Psychiatry: A Course of Lectures - V. S. Bitensky 2004

Schizophrenia

Schizophrenia is a very common disorder. Its prevalence in the population is about one percent, meaning that out of every 100 people on our planet, one suffers from schizophrenia, and approximately one new case per 1,000 population is diagnosed annually. This rate remains constant worldwide, as the incidence does not depend on nationality, race, gender, or social conditions. When the Nazis eliminated the majority of mentally ill individuals in Germany, their proportion in the total population naturally decreased. However, within just 10 years, the status quo was restored. What is the reason behind this? Could such a complex biological system as the human Brain, which ensures our functioning primarily as social beings, fail so frequently? Or perhaps evolution deliberately maintains a certain proportion of people in the population who are unsuited for full-fledged life under normal conditions, but who would prove best prepared for survival and continuation of the human race in the event of sudden environmental changes (various natural disasters)? After all, it is known that under conditions of cosmic overload, hemophilia patients do not require additional correction of the Blood Coagulation SYSTEM.

Future physicians will likely find an answer to this question, but for now, let us turn to the statistics. Single individuals are reliably more likely to fall ill compared to married ones; among married patients, the divorce rate is higher than in the general population. Patients exhibit a reliably higher mortality rate from somatic diseases, dominated by tuberculosis and infectious diseases. Attempts have been made to explain this by living, housing, and Treatment conditions. With improvements in medical care, suicide and accidents more frequently became the causes of death among patients, with the peak risk period occurring around the age of 55. However, it is obvious that the problem cannot be reduced solely to social factors. Studies by various specialists have proven that due to profound disruptions in cerebral Homeostasis, schizophrenia patients are indeed more prone to somatic diseases than "average" members of the population.

Moreover, schizophrenia is the "most costly" of all mental disorders: the annual cost of patient care in the United States alone exceeds 7 billion dollars.

According to the International Classification of Diseases, 10th Revision, schizophrenia manifests with characteristic disorders of perception and thinking, as well as a diminished or inappropriate emotional state. More precisely, we should distinguish groups of primary symptoms of schizophrenia (disturbances in thinking, emotionality, and volitional activity) and secondary symptoms (delusions, pseudohallucinations, and catatonic disorders). As for intellectual impairments, they are likely secondary in nature and determined by the Impairment of the individual's social functioning. History knows prominent figures in science and culture who suffered from schizophrenia yet possessed exceptionally high intellect: physicist N. Tesla, writer V. Garshin, American chess player B. Fischer, artist M. Čiurlionis, Russian psychiatrist V. Kandinsky, poet V. Khlebnikov, and others. We might also recall the film A Beautiful Mind, the plot of which is based on real events.

The so-called phenomenon of openness is characteristic—the patient is certain that their thoughts are known to those around them. To explain this, patients construct a delusional interpretive system, believing that some extraordinary forces are acting upon them or even controlling them. Hallucinations, pseudohallucinations, and psychosensory disorders are also frequent. In the Cytology/cytology/16.html">Early stages of the disease, bewilderment may be observed. The "blocking" of thoughts is most often perceived by the patient as thought theft. The variety of symptoms observed in schizophrenia leads some specialists to believe that we are dealing not with a single mental illness, but with a group of disorders that we fail to separate due to incomplete knowledge of their Etiology AND Pathogenesis.

Diagnostic criteria for schizophrenia

The diagnostic criteria for schizophrenia include:

1. Structural disorders of thinking (incoherence, paralogic thinking, symbolism, bizarre Conclusions, formation of pseudoconcepts, interruptions, blockages, echoing, withdrawal and alienation of thoughts, a sense of openness, external influence, primary delusional interpretation—"first-rank" symptoms).

2. Emotional (psychic) hyperesthesia; inappropriateness, distortion, ambivalence of emotions; emotional flattening and emotional blunting.

3. Phenomena of depersonalization (feelings of splitting, substitution, alienation of feelings and experiences, of one's psychic and somatic "Self"), a-personalization (the sensation of losing one's own "Self"), derealization (feelings of alteration and alienation of the environment), negativism, autism (withdrawal from contact with reality, retreat into a world of unreal and fantastic experiences).

4. Reduction or distortion of drives, Functions of the effector-volitional sphere, ambitendency; catatonic disorders occupy a special place.

