Schizophrenia - Causes, symptoms and treatment. MF.

Schizophrenia. .. For many, if not for all ordinary people, this disease sounds like a stigma."Schizophrenic" - a synonym for the finale, the concreteness of existence and uselessness for society. Is it so? Alas, with this attitude, so it will be. All unfamiliar is frightened and hostile. And the patient suffering from schizophrenia by definition becomes an enemy of society( I want to note, unfortunately, it is our society, in the whole civilized world is not so), because the surrounding people are afraid and do not understand what kind of "Martian" is next. Or, worse, scoff and mock the unfortunate. Meanwhile, do not take such a patient as an unfeeling deck, he feels everything, and very keenly, believe me, and first of all the attitude to yourself. I hope to interest you and show understanding, and therefore, sympathy. In addition, I want to note that among these patients there are a lot of creative( and many famous) personalities, scientists( the presence of the disease does not detract from their merit) and sometimes people who are close to you.

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

With the Greek. Schizis - cleavage, phrenus - diaphragm( it was believed that it was there that the soul was).
Schizophrenia is the "queen of psychiatry".Today, it suffers from 45 million people, regardless of race, nation and culture, it suffers from 1% of the world's population. To date, there is no clear definition and description of the causes of schizophrenia. The term "schizophrenia" was introduced in 1911 by Erwin Bloiler. 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, you should pause and take a closer look at the elements of the definition. From the definition, we can conclude that the disease lasts for a long time and carries a certain stage and regularity in the change of symptoms and syndromes. In this , the negative symptoms of are the "fallout" from the spectrum of mental activity of pre-existing signs characteristic of this person - the flattening of the emotional response, the reduction of the energy potential( but more on this later). Positive symptoms of are the appearance of new signs - delirium, hallucinations.

Symptoms of schizophrenia

To cases of continuous flow of disease, cases with gradual progressive development of the painful process, with different severity of both positive and negative symptoms, are considered. In the continuous course of the disease, its symptoms are noted throughout the life span from the moment of the disease. And 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, commits ridiculous, illogical actions from the point of view of others. The range of his interests is changing, new hobbies are emerging that are not traditional before. Sometimes these are philosophical or religious doctrines of questionable persuasion, or fanatic adherence to the canons of traditional religions. In patients, working capacity decreases, social adaptation. In severe cases, the emergence of indifference and passivity, complete loss of interests, is also possible.

For the paroxysmal course( recurrent or periodic form of the disease) it is characteristic the emergence of distinct seizures, 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 picture of seizures. In the case of a paroxysmal course of the disease, the manifestations of psychosis are observed in the form of separate episodes, between which "light" intervals of a relatively good mental state( with a high level of social and labor adaptation) are noted, which, while sufficiently long, can be accompanied by a complete restoration of work capacity( remission).

Intermediate space between these types of flow takes the cases of the paroxysmal-progredient form of the disease, when in the presence of a continuous course of the disease, there are seizures, the clinical picture of which is determined by the syndromes similar to the attacks of recurrent schizophrenia.

As already mentioned, the term "schizophrenia" was introduced by Erwin Bleuler. He believed that the main for the description of schizophrenia is not the outcome, but the "underlying disorder."He also identified a complex of characteristic signs of schizophrenia, four "A", Bleuler's tetrad:

1. An associative defect is the absence of a connected, purposeful logical thinking( now called "alology").

2. Autism symptom( "autos" - Greek-own - distance from external reality, immersion in one's inner world.)

3. Ambivalence - presence in the patient's mind of differently directed affects I love / hate at the same time. Affective inadequacy - in an ordinary situation gives an inadequate affect - laughs at the report of the death of relatives

Symptoms of schizophrenia

The French psychiatric school proposed scales of deficit and productive symptoms by ranking them according to the degree of increase. Sikhiatrist Kurt Schneider described the symptoms of rank I and II in schizophrenia. "The business card" of schizophrenia is symptoms of the 1st rank, and now they are still "on the go":

1. Sound thoughts - thoughts acquire sonority, essentially pseudo-hallucinations
2. "Voices" that argue among themselves
3. Commenting hallucinations
4. Somatic passivity( the patient feels that his motor acts are controlled).
5. "Getting out" and "introducing" thoughts, sperrung -( "clogging" of thoughts), a break in thoughts.
6. Broadcasting of thoughts( mental broadcasting - as if a radio is switched on in the head).
7. The feeling of "making" thoughts, their alienities - "thoughts are not their own, they were put in the head."The same - with feelings - the patient describes that it is not he who feels hungry, but he is made to feel hunger.
8. Delirium of perception - a person interprets events in his symbolic key.

