Lecture: “The subject and tasks of psychiatry and narcology. Classification of mental disorders and diseases.”
PSYCHIATRY (from Greek words "psyche" - the soul, "iatreia" - treatment) is a medical speciality concerned with the study, diagnosis, treatment and prevention of mental disorders. 
Proceeding from this definition, the main OBJECTIVES of psychiatry as a medical discipline are:
  - to study the etiology and pathogenesis of mental disorders; 
  - to carry out their classification;
  - to investigate the epidemiology of mental disturbances;
  - to develop a network of mental health services for the population;
  - to study the symptoms and signs, as well as syndromes and the clinical course of different mental disorders;
  - to develop and practice effective methods of their diagnosing;
  - to work out and use efficient treatment methods;
  - to develop a system for prevention of mental disorders.
   HISTORICAL TRENDS IN PSYCHIATRY.
On the base of the theory, developed by an outstanding Russian psychiatrist Yu. V. Kannabikh, six historical periods can be distinguished in the development of psychiatry:
1)	the pre-scientific period;
2) the period of ancient antique medicine;
3) the Middle Ages and the Renaissance;
4) from the beginning of the XVIII-th to the beginning of XIX-th century;
5) the XIX century;
6) the modern stage of development of psychiatry.
1. The pre-scientific period was characterized by primitive religious understanding of the mentally ill people's abnormal behaviour when mental disorders were explained with the influence of spirits and were treated by shamans.
 2. The second historical period of development of psychiatry is a period of ancient antique medicine, a more progressive period, when the first attempts at organizing mental health treatment were made. In Ancient Greece some of the diseases were considered “sacred” (such as epilepsy) or caused by evil powers. A ritual called “Incubation” was used as a therapy. It consisted of several stages. At the first stage patients with mental or physical diseases were subjected to ritual purification. Then they went to sleep in the temple in underground corridors constructed to form a maze. While the patient slept, the god Asclepius would appear in their dreams as a man, child, snake, or dog; he would touch the sick part of each patient's body and then disappear. The patient would wake up healed, and would have his dream decoded by an interpreter. As a result of his subsequent recovery,the patient would make votive offerings to Asclepius, as mentioned in Plato's "Phaedo".
In the 4-th cent. B.C., Hippocrates described 4 temperaments (sanguinic, choleric, melancholic and phlegmatic), determined by prevalence of 1 of 4 body humours (blood, yellow bile, black bile and phlegm). He also stated that the personality functioning reached an optimal level when the appropriate interaction of internal and external forces had been achieved. He called this state "crasis". Conflict between these forces, termed "dyscrasia", indicated the presence of excessive bodily humour, which had to be removed by purging, usually with herbs. In the introduction to his work on epilepsy he expressed his opinion on the natural causes of this disease.
In Ancient Rome the legal aspects of mental illnesses were worked out. Insanity and drunkenness could decrease the criminal’s responsibility for his actions. Apparently, however, the state of mind of the defendant was determined by the judge (and not by a psychiatrist). Those persons, who were considered to be mentally ill, were placed under custody of relatives or guardians appointed by legal authorities. 
Soranus (1-2 cent. A.D.) applied humanitarian principles in treatment and management of the mentally ill patients, their rooms were free from disturbing stimuli, the personnel was sympathetic. In lucid intervals patients read and participated in dramatic performances (tragedy was prescribed to counteract mania, comedy to counteract depression), and spoke at group meetings.
  	During the rule of the emperor Justinian (483-565 A.D.) a number of mentally ill patients for whom facilities were not provided earlier were admitted to institutions for the poor and infirm.
 3. The third period, corresponding to the Middle Ages and the Renaissance, was in general a period or regress, when psychiatry returned to its pre-scientific period (theological scholastics). The well-known figures who made their contribution to the studies of mental disorders were Constantinus Africanus (1020-1087), the founder of the medical school in Salerno near Naples, Albert the Great (1193-1280), and Thomas Aquinas (1225-1274).
A more humanistic attitude towards the mentally ill prevailed in Arabian countries. The Arabians translated many Greek classic texts, established flourishing medical schools, and founded a number of asylums for mental patients. In these institutions the atmosphere was relaxed, and the therapeutic regimen included special diets, baths, 
drugs, perfumes and concerts, at which the instruments were tuned in a special way, so that they would not jar the patients' nerves.
   The period of RENAISSANCE, in particular, in Europe, also cannot be haracterized by humanistic attitude towards people with mental disorders. Most of them were considered to be possessed by the devil and to be a witch. This opinion had found expression in the witchcraft mania - persecution of "witches". Most of the people recognized as witches or magicians were immolated. Some of the mentally ill found an outlet for their pathological drives in war or religious manifestations, such as crusades, pilgrimages and heretical movements. Other mental patients were confined to attics and cellars, where they were virtually imprisoned by their relatives. Still others were simply abandoned. By the 14th century, several institutions had been established for the  care, or, more accurately, the custody of mental patients. Traditionally, however, the first  mental hospital was founded in Valencia in 1409. From 1412 to 1489 five similar institutions were established in various cities in Spain, and in 1567, under the Spanish influence, the first mental hospital in the New world was established in Mexico City. 
There was no narrow specialization in the field of medicine neither in the ancient world, nor in the Middle Ages. The only two professions were physicians and surgeons. Physicians studied and treated all kinds of disorders, both physical and mental. Therefore, we can call Johann WEYER (1515-1588), a physician, who concentrated on patients with mental disorders, the first psychiatrist. In his book "De Praestigiis Daemonum" he rejected the belief in witchcraft. On the base of his extensive clinical experience he described a wide range of diagnostic entities and symptoms, including toxic psychoses, epilepsy, senile psychoses, nightmares, hysteria, delusions, paranoia and depressions. Weyer recognized the importance of therapeutic relationship and of the kindness and understanding the therapist must extend towards his patient. But the benevolent attitude must be based on scientific principles: careful psychiatric examination and observation.   
4. The fourth period, from the beginning of the XVIII-th to the beginning of XIX-th century was the stage of formation of psychiatry as a part of the medical science. 
During the 18th century there was a basic contradiction in the attitude towards mental 
illness. On the one hand, the mentally ill were rejected by medical and other professional societies. On the other hand impressive scientific and social accomplishments led to the establishment of modern science. Mental patients were still treated (or mistreated) in the manner of the Middle ages or Renaissance. They were kept in asylums often together with criminals, and measures of restriction were applied to them (many of them were put into chains) Yet, some progress was made in this area, especially by the end of the 18th and the beginning of 19th century.
Philip Pinel (1745-1826) was a French psychiatrist who was the superintendent of the Bicetre (for male patients) and the Salpetriere (for females), which housed criminals and the mentally ill. He freed mentally ill from their chains, attempted to analyze and categorize symptoms and applied a moral treatment (a kind of psychotherapy).
5. The fifth period was in the XIX century when scientific ground of psychiatry was developed. Neurology and psychology played an important role in psychiatry. Several schools of academic psychology appeared in the end of the 19th and the beginning of 20th centuries - structuralism, functionalism, behaviourism, dynamic psychology, etc. Psychodiagnostic testing skills became a part of the psychologists' and psychiatrists' instruments of investigation.
Adolf Meyer (1866-1950, Germany) was the founder of psychobiology, he attempted to present an integrated biological and social view on the personality.
	Emil Kraepelin (1855-1926, Germany) – differentiated between manic-depressive disorders and dementia praecox. He believed that certain types of body constitution were associated with certain types of personalities.
Eugene Bleuler (1857-1939, Switzerland) published a comprehensive study of schizophrenia in which he described the characteristic symptoms of this disease.
Sigmund Freud (1856-1939) was the founder of psychoanalysis. His followers (Carl Gustav Jung, Alfred Adler, Otto Rank, Karen Horney, Erich Fromm and others) developed different psychodynamic schools and elaborated their dynamic psychotherapeutic methods, still used in psychiatry.
6. The sixth, modern stage of development of psychiatry has formed in the XX-th century, especially its last decades, can be called the period of social psychiatry; it is characterized by wide development of community, social forms of mental health services; somatic aspects of mental disorders; the number of issues that are studied by 
specialists in the field of psychiatry has broadly expanded.
RUSSIAN AND UKRAINIAN PSYCHIATRY. 
In the feudal Russia the views on mental illnesses were religious and mystical, but the attitude towards people with mental disorders was softer, than in the European 
countries. Since the XI-th century they lived in the monasteries and convents.
In 1554 czar Ivan the Terrible issued an order, according to which monasteries had to take care of the mentally ill. This form of care existed in Russia up till the XVIII century, and at the time of Peter the Great the law was passed on the provision of special institutions for people with mental disorders. These institutions were designed only for maintenance of these people, no treatment was provided for them.
The medical understanding of mental disorders as a kind of disease influenced the nature of mental health services - hospitals were built for treatment, and not only for maintenance of the mentally ill. In 1776 the St. Katherine's hospital that had a department for psychiatric patients, and in 1832 a psychiatric hospital was opened in St. Petersburg. The personnel of these hospitals was headed by medical doctors. This created conditions for the development of medical regimen, medical care, methods of treatment and analysis of observation. At first, psychiatry in Russia (and Ukraine) was not separated from other medical professions - professors of internal diseases and surgery at some universities were also professors of psychiatry. For instance, P.A. Butkovsky at the Kharkov University was a professor of surgery and psychiatry, in 1834 he wrote the first Russian handbook for students on psychiatry.
The neurophysiological schools of A.A. Ukhtomsky, I.M. Sechenov and 
later I.P.Pavlov created the preconditions of the development of the biological and physiological schools of psychiatry in Russia. 
Not many Russian psychiatrists were known abroad. Among the well-known psychiatrists of the XIX century there were: V.Kh. Kandinsky, who developed the theory on pseudohallucinations; S.S. Korsakoff who is considered to be the founder of new psychiatry in Russia, he worked in the field of mental health services organization; his research work concerned mental disturbances in patients with organic brain damage, in particular alcoholic polyneuritis; the alcohol amnestic syndrome is stilled called after Korsakoff; V.M. Bekhterev was an outstanding investigator of the morphology and physiology of the brain, he developed experimental psychology in Russia, and was the first one to register the EEG without damaging the skull.
   THE HISTORY OF PSYCHIATRY IN ODESSA.
   Odessa was founded in 1794, and the beginning of the mental health services in the city can be attributed to the 40-th year after of its foundation. At that time there was only one hospital in Odessa, and in 1833 a special department for patients with mental disorders (an asylum) was organized in it. The department consisted of three rooms, 
and the number of patients treated in it was small (for example, during the year 1840 only 36 males and 32 females were interned to the department). In 1892, a new psychiatrical hospital was opened in one of the Odessa suburbs, Slobodka. All the patients from the old department were moved to the new hospital. At the beginning it was designed for 150 patients with acute psychoses and a "colony" for 100 chronic 
patients. Dr. Shpakovsky (1865-1924), one of the pioneers of the Russian psychiatry, was the first head of the hospital. Several doctors changed each other at this position during the century of the hospital's functioning. The most outstanding figure among them probably was professor Lev Aikhenvald. He was the head of the hospital for the 
longest term (over thirty years, from 1921 to 1954) and was a highly qualified psychiatrist, the author of over seventy publications on statistics, forensic psychiatry, legislation in psychiatry, etc. 
Now in Odessa there is a large network of mental health services - 2 regional psychiatrical hospitals (in Slobodka - No 1, and in Alexandrovka - No 2), a regional mental health and neuropathological centre with an outpatient department, district, city and regional centres for patients with alcoholism and drug addiction, etc. 
The Chair of Nervous and Mental Diseases was opened at the Odessa University in 1995. The first head of the Chair was professor Nikolay Popov. Under his leadership a team of psychiatrists was formed, who later made an important contribution into the development of psychiatry.  
The succession of professors who were at the head of the chair of psychiatry first at the Odessa University, and later at the Odessa Medical Institute (now - Odessa State Medical University) were: N.M. Popov, E.A.Shevalev, L.A. Mirelson, C.V. Moskiety, V.Ya. Volgin, S.B. Aksentyev (child and adolescent psychiatry), and V.S. Bitensky. 
The staff of the Chair, besides teaching and treatment practice, always carried out research work. The main fields of investigation, developed by the staff during the last decades were: 
a) modelling of psychoses with the purpose of finding their pathogenetic mechanisms (in particular, experimental model of the catatonic syndrome on animals); 
b) research of the micro-elements influence on the human organism, 
especially the nervous system; 
c) comprehensive research in the field of alcoholism and drug addiction, including the fetal alcohol syndrome, that enabled the staff of the Chair to suggest new methods for treatment of alcohol delirium, drug addiction and alcoholism. 
   MENTAL DISORDERS, THEIR CLASSIFICATION AND EPIDEMIOLOGY.    

   In psychiatry, as in the rest of medicine, classification helps to bring order to the great diversity of phenomena seen in clinical practice. Its purpose is to identify groups of patients who are similar in their clinical features, outcome, and response to treatment.
   ILLNESS, DISEASE, AND DISORDER.
Before classification of mental illness is considered, it is useful to consider briefly the concept of illness as it applies to psychiatry. In everyday speech the words "disease" and "illness" are used loosely.  In general medicine a distinction is made between disease (denoting objective physical pathology) and illness (denoting subjective distress). This distinction has little bearing on psychiatric conditions, most of which have no demonstrable physical pathology. Nevertheless, the concept of mental illness is useful in conveying a greater than usual degree of subjective distress or disability. (In psychiatry the term mental disorder is usually applied to a syndrome, as in the terms depressive disorder or anxiety disorder.)
It is surprisingly difficult to produce a more precise definition of mental illness (or disorder). In everyday clinical practice, however, this difficulty does not matter much except in relation to certain legal issues such as compulsory admission to hospital. For example, English law requires psychiatrists to diagnose the presence or absence of "mental illness" when certifying the need for compulsory admission to hospital. Also, in courts of law the definition of mental illness is important in relation to fitness to plead, criminal responsibility, and similar issues. In the Ukrainian psychiatry compulsory admission to hospital is grounded not only on the presence or absence of mental illness, but on the so called "social danger" of the patient, meaning 
his/her tendency to harm others or him/herself.
PRINCIPLES OF CLASSIFICATION. The use of classification in psychiatry has sometimes been criticized as inappropriate or even harmful on the grounds that it may distract attention from understanding the unique problems of the individual patient, or that a diagnosis such as schizophrenia may stigmatize a person. Neither criticism is well founded. Classification can certainly be combined with consideration of a patient's unique qualities; indeed, it is important to consider both beca use individual qualities can modify prognosis and need to be taken into account in treatment. Also, whilst there can be no doubt that the diagnosis of schizophrenia can cause social stigma (as can medical diagnoses such as epilepsy or AIDS), it is essential to recognize the reality and seriousness of the disorder, and the need for treatment. Disorders cannot be made to disappear simply by ceasing to give names to them, and failure to recognize their true nature may deprive people of appropriate treatment.
In general medicine most conditions can be classified on the basis of aetiology (for example, pneumococcal or viral pneumonia) and of structural pathology (lobar pneumonia or bronchopneumonia). Some general medical conditions are not yet classifiable in this way (for example, migraine or trigeminal neuralgia) and they have to be classified solely on the pattern of symptoms. Most psychiatric disorders resemble the second group in having to be classified on symptoms. Only a few psychiatric disorders have an indisputablephysical aetiology, for example Alzheimer's disease, phenylketonuria, Down's syndrome, or general paralysis of the insane.
Considering the aetiology and pathogenesis of mental disorders in general, we can say that mental disorders can be caused by the following groups of reasons: 
1) endogenous disorders, such as schizophrenia, manic-depressive disorder or genuine epilepsy, are caused by internal mechanisms, the nature of which isn't yet quite clear; these are disorders with hereditary predisposition, and according to some authors hereditary disorders, such as phenylketonuria, or Down's syndrome, can also be included in this group; 
2) exogenous disorders are caused by external reasons: infection, intoxication, head injury, etc.; 
3) psychogenous disorders are caused by psychotrauma (posttraumatic stress syndrome) and other psychological factors (adjustment disorders, neuroses, etc.). 
The first stage of classification in psychiatry is to consider how long the disorder of behaviour has lasted. In this way enduring conditions of early onset, for example mental handicap (impairment of intellectual function starting at an early age) and personality disorder (abnormality of behaviour in a wide variety of circumstances, 
present from teenage years), are separated from mental disorder (abnormal behaviour or psychological experience starting after a previous period of normality). Mental disorders are divided on the basis of symptoms into syndromes such as schizophrenia, affective disorders, organic mental states, and others. Certain abnormalities of behaviour are difficult to classify in this way, for example drug abuse or abnormalities of sexual preference. These behaviours are not usually regarded as mental disorders, but since they are deemed suitable for treatment by doctors, they are given a place in the system of classification.
PSYCHOSIS AND NEUROSIS. The terms psychosis and neurosis are used widely, though they are not part of the commonly used systems of classification.
Psychosis is a broad term for the more severe forms of mental disorder, that is organic mental disorders, schizophrenia, and affective disorder, in which hallucinations and delusions may occur.  People with psychoses defined in this way may lack insight and may not recognize that they are unwell. The term psychosis is unsatisfactory because it includes conditions that have little in common; hence diagnosing psychosis is less informative about prognosis and treatment than diagnosing a specific disorder within the rubric of psychosis, for example schizophrenia.
Despite these disadvantages, the term psychosis is still used as a convenient term for disorders with hallucinations and delusions that cannot be given a more precise diagnosis because of insufficient evidence; for example, when there is uncertainty whether a disorder is schizophrenia or mania.  As such it is a provisional category to be replaced by a more precise one when more evidence has accumulated.  
Neurosis refers to mental disorders in which, irrespective of severity, there are no hallucinations or delusions and no loss of insight.  The objections to the term neurosis are similar to those for psychosis: the term is difficult to define, it embraces conditions that have little in common, and it is less informative than a more specific diagnosis such as anxiety disorder. Like psychosis, however, neurosis continues to be 
used in clinical practice as a convenient term for disorders that cannot be assigned to a more precise diagnosis.
TYPES OF CLASSIFICATION. Classification in psychiatry, as in the rest of medicine, uses diagnostic categories defined in terms of patterns of symptoms, course, and outcome. Although this approach has proved useful in both clinical work and research, three objections have been raised. First, the categories may not represent valid disease entities. Second, the categories are not defined very precisely and may be of limited reliability. Third, many psychiatric disorders do not fall neatly within the boundaries of a single category, but have the clinical features of more than one. The main diagnostic systems contain the same basic categories, though they differ in nomenclature and the ways in which categories are grouped.
Basic categories:
*  Mental retardation: impairment of intellectual functioning present continuously from early life.
*  Personality disorder: dispositions to behave in certain abnormal ways present continuously from early adult life.
*  Adjustment disorder: disorders that are less severe than mental disorders and occur in relation to stressful events or changed circumstances.
*  Mental disorders: abnormalities of behaviour or psychological experience with a recognizable onset after a period of normal functioning.
*  Other disorders: conditions that do not fit into the first four groups, for example abnormalities of sexual preference and drug dependence.
*  Disorders of childhood
Some categorical systems have a hierarchy of diagnoses, that is if two diagnoses are made, one takes precedence over the other. For example, if there are symptoms of both organic mental disorder and schizophrenia, only organic disorder is diagnosed (on the grounds that the schizophrenic symptoms are caused by the organic pathology).  However, such systems do not apply this rule to all combinations of diagnosis; for example, depressive disorder and alcohol dependence can be diagnosed in the same patient.
Two broad approaches to psychiatric classification have been used - dimensional and multiaxial. Dimensional systems use a continuum rather than categories. This method has been used mainly to classify personalities; for example, in one system personality is scored on each of three dimensions, neuroticism, psychoticism, and introversion-extroversion.  Multiaxial systems do not attempt to reduce the data to a single diagnosis; instead they categorize the person on several different axes, for example psychiatric diagnosis, intelligence, degree of disability, and associated physical disorder. This system is useful in child psychiatry.
   THE CONSISTENCY OF DIAGNOSIS.
   Diagnosis is of little value unless doctors can achieve reliability, that is agreement with one another in stating a diagnosis.
   INTERVIEWING TECHNIQUE. Doctors vary widely not only in the information they elicit at interview, but also in their interpretation of this information. These differences can be reduced by using standardized interviews in which predetermined questions are asked and rules are used to define whether particular symptoms are present.
   DIAGNOSTIC CRITERIA. Reliability can be increased by providing a clear definition for each diagnosis and by specifying discriminating rather than characteristic symptoms. Discriminating symptoms occur commonly in the defined syndrome but rarely in other syndromes. They are important in diagnosis, but may sometimes be of little concern to patients and of little importance in treatment. An example is the delusion that thoughts are being inserted into the mind, a discriminating symptom for schizophrenia. Characteristic symptoms occur frequently in the defined syndrome but may also occur in other syndromes. Such symptoms do not help in diagnosis, but may be important to the patient and relevant in planning treatment.  An example is thoughts of suicide, which do not help in diagnosis because they occur in several kinds of disorder, but which are very important in planning care.
Diagnostic criteria can be general descriptive statements or more precise criteria. The term operational definition means the specification of a series of precise inclusion and exclusion criteria. For example, in the diagnostic system known as DSM (see below) the category of major depressive disorder requires five current symptoms from a list of nine, together with the exclusion of organic causes, schizophrenia, and bereavement reaction.
SYSTEMS OF CLASSIFICATION.
Current systems can be traced back to the work of a German psychiatrist, Emil Kraepelin, around the end of the last century.  He developed categories on the basis of detailed clinical observations and long-term follow-up studies. He refined the distinction between the organic and functional psychoses, and divided the functional 
psychoses into dementia praecox (now called schizophrenia) and manic depressive disorder.
   The INTERNATIONAL CLASSIFICATION OF DISEASES (ICD).
   This system of classification was developed by the World Health Organization. It is now in its tenth edition (ICD 10), which was introduced in 1992. The section on psychiatry is used in most countries of the world. It is available in two forms, one for clinical practice and the other for research. The former gives descriptions of the features of cases that fit each diagnostic group. The latter provides lists of specific criteria.
The International Classification of Diseases (ICD-10) includes:
F00-F99 - Mental and behavioural disorders
(F00-F09) Organic, including symptomatic, mental disorders
(F10-F19) Mental and behavioural disorders due to psychoactive substance use
 (F20-F29) Schizophrenia, schizotypal and delusional disorders
(F30-F39) Mood (affective) disorders
(F40-F48) Neurotic, stress-related and somatoform disorders
(F50-F59) Behavioural syndromes associated with physiological disturbances and physical factors
 (F60-F69) Disorders of adult personality and behaviour
(F70-F79) Mental retardation
(F80-F89) Disorders of psychological development
(F90-F98) Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
(F99) Unspecified mental disorder

   The DIAGNOSTIC AND STATISTICAL MANUAL (DSM)
   This separate American classification is now in its fourth edition (revised form) known as DSM IV. It is used in many countries outside the United States, particularly for research. The original DSM III was published in 1980 and represented a major change in methods of classification. There were two main innovations.
 I.  Specific operational criteria were provided for each diagnosis.
 2.  A multiaxial classification was adopted with five axes:
     I   - clinical syndromes together with 'conditions not attributable to mental disorder that are the focus of attention and treatment';
     II  -  personality disorders;
     III -  physical disorders and conditions;
     IV  -  severity of psychosocial stressers;
     V   -  highest level of adaptive functioning in the last year.
        Each patient can be described on each of the axes, or on fewer than      five if that is more appropriate for the purpose for which the case is being classified. Axes IV and V are not used routinely.  DSM III and DSM Ill-R have been widely used in the United States and many other countries. They have had a major influence on the development of ICD-10. The next version, DSM IV, is to be published in 1994 and will be largely comparable with ICD 10.
DIAGNOSIS AND CLASSIFICATION IN EVERYDAY PRACTICE.
   A diagnostic classification is made after the history and examination of mental state have been completed. The first step is to review the pattern of symptoms occurring in the past month as reported by the patient and any other informants, and of the symptoms and signs elicited by mental state examination. The pattern is then matched to one or more of the diagnostic categories in the classification system used. If necessary, reference should be made to the precise definitions and rules of application. In practice, only a small number categories need be considered; the rest are obviously inapplicable. In attempting to match a patient's symptoms and signs to a diagnostic category, problems may arise when most fit well but one or two are incongruous. For example, a patient may have depressed mood, morbid self-blame, early morning waking, and diurnal mood variation - all symptoms typical of depressive disorder. In addition, he may have the delusion that the people talk about him on television - a typical symptom of schizophrenia. When this kind of incongruity occurs, the clinician should review the clinical features thoroughly and search for other evidence of the alternative syndrome. If only single incongruous symptom is found among many that are congruous, the diagnostic category generally remains unchanged.
   This kind of problem can sometimes be resolved by looking at the diagnostic category longitudinally as well as cross-sectionally. The process described so is cross-sectional, that is allocation to a category is based on the present mental state and the history of symptoms in the past few weeks. The longitudinal approach deals with the nature and course of a disorder since it first began. For example, the present symptoms can be compared with those in any previous episodes of disorder. If it is found that the patient described has had two previous episodes of clear-cut affective disorder and no episodes of schizophrenia, then the clinician will more readily discount the current atypical symptom (the delusion of being talked about on television). If there have been two episodes of definite schizophrenia, the opposite conclusion will be justified. The time course of the previous disorder is also informative.
EPIDEMIOLOGY in psychiatry is the study of the occurrence of mental disorder within the specified population; often expressed in terms of incidence (the number of new cases that appear during a specified time period, such as the number of first admissions to mental hospitals during one year) and prevalence (the number of cases of any mental disorder that exist currently within the population).

Lecture: “Basic disorders of cognitive and emotional-volitional sphere.”
DISORDERS OF PERCEPTION

Before considering abnormalities of perception, it is necessary to define three terms.  
Sensation is a feeling or impression when the sensory nerve endings of  any  of  the  senses  (taste,  touch,  smell,  sight,  sound   and kinesthesia) are stimulated.  Sensations can also be  determined  from the psychological point of view as the simplest mental processes, that arise owing to the impact of the objects or phenomena of the  material environment  on  the  receptors.  They are reflections  of  separate properties (qualities) of real objects (their  colour,  taste,  sound, smell, etc.).
Perception is the process of becoming aware of what is presented through the sense organs. According to a generally acceptable definition, it is the process of organizing and interpreting sensory data by combining them with the results of previous experience. This definition indicates that perception is a complex process involving the past as well as the present and involving an external stimulus as well  as  an  internal response. Perception can also be defined as a direct reflection of whole objects in the mind. It wouldn't be correct to say that perception is just a combination of sensations. Perception cannot be decomposed to separate sensations, we can never see just red colour, or hear a tone, or feel an abstract pain. We see a specific red object, hear a sound of some musical instrument or feel pain of certain quality in some part of our body. Isolated properties of objects never influence us separately from each other.
Imagery is an experience within the mind, usually without the sense of reality that is part of perception. Imagery is experienced when a face is remembered or when we think in pictures. Imagery differs from perception in that it can be called up and terminated by voluntary effort, and is usually obliterated by actual perception in the same modality.  
Disturbances of perception are of three kinds: changes in the intensity of things perceived (quantitative changes), changes in the quality of perception (senesthopathias and sensory synthesis disorders), illusions and hallucinations (Table 1). 

Table 1.            Disturbances of perception

Changes in intensity          	Hyperesthesia
Hypesthesia
Anaesthesia

Changes in quality	Senesthopathias	
	Sensory synthesis disorders   	Distorted perception of                                       environment	
		Body image disorders	
  
Illusions	Physical	
	Physiological	
	Mental	

Hallucinations	Elementary	visual
auditory
olfactory
gustatory
tactile
deep sensations	
	Simple		
	Complex		
Psuedohallucinations	Simple		
	Complex		

   CHANGES IN THE INTENSITY AND QUALITY OF PERCEPTION
In mental disorders, perception can change in intensity. Such changes are called quantitative. 
Hyperesthesia is abnormally high sensitiveness to external stimuli. It can concern either separate analysers (inordinate sensitiveness to usual smells - hyperosmia; increased sensitivity to sound - hyperacusia, etc.), or their combinations (both light and sounds seem to be too intensive). Usual sounds seem extremely loud, light and colours - too bright, the clothes touching the skin - coarse and uncomfortable. These sensations cause discomfort and irritation. Hyperesthesia usually occurs in patients with asthenic symptoms, for instance in neuroses or after overstrain or physical diseases.

Patient N., 34 years old, an engineer, after a year of extremely intensive work with very little rest, noticed that he could hardly bear all kinds of external stimuli: "The shirt collar seems too tight, bright light simply enrages me, usual conversations between other passengers in the bus irritate me so much, that often I get off before I stop to compose myself".

