Sluggish schizophrenia (low-gradient) is one of the variants of schizophrenia, which is characterized by a slow course of the disease and minimal mental disorders. In modern psychiatry, the term “sluggish schizophrenia” is somewhat outdated, and now it is correct to say “schizotypal personality disorders.” In the USSR, psychiatrists “branded” with this diagnosis all politically dissidents and dissidents. Sluggish schizophrenia gets its name because there are no phases of acute psychosis, and personality changes can last for decades.

Etiopathogenesis

• Genetic predisposition;
• Biochemical disorders of brain neurotransmitters (dopamine, serotatin, acetylcholine and glutamate);
• The damaging effects of stress on personality;
• The influence of social factors on the formation of the psyche (upbringing).

According to statistics, the prevalence of schizophrenia among males and females is the same; city residents get sick more often, as do the poor. In men, schizophrenia begins early and has a severe course, in women it is the opposite.

Sluggish schizophrenia is characterized by the absence of a clear boundary between the manifest and initial periods. Most often, neurosis-like states, asthenization, depersonalization of personality and derealization come to the fore in the clinical manifestations of sluggish schizophrenia. Patients are characterized by schizophrenic psychopathization. Most often, they are socially adapted and can work in various fields, serve themselves, have families and friendships, and are sociable. However, even a non-specialist can see that the person has a “damaged” psyche.

Synonyms for sluggish schizophrenia are “mild”, “hidden”, “slow”, “rudimentary”, “sanatorium”, “laureled”, “prephase” and others. You can also often find in the specialized literature such terms as “failed”, “occult”, “outpatient”, “non-regressive”.

Signs

The first signs of low-grade schizophrenia appear at a young age.

There are three stages during this disease. The onset of schizophrenia has a hidden beginning, almost unnoticeable. As a rule, the first subtle symptoms of mental illness appear during puberty (puberty). Then comes the manifest period of sluggish schizophrenia, but it does not reach a psychotic level. Over the course of several years, a period of stabilization of the disease begins. A decrease in negative symptoms is possible, but the next “revolution” may occur in adults after 45 years.

Variants and forms of the disease:

In patients with sluggish schizophrenia, a certain strangeness and eccentric behavior is observed, disharmony of movements, behavior like a child, angularity, and unreasonable seriousness of the face. Noteworthy is untidiness in clothing, failure to comply with the rules of personal hygiene, awkwardness (short trousers, things that are out of fashion, wrong color combinations in clothes, strange haircuts and hairstyles). The speech is unique, the use of phrases and figures of speech, “emphasis” on unimportant and secondary details.

Despite the eccentric behavior of patients, mental and physical activity remains. Patients walk a lot, are active, talkative, communicate with people around them, but their communication is of a peculiar superficial nature. With a psycho-like defect, patients are bursting with super ideas, they are very passionate about something. This is an active schizoid, but does not bring social benefit to society.

Passive schizoids practically never leave their house, do nothing, and do not want to do anything; they are socially inert. These people may use psychostimulants, alcoholic beverages, and drugs. Drinking alcohol relieves the schizoid component for a while, but such patients behave very aggressively and personality degradation quickly occurs. There are several factors that can adversely affect the outcome of mental illness.

Male gender is an unfavorable factor in the course of persistent schizophrenia, the presence of concomitant organic pathology, acute onset, resistance to therapy, high frequency and duration of hospitalizations (exacerbations), hereditary burden.

40% of patients with schizophrenia attempt suicide.

Diagnosis and differential diagnosis

In the diagnosis of sluggish schizophrenia, an important role is played by the manifestation of signs of negative deformations of the patient’s personality. Important in diagnosis are manifestations of apathy, autism, communication difficulties, various thinking disorders, and disintegration. It is necessary to carry out a differential diagnosis with neuroses. In neurosis-like schizophrenia, characteristic temporary connections with a traumatic situation are not revealed. Sluggish schizophrenia is characterized by a large polymorphism of appearances, incompatible mental disorders, and the presence of subpsychotic episodes in the disease.

Treatment

The main principle of treatment is the biopsychosocial approach. There is no etiological therapy for low-grade schizophrenia. Regardless of the stage of the disease and the severity of the disease, social adaptation of patients, drug treatment and psychotherapy are necessary. It is important to establish psychological contact between the patient and the treating doctor, since many patients are not trusting and deny the fact of mental illness.

It is necessary to start treatment earlier (before the manifest phase) and use monotherapy (do not prescribe a large number of drugs, it is best to start with three and monitor their effect). Schizophrenia is characterized by a long duration of therapy (symptom relief occurs within 2 months, the stabilization period lasts on average six months, remission is 1 year). Prevention of exacerbations of the disease plays an important role; the more frequent the exacerbations, the more severe the disease. The main groups of drugs for the treatment of schizophrenia: antipsychotics, anxiolytics, normomics, antidepressants, nootropic drugs, psychostimulants.

The use of antipsychotics is based on the fact that they block dopamine receptors. It was previously thought that people with schizophrenia had elevated levels of dopamine (the precursor to norepinephrine), but recent studies have shown that dopamine levels are normal, but dopamine receptors are very sensitive.

The “gold standard” for the treatment of low-grade schizophrenia is haloperidol. Classic neuroleptics used to treat flaccid schizophrenia have many side effects and can cause extrapyramidal disorders. The drugs are prescribed in certain regimens, treatment is long-term, oral forms are most preferred. The administration of drugs intravenously is associated with aggression and is used mainly to relieve psychomotor agitation. Very often, patients with schizophrenia do not understand that they are not mentally healthy, and it is almost impossible to convince them of the need to see a doctor and start treatment.

Hospitalization is indicated in cases where the patient’s behavior is aggressive, threatens others, when the patient refuses to eat for 1 week or more, weight loss of more than 20%, aggressive behavior, suicidal attempts, psychomotor agitation, “commanding” hallucinations. In such cases, treatment is “forced” in nature. In a state of remission, drug therapy (maintenance treatment) is mandatory and the patient’s relatives must monitor not only his behavior, but also the regular use of medications. In the West, treatment for schizophrenia is the longest and most expensive.

Sluggish schizophrenia, or low progression schizophrenia, - a type of schizophrenia in which the disease progresses weakly, the productive symptoms characteristic of schizophrenic psychoses are absent, most often only indirect clinical manifestations are observed (neurosis-like, psychopath-like, affective, overvalued, hypochondriacal, etc.) and shallow personality changes. In the modern international classification of diseases (ICD-10) there is no such diagnosis.

Slightly progressive (sluggish) schizophrenia is used as a synonym for schizotypal disorder by many authors.

“Schizotypal personality disorder” in the Russian classification also corresponds to sluggish schizophrenia and coincides with it according to the diagnostic criteria accepted in Russian psychiatry.

The first descriptions of sluggish schizophrenia are often associated with the name of the Soviet psychiatrist A.V. Snezhnevsky. Its diagnostic boundaries, adopted by Snezhnevsky and his followers, were significantly expanded in comparison with the criteria for schizophrenia adopted in the West; the diagnosis of sluggish schizophrenia found application in the practice of repressive psychiatry in the USSR and was used more often than other clinical diagnoses to justify the insanity of dissidents.

The opinion has been repeatedly expressed that the diagnosis of sluggish schizophrenia was received or could be received not only by dissidents, but also by ordinary patients in the absence of schizophrenia and the presence of only neurotic disorders, depressive, anxiety or personality disorders.

The concept of sluggish schizophrenia became widespread only in the USSR and some other Eastern European countries. This concept has not been recognized by the international psychiatric community and the World Health Organization, and the use of diagnostic criteria for low-grade schizophrenia in relation to dissidents has been condemned internationally.

History of diagnosis: the concept of latent schizophrenia since Bleuler

There is an opinion that the authorship of the concept of sluggish schizophrenia is erroneously attributed to Snezhnevsky, since similar disorders were discussed under different names in the works of psychiatrists in different countries. It is also noted that it is in the works of Snezhnevsky and his colleagues that sluggish schizophrenia acts as an independent form and describes various options for its course.

