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 21: NEUROTIC DISODERS. ETIOLOGY AND
PATHOGENESIS. ACUTE REACTION TO STRESS.
MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY
TOPICAL MODULE 5. NEUROTIC, STRESS-RELATED AND SOMATOFORM
DISODERS.
Сhernivtsi, 2009
2
1. ACTUALITY OF THEME:
Mental disorders caused by stress or psychological trauma are called psychogenic. They develop
owing to intense negative emotions caused by serious sudden or prolonged traumatic events (natural
catastrophes, accidents, death of a loved person, or long-term conflict relationships in the family or at work,
etc.). Depending on the circumstances, their interpretation by the person, and on the psychological
characteristics of the person (in particular, his/her temperament, personality accentuation, etc.) adverse
events can cause reactions of different intensity, such as acute reactions to stress, adjustment disorders,
neuroses and even psychotic reactions.
These neurotic disoders are widely spread in modern population.
2. DURATION OF PRACTICAL CLASSES - 2 HOURS.
3. EDUCATIONAL PURPOSE
3.1. To know:
1. Etiology neurotic disoders.
2. Pathogenesis neurotic disoders.
3. Classification neurotic disoders.
4. Clinical manifestations neurotic disoders.
5. Passing neurotic disoders.
6. Acute neurotic reaction.
3.2. Able:
1. To diagnose neurosis.
2. To conduct differential diagnose with other diseases.
3. To treatment neurosis.
3.3. To capture practical skills:
1. To collect anamnesis.
2. The skills of diagnosis different form of neurosis.
3. Basic psychotherapeutical methods of treatment neurosis and acute neurotic reaction .
4. INTERSUBJECT INTEGRATION (base level of preparation).
Names of previous disciplines
1. General and medical psychology.
2. Normal and pathologic physiology.
Skills are got
1. Determine type personality. Determine criteria of
clear consciousness.
2. Determine type HNF.
3. Nervous illnesses.
3.A clinic of functional disoders nervous system.
5. ADVICES TO STUDENTS.
5.1. CONTENTS OF THEME.
There are three components to a stress response: an emotional response, a somatic response,
and a psychological response that reduces the impact of the experience. The emotional and somatic
responses are of two main kinds. The emotional response to danger is fear, and the response to
threatening events is anxiety. The somatic reactions of both kinds of event are those of autonomic
arousal, such as tachycardia, increased muscle tension, and dry mouth. In response to separation or
loss, the emotional reaction is depression, and the bodily reactions are tiredness and reduced
physical activity. The third component of the stress response is a group of psychological
mechanisms that serve to reduce the impact of stressful experiences, thus limiting the extent of the
3
reaction. These psychological mechanisms are called coping strategies and mechanisms of
defence. They are of several kinds and are described next.
Coping Strategies and Mechanisms of Defence
Coping strategies and mechanisms of defence are ways of reducing the effect of strong
emotions so that normal performance can be maintained. The term "coping strategy" is applied to
activities of which the person is conscious; term mechanism of defence refers to unconscious
mental processes.
Potential adaptive coping strategies include avoidance of situations that cause distress, working
through problems, and coming to terms with situations. Maladaptive coping strategies have the
immediate effect of reducing the emotional response to the stressor, but in the longer term are
unhelpful. They include excessive of alcohol or drills, histrionic behaviour, aggression, and deliberate self-harm, strategies listed above as potentially adaptive can become maladaptive if used too
long. For example, avoidance is an appropriate early response but maintained for a long time it prevents solution of problems.
Mechanisms of defence activated most often in response to stressful circumstances are
regression, repression, denial, displacement, and projection. The mechanisms are unconscious
processes; they are not carried out deliberately.
Regression is the adoption of behaviour appropriate to an earlier stage development, for
example dependence on others. Regression often occurs among physically ill people. In the acute
stages of illness it can be adaptive enabling the person to accept the requirements of passively
accepting intensive medical and nursing care. If it persists into the stage of recovery, however,
regression reduces the patient's ability to take responsibility for himself.
Repression is the exclusion from consciousness of impulses, emotions, or memories that
would otherwise cause distress. For example, the memory of a humiliating event may be kept out of
awareness.
Denial is a related concept: it is inferred when a person behaves as if unaware of something
which he may reasonably be expected to know. For example, a person who has been told that he is
dying of cancer may continue to behave as if unaware of the diagnosis.
Displacement is the transfer of emotion from a person, object, or situation with which it is
properly associated to another which causes less distress. For example, after the recent death of his
wife, a man may blame her doctor for failure to give adequate care instead of blaming himself for
putting his work before her needs in the last months of her life.
Projection is the attribution to another person of thoughts or feelings similar to one's own,
thereby rendering one's own feelings more acceptable. For example, a person who dislikes a
colleague may attribute reciprocal feelings of dislike to him. In this way the person can more easily
justify his own feelings of dislike.
The following mechanisms of defence are more often involved in longer-term problems.
Reaction formation is the unconscious adoption of behaviour-opposite to that which would
reflect true feelings and intentions. For example, excessively prudish attitudes to sex are sometimes
(but not always) a reaction to strong sexual urges that the person cannot accept.
Rationalisation is the unconscious provision of a false but acceptable explanation for
behaviour which has a less acceptable origin. For example, a husband may leave his wife at home
because he does not enjoy her company, but he may tell himself falsely that she is shy and would
not enjoy going out.
Sublimation is the unconscious diversion of unacceptable impulses into more acceptable
outlets, for example turning the need to dominate others into the organisation of good works for
charity.
Identification is the unconscious adoption of the characteristics or activities of another
person, often to reduce the pain of separation or loss. For example, a widow may undertake the
same voluntary work that her husband used to do.
