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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.

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Введение.

CONTENTS

4

Basic Definitions of General Psychopathology

Basic Definitions of General Psychopathology 7

7

Disorders of Sensation

10

Disorders of Perception

10

Thought Disorders

Thought Disorders 12

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

Disorders of Consciousness 24

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

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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)

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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;

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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.

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СОДЕРЖАНИЕ ЗАНЯТИЯ

1. Basic Definitions of General Psychopathology

день СОДЕРЖАНИЕ ЗАНЯТИЯ 1. Basic Definitions of General Psychopathology часы 4

часы

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2. Disorders of Sensation and Perception

3. Thought disorders: Disorders of the Form and the Stream of Thought

4. Thought disorders: Disorders of the possession and the content of thought

5. Thought disorders: Delusional disorders syndromes

6. Disorders of memory. Disorders of cognition: Basic Definitions, Mental Handicap (Mental retardation)

7. Disorders of cognition: Dementia

8. Disorders of Will and Behaviour. Symptoms of Affective disorders

9. Affective syndromes

10. Disorders of Motor Behaviour. Disorders of Consciousness (basic defini- tions)

11. Syndromes of Obscured consciousness

12. Treatment of Mental Disorders

13. Classifications Of Mental Disorders

14. Bipolar psychosis and other Affective Disorders. Schizophrenia (basic definitions)

15. Schizophrenia (clinical forms, types of course, treatment)

16. Organic mental disorders

17. Mental Disorders due to Epilepsy

18. Psychogenous reactions and neuroses

19. Personality disorders

20. Psychotherapy

21. Exogenous (symptomatic) Mental Disorders. Disorders due to psychoac- tive substance use

22. Alcohol dependence and Alcohol psychoses

23. Structured patient examination

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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 functions and phenomena which are not known in healthy indi-

AND

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).

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LLeevveellss ooff MMeennttaall DDiissoorrddeerrss

Organic Psychoses Paroxysmal disorders, Delirium etc. Dementia, Korsakoff’s syndrome etc. Functional Psychoses
Organic Psychoses
Paroxysmal disorders,
Delirium etc.
Dementia,
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

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NEGATIVE DISORDERS

LEVELS OF

It is customary to divide mental disorder into severe (psycho- ses) and mild (neuroses). There is no satisfactory way for dis- tinction between these two groups.

MENTAL

DISORDERS.

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 (Alzheimers disease, Picks 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).

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DISORDERS OF SENSATION

нарушения ощущений

Hyperaesthesia

гиперестезия

Hypaesthesia

гипестезия

(symptom of asthenic states)

(symptom of depression)

Anesthesia

анестезия

(for example hysteric anaesthesia)

Hysterical anaesthesia:

Cenesthopathy

сенестопатия

loss of sensory modalities resulting from emotional conflicts

(Cenesthetic hallucinations) unfounded strange inexplicable sensations in bodily organs (usually in case of schizophrenia)

DISORDERS OF PERCEPTION

расстройства восприятия

Illusions (including pareidolia) misperception or misinterpretation of real external sensory stimuli

иллюзии

Pareidolia is a fantastic misperception of reality in case of sufficient information (symptom of delirium)

Hallucinations

галлюцинации

false sensory perception or mental 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. voicesincluding imperative, threatening, commenting)

c) true hallucinations and pseudohallucinations

Derealisation

дереализация

Depersonalisation

деперсонализация

a subjective sense that the environment is strange or unreal; a feeling of changed reality (for example the feeling that world looks flat or made of cardboard)

a subjective sense of being unreal, strange, or unfamiliar to oneself

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True hallucinations

Pseudohallucinations

Истинные галлюцинации

Псевдогаллюцинации (В.Х.Кандинский, 1880)

Bright vivid perception just like the natural one

The lack of the vividness (for example impossible to distinguish male and fe- male voices)

Patient got it with natural way of per- ception (with eyes or ears) from the re- al perceptual space (extraproection)

Patient got it with other (double) per- ception (internal vision or hearing) from out of perceptual space (for ex- ample intraproection).

Confidence in the fact that other peo- ple have the same perceptions

Ideas of distant influence organised especially for the patient

Excitement or attempts to act with the false objects. More abundant in the evening and night

Indifferent behaviour or passive de- fence (for example attempts to shield with metal net or screen)

Typical for delirium and other organic disorders

Typical for paranoid schizophrenia

HALLUCINOSIS

syndrome characterised by abundant hallucinations of only 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)

галлюциноз

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 patients 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.

