Schizoid delusion. Schizophrenia - symptoms and signs in adults, exacerbation and causes of the disorder

There is a widespread belief that schizophrenia is incurable. However, with proper therapy, it is possible to reduce and eliminate symptoms, achieve stable remission and socialization.

What is schizophrenia and how can it manifest?

Schizophrenia– a mental disorder associated with the activity of parts of the brain, which is accompanied by disturbances in the emotional sphere, perception, and thinking. The disease manifests itself in different ways. It is distinguished by multifaceted symptoms, a variety of laboratory and personal manifestations.

Typical manifestations of the disease

Schizophrenia is:

Reasoning about mental retardation wrong in schizophrenia. Intelligence can vary from low to very high.

For example, I had schizophrenia world chess champion B. Fisher, writer N. Gogol, mathematician D. Nash, a lot others.

People suffering from this disease, while perceiving information adequately, are unable to accurately process it in parts of the brain. When a focus of excitation appears in it, hallucinations are born, to fuel which the brain takes energy from other areas. This affects the quality of memory, attention, and emotional state.

Symptoms and signs of schizophrenia appear similarly in men and women, only in men at an earlier age (20-28 years). Women usually get sick from 25 to 32 years old.

Causes of the disease

The nature of the causes of the pathology has not yet been clearly established.

The most common are:

• hereditary predisposition (the risk of occurrence increases by 10%);
• intrauterine infections, complications during childbirth;
• viruses, toxic substances, bacteria that cause brain abnormalities;
• oxygen starvation of the brain.

Symptoms and signs of schizophrenia in women may occur after childbirth and are considered puerperal psychosis. Childbirth can become a trigger if there is an existing predisposition .

ICD 10 classification

In the International Classification of Diseases, schizophrenia belongs to a group of chronic processes accompanied by the breakdown of mental functions and emotional reactions. There is preservation of consciousness and intelligence. However, cognitive abilities may decline. In the ICD-10 classification, various types are distinguished.

Types of schizophrenia according to clinical picture

Each type is characterized by specific symptoms

Simple schizophrenia

Changes in speech, facial expressions, decreased activity. Indifference, apathy, lack of interest and purpose.

Delirium, feelings of persecution, fears, irritability, movement disorders. Can lead to personality changes and depression.

Catatonic

Motor changes: agitation, stupor. Random and meaningless movements.

Hebephrenic

Increased activity, excitability, rapid speech, mood swings, mannerisms, importunity. Strange behavior appears. Occurs rarely, usually in adolescence.

Residual (residual)

Lethargy, lack of will, detachment from society, lack of attention to hygiene.

Types according to the course of the disease

Continuously flowing

There is an increase and progression of negative symptoms leading to a personality defect. Characterized by lethargy, lack of will, deterioration of thinking.

Paroxysmal (fur coat-like schizophrenia)

One of the most common types. The name comes from the German word "shub", meaning shift. Each attack is accompanied by the appearance of new symptoms. The cause can be stress, toxic substances, infections, genetics. Male schizophrenia of this type has more aggressive manifestations. Often progresses to dementia. Attacks with delusions and hallucinations are longer (up to a year) than the intervals between them. The patient distances himself from others and becomes suspicious. The condition is characterized by depression and hysterics. The first episodes can occur from the age of 11.

Sluggish

Slow progress of the disease is recorded. Symptoms are mild. Activity and emotionality decrease for many years with the manifestation of mild depression.

Sometimes diagnosed mixed a type of disease, the course of which becomes either sluggish or paroxysmal.

General signs and symptoms

Severe clinical manifestations usually appear during adolescence. The condition preceding the disease lasts from 2 years.

First signs

They appear gradually, progress, and are supplemented:

• monosyllabic answers, slow speech;
  
• impoverishment of emotions, avoidance through the eyes of the interlocutor;
• weakening of attention and concentration;
• apathy, lack of interest in anything, suspicion;
• delusional ideas, initial manifestations of hallucinations (which later transform into psychosis).

Signs and symptoms vary.

Signs – 4 directions of brain function (Bleuler’s tetrad)

1. Associative defect. Inability to think logically and conduct dialogue. Poverty of speech. Monosyllabic answers without building a logical chain.
2. Presence of autism. Immersion in your own created world with monotony of actions and interests. Stereotyped thinking, lack of sense of humor.
3. Affective inadequacy to current events. Laughter or tears are “inappropriate.” For example, laughter in a stressful situation.
4. Ambivalence. Conflicting feelings (a person loves and hates at the same time, for example, the singing of birds). Moreover, contradictions can be emotional, intellectual, volitional.

With a combination of symptoms, there is a loss of interest in the environment and withdrawal into oneself. Sometimes new hobbies arise, for example, religion, philosophy, and fanaticism appears.

Symptoms These are concrete manifestations. They are positive And negative .

Symptoms are positive

• Hallucinations (usually auditory: voices, threats, orders, comments). As well as tactile, olfactory, gustatory, and visual deceptions.
  
