Recurrent (periodic) schizophrenia. Recurrent schizophrenia and its features What negative and positive symptoms can be found

Schizophrenia... For many, if not all ordinary people, this disease sounds like a stigma. “Schizophrenic” is a synonym for finality, the finiteness of existence and uselessness for society. Is this true? Alas, with this attitude it will be so. Everything unfamiliar is frightening and perceived as hostile. And a patient suffering from schizophrenia, by definition, becomes an enemy of society (I would like to note that, unfortunately in our society, this is not the case throughout the civilized world), because those around them are afraid and do not understand what kind of “Martian” is nearby. Or, even worse, they mock and mock the unfortunate person. Meanwhile, you should not perceive such a patient as an insensitive deck, he feels everything, and very acutely, believe me, and first of all the attitude towards himself. I hope to interest you and show understanding, and therefore sympathy. In addition, I would like to note that among such patients there are many creative (and well-known) personalities, scientists (the presence of the disease does not in any way detract from their merits) and sometimes simply people you know closely.

Let's try together to understand the concepts and definitions of schizophrenia, the characteristics of its symptoms and syndromes, and its possible outcomes. So:

From Greek Schizis - cleavage, phrenus - diaphragm (it was believed that this is where the soul was located).
Schizophrenia is the "queen of psychiatry." Today, 45 million people suffer from it, regardless of race, nation and culture, 1% of the world's population suffers from it. To date, there is no clear definition and description of the causes of schizophrenia. The term "schizophrenia" was coined in 1911 by Erwin Bleuler. Before that, the term “premature dementia” was in use.

In domestic psychiatry, schizophrenia is “a chronic endogenous disease, manifested by various negative and positive symptoms, and characterized by specific increasing personality changes.”

Here, apparently, we should pause and take a closer look at the elements of the definition. From the definition we can conclude that the disease lasts a long time and carries with it a certain stage and pattern in the change of symptoms and syndromes. At the same time negative symptoms- this is a “dropout” from the spectrum of mental activity of pre-existing signs characteristic of this person - a flattening of the emotional response, a reduction in energy potential (but more on that later). Positive symptoms- this is the appearance of new signs - delusions, hallucinations.

Signs of schizophrenia

Continuous forms of the disease include cases with a gradual progressive development of the disease process, with varying severity of both positive and negative symptoms. With a continuous course of the disease, its symptoms are observed throughout life from the moment of illness. Moreover, the main manifestations of psychosis are based on two main components: delusional ideas and hallucinations.

These forms of endogenous disease are accompanied by personality changes. A person becomes strange, withdrawn, and commits absurd, illogical actions from the point of view of others. The range of his interests changes, new, previously unusual hobbies appear. Sometimes these are philosophical or religious teachings of a dubious nature, or fanatical adherence to the canons of traditional religions. Patients' performance and social adaptation decrease. In severe cases, the occurrence of indifference and passivity cannot be excluded, total loss interests.

The paroxysmal course (recurrent or periodic form of the disease) is characterized by the occurrence of distinct attacks combined with a mood disorder, which brings this form of the disease closer to manic-depressive psychosis, especially since mood disorders occupy a significant place in the pattern of attacks. In the case of a paroxysmal course of the disease, manifestations of psychosis are observed in the form of separate episodes, between which there are “bright” intervals of relatively good mental state (with a high level of social and work adaptation), which, being sufficiently long, can be accompanied by complete restoration of working capacity (remission).

An intermediate place between the indicated types of course is occupied by cases of paroxysmal-progressive form of the disease, when, in the presence of continuous flow The disease is characterized by the appearance of attacks, the clinical picture of which is determined by syndromes similar to attacks of recurrent schizophrenia.

As mentioned earlier, the term “schizophrenia” was introduced by Erwin Bleuler. He believed that what is most important in describing schizophrenia is not the outcome, but the “underlying disorder.” He also identified a complex of characteristic signs of schizophrenia, four “A”s, Bleuler’s tetrad:

1. Associative defect - lack of connected, purposeful logical thinking (currently called “alogy”).

2. Symptom of autism (“autos” - Greek - own - distancing from external reality, immersion in one’s inner world.

3. Ambivalence - the presence in the patient’s psyche of multidirectional affects, love/hate at the same time.

4. Affective inadequacy - in a standard situation gives an inadequate affect - laughs when reporting the death of relatives.

Symptoms of schizophrenia

The French school of psychiatry proposed scales of deficit and productive symptoms, arranging them according to the degree of increase. German psychiatrist Kurt Schneider described rank I and rank II symptoms in schizophrenia. The “calling card” of schizophrenia is rank I symptoms, and now they are still “in use”:

1. Sounding thoughts - thoughts acquire sonority, in fact they are pseudohallucinations.
2. “Voices” that argue among themselves.
3. Commentary hallucinations.
4. Somatic passivity (the patient feels that his motor acts are being controlled).
5. "Taking out" and "introducing" thoughts, shperrung - ("clogging" of thoughts), breaking off thoughts.
6. Broadcasting thoughts (mental broadcasting - as if a radio is turned on in your head).
7. The feeling of “made” thoughts, their foreignness - “the thoughts are not your own, they were put into your head.” The same thing - with feelings - the patient describes that it is not he who feels hunger, but he is made to feel hunger.
8. Delusion of perception - a person interprets events in his own symbolic way.

In schizophrenia, the boundaries between “I” and “not I” are destroyed. A person considers internal events external, and vice versa. The borders are "loose". Of the 8 signs above, 6 indicate this.

Views on schizophrenia as a phenomenon are different:

1. Schizophrenia is a disease - according to Kraepelin.
2. Schizophrenia is a reaction - according to Bangöfer - causes different, but the brain responds with a limited set of reactions.
3. Schizophrenia is specific disorder adaptation (American Laing, Shazh).
4. Schizophrenia is a special personality structure (based on a psychoanalytic approach).

Etiopathogenesis (origin, "origins") of schizophrenia

There are 4 “blocks” of theories:

1. Genetic factors. 1% of the population is consistently sick; if one of the parents is sick, the risk that the child will also get sick is 11.8%. If both parents are sick - 25-40% and higher. In identical twins, the frequency of manifestation in both at the same time is 85%.
2. Biochemical theories: metabolic disorders of dopamine, serotonin, acetylcholine, glutamate.
3. Stress theory.
4. Psychosocial hypothesis.

Review of some theories:

Stress (of all kinds) affects a “flawed” personality - most often it is stress associated with the load of adult roles.

The role of parents: American psychiatrists Blazeg and Linds described the “schizophrenogenic mother.” As a rule, this is a woman: 1. Cold; 2. non-critical; 3. Rigid (with a “frozen”, delayed affect; 4. With confused thinking - often “pushes” the child towards severe schizophrenia.

There is a viral theory.

The theory that schizophrenia is a slowly progressive debilitating process such as encephalitis. Brain volume in patients suffering from schizophrenia is reduced.

In schizophrenia, information filtration, selectivity of mental processes, and pathopsychological direction are disrupted.

Men and women suffer from schizophrenia equally often, but city dwellers - more often, poor people - more often (more stress). If the patient is a man, the disease has more early start And severe course, and vice versa.

The American healthcare system spends up to 5% of its budget on treating schizophrenia. Schizophrenia is a disabling disease; it shortens the patient's life by 10 years. In terms of frequency of causes of death for patients, cardiovascular diseases are in first place, and suicide is in second place.

Patients with schizophrenia have a large “reserve” against biological stress and physical activity - they can withstand up to 80 doses of insulin, are resistant to hypothermia, and rarely suffer from acute respiratory viral infections and other viral diseases. It has been reliably calculated that “future patients” are born, as a rule, at the junction of winter and spring (March-April) - either due to the vulnerability of biorhythms, or due to the effects of infections on the mother.

Classification of schizophrenia variants.

According to the type of flow, they are distinguished:

1. Continuously progressive schizophrenia.
2. Paroxysmal
a) paroxysmal-progressive (fur-like)
b) periodic (recurrent).

By stages:

1. Initial stage (from the first signs of the disease (asthenia) to the manifest signs of psychosis (hallucinations, delusions, etc.). There may also be hypomania, subdepression, depersonalization, etc.
2. Manifestation of the disease: a combination of deficiency and productive symptoms.
3. Final stage. A pronounced predominance of deficiency symptoms over productive symptoms and a frozen clinical picture.

