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MINISTRY OF HEALTH OF UKRAINE
BUKOVYNIAN STATE MEDICAL UNIVERSITY
“Approved”
on the methodical meeting
of the Department of neurology, psychiatry
and medical psychology nm. S.M.Savenko
“____” ___________ 2009 (Report № __).
Chief of the Department
_______________________
Professor V.M. Pashkovsky
METHODICAL INSTRUCTION
for 4-th year students of medical faculty №2
(the speciality “medical affair”)
for independent work during preparing to practical class
Theme 22: STRESS-RELATED PSYCHOSIS.
MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY
TOPICAL MODULE 5. NEUROTIC, STRESS-RELATED AND SOMATOFORM
DISODERS.
Сhernivtsi, 2009
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1. ACTUALITY OF THEME:
Doctors see many patients with emotional or other symptoms that are reactions to stressful
experiences. Although such reactions in most cases are not severe enough to be diagnosed as mental
disorders, they are distressing enough to require help and, if no help is given, they may worsen and
develop into mental disorders. Therefore it is important to understand the nature of reactive
psychosis (stress-related psychosis) and to be able to provide appropriate treatment.
Reactive psychosis (stress-related psychosis) – transitory disoders of psychical activity
result in psychical trauma. In it clinical picture symptoms of psychotic level are present.
2. DURATION OF PRACTICAL CLASSES - 2 HOURS.
3. EDUCATIONAL PURPOSE
3.1. To know:
1. The notion emotional stress, psychical trauma.
2. Criteria of Karl Jaspersa.
3. Classification of reactive states.
4. Clinical manifestations of reactive states.
5. Features of passing of reactive psychosis.
6. Differential diagnosis of reactive states.
7. Treatment and prophylactic of reactive psychosis.
8. Expertise of reactive psychosis.
3.2. Able:
1. To collect anamnesis in patient with reactive psychosis.
2. To diagnose and conduct differential diagnosis of reactive states.
3. To give urgent help at shock reactions after extreme situation.
4. To use methods of treatment of reactive psychosis.
5. To conduct prophylactic of reactive disoders.
6. To conduct prophylactic of panic.
3.3. To capture practical skills:
1. To give urgent help at psychogenic stupors.
2. To give urgent help at fugiform excitement.
3. To give urgent help at psychogenic delirium.
4. INTERSUBJECT INTEGRATION (base level of preparation).
Names of previous disciplines
1. Anatomy of human
Skills are got
1. To know structure of brain.
2. General and medical psychology.
2. Determine type personality. Determine criteria of
clear consciousness.
3. Determine type HNA.
3. Normal and pathologic physiology.
5. ADVICES TO STUDENTS.
5.1. CONTENTS OF THEME.
The symptoms of psychogenic disorders can be productive (delusions and hallucinations,
etc.) and negative. To differentiate psychogenic productive symptoms from other similar
manifestations the famous psychiatrist and psychologist Karl Jaspers suggested the following
diagnostic criteria:
1) the disorder develops following a psychological trauma;
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2) the contents of the patient's experiences (e.g. delusions) proceeds from the nature of the
stressful event and there is psychologically understandable association between them;
3) all the course of the disorder is associated with the traumatic situation, and its
disappearance or de-actualization promotes the cessation (or improvement) of the disorder.
Psychiatrists have long recognized that otherwise well-functioning people may develop
psychotic symptoms when they are confronted with overwhelming stress. In certain cultures,
symptoms conform to certain patterns that are recognized by the individual's group as a valid signal
of the person's distress. In Western society, several forms of presentation of brief reactive psychosis
have been described, and terms such as reactive psychosis, psychogenic psychosis, and hysterical
psychosis have all been applied to basically similar reactions.
Unfortunately, a tendency to lump all “psychotic” disorders together has interfered with the
recognition and understanding of brief reactive psychosis and has often stood in the way of
appropriate treatment. For example, the term “3-day schizophrenia” has been used to describe brief
psychotic illnesses such as those seen in young soldiers involved in combat operations in the South
Pacific during World War II. On occasion, massive doses of psychotropic drugs were used, and the
remarkable clearing of symptoms was subsequently attributed incorrectly to the drug therapy.
Symptoms and Signs
Reactive psychosis subdivided into three groups: acute, subacute and prolonged.
I. Acute reactive psychosis: twilight state; reactive stupor; reactive confusion; reactive
paranoid.
Acute twilight state – appears on the background of fear with mimic and vegetative signs,
panic flight from place, where happened any unhappy event (catastrophe, traffic accident, place of
death). It has duration from 1 hour to 1 day.
Acute reactive stupor – that state from oligokinesia to total absence of movements. Mutism
(muteness) is revealed often too. It has duration from several hours to 3 days.
Acute reactive confusion – that state twilight disoder of consciousness with psychomotor
excitement, fear, constantly verbal production.
Acute reactive paranoid – develops acutely with fear, anxiety, paranoid ideas of relation
and persecution. The components Kandinski-Clerambault’s syndrome may be (syndrome of psychic
automatism).