• Rave. Feeling the influence of hypnosis, witchcraft (intelligence, aliens).
• Delusions of persecution, jealousy, one's own defectiveness, self-accusation, grandeur, incurability.
• Impaired motor coordination (stupor, agitation).
• Speech disorders (sometimes to the point of incoherence, loss of meaning), thinking, obsessions.

Symptoms are negative

• Emotional imbalance (impoverishment of emotions).
• Social disorganization, apathy, thirst for loneliness. Dissatisfaction with life.
• Volitional disorders. Inhibition, repeating actions after others without any effort of one’s own will (including committing illegal actions).
• Narrowing of interests, lack of sexual desire, neglect of hygiene, refusal to eat.
• Manifestation of anger, selfishness, cruelty.

Symptoms and signs of schizophrenia in children and adolescents

When problems arise in a child, his exclusion from the life of the group, solitude, and loss of interest are immediately noticeable.

Signs of schizophrenia in a child

• personality disorders;
• change in ideals, behavior, interests;
• lack of contact, gloominess, low self-esteem;
• whimsical ideas;
• excessive shyness, loss of interest in any activity;
• disturbances in the areas: emotional, motor, imaginative.

Teenage symptoms

• speech disorders: slowing down or speeding up, taciturnity, abruptness, stuttering;
• emotional emptiness, inactivity;
• thinking disorders, inconsistency of judgment, decreased intelligence;
• difficulties in communication, difficulties in studying;
• manifestations of rudeness, pride, discontent.

Sick children strive to realize themselves in unrealistic fantasies. Childhood schizophrenia diagnosed 5 times less often than teenage. It is treated quite successfully.

Diagnostics

Diagnostic procedures include collecting anamnesis, interviewing patients and their relatives, and monitoring for six months. There are diagnostic criteria of the first and second rank. To confirm the diagnosis, at least one criterion from the first rank and two criteria from the second rank are required, which have been observed for at least a month.

First rank diagnostic criteria

• hallucinations, often auditory;
• presence of delusional ideas;
• perception of delusional character;
• the sound of your own thoughts.

Second rank diagnostic criteria

• intermittent thoughts;
• movement disorders;
• non-auditory hallucinations;
• pathologies of behavior.

Methodology for using tests

For psycho-emotional assessment, special scales (Carpenter, PANSS) and tests (Lüscher (testing through different colors), MMMI, Leary, others) are used.

Test for schizophrenia “Chaplin's Mask”

The uniqueness of the test is in ascertaining the state of a healthy psyche, for which self-deception and distortion of reality are normal factors.

Presented to your attention rotating Charlie Chaplin mask A. A healthy person appears to have a strange face, since it is convex on both sides. For a person with schizophrenia, the mask is always concave , which is associated with special information processing by the brain.

Test for schizophrenia “Cow”

You are asked to answer what is shown in the picture. For a healthy person, the image is something incomprehensible and blurry. And patients identify a cow due to isolation from reality.

They help in the complexity of the diagnostic process tests for schizophrenia using pictures as additional research. Test data alone is not enough to clarify the diagnosis. They are only accompanying measures for the main diagnosis.

Treatment Basics

Main goal of treatment– achieving the process of remission (weakening, disappearance of symptoms), preventing negative forms, psychosis, complications. Treatment depends on age, personality characteristics, nature and duration of the disease. In the acute phase (psychosis, attack), hospitalization is recommended.

Specialized care is provided in psychoneurology by psychiatry specialists. Drugs that improve brain nutrition are used. It is recommended to cleanse the body, special diets, laser therapy, electrotherapy, and antipsychotic drugs.

Basic treatment methods

Therapy is carried out in the following areas: medication, electroshock, psychotherapy, social adaptation, non-standard techniques .

Drug therapy

It is based on psychotropic drugs, antidepressants, and antipsychotics.
Their goal is to reduce negative symptoms. Drugs are used only on the recommendation of a doctor and in the absence of contraindications.

Effective pills for schizophrenia: Azaleptin, Zyprexa, Solian, Carbamazepine, Cyclodol, Fluanxol, .

Antidepressants: , Ixel, Venlafxin. Neuroleptics: Aminazine, Tizercin, others.

Agonists: Ziprasidone, Aripiprazole.

Physiotherapy

Most commonly practiced procedures :

• influencing the cerebral hemispheres through certain areas of the skin;
• exposure to light impulses on the retina of the eye in order to get rid of phobias, anxiety, neuroses;
• blood purification using laser radiation.

Various methods of increasing immunity are also used using the following means: Echinacea, Timolin, Villazon, Erbisol, Thymogen, Splenin.

Psychotherapy

It aims to improve cognitive and functional skills. Creating a positive atmosphere is of great importance. Psychological support from relatives and friends is used.

The treatment prognosis is more favorable for females and for the disease that began at a later age with minor negative symptoms. A positive effect comes from good social and professional adaptation before the onset of the disease. Recently, non-standard treatment methods have begun to be actively used.

Treatment with creativity

Research confirms the connection between the disease and creativity. The brains of patients with schizophrenia are capable of reproducing non-standard associations. It is not for nothing that many creative people suffered from this disease. Creativity helps restore balance, open up in a new way, and shift attention.

