Psychiatry - O. K. Napryeyenko 2001

General Psychiatry
Psychopathological Syndromes

A disease never manifests as an isolated symptom. When analyzing its clinical picture, interrelated symptoms are observed that form a syndrome. Any pathological process has a certain dynamic, and within a syndrome, there are always symptoms that have already fully developed as well as those still in the making.

A syndrome is a set of interconnected symptoms that share a common Pathogenesis.

A syndrome co-occurs with both positive mental disorders (asthenic, affective, neurotic, delusional, hallucinatory, catatonic, convulsive) and negative ones (destruction, deficit, defect). Positive symptoms are always variable, whereas negative ones are invariant.

Within a syndrome, symptoms are categorized into first-rank (leading), second-rank (major), and third-rank (minor). This Classification makes it possible to examine them within the dynamics of the disease. During Diagnosis, a physician identifies specific symptom patterns unique to a given illness in a particular patient. For example: not just asthenia, but asthenia reflecting the Specific features of the condition (atherosclerotic, traumatic, post-infectious, etc.); not dementia in general, but atherosclerotic, epileptic, paralytic, and so forth.

A syndrome is a stage in the course of a disease. The nosological Specificity of syndromes is inconsistent. The exact same syndrome can be observed in various disorders. For instance, syndromes such as asthenic, catatonic, and comatose lack specificity entirely. The specificity of dysmnestic syndromes and organic psychosyndrome is quite pronounced. Syndromes resulting from diseases with identical etiologies may differ from one another, and conversely, many identical syndromes can arise from different causes.

Below is a Brief Overview of the main syndromes most frequently observed in psychiatric clinical practice.

Classification of the MAIN PSYCHOPATHOLOGICAL SYNDROMES

I. NEUROTIC:

✵ asthenic;

✵ obsessive;

✵ cenestopathic-hypochondriacal;

✵ hysterical;

✵ depersonalization;

✵ derealization.

II. AFFECTIVE:

✵ manic;

✵ depressive;

✵ dysphoric.

III. HALLUCINATORY-DELUSIONAL:

✵ hallucinatory;

✵ paranoid (paranoiac);

✵ paraphrenic;

✵ paranoid;

✵ Kandinsky-Clérambault syndrome of psychic automatism;

✵ Capgras.

IV. Pathologies of the EFFECTOR-VOLITIONAL SPHERE:

✵ catatonic;

✵ hebephrenic.

V. PRODUCTIVE Disorders of Consciousness (CLOUDING):

✵ delirium;

✵ oneiric;

✵ ammental;

✵ delirium acutum;

✵ twilight state of consciousness: ambulatory automatism; trance; somnambulism; fugue.

VI. IMPAIRMENTS IN THE DEPTH OF CONSCIOUSNESS CLARITY (OBNUBILATION):

✵ obnubilation;

✵ torpor;

✵ somnolence;

✵ sopor;

✵ coma.

VII. ORGANIC Brain DAMAGE:

✵ organic psychosyndrome;

✵ Korsakoff's (amnestic);

✵ paralytic (pseudoparalytic);

✵ frontal.

VIII. EPILEPTIC / CONVULSIVE:

✵ grand mal seizure;

✵ adversive seizure;

✵ petit mal seizures: absence;

propulsive seizures;

salaam (seizures) ;

lightning seizures;

clonic propulsive seizures;

retropulsive seizures;

clonic retropulsive seizures;

rudimentary retropulsive seizures;

pyknolepsy;

impulsive seizures;

akinetic seizures;

convulsive syndromes;

✵ Jacksonian seizures (Jacksonian Epilepsy);

✵ hysterical seizure.

NEUROTIC SYNDROMES

Asthenic syndrome (asthenia) is a condition characterized by increased mental and physical fatigue, excessive irritability, lability of mood, and unstable emotions, combined with autonomic symptoms and Sleep disorders. The symptoms of asthenia are less pronounced in the morning and worsen In the second half of the day, especially in the evening.

If the clinical picture of asthenia is dominated by irritability, explosiveness, lack of restraint, impatience, and a sense of internal tension, it is referred to as hypersthenic asthenia. When, In addition to the aforementioned symptoms, There are also manifestations of mental fatigue, it is classified as asthenia with symptoms of irritable weakness. In cases where both mental and physical fatigue dominate, accompanied by a profound sense of exhaustion, asthenia is classified as hyposthenic asthenia, its most severe form.

Asthenic syndrome is frequently observed not only in psychiatric disorders but also in the majority of somatic diseases.

When asthenia is combined with depression, hypochondria, or motor retardation, it is referred to as asthenodepressive, asthenohypochondriacal, and asthenoakinetic syndromes, respectively.

Obsessive syndrome (obsessive-compulsive syndrome, anankastic syndrome) manifests as various obsessions (obsessive thoughts). Obsessions are most commonly characterized by phobias (obsessive fears), obsessive counting, doubts, memories, and " rumination". The clinical picture is dominated by hypochondriacal phobias: cardio-, cancero-, syphilo-, AIDS-, thanato-, nosophobia, as well as claustrophobia, agoraphobia, etc.

In addition to obsessive ideas and fears, compulsive behaviors may be observed (more commonly in children): throat clearing, raising eyebrows, shrugging shoulders, attempts to suck fingers, nail-biting (onychophagia), Hair-pulling (trichotillomania), etc. Certain rituals may also occur—repetitive movements and actions associated with phobias that serve to alleviate other obsessions.

Although patients recognize the absurdity and groundlessness of these habits, they are nevertheless unable to rid themselves of them, and these behaviors impact their daily functioning. By exerting a conscious volitional effort, patients are capable of overcoming these distressing experiences.

Obsessions are observed in obsessive-compulsive neurosis, psychasthenic personality disorder, Schizophrenia, and organic brain lesions.