Unlike the described case of hyperesthesia, in mania (euphoria) sensations seem more intense without causing the patient any discomfort.
Hypesthesia is a decrease of sensitivity towards external stimuli. Sounds seem muffled, the light - dim, colours grow dull ("everything around looks dim and grey, and the lamp light is so faint..."). This state can be a result of a depressive disorder, and some changes of consciousness. 
Anesthesia is a loss of sensitivity. It can concern separate receptors (loss of the skin tactile sensitivity of some parts of the body, loss of sight or hearing on one side), or several receptors (loss of both sight and hearing). In the psychiatric practice this can occur in hysteria, but the hysterical anesthesia must be distinguished from the same symptom in neurological disorders (patients should be 
investigated thoroughly). 
Perceptions can also change in quality, seeming distorted or unpleasant; for example, some schizophrenic patients report that food in general tastes unpleasant or flowers smell acrid. (Sometimes perception is normal in intensity and quality but has a changed meaning for the person who experiences it. This is a disorder of thinking, not of perception; it is sometimes referred to as delusional perception.
Senesthopathias are abnormal unpleasant (and in some cases extremely agonising) sensations in different parts of body or internal organs, which are difficult to describe. Patients complain of different kinds of prickling, pressure, burning, twisting, tension, etc., not associated with any somatic disorders.  
A patient gave the following description of his sensations: "As I was sitting in my chair, I felt warm liquid running down my spine. Then I got a feeling of emptiness inside my body. It began in the upper part of my chest and spread down my body, so in the end both my chest and stomach seemed to be absolutely empty, as if they were filled with air."
Sensory synthesis (psychosensory) disorders manifest in distorted perception of external objects or one's own body, although the objects are recognized, and the patient is usually aware of the abnormal nature of his/her experiences. 
If the psychosensory disorders concern the faulty perception of the environment, they usually manifest in distorted vision. External objects can appear crooked, twisted, or misshapen (metamorphopsia), they can seem smaller or bigger, that they really are (micropsia or macropsia), one object can appear to the subject as two or more (polyopsia), objects seem to move or fall, the space appears to become fragmental.
If the sensory synthesis disorders concern the subject's body, the kinaesthetic and proprioceptive perception becomes distorted. These states are termed "body image disorders", they consist in changes of the usual perception of size and shape of one's body or its parts. For example, a patient can feel, that his head has grown so big, that there isn't enough place for it not only on the pillow, but in the room, that his legs grow directly out of the head, and the body has disappeared; another patient feels that her right arm has grown to a big size and became extremely heavy, and the rest of the body has shrunk; still another patient finds that his legs have multiplied, and now he has four of them. It is important to note, that visual perception is usually correct, so if such patients look at their body directly, or in the mirror, they see it unchanged. 
	Illusions
An illusion is a misperception of an external stimulus. Real objects or phenomena are perceived in a changed, erroneous way. There are three kinds of illusions according to the reasons of their occurrence. PHYSICAL illusions are caused by the refraction of air or water (mirages in the deserts, changes in the size and shape of objects in the water, etc.) and other natural phenomena. PHYSIOLOGICAL ILLUSIONS depend of the normal properties of senses in healthy people (distinction of figure and background, etc.). MENTAL illusions may occur in four circumstances: 
   - when the level of sensory stimulation is reduced, for example at dusk the outline of a bush may be misperceived as a man;
   - when attention is not focused on the sensory modality, for example a person focusing on reading may mistakenly identify a sound as a voice;
   -  when  the level of consciousness is reduced during an illness (see delirium);
  -  when there is a strong mood state such as fear (affective illusions).
   Illusions are experienced by healthy people, particularly when more than one of the above circumstances occur together, for example when a frightened person is in a poorly lit place. Illusions also occur with the reduced consciousness of delirium, particularly when sensory stimulation is reduced (being alone in a quiet room). Visual illusions can occur particularly in acute organic mental disorders.
   PAREIDOLIC illusions are disorders of perception, in which real objects are percepted as strange and fantastic - the patterns on the wallpaper are seen as beautiful landscapes, a shade from a standard lamp appears to be a fantastic dragon, etc. These phenomena usually are symptoms of reduced consciousness.
   Hallucinations
   A hallucination is a perception experienced in the absence of an external stimulus to the corresponding sense organ, for example hearing a voice when no one is speaking within hearing distance.  A hallucination has two special qualities: first, it is experienced as a true, not an imaginary, perception; second, it seems to come from the outside world (except in the rare case of somatic hallucinations (see 
below)). Unless the experience has these two qualities it is not a hallucination. (Experiences that pass one of these tests but fail the other are called pseudo-hallucinations).
    Although hallucinations are generally regarded as the hallmark of mental disorder, healthy people experience them occasionally, particularly when falling asleep (hypnagogic hallucinations) or waking (hypnopompic hallucinations). These normal hallucinations are brief and are generally of a simple kind such as hearing a bell ring or a name called, or seeing patterns, when the eyes are closed. Usually the person wakes suddenly and quickly recognizes the nature of the experience. These two kinds of hallucination do not point to mental disorder, sometimes they occur when a person in tired and over-excited.     Hallucinations can occur in all sensory modalities but those of hearing and seeing are most frequent.

  Table 2. Distinctions of hallucinations and pseudohallucinations.

       HALLUCINATIONS                    PSEUDOHALLUCINATIONS

1. are vivid perceptual images.      	 1. are vivid perceptual images
2. have all the signs of reality. 		 2. are devoid of the signs of 
                                    			  reality
3. have clear space localization.  	3. are located in the subjective 
                                     			(inner) field of perception
4. are percepted in the same way   	4. Are percepted as something
   as real stimuli (objects).        		 unusual, are accompanied by a 
                                      			feeling of compulsion.
5. influence the emotional state  	 5. Patients remain contemplative,
   and behaviour of patients.         	passive, and tend to interpret
                                       			them in a symbolic and delusive 
                                     			 way

           TYPES OF HALLUCINATIONS AND PSEUDOHALLUCINATIONS

   HALLUCINATIONS                 PSEUDOHALLUCINATIONS
 
1. VISUAL                         1. VISUAL
a. microptic (Lilliputian)    a. extrocampine
b. macroptic                        b. panoramic
c. dysmorphoptic
g. panoramic

   HALLUCINATIONS                 PSEUDOHALLUCINATIONS
                                                        
a. imperative                     a. anticipating thoughts        
b. antagonistic                   b. echoing or repeating thoughts
c. commenting                                                                                                 

Signs and symptoms
Auditory hallucinations may be experienced as voices, noises, or music. Hallucinatory voices may seem to speak words, phrases, or sentences. Some address the patient as "you" (second person hallucinations), whilst others talk about the patient as "he" or "she" (third person hallucinations), which occur particularly in schizophrenia. Sometimes a voice seems to say what the patient is about to say; sometimes it repeats what he has just been thinking (thought echo).
Visual hallucinations may be experienced as flashes of light 
(elementary hallucinations), or as complex images such as the figure of a man. They usually appear normal in size, but sometimes are unusually small or large. (Visual hallucinations are associated particularly with organic mental disorders but can occur in other conditions).
Hallucinations of smell and taste may be recognizable smells or flavours, but more often they are unlike any smell or flavour that has been experienced before and they have an unpleasant quality.
Tactile hallucinations may be experienced as superficial sensations of being touched, pricked, or strangled, or as sensations just below the skin which may be attributed to insects or other small creatures burrowing through the tissues.
Hallucinations of deep sensation may be experienced as feelings of the viscera being pulled upon or distended, or as sexual stimulation. A patient may feel an object inside his/her body (a snake in the stomach, "shrimps" in the brain, etc.) 
Hallucinations of smell and taste, of deep sensation, and tactile hallucinations are less common, than visual and auditory. In most cases they are observed in schizophrenia.
Hallucinations may occur in all kinds of severe psychiatric disorder (affective disorders, schizophrenia, and organic disorders) and, as explained above, occasionally among healthy people. Visual hallucinations occur particularly in organic psychiatric disorders, but also in severe affective disorders and schizophrenia. Although not specific to organic disorder, they should always prompt a thorough search for other evidence of this diagnosis. The finding of hallucinations does not generally point to a particular diagnosis. The uncommon hallucinations of taste, smell, and deep sensation occur mainly in schizophrenia. There are some special kinds of hallucination that characterize a particular disorder; they are explained in the chapters on clinical syndromes.

  Methods of investigation
Illusions may come to notice when the history is taken or when the patient is being observed, for example in a medical ward. Visual illusions can be elicited with a question such as "Have you seen anything unusual?" (or frightening if the patient seems afraid). If the answer is positive, the interviewer needs to find out whether the visual experience is based on an actual visual stimulus (for example 
mistaking a shadow for a threatening person).
Enquiries about hallucinations should be made tactfully, lest the patient takes offence. If enquiry is indicated, questions can be introduced by saying: "When their nerves are upset some people have unusual experiences". Questions can then be asked about hearing voices or sounds when there is nobody within earshot, or about seeing unusual things. If the patient says "yes" to either of these questions, he should be asked whether the voice, sound, or vision appeared to be inside or outside his head. When the history makes it relevant, similar questions should be asked about other kinds of hallucinations.  
If the patient describes auditory hallucinations, he should be asked whether he hears sounds or voices; if the latter, whether one voice or more, and whether the voices talk to him or to each other. 
Hallucinations of voices discussing the patient (third-person hallucinations should be distinguished from the delusion that people at a distance are discussing the patient (delusion of reference. If the hallucinatory voices talk to the patient (second-person hallucinations), the interviewer should find out whether they give commands, and, if so, what kind of commands and whether the patient feels impelled to obey them. 
The only SYNDROME in the disorders of perception is the HALLUCINOSIS, that consists in persistent or recurrent appearance of hallucinations, usually in a clear intellectual field, without confusion or intellectual impairment; most commonly due to intoxication with alcohol or drugs, or following traumata such as surgical procedures and childbirth.  Hallucinosis can be acute or chronic.
   
   DISORDERS OF MEMORY

   MEMORY  is  an  ability  to  revive  past   sensory    impressions, experiences, and learned ideas. Memory  includes  three  basic  mental processes:
   1) registration - the ability to perceive, recognize and  establish information in the central nervous system; it is also called fixation;
   2) retention - the ability to retain registered information; and 
   3) recalling - the ability to retrieve stored information at will.
   Since learning requires the modification of future  behaviour  as  a result of past experience, two distinct processes must  be  explained: (1) the neural mechanisms involved in storage of a  representation  of an experience and (2) the neural mechanisms that are intermediaries in the retrieval of such stored  information  and  its  interaction  with present experience. The first function might  be  called  read-in,  or memory, and the second might be called readout, or remembering.
   To describe abnormalities of memory it is necessary to have a classification of normal memory. There are several schemes, of which the following is useful in clinical practice (although it does not correspond completely to research findings). Memory can be thought of as having three kinds of "store". SENSORY memory stores receive information from the sense organs and retain it for a brief period (about 0.5 seconds) until it has been processed. SHORT-TERM memory stores hold information for longer (about 15-20 seconds). Information can be retained for longer by repeated rehearsal, for example when an unfamiliar phone number is repeated until it can be dialed. The third store is LONG-TERM memory: it receives information that has been selected for more permanent storage, and has a much larger capacity than the other two. Information is stored according to characteristics such as meaning or the sound of words. The mood state at the time of storage is important: memories stored when the person was unhappy are recalled more readily in an unhappy than a happy state of mind.
   Two useful distinctions can be made about long-term memory. The first is between memory for events (episodic memory) and memory for language and knowledge (semantic memory). The second is between recognition of material presented, and recall without such a cue (the latter is more difficult). The physiology of memory is presented in Table 3.

Table 3.                PHYSIOLOGY OF MEMORY.

           TYPES OF MEMORY
1. Verbal, logical
2. Image, mechanical

           KINDS OF MEMORY
I.   Visual
     Audial
     Kinesthetic
     Taste
     Olfactorious
II.  Emotional
III. Memory of skills and habits

           STRUCTURE OF MEMORY

1.  Registration (memorizing)     involuntary
                                  voluntary
2.  Retention (keeping in memory)   
3.  Recall  

    THE LAWS OF FORGETTING (Ribo's laws)
1. From the new to the old 
2. From the specific to the general 
3. From the complicated to the simple

   Several technical terms are used to describe abnormalities of memory, and there is a number of kinds of its pathology.

   Table 4.           THE PATHOLOGY OF MEMORY.

    KINDS OF MEMORY DISTURBANCES

1. Hypermnesia        3. Amnesia   
2. Hypomnesia         4. Paramnesia

    CLASSIFICATION OF AMNESIAS

According to their genesis:   Innate
                             Acquired

According to the extend:     General
                             Partly

According to structure:      Anterograde
                             Retrograde
                             Anteroretrograde

According to the mechanism:  Veritable (organic)
of development               Psychogenic (repression)

   KINDS OF PARAMNESIAS

  1. Confabulation          4. Pseudoreminiscence
  2. False recognition      5. Kryptomnesia
  3. Deja Vu                6. Jamais Vu

   KORSAKOFF'S (Wernicke-Korsakoff, amnestic) SYNDROME

1. Anterograde and retrograde amnesia
2. Fixation amnesia (recent memory severely impaired)
3. Amnestic disorientation (in time and space)
4. Confabulations and pseudoreminiscences

   1. Hypermnesia means exaggerated memory, ability to recall material that is not ordinarily available to the memory process. Hypermnesia as a psychopathological phenomenon has been reported in the following conditions: manic phase of manic-depressive psychosis; schizophrenia; some organic brain disorders; fever. In psychoses old recollections sometimes come up in hallucinations. Seemingly forgotten information can also be recalled during hypnosis or psychoanalysis, as well as an effect of certain drugs (amphetamines and other stimulants and hallucinogenic agents).
   2. Hypomnesia is worsened memory, decreased ability to register retain, or recall information.
   3. Amnesia means inability to recall past experiences. If a patient does not remember all events that had happened to him/her in the past, the amnesia is called general (total), and if he/she can not remember only some events, this state is referred to as partial amnesia. If a person is born with inability to retain information, the amnesia is innate, and if it develops later it is acquired.
   Anterograde amnesia occurs after a period of unconsciousness. It is impairment of memory for events between the ending of complete unconsciousness and the restoration of full consciousness.
   Retrograde amnesia is loss of memory for events before the onset of unconsciousness. It occurs after head injury or electro-convulsive therapy. 
  4. Paramnesia is a disturbance of memory in which real facts and fantasies are confused. There are several kinds of paramnesias (see table 2).
   Jamais Vu is failure to recognize events that have been encountered before, whilst Deja Vu is the recognition of events as familiar when they have never been encountered.  Both abnormalities may occur in neurological disorders.
   Confabulation is the reporting as "memories" of events that did not take-,e place at the time in question.  It occurs in some patients with severe disorders of recent memory.
   Pseudoreminiscence means displacement of real events in time: a patient states that some experience he/she had in reality some years or months before, occurred only yesterday.
   False recognition concerns other people: a patient, for example, identifies a doctor or a nurse in the department as one of his/her relatives.     
   Kryptomnesia is a patient's inability to tell whether he had dreamed  or actually experienced a certain event, whether he had read a verse  in a book, or had written it himself.   
   Memory is affected in several kinds of psychiatric disorder.  In depressive disorder unhappy memories are recalled more readily than other kinds of memory. In organic disorder all aspects of long-term memory are usually affected, although the memory of earlier events is impaired less than that of more recent events. 
   In some organic disorders there is a differential impairment - the AMNESTIC (Wernicke-Korsakoff) syndrome, in which the memory for recent events is most affected, and semantic memory least. This syndrome includes anterograde and/or retrograde amnesia (if it develops acutely, for example as a result of alcoholic delirium), fixation amnesia (recent memory is severely impaired), amnestic disorientation (a patient looses orientation in time and in space) and paramnesia (confabulations and pseudoreminiscences).
                             
METHODS OF ASSESSMENT 
   Difficulties in remembering may come to light during history taking, when questions can be asked about everyday memory lapses.  During the examination of mental state, tests are given to assess immediate, recent, and remote memory.  None of these tests is wholly satisfactory, and the results should be assessed cautiously and in relation to other information about the patient's ability to remember.  If there is doubt, standardized psychological tests can be given by a clinical psychologist.
    Short-term memory is assessed by asking the patient to repeat sequences of digits or words immediately after they have been spoken slowly enough for him to register them (the 'digit-span' test).  An easy sequence of three digits is given first to make sure that the patient understands the task. Then a new sequence of four digits is presented. If the patient can repeat four digits correctly, five, six, and then seven are given. If he reaches a level at which he cannot repeat the digits, the test is repeated with a different sequence of the same length. A normal person of average intelligence can repeat seven digits correctly; five or less suggests impairment. (The test involves concentration and therefore, as noted above, cannot be used to assess memory when tests of concentration are abnormal.)
    Next the interviewer assesses the patient's ability to take in and remember new information. By convention, the new information is a name, an address, and the name of a flower. The interviewer should avoid common names and addresses likely to be familiar to the patient.  It is important to ask the patient to reproduce the information straight away to make sure that it has been registered correctly.  If the material is not registered correctly, the information is repeated until there is accurate immediate recall. Other topics are then discussed for 5 minutes, at which time recall is tested. The patient's response should be recorded verbatim and the number of errors noted. A healthy person of average intelligence should make only minor errors in this task.
    Memory of recent events is assessed by asking about news items from the last day or two, or about recent events in the patient's life that are known with certainty to the interviewer (do not ask the traditional question about what the patient had for breakfast unless the answer is known).  Questions about news items should be adapted to the patient's interests, and should have been widely reported in the media.

   Remote memory can be assessed by asking the patient to recall personal events or well-known public events from some years before.  Personal events could be the birth dates of the patient's children or grandchildren (provided that these dates are known with certainty by the interviewer); public events could be the names of earlier political leaders, sportsmen, or musicians.  Awareness of the sequence 
of events is as important as the recall of individual items.
    When a patient is in a general hospital, important information about memory is available from observations made by nurses. These observations include how fast the patient learns the daily routine of the ward, and the names of staff and other patients, and whether he forgets where he has put things or cannot find his way about (though the latter may indicate spatial disorientation rather than poor memory). When the patient is at home, relatives may report comparable observations about the patient's ability to learn and remember.
    Among elderly patients, these questions about memory do not distinguish well between those who have cerebral pathology and those who do not. For cases of doubt there are standardized ratings of memory for recent personal events, past personal events, and general events, which allow a better assessment of severity.  Standardized tests of learning and memory can also help in the diagnosis of organic mental disorder, and can be used for quantitative assessments of the progression of memory disorder. These tests are usually administered by a clinical psychologist.

   DISORDERS OF ATTENTION AND CONCENTRATION

   ATTENTION is the ability to focus on the matter in hand.  CONCENTRATION is the ability to maintain that focus. Attention can also be determined as conscious  and  willful  focusing of mental energy on one object or one component of a  complex  experience and at the same time excluding other emotional or thought content; the act of heeding or taking notice. 
   Traditional psychology divides attention into
   a) involuntary and
   b) intentional (voluntary).
   Involuntary (spontaneous, primary) attention in its essence is  the orientation reflex to  irritants,  meaningful  to  the  organism  (for example, owing to their intensiveness or quality - a  shot,  situation of danger, etc.).
   Intentional attention presupposes deliberation. Selection  in  this case is carried  out  by  way  of  voluntary  organization  of  mental activities. This process is motivated by some need, either  biological or psychological.
   Attention has the following properties:  span  (volume),  intensity (level of concentration), distribution and stability (duration).
   ATTENTION SPAN (also known as perceptual span)  is  a   number  of briefly-presented objects that can be recalled immediately. Usually  5 or 6 elements can be perceived at a time. If it is necessary  only  to count the number of objects in the tachiscopic exposition, the average attention span is 8 objects, with individual variations from 6 to 11.
   ATTENTION INTENSITY is in inverse proportion to the attention span: the wider the span, the weaker the intensity (in the people,  who  can not concentrate).
   ATTENTION STABILITY (duration) -  is  an  ability  to  concentrate uninterrupted on one object or  action.  Objective  measurement  has determined that it is possible for 1/3 to  2  seconds,  and  then  the attention begins to fluctuate.
   DISTRIBUTION OF ATTENTION is an ability to concentrate  on  several objects at the same time (this quality is very important for  drivers, teachers and in some other professions).
    Attention and concentration can be impaired in many kinds of psychiatric disorder, but particularly in anxiety disorder, depressive disorder, mania, schizophrenia, and organic disorder. Disorders of attention and concentration can manifest in the following states: 
   1) Attention deficit, characterized by inadequate or inappropriate attention span and concentration difficulty, when a person can not concentrate on an object; active attention decreases and the passive prevails; this occurs in children with attention deficit disorders, and in patients with anxiety. 
   2) Attention deterioration is one of the fundamental symptoms of schizophrenia, where often there is seen an impairment of the ability to heed, observe and concentrate on external reality; the patient concentrates on his/her inner experiences, inner world.
   3) Abnormal fixation of attention, when a patient is unable to switch his/her attention over to another subject. For example, in depression all the patient's thoughts and recollections are focused on a traumatic event or on his/her own morbid experiences.
   4) Tendency to quick exhaustion of concentration can be observed in organic brain damage or asthenic states. At the beginning of a conversation a patient concentrates on the topic easily and answers questions correctly. But as the conversation continues, the patient gets tired and the concentration decreases, he begins to digress from the topic and make mistakes.
   Detection of impaired attention or concentration does not help in diagnosis but is important in assessing the patient's disability; for example, poor concentration may prevent a person from working effectively in an office.

   METHODS OF ASSESSMENT.
   Whilst taking the history, the interviewer should be alert for evidence of impaired attention and concentration. In the mental state examination, specific tests are given. It is usual to begin with the serial sevens test. The patient is asked to subtract seven from 100 and then to take seven from the remainder repeatedly until it is less than seven. The interviewer assesses whether the patient can concentrate on this task. If it seems that poor performance could be due to lack of skill in arithmetic, the patient should be asked to perform a simpler subtraction or to say the months of the year in  reverse order. If mistakes are made with these tests, he can be given the less demanding task of naming the days of the week in reverse order. Tests of attention are given before tests of memory because poor attention can lead to poor performance in memory tasks, even when there is no memory defect.

  Disorders of thinking
   THINKING is a complex mental process of forming a new representation by transforming available information. Thinking can also be determined as the abstract, generalized learning about the phenomena of reality. Using the reflection theory we can say, that if perception is the process of direct reflection of real objects, thinking is the reflection of relationships between objects, their interactions, natural regularities, etc.
   The information processing involves the interaction of several mental attributes, such as generalizing, abstracting, inferring, reasoning, imagining, judging, problem solving, and, at times, creativity. Thinking has three general features: it occurs in the mind but is inferred from the observable behavior, it is a process that manipulates knowledge in a person's cognitive system, and it is directed towards finding solutions to problems facing the individual (Mayer, 1983).   
   The process of cognition begins with sensation and perception, then goes on to more complicated cognitive acts, such as notion, concept, judgement, deduction. The processes of perception and thinking are closely related to each other. 
   A NOTION is a mental representation of a concrete object or phenomena - an item (this man; this car; this table etc.). It is the first, most simple stage of thinking. 
   CONCEPTS are categories we form, which are mental representations of kinds of related items that are grouped in some way. Concepts are the building blocks of thinking. They enable us to organize knowledge in systematic ways. Concepts may represent objects, activities, or living organisms. They also can represent properties, such as "red", "large", abstractions, such as "truth" or "love", and relations, such as "smarter than", which tells us about the difference between two organisms, but does not tell us about either of the organisms being compared. Concepts in accordance with the item they represent can be concrete (a boy, a tree), generalized (fruit, animals, transport) and abstract (responsibility, relativity). Both a notion and a concept (in this understanding) can usually be expressed by a word or a word combination (musical instruments, domestic animals). Concept formation - identifying the stimuli properties that are common to a class of objects or ideas - is the basic task of thinking. The mind lives by 
   The THINKING PROCESS consist of the following OPERATIONS: analysis, synthesis, comparison, generalization, abstraction, and concretization.   ANALYSIS- is the process of dividing the perceived information into component parts. An object or phenomenon in a person's mind is divided into separate parts with the purpose if learning its properties. For example, a doctor investigates the indices of a blood test: the number of erythrocytes, leukocytes, content of different substances, etc., understanding the meaning of these data for his patient's health.
   SYNTHESIS - is the process of joining separate parts (components) of an object or phenomena together, into the whole.
   The processes of analysis and synthesis are inseparably linked to each other. 
   COMPARISON consists in assessing likeness and/or difference between objects and phenomena.
   GENERALIZATION appears in the process of gaining knowledge and as a result of comparison, when from knowledge about separate details a person goes on to find the principal, general features that can be characteristic of a certain object, phenomenon or situation. As a child grows this property of thinking develops and as time passes begins to ground on the processes of analysis and synthesis.
   ABSTRACTION - is a thinking operation in which an individual, having singled out some certain properties of an object, abstracts (digresses) from its other properties.
   CONCRETIZATION helps to associate theory and practice, to have a deeper understanding of some concepts, using an example of a real object or phenomenon. The need for concretization usually appears in the teaching process.
   REASONING    
   Our thoughts range between two extremes: the autistic and realistic. AUTISTIC THINKING is a personal, idiosyncratic process, involving fantasy, daydreaming, unconscious reactions, and ideas that are not testable by external reality criteria. We can even say that autistic thinking is thinking isolated from reality. This type of 
individualized thought is part of most creative acts. However, when it generates delusions and hallucinations, it can be evidence that the individual has lost touch with reality and is suffering from some type of mental illness. REALISTIC THINKING, by contrast, requires that ideas be fit into the reality of situational demands, time constraints, operational rules, and personal resources. Thinking realistically involves frequent checks on reality and tests that measure the appropriateness and correctness of one's ideas against some acceptable standard.
   REASONING is a process of realistic, goal-directed thinking in which conclusions are drawn from a set of facts. In reasoning information from the environment and stored information are used in accordance with a set of rules (either formal or informal) for transforming information. There are two types of reasoning: deductive and inductive.
   The term THOUGHT DISORDER denotes several kinds of abnormality. They can be classified in different ways. Out department of psychiatry prefers the classification, shown in Table 1. The first group contains disorders of the amount and speed of thought (the stream of thought).  The second group is disorders of the ways in which thoughts are linked together (the form, or structure of thought). The third group is disorders of content of thought: delusional thinking, overvalued ideas and obsessional thinking.

   Table 5.               THOUGHT DISORDERS

1. Disorders of the stream of thought

a. Excitation (acceleration) of thought    Flight of ideas
                                          		    Pressure of thought

b. Retardation (slowing down) of thought  	Poverty of thought
                                          			Thought blocking
                                          			Perseveration and stereotypy
                                          			Pathological thoroughness

2. Disorders of the form (structure) of thought
      a. Paralogic thought        
      b. Symbolic thought         
      c. Autistic thought         
      d. Loosening of associations
      e. Incoherence of thought   
3. Disorders of content of thought 
      a. Delusional thinking  
      b. Overvalued ideas     
      c. Obsessional thinking 
   In disorders of the STREAM OF THOUGHT both the amount and the speed of thoughts are changed. The term pressure of thought denotes thoughts that are unusually rapid, abundant, and varied. The term poverty of thought denotes the opposite, i.e. thoughts that are unusually slow, few, and unvaried. Pressure of thought occurs in mania, and poverty of thought in severe depressive disorder.  Either can occur in schizophrenia.
    In flight of ideas, thoughts and conversations move quickly from one topic to another, so that one train of thought is not completed before the next is taken up. Because the topics change so rapidly the links between one topic and another may be difficult to follow, but none the less linkage is through normal processes of thinking. (This linkage can be detected most easily by tape recording a sample of speech and listening to it repeatedly.) These normal linkages are of several kinds: ordinary logical associations between two ideas; rhyming, for example following a phrase containing the word chair with another containing the word pear (this sequence is sometimes called clang association); punning, that is using a sound that has more than one meaning, for example male/mail. In addition, a new train of thought may be set off by a distracting cue in the environment. Flight of ideas is characteristic of the syndrome mania.
   Healthy people sometimes have the experience of losing the train of thought ("the mind going blank"). A similar but more extreme experience, thought blocking, occurs when the mind seems to be suddenly empty of thoughts.
   Thought blocking should not be confused with sudden distraction, or the intrusion of a different line of thinking.  It should be recorded only when the patient describes the characteristic experience of an abrupt and complete emptying of the mind.  It occurs particularly in schizophrenic patients, who may interpret the experience in an odd way, saying that their thoughts have been removed by another person (thought withdrawal).
   Perseveration or stereotypy is the persistent and inappropriate repetition of the same sequence of thought, as shown by repetition of speech or actions. It can be demonstrated by asking a series of questions: the patient gives the correct answer to the first question, but continues to give the same answer inappropriately to subsequent questions that require a different answer. Perseveration occurs most often in the syndrome of dementia but is not confined to it. Pathological thoroughness means that a patient can not distinguish main ideas from minor ones. As a result, he is incapable of telling things shortly and precisely, his stories become too long and thorough. This happens in organic brain damage.

