Primary psychotic episode. Treatment of the first episode of schizophrenia. Diagnosis of schizophrenia

First episode psychotic unit

Early intervention for psychosis- the concept of a special approach to the first psychotic episode, with the goal of minimizing damage to the patient and achieving better long-term indicators of patient functioning. Underlying this heterogeneous and emerging approach is the assumption that the early stage of psychosis is critical and that the typically observed time delay from the onset of psychosis to the start of treatment is partly responsible for the patient's future decline in functioning. In this regard, the goal of the approach is to identify incipient psychosis as early as possible and select optimal therapy at this stage. Some early intervention programs also emphasize the prodrome in hopes of preventing the onset of mental illness in at-risk individuals.

Early intervention centers have been opened in a number of countries around the world. In Russia there are also first episode psychotic clinics or appropriate departments in existing psychiatric hospitals.

Proponents of the approach cite evidence that the period of time before the start of therapy is associated with the prognosis of the disease. On the other hand, a 2006 Cochrane review of seven studies found that there was insufficient evidence to draw any conclusions about the effectiveness of early intervention programs. There are also studies that have shown that the duration of untreated initial psychosis does not significantly affect the quality of subsequent life, the development of remission of productive symptoms and does not affect cognitive indicators in the future, and demonstrate, through special measurements, the dubiousness of the hypothesis about the neurotoxicity of long-term untreated psychosis.

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AND I. Gurovich, A.B. Shmukler

In recent decades, a significant amount of new data has been accumulated that is important for understanding neurofunctional processes in the brain in patients with schizophrenia and schizophrenia spectrum disorders.

In particular, using neuroimaging methods (positron emission tomography - PET, single photon emission computed tomography - SPECT, magnetic resonance spectroscopy - MRS), similar changes were identified in patients with schizophrenia (including a decrease in the level of metabolism, membrane synthesis and regional blood flow of the prefrontal cortex, as well as a decrease in delta sleep on the EEG) in certain areas of the brain, mainly in the prefrontal cortex, which led to the assumption of the role of “hypofrontality” in the development of symptoms of schizophrenia. Data from neuropsychological studies are even more important. In particular, tests that assess the cognitive function of patients reveal impairments in the same areas of the brain as the results obtained using neuroimaging techniques. All this has led to a new paradigm shift in understanding the pathogenesis of schizophrenia, in which neurocognitive deficits play a significant role. Currently, manifestations of neurocognitive deficits are considered as the third (along with positive and negative disorders) key group of symptoms in schizophrenia, responsible, in particular, for disturbances in the social functioning of patients.

It is shown that 94% of patients with schizophrenia (compared to 7% in a healthy population) to varying degrees exhibit neurocognitive deficits . Cognitive deficits are found in a significant number of cases in relatives of patients suffering from schizophrenia. It is found in untreated patients with the first attack of the disease and, as expected, its greatest deepening occurs in the first 2-5 years after the onset of the disease, which requires the most active intervention (both medicinal and psychosocial) during this period. Atypical antipsychotics (as opposed to traditional antipsychotics) have been shown to reduce the severity of neurocognitive deficits in patients with schizophrenia. All this has attracted the attention of a large number of researchers to the initial, first episodes of schizophrenia and, moreover, is increasingly reflected in the practice of providing psychiatric care. On the other hand, it is noted that the average period from the onset of the disease to seeking psychiatric help is about 1 year and only 1/3 of patients come to the attention of psychiatrists during the first two months.

Reasons for late seeking help and delayed initiation of treatment include patients' insufficient understanding of the nature of existing disorders, fear of the consequences of identifying a mental disorder (stigmatization and self-stigmatization), insufficient screening by general practitioners, and incorrect diagnosis when seeking psychiatric help. The connection between the duration of the initial period of the disease without therapy and subsequent periods of development, as well as the completeness of therapeutic remission, is indicated. Attention is drawn to the “biological toxicity” of a long-term untreated psychotic state during the manifestation of the disease. A severe mental illness that occurs for the first time (the first psychotic episode of the disease) is a severe biological and social stress for the patient and his relatives. At the same time, as has been shown in a number of studies, early detection and treatment of the first psychotic state leads to minimization of psychosocial stress and the negative impact of the disease, and contributes to a more favorable course and social recovery of patients. Taking these data into account, first-episode psychotic clinics are being created in many countries around the world (Australia, Canada, Finland, etc.).

