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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 14: Mental disorders at infectious violations and at cranial-cerebral trauma


MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


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


Сhernivtsi, 2009

^ 1. Actuality of theme

The symptoms and clinical course of mental disorders in infectious diseases depend on the nature of infectious disease, its stage, specific reactions of the patient's nervous system to it, and on the localization of the pathologic process. Mental disorders occur both in general infections, and in the infections of the central nervous system.

That is why it is very important for the doctor of every profession to know mental disorders at infectious violations and at cranial-cerebral trauma.


2. Duration of practical classes - 2 hours.


^ 3. EDUCATIONAL PURPOSE


3.1.A student must know:

  • the reason of mental disorders in infection disease;

  • acute exogenous reactions (by K.Bonhoeffer);

  • clinical courses of mental disturbances in infectious diseases;

  • irreversible psychiatrical disorders with organic brain damage;

  • classification of mental disturbances in infectious diseases in ICD-10.

  • classification of mental disturbances due to traumatic brain injuries;

  • psychological effects in the acute (primary) stage of TBI;

  • psychological effects in the subacute (secondary) stage of TBI;

  • psychological effects in the period of reconvalescence.

 

^ 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.

It should be mentioned that increasingly sensitive techniques for detection of nucleic acids have revealed that the central nervous system (CNS) is susceptible to infection to a degree higher than previously thought. Thus, latent (as opposed to productive) infections are now more easily detected than in the past and reveal the presence of neurotropic and neurovirulent pathogens. In most cases, these CNS infections result in non-specific organic symptoms such as headache, impairment of consciousness, or seizures. Some infectious agents, however, have a particular neurotropism and can cause specific psychopathology.

Infectious diseases give rise to brain dysfunction either by direct invasion of the brain, or by toxic, hypoxic, or allergic effects of infection elsewhere in the body.

Karl Bonhoeffer (a well-known German psychiatrist, 1861-1949), attributed infectious psychoses to symptomatic (organic) psychoses or acute exogenous reactions. They are: delirium, amentive disorder of consciousness, twilight states, hallucinosis, epilepsy-like agitation and some others.

Mental disturbances in infectious diseases can have the following clinical courses:

a) transient (short-term) psychoses that are confined to disturbances of consciousness: sopor or coma, delirium, amentive disorder of consciousness, twilight states, epilepsy-like agitation, or oneiroid;

b) prolonged (lingering) psychoses that do not include changes of consciousness hallucinosis, paranoid states, apathetic stupor, or memory disorders with confabulations;

c) irreversible psychiatrical disorders with organic brain damage — dementia, amniotic syndrome or others.

Transient psychoses are short-term, they do not have any serious after-effects for the patient. They usually occur in acute infectious illnesses.

Delirium is one of the disorders of consciousness, it is the most frequent type of the central nervous system reaction to infection, especially in childhood and adolescence. Delirium in modern classifications is attributed to organic psychiatric disorders, but unlike dementia or amnestic syndrome it is short-term and reversible. impairment of consciousness is the most important symptom of delirium, which is recognised by disorientation, that is uncertainty about the time of day, the place in which the patient finds himself, and the identity of other people. Patients with impaired consciousness are slow to respond and have impaired concentration. Their behaviour may be overactive, with noisiness and irritability, or underactive, with slowness, reduced speech, and perseveration. Behaviour depends on the content of hallucinations the patient may have. Sleep is often disturbed. Mood changes are common. Visual perception may be distorted. Illusions, misinterpretations, and, particularly, visual hallucinations are frequent, and the content may be elaborate. Memory disturbance affects registration, retention, recall, and new learning. Insight is impaired.

In infectious diseases delirium can have specific features, depending on the kind of infection, the patient's age, and the state of his/her nervous system. The symptoms of delirium usually increase in the evening and at night. The content of hallucinations can be different: patients can see scenes of fire, destruction, crowds of people; it may seem to them that they are travelling, or are witnesses of some interesting events or terrible catastrophes. Painful sensations in different parts of the body (caused by the disease) have an important role in forming the content of hallucinations: it may seem to the patient, that his/her leg is being amputated, or someone is stabbing his chest with a knife. Professional delirium is common enough: the patient carries out actions that he/she usually does at his/her working place.