   DISORDERS OF THE FORM (STRUCTURE) OF THOUGHT are disorders of the ways in which thoughts are linked together. Each is related to a particular syndrome, but not so strongly that a confident diagnosis of the syndrome can be made when the particular thought disorder is present.
   Loosening of associations is a lack of logical connection between the parts of a train of thought, which is not explicable by the processes described under flight of ideas. This lack of logical association is sometimes called knight's move thinking (referring to the indirect move of the knight in chess). Usually the interviewer is alerted to the presence of loosening of associations because the patient's conversation seems muddled and hard to follow. This muddled thinking differs from that due to anxiety or low intelligence.  Anxious people become more coherent when put at ease, and those of low intelligence do so when questions are simplified. When there is loosening of associations, the links between ideas cannot be made more understandable in either of these ways. Instead the interviewer has the experience that the more he tries to clarify the patient's thinking, the less he understands it. The phenomenon is difficult to detect reliably. Loosening of associations occurs most often in schizophrenia. 
   Paralogical thinking means perverted logic or reasoning. The conclusions a patient makes are based on minor details (for instance, not on the meaning of words, but on their rhyming, or sounding alike), and as a result, sound senseless: "I am Lenin, because there are three common letters in the word "Lenin" and in my mother's name Nina. Besides, both Lenin and I were born in the months beginning with letter A, only he was born in April, and I - in August."
   A symbol is an object that stands for or represents something else. Symbolism is the act of representing an object or idea by a substitute object, sign, or signal. Sane people often use symbols, in fact even words are symbols of ideas. Symbolic thinking becomes pathological, when a patient begins to ground his ideas and actions not on reality, but on symbols. For example, a patient explains his failure to return to the department after he went home for the weekend as follows: "I promised my doctor to come back Monday morning, but when I was walking out of the hospital, I stepped on some soft cement, and the worker who was cementing the floor smoothed my foot mark over. So I thought that his action meant that I must not come back."
   Autistic thinking, like symbolic, becomes abnormal only if a person can not find any difference between his/her fantasies and the reality, his ideas fail to fit into a real situation. In this case autistic thinking can lead to delusions. Paralogic, symbolic, and autistic thinking are common for schizophrenia 
   Incoherence is total disorganization of thought, when there are no connections at all between parts of the train of thought. The speech becomes disconnected and unintelligible. This thought disorder is characteristic of some disorders of consciousness.

   DISORDERS OF CONTENT OF THOUGHT
   DELUSIONS
   A delusion is a belief that is held firmly but on inadequate grounds, is not affected by rational argument or evidence to the contrary, and is not a conventional belief that the person might be expected to hold given his cultural background and level of education. This rather lengthy definition is required to distinguish delusions, which are indicators of mental disorder, from other kinds of strongly held belief found among healthy people. A delusion is usually, but not always, a false belief (see below).
   The statement that a delusion is held on inadequate grounds means that it is not arrived at through normal processes of thinking. Autistic, paralogic, and symbolic thought processes are at the base of most delusions. A delusion is held so strongly that it is not altered by evidence to the contrary that would convince other people.  For example, a patient who holds the delusion that persecutors are in the next room will not alter his belief when shown that the room is empty; instead he may suggest that the persecutors left in some improbable way before the room was opened. The strength of a belief is not enough to define it as a delusion because some normal people have non-delusional beliefs that are impervious to evidence that would convince most other people.  For example, a person who has been brought up to believe in spiritualism is unlikely to change his conviction when presented with contrary evidence that a nonbeliever would find convincing; but this strongly held conviction is not a delusion.
   Although delusions are almost always false beliefs, occasionally they are true or subsequently become true.  For example, a man may develop the delusional belief that his wife is unfaithful when there is no evidence of infidelity of any kind and no other rational reason for holding the belief. Such a belief has been arrived at in an abnormal way, even if the wife is in fact unfaithful. The important point is that a belief is delusional not because it is false but because it was derived in an abnormal way. Although the point is of theoretical importance, in practice it seldom gives rise to difficulties.                              
   Although delusional beliefs are usually odd, it is a mistake to assume that a belief is delusional simply because of its oddness.  Some people express strange beliefs (for example, attempted poisoning by a relative), which are eventually confirmed by facts.  Therefore such beliefs should be investigated to determine whether they could be factually correct.
   Some delusions occur as sudden and total convictions.  Others develop more gradually, starting from a belief that is not held with complete conviction. Similarly, delusions may weaken gradually as the amount of conviction decreases. Such less firm beliefs are called partial delusions - a term that should be used only when the belief is known to have been preceded by full delusional conviction, or applied with hindsight to a belief that developed later into a full delusion (but could not have been known to be a partial delusion at the time).
   Although a patient may be convinced totally that his delusional belief is true, this conviction does not necessarily influence all his feelings and actions. This separation of belief from feeling and action occurs most frequently in chronic schizophrenia: for example, a patient may have the false fixed belief that he is a member of the Royal Family and yet live contentedly in a hostel for discharged psychiatric patients.

 Primary and secondary delusions
  A primary delusion occurs suddenly and with complete conviction, and without any identifiable mental event leading up to it. For example, a patient may suddenly develop the unshakable conviction that he is changing sex, without ever having thought so before and without any event that could have prompted the idea. In practice it is often difficult to decide whether or not a delusion is primary because 
patients do not find it easy to recall and explain the exact sequence of their abnormal experiences. Primary delusions are rare, and may be too readily diagnosed by inexperienced interviewers. It is important to avoid this error, because primary delusions are important evidence for schizophrenia.
   A secondary delusion arises from a preceding abnormal experience.  This experience may be of various kinds such as a hallucination (for example, a person hears a voice and believes he is being followed), a mood (for example, a person with deep depression believes that other people think he is worthless), or another delusion (e.g. a person with the delusion that he has no money believes that he will be imprisoned for unpaid debt). Some secondary delusions have an integrative function, making more sense of the original abnormal experience (as in the first example). Others increase the patient's distress (as in the other examples). In this way some patients develop a series of secondary delusions related to one another ("systemized delusions" which form a delusional system).
  Three other terms are sometimes used to describe special ways in which delusions begin. The first is used when a delusion is preceded by a change in mood. The patient feels threatened without knowing why, searches for an explanation, and then becomes convinced, for example, that he is being followed. This phenomenon is called DELUSIONAL MOOD (it is really the mood preceding a delusion). The second term is used when a delusion begins as a sudden misinterpretation of the significance of something perceived. For example, a patient may suddenly believe that the arrangement of objects on a table indicates that his life is threatened. This phenomenon is sometimes called DELUSIONAL PERCEPTION (but it is really a delusional misinterpretation of a normal percept). The third term is applied when a delusion occurs as a reevaluation of past events, usually in someone who is already deluded. For example, a patient may hold the delusion that others are trying to poison him; he may then develop the belief that poison was put in his food on a previous occasion when he felt ill, even though he did not hold this belief at the time. Such an experience is called a DELUSIONAL MEMORY. (In fact the memory is normal; it is the new interpretation of the remembered event that is abnormal.)
   SHARED DELUSIONS.
   As a rule, other people recognize delusional beliefs as false and they argue with the deluded person in an attempt to correct him.  Occasionally a person who lives with a deluded patient comes to share the delusional beliefs. The newly deluded person is then said to have shared delusions or folie a deux. The affected person's conviction is   often unshakeable as long as he remains with the patient, but usually 
weakens quickly when the two are separated.
   DELUSIONAL THEMES.
   Delusions are usually grouped according to their main themes. Since there is some correspondence between delusional theme and type of disorder, which is helpful in diagnosis, the main themes will be described briefly and related to the disorders in which they occur most often. The associations are described more fully in the chapters on these disorders.

   Table 6.         DELUSIONAL THEMES

 1  Persecutory delusions are often called paranoid delusions.     (Strictly speaking, the word paranoid refers to all kinds of false     belief about relationships between people, so that grandiose,  jealous, and amorous delusions can also be called paranoid.) Most persecutory delusions are concerned with people or organizations     that are believed by the patient to be trying to inflict harm on     him, damage his reputation, or make him insane. In assessing such     ideas it is important to remember that in some cultures it is normal to ascribe misfortunes to the malign activities of other people who are believed to practice witchcraft, and such ideas are not delusions. Persecutory delusions are common in schizophrenia,     and also occur in organic states and severe depressive disorders.  A patient with a depressive disorder characteristically accepts that the supposed actions of his persecutors are justified by his own wickedness; in schizophrenia he characteristically resents them.
 2  Delusions of reference are concerned with the idea that objects, events, or the actions of people have a special significance for the patient. For example, a remark heard on television is believed to be directed specifically to the patient, or a gesture by a stranger is believed to convey something about the patient. Delusions of this kind are associated with schizophrenia.
 3  Grandiose and expansive delusions are beliefs of exaggerated self-importance. The patient may think himself wealthy, endowed     with unusual abilities, or in other ways special. Such ideas occur mainly in mania and sometimes in schizophrenia.
 4  Delusions of guilt and worthlessness are beliefs that the person has done something shameful or sinful.  Usually the belief concerns an innocent error that did not cause guilt at the time; for example, a patient may be convinced that a small error in an income tax return will be discovered and lead to prosecution.  This kind of delusion occurs most often in severe depressive disorders.
 5  Nihilistic delusions are, strictly speaking, beliefs about the nonexistence of some person or thing, but the meaning is extended to include beliefs that the patient's career is finished, that he is about to die or has no money, or that the world is doomed.  
    Nihilistic delusions occur most often in severe depressive disorders.
 6  Hypochondriacal delusions are false beliefs about illness. The patient believes, in the face of convincing medical evidence to the contrary, that he is ill. Such delusions are more common among the elderly, reflecting the increasing concerns about health in later life. Related delusions are concerned with the appearance of parts of the body, for example the belief that the (normally     shaped) nose is seriously misshapen (dysmorphomania). Patients with these delusions about their appearance may seek the help of plastic surgeons. Delusions of these kinds occur in depressive disorders and schizophrenia.
 7  Delusions of jealousy are more common among men. They may lead to     dangerously aggressive behaviour towards the person who is believed to be unfaithful.
 8  Sexual or amorous delusions are more frequent among women. Usually the woman believes that she is loved by a man who has never spoken to her and who is inaccessible, for example an eminent public figure.
 9  Delusions of control are beliefs that personal actions, impulses, or thoughts are controlled by an outside agency. This experience has to be distinguished from two others: first, hearing hallucinatory voices giving commands which are obeyed voluntarily; second, holding culturally normal beliefs concerning the divine     control of human actions.  Delusions of control strongly suggest schizophrenia.
10  Religious delusions may be guilty (concerned, for example, with divine punishment for minor sins) or expansive (concerned with special powers). It is important to determine whether the belief is a true delusion or is widely held by members of a religious group and therefore not a delusion.
11  Delusions concerning the possession of thoughts. Healthy people have no doubt that their thoughts are their own and can be known to other people only if spoken aloud or revealed through behaviour.  Some patients hold abnormal beliefs concerning the possession of thoughts: (a) some of their thoughts are not their own but have been implanted by an outside agency - the delusion of thought insertion; (b) some of their thoughts have been taken away – the delusion of thought withdrawal; (c) their thoughts are known to other people through telepathy, through radio, or in some other unusual way the delusion of thought broadcasting. There may be an additional abnormal experience that allows such unusual ideas to     develop. All three symptoms are found most frequently in schizophrenia.

   SYNDROMES OF DELUSIONS
   As you should already know, a group of concurrent symptoms that together are indicative of a disease are called a syndrome. We can single out several delusional syndromes, proceeding from the quality, themes, structure and other characteristics of delusions, as well as their combinations with other symptoms.
 
   Table 7.               DELUSIONAL SYNDROMES

1. Paranoia (paranoiac syndrome)
2. Paranoid syndrome
3. Paraphrenia (paraphrenic syndrome)
4. Hypochondriacal syndrome
5. Mental automatism syndrome (Clerambault-Kandinsky syndrome)
      a. Associative automatism
      b. Perception automatism
      c. Kinesthetic automatism
6. Cotard's syndrome.

   Paranoia (paranoiac syndrome) involves insidious development of a fixed delusional system of at least six months duration with preservation of clear and orderly thinking. Delusions in this syndrome are systematized, verisimilar (the events described by the patients can possibly happen); sometimes delusions seam so logical, that they appear to be an extension of premorbid personality. They are not combined with hallucinations. Sometimes this syndrome develops on the base of overvalued ideas. The content of the ideas is usually delusions of jealousy, invention, dysmorphomania, amorous or litigious (querulous) delusions. As a rule it is very stable and lasts for years.
   Paranoid syndrome includes both delusions and hallucinations. Delusions are not systematized or partly systematized, among them delusions of persecution prevail, but other themes also occur. This syndrome is the most common of all the delusional syndromes.
   Paraphrenia (paraphrenic syndrome) means a psychotic disorder characterized by fantastic, absurd, paralogical systematized delusions. In most cases grandiose and expansive delusions prevail, but other themes occur too. Patients do not try to explain or prove their ideas to others, they just state them in a ridiculous way. A patient can say, that he is immortal, has two hearts, is the lord of the Universe, etc... Delusions are usually combined with hallucinations, pseudohallucinations, and sometimes with structural disorders of thinking (paralogic or symbolic thinking, looseness of ideas).
   Hypochondriacal syndrome (see above hypochondriacal delusions). In this syndrome delusions can be combined with disorders of perception, in particular senesthopathias (abnormal unpleasant sensations in different parts of body or internal organs), that increase the manifestations of the syndrome.                   
   Clerambault-Kandinsky (mental automatisms) syndrome is a psychotic syndrome in which the patient feels that his mind is controlled by another person or an outside power (see above delusions concerning the possession of thoughts, delusions of control). There can be tree kinds of mental automatism: associative automatism (possession of thought and speech), perception automatism (the patient thinks that some other person or outside power creates different sensations in his body), and kinesthetic (movement) automatism (a patient feels that somebody else moves his limbs and body).                      
   Cotard's syndrome (Jules Cotard, French neurologist, 1840-87). A psychotic state characterized by anxious depression, suicidal tendencies, and ideas of negation delusions (see nihilistic delusions). A patient can think that he is dead already, and moves only because artificial electric current makes his body move.

   OVERVALUED IDEAS
   The term "overvalued idea" is used to denote an isolated, preoccupying and strongly held belief which dominates a person's life and may affect his actions but (unlike a delusion) has been derived through normal mental processes. For example, a person whose parents developed cancer within a short time may be convinced that cancer is contagious even though his doctor has presented evidence to the contrary, and may avoid visiting a friend with cancer who has asked to see him. The distinction between overvalued ideas and delusions may be difficult to make, since the two kinds of idea can be equally strongly held and the differentiation depends on a retrospective judgement by the interviewer about the way in which the idea was formed. In practice, this difficulty seldom causes problems since diagnoses are not made on a single symptom, but on the pattern of several symptoms. 
   When there is doubt about whether a particular idea is a delusion, there are usually other ideas that are clearly delusional or symptoms of a different kind from which the diagnosis can be made. Overvalued ideas are most common for certain types of personality disorders.

   OBSESSIONAL AND COMPULSIVE SYMPTOMS.
   Obsessions are recurrent and persistent thoughts, impulses, or images that enter the mind despite efforts to exclude them. The characteristic feature is the subjective sense of a struggle (resistance) against the intruding mental phenomena. The person has no doubt that the intruding thoughts are produced in his own mind rather than implanted from elsewhere (a point of contrast with delusions of the possession of thoughts described above). Usually obsessions are about matters which the person finds distressing or unpleasant. The person recognizes that the ideas are senseless and usually feels ashamed to tell other people about them.
   Resistance is an important feature because it distinguishes obsessions (in which resistance is present) from delusions (in which it is absent). When obsessions have been present for a long time, resistance may decrease so that this distinction becomes difficult to make. In practice this difficulty seldom causes diagnostic problems because by the time that resistance has diminished the diagnosis has usually been made.
   Obsessions have to be distinguished from the following:
I   the ordinary preoccupations of healthy people;
2   the intrusive concerns of anxious or depressed patients;
3   the recurring thoughts and images associated with sexual deviancy;
4   the recurring thoughts and images associated with drug dependency;
5   delusions.
  Patients with these non-obsessional ideas do not regard them as unreasonable and do not resist them. Obsessional symptoms are essential features of obsessional neurosis, and sometimes occur in many kinds of psychiatric disorder, particularly anxiety and depressive disorders.
   TYPES OF OBSESSIONAL SYMPTOMS
   Obsessions can occur in several forms (Table 3). Obsessional thoughts are repeated intrusive words or phrases, such as obscenities or blasphemies, or thoughts about distressing occurrences, for example that the hands have become contaminated with bacteria which will spread disease. Obsessional ruminations are more complicated sequences of thoughts, for example about the ending of the world. Obsessional doubts are uncertainties about a previous action, for example whether or not the person has switched off an electrical appliance that might catch fire. Obsessional impulses are urges to carry out actions, which are usually aggressive, dangerous, or socially embarrassing; for example, using a knife to stab someone, jumping in front of a moving train, or shouting obscenities in church. Whatever the urge, the person recognizes that it is irrational and does not wish to carry it out. This is an important point of distinction from delusions, which are regarded as rational by the patient and which may lead to action, such as aggression against a supposed persecutor.
  Obsessional phobia is the term sometimes applied to obsessional thoughts with a fearful content, for example 'I may have cancer', or to obsessional impulses that arouse anxiety, for example the urge to stab another person.                                                                                      
           
Table 8. OBSESSIONAL AND COMPULSIVE SYMPTOMS
    OBSESSIONS
        Thoughts
        Ruminations
        Doubts
        Impulses
        Phobias
   COMPULSIONS (rituals)
        Checking
        Cleaning
        Counting
        Dressing

   THE CONTENT OF OBSESSIONAL THOUGHTS 
   Obsessional thoughts can be about any topic but most are centred around six themes.
   The six themes are as follows:
     COMMON THEMES OF OBSESSIONAL THOUGHTS:
 I   Dirt and contamination, for example the idea that the hands are      contaminated with bacteria;
 2   Aggressive actions, for example the idea that the person may harm another person or shout angry remarks;
 3   Orderliness, for example the idea that objects have to be arranged in a special way or clothes put on in a particular order;
 4   Illness,  for example the idea that the person may have cancer (ideas of contamination may also refer to illness, for example, that a disease may result from the feared bacterial contamination);
 5   Sex, usually thoughts or images of practices that the person finds      disgusting;    
 6   Religion, for example blasphemous thoughts, or doubts about the      fundamentals of belief (for example "does God exist?") or about the adequacy or completeness of a religious ritual such as confession.

   COMPULSIONS
   Although compulsions are not thoughts but abnormal actions, it is convenient to describe them here. Compulsions are repeated, stereotyped, and seemingly purposeful actions which the person feels compelled to carry out but resists, recognizing that they are irrational. (Compulsions are also known as  rituals.) Most 
compulsions are associated with obsessions. In some compulsive cases the association seems understandable, as when hand-washing is associated with ideas that the hands are contaminated. In other cases there is no obvious connection between the actions and the thoughts, as when checking the position of objects is associated with aggressive ideas. Most compulsions produce an immediate reduction of the distress associated with obsessional thoughts (for example hand-washing) although their long-term effect is to prolong them. Compulsions may be accompanied by doubting thoughts that the behaviour has not been executed correctly, leading to further repetitions.  In this way, the behaviour may be prolonged for hours.

   THE CONTENT OF COMPULSIONS
    Compulsions can be of any kind but there are four common themes: 
1.  checking rituals, which are often concerned with safety, for     example checking repeatedly that a gas tap has been turned off;
2   cleaning rituals  such as repeated hand-washing or domestic     cleaning;
3   counting rituals such as counting to a particular number or counting in threes;
4   dressing rituals in which the clothes are set out or put on in a particular way.

    METHODS OF INVESTIGATION
   Preoccupations are themes that recur frequently in thinking but can be put out of mind by an effort of will. Preoccupations are often noticed during history taking; during mental state examination it is appropriate to find out if there are other preoccupations by asking "What sort of things do you worry about?", "What sort of thoughts occupy your mind?". The knowledge of the patient's preoccupations is always important, but particularly so in three conditions: depressive disorders, where preoccupations about suicide should be explored particularly carefully, anxiety disorders, where preoccupations may prolong the disorder, and sexual disorders.
   Obsessional phenomena involve both thinking and behaviour, and it is convenient to consider both at this point. To elicit obsessional thoughts an appropriate question is "Do any thoughts keep coming repeatedly into your mind, even when you try hard to get rid of them?".  
If the patient says "yes", he should be asked for an example. Patients are often ashamed of the content of obsessional thoughts (particularly those with aggressive or sexual themes) and so questioning needs to be patient and sympathetic. The interviewer should make certain that the patient regards the thoughts as his own, because some schizophrenic patients have similar intrusive thoughts which they believe have been implanted from outside ("thought insertion").
   Compulsive rituals may be observed during the mental state examination, although more often they are revealed during history- taking. Although not disorders of thinking, they are conveniently recorded under obsessional phenomena. The following questions can usefully be asked: "Do you ever have to repeat actions over and over which most people would do only once?" or "Do you have to go on repeating the same action when you know this is unnecessary?".
   Delusions are often revealed during history-taking from either the patient or an informant. Delusions may be difficult to elicit because the patient does not regard them as abnormal, and because he may be suspicious or afraid. A good way of starting the enquiry is to ask for an explanation of any unusual statements, unpleasant experiences, or unusual events that the patient has mentioned. For example, a patient may say that his headaches started when his neighbors caused him trouble; when asked why the neighbors should do this, he may say that there is a conspiracy to harm him. Patients may hide delusions, and the interviewer should be alert to evasions, vague replies, or other hints that information is being withheld.
    Having discovered an unusual belief, the interviewer has to decide first whether it is false, second how strongly it is held despite evidence to the contrary, and third whether it is culturally determined. It is important to consider carefully whether the belief could be true. Some beliefs are clearly false, for example that persecutors are damaging the patient's brain by beaming radio-waves on him. Other beliefs need to be checked - for example, that neighbors are mounting a campaign against the patient.
   Tact is required when finding out how strongly the beliefs are held. The patient should feel that he is having a fair hearing, and the interviewer's response is enquiring and not argumentative. The interviewer can say that, in order to help the patient, he needs to know how the problem has been caused; he can then challenge, gently but persistently, the patient's reasons for the belief. At the same time the interviewer has to judge whether the beliefs could be culturally determined ideas, that is ideas accepted by others sharing the patient's culture. Such ideas may be shared by members of an unusual religious sect, or by societies in which ideas about evil forces or witchcraft are widespread. Any doubt can usually be resolved by finding another person from the same religion or country, and by asking whether the patient's ideas would be shared by people from the same background.
    Direct questions may be needed to elicit several kinds of delusion that occur in schizophrenia, namely delusions of thought broadcasting, thought insertion, thought withdrawal, or control. If there are reasons for suspecting schizophrenia, the interviewer can ask questions such as "Do you ever think that other people can tell what you are thinking, even though you have not told them?" or "Do you ever think that thoughts have been put into your mind?". If the answer is "yes", a detailed example should be obtained to make sure that the patient has not answered positively for the wrong reason. For example, he may have answered the first question positively simply because he thinks that it refers to a general tendency for facial expression to reveal what a person is thinking.
    Since questions about such delusions may antagonize a patient with a minor psychiatric problem, they should be reserved for cases in which schizophrenia enters the differential diagnosis.

 INSIGHT 
   As a technical term insight means a correct awareness of one's own mental condition. Insight is not simply present or absent, but a matter of degree. It is described best in terms of four criteria: 
1.  awareness of oneself as presenting phenomena that other people 
    consider abnormal (for example being unusually active and elated);
2.   recognition that these phenomena are abnormal;
3.   acceptance that these abnormal phenomena are caused by one's own 
    mental illness (rather than, for example, poison administered by a 
    persecutor);
4.   awareness that treatment is required.
   In theory, insight is lost in psychosis and retained in neurosis, but this distinction is not invariable and does not provide a reliable way of distinguishing the two conditions.  For this reason, assessment of insight is of little help in diagnosis.  However, it is extremely important in determining the likelihood of a patient's cooperation with treatment: for example, a patient who believes that he is being persecuted may not accept that his beliefs are a sign of illness, and may not be willing to accept treatment.  None the less he may be aware that he is distressed and sleeping badly, and agree to accept help with these problems (which he ascribes to the persecution).

ASSESSMENT:
     By the end of the history-taking and mental state examination, the interviewer should have a provisional estimate of the patient's awareness of the morbid nature of his experiences.  Direct questions should then be asked to assess this awareness further.  First, questions are asked about the patient's awareness of the nature of individual symptoms; for example whether or not he believes that extreme feelings of guilt are justified.  Second, the interviewer finds out whether the patient believes himself to be ill (rather than, say, persecuted by his enemies); if so, whether he thinks that the illness is physical or mental, and whether he sees himself as needing 
treatment.  The answers are important because they suggest how far the patient is likely to collaborate with treatment. The answers to all questions should be noted.  It is of little value to record merely 'partial insight' or 'no insight'.

   INTELLIGENCE is the global capacity to profit from experience and to go beyond given information about the environment. It is the capacity for understanding, recalling, mobilizing, and integrating constructively what one has learned  and for using it to meet new situations. The most widely accepted definition of intelligence is: the capacity to solve new problems by means of reasoning. It involves an understanding of the relevant issues in new tasks and thinking of successful or satisfactory solutions to the tasks. The emphasis on novelty of the tasks serves the purpose of differentiating from memory feats, although memory has a role in reasoning. Tests of intelligence stress reasoning, not concrete performances, because manual performances are easily influenced by transient emotional stress and by training.
   Intelligence is not a single mental function, as is, for example, perception or memory. To solve new problems a person needs to get information, store (remember), and process it. So all the mental functions that we discussed so far at our sessions (perception, attention, memory, and thinking) can be considered component parts of intelligence, as well as language, knowledge and experience.

   INTELLECTUAL LEVEL. The intellectual level, determined by a reliable examination with a sound test after the fourth year of life, is one of the most lasting and most important human traits. Individuals with adequate intelligence may not achieve what they are capable of for a variety of reasons; but no matter how hard a person with insufficient intelligence tries he cannot achieve what is beyond his capacity.