Treatment with creativity(poetry, drawing) allows you to minimize depressive and stressful moments, concentrate your attention, and improve your mood. In addition, it promotes adaptation in society by creating a feeling of need.

Treatment at home

Supportive or homemade treatment for several months (up to two years) is aimed at preventing relapse. It is carried out when the acute period has passed.
Close people participate in the rehabilitation phase. Occupational therapy and special training are practiced, and the recommended medications continue to be taken.

Important for remission trusting relationship. Relatives are trained in the rules of communication with patients of this kind. We must try not to argue with them, not to ask unnecessary questions, to reassure them, and to protect them from emotional experiences. Eliminate all factors that irritate them, do not raise your voice. It is necessary to show patience, friendliness and tolerance.

After hospital treatment it is necessary annual examination, correction.

The full extent of the disease cannot be cured. However, with a qualitative approach, the ability to work and social activity are restored, psychosis is prevented and remission is achieved.

Schizophrenia is the most mysterious and little-studied pathology. A complex, severe mental disorder destroys the human essence, negatively affecting the ability to think, speak, and perceive reality. The name “schizophrenia” was first used by the Swiss psychiatrist Eugen Bleier in 1909.

Before this, the pathology was classified as a type of dementia (dementia). Bleier, for the first time in the psychiatric world, explained what schizophrenia is and proved that its feature is not cognitive impairment (decrease in mental and mental functions), but a complete collapse of a person’s mental makeup.

Schizophrenia is a severe mental disorder

Schizophrenia: what kind of disease is it?

The word "schizophrenia" is of Greek origin and means "to split the mind." This is an endogenous disorder (that is, arising not through external, but through internal mechanisms, where genetic predisposition plays a large role).

Schizophrenia, what is it, according to Eugen Bleier. The scientist classified the disorder as a combined set of “four As”:

1. Autism. Fenced off, disconnected from the surrounding reality. One of the main symptoms of pathology.
2. Affect. A powerful emotional shock that occurs due to the inability of the individual to escape from critical situations.
3. Ambivalence. Splitting of consciousness, dual perception and attitude towards something (when one object evokes opposite feelings in a person at the same time).
4. Associative thinking. The presence in a person of a certain thought process, during which various images appear in the mind, concretizing a certain situation.

Schizophrenia is very often accompanied by alcoholism, drug addiction, and severe depressive disorders. Contrary to popular belief, not many people suffer from severe mental illness. Large-scale studies show that the disorder is diagnosed in 0.4-0.6% of the population.

Residents of large cities are more at risk of encountering the disease. The peak of the disease has age-related characteristics:

• men: 22-30 years old;
• women: 25-33 years.

It has been noted that the disease rarely affects older people and young children. Schizophrenic disorder brings with it deep social problems, up to and including complete maladaptation of the individual (loss of socialization). Disadaptation brings with it homelessness, unemployment and constant thoughts of suicide.

How the disease develops

The essence of the disorder and the definition of schizophrenia is the inability of the individual to adequately perceive reality. The patient’s surrounding world includes facts, sounds, smells, actions, and situations scattered into small components. A sick person adds his own illusions, creating an unimaginable, non-existent reality.

Comparison of the brain of a patient with schizophrenia and a healthy person (on the left is the brain of a healthy person, on the right is the patient’s)

The patient is unable to fit the processes that occur in the inflamed brain into any framework or rules. Schizophrenics react to the quirks of their own brain with inadequate reactions, sometimes reaching the point of a seizure. Doctors were unable to determine exactly how the pathology develops.

The most likely version is the following development of events:

1. In certain areas of the brain, specific hormones (serotonin, dopamine) begin to be produced in large quantities.
2. Excess hormones provoke an acceleration of lipid peroxidation. That is, oxygen oxidation of fats that make up cellular tissue occurs, which accelerates the death of brain cells.
3. Due to the global destruction of brain cells, disruptions begin in the blood-brain barrier (the membrane that prevents contact between the brain and blood).
4. There is an accumulation of debris from dead cells, which leads to the development of an autoimmune conflict. Autointoxication begins (poisoning of the body with the breakdown products of its own substances, when the body’s immune system begins to fight the body’s cells).
5. Such processes lead to the persistent formation of a focus of constant excitation in the cerebral cortex. Prolonged irritation of weakened cells provokes the development of auditory and visual hallucinations, delusional ideas characteristic of the patient.

The brain requires a lot of energy to fuel the focus of excitation. As a result, the body deprives other brain areas of essential nutrients. This leads to the gradual destruction of the ability to think and reason adequately. Memory, attention, emotions, and will suffer.

What causes pathology

Most experts are inclined to believe that schizophrenia is a multifactorial disease. Pathology develops due to the complex influence of exogenous (external) and endogenous (internal) factors on the body.

Schizophrenia is hereditary. The risk of developing the disorder increases 25 times if a family member is diagnosed with schizophrenia.

It is noted that there are more schizophrenics among people born in the summer and spring. Proven factors that directly influence the onset of the disorder include:

• abnormalities of brain development;
• difficult delivery;
• fetal infections during intrauterine development;
• psychological experiences at an early age;
• long-term use of psychoactive substances, drugs, alcohol.

