Psychiatry - O. K. Napryeyenko 2001

General Psychiatry
Disorders of the Effector-Volitional Sphere and Drives

Human activity is driven by needs, interests, and ideals, and is fundamentally determined by life itself. All human needs are socially mediated. Activity should be viewed as a manifestation of three forms of action: volitional, automated, and instinctive. None of these ever occurs in isolation; rather, they are all interconnected.

Will is a conscious, goal-directed mental activity aimed at executing or inhibiting an action. Volitional actions are directed toward a consciously defined goal and are accompanied by focused attention. Automated actions are also directed toward a consciously set goal, but unlike volitional actions, they do not require focused attention. Instinctive actions are likewise goal-oriented, yet they are not driven by a conscious focus on a specific objective, but rather stem from physiological needs.

The behavior of a mentally healthy person is dictated by their needs. A distinction is made between higher needs (such as acquiring knowledge, socializing, working, and attaining a certain social status) and lower, or biological, needs (food, self-preservation, sex). Higher, or psychosocial, needs are formed throughout a person's life, depending on both individual personality and social factors. Higher needs are entirely individual to each person and serve as the foundation for higher feelings: socio-ethical, aesthetic, intellectual, and religious. Both higher and lower needs are subjectively experienced by an individual and manifest as drives and desires.

A drive is a vaguely conscious internal manifestation of a need, expressed as an impulsive emotional tension that prompts action and directs human behavior until the need is satisfied. The force that compels a person to act in order to satisfy their needs is called motivation. Needs represent the internal aspect of motivation, while the goal represents its external manifestation. Disorders of the effector-volitional sphere are described below.

Hyperbulia (an intensification or enhancement of the will) is characterized by hyperactivity, motor restlessness, and accelerated, increased verbal output. Such patients take on a multitude of tasks but never finish a single one. Hyperbulia is observed in manic states and in individuals with psychopathic personality traits. Focal increases in willpower are typical of substance abusers when they need to obtain drugs. Hyperbulia is also characteristic of patients experiencing paranoid and paraphrenic delusions, as they "fight" for their own ideas and rights against imaginary obstacles.

Hypobulia (a weakening of the will) manifests as a decrease in volitional activity. Such patients exhibit a reduction in drives, urges, and desires. Their motility, facial expressions, pantomime, and gesturing are impoverished. Patients neglect their personal appearance and clothing, and tend toward isolation. Hypobulia is typical of asthenic and depressive states, Schizophrenia, and encephalitis.

Abulia is the complete loss of volitional activity, aspirations, and drives to act. Due to the loss of volitional activity, automated and instinctive actions sometimes become disinhibited. Abulia can reach a degree where patients retain only those actions strictly necessary to sustain biological life. Such patients exhibit a marked slowing of facial and pantomimic movements, as well as speech. This pathology is always combined with a reduction or loss of emotions, resulting in The formation of an apathy-abulia syndrome. Abulia is a hallmark symptom of schizophrenia and also arises as a consequence of other mental illnesses.

Parabulia is a distortion of human volitional activity, characterized by alterations not only in volitional actions, but also in automated and instinctive ones. Parabulia manifests through numerous symptoms. Let us examine some of them.

Mutism is a disorder of verbal communication in the absence of focal lesions in the speech centers of the Brain; in other words, unmotivated silence. Patients do not answer questions, and their capacity for spontaneous speech is also lost.

Negativism is an unmotivated counter-impulse—a senseless opposition and resistance by the patient to any external action, sometimes escalating into a stubborn drive to do the exact opposite. Researchers distinguish between active negativism (where the patient's actions run directly counter to instructions) and passive negativism (inaction despite clear instructions).

Atactic actions (ambitendence) represent a dual nature of actions resulting from two opposing motivations, a sort of psychological splitting, wherein a patient simultaneously experiences two contradictory urges and performs two opposing actions within the very same time frame.

Parapraxia is a distortion of movements, where simple actions take on a caricatured, bizarre character (mannerisms, grimacing, etc.).

Paramimia consists of grotesque grimaces and facial expressions that correspond neither to the content of the patient's utterances nor to their actual emotions.

Echomimia is the involuntary copying of the facial expressions of people in the patient's immediate environment.