A similar clinic has existed since November 2000 at the Moscow Research Institute of Psychiatry of the Ministry of Health of the Russian Federation. In the near future, it is planned to organize similar clinics in psychiatric services in a number of other regions of Russia. The population that receives assistance in the clinic for the first psychotic episode are patients with schizophrenia or schizophrenia spectrum disorders with a disease duration of no more than five years from the moment of manifestation, during which no more than 3 psychotic attacks were noted. Preference is given to semi-inpatient and outpatient services for patients, since, as the data obtained show, up to 60% of patients with first psychotic episodes can manage without hospitalization. The remaining patients, after relief of acute manifestations of psychosis in the hospital, can be transferred to the specified clinic.

The tactics of providing assistance in the department of the first psychotic episode should include a number of points.

1. All patients with a first episode of psychosis from a specific catchment area are referred to the clinic.

2. Work is being done to identify initial psychopathological disorders as early as possible, primarily in persons applying to the primary medical network, and to include identified patients in the assistance program (reducing the time of “untreated psychosis”).

3. Help is provided in the least stigmatizing conditions (semi-inpatient, outpatient) based on the principle of partnership with the patient.

4. The clinic for the first episode of the disease operates on the basis of team multiprofessional (with the participation of a psychiatrist, psychologist, psychotherapist, social worker) management of patients.

5. An optimal choice of neuroleptic therapy is made with the preferred use of new generation neuroleptics (atypical antipsychotics).

6. Early inclusion of psychosocial interventions is used: inclusion of patients and their relatives in psychoeducational programs, implementation of social skills training and neurocognitive training.

7. Follow-up care of patients is planned for 5 years after the onset of the disease.

Early detection of psychopathological disorders

Before the first manifest episode, some patients experience a rather long period of disorders of various levels, noted before seeking psychiatric help. In a significant number of cases, in addition to hereditary burden of mental illness, there are phenomena of dysontogenesis (delayed development of motor skills, motor clumsiness, difficulties in acquiring self-care skills; dissociation of speech development with a predominance of mechanical reproduction of the speech of others; dissociation between motor and mental development, insufficient development of the self-preservation instinct) , personal accentuations. The duration of the prodromal period of the disease, defined as the period of time from the onset of any psychopathological disorders (characterological changes with sharpening of premorbid traits or the acquisition of previously unusual ones; psychopathic-like manifestations; affective fluctuations; transient obsessive states; “outpost” - symptoms represented by ideas of attitude, transient depressive- paranoid, hallucinatory-paranoid, oneiric episodes) before the onset of a manifest psychotic state is often quite significant and, as the data obtained show, averages 5.5 years. However, despite the deep, sometimes psychotic level of a number of noted disorders, as a rule, they do not serve as a reason to seek help, even taking into account the clear decline in social functioning in the majority of patients. It should be noted that even after the manifestation of the disease, a significant proportion of patients seek psychiatric help too late.

Thus, the average duration of untreated psychosis (from the onset of psychotic symptoms to seeking specialized help and prescribing antipsychotic therapy) is about 8.5 months. The creation of a specialized clinic focused on early detection and treatment of the initial manifestations of the disease can reduce the period of illness without treatment and thereby reduce the social losses of patients.

Optimal choice of antipsychotic therapy

Atypical antipsychotics are considered in these cases as first-line drugs due to their positive effect on the neurocognitive functioning of patients, as well as better tolerability compared to traditional drugs and a more favorable side effect profile, which is especially important for patients who are prescribed treatment for the first time. Psychopharmacotherapy combines the intensity of prescriptions with the principle of minimal dose sufficiency.

Early inclusion of psychosocial intervention

In the first episode clinic, several types of group work with patients and their relatives are carried out on an ongoing basis: 1) psychoeducational group for patients; 2) psychoeducational group for relatives of patients; 3) social skills training group; 4) neurocognitive training group. In addition, with a number of patients, if necessary, individual social work is carried out, aimed at solving social problems that arise for the patient and his relatives in connection with the development of the disease. Psychosocial therapy begins at the earliest possible stages of treatment after relief of acute manifestations of psychosis, which ensures the most favorable prognosis. Patients are prescribed various types of psychosocial treatment depending on the indications for them. The goal of each intervention is formulated with a definition of the time period during which the specified goal is expected to be achieved. The choice of the form of intervention for a particular patient is carried out in accordance with the characteristics of his social maladjustment. At the completion of each stage, the need for supportive psychosocial interventions is taken into account.

Comprehensive assistance delivery

Treatment of patients in the clinic for the first psychotic episode is based on an integrated approach, implying the unity of psychopharmacotherapy and various methods of psychosocial treatment and psychosocial rehabilitation. Assistance is provided by a multi-professional team of specialists (with the participation of a psychiatrist, psychologist, psychotherapist, social worker), each of whom has his own tasks, coordinated with other members of the “team”.