Cenestopathic-hypochondriacal syndrome is a neurotic syndrome manifested by various highly unpleasant, painful, and intolerably distressing sensations. Patients may complain of burning, tightness, a sensation of fluid shifting, pulling, or Swelling in various PARTS OF THE body or Internal Organs (cenestopathies). Hypochondriacal overvalued ideas—distortions in judgment—also emerge. The patient "discovers" signs of a severe, incurable disease within themselves. These ideas arise on a real basis, but the patient interprets these circumstances in a one-sided manner and remains in a state of emotional tension. The causes of these painful sensations cannot be detected through objective diagnostic Methods.

Cenestopathic-hypochondriacal neurotic syndrome is characteristic of neurotic disorders, predominantly neurasthenia and hysteria.

Cenestopathic syndrome may be part of The Structure of other syndromes, notably delusional ones. It is a variant of Kandinsky-Clérambault syndrome (mental automatism). It is observed in schizophrenia, manic-depressive psychosis (depressive phase), and organic brain lesions.

The hypochondriacal symptom complex can be an integral component of any delusional syndrome (paranoid, paraphrenic, or paranoid-hallucinatory). It is frequently detected in schizophrenia.

Hysterical syndromes. Hysterical neurotic syndrome is characterized by emotional lability with dramatic expression of feelings (sobbing, wailing, groaning), rapid transitions from positive to negative emotions and vice versa, accompanied by various secondary somatic and neurological conversion disorders. Impairments of motor function, sensitivity, and autonomic Functions manifest as functional paresis, paralysis, local contractures, and hysterical seizures. Unlike epileptic seizures, these are not accompanied by disturbances of consciousness (stupor, sopor, coma), Changes in the cardiovascular and respiratory systems, or the sequential phases of a convulsive attack. Manifestations may include hysterical stuttering, aphonia, mutism, surdomutism, blindness, sensory disturbances in the "stocking" or "glove" distribution, or hemidistribution, astasia, and abasia. Autonomic symptoms are also observed, such as vomiting, hiccups, eructation, a feeling of a "lump" in the throat (globus hystericus), tachycardia, shortness of breath, and polyuria. Hysterical syndrome is characteristic of hysterical neurosis.

In addition to neurotic hysterical syndrome, psychotic hysterical syndromes are also observed. These include twilight states of consciousness, Ganser syndrome, and pseudodementia.

Hysterical twilight states of consciousness manifest as a narrowing of consciousness with incomplete orientation to the surroundings, vivid, clear, stage-like, achromatic hallucinations, followed by a subsequent, often delayed, amnesia.

Ganser syndrome is a variant of hysterical twilight state characterized by complete disorientation and visual, or less frequently, auditory hallucinations. Delusions of reference, persecution, and influence are present. Ganser symptoms (approximate Answers) are characteristic. The patient's behavior is absurd, creating the impression of feigned mental illness.

Pseudodementia is a state of helplessness manifested by the loss of the simplest skills and elementary knowledge. The patient purposefully gives wrong answers with an air of silliness and grotesqueness, yet easily orients themselves when asked complex questions concerning their psychotraumatic situation.

Puerilism is a pathological mental state in which an adult's behavior does not match their age and resembles that of a child. It is characterized by regressive behavior with childish manners, intonations, gestures, playfulness, absurdity, and naive judgments against a Background of depressed mood and confusion.

Psychotic hysterical disorders are in most cases caused by psychogenic factors and are classified as reactive psychoses.

Depersonalization syndrome manifests as a disorder of self-awareness. The perception of one's own personality, the "I", is altered. The patient's thoughts and actions are governed by a sense of alienation from their own self (as if standing on the sidelines). The integrity of the personality is lost. Body schema is disrupted: the volume, length, width, and position of individual body parts "change". It frequently accompanies derealization.

Derealization syndrome is a pathological condition in which the world and environment are perceived by the patient as unreal, hazy, indistinct, colorless or monochromatic, and devoid of life. Surroundings appear dim, frozen, and flat. Patients claim that everything has changed and is no longer as it was before the illness, sometimes unable to explain wherein these changes lie. Phenomena closely related to derealization include déjà vu (already seen), déjà entendu (already heard), déjà vécu (already experienced), or jamais vu (never seen), among others.

AFFECTIVE SYNDROMES

Affective syndromes include manic, depressive, and dysphoric syndromes.

Manic syndrome is characterized by a triad of core clinical manifestations: a pathologically elevated mood (euphoria, hyperthymia); accelerated flow of ideas, thoughts, and memories (mental and verbal overactivity); and excessive, hyperactive behavior (motor excitation) accompanied by distractibility. The patient tends to overestimate their abilities and desires, and delusions of grandeur may emerge.

Several variants of manic syndrome are distinguished: happy mania, dominated by an elated affect; angry mania (increased irritability, fault-finding, sarcasm, and wrathfulness); and confused mania (manic speech incoherence combined with psychomotor agitation).

In addition to relatively straightforward variants of manic syndrome, complex forms also occur: manic-Delusional syndromes (a combination of a manic state with acute sensory delusions of persecution and staged scenarios); and manic-hallucinatory syndromes (combined with hallucinations).

Depressive syndrome manifests as the depressive triad: a pathologically lowered, depressed mood (depression, hypothymia) accompanied by profound anguish bordering on despair and hopelessness; slowed flow of ideas, thoughts, and speech (mental and verbal retardation) with attention glued to one's inner distress; and psychomotor retardation. Patients experience delusions of self-blame, self-deprecation, sinfulness, and worthlessness, alongside suicidal ideation and attempts to end their life. Such a combination of depressive symptoms poses a serious risk to the patient due to the potential for suicide.

There are more variants of depressive syndrome than of manic syndrome: anxious depression, characterized by intense anxiety; agitated depression, featuring melancholic excitement with restless fussiness; anesthetic depression, marked by emotional numbness to pain and a profound, conscious distress over the loss or blunting of this capacity (anaesthesia dolorosa psychica); asthenic depression, accompanied by asthenic symptoms (see asthenic syndrome) combined with exhaustion; tearful depression, characterized by emotional lability and tearfulness; and adynamic depression, featuring a loss of drive, desires, and utter powerlessness. Other recognized forms include depressive-paranoid, depersonalization-depressive, and obsessive-depressive syndromes.