II. Subacute reactive psychosis (hysteric psychosis): hysteric twilight state;
pseudodementia; Ganser’s syndrome; hysteric regress of psychic; hysteric stupor; like-mirage
syndrome.
Clinical picture of pseudodementia: patients are giving wrong answers especially, not
right fulfilling simple action, usually all actions they are making inside out (white colour they name
black colour etc.), exaggeratedly mood and foolish.
Other subacute reactive psychosis are found rarely.
III. Prolonged reactive psychosis: reactive depression (paranoid depressive, asthenic
depressive and hysteric depressive forms) and reactive paranoid.
Brief reactive psychoses may take many forms, but they always have certain features in
common. First, there is a precipitating stress. This may be quite obvious, eg, an automobile
accident, natural catastrophe, combat, or the sudden death of a loved one. In other patients, the
precipitating event may not be immediately apparent to an outside observer who is unaware of the
psychologic significance of the event to the patient. The patient's personality structure is an
important consideration in determining how much stress is necessary to precipitate a psychotic
reaction. Patients with certain personality disorders (eg, histrionic or borderline personality) may be
prone to develop psychotic symptoms more easily. It should be noted that the psychosocial stressor
must be sufficiently severe to provoke signs of distress in almost anyone in order for the diagnosis
of brief reactive psychosis to be warranted.
The second feature common to reactive psychoses is abrupt onset of symptoms, often within
a few hours of the precipitating event. There is no history of a gradually developing prodrome, as is
often seen in schizophreniform disorder or schizophrenia.
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The psychotic symptoms themselves may be of various types. Delusions, hallucinations
(auditory hallucinations are common but visual hallucinations occur occasionally), loose or
disconnected verbalization, and bizarre and disorganized behavior are all possible. These symptoms
are often dramatic and florid and are usually thematically related to the precipitating event.
Natural History and Prognosis
The duration of the disorder is brief (no longer than 2 weeks), and there is no residual
deficit. However, many patients will have repeat episodes in response to future stresses, especially
if a basic personality disorder leads to a maladaptive life-style that subjects the individual to
intolerable situations.
Differential Diagnosis
Brief reactive psychosis may be distinguished from various other mental disorders. The
presence of toxic factors, such as withdrawal from alcohol or drugs, should be ruled out by
appropriate history taking, physical examination, and laboratory tests. Schizophreniform disorder
generally lasts longer than 2 weeks, and this diagnosis may be considered if symptoms persist. If
prominent affective symptoms are present after 2 weeks, a diagnosis of affective or schizoaffective
disorder may be warranted. In schizophrenia, the patient should show signs of a chronic disorder
without a return to the level of functioning seen before the onset of illness. Some schizophrenic
patients with chronic, low-level symptoms may experience a brief worsening of psychotic
symptoms in response to stress; this should not be diagnosed as brief reactive psychosis. If no
precipitating event can be identified but symptoms clear within 2 weeks, a diagnosis of atypical
psychosis may be appropriate. Transient psychotic symptoms may be present in patients with
borderline or schizotypal personality disorders, but these are fleeting and not associated with a clear
psychosocial stressor. A few patients may present with factitious symptoms or may be outright
malingerers.
Etiology and Pathogenesis
Brief reactive psychosis is thought to be mainly psychologic in origin (rather than social or
biologic), although the latter factors probably contribute. When confronted with a stressful
situation, the natural response is to use familiar problem-solving behavior patterns either to achieve
a resolution or to maintain psychologic equilibrium until external events change. If an individual's
usual coping strategies are not effective, anxiety increases. Psychotic symptoms may emerge when
the patient's psychologic defenses are completely overwhelmed. How much stress is necessary to
reach this point is partly determined by the patient's structure of defenses. For some patients, only
chaotic events such as natural disasters or combat experiences are severe enough to upset the
equilibrium; other people may be overwhelmed by divorce, physical illness, or financial disaster.
Some patients with character defects (personality disorder) may be unable to cope with transitions
or disappointments that most other people would be able to handle, even though they might find
them unsettling.
Besides signaling psychologic collapse, brief reactive psychosis may provide secondary gain
for the patient and may become a regular method of evading responsibility or unpleasant
circumstances in the future. The dramatic psychotic symptoms make it clear to others that the
patient is helpless. Since the symptoms are accepted as part of legitimate illness and not as evidence
of shirking, others can rush in to the rescue without having any negative feelings toward the patient.
In patients confronted with a chronically intolerable situation, occasional emotional collapses when
the situation gets worse provide a brief escape.
Treatment
A. Drug Treatment: The treatment of psychotic symptoms should be approached
conservatively and should be individualized for each patient. Psychotropic medications have a place
in controlling agitation and insomnia. If brief reactive psychosis is suspected initially, neuroleptic
medications should be limited to short-term use only and then only when absolutely necessary. If
the diagnosis is suspected after neuroleptic treatment has already started, medications should be
discontinued as soon as possible. Symptomatic treatment with benzodiazepines (which are not
associated with the risk of tardive dyskinesia) will often make the patient more comfortable,
although these agents may not relieve all symptoms in some patients.