Nursing and junior medical staff, as members of the therapeutic team, actively participate in this work, motivating patients and their relatives to have a positive attitude towards therapy, creating a psychotherapeutic environment in the department, supporting the psychotherapeutic community of patients, monitoring and consolidating the results of group and individual forms of work. In addition, junior and nursing staff organize leisure time for patients. The results of work in relation to each patient are discussed at weekly meetings of all team members, where joint tactics for the future are developed.

Supportive psychosocial treatment and psychosocial rehabilitation

It should be noted that there is a need for long-term management of patients with a first psychotic episode and after discharge from the department. For this purpose, patients discharged from a day hospital or day hospital unit continue to be observed in the clinic to assess their mental state, provide supportive psychopharmacotherapy and provide supportive psychosocial treatment in the form of monthly group sessions. The latter largely fulfill the task of strengthening the social networks of patients and social support. Special psychoeducational programs continue for relatives of discharged patients. The effectiveness of this form of care was shown by comparing long-term results in patients treated in the first psychotic episode clinic of the Moscow Research Institute of Psychiatry of the Ministry of Health of the Russian Federation with the results of traditional treatment of a similar group of patients in a city psychiatric hospital. Patients treated in the clinic for the first psychotic episode received supportive psychopharmacotherapy throughout the follow-up period in a significantly greater number of cases, showing higher compliance and, as a consequence, better remissions (patients experienced significantly less delusional behavior in remission). Exacerbations of symptoms noted after discharge from the clinic were, as a rule, short-lived (the duration of exacerbations averaged about 3 weeks, while psychotic symptoms were observed only for 10 days, that is, significantly shorter than in patients in the control group - more than 1 month .,p<0,05). Это в большинстве случаев позволяло купировать отмечаемые расстройства во внебольничных условиях. Количество обострений в течение первого года наблюдения в основной и контрольной группах не отличалось, однако через 1,5 года отмечалась отчетливая тенденция к более редким приступам у больных, получавших лечение в клинике первого психотического эпизода.

The total duration of treatment during this period was also shorter in patients of the main group. A larger number of patients in the main group continued their studies; at the same time, they were less inclined to sever social ties and narrow their previous circle of contacts. Thus, the analysis of the data obtained shows that the proposed new organizational form - the first psychotic episode clinic - has obvious advantages in terms of clinical and social results of helping patients with first attacks of schizophrenia and schizophrenia spectrum disorders.

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The effectiveness of treatment for schizophrenia largely depends on the timeliness and adequacy of treatment for the first episode of the disease. There is evidence that a significant period of time passes from the moment psychotic symptoms appear in patients until the start of psychopharmacotherapy: from 12 to 24 months. A prolonged untreated psychotic state affects the nature of the neurobiological processes themselves, contributes to the formation of resistance to psychopharmacotherapy, increases the risk of repeated psychotic exacerbations and causes a negative long-term prognosis of the disease.

Of critical importance in the treatment of the first episode of schizophrenia is not only the early initiation of antipsychotic therapy, but also its duration. It has been established that continuous psychopharmacotherapy for at least 6 months from the first manifest manifestations of psychosis increases the effectiveness of treatment, ensures the restoration of social functioning, and reduces the risk of suicide.

In general, the duration of therapy after the first psychotic episode is determined by its severity, the rate of development of the therapeutic response and ranges from 2 to 5 years.

Timely administration of psychopharmacological agents seems even more important in cases where the first psychotic episode develops in children and adolescents. Schizophrenia, which debuts with a psychotic episode at this age, is a severe mental illness accompanied by dramatic disturbances in the cognitive, emotional, motor-volitional spheres of mental activity. The mechanisms of adequate psychosocial functioning are significantly disrupted, mental development slows down or even stops.

Manifest attacks of schizophrenia in adolescence are characterized by pronounced severity, polymorphism and variability of the clinical picture, which can combine elements of hallucinatory-delusional, affective-delusional syndromes, as well as psychomotor agitation syndrome with impulsivity and heteroaggressive behavior. Such acute conditions require hospital treatment with the prescription of antipsychotics, which have a powerful antipsychotic effect that develops in the shortest possible period of time. Traditionally, in such cases, intramuscular injections of haloperidol are prescribed at a dose of 5-15 mg/day.

Adolescents with a first psychotic episode of schizophrenia show increased resistance to the antipsychotic effects of “traditional” antipsychotics and are more sensitive to extrapyramidal side effects.