Masked (larvated, hidden, somatized) depressions are characterized primarily by diverse somato-vegetative and cenestopathic sensations, and secondarily by a subdepressive state. Variants of masked depression include algic-cenestopathic (cardialgic, abdominal, cephalgic, panalgic), agrypnic (with sleep disturbances), diencephalic (vegeto-visceral, vasomotor, allergic, pseudo-asthmatic), and obsessive-phobic. Suicidal tendencies are also possible in masked depressions.

Depressive states include dysthymia—short-term (lasting from several hours to a few days) mood disorders manifesting as a depressive-anxious state accompanied by irritability, discontent, anger, and reduced drives.

Depressive syndrome may combine with persecutory delusions (depressive-delusional), hallucinations and phenomena of psychic automatism (depressive-hallucinatory), or syndromes of altered consciousness (depressive-amentive, depressive-oneiroid).

Dysphoric syndrome (dysphoria) manifests as a depressed mood, malicious and gloomy irritation, wrathfulness accompanied by fear, morbid ideas of persecution, and aggressive tendencies. Dysphoria can be triggered by minor stimuli that provoke negative emotions (anger, anguish, fear).

Affective syndromes are observed in manic-depressive psychosis, organic brain lesions, schizophrenia, epilepsy, neuroses, and personality reactions to external stressors.

HALLUCINATORY AND DELUSIONAL SYNDROMES

This is a collective group of positive (productive) syndromes that include delusions and hallucinations.

Hallucinatory syndrome (hallucinosis) is characterized by a continuous influx of hallucinations originating from a single analyzer, yet varied in content. Verbal, visual, and tactile hallucinosis are distinguished. Auditory verbal hallucinosis is the most common, consisting of an influx of verbal (human speech) true or pseudohallucinations in the form of a monologue (monovocal hallucinosis), a dialogue, or multiple "voices" of varying content that threaten, accuse, or scold the patient. Command (imperative) hallucinations pose a particularly grave danger to others and to the patient themselves.

Visual hallucinosis involves an influx of numerous true visual hallucinations. Several types are distinguished. For instance, Bonnet's visual hallucinosis develops in elderly individuals experiencing total or partial Vision loss (due to cataracts, etc.); peduncular hallucinosis (Lhermitte's hallucinosis) arises when a pathological process is localized in the Brainstem (Midbrain peduncles) and consists of numerous moving, microscopic, and "lifesize/vivid" visual hallucinations.

Tactile hallucinosis (Ekbom's delusional parasitosis) is manifested by tactile hallucinations, unpleasant sensations on and under the Skin (such as the feeling of crawling skin parasites), and may be combined with delusions of infestation.

Hallucinatory syndromes are observed in schizophrenia, epileptic psychoses, organic brain disorders, etc.

Paranoid syndrome is characterized by primary systematized interpretive delusions, thoroughness of thought, and sthenic affects. The system of distorted judgment (delusions) is built on a chain of evidence possessing an internal subjective logic. Certain facts are interpreted in a one-sided manner, while evidence contradicting a specific belief is ignored. Based on their thematic content, delusions of jealousy, persecution, invention, hypochondriacal delusions, etc., are distinguished. Delusional ideas are grouped around a central concept. Delusional judgments become a system of views that determine the individual's worldview as a general rule. The patient's entire mental life becomes focused on these judgments. Paranoid syndrome typically develops following an unpleasant experience or conflict, originating from overvalued ideas that transform into delusions of grandeur, reference, influence, or persecution. It is observed in schizophrenia, involutional and vascular psychoses, organic brain lesions, and paranoid personality disorder in a state of decompensation.

Paraphrenic syndrome (paraphrenia) combines persecutory delusions—such as ideas of reference, physical and mental influence, and poisoning. During the formation stage of the delusions, ideas of grandeur develop, closely linked with perceptual disorders (hallucinations, phenomena of psychic automatism). According to their Mechanism of formation, paraphrenic delusions can be either interpretive or sensori-figurative. Depending on the predominance of specific mental disorders within the structure of paraphrenic syndrome, several variants are distinguished: systematized paraphrenia, characterized by systematized delusions of persecution and grandeur; fantastic paraphrenia, dominated by numerous expansive grandiose delusions; confabulatory paraphrenia, featuring numerous delusional confabulations; expansive paraphrenia, marked by a pronounced elevated affective state alongside delusional ideas; and hallucinatory paraphrenia, dominated by fantastic grandiose hallucinations.

Paraphrenic syndrome is observed in schizophrenia—as a stage of its continuous or episodic course—as well as in organic psychoses.

Paranoid syndrome includes primary or secondary delusions and perceptual disturbances (hallucinations, illusions, cenestopathies). Most commonly, paranoid syndrome involves persecutory delusional ideas (persecution, reference, poisoning, infestation, dysmorphomania, etc.). These delusional ideas are disjointed, fragmentary, and sporadic. The patient's statements lack a "core" around which a delusional system would form (unsystematized delusions). Delusional ideas are accompanied by affective tension (fear, anxiety, anger, motor agitation).

Paranoid syndrome accompanies many mental illnesses, notably schizophrenia, epileptic, vascular, presenile, reactive, and symptomatic psychoses.

Kandinsky-Clérambault syndrome of psychic automatism is characterized by delusions of persecution, influence (mental or physical), and manifestations of psychic automatism (the patient perceives themselves as alienated, as if no longer belonging to themselves). In this state, they feel that their thoughts, experiences, and actions are not their own, but rather directed by someone else. They lack autonomy regarding their thoughts (compulsory thinking, thought control), emotions ("they force me to feel angry or joyful"), and actions ("someone forces me to speak, walk," etc.). Based on the degree of alienation, control, and influence over various mental processes, Three types of psychic automatisms are distinguished.

Associative automatism includes the alienation of thoughts and memories, involuntary flooding and acceleration of thoughts (mentism); the sensation that one's own thoughts are known to others (the symptom of open thoughts); or the feeling that people surrounding the patient are voicing their thoughts aloud (the "thought-echo" symptom).

