Psychiatry: A Course of Lectures - V. S. Bitensky 2004
Disorders of Sensation, Perception, and the Emotional Sphere
Sensation and perception (the sensory sphere and perception) represent the initial stage, the primary level of human cognitive activity—the "living contemplation" of the surrounding reality. The sensory-perceptive sphere of human cognition is capable of singling out the essential and fundamental from a mass of stimuli originating in both the external and internal environments. Combined with mental imagery, sensation and perception form the foundation of visually active and concrete-imaginal thinking, while serving as the source of Abstract-logical thinking. The subject's intentional set clearly manifests itself in The process of perception. The direction of sensations, desires, and intentions depends on the object being cognized. Furthermore, sensory cognition is significantly influenced by an individual's prior experience and personal traits. In children, perception is often fixed in vivid sensory-visual representations known as eidetic images.
Sensation and perception are characterized by specific features: sensory vividness, extraprojection, and the inability to voluntarily alter sensations and perception. Extraprojection ensures the projection of an image onto the Location where the perceived object or phenomenon is situated. Because these images cannot be altered, they are perceived as they actually exist in reality. The brightness, speed, and completeness of perception depend on age, sex, state of health, individual characteristics, the focus of a person's attention, life experience, and the training of specific analyzers.
The complex Structure OF THE Anatomical and physiological basis of perception—involving the cortical regions of analyzers, associative inter-analyzer areas, and other sections of the Cerebral Cortex, subcortex, and Brainstem—collectively ensures the Processing of incoming information and the evaluation of its individual biological and social significance. According to the theory of holistic brain function, the underdevelopment or functional decline of any link, as well as a disruption in the functional interhemispheric connection, is reflected in the degree of impairment of perception.
The core psychological concepts of the perceptual process include sensation, perception, and mental imagery (representation).
Sensation is a mental process wherein individual properties of objects and phenomena are reflected in the human consciousness through the Direct impact of stimuli on the Sense Organs.
Perception is a mental process wherein objects or phenomena are reflected in the human consciousness in the totality of their properties through their direct impact on the sense organs.
Mental imagery is a subjective representation of objects or phenomena that are not directly acting upon a person's sense organs at the given moment.
The anatomical and physiological mechanisms underlying sensations and perception rely on the systemic interaction of analyzers. The central apparatus of the visual analyzer is located in the occipital lobes of the brain. The primary Zones of the occipital cortex constitute the structure where nerve fibers originating from the retina terminate. Neurons in the secondary Regions of the occipital cortex are not directly connected to the fibers coming from the eye's retina. These secondary zones synthesize visual images and ensure their integration. Lesions of the occipital lobes lead to impairments in the analysis and synthesis of visual information.
Irritation of the primary regions of the visual cortex causes elementary visual hallucinations and sensations such as "photopsias," luminous dots, colored patches, fog, smoke, or flame.
Irritation of the secondary areas of the occipital cortex can stimulate traces of visual images stored in a person's long-term visual memory, as well as trigger complex visual hallucinations (people, animals, intricate scenes, etc.). These areas help integrate individual impressions into holistic images. Impairments to their Functions result in The phenomenon of visual agnosia, where real objects and their representations cannot be recognized (a patient can perceive individual details but fails to see the whole).
Auditory perception is mediated by the Auditory Analyzer. The Auditory pathway originates in The Organ of Corti (the cochlea of the Inner ear). The fibers of the auditory analyzer terminate in the projection areas of the auditory cortex in both hemispheres, though predominantly in the contralateral hemisphere. Fibers of the auditory analyzer end in the primary auditory cortex. The secondary regions of the auditory cortex form an apparatus specially adapted for the analysis and synthesis of speech sounds. Electrical stimulation of the secondary zones of the auditory cortex induces auditory hallucinations (human voices, music, etc.). Focal lesions (deficits) in the secondary regions of the temporo-auditory cortex create conditions for The Development of auditory and speech agnosia (sensory aphasia, temporal aphasia).
This condition manifests as an inability to clearly distinguish speech sounds. A patient with sensory aphasia retains acute Hearing for environmental sounds (engine noise, the clatter of broken Glass), yet is incapable of differentiating speech sounds. In massive lesions of the temporal lobe, all sounds are perceived as continuous noises (such as the rustling of leaves). The word "голос" (voice) cannot be distinguished from "галас" (hubbub) or "колос" (ear of corn). A phenomenon known as the alienation of word meaning occurs—the patient is unable to use cues and struggles with fluent speech. The patient's spontaneous utterances turn into a jumble of words, some structurally altered, others replaced by acoustically similar but semantically inappropriate words. The patient is incapable of clearly perceiving their own speech defects or correcting them. The speech of such an individual turns into a "word salad." A consequence of temporal lobe impairment is the "breakdown of writing." The writing of these patients degrades into a series of attempts to find the correct phonetic and literal composition of a word. Reading ability is only partially impaired in such cases. Complete central deafness occurs solely in bilateral lesions of Heschl's gyrus.
General, or cutaneo-kinesthetic, sensitivity is phylogenetically the oldest. In addition to cutaneous receptors (exteroception), there are receptors located in Muscles, joints, and tendons that are associated with kinesthetic or proprioceptive sensitivity. Golgi tendon organs and Pacinian corpuscles are situated at the junctions between tendons and muscles, providing joint sensation and signaling body posture or movement. Overall, human Skin and The Musculoskeletal System constitute a vast receptor field, representing the peripheral division of the cutaneo-kinesthetic analyzer. Its central division is located in the cortical fields of the postcentral gyrus of the brain. Sensory disorders arise from lesions affecting fibers at various levels (individual nerve trunks, roots, Spinal Cord, Medulla Oblongata, thalamus, and cerebral cortex). Disturbances in sensory functions manifest either as hyperfunction (exaggeration) or hypofunction (loss).
Manifestations of hyperfunction include pain, paresthesias, hyperesthesias, hyperpathia, dysesthesia, and polyesthesia; manifestations of hypofunction include anesthesia and hypesthesia.
Sensory disorders in the functioning of the cutaneo-kinesthetic analyzer are caused by lesions in the secondary regions of the parietal cortex of the brain.
1. Lower parietal syndrome occurs when lesions affect those areas of the parietal cortex that border the representation zones of the hand and face. The patient becomes unable to recognize objects by Touch (astereognosis) or fails to synthesize what can be recognized in parts—such as the inability to recognize the fingers of one's hand with closed eyes. With eyes open, the person can correctly differentiate the fingers.
2. Upper parietal syndrome arises from a lesion in the area bordering that part of the sensory cortex of the cutaneo-kinesthetic analyzer which receives information from all PARTS OF THE body. Such cases most frequently feature symptoms of "body schema disturbance"—namely, disorders in recognizing body parts, their mutual arrangement, and proportions.
3. Damage to the regions of the parietal cortex bordering the occipital and posterior temporal areas of the brain results in visuospatial impairments (disorientation in the environment). Irritation of the primary (projection) zones in the posterior central gyrus causes sharply localized perceptual disturbances. Conversely, irritation of the secondary (associative) areas of the postcentral gyrus or the parietal region leads to various hallucinatory disorders.
A healthy brain possesses a wide array of properties that ensure active interaction with the external environment, adaptation to it, and the Modification of the environment to suit human needs. The entire brain participates in every single moment of perception and cognition of the world. For instance, two individuals with clear consciousness may perceive completely different things in the very same phenomenon. This was first noted by Helvétius. In the example he cited, when observing The surface of a full moon, a priest saw the figure of a monk in the outlines of the lunar landscape, whereas a young fashionista saw the pattern of a new dress.
Disturbances of sensation and perception are diverse. Differentiating between normal and pathological sensations and perception is a rather challenging task. In the everyday life of a healthy person, quite significant variations in sensation and perception may occur depending on their mental and physiological state.
In particular, healthy individuals frequently experience dreams in the form of visual, auditory, tactile, and other phenomena that closely approach hallucinatory events in their nature. Alongside voluntary and involuntary selectivity of perception, as well as increases or decreases in its vividness, one often observes illusory phenomena, exclamations, and the feelings of déjà vu or déjà vécu, which are also frequently noted in mental pathology. The episodic, singular, and isolated nature of these phenomena generally allows one to rule out their morbid origin, although all of this points to a weakening of the brain's regulatory function.
Hypesthesia refers to a reduction in the subjective vividness and intensity of sensation and perception, manifesting as a loss of their sensory concreteness and brightness, sometimes to the point of estrangement. The external world loses its sensory brightness, coloration, and definition in the patient's eyes. Sounds become muffled and indistinct; a voice is perceived as if coming from afar, losing its individual characteristics and leveling out. Everything surrounding the patient becomes pale, seemingly frozen and formless. Hypesthesias are part of The structure of derealization and depersonalization syndromes.
Anesthesia is the abolition of sensations and perception resulting from anatomical or functional damage to analyzers, extending from the peripheral part of the analyzer to its central portion. In mental disorders, anesthesia is observed in acute psychotic states accompanied by sensory deceptions and emotional disturbances. In such cases, patients inflict severe injuries upon themselves. After recovery, they recall that they felt no pain whatsoever during the illness. As recovery progresses, pain sensitivity is fully restored. Painful psychic anesthesia is defined as a reduction or loss of emotional reactions to life experiences.
Complex variants of such disorders carry psychopathological significance. For instance, lesions in the cortical divisions of analyzers lead to agnosias—a failure of recognition. These primarily include visual agnosia, or "mind blindness" (the inability to recognize visual images, letters, and words); auditory agnosia, or "mind deafness" (the inability to recognize sounds or the voices of familiar people, and failure to comprehend words); tactile agnosia (the inability to recognize objects by touch); autotopagnosia (the inability to recognize parts of one's own body); anosognosia (the failure to recognize one's illness despite pronounced symptoms); and autoagnosia (impaired recognition of oneself and one's face).
M. O. Hurevych considered agnosias to be sensory deceptions characterized not by a complete loss of functions, but by pathological alterations leading to a distortion of sensory experience. S. F. Semenov noted that the majority of existing agnosias occur in lesions of the right hemisphere, specifically its parietal and occipital lobes.
Hyperesthesia is an increased sensitivity to previously neutral stimuli. As a rule, this condition is accompanied by heightened irritability and excitability. Ordinary light, sounds, odors, and bodily touch are experienced by the patient so intensely and acutely that enduring them becomes exceptionally difficult.
