспондента РАМН

профессора Иванца Н.Н.

Рекомендовано к изданию Редакционно-издательским советом

Московской медицинской академии им. И.М.Сеченова.
Рекомендовано Учебно-методическим объединением по
медицинскому и фармацевтическому образованию вузов России в
качестве учебного пособия для студентов медицинских вузов с
частичным преподаванием на английском языке.

Москва 2005
Учебно-методическое пособие подготовлено на кафедре психиатрии и медицинской
психологии лечебного факультета Московской медицинской академии им.
И.М.Сеченова (заведующий – член-корр. РАМН, профессор Н.Н.Иванец) в
соответствии с Государственным образовательным стандартом высшего
профессионального образования по специальности 040100 - Лечебное дело.
Авторы: доцент Тюльпин Ю.Г.,
ассистент Жуков А.О.
доцент Кинкулькина М.А.
доцент Балабанова В.В.,
доцент Прохорова С.В.,
доцент Максимова Т.Н.,
ассистент Лукьянова Т.В.
ассистент Бунькова К.М.
к.м.н. Данилов Д.С.

2
 CONTENTS
Введение. 4
Basic Definitions of General Psychopathology 7
Disorders of Sensation 10
Disorders of Perception 10
Thought Disorders 12
Memory Disorders 18
Disorders of Cognition 19
Disorders of Will and Behaviour 20
Disorders of Motor Behaviour 20
Affective Disorders 22
Disorders of Consciousness 24
Treatment of Mental Disorders 25
Classifications of Mental Disorders 30
Bipolar Psychosis and Other Affective Disorders 32
Schizophrenia 34
Organic Mental Disorders. 38
Epilepsy 40
Psychogenous Reactions and Neuroses 42
Psychotherapy 46
Personality disorders 48
Exogenous (symptomatic) Mental Disorders 54
Disorders Due to Psychoactive Substance Use 54
Appendix 1. The Types of Personality Changes 58
Appendix 2. Course of the disease. 63
Appendix 3. Official Statistical Classifications 64
Appendix 4. Clinical cases. 69
Appendix 5. Form for The Psychiatric Examination 87
Appendix 6. Questions for The Examinations. 89

3
 ВВЕДЕНИЕ
Настоящее методическое пособие предназначено для студентов, обучающихся в
медицинском вузе по специальности лечебное дело с частичным или полным
преподаванием на английском языке. Хотя программа обучения иностранных студентов
практически совпадает с той, что предназначена для российских граждан, при
проведении занятий приходится учитывать несколько существенных особенностей. Во-
первых, в большинстве своем данные студенты не владеют русским языком в степени
достаточной для пользования учебниками, написанными российскими авторами. Вместе
с тем, и английский язык в данном случае не является родным ни для учащихся, ни для
преподавателя, а значит, без дополнительного пояснения и обсуждения материал не
будет воспринят достаточно полно. Во-вторых, подавляющая часть иностранцев-
выпускников готовится к работе в своей стране, в Европе или США, поэтому они не
заинтересованы в изучении принципов организации психиатрической помощи в
Российской Федерации. В будущем данные учащиеся вынуждены будут использовать не
только принятую в России в качестве официальной классификацию МКБ-10, но и другие
часто используемые в мире классификации (например, DSM-IV). В третьих, изучение
клинической дисциплины (особенно, психиатрии) невозможно без общения с
пациентами, что требует совершенствования в пользовании русским языком. Наконец,
авторы считают, что было бы неразумным полностью отказаться от изучения
достижений российских ученых, особенностей психиатрической школы,
существовавшей на территории бывшего СССР. Изучение и пропаганда российского
опыта может способствовать более широким контактам между врачами разных стран и
повышению популярности российской медицинской науки.
Исходя из этих положений, авторы считают, что предлагаемое методическое
пособие должно быть билингвальным. Это позволит сравнить термины, применяемые в
разных странах, поскольку они часто являются не вполне совпадающими по своему
значению. В некоторых случаях мы также считаем допустимым использование
немецких и французских терминов, которые получили признание в мире. Во всех
случаях, когда это возможно, даются ссылки на международную классификацию,
указываются шифры МКБ-10, характеристика данной классификации также дана в
приложениях к методическому пособию. Кратко обсуждаются и принципы построения
DSM-IV. Вместе с тем, изложение материала построено на принципах нозологического
подхода, получившего признание в России и СНГ. Это означает, что диагностика
психических расстройств основана на изучении их этиологии, патогенеза, стереотипа
течения, соотношения продуктивных и негативных симптомов, исходов.
Необходимо внести некоторые изменения и в организацию занятий. Так,
традиционные лекции, плохо воспринимаемые студентами, следует заменить
объяснением материала в малой группе, ведь такая форма позволяет убедиться, что
предложенный материал был понят правильно, и внести необходимые пояснения и
исправления немедленно. Самостоятельную курацию больных для написания истории
болезни также из-за понятных трудностей лучше заменить на структурированный
анализ беседы с больным, которую ведет преподаватель. Пример приведен в
приложениях к настоящему пособию. Тестовый контроль является весьма
желательным, однако использовать тестовые задания, разработанные за рубежом
невозможно из-за их несоответствия российским программам. Разработка собственных
полноценных заданий на английском языке в настоящее время проводится. Для
практического усвоения материала большое значение имеет решение клинической
задачи по той же форме, которая используется для курации больных.
В структуру экзамена целесообразно включить 4 различных типа заданий: а)
описание одного из важнейших синдромов с анализом его диагностической
значимости; б) описание одной из нозологических единиц с указанием важнейших
диагностических критериев, вариантов течения, методов лечения и прогноза; в)

4
описание алгоритма действий в типичной экстренной ситуации (алгоритм диагностики
и/или терапии); г) решение клинической задачи по прилагаемой форме.

ЦЕЛИ И ЗАДАЧИ КУРСА

Целью изучения психиатрии на лечебном факультете является освоение навыков
первичной диагностики психических расстройств и расстройств поведения для их
своевременного обнаружения, направления больного к специалисту, оказания
неотложной психиатрической и наркологической помощи, а также фармакологической
и психотерапевтической коррекции мягких психических нарушений в условиях общей
медицинской практики. Еще одна важная задача преподавания — это привить
обучающимся навыки деонтологии, морально-этической и правовой культуры,
необходимые для ведения пациентов с психическими расстройствами и расстройствами
поведения.

По завершении обучения студент обязан ЗНАТЬ:

 принципы построения международной классификации психических расстройств;
 принципы организации психиатрической службы, рекомендуемые ВОЗ, принципы
обеспечения безопасности общества и психически больного при соблюдении его
законных прав;
 основные лекарственные средства, используемые в психиатрии, принципы их
подбора, противопоказания к их назначению, возможные побочные эффекты;
 методы исследования, применяемые в психиатрии, их диагностические
возможности, показания к проведению;
 основные симптомы и синдромы психических расстройств, их диагностическое
значение, роль этих синдромов в выработке врачебной тактики;
 данные о распространенности, проявлениях, течении, терапии, прогнозе наиболее
распространенных психических заболеваний, об их влиянии на адаптацию
пациентов и возможности их трудовой и социальной реабилитации;
 основные типы патологии характера и то влияние, которое они могут оказывать на
течение психических и соматических заболеваний, на выбор методов психотерапии;
 лекарственные средства, медицинские манипуляции, экологические и социальные
факторы, повышающие риск возникновения психических расстройств, принципы
профилактики психических заболеваний.

По завершении курса обучения студент обязан УМЕТЬ:

 своевременно выявлять наиболее острые психические расстройства, которые могут
представлять непосредственную опасность для жизни и здоровья больного и лиц, его
окружающих;
 сформулировать предварительное заключение о психическом состоянии больного и
грамотно составить направление в психиатрическое или наркологическое учреждение;
 оказать помощь в ургентной ситуации и по возможности купировать наиболее
опасные и неотложные психические расстройства (психомоторное возбуждение,
агрессивное и суицидальное поведение, отказ от еды, эпилептической статус,
тяжело протекающий делирий, отравление психоактивными веществами);
 организовать надзор, удержание и транспортировку возбужденного и социально
опасного больного;
 собрать субъективный и объективный анамнез и провести их предварительный анализ;
 распознавать психические расстройства, проявляющиеся соматическими
симптомами для своевременного направления пациента к врачу-психиатру;

5
 использовать элементы психотерапии в комплексном лечении самых различных
заболеваний (включая соматические).

СТРУКТУРА КУРСА
Согласно стандартам, утвержденным в РФ по специальности лечебное дело, на
преподавание психиатрии отводится 90 часов аудиторных занятий, 45 часов
самостоятельной работы, в конце цикла проводится экзамен.

день СОДЕРЖАНИЕ ЗАНЯТИЯ часы

1. Basic Definitions of General Psychopathology 4
2. Disorders of Sensation and Perception 4
3. Thought disorders: Disorders of the Form and the Stream of Thought 4
4. Thought disorders: Disorders of the possession and the content of 4
thought
5. Thought disorders: Delusional disorders syndromes 4
6. Disorders of memory. Disorders of cognition: Basic Definitions, Mental 4
Handicap (Mental retardation)
7. Disorders of cognition: Dementia 4
8. Disorders of Will and Behaviour. Symptoms of Affective disorders 4
9. Affective syndromes 4
10. Disorders of Motor Behaviour. Disorders of Consciousness (basic defini- 4
tions)
11. Syndromes of Obscured consciousness 4
12. Treatment of Mental Disorders 4
13. Classifications Of Mental Disorders 4
14. Bipolar psychosis and other Affective Disorders. Schizophrenia (basic 4
definitions)
15. Schizophrenia (clinical forms, types of course, treatment) 4
16. Organic mental disorders 4
17. Mental Disorders due to Epilepsy 4
18. Psychogenous reactions and neuroses 4
19. Personality disorders 4
20. Psychotherapy 2
21. Exogenous (symptomatic) Mental Disorders. Disorders due to psychoac- 4
tive substance use
22. Alcohol dependence and Alcohol psychoses 4
23. Structured patient examination 4
T o t a l 90

6
BASIC DEFINITIONS OF GENERAL PSYCHOPATHOLOGY

SYMPTOM A manifestation of a pathologic condition. Symptom must not

only differ the patient from other individuals, but provoke the
loss of adaptation. For example the memory which is better
than others is not a symptom, but poor memory causes the loss
of adaptation, so it is a symptom.

SYNDROME A group of signs and symptoms that occur together in a recog-

nisable pattern. Since the true pathogenesis of psychiatric syn-
dromes is not well known, the repetition of these symptoms in
different patients is a feature of great significance for diagnos-
tic. Syndrome defines the actual condition of the patient. It is
not only a stage of nosologic diagnosis. Syndrome is a base of
psychopharmacological treatment (for example a good effect of
neuroleptics in all kinds of paranoid states or antidepressants in
all kinds of depression).

PRODUCTIVE Productive symptoms (plus-symptoms) — new additional

AND functions and phenomena which are not known in healthy indi-
NEGATIVE viduals, appearance of some surplus traits over a normal level
SYMPTOMS: of functioning. These symptoms are reversible, they usually oc-
cur in patients with acute disorders. The majority of psycho-
pharmacological drugs are intended for treatment of productive
symptoms.
Negative symptoms (deficiency) — the loss of normal func-
tions (for example the loss of memory). Usually these symp-
toms are irreversible but it is a mistake to value the negative
symptoms through the acute phase of the illness (for example,
the loss of appetite is reversible if it is a symptom of acute de-
pression). Some negative symptoms can be corrected by vicari-
ous drugs, but they appears again after the withdrawal.

As a rule severe diseases (psychoses) are manifested not only with severe
symptoms but with mild as well. We can see «neurosis inside any psycho-
sis» (see the picture).

7
 Levels of Mental Disorders

Organic Psychoses

Paroxysmal disorders, Dementia,

Delirium etc. Korsakoff’s syndrome etc.

Functional Psychoses

Oneiroid, Schizophasia,
Catatonia, Apathy,
Hallucinations, Abulia etc.
Delusions etc.

Neurotic Disorders

Cenesthopathy, Depersona-
Hyperthymia, lization,
Hypothymia,
Asociality etc.
Anxiety,
Obsessions,
Phobias,
Hysteric conver-
sion etc.

Asthenia

PRODUCTIVE DISORDERS NEGATIVE DISORDERS

8
LEVELS OF It is customary to divide mental disorder into severe (psycho-
MENTAL ses) and mild (neuroses). There is no satisfactory way for dis-
DISORDERS. tinction between these two groups.
Usually the following criteria are used.
Psychoses — severe mental disorders, so patients:
 construct a false environment which they can not distinguish
from the reality (hallucinations, delusions etc.);
 show absurd or even dangerous behaviour (aggression, su-
icide, excitement etc.) which can not be interpreted as un-
derstandable development of the personality;
 have poor insight (no sense of illness)
Neuroses — mild mental disorders, so patients:
 apprehend the real environment and situation without sig-
nificant mistakes;
 do not assume rash, dangerous or antisocial actions;
 realise that they are mentally ill, suffer, seek help (have
good insight)
Organic disorders include trauma, tumour, intoxication (i.e. al-
cohol), epilepsy, degenerative diseases (Alzheimer’s disease,
Pick’s disease etc.), consequences of somatic diseases (arterio-
sclerosis, endocrine pathology, etc.) and others. In psychiatry
we can not directly observe the condition of brain, so the diag-
nosis is based on characteristic symptoms and syndromes: delir-
ium, paroxysmal disorders, impairment of memory and intelli-
gence. Organic disorders are irreversible excepting some acute
states (i.e. delirium and paroxysms).
Functional disorders include stress induced diseases (reactive
psychoses and neuroses), bipolar psychosis, schizophrenia and
some others. No evident impairment of brain can be revealed
with special instrumental methods. All the symptoms are re-
versible. The exception is deep personality changes in schizo-
phrenic patients which are irreversible (so some scientists con-
cern schizophrenia as partially organic disorder).