Echopraxia is a pathological state in which a patient mindlessly repeats the actions and movements of others.

Motor stereotypy is the repetitive performance of the same motor act (such as swaying the entire body, or repeatedly bending and straightening the torso).

Echolalia is the automatic repetition of words and questions posed by an interlocutor.

Verbal stereotypy (verbigeration) is the repetitive utterance of the exact same words or phrases.

Stupor is a marked reduction or complete loss of motor activity.

Parabulias also include hebephrenic behavior, characterized by silliness, absurdity, inappropriate cheerfulness, "inert euphoria," causeless laughter, mischievousness, caricatured movements and actions, and grimacing. The patient may also utter nonsense.

Compulsive actions are simple, involuntary movements—as if some unknown force is compelling a mentally ill person to perform them. The patient is entirely unable to resist these influences (motor psychic automatism).

Obsessive actions are movements or acts performed by a patient against their own will. While they critically recognize the absurdity of these actions, they are powerless to resist them. Obsessive actions monopolize a person's attention until they are carried out. Sometimes they take on a ritualistic character (seemingly intended to ward off disaster from the patient or their loved ones). Obsessive actions are frequently accompanied by obsessive doubts, fears, overthinking, and intrusive thoughts. They are observed in obsessive-compulsive neurosis, psychopathies, and schizophrenia.

DISORDERS OF DRIVES

Disorder of drives manifest as an irresistible urge that overpowers the patient contrary to common sense, emotion, and will, compelling them to perform senseless acts. These include: dromomania—an irresistible, unmotivated urge to wander or run away; pyromania—an insatiable compulsion to set fires without any rational motive; kleptomania—the compulsion to steal entirely useless items without any motivation, incentive, or practical interest; mythomania—a compulsive urge to deceive, lie, fabricate stories, and fantasize (occurring without memory impairment); arithmomania—an irresistible, obsessive desire to count objects of any kind; dipsomania—a sudden, irresistible craving for alcohol, resulting in periodic drinking bouts; coprolalia—an irresistible urge to utter obscenities and resort to compulsive profanity. Impulsive drive disorders are observed in psychopathic personalities, during neuroses, and at the Cytology/cytology/16.html">Early stages of schizophrenia.

Pathological disorders of the nutritional drive (instinct) manifest either as its hyperactivation—polyphagia or bulimia (excessive food intake in the absence of a feeling of satiety), which are observed in neurotic states, schizophrenia, and organic brain lesions—or as its weakening (anorexia), which is characterized by a refusal to eat. Sometimes polyphagia alternates with anorexia, as seen in anorexia nervosa. A weakening of the nutritional instinct accompanies depressive and asthenic states, schizophrenia, and prolonged somatic illnesses. Distortion of the nutritional instinct (drive) is known as coprophagia, where patients ingest inedible substances (such as feces or dirt, or drink urine). This pathological phenomenon occurs in intellectual disability, dementia, and organic brain lesions.

Pathological disorders of the self-preservation instinct manifest as its enhancement, attenuation, or distortion. An intensification of this instinct is expressed through aggressive or panic reactions, motiveless Complaints, suicidal intentions, tendencies, and acts. Distortion of the self-preservation instinct presents as psychomotor agitation resulting in self-inflicted injury. These disorders typically occur in individuals with a psychopathic personality Structure and in patients with schizophrenia.

Pathological disorders of the sexual instinct and sexual drive (libido) manifest as hypersexuality, i.e., an exacerbation of sexual drive (satyriasis in men, nymphomania in women), hyposexuality, or attenuation of libido, and Sexual Perversions (paraphilias). Hypersexuality is observed in manic states, organic brain lesions with mental manifestations—such as progressive paralysis, senile dementia, epidemic encephalitis, and oligophrenia. Hyposexuality accompanies depressive and asthenic states, neuroses, and schizophrenia.

Sexual perversions manifest as an altered direction of sexual drive and the forms of its realization. They can be considered true only when the distorted sexual drive is actualized, replacing normal sexual life.

Sexual deviations are quite diverse. They may include DISORDERS OF SEXUAL identity (transsexualism), and psychosexual orientations regarding the object, age, and sex of the object.