Amentive state of consciousness occurs usually in chronic emaciating diseases, it is a reaction if the weakened nervous system to the harmful influences of the disease. The impairment of consciousness is deeper, the disorientation concerns both self and the environment. Thought and speech are incoherent, confusion prevails. Hallucinations are fragmental, the patients often experience fear and anxiety, are agitated and manifest chaotic excitation within the limits of the bed.

Other disturbances of consciousness, such as oneiroid or twilight states are less frequent in infectious diseases. Classification of mental disturbances in infectious diseases.

In ICD-10 mental disturbances in infectious diseases are included in part F 00 — F 09 "Organic, including symptomatic, mental disorders", and classified (coded) according to the prevailing syndrome (delirium, amnestic syndrome, hallucinosis, delusional, affective, anxiety disorder, or behavioural disorder).

All the traumatic brain injuries can be divided into open (when the skin and external integuments are damaged, the scull is fractured and the brain is uncovered) and closed (injuries in which the brain remains covered by integuments). According to the mechanism they can also be classified into commotion (the most frequent kind of brain trauma, which makes 57% of all TBI), contusion (18%), compression (8%) and combined brain injury.

In the clinical course of TBI four stages are distinguished: the acute or primary stage; the sub-acute or secondary stage; recon-valescence stage and the stage of remote after-effects (or residual stage).

It is convenient to divide mental disorders, which develop as the result of TBI, according to the stages of the clinical course.

Psychological effects in the acute (primary) stage are characterised, first of all, by quantitative changes of consciousness (traumatic coma, sopor or somnolence). Impairment of consciousness occurs after all but the mildest closed injuries but is less common after penetrating injuries. The cause is uncertain but is probably related to rotational stresses within the brain.

^ Traumatic coma is characterised by a profound loss of sdousness, absence of voluntary motor activity, and failure t spond to stimuli. Coma is usually regarded as severe and prolonged if it persists for more than 2 hours.

In the subacute {secondary) stage, traumatic coma may be folowed by stupor, traumatic delirium, epileptiform seizures, twillight states, or Korsakoff's (amnestic) syndrome.

After severe injury there is often a prolonged phase of delirium, sometimes with disordered behaviour, mood disturbance, hallucinations, delusions, and disorientation. On recovery of consciousness, defects of memory are often apparent.

^ Korsakoff's Syndrome (amnestic-confabulatory) may follow an acute delirium, twilight state, or stupor. Such patients have conspicuous memory loss. Confabulation is often employed to compensate for this deficit. In addition, confusion, severe disorientation and amnesia for recent events are present.

In the period of reconvalescence patients may develop acute or prolonged traumatic affective or affective and delusional trauma psychoses, which sometimes have a tendency to periodical course.

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.


^ 5.3. QUESTIONS OF CONTROLS:

  1. The reason of mental disorders in infection disease.

  2. Acute exogenous reactions (by K.Bonhoeffer).

  3. Clinical courses of mental disturbances in infectious diseases.

  4. Irreversible psychiatrical disorders with organic brain damage.

  5. Classification of mental disturbances in infectious diseases in ICD-10.

  6. Classification of mental disturbances due to traumatic brain injuries.

  7. Psychological effects in the acute (primary) stage of TBI.

  8. Psychological effects in the subacute (secondary) stage of TBI.

  9. Psychological effects in the period of reconvalescence.


^ 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 of mental disorders in infection disease.