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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; 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)

(бессвязность)

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Stereotypie Verbale:

(речевые стереотипии)

persisting verbal response to a prior stimulus after a new stimulus has been presented, often associated with cognitive disorders

rhythmical repetition of words or meaningless 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)

Perseveration

(персеверации)

Verbigeration

(вербигерации)

(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

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)

(символическое мышление)

(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- tients 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

Criteria Delusion Overvalued ideas Obsession
Criteria Delusion Overvalued ideas Obsession
Criteria Delusion Overvalued ideas Obsession
Criteria Delusion Overvalued ideas Obsession False, true or meaningless ideas Veracity False ideas
Criteria Delusion Overvalued ideas Obsession False, true or meaningless ideas Veracity False ideas

False, true or meaningless ideas

Veracity

False ideas

True ideas

Insight

Poor

Poor

Behaviour

Poor, dangerous

control

actions are rather probable

Poor but possible

Diagnosis

Organic or func- tional psychoses

Subpsychotic states (initial period of psychoses), para- noid personality

states (initial period of psychoses), para- noid personality Good Good, no danger- ous actions Neuroses or
states (initial period of psychoses), para- noid personality Good Good, no danger- ous actions Neuroses or

Good

Good, no danger- ous actions

Neuroses or mild disorders (initial phase of schizo- phrenia or organic disorders)

14

OBSESSIVE-PHOBIC SYNDROME

Obsessions

(навязчивые мысли)

different types of persistent irrational ideas,

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)

Rituals (compulsions)

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

(навязчивые действия, ритуалы)

repeated symbolic actions, compulsive in nature, anxiety-reducing in origin

15

DELUSIONS

Types according to content:

Persecutory delusions

бред преследования

Depressive

delusions

депрессивный бред

Grandiose delusions

бред величия

могущества

Depressive mood

ideas of persecution преследования

ideas of control (of distant influence) воздействия

ideas of poisoning отравления

ideas of jealousy ревности

ideas of self-reference отношения (особого значения)

ideas of fabrication, staging, put- ting-up, personal doubles (Capgrassyndrome) инсценировки (двойников)

ideas of pilferage материального ущерба

querulous ideas сутяжный (кверулянтский)

Emotions of fear, anxiety or anger

Danger of aggression in some cases

ideas of guilt самообвинения, самоуничижения

ideas of poverty бедности

hypochondriacal ideas ипохондрический

dysmorphophobic

дисморфомани-

ческий

nihilistic delusions (Cotards syn- drome) нигилистический

Danger of suicide

ideas of self- importance собственно величия

ideas of riches богатства

erotic ideas любовный

ideas of power and

might

Euphoria or indifference

Dangerous behaviour is not typical

ideas любовный  ideas of power and might Euphoria or indifference Dangerous behaviour is not typical

Primary delusion (первичный бред) independent disorder of thought which are not associated with other mental dys- function

Secondary delusion (вторичный бред) secondary disorder of thought, which represent the disturbance of other mental functions (affect, perception, memory, consciousness etс.

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

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

II.Paranoid

III. Paraphrenia

primary systematised ideas of persecution, jealousy or inven- tion without hallucinations

(паранойяльный синдром)

hallucinational and delusional states with persecutory ideas of control (distant influence) or poisoning, often associated with mental automatism

(параноидный синдром)

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

Mental Automatism

(псевдогаллюцинации – В.Х.Кандинский, 1880)

(психический автоматизм)

Alienation of Thoughts

Alienation of Perceptions and Emotions сенсорный автоматизм

Alienation of Movements

идеаторный автоматизм

моторный автоматизм

Delusion of control (of distant influence)

17

MEMORY DISORDERS

расстройства памяти

Hypermnesia

(гипермнезия)

Hypomnesia

(гипомнезия)

exaggerated degree of retention and recall (symptom of mania)

difficulties of registration, retention and recall of memories (symptom of vascular deficiency)

Failure of registration

(фиксационная амнезия)

Amnesia

(амнезия)

1. Organic amnesia

(органическая амнезия)

Retrograde amnesia

minute memory (symptom of Korsakovs syndrome)

gap, loss of memories but not the ability to register

(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 – Paramnesias

Allomnesia

(german Pseudoreminiszenz)