5. Auditory hallucinations and pseudohallucinations.

6. Olfactory, gustatory, visual, and somatic hallucinations.

7. Delusional ideas (especially primary ones) of reference, persecution, hypnotic and physical influence, etc.

It is also appropriate to present the diagnostic criteria for schizophrenia (in an adapted version) according to the classification of diseases currently applied in Europe, specifically regarding mental disorders:

— "thought broadcasting," ideas of thought insertion or withdrawal, or thought transmission to other people (openness);

— delusions of control, influence, or passivity directed by other people, involving bodily movement, or the whole body, or limbs, or isolated thoughts or sensations;

— primary delusional perception of reality;

— persistent grandiose delusions that are culturally inappropriate—identification with religious or political figures, claims of superhuman abilities (let us recall primarily Jesus Christ, who was punished for proclaiming himself "King of the Jews");

— hallucinatory "voices" that provide a running commentary on the patient's behavior or discuss the patient among themselves;

— Other types of hallucinatory disorders with unusual localization (e.g., originating from inside the body or HEAD)—referring to the pseudohallucinations well known from general psychopathology courses;

— persistent hallucinations in any sensory modality, accompanied by unformed or only fleeting, emotionally uncharged delusional ideas that appear daily for weeks or months at a time;

— the appearance of neologisms, nonsensical speech, or even so-called incoherence of utterance in the patients' speech;

— catatonic disorders (excitement, posturing, waxy flexibility, stupor) with negativism and mutism;

— "negative" symptoms—apathy, poverty of speech, blunted and inappropriate emotional responses, and social withdrawal (though all these manifestations must not be caused by depression or neuroleptic medication);

— a marked and consistent qualitative shift in behavior marked by loss of interests, lack of purpose, inactivity, and withdrawal into a morbid internal world (autism).

To diagnose the disorder, as few as two of these symptoms are often sufficient (with the first six holding particular diagnostic value), provided they persist for at least a month.

Sometimes, prodromal phenomena may linger for weeks or even months. These include a waning interest in work, social activities, personal appearance, and hygiene, which often coincides with generalized anxiety and mild depression.

History of The Development of Schizophrenia Theory

Psychiatry owes the establishment of schizophrenia as a nosological entity to the German psychiatrist E. Kraepelin (1856–1926). He united previously isolated mental disorders under METABOLISM/2.html">THE CONCEPT OF "dementia praecox" (premature dementia) and outlined the primary subtypes of the condition. The scientist was guided by the criteria for nosological entities formulated by W. Griesinger (1817–1868): The Unity of etiology, symptomatology, clinical course, and neuropathological findings. The work of E. Bleuler (1857–1939) subsequently proved that the nosological entity identified by E. Kraepelin is not premature dementia: first, it can onset in adulthood; second, it does not necessarily culminate in dementia. E. Bleuler proposed the term "schizophrenia" to denote the loss of unity and functional interplay among thought, emotion, and behavior. Later, he introduced THE PRINCIPLE OF varying diagnostic weight for individual symptomatic manifestations, dividing them into primary symptoms—resulting directly from the organic morbid process—and secondary symptoms, which represent patients' psychological reactions to experiencing the illness. According to E. Bleuler, the fundamental disturbances in schizophrenia are associative disorders, affective flattening, autism, and ambivalence. The works of E. Kraepelin and E. Bleuler represent the two foundational psychiatric paradigms that continue to guide research into schizophrenia (as well as other mental disorders) to this day.

Despite compelling advances in the field, the etiology of schizophrenia remains incompletely understood. Therefore, in the absence of a definitive causative agent, the stress-diathesis model offers the most persuasive conceptualization of its etiology. According to this model, the onset of the disorder requires both a specific individual vulnerability (a genetic predisposition or diathesis shaped by alcoholism, trauma, social stress, etc.) and The impact of an environmental stressor (whether biological, such as a virus, or psychosocial, such as adverse family circumstances).

Neuromorphological studies reveal diffuse, nonspecific degenerative changes, while EEG findings are similarly nonspecific. Psychodynamic, immunological, and other conceptual frameworks for The Emergence of schizophrenia also exist.

The Role of heredity is unquestionable, though its precise mechanisms remain elusive. The lifetime risk of developing schizophrenia for the child of an affected individual is 15%; however, if both parents have blood relatives suffering from schizophrenia, this risk escalates to 40%.

The most prominent and widely accepted neurochemical hypothesis centers on the dysregulation of the brain's dopamine system, which governs the "energetic drive" behind mental functions. "Positive symptoms" (or plus-symptoms)—such as delusions, hallucinations, and formal Thought Disorders—are linked to the Hyperfunction of the dopaminergic system. For instance, under normal conditions, our perceptual apparatus accurately reflects surrounding objects and phenomena. With dopaminergic hyperfunction, the overstimulated brain not only perceives external reality but also spontaneously reconstructs and combines memories, mental images, and internal representations. As a result, alongside real objects, unreal ones take shape—hallucinations that the individual perceives as genuinely existing. Conversely, dopaminergic hypofunction gives rise to "negative symptoms" (minus-symptoms), which manifest as a depletion of emotional and volitional functions (apathy, abulia), a loss of drive for social contact (autism), and formal thought disorders.