The symptoms of akathisia that often develop in adolescents, which are extremely poorly tolerated by them and often increase psychomotor agitation and aggressive behavior, can be mistakenly interpreted as an increase in psychotic agitation. Such an incorrect diagnostic interpretation of the phenomena of akathisia leads to an increase in the daily dose of the antipsychotic and an increase in the entire complex of side effects associated with the administration of the drug (the development of extrapyramidal symptoms, akathisia, hyperprolactinemia, as well as a high risk of developing tardive dyskinesia).

Currently, it is successfully used to relieve acute psychotic symptoms of the hallucinatory-delusional register, including those accompanied by aggressive behavior. Zuclopenthixol acetate. Along with the blocking effect on D2 receptors, zuclopenthixol acetate also has antagonism to dopamine Di and serotonin 5HT2A receptors, which may partially explain the weak severity of extrapyramidal side symptoms compared to the “gold standard” of classical antipsychotics - haloperidol.

A feature of the action of zuclopenthixol acetate is the rapid development of antipsychotic and sedative effects, which are detected within 2 hours after an intramuscular injection of 50 mg of the drug and reach a therapeutic maximum 8 hours after the first injection. A significant reduction in acute psychotic symptoms and aggressive behavior is observed after the first 2-3 intramuscular injections of zuclopenthixol acetate. The drug is administered once a day, the maximum dose is 100 mg. 2-3 days after the final intramuscular injection of zuclopenthixol acetate, a transition is made to oral administration of zuclopenthixol at a dose of 6-20 mg / day or a transition to oral administration of other antipsychotics - risperidone, olanzapine, quetiapine, which over the next 4-6 weeks therapy mainly relieves acute affective-psychotic symptoms of an attack. After stabilization of the condition, from the period of therapeutic remission, oral administration of atypical antipsychotics continues (stage of stabilizing antipsychotic therapy). This makes it possible to completely reduce residual productive psychopathological symptoms, correct negative procedural symptoms (possibly due to interaction with serotonin b-HT receptors) and contributes to the restoration of an acceptable level of social functioning. At the same time, a fairly long period (at least two years) of continuous neuroleptic therapy for the first psychotic episode of schizophrenia in adolescents contains an important anti-relapse component of treatment.

Demonstrated high efficacy in the treatment of first episode psychosis in adolescents. olanzapine. Olanzapine therapy is carried out both during the initial, acute phase of the first psychotic attack (on average 6-8 weeks), and further, at the stage of remission. Monotherapy with olanzapine at an average daily dose of 10-15 mg during the first 2 weeks of treatment allows to stop the main manifestations of psychosis and heteroaggression.

Risperidone may be used in the treatment of first episode psychosis. Effective and at the same time well tolerated is the daily dose of risperidone in a relatively narrow range - from 2 to 6 mg. The use of risperidone in an average daily dose of 8 mg can cause a noticeable increase in extrapyramidal symptoms with the appearance of akathisia, dyskinesia, increased salivation, which requires a reduction in the dose of the drug with the simultaneous prescription of correctors - drugs with a predominantly central anticholinergic effect (trihexyphenidyl, biperiden, dexethimide). At the stage of remission, the optimal dose of risperidone is 2-4 mg/day.

One of the new atypical antipsychotics currently used to treat psychotic conditions within schizophrenia and other psychoses is quetiapine. The drug is well tolerated, practically absent or weakly expressed by extrapyramidal symptoms, tardive dyskinesia, hyperprolactinemia and associated adverse neuroendocrine disorders.

Quetiapine therapy begins with a dose of 25 mg twice daily; the average daily dosage is gradually increased to 300 mg over 4 days. Patients receive this daily dose over the next 7 days. In the future, depending on the dynamics of psychopathological symptoms, the dose of quetiapine can be increased to 600-700 mg/day. The average duration of therapy is 8 weeks. After the reduction of psychotic symptoms, patients are transferred to maintenance therapy with quetiapine in lower dosages (200-400 mg/day). In parallel with the improvement in mental state during treatment with quetiapine, the level of social adaptation and activity success significantly improves.

Along with the above atypical antipsychotics (in combination with them), a good effect is observed when prescribing intramuscular benzodiazepine derivatives: diazepam, fe-

nazepama. Benzodiazepines can eliminate agitation and behavioral disorders; they also have a vegetative stabilizing function. Prescribing benzodiazepines (including by intramuscular injection) is advisable in the initial phase of treatment of patients with psychomotor agitation and aggression; Long-term use of benzodiazepines in subsequent stages of therapy can lead to the emergence of a dependence syndrome.

What is the modern concept of psychosis?

