Ministry of Health of Ukraine Bukovynian State Medical University icon

Ministry of Health of Ukraine Bukovynian State Medical University

Скачати 64.39 Kb.
НазваMinistry of Health of Ukraine Bukovynian State Medical University
Розмір64.39 Kb.

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 8: Will and attention disorders


Topical module 2. General psychopathology

Сhernivtsi, 2009

1. Actuality Aim

A man from the moment of birth has the simplest, and afterwards difficult (social) necessities, which matter not only for support of homeostasis but also for self-determination in the conditions of social environment. Realization of necessities would be impossible without reasons and different kinds and forms of activity of, which are directed on achieving a certain goal, that satisfaction of necessities. Such purposeful psychical activity got the name of will. Purposeful activity of man is conscious and includes the picture of eventual or supposed results.

Disorders of volitional sphere of activity are observed not only in the clinic of psychical illnesses but also for patients with a disease internal organs, surgical, skin, infectious and other illnesses. To the student, future doctor, which begins to obtain knowledge, practical skills and abilities in clinics, it is necessary to master the basic forms of disorders of will, able them to diagnose, to give urgent help at the extreme states.


2.1. To know:

  • determination of will;

  • classification of actions;

  • stages of difficult volitional action;

  • determination of train;

  • classification of volitional disorders;

  • clinical displays of parabulias and their diagnostic value;

  • clinical displays of pathological actions;

  • classification of disorders of trains;

  • classification and clinic of tribe disorders;

  • determination of attention and its violation.

    1. Able:

  • to define the presence of disorders of volitional sphere;

  • to find out hypobulia, hyperbulia, abulia;

  • to find out the presence of parabulia;

  • to diagnose pathological actions;

  • to diagnose disorders of trains;

  • to diagnose the different forms of sexual perversions;

  • to find out psychomotor excitation;

  • to conduct the differential diagnosis of different types of excitation;

  • to find out disorders of attention.

    1. To capture practical skills:

  • to collect subjective and objective anamnesis;

  • to find out beginning of psychical disease;

  • to describe disorders of volitional sphere and attention;

  • to organize retaining of patient at excitation for introduction of medical


  • to find out a suicidal conduct for patients.


On practical tutorial a teacher comes into notice of students on practical activity of doctor, improvement of own qualities, necessities, interests and ideals. Consciousness of man not only represents reality but also creates it. A doctor not only finds out ту or other pathology (diagnostics), he treats a patient, deprives him sufferings. Must a doctor be peculiar independence in working out problems, self-control and self-possession in the moments of unexpected complications, unforeseen obstacles.

^ 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 will and attention.


A volitional (purposeful) action is a kind of mental (physical) activity, directed at achieving a consciously set aim, which often involves overcoming obstacles and in which the result of the action is presupposed. Volition (willpower) is a person's capability to self-determination and self-regulation of his/her activities and mental processes.

Volitional behaviour, as well as other forms of behaviour, is based primarily on different needs (both biological and psychological), but it also can be motivated by interests and values (ideals).

A volitional action has a number of stages. At the first stage the person becomes aware of some certain need. A conscious need is called a wish (desire). Then the individual analyses, whether it is possible and appropriate to fulfill this need. In the Ukrainian (and Russian) psychological tradition this stage is called the "motives struggle", because the person has to choose between different motives (for example, wanting to go and have a meal and a need to attend a lecture). Eventually he/she makes a choice, comes to a

certain decision and sets the goal. After that he/she creates a plan of action. When the plan is ready, the person carries out the action. But this might not be the end. He/she has to assess the outcome of their activities and determine whether the goal was achieved. If not, he/she will have to repeat the procedure beginning with one of the stages. It may be necessary to change the decision, revise the goal or work out a new plan. The quality of willpower is obviously assessed from the last stage of the volitional action — its fulfillment, and not the intentions the person has.

Thus, the scheme of a volitional action looks as follows:

1. Wish

2. "Motives struggle"

3. Decision

4. Goal setting

5. Plan

6. Action

A drive is a motivation that is assumed to be primarily biological, such as hunger. Drives are also called instincts, but the first term is preferred in contemporary psychology. Motive usually refers to psychologically and socially based needs which are generally assumed to be learned through personal experience.

Different psychologists mark out different principal drives or instincts. In most cases they speak of drives to: self-preservation (defense), hunger and thirst, sex and rearing the young.

Freud in his psychoanalytic theory discussed two drives (sexual, or Eros, and aggressive, or Tanatos) as having the greatest influence on the human behavior.