Transsexualism is a persistent conviction of belonging to the opposite sex, despite the fact that the Gonads, urogenital Organs, and secondary sexual characteristics correspond to the genetic sex.

Pathological masturbation is the attainment of sexual gratification exclusively through mechanical stimulation of the genitals (physical masturbation) or enhanced erotic fantasizing (psychic masturbation).

Narcissism (autoeroticism) is the redirection of libido onto oneself, sexual self-admiration, and contemplation of one's own naked body (cult of the body), accompanied by sexual arousal.

Exhibitionism is the attainment of sexual arousal and gratification by exposing and displaying the genitals to persons of the opposite sex. It is typically observed in males.

Voyeurism (visionism, scopophilia) is an irresistible urge to peek at sexual acts, sexual activities, naked individuals, and their genitals for the purpose of sexual gratification. A variant of scopophilia includes an obsession with pornography, erotic films, and the like.

Fetishism (idolism, symbolism) is the elevation of a specific object to a cult status (women's underwear, clothing, footwear, or certain body parts—feet, breasts, genitals), resulting in sexual arousal and pleasure derived from contemplating or touching them. It occurs exclusively in males.

Transvestism is the onset of sexual arousal and gratification achieved through cross-dressing in the attire of the opposite sex.

Zoophilia (sodomy, bestiality, zooerasty) is a sexual attraction to animals and the derivation of gratification from sexual intercourse with them.

Necrophilia (bertrandism) is a sexual attraction to corpses, performing sexual acts with corpses, and deriving sexual gratification therefrom.

Pedophilia is a sexual attraction to children accompanied by attempts to engage them in sexual contact.

Ephebophilia is a sexual attraction to adolescents and young men or women.

Gerontophilia is a sexual attraction to elderly individuals, with sexual gratification being derived from sexual intercourse with them.

Homosexuality (sexual inversion) is a disorder of psychosexual orientation characterized by sexual attraction to individuals of the same sex. Male homosexuality is termed uranism (pederasty), while female homosexuality is termed lesbianism, lesbian love, or sapphism.

Sadism is the attainment of sexual gratification during sexual intercourse solely under the condition that pain is inflicted upon the sexual partner. It is a pathological propensity for cruel acts and torture. By inflicting physical suffering on others, the sadist derives pleasure.

Masochism is sexual arousal and gratification that arise exclusively against the backdrop of experiencing pain inflicted by a partner.

Types of psychomotor motor agitation — hyperkinesia

Disorders of effector (motor) activity manifest as psychomotor agitation associated with alterations in consciousness and the emotional sphere.

Psychomotor agitation is an excessively pronounced, inadequate motor and psychic activity, pathological in form and intensity, which creates abnormal conditions and even danger for those around the patient and the patient themselves. In medical practice, the following types of agitation are most frequently encountered: hallucinatory-delusional, manic, depressive, catatonic, hebephrenic, epileptic, amentive, choreic, hysterical, psychopathic, panic, and erotic.

Hallucinatory-delusional agitation is the result of frightening hallucinations (auditory, visual, olfactory, etc.) and delusions of persecution, physical and mental influence, poisoning, and the like. The agitation is accompanied by an affect of fear, anxiety, emotional tension, and fury. Patients are suspicious of their surroundings and interpret every movement in a delusional manner. Psychomotor agitation directed at "suspicious persons" may be accompanied by aggressive actions (eliminating "enemies"). Sometimes patients "save themselves" by performing actions dangerous to themselves, such as jumping out a window without considering the building's floor, self-inflicting injuries, executing suicidal intentions ("better to die an easier death"), etc. Hallucinatory-delusional agitation is observed in schizophrenia and other mental illnesses manifested by hallucinations and delusions.

Manic agitation is accompanied by motiveless gaiety, elevated mood, accelerated thought processes ("flight of ideas"), and speech that becomes incoherent (manic derailment of speech). Patients exhibit a constant urge to act. They motivelessly jump from one line of activity to another without finishing their work. They are restless, fidgety, and sexually aroused. They Sleep little, eat little, and lose weight. Sometimes they become irritable and aggressive (angry mania).

Manic agitation is characteristic of the manic phase of circular or manic-depressive psychosis (bipolar affective disorder) and manic states of other origins.