In schizophrenia, the boundaries between the "I" and "not me" are destroyed. Internal events a person considers external, and vice versa. Borders "loosened up".Of the 8 above mentioned signs, 6 talk about this.

Views on schizophrenia, as a phenomenon, are different:

1. Schizophrenia is a disease - according to Krepelin.
2. Schizophrenia is a reaction - according to Banghofer - the reasons are different, and the brain responds with a limited set of reactions.
3. Schizophrenia is a specific violation of adaptation( Amer., 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. One per cent of the population suffers from a stable disease, if one of the parents is sick, the risk that the child will fall ill is 11.8%. If both parents are 25-40% and higher. The identical twins have a frequency of 85% at the same time.
2. Biochemical theories: disturbances in the metabolism of dopamine, serotonin, acetylcholine, glutamate.
3. Stress theory.
4. Psychosocial hypothesis.

Overview of some theories:

- Stress( the most diverse) affects the "flawed" person - most often it is the stress associated with the load of the adult roles.

- The role of parents: American psychiatrists Blaceg and Linds described the "schizophrenic mother."Typically, this is a woman: 1. Cold;2. non-critical;3. Rigid( with "hardening", delayed affect, 4. With confused thinking, it often "pushes" the child to the severe course of schizophrenia

- There is a viral theory

- The theory that schizophrenia is a slowly progressing weakening process such as encephalitisThe volume of the brain in patients suffering from schizophrenia is reduced

- In schizophrenia information filtration, selectivity of psychic processes, pathopsychological direction is violated

Men and women suffer from schizophrenia equally, however,more often, more poor, more often( more stress) If the patient is a man, the disease has an earlier onset and severe course, and vice versa

The American healthcare system spends up to 5% of the budget for the treatment of schizophrenia, schizophrenia is a disabling disease, it shortens the patient's life10. According to the frequency of the causes of death of patients on the I place are - cardiovascular diseases, on the second suicide

Patients with schizophrenia have a large "reserve of pronicity" before biological stress and physical stress - can withstand up to 80 doses of insulin, are resistant to hypothermia, rarely suffer from ARVI and other viral diseases. It is credibly calculated that "future patients" are born, as a rule, at the junction of winter-spring( March-April) - either because of the vulnerability of biorhythms, or because of the effects of infections on the mother.

Classification of variants of schizophrenia.

According to the type of current, the following are distinguished:

1. Continuously-progredient schizophrenia.
2. Attack
a) paroxysmal-progredient( shuboobraznaya)
b) periodic( recurrent).

On the stages:

1. The initial stage( from the first signs of the disease( asthenia) to the manifest symptoms of psychosis( hallucinations, delirium, etc.). How can there be hypomania, subdepression, depersonalization etc.
2. Manifestation of the disease:combination of deficit and productive symptoms
3. Final stage: marked prevalence of deficit symptoms over productive and congealing of clinical picture

According to the degree of progression:

1. Rapidly advanced( malignant)
2. Medium(

) Exception - recurrent schizophrenia

Description of some types:

Malignant schizophrenia : manifested between the ages of 2 and 16. Characterized by a very short initial stage - up to a year.- up to 4. Features:
a) In premorbid( i.e., in a state preceding the disease) the schizoid personality( closed, uncommunicative, fearing the outside world of the person);
b) Productive symptoms immediately go to a high level;
c) In the 3rd year of the disease apatiko-abulic syndrome is formed( vegetabels - "vegetable life" - while this state can be reversible at the time of severe stress - for example, in case of fire);D) Treatment is symptomatic.