Hyperesthesia of the Senses is observed in organic brain lesions, asthenic states without organic neurological symptoms, and in the Cytology/cytology/16.html">Early stages of acute psychosis. Hyperalgesia and paresthesia can be classified as manifestations of hyperesthesia.
Hyperalgesia is an increased sensitivity to pain. It occurs in depressive states and during opioid-morphine withdrawal, when the patient experiences excruciating pain caused by previous illnesses that were accompanied by pain syndromes.
Paresthesia is the sensation of crawling or tingling on the skin («pins and needles»). Phantom pain refers to pain in a limb that is absent As a result of trauma or surgery.
An exacerbation of perception in the domain of interoception and Proprioception manifests in a more complex pathological phenomenon known as cenestopathy (pulsations, tightness, burning sensations, etc.). This represents a disturbance of internal sensitivity. Clinically, cenestopathies present as vague, diffuse sensations that constantly trouble the interior of the body—in the HEAD, chest, abdomen, or beneath the skin—without any objectively identifiable causes. In their Complaints, patients describe unpleasant, painful sensations inside the body that are difficult to localize (unlike paresthesias) and impossible to put into words. Consequently, when evaluating their symptoms, patients are forced to resort to a "luxury of figurative comparisons," indicating, for instance, that everything is flowing, constricting, crawling, pricking, and so forth.
The following types of cenestopathies exist: cardiovascular, central neurological, abdominal, osteoarticular, and skin-subcutaneous.
Cardiovascular and central neurological cenestopathies are the most common. Clinically, they are distinguished as elementary and complex (psychosensory, hallucinatory, and delusional).
The chaos of unusual and distressing sensations triggers anxiety and suspicion regarding an illness perceived as incurable. Patients with neurotic or depressive states tend to attribute cenestopathic symptoms to internal organ dysfunctions or somatic illness. The content of hypochondriacal complaints in such patients generally does not acquire a delusional character.
In Schizophrenia, against the backdrop of confusion, fear, and adynamia, painful sensations in various parts of the body progressively intensify, frequently acquiring The properties of visceral hallucinations followed by a delusional hypochondriacal interpretation.
In organic brain lesions, cenestopathies are localized in nature, monotonous, poor in content, and show no tendency to transition into other states.
The presence and mental representation of systemic body images, as well as its individual parts, is referred to as the «body schema». In disorders of sensory synthesis concerning the perception of one's own body, a discrepancy arises between METABOLISM/2.html">THE CONCEPT OF the normal «body schema» and pathological changes in function. Disorders of the «body schema» manifest as altered perceptions of the size and shape of one's body or its individual parts, their spatial arrangement, or THE POSITION OF the body as a whole.
Visual psychosensory disorders known as «metamorphopsiae» involve a distortion in the perception of surrounding objects and people while preserving an understanding of their purpose and essence, as well as a critical attitude toward them by the patient. Clinical example: the patient periodically feels that all surrounding objects alternately become large, small, warped, or twisted around their axis. The wardrobe standing in the room appears distorted, the chair legs seem twisted, and the window somehow assumes a rhomboid shape.
Sometimes, not only the size and shape of objects are perceived in an extraordinarily altered form, but also the space surrounding them. The patient feels that the room's walls are closing in and falling upon them, or conversely, moving apart, that the floor is becoming undulating, and so on. Metamorphopsiae are among the simplest psychosensory disorders. They occur paroxysmally, while consciousness and critical evaluation remain intact. As a rule, they are encountered in organic (more frequently toxic and infectious) brain injuries and are often accompanied by accommodation paresis or paralysis.
Metamorphopsiae differ from illusions by the adequacy of perception: the patient knows they are looking at a chair, albeit with crooked legs, rather than seeing a giant spider instead of a chair, which might happen in illusory perception. Metamorphopsiae differ from hallucinations in that the patient perceives actually existing objects in a distorted way, rather than something that does not exist at the moment.
Disorders of the «body schema»—autometamorphopsia—represent a distortion of the shape or structure of one's own body. Autometamorphopsiae can be partial, when individual body parts are perceived as altered (enlarged Tongue, jaw, arm, leg), or total, when There is a sensation of A change in the entire body (enlargement, reduction, or proportional distortion of one's bodily dimensions). Additionally, there may be a disturbed perception of individual body parts in space: arms may seem twisted, the head may appear to face backward, and Internal Organs may feel inverted.
S. V. Batenkova drew attention to the fact that body schema disorders—accompanied by the sensation of enlarged or diminished body parts, the feeling of missing limbs, and impaired right-left orientation—occur predominantly in focal lesions of the right cerebral hemisphere. In organic destructive psychoses, the clinical picture is dominated by relatively simple manifestations of body schema disorders, namely metamorphopsiae. Such symptoms are most frequently episodic; consciousness and critical judgment regarding them are preserved in the patient. In diffuse brain injuries, the patient loses a critical attitude toward these phenomena.
In endogenous psychoses, patients tend to weave such disturbances into hypochondriacal and nihilistic delusions. In Epilepsy, states of derealization featuring signs of metamorphopsia and alterations in spatial and temporal relations are more commonly observed. Typically, these are short-lived, presenting as an aura or as equivalents of a convulsive seizure. In functional disorders manifesting as obsessive states, body schema disorders act as the core symptoms of the condition. They constantly draw the patient's attention and, regardless of the fact that the patient retains critical insight into them, cause unimaginable suffering.
Derealization (allopsychic) is a distorted perception of objective reality and of individual images and phenomena of the surrounding world in terms of time, space, shape, size, color, mutual arrangement, etc. The perception of previously familiar phenomena, objects, living creatures, and spatial relationships begins to be accompanied by a sense of alteration, unnaturalness, unreality, and alienation. The passage of time seems accelerated, slowed down, or completely halted. The patient finds it difficult to determine precisely how everything around them has changed. Derealization is typically accompanied by bewilderment, astonishment, anxiety, fear, and helplessness. Typical derealization disorders are characterized by a critical attitude and an awareness of the unusual and unnatural nature of one's experiences. The patient strives to rid themselves of this state and overcome it. As a rule, this involves comparing new experiences with prior life experience. This disparity between previously acquired knowledge and new impressions distinguishes derealization disorders from illusions and hallucinations. Despite the sense of alteration, the surrounding environment is perceived adequately by patients (unlike in illusory perception). Furthermore, the unreal perceptions characteristic of hallucinations are absent.
As the intensity of derealization disorders and affective tension increases, critical judgment may become impaired. This can lead to The Emergence of delusional interpretations of surrounding events. Transitions from non-psychotic forms of derealization to psychotic ones are sometimes observed. Occasionally, phenomena of spatial and temporal disorientation occur.
Spatial disorientation occurs concurrently with derealization phenomena and may manifest as the sensation that the surrounding world is rotating both vertically and horizontally. This surrounding-rotation syndrome is most frequently observed during altered states of consciousness, predominantly in darkness or with closed eyes. With open eyes (under visual control), the sensation of environmental rotation disappears.
Disorders of time awareness represent disturbances in the perception of the speed at which time flows—hours, days, weeks, months—as well as the pace of real-world processes. Patients complain of failing to notice the passage of time («time has stopped»). Sometimes such sensations occur in patients suffering from Sleep-onset insomnia. After sleeping continuously for 8–10 hours, a patient may complain that they did not sleep at all.
Derealization disorders include symptoms such as déjà vu («already seen»), when a new situation or environment seems familiar, or jamais vu («never seen»), when, conversely, a familiar everyday Setting and situation appear entirely novel and unfamiliar. Closely related to these are the experiences of déjà entendu («already heard») and jamais entendu («never heard»), as well as déjà vécu («already experienced») and jamais vécu («never experienced»). Derealization disorders also encompass phenomena of misidentification of familiar people—such as Capgras syndrome, wherein unfamiliar people are perceived as acquaintances (the «positive double» symptom)—or when a well-known person is perceived as a stranger (the «negative double» symptom). Episodic derealization phenomena resembling misidentification can also be observed in completely healthy individuals when they are fatigued, sleep-deprived, or under extreme stress. Such isolated incidents carry no diagnostic significance.
Derealization disorders also include the disturbance of the so-called «humanization» of inanimate objects. Under normal conditions, a person endows surrounding nature and objects with their own feelings and moods: «the sea is laughing», «the forest is sad», «the walls are oppressive», «the garden is rejoicing», «the trees are mourning». In pathological conditions, humanization is diminished, intensified, or altered in peculiar ways. Such a state typically coincides with psychic anesthetic pain (psychalgia). In other instances, the surrounding world acquires a gloomy, ominous, magical mystery or, conversely, a joyful exaltation.
Depersonalization (autopsychic) exhibits diverse manifestations. The hallmark of autopsychic depersonalization is the sensation of an «I — That» shift, rather than the complete loss of the «I». The patient notes alterations, alienation, and a loss of feelings, thought processes, memories, emotional experiences, and other phenomena while retaining a critical assessment of their condition. Depersonalization phenomena include the following: visually, people appear as lifeless dolls or automatons, and one's own face is perceived as unfamiliar and alien. Auditorily, one's own voice is felt and perceived as distant and foreign. The voices and speech of other people become muffled, distant, unreal, indefinite, and incomprehensible. Alterations in touch, taste, and smell lead to a situation where, upon touching their own body, a person feels it to be altered, alien, and unreal; sometimes unpleasant experiences of the disappearance of one's own body or its dissolution into the surrounding environment may occur.
Thus, the sensation of alteration may pertain to the perception of one's own body or the surrounding environment. Such changes may appear individually or in combination with one another, forming the depersonalization-derealization syndrome. The primary role in the genesis of depersonalization-derealization is played by mechanisms of alienation. The normally natural sense of ownership and autonomy vanishes in depersonalization. Clérambault once viewed depersonalization-derealization through the lens of psychic automatism (sensory, motor, ideo-motor) as the loss of the natural feeling of personal agency, autonomy, and the purposeful execution of movements, thoughts, and feelings.
The division of depersonalization phenomena into psychotic and non-psychotic depends on the patient's ability to critically evaluate their condition and actions, as well as their drive to overcome these morbid experiences. This represents the non-psychotic level of disorders. Conversely, if there is a lack of insight into oneself and one's actions, along with an absence of the desire to conquer these distressing experiences, the disorder is classified as psychotic. In psychotic disorders, a delusional interpretation of morbid phenomena is observed.