 Table 9.        KINDS OF INTELLIGENCE DISORDERS

1. Mental retardation - innate intelligence deficiency
2. Dementia -           acquired intelligence deficiency

    Classification of dementia

According to extent         total, global
                           		partial

According to the course     progredient
                           		   stable
                            		   regredient

According to the mechanism  	organic
of development              		pseudo-dementia

According to clinical       schizophrenic
features                    	organic
                               a) epileptic
                               b) paralytic
                               c) vascular
                               d) traumatic
                               e) old-age

   MENTAL RETARDATION. 
	In ICD 10 and DSM IV the term mental retardation denotes intellectual impairment starting early in life (as distinct from dementia, which is intellectual impairment developing later in life).  
Other terms of this condition include mental deficiency, mental subnormality, mental handicap, and, most recently, learning difficulties. Although the central feature is intellectual impairment, the definition of mental retardation should include social criteria for the practical purpose of distinguishing between people who can and those who cannot lead a near-normal life.  Thus in DSM the definition of mental retardation includes not only intellectual impairment but also the phrase "with concurrent deficits and impairments in adaptive behaviour, taking into account the person's age".  Subgroups of mental retardation are recognized according to the degree of impairment: mild (IQ 50-70), moderate (IQ 35-49), severe (IQ 24-34), and profound (IQ below 20).
   Epidemiology
   Among the population aged 15-19, the prevalence of moderate and severe mental retardation is about 3.0 to 4.0 per thousand.  This prevalence has changed little since the 1930-s, even though the incidence of severe retardation has fallen by a third to a half as a result of improved ante-natal and neonatal care and other factors.  
   Clinical features of mental retardation
   In all forms of mental retardation the characteristic feature is low performance of all kinds of intellectual functioning including learning, short-term memory, the use of concepts, and problem-solving.  Sometimes one specific function is impaired more than the rest, for example the use of language. Mentally retarded children may show any of the common behavioral problems of childhood. These problems tend to occur later and to last longer than in a child of normal intelligence, but they usually improve slowly with increasing age.
   Mild mental retardation (IQ 50-70)
   About four-fifths of mentally retarded people are in this group.  They are usually normal in appearance and have only slight sensory or motor deficits, if any. They usually develop near-normal language abilities and social behaviour during the preschool years; hence in the mildest cases the mental retardation may not be identified until the child starts school. Most adults with mild retardation can live independently, though some need help with housing and employment.  Some need help when experiencing stressful events. The level of their abstract thinking is low.
   Moderate retardation (IQ 35-49)
   About 12 per cent of the mentally retarded are in this group.  Most have enough language development to communicate, and most can learn to care for themselves with supervision.  As adults they can usually find their way about and undertake simple routine work.
   Severe retardation (IQ 20-34)
   About 7 per cent of the mentally retarded have severe retardation. In the preschool years their development is greatly slowed, and at school their learning is delayed.  Eventually many can be trained to care for themselves under supervision and to communicate in a simple way.  As adults most can undertake simple tasks and engaged in limited social activities. Many have associated physical disorders. A few have a highly specific cognitive ability of a kind normally associated with superior intelligence (such as the ability to carry out feats of mental arithmetic or memory). Such people are called idiots savants.
   Profound retardation (IQ below 20)
   Less than 1 per cent of the mentally retarded are in this group.  Few learn to care for themselves completely, and a few eventually achieve some simple speech and social behaviour.  Physical disorders are very frequent.
    Physical disorders among the mentally retarded
   Among the severely and profoundly retarded, most have physical problems such as sensory or motor disabilities, or epilepsy.  Only one third is continent and ambulant; a quarter are highly dependent on other people. Disorders of hearing or vision are an important additional obstacle.  Motor disabilities are frequent and include spasticity, ataxia, and athetosis.  They also frequently have congenital heart and other inner organs and systems developmental abnormalities.
   Psychiatric disorder among the mentally retarded
   All kinds of psychiatric disorder can occur in the mentally retarded. Diagnosis is often difficult because symptoms may be modified by low intelligence, and because patients need a minimum verbal fluency to describe their experiences. 
    Schizophrenia. In the mentally retarded, delusions are less elaborate than in schizophrenics of normal intelligence, and hallucinations have a simple and repetitive content. For these reasons "first-rank" and other typical symptoms of schizophrenia are rarely present, and diagnosis is difficult.  Often the main features are further impoverishment of the person's already limited thinking, and increased disturbance of behaviour and social functioning.  When the IQ is below 45, it is difficult to make a definite diagnosis of schizophrenia.  
   Affective disorders. Mentally retarded people with a depressive disorder are less likely than those of normal intelligence to complain of low mood or to express depressive ideas. Diagnosis has to be made mainly on an appearance of sadness, reduction of appetite, disturbance of sleep, and behavioral changes of retardation or agitation. 
   Adjustment disorders and neuroses are common among the less severely retarded, particularly those who are facing changes in the routine of their lives. Conversion and dissociative symptoms are more conspicuous than in the neurotic disorders of people of normal intelligence.  Treatment is directed at reducing stressers by effecting improvements in the patient's environment; if verbal skills are sufficient, counselling is used as well.
   Personality disorders are common among the mentally retarded, and sometimes lead to greater problems in management than those caused by intellectual retardation. There is no specific treatment.  Management has to be directed at finding the environment best suited to the patient's temperament. If verbal skills are sufficient, counselling may be helpful.
   Overactivity and autistic behaviour. Hyperkinetic syndrome occurs more commonly among mentally retarded children than among those of normal intelligence. Also, many severely retarded children are overactive, distractible, and impulsive, but not to an extent that meets the diagnostic criteria for hyperkinetic syndrome. In severely retarded people, autistic behaviour (stereotyped or repetitive and apparently purposeless activities such as mannerisms, head banging, and rocking) occur in about 40 per cent of children and 20 per cent of adults. Repeated self-injurious behaviour is less frequent but may be more persistent. Other common disturbances are dependency, emotional lability and temper tantrums, and pica. When these problems are severe, admission to hospital may be required.
   Sexual problems. Masturbation in public is the most frequent sexual problem.  Some mentally retarded people show a childlike curiosity about other people's bodies which can be misunderstood as sexual. Concern is sometimes expressed that mentally retarded people may have sexual intercourse and produce mentally retarded children. In fact many kinds of severe retardation are not inherited, and of the heritable kinds most are associated with infertility.  A more important concern is that severely mentally retarded people are unlikely to function well as parents, even if their children are of average intelligence.  
  DEMENTIA, or acquired intelligence deficiency, is a generalized impairment of intellect, memory, and personality, without impairment of consciousness. It is an acquired disorder, as distinct from mental retardation in which impairments are present from birth. Although most cases of dementia are irreversible, a small but important group is remediable.
Clinical features
   Dementia usually presents with impairment of memory; other features include changes in behaviour, mood disorder, delusions, and hallucinations. Though dementia generally develops gradually, it may first come to notice after an acute deterioration caused by either a change in social circumstances or an intercurrent illness. There may also be uncharacteristic aggressive behaviour or sexual disinhibition.   
In a middle-aged or elderly person any uncharacteristic social lapse should always suggest dementia. Behaviour may be disorganized, restless, or inappropriate. Typically there is loss of initiative and reduction of interests. Some patients adopt rigid and stereotyped routines. Some become restless and wander by day and sometimes at night, thus keeping other people awake.  When patients are taxed beyond their restricted abilities, there may be a sudden change to tears or anger (a catastrophic reaction).  As dementia worsens, patients care for themselves less well and may become disinhibited, neglecting social conventions. Behaviour becomes aimless.  Eventually, the patient may become incontinent of urine and faeces. Disorders of cognitive function are salient features.  Forgetfulness usually appears early and is prominent; difficulty in new learning is generally a conspicuous sign. Memory loss is more obvious for recent than for remote events. Patients often make excuses to hide these memory defects, and some confabulate. In some cases there are specific deficits of aphasia, agnosia, or apraxia.  Attention and concentration are also impaired. Disorientation for time, and at a later stage for place and person, are almost invariable once dementia is well established (but in contrast with delirium are not usually prominent in the early stage).

     Table 10.     Clinical features of dementia

   Cognition
       Poor memory
       Impaired attention
       Aphasia, agnosia, apraxia
   Behaviour
       Odd and disorganized
       Restless, wandering
       Disinhibition
       Self-neglect
   Mood
       Anxiety
       Depression
       Irritability
   Thinking
       Slow, impoverished
       Delusions
   Perception
       Illusions
       Hallucinations
       Insight
       Impaired
   In severe cases, there may be disorientation and incontinence.

    In the early stages, changes of mood include anxiety, irritability, and depression.  As dementia progresses emotions and responses to events become generally blunted, though there may be sudden changes of mood without apparent cause.  Thinking slows and becomes impoverished in content.  There may be loss of abstract thinking, reduced flexibility, and perseveration. judgement is impaired.  False ideas, often of a persecutory kind, gain ground easily and may progress to delusions.  In. the later stages, thinking becomes grossly fragmented and incoherent. Disturbed thinking is reflected in the quality of speech, in which syntactical errors and nominal dysphasia are common. Eventually the patient may utter only meaningless noises or even become mute. Perceptual disturbances (illusions and hallucinations) may develop as the condition progresses. Insight is usually lacking into the degree and nature of the disorder.
     The clinical picture depends in part on the patient's premorbid personality; for example, neurotic and paranoid traits may become exaggerated.  Amongst people who are socially isolated or deaf, there is less ability to compensate for failing intellectual abilities.  In contrast, a person with good social skills may maintain a social facade despite severe intellectual deterioration.
Aetiology
   Dementia has many causes, of which the most important are listed in Table 5. Among elderly patients, degenerative disorders (notably Alzheimer's disease) and vascular causes predominate.  

   Table 11.   Some causes of dementia
   Degenarative
         Alzheimer's disease
         Pick's disease
         Huntington's chorea
         Parkinson's disease
     *Normal pressure hydrocephalus
     Creutzfeld-Jacobs disease
Intracranial space occlusion
     *Tumour
     *Chronic subdural haematoma
Traumatic
     Severe head injury
     Effects of repeated boxing
Infections
     Post-encephalitis
     *Syphilis
Vascular
     Multi-infarct dementia
     *Carotid artery stenosis
Toxic
     Alcohol
Anoxia
     Cardiac arrest
     CO poisoning
Vitamin lack
     *BI2
     *Folic acid
     *Thiamine 

Causes that may sometimes be arrested by treatment are indicated by asterisk.
Dementia will be discussed in more details at the lectures on specific mental disorders.

  METHODS OF ASSESSMENT
  During history-taking the interviewer should be alert to the possibility that the person is of low intelligence. If this seems possible and the impression is confirmed during mental state examination, a test of intelligence can be arranged. 
   Psychological testing may help to localize lesions in certain sites, notably the frontal and parietal lobes, but methods of imaging are usually more effective.  A commonly used test is the Wechsler Adult Intelligence Scale (WAIS), which is a well-standardized test providing a profile of verbal and nonverbal abilities.  It should be given by a trained tester.  Organic impairment is suggested by a discrepancy between performance IQ (as an estimate of current capacity) and verbal IQ (as an estimate of previous capacity).  Specific tests of memory, learning, and other aspects of cognitive function are sometimes used by specialists to assess patients with localized brain lesions.
   MOTOR SYMPTOMS AND SIGNS. DISTURBANCES OF VOLITION AND DRIVES. 
   A VOLITIONAL action is a kind of mental (of physical) activity, directed at achieving a consciously set aim, which often involves overcoming obstacles and in which the result of the action is presupposed. VOLITION (willpower) is a person's capability to self-determination and self-regulation of his/her activities and mental processes. 
   Volitional behavior, as well as other forms of behavior, is based primarily on different needs (both biological and psychological), but it also can be motivated by interests and values (ideals).
   A volitional action has a number of stages. At the first stage the person becomes aware of some certain need. A realized need is called a WISH (desire). Then the individual analyzes, whether it is possible and appropriate to fulfil this need. This stage is called the "motives struggle", because the person has to choose between different motives (for example, wanting to go and have a meal and need to attend a 
lecture). Eventually he makes a choice, comes to a certain DECISION and sets his GOAL. After that he has to make a PLAN of action. When the plan is ready, the person carries out the action. But this might not be the end. He has to assess the outcome of his activities and determine whether the goal was achieved. If not, he will have to repeat the procedure beginning with one of the stages. He may have to change his decision, revise the goal or work on the plan. The quality of willpower is obviously judged from the last stage of the volitional action - its fulfilment. 
   Thus, the scheme of a volitional action looks as follows:
 WISH---"MOTIVES STRUGGLE"---DECISION---GOAL SETTING---PLAN---ACTION
   A DRIVE is a motivation that is assumed to be primarily biological, such as hunger. Drives are also called instincts, but the first term is preferred in contemporary psychology. MOTIVE usually refers to psychologically and socially based needs which are generally assumed to be learned through personal experience. 
   Different psychologists mark out different principal drives or instincts. In most cases they speak of drives to:
    self-preservation (defence), 
    hunger and thirst, 
    sex and 
    rearing the young. 
   Freud in his psychoanalytic theory discussed two drives (sexual, or eros, and  aggressive, or tanatos) as having the greatest influence on the human behavior.

   ABNORMALITIES of facial expression, posture, and social behaviour are common in mental disorders of all kinds. Motor symptoms can be divided into pathology of the volitional activities (see Table 4), and involuntary movements, that include tics, choreiform movements, and dystonia. Tics are irregular repeated movements involving a group of muscles, for example a sideways movement of the head. Choreiform movements are brief involuntary movements which are co-ordinated but purposeless, such as grimacing or movements of the arms. Dystonia is a muscle spasm, which is often painful and may lead to contortions. Involuntary movements occur more often in neurological disorders. 

   DISTURBANCES OF VOLITIONAL ACTIONS.

   Table 12.
                  PATHOLOGY OF VOLITIONAL PROCESSES

i. HYPERBULIA              II. HYPOBULIA             III. PARABULIA

a) Increase of          (decrease of volitional     	(Perversion of
volitional activity     activity)                  		volitional activity)
(purposeful activity)
                        		a) Motor retardation        a) Catatonic
b) Redundancy of        (slowness of movements)     manifestations
volitional activity
(motor excitement)      b) Absence of movements     b) Hebephrenic
                                                    manifestations
c) Hyperactivity
   
ABULIA is absence of willpower or wish-power, pathological absence of wishes or motivation to activity. Abulia usually causes adinamia - decrease of movements in a patient. It occurs in different mental disorders, especially schizophrenia, depression. Total abulia is rare, the more frequent disorder is HYPOBULIA that manifests usually in weak motivation, inertia, listlessness and motor retardation - slowing down and decrease of the number of movements.
   ABSENCE OF MOVEMENTS is sometimes called STUPOR in psychiatry. Stupor refers to a state in which the person is mute, immobile, and unresponsive, but appears to be conscious because the eyes are open and follow external objects. (This is the usage in psychiatry; in neurology the same term often implies a degree of impairment of consciousness.)
   HYPERBULIA - the pathologically increased activity can be manifested in three forms: 1) Increase of volitional activity (purposeful activity) - in manic and some other states; 2) redundancy of volitional activity, motor excitement - agitation, general perturbation, when a patient makes quick, usually senseless movements (catatonic state, agitated depression, etc.) ; 3) hyperactivity - manifestation of disturbed child behaviour, when a child is constantly restless and in motion. 
   PARABULIA - perversion of volition or will. Usually occurs in schizophrenia as a manifestation of ambivalence. There are two kinds of parabulia manifestations - catatonic and hebephrenic syndromes.

Table 13.      STRUCTURE OF THE CATATONIC SYNDROME

  CATATONIC EXCITEMENT             CATATONIC MOTOR RETARDATION

1. Speech and motor excitement   	 1. Catatonic stupor (receptor and
2. Impulsiveness                     		effector)
3. Affectation                    		2. Automatic submission
4. Verbigeration                  		3. Negativism (active and passive)
                                  			4. Waxy flexibility of muscles
                                  			5. Mutism
                  1. Stereotypy (posture, pose, place)
                  2. Ambitendency                       
                  3. Paramimia                          
                  4. Echopraxia                         
                  5. Echolalia                          

   The symptoms of the catatonic syndrome are presented in Table 5. Hebephrenic manifestations consist in incongruous, ridiculous, and frolicsome behaviour (pulling paces, grimacing, affectation, mimicking others, unmotivated laughter, etc.). Patients can jump about, ask other people ridiculous questions. The mood is changeable. The speech is fast, the patients use neologisms, sometimes speak in rimes. Both these syndromes will be discussed in the lecture on schizophrenia. 

    DISTURBANCES OF DRIVES (instincts) can manifest in their pathological increase, inhibition, or perversion. These disorders usually concern the nutrition, self-preservation and sexual drives. Disorders of the nutrition drive result in eating disorders. Bulimia means increased appetite, anorexia - loss of appetite; polydipsia - drive to excessive drinking of water; pararexia - drive towards eating uneatable things. Disorders of the self-preservation drive result in the patient trying to hurt himself (self-destructive behaviour). Disturbances of the sexual instinct, especially sexual perversions, are studied in the course of sexology and sexopathology.  
   IMPULSIVE DRIVES are uncontrollable drives (impulses) to achieve goals, inadequate to the real situation. A person can not keep from fulfilling them, but afterward are critical to their actions.  Dromomania- an abnormal impulse to travel, to be on the tramp; dipsomania - alcoholic bouts, impulse to abuse alcohol in bouts; pyromania - morbid impulse to set fire to things; kleptomania - pathologic impulse to steal, "senseless" stealing, objects are taken not for immediate use; coprolalia - impulse to utter vulgar or obscene words; mythomania - morbid interest in myths and telling lies. 
ABNORMALITIES OF EMOTIONS AND MOOD.
AFFECTION referred to the way something affects the individual in  consciousness and outward expression. Affection (in the Western, especially American psychological literature) includes the entire range of feelings and emotions.
The Ukrainian psychologists, following the tradition of the former USSR psychological schools (which to some extent differs from Western schools) prefer the following definitions:
EMOTION: according to Ya.M. Kogan's definition is a special kind of mental reaction, deprived of independence, that accompanies other mental processes and gives them a sensual tone. Emotions can also be described as a living creature's peculiar appraisal of environmental circumstances or of its own internal state. Every fact in the reality can be estimated as comfortable, useful, appropriate (feelings of pleasure) or inappropriate, uncomfortable, or even threatening (feelings of displeasure).
AFFECT: in our tradition in most cases means a very intensive emotion (passion- rage, horror, agony, ecstasy).  (American psychologists, on the contrary, prefer to speak of AFFECTIVE processes in a more general sense, meaning the normal reactions. They use the word EMOTION to define an acutely disturbed affective process or state which originates in the psychological situation and which is revealed by marked bodily changes in smooth muscles, glands, and gross behavior. According to this definition an emotion is a disturbance - a departure from the normal state of composure.) 
MOOD: is a complicated, more or less stable emotional state, tone of feelings; this especially concerns the subjective experience by an individual. It is the sum of different emotions the person experiences simultaneously at a certain moment. Normal mood that changes according to the situation in a healthy individual is called EUTHYMIC. 
The popular term FEELING has many meanings. It refers to tactual perception, cognitive belief, emotion, and the simple experiences of pleasantness and unpleasantness.
Emotions have developed in living creatures long before cognitive processes. They promoted the satisfaction of their fundamental drives. Among the characteristic features of the "emotional mechanism" it is necessary to mark extremely high SENSITIVITY, QUICKNESS AND UNIVALENCE OF ESTIMATION.
Emotions have  the following PROPERTIES: sensitivity (the threshold of excitation), mobility (stability, time of existence), amplitude, rate of arousal (time that passes from the moment of encounter with the cause of the emotion till it reach its full intensity) and the content. 
There are two aspects of all affective processes: (1) an acute, temporary event and (2) a chronic, persisting state. The first aspect is revealed in experience and behavior. The second aspect is actually assumed. When we speak of "an emotionally disturbed child," "emotional development,"  "emotional maturity," "emotional balance," "emotional instability," we simply mean a persisting state of maladjustment, conflict, frustration, or a stable attitude or disposition.
Changes in emotions and mood are the most common symptoms of psychiatric disorders. They occur frequently among patients with physical illness and also in healthy people at times of personal misfortune.  

Table 14.        CLASSIFICATION OF EMOTIONAL DISORDERS
           ACCORDING TO DIFFERENT PROPERTIES OF EMOTIONS:    

I.  According to sensitivity        Irritability 
    and intensity                  	Sensitivity
                                    		Emotional coldness (blunting, 
                                    		flattening)

II. According to stability         Lability (emotional incontinence)
                                    	        Explosion readiness
                                    	        Rigidity

III. Distortion of emotions      Ambivalence
                                    	        Parathymia
                                                Pathologic affect

IV. Mood disorders                Hyperthymia
                                               Euphoria (mania)
                                               Dysphoria
                                               Anxiety
                                               Depression (melancholy)
                                               Apathy

As we had mentioned before, an emotion is a reaction to an external or internal event. Normal emotions are adequate to the situation. Their intensiveness and stability (duration) are different, they depend on the circumstances and on the personality features of an individual. In mental disorders emotions can change according to their sensitivity and intensity; stability, and can be distorted. 
Abnormal readiness to anger is called irritability. Sensitivity is a tendency to exaggerated affective responsiveness. The opposite mental state, diminution of normal emotional responsiveness, is called blunting or flattening of affect. When mood changes are marked, and one emotion quickly changes the other (a patient laughs, and in some minutes begins to cry or gets angry) the terms "emotional lability" or "incontinence" are used; this phenomenon sometimes occurs after strokes or as part of dementia. Physiological emotional lability is characteristic of children. Frequent angry  and aggressive reactions, a tendency to bursting forth violently for no serious reason is termed explosion readiness. When the emotions remain constant in the face of topics that normally call for changes in affect, the condition is known and affective rigidity (in patients with schizophrenia or obsessive- compulsive disorder). 
DISTORTION OF EMOTIONS. Mood is normally consistent with thoughts 
and actions. Thus, a person is likely to experience a mood of depression when recalling a sad event, or to experience a mood of elation when recalling a happy event. Sometimes (mainly in schizophrenia) mood and thinking are not consistent in this way; for example, the person may look and feel happy when thinking about a sad event. This phenomenon is called incongruity of affect (parathymia). It has to be distinguished carefully from apparent cheerfulness that hides embarrassment. Some patients with depressive disorders fail to show the characteristic facial expression of depression even though their mood is very low (sometimes called "smiling depression"). If a patient experiences two opposite feelings towards one object or circumstance (love and hate, for example), this phenomenon is known as ambivalence.
A PATHOLOGICAL AFFECT. As it was mentioned above, the term "affect" in our tradition means a very intensive emotion (passion- rage, horror, agony, ecstasy). A physiological affect is usually more or less adequate to the situation, and, although the feelings can be violent, the individual has a command over his or her actions, can understand their consequences, and later remembers what happened during his/her state of affect. In a pathological affect, though, a change of consciousness occurs in the subject. The intensity of emotions exceeds any reasonable reaction to the situation, feelings become inadequate. In most cases the leading emotion is intensive anger, rage. The person looses control over his/her actions and usually behaves violently, he/she can commit a crime, including a murder. The behaviour often becomes not only aggressive, but senseless. The subject can not assess the results of his/her actions. When the pathological affect ends, the person falls asleep. Later he/she forgets everything about the episode. 
MOOD DISORDERS.
Above we had discussed mostly short-term emotional disorders, lasting from several minutes to hours. Speaking about mood disorders, we mean emotional states that last much longer, for days, weeks, and even many months. They are very common in the mental health practice. In healthy people mood varies from day to day, and depends on the circumstances. Such mood is called euthymic. This normal variation may be disturbed in illness. Change of mood is the prominent symptom of depressive and anxiety disorders but can also occur in every kind of psychiatric disorder, and in the reactions of healthy people to stressful events and to physical illness.
ANXIETY is associated with a characteristic expression in which the brow is furrowed horizontally, the posture is tense, and the person is restless and sometimes tremulous. Often there are accompanying signs of autonomic overactivity, such as pale skin and increased sweating of the hands, feet, and axillae. States of anxiety are frequent in several mental disorders, especially neuroses.
The term PHOBIA denotes the symptom of anxiety or fear arising in relation to a specific stimulus. The association with a particular object, event, or situation defines the phobia as a separate symptom. Phobic anxiety is associated with a tendency to avoid the stimuli that evoke anxiety. A phobic person may experience anxiety when thinking about the stimulus but not in its presence (anticipatory anxiety). Phobias are common in healthy people, for example phobias of spiders, snakes, thunderstorms, and high places. Phobias of these and other kinds are the prominent symptoms of phobic disorders and also occur as minor aspects of other anxiety disorders and of depressive disorders. So-called obsessional phobias are different, they will be described in the lecture on the obsessional-compulsive syndrome.
   SYNDROMES OF MOOD DISORDERS.
DEPRESSION. In psychiatry the classical (typical) depression is a clinical syndrome consisting of lowering of mood-tone (feelings of painful dejection), difficulty in thinking (slowing down of thinking), and psychomotor retardation. Depressive patients experience conscious psychic suffering, anguish, and sometimes feelings of boredom, despair, guilt or other negative emotions. Some patients with depression complain of painful mental insensibility (anesthesia psychica dolorosa) - lack of emotions, especially this concerns feelings of love towards relations and other positive feelings. These experiences are associated with ideas of self-humiliation, loss, or sinfulness. Patients with depression think that they are failures, that there was nothing good in their lives in the past, nothing good occurs at present, and the future will bring them only misfortune.  
Depression of mood is associated with a characteristic expression in which the corners of the mouth are turned down and the centre of the brow has vertical furrows. The head is inclined forward with the gaze directed downwards, and the shoulders are bent. The patient's gestures are reduced. If the psychomotor retardation is pronounced DEPRESSIVE STUPOR can occur, in which patients do not move at all.
In some cases after a long period of motor retardation a sudden episode of wild agitation and frenzy can occur. It is called "raptus melancholicus". Patients in this state beat their heads against a wall, scratch their faces, they can injure themselves seriously, or commit a suicidal attempt or suicide.                    
Depressive patients often have several physical complaints, although no organic changes in their inner organs are found. Mood disorders, though, are in the majority of cases associated with the autonomous nervous system dysfunctions, such as tachicardia, dilation of pupils, and constipation (Protopopov's triad); there are also dryness in the mouth and other symptoms. In depression appetite is usually low, and decrease of weight is observed in the patients.
Sometimes nontypical depressions occur. 
In the cases of ANXIETY-DEPRESSION, besides feelings of sadness or 
dejection, patients feel intensive anxiety and agitation, associated with the expectation of some specific misfortune (death of relations, loss of property, etc.). Such patients, instead of being retarded, cannot stay still for a couple of minutes, they constantly walk around, their gestures become fussy, all the time they complain, ask other people for help, ask them questions whether something fatal had happened, or express their whish to die. If such state of excitement grows very severe, long-termed, and patients go into a frenzy, the depression is called AGITATED.
APATHETIC depression makes the patients indifferent to their environment, to their own state and to their relations, apathetic, inert, and listless. They do not want to communicate with other people, do not complain, and their only wish is to be left alone.
MASKED or SOMATIZED depression is manifested mainly in various physical complaints, such as pains and aches in the chest, stomach, or other parts of the body, decrease of appetite, disturbances of sleep, heart palpitations, headaches, etc. Patients do not feel anguish or despair, they experience only boredom or sadness, but attribute these feelings to their physical problems. They consult different physicians, but no somatic diseases are found in them. It usually takes a considerable time to diagnose the masked depression. 
Depressive states occur in different psychoses (manic-depressive, or bipolar affective disorder, old-age melancholy, reactive states, neuroses  and some others). Depression is one of the most frequent syndromes in psychiatry.
The MANIC SYNDROME is characterized by: a) an elated or euphoric mood (hyperthymia); b) increased psychomotor activity, restlessness;  c) increase in number of ideas, and speed of thinking and speech. The intensity if these symptoms can be different. Elation of mood is associated with a lively cheerful expression. Posture is normal. The patients speak very much and fast, in a loud voice. Often they don't finish sentences. Their movements are quick and active.
The attention in the manic syndrome is unstable, patients are easily distracted and usually can not finish any work they begin doing. Thus, they are extremely active, but not productive. Their memory, on the contrary, increases (hypermnesia). 
These patients do not express any complaints, they experience "moral elation" and increased physical powers. They tend to overestimate their capacities and opportunities. For example, women find themselves extremely attractive, they think that the male personnel of the hospital and the students are in love with them. They decorate their hair and clothes with flowers or bright-coloured ribbons, and use cosmetics too much. Patients may believe, that they are capable of attaining great social changes, or make an important scientific discovery.
Physical symptoms. Manic patients usually have increased appetite, but they do not gain weigh too much owing to their excessive activity. They sleep for only 3 or 4 hours at night (although this fact does not disturb them). Their sexual activity grows.   
                Disorders of consciousness
   THE  NATURE  OF  CONSCIOUSNESS. Consciousness is   an    extremely complicated mental function, it is considered by modern  psychology  to be characteristic only of human beings. It can be determined as a state of awareness of the mind's functioning and its contents, and  also  of the external environment. 
   SELF-AWARENESS - is  a  process  of   becoming    aware    of    the autobiographical character of personally experienced events.
   SELF-CONCEPT (often called in the Russian and  Ukrainian  literature self-consciousness)  is  an  individual's  awareness  of  his  or   her continuing identity as a person.
   FUNCTIONS OF CONSCIOUSNESS. 1) Aiding survival: from the biological 
perspective, consciousness helps individuals to make sense of environmental information and use that information in planning the most appropriate and effective actions.
   2) Personal and cultural construction of reality. Your personal construction of reality is your unique interpretation of a current situation based on a broader scheme or model that includes your general knowledge, memories of past experiences, current needs, values, beliefs, and future goals. Cultural constructions of reality are ways of thinking about the world that are shared by most members of a particular group of people.
   LEVELS OF CONSCIOUSNESS. Psychologists identify three different levels of consciousness. A) A basic level of awareness of the world (awareness that we are perceiving and reacting to available perceptual information). B) A second level of reflexion on what we are aware of (consciousness relies on symbolic knowledge to free us from the constraints of real objects and present events - it gives us imagination). C) A top level of awareness of ourselves as conscious, reflective individuals (the top level of consciousness is self- awareness, that gives us our sense of personal history and identity).