The presence of negative symptoms is mandatory for diagnosing schizophrenia. Positive symptoms may be entirely absent, though their emergence typically signals an acute exacerbation of the illness. The specific subtype of schizophrenia is largely determined by which positive symptoms dominate the Clinical presentation.

Subtypes of Schizophrenia

Let us examine the individual subtypes of schizophrenia.

Paranoid schizophrenia is the most frequently encountered form. The clinical picture is dominated by paranoid delusions accompanied by auditory hallucinations and pseudohallucinations. The progression of the delusional syndrome in this subtype is fairly stereotyped: primary (paranoiac) delusions evolve into paranoid delusions (frequently presenting as Kandinsky–Clerambault syndrome), which eventually give way to paraphrenic delusions. Delusions of persecution, reference, or special significance are most common, while somatic or jealous delusions occur less frequently. Hallucinatory voices typically carry a threatening or commanding tone, though patients may also experience unformatted sounds (noise, humming, clamor, whistling) or hallucinations belonging to other sensory modalities. Emotional disturbances involve affective inappropriateness, irritability, sudden bouts of anger, fear, or suspicion. Over time, emotional responses become blunted and personal volition deteriorates, culminating in anapatico-abulic syndrome—the term also used to describe the primary deficit state resulting from the illness. It should be noted that other deficit states can characterize paranoid schizophrenia, such as psychopath-like, neurosis-like, or simple schizophrenic dementia.

Hebefrenic schizophrenia is distinguished by dominant emotional alterations accompanied by fragmented delusions and hallucinations, unpredictable behavior, inappropriate affect, untimely laughter, mannerisms, and disorganized thinking. This form typically emerges between the ages of 15 and 25 and carries a poor prognosis, characterized by the rapid onset of negative symptoms and the development of an apathy-abulia deficit.

Catatonic schizophrenia is defined by mandatory and dominant psychomotor disturbances that vary widely in presentation. Clinicians distinguish between catatonic excitement and catatonic stupor. Catatonic excitement is characterized by chaotic, purposeless movements, making this state hazardous due to the high likelihood of unpredictable aggression and impulsive actions. Echo-phenomena may also be observed, wherein the patient repeatedly echoes someone else's words (echolalia) or actions (echopraxia). Catatonic excitement is an energy-depleting state that typically lasts a relatively short time—several days or weeks—before potentially transitioning into catatonic stupor, which is marked by a complete absence of movement and activity, greatly reduced environmental responsiveness, and mutism. This state features pronounced Muscle tension with a so-called "plastic tone," leading to frozen postures (the voluntary assumption and holding of awkward positions), waxy flexibility (The ability to mold the patient's limbs into sustained postures), and rigidity (maintaining a rigid posture in response to attempts to alter it). Patients refuse food and can succumb to starvation, thus requiring tube feeding. Catatonic stupor is energetically conservative and may persist for months or even years. Both catatonic excitement and stupor feature active or passive negativism (senseless resistance or compulsive performance of opposite actions in response to any instruction).

Febrile schizophrenia is a notable variant of catatonic schizophrenia. It is marked by a rapid deterioration over 1–2 days into an unconscious state (soporous or comatose), occasionally accompanied by chaotic agitation while in bed that can mimic hyperkinesia. The patient's somatic condition is critically severe: body Temperature soars to 40°C or higher (hence the term febrile) and the pulse is weak. These patients are frequently admitted to general somatic or infectious disease hospitals with misdiagnoses such as encephalitis or meningitis. The following criteria can assist in Differential Diagnosis: relatively "benign" laboratory results (blood and CEREBROSPINAL FLUID tests) that contradict the severity of the physical illness; elevated muscle tone with elements of plastic rigidity; so-called "temperature-pulse dissociation," where the acceleration of the pulse fails to match the proportional rise in temperature; a history of unexplained low-grade fevers lasting 1–2 days prior; and possible prodromal phases involving subtle mental shifts such as motiveless anxiety, vague bodily sensations, and mood swings occurring days before the acute flare-up.

Though less common, simple schizophrenia is of profound importance to the general practitioner. Patients with this form spend the majority of their lives within their usual social circles, are rarely hospitalized in specialized psychiatric facilities, and frequently consult family physicians regarding hypochondriacal Complaints. The onset occurs later in life, sometimes after the age of 40. The clinical course is typically continuous, marked by a gradual escalation of bizarre behaviors, an inability to meet environmental demands, and a decline in overall productivity. A deficit state develops even in the absence of preceding psychotic symptoms (known as psychotic episodes or *schübe*). In other words, this form of schizophrenia is entirely defined by negative symptoms. In everyday life, such individuals are often found among the homeless, eking out a vagrant existence amidst harsh socio-economic conditions.