Motor Disturbances. Abnormalities of facial expression, posture, and social behaviour are common in mental disorders of all kinds. Motor symptoms can be divided into pathology of the volitional activities, and involuntary movement disorders, that include hyperkinesis (increased activity) and hypokinesis (decreased activity). Hyperkinetic movements are manifested in the form of tics, choreiform movements, and dystonia. Tics are irregular repeated movements involving a group of muscles, for example a sideways movement of the head. Choreiform movements are brief involuntary movements which are co-ordinated but purposeless, such as grimacing or movements of the arms. Dystonia is a muscle spasm, which is often painful and may lead to contortions. Epileptic or other kinds of convulsions (see lecture 9) involuntary crying or laughing also belong to involuntary activity. Hypokinesis is manifested in slow and limited activity (bradykinasia). It is characteristic for parkinsonism. Involuntary movements disorders occur more often in neurological disorders.

^ Disturbances of Volitional Actions can develop at any stage of the volitional action: at the level of motivation (wish, drive), at the level of intellectual component of the action ("struggle of motives", goal-setting, planning) and at the level of realization (action). The general classification of volitional processes pathology is shown in Table 3.

Abulia is absence of willpower or wish-power, pathological absense of wishes or motivation to activity. Abulia usually causes adinamia — decrease of movements in a patient. It occurs in different mental disorders, especially schizophrenia, depression. Total abulia is rare, the more frequent disorder is hypobulia that manifests usually in weak motivation, inertia, listlessness and motor retardation - slowing down and decrease of the number of movements.

Absence of movements is sometimes called stupor in psychiatry. Stupor refers to a state in which the person is mute, immobile, and unresponsive, but appears to be conscious because the eyes are open and follow external objects. (This is the usage in psychiatry; in neurology the same term often implies a degree of impairment of consciousness.)

Hyperbulia — the pathologically increased activity can be manifested in three forms:

I) Increase of volitional activity (purposeful activity) — in manic and some other states. The patients' behaviour is overactive and anreasonable, they manifest increased energy and lack of critical attitude towards their actions.

Example: a patient with the manic syndrome decided that his flat needed a new coat of paint. When his wife was away, he spent all the money they had saved for their summer vacation on expensive paints, brushes, etc., and painted each wall and ceiling in the flat a different bright colour (red, bright, yellow, green). He had done all the work in one day and night, so the quality was extremely poor. In addition he splashed the paint all over the carpets and furniture.

^ Table 3. Pathology of Volitional Processes




a)Increase of volitional activity (purposeful activity) b)Redundancy of volitional activity motor excitement)


a) Motor retardation (slowness of movements)

b) Absence of movements (stupor)

a) Catatonic syndrome

b) Hebephrenic syndrome

2) Redundancy of volitional activity, motor excitement — agitation, general perturbation, when a patient makes quick, usually senseless movements (catatonic state, agitated depression, etc.). This state is different from the previous, because there is no conscious purpose in the patients' behaviour and actions.

3) Hyperactivity — manifestation of disturbed child behaviour, when a child is constantly restless and in motion. It is usually combined with attention deficiency.

Parabulia — perversion of volition or will. Usually occurs in schizophrenia as a manifestation of ambivalence. There are two kinds of parabulia manifestations — catatonic and hebephrenic syndromes.

The symptoms of the catatonic syndrome are presented in Table 4. As you can see, there are two variants of this syndrome, manifested in excitement or retardation. There are also some symptoms common for both variants. Some terms used in the table need explanation.

We shall begin with common symptoms. Stereotypy means multiple repetition (of words, phrases, gestures) or preservation (of posture or place). For example, a catatonic patient for whole days long stands in a corner with a slipper in his hands and plucks at it with the same characteristic movement of his fingers. He returns to this place and action every morning and after every meal for several months. Ambitendency means two opposite impulses (wishes) appearing in a person simultaneously (ex. to go and have lunch, and not to do it). Paramimia consists in strange, inadequate facial expressions. Echopraxia and echolalia are repetitions of somebody else's actions or words.

Table 4. ^ Structure of the Catatonic Syndrome

Catatonic excitement

Catatonic motor retaidation

Speech and motor excitement


Affectation Verbigeration

Catatonic stupor (receptor and effector)

Automatic submission

Negativism (active and passive)

Waxy flexibility of muscles


Stereotypy (posture, pose, place)





Catatonic excitement, besides these symptoms, includes purposeless impulsive actions (a patient suddenly tares his/her clothes, runs down the hospital corridor, or hits somebody without any provokation). Verbigeration is meaningless repetition of words and phrases (synonymous to verbal stereotypy).

Catatonic motor retardation can be of different levels. In the state of stupor patients lie in bed in an embryonic postuxe and don't move. If they lie on the back, you can often notice that they hold their head raised above the pillow. This, as well as waxy flexibility of muscles, is caused by increased plastic muscle tonus. If someone shapes a patient's limbs into some posture (raises his/her arm, bends his/her leg), this posture will be preserved for several minutes even if it is uncomfortable. If the retardation doesn't reach the level of total stupor, patients are able to move slowly and, besides common symptoms, can manifest either automatic submission (obedience), or negativism (in passive negativism they simply do not follow instructions, and in active negativism they do the opposite to what is expected from them). Mutism means absence of speech.