9
DISORDERS OF SENSATION
нарушения ощущений

 Hyperaesthesia (symptom of asthenic states)

гиперестезия
 Hypaesthesia (symptom of depression)
гипестезия
 Anesthesia (for example hysteric anaesthesia)
анестезия
 Hysterical anaesthesia: loss of sensory modalities resulting
from emotional conflicts
 Cenesthopathy (Cenesthetic hallucinations) — unfounded
сенестопатия strange inexplicable sensations in bodily organs
(usually in case of schizophrenia)

DISORDERS OF PERCEPTION
расстройства восприятия

 Illusions (including pareidolia) — misperception or misinterpretation

иллюзии of real external sensory stimuli
Pareidolia is a fantastic misperception of reality in case of sufficient information
(symptom of delirium)
 Hallucinations — false sensory perception or mental
галлюцинации impressions of sensory vividness not
associated with real external stimuli
a) of hearing, of vision, of olfaction, of taste, of tactile sensation,
of deep sensation
b) elementary (acousma, photopsia) and organised (verbal hallu-
cinations i.e. “voices” including imperative, threatening,
commenting)
c) true hallucinations and pseudohallucinations

 Derealisation — a subjective sense that the environment is

дереализация strange or unreal; a feeling of changed
reality (for example the feeling that world
looks flat or “made of cardboard”)
 Depersonalisation — a subjective sense of being unreal, strange,
деперсонализация or unfamiliar to oneself

10
 True hallucinations Pseudohallucinations
Истинные галлюцинации Псевдогаллюцинации
(В.Х.Кандинский, 1880)
Bright vivid perception just like the The lack of the vividness (for example
natural one impossible to distinguish male and fe-
male voices)
Patient got it with natural way of per- Patient got it with other (double) per-
ception (with eyes or ears) from the re- ception (internal vision or hearing)
al perceptual space (extraproection) from out of perceptual space (for ex-
ample intraproection).
Confidence in the fact that other peo- Ideas of distant influence organised
ple have the same perceptions especially for the patient
Excitement or attempts to act with the Indifferent behaviour or passive de-
false objects. More abundant in the fence (for example attempts to shield
evening and night with metal net or screen)
Typical for delirium and other organic Typical for paranoid schizophrenia
disorders

HALLUCINOSIS syndrome characterised by abundant hallucinations of only

галлюциноз one modality (most often auditory), that occur within a clear
sensorium. Symptoms resemble delirium, but exist in the con-
text of clear consciousness. (typical for organic disorders)
THE DIAGNOSTIC MEANING OF DEPERSONALISATION AND DEREALISATION
depends upon the other associated symptoms:
1. Patients with acute delusional states often manifest anxiety, excitement,
sleep disorders, non-systematised persecutory ideas. In this case deperson-
alisation and derealisation are congruent to delusional mood, they are posi-
tive (reversible) symptoms of psychosis.
2. Sometimes depersonalisation and derealisation are the symptoms of par-
oxysmal states (for example epileptic seizures). In these cases the feeling
of changing appears suddenly and exists for a short period of time. There
are several examples of such disorder:
a. Deja vu: the false feeling, that a new situation is a repetition of a pre-
vious experience
b. Jamais vu: false feeling of unfamiliarity with a real situation one has
experienced
3. In case of chronic progressive diseases (for example schizophrenia) deper-
sonalisation is a sign of real changes in patient’s personality (flattering
of affect, loss of energy, redundant thoughts). These changes are stable (ir-
reversible), so it means that this kind of depersonalisation is a negative
symptom. The presence of sense of illness (insight) indicates the neurotic
level of a disorder.

11
THOUGHT DISORDERS
расстройства мышления

DISORDERS OF THE FORM AND THE STREAM OF THOUGHT

(ассоциативные расстройства – расстройства мышления по форме)
 Pressure of Talk, (up to Flight of Ideas and Word salad)
(ускорение мышления вплоть до “скачки идей” и “словесной окрошки”) redun-
dancy of associations resulting in distractibility
and chaotic speech.
(symptom of mania)
 Inhibition of Thought
(замедление мышления) slow thinking with poor associations, patient
answers in one word and fails to understand
difficult sentences.
(symptom of depression or clouding of con-
sciousness)
 Circumstantiality (Stiffness)
(патологическая обстоятельность, вязкость)
indirect speech that is delayed in reaching the
point but eventually gets from original point to
desired goal; characterised by an overinclusion
of details and parenthetical remarks.
(symptom of epileptic personality changes)
 Reasoning, Philosophical intoxication (german Räsonierung)
(резонерство) vague thinking (wooliness of thought) with ex-
cessive use of abstract concepts. Tangentiality:
inability to have goal-directed associations of
thought; patient never gets from desired point
to desired goal
(symptom of schizophrenia)
 Schizophasia (Incoherence)
(разорванность, шизофазия) formal speech without any useful content,
grammatically structured but void of sense
(symptom of deep schizophrenic defect)
 Incoherence speech that, generally, is not understandable;
(бессвязность) deep disorganisation of thought that appears
with words or verbal combinations which have
no logical or grammatical connection, often as-
sociated with disorder of consciousness.
(for example in case of amentia)

12
 Stereotypie Verbale:
(речевые стереотипии)
Perseveration persisting verbal response to a prior stimulus
(персеверации) after a new stimulus has been presented, often
associated with cognitive disorders
Verbigeration rhythmical repetition of words or meaningless
(вербигерации) sound combinations, often associated with
«clang association» (association of words simi-
lar in sound but not in meaning; words have no
logical connection, may include rhyming and
punning)
 Mentism
(наплыв мыслей, ментизм) suddenly appeared unmanageable flow of
thought, often with the feeling of distant influ-
ence
(symptom of mental automatism)
 Thought Blocking, Barrage (german – Sperrung)
(шперрунг) abrupt interruption in train of thinking before a
thought or idea is finished; after a brief pause,
the person indicates no recall of what was be-
ing said or was going to be said; the feeling of
distant influence is usual.
(symptom of mental automatism)
 Autistic Thinking
(аутистическое мышление) quasi-existence, preoccupation with inner, pri-
vate world that results in loss of communica-
tion with reality, full of fantastic absolutely
unproductive thoughts
(symptom of schizophrenic personality chang-
es)
 Symbol Thinking
(символическое мышление) thinking basing on a great deal of symbols;
providing common things with the special
meaning, understandable only for themselves.
(symptom of schizophrenic personality chang-
es)
 Paralogia (Illogical thinking)
(паралогическое мышление) thinking containing erroneous conclusions or
internal contradictions; it is psychopathological
only when it is marked and when not caused by
cultural values or intellectual deficit.
(symptom of schizophrenic personality chang-
es)
13
THOUGHT DISORDERS (continuation)
DISORDERS OF THE POSSESSION AND THE CONTENT OF THOUGHT
(расстройства суждений и умозаключений – патологические идеи)

 Delusion
(бред) false belief of great value to a patient, based on incor-
rect inference about external reality, which arises
from internal morbid process (not consistent with pa-
tient’s intelligence and cultural background) and can-
not be corrected by reasoning.
(unspecific productive symptom of different psycho-
ses)
 Overvalued Ideas
(сверхценные идеи) sustained ideas of great personal value, which are not
absolutely false but inadequately significant in such
way, that it disturbs the adaptation of individual.
(productive disorder of subpsychotic level, typical for
paranoid disorder of personality)
 Obsessions
(навязчивые идеи) pathological persistence of an irresistible thought or
feeling that cannot be eliminated from consciousness
by logical effort, usually associated with hypothymia
and anxiety.
(unspecific productive symptom of neurotic level,
usual for neuroses and schizotypal disorder)

Criteria Delusion Overvalued ideas Obsession

False, true or
Veracity False ideas True ideas
meaningless ideas
Insight Poor Poor Good
Poor, dangerous
Behaviour Good, no danger-
actions are rather Poor but possible
control ous actions
probable
Neuroses or mild
Subpsychotic states
disorders (initial
(initial period of
Diagnosis Organic or func- phase of schizo-
tional psychoses psychoses), para-
phrenia or organic
noid personality
disorders)

14
 OBSESSIVE-PHOBIC SYNDROME
Obsessions different types of persistent irrational ideas,
(навязчивые мысли) for example:
Rumination (мыслительная жвачка)
irrational burdensome operating with thoughts,
symbols, words or numbers
Contrast ideas (контрастные навязчивости)
irrational painful thoughts about possibility of
dangerous or antisocial actions

Phobias
(навязчивые страхи) persistent, irrational, exaggerated, and invariably
pathological dread of some specific type of stimu-
lus or situation; results in a compelling desire to
avoid the feared stimulus
a. Social phobia: dread of public humiliation,
as in fear of public speaking, performing, or
eating in public
b. Agoraphobia: dread of open places
c. Claustrophobia: dread of closed places
d. Nosophobia: dread of illness (i.e. cardio-
phobia, syphilophobia, AIDSphobia )
e. Thanatophobia: dread of death
f. Panphobia: dread of everything
g. Acrophobia: dread of high places
h. Xenophobia: dread of strangers
i. Zoophobia: dread of animals
Rituals (compulsions) (навязчивые действия, ритуалы)
repeated symbolic actions, compulsive in nature,
anxiety-reducing in origin

15
 DELUSIONS
Types according to content:

Depressive
Persecutory delusions Grandiose delusions
бред преследования
delusions бред величия
депрессивный бред

 ideas of persecution  ideas of guilt  ideas of self-

преследования самообвинения, importance
 ideas of control самоуничижения собственно величия
(of distant influence)  ideas of poverty  ideas of riches
воздействия бедности богатства
 ideas of poisoning  hypochondriacal  erotic ideas
отравления ideas любовный
 ideas of jealousy ипохондрический  ideas of power and
ревности  dysmorphophobic might
 ideas of self-reference дисморфомани- могущества
отношения (особого значения) ческий
 ideas of fabrication, staging, put-  nihilistic delusions
ting-up, personal doubles (Cotard’s syn-
(Capgras’ syndrome) drome)
инсценировки (двойников) нигилистический
 ideas of pilferage
материального ущерба
 querulous ideas
сутяжный (кверулянтский)
Emotions of fear, anxiety or anger Depressive mood Euphoria or indifference
Danger of aggression in some cases Danger of suicide Dangerous behaviour is
not typical

Primary delusion Secondary delusion

(первичный бред)
independent disorder of thought which
are not associated with other mental dys-
function
Systematised delusion
(систематизированный бред)
false ideas confirmed with some logic as-
sociations (in case of persecution patient
can in details describe the persecutors,
their aims and methods, so he can answer
the questions «Who?», «Why?», How?»)
(symptom of chronic delusional states)
16
(вторичный бред)
secondary disorder of thought, which
represent the disturbance of other
mental functions (affect, perception,
memory, consciousness etс.
Non-systematised delusion
(несистематизированный бред)
fragmentary, not associated false ideas
(symptom of either acute delusional
states or of late stages of chronic pro-
cesses)
Error of interpretation
(интерпретативный бред)
based on logic, systematised
(usually chronic process)
Error of perception
(чувственный бред)
delusional mood, delusional
perception, autochtonous delusion
(usually acute disorders)

CRITERIA OF ACUTE DELUSION:

 non-systematised
 bright affect (fear, anxiety, mania, depression, happiness, guilt)
 mood-congruent ideas of self-reference, fabrication, staging
Acute delusional states can be well controlled by antipsychotic drugs; there is a
real possibility of remission or full recovery.

STAGES OF CHRONIC DELUSION by V.Magnan:

(typical for paranoid schizophrenia)
I. Paranoia primary systematised ideas of persecution, jealousy or inven-
tion without hallucinations
(паранойяльный синдром)
II. Paranoid hallucinational and delusional states with persecutory ideas
of control (distant influence) or poisoning, often associated
with mental automatism
(параноидный синдром)
III. Paraphrenia hallucinational and delusional states with bizarre ideas of
grandeur or persecution, delusional memories, falsification
of memory usually associated with mental automatism, often
non-systematised
(парафренный синдром)
Chronic delusional states can be partially controlled by antipsychotic drugs, re-
mission of high quality and full recovery are not possible.

SYNDROME OF MENTAL AUTOMATISM

(Schneiderian first rank symptoms of schizophrenia – FRS):
(синдром психического автоматизма Кандинского-Клерамбо)

 Pseudohallucinations (псевдогаллюцинации – В.Х.Кандинский, 1880)

 Mental Automatism (психический автоматизм)

Alienation of Thoughts идеаторный автоматизм

Alienation of Perceptions and Emotions сенсорный автоматизм
Alienation of Movements моторный автоматизм
 Delusion of control (of distant influence)

17
MEMORY DISORDERS
 расстройства памяти
 Hypermnesia exaggerated degree of retention and recall
(гипермнезия) (symptom of mania)
 Hypomnesia difficulties of registration, retention
(гипомнезия) and recall of memories
(symptom of vascular deficiency)
 Failure of registration minute memory
(фиксационная амнезия) (symptom of Korsakov’s syndrome)
 Amnesia gap, loss of memories
(амнезия) but not the ability to register
1. Organic amnesia
(органическая амнезия)
Retrograde amnesia (ретроградная амнезия)
extends backwards in time from a point of sudden illness
beginning
Anterograde amnesia (антероградная амнезия)
begins at a given point of illness history
Progressive amnesia (прогрессирующая амнезия)
develop by the law of Ribot (french loi la regression de Ribot)
2. Psychogenic amnesia (for example hysteric)
(психогенная амнезия)

 Парамнезии – Paramnesia’s
Allomnesia (german Pseudoreminiszenz)
(псевдореминсценции) filling of gaps in memory by real experi-
encebut of other time period
Confabulation unconscious filling of gaps in memory by
(конфабуляции) imagined or untrue experiences that patient
believes but that have no basis in fact
KORSAKOV’S SYNDROME
(Корсаковский амнестический синдром)
 Failure of registration (minute memory)
 Anterograde and Retrograde Amnesia
 Amnestic disorientation (for time and place but not for personality)
 Paramnesia (confabulations which cover the gaps in the memory)

18
DISORDERS OF COGNITION (расстройства интеллекта)
Components of intellect:  prerequisites (memory, associations)
 store of knowledge
 ability to understand, abstract thinking
Valuation of intellect Specific tests Wechsler-test (WAIS,
IQ =
Mental age  100% WISC), Progressive Matrices Test,
(Intelligence Quotient)
Chronological age Stanford-Binet Intelligence Scale
(for age 2 – 23).
I. MENTAL HANDICAP (MENTAL RETARDATION) see appendix 1
(олигофрения) retarded intellectual and cognitive development
Causes: a) genetic (chromosomal and inherited); b) embryopathy (intoxication, rubel-
la, other infections); c) fetopathy and perinatal pathology (hypoxia, trauma, in-
fection, Rhesus-conflict etc.)
Levels: ICD-10 IQ (%) Clinical classification
F70 Mild mental retardation 50 – 69 Moronic (дебильность)
F71 Moderate mental retardation 35 – 49
Imbecile (имбецильность)
F72 Severe mental retardation 20 – 34
F73 Profound mental retardation below 20 Idiocy (идиотия)

II. DEMENTIA loss of intelligence after a period of its normal

(слабоумие, деменция) development
Organic Dementia
Dysmnestic (Arteriosclerotic) (лакунарное, дисмнестическое)
 primary marked disorder of memory
 slight deficiency in understanding
 mild personality changes (expression of prior personality traits)
 good insight (sadness because of the sense of illness)
Total (тотальное, глобарное)
(due to GPI, atrophy, frontal lobe tumors etc.)
 primary marked impairment of understanding
 severe personality changes (destruction of nuclear personality traits)
 poor insight (no sense of illness) or formal critical judgement
Epileptic see appendix 1 (концентрическое, эпилептическое)
 severe personality changes (egoism, stiffness, emotional rigidity)
 marked impairment of cognition (loss of ability for abstract thinking) and
memory
 poor vocabulary and perseverative thinking
Schizophrenic Dementia see appendix 1
 severe personality changes (indifference, laziness, autism, apathy, abulia);
 marked cognitive difficulties (schizopasia, paralogia, reasoning etc);
 absence or mild disorders of memory
19
DISORDERS OF WILL AND BEHAVIOUR
расстройства воли и влечений

Hyperbulia (гипербулия) reinforcement, intensification of drives

Hypobulia (гипобулия) weakening of drives
Abulia (абулия) the loss of will and energy, laziness,
reduced impulse to act and think, often
associated with emotional indifference (apathy)
Disorders of behavior and Impulse control disorders (парабулии)
 Dipsomania: compulsion to drink alcohol
 Kleptomania: compulsion to steal
 Nymphomania (Satyriasis): excessive and compulsive need
for coitus in a woman (in a man)
 Trichotillomania: compulsion to pull out one's hair
 Dromomania (poriomania): compulsion to leave home, to rove
insight behavior control
Obsessive bent + +
Compulsive bent + –
Impulsive acts – –

DISORDERS OF MOTOR BEHAVIOUR

двигательные расстройства
Catatonia (кататонический синдром)
Stupor: strange non-convenient posture, waxy flexibility (catalepsy),
negativism (active and passive), automatic obedience
Excitement: purposeless actions, impulsive, brutality, stereotypic speech
and movement (verbigerations, perseverations)
Non-adaptive movements: echo-symptoms (echopraxia, echolalia,
echomimia), manneristic behavior

Other causes of excitement:

 Mania
 Agitated depression (ажитированная депрессия)
 Acute delusional states (острый чувственный бред)
 Disorders of consciousness: delirium, oneiroid, twilight states)
(острое помрачение сознания: делирий, онейроид, сумеречное помрачение)
 Dysphoria
 Hysteric excitement (истерическое возбуждение)
20
 Catatonic excitement
 purposeless, impulsive
 absence or poor reaction
to the acts of spectators
(sometimes muteness)
 stereotypical
 manneristic posture and
facial expression
 echolalia and echopraxia
Maniacal excitement
 purposeful
 marked striving to per-
sonal contacts
 increased drives
 facial expression
of happiness
(sometimes anger)
Hysterical excitement
 stress induced
 evident reaction to the
acts of spectators
 demonstrative behaviour
(loud cries, sobbing,
convulsions, suicide
actions, etc.)
 histrionic posture and fa-
cial expression

Other causes of stupor:

 Depression
 Hysteric stupor (истерический ступор)
 Stress reaction (реакция на психологический стресс)

Catatonic stupor Depressive stupor

 bizarre inconvenient posture
(i.e. foetal posture)
 manneristic facial expression
 muteness (sometimes paradoxical
answers to whispering speech)
 negativism
(often eating is absolutely refused)
 echolalia and echopraxia
 posture of suffering
 facial expression of sadness or anguish
 poor associations, one word answers,
but no muteness
 the loss of appetite but no active
resistance while eating

Amobarbital (Amytal) interview is used as diagnostic and therapeutic in-

strument in situations of catatonia, stupor,
muteness. Improvement is usual in patients
with psychogenic and functional condi-
tions (for example with psychogenic am-
nesia) because of disinhibition, decreased
anxiety and relaxation. Powerful benzodi-
azepines (lorazepam, diazepam) showed
the same effects as amobarbital.

