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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 22: stress-related psychosis.


MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


Topical module 5. Neurotic, stress-related and somatoform

disoders.


Сhernivtsi, 2009

1. Actuality of theme:

Doctors see many patients with emotional or other symptoms that are reactions to stressful experiences. Although such reactions in most cases are not severe enough to be diagnosed as mental disorders, they are distressing enough to require help and, if no help is given, they may worsen and develop into mental dis­orders. Therefore it is important to understand the nature of reac­tive psychosis (stress-related psychosis) and to be able to provide appropriate treat­ment.

Reac­tive psychosis (stress-related psychosis) – transitory disoders of psychical activity result in psychical trauma. In it clinical picture symptoms of psychotic level are present.


2. Duration of practical classes - 2 hours.


3. ^ EDUCATIONAL PURPOSE

3.1. To know:

  1. The notion emotional stress, psychical trauma.

  2. Criteria of Karl Jaspersa.

  3. Classification of reactive states.

  4. Clinical manifestations of reactive states.

  5. Features of passing of reac­tive psychosis.

  6. Differential diagnosis of reactive states.

  7. Treatment and prophylactic of reac­tive psychosis.

  8. Expertise of reac­tive psychosis.


3.2. Able:

  1. To collect anamnesis in patient with reac­tive psychosis.

  2. To diagnose and conduct differential diagnosis of reactive states.

  3. To give urgent help at shock reactions after extreme situation.

  4. To use methods of treatment of reac­tive psychosis.

  5. To conduct prophylactic of reac­tive disoders.

  6. To conduct prophylactic of panic.


3.3. To capture practical skills:

  1. To give urgent help at psychogenic stupors.

  2. To give urgent help at fugiform excitement.

  3. To give urgent help at psychogenic delirium.



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


Names of previous disciplines

Skills are got

1. Anatomy of human


2. General and medical psychology.


3. Normal and pathologic physiology.

1. To know structure of brain.


2. Determine type personality. Determine criteria of clear consciousness.

3. Determine type HNA.


5. Advices to students.


5.1. ^ CONTENTS OF THEME.

The symptoms of psychogenic disorders can be productive (de­lusions and hallucinations, etc.) and negative. To differentiate psy­chogenic productive symptoms from other similar manifestations the famous psychiatrist and psychologist Karl Jaspers suggested the following diagnostic criteria:

1) the disorder develops follow­ing a psychological trauma;

2) the contents of the patient's experiences (e.g. delusions) proceeds from the nature of the stressful event and there is psychologically understandable association between them;

3) all the course of the disorder is associated with the traumatic situation, and its disappearance or de-actualization promotes the cessation (or improvement) of the disorder.

Psychiatrists have long recognized that otherwise well-functioning people may develop psychotic symp­toms when they are confronted with overwhelming stress. In certain cultures, symptoms conform to cer­tain patterns that are recognized by the individual's group as a valid signal of the person's distress. In Western society, several forms of presentation of brief reactive psychosis have been described, and terms such as reactive psychosis, psychogenic psychosis, and hysterical psychosis have all been applied to basi­cally similar reactions.

Unfortunately, a tendency to lump all “psy­chotic” disorders together has interfered with the rec­ognition and understanding of brief reactive psychosis and has often stood in the way of appropriate treat­ment. For example, the term “3-day schizophrenia” has been used to describe brief psychotic illnesses such as those seen in young soldiers involved in combat operations in the South Pacific during World War II. On occasion, massive doses of psychotropic drugs were used, and the remarkable clearing of symptoms was subsequently attributed incorrectly to the drug therapy.

Symptoms and Signs

Reactive psychosis subdivided into three groups: acute, subacute and prolonged.

^ I. Acute reactive psychosis: twilight state; reactive stupor; reactive confusion; reactive paranoid.

Acute twilight state – appears on the background of fear with mimic and vegetative signs, panic flight from place, where happened any unhappy event (catastrophe, traffic accident, place of death). It has duration from 1 hour to 1 day.

^ Acute reactive stupor – that state from oligokinesia to total absence of movements. Mutism (muteness) is revealed often too. It has duration from several hours to 3 days.

Acute reactive confusion – that state twilight disoder of consciousness with psychomotor excitement, fear, constantly verbal production.

Acute reactive paranoid – develops acutely with fear, anxiety, paranoid ideas of relation and persecution. The components Kandinski-Clerambault’s syndrome may be (syndrome of psychic automatism).

^ II. Subacute reactive psychosis (hysteric psychosis): hysteric twilight state; pseudodementia; Ganser’s syndrome; hysteric regress of psychic; hysteric stupor; like-mirage syndrome.

Clinical picture of pseudodementia: patients are giving wrong answers especially, not right fulfilling simple action, usually all actions they are making inside out (white colour they name black colour etc.), exaggeratedly mood and foolish.