The mediocrepid type of schizophrenia : The initial period lasts up to 5 years. There are strange hobbies, hobbies, religiosity. They are ill at the age of 20 to 45 years. In the manifest period - either a hallucinatory form, or delusional. This period lasts till 20 years. At the final stage of the disease - shrapnel nonsense, speech is preserved. Treatment is effective, it is possible to achieve medicinal remissions( temporary improvements in well-being).With continuously-progredient schizophrenia, hallucinatory-delusional symptoms significantly prevail over affective( impaired emotional-volitional spheres);when paroxysmal - the affective symptomatology prevails. Also - when paroxysmal remission is more profound and can be spontaneous( spontaneous).With continuously-progredient the patient stays 2-3 times a year, with a paroxysmal - up to 1 time in 3 years.

Sluggish, neurosis-like schizophrenia : Age of appearance from 16 to 25 years on average. There is no clear boundary between the initial and the manifest periods. Neurosis-like phenomena predominate. There is schizophrenic psychopathy, but the patient can work, maintain family and communication connections. At the same time it is clear that a person is "warped" by illness.

What negative and positive symptoms can be detected?

Let's start with the negative:

1. Engin Bleuler singled out associative defect ;
Stransky - interpsychic ataxia ;
also - the schism of .

All this - the loss of connectivity, the integrity of mental processes -
a) in thinking;B) in the emotional sphere;C) in volitional acts.

The processes are separate, and within the processes themselves "mess."Schism is an unfiltered product of thinking. It is also in healthy people, but it is controlled by consciousness. In patients, it is observed in the initial stage, but, as a rule, disappears with the arrival of hallucinations and delusions.

2. Autism .The patient with schizophrenia experiences anxiety and fear when communicating with the outside world and wants to distance himself from any contacts. Autism - flight from contacts.

3. Resonance - the patient says, but does not move to the target.

4. Apathy - the growing loss of emotional response - an increasing number of situations cause an emotional reaction. First, there is a rationalization instead of immediate emotions. The first thing that disappears is interests and hobbies.("Sergei, my aunt comes" - "come-meet").Adolescents behave like little old men-seemingly answer sensibly, but behind this "reasonableness" is an obvious impoverishment of emotional reactions;("Vitalik, brush your teeth" - "why?")does not refuse and does not agree, but tries to rationalize. If you give an argument, why you need to brush your teeth, there is a counterargument, the belief can be dragged on indefinitely, tk.the patient and is not going to discuss anything in fact - he's just acting.

5. Abulia ( according to Krepelin) - the disappearance of the will. In the early stages it looks like growing laziness. First - at home, at work, then in self-service. Patients are more lying. More often there is not apathy, but impoverishment;not an abulia, but a hypobulosis. Emotions in patients suffering from schizophrenia persist in one isolated "reserve zone", which in psychiatry is called parabulism. Parabulism can be very diverse - one of the patients abandoned the work and walked for months on the cemetery, drawing up his plan. "Labor" took a large volume. The other counted all the letters "H" in "War and Peace."The third one - dropped out of school, walked along the street, collected animal excrement and carefully attached them to the stand, as do entomologists with butterflies. Thus, the patient resembles a "mechanism that works idly."

Positive or productive symptoms:

1. Auditory pseudo-hallucinations ( the patient hears "voices", but perceives them not as existing in nature, but accessible only to him, "induced" by someone, or "descended from above").Usually it is described that such "voices" are audible not as usual, by ear, but by "head", "brain".

2. Syndrome of psychic automatisms ( Kandinsky-Clerambo), including:
a) Delirium of persecution( patients in this state are dangerous, because they can arm themselves for the purpose of defense against imaginary pursuers, and injure anyone who is consideredor attempt to commit suicide in order to "end it");B) delusion of influence;
c) auditory pseudo-hallucinations( described above);
d) Mental automatism-associative( sensation of "made-up" thoughts), sensostatic( sensation of "made-up" of feelings), motor( sensation that some or other movements that he makes are not his, but imposed on him from outside, he is forced to do them).

3. Catatonia, gebefrenia - hardening in one posture, often uncomfortable, for long hours, or vice versa-a sharp disinhibition, foolishness, twisting.

According to neurogenetic theories, the productive symptoms of the disease are caused by dysfunction of the system of the caudate brain nucleus, the limbic system. Disagreement in the work of the hemispheres, dysfunction of the frontal-cerebellar connections are detected. On CT( computed tomography of the brain), it is possible to detect an expansion of the anterior and lateral horns of the ventricular system. At nuclear forms of the disease on the EEG( electroencephalogram), the voltage from the frontal leads is reduced.