(псевдореминсценции)

Confabulation

(конфабуляции)

filling of gaps in memory by real experi- encebut of other time period

unconscious filling of gaps in memory by imagined or untrue experiences that patient believes but that have no basis in fact

KORSAKOVS 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

IQ =

(Intelligence Quotient)

Mental age

100%

Chronological age

Specific tests Wechsler-test (WAIS, WISC), Progressive Matrices Test, 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 (
ICD-10 IQ (%) Clinical classification F70 Mild mental retardation 50 – 69 Moronic (

ICD-10

IQ (%)

Clinical classification

F70 Mild mental retardation 50 – 69 Moronic ( дебильность ) F71 Moderate mental
F70 Mild mental retardation 50 – 69 Moronic ( дебильность ) F71 Moderate mental

F70 Mild mental retardation

50

69

Moronic

(дебильность)

F71 Moderate mental retardation

35

49

F72 Severe mental retardation

20

34

Imbecile (имбецильность)

F73 Profound mental retardation

below 20

Idiocy

(идиотия)

II. DEMENTIA

(слабоумие, деменция)

Organic Dementia Dysmnestic (Arteriosclerotic)

loss of intelligence after a period of its normal development

(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

(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

(тотальное, глобарное)

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:

Kleptomania:

Nymphomania (Satyriasis): excessive and compulsive need

compulsion to drink alcohol

compulsion to steal

for coitus in a woman (in a man)

compulsion to pull out one's hair

Trichotillomania:

Dromomania (poriomania): compulsion to leave home, to rove

insight

behavior control

DISORDERS OF MOTOR BEHAVIOUR

двигательные расстройства

Catatonia

(кататонический синдром)

strange non-convenient posture, waxy flexibility (catalepsy), negativism (active and passive), automatic obedience

Excitement: purposeless actions, impulsive, brutality, stereotypic speech and movement (verbigerations, perseverations)

(echopraxia, echolalia,

Non-adaptive movements:

Stupor:

echo-symptoms

echomimia), manneristic behavior

Other causes of excitement:

Mania

Agitated depression

Acute delusional states

Disorders of consciousness: delirium, oneiroid, twilight states)

(ажитированная депрессия)

(острый чувственный бред)

(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)

 facial expression of happiness (sometimes anger) Hysterical excitement  stress induced  evident

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

behaviour (loud cries, sobbing, convulsions, suicide actions, etc.)  histrionic posture and fa- cial expression

Other causes of stupor:

Depression

Hysteric stupor

Stress reaction

(истерический ступор) (реакция на психологический стресс)

Catatonic stupor

Depressive stupor

bizarre inconvenient posture (i.e. foetal posture)

posture of suffering

manneristic facial expression

facial expression of sadness or anguish

muteness (sometimes paradoxical answers to whispering speech)

poor associations, one word answers, but no muteness

negativism (often eating is absolutely refused)

the loss of appetite but no active resistance while eating

echolalia and echopraxia

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)

stable unreasonable elevation of mood (symptom of mania)

elevated but serene careless mood, complacency often associated with poor insight or even dementia (symptom of organic disorders, e.g. intoxication)

sullenness and grumbling, unpleasant mood, up to anger and irritation, often paroxysmal (symptom of organic disorders, e.g. epilepsy)

dulled emotional tone associated with detachment or

indifference (symptom of schizophrenic defect or frontal lobe damage)

Hyperthymia

Euphoria

Dysphoria

Apathy

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 ( депрессивный )  hypothymia (up to an- guish)  inhibition of thought 
Depression ( депрессивный )  hypothymia (up to an- guish)  inhibition of thought 
Depression ( депрессивный )  hypothymia (up to an- guish)  inhibition of thought 

Depression

(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

Mania

(маниакальный)

Apathy and abulia

(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

no disorders of sleeping

well healthy, no somatic complaints

hyperthymia

pressure of talk

pressure of activity

self-over-rating

mood-congruent delusion

(ideas of granduer)

bulimia, abuse of alcohol,

spending money

hypersexuality

behavior

distractibility

passivity

insomnia (sleeps shortly but without sense of tiredness)

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:

(делирий)

acute psychosis with illusions and true hallucinations, excitement, disorientation in time, place, situation

Amentia (Incoherence syndrome, Delirium)

(аменция)

Oneiroid State:

(онейроид)

