Lecture
Syndromes of Hysterical Psychotic Disorders
The pathogenetic basis of hysterical psychotic disorders lies in dissociation mechanisms (i.e., the loss of the ability to synthesize mental functions and consciousness).
Dissociative amnesia- complete or partial loss of the ability to recall important information about one's own identity. The ability to learn new information is preserved.
Dissociative fugue – a flight reaction. It manifests as a completely unexpected departure from home or work, followed by loss of the ability to recall basic information about one's own identity.
Hysterical stupor and hysterical motor excitement – the stupor may be complete or incomplete, an independent form of reaction or the initial stage of other hysterical psychoses. Complete hysterical stupor is characterized by total immobility, mutism, often waxy flexibility, and less often – muscular rigidity. Excitement represents a violent emotional reaction with rage, anger, and chaotic thrashing about.
Trances and possession states- a trance is a state of disturbed consciousness with a reduced ability to respond to external stimuli. A possession state is characterized by the sensation of a spirit, a devil, or a deity existing within one's body, agitation, and altered speech: the patient speaks in a voice not their own, convinced that it is the voice of another being.
Ganser syndrome (Ganser twilight state) - includes four features: 1) «approximate answers», for example, when asked how much two times two is – the patient answers, «five»; 2) performing actions in reverse; 3) narrowing of consciousness; 4) partial and complete amnesia. This symptomatology is sometimes accompanied by puerile or clownish behavior, depressed mood, and motor excitement.
Pseudodementia syndrome – also characterized by an apparent decline in intellectual functioning (symptoms of approximate speech, approximate actions, silliness), however consciousness is disturbed to a lesser degree. A distinction is made between depressive pseudodementia (accompanied by anxious-depressive affect) and agitated pseudodementia.
Puerilism – manifests as behavioral reactions characteristic of early childhood: walking with small steps, speaking in a lisping voice, collecting candy wrappers and bits of thread, and playing with dolls using random objects.
Multiple personality disorder- a state in which a person alternately experiences themselves as one personality, then another. Behavior in this case is determined by which of these personalities dominates. The appearance of the original personality completely disappears from memory during the period when the other one is present.
Delusion-like fantasies – described by K. Birnbaum (1908). Unlike delusional ideas, they do not have an elaborate system of justification or signs of pathological reinterpretation of objects and phenomena. The fantasizing occurs with clear consciousness; its content includes material from fantasy and adventure literature and various occult sources; patients often speak of adventure heroes, ascribing themselves the central role. The fantasies are short-lived, and their distinctive feature is that patients are not in the least embarrassed when contradicted or caught in inconsistencies.
Hysterical twilight state – includes symptoms characteristic of any type of clouding of consciousness: disorientation, disengagement from the situation, and disruption of contact with reality. In some cases the symptomatology is limited to a vivid and expressive display of apparent feeble-mindedness and childish emotional reactions; in others, it forms complex polymorphic pictures. More elaborate variants of the psychosis are characterized by states with vivid, emotionally charged visualized representations that, despite their fragmentary and shifting nature, are united by a single storyline accompanied by fear, tension, or merriment. In patients who had religious experience prior to the onset of the psychosis, ecstatic sensory delusion-like fantasies with religious-erotic content often form. Twilight states with incoherent speech manifest as a stream of speech consisting of individual words, fragments of words, and interjections reflecting affective tension. The course of the hysterical twilight state is undulating; from time to time the disorientation diminishes, but then recurs. At the point of emergence from the psychosis, post-reactive asthenia forms. Memories of the episode are either entirely absent or remain vague and fragmentary.
Dissociative Disorder
According to the psychological interpretation of P. Janet (1911), dissociation refers to the splitting off of mental complexes that temporarily acquire autonomy and govern mental processes in isolation from the integrity of mental life.
Hysterical disorders of the dissociative type are rarely observed within the structure of neurotic disorders; more often they are seen in the context of reactive psychoses.
Dissociative disorder – a disruption of the normal integration of mental functions (consciousness, perception, memory, identity, motor control) – predominantly a mental disorder
Janet (1892) considered hysteria a manifestation of a disturbance in the function of personality synthesis, expressed above all by a loss of the ability to synthesize mental functions and consciousness, characterized mainly by a narrowing of the field of consciousness
A narrowing of the field of consciousness allows for dissociation (splitting off) of certain mental functions, i.e., their falling out of the control of the personality, whereby they gain autonomy and begin to govern the person's behavior independently («independent of will»).
Dissociation — is the name for the mechanism of hysterical disintegration, which manifests as a lowering of the level of consciousness (in other words, a narrowing of consciousness), i.e., a shift of self-regulation from the level of semantic consciousness to the level of sensory consciousness, as well as a disturbance of the integrative functions of the structure of the «Self». The mechanism of dissociation sets in motion only automatized mental functions, i.e., those representing the lowest rung in the hierarchy.