Diagnosis of schizophrenia

The diagnosis is based on the identification of the main productive symptoms of the disease, which are combined with negative emotional-volitional disorders, leading to loss of interpersonal communications with a total duration of observation of up to 6 months. The most important value in the diagnosis of productive disorders is the identification of symptoms of influence on thoughts, deeds and mood, auditory pseudo-hallucinations, symptoms of openness of thought, gross formal disorders of thinking in the form of rupturedness, catatonic motor disorders. Among the negative violations draw attention to the reduction of energy potential, alienation and coldness, unreasonable hostility and loss of contacts, social decline.

At least one of the following signs should be noted:

"Echo of thoughts"( sounding of one's own thoughts), insertion or withdrawal of thoughts, openness of thoughts.
Delirium of influence, motor, sensory, ideator automatism, delusional perception.
Auditory commenting on true and pseudo-hallucinations and somatic hallucinations.
Delusional ideas that are culturally inadequate, ridiculous and grandiose in content.

Or at least two of the following:

Chronic( more than a month) hallucinations with delirium, but without pronounced affect.
Neologisms, sperrungs, speech rupture.
Catatonic behavior.
Negative symptoms, including apathy, abulia, impoverishment, emotional inadequacy, including coldness.
Qualitative changes in behavior with loss of interest, non-purposefulness, autism.

The diagnosis of the paranoid form of schizophrenia is made in the presence of common criteria for schizophrenia, as well as the following features:

1. the dominance of hallucinatory or delusional phenomena( ideas of persecution, attitudes, descent, transmission of thoughts, threatening or harassing voices, hallucinations of smell and taste, senesthesia);
2. catatonic symptoms, flattened or inadequate affect, speech rupture can be presented in mild form, but do not dominate the clinical picture.

The diagnosis of the hebephrenic form of is made when there are common criteria for schizophrenia and:

of one of the following symptoms;

• a distinct and persistent flatness or affect surface,
• a distinct and persistent inadequacy of the affect,

of one of the other two symptoms;

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

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

Photo of a patient with a hebephrenic form of schizophrenia

The diagnosis of the catatonic form of is made in the presence of general criteria for schizophrenia, as well as the presence of at least one of the following signs for at least two weeks:

• stupor( a distinct decrease in response to environmental, spontaneous mobility and activity) ormutism;
• excitation( externally senseless motor activity, not caused by external stimuli);
• stereotypes( voluntary acceptance and retention of meaningless and pretentious poses, the implementation of stereotyped movements);
• negativism( externally unmotivated resistance to external appeals, execution of the opposite to the required one);
• stiffness( maintaining the pose, despite external attempts to change it);
• wax flexibility, congested limbs or body in preset external poses);
• automatability( immediate adherence to indications).

Photo of patients with catatonic form of schizophrenia

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

The diagnosis of post-schizophrenic depression is made if:

1. status during the last observation year was consistent with the criteria common to schizophrenia;
2. , at least one of them is stored;3) depressive syndrome should be so long, pronounced and developed to meet the criteria of no less than mild depressive episode( F32.0).

For the diagnosis of residual schizophrenia , the condition should in the past correspond to the criteria common to schizophrenia, not detectable at the time of the examination. In addition, during the last year, at least 4 of the following negative symptoms should be present:

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

The diagnosis of a simple form of schizophrenia is based on the following criteria:

1. gradual increase in all three of the following characteristics for at least a year:

• distinct and persistent changes in some premorbid personality traits, manifested in the reduction of motivations and interests, the purposefulness and productivity of behavior, withdrawal from oneself and social isolation;
• negative symptoms: apathy, speech impairment, decreased activity, distinct flattening of affect, passivity, lack of initiative, reduction of non-verbal characteristics of communication;
• a distinct decrease in productivity in work or study;The

1. state never corresponds to the common characteristics for paranoid, gebefrena, catatonic and undifferentiated schizophrenia( F20.0-3);
2. no signs of dementia or other organic brain damage( FO).

The diagnosis is also confirmed by the data of the pathopsychological study, the clinical genetic data on the burden of schizophrenia of relatives of the first degree of kinship are of indirect importance.

Pathological tests for schizophrenia.