Twilight states

deep disorder of consciousness with incoherence

dream-like states with dual orientation, pseudohallucinations, catatonic behavior

(including Fugas, Ambulatory automatism, Spontaneous somnambulism) (сумеречное помрачение сознания) paroxysmal states with total amnesia

Syndrome Beginning Symptoms Duration Ending Amnesia Outcome Nosology Delirium Oneiroid Twilight states
Syndrome Beginning Symptoms Duration Ending Amnesia Outcome Nosology Delirium Oneiroid Twilight states
Syndrome Beginning Symptoms Duration Ending Amnesia Outcome Nosology Delirium Oneiroid Twilight states
Syndrome Beginning Symptoms Duration Ending Amnesia Outcome Nosology Delirium Oneiroid Twilight states
Syndrome Beginning Symptoms Duration Ending Amnesia Outcome Nosology Delirium Oneiroid Twilight states

Syndrome

Beginning

Symptoms

Duration

Ending

Amnesia

Outcome

Nosology

Delirium

Oneiroid

Twilight states

Delirium Oneiroid Twilight states Gradual within 1-2 days through the states of anxi- ety, sleep disorders

Gradual within 1-2 days through the states of anxi- ety, sleep disorders

Gradual through the stage of acute delusions and de- realization

Sudden

Illusions, true halluci- nations, excitement

Catatonia, pseudohalluci- nations, dual orientation

Brutal aggression or au- tomatic behavior

3-5 days

Several days or weeks

Several minutes or hours

Critical after deep sleeping

Gradual

Sudden

Partial

Partial

Total

Full recovery, in severe cases Korsakovs syndrome, dementia or death

Remission of high quality

Status idem

Organic damage or intox- ication

Schizophrenia or abuse of hallucinogen drugs

Epilepsy or other organic 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

1971-1988Several 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

EXAMPLES

Excitement

Chlorpromazine (Thorazine, Largactil) Levomepromazine (Nosinan, Tisercin) Chlorprothixene (Taractan, Truxal) Clozapine (Leponex, Azaleptin) Droperidol (Inapsine) Zuclopenthixol (Clopixol)

Productive symptoms: delusions, hallu- cinations, catatonia

Haloperidol (Haldol) Trifluoperazine (Stelazine, Trazin) Trifluperidol (Trisedil)

Progression of negative symptoms of schizophrenia

Clozapine (Leponex, Azaleptin) Thioproperazine (Majeptil) Perphenazine (Trilafon, Aethaperazin) Trifluperidol (Trisedil) Pipothiazine (Piportil) Risperidone (Risperdal, Rispolept) Olanzapine (Ziprexa)

Loss of energy (for activation)

Methophenazine (Frenolon) Fluphenazine (Prolixin, Permitil, Moditen) Sulpiride (Eglonil, Dogmatil) Flupenthixol (Fluanxol)

Correction of behavior of patients with neuroses, organic disorders and person- ality disorders

Thioridazine (Melleril, Mellaril, Sonapax) Periciazine (Neuleptil) Alimemazine (Theralen) Sulpiride (Eglonil, Dogmatil) Perphenazine (Trilafon, Aethaperazin)

Long-term treatment of patients with chronic psychoses

Haloperidol-decanoat Clopixol-depo Fluphenazine-depo (Moditen-depo) Pimoside (Orap) Penfluridol (Semap) Fluspirelen (Imap)

Depression with anxiety and agitation

Levomepromazine (Nosinan, Tisercin) Sulpiride (Eglonil, Dogmatil) Chlorprothixene (Taractan, Truxal)

26

CLASSIFICATION OF NEUROLEPTICS BY CHEMICAL STRUCTURE

Chemical class derived of:

Chemical class — derived of: Examples

Examples

PHENATHYAZINE:

aliphatic

Chlorpromazine (Thorazine, Largactil) Levomepromazine (Nozinan,Tisercin) Alimemazine (Theralen) Promethazine (Diprazine, Pipolphen) Trifluoperazine (Stelazine, Trazin) Perphenazine (Trilafon, Aethaperazinum) Thioproperazine (Majeptil) Fluphenazine (Permitil, Prolixin, Moditen) Metofenazat (Frenolon) Prochlorperazine (Compazine, Metherazine) Thioridazine (Mellaril, Sonapax) Periciazine (Neuleptil) Pipothiazine (Piportil))

piperazine

piperidine

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 Drugs

Imipramine (Imizine, Tofranil, Melipramin) Amitriptyline (Elavil, Elivel, Triptizole, Saro- tene) Clomipramine (Anafranil) Doxepin (Sinequan, Adapin) Nortriptylin (Pamelor, Aventyl) Desipramine (Pertofran) Trimipramine (Surmontil, Herfonal) Maprotilin (Ludiomil) Cardiotoxic and anticholinergic effects:

tachicardia, dry mouth, constipation, blurred vision, urinary retention, weight gain.