Depressive (melancholic) agitation, or agitated depression. The depressive syndrome manifests as a depressed mood, profound sorrow, boredom, slowed thinking, and generalized psychomotor retardation.

Agitated depression occurs suddenly, like a flash, interrupting psychomotor retardation or stupor. Patients become frantic, unable to sit still, screaming, pacing wildly, banging their heads against the wall, tearing their clothes, pulling out their Hair, wringing their hands, and attempting suicide. All of this is accompanied by despair, excruciating anxiety, anguish, and boredom. Such patients express delusional ideas of self-debasement and self-blame.

Agitated depression is observed during the depressive phase of manic-depressive psychosis, as well as in involutional depression and depression of vascular origin.

Catatonic agitation is accompanied by motor restlessness and absurd stereotypes in both speech and movement. Characteristic Features of this condition include grimacing, mannerisms, caricatured ("exquisite") movements, unusual body postures, and paramimia (incongruity between facial expression and emotion). Catatonic agitation may involve impulsive actions, aggression, and destructive behavior. Negativism, ambitendency, echolalia, echopraxia, and other phenomena may also be present. This state is typically followed by catatonic stupor.

This type of agitation is observed in the catatonic form of schizophrenia.

Hebephrenic agitation manifests as motor and verbal hyperactivity with silly, foolish behavior. Patients become restless; against the Background of an elevated, absurd mood, stereotyped movements emerge (playful euphoria): inappropriate laughter and grimacing. They mimic others, acting like buffoons by copying their actions. They jump, clap their hands, and undress. Postures change kaleidoscopically and repeat. Impulsive, antisocial actions are possible. Hebephrenic agitation is more commonly seen in adolescent patients with the hebephrenic form of schizophrenia.

Epileptic agitation frequently arises in altered states of consciousness, preceding or following convulsive seizures, and manifests as dysphoria (pronounced affective states of anger, fear, and outbursts of rage and aggression). During epileptic agitation, patients resort to brutality and may injure or even kill. The agitation occurs suddenly, without a clear motive, As a result of a narrowed field of Vision. It is observed in Various Forms of Epilepsy and epileptiform syndromes.

Amentive agitation presents as chaotic behavior. Patients are restless and bewildered; their movements are uniform and haphazard. They are disoriented in their surroundings, fail to understand what is happening around them, and repeatedly look around and peer into people's faces. They constantly ask questions: "Where am I?", "Who are they?", "What is happening?". Their utterances are incoherent and fragmentary (amentive speech clutter). Occasionally, a chaotic sequence of phrases is interrupted by melancholy laughter or sobs. The patients' facial expressions convey astonishment combined with anxiety, fear, and helplessness.

Amentive agitation is observed in infectious psychoses and exhaustion psychoses.

Choreic agitation develops acutely, most often in the evening or at night, and is characterized by profound confusion and disorientation. Movements are chaotic and amorphous, confined to the bed (jactitation). The patient flails their arms, throws the bedding onto the floor, twists it, and dangles their legs. Speech is poorly modulated: they shout individual words, fragments of phrases, syllables, and sounds (choreic speech clutter). The somatic condition is severe. The Skin and mucous membranes are dry and pale. The face is flushed, and the sclerae are injected. The Lips are cracked, often with herpetic eruptions. The Tongue is dry and coated with a greyish-brown film. Petechiae and bruises are visible on the body. Hyperhidrosis and physical exhaustion are present. Body Temperature reaches 40–41 °C. Choreic agitation is observed in infectious psychosis of the "acute delirium" type and in febrile schizophrenia.

Hysterical agitation manifests as disturbances in the affective sphere (heightened affectivity, irritability, and emotional instability). Against the background of a depressed mood, patients display demonstrative weeping, wailing, pounding their fists on the table, stamping their feet, breaking dishes, and tearing their clothes over trivial matters. Sometimes, the depressed mood gives way to gaiety, with the patients laughing inappropriately. At the peak of agitation ("motor storm"), they scream, tremble, and thrash about, sometimes progressing to convulsions. They demonstratively speak of suicide and occasionally even make suicide attempts. Hysterical agitation may be accompanied by hysterical clouding of consciousness and hysterical seizures. The patient's behavior is always influenced by a specific psychotraumatic situation. Occasionally, hysterical agitation manifests as puerilism, pseudodementia, and Ganser syndrome.