In Russia, unfortunately, psychological examination of mentally ill patients is not very developed. Although honey.psychologists in the state hospitals.

The main method of diagnosis is a conversation. The logical sequence of thinking in a patient with schizophrenia inherent in a mentally healthy person is, in most cases, upset, and associative processes are violated. As a result of such violations, the patient speaks as if consistently, but his words do not have a semantic connection among themselves. For example - the patient says that he is "hunted by the laws of the justice of the sages, in order to pull out the wings with straight noses all around the world."

As tests are asked to clarify the meaning of expressions and sayings. Then you can "dig out" the formality, the earthiness of judgments, the lack of understanding of the portable sense. For example, "the wood is chopped, the chips are flying" - "yes, the tree is made of fibers, they break off when they hit with an ax."Another patient on the proposal to explain what the expression "This person has a heart of stone", says this: "There is a heart layer among the growth times, and this is the appearance of human growth." These phrases are inaccessible to understanding. This is a typical example of a "broken speech".In a number of cases, speech is reduced to the pronunciation of individual words and phrases without any sequence. For example, "... the smoke is poured. .. nowhere will be. .. the kingdom of heaven. .. it is wrong to buy water. .. tes from two without a name. .. six wreaths. .. a cutthrough of a lasso and a cross. .."this is the so-called verbal okroshka, or verbal salad. You can ask to draw the meaning of the phrase "delicious dinner." There, where an ordinary person draws a chicken leg, a smoking plate with soup or a plate with a fork and knife, a patient suffering from schizophrenia draws two parallel lines. To the question - "what is this?"- responds that "lunch is delicious, everything is in high, harmony, that's how these lines" Another test - to exclude the fourth superfluous - from the list "jackdaw, tit, crow, airplane" - may or may not exclude the aircraft( all from the listflies), or exclude, but relying on him alone led signs( "the first three of the list can sit on the wires, and the plane - no." And not alive / lifeless, like ordinary people).

Drawings of a patient with schizophrenia

Forecasts for schizophrenia.

We will disclose four types of forecasts:

1. The general prognosis of the disease - concerns the timing of the onset of the final state and its characteristics.

2. Social and Labor Forecast.

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

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

Approximately 40 factors have been identified to determine the prognosis of the course of the disease. Here are some of them:

1. Paul. Male - an unfavorable factor, female - favorable( nature is designed so that women are the keepers of the population, men are researchers, they have more mutations).

2. Presence of associated organic pathologies - poor prognosis.

3. Hereditary burden of schizophrenia - unfavorable prognosis.

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

5. An acute onset is a good predictor;erased, "smeared" - bad.

6. The psychogenic "triggered" mechanism - well, spontaneous, not having an obvious reason - is bad.

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

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

9. The high frequency and duration of hospitalizations is a poor prognostic sign.

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

40% of patients with schizophrenia commit suicidal actions, 10-12% die from suicide.

List of risk factors for suicide in schizophrenia:

1. Male gender.
2. Young age.
3. Good intellect.
4. The first episode.
5. A suicide in the anamnesis.
6. Prevalence of depressive and anxiety symptoms.
7. Imperative hallucinosis( hallucinations, ordering to perform certain actions).
8. The use of psychoactive substances( alcohol, drugs).
9. The first three months after discharge.
10. Inadequately small or large doses of drugs.
11. Social problems in connection with the disease.

Risk factors for homicidal( attempted murder):

1. Former( former) criminal episodes with an attack.
2. Other criminal acts.
3. Male gender.
4. Young age.
5. Use of psychoactive substances.
6. Hallucinatory-delusional symptomatology.
7. Impulsivity.

Sluggish schizophrenia

Statistically, half of patients with schizophrenia "possess" it in a sluggish manner. This is a certain category of people, which is difficult to delineate. Recurrent schizophrenia also occurs. Let's talk about them.

By definition, sluggish schizophrenia, this is schizophrenia, which does not show any pronounced progredness all over the entire course and does not reveal manifest psychotic phenomena, the clinical picture is represented by disorders of the lungs "registers" - neurotic personality disorders, asthenia, depersonalization, derealization.