Serotonin (5-hydroxitryptamin) Specific Reuptake Inhibitors - SSRI

Fluoxetine (Prozac, Prodep) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Cipramil) Fluvoxamine (Fevarin)

No cardiotoxic or anticholinergic effects, no weight gain. If combined with monoamine oxidase inhibitors malignant serotonin syndrome is possible

MONOAMINE OXIDASE INHIBITORS

Non-selective (hydrazine) non-reversible:

Selective reversible:

Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) Nialamid (Nuredal) No anticholinergic effects, severe ad- verse effects if combined with other psychoactive drugs

Monocyclic:

Befol Moclobemide (Aurorix) Tetracyclic:

Pyrazidol Tetrindol Rather safe but less effective

O

T

H

E

R

Mianserine (Lerivon) Mirtazapine (Remeron) Milnazipran (Ixel)

Tianeptine (Coaxil) Ademethionin (Heptral) 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 Zopiclone, zolpidem, triazolam, estazolam, midazolam

effect of short duration

Anxiety and excitement:

 

effect of long duration

Chlordiazepoxide, phenazepam, bromazepam Lorazepam, oxazepam

effect of short duration

Anxiety and loss of energy:

 

effect of long duration

Diazepam, medazepam Alprazolam

effect of short duration

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 Fluoxetine Monoamine oxidase inhibitors

Mianserine

Tianeptine

Fluvoxamine

Paroxetine

Trimipramine

Sertraline

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, mental disorders F1 Mental and behaviour disorders due to psycho-active substance use F2 Schizophrenia, schizotypal states, and delusional disorders F3 Mood (affective) disorders F4 Neurotic, stress-related, and somato- form disorders

F5 Physiological dysfunction, associated with mental and behavioural factors F6 Abnormalities of adult personality and behaviour F7 Mental retardation F8 Development disorders F9 Behavioural and emotional disorders with onset usually occurring in childhood or adolescence

DSM IV see appendix 3

(criteria of inclusion and exclusion, multiaxial diagnosis, special glossaries)

 

Clinical Disorders

Other Conditions That

Other Conditions That

Axis I

May Be a Focus of Clinical Attention

 

Personality Disorders

Axis II

Axis II

Mental Retardation

Axis III Axis IV General Medical Conditions Psychosocial and Environmental Problems Axis V Global Assessment

Axis III

Axis IV

General Medical Conditions

Psychosocial and Environmental Problems

Axis V

Global Assessment of Functioning

30

Aetiologic Classification

C A U S E S

 

I n t e r n a l

 

E x t e r n a l

Heredity and physiologic constitution

Vascular, de-

Trauma,

Emotional stress and in- tapsychic conflict

 

ficiency,

intoxication,

 

tumours,

infection,

 

somatic dis-

radiation

eases

 

ENDOGENOUS

 

EXOGENOUS (and somatogenous)

 

PSYCHOGENOUS

o

Schizophrenia

o

Extracranial and intracra- nial tumours

o

Acute stress in- duced psychoses

o

Bipolar psychosis

o

Epilepsy

o

GPI (syphilitic psychosis)

o

Neuroses

o

Alzheimers disease

o

Symptomatic psychoses

o

PTSD (post- traumatic stress disorder)

o

Picks disease

o

Traumatic, toxic and in- fectious psychoses

Diagnostical traits of endogenous diseases:

spontaneous onset, autochtonous course in accord- ance with internal biological rhythms, pathologic he- redity, specific traits of patients constitution before the beginning of the disease.

Types of Course

see appendix 2

Chronic progressive

e.g. schizophrenia, epilepsy, Alzheimer’s disease, tumours, alcoholism.

epilepsy, Alzheimer’s disease, tumours, alcoholism. Chronic recurrent (periodic) e.g. bipolar psychosis. 31

Chronic recurrent (periodic)

e.g. bipolar psychosis.