Sensory (cenestopathic) automatism manifests as pseudohallucinations and cenestopathies accompanied by a sense of external influence, intrusion, and alienation ("they induce feelings of constriction, twisting, pain, cold, and distort appetite or sexual desire">

Motor (kinesthetic) automatism involves the patient's conviction that all movements, including speech, occur under METABOLISM/18.html">The Influence of an external force ("turning them into a robot or puppet," "controlling them from space").

When a patient exhibits symptoms of associative, sensory, and kinesthetic automatism simultaneously, it indicates a fully developed syndrome of psychic automatism. Kandinsky-Clérambault syndrome is observed in schizophrenia and organic brain lesions.

Capgras syndrome (J. M. J. Capgras, 1923) is characterized by an impaired ability to recognize people. Patients fail to recognize their relatives or acquaintances, claiming they are impostors, twins, or doubles. They believe these individuals are disguised as specific people (the negative double symptom). Conversely, strangers may be perceived as close acquaintances (the positive double symptom).

Capgras syndrome includes the Fregoli phenomenon, wherein patients assert that their "persecutor" constantly changes appearance to avoid recognition. Delusions of intermetamorphosis represent another variant of misidentification. Patients are convinced that "persecutors" alter not only their own appearance but also the moral and spiritual state of others, as well as the surrounding environment. In this case, misidentification extends to numerous people rather than just a single individual. Some authors consider the Fregoli syndrome to be an independent entity.

Capgras syndrome is frequently combined with delusions of persecution, influence, and manifestations of psychic automatism, and it occurs across various mental disorders. Nosologically, it possesses low specificity.

SYNDROMES OF Pathology of the AFFECTIVE-VOLITIONAL SPHERE

Catatonic syndrome is a symptom complex of mental disorders predominantly affecting the motor sphere. It consists of catatonic stupor or catatonic excitement. Several forms of catatonic stupor are distinguished: stupor with waxy flexibility (catalepsy), increased Muscle tone, the "air pillow" sign (Dupré), and an embryonic posture, among others; negativistic stupor featuring complete immobility and passive negativism; and stupor with muscular rigidity (the most severe form of stupor, involving a prolonged embryonic posture with marked tension across all muscle groups, along with the snout reflex).

Among the variants of catatonic excitement, researchers distinguish: bewildered-pathetic excitement (a combination of perplexity and exaltation with incoherent chatter and motor agitation); and impulsive excitement (sudden, destructive, and short-lived).

Catatonic disorders may occur with preserved consciousness (lucid catatonia) or within a dream-like state (oneiroid catatonia).

Catatonic stupor and catatonic excitement constitute indications for emergency hospitalization.

Hebefrenic syndrome manifests as inert euphoria (bizarre, inappropriate gaiety, silliness, playfulness, and sometimes infantile behavior). The patient becomes mannered, exhibiting theatrical and inappropriate gestures, postures, and facial expressions. Hebefrenic excitement is characterized by a mannered, silly behavior combined with echo-symptoms (echolalia, echopraxia, echomimia, etc.). Catatonic and hebefrenic syndromes are characteristic of the respective forms of schizophrenia.

SYNDROMES OF DISORDERED CONSCIOUSNESS

Disturbances of consciousness are divided into syndromes of clouded consciousness and syndromes of impaired/abolished consciousness.

Syndromes of clouded consciousness include delirium, oneiroid syndrome, ammentia, and delirium acutum ("acute delirium," choreatic delirium). Although they differ in Clinical presentation, they share common features. To diagnose such disorders, K. Jaspers proposed the following criteria.

1. Alienation from the real world, expressed as perplexity accompanied by an affect of incomprehension, impaired reasoning, blurred perception of the environment, difficulties in sustaining attention, and an inward withdrawal into a world of painful inner experiences.

2. Complete or partial disorientation in time, place, situation, and personal identity.

3. Impairment of the comprehension process, manifested by weakened or impossible judgment, up to disorganized thinking.

4. Difficulty in recalling current events and subjective painful experiences (complete or partial amnesia).

Delirium syndrome (Latin delirium — madness) is characterized by: a surge of pareidolic illusions, scene-like, true multiple moving visual hallucinations combined with tactile (haptic) and auditory ones; secondary delusions of reference and persecution, affects of anxiety and fear, motor agitation with aggressiveness against the background of allopsychic disorientation (in time, situation, etc.).

Three stages can sometimes be traced in The Development of delirium syndrome. The first (initial) stage manifests as mood changes, talkativeness, restlessness, hypersensitivity to external stimuli, and superficial, fragmented sleep. The Second Stage of delirium features numerous pareidolias, visual hypnagogic hallucinations, anxiety, superficial fragmented sleep with terrifying dreams, and heightened hypersensitivity. The Third Stage of delirium syndrome is characterized by visual scene-like, kaleidoscopic, terrifying hallucinations combined with tactile and auditory hallucinations, acute sensory delusions, anxiety, and psychomotor agitation with aggressiveness or autoaggressiveness. All four diagnostic criteria for altered states of consciousness are mandatory here.

Sometimes, without adequate Treatment, delirium syndrome can progress to professional or muttering delirium, which is a prognostically unfavorable sign.

In professional delirium, against the background of a certain level of stupor, agitation arises, manifested by habitual professional automated motor acts (e.g., hand movements imitating typing) accompanied by isolated professional hallucinations.

Muttering delirium manifests as moderate to deep stupor, chaotic agitation, "picking" behaviors (as if small objects were stuck to clothing or blankets), and unintelligible mumbling. Muttering delirium is frequently followed by sopor and coma, and the patient may die.

Painful experiences are imprinted in memory much more vividly than real events.

Delirium syndrome is observed in intoxication and symptomatic psychoses, neuroinfections, and epilepsy.