Clinical symptoms

The onset of the disease is represented by a specific period, which is called the “premorbid phase”. Its duration varies between 1-2 years. This time is marked by the development of the following nonspecific symptoms in the individual:

• constant irritability;
• sharpening of inherent character traits;
• bizarre, unusual behavior;
• decreased need to communicate with other people, withdrawal into oneself;
• the appearance of dysphoria (painfully gloomy mood, hostility towards others).

The premorbid phase gradually develops into another period - the prodrome, preceding the onset of the disease. At this time, the person completely withdraws from others, and severe absent-mindedness develops.

Clinical signs of relapse of the disorder

In the premorbid phase, the symptoms of schizophrenia become psychotic. Short-term disorders develop. Then a full-blown psychosis develops, leading to illness.

Doctors divide all symptoms of schizophrenia into two main categories. Let's take a closer look at them.

Positive symptoms

These are signs that are “added” to a person, such that were not previously observed (in a healthy state). These include:

Hallucinations. Schizophrenia is most often marked by auditory hallucinations. The patient feels that non-existent voices are sounding in his brain or are trying to capture his attention, sounding from the outside, from various foreign objects.

There are cases when a schizophrenic simultaneously heard 2-3 voices, which also argued among themselves.

In addition to auditory hallucinations, tactile hallucinations are also added (the patient thinks that something is happening to him). For example, ants biting the skin, fish in the stomach causing pain, slimy toads in the hair. Visual hallucinations in schizophrenic disorder are very rare.

Rave. It seems to the patient that some enemy otherworldly force is powerfully acting on his psyche and subconscious, pushing him to carry out certain actions. The influence (according to patients) occurs through the method of hypnosis, some technical forces, witchcraft, telepathy. Doctors note other delusional signs of schizophrenia:

• persecution (the patient feels that he is being followed, being watched);
• self-accusation (the patient considers himself guilty of death, misfortunes, illnesses of relatives and friends);
• hypochondria (there is a strong belief that the person has a serious, incurable disease);
• jealousy (the sick spouse develops a strong belief in the infidelity of the other half);
• greatness (a person is convinced of the presence of supernatural abilities or unconditionally believes that he occupies a high position in society);
• dysmorphic (a schizophrenic is confident in personal ugliness, the presence of a non-existent deformity, the absence of a body part, gross scars, defects).

Obsessions. In the consciousness of a sick person, thoughts and ideas of an abstract orientation are constantly present. They are global and large-scale in nature. For example, a person constantly thinks about the collision of the earth with an asteroid, the fall of the Moon on the planet, the explosion of the Sun, etc.

Mechanism of development of schizophrenia

Movement disorder. Such symptoms appear as:

1. Catatonic excitement. Inadequate state in the form of psychomotor restlessness: foolishness, pretentiousness of speech, arrogance, exaltation.
2. Catatonic stupor. Decreased psychomotor activity. Being in this state, the patient becomes completely immobilized, the muscles of the body tense greatly, freezing in an elaborate and unusual position.

Speech disorders. People suffering from schizophrenia engage in lengthy and meaningless spatial reasoning. Their speech is filled with numerous neologisms and overly detailed descriptions. Schizophrenics in a conversation quickly jump from the current topic to another reasoning.

Negative symptoms

Such symptoms are classified as degradative - the person’s skills and abilities that were previously present (when the person was healthy) disappear. These are the following disorders:

Emotional. The patient experiences a noticeable depletion of emotions, and there is a prolonged deterioration in mood (hypotymia). The number of contacts is sharply reduced, a person strives for privacy, and ceases to be interested in the wishes of his relatives. Schizophrenia gradually leads to complete social isolation.

Strong-willed. Disorders in this area are manifested by the growing passivity of the individual. Patients lose the ability to make their own decisions; they live by habit, armed with memories of their own habitual behavior, or copy the behavioral reactions of others.

At the onset of the disease, many people experience attacks of hyperbulia (increased libido and appetite).

This can lead to the development of antisocial behavior: illegal actions, alcoholism, drug addiction. At the same time, the patient does not get pleasure and cannot form a personal attitude towards situations.

The needs of a schizophrenic are significantly reduced, intimate attraction disappears, and the circle of common interests narrows. Gradually, patients begin to forget about hygiene and refuse to eat.

Classification of schizophrenia

Based on the manifestation of certain symptoms, pathology is divided into five main types:

1. Catatonic. The disease progresses with a predominance of various psychomotor disorders.
2. Residual. Schizophrenia is marked by mild symptoms related to positive factors.
3. Disorganized (or hebephrenic). It manifests itself as an impoverishment of the emotional component of the personality and a pronounced disorder of thinking.
4. Undifferentiated. It is characterized by an increase in psychotic symptoms, while undifferentiated schizophrenia does not fit into the picture of other types of illness.
5. Paranoid. Delusions and obsessive hallucinations are observed. Emotions do not suffer, unlike the ability to think and behave, which are clearly impaired.

