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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 9: Disorders of consciousness and self-consciousness


MODULE 1. GENERAL QUESTIONS OF PSYCHIATRY AND NARCOLOGY. GENERAL PSYCHOPATHOLOGY


Topical module 2. General psychopathology


Сhernivtsi,2009


1. Actuality Aim

Consciousness, as a higher level of the psychical mapping, inherent only to the man. It arose up on the certain historical stage of becoming of psyche of man and is the product of its labour activity. Consciousness shows up ability to represent and understand surrounding the world, him nowadays and past, to make decision and, in accordance with a situation, to manage the conduct.

It is known that at psychical diseases the functions of higher departments of brain are violated: disorder of intercommunications comes between basic nervous processes, between a bark and below placed parts of brain. These changes predetermine forming of certain symptoms of abnormal psychologies and syndromes. But not only psychical diseases are accompanied violation of nervous processes and consciousness but also any diseases of organism can cause similar disorders.

That is why it is very important for the doctor of every profession to know physiological bases of psychical activity and able to estimate correctly the state of consciousness of sick.


^ 2. EDUCATIONAL PURPOSE

2.1.A student must know:

  • determination of consciousness and self-consciousness;

  • criteria of clear consciousness;

  • clinical aspects of consciousness;

  • criteria of consciousness on K.Jaspers;

  • criteria of violation of consciousness;

  • classification of syndromes of consciousness disorder;

  • clinical displays of different degree of exception of consciousness;

  • basic  clinical signs of the twilight state of consciousness;

  • basic  clinical signs of delirium state of consciousness;

  • basic  clinical signs of oneiroid state of consciousness;

  • disorders of self-consciousness.

 2.2. 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.

2.3. A student must   capture practical skills:

  • determination of criteria of clear and broken consciousness;

  • determination of the state of consciousness.


^ 3. EDUCATE PURPOSE.

Importance of knowledge of scientific developments of physiologists І.М.Sechenov and І.P.Pavlov students is underlined about reflex nature of psychical activity and value of correct estimation of the state of consciousness of man for giving her necessary medical assistance.


^ 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 consciousness and self- consciousness.


^ 5. CONTENTS OF THEME.

Classification of frustration of consciousness:

  1. Set of symptoms of the switched off consciousness. Allocate the following stages:

- an obnubilation,

- a sopor,

- a coma - the consciousness is absent.

  1. Sets of symptoms of the changed consciousness - the consciousness is kept, but in new quality - patients behave unusually. Then do not remember or badly remember, happened with them at the moment of obscuring event. Experiences bright, externally not clear.

^ Criteria of the changed consciousness (on K.Jaspers):

а) detachment from the real world

б) infringement of orientation

в) an amnesia - specific to each variant.

Jaspers has described stages of development of delirium.

There are 4 basic such as stupefaction:

  • a delirious stupefaction - more often;

  • an oneiric stupefaction;

  • an amental stupefaction;

  • a twilight stupefaction.

The Delirium- non-specific reaction of mentality to the fact of an intoxication. In the majority there is a delirium - an alcoholic genesis.

The delirium is one of many alcoholic psychosis’s. Develops only on 2 or 3 stages of an alcoholism. It is a lot of signs.

"Delirium tremens" is preceded with an alcoholic abstinent set of symptoms. On the CART the alcoholic abstinent set of symptoms is a set of somatic, vegetative neurological and psychopathological sets of symptoms which arise at sudden deprivation of alcohol, and all these displays reduce the expressiveness and intensity at addition of new doses of alcohol. The abstinence is preceded with a drinking-bout, as a rule, a true drinking-bout (5-7 days) after which reception of alcoholic drinks suddenly stops that results in occurrence of a symptomatology.

For 2-3 day after deprivation of alcohol, is closer by the night the delirium develops.
^

Clinical displays of a 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.

In treatment of patients by a delirium it is important to achieve dream which will be an output from a delirium. During 2-3 months after an output from a delirium - an asthenic condition.

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|. This state|figure,camp,mill| is observed|exists| at epilepsy, organic diseases of cerebrum.

Ambulatory automatism is characterized|described| by mobile excitation noninfringement other any|some| in the spheres of perception, thought and emotional. Can show up in the series of successive|logical|, stereotyping|stereotypes| motions|movements| or in more difficult|complex| purposeful motive acts on motion. If irresponsible motions|movements| are chaotic, nonsense, brief (a patient rolls|displaces| up a| sheet, rummages by hands|arms| the body, head, twirls on a city|town|, suddenly begins to hurry|runs| and other) name|calls| such type of ambulatory automatism fugue. More protracted|prolonged| states|figures,camps,mills| (a few|a little| days, weeks, months|moons|) and с more well-organized conduct is named|called| trances.

^ Disorder|discord| of consciousness is| depersonalization - the pathologically changed perception of surrounding reality and (or) own “Я”. Depersonalisation is divided into the derealization|.

The derealization is violation of reflection of circumferential. The all circumferential acquires|buys| unusual internalss: “allegedly artificial”, unreal, “people as dolls|puppet|, lifeless”. The imperception time is experienced as “stop of time”, “delay of time”, “acceleration of time”, “loss of sense|feeling,sentiment| of time” and other Meets at epilepsy, affects violations.

At the different|diverse| forms|shapes| of stupefaction| of consciousness|intelligent| original appearance of patient, conduct, state|figure,camp,mill| of emotional sphere, is described. If it is succeeded to set the contact with a patient, next to verification of correct orientation and collection|assembling,collecting| of anamnesis, it is necessary to find out character|nature| of disorders|discords| in spheres perception, thought, possibility of critical estimation|appraisal| of that happened, and also to explore the features of disorders|discords| of memory and attention.

Students on the basic stage of tutorial independently under the direction of teacher inspect mentally patients with consciousness and self-consciousness disorders. Independently collect information of anamnesis, find out quantitative and high-quality violations of consciousness.

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.


^ 5.1. QUESTIONS OF CONTROLS:

  1. Determination of consciousness and self-consciousness.

  2. Criteria of clear consciousness.

  3. Clinical aspects of consciousness.

  4. Criteria of consciousness on K.Jaspers.

  5. Criteria of violation of consciousness.

  6. Classification of syndromes of consciousness disorder.

  7. Clinical displays of different degree of exception of consciousness.

  8. Basic  clinical signs of the twilight state of consciousness.

  9. Basic  clinical signs of delirium state of consciousness.

  10. Basic  clinical signs of oneiroid state of consciousness.

  11. Disorders of self-consciousness.


^ 6. MATERIALS OF METHODICAL PROVIDING OF EMPLOYMENT (MATERIALS OF CONTROL OF BASE (INITIAL LEVEL) PREPARATION OF STUDENTS):

6.1. Additions. Facilities for control:

Questions of controls:

  1. Determination of consciousness and self-consciousness.

  2. Criteria of clear consciousness.

  3. Clinical aspects of consciousness.

  4. Criteria of consciousness on K.Jaspers.

  5. Criteria of violation of consciousness.

  6. Classification of syndromes of consciousness disorder.

  7. Clinical displays of different degree of exception of consciousness.

  8. Basic  clinical signs of the twilight state of consciousness.

  9. Basic  clinical signs of delirium state of consciousness.

  10. Basic  clinical signs of oneiroid state of consciousness.

  11. Basic  clinical signs of amentic state of consciousness.

  12. Disorders of self-consciousness.


The 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.

Clinical 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?


^ 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

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