  2. Acute exogenous reactions (by K.Bonhoeffer).

  3. Clinical courses of mental disturbances in infectious diseases.

  4. Irreversible psychiatrical disorders with organic brain damage.

  5. Classification of mental disturbances in infectious diseases in ICD-10.

  6. Classification of mental disturbances due to traumatic brain injuries.

  7. Psychological effects in the acute (primary) stage of TBI.

  8. Psychological effects in the subacute (secondary) stage of TBI.

  9. Psychological effects in the period of reconvalescence.


B. Tests and tasks:

1. A male patient, 37 years old, became too cheerful for no particular reason, 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. After a head injury that the patient had 5 years ago he developed affec-tive disturbances: suddenly and for no serious reason he feels anger. His mood during these periods is characterised by tension, depression combined with anger or even rage, high irritability with a tendency to aggressive actions.

^ Name the syndrome:

A. Phobic syndrome

B. Dysphoric syndrome

C. Depressive syndrome

D. Manic syndrome

E. Asthenic syndrome

4. At the inpatient department of a psychiatric hospital a female patient is passive, inert and is never involved in any activities on her own accord. Does some primitive work (makes cardboard boxes), but constantly needs induce­ment and activation. She is completely indifferent to the situation in the de­partment, to the members of her family and her own situation, does not care about being discharged from the hospital or left at the department for a longer time.

^ Name the probable syndrome:

A. Asthenic syndrome

B. Apathetic and abulic syndrome

C. Organic brain syndrome

D. Encephalopathic syndrome

E. Depressive syndrome


5. In a month after having flu the patient began to complain of persistent headaches, sleep and eating disorders; other complaints were irritability for no serious reason and emotional instability. Gets exhausted quickly, feels tired even after 20 or 30 minutes of conversation with the psychiatrist. Practically isn't able to read books, because can not concentrate, is easily distracted to other subjects. Is critical to the state of his health, understands that is ill and needs treatment.

^ Name the probable syndrome:

A. Apathetic syndrome

B. Neurotic syndrome

C. Hysterical syndrome

D. Asthenic syndrome

E. Organic syndrome


6. The observed patient's movements are retarded, she doesn't react to the attempts to contact her, answers no questions. Sometimes she spontane­ously stays in strange postures. It is possible to set (form) her body and limbs into different positions artificially. For instance, if the psychiatrist lifts her arm or leg, so that she remains standing on the other leg, the patient can stay in such an inconvenient position for quite a long time.

^ Name the probable syndrome:

A. Depressive stupor

B. Apathetic stupor

C. Psychogenic stupor

D. Catatonic stupor

E. Neurotic stupor


7. At the psychiatric department the patient monotonously walks along a corridor wall, doing a certain number of paces. Then he stops, makes a decisive gesture with his hand, calls out a senseless phrase and sharply turning round walks the same number of paces along the corridor and again re­peats the same gesture and phrase. He repeats this type of behavior several times, and it is impossible to stop him because he shows resistance. Name the probable syndrome:

A. Catatonic syndrome

B. Manic syndrome

C. Hebephrenic syndrome

D. Heboid syndrome

E. Hysterical syndrome

8. At the psychiatric department the patient has no motivation, no incen­tive, and no wishes. She doesn't speak to anybody, spends all her time in bed, fencing herself from others with a blanket. Eats only if she is led to the table under compulsion and fed with a spoon. Often urinates in bed and has no initiative to ask someone to change her bedclothes.

^ Name the probable syndrome:

A. Organic syndrome

B. Apathetic-abulic syndrome

C. Asthenic syndrome

D. Depressive syndrome

E. Catatonic syndrome


9. A male teenager (15 years old) with a normal level of intelligence and no conduct disorders before the age of 14, is characterized by rudeness, neg­ativism, perverted emotional reactions and drives with antisocial tendencies. His attitude to others, especially members of his family, is often cruel, he seems to enjoy hurting people. At school he sometimes bites or pinches girls painfully, and says that he does this because he "likes them." He often of­fends and beats his grandmother and mother, when they "irritate" him.