   STRUCTURES OF CONSCIOUSNESS. 
   NONCONSCIOUS PROCESSES involve information not represented in either consciousness or memory but that still influences fundamental bodily or mental activities. An example of nonconscious processes at work is the regulation of blood pressure.
   PRECONSCIOUS MEMORIES are memories accessible to consciousness only 
after something calls our attention to them. They function silently in the backgrounds of our minds until needed or stimulated (recollections of personally experienced events, or the procedures for skilled performance, like riding a bike, etc.).
   SUBCONSCIOUS AWARENESS involves processing information not currently in consciousness but retrievable from memory by special recall or attention-getting processes. For example, at a noisy party, you might focus your attention on an attractive girl, seemingly oblivious to a nearby conversation - until you overhear your name mentioned. Suddenly you are aware that you must have been monitoring the conversation to detect that special signal amid the noise.
   THE UNCONSCIOUS refers to mental processes that keep out of conscious awareness any information if recognized (see below - Freudian Psychoanalysis).
    Many different research techniques are employed to study different aspects of  consciousness.  These  include  think-aloud protocols, experience sampling and dichotic listening tasks.
   EVERYDAY  CHANGES  IN  CONSCIOUSNESS. Ordinary alterations of consciousness include daydreaming, fantasy, sleep, and dreams.  Daydreaming is a common experience when attention is shifted from the immediate situation to   other    thoughts    that    are elicited semi-automatically. Both genetical and volitional factors determine  the length of sleep for humans. Sleep  patterns  change  
with  age.  Babies sleep about 16 hours each day, and by old age sleep may last fewer than 6 hours. Freud proposed  that  the  content  of  dream  is  unconscious material stimulated by the day's events. The activation-synthesis dream theory  challenges  Freud's  psychodynamic approach  with a purely biological explanation.
   EXTENDED STATES OF CONSCIOUSNESS. Lucid dreaming is  awareness  that one is dreaming in an attempt to control the dream.
   Hypnosis is an alternate state of consciousness characterized by the ability of hypnotizable people  to  respond  to  suggestions  from  the hypnotizer  with  changes  in  perception,  motivation,   memory    and self-control. Pain control is one of the major benefits of hypnosis. Meditation changes conscious functioning by ritual practices that focus attention away from external concerns to inner experience that may enhance self-knowledge. 
   Meditation changes conscious functioning by ritual practices that focus attention away from external concerns to inner experience that may enhance self-knowledge and well-being by reducing self-awareness.
   Psychoactive drugs affect mental processes by temporarily changing consciousness as they modify CNS activity.
    DISORDERS OF CONSCIOUSNESS
   The level of consciousness varies between the extremes of coma and alertness. Several terms are used for the intervening states of consciousness.
Table 15.    CLASSIFICATION OF THE DISORDERS OF CONSCIOUSNESS
                (Odessa Department of psychiatry)

 CLEARNESS OF         KINDS OF CLOUDING OF      KINDS OF CONFUSIONAL
 CONSCIOUSNESS        CONSCIOUSNESS             STATES OF CONSCIOUSNESS 

- Intact and clear   1. Clouding of con-        1. Delirium state
state of all kinds    sciousness
of orientation        (obnubilation)            2. Oneiroid state
                                                
DEPERSONALIZATION    2. Somnolence              3. Amentive state
- Impaired  orien-                              
tation in self       		     3. Sopor                   4. Twilight state

DEREALIZATION             4. Coma
- Indistinct per-
ception and
orientation in
the environment

   The Chair of Psychiatry of the Odessa State Medical University uses the classification of consciousness disturbances presented in Table 1. All the disorders of consciousness are divided into 2 groups: clouding of consciousness and confusional states of consciousness. Clouding of consciousness consists in its quantitative changes. It can be of different extent (obnubilation, somnolence, sopor, and coma). The state of awareness gets dimmer, but the patients do not experience any hallucinations, delusions or any other positive symptoms. In confusional states of consciousness besides other symptoms, illusions, hallucinations and delusions occur.
   COMMON SYMPTOMS for all the disturbances of consciousness are impairments of orientation. There is disorientation as to place, and time , it occurs in all these disorders, whereas disorientation in person (self-orientation) occurs only in some of them. Orientation is assessed by asking about the patient's  awareness of time, place, and personal identity.  Questions begin with the time, day, month, year, and season. In the Ukrainian psychiatry disorientation in the environment is often referred to as DEREALIZATION, and disorientation in  person is called DEPERSONALIZATION, although these terms can have other meanings too (see below).
    In assessing responses to questions about time, the interviewer should remember that many people do not know the exact time of day (though they usually know it to the nearest hour) or the exact date (though they are usually accurate to a few days).  Orientation in place is assessed by asking the patient to name the place in which the interview is held.  If the answer is inaccurate, further questions are asked about the kind of place (for example his home, a hospital ward, or a home for the elderly) and the name of the town.

    Orientation for persons is assessed by asking about other people in the same place: for example relatives in the home or the staff in a hospital ward.  If the patient gives wrong answers, he should be asked about his own identity:  his name, occupation, and role in life.

   DEPERSONALIZATION AND DEREALIZATION.

   These symptoms are less easy to comprehend than anxiety or depression because they are less often experienced by healthy people.  Depersonalization is the experience of feeling unreal, detached, and unable to feel emotion. The lack of emotional responsiveness can be extremely distressing. People with this condition find it difficult to describe, and often use figures of speech, such as "it is as if I am 
cut off by a wall of glass". A statement of this kind is a fanciful comparison ("as if") and not a delusion. In the disturbances of consciousness depersonalization can reach such a level, when the patient in fact becomes unaware of who he/she is.
  Derealization is a similar experience in relation to the environment: other people seem lifeless ("as if made of cardboard") and objects lose their emotive quality. In the clinical course of disturbances of consciousness derealization can result in the patient. 
   Mild forms of depersonalization and derealization can occur in healthy people (often when tired), and also as symptoms of any kind of psychiatric disorder, most often anxiety disorders, depressive disorders, and schizophrenia. In the meaning of disorientation as to environment and/or person, they are common symptoms of disorders of consciousness. They also occur in temporal lobe epilepsy.

   CLOUDING OF CONSCIOUSNESS. 
   Clouding of consciousness can be of several states of gravity (extent). It occurs in the majority of cases not in mental, but in somatic disorders (diabetes melitus, renal or liver insufficiency, etc.) and is of toxic nature. Sometimes it can be caused by organic brain damage, for instance injury or tumors. As it was mentioned above, the consciousness gradually grows dimmer and there are no delusions or hallucinations.
   OBNUBILATION of consciousness refers to a state of drowsiness with incomplete reaction to stimuli, impaired attention, concentration, and memory, and slow muddled thinking. In this state a patient still can move, walk, answer simple questions, although he/she doesn't have initiative, his/her reactions are slow, and the answers are short and often incoherent. Reflexes are normal, or a little decreased.
   SOMNOLENCE is the next state of the clouding of consciousness. It is unnatural sleepiness, drowsiness. The patient is passive, stays in bed, and makes an impression of a person asleep. He/she can be "awakened" for a short period of time, can give short answers to simple questions, but then returns to the same state.

   SOPOR (torpor) is numbness, stupefaction; when consciousness is so disordered that only very strong stimuli produce the reaction. The patient does not react to speech, only to painful stimuli. The reflexes are suppressed, but the corneal reflex is present. 
  The term STUPOR refers to a state in which the person is mute, immobile, and unresponsive, but appears to be conscious because the eyes are open and follow external objects. (This is the usage in psychiatry; in neurology the same term often implies a degree of impairment of consciousness, and it is used similarly to the term "sopor" or torpor.)
   COMA is the profoundest degree of clouding of consciousness, in which consciousness is lost and there is no voluntary activity of any kind. Among the various conditions that may produce coma the most common are: encephalitis, cerebral hemorrhage, cerebral thrombosis or embolism, subarachnoid hemorrhage, intracranial tumor, head injury, postepileptic coma, diabetic coma, hypoglycemic coma, hypertensive encephalopathy, uremic coma and some others. It is different from the sopor in that all the reflexes, including the corneal reflex are absent, and the bodily functions are impaired.
   CONFUSION refers properly to muddled thinking, but the term CONFUSIONAL STATE is applied to a state in which muddled thinking is associated with impairment of consciousness, illusions, hallucinations, delusions, and anxiety. In the Ukrainian psychiatry they include the following states: delirium, oneiroid, amentive, and twilight states of consciousness.
   DELIRIUM is a common accompaniment of physical illness, occurring in about 5-15 per cent of patients in general medical or surgical wards, and in about 20-30 per cent of patients in surgical intensive care units. Most patients recover quickly and only a few need specific treatment. Among other disorders of consciousness delirium is the most common.
   Impairment of consciousness is the most important symptom of delirium, but it is not always the most obvious; indeed, it may be hard to detect because it may fluctuate in intensity through the day, usually being worse at night. Impairment of consciousness is recognized by disorientation, that is uncertainty about the time of day, the place in which the patient finds himself, and the identity of other people.  Patients with impaired consciousness are slow to respond and have impaired concentration.  The features fluctuate in intensity, and it may be necessary to examine the patient more than once in order to detect them. They are often worse in the evening and so more detectable at this time.

   Table 16.    SYMPTOMS OF DELIRIUM
  Impaired consciousness   
      Disorientation
      Poor concentration
  Behaviour
      Overactive
      Underactive
  Mood
      Anxious, irritable
      Depressed
      Perplexed
  Thinking
      Muddled (confused)
      Ideas of reference
      Delusions
  Perception
      Misinterpretation
      Illusions
      Hallucinations (mainly visual)
  Memory
      Impaired
  Fluctuating course, worse in evening and at night

   Behaviour may be overactive, with noisiness and irritability, or underactive, with slowness, reduced speech, and perseveration.  In either case, repetitive purposeless movements are common. Sleep is often disturbed. Mood changes are common. The patient may be anxious, irritable, or depressed. Depersonalization and derealization are also reported by some patients. Thinking is slow and muddled but the content is often complex. Ideas of reference and delusions (which are often persecutory) are common, but are usually transient and poorly elaborated. Visual perception may be distorted. Illusions, misinterpretations, and visual hallucinations are frequent, and the content may be elaborate. Tactile and auditory hallucinations occur, but less often than visual ones. Memory disturbance affects registration, retention, recall, and new learning.  Insight is impaired. On recovery there is usually amnesia for much of the illness. 
    Features of delirium vary between patients.  The variations are related partly to personality; for example, ideas of persecution are more likely in a person who is habitually suspicious and touchy.  There are two main patterns of presentation; in the first, the patient is restless and oversensitive to stimuli, and may have hallucinations and delusions; in the second, the patient is inactive and lethargic and 
is less likely to have hallucinations and delusions.
  AETIOLOGY. There are many causes of delirium, of which the most important are listed in Table 3. They can be divided usefully into causes inside and causes outside the brain.  Causes outside the brain include intoxication with drugs (whether prescribed or obtained illegally) and alcohol withdrawal, cardiac and respiratory failure reducing the oxygenation of the brain, renal and hepatic failure resulting in toxic effects on the brain, and hypoglycemia.  High fever also causes delirium.  Common causes within the brain are listed in Table 3.

        Table 17.    CAUSES OF DELIRIUM
   Drug intoxication
  Alcohol withdrawal
  Metabolic failure
      Cardiac
      Respiratory
      Renal
      Hepatic
      Hypoglycemia
  Systemic infection
      Fever
  Neurological causes
      Encephalitis
      Space-occupying lesions (tumors, hemorrhages)
      Raised intracranial pressure
      Following an epileptic seizure

  Not all patients with one of the conditions listed develop delirium.  It is more frequent among children and the elderly, after brain damage of any kind, and in conditions of low sensory input (such as isolation and low levels of illumination).
   MANAGEMENT. Treatment (Table 4.) is directed mainly to the physical cause. Drug treatment may also be needed to control the delirious symptoms until the physical cause is under control.  It is important to reduce the patient's anxiety, and to avoid too much or too little sensory stimulation.

Table 18.     TREATMENT OF DELIRIUM

Treat the cause
Reduce disorientation 
   Re-orientation
   Consistent routine
Reduce anxiety
   Reassurance
   Medication
Avoid over- or understimulation
Inform and support relatives

   GENERAL MEASURES Patients need reassurance and reorientation to reduce anxiety and disorientation. Memory is poor in delirium, and so these measures should be repeated frequently. If the patient is treated at home, it is important to give relatives a clear explanation of the nature of the disorder in order to relieve their anxiety and to help them reassure and reorient the patient. If the patient is in the unfamiliar surroundings of a hospital ward, even more repeated reassurance and reorientation will be needed. As far as possible, it is helpful to avoid changes in the staff caring for the patient.  Relatives and friends should be encouraged to stay with the patient or to visit frequently so that he sees familiar people. As in home care, they should be advised how to orientate the patient and reassure him.  A predictable and consistent routine is helpful.

   The level of stimulation is important. To avoid overstimulation there are advantages in nursing the patient in a quiet single room. To avoid understimulation there should be enough light at night to enable the patient to know easily where he is.  Conditions should be such that he can sleep undisturbed.

   DRUG TREATMENT
   It is important to give as few drugs as possible and to avoid any drugs that may increase impairment of consciousness. Nevertheless, medication may be needed by day to calm the patient, and by night to help him to sleep.
  To calm the patient by day, the drug of choice is an antipsychotic drug which does not cause drowsiness, hypotension, or cardiac side-effects. A suitable choice is haloperidol; the effective daily dose usually varies between 10 and 60 mg. If necessary, the first dose of 2-10 mg can be given intramuscularly. Chlorpromazine and other phenothiazines are also used, but they are more likely to cause side-effects of hypotension and sedation. Chlorpromazine should not be given when there is liver disease or when the organic state may be due to withdrawal from alcohol (when the drug can increase the risk of seizures).
   Although benzodiazepines may be appropriate for promoting sleep at night, they should generally be avoided in the daytime because their sedative effects may increase disorientation. The exception is that benzodiazepines are valuable by day if there is liver failure, since they are less likely than other drugs to provoke hepatic coma.
   If delirium is caused by intoxication, detoxication with intravenous injection of solutions (Hemodez, 5-20% solutions of glucose, physiological solution, etc.), vitamins and some other medicines are indicated. 
   The ONEIROID (dreamlike) STATE is a confusional state of consciousness with a inflow of involuntarily appearing fantastic dream- like images (pseudo-hallucinations). These images present pictures or scenes complete as to their content and following one another in a certain consequence, sometimes forming a whole story. This state involves total or partly estrangement from the environment (the patient simply does not percept or has partly perception of things around him/her), disorientation as to time, place and person, depressive or manic mood, and catatonic symptoms. After the oneiroid state is over, the patient remembers his/her dreamlike experiences, but forgets everything that had happened to him and around him in reality.
   The oneiroid state can develop suddenly or gradually. If it develops slowly, first the patient has sleep disorders, then has staging delusions (he thinks that all the events around him are specially staged, played for him). During this period he has a kind of double orientation: the patient seams to live in two words at once, in the real situation and in his own fantastic one. Real and hallucination events intertwine strangely. Patients can have fantastic delusions, the content of which depends on the content of the hallucinations. For example, they can believe that they have a special mission - to defend the Earth from aliens, to participate in the battle of powers of good and evil, etc. As the disturbance of consciousness grows deeper, the patient becomes totally submerged in his inner experiences and can not percept the reality. 
   Unlike the delirium, the patients behaviour does not correspond to their experiences. They remain contemplative, some of them can walk around the rooms, scrutinizing things around them, sometimes smiling. They can answer direct questions shortly, but the contact with them is difficult. Other patients who have catatonic symptoms spend most time in bed, their movements are slow and sometimes they have waxy flexibility of muscles (see lecture No 2). Usually they do not react to other people.

     Example: Patient K., 29 years old, a worker, lived at a factory hostel. He was brought to the psychiatric hospital by an ambulance. It was his third hospitalization, and the clinical course of his disorder was similar every time. Gradually he became passive, silent, stayed most of the time in bed, but did not sleep. Then he stopped answering his neighbour's questions and refused to eat. At    the hospital he had catatonic stupor with waxy flexibility of muscles. This state lasted for 12 days, then the patient began to move slowly, and in 2 days returned to his normal state. He told the doctor that he didn't remember how he was brought to the hospital, or what happened to him there. He recalled that he found himself in    a huge hall with tall columns and marble floor. The hall was so high, that clouds gathered near its ceiling. One staircase led to the hall from the sky, and another came up to in from below. Then he saw angels coming down the first staircase and devils coming up the second. They began a battle, and K. felt great responsibility    for its outcome: it was his mission to save the world from evil powers.
   The oneiroid state of consciousness occurs usually in schizophrenia. It does not cause behavioral disorders and thus does not demand special measures of management. The treatment and management of the catatonic stupor will be discussed at the lecture on schizophrenia.
   AMENTIVE STATE OF CONSCIOUSNESS. The term AMENTIA in the Western and Ukrainian (Russian) psychiatry is used in different meanings. In Western (American, English) books it implies lack of intellectual development (mental retardation), whereas in the countries of the former Soviet Union AMENTIVE STATE OF CONSCIOUSNESS is characterized by confusion, affect of bewilderment and incoherence of thinking. The patients can not percept the events that happen around them in general, catch the connections between objects and phenomena. They percept only fragments of the situation, but are unable to connect them in their mind into a joint, coherent picture. Deap disorientation as to time, place, people and self is observed. The patients can not say where they are and assess the situation. The speech of the patients is incoherent, they say senseless, disconnected consequences of words; delusions are either absent, or are incoherent. The mood is changeable. Chaotic excitation within the limits of the bed and chorea-like movements are characteristic of this state.
   After the amentive state patients have absolutely no recollections about their experience or the real events that happened during that time - there is total amnesia for the period of amentia.
   Amentive state of consciousness occurs in grave chronic physical diseases, on chronic generalized infection, organic brain damage, seldom - in reactive psychoses and schizophrenia. Amentia can last for several weeks or months. The treatment depends on the cause of the state - the principal disease is treated.
   TWILIGHT SATES are characteristic of epilepsy, and in some cases occur in organic brain disorders. This term means a transitory disturbance of consciousness, during which many acts, sometimes very complicated, may be performed without the subject's conscious volition and without retaining any remembrance of them. Twilight states begin and end suddenly. Sometimes they are accompanied with hallucinations, delusions, and/or intensive emotions of fear, despair, rage or ecstasy. These experiences influence the behaviour of a patient. There are several kinds of twilight states (ambulatory automatism, fuges, somnambulism, etc.), but all of them can be characterized by the following common features: paroxysmal, sudden nature of beginning and end; automatic activity; total amnesia for the period of twilight state. Here are some examples of twilight states.
   AMBULATORY AUTOMATISM is a kind of twilight state, in which in spite of severe disorientation, patients are capable of orderly behaviour. In such a state a person can leave home, and in some hours find himself in some other district of city, or in another city, where he was not intending to go. His behaviour remained adequate during all his journey, he bought tickets and traveled by different kinds of 
transport, answered other people's questions. He may have seamed rather absent-minded, but did not attract anyone's attention by his behaviour. Later amnesia occurs for all the period of ambulatory automatism.
   FUGES are short-term states of ambulatory automatism, during which a patient is generally agitated and confused. His/her actions have no apparent relation to what he/she was doing before, sometimes they are senseless. A patient may start running down the street, or undress in public. When the state ends, he completely forgets what she was doing during the fuge. 
   If a patient has hallucinations and delusions during a twilight state, he may commit aggressive actions and crimes (even a murder) caused by their influence. This concerns especially frightening or antagonistic hallucinations.

Lecture: “Mental disorders due to use of psychoactive substances and addiction to them. Medical and social problems of psychoactive substances abuse.”
This lecture is concerned with conditions caused by excessive use of alcohol, psychoactive drugs, and certain other chemical substances.  For each substance it is necessary to consider the following:
I. intoxication - the psychological and physical effects of the    substance which  disappear when the substance is eliminated; 
2. withdrawal state - symptoms and signs occurring when the substance    is reduced or stopped;
3. tolerance - the state in which repeated administration of the substance leads to decreasing effect; 
4. dependence - a syndrome that includes withdrawal states, sometimes    tolerance, and other features such as persistent use despite harmful    effects.   
   These conditions are commonly encountered by doctors working in primary care and hospital medicine. 
     ALCOHOL ABUSE
     TERMINOLOGY.
     The term "alcoholism" is used widely in everyday life but has too broad a meaning. The problem is that the term can refer to excessive consumption of alcohol, dependence on alcohol, or the damage caused by this practice. For this reason, it is more useful to employ four terms that are more specific: excessive consumption of alcohol, problem drinking, alcohol-related disability, and alcohol dependence (in the Ukrainian psychiatry the term "alcoholism" means alcohol dependence).
Excessive consumption refers to use that is above the limit at      which alcohol is thought to be harmful.  Problem drinking is drinking that has caused disability but not dependence.
Alcohol dependence is defined below.
  	Alcohol-related disability refers to any mental, physical, or      social harm resulting from excessive alcohol consumption.
     THE CONSUMPTION OF ALCOHOL
      What is a safe level of alcohol consumption?
   Alcohol is consumed by many people without harmful effects.  So what is a safe level of alcohol consumption?  The question. is not easy to answer because it is difficult to obtain accurate information about the drinking of large representative population samples, and difficult to follow population samples for many years to discover what level of drinking leads to adverse consequences. Nevertheless, certain "safe levels" are widely accepted. To understand these levels and to give advice that can be easily understood, the term "UNIT" of alcohol can be helpful. A unit of alcohol corresponds to the following measures in which alcohol is usually consumed:
   *   half a pint of beer;
   *   a wine glass of wine;
   *   a sherry glass of sherry or other fortified wine;
   *   a standard measure of spirits.
   These measures are useful but cannot be precise because the strengths of different beers and wines vary.
   In these terms, the safe level of alcohol consumption for men is up to 21 units per week; for women up to 14 units per week; provided that the whole amount is not taken on one occasion and that there are occasional drink-free days. (This level is equivalent, for example, to an average of three half pints of beer a day for a man.) Hazardous levels are thought to be levels above these limits. To ensure the safety of the fetus, however, pregnant women are advised to abstain from alcohol.
    THE CAUSES OF EXCESSIVE CONSUMPTION
    Several factors affect the likelihood that a person will consume excessive amounts of alcohol. Consumption in the community. The higher the average consumption in a community, the greater the number of people who are likely to 
drink more alcohol than the safe amount.
     Age and sex.  The heaviest drinkers are among young men in their late teens and early twenties.  It is a matter of concern that increasing drinking problems have been identified among 15-16 year olds. Fewer women than men abuse alcohol, but rates in women are rising more quickly than in men so that the differences between the sexes are becoming less marked.
     Occupation.  The rates of excessive consumption of alcohol are much increased among people in occupations that provide easy access to alcohol, for example barmen, brewery workers, and kitchen porters.  It is also higher among executives, salesmen, journalists, actors, and others whose work is associated with social drinking.  Rates of excessive consumption are also high among doctors.  
    Genetic factors. Excessive drinking runs in families, but this could result from social factors.  Genetic influences are suggested by some twin studies though the evidence is conflicting.  A genetic cause is also suggested by the finding that the rate of problem drinking is greater among children of an alcoholic parent who have been adopted by nonalcoholic substitute parents than among adopted children of other biological parents. If genetic factors are confirmed, it will still be necessary to determine whether they act through biochemical mechanisms such as differences in the metabolism of alcohol or through personality.
    Personality factors are suggested by clinical experience, for it is common to find alcohol problems associated with a pervading sense of inferiority, self- indulgent tendencies, and readiness to anxiety.  However, there is no epidemiological data or other evidence to support this view, and it is certain that some people without these traits abuse alcohol.
    THE EPIDEMIOLOGY OF ALCOHOL ABUSE
    Reliable epidemiological data are difficult to obtain because people tend to be evasive about the amount they drink and the consequences of their drinking.  However, other relevant information can be obtained from three sources: first from records of the national consumption of alcohol, second from records of people admitted to hospital with alcohol problems, and third from deaths from cirrhosis of the liver (of which alcohol is a major cause).  All three sources are imprecise, but each has shown a trend towards a substantial increase of alcohol abuse even though the size of the increase is uncertain.  Alcohol abuse has increased among young women as their social roles have changed.
    ALCOHOL-RELATED DISABILITIES
   Continued excessive drinking of alcohol can lead to physical, psychiatric, and social disability. This damage can occur whether or not the person has become dependent on alcohol, though very high levels of consumption are likely to cause both damage and dependency.
    PHYSICAL EFFECTS OF ALCOHOL ABUSE
     Excessive consumption of alcohol may lead to physical damage in several ways:
  *  a direct toxic effect on certain tissues, notably the brain and liver; 
  *  associated poor diet leading to deficiency of protein and B vitamins; 
  *  an increased risk of accidents, particularly head injury;         
  *  associated general neglect leading to increased susceptibility to infection.
    The main physical consequences of excessive consumption of alcohol (Table 1.) are as follows.
    Table 1.     MEDICAL EFFECTS OF EXCESSIVE USE OF ALCOHOL
    Alimentary
       Gastritis and peptic ulcer
       Oesophageal varices
       Acute and chronic pancreatitis
       Hepatitis and cirrhosis
    Neurological
       Peripheral neuropathy
       Dementia
       Cerebellar degeneration
       Epilepsy
    Other
       Anaemia
       Episodic hypoglycemia
       Haemochromatosis
       Cardiomyopathy
       Myopathy
       Obesity
I   Alimentary disorders, notably gastritis and peptic ulcer, damage to     the liver, oesophageal varices and carcinoma, and acute or chronic pancreatitis, are common. Damage to the liver includes fatty     infiltration, hepatitis, cirrhosis, and hepatoma. A person dependent on alcohol has a tenfold greater than average risk of dying of cirrhosis of the liver.
2   Disorders of the nervous system include peripheral neuropathy, dementia, cerebellar degeneration, and epilepsy, as well as several less common effects on the optic nerve, pons, and corpus callosum.  Neuropsychiatric disorders are described below.
3   Other physical disorders include anaemia, episodic hypoglycemia,    haemochromatosis, cardiomyopathy, and myopathy.
   From these and other causes, the overall mortality rate of excessive drinkers is about twice the expected level. These disorders are discussed in textbooks of medicine and will not be considered further here.
   EFFECTS ON THE FETUS. When a pregnant woman drinks excessively, the fetus may suffer damage and the child may be born with a syndrome of facial abnormality, low weight, low intelligence, and hyperactivity. It is not certain whether such effects are seen only after very heavy drinking by the mother, or whether lesser degrees of damage are seen after less heavy drinking.  Nevertheless, it is prudent to advise Pregnant women to abstain from alcohol throughout pregnancy; if they will not accept this advice, they should be counseled strongly to avoid drinking in the first trimester and to avoid bouts of heavy drinking.
   NEUROPSYCHIATRIC DISORDERS. Alcohol-related psychiatric disabilities (Table 2.) fall into four groups: abnormal forms of intoxication, withdrawal phenomena, toxic or nutritional disorders, and associated psychiatric disorders.
 Table 2.    NEUROPSYCHIATRIC EFFECTS OF EXCESSIVE USE OF ALCOHOL
        Intoxication states 
           Memory blackouts
           Idiosyncratic intoxication
        Withdrawal states
           Delirium tremens
        Toxic and nutritional states
           Korsakov's syndrome
           Wernicke's encephalopathy
           Alcoholic dementia
        Associated states
           Depressive disorder
           Anxiety symptoms
           Suicide and deliberate self-harm
           Personality change
           Pathological jealousy
           Sexual dysfunction
           Transient hallucinations
           Alcoholic hallucinations
    ABNORMAL FORMS OF INTOXICATION. As well as the familiar picture of drunkenness, two syndromes occur in people who abuse alcohol persistently. Memory blackouts are losses of memory of events that occurred during a period of intoxication. Such episodes can occur after a single episode of heavy drinking in people who do not habitually abuse alcohol. When these episodes occur regularly they indicate frequent heavy drinking; when they are prolonged, affecting the greater part of a day or whole days, they indicate sustained excessive drinking.
   Idiosyncratic intoxication (or pathological drunkenness) is a marked change of behaviour occurring within minutes of taking alcohol in amounts that would not induce drunkenness in most people.  Often the behaviour is aggressive. The condition is rare, but apparent cases may occur after a further small intake of alcohol in a person who already has a raised blood alcohol level from unadmitted drinking.
    Withdrawal phenomena. Withdrawal phenomena will be described under dependency.  Toxic and nutritional conditions. There are three neuropsychiatric disorders of this kind: Korsakov's syndrome, Wernicke's encephalopathy, and alcoholic dementia. The first two are described in lecture 4 on disturbances of memory and intellect because alcohol is not their only cause.
     Alcoholic dementia can arise after prolonged abuse of alcohol.  Intellectual impairment is often associated with enlarged ventricles and widened cerebral sulci seen on a CT scan.  After prolonged abstinence, some gradual improvement occurs in these changes, suggesting that the shrinkage is not wholly due to the loss of brain cells.  The causes of the dementia are uncertain, but probably include a direct toxic effect of alcohol on the brain and secondary effects of liver disease.
   ASSOCIATED PSYCHIATRIC DISORDERS
I  Depressive disorder can be induced by prolonged abuse of alcohol,    but depressed patients sometimes drink excessively to relieve their symptoms and so care needs to be taken to find out the sequence of changes.
2  Anxiety symptoms occur commonly, particularly during periods of partial withdrawal of alcohol.  However, some patients with an anxiety disorder from other causes drink to relieve anxiety.  Therefore, as with depression, care is needed to determine the sequence.
3  Suicidal behaviour and deliberate self-harm are more frequent among people who abuse alcohol than among other people of the same age. Estimates of the proportion of alcoholics who eventually kill themselves vary from 6 to 20 per cent.
4  Personality change in excessive drinkers often includes self-centredness, lack of concern for others, and a decline in standards of conduct, particularly honesty and responsibility.
5  Pathological jealousy is an infrequent but serious complication of chronic alcohol abuse.  It is described on p. 188.  Non-delusional suspiciousness of the sexual partner is more common.
6  Sexual dysfunction is common, usually as erectile dysfunction or delayed ejaculation.  The causes include the direct effects of alcohol and a generally impaired relationship with the sexual partner as a result of heavy drinking.
7  Transient hallucinations of vision or hearing are reported by some heavy drinkers; they generally occur during withdrawal, but without all the features of delirium tremens or alcoholic hallucinosis.
8  Alcoholic hallucinosis is a rare condition characterized by distressing auditory hallucinations, usually of voices uttering threats, occurring in clear consciousness.  Some patients argue aloud with the voices; others feel compelled to follow instructions from them.  Delusional misinterpretations may follow, often of a   persecutory kind, so that the clinical picture can resemble schizophrenia.  The condition can arise while the person is still drinking heavily or when intake has been reduced.  It lasts up to a few weeks.  The few cases that last longer may be of schizophrenia not primarily due to drinking.
   SOCIAL DAMAGE
   Excessive drinking can cause serious social damage, for example marital and family problems including violence to the spouse, emotional and conduct problems in the children, poor performance at work, and unemployment. There are important associations between alcohol abuse and road accidents.  In the United Kingdom about a third of drivers killed on the road have blood alcohol levels above the statutory limit, and among those killed on a Saturday night the figure is estimated to be three-quarters.  Excessive drinking is also associated with crime, mainly petty offences, but also with fraud, sexual offences, and crimes of violence including murder.
   THE SYNDROME OF ALCOHOL DEPENDANCE
   Excessive drinking can lead to physical dependence on alcohol.  This depend- ence is experienced clinically as a syndrome with seven essential features (Table 3.).
   Table 3.    THE ALCOHOL DEPENDENCE SYNDROME
I   The feeling of being compelled to drink. The dependent drinker is     unsure that he can stop drinking once started.  If he tries to give     up alcohol, he experiences a craving for it.
2   Primacy of drinking over other activities. For the dependent     drinker alcohol takes priority over everything else, including health, family, home, career, and social life.
3   Altered tolerance to alcohol. The dependent drinker becomes able to drink quantities of alcohol that would incapacitate a normal drinker. Since he can "hold his drink", he may persuade himself that alcohol is no problem to him. In fact increasing tolerance is an important sign of increasing dependence. In the late stages of dependence, tolerance falls and the dependent drinker becomes    incapacitated after only a few drinks.