21
AFFECTIVE DISORDERS
аффективные расстройства
 Hypothymia stable unreasonable feeling of sadness
(symptom of depression)
 Hyperthymia stable unreasonable elevation of mood
(symptom of mania)
 Euphoria elevated but serene careless mood, complacency
often associated with poor insight or even dementia
(symptom of organic disorders, e.g. intoxication)
 Dysphoria sullenness and grumbling, unpleasant mood,
up to anger and irritation, often paroxysmal
(symptom of organic disorders, e.g. epilepsy)
 Apathy dulled emotional tone associated with detachment or
indifference
(symptom of schizophrenic defect or frontal lobe
damage)
 Anaesthesia psychyca dolorosa painful feeling that the patient lost his
feelings
(symptom of depression)
 Anxiety (тревога) feelings of tension and apprehension caused by an-
ticipation of uncertain danger
(often is the debut symptom of acute psychosis)
 Ambivalence (амбивалентность) coexistence of two opposing impulses to-
ward the same thing in the same person at the same
time
(symptom of schizophrenic personality changes)
 Emotional (affective) rigidity, stiffness (эмоциональная ригидность)
pathologic steadfastness (persistence) of emotions,
often accompanied by obstinacy and rancour
(symptom of organic and epileptic personality changes)
 Emotional (affective) lability (эмоциональная лабильность)
fast changes in mood from tears to laughter.
(symptom of neurosis, e.g. hysteria)
 Emotional Incontinence (слабодушие)
subject bursts to tears for little or no reason,
e.g. being touched with sad or pleasant event
(symptom of encephalopathy due to vascular
deficiency)

22
 AFFECTIVE SYNDROMES

Depression Mania Apathy and abulia

(депрессивный)
 hypothymia (up to an-
guish)
 inhibition of thought
 motor retardation (except
when agitated)
 self-concerned
 painful thoughts
 mood-congruent delusion
(ideas of guilt)
 loss of appetite
 hyposexuality
 loss of interests
 anhedonia
 insomnia (early wake up,
the loss of the sense of
sleep)
 dry skin
 arterial hypertension
 constipation
 tachycardia
 mydriasis
(маниакальный)
 hyperthymia
 pressure of talk
 pressure of activity
 self-over-rating
 mood-congruent delusion
(ideas of granduer)
 bulimia, abuse of alcohol,
spending money
 hypersexuality
 distractibility
 insomnia (sleeps shortly
but without sense of
tiredness)
 well healthy, no somatic
complaints
(апатико-абулический)
 apathy (indifference)
 normal speech but short
answers
 passivity but no difficul-
ties in movement
 no special disorder of
thought
 normal appetite
 unexpected sexual
behavior
 passivity
 no disorders of sleeping
 well healthy, no somatic
complaints

Depression with anxiety up to agitation (ажитированная депрессия)

depression associated with severe anxiety, excitement
and motor restlessness, more common for patients of in-
volution age. Special observation is strongly recom-
mended because of a high suicidal risk.

Masked depression (маскированная депрессия)

depression manifested by somatic symptoms (heartache,
headache, stomachache, arterial hypertension, constipa-
tion, tachycardia, arrhythmia).

Dexamethasone-suppression test is used to confirm a diagnostic impression

of endogenous depression (major depressive disorder).
After taking 1 mg dexamethasone by mouth at 11 pm
plasma cortisol concentration at 8 am comes down in
healthy patients (negative test result) and remain above 5
g/dL (nonsupression) in depressed individuals (positive
test result).

23
DISORDERS OF CONSCIOUSNESS
расстройства сознания
Definitions by Karl Jaspers
There should be found deficiencies of:
1. Grasp, comprehension, attention (difficulties or loss of contact)
2. Orientation (in time, of place, of situation, self-orientation)
3. Thinking (poor associations up to incoherence)
4. Retention (congrade amnesia)
Deterioration of consciousness (quantitative — no productive symptoms)
(снижение уровня сознания)
I. Clouding of Consciousness (оглушение)
II. Organic Stupor (german Sopor) (сопор)
III. Coma (кома)
Obscured consciousness (qualitative) (a lot of productive symptoms)
(помрачение сознания)
Delirium: acute psychosis with illusions and true hallucinations,
(делирий) excitement, disorientation in time, place, situation
Amentia (Incoherence syndrome, Delirium)
(аменция) deep disorder of consciousness with incoherence
Oneiroid State: dream-like states with dual orientation,
(онейроид) pseudohallucinations, catatonic behavior
Twilight states
(including Fugas, Ambulatory automatism, Spontaneous somnambulism)
(сумеречное помрачение сознания) paroxysmal states with total amnesia

Syndrome Delirium Oneiroid Twilight states

Beginning Gradual within 1-2 days Gradual through the stage Sudden
through the states of anxi- of acute delusions and de-
ety, sleep disorders realization
Symptoms Illusions, true halluci- Catatonia, pseudohalluci- Brutal aggression or au-
nations, excitement nations, dual orientation tomatic behavior
Duration 3-5 days Several days or weeks Several minutes or hours
Ending Critical after deep sleeping Gradual Sudden
Amnesia Partial Partial Total
Outcome Full recovery, in severe Remission Status idem
cases Korsakov’s of high quality
syndrome, dementia
or death
Nosology Organic damage or intox- Schizophrenia or abuse of Epilepsy or other organic
ication hallucinogen drugs paroxysmal disorders
24
TREATMENT OF MENTAL DISORDERS
HISTORY OF BIOLOGIC TREATMENT OF MENTAL DISEASES
1869 — Chloral hydrate introduced as a treatment for melancholia and mania
1882 — Paraldehyde introduced for a treatment of epilepsy
1903 — Barbiturates introduced as a sedative and anticonvulsant
1917 — Malaria fever therapy of GPI (psychosis of syphilis) [Ju.Wagner von
Jauregg]
1927 — Insulin shock for treatment of schizophrenia [M.Sakel]
1934 — Cardiazol (pentylenetetrazol) induced convulsions [L.Meduna]
1936 — Frontal lobotomies [E.Moniz]
1938 — Electroconvulsive therapy [U.Cerletti, L.Bini]
1940 — Phenytoin introduced as anticonvulsant [T.Putnam]
1948 — Disulphiram introduced for treatment of alcohol dependence
[E.Jacobsen, J.Hald]
1949 — Lithium introduced for treatment of bipolar psychosis [J.F.Cade]
1952 — Chlorpromazine introduced [J.Delay, P.Deniker]
1953 — Monoanine oxidase inhibitors treatment of depression [G.E.Crain,
N.S.Kline]
1956 — Imipramine (the first tricyclic drug) for treatment of depression
[R.Kuhn]
1960 — First tranquilizer — chlordiazepoxide introduced [Roche Laboratories,
France]
1963 — Valproic acid introduced as anticonvulsant [France]
1963 — Pyracetam introduced [UCB, Belgium]
1965 — First atypical neuroleptic — clozapine introduced
1971-1988— Several serotonin-specific reuptake inhibitors introduced
1986 — Atypical tranquilizer — buspirone introduced

CLASSIFICATION OF PSYCHOPHARMACOLOGICAL DRUGS

Antipsychotics (neuroleptics) — treat the symptoms of psychosis (excite-
ment, delusions, hallucinations etc.), usually by blocking dopa-
mine and serotonin receptors.
Antidepressants — treat depressed mood, usually by increasing the activity of
monoamine receptors. The effect develops slowly (in 2-3
weeks).
Mood stabilizers (lithium, carbamazepine, valproic acid) — treat elevated
mood and prevent new exacerbations of affective psychoses.
Tranquilizers and sedative — treat anxiety and sleep disorders, usually by in-
ducing GABA-receptors. The effect is fast and short. Long treat-
ment is not recommended because of the possibility of dependence.

25
Stimulating drugs (caffeine, amphetamine, methylphenidate, sydnocarb, meso-
carb) — increase activity, decrease appetite, disturb the sleep, in-
tensify psychosis (delusion, hallucination, excitement). High risk
of dependence.
Nootrops (pyracetam, GABA, pyriditol, ACTH, semax, acetylcholinester-
ase inhibitors etc.) — bioactive substances which correct defi-
ciency of memory and thinking. Effect is possible only after long
treatment.

INDICATIONS FOR NEUROLEPTIC TREATMENT

THERAPEUTIC INDICATIONS
Excitement
Productive symptoms: delusions, hallu-
cinations, catatonia
Progression of negative symptoms of
schizophrenia
Loss of energy (for activation)
Correction of behavior of patients with
neuroses, organic disorders and person-
ality disorders
Long-term treatment of patients with
chronic psychoses
Depression with anxiety and agitation
EXAMPLES
Chlorpromazine (Thorazine, Largactil)
Levomepromazine (Nosinan, Tisercin)
Chlorprothixene (Taractan, Truxal)
Clozapine (Leponex, Azaleptin)
Droperidol (Inapsine)
Zuclopenthixol (Clopixol)
Haloperidol (Haldol)
Trifluoperazine (Stelazine, Trazin)
Trifluperidol (Trisedil)
Clozapine (Leponex, Azaleptin)
Thioproperazine (Majeptil)
Perphenazine (Trilafon, Aethaperazin)
Trifluperidol (Trisedil)
Pipothiazine (Piportil)
Risperidone (Risperdal, Rispolept)
Olanzapine (Ziprexa)
Methophenazine (Frenolon)
Fluphenazine (Prolixin, Permitil, Moditen)
Sulpiride (Eglonil, Dogmatil)
Flupenthixol (Fluanxol)
Thioridazine (Melleril, Mellaril, Sonapax)
Periciazine (Neuleptil)
Alimemazine (Theralen)
Sulpiride (Eglonil, Dogmatil)
Perphenazine (Trilafon, Aethaperazin)
Haloperidol-decanoat
Clopixol-depo
Fluphenazine-depo (Moditen-depo)
Pimoside (Orap)
Penfluridol (Semap)
Fluspirelen (Imap)
Levomepromazine (Nosinan, Tisercin)
Sulpiride (Eglonil, Dogmatil)
Chlorprothixene (Taractan, Truxal)

26
CLASSIFICATION OF NEUROLEPTICS BY CHEMICAL STRUCTURE
Chemical class — derived of: Examples
PHENATHYAZINE:
aliphatic Chlorpromazine (Thorazine, Largactil)
Levomepromazine (Nozinan,Tisercin)
Alimemazine (Theralen)
Promethazine (Diprazine, Pipolphen)
piperazine Trifluoperazine (Stelazine, Trazin)
Perphenazine (Trilafon, Aethaperazinum)
Thioproperazine (Majeptil)
Fluphenazine (Permitil, Prolixin, Moditen)
Metofenazat (Frenolon)
Prochlorperazine (Compazine, Metherazine)
piperidine Thioridazine (Mellaril, Sonapax)
Periciazine (Neuleptil)
Pipothiazine (Piportil))
BUTIROPHENONE: Haloperidol (Haldol, Senorm)
Trifluperidol (Trisedil)
Droperidol (Inapsine)
Melperone (Eunerpan)
Pipamperone (Dipiperon)
DIPHENILBUTHYLPIPERIDINE: Pimozide (ORAP)
Penfluridole (Semap)
Fluspirilene (IMAP)
THIOXANTENE: Chlorprothixene (Taractan, Truxal)
Thiotixene (Navan)
Flupentixol (Fluaxol)
Zuclopentixol (Clopixol)
BENZAMIDE: Sulpiride (Eglonil, Dogmatil)
Tiapride (Tiapridal)
Sultopride (Topral)
Metoclopramide (Cerucal, Reglan)
DIBENZODIAZEPINE Clozapine (Leponex, Azaleptin)
DIBENZOXAZEPINE Loxapine (Loxitan, Loxapac)
THIENOBENZODIAZENINE Olanzapine (Ziprexa)
BENZISOXAZOL Risperidone (Risperdal)
DIBENZOTHIAZEPINE Quetiapine (Seroquel)

27
ANTIDEPRESSANT SUBSTANCES
INHIBITORS OF MONOAMINE (norepinephrine, serotonin, dopamin) REUPTAKE
Non-selective: Tricyclic and Heterocyclic Serotonin (5-hydroxitryptamin)
Drugs Specific Reuptake Inhibitors -
SSRI
Imipramine (Imizine, Tofranil, Melipramin) Fluoxetine (Prozac, Prodep)
Amitriptyline (Elavil, Elivel, Triptizole, Saro- Sertraline (Zoloft)
tene) Paroxetine (Paxil)
Clomipramine (Anafranil) Citalopram (Cipramil)
Doxepin (Sinequan, Adapin) Fluvoxamine (Fevarin)
Nortriptylin (Pamelor, Aventyl)
Desipramine (Pertofran) No cardiotoxic or anticholinergic
Trimipramine (Surmontil, Herfonal) effects, no weight gain. If combined
Maprotilin (Ludiomil) with monoamine oxidase inhibitors
Cardiotoxic and anticholinergic effects: malignant serotonin syndrome is
tachicardia, dry mouth, constipation, possible
blurred vision, urinary retention, weight
gain.
MONOAMINE OXIDASE INHIBITORS
Non-selective (hydrazine) non-reversible: Selective reversible:
Isocarboxazid (Marplan) Monocyclic:
Phenelzine (Nardil) Befol
Tranylcypromine (Parnate) Moclobemide (Aurorix)
Nialamid (Nuredal) Tetracyclic:
No anticholinergic effects, severe ad- Pyrazidol
verse effects if combined with other Tetrindol
psychoactive drugs Rather safe but less effective
O T H E R
Mianserine (Lerivon) Tianeptine (Coaxil)
Mirtazapine (Remeron) Ademethionin (Heptral)
Milnazipran (Ixel) The high safety is the main distin-
guishing feature of new drugs

