Clinical variants of pathological drives
Pathological drives are divided into three main groups depending on the preservation of insight and volitional control in the patient:
- Obsessive drive: insight and the struggle of motives are preserved, and volitional control is possible. Antisocial or absurd behavior in this case is completely ruled out.
- Compulsive drive: critical attitude toward one's condition is present, but the capacity for volitional control is practically lost. Consequently, the probability of antisocial actions is high.
- Impulsive acts: insight is completely absent, and volitional control is impossible. The patient's behavior is always absurd or antisocial in nature (for example, a patient may commit theft and immediately throw away the stolen item). Impulsivity is frequently a manifestation of epileptiform paroxysms or occurs in schizophrenia with catatonic syndrome.
Parabulias (Drive perversions)
Parabulias are never considered independent diseases; they are strictly a clinical symptom. The main causes for their emergence include:
- Gross intellectual defect: various forms of oligophrenia and global dementia.
- Schizophrenia: abnormalities are characteristic both of the initial period of the illness and its final stage (schizophrenic dementia).
- Psychopathies: the consequence of persistent personality disharmony.
- Metabolic disorders: for instance, the craving to eat non-food items may arise against the background of pronounced anemia or pregnancy.
- Endocrine pathology: diabetes mellitus can provoke an uncontrolled increase in appetite; hyperthyroidism leads to hyperactivity, whereas hypothyroidism results in abulia (lack of willpower); sex hormone imbalances cause distortions in sexual behavior.
Differential diagnosis
When assessing a patient's behavior, it is important not to confuse true disorders of drives with actions dictated by impairments in other mental spheres (such as delusions or hallucinations).
- Refusal to eat is far from always associated with a loss of appetite. It can be the result of catatonic stupor, imperative (commanding) hallucinations prohibiting food intake, or severe poisoning delusions.
- Pseudo-suicide refers to actions leading to death without the conscious intent to end one's life. These may occur against the background of altered consciousness (during delirium, a patient might jump out of a window mistaking it for a door while fleeing imaginary pursuers) or under the influence of threatening hallucinations.
Disorders of drives in emotional-volitional syndromes
Drives inevitably undergo transformation within the framework of three major affective and volitional syndromes:
- Depressive syndrome: characterized by hypobulia (suppression of all basic drives) and anhedonia (loss of the ability to experience pleasure). Appetite and libido drop sharply. Patients avoid social contact (other people's laughter only accentuates their pain). Painful psychic anesthesia—Anaesthesia psychica dolorosa—is typical. Suicidal risk is extremely high, especially in the morning hours when anguish reaches its peak.
- Manic syndrome: a sharp enhancement of drives is observed. Patients are prone to hedonism, with increased appetite and sexual activity. An excessive striving for communication and altruism emerges.
- Apathetic-abulic syndrome: basic physiological drives (such as appetite) retain their usual intensity. However, due to apathy and passivity (abulia), control over one's behavior is lost, and the need for communication with others disappears.
Somatovegetative symptoms in depression
Severe depression with the suppression of drives is accompanied by pronounced peripheral sympathicotonia. Its classical manifestation is Protopopov's triad:
- Tachycardia.
- Pupillary dilation (mydriasis).
- Tendency toward constipation.
The appearance and trophic state of the tissues change: the skin becomes dry, pale, and flaking, its turgor decreases, which deepens wrinkles and makes the patient look significantly older than their years. Brittleness of nails and hair loss are typical. The secretory function of the glands drops sharply, manifested by a complete absence of tears. Additionally, a specific mimic fold—an atypical eyebrow break—frequently forms on the face.
Briefly: answers to topical questions
What are the types of parabulias (impulsive drives)?
The following types of parabulias are distinguished:
- Appetite perversions — overeating (bulimia), refusal to eat (anorexia nervosa), eating non-food substances (pica, coprophagia).
- Perversions of sexual drive.
- Striving for antisocial acts — theft (kleptomania), vagrancy (dromomania), arson (pyromania), gambling.
Impulsive drives also include dipsomania, pyromania, dromomania, and kleptomania.
How are eating drive disorders classified?
Eating drive disorders are classified as independent disorders, manifestations of other syndromes, and according to typical forms of appetite disturbance.
Eating disorders:
- Independent disorders — anorexia nervosa, bulimia, pica, pica in children.
- Manifestations of other syndromes — in depression, catatonia, poisoning delusions, and withdrawal syndrome.
Typical forms of appetite disturbance:
- Anorexia — complete lack of appetite.
- Hyporexia — decreased appetite.
- Hyperrexia — pathological increase in appetite.
- Pararexia — perversion of appetite.
What sexual drive disorders are distinguished?
Sexual drive disorders are divided into sexual behavior disorders and sexual dysfunctions.
Sexual behavior disorders:
- Gender identity disorders — transsexualism, transvestism.
- Disorders of sexual preference (paraphilias) — fetishism, exhibitionism, voyeurism, pedophilia, sadomasochism.
- Experiences — related to sexual development and orientation.
Manifestations of sexual dysfunctions:
- Arousal disorders — impotence in men and frigidity in women.
- Orgasmic disorders — anorgasmia, premature or delayed ejaculation.
- Painful sensations during intercourse — dyspareunia, vaginismus, postcoital headache.
TZR — Protopopov's triad in depression: Tachycardia, Constipation, Pupillary dilation.
Class and exam questions
In a compulsive drive, insight is preserved and the patient understands the pathological nature of the state, even though they cannot resist. In an impulsive act, insight is completely absent from the very beginning.
In a compulsive drive, insight is preserved and the patient realizes the impropriety of the urge, although volitional control is almost lost. In an impulsive act, both insight and the conflict of motives are absent.
When does suicide risk reach its peak in depression?
Suicidal risk is highest in patients with severe depression if their motor activity is preserved. The daily peak of danger occurs in the morning hours due to the intensification of anguish.
Is mutism characteristic of severe depression?
No. Despite pronounced poverty of speech, monosyllabic and slowed-down responses, complete silence (mutism) does not occur in classical depressive syndrome.
What else to study on this topic
- Depressive and manic triads: a detailed breakdown of symptoms.
- Sleep disturbances in depression: lack of the feeling of sleep and insomnia.
- Delusional ideas in affective disorders (self-blame, grandiosity, hypochondria).
- Features of extended suicide in psychiatric practice.
- The impact of depressive stupor on the execution of suicidal intentions.
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