^ Name the probable syndrome:

A. Hebephrenic syndrome

B. Hyperkinetic syndrome

C. "Wildness"

D. Alienation

E. Heboid syndrome


10. A male patient, 51 years old, is sure that he has a serious incurable illness. He presents several physical complaints (unpleasant feelings in his chest and stomach, constipation, etc.) and regularly consults all the medical specialists in the outpatient department. He doesn't believe them, when they assure him that the results of investigations are normal. The patient is sure that a horrible diagnosis is being concealed from him. Demands more addi­tional investigations and a professor's consultation.

^ Name the probable syndrome:

A. Hysterical syndrome

B. Hypochondriac syndrome

C. Depressive syndrome

D. Paranoia

E. Overvalued ideas


11. The patient consulted a psychiatrist with a complaint of being what he called "too pedantic." He told the doctor that he simply couldn't begin doing any work without putting all his instruments symmetrically. "Recently I had to repair my car, but was putting the wrenches and screw drivers sym metrically instead." Conflicts often occurred in the family about trifles: the patient insisted that all the things had to lie symmetrically. Otherwise he felt discomfort and nervous tension.

^ What is the probable syndromal diagnosis?

A. Depressive syndrome

B. Obsessive-compulsive syndrome

C. Asthenic syndrome

D. Cotard's syndrome

E. Dysmorphomanic syndrome


12. A 17-year-old girl, after her mother's serious illness became anxious and irritable. Waited impatiently for the classes to be over, then ran home as fast as possible, imagining the horrible picture of her mother's death. Her heart palpitated, she felt heaviness in the stomach and trembled all over. The girl got calm again only when she saw that her mother was well.

^ What is the syndromal diagnosis?

A. Cotard's syndrome

B. Asthenic syndrome

C. Depressive syndrome

D. Obsessive-phobic syndrome

E. Syndrome of overvalued ideas


13. The patient had consulted the psychiatrist several times. During this visit the complaints were as follows: the state occurred acutely, she felt that her body had changed "as if it was not hers", her voice became "somehow different." As she stood at night near the window, she suddenly saw her body as if from aside, and "felt the experiences and sensations of both bodies si­multaneously." The patient told the psychiatrist that all night she seamed to "live double life."

^ What is the syndromal diagnosis?

A. Apathetic syndrome

B. Derealisation syndrome

C. Depersonalisation syndrome

D. Paraphrenic syndrome

E. Visual hallucinosis syndrome

14. At the psychiatric department the patient is lively and cheerful, her eyes shine, and her mood is elevated almost all the time. Her clothes look rather extraordinary: the slippers are decorated with bows and a lot of cot­ton wool balls are sewn all over her jersey. Her hair is made into a strange coiffure, her lips are painted with bright lipstick. The patient is excessively energetic and restless, she intrudes into every activity going on at the depart­ment, dances, sings, makes sexually advances to male visitors of the depart­ment. Seems never to get tired, sleeps only for 3 or 4 hours at night, her appe­tite is increased. Speaks very quickly, with no pauses, can't keep one line of conversation, and constantly "skips" from one topic to another.

^ Name the syndromal diagnosis.

A. Catatonic excitation

B. Manic syndrome

C. Hebephrenic excitation

D. Hyperbulic syndrome

E. Hysterical syndrome


15. The patient is excited and restless, incessantly walks around the room, wrings her hands, weeps and groans. There is an expression of fear on her face. Asks the people around her to save her family, which is sure to be in great danger. Promises to give the people much money for rescuing her rela­tions. The personnel can't dissuade her: the patient stays extremely anxious. Couldn't sleep for two nights, and hasn't eaten any food for three days, say­ing, "How can I eat, when my dear ones are dying?" Tried to commit sui­cide.

^ Name the syndromal diagnosis.

A. Hypochondriac syndrome

B. Anxiety and depressive syndrome

C. Agitated depression syndrome

D. Masked depression syndrome

E. Catatonic syndrome

16. 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?


^ 8. LITERATURE IS RECOMMENDED:

8.1. 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.

8.2. 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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