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Ministry of Health of Ukraine Bukovynian State Medical University




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Ministry of Health of Ukraine

Bukovynian State Medical University


“Approved”

on the methodical meeting

of the Department of neurology, psychiatry

and medical psychology nm. S.M.Savenko

“____” ___________ 2009 (Report № __).

Chief of the Department

_______________________

Professor V.M. Pashkovsky


Methodical INSTRUCTION

for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class


Theme 13: Mental disorders in patients with somatopathies, endocrine disease and vascular pathology of the brain.


^ MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


Topical module 3. Organic (including symptomatic) psychic disorders. Ecological psychiatry


Сhernivtsi, 2009


1. Actuality of theme:


Cerebral vascular disorders are usually caused by general vascular diseases like atherosclerosis, hypertensive or hypotonic diseases, and only in rare cases — by local processes (obliterating cerebral thromboangitis). Physical symptoms and psychiatric disorder commonly occur together both in patients who consult general practitioners, and in patients referred to all specialists in all branches of medicine and surgery. This association arises partly because psychiatric disorders can present with physical symptoms (for example an anxiety disorder with palpitations), partly because physical illness can provoke a psychological reaction (for example heart disease provoking anxiety), and partly through chance association.

That is why it is very important for the doctor of every profession to know mental disorders in patients with somatopathies, endocrine disease, vascular pathology of the brain.


2. Duration of practical classes - 2 hours.


^ 3. EDUCATIONAL PURPOSE


3.1. To know:

  • the reason why psychiatric disorders should not be missed during physical illness;

  • associations between physical and psychiatric disorder;

  • psychological factors as causes of physical illness;

  • psychiatric disorders presenting with physical symptoms;

  • psychiatric and physical disorder occurring together by chance.

  • associations Between Physical Disorders and Psychiatric Symptoms;

  • mental disorders of vascular genesis;

  • mental Disorders Caused by Cerebral Atherosclerosis;

  • mental Disorders Caused by Hypertension.

 3.2. A student must be able:

  • to determine the criteria of clear consciousness;

  • to determine the criteria of consciousness disorders;

  • to use the clinical method of research of consciousness and self-consciousness.

3.3.To capture practical skills:

  • determination of psychopathological syndromes;

  • determination of criteria of clear and broken consciousness;

  • determination of the state of consciousness.



^ 4. INTERSUBJECT INTEGRATION (base level of preparation).


Names of previous disciplines

Skills are got

1. Anatomy.


2. Physiology.


3. General psychology.



  1. To know an anatomy and topographical anatomy of cerebrum.

  2. To know the basic cork functions of cerebrum. Able to define the type of higher nervous activity.

  3. To know psychology of psychical processes, consciousness and self- consciousness.



5. Advices to students.

5.1. ^ CONTENTS OF THEME.


In the care of every patient, attention must be given to the effects of physical illness on psychological and social functioning. It is particularly important to identify the sizeable minority of patients who develop psychiatric disorders during physical illness. There are three reasons why these psychiatric disorders should not be missed:

— a severe psychiatric disorder is likely to need immediate treatment, particularly if there is a risk of suicide or violence;

— a moderately severe psychiatric disorder, if left untreated, can delay recovery from physical illness;

— a mild psychiatric disorder causes suffering which could be alleviated.

Mild and moderately severe mental disorders can usually be treated by the doctor who is treating the physical illness. For severe disorders and those that are less severe but persistent, treatment by a psychiatrist is likely to be required. Also an advice of a psychiatrist can be valuable in the differential diagnosis of medically unexplained somatic symptoms that may have psychological causes.

^ Associations Between Physical and Psychiatric Disorder

Psychological factors as causes of physical illness

Psychiatric disorders presenting with physical symptoms

Psychiatric and physical disorder occurring together by chance

Psychiatric consequences of physical illness

Organic disorders

Functional disorders (depression, anxiety)

Other associations

Deliberate self-harm

Alcohol and other substance abuse

Eating disorders

1. Psychological factors as causes of physical illness. Psychological factors may cause psychosomatic disorders — physical illnesses which develop as the result of acute or chronic stress. The psychosomatic approach in medicine proceeds from the belief that mind and body are tightly connected, and every significant change in the state of mind (like intensive affect) causes bodily changes through the influence of the autonomous nervous system. Normal functioning implies that the organism is able to make adequate adjustment to the short- and long-term demands of its environment and is therefore able to carry on without prolonged somatic or mental distress. When, however, environmental pressures or internal resources are such that adaptation cannot be maintained without disorganisation of behaviour, the organism will react to the pressures or stresses by developing a neurotic, psychotic or psychosomatic reaction. Which manner of response will be favoured depends on a great many factors, constitutional as well as environmental.