According to the degree of progression (speed of development):

1. Rapidly progressive (malignant);
2. Moderately progressive (paranoid form);
3. Low-progressive (sluggish).

The exception is recurrent schizophrenia.

Description of some types:

Malignant schizophrenia: appears between the ages of 2 and 16 years. It is characterized by a very short initial stage - up to a year. The manifest period is up to 4 years. Peculiarities:
a) In premorbid (i.e. in the state preceding the disease) schizoid personality (closed, uncommunicative, fearful of the outside world);
b) Productive symptoms immediately reach a high level;
c) In the 3rd year of the disease, apathetic-abulic syndrome is formed (vegetabels - “vegetable life” - and this condition can be reversible at the time of severe stress - for example, in a fire);
d) Treatment is symptomatic.

Moderate progressive type of schizophrenia: The initial period lasts up to 5 years. Strange hobbies, interests, and religiosity appear. They get sick between the ages of 20 and 45 years. In the manifest period - either a hallucinatory form or a delusional form. This period lasts up to 20 years. At the final stage of the disease - splinter delirium, speech is preserved. The treatment is effective, it is possible to achieve drug remissions (temporary improvements in well-being). In continuously progressive schizophrenia, hallucinatory-delusional symptoms significantly predominate over affective symptoms (violations of the emotional-volitional sphere); in the paroxysmal form, affective symptoms predominate. Also, in the paroxysmal form, the remissions are deeper and can be spontaneous (spontaneous). With continuously progressive disease, the patient is hospitalized 2-3 times a year, with paroxysmal disease - up to 1 time every 3 years.

Sluggish, neurosis-like schizophrenia: Age of appearance ranges from 16 to 25 years on average. There is no clear boundary between the initial and manifest periods. Neurosis-like phenomena dominate. Schizophrenic psychopathization is observed, but the patient can work and maintain family and communication ties. At the same time, it is clear that the person is “distorted” by the disease.

What negative and positive symptoms can be found?

Let's start with the negative:

1. Engin Bleuler highlighted associative defect;
Stransky - interpsychic ataxia;
Also - schisis.

All this is a loss of coherence, the integrity of mental processes -
a) in thinking;
b) in the emotional sphere;
c) in acts of will.

The processes themselves are scattered, and even within the processes themselves there is chaos. Schisis is an unfiltered product of thinking. It is also present in healthy people, but is controlled by consciousness. In patients, it is observed in the initial stage, but, as a rule, disappears with the onset of hallucinations and delusions.

2. Autism. A patient with schizophrenia experiences anxiety and fear when communicating with the outside world and wants to distance himself from any contact. Autism is an escape from contact.

3. Reasoning- the patient speaks, but does not move towards the goal.

4. Apathy- increasing loss of emotional response - fewer and fewer situations cause an emotional reaction. First there is rationalization instead of direct emotion. The first thing that disappears is interests and hobbies. (“Sergey, aunt is coming” - “he’ll come, we’ll meet you”). Teenagers behave like little old men - they seem to respond judiciously, but behind this “judgment” there is a clear impoverishment of emotional reactions; (“Vitalik, brush your teeth” - “why?”) That is. does not refuse or agree, but tries to rationalize. If you give an argument as to why you need to brush your teeth, there will be a counterargument; the conviction can drag on indefinitely, because... the patient is not really going to discuss anything - he is simply reasoning.

5. Abulia(according to Kraepelin) - disappearance of will. In the early stages it looks like increasing laziness. First - at home, at work, then in self-service. Patients lie down more. More often, what is observed is not apathy, but impoverishment; not abulia, but hypobulia. Emotions in patients suffering from schizophrenia are stored in one isolated “reserve zone,” which in psychiatry is called parabulia. Parabulia can be very diverse - one of the patients abandoned work and walked around the cemetery for months, drawing up his plan. “Work” took up a large volume. Another - counted all the letters "N" in "War and Peace". The third one dropped out of school, walked along the street, collected animal excrement and carefully attached it to a stand at home, as entomologists do with butterflies. Thus, the patient resembles a “mechanism running idle.”

Positive or productive symptoms:

1. Auditory pseudohallucinations(the patient hears “voices”, but perceives them not as really existing in nature, but as accessible only to him, “induced” by someone, or “descended from above”). It is usually described that such “voices” are heard not as usual, by the ear, but by the “head”, “brain”.

2. Mental automatism syndrome(Kandinsky-Clerambault), including:
a) Delusion of persecution (patients in this state are dangerous, because they can arm themselves in order to defend themselves from imaginary pursuers, and injure anyone they consider to be such; or attempt suicide in order to “get it over with”);
b) delusion of influence;
c) auditory pseudohallucinations (described above);
d) Mental automatism - associative (feeling of “made” thoughts); senestopathic (feeling of “made” feelings); motor (feeling that certain movements that he makes are not his, but are imposed on him from the outside, he is forced to do them) .

3. Catatonia, hebephrenia- freezing in one position, often uncomfortable, for long hours, or vice versa - sudden disinhibition, foolishness, antics.

According to neurogenetic theories, the productive symptoms of the disease are caused by dysfunction of the caudate nucleus of the brain, the limbic system. A discrepancy in the functioning of the hemispheres and dysfunction of the fronto-cerebellar connections are detected. CT scan (computed tomography of the brain) can detect expansion of the anterior and lateral horns of the ventricular system. In nuclear forms of the disease, the EEG (electroencephalogram) shows reduced voltage from the frontal leads.

Diagnosis of schizophrenia

The diagnosis is made on the basis of identifying the main productive symptoms of the disease, which are combined with negative emotional and volitional disorders, leading to loss of interpersonal communications with a total observation period of up to 6 months. Most important in the diagnosis of productive disorders has the identification of symptoms of influence on thoughts, actions and mood, auditory pseudohallucinations, symptoms of openness of thought, gross formal thinking disorders in the form of fragmentation, catatonic movement disorders. Among the negative violations, attention is paid to a reduction in energy potential, alienation and coldness, unreasonable hostility and loss of contacts, and social decline.

At least one of the following signs must be present:

“Echo of thoughts” (the sound of one’s own thoughts), putting or taking away thoughts, openness of thoughts.
Delusions of influence, motor, sensory, ideational automatisms, delusional perception.
Auditory commentary on true and pseudohallucinations and somatic hallucinations.
Delusional ideas that are culturally inappropriate, ridiculous and grandiose in content.

Or at least two of the following signs:

Chronic (more than a month) hallucinations with delusions, but without pronounced affect.
Neologisms, sperrungs, broken speech.
Catatonic behavior.
Negative symptoms, including apathy, abulia, impoverished speech, emotional inadequacy, including coldness.
Qualitative changes in behavior with loss of interests, lack of focus, autism.

Diagnosis of paranoid schizophrenia diagnosed if there are general criteria for schizophrenia, as well as the following signs:

dominance of hallucinatory or delusional phenomena (ideas of persecution, relationship, origin, transmission of thoughts, threatening or haunting voices, hallucinations of smell and taste, senesthesia);
catatonic symptoms, flattened or inappropriate affect, and intermittent speech may present in mild form, but do not dominate the clinical picture.

Diagnosis of hebephrenic form diagnosed if there are general criteria for schizophrenia and:

one of the following signs;

a distinct and persistent flattening or superficiality of affect,
clear and persistent inadequacy of affect,

one of the other two signs;

lack of focus, concentration of behavior,
distinct disturbances in thinking, manifested in incoherent or broken speech;

hallucinatory-delusional phenomena may be present in a mild form, but do not determine the clinical picture.

Diagnosis of catatonic form diagnosed if the general criteria for schizophrenia are met, as well as the presence of at least one of the following symptoms for at least two weeks:

stupor (a distinct decrease in reaction to the environment, spontaneous mobility and activity) or mutism;
agitation (apparently meaningless motor activity not caused by external stimuli);
stereotypies (voluntary adoption and retention of meaningless and pretentious poses, performance of stereotypical movements);
negativism (externally unmotivated resistance to outside requests, doing the opposite of what is required);
rigidity (maintaining a posture despite external attempts to change it);
waxy flexibility, freezing of limbs or body in externally prescribed poses);
automaticity (immediate following of instructions).