N. I. Bragina and T. A. Dobrokhotova suggest that lesions of the right cerebral hemisphere in right-handed individuals lead to a sense of spatial and temporal uncertainty, as well as phenomena of derealization and depersonalization—specifically, the déjà vu or jamais vu phenomena—which are either absent or rare in left-hemisphere lesions. Disorders in perceiving the unity and content of the «self» amidst clear consciousness contribute to the sensation of personal alienation and derealization. All of this points to the complex genesis and interconnectedness of various human psychological experiences.
Illusions are perceptual disorders in which real objects or phenomena are perceived by an individual in a distorted manner. Normal illusory perception refers to the distorted perception of a specific environmental stimulus accompanied by the capacity to correct this distortion. A classic example of this is a spoon in a glass of Water that appears bent. Regarding this, R. Descartes remarked: «My eye bends it, while my mind straightens it». In healthy individuals, illusions typically arise under unusual, most commonly unfavorable conditions of perception, as well as during pronounced emotional stress. However, unlike a patient, a healthy person has ample opportunity to verify the accuracy of their perception and refine their first impression.
Illusions must be distinguished from errors in judgment and incorrect Conclusions. When a person mistakes a glass fragment brightly illuminated by the sun for a diamond, this is not yet an illusion or a deception of sensory cognition, but rather an erroneous judgment. The mandatory presence of a misperceived real object is what distinguishes illusions from hallucinations. Based on their mechanisms of origin, illusions are categorized into physical, physiological, and psychic. Furthermore, illusions are classified according to specific analyzers: visual, auditory, gustatory, olfactory, tactile, etc.
A physical illusion is the distorted perception of a genuinely existing object or phenomenon, typically accompanied by a full awareness of its distortion. It arises due to Certain physical properties of objects and substances: the alteration of object outlines at the boundary of two media with different properties (mirages), or the placement of certain objects of a specific size among other objects of contrasting size. For example, two circles of identical size appear different when one is surrounded by small circles and the other by large ones.
A physiological illusion is the distorted perception of a genuinely existing object or phenomenon resulting from the Functional Characteristics of analyzers or the complex perception system. Examples include two identical lines with oppositely directed ends appearing different in length; the sensation of continued motion when a train car stops; or the sensation of the ground swaying beneath one's feet after a prolonged stay on a ship.
Psychic illusions are the distorted perception of a genuinely existing object accompanied by an inadequate understanding of its true essence. The perceived object is evaluated insufficiently clearly or in a distorted form. The primary states that contribute to this may include emotional stress, emotional set (attitude), and emotionally narrowed consciousness. Unconscious fears, anxieties, and anticipations that outpace events assume a decisive role. Illusions associated with impaired mental activity are subdivided into affective (affectogenic), verbal, and pareidolic.
Affective illusions most commonly arise against the backdrop of fear and an anxious-depressed mood. In such a state, a bathrobe hanging in the corner of a room is perceived as a lurking criminal, the clatter of dishes in the kitchen is perceived as the clicking of a weapon, and street noise is heard as the voice of a crowd gathering for a public execution.
Verbal illusions are characterized by the misperception of the speech of others. Instead of a conversation that is neutral to the patient, they hear threats and accusations directed at them.
Pareidolic illusions (pareidolias) occur without significant alterations in affect against the Background of a reduced tone of mental activity and its passivity. Frequently, they are fantastical and dynamic. Instead of patterns on a carpet, wallpaper, wall cracks, or the play of light and shadow, the individual perceives fairy-tale plots, fantastic spectacles, moving and constantly changing animals, etc.
In the case of illusions, a person clearly points to a specific object that serves as the source of illusory perception. It must be emphasized that illusions are not an absolute sign of mental illness; they also occur in completely healthy individuals during states of fatigue, emotional stress, or lowered alertness. However, this is typically episodic and short-lived. Most importantly, it is immediately evaluated critically by the person. The presence of critical judgment is the most vital criterion distinguishing the illusions of a healthy person from those of a patient. In psychiatric disorders, illusory disturbances often recur; they are massive, manifold, and interwoven into the overall psychopathological symptomatology of a given condition. They can be so vivid that they are sometimes difficult to distinguish from hallucinations, particularly so-called functional hallucinations.
Functional hallucinations occur only in the presence of a real external stimulus and, without merging with it, persist until the cessation of its action. Functional hallucinations differ from true hallucinations in that they arise in the same manner as illusions under The Influence of real stimuli. In contrast to illusions, the reflection of the real object in these hallucinations does not merge with morbid ideas, but rather coexists with them. At the same time, the mentally ill person perceives what seems to be the case as reality, lacking the capacity to analyze the pathological disorders with sufficient critical judgment. The patient asserts with conviction that alongside the ticking of the metronome, they also heard the «voice» of a specific person. In terms of their developmental mechanisms, functional hallucinations occupy an intermediate position between illusions and true hallucinations.
Reflex hallucinations occur within the domain of one analyzer (visual, auditory, tactile, olfactory, gustatory) upon the action of a real stimulus on a different analyzer.
Hallucinations belong to the category of severe and complex Disorders of Sensation and perception. Modern researchers define hallucinations as false perceptions that arise on a morbid basis without a real object and possess the character of objective reality for the patient.
Representations are invariably involved in every act of perception. According to E. O. Popov, hallucinations are «representations that are experienced as if they were perceptions».
Hallucinations possess the following primary characteristics: they are unrelated to the perception of genuinely existing objects or phenomena (with the exception of functional hallucinations); a patient experiencing hallucinations is simultaneously capable of perceiving objective reality adequately, even though their attention may be absorbed by the perception of hallucinatory images. When their attention shifts entirely to the perception of hallucinations, the patient becomes completely incapable of perceiving the surrounding reality realistically.
Hallucinations are morbidly altered representations that are intensely colored with sensory qualities. They are always perceived externally (extraprojection) and are tied to a real, concretely existing situation: a «voice» is heard through a specific wall, «outside that very window», in a certain corner of the room. A patient pleads for rescue, sees that a large crowd has gathered on the street, and hears a «voice»: «Bring the criminal to justice!...» Hallucinations are characterized by vivid corporeality and are sometimes perceived by the patient even more vividly than genuinely existing objects and phenomena. Critical insight is absent. The patient harbors not the slightest doubt regarding the reality of everything they see and hear.
According to the analyzers involved, hallucinations are classified into visual, auditory, tactile, olfactory, gustatory, and visceral. So-called elementary hallucinations are known, manifesting as unformed auditory and visual images. For example, the perception of indefinite sounds, noises, knocking, or calling out constitutes akoasmas; the perception of glowing sparks or flashes constitutes photopsies. A patient may see red circles floating before them from left to right. Relatives of a patient recount that their brother frequently picks up the telephone receiver and asks: «Who is speaking? Who is needed?» Meanwhile, no one other than him hears the telephone ring. When asked, «Why are you picking up the phone?», he replies, «Can't you hear them calling us?»
Such hallucinatory phenomena are classified as elementary solely because they are very simple in content. At the same time, their significance as a psychopathological symptom is far from simple. Their appearance is associated with pathological changes in specific areas of the brain. The emergence of elementary hallucinations in a patient should alert the physician, as failing to act may mean missing the development of an organic brain disease (such as a tumor or an inflammatory process of the occipital and temporal localization). The remaining hallucinations are more complex in their clinical manifestations and progression.
In terms of complexity, visual hallucinations can be singular or multiple, stationary or moving, colored or black-and-white, scene-like or fragmentary. They may resemble the normal appearance of an object, be distorted (metamorphopsic hallucinations), or appear in vastly magnified sizes (macropsia) or reduced sizes (micropsia).
Auditory hallucinations are even more diverse. In relation to the individual, they may manifest as commentary with varying subtexts (neutral, threatening, condemning, approving); commands (imperative); or prophecies (apocalyptic).
Auditory hallucinations in the form of a monologue or dialogue that typically concern the patient, their life, thoughts, and actions indicate the presence of a mental illness. They may be pleasant to the patient—soothing and supportive—or, conversely, condemning and threatening murder, penal servitude, etc. It should be noted that the latter occur much more frequently.
The projection of hallucinations can vary. Visual perceptual deceptions may arise either in front, to the side, behind, or outside the field of Vision (extracampine hallucinations), while auditory hallucinations may seem very close or the «voices» may be heard from far away.
Olfactory hallucinations most frequently represent the deceptive perception of unpleasant odors. The patient smells rotting meat, smoke, foul stenches, etc. Olfactory hallucinations involving pleasant scents (the smell of flowers, cologne) are less common. Frequently, patients with olfactory hallucinations refuse food because they are convinced they are being fed «rotting meat» or that poisonous substances are being slipped into their meals.
The onset of olfactory hallucinations should alert the physician, as it often indicates the beginning of an organic brain disease or schizophrenia.
Visceral and general-sense hallucinations occur in various organs and parts of the body, acquiring a distinct sense of objectivity. For instance, a patient may report that "a wedge has been driven into their Heart" or that "insects are crawling in their bladder." Such sensations are extremely unpleasant. Hallucinations of general sensation manifest as pulling, shifting, heat, or cold inside the brain. They differ from cenestopathies in that cenestopathies involve diffuse, poorly localized intra-body sensations. While general-sense hallucinations are quite common in schizophrenia, cenestopathies occur just as frequently in disorders of infectious and somatic origin. The primary distinction between cenestopathies and general-sense hallucinations is that cenestopathies are more elementary in content and lack any sense of objectivity. Their onset is believed to be associated with heightened excitability of internal organ receptors, which in turn correlates with various alterations in the autonomic divisions of The Nervous system. Unlike cenestopathies, bodily and visceral hallucinations typically feature unusual characteristics, such as "having a toad sitting in one's abdomen."
Hallucinations frequently occur in the evening and morning hours when the patient is in a so-called hypnagogic state; hallucinations occurring prior to falling asleep are termed hypnagogic, while those occurring upon awakening are called hypnopompic.
The predominance of a particular type of hallucination, their character, rapidity of onset, and their interrelationship with illusions are of diagnostic significance. Thus, rapidly developing visual, auditory, and tactile hallucinations and illusions are more characteristic of acute intoxication or infectious psychosis. The prevalence of olfactory, auditory, or tactile hallucinations is most typical of protracted psychoses, such as schizophrenia and alcohol hallucinosis.
Hallucinosis is a condition in which a patient experiences prominent and persistent, most commonly verbal, hallucinations.