As a rule, falling into a psychotic state represents a certain temporary departure from existing reality, a change in perception and understanding of the surrounding reality. First of all, sensory perceptions undergo changes; they become as if willful, and thinking becomes spasmodically associative, for example, in schizophrenic psychoses. Such changes are rather a reaction to strong fluctuations in mood and impulses; for example, with affective psychoses they are more often of a depressive nature, or unipolar, and when alternating phases of the course they are of a manic-depressive nature, or bipolar.

This withdrawal from reality serves as a specific defense mechanism because reality becomes too painful, the contradictions too great, solutions impossible, and the feelings unbearable. Under extreme stress and mental trauma, as well as complete loss of sensation, even very strong people can react in this way. For highly sensitive people, a small number of experiences or life problems are enough to trigger psychotic reactions in them, especially during difficult periods. This kind of vulnerability is not a sign of an early stage of the disease, but rather one of the variations in sensitivity. It may well have a negative impact on the mental and physical condition, as well as on family relationships and social life of the patient. Certain cognitive patterns increase depression, metabolic changes in the brain increase sensitivity, social fears increase isolation, and family disputes increase contradictions.

Psychotic symptoms can take completely different forms, it all depends on internal desires and fears, as well as lifestyle. Examples of psychotic symptoms include auditory and visual symptoms, delusions, or impaired thinking. Patients, for example, hear voices, feel unreal threats, it seems to them that someone is following or controlling them, they come up with distorted reasons between events and their personality, they think that they can read other people’s thoughts, or they declare that they have impaired harmony and clarity thinking. They often experience changes in behavior, decreased performance, and withdraw from family and friendships.

What is the frequency of psychosis?

Psychosis is a relatively common disease; approximately 1-2% of the total population of the planet suffers from psychosis once in their life. Only 51 million people suffer from it in the world today. The age at which the first episode of the disease occurs is predominantly between 15 and 25 years, thus suggesting a prevalence of primary psychotic episodes among adolescents and young adults. Approximately 20% of all patients experience psychosis for the first time at a young age. In this age category, three out of a hundred people suffer from the disease.

What is the course of psychosis?

The course of psychosis depends on many factors, however, only a limited number of studies have examined this problem. Most longitudinal studies cover a period of time from five to twenty years and describe patients with schizophrenia spectrum disorders, which are characterized by the following features.

10-20% of all patients have isolated cases of psychosis, they represent a kind of reaction to some kind of life crisis, overcoming which relieves symptoms; and the psychosis does not recur. Such patients use drugs less often, better understand the nature of the disease, have a higher level of functionality before an attack of the disease, and most of them are female.

In approximately 30% of cases, patients experience a repeat acute psychotic episode, but without new psychotic symptoms between episodes. This means that in people with increased long-term sensitivity, psychosis may occur again during new life crises; this can be avoided if you take certain precautions, protect yourself from dangers and activate the internal forces of the body.

In approximately 30% of cases, patients experience a recurrent acute psychotic episode with psychotic symptoms between episodes. Patients in this subgroup are forced to reckon with certain physical impairments for a long time; they are able to correctly adapt their self-concept to the current circumstances, deal habitually with family members and behave in society, and also revise other people’s expectations.

Approximately 5-10% of patients progress immediately after the first episode and experience persistent psychotic symptoms. This means that for most patients, persistent psychotic experiences arise only if they have already experienced a repeated phase of psychosis.

Phases of psychotic disorder

As is known, psychoses occur in the form of attacks, or phases, the most important of which include:

Prodromal phase: Represents the initial phase of the disease, the period from initial mental changes and/or negative symptoms to the persistent manifestation of positive symptoms of a psychotic illness, such as hallucinations or delusions. The average course duration is approximately two to five years;
Untreated psychosis phase: Represents the period from the persistent occurrence of psychotic symptoms, such as hallucinations or delusions, until the start of treatment. The average duration of the course is approximately six to twelve months;
Acute phase: During this period, the disease enters an intensive stage and is manifested by hallucinations, delusions and confusion of thinking. The peculiarity of this phase of the disease is that the patient has difficulty realizing that he is sick;
Residual or residual phase: Occurs after acute symptoms have subsided and the condition has stabilized; negative symptoms may persist for a certain period of time. This phase can last for many years, sometimes with relapses leading to the acute phase.

What are the first signs of a psychotic episode?

Many symptoms of acute psychosis can occur in a mild form long before the disease itself and thus serve as important precursors. True, the very first signs of psychosis are in most cases very difficult to recognize. Many people subsequently recall that long before the onset of psychosis they suddenly began to behave unusually, quite often such signs are attributed to the stages of growing up and puberty, drug abuse or simple laziness, arrogant behavior or unwillingness to cooperate.