Photos of patients with catatonic schizophrenia

Undifferentiated form Diagnosed when the condition meets the general criteria for schizophrenia but not the specific criteria for individual types, or the symptoms are so numerous that they meet the specific criteria for more than one subtype.

Diagnosis of post-schizophrenic depression is set if:

the condition during the last year of observation met the general criteria for schizophrenia;
at least one of them is retained; 3) depressive syndrome must be so prolonged, severe and widespread as to meet the criteria for at least a mild depressive episode (F32.0).

For diagnosis of residual schizophrenia the condition must in the past meet the general criteria for schizophrenia, not detected already at the time of examination. In addition, at least 4 of the following negative symptoms must have been present during the last year:

psychomotor retardation or decreased activity;
distinct flattening of affect;
passivity and decreased initiative;
depletion of volume and content of speech;
decreased expressiveness of nonverbal communication, manifested in facial expressions, eye contact, voice modulations, gestures;
decreased social productivity and attention to appearance.

Diagnosis of simple form of schizophrenia is placed based on the following criteria:

gradual increase in all three of the following symptoms over at least a year:

distinct and persistent changes in some premorbid personal characteristics, manifested in a decrease in motives and interests, purposefulness and productivity of behavior, withdrawal and social isolation;
negative symptoms: apathy, impoverished speech, decreased activity, a distinct flattening of affect, passivity, lack of initiative, decreased nonverbal characteristics of communication;
a distinct decrease in productivity at work or school;

the state never corresponds to the symptoms common to paranoid, hebephrenic, catatonic and undifferentiated schizophrenia (F20.0-3);
there are no signs of dementia or other organic brain damage (FO).

The diagnosis is also confirmed by the data of a pathopsychological study; clinical and genetic data on the burden of schizophrenia in first-degree relatives are of indirect significance.

Pathopsychological tests for schizophrenia.

In Russia, unfortunately, psychological examination of mentally ill patients is not very developed. Although honey There are psychologists on staff at hospitals.

The main diagnostic method is conversation. The logical sequence of thinking inherent in a mentally healthy person in a patient with schizophrenia is in most cases upset, and associative processes are disrupted. As a result of such violations, the patient speaks as if sequentially, but his words have no semantic connection with each other. For example, the patient says that “the laws of justice of the sages are hunting for him in order to take away lambs with straight noses all over the world.”

As tests, they are asked to explain the meanings of expressions and sayings. Then you can “unearth” the formality, the mundaneness of judgments, the lack of understanding of the figurative meaning. For example, “the forest is being cut down, the chips are flying” - “well, yes, the tree is made of fibers, they break off when hit with an ax.” Another patient, when asked to explain what the expression “This man has a heart of stone” means, says: “Among the times of growth, there is cardiac layering, and this is an appearance human size"The given phrases are incomprehensible. This is a typical example of “disconnected speech.” In some cases, speech comes down to the pronunciation of individual words and phrases without any sequence. For example, “...spreading smoke...there will be nowhere...the kingdom heavenly...it’s wrong to buy water...one of two without a name...six crowns...cutting a lasso and a cross..." - this is the so-called verbal okroshka, or word salad. They may be asked to draw the meaning of the phrase "delicious lunch ".Where ordinary person draws a chicken leg, a steaming bowl of soup or a plate with a fork and knife, a patient suffering from schizophrenia draws two parallel lines. To the question - “what is this?” - replies that “dinner is delicious, everyone is having a blast, harmony, that’s how these lines are.” Another test is to exclude the fourth odd one - from the list “jackdaw, tit, crow, plane” - it may or may not exclude the plane (everything from the list flies), or exclude, but relying only on the signs known to him ("the first three from the list can land on wires, but the plane cannot." And not living/non-living, like ordinary people).

Prognosis for schizophrenia.

Let's reveal four types of forecasts:

1. General prognosis of the disease - concerns the time of onset of the final condition and its characteristics.

2. Social and labor forecast.

3. Prognosis of the effectiveness of therapy (whether the disease is resistant to treatment).

4. Forecasting the risk of suicide and homicide (suicide and murder).

About 40 factors have been identified that help determine the prognosis of the disease. Here are some of them:

1. Gender A male factor is an unfavorable factor, a female factor is a favorable one (nature dictates that women are the guardians of the population, while men are researchers, and they account for more mutations).

2. The presence of concomitant organic pathologies is a poor prognosis.

3. Hereditary history of schizophrenia - unfavorable prognosis.

4. Schizoid character accentuation before the onset of the disease.

5. Acute onset is a good prognostic sign; erased, “smeared” - bad.

6. A psychogenic “triggering” mechanism is good, spontaneous, without an obvious cause - bad.

7. The predominance of the hallucinatory component is bad, the affective component is good.

8. Sensitivity to therapy during the first episode - good, no - bad.

9. High frequency and duration of hospitalizations are a poor prognostic sign.

10. The quality of the first remissions - if the remissions are complete, good (meaning remissions after the first episodes). It is important that there are no or minimal negative and positive symptoms during remission.

40% of patients suffering from schizophrenia commit suicidal acts, 10-12% die from suicide.

List of risk factors for suicide in schizophrenia:

1. Male gender.
2. Young age.
3. Good intelligence.
4. First episode.
5. History of suicide.
6. Predominance of depressive and anxiety symptoms.
7. Imperative hallucinosis (hallucinations ordering certain actions to be performed).
8. Use of psychoactive substances (alcohol, drugs).
9. The first three months after discharge.
10. Inappropriately small or large doses of drugs.
11. Social problems in connection with the disease.

Risk factors for homicide (attempted murder):

1. History of (previous) criminal episodes with assault.
2. Other criminal acts.
3. Male gender.
4. Young age.
5. Substance use.
6. Hallucinatory-delusional symptoms.
7. Impulsiveness.

Sluggish schizophrenia

According to statistics, half of patients with schizophrenia “have” it in a sluggish form. This is a certain category of people that is difficult to define. Recurrent schizophrenia also occurs. Let's talk about them.

By definition, sluggish schizophrenia is schizophrenia, which throughout its entire duration does not show pronounced progression and does not show manifest symptoms. psychotic phenomena, the clinical picture is represented by disorders of the lung “registers” - neurotic personality disorders, asthenia, depersonalization, derealization.

Titles low-grade schizophrenia, accepted in psychiatry: mild schizophrenia (Kronfeld), non-psychotic (Rozenstein), Current without a change in character (Kerbikov), microprocessual (Goldenberg), rudimentary, sanatorium (Connaibeh), prephase (Yudin), slow-flowing (Azelenkovsky), larved, hidden ( Snezhnevsky). You can also find the following terms:
failed, amortized, outpatient, pseudo-neurotic, occult, non-regressive.

Sluggish schizophrenia has certain stages:

1. Latent (debut) - occurs very hidden, latent. As a rule, at the age of puberty, in adolescents.

2. Active (manifest) period. The manifesto never reaches a psychotic level.

3. Stabilization period (in the first years of the disease, or after several years of the disease).
In this case, the defect is not observed, there may even be regression negative symptoms, its reverse development. However, there may be a new impulse at the age of 45-55 years (involutional age). General characteristics:
Slow, long-term development of the stages of the disease (however, it can stabilize in early age); long subclinical course in the latent period; gradual reduction of disorders during the stabilization period.

Forms, variants of low-progressive schizophrenia:

1. Asthenic variant - symptoms are limited to the level of asthenic disorders. This is the softest level.
Asthenia is atypical, without the “match symptom”, irritability - in this case, selective exhaustion of mental activity is observed. There are also no objective reasons for asthenic syndrome - a somatic illness, organic pathology in premorbid. The patient gets tired of ordinary everyday communication, ordinary affairs, while he is not exhausted by other activities (communication with asocial individuals, collecting, and often pretentious ones). This is a kind of hidden schism, a splitting of mental activity.