A psychosomatic breakdown implies that appropriate action (corresponding to the emotion) is either impossible, or the discharge of excitation is inadequate, and the excess floods the central nervous system or the vegetative system. Because adequate discharge is impossible, the organ system remains chronically innervated "excited." If this condition persists long enough, or if there is some constitutional weakness in the organ system, a somatic breakdown occurs and new adjustments must ensue.

The examples of illnesses in the development of which psychosomatic mechanisms play an important role are: bronchial asthma, gastric and duodenal ulcer disease, chronic ulcer colitis, hypertonic disease, ischaemic heart disease (coronary insufficiency), chronic headaches and some others.

Specific mechanisms of psychosomatic disorders development are still not known, but one of them is immunity insufficiency or dysfunction. Immunity is regulated by the central nervous system, and in mental disorders many kinds of immunological indices are changed. There is a hypothesis that some kinds of auto-immune illnesses and immunity deficiency states are caused by psychological factors.

2. Psychiatric disorders presenting with physical symptoms. This situation concerns neurotic (especially anxiety) disorders or depression, in which internal organs are not damaged, and only functional changes in them can be registered. For example, in somatised depression the heart rate is increased, mouth dry, the patients develop constipation, their appetite decreases and they loose weight.

3. Psychiatric and physical disorder occurring together by chance. Psychiatric and physical disorders may occur together by chance and may then interact. For example, a depressive disorder piovoked by business failure might lessen a patient's resilience to an unrelated physical illness, lowering his compliance with treatment. Conversely, physical illness may exacerbate psychiatric symptoms; for example, a virus infection could delay recovery from a depressive disorder. Sometimes the psychiatric symptoms are judged to be a reaction to the physical illness rather than being independent, and when this happens treatment may be directed to the wrong causes. Patients with schizophrenia, epilepsy or other mental disorders can develop the same concomitant physical illnesses (flue, pneumonia, cancer, appendicitis, etc.) that occur in people with good mental health, and they need the appropriate treatment of both disorders.

4. Other associations. Deliberate self-harm and suicidal behaviour is not a direct consequence of a mental illness. Sometimes people who are mentally healthy, but have maladjustive patterns of behaviour, commit suicidal attempts in stressful situations. On the other hand, depression or schizophrenia belong to serious risk factors of suicide. Alcohol and other substance abuse are considered a kind of social behaviour. They may cause physical disorders (ex. liver cirrhosis, toxic myocardiopathy, etc.), and they are the first step to the development of addictive disorders. Eating disorders are studied in the context of mental pathology, but they result in bodily changes (underweight, overweight and their consequences).

^ Associations Between Physical Disorders

and Psychiatric Symptoms


Psychiatric Symptom

Physical Disorder


Depression


Fatigue (asthenic syndrome)


Anxiety

Carcinoma, infection, neurological disorder,

endocrine disorder


Anaemia, sleep disorder, chronic infection, hypothyroidism, diabetes, carcinoma, radiotherapy


Hyperthyroidism, hyperventilation, hypoglycemia, drug withdrawal



Asthenic syndrome. The most frequent disorder, common for almost all physical (and some mental) illnesses is the asthenic syndrome (asthenia). It is a state of fatigue, which includes emotional and hyperesthetic disturbances. The main symptoms of this syndrome are fatigability, weakness, low working ability and increased exhaustibility of all mental functions. As the result, patients develop concentration disorders (high distractibility and exhaustibility of attention), functional memory disorders (it is difficult for them to memorise new information and to recollect previously known information actively), and mild thinking impairment (patients experience difficulties in understanding new material). For example, when they try to read a book, reading soon becomes a mechanical process with no understanding of the content. Patients get tired and need rest even when doing an easy work. In addition to fatigue, patients also have emotional, hyperesthetic and functional somatic disturbances. Affective disorders include irritability and emotional lability, the mood is usually low or changeable. Hyperesthesia causes low tolerance to noise, bright light and other intensive stimuli, they make the patients feel discomfort and irritate them. Sometimes they complain that even their usual clothes seem rough, stiff and uncomfortable to them. Functional somatic disturbances are caused by the autonomous nervous system dysfunction, they include headache, increased heart rate, excessive sweating, changes in body temperature, etc. The asthenic syndrome can be caused by each of the disorders described below.

Mental disorders of vascular genesis are different both in clinical symptoms and in the course of development. Usually the following groups of disorders are distinguished:

a) non-psychotic disorders: the asthenic or asthenic-depressive syndromes, organic neurotic symptoms and personality changes; these disorders usually develop at the first stages of vascular diseases;

b) vascular psychoses, which usually manifest in different changes of consciousness, mood disorders, hallucinations and delusions; psychoses can be acute and short-term, or prolonged;

c) vascular dementia.