TRANQUILIZERS AND SEDATIVE (including benzodiazepines)

THERAPEUTIC INDICATIONS EXAMPLES
Sleep disorders:
— effect of long duration Nitrazepam, flurazepam, flunitrazepam
— effect of short duration Zopiclone, zolpidem, triazolam,
estazolam, midazolam
Anxiety and excitement:
— effect of long duration Chlordiazepoxide, phenazepam, bromazepam
— effect of short duration Lorazepam, oxazepam
Anxiety and loss of energy:
— effect of long duration Diazepam, medazepam
— effect of short duration Alprazolam
Atypical epileptic seizures: Clonazepam, clorazepate, clobabazam
(all these drugs of long lasting effect)

28
ADDITIONAL SHORT-TERM EFFECT OF ANTIDEPRESSANTS
SEDATIVE HARMONIZING STIMULATING
Amitriptyline Maprotilin Imipramine
Mianserine Tianeptine Fluoxetine
Fluvoxamine Paroxetine Monoamine oxidase
Trimipramine Sertraline inhibitors

ADVERSE EFFECTS OF PSYCHOACTIVE DRUGS

Neuroleptics: Induce the symptoms of parkinsonism (muscle stiffness, stooped
posture, tremor), attacks of acute dystonia (muscular spasm involving the
neck, the jaw, the tongue or entire body), akathisia (subjective feeling of
muscular discomfort, restlessness which is difficult distinguish from the
psychosis), tardive dyskinesia (choreoathetoid movements of head, limbs,
trunk, chewing, lip puckering, facial grimacing). Somatic adverse effects:
dryness of the mouth or hypersalivation, postural hypotension, tachycardia,
gain of weight, sexual disorders due to high prolactin level. Neuroleptic
malignant syndrome is a rare life-threatening state (fever, sweating, tachi-
cardia, increased level of creatinin phosphokinase and myoglobinuria).
Treatment of parkinsonism, akathisia and acute dystonia: anticholinergics
(biperiden — akineton, trihexiphenidil — parkopan), antihistaminergics
(diphenhydramin — dimedrol), benzodiazepines or barbiturates. No effec-
tive methods of treatment of tardive dyskinesia exist. Treatment of neuro-
leptic malignant syndrome — symptomatic (immediate disconuation of an-
tipsychotic drugs, cooling, monitoring of vital signs, correction of renal
output), bromocriptine or amantadine can be added.

Tricyclic antidepressants: anticholinergic effects, e.g. retention of urine, tachy-

cardia, heart failure, postural hypotension, constipation, difficulty with
visual accommodation, mydriasis, danger of glaucoma attack.

Tranquilizers: drowsiness, muscular relaxation, danger of breathing stoppage

(especially in case of myasthenia!), slow reactions (transport driving is re-
stricted), dependence.

Lithium carbonate: tremor, taste of metal, nausea, vomiting, hypofunction of

thyroid gland, thirst and polyuria. Control of serum level should be regular
(therapeutic level is within 0,6 — 0,9 mmol/l, never more than 1,2 mmol/l)

Stimulants: anxiety, sleep disorders, loss of appetite, dependence.

29
CLASSIFICATIONS OF MENTAL DISORDERS
Nosological Classification
нозологическая (теоретическая) классификация
Based on knowledge of:
1. Aetiology, cause of the disorder: endogenous, exogenous (and somatog-
enous), psychogenous
2. Deterioration of structure: organic or functional
3. Type of course and prognosis:
PROCESS by К.Jaspers (disease) (болезнь, процесс):
different types of course (acute, chronic with progression or regres-
sion, recurrent, undulating)
STABLE DEFECT (дефект): no course
PATHOLOGICAL DEVELOPMENT by K.Jaspers (патологическое развитие):
no course after the development is finished
4. Signs, symptoms and syndromes: neurosis and psychosis
5. Outcome: recovery, death, personality changes or other stable defect.
Official Classifications
Basic concepts:
 Definition of mental disorder (but not only social deviance)
 Descriptive and nontheoretic approach
 Reliable and valid categories and criteria
ICD-10 see appendix 3 (МКБ-10)
F0 — Organic, including symptomatic, F5 — Physiological dysfunction, associated
mental disorders with mental and behavioural factors
F1 — Mental and behaviour disorders due F6 — Abnormalities of adult personality and
to psycho-active substance use behaviour
F2 — Schizophrenia, schizotypal states, and F7 — Mental retardation
delusional disorders F8 — Development disorders
F3 — Mood (affective) disorders F9 — Behavioural and emotional disorders
F4 — Neurotic, stress-related, and somato- with onset usually occurring in childhood or
form disorders adolescence
DSM IV see appendix 3
(criteria of inclusion and exclusion, multiaxial diagnosis, special glossaries)
Clinical Disorders General Medical
Axis III
Other Conditions That Conditions
Axis I
May Be a Focus of Psychosocial and
Clinical Attention Environmental
Axis IV
Personality Disorders Problems
Mental Retardation
Axis II
Global Assessment
Axis V
of Functioning

30
 Aetiologic Classification
CAUSES
Internal External
Heredity and physiologic Vascular, de- Trauma, Emotional stress and in-
constitution ficiency, intoxication, tapsychic conflict
tumours, infection,
somatic dis- radiation
eases
ENDOGENOUS EXOGENOUS PSYCHOGENOUS
(and somatogenous)
o Schizophrenia o Extracranial and intracra- o Acute stress in-
o Bipolar psychosis nial tumours duced psychoses
o Epilepsy o GPI (syphilitic psychosis) o Neuroses
o Alzheimer’s disease o Symptomatic psychoses o PTSD (post-
o Pick’s disease o Traumatic, toxic and in- traumatic stress
fectious psychoses disorder)
Diagnostical traits of endogenous diseases:
spontaneous onset, autochtonous course in accord- Acute e.g. alcohol delirium,
acute stress reactions.
ance with internal biological rhythms, pathologic he-
redity, specific traits of patient’s constitution before
the beginning of the disease.

Types of Course see appendix 2

Chronic progressive Chronic regressive

e.g. schizophrenia, epilepsy, Alzheimer’s e.g. trauma, consequences of
disease, tumours, alcoholism. intoxication, Korsakov’s disease.

Chronic recurrent (periodic) Chronic undulating (waving)

e.g. bipolar psychosis. e.g. cerebral arteriosclerosis.

31
BIPOLAR PSYCHOSIS AND OTHER AFFECTIVE DISORDERS F3
Nosological definition
1. Aetiology: Endogenous
2. Structure deterioration: no, functional disorder
3. Course: chronic without progression, cyclic (phasic). Outcome: chronic
course without stable defect of personality or intelligence
4. Symptoms and syndromes: Depression (subdepression) or mania (hypoma-
nia)
Productive symptoms Negative symptoms
Disorders of sensation depersonalisation not typical
and perception derealisation
Thought disorders mood congruent delusions, not typical
overvalued ideas, obses-
sions
Affective disorders hyper- or hypothymia, not typical
mania or depression
Disorders hyper- or hypobulia, in- not typical
of will and behaviour creased sexuality etc.
Memory disorders not typical
Disorders of cognition not typical
Disorders depressive stupor, manic not typical
of motor behaviour excitement etc.
Disorders not typical
of consciousness

Types of course
BIPOLAR This disorder is characterised by repeated (i.e. at least two)
AFFECTIVE episodes in which patient’s mood and activity levels are sig-
DISORDER nificantly disturbed, this disturbance consisting on some oc-
F31 casion of an elevation of mood and increased energy and ac-
биполярный tivity (MANIA or hypomania), and on others of lowering of
психоз mood and decreased energy and activity (DEPRESSION). Char-
acteristically, recovery is usually complete between episodes
(INTERMISSION).
Manic episodes usually begin abruptly and last for between 2
weeks and 4-5 months (median duration 4 months). Depres-
sions tend to last longer (median length about 6 months),
though rarely for more then a year, except in the elderly. Epi-

32
 sodes of both kinds often follow stressful life events or other
mental trauma, but the presence of such stress is not essential
for the diagnosis. The first episode may occur at any age
from childhood to old age.
TYPE CONTINUA appears with cyclic prominent changing in
mood without any periods of intermission.
RECCURENT The disorder is characterised by repeated episodes of depres-
DEPRESSIVE sion without any history of independent episodes of mood el-
DISORDER evation and overactivity, which can be verified as mania.
F33
Recovery is usually complete between episodes, but a minority of
монополярная patients may develop a persistent depression, mainly in old
депрессия age. The risk that a patient with reccurent depressive disorder
will have an episode an episode of mania never disappears
completely, however many depressive episodes there were
be. If a manic episode occurs, the diagnosis should change to
bipolar affective disorder.

PERSISTENT AFFECTIVE DISORDERS F34

CYCLOTHYMIA A persistent instability of mood, involving numerous periods

F34.0 of mild depression and mild elevation. This instability usual-
циклотимия ly develops early in adult life and pursues a chronic course,
although at times the mood may normal and stable for
months at time. The mood swings are usually perceived by
the individuals as being unrelated to life events.

DYSTHYMIA A chronic disorder characterised by the presence of a de-

F34.1 pressed (or irritable in children and adolescents) mood that
дистимия lasts most of the day and is present on most days. Earlier
most patients now classified as having dysthymic disorder
were classified as having depressive neuroses (also called
neurotic depression), although some patients - cyclothymic
personality.

33
SCHIZOPHRENIA F20
(dementia praecox)
Nosological definition
(by Emil Kraepelin and Eugen Bleuler)
1. Aetiology: Endogenous
2. Structure deterioration: no, functional disorder
3. Course: chronic progressive. Outcome: stable defect of personality
[with autism, formal disorders of thought and impoverishment of will and emotions, up
to apathy, abulia and schizophrenic dementia (if malignant cases)]. see appendix 1
4. Symptoms and syndromes:
Productive symptoms Negative symptoms
Disorders of sensation cenesthopathy, pseudohal- subjective feeling of self-
and perception lucinations, depersonalisa- changing (depersonalisa-
tion, derealisation tion)
Thought disorders alienation of thoughts, autism, ambivalence, rea-
mentism, thought block- soning, schizophasia, ob-
ing, persecutory scurity of expression, pa-
delusions (delusion of ralogia, symbolism, phil-
control), overvalued ideas, osophical intoxication, pon-
obsessions tifical woolliness (up to
incoherence) etc.
Affective disorders anxiety, perplexity (acute ambivalence, decreased
delusion), mania or de- affect (monotonous, flat-
pression may be, but not tering and incongruity of
specific affect), apathy
Disorders ambivalence, loss of will
of will and behaviour and energy, abulia, pa-
rabulias, unexpected sex-
ual behaviour, laziness,
passivity
Memory disorders not typical
Disorders of cognition not typical
Disorders catatonia (stupor, excitement, non-adaptive movements
of motor behaviour echo-symptoms) (mannerism)
Disorders dual orientation, oneiroid not typical
of consciousness

34
 The four A’s
(primary symptoms of schizophrenia described by E.Bleuler):
1. Associational disturbances (thought disorder)
2. Affective disturbances (flattering of affect)
3. Autism
4. Ambivalence
First-rank symptoms
(K.Schneider, 1925)
These symptoms coincide with the features of mental automa-
tism syndrome (В.Х.Кандинский, 1880; G. de Clerambault,
1920). They are not absolutely specific, diagnosis of schizophre-
nia should be made in certain patients who failed to show first-
rank symptoms.

a) Audible thoughts
b) Voices arguing or discussing or both
c) Voices commenting
d) Somatic passivity experience
e) Thought withdrawal and other experience of influenced thought
f) Thought broadcasting
g) Delusional perceptions
h) All other experiences involving volition, made affects,
and made impulses

ICD-10
According to ICD-10 the diagnosis of schizophrenia cannot be established
without 1-month duration criterion. Conditions clinically equal to schizophrenia
but of duration less than 1 month (whether treated or not) should be diagnosed
in the first instance as acute schizophrenia-like psychotic disorder [F23.2] and
reclassified as schizophrenia if symptoms persist for longer periods.
It’s specially marked that 1-moth duration criterion applies only to the specific
symptoms (like listed above) and not to any prodromal nonpsychotic phase.
Also mentioned that diagnosis of schizophrenia should not be made in the pres-
ence of extensive depressive or manic symptoms unless it is clear that schizo-
phrenic symptoms antedated the affective disturbance.
35
SCHIZOPHRENIA (continuation)
Syndromal forms
PARANOID This is characterised by the development of delusions (of persecu-
SCHIZOPHRENIA tion, of distant influence, of grandeur, sometimes hypochondriacal).
F20.0 It usually has a later age of onset and patients have a better preser-
vation of personality than in other forms of schizophrenia. The de-
lusions may be variable, transient and poorly held in some patients
whereas in others delusions are systematised, highly complex and
relatively fixed. It is usually characterized with the syndrome of
mental automatism.
It was customary in the past to regard Paraphrenia and Paranoia,
which are really subtypes of paranoid schizophrenia, as distinct dis-
eases.
Paraphrenia is characterised by a late age of onset with the exist-
ence of semi-systematised delusions occurring with hallucinations,
thought disorder becoming more apparent when the patient talks
about his delusions or when he get emotionally disturbed.
Paranoia was the term given to patients showing fixed delusional
system without evidence of thought disorder and without hallucina-
tions and good preservation of personality.
HEBEPHRENIA This has an insidious onset in early life and is characterised by
(DISORGANISED thought disorder and emotional abnormalities.
TYPE) Characteristically the affect is inappropriate and fatuous, with
F20.1 meaningless giggles and often a self-satisfied smile. Thought disor-
der and delusions, which are often changeable, are common. Hallu-
cinations occur, particularly auditory hallucinations. Behaviour is
often silly, mischievous, eccentric, showing much grimacing and
mannerism, or the patient may be inert and apathetic.
CATATONIC Clinical picture is dominated by disturbance of behaviour and motor
SCHIZOPHRENIA phenomena (catatonic syndrome).
F20.2 The onset is in adolescence or early adult life, but occasionally in the
fourth decade or later. The course of the illness often shows extreme
alterations in behaviour, varying from stupor to excitement.
Catatonic schizophrenia provides the best examples of disconnec-
tion in conduct, ranging from mannerism, constrained attitudes, au-
tomatic responses to stimuli including automatic obedience, echola-
lia, echopraxia; spontaneous purposeless over-activity, the mainte-
nance of imposed postures, negativism. Hallucinations, delusions,
thought disorder and emotional disorder are also present but less
prominent than motor phenomena.
SIMPLE This characterised by an insidious onset, with a gradual deteriora-
SCHIZOPHRENIA tion socially and very often a difficulty in establishing the exact
F20.6 time of onset because of its insidious development.
Clinically, it takes the form mainly of withdrawal of interest from
the environment, apathy, difficulty in making social contacts, pov-
erty of ideation, a decline in total performance with marked sensi-
tivity and ideas of reference.
Simple schizophrenics go downhill socially and many become
tramps, beggars, thieves or dupes for criminals.

36
ATYPICAL (SPECIAL) FORMS:
Schizo-affective (cycloid)
psychosis — F25
(циркулярная форма)
Pseudoneurotic schizophrenia
(e.g. cenesthopathic schizophrenia) — with stress and appears with subpsychotic symp-
(неврозоподобная и
психопатоподобная формы)
Acute psychosis with bright affect (mania, de-
pression, fear) and specific symptoms of schiz-
ophrenia (nonsystematized delusion, oneiroid
states, pseudohallutinations etc.)
F21 — mild disorder which has no connection
toms (obsession, phobia, depersonalization,
overvalued ideas) and sluggish progression of
schizophrenic negative symptoms.
F20.8 — endogenous form of hypochondria
with strange inner sensations (cenesthopathia).