Other subacute reactive psychosis are found rarely.

III. ^ Prolonged reactive psychosis: reactive depression (paranoid depressive, asthenic depressive and hysteric depressive forms) and reactive paranoid.


Brief reactive psychoses may take many forms, but they always have certain features in common. First, there is a precipitating stress. This may be quite obvious, eg, an automobile accident, natural catas­trophe, combat, or the sudden death of a loved one. In other patients, the precipitating event may not be im­mediately apparent to an outside observer who is una­ware of the psychologic significance of the event to the patient. The patient's personality structure is an important consideration in determining how much stress is necessary to precipitate a psychotic reaction. Patients with certain personality disorders (eg, histrionic or borderline personality) may be prone to develop psy­chotic symptoms more easily. It should be noted that the psychosocial stressor must be sufficiently severe to provoke signs of distress in almost anyone in order for the diagnosis of brief reactive psychosis to be war­ranted.

The second feature common to reactive psy­choses is abrupt onset of symptoms, often within a few hours of the precipitating event. There is no history of a gradually developing prodrome, as is often seen in schizophreniform disorder or schizophrenia.

The psychotic symptoms themselves may be of various types. Delusions, hallucinations (auditory hal­lucinations are common but visual hallucinations occur occasionally), loose or disconnected verbaliza­tion, and bizarre and disorganized behavior are all possible. These symptoms are often dramatic and florid and are usually thematically related to the pre­cipitating event.

^ Natural History and Prognosis

The duration of the disorder is brief (no longer than 2 weeks), and there is no residual deficit. How­ever, many patients will have repeat episodes in re­sponse to future stresses, especially if a basic person­ality disorder leads to a maladaptive life-style that subjects the individual to intolerable situations.

^ Differential Diagnosis

Brief reactive psychosis may be distinguished from various other mental disorders. The presence of toxic factors, such as withdrawal from alcohol or drugs, should be ruled out by appropriate history tak­ing, physical examination, and laboratory tests. Schizophreniform disorder generally lasts longer than 2 weeks, and this diagnosis may be considered if symptoms persist. If prominent affective symptoms are present after 2 weeks, a diagnosis of affective or schizoaffective disorder may be warranted. In schizo­phrenia, the patient should show signs of a chronic disorder without a return to the level of functioning seen before the onset of illness. Some schizophrenic patients with chronic, low-level symptoms may ex­perience a brief worsening of psychotic symptoms in response to stress; this should not be diagnosed as brief reactive psychosis. If no precipitating event can be identified but symptoms clear within 2 weeks, a diag­nosis of atypical psychosis may be appropriate. Tran­sient psychotic symptoms may be present in patients with borderline or schizotypal personality disorders, but these are fleeting and not associated with a clear psychosocial stressor. A few patients may present with factitious symptoms or may be outright malingerers.

Etiology and Pathogenesis

Brief reactive psychosis is thought to be mainly psychologic in origin (rather than social or biologic), although the latter factors probably contribute. When confronted with a stressful situation, the natural re­sponse is to use familiar problem-solving behavior patterns either to achieve a resolution or to maintain psychologic equilibrium until external events change. If an individual's usual coping strategies are not effec­tive, anxiety increases. Psychotic symptoms may emerge when the patient's psychologic defenses are completely overwhelmed. How much stress is neces­sary to reach this point is partly determined by the patient's structure of defenses. For some patients, only chaotic events such as natural disasters or combat experiences are severe enough to upset the equilib­rium; other people may be overwhelmed by divorce, physical illness, or financial disaster. Some patients with character defects (personality disorder) may be unable to cope with transitions or disappointments that most other people would be able to handle, even though they might find them unsettling.

Besides signaling psychologic collapse, brief reactive psychosis may provide secondary gain for the patient and may become a regular method of evading responsibility or unpleasant circumstances in the fu­ture. The dramatic psychotic symptoms make it clear to others that the patient is helpless. Since the symp­toms are accepted as part of legitimate illness and not as evidence of shirking, others can rush in to the rescue without having any negative feelings toward the pa­tient. In patients confronted with a chronically intoler­able situation, occasional emotional collapses when the situation gets worse provide a brief escape.

Treatment

A. Drug Treatment: The treatment of psychotic symptoms should be approached conservatively and should be individualized for each patient. Psy­chotropic medications have a place in controlling agi­tation and insomnia. If brief reactive psychosis is sus­pected initially, neuroleptic medications should be limited to short-term use only and then only when absolutely necessary. If the diagnosis is suspected after neuroleptic treatment has already started, medications should be discontinued as soon as possible. Symp­tomatic treatment with benzodiazepines (which are not associated with the risk of tardive dyskinesia) will often make the patient more comfortable, although these agents may not relieve all symptoms in some patients.