Possible early signs of psychosis:

Changes in character;
Anxiety, nervousness, irritability;
Increased sensitivity, hypersensitivity, anger;
Sleep disorders (excessive sleep cravings or sleep refusal);
Lack of appetite;
A careless attitude towards oneself, wearing strange clothes;
Unexpected lack of interest, energy, lack of initiative;
Change of feelings;
Depression, primitive feelings, or mood swings;
Fears;
Changes in performance;
Decreased resistance to stress;
Poor attention, increased distractibility
A sharp decline in activity;
Changes in social life;
Mistrust;
Social isolation, autism;
Problems in relationships with people, termination of contacts;
Change of interests;
Unexpected expression of interest in unusual things;
Unusual perceptions, such as increased or distorted perception of noise and color;
Peculiar performances;
Unusual experiences;
Feeling of being watched;
Delirium of influence.

Variety of psychotic symptoms

The main symptoms of psychosis can be divided into four categories:

Positive symptoms
Negative symptoms;
Cognitive symptoms;
Disorders of the self.

Positive symptoms

Hallucinations are the imaginary perception of really non-existent visual images, sounds, sensations, smells and tastes; their most common type is auditory hallucinations.
Delusion is an absolute belief in ideas that have no basis in reality.

Negative symptoms

Apathy, in which interest in all aspects of life is lost. At the same time, the patient has no energy, he experiences difficulties in performing basic tasks;
Social isolation, in which the patient loses interest in communicating with friends and mostly wants to spend time alone; at the same time, the person often experiences a strong feeling of isolation;
Decreased attention when reading books, difficulty remembering certain objects or events.

Cognitive symptoms

Thinking disorders, which are often accompanied by loss of attention and confusion;
Impoverishment of speech and thinking, in which the patient may forget what he began to talk about, the process of thinking is difficult.

Disorder of self

and, in which the surrounding people, objects and everything around seems unreal, alien, loses volume and perspective, first of all, the perception of oneself is disrupted;
Withdrawal, insertion, suggestion of thoughts, in this condition the patient experiences the feeling that his thoughts are influenced from the outside, that they are invested, controlled,
controlled, indoctrinated or imposed by other people.

Additional symptoms

In addition to the common common symptoms, there are some additional ones, which include:
1. Aggressiveness, irritability, hostility, internal anxiety, feeling of tension, psychomotor agitation. These symptoms arise from obsessions with persecution, dangerous misinterpretations of the environment, and a sense of being controlled and influenced by others. In the future, such behavior patterns may arise as a reaction to scolding, threatening or commenting voices.
2. Behavior that is dangerous to oneself and others. A person suffering from a psychotic disorder may commit risky behavior, which is expressed on the one hand in the fact that the patient is involved in dangerous situations, for example. a provoked fight, and on the other hand, that the patient is engaged in self-harm, inflicting cut wounds on himself with sharp objects.

What influences the prognosis of treatment for psychotic disorders?

Family relationships are recognized as one of the most significant predictors of psychotic relapses. Good awareness of the disease and emotional support from family will help prevent a new exacerbation. It is necessary to involve the family in the treatment process as early as possible, since the family is the most important support and support for a sick person.
If the patient continues to abuse drugs, the consequences for the disease will be the most negative: symptoms will worsen, the number of relapses will increase, and cases of abrupt cessation of treatment will become more frequent. Without stopping drug use, further treatment is almost impossible.
Much attention is paid to early diagnosis of the disorder, since the longer psychotic symptoms remain untreated, the less chance of recovery.
A positive reaction to drug treatment, expressed in the disappearance of voices, delirium and other symptoms, is a significant factor determining the prognosis of subsequent treatment. However, it is necessary to maintain a balance between beneficial therapeutic effects and side effects, which is sometimes difficult to achieve.
According to statistics, the chances of recovery are high if you carry out combination therapy, combining medication and psychosocial assistance. It is important to find the right ratio. And precisely because every psychosis is individual, autonomous, everyone who is sick has to look for his own path of treatment and count on help that meets his requirements.
Cognitive abilities such as concentration, attention and memory are essential for professional and social reintegration. The better these abilities are developed, the higher the chances of recovery.
Prolonged social isolation and the breakdown of family and friendships do not contribute to recovery. Some activities that require excessive effort also have a detrimental effect on the healing process.
The conditions and characteristics of individual development before the onset of the disease are important factors influencing recovery; these include level of education and social contacts.
An individual approach to the patient and integrated treatment can be considered an important condition for recovery. A combination of medication and psychosocial treatment increases the chances of recovery for most patients. Treatment must meet the following parameters: efficiency, continuity, unification, resource orientation and recovery orientation.