Types of course
F20.*0 Continuous progression — непрерывно-прогредиентное течение
F20.*1 Progression with acute attacks [german Schub] —
(приступообразно-прогредиентное (шубообразное) течение
F20.*3 Periodic (recurrent) — периодическое (рекуррентное) течение
F21 Special type with slow (sluggish) progression — In ICD-10 Schizo-
typal disorder (eccentric, bizarre behavior — german Verschroben)
— малопрогредиентная (вялотекущая) шизофрения.

continuous progression progression with acute attacks

P+ P+

N- N-
— —
periodic (recurrent)
slow (sluggish) progression with slow progression

P+ P+

N- N-
— —
37
ORGANIC MENTAL DISORDERS F00 - F09
(органические заболевания)

SPECIFIC SYMPTOMS (Walter-Buel H. triad):

1. Difficulties in retention (up to amnesia – F04)
2. Difficulties in understanding (up to dementia – F00-F03)
3. Difficulties in keeping feelings in (e.g. disphoria or
emotional incontinence)

ADDITIONAL SYMPTOMS:
4. Changes in personality and general behaviour [F07] see appendix 1
5. Neurological signs and symptoms
6. Asthenia (emotional hyperaesthetic syndrome)
7. Somatic symptoms (headache etc.)
8. Weather sensitivity.

METHODS OF DIAGNOSTIC:
 EEG  Rheoencepalography
 CT (Computer Tomography) or MRI  Doppler ultrasound
(Magnetic Resonance Imaging)  Cerebro-spinal fluid (CSF) tests
 Ophthalmologist examination  Neuropsychological tests
 Neurologist examination

PSYCHO-ORGANIC SYNDROME
A heterogeneous group of states usually observed in individual stages of the
course of various organic diseases. In the first stages of development increasing
manifestations of mental weakness and increased fatigability are usually
discovered. Later these are joined by disorders of attention, memory and
intellectual activity, psychopathic like disturbances, and various emotional
disorders. Delirium [F05], true hallucinations and delusional disturbances [F06]
may be observed. Delusional disturbances are fleeting and fragmentary, with no
tendency towards systematization, and they vary in content. Affective disorders
fluctuate from an uplifted mood with euphoria to depression and increased
irritability, peevishness, sometimes with an overlay of dysphoria and
maliciousness.
38
DEGENERATIVE Alzheimer’s disease [F00, G30] – degenerative disease
CEREBRAL with insidious onset at age 55—65 or later (occur in
DISEASES women 3-5 times more often than in men) with promi-
nence of features of parietal and temporal lobe damage
(loss of memory, apraxia, acalculia, dysgraphia, dysar-
tria). It develops slowly but steadily. Formal complaints
coexist with poor insight (total dementia).
Pick’s disease [F02, G31] – a progressive dementia
with onset at age 50-60 with features of selective atro-
phy of frontal and temporal lobe (apathy, euphoria, se-
vere character changes, verbal and motor stereotypy).
The course is rather malignant; no sense of illness exists
(total dementia).
CEREBRAL System disease with slow progression and evident wav-
ARTERIO- ing course. Cerebral symptoms coexist with features of
SCLEROSIS ischaemia of heart or extremities. The first symptoms
are asthenia and hypomnesia. Dementia appears later,
insight is rather good (partial dementia – F01)
TUMOURS Neurological symptoms are common in onset (paraly-
sis, disorders of co-ordination of movement, disorders
of vision, epileptic seizures etc.). If the frontal lobes are
impaired, the changes of character, apathy and poor in-
sight are typical. The symptoms of cranial hypertension
are common (headache with retching increasing by the
morning, clouding of consciousness).
TRAUMA Acute or chronic regressive course. Stages are: loss of
consciousness (up to coma), acute period (sometimes
with acute psychosis, for example delirium), convales-
cence (through the stage of asthenia), consequences
(cerbrasthenia, Korsakov’s syndrome, dementia, epilep-
tic seizures, personality disorder).
INFECTIONS GPI (general paralysis of insane – F02.8, A52.1) – syphi-
litic psychosis which appears in some patients in 10-15
years after infection. The symptoms of encephalitis are
the loss of insight, euphoria, dementia, severe personal-
ity changes, delusions of grandeur. Neurological signs:
Argyll-Robertson symptom, asymmetry of tendon re-
flexes. Wassermann test is positive in 95% of patients.
Treatment: antibiotics, iodotherapy, bismuth drugs.
AIDS dementia [F02.4, B22.0] – up to total is common
in terminal phase. Treatment is symptomatical.

39
EPILEPSY G40
Эпилепсия
Nosological definition:

1. Aetiology: Endogenous
2. Structure deterioration: organic
3. Course: chronic progressive.
Outcome: Epileptic dementia (if malignant cases). see appendix 1
4. Symptoms and syndromes:
Productive symptoms: rather different but ever paroximal.
Negative symptoms: stable defect of personality with egocentrism
(selfishness), circumstantiality (stiffness), emo-
tional rigidity and explosivity.

PAROXYSMAL DISORDERS (эпилептические пароксизмы):

With deterioration of consciousness Without deterioration
c выключением сознания of consciousness
без выключения сознания
Grand mal – Dysphoria – дисфория
большой судорожный припадок Paroxysmal derealisation
Petit mal – (déja vu, jamais vu) – приступы
малый припадок (абсанс) дереализации (уже виденное,
Twilight states – никогда не виденное)
сумеречное помрачение Paroxysmal hallucinations and
сознания delusions – приступы
галлюцинаций и бреда
INTERNATIONAL CLASSIFICATION OF SEIZURES:
Primary generalised seizures Partial (focal) seizures
Abrupt loss of consciousness (up to No loss of consciousness or partial
coma) without any prodrome changed consciousness
symptoms (no aura) Partial or no amnesia
Total amnesia Focal changes in EEG
Simultaneous changes in all areas in Examples: abrupt attacks of hallucina-
EEG tion, delusion, disorders
Examples: petit mal (absence, myo- of drives
clonic seizures), grand mal with- Secondary generalised seizures
out aura (tonic, clonic, tonic- Loss of consciousness after a stage of
clonic, atonic) prodrome symptoms (aura)
Examples: grand mal with aura
40
DIFFERENTIAL DIAGNOSIS
should be done against the tumours, alcoholic or sedative drug withdrawal syn-
drome, child fever convulsions, hysterical conversion.
GRAND MAL HYSTERICAL CONVULSIONS
(pseudoseizures)
Abrupt spontaneous onset with sharp fall Induced by emotional stress. Careful fall-
often with self-injury. Nocturnal seizures ing without self-injury.
are common.
The face is pale at the beginning and then Flushing or no changes in face colour.
cyanotic
No deep reflexes, no reaction in case of Deep reflexes are vivacious, affection by
suggestion suggestion
Stereotypical tonic and clonic convulsionsNon-stereotyped asynchronous body
movements
Convulsive meaningless facial expression Facial expression of suffering, fear or de-
light
Duration — 30 s up to 2 min Long duration (several min up to an hour)
Spikes, pathologic waves and postictal No specific EEG changes
slowing on EEG
Abrupt spontaneous recovery through the Sometimes partial amnesia, good effect of
stage of somnolence, postictal confusion. psychotherapy
Total amnesia

TREATMENT OF EPILEPSIA
Should be continuous without any kind of stop or fast dose changes because of
the danger of status epilepticus. Cautious dose titration (‘low and slow’). The
aim of treatment – best adaptation (control over the seizures without prominent
adverse affects). The drugs with universal action are preferable.
All kinds of seizures: valproates, carbamazepine, lamotrigin, topiramate
Petit mal: valproates, ethosuximide, clobazam, clorazepate, clonazepam
Grand mal: phenobarbital, phenytoin, vigabatrin, gabapentin, topiramate
Partial (focal) seizures: carbamazepine

STATUS EPILEPTICUS — repeated seizures against a background of coma.

Cause: abrupt withdrawal of anticonvulsants, cerebral tumours, eclampsia.
Outcome: Death because of the respiratory deficiency induced by cerebral oe-
dema.
Treatment:
1. anticonvulsants — diazepam intravenously; chloral hydrate, valproates or
barbiturates per rectum.
2. For treatment of oedema — diuretics, corticosteroid hormones (predniso-
lone, cortisol), heamodynamics correction, anticoagulants (heparin).

41
PSYCHOGENOUS REACTIONS AND NEUROSES
психогенные заболевания
Триада К.Ясперса — Diagnostic triada (Jaspers K., 1913):
 Close temporary relation between the stressor and the development of the
disease
 Symptoms show the reflection of the nature of the traumatic experience
 Generally benign course of the disease with the complete recovery after the
psychological problem is solved

CLASSIFICATION:
russian terminology ICD-10 categories
ACUTE STRESS INDUCED PSYCHOSES (реактивные психозы)

Аффективно-шоковые реакции F43.0 – Acute stress reaction

F44.80 – Ganser’s syndrome, or

Истерические психозы F44.1-F44.3 – Dissociative fugue, stupor,
trance
Реактивная депрессия F32 – Depressive episode
Посттравматическое стрессовое
расстройство (ПТСР) F43.1 – Post-traumatic stress disorder

F23.31 – Other acute predominantly delu-

Реактивный параноид sional psychotic disorders (including para-
noid reaction)

NEUROSES (неврозы)
F48.0 – Neurasthenia
Неврастения
F40 – Phobic anxiety disorders,
F41 – Other anxiety disorders
(including panic disorder),
Невроз навязчивых состояний
F42 – Obsessive-compulsive disorder,
F45.2 – Hypochondriacal disorder
(including nosophobia)
F44 – Dissociative [conversion] disorders,
Истерический невроз
F45 – Somatoform disorders
F45.2 – Hypochondriacal disorder
Ипохондрический невроз
(nondelusional)
F34.1 – Dysthymia,
Депрессивный невроз F43.2 – Adjustment disorders,
F43.1 – Post-traumatic stress disorder

42
Acute Stress Induced Psychoses
реактивные психозы

Nosological definition:
1. Aetiology: psychogenous, the result of acute irresistible stressors concerning
the primary personal needs (safety, health, honour, freedom and so on)
2. Structure deterioration: functional
3. Course: acute (no longer than several months). Outcome: full recovery.
4. Symptoms and syndromes:
Productive symptoms: rather prominent (psychotic level), often with
dangerous (or suicidal) behaviour, sometimes with ob-
scured consciousness.
Negative symptoms: no.

Clinical forms:
Acute stress reaction – a short period of excitement or stupor, associated with
disorder of consciousness and amnesia in case of real threat of death.
Hysterical psychoses — psychotic symptoms (regression to childish or animal
behaviour, imaginary ‘dementia’, twilight states, hallucinations), pro-
duced unconsciously by autosuggestion in case of acute irresistible stress.
Variants: Ganser’s syndrome, pseudodementia, dissociative fugue, puer-
ility.
Reactive depression — depression as a result of irresistible loss (the death of a
relative, divorce, fired from work, loss of money, being a victim of crime
and so on). Suicidal behaviour is possible.
Reactive paranoid — delusional ideas of persecution provoked by the situation
of uncertain threat (unusual vague situation, incomprehensible language,
war threat, fast changed events and so on).
Post-traumatic stress disorder (PTSD) – a mixture of anxiety symptoms (pan-
ic, intrusive thoughts, memories or images of event, sleep disorders) that
occur in a person who has experienced a severe psychological trauma and
last longer than a month.
Treatment:
In case of anxiety and panic — tranquilizers (one injection or short course).
In case of hysterical (dissociative) disorders and psychogenous stupor — sug-
gestive psychotherapy, tranquilizers (once or short course), placebo.
In case of depression or PTSD — group and supportive psychotherapy, antide-
pressants, short course of sedatives for correction of sleep disorders
In case of delusional states — neuroleptics and supportive psychotherapy
43
PSYCHOGENOUS REACTIONS AND NEUROSES (continuation)
Neuroses (неврозы)
Neuroses — a spectrum of illnesses appeared with mild mental or somatic
symptoms, which production is unconscious and originated from unconscious
motives and conflicts.
Nosological definition:
1. Aetiology: psychogenous, the result of internal conflicts
2. Structure deterioration: functional
3. Course: prolonged without progression. Outcome: recovery or stabiliza-
tion with pathologic development of personality (pathologic personality).
4. Symptoms and syndromes:
Productive symptoms: rather different but ever mild (neurotic level).
Negative symptoms: no.

SOME THEORETICAL APPROACHES

in investigations of the origin of neuroses
Interpersonal conflicts — the result of irreconcilable contradictions between
the interests or motives of two or several individuals.
Intrapersonal (internal) conflicts — the result of irreconcilable contradictions
between two or several motives of one person.
Individuals, which provoke interpersonal conflicts, make other people to
suffer a lot and tend to be diagnosed as psychopaths. Individuals, who pro-
voke intrapersonal conflicts, make themselves to suffer a lot and tend to be
diagnosed as neurotics.

According to I.P.Pavlov
the kind of neurosis depends upon the type of personality.
‘intellectual’ type with predominance of the second set of conditioned stimuli
(language, logic, operating with symbols) over the first is common for
patients with obsessive-phobic neurosis
‘artistic’ type with predominance of the first set of conditioned stimuli (emo-
tions, sensations and intuition) over the second is common for patients
with hysteric neurosis

According to S.Freud
the symptoms of neuroses represent unconscious psychological defence against
the irresistible internal conflicts (often sexual problems). Unconscious motives
are the cause of the poor insight and resistance against the treatment.

44
CLINICAL FORMS

Neurasthenia appears with the symptoms of asthenia (fatiguability in combina-

tion with irritability) that are linked to meaningful psychological stressors.
Symptoms:
Psychological: tiredness, poor memory, sleep disorders, lack of restraint,
psychological sensibility (appeared with tears or verbal vio-
lence).
Somatic: functional pain (headache, stomachache, backache), arterial hy-
po- or hypertension, palpitation, sweating, linked to psycholog-
ical troubles or physical difficulties.

Hysteria (dissociative [conversion] disorders, somatoform disorders, somatiza-

tion disorder) is characterized by physical or psychological symptoms for which
no physical cause can be identified but which are linked to meaningful psycho-
logical stressors. The symptoms may help patients unconsciously deal with in-
ternal conflicts. More common in women and patients with demonstrative (his-
trionic) features of personality.
It is strongly recommended to make special investigation to exclude any oth-
er cause of the somatic symptoms because about 30% of patients with prelim-
inary diagnose of hysteria are later diagnosed with organic disorders (cancer,
multiple sclerosis, Wilson’s disease, duodenal ulcers and so on).
Symptoms:
Neurological: loss or change in sensory or motor function, blindness, gait
or coordination disturbances, seizures and so on.
Somatic: functional pain (headache, stomachache, painful extremities),
lump in throat (difficulty swallowing), vomiting, palpitation,
shortness of breath, dysmenorrhea, burning in sex organ and so
on.
Psychological: amnesia, false visions, unstable fears, bright emotional re-
actions (crying, laughting), substance abuse.