2. Form with obsession. Looks like a neurosis obsessive states. However, in schizophrenia, no matter how hard we try, we will not detect psychogenesis and personality conflict. Obsessions are monotonous and not emotionally rich, “not charged.” At the same time, these obsessions can grow a large number rituals performed without emotional involvement of a person. Characterized by monoobsessions (monothematic obsession).

3. Form with hysterical manifestations. "Cold hysteria" is typical. This is a very “selfish” schizophrenia, while it is exaggerated, grossly selfish, exceeding hysteria in a neurotic. The rougher it is, the worse and deeper the violation.

4. With depersonalization. In human development, depersonalization (violation of the boundaries “I am not me”) can be the norm in adolescence, but in schizophrenia it goes beyond this framework.

5. With dysmorphomaniac experiences ("my body is ugly, my ribs stick out too much, I am too thin/fat, my legs are too short, etc.). This also occurs in adolescence, but with schizophrenia there is no emotional involvement in the experience." Defects" ostentatious - "one side is more ostentatious than the other." Early-onset anorexia nervosa syndrome also belongs to this group.

6. Hypochondriacal schizophrenia. Non-delusional, non-psychotic level. Characteristic of adolescence and involutionary age.

7. Paranoid schizophrenia. Reminds me of paranoid personality deviation.

8. With predominance affective disorders. Possible hypothymic variants (subdepression, but without intellectual inhibition). In this case, a schism is often visible between a reduced background mood and intellectual, motor activity, and volitional component. Also - hypochondriacal subdepression with an abundance of senestopathies. Subdepression with a tendency to introspection and soul-searching.
Hyperthymic manifestations: hypomania with a one-sided nature of passion for one activity. “Zigzags” are typical - a person works, is full of optimism, then a decline for several days, and then works again. Schisic variant - hypomania with simultaneous health complaints.

9. Option of non-productive disorders. "Simple option." Symptoms are limited to negative ones. There is a gradual defect that grows over the years.

10. Latent sluggish schizophrenia (according to Smulevich) - everything that was listed above, but in the mildest, outpatient form.

Defects in low-grade schizophrenia:

1. Defect of the ferschreuben type (from German strangeness, eccentricity, eccentricity) - described by Krepeleny.
Externally - disharmony of movements, angularity, a certain juvenileness (“childishness”). Unmotivated seriousness of facial expression is characteristic. There is a certain shift with the acquisition earlier (before the illness) of traits not characteristic of this personality. In clothing - sloppiness, awkwardness (short trousers, bright hats, clothes like from the century before last, randomly chosen things, etc.). Speech is unusual, with a selection of peculiar words and speech patterns, and “getting stuck” on minor details is typical. There is safety of mental and physical activity, despite the eccentricity (there is a schism between social autism and lifestyle - patients walk a lot, communicate, but in a peculiar way).

2. Psychopathic-like defect (pseudopsychopathy according to Smulevich). The main component is schizoid. An expansive schizoid, active, “gushing” with super-valuable ideas, emotionally charged, with “autism inside out,” but at the same time flattened, not solving social problems. In addition, there may be a hysterical component.

3. Reduction of energy potential of a shallow degree of expression (passive, live within the confines of the house, do not want and cannot do anything). It looks like a typical reduction in energy potential in schizophrenia, but to a much less pronounced degree.

These people often resort to psychoactive substances, more often to alcohol. At the same time, emotional flatness decreases, the schizophrenic defect decreases. The danger, however, is that alcoholism and drug addiction become uncontrollable, since their reaction stereotype to alcohol is atypical, alcohol often does not bring relief, and the forms of intoxication are expansive, with aggression and brutality. However, alcohol is indicated in small doses (psychiatrists of the old schools prescribed it to their patients with low-grade schizophrenia).

And finally - recurrent, or periodic schizophrenia.

It is rare, in particular due to the fact that it is not always possible to diagnose it in time. In the International Classification of Diseases (ICD), recurrent schizophrenia is designated as schizoaffective disorder. This is the most complex form of schizophrenia in its symptoms and structure.

Stages of occurrence of recurrent schizophrenia:

1. The initial stage of general somatic and affective disorders (subdepression with severe somatization - constipation, anorexia, weakness). Characterized by the presence of overvalued (i.e., based on real, but grotesquely exaggerated) fears (for work, relatives). Lasts from several days to several months (usually 1-3 months). This may be all there is to it. Beginning - adolescence.

2. Delusional affect. Vague, undeveloped fears of delusional, paranoid content (for oneself, for loved ones) appear. There are few delusional ideas, they are fragmentary, but there is a lot of affective charge and motor components - thus, this can be attributed to acute paranoid syndrome. Incipient changes in self-awareness are characteristic. There is a certain alienation of one’s behavior, depersonalization manifestations of a shallow register. This stage is extremely labile, symptoms may fluctuate.

3. Stage of affective-delusional depersonalization and derealization. Disorders of self-awareness sharply increase, and a delusional perception of the environment appears. Delirium of intermetamorphosis - “everything around is rigged.” False recognition, a symptom of doubles, appears, automatisms (“I am being controlled”), psychomotor agitation, and substupor are present.

4. Stage of fantastic affective-delusional depersonalization and derealization. The perception becomes fantastic, the symptoms become paraphrenized (“I’m at a school for space reconnaissance and they’re testing me”). The disorder of self-awareness continues to worsen (“I am a robot, I am being controlled”; “I run a hospital, a city”).

5. Illusory-fantastic derealization and depersonalization. Self-perception and reality begin to suffer severely, to the point of illusions and hallucinations. In essence, this is the beginning of oneiric clouding of consciousness (“I am me, but now I am a technical device - pockets are special devices for disks”; “the policeman speaks - I hear him, but this is the voice that controls everything on Earth”).

6. Stage of classic, true oneiric clouding of consciousness. The perception of reality is completely disrupted, it is impossible to come into contact with the patient (only for a short time - due to the lability of the processes). There may be motor activity dictated by experienced images. Self-awareness is disrupted (“I am not me, but an animal of the Mesozoic era”; “I am a machine in the struggle between machines and people”).

7. Stage of amentia-like clouding of consciousness. In contrast to the oneiroid, psychopathological experiences of reality are extremely impoverished. The amnesia of experiences and images is complete (not with oneiroid). Also - confusion, severe catatonic symptoms, fever. This is the pre-phase of the next stage. The prognosis is unfavorable. (There is also a separate form - “Febrile schizophrenia”). The main “psychiatric” remedy in this case is electroconvulsive therapy (ECT) - up to 2-3 sessions per day. This is the only way to break this state. There is a 5% chance of improvement. Without these measures, the prognosis is 99.9% unfavorable.

All of the above levels can be an independent picture of the disease. As a rule, from attack to attack the condition becomes more severe until it “freezes” at some stage. Recurrent schizophrenia is a low-progressive form, so between attacks full recovery no, but the remissions are long, the manifestations of the disease are barely noticeable. The most common outcome is a reduction in energy potential; patients become passive, isolated from the world, nevertheless often maintaining a warm atmosphere towards family members. In many patients, recurrent schizophrenia can turn into fur-like schizophrenia after 5-6 years. IN pure form recurrent schizophrenia does not lead to a permanent defect.

Treatment of schizophrenia.

General methods:

I. Biological therapy.

II. Social therapy: a) psychotherapy; b)methods social rehabilitation.

Biological methods:

I "Shock" methods of therapy:

1. Insulin-comatose therapy (introduced by the German psychiatrist Zakel in 1933);

2. Convulsive therapy (using camphor oil injected under the skin - Hungarian psychiatrist Meduna in 1934) - is not currently used.

3) electroconvulsive therapy (Cerletti, Beni in 1937). ECT treats mood disorders very effectively. In schizophrenia - with suicidal behavior, with catatonic stupor, with resistance to drug therapy.

4) Detoxification therapy;

5) Diet-unloading therapy (for low-grade schizophrenia);

6) Sleep deprivation and phototherapy (for affective disorders);

7) Psychosurgery (in 1907, Bekhtnrnva's staff performed a lobotomy; in 1926, the Portuguese Moniza performed a prefrontal leucotomy. Moniz was later wounded by a patient with a pistol shot after performing an operation on him);

8) Pharmacotherapy.