Chronic recurrent (periodic) e.g. bipolar psychosis. 31 Acute e.g. alcohol delirium, acute stress reactions.

31

Acute e.g. alcohol delirium, acute stress reactions.

31 Acute e.g. alcohol delirium, acute stress reactions. Chronic regressive e.g. trauma, consequences of

Chronic regressive

e.g. trauma, consequences of intoxication, Korsakov’s disease.

trauma, consequences of intoxication, Korsakov’s di sease. Chronic undulating (waving) e.g. cerebral arteriosclerosis.

Chronic undulating (waving)

e.g. cerebral arteriosclerosis.

trauma, consequences of intoxication, Korsakov’s di sease. Chronic undulating (waving) e.g. cerebral arteriosclerosis.

BIPOLAR PSYCHOSIS AND OTHER AFFECTIVE DISORDERS

Nosological definition

1. Aetiology: Endogenous

F3

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 and perception depersonalisation not typical
Productive symptoms
Negative symptoms
Disorders of sensation
and perception
depersonalisation
not typical
derealisation
Thought disorders
mood congruent delusions,
overvalued ideas, obses-
sions
not typical
Affective disorders
hyper- or hypothymia,
mania or depression
not typical
Disorders
of will and behaviour
hyper- or hypobulia, in-
creased sexuality etc.
not typical
Memory disorders
not typical
Disorders of cognition
not typical
Disorders
of motor behaviour
depressive stupor, manic
excitement etc.
not typical
Disorders
of consciousness
not typical

Types of course

BIPOLAR

AFFECTIVE

DISORDER

F31

биполярный

психоз

This disorder is characterised by repeated (i.e. at least two)

episodes in which patients mood and activity levels are sig-

nificantly disturbed, this disturbance consisting on some oc-

casion of an elevation of mood and increased energy and ac-

tivity (MANIA or hypomania), and on others of lowering of

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.

P ERSISTENT A FFECTIVE D ISORDERS

PERSISTENT AFFECTIVE DISORDERS

F34

CYCLOTHYMIA

F34.0

циклотимия

DYSTHYMIA

F34.1

дистимия

A

persistent instability of mood, involving numerous periods

of

mild depression and mild elevation. This instability usual-

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.

A chronic disorder characterised by the presence of a de-

pressed (or irritable in children and adolescents) mood that

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

(dementia praecox)

Nosological definition

F20

(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 and perception cenesthopathy, pseudohal- lucinations,
Productive symptoms
Negative symptoms
Disorders of sensation
and perception
cenesthopathy, pseudohal-
lucinations, depersonalisa-
tion, derealisation
subjective feeling of self-
changing (depersonalisa-
tion)
Thought disorders
alienation of thoughts,
mentism, thought block-
ing, persecutory
delusions (delusion of
control), overvalued ideas,
obsessions
autism, ambivalence, rea-
soning, schizophasia, ob-
scurity of expression, pa-
ralogia, symbolism, phil-
osophical intoxication, pon-
tifical woolliness (up to
incoherence) etc.
Affective disorders
anxiety, perplexity (acute
delusion), mania or de-
pression may be, but not
specific
ambivalence, decreased
affect (monotonous, flat-
tering and incongruity of
affect), apathy
Disorders
of will and behaviour
ambivalence, loss of will
and energy, abulia, pa-
rabulias, unexpected sex-
ual behaviour, laziness,
passivity
Memory disorders
not typical
Disorders of cognition
not typical
Disorders
of motor behaviour
catatonia (stupor, excitement,
echo-symptoms)
non-adaptive movements
(mannerism)
Disorders
of consciousness
not typical
dual orientation, oneiroid

34

The four As

(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.

Its 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 SCHIZOPHRENIA F20.0 HEBEPHRENIA (DISORGANISED TYPE) F20.1 CATATONIC SCHIZOPHRENIA F20.2 SIMPLE
PARANOID
SCHIZOPHRENIA
F20.0
HEBEPHRENIA
(DISORGANISED
TYPE)
F20.1
CATATONIC
SCHIZOPHRENIA
F20.2
SIMPLE
SCHIZOPHRENIA
F20.6

This is characterised by the development of delusions (of persecu- tion, of distant influence, of grandeur, sometimes hypochondriacal). 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.

This has an insidious onset in early life and is characterised by thought disorder and emotional abnormalities. Characteristically the affect is inappropriate and fatuous, with 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.