Obsessive-phobic neurosis (phobic disorder, obsessive-compulsive disorder,

anxiety disoder) — a spectrum of illnesses appeared with the symptoms of anx-
iety, unreasonable fears, obsessions and rituals, associated with internal con-
flicts.
Symptoms:
Psychological: phobias, obsessions, compulsive acts, panic attacks (sud-
den, unexpected episode of intense fear), obsessive hypochon-
driac ideas, diffidence, low self-appraisal and so on.
Somatic: all the kind of somatic sensations, which make the patients to pay
especial attention, often the episodes of palpitation, sweating,
shaking, chest pain or discomfort, dizziness, chills or hot flash-
es and so on.
45
PSYCHOTHERAPY психотерапия
PSYCHOTHERAPY is a method of working with patients to assist them to modify,
change or reduce factors/disorders that interfere with effective living. These factors
may localize in individual psychic functioning and patterns of functioning as well as in
interpersonal systems. Psychotherapy relates on the whole to interventions directed to
patterns of functioning and interpersonal systems. As to interventions directed to indi-
vidual psychic functions they are called training of functions (for instance training of
memory). Both of these concepts contain an aspect of psychotherapy.
All psychotherapeutic methods have:
General time organization (fazes):
1) definition of indications (diagnosis, choosing of psychotherapeutic method, infor-
mation, and informed consent);
2) creation of therapeutic alliance and explanation of problem and therapeutic goals;
3) therapeutic learning;
4) assessment before and after the end of psychotherapy.
General mechanisms (refers to those processes that make psychotherapy work):
 Mastery/coping – refers to patient’s ability to acquire skills and habits to cope that
are absent on disease;
 Clarification on meaning – for instance help to patient to aware that anxiety may
have a source in estimation some situation as threatening;
 Actualizing of problem – activating of emotional patterns that are connected with a
problem to create best conditions for learning;
 Activation of resources - mobilization of patient’s forces for changers take place
and become stable.
General processes (undisguised and hidden kinds of activity of individual that be-
comes involved to change his problem/unhealthy behavior):
 Self-exploration/consciousness raising – receiving new information about self and
problems: superintendence, confrontation, interpretation; bibliotherapy;
 Self-reevaluation – statement how individual experiences and thinks about himself
in respect to some problem: clarification of meaning, work of notions, correcting
emotional experience;
 Self-liberation – making a decision to change behavior, enforcement of confidence
in ability for changing: decision-making therapy, logo therapy, motivating therapy;
 Counter-conditioning – substitution of problem behavior by adaptive one: relaxa-
tion, desensibilization, self-confidence training, positive self-instructions;
 Stimulus control – avoidance or fight with stimuli that provoked problem behavior,
avoidance of dangerous situations of risk;
 Reinforcement management – self-reinforcement or reinforcement by others health
behavior: contract about strict frame of behavior, undisguised and hidden rein-
forcement, self-reward;
 Helping relationships – trust people able to help: therapeutic alliance, social sup-
port, self-help groups;
 Dramatic relief – skill to revile and to express senses with reference to problems
and their solution: psychodrama, role playing;

46
 Reevaluation of others – awareness about other’s being influenced by their own
problems, empathy training;
 Social liberation – acquisition or consolidating constructive social behavior: com-
ing out in defense of oppressed people, active position in life.
General psychological tools of therapeutic learning:
 Forming of stereotypes by training – it means those tools that enforce affective,
cognitive, motor and other disposals by repetition of behavior, including mental
training (behavior is repeated accordingly notion);
 Confrontation with situation that provokes anxiety for reduction of affective reactions;
 Positive or negative, verbal or inverbal feedback from psychotherapist (motivate
feedback);
 Psychotherapist as a model of adequate human relations and interactions;
 Cognitive tools – exploration, persuasion, informative feedback are directed to in-
fluencing on cognitive representations and expectations;
 Psychophysiology oriented methods – involvement of soma into psychotherapy
(body oriented psychotherapy, biofeedback).
General factors of psychotherapeutic influence:
1) changing of self-feeling;
2) changing of symptoms;
3) changing of personality’s structure.
The first two factors precede the third one.
General variables of psychotherapist:
o Age, gender, ethnicity comparable with patient’s ones may have positive influence;
o Ability to establish warm, respectable and no anxiety evoking relations with pa-
tient (three Roger’s variables – warmth, empathy and authenticity);
o Personal features – self-confidence, self-accept, calm, frustration tolerance, gen-
eral and meaning establishment;
o Variable of experience – more experienced psychotherapists achieve better results
with difficult patients.
General variables of patient:
 Attractiveness – it is easier to establish positive relations with YAVIS-patients
(young, attractive, verbal talented, intelligent, successful);
 Therapeutic expectations, including expectation of success and trust to psychother-
apist;
 Measure of defense that correlate with readiness to start psychotherapy and varia-
ble of self-exploration;
 Features of personality – age, gender, strength of Ego, level of intelligence;
 Gravity and kind of disorder.
General features of relations between psychotherapist and patient:
 Reciprocal affirmation;
 Correspondence of features to each other in sense of personal resemblance and
supplement to each other;
 Formal signs of interactions: rhythm of interchange of remarks, reciprocal social re-
inforcement and punishment.
47
EXOGENOUS (SYMPTOMATIC) MENTAL DISORDERS
Реакции экзогенного типа (Bonhoeffer K., 1908, 1910) — Bonhoeffer’s
forms of exogenous reactions (acute brain syndromes): on the whole the type
of mental disorder produced by coarse brain damage depends on the site, extent,
and tempo of the morbid process rather than on the specific nature of the brain
disease.
Typical are the syndromes mentioned below:
1) Asthenia
2) Disorders of consciousness: clouding of consciousness, coma, delirium,
twilight states, amentia
3) Hallucinosis: acute psychosis with abundant true hallucinations without
disorder of consciousness
4) Paroxysmal states: epileptic seizures
Later:
5) Korsakov’s syndrome
6) Dementia

DISORDERS DUE TO PSYCHOACTIVE SUBSTANCE USE F1

(aлкоголизм, наркомании и токсикомании)
Критерии диагностики — Diagnostic criteria:
1. Зависимость — Dependence:
Психическая — Persistent desire and unsuccessful efforts to cut down or
control substance use, a great deal of time is spent in activity necessary to
obtain the substance
Физическая (Абстинентный синдром) — Physiological dependence
(Withdrawal syndrome)
2. Изменение толерантности — Tolerance
3. Социальная дезадаптация — Important social, occupational or recreational
activities are given up or reduced because of substance use
4. Продолжение употребления психоактивного вещества (ПАВ) несмотря
на наличие явных тяжелых последствий для физического и психического
здоровья — the substance use is continued despite knowledge of having a per-
sistent or recurrent physical or psychological problem caused or exacerbated by
the substance.

54
 SPECIAL TYPES OF DRUG ABUSE
Group Drugs Duration Symptoms of in- Withdrawal
of effect toxication syndrome
Opiates Opium, mor- 3 - 6 h, Drowsiness, motor Dysphoric mood,
phine, heroin, metha- retardation, altered nausea, muscle
methadone done — mood, pupillary aches, rhinorrhea,
(F11) 12-24 h constriction, brad- pupillary dilata-
ycardia and brad- tion, insomnia,
ypnoea diarrhea
Stimulants Cocaine 2-4h Motor agitation, Depression, fa-
(F14), pupillary dilata- tigue, sleep disor-
ampheta- tion, elevated der, vivid un-
mines (F15) blood pressure, pleasant dreams,
nausea, chest pain, increased appetite
weight loss
Psychoto- Cannabis sa- up to Aroused drives, Insomnia, anxie-
mimetica tiva (marihu- 8-12 h dry mouse, con- ty, perspiration,
ana, hashish) junctival injection, loss of appetite
(F12) tachycardia, in-
creased appetite
LSD, DMT, up to Not ever euphoria, Not marked
ibogaine days illusions, halluci-
(F16) nations, derealisa-
tion, pupillary dila-
tation, tremors
Sedative Barbiturates, 4-6 h, up to Motor retardation, Tremor, insomnia,
benzodiaze- 12-20 h nystagmus, incoor- nausea, anxiety, ag-
pines, mepro- (diazepam, dination, unsteady itation, tachycardia,
bamate, chloral pheno- gait, slurred speech, delirium, seizures
hydrate, potas- barbital) impairment in atten-
sium oxy- tion or memory
butirate etc.
(F13)
Lighter flu- Glue, ace- 1-3 h The same The same
ids tone, petrole-
um (F18)
Anticholin- Belladonna, up to Mydriasis, hot Not marked
ergic antiasthmatic days skin, dry mouth,
and antipar- urinary retention,
kinsonic confusion, excite-
drugs (F19) ment, delirium

55
DISORDERS DUE TO PSYCHOACTIVE SUBSTANCE USE (continuation)
ALCOHOL DEPENDENCE (ALCOHOLISM) F10
(алкоголизм)

Nosological definition
1. Aetiology: Chronic alcohol abuse
2. Structure deterioration: organic changes (except the early stages)
3. Course: chronic progressive. Outcome: toxic encephalopathy (up to de-
mentia) with special personality changes (alcohol degradation)
4. Symptoms and syndromes: Psychological and often physiological depend-
ence (abstinent syndrome), changes in tolerance, marked personality
changes (the loss of will, disregard of duties and norms of behaviour, mor-
al degradation)
Classification by E.M. Jellinek (1952)
(1) Alpha alcoholism. Excessive and inappropriate drinking without loss of con-
trol or ability to abstain.
(2) Beta alcoholism. Excessive and inappropriate drinking without clear psy-
chological or physical dependence but with physical complications such as cir-
rhosis, neuritis or gastritis.
(3) Gamma alcoholism, characterised by physical dependence, tolerance, and
inability to control drinking, with a progressive course.
(4) Delta alcoholism. This type occurs in wine-consuming countries and is
characterised by inability to abstain, tolerance, withdrawal symptoms, but the
quantity consumed can be controlled.
(5) Epsilon alcoholism. Intermittent or spree drinking. The prevalence of alco-
holism is difficult to assess reliably for a variety of reasons.
Российская Традиционная Классификация
(Стрельчук И.В., 1940; Портнов А.А., 1959, Иванец Н.Н., 1988).
Stage I — only psychological dependence, the loss of dose control, increase of
tolerance (up to loss of vomiting reflex), amnestic forms of intoxication (black-
outs, palimpsests)
Stage II — psychological and physiological dependence (abstinent syndrome,
alcohol withdrawal syndrome), alcohol psychoses, marked personality changes,
the loss of situation control, the highest tolerance (plateau of tolerance), drink-
ing of nonbeverage alcohol, repeated efforts to control drinking, periods of
binge and temporary abstinence caused by situation
Stage III — reduced tolerance (more frequent consuming of low doses of alco-
hol, periods of intolerance), irreversible changes in internal organs, peripheral
neuropathy, encephalopathy (up to dementia or Korsakov’s syndrome)

56
Alcohol Withdrawal Syndrome F10.3
(алкогольный абстинентный синдром)
Symptoms: desire for alcohol, affective instability (dysphoria, depression, anxi-
ety), neurologic symptoms (nystagmus, tremor — «morning shakes», ataxia),
malaise, sleep disorders, facial flushing, arterial hypertension, tachycardia
(heart-hurry), breath disorder (air shortage), sweating, nausea and retching, epi-
leptic seizures.
Treatment: fluids by mouse or i.v., diuretics, vitamins (C, B1), nootrops, benzo-
diazepines, magnesium sulfate i.v., clonidin, carbamazepine, sometimes neuro-
leptics (haloperidol, perphenazine, neuleptil, chlorprothixene).

Alcohol Psychoses
Delirium tremens – F10.4 (Белая горячка, алкогольный делирий) — acute
psychosis induced by severe alcohol withdrawal syndrome. Symptoms: illu-
sions, true hallucinations and excitement on the background of obscured con-
sciousness. Treatment: sedative (benzodiazepines, potassium oxybutirat or bar-
biturates; antipsychotics are not recommended but the use of haloperidol is pos-
sible in case of excitement), treatment of withdrawal syndrome (fluids, diuret-
ics, nootrops, vitamins, adequate nutrition etc.).
Alcohol hallucinosis – F10.5 (Алкогольный галлюциноз) — acute psychosis
induced by severe alcohol withdrawal syndrome. Symptoms: abundant true hal-
lucinations without disorder of consciousness. Treatment: antipsychotics, ben-
zodiazepines.
Delusional alcohol psychosis – F10.5 (Алкогольный параноид) — acute
psychosis induced by severe alcohol withdrawal syndrome. Symptoms: non-
systematised persecutory delusions (sometimes ideas of jealousy). Treatment:
antipsychotics, benzodiazepines.
Korsakov’s psychosis – F10.6 (Корсаковский психоз) — encephalopathy in-
duced by severe alcohol delirium. Symptoms: amnestic syndrome with periph-
eral neuropathy. Treatment: vitamin B1 (thiamin), nootrops (pyracetam)
Gayet-Wernicke encephalopathy – F10.6 (Энцефалопатия Гайе-Вернике)
— acute alcohol encephalopathy. Symptoms: ataxia, vestibular dysfunction, oc-
ular motility abnormalities, disorder of consciousness. Treatment: thiamin (up
to 300-500 mg per day), treatment of cerebral oedema (diuretics, corticosteroid
hormones, heamodynamics correction, anticoagulants).

Treatment of Alcohol Dependence

 Psychotherapy
 Aversive drugs (disulfiram — antabus, naltrexon)
 Correction of affective disorders: antidepressants, carbamazepine, valproates
 Drug control of drives: low doses of neuroleptics (e.g. sulpiride, thioridazine).

57
appendix 1
THE TYPES OF PERSONALITY CHANGES

Absence of personality changes

States in which the clinical picture comprises only so-called positive symptoms,
and no changes can be found in the premorbid properties of the personality, are
included here. It must be recalled that when acute psychotic states arise it is
extremely difficult to assess personality changes, and sometimes may be
virtually impossible. In such cases the code number corresponding to the pattern
of personality changes before the onset of the particular state, i.e., changes
observed before the onset of the psychotic attack, should be used.

Personality changes in schizophrenia

Mild schizophrenic personality changes

The degree of the changes in the premorbid personality features to be included

in this rubric is slight. Mild manifestations of autism, narrowing of the circle of
interests, some weakening and monotony of emotional experiences and loss of
emotional flexibility are observed in this case. Sometimes increased
vulnerability, sensitivity, shyness, and indecision (a tendency towards self-
analysis and lack of self-confidence) may appear, or if present previously, may
increase abruptly in severity. Although intellectual-creative and occupational
abilities may remain intact, the patient shows passiveness, contacts with other
people are limited, and there is incomplete awareness by patients of their
position in society and in the family. Sometimes patients become submissive
and "controlled" by relatives and friends. In other cases the patients become
rigid and sthenic, with a tendency towards monotonous, stereotyped activity,
poverty of interests, and monotony of emotional responses. Sometimes
personality changes are manifested as exaggerated, at times caricature-like
exacerbation of premorbid features. In all cases, however, features of autism,
weakening of emotional experiences, and diminution of creative powers are
observed. Thinking becomes a pile of arguments. Powers of adaptation to new
conditions are impaired.

58
Marked schizophrenic personality changes

In this case further development of the negative changes is observed. There is a

marked increase in severity of the autistic features and emotional
impoverishment. These patients1 need for contacts with other people is greatly
reduced, they become reserved, reticent, and often taciturn. They gradually lose
interest in their surroundings, their work, and creative activities. Their emotional
responses become gradually less clear and differentiated, and they lose their
relevance. Emotional coldness predominates, and they often exhibit callousness,
egoism and cruelty. The patients' mental activity and the productivity of their
work are drastically reduced. The patients' entire mental activity becomes
monotonous and stereotyped in character. They cease to be able to adapt
themselves in practical problems of life. In some cases they appear apathetic and
indifferent, in others their behaviour is dominated by eccentricity and
strangeness. Motor disorders become even more prominent.