The concept of “latent schizophrenia” was first used by Eugen Bleuler in 1911 (its criteria were not clearly defined by him):

These simple schizophrenics make up the majority of all “brains on one side” (reformers, philosophers, artists, degenerates, eccentrics). There is also latent schizophrenia, and I actually think these are the most common cases.

According to Bleuler, the diagnosis of latent schizophrenia can be made by studying the patient's condition retrospectively: when studying the past of persons with schizophrenia in whom the disease has become obvious, prodromes of the latent form can be detected.

E. Bleuler proposed considering a number of cases of psychasthenia, hysteria, and neurasthenia as manifestations of unrecognized schizophrenia. According to E. Bleuler, schizophrenia, which is most characterized by a peculiar splitting of the unity of personality, more often occurs “in latent forms with mild symptoms than in obvious forms with complete symptomatology...”.

Subsequently, descriptions of relatively favorable forms corresponding to the concept of sluggish schizophrenia became widespread under various names in studies of national psychiatric schools in Europe, the USA, Japan, etc. The most famous of these names are “mild schizophrenia”, “microprocessual”, “micropsychotic”, “rudimentary” "", "sanatorium", "amortized", "abortive", "prephase of schizophrenia", "slow", "subclinical", "pre-schizophrenia", "non-regressive", "latent", "pseudo-neurotic schizophrenia", "schizophrenia with obsessive-compulsive disorders”, slowly developing schizophrenia with “creeping” progression.

In Soviet psychiatry, the description of similar forms of disorders has a long tradition: for example, A. Rosenstein and A. Kronfeld in 1932 proposed the term “mild schizophrenia”, which is similar in content; in this regard, we can mention the works of B. D. Friedman (1933), N. P. Brukhansky (1934), G. E. Sukhareva (1959), O. V. Kerbikov (1971), D. E. Melekhov (1963 ), etc.

The author of the monograph “History of Schizophrenia,” French psychiatrist J. Garrabe, notes that in the period before World War II, the criteria for “schizophrenia without schizophrenic symptoms” underwent changes, being expanded to include a number of atypical, borderline conditions: in particular, Zilberg wrote about “outpatient schizophrenia " Often, studies dealt with so-called prepsychotic or pre-schizophrenic conditions - occurring in the period before the onset of psychosis, which, however, most often did not occur in this case.

The problem of “pseudoneurotic schizophrenia” was developed in American psychiatry throughout the 1950s and 60s, in particular by P. Hoch and P. Polatin, who proposed this term in 1949. According to J. Garrabe, in this case it would be more accurate to talk not about mental illness itself, which is characterized by processual (progressive) development, but about personality disorders (psychopathy), in particular about “borderline”, Russian. borderline personality disorder. The clinical and genetic study of schizophrenia spectrum disorders led to the interest of American researchers in the problem of pseudoneurotic schizophrenia in the next decade and a half (the concept of “borderline schizophrenia” by D. Rosenthal, S. Kety, P. Wender, 1968).

The broad interpretation of the concept of “schizophrenia” that prevailed in American psychiatry (the concept of “pseudoneurotic schizophrenia”) was formed under the influence of the ideas of Bleuler, who considered schizophrenia mainly a psychological disorder - perhaps with a psychogenic basis - rather than a pathological state of the nervous system, and significantly expanded the boundaries of this concept in comparison with Emil Kraepelin. As a result, in the United States the diagnosis of schizophrenia was extended to those patients who in Europe would have been diagnosed as depressive or manic psychosis, or even considered as suffering from a neurotic or personality disorder rather than a psychotic one. Patients were diagnosed with schizophrenia based on a wide range of neurotic symptoms, such as phobias or obsessions.

In 1972, a joint UK-US diagnostic project found that schizophrenia was diagnosed much more frequently in the US than in the UK. After this, the idea spread that standardized methods of diagnosis were needed. In the last quarter of the twentieth century, several diagnostic schemes were developed and continue to be widely used. These systems (particularly ICD-10 and DSM-IV) require clear evidence of current or past psychosis and that emotional symptoms are not predominant.

The concept of sluggish schizophrenia was proposed by Professor A.V. Snezhnevsky, according to some sources, in 1969. However, a report on latent schizophrenia (this concept was literally translated into English as “sluggish course”) was read by him back in 1966 in Madrid at the IV World Congress of Psychiatrists). Snezhnevsky's concept of sluggish schizophrenia was based on Bleuler's model of latent schizophrenia. Western psychiatrists considered this concept as unacceptable, since it led to an even greater expansion of the already expanded (including in English-speaking schools) diagnostic criteria for schizophrenia.

J. Garrabe notes that, according to the views of Snezhnevsky, expressed by him in 1966, latent (“torpid”, “flaccid”) schizophrenia means “chronic lesions that develop neither in the direction of deterioration nor in the direction of recovery.” Unlike Bleuler's latent schizophrenia, Snezhnevsky's concept of sluggish schizophrenia did not imply a mandatory development that would lead to the emergence of schizophrenic symptoms proper, but was limited only to latent (pseudo-neurotic or pseudo-psychopathic) manifestations.

In the chapter of the “Manual of Psychiatry” written by R. Ya. Nadzharov, A. B. Smulevich, which was published in 1983 under the editorship of Snezhnevsky, it is argued that, contrary to the traditional idea of ​​“sluggish schizophrenia” as an atypical variant of the disorder (i.e. . about deviation from the natural, more unfavorable development of the disease), low-progressive schizophrenia is not a protracted stage preceding major psychosis, but an independent variant of the endogenous process. In some cases, its characteristic signs determine the clinical picture throughout the entire course of the mental disorder and are subject to their own developmental patterns.

It is also worth noting that there were significant differences between the “mild schizophrenia” of A. Kronfeld, whose works were not republished during the 1960-80s, and the “sluggish schizophrenia” of A. V. Snezhnevsky. Thus, at the II All-Union Congress of Psychiatrists in 1936, Kronfeld made an explanation that the “mild schizophrenia” he identified is a variant of the overt schizophrenic process: this form always begins with a phase of acute psychosis and for many years retains this symptomatology, which, however, patients compensate so much that they remain socially safe. He noted the “exorbitant expansion” of his original concept of “mild schizophrenia” by Moscow authors, which led to its unjustified diagnosis in cases where we are talking about supposedly initial, rather than reliably residual symptoms and when these symptoms are not manifest. According to Kronfeld, the use of this concept in recent years has often been unfounded and due to fundamental clinicopathological errors.

Clinical manifestations and symptoms

As in the case of “ordinary” schizophrenia, the clinical criteria identified by proponents of the concept of low-grade schizophrenia are grouped into two main registers:

• pathologically productive disorders (“positive psychopathological symptoms”);
• negative disorders (manifestations of deficit, psychopathological defect).

In the clinical picture of sluggish schizophrenia, variants with a predominance of either productive disorders (obsessive-phobic, hysterical, depersonalization, etc.) or with a predominance of negative disorders (“sluggish simple schizophrenia”) are distinguished.

Accordingly, the following variants of sluggish schizophrenia are distinguished:

• with symptoms of obsession, or with obsessive-phobic disorders;
• with phenomena of depersonalization;
• hypochondriacal;
• with hysterical (hysteria-like) manifestations;
• poor (simple, sluggish) schizophrenia - with a predominance of negative disorders.

According to A. B. Smulevich, the following stages of development of low-progressive schizophrenia are distinguished:

1. Latent a stage that does not show clear signs of progression.
2. Active(with a continuous course, in the form of an attack or a series of attacks), or the period of full development of the disease.
3. Stabilization period with a reduction in productive disorders, personal changes coming to the fore, and signs of compensation emerging in the future.