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B. Psychologic Treatment: Psychologic treatment may take several forms. Simply being
removed from the crisis and having the care and attention of the hospital staff may allay the
patient's anxiety enough to permit constructive discussion and problem solving. Once the resources
of the staff become available, the stress may no longer seem overwhelming. Enlisting the aid of
family members may also be important for the same reason. In individual psychotherapy, encouraging the patient to recount the events that led to the breakdown and to discuss their impact and
meaning will facilitate recovery. Such discussion has 2 effects: It allows the patient to control
anxiety by breaking down the experience into understandable units, and it offers the patient a model
for dealing with crises in the future. Longer-term psychotherapy directed at more fundamental
psychologic conflicts may be indicated for some patients.
5.2. THEORETIC QUESTIONS:
1. The definition of notion “emotional stress”, “psychical trauma”.
2. Criteria of Karl Jaspersa.
3. Classification of reactive states.
4. Etiology and pathogenesis of reactive psychosis.
5. Clinical manifestations of acute reactive psychosis.
6. Clinical manifestations of sub acute reactive psychosis.
7. Prolonged reactive psychosis.
8. Clinical picture of reactive depression.
9. Clinical picture of reactive paranoid.
10. Differential diagnosis of reactive states.
11. Treatment and prophylactic of reactive psychosis.
12. Urgent help at shock reactions after extreme situation.
5.3. PRACTICAL TASKS ON THE CLASS:
1. To collect anamnesis, clinical psychopathological examination of patients with reactive
psychosis.
2. Make up plan of examination and treatment of patient with reactive psychosis..
3. To solve tests and tasks.
5.4. MATERIAL FOR SELF-CONTRROL.
A. Questions of self-controls:
1. Classification of reactive states.
2. Etiology and pathogenesis of reactive psychosis.
3. Clinical manifestations of acute reactive psychosis.
4. Clinical manifestations of sub acute reactive psychosis.
5. Prolonged reactive psychosis.
6. Clinical picture of reactive depression.
7. Clinical picture of reactive paranoid.
8. Differential diagnosis of reactive states.
9. Treatment and prophylactic of reactive psychosis.
B. TESTS:
1. Etiological factors of reactive psychosis are:
A. Biological
B. Psychological
C. Social
D. All above mentioned
E. Phisical
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2. Specific clinical signs of reactive psychosis are:
A. Karl Jasper’s syndrome
B. Kandinski-Clerambault’s syndrome
C. Korsakoff’s syndrome
D. Paranoid syndrome
E. All mentioned
3. Acute reactive psychosis are:
A. Twilight state
B. Reactive stupor
C. Reactive confusion
D. Reactive paranoid
E. All above mentioned
4. On the background of fear with panic flight does appear:
A. Acute twilight state
B. Acute reactive stupor
C. Acute reactive confusion
D. Acute reactive paranoid
E. Acute hallucinosis
5. State from oligokinesia to total absence of movements with mutism are specific for:
A. Acute twilight state
B. Acute reactive stupor
C. Acute reactive confusion
D. Acute reactive paranoid
E. Acute hallucinosis
6. Psychomotor excitement with fear, constantly verbal production are specific for:
A. Acute twilight state
B. Acute reactive stupor
C. Acute reactive confusion
D. Acute reactive paranoid
E. Acute hallucinosis
7. Fear with anxiety, paranoid ideas of relation and persecution are specific for:
A. Acute twilight state
B. Acute reactive stupor
C. Acute reactive confusion
D. Acute reactive paranoid
E. Acute hallucinosis
8. Subacute reactive psychosis are:
A. Twilight state
B. Pseudodementia
C. Ganser’s syndrome
D. All above mentioned
E. Delirium
9. Clinical signs of pseudodementia are:
A. Wrong answers
B. Not right actions
C. Foolish
D. All above mentioned
E. Hallucinatoins
10. Prolonged reactive psychosis are:
A. Paranoid depressive
B. Hysteric depressive
C. Asthenic depressive
D. All above mentioned
E. Hallucinatoin paranoid
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A. SITUATIONAL TASKS
1. During fire of own house patient lost speech suddenly. He is without movements, pale, his
eye is widely opened, tachycardia. Amnesia of above mentioned situation. Determine
psychopathological disoder.
2. Woman P, 35 old year, economist. After arrest she is giving wrong answers on questions, not
right fulfilling simple action, has exaggeratedly mood and foolish. Determine psychopathological
disoder.
3. After fire girl ran out from the house on the street. She was fulfilling many unsuitable
movements, asked for help. Her skin is pale, hypertension, tachycardia, amnesia of morbidity state.
Determine form of psychomotor excitement.
6. RECOMMENDED LITERATURE IS:
6.1. Basic:
1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York:
Williams @ Wilkins. – 1997.
2. Psychiatry. Course of lectures. – Odessa: The Odessa State Medical University. – 2005. – 336
p.
3. Lectures.
4. Internet resource.
6.2. Additional:
1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород:
Изд-во НГМА, 1998.
2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.
3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. –
К.: Здоров’я, 2006.
Prepared by assistant
S.D.Savka