4   Repeated withdrawal symptoms (Table 4). Withdrawal symptoms appear    characteristically on waking, after a fall in blood alcohol concentration during sleep. The earliest and commonest feature is acute tremulousness affecting the hands, legs and trunk ("the shakes"). The sufferer may be unable to sit still, hold a cup steady, or do up buttons. He is also agitated and easily startled, and often dreads facing people or crossing the road. Nausea, retching, and sweating are frequent. If alcohol is taken, these symptoms may be relieved quickly; if not, they may last for several days. As withdrawal progresses, misperceptions and    hallucinations may occur, usually only briefly. Objects appear distorted in shape or shadows seem to move; disorganized voices,  shouting, or snatches of music may be heard. Later there may be epileptic seizures, and finally after about 48 hours delirium tremens may develop (see below).
 Table 4.    SYMPTOMS OF ALCOHOL WITHDRAWAL
        Tremor
        Agitation
        Nausea
        Sweating
        Misperception, hallucinations
5   Relief drinking. Since they can stave off withdrawal symptoms     only by further drinking, many dependent drinkers take a drink     on waking. In most cultures, early morning drinking is diagnostic     of dependency. With increasing need to stave off withdrawal symptoms during the day, the drinker typically becomes secretive about the amount consumed, hiding bottles or carrying them in a     pocket. Rough cider and cheap wines may be drunk regularly to obtain the most alcohol for the least money.
6   Stereotyped pattern of drinking. Whereas the ordinary drinker varies his intake from day to day, the dependent person drinks at regular intervals to relieve or avoid withdrawal symptoms.
7   Reinstatement after abstinence. After a period of abstinence, a severely   dependent person who drinks again is likely to relapse quickly and totally,    returning to his old drinking pattern within a few days.
   The dependence syndrome becomes established most often in the mid-forties for men and a few years later for women. It is now occurring increasingly among teenagers, and is sometimes seen for the first time in elderly people after retirement. Once established, the syndrome usually progresses steadily and destructively unless the patient stops drinking or manages to bring it under control.

   DELIRIUM TREMENS. Delirium tremens is a severe form of withdrawal syndrome and an alcohol psychosis, which occurs when alcohol is withdrawn after several years of excessive drinking. The features are as follows.           
*   Those seen in any delirium: confused state of consciousness,   disorientation in time and place, impairment of recent memory, 
    illusions and hallucinations, fearfulness, and agitation.          
*   Special features including gross tremor of the hands (which gives     the condition its name), autonomic disturbance (sweating, tachycardia, raised blood pressure, dilation of the pupils), and marked insomnia. There may also be fever.                          
*   Hallucinations which are characteristically visual and often frightening, involving people or animals.  Auditory and tactile hallucinations also occur.  
*   Dehydration and electrolyte  disturbance are characteristic. Blood testing shows leucocytosis, a raised erythrocyte sedimentation rate, and impaired liver function.  
    Delirium tremens usually last 3-4 days.  As in other kinds of delirium, the symptoms are characteristically worse at night.  The condition often ends in deep and prolonged sleep, from which the person awakes with no symptoms and little or no memory of the period of delirium.  The treatment of delirium tremens is described below.
     THE DISEASE OF "ALCOHOLISM"
   Alcoholism is regarded as a disease in the countries of the former Soviet Union (Ukraine, Russia, etc.). This terminology initially was used in arguments against the idea that alcohol abuse and its effects are a form of moral failure, and for the idea that people with these problems should receive help from doctors. By regarding it as a disease, alcoholism could be included among the proper concerns of doctors.  However, in the Westaern states (USA, England and others) specialists think that it is more logical to regard excessive use of alcohol as a form of behaviour that can cause mental or physical disease. With greater acceptance that people with alcohol problems need the help of doctors, it is no longer helpful to say that alcoholism is a disease; indeed, it can be unhelpful because a person abusing alcohol may make little effort to control his behaviour on the grounds that it is caused by a disease.
   RECOGNITION OF THE PROBLEM DRINKER
   Treatment is much more difficult in the late than in the early stages of abuse, and so it is important that neither excessive use of alcohol nor problem drinking should go unrecognized.  General practitioners are well placed to identify these problems.  Hospital doctors are also well placed because drinking problems can be detected in 10-30 per cent of patients in general hospitals; the higher rates  being in accident and emergency wards.  Every patient should be asked how much alcohol he drinks per week.  Problem drinking should be sought particularly carefully among the following at risk groups: those with medical or psychiatric conditions that can be caused by alcohol, those with marital or sexual problems or problems with children, particularly when there is violence, and those with difficulties at work, trouble with the law, or financial problems. Repeated absences from work for minor medical reasons suggest a drinking problem, and repeated absences on  Mondays suggest heavy weekend drinking.
Table 5.        IDENTIFYING THE PROBLEM DRINKER
   Be suspicious in cases of:
      medical or psychiatric conditions possibly caused by alcohol 
      marital or sexual problems
      trouble with the law 
      repeated absences or poor record at work           
      problems with the patient's children 
   Ask screening questions (and/or CAGE or MAST - see below).   Ask about symptoms of alcohol dependence.  
   Physical examination for alcohol-related medical conditions 
   Further investigations 
      Alcohol diary 
      Laboratory tests (WCV, GGT - see below)
      The medical conditions that raise suspicion include gastritis, peptic ulcer, liver disease, peripheral neuropathy, seizures, particularly those starting in middle life, and, in the elderly, repeated falls. Psychiatric conditions with the same significance include anxiety, depression, erratic moods, poor concentration, memory impairment, and sexual dysfunction. Some excessive drinkers give misleading answers, and so in appropriate cases it is good clinical practice to ask four questions that are particularly likely to be informative.
I   Have you ever felt you ought to Cut down your drinking?
2   Have people Annoyed you by criticizing your drinking?
3   Have you ever felt Guilty about your drinking?
4   Have you ever had a drink first thing in the morning as an 
    "Eye-opener"?

  A mnemonic for these questions is CAGE, derived from the initial letters of the words Cut, Annoyed, Guilty, and Eye-opener. Two or more positive replies identify problem drinkers; one positive reply is an indication for further enquiry about the person's drinking. Some patients respond more honestly to written questions than to an interview. A widely used screening questionnaire is the Michigan Alcohol Screening Test (MAST). There are two versions. The shorter version, which is self-rated, is shown in Table 6; a score of five points or more indicates alcohol abuse.
   Screening questions should be followed by more detailed enquiries.  
How much alcohol is drunk on a typical "drinking day"? (Start by asking about the amount drunk in the second half of the day, before asking about morning drinking.) How does the person feel after going without alcohol for a day or two? How does the person feel on waking? Questions should be asked about performance at work and in family life, and about any legal problems. Relevant questions about work include extended meal-breaks, lateness, absences, declining efficiency, missed promotions, and accidents.

Table 6.      ASKING THE RIGHT QUESTIONS - BRIEF MAST
   Circle correct answer
Do you feel that you are a normal drinker?      YES          NO (2 pts)
Do friends or relatives think you are a normal
drinker ?                                       YES          NO (2 pts)  
Have you ever attended a meeting of Alcoholics                         
Anonymous?                                      YES (5 pts)  NO 
Have you ever lost friends or girlfriends (or 
boyfriends) because of drinking?                YES (2 pts)  NO        
Have you ever neglected your obligations, your   
family, or your work for two or more days in a                          
row because you were drinking/                  YES (2 pts)  NO                           
Have you ever had delirium tremens (DTs)
severe shaking, heard voices, or seen things
that were not there after heavy drinking?       YES (5 pts)  NO     
Have you ever gone to anybody for help about 
your drinking?                                  YES (5 pts)  NO        
Have you ever been in a hospital because of 
drinking                                        YES (5 pts)  NO        
Have you ever been arrested for drunken          YES (2 pts)  NO
driving or driving after drinking?
    Total score
 From A.D. Pokorny, B.A. Miller, and H.B. Kaplan Am. J. Psychiat. 1972; 
 129.  342-5.
   When appropriate, systematic enquiry should be made about features of the alcohol dependence syndrome and about all the physical, psychological, and social disabilities described above.
   Finally, laboratory tests can be used. The most direct measure is BLOOD ALCOHOL concentration, although this does not distinguish between a single recent episode of heavy drinking and chronic abuse.  In someone who does not show signs of intoxication, a high blood alcohol suggests tolerance to alcohol, which in turn suggests chronic abuse with dependence. Levels of gamma- glutamyl-transpeptidase (GGT) are raised in about 80 per cent of problem drinkers, whilst mean corpuscular volume (MCV) is increased in about 60 per cent. If other causes of abnormality can be excluded, these tests strongly suggest excessive drinking. They have the advantage that values do not return to normal for some weeks after the last period of heavy drinking.  Urate concentrations are raised in about half of all heavy drinkers, but as screening tests they are useful only for men since they are poor discriminators in women.

   THE TREATMENT OF THE PROBLEM DRINKER
   THE VALUE OF THE ASSESSMENT INTERVIEW. A thorough enquiry into drinking habits and related problems is not only a way of detecting the problem drinker, but is also a first step in treatment because it helps the patient to recognize the extent and seriousness of his problem.  This recognition is needed as a means of motivating the patient to control his drinking.  Without such motivation, treatment will fail.  Enquiries should be persistent to uncover the extent of the problem, but not judgmental.  The assessment should normally involve the partner, for whom it may be the first opportunity to unburden feelings and obtain help.
   THE TREATMENT PLAN. Treatment begins with a review of the extent of the drinking, the evidence for dependence, the effects of the patient's excessive drinking, and the probable consequences if it continues.  Any urgently needed medical treatment is arranged and a decision is made about withdrawal (see below). The patient should be involved in formulating the treatment plan, and if possible the partner should take part. Specific and attainable goals should be set and the patient given responsibility for reaching them. These goals should include control of drinking, collaboration with treatment for any associated medical condition, and resolution of problems in the family, at work, and with the law. These initial goals should be short term and achievable; for example, to reduce consumption to the safe limit in the first 2 weeks. Unrealistic goals, particularly in the early stages, will lead to failure, demoralization, and a return to drinking.