Latent period. The clinical picture of this stage (and the so-called latent schizophrenia, which means a favorable form of sluggish schizophrenia, manifested only by symptoms of the latent period) is most often limited to a range of psychopathic and affective disorders, obsessions, and phenomena of reactive lability. Among psychopathic disorders, schizoid traits predominate, often combined with features reminiscent of hysterical, psychasthenic or paranoid personality disorder. Affective disorders in most cases manifest themselves as erased neurotic or somatized depression, prolonged hypomania with persistent and monotonous affect. In some cases, clinical manifestations of the initial (latent) stage of sluggish schizophrenia may be limited to special forms of response to external harm, often repeated in the form of a series of 2-3 or more psychogenic and somatogenic reactions (depressive, hysterical-depressive, depressive-hypochondriacal, less often - delusional or litigious).

According to A. B. Smulevich, mental disorders in the latent period are not very specific and can often manifest themselves only at the behavioral level; Children and adolescents are characterized by reactions of refusal (from taking exams, from leaving the house), avoidance (especially in cases of social phobia), and well-known states of youthful failure.

Active period and stabilization period. A distinctive feature of the development of most forms of low-progressive schizophrenia is considered to be a combination of attacks with a sluggish continuous course. Symptoms sluggish schizophrenia with obsessive-phobic disorders characterized by a wide range of anxiety-phobic manifestations and obsessions: panic attacks that are atypical in nature; rituals that take on the character of complex, fanciful habits, actions, mental operations (repetition of certain words, sounds, obsessive counting, etc.); fear of an external threat, accompanied by protective actions, “rituals” (fear of toxic substances, pathogenic bacteria, sharp objects, etc. entering the body); phobias of contrasting content, fear of madness, loss of control over oneself, fear of causing harm to oneself or others; constant obsessive doubts about the completeness of one’s actions, accompanied by rituals and double-checks (doubts about the purity of one’s body, clothes, surrounding objects); fear of heights, darkness, being alone, thunderstorms, fires, fear of blushing in public; etc.

Sluggish schizophrenia with symptoms of depersonalization characterized primarily by the phenomena of alienation, extending to the sphere of the autopsyche (consciousness of changes in the inner world, mental impoverishment), and a decrease in vitality, initiative and activity. A detached perception of objective reality, a lack of a sense of appropriation and personification, and a feeling of loss of flexibility and sharpness of intellect may prevail. In cases of prolonged depression, the phenomena of painful anesthesia come to the fore: loss of emotional resonance, lack of subtle shades of feelings, the ability to feel pleasure and displeasure. As the disease progresses, a “feeling of incompleteness” may arise, extending both to the sphere of emotional life and to self-awareness in general; patients recognize themselves as changed, dull, primitive, and note that they have lost their former spiritual subtlety.

Clinical picture sluggish hypochondriacal schizophrenia consists of senestopathies and anxiety-phobic disorders of hypochondriacal content. There is non-delusional hypochondria (which is characterized by phobias and fears of hypochondriacal content: cardiophobia, cancerophobia, fears of some rare or unrecognized infection; obsessive observations and fixation on the slightest somatic sensations; constant visits to doctors; episodes of anxiety-vegetative disorders; hysterical, conversion symptoms ; senestopathies; overvalued desire to overcome the disease) and senestopathic schizophrenia (characterized by diffuse, varied, fanciful senestopathic sensations).

At sluggish schizophrenia with hysterical manifestations the symptoms take on grotesque, exaggerated forms: rude, stereotyped hysterical reactions, hypertrophied demonstrativeness, affectation and flirtatiousness with traits of mannerism, etc.; hysterical disorders appear in complex comorbid relationships with phobias, obsessive drives, vivid mastering ideas and senesto-hypochondriacal symptom complexes. Characteristic is the development of prolonged psychoses, the clinical picture of which is dominated by generalized hysterical disorders: confusion, hallucinations of the imagination with mystical visions and voices, motor agitation or stupor, convulsive hysterical paroxysms. At later stages of the disease (stabilization period), gross psychopathic disorders (deceit, adventurism, vagrancy) and negative disorders become more and more pronounced; Over the years, patients take on the appearance of lonely eccentrics, degraded but loudly dressed women who abuse cosmetics.

For sluggish simple schizophrenia characteristic phenomena of autochthonous asthenia with impaired self-awareness of activity; disorders of the anergic pole with extreme poverty, fragmentation and monotony of manifestations; depressive disorders related to the circle of negative affectivity (apathetic, asthenic depression with poor symptoms and an undramatic clinical picture); in phase disorders - increased mental and physical asthenia, depressed, gloomy mood, anhedonia, alienation phenomena, senesthesia and local senestopathies. Slowness, passivity, rigidity, mental fatigue, complaints of difficulty concentrating, etc. gradually increase.

According to a number of Russian authors (M. Ya. Tsutsulkovskaya, L. G. Pekunova, 1978; “Manual of Psychiatry” by A. S. Tiganov, A. V. Snezhnevsky, D. D. Orlovskaya, 1999), in many or even in most cases, patients with sluggish schizophrenia achieve compensation and full social and professional adaptation. According to Professor D. R. Luntz, the disease can theoretically be present even if it is not clinically demonstrable, and even in cases where there are no personality changes. R. A. Nadzharov and co-authors (chapter of the “Manual of Psychiatry” edited by G. V. Morozov, 1988) believed that this type of schizophrenia “due to the low severity of personality changes and the predominance of syndromes uncharacteristic for “major schizophrenia” presents significant difficulties for distinctions from psychopathy and neuroses.”

Sluggish schizophrenia and international classifications

In 1999, Russia switched to the ICD-10 classification of diseases, which has been used in WHO member countries since 1994. The concept of “sluggish schizophrenia” is absent in the ICD-10 classification, but it is mentioned in the Russian, adapted version, prepared by the Ministry of Health of the Russian Federation. In this version "forms that in the domestic version ICD-9 qualified as low-progressive or sluggish schizophrenia", classified under the heading “schizotypal disorder” (with the indication that their diagnosis requires additional signs). However, in the previous, also adapted version of the ICD-9 classification, used in the USSR since 1982, low-grade schizophrenia was included in the heading of another nosological unit - latent schizophrenia.

Many Russian authors use the terms “schizotypal disorder” and “sluggish schizophrenia” (“low-progressive schizophrenia”) as synonyms. On the other hand, there is also an opinion that schizotypal disorder represents only some of the clinical variants of sluggish schizophrenia, mainly pseudoneurotic (neurosis-like) schizophrenia and pseudopsychopathic schizophrenia. A. B. Smulevich writes about “the desirability of isolating sluggish schizophrenia from the polymorphic group of schizophrenia spectrum disorders, united by the concepts of “schizotypal disorder” or “schizotypal personality disorder”, considering it as an independent form of the pathological process. Some authors have stated the need to consider forms with neurosis-like (obsessive-compulsive) disorders within the framework of schizophrenia.

“Sluggish schizophrenia” in the Russian-Soviet classification is also identified with the diagnosis of “schizotypal personality disorder”, sometimes with borderline personality disorder or cyclothymia.

The opinion was also expressed that certain forms of sluggish schizophrenia in adolescents correspond to such concepts within the framework of the ICD-10 and DSM-III classifications as schizoid, impulsive, dissocial (asocial), histrionic (hysterical) personality disorders, residual schizophrenia, hypochondriacal syndrome ( hypochondria), social phobia, anorexia nervosa and bulimia, obsessive-compulsive disorder, depersonalization-derealization syndrome.

Practice of using diagnosis in the USSR

In 1966, the Soviet Union participated, among nine countries, in an international pilot study on schizophrenia organized by WHO. The study demonstrated that the diagnosis of “schizophrenia” was especially often made at the A. V. Snezhnevsky Center in Moscow; American researchers also adhered to an expanded diagnostic framework. 18% of patients diagnosed with schizophrenia were classified by the Moscow research center as having low-grade schizophrenia, a diagnosis that, however, was not registered in any of the other eight centers. This diagnosis was established in cases where computer processing reliably determined the presence of manic disorder, depressive psychosis, or, much more often, depressive neurosis in patients. The diagnosis of latent schizophrenia (a rubric not recommended by ICD-9 for widespread use) was also used by 4 of the 8 other study centers; it was exhibited by a total of less than 6% of the patients who took part in the study.