Drug groups:

a) Neuroleptics;
b) Anxiolytics (reducing anxiety);
c) Normotimics (regulating the affective sphere);
d) antidepressants;
e) nootropics;
e) psychostimulants.

In the treatment of schizophrenia, all of the above groups of drugs are used, but neuroleptics are in first place.

General principles of drug treatment of schizophrenia:

1. Biopsychosocial approach - any patient suffering from schizophrenia needs biological treatment, psychotherapy and social rehabilitation.

2. Particular importance is given to psychological contact with the doctor, because Patients with schizophrenia have the lowest interaction with the doctor - they are distrustful and deny the presence of the disease.

3. Early initiation of therapy - before the onset of the manifest stage.

4. Monotherapy (where 3 or 5 drugs can be prescribed, choose 3, so you can “track” the effect of each of them);

5. Long duration of treatment: relief of symptoms - 2 months, stabilization of the condition - 6 months, formation of remission - a year);

6. The role of prevention - special attention is paid to drug prevention of exacerbations. The more exacerbations, the more severe the disease. In this case we're talking about about secondary prevention of exacerbations.

The use of antipsychotics is based on the dopamine theory of pathogenesis - it was believed that patients with schizophrenia have too much dopamine (the precursor of norepinephrine), and it must be blocked. It turned out that there is no more of it, but the receptors are more sensitive to it. At the same time, disturbances in serotonergic mediation, acetylcholine, histamine, and glutamate were discovered, but the dopamine system reacts faster and stronger than others.

The gold standard treatment for schizophrenia is haloperidol. The power is not inferior to subsequent drugs. Classic antipsychotics, however, have side effects: they have a high risk of extrapyramidal disorders, and they have a very brutal effect on all dopamine receptors. IN lately atypical antipsychotics appeared: Clozepine (Leponex) - the first atypical antipsychotic to appear; the most famous currently:

1. Respiredon;
2. Alanzepine;
3. Clozepine;
4. Quetiopine (Serroquel);
5. Abilefay.

There is a prolonged version of the drugs that allows you to achieve remissions with less frequent administrations:

1. Moditen depot;
2.Haloperidol decanoate;
3. Rispolept-consta (taken once every 2-3 weeks).

As a rule, when prescribing a course, oral drugs are preferable, since injection of the drug into a vein or into a muscle is associated with violence and causes a peak concentration in the blood very quickly. Therefore, they are used mainly to relieve psychomotor agitation.

Hospitalization.

In schizophrenia, hospitalization is indicated in acute conditions - refusal to eat for a week or more, or leading to a loss of body weight of 20% of the original or more; the presence of imperative (commanding) hallucinosis, suicidal thoughts and tendencies (attempts), aggressive behavior, psychomotor agitation.

Because people with schizophrenia often do not realize they have the disease, it is difficult or even impossible to persuade them to seek treatment. If the patient's condition worsens, and you can neither convince nor force him to undergo treatment, then you may have to resort to hospitalization in psychiatric hospital without his consent. The main purpose of both involuntary hospitalization and the laws governing it is to ensure the safety of the patient himself who is in acute stage, and the people around him. In addition, the tasks of hospitalization also include ensuring timely treatment the patient, even against his wishes. After examining the patient, the local psychiatrist decides under what conditions to carry out treatment: the patient’s condition requires urgent hospitalization in a psychiatric hospital, or it can be limited to outpatient treatment.

Article 29 of the Law of the Russian Federation (1992) " “On psychiatric care and guarantees of citizens’ rights during its provision” clearly regulates the grounds for involuntary hospitalization in a psychiatric hospital, namely:

“A person suffering from a mental disorder may be hospitalized in a psychiatric hospital without his consent or without the consent of his legal representative until a judge’s decision, if his examination or treatment is possible only in inpatient conditions, and the mental disorder is severe and causes:

his immediate danger to himself or others, or
his helplessness, that is, his inability to independently satisfy the basic needs of life, or
significant harm to his health due to a deterioration in his mental state if the person is left without psychiatric help."

Treatment during remission

During the period of remission, maintenance therapy is required; without this, the condition will inevitably worsen. As a rule, patients feel much better after discharge, believe that they are completely cured, stop taking medications, and the vicious circle starts again. This disease cannot be completely cured, but with adequate therapy it is possible to achieve stable remission with maintenance treatment.

Do not forget that the success of treatment often depends on how quickly after an exacerbation or initial stage the person contacted a psychiatrist. Unfortunately, the relatives, having heard about the “horrors” of the psychiatric clinic, are opposed to the hospitalization of such a patient, believing that “everything will go away on its own.” Alas... Spontaneous remissions are practically not described. Therefore, they apply later, but in a more difficult situation.

Remission criteria: disappearance of delusions, hallucinations (if any), disappearance of aggression or suicidal attempts, and, if possible, social adaptation. In any case, the decision on discharge is made by the doctor, as well as on hospitalization. The task of the relatives of such a patient is to cooperate with the doctor, informing him about all the nuances of the patient’s behavior, without hiding or embellishing anything. And also - monitor the intake of medications, since such people do not always comply with the psychiatrist’s prescriptions. In addition, success also depends on social rehabilitation, and half the success in this is creating a comfortable atmosphere in the family, and not an “exclusion zone.” Believe me, patients of this profile very sensitively feel the attitude towards themselves and react accordingly.

If we take into account the cost of treatment, disability payments and sick leave, then schizophrenia can be called the most expensive of all mental illnesses.

Psychiatrist A.V. Khodorkovsky

– characterized, according to domestic researchers, by psychotic attacks of varying duration (from several days to a number of years), with various psychopathologies (affective, delusional, hallucinatory, paraphrenic, catatonic, oneiric disorders) and long-term remissions of sufficiently high quality, close to intermissions or identical to them . The number of attacks can reach 3-4 or more; a third of patients have only one attack throughout their lives. In some patients, attacks occur in the same way, that is, according to a cliché type; in other patients, attacks of different types occur, the clinical picture of which can be used to judge the dynamics of the process as a whole. If their clinical structure becomes more severe from one attack to another, then a tendency towards progression should be assumed; if the opposite picture is observed, then the hypothesis about a tendency towards a reverse development of the process and, accordingly, a favorable prognosis of the disease seems more justified. It is noteworthy that the first attack is the most severe - usually an attack of oneiric catatonia. The initial period of the disease lasts up to several months. At this time, asthenic, affective, neurosis-like disorders are observed. The onset of the manifest stage occurs between the ages of 17 and 25 years. Psychotic attacks that occur at this time can stop at any phase without reaching their climax, that is, oneiric catatonia. These are attacks of acute paraphrenia, acute fantastic delusions (with delusions of staging, intermetamorphosis, antagonistic delusions, delusions of negative and positive doubles), acute hallucinatory-paranoid, affective-delusional or affective-hallucinatory syndromes, acute paranoia or affective disorder. Affective disorders, as a rule, persist in the clinical structure of more severe attacks of the disease. Attacks with depressive-paranoid symptoms most often have an unfavorable prognosis, indicating the possibility of their long-term course. Affective attacks(“circular schizophrenia”) are atypical; they rarely present the classic triad of signs of an affective disorder, but mixed states and dual phases often occur. In the residual period of the disease, deficiency symptoms may not be detected at all, but in some cases, as the disease moves from one attack to another, its gradual accumulation occurs. In some cases, a transition occurs from periodic to fur-like schizophrenia. Treatment of the disease is reduced to the relief of psychotic attacks using mainly drugs with a sedative effect (tizercin, azaleptin, chlorprothixene, phenazepam), antidepressants and antimanic drugs. It is recommended to prevent attacks with carbamazepine and verapamil. Synonym: Recurrent schizophrenia. In ICD-10, this form of schizophrenia is coded under different headings, including included in schizoaffective psychosis.

Etiology

The main role among the reasons for the development of the recurrent form of schizophrenia is played by heredity. Some close relative suffered from a mental disorder or psychopathy.

There is a hypothesis that most often hyperthymic individuals suffer from this form of the disease, less often the periodic form of schizophrenia occurs in schizoids.