Verbal hallucinosis (acute or chronic) is among the fairly frequent clinical manifestations of both acute psychotic states (such as alcoholic hallucinosis) and chronic mental illnesses. It is characterized by auditory hallucinations in the form of monologues or dialogues, commentaries on past or ongoing actions, and direct or indirect demands. The patient remains fully oriented regarding their surroundings and their own identity. They constantly hear a multitude of voices, converse with them, and are unable to distinguish them from real ones. Male and female voices command the patient not to obey the doctor or answer their questions. Clouding of consciousness is not observed, and partial critical insight may be preserved. In acute hallucinosis, awareness of the environment may be impaired, critical insight absent, and accompanied by fear and persecutory delusions.
The character and content of verbal hallucinations are closely linked to the person's emotional state: when the mood is good, the "voices" are benevolent, friendly, and pleasant to the ear; when the mood is poor, they are hostile, threatening, and may mock the patient.
During the reverse development of hallucinosis, hallucinations first become less diverse, after which they lose their sensory vividness, extraprojection, and specific localization, being heard only when the surroundings are quiet. It is worth noting a crucial feature common to all forms of hallucinosis: regardless of which analyzer (visual, auditory) the hallucinations belong to, they develop without signs of altered consciousness and possess all the qualities of a genuinely existing object or item.
Pseudohallucinations were detailed by V. Kh. Kandinsky, who emphasized that they are extremely vivid and sensory-rich images. They differ from hallucinations in that they possess a peculiar subjective reality. Whereas true hallucinations involve the simultaneous perception of both the real surrounding environment and the associated hallucinatory image, in pseudohallucinations the patient perceives the image outside of actual reality (seeing an image outside the hospital ward while physically inside it, or hearing a "voice" somewhere outside their room while aware they are inside it).
Pseudohallucinations differ from hallucinations in their insufficient persistence, lack of three-dimensionality and sensory depth, and the absence of objectivity, corporeality, and extraprojection. They are accompanied by a sense of subjectivity of the perceived image and a feeling of imposition (psychic automatism).
Pseudohallucinations most closely resemble mental representations—erroneous, vivid memories. Critical insight into them is typically absent. However, a patient experiencing pseudohallucinations distinguishes pseudohallucinatory images from real ones. They typically experience a feeling of "their fabricated, artificial nature and imposition," which stems from their relatively low dependence on thought and will, spontaneous onset, and the lack of a sense of internal agency. As a rule, the patient sees the image with the "inner eye" and hears it with the "inner ear"; that is, internal projection of perceptual disorders predominates. The patient constantly sees scenes from their past life "somewhere inside their head."
Clinical practice indicates that perceptual disorders exhibit great diversity. Neurological types of hallucinations include Lhermitte's peduncular hallucinosis and Charles Bonnet hypnagogic hallucinations. Among tactile hallucinations are Ekbom's delusional parasitosis (dermatozoic hallucinations) and Seglas's pharyngeal and oral hallucinations.
Lhermitte's peduncular hallucinations arise from localized lesions of the cerebral peduncles and the mesencephalic region (mesencephalic hallucinosis). These are typically vivid, colorful, moving, kaleidoscope-like visual hallucinations that occur in the evening and upon falling asleep, with eyes closed in a dark room. The patient generally maintains a calm and critical attitude toward them, observing them in a state of repose with preserved insight into the experience. Occasionally, these may be accompanied by auditory and visual hallucinations.
Closely related are hypnagogic hallucinations, which occur during the transition from wakefulness to sleep with closed eyes. They frequently have a panoramic character akin to nightmares, with the patient seeing distorted faces, monsters, and bizarre plants.
Charles Bonnet syndrome involves visual hallucinations of a contemplative type. Patients see various landscapes, dynamic images of animals, etc. These hallucinations occur in elderly individuals in the presence of vascular and senile pathology. A characteristic feature is that the hallucinations reflect the patient's personal concerns—for instance, if a patient's young granddaughter has fallen ill with measles, her grandfather may envision her as healthy. Critical insight into these experiences may be preserved, and there is no delusional interpretation of the hallucinatory imagery.
Ekbom's dermatozoic hallucinations involve the sensation of parasites on or beneath the skin. For example, if a patient has an eczematous skin lesion, they feel that parasites are crawling precisely in that area beneath the skin.
Seglas's oral hallucinations are the sensation of a foreign body (threads, Hair) in the Mouth or throat. Such hallucinations may appear suddenly or gradually against the background of formally preserved orientation in place and time, but they can also occur against a background of altered consciousness, forming part of a psychopathological syndrome of clouded consciousness—delirium, oneiroid state, amurence, or twilight state. Acute hallucinatory confusion syndrome is characterized by a complex psychopathological constellation.
It should be noted that perceptual disorders are much more frequently observed not in isolation, but in combination with a morbidly altered interpretation of surrounding reality and one's own sensations. That is, they are associated with Thought Disorders and constitute an integral part of hallucinatory-paranoid Psychopathological Syndromes (paranoid, paraphrenic, and Kandinsky-Clerambault syndromes).
Hallucinations quite frequently appear during various intoxications, most notably alcoholic ones. In alcohol delirium (delirium tremens), the patient experiences visual, auditory, and tactile hallucinations. Visual hallucinations are distinguished by extreme sensory vividness, mobility, and multiplicity. Characteristic features include "zoopsias"—small insects, spiders, and little devils. Furthermore, while the patient is disoriented in space and time, their self-orientation remains intact.
Hallucinations associated with infectious diseases differ in that their content is less tied to the patient's daily activities. Visual hallucinations predominate, particularly within the structure of hallucinatory confusion syndrome.
Epileptic hallucinations are distinguished by exceptional sensory vividness. They may appear as prodromal signs of a seizure—most commonly as vivid, emotionally intense visual hallucinations of a terrifying nature, and more rarely of a religious-mystical content.
Perceptual disturbances are quite characteristic of schizophrenia (visual, auditory, etc.), particularly when accompanied by various thought disorders (hallucinatory-paranoid syndromes).
In hysteria, hallucinations are superficial and dynamic, often taking the form of hypnological hallucinations. In content, they are close to the visualization of the patient's ideas and experiences, and more rarely of a terrifying or religious nature (occurring in hysterical twilight states of consciousness, the so-called altered states of consciousness).
Sensory deprivation, or "sensory vacuum" accompanied by anxious apprehensions or the expectation of threat, belongs among the triggering and determining factors for the onset and persistence of hallucinatory experiences. Modern neurophysiologists have established that normal brain function can be sustained only by an adequate inflow of information. Under conditions of informational "underload" or "overload," various hallucinatory phenomena may arise.
Proponents of the neuropsychological approach in psychiatry describe the features of hallucinations depending on which brain regions are damaged. Specifically, N. N. Bragina and T. A. Dobrokhotova discovered that olfactory and visual hallucinations observed in various lesions of the right cerebral hemisphere are indistinct, lack spatiotemporal Specificity, and are projected into the dark visual field of closed eyes, being seen with the "inner eye." In lesions of the left hemisphere, auditory-verbal hallucinations predominate, while visual hallucinations possess concrete spatiotemporal orientation and extraprojection.
Experience with psychotropic medications has demonstrated variable efficacy in clinically homogeneous hallucinations, highlighting The complexity of the pathological mechanisms underlying perceptual disturbances.
Among various sensory perception disorders (disturbances of sensation, perception, and mental imagery) in children and adolescents, The most significant are coenesthesias, illusions, hallucinations, and pseudohallucinations, all of which exhibit distinct age-related features. This specificity is linked to the GENERAL PATTERNS OF cognitive activity in childhood. On the one hand, it stems from the developmental immaturity and incompleteness of cognitive processes; on the other hand, it is driven by the insufficient formation, instability, and lability of mental disorders.
In early school-age children, coenesthesias typically manifest alongside hypochondriacal experiences, taking the form of coenestho-hypochondriacal states. They begin to be accompanied by elaborate interpretations, such as: "something is sloshing in my head like liquid," "something is pricking my chest like a needle," and so forth. One observes a morbid fixation of attention on health status and bodily sensations, accompanied by overvalued and obsessive ideas about having a particular disease. Unpleasant sensations in the head and chest usually predominate.
In schizophrenia, coenesthesias assume a distorted character and acquire bizarre interpretations, such as "The Heart has fallen into The Stomach," "the thighs are Swelling," "the genitals are withering away," etc., and are frequently accompanied by delusional hypochondriacal ideas. They are not uncommonly localized in the genital area.
In organic brain diseases, coenesthesias tend to be quite vivid and intensely colored in sensory terms. This is most frequently observed in neurosyphilis and neurorheumatism. In residual-organic mental disorders resulting from TRAUMATIC BRAIN INJURIES and neuroinfections, coenesthesias take on an algic and hyperpathic coloration.
In Psychogenic Disorders, coenesthesias are low in intensity, unstable, and prone to frequent shifts in their manifestations.
Illusions are significantly more common in childhood than in adulthood. Younger children typically experience visual illusions accompanied by elements of pathological imaginative fantasy. At night, a lamp outside the window may be perceived by a child as "a scary bird with a fiery eye trying to fly into the room." Such illusions incorporate feelings of threat driven by a morbidly heightened imagination.
Auditory illusions (for example, the sound of rain being perceived as approaching footsteps) are observed in older children and adolescents. Misinterpretations driven by intense emotional experiences can occur just as frequently. Tactile and olfactory illusions are much less common in children and adolescents.
In infectious and intoxication psychoses, the most complex and diverse illusions occur. These cases are typically dominated by vivid visual illusions, including pareidolias, where wallpaper patterns or cloud formations are perceived as shifting scenes of wondrous imagery. Such illusions frequently form an integral part of delirium states of clouded consciousness. Isolated visual and tactile illusions may also arise at the peak of a fever.
In schizophrenia, illusions tend to be fantastic and unusual (e.g., a lampshade perceived as "a headless bird"). They are frequently accompanied by delusional interpretations.
The Emotional Sphere and Its Disorders
Emotion, or affect, as defined by Ya. M. Kogan, is a specific type of mental response that lacks autonomy yet accompanies other mental processes, imparting a sensory coloring to them.
Every individual is personally familiar with specific mental experiences associated with various Changes in the external and internal environment. Emotions of pleasure and displeasure can be observed in the human fetus as early as the 5th–6th months of development. Such early manifestations of activity in this mental sphere are by no means accidental; they point to the exceptionally vital role that emotions play in human life. According to P. K. Anokhin, emotion is a mechanism for evaluating changes in living conditions, endowed to living creatures by nature long before the emergence of the capacity for cognition. Thus, emotions can be defined as the component of the psyche capable of evaluating changes occurring in the internal or external environment from the standpoint of their utility. Compared to the cognitive mechanism, the Features of the "emotional mechanism" include extraordinarily high sensitivity, speed of action, and unambiguous evaluation. It is well known how significant a role is played by first impressions upon encountering new circumstances and new people, and how difficult it is not only to evaluate them, but often even to understand the causes underlying one's established attitude toward ongoing events. Thus, P. K. Anokhin's biological theory views emotion as a product of evolution that facilitates adaptation, possessing two key aspects: evolutionary and physiological.