Mental Disorders Caused by Cerebral Atherosclerosis

Atherosclerosis is a general chronic vascular disease, which effects the arterial blood vessels in different organs, including the brain. It usually develops in elderly people. Cerebral atherosclerosis causes several neurological and psychiatric problems, and in severe cases it may lead to profound dementia.

Students on the basic stage of tutorial independently under the direction of teacher inspect mentally patients with mental disorders. Independently collect information of anamnesis, find out quantitative of psychopathological syndromes.

With the purpose of mastering of new knowledges and abilities on this stage of employment the tasks of situations are used and questions, which are executed in writing, checked up a teacher during employments and results come into question, are standardized.


^ 5.2. QUESTIONS OF CONTROLS:

  1. The reason why psychiatric disorders should not be missed during physical illness.

  2. Associations between physical and psychiatric disorder.

  3. Psychological factors as causes of physical illness.

  4. Psychiatric disorders presenting with physical symptoms.

  5. Psychiatric and physical disorder occurring together by chance.

  6. Associations Between Physical Disorders and Psychiatric Symptoms.

  7. Mental disorders of vascular genesis.

  8. Mental Disorders Caused by Cerebral Atherosclerosis.

  9. Mental Disorders Caused by Hypertension.



^ 5.3. MATERIALS OF METHODICAL PROVIDING OF EMPLOYMENT (MATERIALS OF CONTROL OF BASE (INITIAL LEVEL) PREPARATION OF STUDENTS):

A. Questions of self-controls:

  1. The reason why psychiatric disorders should not be missed during physical illness.

  2. Associations between physical and psychiatric disorder.

  3. Psychological factors as causes of physical illness.

  4. Psychiatric disorders presenting with physical symptoms.

  5. Psychiatric and physical disorder occurring together by chance.

  6. Associations Between Physical Disorders and Psychiatric Symptoms.

  7. Mental disorders of vascular genesis.

  8. Mental Disorders Caused by Cerebral Atherosclerosis.

  9. Mental Disorders Caused by Hypertension.

B. Tests:

1. The high level of capabilities is named:

A. temperament.

B. character.

C. capability.

D. creation.

*E. talent.

2. A memory disorder in which someone can recall certain information, but they do not know where or how they obtained the information, named:

*A. Retrograde amnesia

B. Gypomnezia.

C. Anterograde amnesia.

D. Traumatic amnesia

E. Lacunar amnesia.


3. A patient actively casts aside ideas about illness and her consequences are possible, estimates the displays of illness as not "serious feelings", that is why renounces an inspection and treatment or limited to "self-treatment". Which type of reacting on illness?

A. Egocentric.

B. Harmonious.

C. Apathetical.

D. Euphoric.

*E. Anosognosia.


4. Purchased organic and global deterioration of intellectual functioning without clouding of consciousness named:

A. Concrete thinking.

B. Abstract thinking.

C. Mental retardation.

*D. Dementia.

E. Pseudodementia.


5. A patient is sure of presence for him of serious illness, constantly concentrated on the sickly feelings, experiencing and continuous talks about illness result in the exaggerated subjective perception of those, that is present and search of pseudo maladies. Desires to treat oneself are combined with disbelief in success. Which type of reacting on illness?

A. Anxiously-depressed.

*B. Hypochondria.

C. Apathetical.

D. Egocentric.

E. Dysphoric.


6. Ability to appreciate nuances of meaning, multidimensional thinking with ability use metaphors and hypotheses appropriately named:

A. Concrete thinking.

*B. Abstract thinking.

C. Mental retardation.

D. Dementia.

E. Volubility.


7. Ability to understand, recall, mobilize, and constructively integrate previous learning in meeting new situations named:

A. Feeling.

B. Perception.

C. Memory.

*D. Intellect.

E. Thought.


8. False belief, based on incorrect experience about external reality, cannot be corrected named:

*A. Delusion.

B. Neologism.

C. Verbigeration.

D. Derailment.

E. Blocking.


9. Literal thinking, limited use of metaphor without understanding of nuances of meaning named:

*A. Concrete thinking.

B. Abstract thinking.

C. Mental retardation.

D. Dementia.

E. Volubility.


10. The inability to recall some memory or memories of the past, beyond ordinary forgetfulness named:

*A. Retrograde amnesia

B. Gypomnezia.

C. Anterograde amnesia.

D. Traumatic amnesia

E. Lacunar amnesia.


11. A psychical process, higher form of creative activity of man through which the most substantial signs of objects and phenomena of the objective world are represented and their intercommunications open up named:

A. Feeling.

B. Perception.

C. Memory.

D. Attention.

*E. Thought.