Attacks of the disease can occur spontaneously, in some cases the provoking factor is a severe disease of the internal organs, stress, intoxication or childbirth (as happens with).

Symptoms

The most typical symptoms of recurrent schizophrenia are affective, oneiric and catatonic manifestations, delusions.

Affective disorders can occur as a depressive type (with apathy, low mood, self-condemnation) or a manic type (apathy, an irresistible desire to do something, fun prevails). The most common catatonic manifestations are stupor and agitation (they are described in detail in the article about).

There may be problems with sleep (insomnia or, conversely, vivid dreams), and groundless anxiety. Sometimes patients have the feeling that something terrible will happen soon, that they may go crazy.

Characteristics of a classic attack

In typical cases, an attack of recurrent schizophrenia develops according to the following pattern:

Emotional disturbances appear first. Periods of high spirits, when enthusiasm prevails, you want to do something, alternate with inactivity, bad mood, autonomic disorders.
The next stage is the appearance of delirium. It seems to a person that a play or film is being played out around him, and everyone around him is an actor, and someone is directing them (staging syndrome). In the statements of others, the patient begins to grasp a hidden meaning that is understandable only to him. It seems to a person that someone controls his thoughts, puts them in his head.
With further progression of the disorder, antagonistic delusion syndrome occurs. The patient begins to think that his environment consists of representatives of good and evil who are fighting among themselves (antagonistic delusion). Delusions of grandeur may also occur.
At the peak of exacerbation, oneiric and catatonic disorders are noted. A person may freeze in one position and not respond to calls to him. Oneiric clouding of consciousness may also occur when visions of fantastic content flash before the patient’s eyes.
During regression of the exacerbation, emotional disorders again become the leading symptoms.

An attack of periodic schizophrenia does not always go through all stages. Its development may stop at one stage, and the manifestations of subsequent stages will be only short-term episodes against the background of protracted main symptoms.

On average, an attack lasts several months, but can be shorter (from several days to a couple of weeks).

Similarities with TIR

Recurrent schizophrenia has many similarities to manic depression, or bipolar personality disorder as it is now called. It has a fairly favorable prognosis; in most cases, exacerbations are accompanied by affective disorders. At the same time, symptoms of recurrent schizophrenia may include delusions and catatonic disorders, which are not typical for MDP.

Affective disorders that occur during periodic schizophrenia, although similar to schizophrenia, are blurred and can only be individual symptoms. For example, if a person shows signs of depression, then all three symptoms of the classic triad (low mood, motor and intellectual retardation) will not occur simultaneously.

During the interictal period, phases of mood changes similar to those may be observed. However, since emotional disorders are not clearly expressed, the person continues to lead his usual lifestyle, work, and does not consult a psychiatrist.

There are 2 variants of the course of the periodic form of schizophrenia: with the same type of attacks or with different ones.

The nature of exacerbations depends on the age of onset of the disease:

if the onset of the disease occurs before the age of 30, then most often the attacks are accompanied by oneiric-affective disorders;
if the disease debuted at an older age, then oneiric-catatonic manifestations are not typical, but delirium or emotional disturbances predominate.

Remission

Although remissions for this disease are of fairly high quality, some may still occur, for example, emotional disturbances.

Personal changes may appear in the form of asthenia, limited contact, and decreased activity. Some patients become pedantic, passive, submissive. Others begin to over-monitor their mental health– avoid in every possible way information and situations that can have a negative impact on the psyche.

Treatment

Antipsychotics (haloperidol, triftazine, Truxal, Rispolept) are used to treat recurrent schizophrenia. These drugs affect catatonic, oneiric manifestations, delirium, and help cope with agitation.

If the patient has severe depressive disorders, then antidepressants (fluvoxamine, paroxetine) can be used. A specific drug is chosen based on which symptoms are dominant - anxiety or depression.

(recurrent) occurs in the form of attacks, followed by remissions - the complete disappearance of mental disorders. Seizures are determined by a variety of disorders. The same patient may experience psychoses that are similar in clinical picture (the “cliché” type), but more often the picture of the disease changes from attack to attack. The number of attacks can vary from one to many dozens, the duration - from days and weeks to many months and even years.

The attack usually begins with affective disorders (see. Affective syndromes). A low mood can only be melancholy, but anxiety, resentment, moodiness, complaints of weakness and impotence are more common. Hypomanic states are accompanied by enthusiasm and tenderness. The intensity of affective disorders is subject to significant fluctuations. Opposite affective states easily replace each other. At the same time, especially with the predominance of depressive disorders, appetite deteriorates, constipation and discomfort in the heart area appear. Patients often lose weight.

As the disease deepens, anxiety sharply intensifies, fear, acute sensory delirium, and false recognitions appear (see). The growing excitement is at first of an enthusiastic-pathetic nature, and later can be replaced by excitement with impulsiveness. Phenomena of confusion are common.

Subsequently, delusional and hallucinatory disorders increasingly acquire fantastic content. Memories of the past, much previous knowledge, and what is happening around receive fantastic meaning. Excitement is increasingly replaced by states of inhibition and, finally, at the height of the attack, stupor develops, accompanied by oneiric stupefaction. This condition is called oneiric catatonia.

An attack of recurrent schizophrenia can stop at any stage of its development. In some cases, the disease is limited only to the appearance of affective disorders; in others, development can reach the oneiroid stage. Between these extreme stages there is a large number intermediate states. In remissions in periodic schizophrenia, mild depressive and hypomanic states most often persist from mental disorders.

Personality changes in periodic schizophrenia occur after the patient has suffered several attacks and are expressed in a slight decrease in mental activity, a narrowing of the range of interests limited only to home and work, the appearance of isolation, increased vulnerability, and subordination to loved ones. As a rule, the feeling of being painfully changed remains.

Schizophrenia(schizophrenia; Greek schizō split, divide + phrēn mind, mind; synonym Bleuler's disease) is a mental illness with a long-term chronic progressive course, accompanied by dissociation of mental processes, motor skills and increasing personality changes. The inconsistency of the entire mental life in schizophrenia allows us to designate it with the concept of “discordant psychosis.” A characteristic feature of schizophrenia is the early appearance of signs of a personality defect. The cardinal signs are autism (the patient’s isolation from reality with loss of emotional connections and fixation on internal experiences, ideas, fantasies), ambivalence (duality in the affective sphere, thinking, behavior), disorders of associative activity, emotional impoverishment, as well as those noted at different stages of the disease positive disorders - delusional, hallucinatory, catatonic, hebephrenic, senestohypochondriacal, neurosis-like psychopathies, affective.
At the same time, positive disorders differ significantly from psychogenic, somatogenic and organic mental disorders.

Negative disorders in schizophrenia include manifestations of pseudoorganic (rigidity of thinking, intellectual decline), asthenic (decreased mental activity, or reduction in energy potential) and psychopathic-like defect (mainly schizoid personality changes).

ETIOLOGY, PATHOGENESIS AND PATHOMORPHOLOGICAL CHARACTERISTICS schizophrenia. Schizophrenia belongs to a group of diseases with a hereditary predisposition. This is evidenced by the accumulation of cases of this disease in families of patients with schizophrenia, as well as the high concordance of identical twins with schizophrenia. There are several hypotheses for the pathogenesis of schizophrenia. Thus, the biochemical hypothesis assumes, first of all, disturbances in the metabolism of biogenic amines or the functions of their enzymatic systems. The immunological hypothesis is based on a number of biological abnormalities (membrane insufficiency of brain tissue cells, changes in autoimmune reactions), accompanied by the production in the body of a patient with schizophrenia of antibodies that can damage brain tissue.

Along with biological hypotheses, concepts of the psycho- and sociogenesis of schizophrenia are also put forward, based on behaviorist, psychological and other theories (for example, the theory of communication, filters, excessive inclusion), which have not received wide recognition due to insufficient scientific validity of a number of provisions.

From a psychoanalytic and psychodynamic perspective, schizophrenia is considered as one of the forms of personality maladaptation, as a result of its special development, the impetus for which was early interpersonal conflicts.