  Table 7.          TREATMENT PLAN FOR A PROBLEM DRINKER
     Review with the patient
         extent of drinking
         evidence for dependence
         alcohol related disabilities
     Arrange withdrawal of alcohol
     Treat urgent medical or psychiatric illness,
     Set attainable goals for
         control of drinking*
         treatment of medical disabilities
         resolution of interpersonal problems
         dealing with practical difficulties (finance, employment, the          law)
         establishing new interests
     Plan longer term help
         Individual or group counselling
         AA meetings
         Help for the family
     * Abstinence if there is evidence of dependence
   As treatment progresses, longer-term goals may be added concerned with improving marital relationships or changing the use of leisure time. Potential obstacles to progress need to be identified; for example, the patient may work in a job where drink is readily available or may have social relations only with people who drink heavily.  The patient should be helped to overcome these problems.
  The plan should include help for the family.  The spouse or teenage children may need counselling about problems of their own that are consequent upon the patient's heavy drinking.  They may also need help in supporting the patient's efforts to reduce his drinking.
   ABSTINENCE VERSUS CONTROLLED DRINKING.  It is important to decide whether to aim for total or partial abstinence from alcohol.  The traditional advice is that a person with alcohol dependence should not drink alcohol again because of the high risk of relapse.  Not all dependent patients will accept this goal; they either refuse treatment or report abstinence while continuing to drink alcohol.  Even so, abstinence remains the most appropriate goal for people with alcohol dependence. For those who drink excessively but are not dependent on alcohol, the appropriate goal can be the reduction of drinking to a safe level provided that the person (i) has not incurred serious physical consequences of drinking which require abstinence, (ii) is not in a job (such as lorry driving) that carries a risk to others, and (iii) is not pregnant.  The target can be the usual safe limits of 21 units per week for men and 14 for women.  Reduction to these limits should be in achievable stages, say 5 or 10 units a week, but the process should not be so prolonged that motivation is lost.
   TREATMENT FOR SPECIAL GROUPS
   WOMEN. Drinking of alcohol by pregnant women carries risks for the fetus. Despite the social changes that have led women to drink more alcohol, it is still difficult for them to admit to alcohol dependency or alcohol-related problems.  For this reason treatment is often difficult. The safe limits set in treatment should be lower than for men.
   DOCTORS. Doctors have higher than average rates of alcohol abuse and often have difficulty in admitting their problems and seeking help, particularly from colleagues working in the same areas. In some countries, including the United Kingdom, there are arrangements for doctors to obtain help outside their area of work through a national scheme for sick doctors.
   WITHDRAWAL FROM ALCOHOL. When the amount of alcohol taken has been large, and particularly when there is a dependence syndrome, the patient may develop delirium tremens or seizures if he stops drinking suddenly. Since both these complications may be dangerous, withdrawal should be carried out carefully in hospital or, if outside hospital, under close medical supervision. In less severe cases, withdrawal can be at home provided that there is someone to look after the patient and that the general practitioner can visit daily.  Since dependent patients are unlikely to succeed in reducing alcohol gradually, it is usually best to stop the alcohol, replace it with a drug that will prevent delirium tremens or fits, and then withdraw this drug gradually. Chlormethiazole, chlordiazepoxide, and diazepam are the drugs used most often. (Chlorpromazine is not suitable since it may provoke seizures.) These drugs should not be continued after the stage of withdrawal because the patient may become dependent on them.
    Whichever drug is chosen, it is started in a moderate to high dose and then reduced progressively. The details of the dosage regimen vary with different drugs and different practitioners. One scheme begins with chlordiazepoxide 50 mg or 100 mg by intramuscular injection every 6 hours over the first 24 hours. If convulsions occur, larger doses are given immediately; otherwise equivalent oral doses are substituted for the intramuscular dosage and then reduced progressively over the next 5 days. Chlormethiazole can be used instead of diazepam; the dosage schedule is more complex and a pharmacopoeia should be consulted. Careful supervision is required since dangerous respiratory depression can occur if alcohol and chlormethiazole are taken together. If the patient is treated at home, he should be visited regularly by the family doctor and community nurse who should make checks on pulse, blood pressure, hydration, and level of consciousness. During the intervals family or friends should check the patient's general condition every 2 hours for the first few days. The patient should take adequate fluid and a light diet. B vitamin supplements are often given during withdrawal as a measure against development of the amnesic syndrome.
   PSYCHOLOGICAL TREATMENT
   Psychological treatment has three main aims: (i) to sustain the patient's motivation; (ii) to help the patient to avoid relapse; (iii) to relieve any psychological problems that have contributed to the development of the alcohol abuse.
    The treatment can be given as individual counseling or group therapy.  Individual counseling can be provided by the general practitioner or by a member of a specialist team.  Problem-solving techniques are generally used. It is valuable for the patient to keep a diary of his alcohol consumption, and also of the circumstances of any relapse.  Many patients have relapses, and by keeping diaries they can learn how to avoid them in the future.  In specialist units, group therapy is probably the most widely used treatment because patients are often more willing to accept advice and support from other patients with similar problems than from doctors.
    In pursuing the first two aims above (sustaining motivation, avoiding relapse) help should be provided in developing new activities, whether with the family or as personal hobbies.  In pursuing the third aim (relieving psycho- logical problems that have led to alcohol abuse), counseling or short-term dynamic treatment can be used.  Thus marital problems may require marriage guidance counseling, whilst difficulty in dealing with angry feelings in other relationships may require short-term psychotherapy.
   MEDICATION TO MAINTAIN ABSTINENCE. Disulfiram (Antabuse) and citrated calcium carbamide (Abstem) are used occasionally in specialist practice as deterrents to impulsive drinking. It is not recommended that either drug be used by non-specialists.
   Disulfiram interferes with the metabolism of alcohol by blocking one of the enzymes involved. As a result, when alcohol is taken acetaldehyde accumulates with consequent flushing, headache, choking sensations, rapid pulse, and anxiety. These unpleasant effects discourage the patient from drinking alcohol whilst on the drug.  Citrated calcium carbamide has actions like those of disulfiram, but is absorbed and excreted more rapidly. Treatment with either drug carries the risks of occasional cardiac irregularities or rare cardiovascular collapse. Therefore the drug should not be started until at least 12 hours after the last ingestion of alcohol. These drugs also have unpleasant side-effects, including a persistent metallic taste in the mouth, gastrointestinal symptoms, dermatitis, urinary frequency, impotence, peripheral neuropathy, and toxic confusional states.
  These drugs are used for the few patients who experience strong urges to drink which they cannot control, and who also have enough motivation to take a drug regularly in the morning.
   SELF-HELP GROUPS 
   ALCOHOLICS ANONYMOUS (AA) hold group meetings at which members obtain support from one another. If members are in crisis between meetings, they can obtain support from other members by telephone.  Not all problem drinkers are willing to join the organization because total abstinence is required and because the meetings involve repeated confession of each person's faults and problems. Those who remain in the organization are usually helped, and anyone with a drink problem should be encouraged to try it.  
   AL-ANON is a parallel organization providing support for the spouses of excessive drinkers, and Al-Ateen does the same for the teenage children.
   COUNCILS ON ALCOHOLISM are voluntary agencies that advise problem drinkers where to obtain help, provide social activities for those who have recovered, train counsellors, and coordinate services.  HOSTELS for homeless problem drinkers are provided in some places, often by voluntary organizations.  Usually abstinence is a condition of residence, and counselling and rehabilitation are provided.
   WHEN TO OBTAIN SPECIALIST HELP. General practitioners are well placed to help problem drinkers. The general practitioner knows the patient and the family, and can carry out the treatment of the problem drinking in the context of the patient's general health, an approach that is often more acceptable. The general practitioner can also ensure that the needs of the spouse and of any children in the household are assessed and met. Demands on the general practitioner's time need not be excessive since non-medical members of the general practice team can share in counselling the patient and the family.
   Among the reasons for specialist referral are (a) severe withdrawal symptoms, particularly fits or delirium tremens, which should be treated as emergencies, (b) planned withdrawal from alcohol when home withdrawal is inappropriate, (c) medical or psychiatric complications requiring specialist assessment (see Tables 14.2 and 14.3), and (d) complex personal or interpersonal problems requiring more intensive psychological treatment than simple counseling.  Many patients referred for specialist help fail to keep appointments; the general practitioner should ensure that this problem is detected.
   THE RESULTS OF TREATMENT. The results of treatment for patients with serious drinking problems are not good: among patients who had been through treatment centres in the United States, only a quarter remained abstinent for 6 months, at 18 months only 10 per cent were abstinent, and less than 20 per cent were drinking less alcohol than before treatment.  Results do not seem to differ with the kind of treatment.  Indeed, one well-conducted study found that a single intensive day of assessment and advice was as effective as more elaborate treatment using counseling, medication, introduction to AA, and in selected cases admission to hospital. These are reasons for early detection and counseling of those who drink excessively.
   These and other findings suggest that outcome depends more on the patient than on the treatment. A good outcome is related to good insight, strong motivation, a supportive family, a stable job, and an ability to form good relationships, to control impulsivity, and to defer gratifications. Since several of these factors are more likely to be present in the early stages of the condition, early detection and counseling is clearly important.
   PREVENTION OF ALCOHOL PROBLEMS
   Several social measures might help to prevent excessive drinking by reducing the general level of alcohol consumption in the population. Raising the price of alcoholic drinks.  Total consumption in the population is related to the price of alcohol: when the price is lowered more alcohol is consumed, and when it is raised by taxation, consumption tends to fall. Licensing laws are intended, in part, to reduce alcohol abuse by limiting the hours when alcohol is available.  It is not certain how effective they are in achieving this aim.
*  Control of advertising of alcoholic drinks has been proposed -    particularly of advertising targeted on young people.  It is not  certain how effective such measures would be, a ban on press and television advertising of alcoholic drinks in British Columbia made little difference.
*  Controlling the sale of alcohol by limiting sales in shops might be effective.  It is known that relaxation of restriction on sales can lead to increased sales, but it is not certain that increasing restriction would reduce established rates of drinking.
*  Health education seems desirable since the best control on drinking is self-control.  Customs and moral beliefs are important determinants of alcohol use, but it has not yet been proved that any form of classroom or media education can alter drinking habits.
                 ABUSE OF PSYCHOACTIVE SUBSTANCES
   The term psychoactive substance abuse is used instead of the term drug abuse because some people abuse substances that are not generally regarded as drugs, for example organic solvents or mushrooms with psychedelic properties. The many abused substances fall into six groups:
*  opioids;
*  anxiolytics and hypnotics;
*  stimulants;
*  hallucinogens;
*  cannabis;
*  organic solvents.
   Nicotine is the most widely used drug that causes dependency; its use is accepted by society despite the harmful medical consequences of smoking.
   Before describing the main features of abuse of these groups, certain general features of substance abuse will be considered.
   THE PREVALENCE OF ABUSE
   Although population surveys of drug abuse have been attempted, reliable estimates of prevalence are lacking because abuse is concealed. In the former Soviet Union indirect information has been collected about drug-related offences, hospital treatment for drug abuse, and cases reported to government agencies, but none of these sources is informative. Similar difficulties are met in other countries;  hence no accurate international comparison can be made, though there is convincing empirical evidence of high rates in, for example, some large cities in the United States. It is generally considered that rates are higher in disadvantaged areas and among unemployed young people with disorganized lives and few stable relationships. Abuse is certainly not restricted to people of this kind. The rate of drug and other psychoactive substances abuse in the Ukraine has probably grown considerably during the last years.
     THE CAUSES OF DRUG ABUSE AND DEPENDANCE
     CAUSES OF DRUG ABUSE. Four kinds of causes are important: properties of the drug, availability of the drug, characteristics of the person taking the drug, and social factors.
*    Properties of drugs of abuse are discussed later in this section.
*    Availability is of three kinds: drugs may be prescribed by doctors      (for example benzodiazepines), bought legally (nicotine and alcohol), or bought illegally (most of the drugs discussed in this      chapter). Control of the availability of drugs of abuse is important; it depends on political actions and on the activities      of the police and other enforcement agencies in detecting the import and distribution of drugs.
*    Personal characteristics determine why one person with access to a drug abuses it, while another person with similar access does not.  
     Among people who abuse drugs, many have some degree of vulnerability because they lack the personal resources needed to cope with the challenges of life.  This problem is often manifest in teenage years as difficulty in accepting authority, or truancy or underachievement at school, or delinquency. Many of these     vulnerable people come from disorganized families, and many were unhappy in childhood.  Some give a history of mental illness or personality disorder in the family.  Some report being depressed or anxious when they take drugs, but these mood states may be the result of previous drug-taking rather than the cause of abuse.  
     Many drug abusers show none of these features.
•	Social pressures are important. Some social groups disapprove of drug-taking and this shared value helps to restrain its members; 
•	in other groups drug- taking is condoned or even encouraged, and      it gives a young person status among his peers.
     CAUSES OF DRUG DEPENDANCE
   Not all people who abuse drugs become dependent on them. Dependence has both pharmacological and psychological causes. Some drugs are potent in causing pharmacological dependence amongst most people who take them; examples are opioids and nicotine. Other drugs are much less likely to cause pharmacological dependence; examples are cannabis and hallucinogens. Pharmacological dependence is caused by changes in the receptors and other cellular mechanisms affected by the drugs.
    Psychological dependence operates partly through conditioning: as a drug is withdrawn, some of the symptoms experienced (for example, anxiety) become conditioned responses which appear when withdrawal takes place again.  Cogni- tive factors are probably more important than these automatic responses; patients expect unpleasant symptoms and become anxious.  For this reason, reassurance is important in the treatment of patients who are withdrawing from drugs.
   CONSEQUENCES OF DRUG ABUSE
   THE CONSEQUENCES OF INTRAVENOUS DRUG-TAKING. Some drug abusers administer drugs intravenously in order to obtain an intense and rapid effect. This practice is particularly common with opioids, but barbiturates, benzodiazepines, and amphetamines are among other drugs that may be taken in this way. Intravenous drug use has important consequences, some local and some general. Local effects include thrombosis of veins, infection at the injection site, and inadvertent damage to arteries. General effects are due to transmission of infection, particularly when needles are shared.  Bacterial endocarditis, hepatitis, and AIDS can be acquired in this way.  At present, the spread of AIDS is giving rise to the most concern.
   SOCIAL CONSEQUENCES. There are three reasons why drug abuse has undesirable social effects.  First, chronic intoxication may affect behaviour adversely, leading to a poor work record, unemployment, motoring offences, failures in social relations, and family problems including neglect of children.  Second, because most illicit drugs are expensive, the abuser may cheat or steal to obtain money, and women may become prostitutes, thereby contributing further to the spread of AIDS.  Third, drug abusers often keep company with one another, and those with previously stable social behaviour may be under pressure to conform to a group ethos of antisocial or criminal activity.
   CONSEQUENCES OF DRUG ABUSE IN PREGNANCY. When a pregnant woman abuses drugs, the fetus may be affected. When drugs are taken in early pregnancy there is a risk of fetal abnormality. Also, intravenous drug use may lead to infection of the mother with AIDS or other conditions that can affect the fetus.  When drugs are taken in late pregnancy, the fetus may become dependent on them and may develop a withdrawal syndrome after delivery.  With heroin and related drugs, the risk of fetal dependence is great and the withdrawal syndrome can be serious, requiring skilled care.
    DIAGNOSIS OF DRUG DEPENDANCE
   It is important to diagnose drug dependence early at a stage when tolerance is less established, behaviour patterns are less fixed, and the complications of intravenous use have not developed.  Dependent people may come to medical attention in several ways.
*   Some declare that they are dependent on drugs.
*   Some conceal their dependency, instead asking for opioids to     relieve pain or for powerful hypnotics to improve sleep.  General     practitioners and emergency department staff should be wary of such requests from temporary patients, and if possible should obtain information about previous treatment (if necessary by telephone) before prescribing.
*   Some drug-dependent people ask for help with the complications of drug- taking such as cellulites, pneumonia, hepatitis, AIDS, or accidents, or for the treatment of a drug overdose, withdrawal symptoms, or an adverse reaction to a hallucinogenic drug.
*   A few dependent people are detected during treatment of an unrelated illness.
   For the doctor who is not used to treating drug-dependent people, it is important to remember that the patient may be trying to deceive him. Some patients overstate the dosage in the hope of obtaining extra supplies to use themselves, give to friends, or sell. Others take more than one drug but do not admit it. It is important to check the patient's account for internal inconsistencies, and to seek external verification whenever possible (for example by obtaining permission to contact another doctor who has treated the same patient). 
    Several clinical signs lead to suspicion that drugs are being injected:
*   needle tracks and thrombosis of veins, especially in the antecubital fossa;
*   scars of previous abscesses;
*   concealment of the forearms with long sleeves even in hot weather.
   Intravenous drug use should be considered in any patient who presents with subcutaneous abscesses, hepatitis, or AIDS, whether or not the person is asking for help with drug abuse.
   Behavioral changes may suggest drug dependence. These changes include absence from school or work, occupational decline, self-neglect, loss of former friends, and joining the "drug culture".  Petty theft and prostitution are other indicators. 
   Laboratory tests should be used whenever possible to confirm the diagnosis. Most drugs of abuse can be detected in the urine; the notable exceptions are cannabis and LSD.  Urine specimens should be examined as quickly as possible, with an indication of the interval between the last admitted drug dose and the collection of the urine sample. The laboratory should be provided with as complete a list as possible of drugs likely to have been taken, including those prescribed as well as those obtained in other ways.
   PRINCIPLES OF PREVENTION
   Because treatment is often unsuccessful, considerable efforts should be made to prevent drug taking. The first measure is to limit availability of drugs. The second measure is to change public attitudes through education, particularly in schools; the value of wider publicity campaigns through the media is uncertain - they may glamorize drug-taking instead of discouraging it.  The third measure is to alleviate the social causes of drug-abuse such as poor social conditions, unemployment among young people, and lack of leisure facilities.
    Several measures have been used to prevent harm among people who insist on continuing to take drugs.  A serious danger is the spread of HIV infection through the sharing of needles and through sexual intercourse. Measures to counteract this spread include the following:
*  education of drug users about the dangers - such advice is often    more effective when given by ex-drug-users than by doctors;
*  schemes for providing clean syringes and needles in exchange for    used ones, in the hope of reducing the risk of contamination caused by sharing;
*  the free supply of condoms to reduce sexual spread of the virus.
   These approaches are controversial since some of the measures can be seen to condone drug-taking, but the danger of HIV infection is now generally considered greater than that of increasing drug abuse.
    PRINCIPLES OF TREATMENT AND REHABILITATION
    The essential first step is to motivate the drug taker to change his behaviour. This requires first a review of the type, amount, and route of drug-taking, and the evidence for dependence, and second advice about the dangers of continued drug-taking.  Help should be offered with any personal and social problems that are contributing to the maintenance of the behaviour.  If the person is a member of a drug-taking group, he should be urged to leave it and to develop new friendships and interests.
   The next step is to withdraw the drug.  If the person is severely dependent or at risk of serious withdrawal effects, (for example, seizures during withdrawal from barbiturates), then withdrawal should be in hospital. Otherwise it can be at home under close supervision. Withdrawal is achieved by reducing the dose progressively over a period of 1-3 weeks depending on the initial dose.  With opioids and benzodiazepines it is usual to begin by replacing the abused drug with an equivalent dose of a longer-acting compound of the same type, which is then withdrawn. (A longer-acting compound is chosen because withdrawal effects are less acute.) Psychological factors contribute to drug dependence; hence strong and repeated reassurance is an important part of treatment.
Table 1          TREATMENT PLAN FOR A PERSON ABUSING DRUGS
    Review with the patient
        Type of drug(s) and amounts taken
        Intravenous usage and its dangers, particularly HIV
        Evidence of dependence
        Consequences of drug-taking: caused by the drug and related   to IV use 
        Social nd psychological
        Patient's personal and social resources and problems  
    Arrange withdrawal
    Treat urgent medical or psychiatric complications
    Set attainable short- and medium-term goals for 
        abstaining from drug
        parting from the drug culture
        dealing with personal and financial problems
        establishing new interests
    Plan longer-term help  
        Individual or group counselling
        Help for the family
   Next, attainable goals should be agreed with the patient. These goals include abstaining from drugs for a defined period, breaking contact with people who take drugs, attempting to establish new relationships, starting to deal with debts or personal problems, and taking new hobbies or interests to occupy the time previously spent on obtaining and taking drugs.
   DRUG MAINTENANCE. The term drug maintenance refers to the continued prescribing of a drug for a person who is unwilling to withdraw; it also denotes help with social problems and a continuing effort to bring the person to accept withdrawal. Drug maintenance is therefore more than merely providing drugs. The rationale for this procedure is threefold. first, prolonged prescribing should remove the need to obtain "street" drugs, and thereby the need to steal, engage in prostitution, or associate with other drug users.  Second, the prescribing of oral drugs may stop intravenous use, thus reducing the spread of AIDS. Third, the associated social and psychological help should enable the person to become willing to give up drugs.  
Unfortunately, the available evidence does not suggest that these aims are achieved regularly; many patients continue in their previous way of life, many continue to take street drugs as well as the prescribed methadone, and few become willing to give up drugs.  Despite these drawbacks, this treatment continues in use in the hope that it may have some effect in reducing intravenous usage, thereby limiting the spread of AIDS.
    Some patients on maintenance therapy attend a succession of general practitioners in the hope of obtaining supplementary supplies of drugs; for this purpose they may pose as temporary residents. The doctor should not prescribe but should help the patient to return to the clinic for treatment.
    REHABILITATION. After abusing drugs for a long time, patients may need considerable help in making social relationships and in obtaining and retaining a job. When these problems are severe, treatment in a therapeutic community can be helpful. 
   ABUSE OF SPECIFIC TYPES OF DRUG
   OPIOIDS. This group of drugs includes morphine, heroin, codeine, and synthetic analgesics such as pethidine and methadone, as well as self-mede surrogates derived from the opium poppy plants, used often in the Ukraine. These drugs produce the desired effect of euphoria, but also produce analgesia, respiratory depression, constipation, reduced appetite, and low libido. They can be taken by mouth, intravenously, or by smoking. The most widely abused of these drugs is heroin, which has a particularly powerful euphoriant effect. Although some people take heroin intermittently without becoming dependent, regular users rapidly develop dependence, particularly when they take it intravenously.
   Tolerance develops rapidly, leading to increasing dosage. When the drug is stopped, tolerance diminishes so that a dose taken after an interval of abstinence has a greater effect than it would have had before the interval. This loss of tolerance can result in dangerous, sometimes fatal, respiratory depression if a previously tolerated dose is resumed after a drug-free interval, for example after a stay in hospital or prison. 
    Withdrawal symptoms include intensive craving for the drug, restlessness and insomnia, pains in muscles and joints, running nose and eyes, sweating, abdominal cramps, vomiting, and diarrhoea, piloerection, dilated pupils, raised pulse rate, and disturbance of temperature control.  With heroin, these features usually begin about 6 hours after the last dose, reach a peak after 36-48 hours, and then wane.  They cause great distress, which drives the person to seek further supplies, but they seldom threaten life if he is in reasonable health.
      THE COURSE OF OPIATE DEPENDANCE. After 7 years only a quarter to a third of opiate-dependent people have become opiate dependence abstinent, and between 10 and 20 per cent have died from causes related to drug-taking. Deaths are from accidental overdose, often related to loss of tolerance after a period of enforced abstinence, and from the effects of HIV infection.  When abstinence is achieved, it is often related to changed circumstances of life, such as a new relationship with a caring person.
    PREGNANCY AND OPIOID DEPENDANCE. The babies of opioid-dependent 
women are more likely than other babies to be premature and of low birth weight. They may also show withdrawal symptoms after birth, including irritability, restlessness, tremor, and a high-pitched cry.
These signs appear within a few days of birth if the mother has been taking
heroin, but are delayed if she has been taking methadone which has a longer half-life.
  Later effects have been reported; these children are more likely to be overactive toddlers and to show poor persistence. It is uncertain whether these late effects result from the unsuitable family environment provided by these mothers, or from a lasting effect of exposure to the drug.
    TREATMENT OF OPIOID DEPENDANCE
    TREATMENT OF CRISIS. Heroin-dependent people may present in crisis to a general practitioner or casualty doctor in three circumstances, first, when their supplies have run out, they may seek the prescription of drugs either by requesting them directly or by feigning a painful disorder. Although withdrawal symptoms are very unpleasant, they are not usually dangerous to an otherwise healthy person. Therefore it is best not to offer drug unless this is the first step in an agreed withdrawal or maintenance programme. (In Ukraine doctors may not legally prescribe heroin or certain related drugs as maintenance treatment to a drug-dependent person.) The second form of crisis is drug overdose requiring medical treatment, which should be directed particularly to any respiratory depression produced by the drug. The third form of crisis is a complication of intravenous drug usage such as an acute local infection, necrosis at the injection site, or infection of a distant organ, usually the heart or liver.
    PLANNED WITHDRAWAL OF OPIOIDS ("DETOXIFICATION"). The general principles of drug withdrawal have been outlined above. When heroin is withdrawn, psychological management is particularly important. The usual pharmacological management is by substituting methadone (a longer-acting drug) for heroin. Although the procedure is straightforward, it is frequently very difficult to judge the starting dose because patients often take adulterated preparations of heroin (and may lie about the amount taken). For this reason treatment should be discussed with and often carried out by a specialist in drug dependence.  When the starting dose is very high, withdrawal should generally be in hospital.  Methadone is generally prescribed in liquid form. The starting dose is generally 20-70 mg per day, depending on the patient's consumption of opioids; doses above 40 mg per day should be given with great caution.  The starting dose is usually reduced by about a quarter every 2-3 days, but a slower rate may be needed.  The regime should be agreed with the patient as a contract that he will accept throughout treatment. After withdrawal, urine tests for drugs should be carried out weekly until the doctor is confident that the patient is remaining drug free.
      CONTINUED PRESCRIBING ("MAINTENANCE"). The principles of maintenance treatment for opiate dependence have been discussed above. Methadone is prescribed, usually in a liquid preparation formulated to discourage use by injection. The equivalent dosage is difficult to determine since street drugs are adulterated to varying degrees.  Forthis and other reasons (including legal restrictions on prescribing to addicts) maintenance treatment is given by a specialist. When patients refuse to stop taking street drugs by injection, it may be appropriate to provide sterile needles and syringes in order to reduce the risks of spread of HIV through injecting.  Condoms are often supplied in an attempt to prevent the spread of HIV through sexual intercourse.
REHABILITATION. Rehabilitation follows the general lines described above.
RESULTS OF TREATMENT.    Although many patients can be withdrawn from opioids, it seems that most relapse within a year. The doctor should be prepared for these failures, and should continue to help patients to limit the harm done by intravenous usage and to offer further help if they again become motivated to change.
ANXIOLYTIC AND HYPNOTIC DRUGS
The most serious problems are presented by barbiturates which, although seldom used therapeutically, are widely available as "street" drugs.  The most frequently abused drugs are now benzodiazepines. Other currently abused drugs of this kind include chlormethiazole and glutethimide.
BARBITURATES. Barbiturates are taken by mouth and intravenously. Some middle-aged or elderly people are dependent on barbiturates that were originally prescribed as hypnotics many years previously. Younger dependent people use illegal supplies of barbiturates, and some dissolve capsules to inject intravenously – a particularly dangerous practice leading to phlebitis, ulcers, abscesses, and gangrene. The symptoms of intoxication resemble drunkenness, with slurred speech, incoherence, drowsiness, and depression of mood.  Younger intravenous users are often unkempt, dirty, and malnourished. Nystagmus, a useful diagnostic sign, is often present. Urine should be examined to investigate the possible simultaneous abuse of other drugs. Blood levels are generally useful only in acute poisoning. Tolerance develops to barbiturates, though less quickly than to opioids. Tolerance to the psychological effects of barbiturates is greater than tolerance to the depressant effects of these drugs on respiration, thus increasing the risks of unintentional fatal 	overdose.
Abrupt withdrawal of barbiturates from a dependent person can be followed by a withdrawal syndrome resembling that occurring with alcohol. The risk of seizures is high.  With longer-acting drugs, the withdrawal syndrome may be delayed for several days after the drug has been stopped; for this reason observation should be prolonged to ensure that dangerous consequences are avoided. The syndrome of barbiturate withdrawal begins with anxiety, restlessness, disturbed sleep, anorexia, and nausea. It may progress to tremulousness, disorientation, hallucinations, vomiting, hypotension, pyrexia, and major seizures. If the withdrawal syndrome is not treated, some patients die. When drugs are withdrawn as part of treatment, the patient should be admitted to hospital except when the starting dose is small and when there is no history of epilepsy before drug abuse or of recent anti-epileptic medication.  Phenothiazines should not be given because they may lower the seizure threshold. Unless it is certain that the dosage is small, the advice of a specialist should be obtained.
BENZODIAZEPINES. Benzodiazepines cause symptoms of intoxication similar to those of barbiturates (see above).  Tolerance and dependence develop when the drugs are prescribed continuously for a long period. The exact period is uncertain, but 6-8 weeks is widely accepted as the limit without risk.
The benzodiazepine withdrawal syndrome resembles that of barbiturate withdrawal. There is irritability, anxiety, disturbed steep and nausea, increased perceptual sensitivity, and somatic symptoms such as tremor, sweating, palpitations, headache, and muscle pain.  Seizures are less likely in withdrawal from benzodiazepines than in withdrawal from barbiturates, but they can occur when the benzodiazepine has been taken in large amounts. When benzodiazepines are withdrawn therapeutically, the dose is reduced gradually, usually over a period of 4-6 weeks, though longer periods are sometimes used.  Withdrawal symptoms are less pronounced with long-acting than with short- acting benzodiazepines. For this reason some doctors replace a short-acting drug with a long-acting drug in equivalent dose before starting withdrawal.  The dose is reduced, usually in steps of 0.5-2.5 mg per week for diazepam or the equivalent amounts for other benzodiazepines.  If withdrawal symptoms appear during withdrawal, the dose can be increased slightly and then reduced again by a smaller amount than before.  As the dose decreases, it may not be possible to achieve the required dose reduction with the strengths of tablets available; at this stage the drug can be taken on alternate days. Some doctors use a liquid preparation (for example diazepam elixir or nitrazepam syrup) to overcome this problem.  Clonidine (an alpha-2 adrenoceptor agonist) is some- times prescribed to reduce the intensity of the withdrawal effects, as is the beta-adrenergic blocker propranotol, but most patients do not need these additional treatments. Anxiety management techniques help to reduce the distress caused by withdrawal symptoms. They have the advantage that they should reduce the need for anxiolytic medication if anxiety recurs in the future.
STIMULANT DRUGS
The stimulant drugs abused most often are the amphetamines and cocaine.
*   Amphetamine sulfate is taken by mouth or by intravenous injection.
*   Free-base amphetamine (made by heating amphetamine sulfate) is usually smoked and absorbed through the lungs, from which it is absorbed rapidly.
*   Cocaine hydrochloride is taken by sniffing into the nose (where it is absorbed through the nasal mucosa) or by injecting.
*   Free-base cocaine ("crack") is usually smoked to give a rapid and intense effect.
These drugs produce an elevation of mood, hyperactivity, overtalkativeness, insomnia, anorexia, and dryness of the mouth and nose. The pupils dilate, the pulse rate and blood pressure increase, and with large doses there may be cardiac arrhythmia and circulatory collapse. Occasionally patients complain of an unusual feeling like insects under the skin ("formication"). Prolonged use of large quantities of these drugs may result in a paranoid psychosis, closely resembling the paranoid form of schizophrenia, with persecutory delusions, auditory and visual hallucinations, and sometimes aggressive behaviour. This condition usually subsides within a week or two of stopping the drug, but occasionally persists for months. In some of these prolonged cases the diagnosis proves to be schizophrenia, not drug-induced psychosis. Stimulant drugs do not readily induce tolerance.  The withdrawal syndrome is not severe, consisting mainly of low mood and energy; hence physical dependence is not severe although psychological dependence can be. Treatment of overdose requires sedation and the management of any hyperpyrexia or cardiac arrhythmia. Paranoid symptoms can be controlled with an antipsychotic drug.
HALLUCINOGENS
This group of drugs includes synthetic compounds such as lysergic acid diethylamide (LSD) and dimethytryptamine, and naturally occurring substances found in some species of mushroom.  Synthetic and naturally occurring anticholinergic drugs are also abused for their hallucinogenic effects.
The drugs produce distortions or intensifications of sensory perception, sometimes with "crossover" between sensory modalities so that, for example, sounds are experienced as visual sensations. Objects may seem to merge or move rhythmically, time appears to pass slowly, and ordinary experiences seem to have a profound meaning.  The body image may seem distorted or the person may feel as if outside his body.  These experiences may be pleasurable, but at times they are profoundly distressing and lead to unpredictable and dangerous behaviour.  The physical effects of hallucinogens are variable; LSD can cause a rise in heart rate and dilation of the pupils.
Frightening experiences can usually be controlled by strong reassurance; otherwise an anxiolytic such as diazepam should be given. Antipsychotic drugs are also effective but those with anticholinergic effects (such as chlorpro- mazine) must not be given if the patient has taken an anticholinergic drug such as benzhexol or phencyclidine (PCP) which has anticholinergic properties. Flashbacks are recurrences of experiences that occurred originally during intoxication with hallucinogens weeks or months after the drug was last taken.  The experience may be distressing, and may require reassurance and treatment with an anxiolytic drug.  Although flashbacks may recur, they subside eventually. Methylene-dioxy-methamphetamine (MDMA) is an amphetamine derivative known as 'ecstasy'  and is classed as a hallucinogen; it is used to reduce social anxiety and promote aesthetic pleasure.
Phencyclidine, PCP, or angel dust, is a synthetic hallucinogen with particularly dangerous effects.  Intoxication can be prolonged and hazardous, with agitation, aggressive behaviour, and hallucinations, together with nystagmus and raised blood pressure.  With high doses there may be ataxia, muscle rigidity, and convulsions, and in severe cases an adrenergic crisis with heart failure, cerebrovascular accident, or malignant hypothermia.  In treatment, chlorpromazine should be avoided since it may increase the anticholinergic effects of PCP. Haloperidol or diazepam may be given instead.
CANNABIS
Cannabis, which is derived from the plant Cannabis sativa, is taken in two forms. The dried vegetative parts of the plant form marijuana ("grass"); the resin secreted by the flowering tops of the female plant form cannabis resin. In many parts of the world, cannabis is consumed widely, much as alcohol is consumed in the West.  In most Western societies use of cannabis is illegal but widespread. The effects of cannabis vary with the dose, the user's expectations, and the social setting.  Like alcohol, cannabis seems to exaggerate the pre-existing mood, whether euphoria or dysphoria.  It produces a feeling of enhanced enjoyment of aesthetic experiences and distorts experiences of time and space.  Cannabis intoxication can lead to dangerous driving.  The physical effects of cannabis include reddening of the conjunctiva, dry mouth, and tachycardia. Cannabis does not produce a withdrawal syndrome, and although psychological dependence can develop, physical dependence does not seem to occur.  It is not certain whether cannabis causes a psychosis.  Some patients develop an acute psychosis while consuming large amounts of cannabis, recovering quickly when the drug is stopped.  In these cases it is uncertain whether cannabis caused the psychosis, or whether an increased use of cannabis was a response to the early symptoms of a psychosis with a different cause.  Fortunately this uncertainty seldom causes practical problems since the clinical management is unaffected; the drug should be stopped, the progress of the symptoms observed, and chlorpromazine or another antipsychotic drug prescribed if symptoms do not subside within a week.
SOLVENT ABUSE
Abuse of volatile solvents occurs mainly among teenagers, usually as occasional experimentation.  Serious problems arise in a minority who abuse solvents regularly, and any user may take an accidental overdose or become asphyxiated while taking the substance.
The solvents abused most often are cleaning fluids, adhesives, and aerosols.  Petrol butane, and other substances may also be used. The substance is inhaled from a partially closed container in which the concentration can build up, an impregnated cloth, or a plastic bag. Intoxication with solvents resembles that with alcohol: there is slurring of speech, disorientation, uncoordinated gait, nausea, vomiting, and eventually coma.  Some people develop hallucinations which are usually visual and often frightening.  The effects begin and recede more quickly than those of alcohol.  Psychological dependence occurs but physical dependence is unusual.  Chronic heavy users may develop a transient psychosis.
Some of these substances have neurotoxic effects with resultant peripheral neuropathy and cerebellar dysfunction.  Overdose can be fatal, resulting from the direct effects of the drug, or from asphyxia or the inhalation of vomit. Treatment is along the general lines of treatment for drug abuse described above with emphasis on improving any personal or family problems contributing to the abuse.