12. Inborn lack of intellect to a degree in which there is interference with social and vocational performance named:

A. Concrete thinking.

B. Abstract thinking.

*C. Mental retardation.

D. Dementia.

E. Pseudodementia.

C. Situational tasks:

1. A male patient, 37 years old, became too cheerful for no particular rea-son, he has a subjective feeling of high creative abilities, enthusiasm, elation and increased productivity, in spite of manifest disability to concentrate (im­paired attention); his speed of thinking processes is too high. He is uncritical to his state, and finds it normal.

^ Name the syndrome:

A. Manic (non-psychotic) syndrome

B. Syndrome of dysphoria

C. Hypomanic (non-psychotic) syndrome

D. Obsessive syndrome

E. Depersonalization syndrome

2. A male patient 22 years old, complained of the decrease of physical and mental productivity, as well as increased fatigue, weakness, increased need for rest after easy work. He became irritable, impatient and less toler­ate towards people, it is difficult for him to wait even for a short time; he often has headache, sweats easily, feels prickling sensations in the heart re-gion when worries.

^ Name the syndrome:

A. Depressive syndrome

B. Hypochondriac syndrome

C. Asthenic syndrome

D. Paranoia syndrome

E. Obsessive syndrome


3. The patient's mother complains that at night he gets up from bed with open eyes and roams around the room aimlessly with a vacant expression on his face. He walks around the room, opening wardrobes and drawers of the writing table, goes through the things as though looking for something. One day being in this state, he opened the window, got onto the roof and walked near its edge with no signs of fear. All efforts to wake the patient up when he is in such a state are use­less. The patient doesn't remember anything about his night adventures.

^ Name the probable syndrome:

A. Fugue

B. Trance

C. Ambulatory automatism

D. Somnambulism

E. Motor automatism

4. A patient, while making repairs at home, suddenly stood quite still with the painting brush in his hand, then dropped it. This state lasted for a few seconds. After that the patent was rather confused, for some moments he couldn't understand what was happening. He totally forgot the state he was in and the events around him, occurring while he was in that state.

^ Name the syndrome:

A. Obnubilation

B. Trance

C. Fugue

D. Absence (petit mal)

E. Derealisation

5. A male patient 27 years old complained that suddenly and unintention­ally he found himself in a different city. He couldn't understand, how this could happen. During his travel, of which he was completely unaware, he made an impression of a person who was slightly confused and absentmind­ed, absorbed in his thoughts, but his behaviour was more or less normal.

^ Name the probable syndrome:

A. Fugue

B. Trance

C. Clerambault-Kandinsky syndrome

D. Somnambulism

E. Absence (petit mal)

6. At the hospital department the patient suddenly and unconsciously begins to turn round and round, then undresses quickly, throwing his clothes down. This state lasts for approximately one minute, then suddenly ends. The patient does not remember anything he was doing and what was happening during this period.

^ Name the probable syndrome:

A. Fugue

B. Trance

C. Clerambault-Kandinsky syndrome

D. Somnambulism

E. Absence (petit mal)

7. The parents of a 5-year-old child noticed the strange nature of his games. The boy seemed to transform persistently and for long periods of time into different characters, and this was associated with behavioral disorders. For example, pretending to be a dog, the boy asked for a bone, barked and refused to speak with his parents, explaining later, that "dogs don't speak The intelligence level is normal.

^ Name the probable syndrome

A. Overvalued ideas

B. Delusion-like fantasies

C. Delusions of imagination

D. Paranoia syndrome

E. Depersonalisation syndrome

8. Patient of 39 years old, doctor. Constantly something writes and the written hides with application. In a linguistic contact enters reluctantly, suspicious. Told a treating doctor, that opened the method of treatment of AIDS, but «all his developments were stolen by the agents of institute of oncology». Convinces a doctor, that kidnappers «hired three killers, to put to death me».

1. What pathology of thoughtis it?

2. What syndrome?


^ 6. LITERATURE IS RECOMMENDED:

6.1. Basic:

  1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York: Williams @ Wilkins. – 1997.

  2. Psychiatry. Course of lectures. – Odessa: The Odessa State Medical University. – 2005. – 336 p.

  3. Lectures.

  4. Internet resource.

6.2. Additional:

  1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород: Изд-во НГМА, 1998.

  2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.

  3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. – К.: Здоров’я, 2006.   



  


Prepared by assistant S.D.Savka


The review is positive

Reviewer, ass. proff. _________


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