Clinical picture is dominated by disturbance of behaviour and motor phenomena (catatonic syndrome). 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.

This characterised by an insidious onset, with a gradual deteriora- tion socially and very often a difficulty in establishing the exact 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)

(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 with stress and appears with subpsychotic symp- 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

F20.*1 Progression with acute attacks [german Schub]

Continuous progression непрерывно-прогредиентное течение

(приступообразно-прогредиентное (шубообразное) течение Periodic (recurrent) периодическое (рекуррентное) течение

F20.*3

F21 Special type with slow (sluggish) progression In ICD-10 Schizo- typal disorder (eccentric, bizarre behavior german Verschroben) малопрогредиентная (вялотекущая) шизофрения.

continuous progression

P + N -
P
+
N -

slow (sluggish) progression

P + N -
P
+
N
-

progression with acute attacks

P + N -
P
+
N -

periodic (recurrent)

with slow progression

P + N -
P
+
N
-

37

ORGANIC MENTAL DISORDERS

(органические заболевания)

SPECIFIC SYMPTOMS (Walter-Buel H. triad):

1. Difficulties in retention

2. Difficulties in understanding

3. Difficulties in keeping feelings in

F00 - F09

(up to amnesia F04) (up to dementia F00-F03) (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

CT (Computer Tomography) or MRI (Magnetic Resonance Imaging)

Ophthalmologist examination

Neurologist examination

Rheoencepalography

Doppler ultrasound

Cerebro-spinal fluid (CSF) tests

Neuropsychological tests

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

Alzheimers disease [F00, G30] degenerative disease with insidious onset at age 5565 or later (occur in 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). Picks 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

DISEASES

CEREBRAL

System disease with slow progression and evident wav- ing course. Cerebral symptoms coexist with features of ischaemia of heart or extremities. The first symptoms are asthenia and hypomnesia. Dementia appears later, insight is rather good (partial dementia F01)

ARTERIO-

SCLEROSIS

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, Korsakovs 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

Эпилепсия

Nosological definition:

1. Aetiology: Endogenous

G40

2. Structure deterioration: organic

3. Course: chronic progressive. Outcome: Epileptic dementia (if malignant cases). see appendix 1

4. Symptoms and syndromes:

Productive symptoms:

Negative symptoms:

rather different but ever paroximal. stable defect of personality with egocentrism (selfishness), circumstantiality (stiffness), emo- tional rigidity and explosivity.

PAROXYSMAL DISORDERS (эпилептические пароксизмы):

With deterioration of consciousness c выключением сознания

Without deterioration of consciousness без выключения сознания

Grand mal большой судорожный припадок Petit mal малый припадок (абсанс) Twilight states сумеречное помрачение сознания

Dysphoria дисфория Paroxysmal derealisation (déja vu, jamais vu) приступы дереализации (уже виденное, никогда не виденное) Paroxysmal hallucinations and delusions приступы галлюцинаций и бреда

INTERNATIONAL CLASSIFICATION OF SEIZURES:

 

Primary generalised seizures

Partial (focal) seizures

 

Abrupt loss of consciousness (up to coma) without any prodrome symptoms (no aura) Total amnesia Simultaneous changes in all areas in EEG Examples: petit mal (absence, myo- clonic seizures), grand mal with- out aura (tonic, clonic, tonic- clonic, atonic)

No loss of consciousness or partial changed consciousness Partial or no amnesia Focal changes in EEG Examples: abrupt attacks of hallucina- tion, delusion, disorders of drives

Secondary generalised seizures

Secondary generalised seizures

Loss of consciousness after a stage of 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 often with self-injury. Nocturnal seizures are common. The face is pale at the beginning and then cyanotic No deep reflexes, no reaction in case of suggestion Stereotypical tonic and clonic convulsions

Convulsive meaningless facial expression

Induced by emotional stress. Careful fall- ing without self-injury.

Flushing or no changes in face colour.

Deep reflexes are vivacious, affection by suggestion Non-stereotyped asynchronous body movements Facial expression of suffering, fear or de- light Long duration (several min up to an hour) No specific EEG changes

Sometimes partial amnesia, good effect of psychotherapy

Duration 30 s up to 2 min Spikes, pathologic waves and postictal slowing on EEG Abrupt spontaneous recovery through the stage of somnolence, postictal confusion. 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