Oneiric syndrome (Greek oneiros — dream + eides — similar, resembling) is a clouding of consciousness with an involuntary surge of fantastical imagery. In content, these are altered fragments of things seen, read, heard, or experienced, interwoven with the realities of life. The patient experiences scenes of a fantastic, supernatural nature that resemble dreams. These scenes replace one another in a specific sequence, like in a kaleidoscope, with one event seemingly flowing out of another (scene-like).

As the syndrome develops, a state of delusional mood is created. The patient perceives everyday life as altered, incomprehensible, and sinister, sometimes taking on the appearance of a "grandiose catastrophe." Emotional tension develops, occasionally turning into despair. The patient experiences delusions of persecution, staging, special significance, and intermetamorphosis. Patients report that something is happening around them as if in a movie or play, and they are either participating in it or becoming spectators. Sometimes certain individuals transform into others, and occasionally this mimicry extends to objects. Periodically, psychomotor (pathetic) agitation or, conversely, inhibition (oneiric stupor) occurs, alongside Affective Disorders (depressive or manic). There is a dual orientation toward both the surrounding situation and one's own person. A transformation of the patient's ego takes place, and the opposition between the patient's ego and the experienced situation disappears. The patient often lies motionlessly with a frozen, sometimes rapturous-ecstatic facial expression. Occasionally, they are overly agitated.

The reduction of oneiric symptoms occurs gradually. Patients reproduce the content of psychopathological disorders either fragmentarily or in considerable detail. Amnesia for real events that took place develops.

Oneiric syndrome accompanies infectious psychoses, schizophrenia, epileptic and symptomatic psychoses, and organic brain lesions.

Amentia syndrome (a- + Latin mens — mind, thinking) manifests as gross disorientation (allopsychic and autopsychic disorientation), perplexity, incoherence of thinking, and the inability to comprehensively grasp the surrounding world (incapable of synthesis). The patient's speech is inconsistent, disjointed (amentive speech disorder), and devoid of intonation. They recall events from past life in which logical connections are difficult to trace. Concepts have a concrete, everyday meaning and depend on the affective state. Sometimes speech is interrupted by brief, mirthless laughter or sobbing (exhaustion). The patient's statements lead to the Conclusion that they are in a state of affective underthinking and incapacity. Establishing verbal contact with the patient is practically impossible. Complete clarification of consciousness does not occur in amentia. Amentia syndrome is characterized by hallucinations, predominantly auditory, and fragmented persecutory delusions. Psychomotor agitation is occasionally observed.

During a temporary remission of amentive clouding of consciousness, the patient calms down and becomes less talkative, though exhaustion and depression remain noticeable. After emerging from the state of amentia, no memories of the illness remain, or they are fragmentary. Asthenia is clearly expressed, accompanied by exhaustion, lethargy, dysthymic mood, tearfulness, irritability, and hypersensitivity (emotional-hypersthenic weakness).

Amentia was first described by T. Meynert (1881) under the name "acute hallucinatory confusion." Many modern psychiatrists deny amentia as an independent entity, considering it a variant of delirium.

Amentia most commonly develops during acute and protracted symptomatic (infectious) psychoses and exhaustion psychoses. This indicates an unfavorable course of the underlying disease.

Amentia may progress into a state of stupor and delirium acutum (acute delirium).

"Acute delirium" syndrome, choreic syndrome. The development of this syndrome begins with prodromal phenomena lasting hours, or sometimes several days. Patients complain of a feeling of physical malaise, headache, and sleep disorders with terrifying dreams. Mood is capriciously depressed or sentimentally optimistic.

During the period of full development of pathological disorders, the clinical picture is dominated by uncoordinated motor agitation within the bed — hyperkinesias (choreic, athetotic, myoclonic), clonic and tonic seizures, and chewing movements. Speech is incoherent. Agitation is replaced by adynamia, indicating deterioration. Clouding of consciousness resembling deep amentia or stupor is accompanied by isolated hallucinations and delusional statements with an anxious-depressive affect or fear.

Significant autonomic disorders and dehydration accompanied by oliguria are observed. Plasma potassium levels decrease, accompanied by azotemia and leukocytosis with neutrophilia. The patient experiences severe weight loss, up to cachexia. Characteristic appearance includes sharpened facial features, sunken eyes, dry and thirsty Lips, and a dry Tongue (Hippocratic facies). The skin is pale, sometimes with an earthy or cyanotic hue and numerous bruises. Body Temperature rises, sometimes reaching 39–40 °C. Tachycardia, tachypnea, and a drop in Blood pressure are present.

Without adequate treatment, death in a state of hyperthermic coma may occur a few days after the onset of such a pathological condition.

Delirium acutum is most frequently observed in febrile schizophrenia, infectious psychoses, and septic (postpartum) conditions.

Twilight state of consciousness develops suddenly, paroxysmally, and lasts from a minute to several hours or days. At the same time, the field of consciousness narrows; the circle of perceived objects is limited, unclear, blurred, and fragmentary. Everything familiar is perceived as seen for the first time, or as completely unfamiliar. Due to the preservation of automatism, external orderliness of behavior, as well as the connectivity and sequence of actions, are maintained.

In this syndrome, profound disorientation is accompanied by terrifying visual, auditory, and other hallucinations, acute and sensual fragmented delusions of reference, poisoning, and persecution, affect of anguish, anger, and fear, along with violent psychomotor agitation! Driven by hallucinations, delusional ideas, and emotions, such patients may kill or maim strangers or relatives, mistaking them for enemies. In a state of rage, they senselessly destroy everything in their path (both animate and inanimate). This is followed by deep sleep. Patients have no memory of this period (amnesia). They remember neither the real events of that time nor their subjective experiences.

A twilight state of consciousness is observed in epilepsy and organic brain lesions (traumatic brain injury, vascular pathology, etc.).

Varieties of this syndrome include ambulatory automatism, trance, fugue, and somnambulism.

Ambulatory automatism (Lat. ambulare — to walk, to move about) is a state of narrowed consciousness devoid of hallucinations, delusions, or affective states. For several hours, patients act like automatons: they wander aimlessly, buy things, return home, and so on. They appear somewhat preoccupied and inattentive. Amnesia following the resolution of this state serves as an indicator of the severity of the consciousness impairment.