Psychotic disorders are a group of serious mental illnesses. They lead to impaired clarity of thinking, the ability to make correct judgments, react emotionally, communicate with people and adequately perceive reality. People with severe symptoms of the disease are often unable to cope with everyday tasks. Interestingly, such deviations are most often observed among residents of developed countries.

However, even severe types of diseases are amenable to drug treatment to one degree or another.

Definition

Psychotic-level disorders cover a range of illnesses and associated symptoms. Essentially, such disorders are some form of altered or distorted consciousness that persists for a significant period of time and interferes with the normal functioning of a person as a full-fledged member of society.

Psychotic episodes may occur as isolated events, but most often they are a sign of significant mental health problems.

Risk factors for the occurrence of psychotic disorders include heredity (especially for schizophrenia), frequent drug use (mainly hallucinogenic drugs). The onset of a psychotic episode can also be triggered by stressful situations.

Species

Psychotic disorders have not yet been fully considered; some points differ depending on the approach to their study, so certain disagreements may arise in classifications. This is especially true due to conflicting data on the nature of their occurrence. In addition, it is not always possible to clearly determine the cause of a particular symptom.

Nevertheless, the following main, most common types of psychotic disorders can be distinguished: schizophrenia, psychosis, bipolar disorder, polymorphic psychotic disorder.

Schizophrenia

The disorder is diagnosed when symptoms such as delusions or hallucinations persist for at least 6 months (with at least 2 symptoms occurring continuously for a month or more), with corresponding changes in behavior. Most often, the result is difficulty performing everyday tasks (for example, at work or while studying).

Diagnosis of schizophrenia is often complicated by the fact that similar symptoms can also occur with other disorders, and patients can often lie about the degree of their manifestation. For example, a person may not want to admit that they hear voices due to paranoid delusions or fear of stigmatization, and so on.

Also distinguished:

Schizophreniform disorder. It includes but lasts a shorter period of time: from 1 to 6 months.
Schizoaffective disorder. It is characterized by symptoms of both schizophrenia and diseases such as bipolar disorder.

Psychosis

Characterized by some distorted sense of reality.

A psychotic episode may include so-called positive symptoms: visual and auditory hallucinations, delusions, paranoid reasoning, and disoriented thinking. Negative symptoms include difficulties in constructing indirect speech, commenting and maintaining a coherent dialogue.

Bipolar disorder

Characterized by sudden mood swings. The condition of people with this disease usually changes sharply from maximum excitement (mania and hypomania) to minimum (depression).

Any episode of bipolar disorder may be characterized as an “acute psychotic disorder,” but not vice versa.

Some psychotic symptoms may only subside during the onset of mania or depression. For example, during a manic episode, a person may experience grandiose feelings and believe that they have incredible abilities (for example, the ability to always win any lottery).

Polymorphic psychotic disorder

It can often be mistaken for a manifestation of psychosis. Since it develops like psychosis, with all the accompanying symptoms, but it is also not schizophrenia in its original definition. Refers to the type of acute and transient psychotic disorders. Symptoms appear unexpectedly and constantly change (for example, a person sees new, completely different hallucinations each time), the general clinical picture of the disease usually develops quite quickly. This episode usually lasts from 3 to 4 months.

There are polymorphic psychotic disorder with and without symptoms of schizophrenia. In the first case, the disease is characterized by the presence of signs of schizophrenia, such as prolonged persistent hallucinations and a corresponding change in behavior. In the second case, they are unstable, the visions often have an unclear direction, and the person’s mood constantly and unpredictably changes.

Symptoms

And with schizophrenia, and with psychosis and all other similar types of diseases, a person always has the following symptoms characterizing a psychotic disorder. They are often called “positive”, but not in the sense that they are good and useful to others. In medicine, a similar name is used in the context of the expected manifestations of a disease or a normal type of behavior in its extreme form. Positive symptoms include hallucinations, delusions, strange body movements or lack of movement (catatonic stupor), peculiar speech, and strange or primitive behavior.

Hallucinations

They include sensations that do not have a corresponding objective reality. Hallucinations can appear in various forms that parallel the human senses.

Visual hallucinations include deception and seeing objects that don't exist.
The most common type of hearing is voices in the head. Sometimes these two types of hallucinations can be mixed, that is, a person not only hears voices, but also sees their owners.
Olfactory. A person perceives non-existent odors.
Somatic. The name comes from the Greek “soma” - body. Accordingly, these hallucinations are physical, for example, the feeling of the presence of something on or under the skin.

Mania

This symptom most often characterizes an acute psychotic disorder with symptoms of schizophrenia.