In addition to the main classification of pathology, psychiatrists distinguish two more categories of disease (according to the ICD-10 classification):

1. Schizophrenia of a simple type with gradual personality regression and the absence of acute psychosis.
2. Post-schizophrenic depressive state. It is characterized by a steady decline in emotional qualities.

Russian psychiatrists also have a gradation of the disease according to the nuances of its course:

• sluggish;
• continuously flowing;
• periodic (recurrent);
• paroxysmal (fur-like).

This variety of gradations of the disease helps doctors more accurately develop drug therapy and predict the development of pathology.

Treatment of the disease

Therapy for schizophrenia takes a comprehensive approach, including the following types of treatment:

Medication. The basis of pharmacological treatment is the use of antipsychotropic medications. Preference is given to atypical antipsychotics. To stop the development of side effects, antipsychotics are combined with drugs from the benzodiazepane group and mood stabilizers.

If medications are ineffective, psychiatrists prescribe ICT (insulinocomatose therapy) and ECT (electroconvulsive therapy).

Psychocorrection. The main goal of psychotherapy is to restore the patient’s cognitive skills and improve his socialization. Psychiatrists work on the patient’s awareness of his own characteristics. Family therapy becomes effective; it is needed to create a favorable climate in the patient’s home environment.

Treatment goals for schizophrenia

Disease prognosis

The final result of treatment is influenced by many factors: the gender of the patient, the age at which the disease began, the characteristics of the onset, the type and form of the disease. According to statistics, the pathology prognosis is as follows:

1. In approximately 40-45% of cases, the appearance of stable remission in the patient's condition is noted. The patient can return to work and lead a normal life.
2. In 55-60% of cases, schizophrenia develops into a sluggish chronic form, manifested by moderate disorders. The quality of life of people is still decreasing, but it is within the psychological comfort zone.

We can talk about remission when signs of the disorder are not observed for six months. But this does not mean that the patient has recovered. In the case of schizophrenia, unfortunately, it is impossible to talk about complete recovery. The patient's condition can only be significantly improved and the person returned to normal life.

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 it so? 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. Wherein 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 emergence of indifference and passivity, complete loss of interests, cannot be ruled out.

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 a continuous course of the disease the appearance of attacks is noted, 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), interruption of 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 - the reasons are different, and the brain responds with a limited set of reactions.
3. Schizophrenia is a specific adaptation disorder (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 an earlier onset and a more 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 mismatch in the functioning of the hemispheres and dysfunction of the fronto-cerebellar connections are detected. CT (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. The most important thing in the diagnosis of productive disorders is 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 motor 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.
Delusional 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:

1. dominance of hallucinatory or delusional phenomena (ideas of persecution, relationship, origin, transmission of thoughts, threatening or haunting voices, hallucinations of smell and taste, senesthesia);
2. catatonic symptoms, flattened or inadequate affect, and intermittent speech may be present in a 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:

1. the condition during the last year of observation met the general criteria for schizophrenia;
2. at least one of them is retained; 3) the depressive syndrome must be so prolonged, severe and developed that it meets the criteria for no less than 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 at the time of examination. In addition, at least 4 of the following negative symptoms must have been present during the last year:

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

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

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

• distinct and persistent changes in some premorbid personality characteristics, manifested in a decrease in motivations 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;

1. the state never corresponds to the symptoms common to paranoid, hebephrenic, catatonic and undifferentiated schizophrenia (F20.0-3);
2. 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 first-degree relatives with schizophrenia 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” formality, mundane judgments, 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 this: “Among the times of growth, there is cardiac layering, and this is the appearance of human growth.” The above phrases are incomprehensible. This is a typical example of "speech breakdown". In some cases, speech comes down to the pronunciation of individual words and phrases without any sequence. For example, “...to pour out smoke...will not be anywhere...the kingdom of heaven...it is wrong to buy water...one of two without a name...six crowns...cutting a lasso and a cross...” - This is the so-called word okroshka, or word salad. They may be asked to draw the meaning of the phrase “delicious lunch.” Where an ordinary person would draw 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 reveal manifest psychotic phenomena; the clinical picture is represented by disorders of the mild “registers” - neurotic personality disorders, asthenia, depersonalization, derealization.

The names of sluggish schizophrenia accepted in psychiatry: mild schizophrenia (Kronfeld), non-psychotic (Rozenstein), Current without a change in character (Kerbikov), microprocessual (Goldenberg), rudimentary, sanatorium (Connaybeh), prephase (Yudin), slow-flowing (Azelenkovsky), larvated , 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 a regression of negative symptoms, their 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 at an 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 - somatic illness, organic pathology in premorbidity. 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. Similar to obsessive-compulsive disorder. 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.” Moreover, these obsessions can become overgrown with a large number of rituals performed without the emotional involvement of the person. Characterized by monoobsessions (monothematic obsession).