Trance (Lat. trans — movement across or beyond) is a more prolonged form of ambulatory automatism lasting several hours or days. Sometimes patients retain a rudimentary orientation in simple situations. In a state of trance, they can cover great distances and travel from one locality to another. A trance begins and ends abruptly. No memories of this period remain (amnesia).

Somnambulism, sleepwalking, or noctambulism (Lat. somnus — sleep + ambulare) is a seizure of ambulatory automatism that interrupts nocturnal sleep. The patient unconsciously performs automated actions: gets out of bed, walks around the room, rearranges objects, and goes outside, while exhibiting motor agility. Their movements are coordinated, and they show no fear. No memories of these nocturnal wanderings persist.

Fugue (Lat. fuga — flight) is a psychopathological state characterized by a transient narrowing of the field of consciousness with a sudden, impulsive onset. Unaware of their surroundings, the patient automatically performs inappropriate actions—for instance, spinning in place, bolting into a run, or undressing in public places. A fugue is always accompanied by pronounced motor agitation, often chaotic and nonsensical, lasting up to several minutes and terminating in amnesia for the experiences.

IMPURITIES IN THE DEPTH OF CLEARNESS (SHUTTING DOWN) OF CONSCIOUSNESS

Syndromes of impaired consciousness include nubilation, obtundation, somnolence, stupor, and coma. These syndromes frequently transition into one another.

Nubilation is a mild degree of impaired consciousness, where consciousness appears clouded (Lat. nubilum — a cloud). Everything is perceived as if through a mist. The patient is disoriented in time and The sequence of events. Thinking and movements slow down, and the comprehension of the overall situation is impaired. Patients are indifferent and passive, perceive the meaning of questions with noticeable effort, and answer slowly, with a delay and in fragments. Reactions to external stimuli are sluggish. New information cannot be memorized, and recall is difficult. The duration of nubilation depends on the course of the underlying somato-neurological disease process.

Obtundation is among the most frequent and widespread syndromes of deep consciousness impairment. It is characterized by difficulties in perceiving external stimuli, along with disorientation not only in time but also in the environment, Setting, and situational assessment. Patients do not react to questions asked in a soft voice and show only a weak reaction to normal speech, responding solely to loud questions. Similar reactions are observed regarding light, odors, and Touch.

During obtundation, the associative process is impaired, making it difficult for patients to comprehend the situation. The retrieval of past experience is limited to the simplest concepts and skills. The vocabulary is impoverished, and answers are monosyllabic. Productive psychopathological disorders (hallucinations, delusions, psychic automatisms) are absent. Patients are akinetic and hypokinetic. Facial expressions are monotonous and impoverished, and gestures are inexpressive. Such individuals remain alone, maintain the same posture for a long time, and are indifferent to everything, though occasional euphoria is observed. The state of obtundation lasts from a few minutes to several days.

Somnolence (Lat. somnolentus — sleepy) is a more severe degree of impaired consciousness than obtundation. Patients lie with their eyes closed, and spontaneous speech is lost. The threshold for perceiving external stimuli is elevated. They respond to questions slowly, even when asked loudly. Conceptualization is limited, and judgment is impaired. Patients do not grasp complex tasks and solve simple ones with great difficulty and slowness. Facial expressions are impoverished, and the expression is indifferent. They are silent and psychomotorically retarded. The reaction to pain stimuli is reduced. They remain primarily in a state of drowsiness, occasionally leaning toward sleepiness.

Sopor (Lat. sopor — torpor, deep sleep). Patients predominantly lie with their eyes closed. Communication is impossible. To strong stimuli (such as pain), they respond with elementary, poorly differentiated movements (turning the HEAD, moving the limbs, etc.). They are disoriented regarding place, time, and even their own identity. Pupillary, corneal, and swallowing Reflexes remain preserved.

Coma (Greek koma — deep sleep) is the most severe degree of consciousness impairment, characterized by complete unconsciousness. The patient does not react to any stimuli. Tendon and periosteal reflexes are absent. Respiratory and cardiovascular functions are impaired. Upon emerging from a comatose state, complete amnesia persists.

Syndromes featuring a general impairment of consciousness occupy an important place in general psychopathology. They are observed in intoxications, epilepsy, and organic brain lesions (tumors, trauma, vascular disorders). A comatose state indicates the severity of brain damage.

SYNDROMES OF ORGANIC BRAIN DAMAGE

These syndromes include organic psychosyndrome, Korsakoff's (amnestic), paralytic (pseudoparalytic), and frontal syndromes, which combine both positive and negative symptoms.

Organic psychosyndrome. Strictly speaking, this is a group of psychopathological syndromes caused by organic brain lesions. The similarity of pathogenetic mechanisms determines several common features of such syndromes across various etiologies.

Organic psychosyndrome (psycho-organic syndrome) is characterized by general mental incapacity, memory impairment (especially for recent events), reduced ingenuity and working capacity, and a weakening of affective-volitional properties (E. Bleuler, 1916).

N. Walther-Buel (1951) identified a triad of symptoms characterizing the clinical manifestations of organic psychosyndrome: memory impairment that may reach the level of Korsakoff's syndrome (impaired comprehension and understanding); uninhibited behavior; and emotional lability.

The clinical picture of the syndrome includes signs of focal disorders of speech, agnosia/apraxia. Dementia is a mandatory symptom.

Organic psychosyndrome may assume a residual character as a consequence of acute exogenous psychosis, in which case its course is stable. However, it is frequently a sign of a progressive organic disease, revealing a clear dynamic ranging from cerebroasthenic symptoms to profound dementia.

Alongside dementia, psychopath-like personality changes are observed in organic psychosyndrome. Depending on the predominance of dementia or psychopath-like changes in the clinical picture, two variants of organic psychosyndrome are distinguished: characterological and demented. These may represent stages of a pathological process, wherein characteropathic changes transition into gross psycho-organic dementia.