Sluggish schizophrenia was systematically diagnosed to ideological opponents of the political regime that existed in the USSR with the aim of their forced isolation from society. When diagnosing dissidents, they used, in particular, criteria such as originality, fear and suspicion, religiosity, depression, ambivalence, guilt, internal conflicts, disorganized behavior, insufficient adaptation to the social environment, change of interests, and reformism.

There are no exact statistics on the abuse of psychiatry for political purposes, however, according to various data, thousands of people became victims of political abuse of psychiatry in the USSR. In particular, according to R. van Voren, secretary general of the Global Initiative in Psychiatry, which deals with the problem of abuse in psychiatry and reforms of the mental health care system, in the Soviet Union about a third of political prisoners were placed in psychiatric hospitals. In addition to dissidents, the diagnosis of sluggish schizophrenia was also received, for example, by army evaders and tramps.

Individuals diagnosed with this condition were subject to severe discrimination and limited opportunities to participate in society. They were deprived of the right to drive a car, enter many higher educational institutions, and became “restricted from traveling abroad.” Before each holiday or state event, persons with this diagnosis were involuntarily hospitalized for the duration of the event in a psychiatric hospital. A person diagnosed with “sluggish schizophrenia” could easily get a “SO” (socially dangerous) stamp in his medical history - for example, when trying to resist during hospitalization or in the case when he became a participant in a family or street fight.

Patients who were diagnosed with “sluggish schizophrenia” by representatives of the Moscow school of psychiatry were not considered schizophrenics by psychiatrists in Western countries on the basis of the diagnostic criteria adopted there, soon officially enshrined in ICD-9. Supporters of other trends in Soviet psychiatry (especially representatives of the Kyiv and Leningrad schools) for a long time strongly opposed Snezhnevsky’s concept and the related concept of overdiagnosis of schizophrenia. Throughout the 1950s and 60s, representatives of the Leningrad school of psychiatry refused to recognize dissidents who were diagnosed with sluggish schizophrenia in Moscow as schizophrenics, and only by the late 1960s and early 1970s did Snezhnevsky’s concept finally prevail in Leningrad.

In the early 1970s, reports of the unnecessary hospitalization of political and religious dissidents in psychiatric hospitals reached the West. In 1989, a delegation of American psychiatrists visiting the USSR re-examined 27 suspected victims of abuse, whose names were provided to the delegation by various human rights organizations, the US Helsinki Commission and the State Department; clinical diagnosis was carried out in accordance with American (DSM-III-R) and international (ICD-10, draft) criteria. The delegation members also conducted surveys of patients' family members. The delegation concluded that in 17 of the 27 cases there was no clinical basis for exculpation; in 14 cases there were no signs of mental disorders. A review of all cases demonstrated a high incidence of schizophrenia diagnosis: 24 out of 27 cases. The report presented by the delegation noted that some of the symptoms included in the Soviet diagnostic criteria for mild (“sluggish”) schizophrenia and moderate (“paranoid”) schizophrenia are unacceptable for making this diagnosis according to American and international diagnostic criteria: in particular, Soviet psychiatrists attributed “ideas of reformism,” “increased self-esteem,” “increased self-esteem,” etc. to painful manifestations.

Apparently, this group of patients interviewed is a representative sample of the many hundreds of other political and religious dissidents declared insane in the USSR, mainly during the 1970s and 80s.

Famous examples of diagnosing dissidents

Viktor Nekipelov, accused under Article 190-1 of the Criminal Code of the RSFSR (“dissemination of deliberately false fabrications discrediting the Soviet political system”), was sent for examination to the Serbsky Institute with the following conclusion made by the expert commission of the city of Vladimir: “Excessive, excessive temper, arrogance... a tendency towards truth-seeking, reformism, as well as reactions from the opposition. Diagnosis: low-grade schizophrenia or psychopathy". He was declared mentally healthy at the Institute. Serbsky, served his time in a criminal camp.

Eliyahu Rips, accused under Article 65 of the Criminal Code of the Latvian SSR, corresponding to Art. 70 of the Criminal Code of the RSFSR (anti-Soviet agitation and propaganda), who attempted self-immolation in protest against the entry of Soviet troops into Czechoslovakia, was subjected to forced treatment in a “special type of mental hospital” with the same diagnosis.

Olga Iofe was accused under Article 70 of the Criminal Code of the RSFSR that she took an active part in the production of leaflets with anti-Soviet content, storage and distribution of documents with anti-Soviet content, seized from her during a search. Preliminary examination carried out by the Institute named after. Serbsky (Professor Morozov, Doctor of Medical Sciences D.R. Lunts, doctors Felinskaya, Martynenko), declared O. Iofe insane with a diagnosis of “sluggish schizophrenia, simple form.”

Many more examples can be given. They tried to make this diagnosis to V. Bukovsky, but the commission, which consisted mainly of opponents of the theory of sluggish schizophrenia, eventually declared him sane. This diagnosis was also made to Zhores Medvedev, Valeria Novodvorskaya, Vyacheslav Igrunov, who distributed the “Gulag Archipelago”, Leonid Plyushch, accused of anti-Soviet propaganda, Natalya Gorbanevskaya, charged under Article 190.1 of the Criminal Code of the RSFSR for the famous demonstration on Red Square against the entry of Soviet troops into Czechoslovakia - according to the conclusion of Professor Luntz, “the possibility of sluggish schizophrenia cannot be excluded”, “should be declared insane and placed for compulsory treatment in a special type of psychiatric hospital.”

Using the example of an examination carried out on April 6, 1970 in relation to Natalya Gorbanevskaya, the French historian of psychiatry J. Garrabe concludes about the low quality of forensic medical examinations carried out in relation to dissidents: the absence in the clinical description of changes in thinking, emotions and the ability to criticize, characteristic of schizophrenia; the absence of any expertly established connection between the action giving rise to the charge and the mental illness that could explain it; indication in the clinical description only of depressive symptoms that do not require hospitalization in a psychiatric hospital.

Condemnation of the practice of using diagnosis in the USSR by the international psychiatric community

In 1977, at a congress in Honolulu, the World Psychiatric Association adopted a declaration condemning the use of psychiatry for the purposes of political repression in the USSR. She also came to the conclusion that it was necessary to create a committee, later called the Committee of Inquiry. Review Committee) or more precisely - the WPA Committee on the Investigation of Abuse of Psychiatry (eng. WPA Committee to Review the Abuse of Psychiatry), which, according to its competence, must investigate any alleged cases of the use of psychiatry for political purposes. This committee is still active today.

Condemnation of the practice of using the diagnosis “sluggish schizophrenia” in the USSR led to the fact that in 1977, at the same congress, the World Psychiatric Association recommended that psychiatric associations in various countries adopt classifications of mental illnesses that are compatible with the international classification in order to be able to compare the concepts of different national schools. This recommendation was followed only by the American Psychiatric Association: in 1980 it adopted the DSM-III (Diagnostic and Statistical Manual of Mental Disorders), which excluded diseases without obvious psychiatric signs and recommended for what was previously called “latent”, “borderline”, “ "sluggish" or "simple" schizophrenia, make a diagnosis of a personality disorder, for example, schizotypal personality.

The All-Union Scientific Society of Neuropathologists and Psychiatrists of the USSR, refusing to acknowledge the facts of abuse, chose to leave the WPA in 1983, along with the psychiatric associations of other countries of the Soviet bloc. In 1989, at the IX Congress of the WPA in Athens, in connection with perestroika, it was again admitted to the World Psychiatric Association, pledging to rehabilitate the victims of “political psychiatry.” Victims of “political psychiatry” who were subjected to repression in the form of forced placement in psychiatric institutions and rehabilitated in accordance with the established procedure should be paid monetary compensation by the state. Thus, the facts of the use of psychiatry for political purposes were recognized.