Schizophrenic dementia

States with the severest schizophrenic personality changes are included in this
rubric. Profound emotional impoverishment, loss of mental activity, a drastic
decline in productivity, and inability to learn anything new dominate this state.
Even if productive symptoms are absent or mild, these patients' ability to work
is greatly reduced and not only do they not acquire new occupational skills, but
they also lose the old ones acquired previously. The patients are completely
helpless in practical tasks and become entirely dependent on the care of
relatives. Sometimes predominant features are the oddity of their appearance,
movements and behaviour, and their movements lose their harmony and
plasticity. In other cases the predominant features are diminution of motivations,
indifference, aloofness from their surroundings, and complete helplessness. If
encouraged by others the patients can do simple tasks, but usually do not
complete them, and if the slightest difficulty arises, all activity is immediately
discontinued. All patients exhibit complete loss of their previous interests,
sympathies and attachments, and considerable general hardening and levelling
of the personality are characteristic. In the severest cases, against the
background of general apathy and inertia, sometimes gross disinhibition and

59
perversion of instinctive activity may stand out in sharp contrast (extreme
gluttony, masturbation, and slovenliness, with manifestations of coprophagy).

Personality changes in epilepsy

Mild epileptic personality changes

This code is used for mild personality changes, expressed as the appearance of a
hitherto untypical tendency towards pedantry, overpunctuality and excessive
accuracy, great attention to detail, rigidity of thinking with difficulty in
switching the attention, and so on. The patients' circle of interests is somewhat
narrowed and their creative powers diminished. A tendency towards explosive
outbursts appears. However, the patients' ability to work is usually preserved or
only a little impaired. In some cases, on the other hand, "oversociability" is
observed, with exaggerated conscientiousness and diligence in the performance
of their routine tasks.

Marked epileptic personality changes

In this case the changes are much more profound. All the patients' mental
processes gradually lose their plasticity. Thinking becomes inert, rigid and
inflexible, unproductive, and with a tendency to freeze on a particular theme.
The patients’ circle of interests is considerably narrowed and their direction is
changed — principally towards their own illness and condition. Egocentrism
develops. A combination of feeblemindedness with rancourousness and
vindictiveness is observed. Pedantry and overaccuracy in all patients become
caricature-like in character. Gradually their creative powers are completely lost
and their ability to work drastically impaired. Turgidity of affect becomes more
pronounced in all patients.

Epileptic dementia

This term is used to describe profound personality changes with obliteration of

individual personality traits, severe loss of memory, and often with a reduction
of the vocabulary. Thinking becomes concrete and descriptive, with inability to
distinguish what is most important, or to reflect abstract connections between
phenomena. The circle of interests is extremely narrowed. Servile

60
obsequiousness is combined with badtemperedness, maliciousness and extreme
cruelty. The patients' critical attitude toward their own state and their
surroundings and their ability to work are completely lost.

Personality changes of organic type

Deterioration of the personality

This rubric includes mild initial stages of changes in the premorbid personality
makeup observed in organic diseases, including alcoholism, atherosclerosis, and
the senile type. In some cases this is manifested as accentuation of the
premorbid properties of the personality, whereas in others some levelling of
individual personality features is found. Some degree of simplification of all
mental activity arises, with lowering of the level of mental activity and of the
productivity of intellectual activity, impairment of adaptive powers and of
ability to utilise previous experience. Initial signs of intellectual deterioration
also are found: slight loss of memory, deterioration of judgements and critical
awareness, some narrowing of interests, and weakening of initiative. Depending
on the genesis of the state quite substantial differences in the clinical picture
may be observed: rigidity, egocentrism, and peevishness in the senile type,
complacency and "flat humour" in alcoholism, and so on.

Considerable organic deterioration of the personality

In this degree of organic changes a considerable further aggravation of the

disturbances described previously is observed. Memory disorders become
increasingly pronounced, attention lapses, quickness of wit declines, and ideas
and concepts are impoverished. Ability to acquire new knowledge and skills is
completely lost. The patient's previous distinctive personality qualities and his
former emotional resonance are considerably obliterated. Their ability to work is
drastically reduced or completely lost. Cases with marked deterioration of
personality associated with alcoholism, atherosclerosis, and of the senile type
belong in this rubric.

Organic dementia

This code is used in the severest cases of personality changes of varied

61
exogenous-organic nature, with profound mnemic and general intellectual
disorders. Complete loss of the premorbid personality qualities and profound
mnemic disorders are observed in this case. Often not only critical awareness of
the patients1 own state, but also awareness of their mental insufficiency (illness)
is lost. The patients are dependent on the care of relatives, and are often
completely unable to care for themselves.

Syndrome of retardation of mental development

Retardation of mental development to the feebleminded degree

This code is used for states with a very mild degree of retardation of mental
development. These patients have a certain store of abstract concepts and their
speech is sufficiently well developed. They exhibit some capacity for learning
and acquisition of occupational skills. However, poverty of ideas and fantasies
are observed, and capacity for abstract thinking and for determining logical
connections between phenomena is weak. Knowledge and skills are concrete,
and speech is characterised by limited vocabulary there is some poverty of the
emotions. The patients’ ability to adapt themselves independently to the
demands of practical life is often limited.

Retardation of mental development to the imbecility degree

These patients have marked retardation of mental development. The clinical

picture is determined by the extreme primitiveness of thinking, drastic limitation
of vocabulary, concreteness of thought, and absence of generalising words in the
vocabulary. Articulation is poorly developed. By systematic training the patients
can acquire simple skills for physical work, but need constant guidance. The
patients' emotions are distinguished by extreme poverty, monotonousness and
shallowness.

Retardation of mental development to the idiocy degree

Cases of total or almost total absence of development of mental activity are

included in this rubric. Thinking and ability to comprehend what is going on
around are virtually absent. Speech is either absent or limited to the use of single
words.

62
appendix 2

COURSE OF THE DISEASE

Exacerbation, attack, phase

Cases when the clinical picture of the patient's state is characterised by the onset
of a new syndrome compared with the previous one (most frequently more
severe), or by a temporary and sudden exacerbation of existing disorders belong
in this rubric. In these cases features of the acuteness of the state are always
found: an acute or subacute onset, phenomena of confusion and acute sensory
delusions (in acute psychotic attacks), polymorphism of productive disorders,
and invariably the presence of marked affective disturbances (lability of affect,
polarisation of its fluctuations, anxious and timid affect, and so on).

Course outside exacerbation

All cases, in which the course of the disease is outside exacerbations, attacks,
and phases, belong in this rubric. In some cases the patients' state can be
regarded as a stage of the continuously progressive development of the disease
with regular alternation of positive syndromes and the gradual discovery of
features of deficiency. In other cases it can be regarded as stages of the course of
episodic-progressive and episodic diseases outside an attack. Finally, this rubric
includes stages of development of diseases with a non-progressive or mildly
progressive and continuous course.

Residual state
This rubric includes only the various kinds of residual states with a stable
clinical picture. In this case there is usually considerable diminution of the
symptoms compared with the previous state. Throughout this stage no new
positive disorders appear and features of deficiency do not increase. These states
must not be confused with remissions, during which an increase in either
productive or negative symptoms is observed.

63
appendix 3
OFFICIAL STATISTICAL CLASSIFICATIONS

ICD-10 — International Classification of Mental Disorders

Mental and behavioral disorders are housed within Chapter V of ICD-10 and are
coded with the letter F. The use of the sixth letter of the Gregorian alphabet to
denote chapter V is explained by the assignment of two letters to a very lengthy
list of conditions in chapters on infectious and parasitic diseases. After the letter
F, the first digit of the Chapter V diagnostic codes denotes 10 major classes of
mental and behavioral disorders: F0 through F9. The second and third digits
(third and fourth characters) identify progressively finer categories. For
example, the code F30.2 sequentially denotes the mental chapter, mood
disorders class, manic episode, and the presence of psychotic symptoms. In this
manner, 1000 four-character mental disorder categorical slots are available in
ICD-10.
F0 – Organic, Including Symptomatic, Mental Disorders. This class is
etiologically based on physical disorders or conditions involving or leading to
brain damage or dysfunction. The first clusters have disturbances of cognitive
functions as prominent features and include the dementias (Alzheimer's,
vascular, associated with other diseases, and unspecified), organic amnestic
syndrome, and delirium not induced by psychoactive substances. The second
cluster has as its most conspicuous manifestations alterations in perception
(hallucinations), thought (delusions), mood (depressed or manic), various
emotional domains (such as anxiety and dissociation), and personality.
F1 – Mental and Behavioral Disorders Due to Psychoactive Substance. Use
In contrast to earlier classifications, this class subsumes all mental disorders
related to psychoactive substance use, from patterns of dependence and harmful
use to various organic brain syndromes induced by substances. The diagnostic
process and coding starts with identification of the substance involved (i.e.,
alcohol, opioids, cannabinoids, sedatives, or hypnotics, cocaine, other
stimulants, hallucinogens, tobacco, volatile solvents, and other substances and
combinations of them). Identified next in the code is the involved clinical
condition: acute intoxication, harmful use (previously known as abuse and
characterized by a pattern of use causing damage to physical or mental health),
dependence syndrome, withdrawal state (with or without delirium), psychotic
disorder, amnesic syndrome, residual and late-onset psychotic disorder, and
other and unspecified mental disorders.

F2 – Schizophrenia, Schizotypal, and Delusional Disorders. This class has

schizophrenia as its centerpiece, a disorder characterized by fundamental and
distinctive distortions of thinking and perception and by inappropriate or blunted
affect. The remaining categories of nonorganic, nonaffective psychoses are

64
considered somewhat related, phenomenologically or genetically, to
schizophrenia. Particularly interesting is the cluster of acute and transient
psychotic disorders, which encompasses a heterogeneous set of acute-onset and
relatively short-lived psychoses (polymorphic with or without schizophrenic
symptoms, acute schizophrenia-like, and others) reportedly frequent in
industrially developing countries (where most of the world population lives).
F3 – Mood (Affective) Disorders. The fundamental disturbance in this class is
a change in mood or affect, usually involving depression or elation, often
accompanied by a change in level of activity. Included here are manic episode,
bipolar affective disorder (characterized by recurrent episodes involving both
depression and elation), depressive episode, recurrent depressive disorder,
persistent mood disorder (cyclothymia, dysthymia), and other and unspecified
mood disorders.

F4 – Neurotic, Stress-Related, and Somatoform Disorders. This grouping is

based on a historical concept of neurosis that presumes a substantial role played
by psychological causation and that mixtures of symptoms are common,
particularly in less severe forms often seen in primary care. Included in this
book are phobic anxiety and other anxiety disorders, obsessive-compulsive
disorder, reactions to severe stress and adjustment disorders, dissociative and
conversion disorders, somatoform disorders, and other neurotic disorders (e.g.,
neurasthenia and depersonalization-derealization syndrome).

F5 – Behavioral Syndromes Associated With Physiological Disturbances

and Physical Factors. Included here are eating disorders, nonorganic sleep
disorders, and sexual dysfunction, mental disorders associated with the
puerperium and not elsewhere classified, psychological factors influencing
physical disorders, and abuse of non-dependence-producing substances (e.g.,
antidepressants, hormones, analgesics, and many folk remedies).
F6 – Disorders of Adult Personality and Behavior. This class includes
clinical conditions and behavioral patterns that tend to persist and the expression
of an individual's characteristic lifestyle and mode of relating to self and others.
The main subclass involves personality disorders, which are deeply ingrained
and enduring behavior patterns, manifesting as inflexible responses to a broad
range of personal and social situations. An innovative category is that of
enduring personality change, neither developmental nor attributable to brain
damage or disease, and usually emerging after catastrophic experiences or
another psychiatric illness. The broad class also includes impulse, gender
identity, sexual preference, and sexual development and orientation disorders.

F7 – Mental Retardation. Mental retardation, one of the oldest in the history of

psychiatric classifications, involves arrested or incomplete mental development,
characterized by impaired cognitive, language, motor, and social skills
evidenced during the person's formative period and contributing to the overall
65
level of intelligence. Its subcategories correspond to various levels of severity:
mild, moderate, severe, and profound mental retardation. Extent of behavioral
impairment is also coded.
F8 – Disorders of Psychological Development. Disorders of psychological
development are characterized, as a class, by the following attributes: onset
during infancy or childhood, impairment or delay of functions connected to the
maturation of the central nervous system, and a steady course unlike the
remissions and relapses usual in many mental disorders. The functions affected
most frequently include language, visuospatial skills, and motor coordination. A
major subclass encompasses a variety of specific developmental disorders,
classified by the abilities involved: speech and language, scholastic skills, and
motor function. The other major subclass corresponds to pervasive
developmental disorders, many of which are more saliently characterized by
deviance rather than delay in development but always involving some degree of
delay. Most conspicuous here are childhood and atypical autistic disorder and
Rett's syndrome and other childhood disintegrative disorders.

F9 – Behavioral and Emotional Disorders. With Onset Usually Occurring in

Childhood and Adolescence This complex class complements F7 and F8. Child-
onset disorders included first are hyperkinetic disorders characterized by early
onset, overactive and poorly modulated behavior associated with marked
inattention, lack of persistent task involvement, and pervasiveness over
situations and time. Conduct disorders are defined by a repetitive and persistent
pattern of dissocial, aggressive, or defiant behavior. Also included in this class
are emotional, social-functioning, tic, and other disorders usually starting in
childhood or adolescence.
The full ICD-10 classification of mental disorders has three presentations
corresponding to various degrees of definitional detail, aimed at serving
different purposes and uses:
1. An abbreviated glossary containing the principal features of each disorder,
for the use of statistical coders and medical librarians, published within the
ICD-10 general volume
2. Clinical descriptions and diagnostic guidelines, containing widely accepted
characterizations of an intermediate level of specificity, intended for
regular patient care and broad clinical studies
3. Diagnostic criteria for research, characterized by more-precise and
rigorous definitions

66
 DSM-IV
Diagnostic & Statistical Manual of Mental Disorders
DSM-IV is a multiaxial system that comprises five axes and evaluates the
patient along each. Axis I and Axis II comprise the entire classification of
mental disorders: 17 major groupings, more than 300 specific disorders, and
almost 400 categories. In many instances the patient has one or more disorders
on both Axes I and II. For example, a patient may have major depressive
disorder noted on Axis I and borderline and narcissistic personality disorders on
Axis II. In general, multiple diagnoses on each axis are encouraged.

Axis I consists of all mental disorders except those listed under Axis II, and
other conditions that may be a focus of clinical attention.

Axis II consists of personality disorders and mental retardation. The habitual

use of a particular defense mechanism can be indicated on Axis II.
Axis III lists any physical disorder or general medical condition that is present
in addition to the mental disorder. The identified physical condition may be
causative (e.g., hepatic failure causing delirium), interactive (e.g., gastritis
secondary to alcohol dependence), an effect (e.g., dementia and human
immunodeficiency virus [HIV]-related pneumonia), or unrelated to the mental
disorder. When a medical condition is causally related to a mental disorder, a
mental disorder due to a general condition is listed on Axis I and the general
medical condition is listed on both Axis I and III.
Axis IV is used to code psychosocial and environmental problems that
contribute significantly to the development or the exacerbation of the current
disorder (Table 9.1-4). The evaluation of stressors is based on the clinician's
assessment of the stress that an average person with similar sociocultural values
and circumstances would experience from psychosocial stressors.
Axis IV: Psychosocial and Environmental Problems
 Problems with primary support group
 Problems related to the social environment
 Educational problems
 Occupational problems
 Housing problems
 Economic problems
 Problems with access to health care services
 Problems related to interaction with the legal system/crime
 Other psychosocial and environmental problems

Axis V is the Global Assessment of Functioning (GAP) scale with which the
clinician judges the patient's overall level of functioning during a particular time
period (e.g., the patient's level of functioning at the time of the evaluation or the

67
patient's highest level of functioning for at least a few months during the past
year). Functioning is conceptualized as a composite of three major areas: social
functioning, occupational functioning, and psychological functioning. The GAF
scale, based on a continuum of severity, is a 100-point scale with 100
representing the highest level of functioning in all areas.

GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE

Consider psychological, social, and occupation functioning on hypothetical
continuum of mental health-illness. Do not include impairment in functioning
due to physical (or enviromental) limitations.
Code (Note: Use intermediate codes when appropriate, e.g., 45,68,72)
100 Superior functioning in a wide range of activities, life’s problems never seem to get
| out of hand, is sought out by others because of his or her many positive qualities. No
91 symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning
| in all areas, interested and involves in a wide range of activities, socially effective,
| generally satisfied with life, no more than everyday problems or concerns (e.g., an
81 occasional argument with family members).
80 If symptoms are present, they are transient and expectable reactions to psychosocial
| stressors (e.g., difficulty concentrating after family argument); no more than slight
| impairment in social, occupational, or school functioning (e.g., temporarily falling
71 behind in schoolwork).
70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty
| in social, occupation, or school functioning (e.g., occasional truancy, or theft within
| the household), but generally functioning pretty well, has some meaningful
61 interpersonal relationships.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic
| attacks) OR moderate difficulty in social, occupational, or school functioning (e.g.,
51 few friends, conflicts with peers or coworkers).
50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent
| shoplifting) OR any serious impairment in social, occupational, or school
41 functioning (e.g., no friend, unable to keep a job)
40 Some impairment in reality testing or communication (e.g., speech is at times
| illogical, obscure, or irrelevant) OR major impairment in several areas, such as work
| or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids
| friends, neglects family, and is unable to work; child frequently beats up younger
31 children, is defiant at home, and is failing at school).
30 Behavior is considerably influenced by delusions or hallucinations OR serious
| impairment in communications or judgment (e.g. sometimes incoherent, acts grossly
| inappropriately, suicidal preoccupation) OR inability to function in almost all areas
21 (e.g., stays in bad all day; no job, home or friends).
20 Some danger of hurting self or others (e.g., suicide attempts without clear
| expectation of death, frequently violent, manic excitement) OR occasionally fails to
| maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in
11 communication (e.g., largely incoherent or mute).
10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR
| persistent inability to maintain minimal personal hygiene OR serious suicidal act
0 with clear expectation of death.
0 Inadequate information

68
PERSONALITY DISORDERS F6
психопатии

Diagnostic criteria (П.Б.Ганнушкин, 1933):

1. Относительная стабильность — Relative stability (appear during
childhood or adolescence and continue into adulthood without evident
progression)
2. Тотальность — Marked disharmony, involving several areas of function-
ing (affectivity, arousal, impulse control, ways of perceiving and thinking,
style of relating to others). Behaviour pattern is pervasive and clearly mal-
adaptive to a broad range of personal and social situations.
3. Дезадаптация — Poor adaptation (significant problems in family, occu-
pational and social performance)

Nosological definition:
1. Aetiology: complex of endogenous, biological, psychological and social fac-
tors (the result of pathological heredity and problems of development due to
poor health or bad breeding).
2. Structure deterioration: functional
3. Course: no course in adults, but some dynamic is possible (evolutional, de-
compensation due to bad situation, endogenous affective cyclic changes).
Outcome: stable, no outcome.
4. Symptoms and syndromes:
Productive symptoms: rather different but ever non-psychotic, more
prominent during the periods of decompensation.
Negative symptoms: stable peculiarities of the behaviour and emotion-
al reactions (disorders of will and behaviour).

Accentuated personalities — nonpathologic variants of personality some traits

of which are little bit out of usual limits. Being generally well
adapted these people can show better possibility (talent) to stand
some special kinds of situations but greater sensitivity (marked
desadaptation) to some other kinds.
Decompensation — disease induced by poor adaptability to situation of indi-
vidual with personality disorder (for example neurosis, reactive
depression, reactive paranoid psychosis, alcoholism, drug de-
pendence, pathologic affects).
Treatment — the aim is not recovery but compensation:
Biologic: the usage of tranquilizers is not recommended because
of high risk of dependence.
Neuroleptics (neuleptil, risperidon, melleril, chlorprotixene and
others) — often show good effect in low doses in case of antiso-
48
 ciality, aggressiveness, low control upon behavior.
Antidepressants — show good effect in case of obsessions, hy-
pothimia, pessimism, low self-rating.
Anticonvulsants (carbamazepine, valproates) — should be indi-
cated in case of mood instability, dysphoria, aggression, self-
aggression
Psychotherapy: more effective group-therapy and different
methods of psychodynamic therapy

CLASSIFICATIONS:

Etiology classification (Кербиков О.В., 1968)

Constitutional («nuclear») Pathologic development
Induced by genetic predisposition or Induced by microsocial situation and
early organic disorder affected consti- social education
tution
Poor prognosis. Favourable prognosis.
Correction by drugs. Correction by psychotherapy

Socially oriented classification of О.В.Кербиков (1968)

Возбудимые типы — Тормозимые типы —
excessive behaviour restrictive behaviour
Asocial behaviour and antisocial acts No antisocial acts
Paranoid Anankastic
Dissocial Anxious
Emotionally unstable Dependent (Asthenic)
Histrionic Dysthymic
Hyperthymic Schizoid (sensitive group)
Schizoid (expansive group)

Symptomatically oriented classification — DSM IV

Cluster A Cluster B Cluster C
odd or eccentric dramatic, erratic and fearful, inhibited and
labile anxious
Paranoid Antisocial Avoidant
Shizoid Borderline Dependent
Schizotypal Histrionic Obsessive-compulsive
Narcissistic
Provided for further study: Depressive
Passive-agressive (negativistic)

49
PERSONALITY DISORDERS (continuation)
ICD-10
A personality disorder is a severe disturbance in the characterological constitu-
tion and behavioural tendencies of the individual, usually involving several are-
as of the personality, and nearly always associated with considerable personal
and social disruption. Personality disorder tends to appear in late childhood or
adolescence and continues to be manifest into adulthood. It is therefore unlikely
that the diagnosis of personality disorder will be appropriate before the age of
16 or 17 years.
General Diagnostic Guidelines
Conditions not directly attributable to gross brain damage or disease, or to an-
other psychiatric disorder, meeting the following criteria:
(a) markedly dysharmonious attitudes and behaviour, involving usually several
areas of functioning, e.g. affectivity, arousal, impulse control, ways of per-
ceiving and thinking, and style of relating to others;
(b) the abnormal behaviour pattern is enduring, of long standing, and not lim-
ited to episodes of mental illness;
(c) the abnormal behaviour pattern is pervasive and clearly maladaptive to a
broad range of personal and social situations;
(d) the above manifestations always appear during childhood or adolescence
and continue into adulthood;
(e) the disorder leads to considerable personal distress but this may only be-
come apparent late in its course;
(f) the disorder is usually, but not invariably, associated with significant prob-
lems in occupational and social performance.
For different cultures it may be necessary to develop specific sets of criteria
with regard to social norms, rules and obligations.

F60.0 Personality disorder characterized by at least 3 of the following:

PARANOID (a) excessive sensitiveness to setbacks and rebuffs;
PERSONALITY (b) tendency to bear grudges persistently, i.e. refusal to forgive insults and
DISORDER injuries or slights;
(c) suspiciousness and a pervasive tendency to distort experience by mis-
construing the neutral or friendly actions of others as hostile or con-
temptuous;
(d) a combative and tenacious sense of personal rights out of keeping with
the actual situation;
(e) recurrent suspicions, without justification, regarding sexual fidelity of
spouse or sexual partner;
(f) tendency to experience excessive self-importance, manifest in a persis-
tent self-referential attitude;
(g) preoccupation with unsubstantiated "conspiratorial" explanations of events
both immediate to the patient and in the world at large.

50
F60.1 Personality disorder characterized by at least 3 of the following:
SCHIZOID (a) few, if any, activities, provide pleasure;
PERSONALITY (b) emotional coldness, detachment or flattened affectivity;
DISORDER (c) limited capacity to express either warm, tender feelings or anger to-
wards others;
(d) apparent indifference to either praise or criticism;
(e) little interest in having sexual experiences with another person (taking
into account age);
(f) almost invariable preference for solitary activities;
(g) excessive preoccupation with fantasy and introspection;
(h) lack of close friends or confiding relationships (or having only one) and
of desire for such relationships;
(i) marked insensitivity to prevailing social norms and conventions.
F60.2 Personality disorder, usually coming to attention because of a gross dispari-
DISSOCIAL ty between behaviour and the prevailing social norms, and characterized by
(ANTISOCIAL) at least 3 of the following:
PERSONALITY (a) callous unconcern for the feelings of others;
DISORDER (b) gross and persistent attitude of irresponsibility and disregard for social
norms, rules and obligations;
(c) incapacity to maintain enduring relationships, though having no diffi-
culty in establishing them;
(d) very low tolerance to frustration and a low threshold for discharge of
aggression, including violence;
(e) incapacity to experience guilt and to profit from experience, particularly
punishment;
(f) marked proneness to blame others, or to offer plausible rationalizations,
for the behaviour that has brought the patient into conflict with society.
There may also be persistent irritability as an associated feature. Conduct
disorder during childhood and adolescence, though not invariably present,
may further support the diagnosis.
F60.3 A personality disorder in which there is a marked tendency to act impulsive-
EMOTIONALLY ly without consideration of the consequences, together with affective insta-
UNSTABLE bility. The ability to plan ahead may be minimal, and outbursts of intense
(BORDERLINE) anger may often lead to violence or "behavioural explosions"; these are
PERSONALITY easily precipitated when impulsive acts are criticized or thwarted by others.
DISORDER Two variants of this personality disorder are specified, and both share this
general theme of impulsiveness and lack of self-control.
Impulsive type:
The predominant characteristics are emotional instability and lack of im-
pulse control. Outbursts of violence or threatening behaviour are common,
particularly in response to criticism by others.
Borderline type:
Several of the characteristics of emotional instability are present; in addi-
tion, the patient's own self-image, aims, and internal preferences (including
sexual) are often unclear or disturbed. There are usually chronic feelings of
emptiness. A liability to become involved in intense and unstable relation-
ships may cause repeated emotional crises and may be associated with ex-
cessive efforts to avoid abandonment and a series of suicidal threats or acts
of self-harm (although these may occur without obvious precipitants).
51
F60.4 Personality disorder characterized by at least 3 of the following:
HISTRIONIC (a) self-dramatization, theatricality, exaggerated expression of emotions;
PERSONALITY (b) suggestibility, easily influenced by others or by circumstances;
DISORDER (c) shallow and labile affectivity;
(d) continual seeking for excitement, appreciation by others, and activities
in which the patient is the centre of attention;
(e) inappropriate seductiveness in appearance or behaviour;
(f) over-concern with physical attractiveness.
Associated features may include egocentricity, self-indulgence, continuous
longing for appreciation, feelings that are easily hurt, and persistent manipu-
lative behaviour to achieve own needs.
F60.5 Personality disorder characterized by at least 3 of the following:
ANANKASTIC (a) feelings of excessive doubt and caution;
(OBSESSIVE- (b) perfectionism that interferes with task completion;
COMPULSIVE) (c) excessive conscientiousness, scrupulousness, and undue preoccupation
PERSONALITY with productivity to the exclusion of pleasure and interpersonal rela-
DISORDER tionships;
(d) excessive pedantry and adherence to social conventions;
(e) rigidity and stubbornness;
(f) unreasonable insistence by the patient that others submit to exactly his
or her way of doing things, or unreasonable reluctance to allow others
to do things;
(g) intrusion of insistent and unwelcome thoughts or impulses.
F60.6 Personality disorder characterized by at least 3 of the following:
ANXIOUS (a) persistent and pervasive feelings of tension and apprehension;
(AVOIDANT) (b) belief that one is socially inept, personally unappealing, or inferior to others;
PERSONALITY (c) excessive preoccupation with being criticized or rejected in social situations;
DISORDER (d) unwillingness to become involved with people unless certain of being liked;
(e) restrictions in lifestyle because of need to have physical security;
(f) avoidance of social or occupational activities that involve significant inter-
personal contact because of fear of criticism, disapproval, or rejection.
Associated features may include hypersensitivity to rejection and criticism.
F60.7 Personality disorder characterized by at least 3 of the following:
DEPENDENT (a) encouraging or allowing others to make most of one's important life de-
PERSONALITY cisions;
DISORDER (b) subordination of one's own needs to those of others on whom one is de-
pendent, and undue compliance with their wishes;
(c) unwillingness to make even reasonable demands on the people one de-
pends on;
(d) feeling uncomfortable or helpless when alone, because of exaggerated
fears of inability to care for oneself;
(e) preoccupation with fears of being abandoned by a person with whom
one has a close relationship, and of being left to care for oneself;
(f) limited capacity to make everyday decisions without an excessive
amount of advice and reassurance from others.
Associated features may include perceiving oneself as helpless, incompe-
tent, and lacking stamina.

52
 LINKS BETWEEN ICD-10 AND CLASSIFICATIONS
USED IN RUSSIA (П.Б.Ганнушкин, О.В.Кербиков, А.Е.Личко)
Признанные в Correspond with Main features
России типы ICD-10 items
психопатий
Паранойяльная F60.0 Paranoid personality Strong will, suspiciousness, overvalued
disorder ideas, jealousy, misconstruing the neu-
tral actions of others as hostile
Шизоидная F60.1 Schizoid personality Introversion, low interest in others, inde-
disorder pendence, indifference to either praise or
F21 Schizotypal disorder criticism, strange mixture of emotional
coldness and marked sensitivity (‘glass or
wood’)
Истерическая F60.4 Histrionic personality Strong tendency to demonstrate their indi-
disorder viduality, to be the centre of attention, self-
F60.8 Narcissistic personal- dramatization, theatricality, egocentricity,
ity disorder persistent manipulative behaviour, pseudo-
logia phantastica.
Неустойчивая F60.2 Dissocial (antisocial) The lack of will and patience, tendency
personality disorder to realise any need immediately without
F60.3 Emotionally unstable regard for the circumstances, hedonism,
(borderline) personality
disorder: borderline type.
uncontrolled use of drugs and alcohol,
antisocial acts due to influence of
friends, irresponsibility.
Возбудимая F60.2 Dissocial (antisocial) The lack of impulse control, outbursts of
personality disorder violence, aggressiveness, intolerance to
F60.3 Emotionally unstable criticism by others.
(borderline) personality dis-
order: impulsive type.
Гипертимная F34.0 Cyclothymia Excessive activity, optimism, distracti-
bility, low ability to lead the deals to the
end.
Дистимическая F34.1 Dysthymia Pessimistic predisposition, low self-
appraisal, passiveness
Психастения F60.5 Anankastic (obses- Over-anxious person, which can not
sive-compulsive) personali- make his own decision because of the
ty disorder
fear to make a mistake. His rigidity, pe-
F60.6 Anxious (avoidant)
personality disorder
dantic attitude towards others are the de-
F60.7 Dependent personali- fense mechanism against the fear of
ty disorder novelty.
Астеническая F60.6 Anxious (avoidant) Excessive fatigability and irritability,
personality disorder low energy and poor health.
F60.7 Dependent personali-
ty disorder

53