Organic psychosyndrome is observed in chronic exogenous and endogenous-organic brain lesions (general paralysis of the insane, vascular psychoses, senile dementia, Pick's and Alzheimer's diseases, consequences of TRAUMATIC BRAIN INJURIES, Brain Tumors, and infectious-intoxication psychoses with an unfavorable course).

The Korsakoff (amnestic) syndrome was described by S. S. Korsakoff in 1887 as an independent disease (encephalopathy) caused by alcoholism. However, it was later observed that this mental disorder also occurs in various organic brain lesions. Some authors equate the Korsakoff syndrome with the organic psychosyndrome (E. Bleuler, K. Jaspers, et al.). It is more appropriate to view the amnestic syndrome as a variant of the psycho-organic syndrome.

The primary deficit in Korsakoff syndrome is the inability to retain recent (current) events in memory (fixation amnesia) while memory for past events remains intact. All new impressions instantly vanish from memory. Patients remember nothing; they do not know where they are, who is with them, what day of the week it is, or the current date and year. After conversing with a physician, they forget the very fact of the conversation. Meeting the physician a minute later, they perceive them as a stranger. They do not know their ward or bed, and cannot remember whether they have had breakfast or lunch (amnestic disorientation). Everything that occurred before the onset of the illness is preserved in memory and recalled adequately, as is previously acquired knowledge. As the disease progresses, memory for past events is also lost (Ribot's law). Memory gaps are filled with false recollections (confabulations), or the chronology of actions is distorted (pseudoreminiscences). Such patients are hypoactive, helpless, sluggish, and passive. Affective lability or euphoria is pronounced.

Korsakoff syndrome may be of alcoholic, traumatic, vascular, or other organic Etiology.

The paralytic (pseudoparalytic) syndrome is a variant of the organic psychosyndrome characterized by a marked reduction or complete absence of self-awareness and critical judgment regarding one's surroundings, profound impairment of reasoning, memory deficits primarily affecting recent and past events, and attention disturbances. These patients are highly suggestible. Against a backdrop of good-natured demeanor, blunt euphoria emerges, accompanied by irritability and emotional lability. Drives are heightened, and appetite may reach the level of bulimia. Patients are untidy, neglect their personal hygiene, eat with their hands, pick up scraps of food, and sleep in their clothes. They may take food and belongings from other patients without permission. Their mood is elevated, and grandiose delusions (of wealth, high status, or noble origin) develop. Patients are talkative, constantly laughing, unceremonious in communication, and prone to inappropriate jokes or obscene language. They are hyperactive and may exhibit a pointless, busy demeanor.

Neurological signs include dysarthria, anisocoria, sluggish pupillary light reflex, miosis, Facial Nerve Asymmetry, anisoreflexia, and convulsive seizures.

Paralytic syndrome is observed in progressive paralysis (late neurosyphilis).

Pseudoparalytic syndrome has a similar Clinical Presentation and develops in numerous organic brain disorders (traumatic brain injuries, vascular and neoplastic processes, toxic psychoses). It may appear immediately following delirium or stupor.

Frontal syndrome is characterized by a combination of features typical of global dementia, along with aspontaneity or generalized disinhibition. Aspontaneity is accompanied by a marked decrease or complete loss of drive, adynamia, taciturnity, impoverishment of expressive speech, loss of interest in the environment, and apathy.

In cases of disinhibition, mood is elevated, carefree attitudes are prominent, and in some instances, there is silly behavior accompanied by a tendency toward inappropriate jokes and actions resembling childish pranks (witzelsucht), as well as heightened drives. Patients lose self-awareness and exhibit a gross leveling of personality traits.

Frontal syndrome may be transient, evolving into an organic psychosyndrome (traumatic brain injuries, alcoholic encephalopathies), or chronic with a progressive course (Pick's disease, frontal lobe tumors).

CONVULSIVE SYNDROMES

A generalized tonic-clonic seizure (grand mal) is characterized by a staged progression. Several hours or sometimes days before the seizure, prodromal signs appear: increased anxiety, irritability, and a sensation of twitching in individual facial and body Muscles. Vasomotor disturbances may occur, such as palpitations, a feeling of heaviness in the head, photophobia, impaired Hearing, and altered Olfaction and Taste.

The First stage of a major convulsive seizure is the aura (from Greek aura — breeze, breath), which occurs in nearly 50% of epilepsy patients. It presents in several forms: sensory (sudden onset of various sensory perceptions); visual (patients perceive everything in bright colors or flashes of light); auditory (hearing sounds, voices, noise, or music); olfactory (smelling smoke or aromatic substances); visceral (unpleasant abdominal sensations, nausea, vomiting, palpitations); motor (stereotypic movements, impulsive actions, turning around); and psychic (experiencing a sense of terror or impending threat). This state lasts for several seconds.

Following the aura, the tonic seizure stage develops. The patient suddenly loses consciousness, accompanied by a sharp, tonic contraction of all muscles. Due to air being forced from the Lungs through a spastically narrowed glottis, a characteristic cry may occur. The person falls face forward, risking bone fractures, joint dislocations, and bruises. During the seizure, patients do not react to light, their pupils are dilated, Respiration ceases, pallor or cyanosis of the skin and mucous membranes appears, along with involuntary urination and, less commonly, fecal incontinence. The tonic phase lasts approximately 30 seconds and is followed by the clonic phase.

The clonic seizure stage is characterized by rhythmic, alternating contractions of the flexor and extensor Muscles of the limbs and trunk. Stertorous breathing begins, the eyes roll upward, and cyanosis gradually fades. Foam emerges from the Mouth (tinged pink if the cheek or tongue has been bitten). The intensity of the clonic spasms decreases after 1–2 minutes and then ceases entirely. This leads to the postictal stage, lasting from several minutes to 1–2 hours. The patient's consciousness is clouded, speech is incoherent (oligophasia), and their gaze is vacant. Most commonly, a deep sleep ensues. Upon waking, patients feel bruised, weak, incapable of work, and have no memory of the seizure period (acute episodic amnesia).