Manias are strong irrational and unrealistic beliefs of a person that are difficult to change, even in the presence of indisputable evidence. Most people not associated with medicine believe that mania is only paranoia, persecution mania, excessive suspicion, when a person believes that everything around him is a conspiracy. However, this category also includes unfounded beliefs, manic love fantasies and jealousy bordering on aggression.

Megalomania is a common irrational belief that results in the importance of a person being exaggerated in various ways. For example, the patient may consider himself a president or a king. Often delusions of grandeur take on religious overtones. A person may consider himself a messiah or, for example, sincerely assure others that he is the reincarnation of the Virgin Mary.

Misconceptions related to the characteristics and functioning of the body can also often arise. There have been cases where people refused to eat due to the belief that all the muscles in the throat were completely paralyzed and all they could swallow was water. However, there were no real reasons for this.

Other symptoms

Other symptoms tend to characterize short-term psychotic disorders. These include strange body movements, constant grimaces and facial expressions uncharacteristic for the person and situation or, as the opposite, catatonic stupor - lack of movement.

There are distortions of speech: incorrect sequence of words in a sentence, answers that make no sense or do not relate to the context of the conversation, mimicking the opponent.

Aspects of childishness are also often present: singing and jumping in inappropriate circumstances, moodiness, unconventional uses of ordinary objects, for example, creating a tin foil hat.

Of course, a person with psychotic disorders will not experience all symptoms at the same time. The basis for diagnosis is the presence of one or more symptoms over a long period of time.

Reasons

The following are the main causes of psychotic disorders:

Reaction to stress. From time to time, under severe prolonged stress, temporary psychotic reactions may occur. At the same time, the cause of stress can be both situations that many people face throughout life, for example, the death of a spouse or divorce, as well as more severe ones - a natural disaster, being in a place of war or in captivity. Typically, a psychotic episode ends as the stress decreases, but sometimes the condition can drag on or become chronic.
Postpartum psychosis. For some women, significant hormonal changes as a result of childbirth can cause. Unfortunately, these conditions are often misdiagnosed and mistreated, resulting in cases where the new mother kills her child or commits suicide.
Protective reaction of the body. It is believed that people with personality disorders are more susceptible to stress and are less able to cope with adult life. As a result, when life circumstances become more severe, a psychotic episode may occur.
Psychotic disorders based on cultural characteristics. Culture is an important factor in determining mental health. In many cultures, what is usually considered a deviation from the generally accepted norm of mental health is part of traditions, beliefs, and references to historical events. For example, in some regions of Japan there is a very strong, even manic, belief that the genitals can shrink and be pulled into the body, causing death.

If a behavior is acceptable in a given society or religion and occurs under appropriate conditions, then it cannot be diagnosed as an acute psychotic disorder. Treatment, accordingly, is not required under such conditions.

Diagnostics

In order to diagnose a psychotic disorder, a general practitioner needs to talk with the patient and also check the general state of health to rule out other causes of such symptoms. Most often, blood and brain tests are performed (for example, using MRI) to rule out mechanical brain damage and drug addiction.

If no physiological reasons for such behavior are found, the patient is referred to a psychiatrist for further diagnosis and determination of whether the person truly has a psychotic disorder.

Treatment

Most often, a combination of medication and psychotherapy is used to treat psychotic disorders.

As a medicine, specialists most often prescribe antipsychotics or atypical antipsychotics, which are effective in relieving anxiety symptoms such as delusions, hallucinations and distorted perception of reality. These include: "Aripiprazole", "Azenapine", "Brexpiprazole", "Clozapine" and so on.

Some drugs come in the form of tablets that need to be taken daily, others come in the form of injections that only need to be given once or twice a month.

Psychotherapy includes various types of counseling. Depending on the patient’s personality characteristics and how the psychotic disorder progresses, individual, group or family psychotherapy may be prescribed.

For the most part, people with psychotic disorders receive outpatient treatment, meaning they are not constantly in a medical facility. But sometimes, if there are severe symptoms, there is a threat of harm to oneself and loved ones, or if the patient is unable to take care of himself, hospitalization is performed.

Each patient being treated for a psychotic disorder may respond differently to therapy. For some, progress is noticeable from the first day, for others it will take months of treatment. Sometimes, if you have several severe episodes, you may need to take medication on an ongoing basis. Usually in such cases a minimum dose is prescribed to avoid side effects as much as possible.

Psychotic disorders cannot be prevented. But the sooner you seek help, the easier it will be to undergo treatment.

People at high risk of developing such disorders, such as those with close family members with schizophrenics, should avoid drinking alcohol and any drugs.