The names of sluggish schizophrenia adopted in psychiatry: mild schizophrenia( Kronfeld), nonpsychotic( Rosenstein), current without character change( Kerbikov), microprocess( Goldenberg), rudimentary, sanatorium( Konnaibeh), prephase( Yudin), slow-flowing( Azelenkovsky)latvirovannaya, hidden( Snezhnevsky).You can also find such terms:
failed, amortized, outpatient, pseudo-neurotic, occult, non-progressive.

Sluggish schizophrenia has certain stages, stages:

1. Latent( debut) - flows very secretly, latently. Typically, the age of puberty, in adolescents.

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

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

Forms, variants of malopredged schizophrenia:

1. Asthenic variant - the symptomatology is limited by the level of asthenic disorders. This is the softest level.
Asthenia is atypical, without a "match symptom", irritability - in this case there is selective exhaustion of mental activity. There are also no objective reasons for asthenic syndrome - somatic disease, organic pathology in premorbid. The patient gets tired of ordinary everyday communication, ordinary affairs, while he does not exhaust other activities( communication with antisocial personalities, collecting, often fanciful).This is a kind of hidden schism, the splitting of mental activity.

2. Form with obtrusiveness. Similar to the neurosis of compulsive states. However, in schizophrenia, no matter how hard we try, we will not find psychogenesis and personal conflict. Obsessions are monotonous and emotionally not saturated, "not charged".At the same time, these obsessions can be accentuated by a large number of rituals performed without the emotional involvement of a person. Characteristic mono-experiences( monotematic obsession).

3. Form with hysterical manifestations. Characteristic of "cold hysteria."This is a very "selfish" schizophrenia, while it is exaggerated, grossly selfish, exceeding hysteria in the neurotic. The more coarse it is, the worse, deeper the violation.

4. With depersonalization. In human development, depersonalization( breaking the boundaries of "I am not me") can be the norm in adolescence, with schizophrenia goes beyond this framework.

5. With dysmorphomaniacal experiences( "my body is ugly, the ribs stick out too much, I'm too thin / fat, the legs are too short, etc.). This also occurs in adolescence, but with schizophrenia there is no emotional involvement in experiences."Freaky" defects are "one side more fanciful than the other." Syndrome of anorexia nervosa at an early age also belongs to this group:

6. Hypochondriacal schizophrenia: Negligible, nonpsychotic level: typical for adolescent and involutionary age.

7. Paranoid schizophrenia

8. With a predominance of affective disorders, hypotymic variants( sub-depressions, but without intellectual inhibition) are possible, with a schism between the decreased background mood and intellectual, motor activity, the volitional component, and hypochondrial subdepressionwith an abundance of senestropathies. Subdresses with a tendency to introspection, self-digestion.
Hyperthymic manifestations: hypomania with a one-sided nature of passion for some one activity. Characteristic "zigzags" - a person works, full of optimism, then a decline for several days - and again works. The schizis variant is hypomania with simultaneous complaints about health.

9. Option of non-productive disorders."A simple option."Symptom is limited to negative. There is a gradual, with years of growing defect.

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

Defects in Sluggish Schizophrenia:

1. Defect of the Ferhreoben type( with its strange, eccentricity, irregularity) - described by the Fixed.
Externally - the disharmony of movements, angularity, a certain juvenility( "childishness").The unmotivated seriousness of the facial expression is characteristic. There is a certain shift with the acquisition earlier( before the illness) of traits that are not characteristic of this personality. In clothes - untidiness, absurdity( short trousers, bright hats, clothes, like from the century before last, randomly chosen things, etc.).Speech - unusual, with the selection of unique words and speech turns, is characterized by "stuck" on minor details. There is a safety of mental and physical activity, despite the eccentricity( there is a schism between social autotyping and lifestyle - patients walk a lot, communicate, but in a peculiar way).

2. Psychopath-like defect( pseudo-psychopathy according to Smulevich).The main component is schizoid. The espousive schizoid, active, "gushing" with supervalued ideas, emotionally charged, with "autism inside out", but at the same time flattened, not decisive social tasks. In addition, there may be a hysterical component.

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

These people often begin to resort to psychoactive substances, more often to alcohol. At the same time, emotional flatness decreases, the schizophrenic defect decreases. The danger, however, is that alcoholization and anesthesia acquire an uncontrolled nature, since the stereotype of responding to alcohol is atypical, alcohol often does not bring relief, forms of intoxication expansive, with aggression and brutality. However, in small doses alcohol is indicated( psychiatrists of old schools assigned it to their patients with sluggish schizophrenia).