Hebephrenic manifestations consist in incongruous., ridiculous, and frolicsome behaviour (pulling faces, grimacing, affectation, mimicking others, unmotivated laughter, etc.). Patients can jump about, ask other people ridiculous questions. The mood is changeable. The speech is fast, the patients use neologisms, sometimes speak in rimes. Both these syndromes occur in schizophrenia.

Disturbances of drives (instincts) can manifest in their pathological increase, inhibition, or perversion. They can occur in patients with different mental disorders: mental retardation (especially severe and profound), psychotic states (especially schizophrenia), and organic brain damage. Some of them (anorexia or bulimia) can develop in neurotic patients, and some (sexual perversions) — in people with personality disorders. Disturbances of drives concern the nutrition, self-preservation and sexual instincts. Disorders of the nutrition drive result in eating disorders. Bulimia means increased appetite, anorexia — loss of appetite; polydipsia — drive to excessive drinking of water; pararexia — drive towards eating uneatable things. Disorders of the self-preservation drive result in the patient trying to hurt himself (self-destructive behaviour).

^ Disturbances of the sexual instinct, especially sexual perversions, are studied in the course of sexology and sexopathology.

Impulsive drives are uncontrollable drives (impulses) to achieve goals, inadequate to the real situation. Patients can not keep from fulfilling them, but afterward are critical to their actions.

Dromomania — an abnormal impulse to travel, to be on the tramp; dipsomania — alcoholic bouts, impulse to abuse alcohol in bouts; pyromania — morbid impulse to set fire to things; kleptomania — pathologic impulse to steal, "senseless" stealing, objects are taken not for immediate use; coprolalia — impulse to utter vulgar or obscene words; mythomania — morbid interest in myths and telling lies.

Methods of Investigation. Main methods of diagnosing disturbances of movements, voluntary behaviour and drives include observation, interview and collecting subjective and objective anamnesis. Direct observation of a patient's behaviour and appearance helps to diagnose motor disturbances he/she suffers from at the present moment (ex. catatonic excitement or stupor). Long-term behaviour can be assessed with the help of prolonged observation (at an in-patient psychiatric department) and collecting anamnesis data from the patient and his/her relations. Objective anamnesis is very important in these cases, because psychotic patients are often not critical towards their actions and can not describe them realistically.


  1. Conduct classification of disorders of volitional sphere.

  2. Give determination of parabulia and name its basic subspecieses.

  3. Give determination of stupor.

  4. Classification of pathological actions, differential diagnostics.

  5. Give determination a train.

  6. Name basic disorders of trains, their clinical description.

  7. Give determination and describe sexual perversion.

  8. Give determination of psychomotor excitation and conduct his classification.

  9. Describe the clinic of maniac excitation.

  10. Describe the clinic of the depressed excitation.

  11. Describe the clinic of catatonic excitation.

  12. Describe the clinic of hebephrenic excitation.

  13. Describe the clinic of epileptic excitation.

  14. Describe the clinic of hysterical excitation.

  15. Describe the clinic of psychopathy excitation.

  16. Describe the clinic of panic excitation.

  17. Describe the clinic of senile excitation.

  18. Give determination of concept «attention». Name the basic forms of violation of attention.

  19. Name basic diseases with attention disorders.


6.1. Additions. Facilities for control:

Questions of controls:

  1. Conduct classification of disorders of volitional sphere.

  2. Give determination of parabulia and name its basic subspecieses.

  3. Give determination of stupor.

  4. Name basic disorders of trains, their clinical description.

  5. Give determination and describe sexual perversion.

  6. Give determination of psychomotor excitation and conduct his classification.

  7. Describe the clinic of maniac excitation.

  8. Describe the clinic of the depressed excitation.

  9. Describe the clinic of catatonic excitation.

  10. Describe the clinic of hebephrenic excitation.

  11. Describe the clinic of panic excitation.

  12. Give determination of concept «attention». Name the basic forms of violation of attention.

  13. Name basic diseases with attention disorders.

Tests and 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. 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


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


Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of health of ukraine bukovynian state medical university

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of health of ukraine bukovynian state medical university

Ministry of Health of Ukraine Bukovynian State Medical University iconMinistry of Health of Ukraine Bukovynian State Medical University

Додайте кнопку на своєму сайті:

База даних захищена авторським правом © 2000-2013
При копіюванні матеріалу обов'язкове зазначення активного посилання відкритою для індексації.
звернутися до адміністрації