B. Psychologic Treatment: Psychologic treat­ment may take several forms. Simply being removed from the crisis and having the care and attention of the hospital staff may allay the patient's anxiety enough to permit constructive discussion and problem solving. Once the resources of the staff become available, the stress may no longer seem overwhelming. Enlisting the aid of family members may also be important for the same reason. In individual psychotherapy, en­couraging the patient to recount the events that led to the breakdown and to discuss their impact and meaning will facilitate recovery. Such discussion has 2 effects: It allows the patient to control anxiety by breaking down the experience into understandable units, and it offers the patient a model for dealing with crises in the future. Longer-term psychotherapy directed at more fundamental psychologic conflicts may be indicated for some patients.


^ 5.2. Theoretic QUESTIONS:


1. The definition of notion “emotional stress”, “psychical trauma”.

2. Criteria of Karl Jaspersa.

3. Classification of reactive states.

4. Etiology and pathogenesis of reac­tive psychosis.

5. Clinical manifestations of acute reactive psychosis.

6. Clinical manifestations of sub acute reactive psychosis.

7. Prolonged reac­tive psychosis.

8. Clinical picture of reactive depression.

9. Clinical picture of reactive paranoid.

10. Differential diagnosis of reactive states.

11. Treatment and prophylactic of reac­tive psychosis.

12. Urgent help at shock reactions after extreme situation.


^ 5.3. Practical tasks on the class:

1. To collect anamnesis, clinical psychopathological examination of patients with reac­tive psychosis.

2. Make up plan of examination and treatment of patient with reac­tive psychosis..

3. To solve tests and tasks.


5.4. Material for self-contrrol.


A. Questions of self-controls:

1. Classification of reactive states.

2. Etiology and pathogenesis of reac­tive psychosis.

3. Clinical manifestations of acute reactive psychosis.

4. Clinical manifestations of sub acute reactive psychosis.

5. Prolonged reac­tive psychosis.

6. Clinical picture of reactive depression.

7. Clinical picture of reactive paranoid.

8. Differential diagnosis of reactive states.

9. Treatment and prophylactic of reac­tive psychosis.


B. TESTS:

1. Etiological factors of reac­tive psychosis are:

A. Biological

B. Psychological

C. Social

D. All above mentioned

E. Phisical


2. Specific clinical signs of reac­tive psychosis are:

A. Karl Jasper’s syndrome

B. Kandinski-Clerambault’s syndrome

C. Korsakoff’s syndrome

D. Paranoid syndrome

E. All mentioned

3. Acute reactive psychosis are:

A. Twilight state

B. Reactive stupor

C. Reactive confusion

D. Reactive paranoid

E. All above mentioned

4. On the background of fear with panic flight does appear:

A. Acute twilight state

B. Acute reactive stupor

C. Acute reactive confusion

D. Acute reactive paranoid

E. Acute hallucinosis

5. State from oligokinesia to total absence of movements with mutism are specific for:

A. Acute twilight state

B. Acute reactive stupor

C. Acute reactive confusion

D. Acute reactive paranoid

E. Acute hallucinosis

6. Psychomotor excitement with fear, constantly verbal production are specific for:

A. Acute twilight state

B. Acute reactive stupor

C. Acute reactive confusion

D. Acute reactive paranoid

E. Acute hallucinosis

7. Fear with anxiety, paranoid ideas of relation and persecution are specific for:

A. Acute twilight state

B. Acute reactive stupor

C. Acute reactive confusion

D. Acute reactive paranoid

E. Acute hallucinosis

8. Subacute reactive psychosis are:

A. Twilight state

B. Pseudodementia

C. Ganser’s syndrome

D. All above mentioned

E. Delirium

9. Clinical signs of pseudodementia are:

A. Wrong answers

B. Not right actions

C. Foolish

D. All above mentioned

E. Hallucinatoins

10. Prolonged reactive psychosis are:

A. Paranoid depressive

B. Hysteric depressive

C. Asthenic depressive

D. All above mentioned

E. Hallucinatoin paranoid


  1. Situational tasks

1. During fire of own house patient lost speech suddenly. He is without movements, pale, his eye is widely opened, tachycardia. Amnesia of above mentioned situation. Determine psychopathological disoder.

2. Woman P, 35 old year, economist. After arrest she is giving wrong answers on questions, not right fulfilling simple action, has exaggeratedly mood and foolish. Determine psychopathological disoder.

3. After fire girl ran out from the house on the street. She was fulfilling many unsuitable movements, asked for help. Her skin is pale, hypertension, tachycardia, amnesia of morbidity state. Determine form of psychomotor excitement.

^ 6. RECOMMENDED LITERATURE IS:

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


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