The Role of the emotional sphere lies in evaluating the degree to which obtained results (via feedback / reverse afferentation) match the action result acceptor (by comparing them with the anticipated ideal result).
The "information theory of emotions" by P. V. Simonov approaches the role of the emotional sphere in human life from a similar perspective:
1. Emotion does not arise if there is no need or if the need is fully satisfied, meaning the system is completely informed.
2. In the event of an information deficit, a negative emotion emerges, reaching its maximum when information is entirely absent.
3. A positive emotion arises when the available information exceeds the amount prognostically necessary to satisfy the given need.
Thus, both theories proceed from the premise that the source of emotion is objective reality.
Recent studies have significantly clarified the anatomical and Physiological Basis of emotional manifestations. The leading role of limbic system structures has been proven: the hippocampus, amygdala, septum, fornix, olfactory structures, areas of the archaepaleocortex, and hypothalamic structures. Classic experiments involving the ablation of the temporal pole and amygdaloid complex led to the development of emotional unresponsiveness (Klīver–Bucy syndrome), alongside attempts at self-stimulation of "reward areas" and avoidance of stimulation in "punishment areas" (J. C. Olds, P. Milner, J. Delgado).
Neurochemical maintenance is carried out by specific ratios of system activity unique to certain emotional states, utilizing Neurotransmitters such as noradrenaline, dopamine, serotonin, gamma-aminobutyric acid, and Neuropeptides. The complex interactions and patterns of mutual influence among these structures and systems are currently the focus of active research by clinicians as well as specialists in psychophysiology, neuro- and Pathophysiology, and general pathology. From the standpoint of psychology and general psychopathology, the crucial aspect here is the evolutionary dynamics of emotional manifestations against the backdrop of the Increasing complexity of brain architecture.
The task of the emotional sphere is to provide a dynamic, unambiguous, and adequate evaluation of changes occurring both externally and internally within the human Organism. Consequently, emotional manifestations must possess certain qualities that enable the realization of this function. Among such properties (characteristics) are sensitivity (elicitation threshold), lability (stability), amplitude, rate of rise, and emotional content. Building upon this approach, emotional manifestations can be classified according to excitability (taking into account characteristics such as the elicitation threshold, rate of rise, and, to some extent, amplitude) and stability (considering the duration of a given emotion and the threshold for triggering changes).
It must be emphasized that the Classification of emotional manifestations based on excitability and stability is largely quantitative in nature, describing varying degrees of change in emotional characteristics along a corresponding scale. At the same time, one should bear in mind that a certain degree of emotional excitability and stability is also characteristic of healthy individuals. Their affective manifestations can be evaluated using the same scales, even though they do not reach extreme values. It is also worth noting that the "norm of reaction" (the range of normal fluctuations) depends on temperament, sex, age, national-racial and cultural background, and many other factors.
Therefore, among emotional disorders related to excitability, researchers distinguish emotional coldness, sensitivity, and irritable weakness.
Emotional coldness is generally understood as a cold, indifferent attitude of an individual toward ongoing events. Patients with these Specific features of the emotional sphere exhibit a high threshold for emotional elicitation and a low amplitude (depth) of emotional experiences. An example of emotional coldness is The behavior of a schizophrenic patient who came out to meet his father and, without greeting him or uttering a single word, took the food brought to him and immediately returned to his ward. Another female patient was hospitalized in a psychiatric facility because she attempted to throw her child into the oven simply because the baby was disturbing her sleep. The maximal manifestation of emotional coldness is emotional dullness. The consequences of emotional dullness include untidiness, indifference to contamination, and a lack of modesty in patients, as a result of which their appearance and living quarters acquire an extremely repulsive look.
Sensitivity is characterized by a lowered threshold for emotional reactions. The slightest change in circumstances triggers a shift in emotional state. Individuals with this specific type of emotional responsiveness resemble a mimosa plant; they are often forced to consciously limit their contacts and sphere of activity in order to avoid an excessive burden of emotional experiences.
Irritable weakness is characterized by a lowered threshold of emotional reactivity, rapid onset, and a relatively high amplitude of emotional response. At the same time, such a response is short-lived, quickly depleted, and often ends in tears or verbal remorse. Irritable weakness is frequently observed in asthenic states of various origins (intoxications, somatic diseases, and brain atrophy).
In terms of stability, emotional disorders can be classified into several variants: lability, explosiveness, and viscosity (rigidity).
Emotional lability manifests as frequent shifts in the emotional background, typically driven by changing external circumstances. Thus, the leading characteristic here is the insufficient Stability of the emotional response. The amplitude of emotional expression in this case is quite significant. An example of emotional lability is the behavior of children, in whom sadness, joy, anger, and other emotions rapidly replace one another over a short period. When emotional lability is accompanied by a lowered threshold, high amplitude, and rapid emotional reactivity, it is referred to as emotional fragility or lability with weakness. As an example, we can mention elderly individuals in whom relatively minor events trigger a stormy emotional outburst with tears, regardless of whether the emotion is positive or negative.
Explosiveness is understood as emotional volatility, frequently associated with fits of anger and aggressive behavior. Alongside instability, the characteristics of this reaction include a low threshold, high amplitude, and a very rapid onset. Unlike emotional fragility, explosiveness is accompanied by high energy and a drive to release emotional tension directly through behavior.
Emotional viscosity (rigidity, inertia) is manifested in the "stuckness" of an emotional response, its pathological persistence, and the inability to experience other emotions appropriate to the current circumstances. This disorder is most characteristic of patients with epilepsy, who may remain in a state of euphoria for extended periods, praising those around them with overly sweet and affectionate expressions. Conversely, opposing emotional states involving anger, boredom, or fear—as well as combinations thereof—can be equally persistent. These states are dangerous due to their high energetic intensity and the impossibility of rapid discharge. The prolonged retention of pathologically persistent emotions leads to personality changes specific to epilepsy.
Affective torpor (frozen affect, stagnant affect) refers to a loss of affective modulation, characterized by a persistent, tense affect that is independent of external circumstances.
The most important qualitative characteristic of emotional manifestations is their adequacy—the correspondence between the intensity and content of emotions and the circumstances that provoked them. Adequacy and unequivocal evaluation of ongoing events are Fundamental properties of the emotional sphere. In psychopathology, we frequently encounter distortions of emotion: emotional inadequacy and ambivalence, and (much less frequently) pathological affect.
Inadequacy refers to the emergence of emotions that do not correspond to the circumstances in terms of content and affective force (depth). A classic example of emotional inadequacy is the pleasure experienced by some schizophrenia patients in response to the moral and physical suffering of their loved ones. In situations where an emotional reaction is adequate to the stimulus in content, but grossly disproportionate in strength (depth of expression), we speak of pathological affect. Pathological affect (an acute affective condition) is a short-lived, violent emotional discharge accompanied by impaired consciousness (typically a twilight narrowing of consciousness) followed by amnesia, which deprives a person of The ability to control their behavior and comprehend their actions. Against the backdrop of anger, rage, or frenzy, an individual resorts to unprovoked aggression, their behavior is inadequate, and the affect is accompanied by strong autonomic reactions, often followed by an emotional stupor.
The signs of pathological affect that distinguish it from physiological affect are as follows:
— the disproportion between the excessive intensity of the emotional reaction and the strength of the triggering stimulus;
— the short duration of the affect, lasting only a few minutes;
— a sharp narrowing or clouding of the field of consciousness;
— a violent motor discharge;
— amnesia for the period of pathological affect;
— nervous system exhaustion following the pathological affect;
— sometimes the pathological affect culminates in a critically deep sleep;
— the psychopathological radical against which the pathological affect develops.
Pathological affect most commonly arises in patients with the consequences of organic brain damage (not always severe, often subclinical). It undergoes three phases of development: preparatory, explosive, and terminal. During the preparatory phase, so-called accumulation of affect occurs without pronounced external manifestations; in the explosive phase, the aforementioned emotional discharge with impaired consciousness takes place; and in the terminal phase, emotional stupor or deep sleep ensues.
Ambivalence refers to the simultaneous existence of opposing feelings toward the same object or event. For instance, a patient with catatonic schizophrenia may refuse food, pushing the plate away, yet when someone attempts to take the plate back, they refuse to let go. Examples of ambivalent attitudes toward the environment can also be encountered in healthy individuals, particularly in situations involving the blockage of an active need—frustration. A classic example of a frustration situation is the fable of the fox and the grapes, which are simultaneously appealing to the taste and frustrating because they are unreachable. Even more familiar are the contradictory emotional experiences associated with the desire to fulfill fundamental drives versus the impossibility of doing so due to emotions dictated by generally accepted social norms and rules. It must be noted that despite the unpleasant experiences associated with frustration, a healthy individual does not remain in a state of ambivalence for long, leaning toward behavior driven by one emotion or the other; in a pathological state, this choice becomes impossible.
Based on their degree of complexity, emotions are divided into primary (fundamental) and complex (mixed). C. Izard considers interest, joy, surprise, distress, disgust, anger, contempt, and shame to be fundamental emotions. Complex (mixed) emotions, such as jealousy, are combinations of various emotions—in this case, love and anger.
We distinguish between sthenic and asthenic emotions based on whether they stimulate or inhibit the personality, prompting a person to action and activity or hindering them. Examples of the former include anger and joy, while the latter include sadness, shame, and fear.
While lower emotions (fear, anger, pleasure, etc.) are driven by instincts and are common to humans and higher animals, higher emotions are characteristic of humans and evolved as a result of social life. Examples include the feelings of righteousness, justice, truthfulness, and aesthetic pleasure.
Modern classifications also take into account the following characteristics of emotions:
— they vary in intensity (pleasure versus happiness);
— they can be positive or negative (joy versus sadness);
— they exist in opposites (love — hatred, joy — sadness).