According to data published by the International Society for Human Rights in the White Book of Russia, in the country as a whole, the diagnosis of low-grade schizophrenia resulted in the recognition of about two million people as mentally ill. They began to be gradually discharged from psychiatric hospitals and removed from psychiatric registration in psychoneurological dispensaries only in 1989 in order to achieve admission of the All-Union Scientific Society of Neuropathologists and Psychiatrists of the USSR to the World Psychiatric Association, which it was forced to leave at the VII Congress in 1983. In 1988-1989, at the request of Western psychiatrists, as one of the conditions for the admission of Soviet psychiatrists to the WPA, about two million people were removed from psychiatric registration.

Modern Russian psychiatry relies heavily on the works of A.V. Snezhnevsky: for example, in A.B. Smulevich’s book “Low-progressive schizophrenia and borderline states,” a number of neurotic, asthenic and psychopathic conditions are classified as low-progressive schizophrenia. J. Garrabe in the monograph “History of Schizophrenia” notes:

Harold Merskey, Bronislava Shafran, who devoted a review to “sluggish schizophrenia” in the British Journal of Psychiatry, find no less than 19 publications on this issue in the S. S. Korsakov Journal of Neuropathology and Psychiatry between 1980 and 1984, of which 13 were signed by Soviet authors, Moreover, these articles do not bring anything new in comparison with the report on this by A.V. Snezhnevsky. This fidelity of the Moscow school to a controversial concept at the very moment when it is attracting such criticism from the scientific community is surprising.

Overdiagnosis of schizophrenia also occurs in post-Soviet times. Thus, systematic studies show that the diagnosis of the entire group of affective pathology in modern Russian psychiatry is negligibly small and relates to schizophrenia in a factor of 1:100. This completely contradicts the data of foreign genetic and epidemiological studies, according to which the ratio of these diseases is 2:1. This situation is explained, in particular, by the fact that, despite the official introduction of ICD-10 in 1999, Russian doctors still continue to use the version of this manual adapted for Russia, which is similar to the version of ICD-9 adapted for the USSR. It is also noted that patients with severe and long-term panic disorder or obsessive-compulsive disorder are often unfoundedly diagnosed with sluggish schizophrenia and prescribed antipsychotic therapy.

Views and assessments

On the broad scope of diagnosis and prerequisites for its use for non-medical purposes

The opinion is often expressed that it was the broad diagnostic criteria for sluggish schizophrenia, promoted by Snezhnevsky and other representatives of the Moscow school, that led to the use of this diagnosis for repressive purposes. Western, as well as modern Russian psychiatrists and human rights activists note that the diagnostic criteria of the disease, which included erased, unexpressed symptoms, made it possible to diagnose it for anyone whose behavior and thinking went beyond social norms.

Canadian psychiatrist Harold Merskey and neurologist Bronislava Shafran in 1986, after analyzing a number of publications in the S.S. Korsakov Journal of Neurology and Psychiatry, came to the conclusion that “the concept of sluggish schizophrenia is obviously very flexible , is diverse and includes much more than our ideas about simple schizophrenia or a residual defective state. Many mental conditions that in other countries would most likely be diagnosed as depressive disorders, anxiety neuroses, hypochondria or personality disorders, according to Snezhnevsky’s theory, invariably fall under the concept of sluggish schizophrenia.”

Russian psychiatrist Nikolai Pukhovsky calls the concept of mild (sluggish, slow and imperceptible) schizophrenia mythologized and points out that the fascination of Russian psychiatrists with it coincided with a legal deficiency that allowed the state to use this diagnosis for the purposes of political repression. He notes the absurdity of such formulations as “the reason for the difficulty of recognizing schizophrenia with a slow, sluggish onset is the absence of any pronounced disturbances in mental activity in the initial period” And “outpatient treatment is also carried out for patients with a sluggish, slow and imperceptible type of schizophrenia, not accompanied by noticeable personality changes”, and indicates that the fascination with the theory of mild schizophrenia, as well as the idea of ​​the inferiority of the mentally ill and the supposedly inevitable outcome of mental illness into dementia, was associated with manifestations of overprotection, systematic disregard of the interests of patients and actual evasion of the idea of ​​service, the idea of ​​therapy; the psychiatrist, in fact, acted as an adherent of dubious esoteric knowledge.

The famous Ukrainian psychiatrist, human rights activist, executive secretary of the Association of Psychiatrists of Ukraine Semyon Gluzman notes that in the 1960s, the diversity of Soviet psychiatric schools and directions was replaced by the dictates of the school of Academician Snezhnevsky, which gradually became absolute: alternative diagnostics were persecuted. This factor - as well as the peculiarities of the legal field in the USSR (the absence of legal acts at the legislative level regulating the practice of compulsory treatment), as well as the “Iron Curtain” that separated Soviet psychiatrists from their Western colleagues and prevented regular scientific contacts - contributed to massive abuses in psychiatry , the frequent use in judicial and extrajudicial psychiatric practice of the diagnosis “sluggish schizophrenia” and its presentation to political dissidents.

In the “Manual on Psychiatry for Dissenters,” published in the “Chronicle of the Defense of Rights in the USSR” (New York, 1975, issue 13), V. Bukovsky and S. Gluzman express the opinion that the diagnosis of sluggish schizophrenia in mentally healthy people is socially adapted and prone to creative and professional growth, could determine the presence of such characterological features as isolation, a tendency to introspection, lack of communication, and inflexibility of beliefs; with objectively existing surveillance and wiretapping of telephone conversations, a dissident could be revealed to have “suspicion” and “delusions of persecution”. V. Bukovsky and S. Gluzman quote the words of an experienced expert, Professor Timofeev, who wrote that “dissent can be caused by a brain disease, when the pathological process develops very slowly, gently, and its other signs remain for the time being (sometimes until the commission of a criminal act) invisible”, who mentioned the difficulties of diagnosing “mild and erased forms of schizophrenia” and the debatability of their very existence.

Ukrainian forensic psychiatrist, Candidate of Medical Sciences Ada Korotenko points out that the school of A.V. Snezhnevsky and his colleagues, who developed a diagnostic system in the 1960s, including the concept of sluggish schizophrenia, was supported by F.V. Kondratiev, S.F. Semenov , Ya. P. Frumkin and others. Vague diagnostic criteria, according to A. I. Korotenko, made it possible to fit individual personal manifestations into the framework of the disease and recognize healthy people as mentally ill. Korotenko notes that the establishment of mental pathology in free-thinking and “dissident” citizens was facilitated by the lack of diagnostic standards and the USSR’s own classification of forms of schizophrenia: diagnostic approaches of the concept of sluggish schizophrenia and paranoid states with delusions of reformism were used only in the USSR and some Eastern European countries.

St. Petersburg psychiatrist Doctor of Medical Sciences Professor Yuri Nuller notes that the concept of the Snezhnevsky school allows, for example, to consider schizoid psychopathy or schizoidness as early, slowly developing stages of an inevitable progressive process, and not as personality traits of an individual, which do not necessarily have to develop along the way schizophrenic process. From here, according to Yu. L. Nuller, comes the extreme expansion of the diagnosis of sluggish schizophrenia and the harm that it brought. Y. L. Nuller adds that within the framework of the concept of sluggish schizophrenia, any deviation from the norm (according to the doctor’s assessment) can be considered as schizophrenia, with all the ensuing consequences for the person being examined, which creates a wide opportunity for voluntary and involuntary abuse of psychiatry. However, neither A.V. Snezhnevsky nor his followers, according to Nuller, found the civil and scientific courage to reconsider their concept, which had clearly reached a dead end.