3. Form with hysterical manifestations. “Cold hysteria” is characteristic. 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 a predominance of 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 preservation 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 begin to resort to psychoactive substances, often 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 condition. 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 there is no complete recovery between attacks, but remissions are long, and the manifestations of the disease are subtle. 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 its 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 of 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 are talking 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. Recently, atypical antipsychotics have appeared: Clozepine (Leponex) is 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 cannot convince or force him to undergo treatment, you may have to resort to hospitalization in a psychiatric hospital without his consent. The main purpose of both involuntary hospitalization and the laws governing it is to ensure the safety of the acutely ill patient and the people around him. In addition, the tasks of hospitalization also include ensuring timely treatment of 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 an inpatient setting, and the mental disorder is severe and causes:

1. his immediate danger to himself or others, or
2. his helplessness, that is, his inability to independently satisfy the basic needs of life, or
3. 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

Chapter Eleven

Delusions in schizophrenia and delusions of other origins, their commonalities and differences

As already mentioned, the symptom of delirium, taken in isolation from the clinical picture as a whole, does not have absolute diagnostic value and does not indisputably speak for schizophrenia. It only indicates a disease process in general or a pathological condition of the brain, most often caused by toxicity. Delirium almost identical or even completely identical in structure to schizophrenic occurs in various other diseases: epilepsy, epidemic encephalitis, progressive paralysis, especially treated with malaria, syphilis of the brain, arteriosclerosis with additional intoxication of somatogenic origin, alcoholic and other intoxicating psychoses. Let us point out its common features in these cases with those in schizophrenia, the predominant predominance of one or another of its forms, as well as differential diagnostic differences.

The least pathognomonic for schizophrenia are delusions of jealousy, which occur in various organic diseases (it is sometimes difficult to distinguish from an overvalued idea), and acute delusions of persecution, which also occur in intoxication psychoses of alcohol, cocaine and other origins.

Systematized delusions of persecution, slowly developing in the manner of Magnan's chronic delusions, combined with delusions of relation, are typical of schizophrenia. The most pathognomonic for schizophrenia is delusion of influence, which concerns not the somatic sphere of patients (delusion of physical influence), but the intimate subjective experiences of the patient, namely the processes of his thinking and volitional sphere - the introduction of other people’s thoughts, guessing the patient’s thoughts, capturing his will, etc., reflecting such thus a violation of the integrity of the individual, typical of schizophrenia.

Typical for schizophrenia is also the delusion of meaning, the perception of the environment in a different meaning (and delusional perception in general) - an allegorical understanding of words, gestures, movements, etc. As for the delusion of physical influence with accompanying pathological bodily sensations - exposure to devices, currents, burning rays, then it occurs not so rarely in epilepsy in shallow twilight states, in some organic diseases of the brain (for example, cerebral syphilis), and also sometimes in alcoholic psychoses for a short time at the height of the severity of the condition.

We also observed hypochondriacal delusions with ideas of the presence of a living being in the body or others in epilepsy and epidemic encephalitis. With the latter, various delusional ideas - relationships, influences, especially hypochondriacal ones - are not uncommon. Thus, one patient with epidemic encephalitis claimed that he had a tapeworm in his body, which caused abdominal pain, moved, and interfered with sexual intercourse. It seemed to this patient that people were reading his thoughts, watching him, “seeing him off with evil eyes,” and putting special food on him in order to drive out the tapeworm. The patient's personality showed changes typical of epidemic encephalitis. Also common in cases of epidemic encephalitis in uncultured patients are the ideas of witchcraft, damage, with the interpretation being due to damage to one’s disease. Unlike schizophrenia, delusions in epidemic encephalitis are simpler, more specific, personality traits characteristic of this disease are noted: with full accessibility, an insistent desire to be treated for one’s illness, viscosity, “clinginess.” In epilepsy, delirium, which is mainly characterized by greater simplicity and specificity compared to schizophrenic delirium, is more often observed in states of mild changes in consciousness - shallow twilight (special) states.

“Archaic” (in the form of superstitious ideas) form of delusions of various types (delusions of corruption, witchcraft, possession of animals, etc.) often occurs in organic diseases, especially in epidemic encephalitis and epilepsy. In contrast to them, here too schizophrenia is characterized by a greater pretentiousness of the verbal style of delusional statements.

The most common types of delusions found in organic (toxic-organic) diseases of the brain are hypochondriacal delusions, which are based on pathological sensations - “cathethetic” in the terminology of V. A. Gilyarovsky, as well as “fantasizing”, which mainly refers to delusions greatness, wealth, all kinds of travel. Thus, with various organic diseases of the brain, more often with an additional toxic factor, we encountered individual delusional statements regarding one’s own body: “No stomach, lost it,” “stomach remained in the bathroom,” “lungs were taken somewhere,” “doctor cut off his fingers”, “neighbors change their legs”, “the body is made of plaster”, “potato flour comes out of the fingers”, “there is a cat in the stomach”, “diamond bones”, etc.

In contrast to the corresponding hypochondriacal delusional statements in schizophrenia, delusions in organic diseases of the brain are constructed in a more elementary way and are poorer, more monotonous, and fragmentary in nature. It is less stable, not systematized, and has little connection with the intimate tendencies of the patient’s personality. The matter is limited to one or several delusional ideas, remaining unchanged for some time, and then disappearing, sometimes not even remaining in the patient’s memory, or being replaced by others.

