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Ministry of Health of Ukraine

Bukovynian State Medical University


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


for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class

Theme 15: Problems of ecological psychiatry


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

Сhernivtsi, 2009

^ 1. Actuality of theme

Toxic psychoses may he caused by ingestion or inhalation of or continuous contact with a wide variety of substances. The mental symptoms depend not only on the toxic agent but also on the con­ditions under which the person is subjected to the agent. Personal­ity, past experience, age, and other attributes of the patient are also significant factors.

2. Duration of practical classes - 2 hours.


3.1.A student must know:

  • what does study ecological psychiatry;

  • clinical picture of intoxication delirium;

  • clinical picture of intoxication onei­roid;

  • clinical picture of intoxication amentia;

  • clinical picture of twilight stupefaction|

  • clinical picture of paranoid states;

  • clinical picture of manic disorder;

  • treatment of toxic disoders;


^ 3.2. A student must be able:

  • to collect subjective and objective anamnesis;

  • to determine the criteria of toxic disoders;

  • to give first help of toxic disoders.

  • to use the clinical method of research of toxic disoders;.

  • make up plan of treatment of patients.

3.3.To capture practical skills:

  • determination of psychopathological syndromes;

  • to establish psychological contact with patient;

  • to conduct clinical psychological examination.

^ 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.


Psychiatric symptoms in different kinds of poisoning are simi­lar enough. In their clinical course the following syndromes can be observed: consciousness disorders (intoxication delirium, onei­roid, coma, and amentia), paranoid states, and manic disorder . In the full-blown acute syndrome, one sees a restless, suggestible, confused patient in a clouded state of consciousness with a high frequency of visual hallucinations and paranoid tendencies and ideas. The mood is labile, and the person may be predominantly irritable, anxious, fearful, and depressed. The chronic toxic reactions are characterised by intellectual dete­rioration with impairment of orientation and memory.

Intoxication delirium: the patient lays in bed fixed, but the patient unshaven, dirty, "vegetative" tries to rise, tongue is impose with a brown raid, frustration of perception, frustration of thinking are observed. The behaviour of the patient is defined by potent hallucinate experiences. The patient in own person, a place, time is focused. Frustration of perception are shown by true hallucinations, all the images long with a negative shade (draw, mice, rats, cockroaches). Huge value for statement of the correct diagnosis is played with emotional reaction of the patient. The patient defends actively, protected from hallucinate images.

Deeper than delirium form|shape| - oneiric stupefaction of consciousness|intelligent|, - dreamlike panoramic hallucinations|||discords|, which|what| unite|combine| with the conduct after the type of “charmed|bewitched|”, prevail|dominates| in the clinical picture|painting| of which|what|. It is observed|exists| at psychical disorders|discords|, more frequent at schizophrenia.

Complete disorientation|confusion| is|appears| the basic|main| clinical displays of amental stupefaction of consciousness|intelligent| in circumferential and own personality|individual|, fragmentaryness of perception of circumferential, inconsistence of thought, confusion, fearfulness. Patients are uneasy, restless|bustles| within the limits of the limited space. Amention| is finished|ends| by deep amnesia. Develops mainly on a background the heavy|difficult| exhausting somatopathies and is|appears| the sign of heavy|difficult| decompensation of bodily condition|figure,state,camp,mill| and worsens the prognosis of basic|main| disease.

At twilight stupefaction| of consciousness|intelligent|, which|what| is|appears| characteristic|character,typical| for the state|figure,camp,mill| of heavy|difficult| intoxication (at the infectious diseases| febril schizophrenia) a patient is fully confused, contact with him impossible, he can be excited within the limits of bed, original appearance is|appears| characteristic|character,typical| is face|person| of Hippocrates, is accompanied by the grave|difficult| common condition|figure,state,camp,mill| of patient.

For the twilight state|figure,camp,mill| of consciousness|intelligent| is|appears| characteristic|character,typical| outbreak, briefness and rapid|quick,fast| (critical) exit from him, shows up disorientation|confusion| or Riga narrowing of the field of consciousness|intelligent|, often with ability|power| to execute|implements| enough difficult|complex|, but inadequate actions|acts|. Delusions| and hallucinations under act of which|what| a patient can have the flashes of aggressively-destructive excitation is possible. Takes place complete amnesia of period of stupefaction| of consciousness|intelligent|.

Coma is the profoundest degree of clouding of consciousness, in which consciousness is lost and there is no voluntary activity of any kind. Among the various conditions that may produce coma the most common are: encephalitis, cerebral haemorrhage, cere­bral thrombosis or embolism, subarachnoid haemorrhage, intrac­ranial tumour, head injury, postepileptic coma, diabetic coma, hypoglycaemic coma, hypertensive encephalopathy, uremic coma and some others. It is different from the sopor in that all the re­flexes, including the corneal reflex are absent, and the bodily func­tions are impaired.

There are some characteristic features depending on the kind of toxic sub­stance.