There are two aspects of emotional expression: the subjective experience of an emotion and its external manifestation. Unlike cognitive processes (thoughts, memories), which are expressed primarily at the verbal level (through words), emotions are expressed mainly at the non-verbal level—primarily through facial expressions, as well as posture, gestures, and movements. Furthermore, strong emotions are accompanied by autonomic reactions (paleness or flushing of the skin and face, sweating, accelerated heart rate, and Respiration, among others).
In human society, all social bonds are rooted in emotions, which other people can gauge largely through facial expressions. The face serves as the central hub for transmitting and receiving social signals that are crucial for an individual's development. Long before children begin to speak, their faces convey messages essential for mother-infant attachment. People worldwide, regardless of their social and cultural background, are equally capable of recognizing the emotions conveyed by facial expressions.
According to C. Izard, the movements of our facial muscles not only express our feelings but, in turn, influence them. This hypothesis, known as the facial feedback hypothesis, posits that feedback from the nervous system to the facial muscles helps us experience emotions by providing information about the feelings we are currently undergoing. Try smiling right now. How do you feel now? Now frown and clench your Teeth. Is there a difference in how you felt when smiling versus frowning? This phenomenon has been confirmed in the works of Ekman, Levenson, and Friesen. Consequently, the expression of emotion is not merely triggered by physiological processes, but also contributes to the experience of physiological arousal.
The degree and intensity of the external manifestation of feelings depend on numerous factors, among which an individual's character and temperament, upbringing, cultural background, and situational context are particularly noteworthy. For instance, certain cultures encourage restraint and condemn excessive forms of emotional expression. As noted above, facial expressions and other emotional manifestations possess not only biological significance, but also psychological and social importance. The ability to understand another person's state and empathize with them is known as empathy. This human trait plays a vital role in interpersonal communication and the establishment of social connections.
In cases of mental disorders, a dissociation between the intensity of subjective emotional experience and the degree of its external manifestation is quite common. For instance, in schizoid personality disorder, a patient may experience profound emotions, yet their facial expressions and other external manifestations of emotion remain muted, failing to match the intensity of their inner experience. Conversely, in histrionic personality disorder, patients express grief, anger, or joy dramatically and somewhat theatrically, despite the relatively mild underlying intensity of these emotions.
Emotions represent an individual's subjective reaction to reality, serving as a direct indicator of how a person perceives the world around them. It should be noted that within the emotional sphere of mental activity, establishing clear boundaries between normality and pathology is challenging. For example, when evaluating emotions related to excitability and stability, only extreme deviations of these characteristics can be considered pathological. Furthermore, there are no distinct types of affective states and mood fluctuations that are exclusively characteristic of patients and never encountered in healthy individuals. States of fear, anxiety, and depression, for instance, are not unequivocally pathological. All emotional reactions must undoubtedly be evaluated in conjunction with the state of other mental functions and the individual's personality as a whole.
Below is a description of several affective states that frequently occur in various mental disorders, though they are not pathognomonic to any specific psychiatric illness on their own; in some cases, they may also be experienced by healthy individuals. When describing various approaches to classifying emotional disorders, it is also necessary to mention the possibility of dividing them into negative and positive disorders.
Apathy is a complete indifference to everything around oneself and one's own situation, accompanied by a lack of thought. Nothing elicits interest or an emotional response. This state must be distinguished from the feeling of emotional numbness (a painful insensitivity characterized by a profound sense of emotional devastation, an irreversible loss of the capacity to feel, where neither joy, love, nor sadness remains).
Emotional tension is a subjectively unpleasant increase in the intensity of inner experience, alongside heightened mental and motor activity (for example, in anxious agitation — anxiety accompanied by increased motor activity).
Anxiety is a diffuse, highly unpleasant, and often vague sense of apprehension, a premonition of internal or external danger, accompanied by somatic sensations (such as a hollow feeling in the stomach, a sinking sensation in the chest, chest tightness, sweating, headaches, etc.). This state is also characterized by restlessness and an urge to move.
Fear is agitation associated with a known and realistic danger facing an individual, triggered by a specific object.
Anxiety and fear serve as warning signals of danger, allowing a person to take measures to avoid it. Psychologically, distinguishing between fear and anxiety is fully justified. The emotion triggered by a car suddenly appearing from around a corner while crossing the street differs from the mild discomfort that occasionally arises when meeting new people in unfamiliar circumstances. Fear differs from anxiety in that it is real in nature. Anxiety, on the other hand, is a reaction to an unknown, internal, ambiguous, or contradictory threat. Sometimes referred to as "free-floating" anxiety, this denotes unfocused anxiety that is not directed at any specific thought.
C. Darwin, who studied the expression of emotions in humans and certain animal species, described the onset of fear as follows: "Fear is often preceded by terror, and both feelings are closely related; both instantly sharpen vision and attention. In both cases, the eyes and mouth are wide open, and the brows are raised. A terrified person initially stands like a statue, motionless and holding their breath, or crouches down as if instinctively trying to hide. The heart beats rapidly and violently, fluttering and pounding against the Ribs, though it is doubtful whether it functions more efficiently than usual in supplying Blood to all parts of the body, as the skin immediately turns pale, as before a faint... That the emotion of fear profoundly affects the skin is confirmed by the strange and unexplained rapidity with which it becomes covered in sweat. This perspiration is particularly unusual because the surface of the skin is cold at the time, which is the Origin of the phrase ‘cold sweat’... The mouth becomes dry during fear and frequently opens and closes. One of the most striking symptoms is the trembling of all the Muscles of the body, initially noticeable in the Lips. As a result of this and dry mouth, the voice becomes hoarse or may fail entirely..." (C. Darwin, 1896).
In pathological conditions, anxiety and fear are extremely common manifestations; they arise in numerous disorders, including the aftermath of stress and practically all forms of psychoses. The 10th revision of the classification of mental disorders distinguishes so-called anxiety disorders: panic disorders, phobias, obsessive-compulsive syndrome, and generalized anxiety disorder.
Panic (panic disorder) is an acute, episodic, and intense attack of overwhelming terror, accompanied by marked autonomic reactions and irresistible motor responses (flight or freezing).
Panic, as one of the psychogenic Shock reactions, is most frequently observed in healthy individuals in the face of sudden, life-threatening danger (during natural disasters or military conflicts). In pathological cases, panic attacks occur without an apparent cause, for example, in patients with mitral valve disease. The Etiology of this disorder remains unclarified.
Pathological fears are heterogeneous in their clinical manifestations. Phobias (obsessive fears) are the most frequently encountered and thoroughly studied among them.
A phobia is an irrational, unjustified, obsessive fear that leads to the deliberate avoidance of a specific activity or situation. Like other obsessive phenomena, phobias are accompanied by a sense of alienness and an inner lack of freedom. The individual wishes to overcome the fear and understands that it is groundless, yet is practically incapable of overcoming it through willpower alone.
Obsessive fears most commonly arise as a symptom of obsessive-phobic disorders and can be directed toward various objects, situations, and activities. Simple phobias involve a fear of a specific object (e.g., fear of snakes, spiders, etc.). Social phobia is the fear of "making a fool of oneself," leading to anxiety regarding public speaking, performing on stage, interacting with strangers, or even eating in public places. Acrophobia is the fear of heights, algophobia is the fear of pain, xenophobia is the fear of strangers and unfamiliar customs, zoophobia is the fear of animals, claustrophobia is the fear of enclosed spaces, and agoraphobia is the fear of open spaces, in which patients may sometimes fear even leaving their home, being in a crowd, or visiting stores and public places. Many Other types of phobias also exist. In psychiatric illness, a patient may initially develop a single phobia which, in some cases, persists over a long period, either intensifying or diminishing under the influence of Treatment. In other instances, the number of phobias increases and their clinical picture becomes more complex. For example, following a heart attack, a patient may develop a fear of heart disease (cardiophobia) or a fear of death (thanatophobia). If the attack occurred in a confined space (such as an elevator), claustrophobia may also develop. In some patients, the number of feared objects is so vast that one can speak of panphobia, meaning a "fear of everything."
Let us consider a clinical case.
Patient L., 28 years old, a housewife, expresses concern during a doctor's consultation that she will no longer be able to care for her three children. Over the past year, she has experienced recurrent attacks of "nervousness," sudden fear unrelated to external causes, dizziness, accelerated breathing, and palpitations, accompanied by trembling throughout her body. During these attacks, everything around her seemed unfamiliar, unreal, and frightening.
Previously, she was active and sociable. However, over the past 6 months, she has become afraid to leave her apartment without her husband or mother. She avoids stores and states that she feels unwell in crowds. If she fails to avoid such situations, she tries to remain close to doors and windows, constantly checking where the exit is. Neither she nor her family members understand what is happening to her.
Summary. The patient experiences panic attacks accompanied by dizziness, palpitations, and rapid breathing, which have led to the development of a fear of leaving home and visiting public places (agoraphobia). This can presumably be explained by the fact that she associated her panic attacks with the specific locations where they first occurred.
Unlike emotions, which are immediate reactions to a specific stimulus or an individual's internal state, mood represents a complex and relatively stable psychological background—the cumulative result of various emotions experienced simultaneously. Everyone experiences different moods, ranging from depressed and angry to elevated, depending on the situation. A normal mood that shifts appropriately with changing circumstances in a healthy individual is termed euthymic. In mental disorders, mood disturbances frequently occur in terms of both appropriateness and stability. Unstable mood is characterized by rapid shifts from an elevated to a depressed state over short intervals (hours), often driven by minor external circumstances.
Dysphoria is a gloomy, irritable mood state accompanied by heightened sensitivity to external stimuli. The nuances of dysphoria can vary. Sometimes it manifests as a sullen pessimism marked by fault-finding and conflict-seeking behavior, which in certain cases may lead to aggressive outbursts directed at others. In some patients, dysphoria is accompanied by pronounced aggression, verbal abuse, and the destruction of surrounding objects. Occasionally, patients exhibit impulsive wandering or leaving home. Dysphoretic episodes can arise as a psychic equivalent of epileptic seizures, and they are also characteristic of organic Central nervous system damage.
The following clinical case is typical.
Patient D., aged 32, experienced a sudden onset of a sullen, melancholic mood. Initially, he complained that people around him were treating him poorly. Shortly after, he attacked a neighbor with a knife and brutally beat his wife and child. This state subsided as abruptly as it had begun. The patient retained a complete and vivid memory of the experience and his actions.
Anhedonia refers to the loss of interest in, and withdrawal from, recreational pursuits and all activities that previously brought pleasure and gratification. This phenomenon is frequently observed in depressive states.