In the book “Sociodynamic Psychiatry,” Doctor of Medical Sciences, Professor T. P. Korolenko and Doctor of Psychological Sciences N. V. Dmitrieva note that the clinical description of sluggish schizophrenia according to Smulevich is extremely elusive and includes almost all possible changes in the mental state, as well as partially conditions that occur in a person without mental pathology: euphoria, hyperactivity, unreasonable optimism and irritability, explosiveness, sensitivity, inadequacy and emotional deficit, hysterical reactions with conversion and dissociative symptoms, infantility, obsessive-phobic states, stubbornness.

The President of the Independent Psychiatric Association, Yu. S. Savenko, wrote that the complete distortion of the phenomenological approach in conditions of total ideologization and politicization led to an unprecedented scale of overdiagnosis of schizophrenia. He noted that Snezhnevsky and his followers considered any processuality, that is, the progression of the disease, as a specific pattern of schizophrenia, and not a general psychopathological, general medical characteristic; hence the desire to diagnose schizophrenia in any syndromic picture and any type of course, although in reality the differential diagnosis of erased, outpatient forms of schizophrenia with other endogenous disorders requires careful individualization. Ultimately, this led to the inevitable attribution of many neurosis-like and paranoid states to schizophrenia, often even in the absence of procedurality. According to Yu. S. Savenko, the clear delineation of the diagnostic framework of Kronfeld’s “mild schizophrenia” turned out to be replaced in the 1960-80s by “a continuous continuum of quantitative differences from the healthy norm.” Yu. S. Savenko pointed out that the academic approach of Snezhnevsky and his followers is characterized by “refined sophistication, not suitable, even contraindicated, for widespread use, divorced from taking into account the social aspect: the possibilities of real practice, social compensation, the social consequences of such diagnostics.”

American psychiatrist Walter Reich (lecturer of psychiatry at Yale University, head of the program of medical and biological sciences at the Washington School of Psychiatry) noted that due to the nature of political life in the Soviet Union and the social stereotypes formed by this life, nonconformist behavior there really seemed strange and that in connection with the nature of Snezhnevsky’s diagnostic system, this oddity in some cases began to be perceived as schizophrenia. According to Reich, in many and perhaps most cases where such a diagnosis was made, not only the KGB and other responsible persons, but also the psychiatrists themselves actually believed that the dissidents were sick. Discussing during a personal meeting with Snezhnevsky in the early 1980s a program to study borderline states planned for the Scientific Center for Mental Health, Reich came to the conclusion that there is no significant difference between these borderline states and some “mild” forms of schizophrenia, especially low-grade schizophrenia. : It is possible that many or even most people whose behavioral characteristics meet Snezhnevsky’s criteria for this disorder do not actually suffer from it, since these behavioral manifestations should be considered within the framework of a neurotic disorder, character abnormalities, or simply qualified as normal behavior.

On the creation of the concept of low-grade schizophrenia

Different points of view have been expressed regarding the question of whether the concept of low-grade schizophrenia was created specifically to combat dissent.

Walter Reich noted that Snezhnevsky's concepts were formed under the influence of a number of his teachers and acquired their final form long before the placement of dissidents in psychiatric hospitals acquired any noticeable proportions; thus, these views arose independently of their supposed usefulness in diagnosing dissenters. However, it was precisely the errors contained in these theories that made them easy to apply to dissidents. The presence of these concepts, according to Reich, was only one of the reasons why dissidents in the USSR were diagnosed with mental illness, but a very important reason.

Vladimir Bukovsky, who was diagnosed with “sluggish schizophrenia” by Snezhnevsky in 1962, spoke as follows:

I don’t think that Snezhnevsky created his theory of sluggish schizophrenia specifically for the needs of the KGB, but it was unusually suitable for the needs of Khrushchev’s communism. According to the theory, this socially dangerous disease could develop extremely slowly, without manifesting itself or weakening the patient’s intelligence, and only Snezhnevsky himself or his students could determine it. Naturally, the KGB tried to ensure that Snezhnevsky’s students more often became experts on political affairs.

The French scientist J. Garrabe shares Bukovsky's opinion on this matter and comes to the conclusion that the repressive apparatus penetrated into a theoretical weak point, and it was not the Moscow school of psychiatry that deliberately committed scientific forgery in order to make it possible to use psychiatry for repression against dissidents. According to Garrabe, Snezhnevsky alone should not be held responsible for psychiatric abuses; Perhaps some of his students shared Snezhnevsky's views on sluggish schizophrenia quite sincerely, while other experts, disapproving of these views, may have been wary of criticizing them publicly. Nevertheless, Garrabe emphasizes that condemnation of the abuses of psychiatry that took place in the USSR should be based not only on ethical considerations, but also on scientific criticism of the concept of “sluggish schizophrenia.”

An article published in the Independent Psychiatric Journal on the occasion of the 100th anniversary of A.V. Snezhnevsky mentions the expanded diagnosis of schizophrenia (three times the international one) used for non-medical purposes. But the same article cites the opinion of Yu. I. Polishchuk, who worked for many years under the leadership of A.V. Snezhnevsky, who wrote that the basis for the abuse of psychiatry was created by the totalitarian regime, and not by the concept of sluggish schizophrenia, which served only as a convenient reason for them. According to the editors, the extensive diagnosis of schizophrenia in different eras could acquire different meanings: in 1917-1935, concepts such as “mild schizophrenia” by L. M. Rosenstein and “schizophrenia without schizophrenia” by P. B. Gannushkin saved from execution, in In the 1960s and 70s, an overly broad diagnostic framework, on the contrary, served to discredit and suppress the human rights movement.

American psychiatrist Elena Lavretsky believes that the weakness of the democratic tradition in Russia, the totalitarian regime, repression and the “extermination” of the best psychiatrists between 1930 and 1950 paved the way for the abuse of psychiatry and the Soviet concept of schizophrenia.

On the other hand, according to R. van Voren, most experts are of the opinion that the psychiatrists who developed the concept of sluggish schizophrenia did this on the instructions of the party and the State Security Committee, understanding very well what they were doing, but at the same time believing that this concept logically explains a person's willingness to sacrifice well-being for an idea or belief that is so different from what most people believed or forced themselves to believe.

A similar opinion was expressed by the famous human rights activist Leonard Ternovsky: according to his assumption, the diagnosis “sluggish schizophrenia” was invented by the staff of the Serbsky Institute, Academician A.V. Snezhnevsky, G.V. Morozov and D.R. Lunts specifically for the needs of punitive psychiatry.

Western researchers of the political abuses of psychiatry in the USSR, political scientist P. Reddaway and psychiatrist S. Bloch, consider Snezhnevsky one of the key figures who led the use of psychiatry to suppress free thought in the Soviet Union, noting that Snezhnevsky introduced a new interpretation of the disease, which created the possibility of viewing ideological dissent as a symptom of a severe mental disorder.

Sluggish schizophrenia in art

• “Sluggish schizophrenia” is the title of an album of songs by Alexander Rosenbaum, released in December 1994.
• “It flows sluggishly, like the Moscow River, my dear has schizophrenia” - a line from the song “Steppen Wolf” (album “Mythology”) by the rock group “Crematorium”

Literature

• Snezhnevsky A.V. Schizophrenia and problems of general pathology. Bulletin of the USSR Academy of Medical Sciences, Medicine, 1969.
• Schizophrenia. Multidisciplinary research / Ed. A. V. Snezhnevsky, M., 1972.
• Endogenous mental illnesses. Edited by Tiganov A.S.
• Panteleeva G. P., Tsutsulkovskaya M. Ya., Belyaev B. S. Heboid schizophrenia. M., 1986.
• Bashina V. M. Early childhood schizophrenia, M., 1989.
• Lichko A. E. Schizophrenia in adolescents, L., 1989.
• Smulevich A. B. Low-progressive schizophrenia and borderline states, M., 1987.

Sluggish schizophrenia is one of the few types of mental illness that is usually not accompanied by the appearance of pronounced productive symptoms, that is, delusions and hallucinations. This type of schizophrenia is the most favorable, since with proper treatment complete remission can be achieved. The thing is that the sluggish type of schizophrenia is characterized by an extremely slow development of this mental illness, which leads to minimal mental disorders, abilities for thought processes and adequate perception of the surrounding world.