And finally - recurrent, or periodic schizophrenia.

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

Stages of recurrent schizophrenia:

1. The initial stage of general somatic and affective disorders( subdepression with severe somatization - constipation, anorexia, weakness).Characteristic of the presence of overvalued( ie, based on real, but grotesquely exaggerated) fears( for work, relatives).It lasts from several days to several months( usually 1-3 months).This all can and be limited. The beginning is adolescence.

2. Delirious affect. There are indistinct, undeveloped fears of delusional, paranoid content( for oneself, for loved ones).Delirious ideas are few, they are sketchy, but a lot of affective charge and motor components - thus, it can be attributed to acute paranoid syndrome. Characteristic of the beginning changes in self-consciousness. There is some alienation of their behavior, depersonalization manifestations of a shallow register. This stage is extremely labile, the symptomatology can fluctuate.

3. Stage of affective-delirious depersonalization and derealization. Sharply increased self-awareness disorders, there is a delirious perception of the environment. Brad intermetamorphosis - "everything is arranged around."There is a false recognition, a symptom of twins, there are automatisms( "I run"), psychomotor agitation, sub-stage.

4. The stage of fantastic affective-delirious depersonalization and derealization. Perception becomes fantastic, there is a paraphrenic symptom( "I'm at the Space Intelligence School and I'm being tested").The development of self-awareness( "I am a robot, controlled by me", "I run a hospital, a city") continues to worsen.

5. Illusory and fantastic derealization and depersonalization. The perception of oneself and reality begins to suffer grossly until illusions and hallucinations. In fact, this is the beginning of the ONEIROID obscuration of consciousness( "I am I, but now I am a technical device - pockets are special devices for disks", "a policeman says - I can hear it, but it's a voice that controls everything on Earth").

6. Stage of classical, true onyroid occultation of consciousness. The perception of reality is completely violated, it is impossible to enter into contact with the patient( only for a short time - due to the lability of the processes).There may be motor activity dictated by the experiences experienced. Self-awareness is violated( "I am not I, but an animal of the Mesozoic era", "I am a machine in the struggle of machines and people").

7. Stage of an amenitively similar obscuration of consciousness. Unlike the onyroid, psychopathological experiences of reality are greatly impoverished. Amnesia of perdition and images is complete( in the case of an onyroid, no).Also - confusion, severe catatonic symptoms, fever. This is the pre-phase of the next stage. The outlook is unfavorable.(Separate and a separate form - "Febrile schizophrenia").The main "psychiatric" means at the same time - electro-convulsive therapy( ECT) - up to 2-3 sessions per day. This is the only way to break this state. There is a 5% chance of improvement. Without these measures, a 99.9% run-in is unfavorable.

All of the above levels can be an independent picture of the disease. As a rule, from an attack to an attack the condition becomes heavier, until it "stiffens" at some stage. Recurrent schizophrenia is a low-progestogen form, so there is no complete recovery between attacks, but remissions are prolonged, the manifestations of the disease are subtle. The most frequent outcome is the reduction of the energy potential, patients become passive, fenced off from the world, while retaining, nevertheless, often a warm atmosphere to the members of the family. In many patients, through recurrent schizophrenia, after 5-6 years, it can migrate into a fur coat. 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" therapies:

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

2. Convulsive therapy( with camphor oil injected under the skin - the Hungarian psychiatrist Medun in 1934) - is now not used.

3) electro-convulsive therapy( Cherletti, Beni in 1937).Affective disorders ECT treats very effectively. In schizophrenia - with suicidal behavior, with catatonic stupor, with resistance to drug therapy.

4) Detoxification therapy;

5) Diet-discharge therapy( with slow-moving schizophrenia);

6) Deprivation( deprivation) of sleep and phototherapy( with affective disorders);

7) Psychosurgery( in 1907 employees of Bechtnrva conducted a lobotomy, in 1926 the Portuguese Monica had a prefrontal leukotomy.) Monitz was later wounded by a patient with a pistol shot after having performed an operation on it);

8) Pharmacotherapy.