Psychogenic amnesia
A sudden inability to recall current and significant events. The loss of memories is so pronounced and prolonged that it cannot be explained by ordinary forgetfulness. It typically focuses on psychologically traumatic events (accidents, tragic incidents) and is most often partial. It ends as suddenly as it began. This is a selective repression from memory of certain facts and events following a psychological trauma.
It is much more pronounced than in ordinary forgetting, arises suddenly, and can last several hours, but sometimes an entire lifetime. There is usually a single episode of hysterical amnesia, but with repeated psychological traumas, repeated episodes are also possible.
The psychological trauma causing hysterical amnesia is, as a rule, extremely severe - a threat to life, combat action, severe physical injury, violence, or the commission of an act incompatible with the person's moral principles.
Four types of psychogenic amnesia:
localized(remembers nothing of what occurred during a specific period of time, usually the first hours after the traumatic event)
selective (forgets some but not all of what happened during a specific period)
generalized(completely forgets the history of their own life)
continuous(remembers nothing of past events up to a certain specific moment)
Dissociative amnesia is quite common as a primary reaction to unbearable traumatic experiences (war, disaster). In typical dissociative amnesic reactions, people cannot remember their own name, do not know how old they are, where they live, and do not recognize their parents, spouses, relatives, or friends. At the same time, their basic behavioral patterns are not disrupted – they can read, hold a conversation, perform skilled work, and appear entirely normal. Only a specific type of memory is disrupted, known as episodic or autobiographical memory. Other forms of memory are almost always unaffected. It may be accompanied by confusion and disorientation
Many authors also describe hysterical amnesia as an isolated mono-symptom; among other hysterical disorders it occurs in 5-14% of cases. What is amnesized are unpleasant experiences, actions that undermine one's sense of self-worth, as well as situations and events colored by pronounced negative emotions. The essence of hysterical amnesia lies in the selective blocking of the mechanism for retrieving information encoded by cognitive structures.
Psychogenic fugue
Psychogenic wanderings (fugues) - an acute dissociative state (from the Latin fuga — «flight») in which people not only temporarily forget who they are, but also drop out of their home environment, often fully or partially identifying themselves with another person and acquiring a new identity. They almost always fail to remember their past, date, and place of birth.
In doing so, they suddenly leave for somewhere - usually far away, to a place where no one knows them.
This journey is not simple wandering, but is undertaken with some purpose, arising after severe stress. During a fugue, people often begin using alcohol or drugs
The departure is unpredictable and occurs suddenly.
The new image (identity) differs significantly from the previous one: people who were initially quiet and withdrawn suddenly become sociable, outgoing, and engage in activity that is sometimes purposeless and completely unrelated to their previous activity. In doing so, aggressive acts or delicts incompatible with the person's original personality traits may be committed.
After days, weeks, or sometimes years, such people may find themselves in an unfamiliar place, not knowing how they got there, along with a clear and complete amnesia for the entire period of the fugue.
Actions can range from a simple trip to the cinema to travel across the whole country, acquiring a new profession, or leading a completely new life started from scratch.
During the fugue period the person seems normal and is capable of engaging in complex activity.
Fugues are protective manifestations (flight from a traumatic situation) or the fulfillment of wishes (for example, a striving for adventure, the realization of fantasies, being someone else, starting life again), although they usually combine both aspects.
Fugues appear and disappear suddenly, and are fully or partially amnesic
The reality of experiences during a hysterical fugue is clearly «delimited» from preceding events, so the actions are not connected with the person's usual occupations, profession, or family.
when the actions become more complex and purposeful, the person begins to function as another individual, with a new sense of identity, and often with a new surname — in these cases one speaks of an alternating personality.
With an alternating personality, the hysterical disintegration of the structure of the «self» causes it to split, as it were, into parts that acquire integrative-regulatory autonomy (including a sense of identity, control over the environment, and so on), which, given fluctuations in the level of consciousness, allows a shift from self-regulation based on the true personality to the self-regulation functions of the split-off personality.
During this period the memory reflects one of the «split-off» personalities.
At the moment of returning to the primary personality, amnesia arises for the period during which the split-off personality was functioning; sometimes only vague, hazy memories, «islands» of memory, are retained. Internal information structures reflecting the world of fantasy and daydreams play a leading role in the genesis.
Depersonalization
Depersonalization – a feeling of estrangement from one's own self
A feeling of otherness suddenly develops, often accompanied by the sensation that individual parts of the body do not belong to one's own body or that they belong to other people.
In derealization the surroundings (people, objects) are experienced as alien and unreal. The patient feels their own body, thoughts, and sensations to be unreal, distant, alien; they live as if in a dream, act like an automaton, or watch themselves from the outside. They may feel as though they are hovering above their physical bodies and observing what is happening below.
Sensations of numbness and lifelessness are common; they feel "toy-like" or reduced in size. Sensations of distorted shape or size of body parts are possible, especially of the arms and legs. These sensations are often experienced painfully.
Understanding of reality in depersonalization disorder, unlike in delusional states, remains intact.
+They are aware of their feelings of estrangement, are very troubled by them, but remain oriented in reality. No hallucinations or delusions occur.
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