Some researchers believe that calling schizophrenia sluggish in a certain sense is incorrect and it would be more correct to consider such manifestations in humans as schizotypal disorder or low-progressive schizophrenia. Such a schizotypal disorder can be easily treated with medication, and if patients follow preventive measures, unpleasant symptoms will manifest themselves extremely weakly or not at all.

Symptoms

According to statistics, low-progressive schizophrenia occurs much more often in women than in men. Over a long period of time, the symptoms caused by such a schizotypal personality disorder can be so subtle and mild that most people around them perceive the existing manifestations as minor personality traits. At the same time, it should be borne in mind that low-grade schizophrenia, like any other type of this mental illness, has several stages of development, including:

• latent;
• active;
• stabilizing.

During the latent period, a person with sluggish schizophrenia may experience only minor manifestations, including refusal to communicate with other people, long-term depression, somatic reactions, social phobia, etc. If treatment for sluggish schizophrenia in women has not been carried out, there may be attacks of exacerbation of the course, accompanied by severe hysterics, progressive hypochondria, in which a person begins to experience irrational fear that he has some kind of terrible disease.

Such neurosis-like schizophrenia during the period of exacerbation makes a person simply unbearable and touchy, which often becomes the reason that many relatives and friends abandon him. Often, against the background of the progression of sluggish schizophrenia, patients may experience a pathological condition such as depersonalization. This state is characterized by the feeling that all the actions that the patient performs are perceived by him detachedly, as if he were an outside observer of all the events in which he was directly involved.

People suffering from sluggish schizophrenia, as a rule, maintain sobriety of thought, can perfectly put together logical chains without obvious errors, but at the same time they have a number of irrational fears and phobias that determine their damage. Signs of low-grade schizophrenia in women may increase significantly during pregnancy and childbirth. In women suffering from such a schizotypal disorder, exhaustion of the body and labor are much more likely to provoke the development of postpartum depression. The reasons for the exacerbation of sluggish schizophrenia after childbirth may be rooted in hormonal changes that occur during this period.

Treatment methods

Given that low-grade schizophrenia has very few symptoms, many people suffering from this mental illness do not receive proper medical care due to lack of timely diagnosis.

Treatment at an early stage of development of sluggish schizophrenia guarantees a quick and very high-quality effect.

It is important to note that people suffering from such a schizotypal disorder do not need urgent hospitalization, routine examinations in a hospital, or treatment at home. If you have any concerns about the presence of sluggish schizophrenia, you should not think that treatment will take place within the walls of a psychiatric hospital and under the close supervision of doctors. Treatments for people suffering from low-grade schizophrenia include:

• drug support;
• psychocorrection;
• socialization;
• encouragement for work or creative activity.

Usually, in order to eliminate existing symptoms, drugs belonging to the group of antipsychotics are selected, and in maintenance dosages. A person suffering from indolent schizophrenia must undergo treatment with a psychotherapist, as this will allow him to quickly get rid of existing phobias and behavioral quirks, and then acquire skills to interact with other members of society. In addition, you need to pay special attention to the fact that some people suffering from low-grade schizophrenia feel a surge of creative energy. It is very important to support such aspirations, since creativity allows you to release those emotions that a person tries to suppress. Expressing oneself in creativity allows a person suffering from low-grade schizophrenia to quickly regain confidence and learn to be part of social society again.

Sluggish schizophrenia is also called low-progressive, non-psychotic, microprocessual, rudimentary, hidden, larved, etc. The main feature of this form is slow progress, with indirect manifestations of the clinical picture. The pathology is not characterized by productive symptoms; the clinical picture is based on neurotic disorders, partially negative signs with shallow personality changes.

Stages of the pathology

As a rule, sluggish schizophrenia begins its debut in adolescence, but since its signs are weakly expressed, the pathology can be recognized after a considerable time.

This type of schizophrenia is characterized by stages in the manifestation of symptoms. Pathology is conventionally divided into three periods:

• debut or latent period;
• manifest or active phase;
• stabilization.

The onset is unnoticeable, the symptoms are relative. Depressive states may occur, accompanied by isolation and a person’s withdrawal into his own invented world. Various ideas begin to arise, the patient is prone to abstract thinking, philosophizing, which has no values.

The debut gives way to the manifest; during this period, the symptoms of the disease clearly begin to appear and, as a rule, a diagnosis is established. During this period, absurd fears often arise, for example, a person dressed in a uniform or a purple jacket can cause an unbearable state of horror and a desire to run away. Symptoms such as isolation become more pronounced, it can reach the state of autism, the patient is exhausted, often experiences insomnia, and his range of interests is narrowed.

The manifestation can occur with different clinical signs; neuroses, paranoia, hysteria, obsessive-compulsive disorder, hypochondria, and others may predominate. Also, low-grade schizophrenia has a history of one or two of the following defects:

• Verschreuben, the main sign of this defect is strange behavior, pronounced foolishness, eccentricity, eccentricity. This behavior is expressed in sloppiness, awkwardness in appearance, for example, the patient can wear shorts with a down jacket in the summer, etc. His movements are uncertain, angular, reminiscent of a small child, but he does it all with a serious look. Changes are also observed in speech, it is full of all sorts of pretentious turns of phrase, the patient speaks quickly and not to the point, dangling thoughts are often observed, he begins his story with one thing, forgetting what he was talking about at the beginning, jumps to another topic of conversation. At the same time, everything remains, mental and physical activity is preserved;
• pseudopsychopathy - this defect is expressed in a large number of different ideas in the patient, which he considers extremely valuable and does not tolerate any criticism on this matter. The patient is emotionally excited and involves everyone around him to implement his brilliant ideas. Naturally, the result of such actions is negligible or non-existent;
• a reduction in energy potential manifests itself in depression, self-isolation, lack of any motivation to do anything, a desire to spend time alone, and isolate from society.

The stabilization stage is the main goal pursued when treating patients. In fact, this is a remission with partial or complete disappearance of symptoms characteristic of the manifest period. Unfortunately, stable and long-term stabilization is not always possible to achieve, but even without treatment the situation will only worsen, leading the patient to an irreversible personality defect.

General clinical picture

In addition to the three conditions described, low-grade schizophrenia can manifest itself with various symptoms, for example:

Low-progressive schizophrenia and its forms

Sluggish schizophrenia can occur in the following forms:

Personality defect

The most difficult and often irreversible consequence of a long course of schizophrenia is the development of a personality defect. In this case, all human qualities suffer: emotions, will, thinking and intellect.

A personality or schizophrenic defect consists of the following manifestations:

• autism;
• speech disorder;
• impoverishment of the emotional sphere;
• inability to adapt to society;
• thinking disorder.

All these signs steadily develop in any form of schizophrenia; the sluggish process, unfortunately, is no exception, with the only difference being that such symptoms arise later than in other types of pathology.

Therapy

For the most favorable outcome of schizophrenia, it is important to begin treatment before the onset of the manifest stage. A distinctive feature in the treatment of the indolent form is the use of drugs in relatively small doses compared to other more malignant types of pathology.

For treatment, one drug is determined that is best able to relieve the symptoms of the disease and lead to remission. Slightly progressive schizophrenia is a chronic disease and requires continued treatment even during a period of stabilization and even complete remission. As a rule, they leave the same drug that was used and during the manifestation period they only reduce the dosage to the minimum. The main groups of drugs for schizophrenia are as follows:

• neuroleptics of new and old generation;
• anxiolytics;
• normomitics;
• antidepressants;
• nootropic drugs;
• psychostimulants.

The main drug for the indolent form of schizophrenia is considered to be a new generation antipsychotic - haloperidol. Less commonly prescribed are classic, typical, or previous generation antipsychotics. Their disadvantage is a large number of side effects. Basically, drugs are prescribed orally; medications are administered intravenously or intramuscularly only when it is urgently necessary to stop psychomotor agitation.