Drug Groups:

a) Neuroleptics;
b) anxiolytics( reducing anxiety);C) Normotimiki( regulating the affective sphere);D) antidepressants;E) nootropics;E) Psychostimulants.

All the above groups of drugs are used for the treatment of schizophrenia, but antipsychotics are on the 1st 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 a doctor, tk.in patients with schizophrenia, the lowest interaction with the doctor - they are incredulous, they deny the presence of the disease in their presence.

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

4. Monotherapy( where you can assign 3 or 5 drugs, choose 3, so you can "track" the effect of each of them);

5. Long duration of treatment: symptomatic relief - 2 months, stabilization of the condition - 6 months, remission formation - 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 it is a question of secondary prevention of exacerbations.

The use of neuroleptics is based on the dopamine pathogenesis theory - it was thought that patients with schizophrenia had too much dopamine( a predecessor of norepinephrine), and it should be blocked. It turned out that there is not more of it, but the receptors to it are more sensitive. In parallel, violations of serotonergic mediation, acetylcholine, histamine, glutamate, but the dopamine system react faster and stronger than others.

The gold standard for the treatment of schizophrenia is haloperidol. By power is not inferior to subsequent drugs. Classical neuroleptics, however, have side effects: they have a high risk of extrapyramidal disorders, and they are very brutally acting on all dopamine receptors. Recently, atypical antipsychotics have appeared: Clozepine( leponex) - the first appeared atypical antipsychotic;the most known at the present time:

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

There is a prolonged version of the drugs that allows to achieve remissions with more rare injections:

1. Moditen Depot;
2. Haloperidol-decanoate;
3. Rispolept-konsta( reception once every 2-3 weeks).

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

Hospitalization.

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

Because people with schizophrenia often do not realize that they are sick, it is difficult or even impossible to convince them of the need for treatment. If the patient's condition worsens, and you can not convince or force him to be treated, you may have to resort to hospitalization in a psychiatric hospital without his consent. The main goal of both involuntary hospitalization and the laws that regulate it is to ensure the safety of the patient, who is in acute stage, and the people surrounding him. In addition, the task of hospitalization is also to ensure the timely treatment of the patient, even if not in addition to his desire. After examining the patient, the district psychiatrist decides the conditions under which the treatment should be administered: the patient's condition requires an urgent hospitalization in a psychiatric hospital, or he can restrict himself to outpatient treatment.

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

"A person suffering from a mental disorder may be hospitalizedto a psychiatric hospital without his consent or without the consent of his legal representative before the judge's decision if his examination or treatment is possible only in a hospital setting and the mental disorder is severeand determines:

1. its immediate danger to itself or others, or
2. its helplessness, that is, the inability to satisfy basic necessities of life itself, or
3. significant harm to its health due to deterioration of mental state, if the person is left without psychiatric help. "

Treatment during remission of

During the period of remission, maintenance therapy is mandatory, without this, impairment of the condition is inevitable. As a rule, patients feel better after discharge, they think they have cured completely, stop taking drugs, and the vicious circle starts again. Completely this disease is not cured, but with adequate therapy it is possible to achieve a stable remission on the background of maintenance treatment.

Do not forget that often the success of treatment depends on how quickly after an exacerbation or the initial stage there was an appeal to a psychiatrist. Unfortunately, relatives who heard about the "horrors" of the psychiatric clinic are opposed to the hospitalization of such a patient, believing that "everything will pass by itself".Alas. .. Spontaneous remissions are almost not described. Therefore, they apply later, but in an even more difficult situation.

Criteria for remission: disappearance of delusions, hallucinations( if any), disappearance of aggression or suicide attempts, if possible, social adaptation. In any case, the doctor decides on the discharge, as well as about hospitalization. The task of the relatives of such a patient is to cooperate with a doctor, informing him of all the nuances of the patient's behavior, nothing to hide or embellish. And also - to monitor the intake of drugs, because not always such people perform the appointment of a psychiatrist. In addition, success depends on social rehabilitation, and half the success in this - the creation of a comfortable atmosphere in the family, and not a "zone of alienation."Believe me, patients of this profile feel very sensitive to themselves and react accordingly.

If you consider the cost of treatment, disability payments and sick leave, schizophrenia can be called the most expensive of all mental illnesses.

Doctor psychiatrist Khodorkovsky A.V.