In the origin of delusional ideas in patients with organic diseases of the brain, as well as in intoxication psychoses, changes in consciousness of varying depths often play a role. In patients with schizophrenia, with the same forms of delusion, we find more richly developed and complex delusional-mental products, greater pretentiousness of delusional statements, and sometimes the use of peculiar expressions and neologisms. The description of pathological sensations is also more varied and elaborate. It should be noted, however, that these differences in relation to schizophrenia are not absolute. Thus, some patients with schizophrenia for a long period of time can express the same hypochondriacal delusional idea, for example, about infection with syphilis, cancer, or another, without any systematization and addition of other delusional ideas, revealing a certain preservation of personality.

On the other hand, we observed patients with progressive paralysis with a kind of fanciful delirium: one patient spoke of pulling out his thoughts and winding them around an electric light bulb; another patient, also with progressive paralysis, treated with malaria, spoke of two women who are trying to “get through”, “shout out” to his body, “look through his eyes”, etc. In these cases, it is sometimes difficult to exclude a combination of an organic brain disease with schizophrenia . The criterion for diagnosis is the entire clinical picture - the background against which the delusion develops, the personality of the patients and the form of expression of the delirium.

One should also dwell on the formation of delusions in syphilis of the brain. The question of it is closely related to the question of delimiting schizophrenia, namely, delimiting it from syphilitic psychoses. Much remains unclear in this regard, and patients falling into this category are diagnosed differently by different doctors.

It is necessary first of all to point out the frequency of paranoid syndromes, close to those in schizophrenia, with indisputably established syphilis of the brain. Organic damage in these cases is not massive. We have evidence of the existence of paranoid forms of cerebral syphilis from various authors, both Russian and foreign. In addition to the delusions of grandeur that characterize the pseudoparalytic pictures of cerebral syphilis, we can have in these patients delusional ideas of persecution combined with auditory hallucinations and delusions of relation, delusions of self-blame, poisoning, physical impact, as well as paraphrenic syndromes. The difference between these psychotic pictures and those in schizophrenia is, as is commonly believed, the mental background against which delirium develops - a change in personality of an organic type, the absence of typical schizophrenic symptoms - thinking disorders, pretentiousness, negativism. The nonsense itself is often fragmentary in nature, simpler, more elementary in its structure. However, this is not always the case, and the differential diagnosis between the paranoid form of schizophrenia and syphilis of the brain with paranoid syndrome can sometimes be difficult in cases where the neurological symptoms are not pronounced and serological data do not give very definite results.

On the other hand, there are a large number of observations when, with a typical clinical picture of the paranoid form of schizophrenia in all respects, neurological symptoms and changes in the cerebrospinal fluid of varying degrees of severity are also noted, forcing with a high degree of probability, and sometimes with complete certainty, to diagnose syphilis of the brain. Whether in all these cases there is a combination of two diseases, or cerebral syphilis, sometimes in combination with visceral (most of these patients have certain somatic abnormalities), can cause clinical pictures indistinguishable from schizophrenia. The possibility of a combination of schizophrenia with syphilis of the brain cannot be denied, but the number of such observations is too large to think about the combination every time. In addition, there is also a fairly large number of patients with the paranoid form of schizophrenia, who, in addition to individual, often pronounced neurological symptoms, sometimes with mild changes in cerebrospinal fluid (cytosis or wave in the Lange reaction, positive globulin reactions, etc.), various signs of dystrophy are also noted - improper development of the skeletal system, etc., leading to the assumption of congenital syphilis. Its etiological role in the paranoid form of schizophrenia was pointed out by A. S. Chistovich, not without reason).

It can be assumed, therefore, that syphilis of the brain of ancient origin, especially congenital, causing not only in the brain, but throughout the body a number of changes associated with disruption of the endocrine-vegetative system and metabolism, may in some cases cause a picture not distinguishable from schizophrenia with corresponding delusional syndromes. There is no need to talk about differential diagnostic differences between delusions in these cases and those in schizophrenia. Of the delusional syndromes with a presumed syphilitic etiology of the disease, most often we observed in these cases delusions of physical influence with pathological sensations, olfactory and auditory hallucinations, hypochondriacal, sometimes paraphrenic syndromes, but there may be other delusional syndromes.

Let us present an observation of a patient in whom, with a typical picture of schizophrenia, the etiological role of syphilis in the genesis of psychosis is very likely.

Patient L., 40 years old, born in 1913, was several times in the psychoneurological hospital named after. Kashchenko, starting in 1945, the last time in 1953. From the anamnesis it is known that the father suffered from progressive paralysis, one brother suffers from schizophrenia. As a child, the patient was “fragile,” sensitive, withdrawn, but with good abilities. She graduated from some technical school and worked as a mechanic. Menstruation began at the age of 18. She was married, left her husband, then returned to him, had casual relationships, had two miscarriages, two children are healthy. In 1945, when she was first admitted to a psychiatric hospital, she was formally accessible, exhibited reasoning, and expressed delusional ideas of persecution, greatness and influence. It seemed that some kind of energy was emanating from her, so her husband had sparkles in his eyes, she spoke of the existence of a sabotage organization that was preventing the union of souls. A diagnosis of paranoid schizophrenia was made. Subsequently, she was admitted several more times in 1946 and later; expressed love delirium towards one responsible employee, pursued him with her love, experienced his influence at a distance - he let her know that she was his “special purpose wife.” In the hospital she expounded verbosely and with elements of reasoning her theory of love. She also expressed other crazy ideas. The Wasserman reaction in the blood gave a positive result (4+) from the very beginning. In the interval between admissions, she often changed jobs and behaved incorrectly. Lately she has been talking about some kind of discovery for which she will be “rich.”