Euphoria is an elevated mood characterized by passive contentment, joy, and lightheartedness, occurring without acceleration of thought processes and sometimes even accompanied by their slowing.
Ecstasy is the profound experience of rapture and absolute happiness.
Alexithymia is the difficulty or inability to identify, describe, or comprehend one's own mood or emotional reactions.
Depressive states rank among the most widespread Affective Disorders. According to the World Health Organization, approximately 5% of the global population suffers from depression, and among elderly psychiatric patients, its prevalence reaches 40–60%.
A depressive state can be defined as a pathologically lowered, depressed mood accompanied by diminished mental and motor activity, alongside somatic disturbances—first and foremost vegetative ones.
The core symptoms of depression include a depressed mood lasting for a prolonged period (most of the day, nearly every day) and a marked diminution of interest in almost all activities. Patients complain of profound melancholy, increased fatigability, and a lack of positive emotional responsiveness to events and activities that previously brought them pleasure. In some cases, anxiety predominates over melancholy.
In typical depressive syndrome, E. Kraepelin identified a triad of symptoms: 1) a melancholic mood; 2) intellectual and verbal inhibition (slowing of thought processes to the point of monoidism); and 3) motor retardation, which in severe cases reaches the level of melancholic stupor.
Against the backdrop of a depressed mood, ideas of self-blame, self-deprecation, an overwhelming sense of guilt, and self-reproach emerge. Depending on the underlying disorder causing the depression, these ideas may be delusional in nature or take the form of obsessions. Suicidal ideation is frequent, and patients not infrequently attempt to act upon it. Patients display a pessimistic outlook, negatively evaluating their past, present, and future, and they often describe depression as an unbearable psychological agony. Nearly all patients complain of reduced energy and working capacity, struggling with concentration and decision-making. The mood remains depressed for the greater part of the day; patients feel at their worst in the morning and early hours, while toward evening their condition often improves slightly.
In most cases of typical depression, patients exhibit thought and speech retardation that is not only subjectively perceived by the patient but also objectively observable by the physician. Patients respond to questions only after a sometimes significant pause; their speech tempo is slowed, and their voice is quiet, poorly modulated, and "colorless." Motor activity is characteristically reduced: patients walk slowly and sit in monotonous postures, often with their heads bowed and shoulders slumped. Their facial expression is doleful and sorrowful. Due to their pessimistic mindset, as well as psychomotor inhibition, patients become irresolute in their actions. Even when the depression is not excessively deep, they find it difficult to make decisions, navigate life situations, and draw upon personal experience.
In addition to the aforementioned psychopathological symptoms, depression manifests a range of somatic signs—encompassing both subjective patient complaints and Objective Examination findings. Patients may report unpleasant sensations in the chest or upper abdomen, headaches, a "lump" in the throat, or bodily numbness. One of the most agonizing sensations in depression is so-called "cardiac anguish," a distinctive pain or constriction in the chest or upper abdomen. Patients feel as though something foreign is lodged inside them—a piece of ice, wood, or a sensation that "the heart is being gripped in a vise"; notably, patients distinguish these sensations from ordinary physical pain. Sleep disturbances are extremely common: patients have difficulty falling into sleep, sleep is shallow, and it is frequently accompanied by terrifying dreams. Among vegetative disorders, the Protopopov triad is the most well-known: pupillary dilation, tachycardia, and constipation. These symptoms indicate an increased tone of the sympathetic nervous system. Patients lose their appetite and experience weight loss. Skin turgor declines, the hair becomes dull, and patients appear older than their chronological age. Libido decreases, and women frequently experience dysmenorrhea or Amenorrhea.
The following clinical case is typical.
Patient Z., aged 45, was admitted to a psychiatric hospital following a suicide attempt (she tried to hang herself). In the ward, the patient sits with a sorrowful facial expression; her movements are slowed, and she does not initiate conversation with others. She Answers questions only after a pause, speaking in a quiet, poorly modulated voice. Occasionally she whispers: "What is the point of all this, nothing matters anymore anyway..." According to her relatives, over the past few days she had stopped going to work and performing household chores, spent most of her time sitting in a monotonous posture, showed no interest in anything, and answered questions briefly and reluctantly. She expresses no remorse for her suicide attempt.
It must be emphasized that the clinical picture described above represents typical depression, also known as retarded or inhibited depression. There are several variants of depressive states that differ in their clinical manifestations and severity. The clinical profile and course of depression are influenced by the nosological category, the patient's age, personality traits, and numerous other factors.
Anxious-agitated depression differs from retarded depression in the dramatic Nature of the patient's behavior. The mood is depressed, but the predominant affective state is not inhibition, but anxiety and causeless dread. Instead of psychomotor retardation, motor agitation appears. Patients cannot find a place for themselves, pace frantically around the ward, tear at their hair, bang their heads against the wall, moan loudly, weep, and make obsessive, repetitive requests of others. This form of depression occurs more frequently in involutional psychoses.
The clinical picture of anxious-agitated depression is vividly illustrated in the case below.
Patient N., aged 62, expresses the conviction that she is unwanted and useless to everyone. Over recent weeks, her condition has steadily deteriorated. In the ward, she appears anxious and distressed. She paces the room, wringing her hands and crying out, "Oh, when will all this ever end?" She tells her doctor that she is a moral monster, a criminal who has disgraced herself and her daughter, who will now hate and curse her for the rest of her life.
Hypochondriacal depression (depressive-hypochondriacal syndrome) is characterized by a multitude of unpleasant somatic sensations localized across various parts of the body. These sensations lack clear localization and may present as constricting, dull, or boring pains. The patient's complaints are idiosyncratic, vague, and fail to fit the framework of any specific somatic illness. The clinical picture is defined by hypochondriacal fears, with patients predominantly preoccupied with the belief that they are suffering from a severe physical disease. The intensity of the depressed, melancholic mood may be less pronounced than in typical depression. When cenesthesias dominate the Clinical presentation, this form is occasionally referred to as cenesthetic depression.
Depressive-paranoid syndromes encompass not only the symptoms characteristic of depression but also delusional ideas and, at times, hallucinatory experiences. Delusions in patients with these syndromes invariably carry a negative content: ideas of persecution, poisoning, self-blame, ruin, and so forth. If a patient speaks of the destruction or absence of their internal organs, the condition is termed depression with nihilistic delusions, the extreme variant of which is Cotard's syndrome—a combination of anxious-agitated depression with grandiose nihilistic delusions. Patients assert that their "intestines are glued together," their "Lungs have rotted away," or that they possess no internal organs at all, and they may even believe they are dead. This denial can extend to the external world—claiming that no one is left in the world, and the planet has grown cold and empty.
Masked (vegetative or somatized) depression is a form of depression in which somatic and vegetative symptoms come to the forefront, while emotional disturbances recede into the background. Somatic complaints include pains in the cardiac region, abdomen, and head. Functional disorders of internal organs are sometimes observed, such as tachycardia, gastrointestinal disturbances, or dysmenorrhea. Such patients most frequently find themselves under the care of a general practitioner or surgeon and may be diagnosed with neurocirculatory dystonia, diencephalic crises, or conversion disorders. Simultaneously, careful probing and examination reveal characteristic depressive symptoms («minor» mood, thought slowing, diminished initiative, loss of interest, etc.).
Subdepression is a mild form of depression in which patients do not always complain of profound melancholy, speaking more often of a generalized sense of boredom and listlessness. Tasks that lie ahead appear complex, insurmountable, and uninteresting, particularly work involving intellectual effort or decision-making. Working capacity declines, which elicits feelings of guilt in the patients. Sleep disturbances arise, with patients waking early, preoccupied by thoughts and anxiety regarding the upcoming day. Somatic symptoms, as in Other forms of depression, include decreased appetite and weight loss; patients appear emaciated and prematurely aged. They may experience sensations of coldness or chills. Occasionally, an internal "tremor" is reported, which patients describe as distinct and unlike ordinary shivering. Some patients exhibit irritability, heightened vulnerability, and tearfulness. This variant of depression is also referred to as hypothymic depression.
Based on etiology, one can distinguish somatogenic depressions (arising as a consequence of somatic illnesses), endogenous depressions (associated with affective disorders, schizophrenia, and involutional psychoses), and psychogenic depressions (linked to stress-related disorders) (P. Kielholz, 1962).
It should be emphasized once again that The problem of suicide in depressed patients is relevant across all age groups. More than two-thirds of patients with these conditions experience suicidal ideation, up to 40% make suicide attempts, and up to 15% complete suicide. This fact highlights the critical need for timely Diagnosis and treatment of depressive states.
The following clinical case is characteristic.
Patient D., aged 56, was admitted to a psychiatric inpatient unit complaining of anxiety, fear, depressed mood, and insomnia. The patient is restless, unable to sit still for long, paces the ward constantly, wringing her hands and sighing. She expresses self-blaming ideas, believing that she is a burden to her children, that she «makes her children and grandchildren unhappy», that she «has done nothing good in life», and that everyone despises her for this. Periodically, she hears «voices» behind the ward wall calling her a «worthless person» and threatening her. The patient has suicidal thoughts but has made no suicide attempts. It was established that she has lost 6 kg over the past few months. Her appetite is very poor, and food tastes bland to her. Recently, she has developed persistent constipation. The patient appears older than her age.
Such clinical manifestations are typical of agitated depression.
Manic syndrome is a combination of elevated mood, accelerated thought tempo, and excessive motor activity.
The degree of expression of the aforementioned disorders (the manic triad) can vary among different patients.
In mild mania (a hypomanic state), patients appear simply cheerful, optimistic, and active. They are sociable, witty, self-confident, and often look younger than their years. However, they tend to be inconsistent in their actions and frequently fail to see tasks through to completion. The pathological nature of their condition usually becomes apparent only upon thorough examination or when their state transitions into a subdepressive or more pronounced manic phase.