Three clinical forms or pathologic or extreme acute reactions (shock reactions) to stress,
differing in behaviour, are distinguished, they are: panic agitated reactions, psychogenic stupor
and emotional paralysis.
4
Anxiety disorders are classified as follows:
— generalized anxiety disorders, in which symptoms are persistent, varying little from
one situation to another;
— phobic disorders, in which symptoms are episodic and associated with defined
circumstances;
— panic disorder, in which symptoms are episodic but not associated with defined
circumstances.
Obsessive-compulsive disorder is characterised by obsessional thinking, compulsive
behaviour, and varying degrees of anxiety, depression, and depersonalisation.
In dissociative and conversion disorders the predominant symptoms are physical. The term
“conversion” relates to the idea that anxiety has been replaced by (“converted into”) physical
symptoms. The term “dissociative” relates to the idea that symptoms result from a lack of
coordination of different psychological functions. An alternative name for these disorders is
hysteria. The term “hysteria” is also still in use in clinical practice.
Types of dissociative (or conversion) disorder:
1. Motor disorders: paralysis of voluntary muscles, disordered gait, tremor and tics,
aphonia and mutism, convulsions.
2. Sensory disorders: hyperaesthesia and paraesthesia, anaesthesia, pain, blindness and
tunnel vision, deafness.
5.2. THEORETIC QUESTIONS:
1. The definition of notion “psychical trauma”.
2. The definition of notion “neurosis”, “acute neurotic reaction”.
3. Etiology neurotic disoders.
4. Pathogenesis neurotic disoders.
5. Classification of neurotic disoders.
6. Clinical picture of neurasthenia, hysteria, annoying states.
7. Passing of neurotic disoders.
8. The phobic disoders.
9. The anxiety disoders.
10. The obsessive compulsive disoders.
11. The dissociative (conversive) disoders.
12. Depressive neurotic disoders.
13. The differential diagnosis of hysterical and epileptic fits.
14. The manifestations of acute neurotic reactions.
15. The principles and methods of treatment patient with neurotic disoders.
16. First aid about hysterical excitement.
17. First aid about psychical disoders result in extreme situation (panic agitated reactions,
psychogenic stupor and emotional paralysis).
18. Prophylactic of neurotic disoders.
19. Expertise of neurotic disoders.
5.3. PRACTICAL TASKS ON THE CLASS:
1. To collect anamnesis, clinical psychopathological examination of patients with neurotic
disoders.
2. Make up plan of examination and treatment of patient with neurotic disoders.
3. The participation at performance psychotherapeutical methods of treatment neurosis.
5.4. MATERIAL FOR SELF-CONTRROL.
A. Questions of self-controls:
1. The definition of notion “psychical trauma”.
2. The definition of notion “neurosis”, “acute neurotic reaction”.
3. Etiology neurotic disoders.
5
4. Pathogenesis neurotic disoders.
5. Classification of neurotic disoders.
6. Clinical picture of neurasthenia, hysteria, annoying states.
7. Passing of neurotic disoders.
8. The phobic disoders.
9. The anxiety disoders.
10. The obsessive compulsive disoders.
11. The dissociative (conversive) disoders.
12. Depressive neurotic disoders.
13. The differential diagnosis of hysterical and epileptic fits.
14. The manifestations of acute neurotic reactions.
15. The principles and methods of treatment patient with neurotic disoders.
16. First aid about hysterical excitement.
17. First aid about psychical disoders result in extreme situation (panic agitated reactions,
psychogenic stupor and emotional paralysis).
18. Prophylactic of neurotic disoders.
19. Expertise of neurotic disoders.
B. TESTS:
1.In girl A. 19 years old after rope diagnosed stupor neurotic reactions: general constraint,
inhibition of motions, indifference to herself and surrounding events. Speech is slowly and silent.
Consciousness is narrowed. What medicine will you use?
A. Solution of sibasoni 0,5 %, 2 ml
B. Solution of melipramini 1,25 %, 1 ml
C. Solution of caffeine 20 %, 1 ml
D. Solution of halloperidoli 0,5 %, 1 ml
E. Solution of sodium-barbitali 10%, 5 ml
2. Patient T., 26 years old after rope was hospitalized: she is crying in voice and
demonstrative, banging ones fists on the table, stamping ones feet, tearing herself garment, thinking
about suicide. Diagnosis?
A. Erotic excitement
B. Hysterical excitement
C. Panic excitement
D. Epileptic excitement
E. Amential excitement
3. Patient B., 21 years old after traffic accident was hospitalized with next clinical picture:
chaotic movements, tremor of hands, rapidity of speech, fear, anxiety. Orientation is present,
disturbance of perception, delusion did not reveal. Diagnosis?
A. Stuporous neurotic reaction
B. Psychogenic delirium
C. Psychogenic stupor
D. Anxiety neurotic reaction
E. Fugiform excitement
A. SITUATIONAL TASKS
1. Patient K., 25 old year after intensive intellectual work has complaints on increased
emotional sensitivity and irritation, instable mood, bad feels, headache, sleeplessness with hardening
asleep, sudden decreased work ability in second half day, tachycardia, higher perspiration. Draw up
diagnosis.
6
2. Women N, 24 old year, economist. Always was over-anxiousness, timidity. After
conflict at her work appeared fears and uncertainty at fulfilling professional duties, doubt as to
mathematic calculations. She is verifying presence documents inside folder often.
Put your diagnosis.
3. Women D, 28 old year, had conflict in family. She has complaints on dumbness of arm
and feet, feeling of a lump in the throat, tremor of hand. She is egoistical, demonstrative, emotional
lability, talking about her unhealthy feeling. Tremor of hands, lacrimal reactions, broken gasp are
present. Organic changes of CNS absent. Put your diagnosis.
8. RECOMMENDED LITERATURE IS:
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