Hysterical agitation may accompany hysterical psychopathy, hysterical forms of reactive psychoses, and neurotic hysteria.

Psychopathic agitation is most often psychogenically conditioned, has a specific purpose, and exhibits quite diverse manifestations (depending on the form of psychopathy). Psychopathic individuals create a tense environment, drawing other people into conflicts. If the patient is restrained, the agitation will escalate. The content of their speech (shouts, demands, insults, threats, profanity) changes depending on the actions of those around them and the situation. It is observed in psychopathy and in patients with psychopath-like symptomatology.

Panic agitation is characterized by chaotic, absurd motor agitation that occurs suddenly as a result of natural disasters, catastrophes, or life-threatening situations. The person rushes about, makes senseless movements, flails their arms, screams, and begs for help, failing to notice viable escape routes. Sometimes they suddenly run off without any purpose, often toward danger (fugiform reaction). Panic agitation may be accompanied by clouding of consciousness with subsequent amnesia. Autonomic disturbances are characteristic of panic agitation: elevated Blood pressure, tachycardia, skin pallor, sweating, and diarrhea.

When several individuals are gripped by such a state, general panic ensues. This phenomenon sometimes takes on the character of mass induced psychosis, especially in cases where the "inductor" is a highly suggestible personality.

Eretic agitation is observed in oligophrenia and manifests as senseless motor agitation, sometimes involving destructive actions, accompanied by screaming and occasionally self-inflicted injury.

Types of psychomotor retardation — hypokinesia

Catatonic stupor (Latin *stupor* — numbness) is a manifestation of catatonic syndrome. It is characterized by immobility, prolonged maintenance of a monotonous posture — such as the fetal position, Dupre's "air cushion" (when lying on the back, the HEAD, neck, and shoulder girdle remain elevated), the "hood" posture (patients sit or lie with a blanket, robe, etc., pulled over their head, leaving only the face exposed), and others. In this state, the person does not react to wet bedding, room temperature fluctuations, hunger, thirst, pinpricks, thermal stimuli, or even danger (for example, a fire). Muscle hypertonus or waxy flexibility (maintaining the body in whatever position it is placed by others) and mutism (silence) are also characteristic. It may be accompanied by negativism — active (absurd, purposeful active resistance to instructions) or passive (external unresponsiveness). Memories of this period are preserved. A substuporous state is incomplete stupor, varying degrees of mutism, unnatural posture, and partial refusal to eat (patients can be fed by others).

Depressive stupor involves complete or nearly complete immobility, a sorrowful posture, and a suffering facial expression. Verbal contact is difficult, and responses are monosyllabic. Patients are sometimes untidy. Stupor can suddenly transform into acute agitation — *raptus melancholicus* — during which the patient may inflict serious harm upon themselves. It is observed in severe endogenous depressions.

Psychogenic (hysterical) stupor arises as a result of psychogenic trauma — experiencing a catastrophe, fear, horror, the sudden death of loved ones, etc. It most commonly occurs in hysteroid personalities. It is characterized by generalized retardation, up to the point of stupor. Sometimes it is accompanied by mutism and muscle relaxation. It is also known as "feigned death".

Apathetic stupor is characterized by indifference to everything, inactivity, disorientation, complete exhaustion, insomnia, anorexia, decreased muscle tone, and untidiness. It develops against the background of severe physical exhaustion and cachexia in prolonged symptomatic psychoses and encephalopathies. It is also referred to as akinetic, aspontaneous, or abulic stupor.

Exogenous stupor is hypo- or akinesia observed in toxic or infectious lesions of the brain.

Review Questions

1. Instincts and volitional activity.

2. Classification of disorders of the effector-volitional sphere and drives.

3. Characteristics of volitional disorders.

4. Classification of motor activity disorders.

5. Types of psychomotor agitation.

6. How does manic agitation differ from catatonic agitation?

7. Types of psychomotor retardation.

8. Differences between catatonic, depressive, and psychogenic stupor.

9. Disorders of instinctual drives: eating, self-preservation, and sexual drives.

10. Impulsive drives and impulsive actions.