In pronounced manic syndrome, classic cases present with an elevated mood (hyperthymia) regardless of external circumstances; however, patients may also exhibit irritability, anger, and belligerence, and their emotions are almost invariably sthenic. Their rate of association is significantly increased, thoughts flow in an unstoppable stream, speech is accelerated, and the voice is loud, often hoarse. When conversing with such patients, they attempt to hijack the conversation, making it very difficult to interrupt them; they become intrusive, constantly seek interaction with others, and indulge in joking, punning, and rhyming words. As the disorder deepens, associative links are disrupted, attention becomes unstable and easily distracted by extraneous stimuli, and flight of ideas emerges, which can reach the point of a veritable «salad» of words (speech incoherence). Manic patients are observant; their perception becomes sharpened, and the external world appears brighter and more high-contrast. Memory is enhanced (hypermnesia). Motor activity is increased. In moderately expressed manic states, goal-directed activity is enhanced; as the illness worsens, patients become impulsive, their behavior is inadequate to the situation, and in severe mania, it reaches the level of psychomotor agitation. Regarding the content of their ideas, patients express delusions of self-overestimation, developing overvalued ideas of grandeur. They plan to achieve fame in some field, are certain they know everything better than others, and intensely criticize everything around them. Due to elevated mood, accelerated thinking pace, and content disturbances, patients with manic syndrome experience a subjective feeling of heightened intelligence, exceptional work capacity, and a surge of energy. A drive for activity appears, and patients undertake numerous tasks simultaneously. Drawing up numerous unrealistic plans, they fail to perceive any obstacles to their Implementation. Sometimes patients can be briefly convinced that their self-assessment is exaggerated, while at other times they remain unwaveringly confident in their limitless capabilities, physical strength, and high origin. In such cases, one speaks of expansive forms of delusion.
Autonomic functions and physical work capacity correspond to this heightened sense of well-being. Patients appear younger. Their skin turgor is high, and their complexion is fresh. Sleep in manic patients is brief; they sleep only 2–4 hours per night, yet The Need for sleep is diminished, and they continue their active pursuits throughout the night. Appetite may be increased, but patients frequently do not gain weight due to their heightened activity. Libido is often enhanced, resulting in increased sexual activity. They voice no somatic complaints, assessing their well-being as «wonderful». At the same time, without treatment, a state of exhaustion sets in within weeks or months of the illness.
The main manifestations of a manic state are illustrated in the following clinical case.
Patient S., 31 years old, exhibits an unmotivated cheerful mood, views everything through «rose-colored glasses», lacks insight, and overestimates his capabilities and skills. Excessively talkative to the point of hoarseness, he tries to chat with every patient, but without listening to his interlocutor, he enthusiastically recites poetry to another. Seeing a cleaning lady mopping the floor, he rushes to help her, but soon abandons the task to give advice to patients playing chess. He is tireless in his activities, speaks rapidly, and sleeps very little at night.
Variants of manic syndrome include: cheerful mania (hyperthymia with moderate speech and motor agitation); angry mania (a combination of elevated mood with irritability, dissatisfaction, fault-finding, and heightened demands on others); delusional mania (a combination of elevated mood with Various Forms of delusions); inhibited mania (where, against a background of elevated mood, motor retardation is observed instead of agitation, which can reach the point of stupor); and several other forms.
When caring for manic patients, one must take into account the impulsivity of their actions, as well as the potential for aggressive behavior, particularly in angry mania.
The diagnosis of manic states generally presents no special difficulties and is based on Clinical examination of patients. Most commonly, manias are observed as an episode of affective disorders; however, manic-like states, although much less frequent than depressive ones, do occur in schizophrenia, somatogenic psychoses, and certain other mental disorders.
A characteristic manifestation of a manic state is demonstrated in the following case.
Patient N., 46 years old, was hospitalized in a psychiatric hospital due to absurd and dangerous behavior on the street: he danced on the roadway, then chased a trolleybus and stopped it by pulling its poles off the overhead wires. During the conversation with the doctor, he explained this action by saying that he was rushing to a store that was about to close for lunch. In the hospital ward, he is perpetually cheerful, overly sociable to the point of being intrusive, verbose during conversations with patients and staff, and constantly joking regardless of circumstances. He offers help with cleaning, but quickly drops what he has started and moves on to something else. His work is unproductive due to constant distraction by extraneous matters and conversations. He makes numerous plans for the future, overestimating his capabilities. He considers himself a «wonderful family man», a physically strong, skilled, and agile person. He evaluates all his actions positively, lacking critical insight; on the contrary, he constantly attempts to offer others unsolicited advice, holding himself up as a positive role model.
The age factor leaves a significant mark on the symptomatology and course of mental illnesses in childhood and adolescence. Due to children's PHYSIOLOGICAL CHARACTERISTICS OF Higher Nervous Activity, the weakness of active inhibition processes, and the predominance of excitation processes, all mental functions in children differ from those in adults.
The emotional sphere in children is characterized by a certain instability of mood, physiological emotional lability, and the rapid replacement of positive emotions by negative ones and vice versa. Against a background of good, cheerful spirits, under the influence of minor events from an adult's perspective, children may develop a state of depression, tearfulness, or irritability. Children do not suppress the external manifestations of their emotions. Such mood swings in children are physiological. In prepuberty and early Puberty, adolescents normally display a certain emotional instability, increased affective excitability and unconstraint, and mood swings over minor causes. The harmonization of an adolescent's personality, with the gradual balancing of the emotional-volitional sphere, typically occurs by the age of 15–16.
Emotional disorders in children occur frequently and differ from similar disorders in adults. Emotional experiences in younger children (from birth to 2–3 years) impact somatovegetative development, and are accompanied by somatic disturbances and sleep disorders. Digestive System dysfunctions (regurgitation, periodic vomiting, diarrhea, constipation) are observed, along with other autonomic disorders, such as low-grade fever, vasomotor disorders (paleness and mottling of the skin), and arrhythmias. Children become fretful and tearful. Sleep is light, and its rhythm may be disrupted. Such phenomena are observed in childhood emotional disorders, as well as as a result of Separation from loved ones, starting nursery school, or as a reaction to new, unfamiliar circumstances.
At a later age, emotional reactions become more mature and differentiated. Gradually, alongside lower emotions, higher emotions associated with the child's social life develop. It should be noted here that certain pathological conditions lead to delayed development or underdevelopment of the emotional sphere.
Immaturity of the emotional-volitional sphere is observed in hysterical personality disorders, where emotional development does not correspond to the child's age; the reactions of such children resemble an earlier age period, manifesting as increased emotional vivacity, instability, and the predominance of the pleasure-seeking motive. In complicated hysterical personality disorders (disharmonious, organic), emotional disorders are more pronounced, featuring irritability, quick temper, and emotional instability.
In childhood, the affect of fear easily arises. V. V. Kovalyov identifies five Variants of the fear syndrome in children: 1) obsessive fears; 2) fears with overvalued content; 3) undifferentiated, formless fears; 4) delusional fears; 5) night terrors.
Obsessive fears (phobias) in young children, unlike in adults, are not accompanied by critical awareness, a sense of their alien nature, or an active struggle against them. Nevertheless, their persistence and occurrence contrary to the child's wishes allow them to be classified as obsessive states.
Fears with overvalued content are not perceived by the patients themselves as a pathological phenomenon; the child is certain of their validity, the idea of the object causing fear dominates consciousness, and reassuring arguments from people around have no effect on the child. Such fears in children include the fear of darkness, loneliness, and objects that once frightened the child (various animals, a «strange man», etc.). These fears typically arise in children with anxious personality traits or in neurotic anxiety disorders.
Close to overvalued fears are delusional fears, toward which patients also lack critical insight, and which do not respond to rational psychotherapy. However, in content, they are more absurd and arise mainly against the background of persecutory delusions—for instance, fear of characters from books, fairy tales, or TV shows, and in younger children, fear of operating machinery, household appliances, or unfamiliar people. Delusional fears are most commonly observed in schizophrenia and occasionally appear in stress-related disorders.
Undifferentiated, non-specific fears manifest as episodes resembling panic attacks in adults. Affected children experience an undefined sense of impending doom but are unable to articulate their feelings. Such fears typically arise in the context of neurotic disorders.
Night terrors are a collective category of fears that occur in children during the night. They can vary in content and etiology. Episodes of night terrors are sometimes manifestations of epilepsy.
A distinctive feature of depressive states in children and adolescents is the higher prevalence of somatized forms of depression. Children, particularly those of pre-pubertal age, rarely complain of profound sadness; instead, they speak of being “lazy” or bored, and of losing interest in learning, socializing with peers, or engaging in activities that previously brought them joy. At the same time, frequent complaints include weakness, fatigue, abnormal sensations of numbness, heat, or an “empty” feeling in the head, chest, or abdomen (cenestopathies), as well as precordial pain, abdominal pain, nausea, and headaches. Almost all children with depression experience a decrease in appetite and weight loss, although increased appetite occurs in isolated cases. It should be noted that behavioral deviations can also be signs of depression in children. They may run away from home or wander. Deviant behaviors, alcohol abuse, and substance use are frequently observed. A drop in academic performance is very common. Typical forms of depression, presenting with all the symptoms described in adults, are observed only after puberty. The atypical presentation of depression in childhood complicates the diagnosis of this condition. Meanwhile, suicide rates among children and adolescents are increasing in many countries worldwide, making The Challenge of diagnosing depression in this population critically important. Depressive disorders are frequently encountered, as illustrated by the following clinical case.
A 4-year-old girl suffered from a severe case of Influenza accompanied by a high fever. A week after the illness, the girl became sullen, complaining of discomfort in the cardiac region, a feeling of heat in her chest, and heaviness in her abdomen. Physical examination revealed no abnormalities in her internal organs. The girl remained sad, cried frequently, tried to stay close to her mother, and repeatedly said, “I feel unwell, I will die soon, and you and Daddy will be left alone.” She stated that she was “bored.” A month later, this condition gradually resolved, and the girl returned to her pre-illness cheerful self.
Manic states in children and adolescents differ less from their adult counterparts than depression does. Children become excessively restless and active, with a predominance of playfulness. In adolescents, manic states often manifest as behavioral disturbances; they become uninhibited and defiant, and their behavior can sometimes assume a heboid character (meaning adolescents do not merely act playfully, but ignore or even reject established, socially accepted forms of behavior and moral norms). In search of entertainment, adolescents engage in crude pranks that border on hooliganism, resulting in property damage, the spending of large sums of money, and so on. They are excessively sociable, easily striking up new acquaintances and joining new peer groups. Their future plans are unrealistic, and the number and variety of their hobbies multiply. Diagnosing pronounced manic states is straightforward, whereas atypical manic states present significant diagnostic challenges.
It should be emphasized once again that affective disorders in childhood and adolescence frequently follow an atypical course and may manifest primarily as behavioral disturbances (such as running away from home or school, truancy, impaired communication with peers and adults, and conflicts). Therefore, in cases of deviant behavior in children and adolescents, a thorough evaluation should be conducted, and if emotional disorders are present, they should be treated, which will also have a positive impact on the patient’s behavior.
Last update: 08/08/2026
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