If major convulsive seizures occur in rapid succession without the patient regaining consciousness in the intervals, this condition is known as status epilepticus.

An adversive seizure, much like the classic grand mal, begins with a tonic phase, though it unfolds more slowly and without a preceding aura. It features a distinctive Rotation of the body along its longitudinal axis: first, a forced deviation of the eyeballs occurs, followed by the head and then the entire torso turning in the same direction before the patient falls. This is followed by the clonic phase, similar to a generalized tonic-clonic seizure. An adversive seizure results from an organic lesion in the frontal lobes of the brain.

A minor seizure (petit mal) is generally characterized by the absence of pronounced motor components. During conversation or work, the patient suddenly turns pale, and their gaze becomes fixed straight ahead or to the side. They lose consciousness for 2–5 seconds but do not fall, often maintaining the exact posture they were in prior to the seizure. Occasionally, brief muscle twitches of the face or limbs are noticeable. Upon regaining consciousness, the patient resumes their activity without any memory of the event (amnesia) or expresses surprise at newly appeared surroundings. There are no cries or tongue biting. A minor seizure manifesting as rudimentary convulsive symptoms (licking, sucking and chewing movements, lip-smacking, blinking, eye-rolling, fumbling with fingers, or treading in place) is a manifestation of epileptic automatism (Ya. P. Frumkin).

Minor convulsive seizures exhibit a diverse clinical presentation.

Absence seizure (from French absence — absence) is a brief loss of consciousness (1–2 seconds). During this period, the patient's activities cease, their face turns pale, and their gaze is vacant. There are no convulsions.

Propulsive seizures are characterized by jerking movements forward (propulsions).

Salaam seizures (where the patient makes movements resembling an oriental greeting). The seizure begins with a tonic contraction of the trunk muscles, causing the torso to bend forward, the head to bow, and the arms to extend forward. As a rule, the patient does not fall.

Lightning seizures differ from salaam seizures only in the speed of their onset, while the clinical picture is identical. However, due to the lightning-fast Development of the tonic spasm and the sharp forward motion of the torso, patients frequently fall face down.

Clonic propulsive seizures manifest as sharp, intense forward Movements of the upper body, causing the patient to fall face down.

Retropulsive seizures involve jerking movements backward (retropulsions).

Clonic retropulsive seizures (as if the patient is trying to reach for something behind them). Fine clonic twitching of the eyelids and eyeballs (upward deviation), head retraction, and backward movement of the arms. The patient does not fall. Pupils are non-reactive to light. Pronounced sweating and hypersalivation.

Rudimentary retropulsive seizures manifest as nystagmoid jerking of the eyeballs, as well as myoclonic twitching of the eyelids.

Pyknolepsy is characterized by a series of retropulsive clonic or rudimentary retropulsive clonic seizures.

Impulsive seizures involve a sudden lightning-fast throwing of the arms forward, spreading them apart or bringing them together, and a jerking forward movement of the torso. The patient falls backward. After the fall, they immediately stand back up. Impulsive seizures are triggered by sleep deprivation, sudden awakening, or alcohol excesses.

Akinetic seizures. Against the background of affect or other states, muscle tone relaxes, causing the patient to fall and immediately stand up again.

Convulsive syndromes are observed in epilepsy and organic brain lesions.

Jacksonian seizures (Jacksonian epilepsy) were discovered by J. H. Jackson (1870). They are characterized by the tonic and clonic phases being limited to a specific muscle group, with generalization of the seizure resembling a grand mal attack occurring only in some cases. However, the difference is that the convulsions are more intense on one side of the body. During the generalization of Jacksonian seizures, the person loses consciousness in the majority of cases. Jacksonian seizures are observed in organic brain diseases.

An hysterical attack occurs following psychological trauma. The structure and sequence of motor manifestations are quite polymorphic. There is no aura, and the transition between tonic and clonic convulsions is inconsistent. Patients do not fall; instead, they slowly lower themselves to the floor. The skin and mucous membranes remain unchanged. Patients groan, sob, scream, and repeat the same phrase over and over. Their facial expressions convey suffering, pain, fear, and sometimes fascination. Pupil reaction to light is unimpaired. Biting of the tongue and mucous membranes, as well as involuntary urination, are not typical. Occasionally, a brief narrowing of the field of consciousness (lasting from a few seconds to minutes) is observed, resembling an hysterical twilight state. Reaction to painful stimuli is preserved. Patients even respond to remarks, which can help abort the attack. The duration of an hysterical attack ranges from a few minutes to several hours. It increases if people gather around the patient, especially when they are distressed by their condition. No sleep follows the end of the attack. Partial amnesia is possible.

Hysterical attacks are observed in hysterical psychopathy and hysterical neurosis.

CONTROL QUESTIONS

1. Hallucinatory syndrome — hallucinosis. Types of hallucinosis.

2. Paranoid syndrome.

3. Paranoid-hallucinatory syndrome.

4. Hallucinatory-paranoid syndrome.

5. Syndrome of psychic automatism (Kandinsky-Clérambault syndrome).

6. Cotard's syndrome.

7. Dysmorphomania-dysmorphophobia syndrome.

8. Obsessive-compulsive syndrome (anankastic). Obsessive fears (phobias), impulses, ideas, and actions.

9. Manic syndrome.

10. Depressive (melancholic) syndrome.

11. Asthenodepressive, anxious-depressive, and depressive-paranoid syndromes.

12. Apathetic-dissociative syndrome.

13. Korsakoff's Amnestic Syndrome.

14. Syndromes of altered consciousness (delirious, oneiroid, amhenthic, twilight state of consciousness).

15. Syndromes of impaired consciousness — nubility, obtundation, sopor, coma, syncope.

16. Asthenic syndrome.

17. Hypochondriacal syndrome.

18. Convulsive syndromes.

19. Pseudoparalytic syndrome.

20. Pseudodementia syndrome.

21. Psychoorganic syndrome.

22. Catatonic syndromes.