A pathological examination of the brain of patients with schizophrenia revealed pronounced encephalopathic changes of a toxic-hypoxic nature.
In cases of a malignant, protracted course of schizophrenia, shrinkage of pyramidal nerve cells and their disappearance with the formation of foci of loss of cytoarchitecture of the cerebral cortex, as well as pigmented sclerosis of neurons, and areactivity of microglia are observed.

CLINICAL PICTURE
There are continuous, paroxysmal-progressive and recurrent types of schizophrenia.

Continuous schizophrenia is characterized by chronic, progressive development without deep remissions pathological process. The weakening of progressive dynamics is accompanied only by relative stabilization psychopathological manifestations with a slight reduction in both positive and negative disorders. Depending on the degree of progression of the process, malignant (nuclear), progressive and sluggish schizophrenia are distinguished. According to the characteristics of psychopathological manifestations within each of them, they are distinguished separate forms schizophrenia.

Malignant schizophrenia most often develops in childhood or adolescence.
Among the manifestations of the disease, a decrease in mental activity, increasing emotional changes and signs of distorted puberty. At the initial stages of malignant schizophrenia, patients already experience thinking disorders and their ability to concentrate is impaired. Despite the efforts spent on preparing school assignments, children's academic performance drops sharply. If previously brilliant abilities were discovered, now patients are forced to stay for a second year, and sometimes stop studying. As emotional changes deepen, alienation from relatives increases, often combined with irritability and even aggressiveness.

In cases where the disease is limited primarily to negative disorders (progressive emotional impoverishment, loss of interests, lethargy, intellectual unproductivity), a simple form of schizophrenia is diagnosed.

With the development of the clinical picture of psychosis, positive disorders observed along with negative ones are polymorphic, sometimes undeveloped.
Thus, in some cases, phenomena of silly excitement (hebephrenic form of schizophrenia) prevail - clowning, grimacing, rudeness, malice and sudden changes mood; at the same time, phenomena of behavioral regression may come to the fore - sloppiness in food and clothing, a tendency to ridiculous actions. In other cases of malignant schizophrenia, delusional and hallucinatory disorders are expressed (unsystematized delusions of persecution, poisoning, grandeur, phenomena of mental automatism, pseudohallucinations).

Most malignant course schizophrenia is noted with the early appearance, and later predominance in the clinical picture, of catatonic disorders (catatonic form of schizophrenia), which can be either in the form of akinetic manifestations with increased muscle tone, phenomena of waxy flexibility, negativism (catatonic stupor), or in the form of hyperkinesia with impulsiveness, outbursts of aggression, meaningless stereotypical movements, repetition of words and movements of others (catatonic agitation).

Progressive (paranoid) schizophrenia develops in people over 25 years of age; occurs with a predominance of delusional disorders. The initial stage of the disease is characterized by neurosis- and psychopath-like disorders and unstable delusional ideas. The manifestation of the process is manifested by the formation of delusional or hallucinatory disorders. There are three stages in the development of paranoid schizophrenia - paranoid, paranoid, paraphrenic. At the first stage, delusional ideas of ordinary content arise (delusions of jealousy, invention, reform, etc.), which, as the disease develops, are gradually systematized and take the form of delusions of persecution.

At the paranoid stage, manifested by the phenomena of anxious-fearful arousal, there is a change in the delirium of physical influence to the phenomena of mental automatism, when the patient seems that his thoughts and movements are controlled from the outside, influencing his feelings and functions of internal organs.

At the paraphrenic stage, delusions with ideas of greatness, high origin, false, fictitious memories (confabulation) dominate. In the clinical picture, delusions of grandeur, which form against the background of altered, usually increased affect, are combined with delusions of persecution, as well as auditory hallucinations and phenomena of mental automatism.

Sluggish schizophrenia often debuts in adolescence. However, clear manifestations may be detected later. The slow, long-term development of the disease is accompanied by gradually increasing personality changes. Sluggish schizophrenia is characterized by a predominance of neurosis-like or psychopathic-like disorders in the clinical picture. In the first case, it is noted asthenic conditions with a polar change of painful manifestations (for example, hyperesthesia - hypoesthesia); hysterical states with transformation of hysterical manifestations in the bodily sphere (hysteralgia, spasms, tremors, etc.); obsessive-phobic states, in which there is a consistent modification of phobias or obsessive fears (from simple to generalized), accompanied by ritual behavior that loses its previous affective coloring; hypochondriacal conditions, characterized by a transition from neurotic and overvalued hypochondria to senestohypochondria (see Senestopathies); depersonalization states with a persistent modification of the consciousness of the “I”, the phenomena of autopsychic depersonalization (alienation of higher emotions, awareness of one’s own mental alteration).

The clinical picture of schizophrenia with a predominance of psychopathic-like disorders resembles manifestations of psychopathy.

A special place is occupied by schizophrenia, which occurs with highly valuable formations; At the same time, the following dynamics in the clinical picture are noted: overvalued ideas - overvalued delirium - systematized paranoid delirium with a plot divorced from reality.

Paroxysmal-progressive (fur coat) schizophrenia is characterized by delineated attacks (fur coats) separated by remissions. The disease may be limited to one attack, and when progressive development manifests itself as repeated, more severe attacks with a deterioration (due to the deepening of the personality defect and the expansion of the range of residual disorders) in the quality of remissions. The attacks are varied; in the initial period, neurosis-like, paranoid, paranoid, hallucinatory, catatonic-hebephrenic disorders may be observed. The attack is characterized by acute variability, polymorphism of symptoms, and severity of affective disorders. There are acute affective-delusional, affective-hallucinatory attacks, acute paraphrenia, and attacks with a predominance of mental automatism.

Recurrent schizophrenia occurs in the form of acute, prolonged or transient attacks with a predominance of affective disorders (schizoaffective psychoses). The attacks are separated by persistent and deep remissions, without pronounced negative disorders, in the clinical picture of which recurrent, erased hypomanic and subdepressive states are more often noted. The following types of attacks are characteristic of recurrent Sh. Oneiric-catatonic attack is determined by clouding of consciousness, fantastic content of experiences (planetary flights, world catastrophes, etc.). The picture of a depressive-paranoid attack is dominated by sensual, unsystematized delirium with vivid ideas that reflect the unusual, staged nature of everything that is happening around, the clash of antagonistic, opposing forces. Affective attacks are defined by manic, depressive and mixed states, interrupted by delusional episodes and short periods of dream-altered consciousness. The attacks occur with a disturbance in the perception of the surroundings: with elated-ecstatic affect, reality is perceived brightly, colorfully, with anxious-suppressed affect - gloomily, as a harbinger of trouble.

In some cases of recurrent and paroxysmal-progressive schizophrenia, continuous, tireless motor agitation and confusion are noted, accompanied by high body temperature, acrocyanosis, subcutaneous hemorrhages, the development of exhaustion and coma (hypertoxic, or febrile, schizophrenia).

DIAGNOSIS Schizophrenia is diagnosed based on history and clinical picture.

Differential diagnostics are carried out primarily with borderline states (psychopathy, psychogenia).

In contrast to psychogenies and psychopathy, in schizophrenia autochthonous disorders not associated with external influences predominate. Psychogenic provocation of schizophrenia is characterized by a discrepancy between the severity of clinical manifestations and the strength of the mental impact. With further development, the close dependence of symptoms on external hazards is not revealed, and the content of painful manifestations gradually loses connection with the traumatic situation. As schizophrenia develops, there is not only a sharpening of premorbid features, which is also characteristic of psychopathy, but also a complication of the clinical picture due to the appearance of new, previously undetected psychopathic properties and symptoms that are not typical for decompensation of psychopathy (suddenly arising unmotivated anxiety, acute depersonalization disorders, false recognitions, etc.).

In contrast to borderline conditions, with the development of schizophrenia, signs of social maladjustment gradually increase - a weakening, and in some cases a complete severance of ties with the previous environment, an unmotivated change of profession and entire lifestyle.

IN outpatient practice The greatest difficulties are caused by recognizing schizophrenia at the initial stages of the process, as well as during its slow development (sluggish schizophrenia), especially in cases when mental disorders perform under a mask somatic disease, and the clinical picture is dominated by somatoform (including hypochondriacal) disorders. The assumption of the presence of Sh. arises in connection with polymorphism, stereotypical repetition of somatic sensations, inconsistency of their localization with anatomical formations, as well as a persistent hypochondriacal attitude with a peculiar (elements of paralogical thinking, and sometimes absurdity) interpretation of pathological sensations.