At the last admission on 25/III-53, there were no special deviations from the somatic sphere, blood pressure was not elevated. The aorta is within normal limits. Clinical analysis of blood and urine without any abnormalities. Nervous system - pupils: the left one is larger than the right one, there is no pupillary reaction to light and to convergence. Knee reflexes; the right is higher than the left. There are no pathological reflexes. Cerebrospinal fluid: cytosis 18/3. Protein 0.231 0/00. Lange reaction and other reactions are normal. R.V. - negative. In the blood of R.V. 4+.

Mental condition. The patient is oriented in place and time, mannered. At first she was angry, aggressive, expressed ideas of poisoning, and spat in the faces of the sick. Later she became calmer, but she behaves arrogantly and formally. Has a negative attitude towards examinations. Self-esteem is increased. Emotionally cold, uncommunicative. She reported that she experienced loving feelings first for one responsible person, then for another, he reciprocated her feelings and “all nature blossomed,” but he was “forbidden” to love her. From time to time I heard voices and experienced influences - “an electric charge, like the wind.” She created, in her words, a theory of love, immortality and energy, into which she included religious ideas, and sought everywhere to be allowed to give a report on this topic. The speech is formally coherent, but with pronounced reasoning and elements of irony. Memory and counting are not grossly impaired.

The clinical picture in this case fully corresponds to the paranoid form of schizophrenia with a syndrome close to paraphrenic. The most typical symptoms for her are evident: emotional emasculation, thinking disorders, mannerism, pretentiousness, especially expressed in her absurd delusional system. The diagnosis of schizophrenia that was given to her was therefore completely justified. At the same time, in this case there is also no doubt about the presence of syphilis of the brain. In the anamnesis, attention is drawn to the fact that the patient’s father died of progressive paralysis. This raises the question of the syphilitic etiology of mental illness in this patient.

Here's another observation:

Patient B., 43 years old. He is located in the psychoneurological hospital named after. Kashchenko since July 1955. From the anamnesis it is known that the patient’s brother suffers from some kind of seizures. The patient also had convulsive seizures in early childhood, at the age of 1–2 years her legs “were taken away”, and she did not walk for a long time. I studied at school with great difficulty and had poor abilities. At the age of 16, headaches began, after a blood test she was diagnosed with a sexually transmitted disease (syphilis) and was treated with injections in the buttocks. She worked as a worker, most recently as a watchman. I was not sexually active. She was withdrawn and silent by nature. Since 1948, sharp headaches appeared, blood pressure increased, and she was treated for hypertension. 2 months ago, hallucinations appeared before falling asleep, she saw some men and women, it seemed that they were burning her genitals with rays, she felt heat in them, and also began to hear voices. In the hostel and at work she showed increased irritability and believed that she was being persecuted.

Physical state. The patient is infantile and looks younger than her age. The teeth are irregular, uneven, approaching Hutchinson's. Bilateral adhesive pleurisy and popliteal bursitis are noted. Blood pressure 160 90 From the neurological side - a sharp increase in knee reflexes, noticeably tightens the left corner of the mouth, the tongue slightly deviates to the right. Livor - cytosis 6/3 (of which 5 lymphocytes). Protein-0.264 0/00. Lange reaction is normal. Weichbrod reaction 2 + R.V. is negative. Blood and urine are within normal limits.

Mental state: orientation in place and time is preserved; the patient is mannered, inaccessible, answers in monosyllables, exhibits negativism, is angry at times, gets excited, and therefore was transferred to a restless department. It turns out that she has headaches; hears the voices of some people who scold her with indecent words. Voices “get into her eyes and ears,” and sometimes she says that they are being “launched” on her. She also feels that the rays are burning her genitals, and smells unpleasant odors. After treatment with bioquinol and insulin, and subsequently with sulfozine, her condition improves somewhat, pathological sensations decrease, but the voices continue, and remain inaccessible and mannered.

Signs of inferiority and painful phenomena observed in the patient from early childhood make one think that syphilis, discovered in her at the age of 16, is congenital. The picture of psychosis, in which the main one is hallucinatory-paranoid syndrome (delusions of physical influence) with low availability, negativism and a tendency to states of excitement, corresponds to schizophrenia. However, the suggestion arises that what we have here is not a combination of two diseases, but that syphilis, which caused mild organic brain damage or simply toxic encephalopathy, as evidenced by changes in the cerebrospinal fluid, is in this case the etiological factor of psychosis. Its development at a relatively late age is apparently facilitated by the involutionary period, as well as vascular disorders associated with hypertension.