The diagnosis of toxic psychosis on a reliable history, psychiat­ric evaluation, physical examination and appropriate laboratory studies. Table shows some of the possible psychiatric side-effects of medicines.

Psychiatric Side-Effects of Drugs




Central nervous system depressants, digoxin, cimetidine, anticholinergic drugs

Psychotic symptoms

Hallucinogenic drugs, appetite suppressants, sympathomimetic drugs, corticosteroids


Antihypertensive drugs, oral contraceptives, neuroleptics, anticonvulsants, corticosteroids, L-dopa, beta-blockers


Antidepressants, corticosteroids, isoniazide anticholinergic drugs

Below we shall talk primarily about poisoning with some of the toxic substances with which people contact in the process of work at different industrial enterprises and other labour circumstances.

Gasoline. Repeated inhaling of gasoline causes extensive sali­vation, drowsiness, weakness, light-hea-dedness, nausea, amnesia, and a sense of physical lightness, spinning, and floating with dis­torted space perception. There may also be hyperacusis and visu­al, auditory and tactile hallucinations. Transient euphoric states can be produced by the inhalation of kerosene vapour.

Solvents. Intoxication with carbon tetrachloride may be associ­ated with motor disturbances, nausea, vomiting, anorexia, depres­sion, apathy, and mental confusion. With continued exposure un­der chronic conditions, kidney and liver damage results. Neurolog­ical and psychiatric symptoms may also be produced by methyl-bromide and methylchloride. The fat solvent disulfide can produce various psychotic states, irritability, loss of memory, disturbed sleep, and terrifying dreams.

^ Metals:

Mercury. Chronic mercury poisoning may be characterised by disturbances of the alimentary tract, renal damage, anaemia, high blood pressure, and peripheral neuritis. The central nervous sys­tem may be involved, with tremors varying in degree. There can be irascibility, depression, despondency, timidity, desire of solitude, and sometimes hallucinations.

Lead. The most consistently harmful effect is on the blood sells, and anaemia is invariably present. Gastrointestinal symptoms are numerous and tend to result from slowly developing intoxication with small quantities of lead over long periods of time. More in­tense exposures result in neuromuscular and central nervous sys­tem effects — considerable wasting of muscles, wrist drop. A most serious condition is lead encephalopathy (organic brain damage) with motor incoordination, ataxia, headache, sleeplessness, and ir­ritability. As this condition develops, there may be increased in­tracranial pressure, convulsions, excitement, confusion, delirium, lethargy, and coma. Patients who die may have edema of the brain and signs of proliferative meningitis. The survivors may be perma­nently impaired, mentally.

Tetraethyl lead and tetramethyl lead (found in leaded gasoline) in chronic poisoning may produce early symptoms of sleeplessness with terrifying dreams, loss of appetite, nausea, vomiting, head­ache, weakness, and emotional lability. The victims are irritable, restless and anxious. More serious manifestations include delirium, delusional states and maniacal excitement, later — convulsions or coma.

Manganese. The source of manganese toxicity is exposure to manganese-containing dusts. The most frequent early symptoms are headache, weakness, increased sleepiness, spasms in the legs, joint pains and irritability. There may be psychomotor irritability associated with impulsive acts such as a deep desire to walk and to work. Euphoria, absent-mindedness, mental confusion, aggres­siveness, and hallucinations may also be present. Chronic toxicity is characterised by neurological lesions, headache, back pains, equi-libratory disturbances, unintelligible and monotonous speech, trem­ors, immobility of facial expression, and uncontrollable laughter.

Classification. According to ICD-10 toxic mental disorders are included in the group of "Organic, including symptomatic, mental disorders" (F 00 — F 09) and coded according to the leading syn­drome.

The treatment of toxic disorders begins with removing the pa­tient from the source of poison. Further methods depend on the to­xic substance and way of its entering the organism. Detoxification methods are studied in more detail, in the courses of general medi­cal substances.


1. What does study ecological psychiatry;

2. Clinical picture of intoxication delirium;

3. Clinical picture of intoxication onei­roid;

4. Clinical picture of intoxication amentia;

5. Clinical picture of twilight stupefaction|

6. Clinical picture of paranoid states;

7. Clinical picture of manic disorder;

8. Treatment of toxic disoders;

^ 5.3. Practical tasks on the class:

1. To collect anamnesis, clinical psychopathological examination of patients with toxic disoders

2. Make up plan of examination and treatment of patient with toxic disoders

3. To solve tests and tasks.

5.4. Material for self-contrrol.

A. Questions of self-controls:

1. What does study ecological psychiatry;

2. Clinical picture of intoxication delirium;

3. Clinical picture of intoxication onei­roid;

4. Clinical picture of intoxication amentia;

5. Clinical picture of twilight stupefaction|

6. Clinical picture of paranoid states;

7. Clinical picture of manic disorder;

8. Treatment of toxic disoders;

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?


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.

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


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