Significant difficulties arise in recognizing incipient schizophrenia, the manifestations of which are similar to the picture of a pathologically occurring puberty. In these cases, the diagnosis of schizophrenia is facilitated by severe thinking disorders and gross heboid manifestations, accompanied by persistent falling mental activity and performance.

TREATMENT carried out by psychotropic drugs; If necessary, electroconvulsive therapy and insulin are also used. These treatments are combined with psychotherapy and occupational and social adaptation. The choice of method and optimal timing of treatment are determined by the clinical picture (primarily the structure of the syndrome), age, somatic condition and individual sensitivity of the patient to certain medications.

To relieve acute psychomotor agitation, the patient is administered hexenal intramuscularly or chloral hydrate in an enema. If necessary, use psychotropic drugs - intramuscular injections neuroleptics (aminazine, tizercin, haloperidol), as well as tranquilizers (Elenium, Relanium, phenazepam).

Treatment of patients with malignant and progressive (paranoid) schizophrenia is carried out with antipsychotics with high psychotropic activity (aminazine, stelazine, mazeptil, haloperidol, trisedil, leponex). In severe cases resistant to psychotropic drugs, electroconvulsive and insulin therapy is used.

To relieve attacks of paroxysmal-progressive and recurrent schizophrenia, psychotropic drugs are prescribed, for example, antipsychotics for manic-delusional and oneiric-catatonic attacks. For depressive-paranoid attacks, anxiety, asthenic, hypochondriacal depression, a combination of antidepressants (amitriptyline, anafranil, melipramine, ludiomil) with neuroleptics and tranquilizers (Relanium, Elenium, phenazepam, tazepam, etc.) is recommended. For affective-delusional attacks that occur with psychomotor agitation, anxiety, and suicidal tendencies in the case of resistance to psychotropic drugs, electroconvulsive therapy is recommended.

Treatment of sluggish schizophrenia is carried out with psychotropic drugs (tranquilizers) in combination with antipsychotics and antidepressants, taken in small doses and with the help of psychotherapy.

A significant number of patients with schizophrenia can be treated in outpatient setting. This contingent includes the majority of patients with sluggish schizophrenia, as well as patients with progressive development of the disease, who are not in a state of psychosis, but who also exhibit relatively isolated delusional (paranoid, residual delusions) and hallucinatory disorders during the period of stabilization of the pathological process (remissions, residual states), as well as psychopathic, obsessive-phobic, senesto-hypochondriacal, astheno-hypochondriacal, depersonalization and erased affective disorders.

Outpatient therapy prevents exacerbation of the process and repeated hospitalizations, helps reduce affective tension and reduce the intensity of painful manifestations, and social readaptation of patients. Treatment on an outpatient basis should not be accompanied by noticeable side effects. The choice of psychotropic drugs, the time of their administration, as well as the distribution of the daily dose are correlated with labor activity sick.

For outpatient treatment of paranoid states, as well as delusional and hallucinatory disorders observed at late stages of the process, antipsychotics (stelazine, etaparazine, frenolone, trisedyl), incl. prolonged action (moditene-depot, imap, haloperidol-decanoate).

The predominance in the clinical picture of gross psychopathic-like manifestations (heboid disorders, schizoid personality changes in the form of eccentricities and inappropriate behavior) is also an indication for the prescription of antipsychotics (neileptil, stelazine, haloperidol) and tranquilizers.

Treatment of obsessive-phobic and senestohypochondriacal conditions is carried out with tranquilizers; if necessary, they are combined with mild antipsychotics (chlorprothixene, sonapax, teralen, etaprazine, frenolone) in small doses and antidepressants (anafranil, amitriptyline, ludiomil).

For the treatment of depersonalization disorders that are part of the structure of residual states and occur with a feeling of “incompleteness,” intellectual and emotional insufficiency, as well as astheno-hypochondriacal states (lethargy, passivity, decreased initiative and mental activity), psychoactivators (sydnocarb) are used along with neuroleptics and tranquilizers in small doses , nootropil, pyriditol).

When treating affective disorders (usually in the form of erased depressive or hypomanic phases), antidepressants (pirazidol, incasan, petilil), antipsychotics and tranquilizers are prescribed. The most effective preventive agents are lithium salts (lithium carbonate) and finlepsin, tegretol (carbamazepine).

Children and adolescents with schizophrenia, as well as elderly and old age To avoid side effects, smaller daily doses of psychotropic drugs are prescribed, on average 1/2-2/3 of the dose used in middle-aged people.

Persons with suicidal ideas and especially suicidal tendencies are indicated for urgent specialized care in a psychiatric hospital.

Rehabilitation is carried out throughout the course of the disease; in the first stages, it includes both limiting restraint measures (reducing the length of stay in the observation ward, closed department), and active, as psychosis is relieved, involvement in occupational therapy. Medical leave, transfer to light-duty departments, and semi-stationary forms of care are widely practiced ( day hospital). Rehabilitation carried out on an outpatient basis is carried out under the guidance of doctors from psychoneurological dispensaries and specialized offices operating on the basis of enterprises.

The implementation of problems of labor and social adaptation of patients with unfavorable development of schizophrenia and a pronounced personality defect is carried out in special conditions that provide the necessary medical care (for example, occupational therapy workshops, special workshops).

FORECAST is determined by the type of course of schizophrenia, the tendency towards short-term or long-term exacerbations of the process, as well as the degree of severity and rate of development of the personality defect. The influence of a number of other factors is also taken into account (gender, hereditary predisposition, premorbid characteristics, social status before the manifestation of Sh., as well as the age at which the disease manifested itself).

The outcomes of the schizophrenic process are different. In the most severe cases, along with the formation of a pronounced personality defect, there is a gradual, but far from complete (with persistent catatonic, hallucinatory and delusional symptoms) reduction of the manifestations of chronic psychosis. With progressive schizophrenia, late long-term remissions can be observed, occurring as paranoid, hallucinatory with phenomena of monotonous activity, apathetic, asthenic, etc.

Sluggish schizophrenia often ends in residual states with a predominance of persistent psychopathic, obsessive-phobic, hypochondriacal disorders(pseudopsychopathy, pseudoneurosis). Among continuous forms of schizophrenia, both clinical and social prognosis is most favorable when the process develops slowly. The prognosis for paranoid schizophrenia is relatively favorable - only half of the patients experience severe final conditions; in some cases, despite the presence of delusional disorders, patients remain at home for a long time, adapting to the requirements everyday life, and some even remain operational. Patients with malignant schizophrenia often become permanent residents of psychiatric hospitals and boarding schools; they retain the possibility only of intra-hospital resocialization. The prognosis of paroxysmal-progressive and recurrent schizophrenia is most favorable with a small number of attacks and long-term remissions. However, even with an increase in the number of attacks, most patients continue to work.

Forensic psychiatric examination. Clear manifestations of psychosis or signs of a pronounced personality defect in patients with schizophrenia during a forensic psychiatric assessment indicate insanity, since patients are not able to understand the meaning of their actions and manage them. They are sent to compulsory treatment. The potential for committing socially dangerous actions is greatest during the period of manifestation of psychosis, accompanied by confusion, anxiety, and fears of the patient, as well as in delusional patients with ideas of persecution, physical and hypnotic influence. With sluggish schizophrenia and post-processual states (the appearance after an attack of schizophrenia of personality changes, primarily psychopathic ones) expert assessment is strictly individual and determined by the severity and depth of mental disorders in a specific criminal situation.

During the forensic psychiatric examination of schizophrenia in connection with civil cases, the resolution of issues of legal capacity and guardianship is based on determining the mental state at the time of certain legal acts (property transactions, wills, marriages). Patients with sluggish schizophrenia, which occurs with a predominance of neurosis-like disorders without clear signs of progression, more often retain their legal capacity. Patients in a state of psychosis are recognized as incompetent.

For severe and persistent mental changes, leading to permanent violations of adaptation processes and excluding full-fledged social connections, recognition of incapacity is combined with the imposition of guardianship.