Lecture: “Psychogenic mental disorders. Classification of psychogenic disorders. Neurotic disorders. Mental disorders in diseases of oral cavity and maxillofacial region.”
   NEUROSIS
   The word neurosis is a convenient collective term for a group of psychiatric disorders which, however severe, do not involve hallucinations, delusions, and loss of insight. Neuroses are functional disorders, that is disorders with no organic pathology.  
   The basic classification of the neuroses is into five groups (Table 1). Each group is subdivided as explained later in this lecture. Neuroses are common, and frequently encountered by doctors working in general practice and general hospitals.
 Table 1.     BASIC CLASSIFICATION OF NEUROSIS.
   Anxiety disorder
   Obsessive-compulsive disorder
   Dissociative and conversion disorder
   Depersonalization disorder
   Hypochondriasis
    ANXIETY DISORDERS.
    As the name suggests, the main clinical features of anxiety disorders are the mental and physical symptoms of anxiety.  Anxiety disorders are classified as follows:
*   generalized anxiety disorders, in which symptoms are persistent, varying little from one situation to another;
*   phobic disorders, in which symptoms are episodic and associated with defined circumstances;
*   panic disorder, in which symptoms are episodic but not associated with defined circumstances.
   Unfortunately there are two differences between ICD 10 and the American classification DSM IV in the way that anxiety disorders are classified (Table 2).  First, in DSM IV obsessional disorders are included under the rubric of anxiety disorders, but in ICD 10 and in this lecture they are classified separately. Second, there is difference in the classification of agoraphobia.
 Table 2.        CLASSIFICATION OF ANXIETY DISORDERS.
    DSM - IV                         ICD - 10
Generalized anxiety disorder         Generalized anxiety disorder
Agoraphobia (without panic)*         Agoraphobia 
                                       (i)  Without panic disorder
                                       (ii) With panic disorder
Social phobia                        Social phobia
Simple phobia                        Specific isolated phobia
Panic disorder without agoraphobia   Panic disorder
Panic disorder with agoraphobia*     
                                     Mixed anxiety and
                                     depressive disorder
Obsessive-compulsive disorder
*  Together equivalent to agoraphobia in ICD 10.
   GENERALIZED ANXIETY DISORDERS.
   Generalized anxiety disorders are frequently seen in general medical practice.  The 1 year prevalence is 25-65 per thousand.
   CLINICAL PICTURE. A person with generalized anxiety disorder has a characteristic appearance.  His face looks strained and his brow furrowed, his posture is tense, and he is restless and often tremulous.  The skin is pale. There is often sweating, particularly from the hands, feet, and axillae. Readiness to tears, which may at first suggest depression, reflects a generally apprehensive state. 
    The psychological symptoms (Table 3) are a feeling of fearful anticipation, irritability, sensitivity to noise, a feeling of restlessness, and difficulty in concentration.  Patients experiencing the effects of reduced concentration may complain of poor memory, but true memory impairment does not occur in an anxiety disorder; if it is present a careful search should be made for an organic syndrome.  Repetitive worrying thoughts are an important part of generalized anxiety disorder. These thoughts are often concerned with sudden illness and the physical symptoms of anxiety.
Table 3.     SYMPTOMS OF GENERALIZED ANXIETY DISORDER.
Psychological     Fearful anticipation           
                           Irritability                   
                           Sensitivity to noise           
                           Restlessness                   
                           Poor concentration             
                           Worrying thoughts              
Physical                                                  
Gastrointestinal        Dry mouth                      
                           Difficulty in swallowing       
                           Epigastric discomfort          
                           Excessive wind                 
                           Frequent or loose motions      
   Respiratory             Constriction in the chest      
                           Difficulty inhaling            
                           Overbreathing                  
   Cardiovascular          Palpitations                   
                           Discomfort in chest            
                           Awareness of missed beats      
   Genitourinary           Frequent or urgent micturition 
                           Failure of erection            
                           Menstrual discomfort           
                           Amenorrhoea                    
   Neromuscular system     Tremor
                           Prickling sensations
                           Tinnitus
                           Dizziness
                           Headache
                           Aching muscles
   Sleep disturbance       Insomnia
                           Night terror
   Other symptoms          Depression
                           Obsessions
                           Depersonalization 
  The physical symptoms of a generalized anxiety disorder result from  hyperactivity of the sympathetic nervous system and from increased tension in skeletal muscles. The list of symptoms is long, and can be grouped conveniently by the systems of the body (Table 3). Symptoms related to the gastrointestinal tract include dry mouth, difficulty in swallowing, epigastric discomfort, excessive wind (caused by aerophagy), borborygmi, and frequent or loose motions.  Common respiratory symptoms include a feeling of constriction in the chest, difficulty in inhaling (which contrasts with expiratory difficulty in asthma), and overbreathing. (The consequences of overbreathing are described below.) Cardiovascular symptoms include palpitations, a feeling of discomfort or pain over the heart, awareness of missed heart beats, and throbbing in the neck.  Common genitourinary symptoms are frequency and urgency of micturition, failure of erection, and lack of libido. Women may complain of increased menstrual discomfort and sometimes amenorrhoea.
   Symptoms related to the neuromuscular system include tremor, prickling sensations, tinnitus, and dizziness (which is not rotational). Some patients complain of blurred vision (their visual acuity is normal) There may be headache, typically in the form of constriction or pressure, which is usually bilateral and often frontal or occipital. Aching, particularly in the back and shoulders, is common.
  It is important to remember that any of these physical symptoms may be the presenting complaint, particularly among patients seen in general practice or hospital.  For example, the complaint may be of palpitation or headache, without any mention of anxiety.  It is also important to remember that each of these physical symptoms may be caused by physical illness. 
  Sleep is disturbed in a characteristic way. On going to bed the patient lies awake worrying; when at last he falls asleep, he wakes intermittently. He often reports unpleasant dreams.  Occasionally he experiences "night terrors" in which he wakes suddenly feeling intensely fearful, sometimes remembering a nightmare and sometimes uncertain why he is so frightened.  In the morning he often feels unrefreshed.  
   Patients with generalized anxiety disorder usually have other symptoms, notably depressive symptoms but also obsessional symptoms and depersonalization.  However, these symptoms are not the major feature of the syndrome.
   Hyperventilation is breathing, usually rapid and shallow, that results in a fall in the concentration of carbon dioxide in the blood.  The resultant symptoms are listed in Table 4. There is also a feeling of breathlessness, which may prolong the condition.  When a patient has unexplained bodily symptoms, the possibility of persistent overbreathing should be considered.  The diagnosis can sometimes be made by watching the pattern of breathing.  Alternatively, the patient may be asked to overbreathe in the doctor's presence to find out whether this leads to the symptoms reported.
    Some patients with generalized anxiety disorder experience occasional panic attacks.  This term denotes sudden episodes of severe anxiety with marked physical symptoms and extreme apprehension. Some panic attacks are caused by involuntary hyperventilation, but others are unexplained (spontaneous). (Panic attacks are more characteristic of panic disorder; in that condition they are more frequent and between attacks there is little anxiety.)
    Table 4.    SYMPTOMS AND SIGNS OF HYPERVENTILATION
    Rapid and shallow breathing
    Dizziness 
    Tininnitus
    Headache
    Precordial discomfort
    Weakness
    Faintness
    Numbness and tingling in the extremities
    Carpopedal spasm
   DURATION OF SYMPTOMS. Generalized anxiety disorder is diagnosed only when the symptoms have been present for several months. In DSM IV the period is specified as 6 months.
   DIFFERENTIAL DIAGNOSIS. Generalized anxiety disorder has to be distinguished from other psychiatric disorders and from physical disorders. Anxiety symptoms can occur in any psychiatric disorder, but with some disorders there are likely to be particular diagnostic difficulties. 
   PROGNOSIS.
   Before the diagnosis of generalized anxiety disorder can be made, the symptoms must have been present for several months (more than 6 months for DSM IV). Recovery is often slow; without treatment up to 80 per cent of sufferers still have the disorder 3 years after the onset.  
   TREATMENT
   Psychological and social treatments are important.  Patients who attribute their symptoms to physical causes are generally less easy to help than those who recognize the emotional basis for their disorder.
Table 5.    TREATMENT PLAN FOR GENERALIZED ANXIETY DISORDER.
Initial treatment
   Exclude concomitant depressive disorder
   Explain nature and cause of symptoms, reassure about specific
   concerns
   If anxiety severe, short-term benzodiazepine treatment
   Give help in solving stressful problems or coming to terms
   with them
Further treatment
   Relaxation training; respiratory control if hyperventilating
   Continue problem solving
   If anxiety still severe, consider tricyclic antidepressant
   Consider specialist referral for anxiety management training
   SUPPORTIVE AND SOCIAL MEASURE. General practitioners see many patients with anxiety of shorter duration than the 6 months needed to make a formal diagnosis of generalized anxiety disorder.  At this early stage the formal diagnosis is ADJUSTMENT DISORDER, and the appropriate measures are discussion and reassurance. Anxiety is prolonged by uncertainty, and can be reduced by a clear treatment plan (Table 5). These measures are also important for patients with prolonged symptoms, but additional measures are likely to be needed.
   PSYCHOLOGICAL TREATMENT is most important. It includes behavioral therapy: relaxation training in a group may improve motivation, and some patients prefer to relax as part of yoga exercises.  Some family doctors provide relaxation groups for their patients. It is necessary to treat  HYPERVENTILATION. It can be reduced in two ways. To terminate an acute episode, the patient should rebreathe expired air from a paper bag, thereby increasing the alveolar concentration of carbon dioxide. Rebreathing during an episode is also an effective way of demonstrating that some symptoms are caused by hyperventilation. To prevent further episodes of hyperventilation, patients should practice slow controlled breathing, first under supervision and then at home. COGNITIVE therapy is designed to enable patients to give up their fearful concerns by questioning the underlying logic, and to develop more rational ways of thinking about provocative situations. Because cognitive therapy requires special training, patients judged suitable should be referred to a psychiatrist or clinical psychologist.
   TREATMENT WITH DRUGS. Although anxiolytic drugs bring symptoms under control quickly, they should not be used for long because patients may become dependent on them. Therefore they should be reserved for brief exacerbations of symptoms and not used continuously. In generalized anxiety disorders a long-acting benzodiazepine is appropriate, for example diazepam in a dose ranging from 5 mg twice daily in mild cases to 10 mg three times daily in severe cases.  Barbiturates should not be used because they are more likely to cause dependence.  Beta-adrenergic antagonists have a limited use for controlling severe palpitations in the occasional patients for whom these symptoms are the most troublesome.
  Tricyclic antidepressants and related compounds are used to treat generalized anxiety disorders in two circumstances: first when there is an associated depressive disorder, and second when long-term anxiety has to be controlled. No one antidepressant is definitely more effective then the rest. Amitriptyline is often used as an inexpensive, safe, and well-tried drug (75-100 mg of amitriptyline is usually adequate). 
   Monoamine oxidase inhibitors have also been used for the two purposes described under tricyclic antidepressants above. Because they interact with some drugs and foodstuffs, monoamine oxidase inhibitors should be used only in patients for whom other drugs and psychological treatments have been tried without success.
   PHOBIC ANXIETY DISORDERS.
   Phobic anxiety disorders produce the same symptoms as generalized anxiety disorders but occur only in specific circumstances. In some phobic disorders there are few such circumstances, and the patient is free from anxiety most of the time; in others there are many such circumstances, and the patient is anxious more often. Two other features characterize phobic disorders:  avoidance of circumstances that provoke anxiety, and anticipatory anxiety when there is the prospect of meeting such circumstances.  Anxiety-provoking circumstances include situations (for example crowed places), living things (for example spiders), and natural phenomena (for example thunder). For clinical purposes it is usual to recognize three principal groups of phobic disorder:  simple phobia, social phobia, and agoraphobia. These common syndromes will be described next; less common phobic syndromes will be mentioned later.
   There is one difference between ICD 10 and DSM IV in the classification of phobias. In DSM IV agoraphobic patients with regular panic attacks are classified under panic disorder with secondary phobic symptoms; in ICD 10 they are classified under agoraphobia.  Panic is given this diagnostic importance in DSM IV because it is thought to be the primary disorder.
   SIMPLE PHOBIA
   A person with a simple phobia is inappropriately anxious in the presence of a particular object or situation, and tends to avoid it. Any of the anxiety symptoms described above may be experienced. The urge to avoid the stimulus is strong, and in most cases there is avoidance. The prospect of experiencing the stimulus provokes anticipatory anxiety; for example, a person who fears storms may become anxious when there are black clouds.
   Simple phobias are often classified by adding the name of the stimulus, for example spider phobia.  Sometimes terms such as arachnophobia (to denote spider phobia) or acrophobia (to denote phobia of heights) are used, but this is an unnecessary complication.  The following varieties of simple phobia are common clinical problems and require separate comment.
*    Phobia of dental treatment. About 5 per cent of adults have      specific fears of dentistry which can be so severe that all dental treatment is avoided and serious caries develops.
*    Phobia of flying. Anxiety during aeroplane travel is common. A few      people have such intense fear that flying is totally avoided.  This fear occurs occasionally among pilots, usually following a serious accident while flying.
*    Phobia of excretion. Some patients become anxious when attempting to pass urine in public lavatories. Others have frequent urges to pass urine when away from home; they fear incontinence and they arrange their lives so as never to be far from a lavatory.  A few patients have similar symptoms concerning defecation.
*    Phobias of vomiting. Some patients fear that they may vomit in a public place, such as a bus or train, or that other people may do so.
       Many people have simple phobias but very few seek medical help.  The lifetime prevalence is probably 40-150 per thousand for men and 90-260 per thousand for women.
   DIFFERENTIAL DIAGNOSIS.  The possibility of an underlying depressive disorder should be kept in mind, since some patients seek help for longstanding simple phobias when a depressive disorder makes the phobic symptoms less tolerable.  Otherwise the diagnosis is usually straightforward.
   PROGNOSIS. There has been no systematic study of prognosis. Clinical experience indicates that simple phobias starting in childhood continue for many years, whilst those starting after a stressful experience in adult life have a better prognosis.
   TREATMENT RESULTS. The exposure form of behaviour therapy generally gives good Such treatment is straightforward but time consuming. Most general practitioners arrange treatment with a clinical psychologist.
   SOCIAL PHOBIA. Social phobia is inappropriate anxiety occurring when a person is observed and could be criticized by others (Table 6). 

Table 6. SITUATIONS FEARED AND AVOIDED BY PATIENTS WITH SOCIAL PHOBIAS.
Common theme
   Being observed and open to criticism
Examples
   Committees, seminars
   Eating or drinking in public
   Social gatherings
   Writing or performing in front of others
   Such situations are avoided, wholly or in part, and there is anticipatory anxiety at the prospect of entering them. Partial avoidance involves, for example, entering a social group but failing to make conversation by sitting in an inconspicuous place. People with social phobia have specific concerns about being observed critically by other people. They realize that this concern is irrational. Alcohol may be taken to relieve anxiety, and alcohol abuse is more common among social phobias than among people with other phobias. 
   DIFFERENTIAL DIAGNOSIS. Social phobia should be distinguished from generalized anxiety disorder (distinguished by the pattern of situations in which anxiety occurs) and from depressive disorder or schizophrenia (both distinguished by the finding of characteristic symptoms on mental state examination). It also has to be distinguished from personality disorders characterized by lifelong shyness and lack of self-confidence; the distinguishing feature is that social phobia has a recognizable onset and a shorter history. Social phobia has to be distinguished from social inadequacy. Patients with social phobia possess these basic social skills, though they may be unable to use them because of severe anxiety. 
   PROGNOSIS. There is no systematic information on the long-term course of social phobia. Clinical experience suggests that the condition persists for many years, eventually improving in mid-life.
   TREATMENT.  Anxiolytic drugs can provide short-term relief for patients who request urgent help in dealing with an important social situation.  These drugs should not be used regularly because of the possibility of dependency. Most patients respond to cognitive behaviour therapy in which exposure to feared situations is combined with measures to reduce the patient's concerns that others are evaluating him critically.
   AGORAPHOBIA.
   CLINICAL FEATURES. Agoraphobic patients are anxious when they are away from home, in crowds, or in situations that they cannot leave easily (Table 7). They usually fear open spaces and social situations. The symptoms are those of generalized anxiety disorder, together with a varying combination of depression and depersonalization. As in the other phobic disorders, there is avoidance of anxiety-provoking situations and also anticipatory anxiety.
 Table 7.     SITUATIONS FEARED AND AVOIDED BY AGORAPHOBICS.
    Common themes          
          Distance from home
          Crowding
          Confinement
          Open spaces
          Social situation
    Examples
          Public transport
          Crowded shops
          Empty streets
          School visits
          Cinemas, theatres                                                                                             
   Two groups of anxiety symptoms are particularly frequent in agoraphobia.  First, panic attacks occur both in response to environmental stimuli and spontaneously. Second, anxious thoughts about fainting and loss of control are frequent among agoraphobic patients.   
Many situations provoke anxiety and avoidance (Table 7). As explained above, there are certain common themes, particularly distance from home, crowding, and confinement. Specific situations include buses and trains, shops and supermarkets, and places that cannot be left suddenly without attracting attention, for example the hairdresser's chair or a seat in the middle of a row at the cinema.  Two other themes occur less commonly: open spaces (for example, parks and open country), and social situations (for example talking at a party or in front of a group of strangers). As the condition progresses, patients avoid more and more of these situations until in severe cases they may be more or less confined to their homes. The effect of these situations may be reduced in several ways.  Most patients are less anxious when accompanied by a trusted companion, and some are helped by the presence of a child, a pet dog, or even a reassuring object such as a bottle of tablets (which are not taken).  These effects can produce an apparently inconsistent clinical picture which suggests, wrongly, that the person is exaggerating his true disability.
   Anticipatory anxiety is common.  In severe cases this anxiety can appear several hours before the person has to enter a feared situation, thus adding greatly to the patient's distress. Symptoms of depression and depersonalization are common, and  obsessional symptoms occur in some cases.
   Agoraphobia begins mainly in the early or middle twenties, with a further period of high onset in the mid-thirties. Occasionally the symptoms begin soon after childbirth. The 6 months prevalence of agoraphobia is 30-60 per thousand, with the rate for women being twice that for men.
   DIFFERENTIAL DIAGNOSIS. Agoraphobia has to be distinguished from generalized anxiety disorder, social phobic disorder, depressive disorder, and paranoid disorder. When DSM IV is used for classification, agoraphobia without panic has to be distinguished from agoraphobia with regular panic attacks, which is diagnosed as a form of panic disorder. 
   PROGNOSIS.   When agoraphobia has been present continuously for a year, it is likely to persist for at least 5 years.  Brief episodes of depressive symptoms often occur in the course of chronic agoraphobia.
   TREATMENT. Since avoidance is the most important factor maintaining agoraphobia, patients should be encouraged strongly to return to the avoided situations (a procedure known as exposure).  Exposure should begin with the situations that provoke least anxiety, and should proceed to a graded series of situations that provoke increasing anxiety (a "hierarchy"). When patients enter one of these situations they feel anxious at first; however, as they remain in the situation, anxiety subsides. It is essential that patients stay in the situation until anxiety has subsided; if they leave, the experience may increase rather than diminish the phobic response when the situation is encountered again.
   Table 8.        TREATMENT PLAN FOR AGORAPHOBIA
     Assess severity; obtain specialist help for severe cases
     Prepare a hierarchy
     Teach coping skills, including relaxation
     Anxiolytics only for essential commitments and initial attempts at 
      exposure
     Imipramine for spontaneous panic attacks
     Specialist advice if progress is limited
   Some patients with agoraphobia have panic attacks which are spontaneous; such unpredictable attacks may interfere with the orderly sequence of exposure treatment. The panic attacks can usually be controlled by giving imipramine, and exposure can then continue.  Imipramine is chosen because its effects have been tested thoroughly in clinical trials, but other tricyclics seem to have similar effects, as do monoamine oxidase inhibitors. If the patient does not improve with the above treatment or if the condition is severe, specialist advice should be sought because more intensive cognitive - behaviour therapy will usually be effective.
   PHOBIAS OF ILLNESS. Some patients experience repeated fearful thoughts that they may have cancer, venereal disease, or some other serious illness.  Such thoughts are obsessional or hypochondriacal symptoms and not true phobic disorders, though they may be associated with avoidance of hospitals.
   PANIC DISORDER.
   CLINICAL FEATURES. The symptoms of a panic attack are listed in Table 9. Important features of panic attacks are that anxiety builds up quickly, the response is severe, and there is fear of a catastrophic outcome. The diagnosis of panic disorder is made when the attacks occur unexpectedly (i.e. not in response to a known phobic stimulus) and when they are repeated. (For DSM IV diagnosis there must be more than four attacks in four weeks, or one attack followed by four weeks of persistent fear of another attack.) Panic disorder patients often seek advice from general practitioners, cardiologists, and other physicians for complaints of palpitations and fears of heart disease.
   Table 9.     SYMPTOMS OF A PANIC ATTACK
         Palpitations
         Dyspnoea 
         Chest discomfort
         Sweating
         Trembling
         Dizziness or fainting
         Flushing
         Nausea
         Fears of impending death, loss of control, or madness
         Depersonalization
   The prevalence of panic disorder is about 6-10 per thousand, with the prevalence in women being about twice that in men.  Some people experience frequent panic attacks, but do not meet the criteria for panic disorder; they number about 30 per thousand.
   DIAGNOSIS. Panic attacks occur in many other conditions, notably generalized anxiety disorders, phobic anxiety disorders (particularly agoraphobia), and depressive disorders, and during alcohol withdrawal.
   PROGNOSIS
   Systematic follow-up data have not been reported, but clinical observation indicates that some patients recover within weeks whilst others (those whose symptoms persist for 6 months) usually have a prolonged and often fluctuating course.
   TREATMENT
   Panic disorder can be treated psychologically or with drugs.  A doctor who sees the patient soon after a first panic attack should attempt to prevent progression to panic disorder by giving specific reassurance about any concerns that may develop.  
   If the patient has an established panic disorder, drug treatment can be used to suppress the panic attacks. Benzodiazepines can be used but doses need to be high and usually continued for several months, with the consequent problem of withdrawal symptoms and the potential problem of dependency when the drug is stopped. Alprazolam, a high potency benzodiazepine, has been recommended because in high doses it is less likely than diazepam to cause sedation.  Up to 6 mg per day of alprazolam may be needed to suppress panic attacks (equivalent to about 60 mg of diazepam). Such high doses should be built up gradually over 2-3 weeks and withdrawn slowly over about 6 weeks.   Alternatively, the antidepressant drug imipramine can be used.  It appears to be as effective as benzodiazepines in reducing panic attacks, seldom gives rise to withdrawal symptoms, and does not cause dependency. But, it does cause more side-effects. The most effective psychological treatment for established panic disorder is a form of cognitive therapy, a specialized treatment requiring referral to a clinical psychologist or psychiatrist. 
   OBSESSIVE-COMPULSIVE DISORDER
   CLINICAL PICTURE.
   Obsessive-compulsive disorder is characterized by obsessional thinking, compulsive behaviour, and varying degrees of anxiety, depression, and depersonalization.
  Obsessional thoughts are words, ideas, and beliefs, recognized by the patient as his own, which intrude in a compelling way into the patient's mind and which he tries to exclude.  It is the combination of being compelled to have the thoughts and of resisting them that characterizes obsessional thinking.  Obsessional thoughts may be single words, phrases, or rhymes; to the patient they may be unpleasant, shocking, obscene, or blasphemous.  Obsessional images have the same characteristics of intrusion and resistance but are experienced as vivid scenes, often violent or disgusting, involving for example abnormal sexual practices.  Obsessional ruminations are internal debates in which arguments are reviewed endlessly.
   Obsessional doubts are thoughts about actions that may have been completed inadequately, such as failing to turn off a gas tap completely, or about actions that may have harmed other people, for example, the idea that the patient might have driven past a cyclist and caused an accident without noticing.  Doubts are often related to religious observances.
  Obsessional impulses are urges to perform acts, usually of a violent or embarrassing kind, for example leaping in front of a car, injuring a child, or shouting blasphemies in church.  The urges are resisted strongly and are not carried out, but the internal struggle may be very distressing.
  Obsessional rituals include mental activities such as counting repeatedly in a special way or repeating a certain form of words, and repeated but senseless behaviour such as washing the hands 20 or more times a day. Some rituals have an understandable connection with obsessional thoughts preceding them, for example repeated handwashing following thoughts about contamination.  Other rituals have no such obvious connection; for example, routines concerned with laying out clothes in a complicated way before dressing may follow obsessional symptoms of an unconnected kind. Patients are aware that their rituals are illogical and usually try to hide them. Many have fears that their symptoms are a sign of a serious and progressive mental illness; such fears are often helped by reassurance about their true nature.
   Anxiety is an important component of obsessive-compulsive disorders; it usually falls temporarily after a ritual has been performed but occasionally the reverse happens.  Obsessional patients are often depressed. In some, depression seems to be an understandable reaction to the obsessional symptoms: other patients have recurring depressive moods that arise independently of the other symptoms.  Finally, some patients experience depersonalization.
   The obsessional personality is described in the next lecture. Obsessional personality and obsessive-compulsive disorder does not have a simple one-to-one relationship.  Obsessional personality is over-represented among patients who develop obsessive-compulsive disorder, but about a third of patients with this disorder have other types of personality. 
   Obsessive-compulsive disorders are much less frequent that anxiety neuroses. Estimates of 1 year prevalence vary from 0.I to 2.3 per thousand, with men and women affected about equally.
   DIFFERENTIAL DIAGNOSIS
   Obsessive-compulsive disorders have to be distinguished from other disorders in which obsessional symptoms occur. The distinction from generalized anxiety disorder, panic disorder, or phobic disorder should seldom be difficult provided that a careful history and mental state examination are available. The differentiation from depressive disorder is less easy because the course of obsessive-compulsive disorder is often punctuated by periods of depression, but a history of the course of the disorder will usually make the diagnosis clear.  
    PROGNOSIS
   About two-thirds of patients improve within a year; the remaining third run a prolonged and usually fluctuating course with periods of partial or complete remission lasting from a few months to several years. Prognosis is worse when the personality is obsessional, the symptoms are severe, and stressful circumstances persist.
    TREATMENT
   Patients with obsessional-compulsive disorders often fear that they are developing a more serious mental disorder. Therefore it is important to explain that obsessive-compulsive disorder does not progress in this way, and that the patient is unlikely to act on any impulses that he is resisting. It is also important to explain that great effort should be made to resist the urge to carry out rituals, since these maintain the disorder. With the patient's agreement it is appropriate to give these explanations to one or more family members so that they can help the patient to resist urges to carry out rituals.  Obsessive-compulsive symptoms may be provoked by stressful circumstances, including any that provoke unexpressed anger.  It is often helpful to discuss these circumstances, and to suggest ways of dealing with them or avoiding them.
  Table 10. MANAGEMENT PLAN FOR OBSESSIVE-COMPULSIVE DISORDER
   Explain the nature of the disorder
   Discourage performance of rituals
   Reduce stressors if possible
   Anxiolytics only for short-term relief; antidepressants if 
    concurrent depressive disorder
   5HT-uptake blocker to suppress symptoms
   Behaviour therapy if no progress or the condition is initially severe
   Drug treatment is considered next.  There are three possibilities: anxiolytics, general antidepressants, and 5HT-uptake blockers.  Anxiolytic drugs are useful for short-term relief of the distress associated with obsessional symptoms but should not be prescribed for more than a few weeks.  When there is an associated depressive disorder, treatment with antidepressant drugs usually leads to improvement in obsessive-compulsive symptoms.  When there is no depressive disorder, amitriptyline and related antidepressants are useful only for their anxiolytic actions.
   DISSOCIATIVE AND CONVERSION DISORDERS
   In dissociative and conversion disorders the predominant symptoms are physical. The term "conversion" relates to the idea that anxiety has been replaced by ("converted into") physical symptoms.  The term "dissociative" relates to the idea that symptoms result from a lack of coordination of different psychological functions.  An alternative name for these disorders is hysteria.  The term "hysteria" is also still in use in clinical practice.   
   Unfortunately, the usage of these terms varies between DSM IV and ICD 10. In DSM IV the term conversion disorder is used to denote only those psychologically determined disorders that have physical symptoms as their principal manifestation, whilst the term dissociative applies to psychological symptoms such as amnesia.  In ICD 10 both physical and psychological manifestations are called dissociative disorders.  
   DISSOCIATIVE (AND CONVERSION) SYMPTOMS AND SYNDROMES 
A dissociative (or conversion) symptom suggests physical illness but occurs in the absence of relevant physical pathology, and is produced through unconscious psychological mechanisms.
   The prevalence of dissociative and conversion disorder varies between countries, and is probably greater in less industrialized societies. In Western societies the prevalence is three to six per thousand women and substantially less for men.  
   GENERAL FEATURES OF THE CLINICAL PICTURE
   Dissociative and conversion symptoms can be regarded as the result of a breakdown in the normal conscious control over the selection of movement, ensory input, and memory.
   Although dissociative and conversion symptoms are not produced deliberately, they are nevertheless shaped by the patient's concepts of illness. 
   The symptoms of dissociative and conversion disorder usually confer some immediate advantage on the patient (though in the longer term they do the reverse).  This idea of advantage is expressed in the term "secondary gain" (as against the primary gain of not feeling anxious, the physical symptoms having taken the place of anxiety). An example of secondary gain is the advantage that conversion disorder with paralysis might confer by exempting a patient from taking part in the stressful care of an elderly relative.
   Patients with dissociative and conversion symptoms often show a striking lack of distress despite their physical symptoms. This lack of distress is sometimes called "belle indifference".
  TYPES OF DISSOCIATIVE (OR CONVERSION) DISORDER
The various types of dissociative disorder are summarized in Table 11.
Table 11.  MOTOR AND SENSORY DISSOCIATIVE (OR CONVERSION) DISORDERS
   Motor disorders
      Paralysis of voluntary muscles
      Disordered gait
      Tremor and tics
      Aphonia and mutism
      Convulsions
   Sensory disorders
      Hyperaesthesia and paraesthesia
      Anaesthesia
      Pain*
      Blindness and tunnel vision
      Deafness
 * Extra caution in diagnosis (see text)
   MOTOR DISORDERS.
   Motor disorders include paralysis of voluntary muscles, tremors, tics, and abnormalities of gait. Reflexes are not altered (in particular, the plantar response is flexor) and there is no wasting except for disuse atrophy which has been reported in rare chronic cases. With rare exceptions, contractions do not occur. Dissociative disorders of gait are usually striking and unlike any gait disorder of neurological origin; also, they worsen when the patient is observed.
   Psychogenic tremor is coarse and involves the whole limb. It worsens when attention is drawn to it, but so do many tremors with neurological causes.  Psychogenic tics also occur. Disease of the nervous system should be considered carefully for all tremors or tics. Dissociative disorders with aphonia and mutism are not accompanied by any disorder of the lips, tongue, palate, or vocal cords, and the patient is able to cough normally.
   Dissociative convulsions (a "hysterical fit") differ from epilepsy in three ways. First, the patient does not become unconscious, although he may appear inaccessible; second, the pattern of movements is not regular and stereotyped as in a seizure; third, there is no incontinence, cyanosis, or injury, and the tongue is not bitten.  EEG findings are normal.  Occasionally complex partial seizures (temporal lobe epilepsy) are difficult to distinguish from psychogenic convulsions, but continuous EEG monitoring will often reveal whether there are changes when the behaviour is abnormal.
   SENSORY DISORDERS
   Sensory symptoms of dissociative (or conversion) disorder include anaesthesia, paraesthesiae, hyperaesthesiae, pain, deafness, and blindness. In general, the sensory changes are distinguished from those in organic disease by their distribution, which does not conform to the known innervation of the part, their varying intensity, and their responsiveness to suggestion. Anaesthesia does not follow anatomical patterns (anesthesia of the "glove" or "sock" type). Chronic pain should be regarded as a dissociative (or conversion) symptom only after a most thorough search for organic causes.
   Dissociative tunnel vision may occur.  Psychogenic blindness presents as reported inability to see.  The condition is not accompanied by changes in pupillary reflexes, whilst visual evolved responses are normal.  There may be indirect evidence that the person can see more than he reports; for example, he may avoid bumping into furniture.  Similar considerations apply to psychogenic deafness.
    DIFFERENTIAL DIAGNOSIS OF DISSOCIATIVE AND CONVERSION DISORDERS
   It is most important to exclude organic disease of the central nervous system, but often difficult to do so; from the demonstrative presentation of physical symptoms by some people with a histrionic personality (so-called "hysterical overlay" or "functional overlay").
    Dissociative or conversion disorders (which develop unconsciously) have to be distinguished from malingering, i.e. feigning illness deliberately to avoid something unpleasant or to gain compensation.  
   PROGNOSIS. Most patients with dissociative and conversion disorders of recent onset seen in general practice or hospital emergency departments recover quickly.  Those cases that persist for longer than a year are likely to continue for many more years.  As mentioned above, organic disease may be present but undetectable when patients are first seen, becoming obvious later.  For this reason patients should be followed-up very carefully.
   TREATMENT.
   When acute dissociative or conversion disorders present in general practice or hospital casualty departments, they usually respond to efforts to resolve any provoking stressful circumstances combined with strong suggestion that the symptoms will recover. When the disorders persist, the general approach is similar though the results are loss satisfactory.  It should be explained to the patient that the disability is caused not by a physical disease but by an interference with conscious control over action, perception, or memory.  The patient should be advised that repeated and determined efforts to produce the action, perception, or memory will succeed in restoring control. Practice can be encouraged by some form of physiotherapy.  Otherwise attention is directed away from the symptoms and towards the problems that have provoked the disorder.
 Table 13. MANAGEMENT PLAN FOR DISSOCIATION (OR CONVERSION) DISORDER
   Explain psychological origin of symptoms
   Resolve stressors if possible
   Encourage function by suggestion and graded exercises
   Follow-up for unrevealed organic illness
   The staff should show concern for the patient, but also encourage self-help; for example, a patient with a dissociative disorder of gait should be encouraged to walk unaided and should not be offered a wheelchair.  To achieve these ends, there must be a clear plan and a consistent approach by all staff.
   MEDICATION
   Drug treatment has no part to play in the treatment of these conditions, except when conversion symptoms are secondary to a depressive disorder that requires treatment.
  DEPERSONALIZATION DISORDER.
   Depersonalization disorder is characterized by an unpleasant state in which external objects or parts of the body are experienced as changed in quality, unreal, remote, or automatized.  The patient is aware of the subjective nature of this experience.
   CLINICAL PRESENTATION
   As well as describing feelings of being unreal and experiencing an unreal quality to perceptions, patients report that their emotions are dulled and their actions feel mechanical.  They no longer experience strong emotions such as love, hatred, anger, or pleasure; paradoxically, they complain that this lack of feeling is extremely unpleasant.  They retain insight into the subjective nature of the experiences.  These symptoms may be accompanied by anxiety, depression, deja vu, and changes in the experience of passage of time.  Some patients complain of sensory distortions affecting parts of the body, such as the head, the nose, or limbs, which may be described as feeling as if made of cotton wool.  Two-thirds of the patients are women.  The symptoms usually begin suddenly, often in adolescence or early adult life.
   TREATMENT
   If depersonalization symptoms are secondary to another condition, treatment should be directed to that primary cause.  Treatment of primary depersonalization is difficult.  An anxiolytic drug may give temporary relief at times when symptoms have increased, but the drug should not be continued for long because of the risk of dependency.  Other drugs are not usually effective.  Behaviour therapy and psychotherapy have no specific value, although patients may be helped by supportive interviews, and by reducing stressful events in their lives.