Sluggish schizophrenia is treated in most cases on an outpatient basis; less often, during the period of manifestation, the patient may be in a hospital setting. Hospitalization may be indicated in the following cases:

• refusal to eat for more than a week;
• loss of body weight by more than 20%;
• aggressive conditions;
• psychomotor agitation;
• suicide attempts.

In addition to drug treatment, psycho-emotional support from relatives and doctors is important. Group sessions with a psychotherapist, which involve patients with the same diagnosis, are encouraged. It is important not to criticize the patient’s behavior, but to create psychologically favorable conditions for life.

The prognosis for low-grade schizophrenia is more favorable compared to other forms. Treatment requires smaller doses of medications, and the personality defect occurs slowly and is not pronounced. The main goal in the treatment of pathology is based on achieving high-quality and long-term remission, preferably without repetitions of manifest periods.

Reading strengthens neural connections:

Sluggish (slightly progressive) schizophrenia is divided into three types - psychopathic schizophrenia, simple and neurosis-like schizophrenia, and is classified as transitional forms. This means that it does not clearly express the signs of schizophrenia, but has only isolated symptoms, being partially in contact with the disease. It is expressed by asthenic, obsessive-phobic, hypochondriacal, paranoid disorders and is defined as a benign form of schizophrenia.

If classical schizophrenia is characterized by deep personality degradation, then sluggish schizophrenia carries only a deformation of the essence of the personality (changes in behavior, range of interests, motives) and develops slowly, over decades, with a gradual deepening of deficient personality characteristics. In some cases, the disease resembles a protracted neurosis, in others it resembles psychopathy, that is, a combination of symptoms from different syndromes. This pathology can be provoked by various psychological traumas, poor lifestyle and stress, and recovery is possible even without treatment. In the International Classification of Diseases (ICD-10), there is no such diagnosis of “sluggish schizophrenia”; many authors use this concept as a synonym for schizotypal disorder.

Sluggish schizophrenia and gender

The gender of patients is not a factor that significantly influences the typology of the course of the schizophrenic process. The risk of the disease is approximately the same in men and women, but women tend to have a later onset of the disease and a faster recovery than men. The main difference is that women are more likely to have a paroxysmal form, while men are more prone to a continuous form. Typically, the symptoms in men are more pronounced, and the external signs of the disease are more noticeable: an unkempt appearance, a reluctance to take care of oneself. At the same time, if such signs occur in women, those around them immediately notice them, although it is impossible to say at what stage of the disease these manifestations of the disease become noticeable.

Neurosis-like schizophrenia

This form of schizophrenia is considered the most favorable, as it has a large number of persistent remissions. It includes a wide range of anxious-phobic obsessions and usually begins in adolescence, with the formation of a shallow personality defect such as mental infantilism. It was noticed that the later the process begins, the smoother it proceeds.

The most pronounced symptoms are dysmorphomania, panic attacks, derealization, depersonalization; obsessions may be present, which differ from neurotic disorders by being more irresistible. If, with neuroses, patients hide their rituals from others, then with neurosis-like schizophrenia, rituals are performed openly, and patients can even involve others in them. These rituals are protective in nature, relieve nervous tension and, according to the patient, prevent trouble. They can be very complex, sometimes last for hours and gradually take a leading position in the clinical picture, completely displacing other human actions, that is, he cannot take a step until he performs a lot of rituals, which can sometimes lead to complete isolation from society.

Phobias, which can be especially strange, are colored with less emotionality, but, nevertheless, can lead to suicide. The patient spends all his time at home, and even there he does not feel completely safe.

Hypochondriacal sluggish schizophrenia

Hypochondriacal sluggish schizophrenia is expressed by an obsessive fear of having some kind of disease (most often cancer), with an exaggerated assessment of its consequences, despite the negative results of a medical examination. Its main core consists of ideas and thoughts associated with pathological, unusual sensations that arise in one’s own body. The patient may feel certain somatic ailments in the body, or claim that there is some kind of creature in his body, for example, a worm, and colorfully describe the movements of the animal within himself. The queues at clinics are 60% made up of just such people. They believe that doctors made a mistake in diagnosis, and are firmly convinced that they have a serious, incurable disease, although they cannot accurately convey in words their painful sensations. Such patients, as a rule, use metaphorical comparisons: “the heart burns,” “there is a fire in the stomach,” “pus fills the whole body,” etc.

Latent schizophrenia

A number of researchers classify latent schizophrenia, expressed by mild disturbances, as a latent form of sluggish schizophrenia; its existence is not recognized by all authors and is actively disputed by them. Psychotic symptoms are usually not observed with it, but over time they can appear under the influence of various unfavorable factors. Personality changes are weakly expressed, the behavior and priorities of patients do not change much, and mental disorders are minimal.

Signs of low-grade schizophrenia

Sluggish schizophrenia has various signs, one of them is alienation. The patient is completely immersed in himself and constantly listens to the processes occurring in his body and engages in soul-searching. At the same time, his mental abilities become impoverished, activity and initiative disappear, and there is a detached perception of reality. The patient has an increased interest in abstract, abstract problems (magic, religion, problems of the universe); he often studies a lot of philosophical literature (philosophical intoxication). The volitional sphere also suffers; a person rushes between opposing decisions and ultimately refuses to make any choice at all. The attitude towards relatives changes noticeably, a person becomes indifferent to their needs, and the ability to empathize disappears. Previously unusual demonstrativeness, coquetry, affectation and hysterical notes may appear. Gradually, his appearance takes on eccentric features, sloppiness appears, which causes ridicule and rejection from others. His speech becomes pompous, meaningful, but at the same time poor in intonation.

The main symptoms (obsessions, phobias, overvalued ideas) dominate throughout the disease. The course of the disease is uneven, at first the symptoms develop quite quickly, then the course slows down and is accompanied by ups and downs of mental disorders. Occasionally, fragmentary delusional ideas, hallucinations and individual mental automatisms may occur. Patients are most often socially adapted and may have families and friendships, although their mental disorders are noticeable even to a non-specialist. To relieve symptoms, such people may begin to use alcohol and drugs, in which case an almost irreversible personality defect quickly sets in.

Treatment of low-grade schizophrenia

Treatment of patients diagnosed with low-progressive schizophrenia, especially with a predominance of hysterical and neurosis-like disorders, should include a course of psychotherapy, which involves targeted and sometimes painful work on oneself. A person needs to learn to take responsibility for his life and understand that he has the opportunity to choose, that he is not a helpless victim of an illness, his future depends only on himself and positive changes are possible. You cannot convince a person that he must learn to live with his symptoms, that his illness is chronic and focus his attention on this. Recovery can take a long time, since change and self-knowledge is an internal process, and it cannot be artificially accelerated, because acquired painful manifestations are firmly held in the structure of the personality.

In some cases, psychotropic drugs are used. Treatment of sluggish schizophrenia with this technique is determined by the course of the disease process, and the use of medications reduces emotional stress and eliminates hysterical and phobic reactions. After several years of active therapy, complete disappearance of psychopathological manifestations is possible.

Patients with schizophrenia who are undergoing successful treatment can sometimes experience emotional complications that cause a relapse of the disease. To prevent a relapse, it is important to promptly recognize signs that portend danger (for example, nightmares) and stop them in a timely manner, which does not require harsh measures. The patient's consciousness must be moved away from the unconscious by simple therapeutic methods. You can invite the patient to draw a picture of his internal state, as a result of which all the chaos is objectified and can already be viewed from a distance. Such a picture reduces the significance of the horror, makes it tame, ordinary, removes reminders of the original experience and allows the patient to explore and interpret it consciously.

Often relatives are interested in how to behave with a patient with schizophrenia. First, the healthy parts of the personality must be addressed and supported. You should not treat the patient as a dangerous person who does not control his actions, because he needs increased attention, care and patience, and a favorable climate at home has a very positive effect on the treatment being carried out.