Residual schizophrenia closely resembles the simple form, occurring when one or more acute episodes give way to long-standing (though not necessarily irreversible) chronic states dominated by negative symptoms. These include psychomotor slowing, diminished drive, lack of initiative, emotional blunting, impoverished speech in both content and volume, restricted non-verbal communication (marked limitation of facial expressions and gestures, vacant eyes, lack of vocal inflection), and a significant loss of personal hygiene and self-care skills. Due to the absence of acute exacerbations, these patients are likewise managed primarily by general practitioners or community clinic physicians.

Schizoaffective disorders occupy an intermediate position between schizophrenia and manic-depressive psychosis. They manifest as depressive and manic phases featuring atypical clinical presentations. Intermissions (lucid intervals) occur between phases, often bringing practical recovery following initial episodes, yet displaying signs of a progressive schizophrenic defect upon recurrence.

Childhood schizophrenia is relatively rare. Its onset is usually insidious, characterized by motiveless and absurd terrors, motor and verbal stereotypies (the repetitive execution of identical movements or shouting of fixed words), and a pathological capacity for fantasy that fails to distinguish itself from reality. The clinical course is typically malignant. Beyond core negative symptoms, the resulting deficit involves an arrest of psychological development at the exact chronological age when the illness struck. Consequently, early childhood onset results in a combination of a schizophrenic defect and intellectual developmental delay, whereas adolescent onset leads to enduring psychic infantilism.

The clinical trajectory of schizophrenic disorders varies across different subtypes. Clinicians distinguish the continuous type (most typical of the simple form), the episodic type with progressive deficit (where acute flare-ups alternate with remissions, but the negative symptom deficit deepens after each episode, as seen in the paranoid form), the episodic type with stable deficit, and the episodic remitting type.

The Challenge of describing schizophrenia stems from the fact that various psychiatric traditions have adhered to differing conceptual frameworks for the disease. Alongside the classical approach characteristic of the European psychiatric school, an American system for delineating schizophrenia subtypes also exists, which primarily classifies the condition into acute and chronic forms.

Acute schizophrenia is defined primarily by delusions, hallucinations, and thought disorders. It may eventually transition into a chronic form or culminate in recovery.

Acute schizophrenia presents with the following symptoms (listed in descending order of frequency):

1. Lack of insight (awareness of illness) 97%

2. Auditory hallucinations   74 %

3. Delusions of reference    70 %

4. Suspiciousness     66 %

5. Affective flattening  66 %

6. Voices conversing with the patient 65 %

7. Delusional mood    64 %

8. Persecutory delusions  64 %

9. Thought alienation   52 %

10. Thought broadcasting (or echoing)    50 %

Chronic schizophrenia is characterized by apathy, lack of drive, lethargy, and social withdrawal. Recovery is generally not observed.

In chronic schizophrenia, the following symptoms occur (in descending order of frequency):

1. Social withdrawal  74 %

2. Reduced activity   56 %

3. Reluctance to converse 54 %

4. Lack of leisure interests 50 %

5. Slowness, lethargy  48 %

6. Hyperactivity    41 %

7. Unusual ideas    34 %

8. Depression    34 %

9. Unusual behavior   34 %

10. Indifference to personal appearance 30 %

11. Bizarre postures and movements  25 %

12. Threats or acts of violence 23 %

13. Untidy eating habits 13 %

14. Behavior violating social norms and conventions 8 %

15. Unusual Sexual Behavior 8%

16. Suicidal attempts  4%

17. Urinary and fecal incontinence  4%

Various symptoms may dominate within the syndrome: in one patient with acute schizophrenia, paranoid delusions prevail, whereas in another, structural thought disorders are prominent. Furthermore, signs of both acute and chronic syndromes may coexist in the same patient.

Treatment of Schizophrenia

The treatment of schizophrenia consists of biological therapy and pharmacotherapy.

The goal of biological therapy is to alter the body's reactivity through intensive interventions: Insulin coma therapy (for paranoid schizophrenia) and electroconvulsive therapy (for intractable catatonia, febrile schizophrenia, and severe depression in schizoaffective psychoses). These Methods are used only with the consent of the patient's relatives when pharmacotherapy yields no effect.

Pharmacotherapy is the primary treatment method for patients with schizophrenia. It utilizes neuroleptics, which revolutionized the Treatment of the disease in the 1950s. Until the 1990s, so-called "typical" neuroleptics were widely prescribed; they blocked dopamine production by acting on dopamine receptors, thereby reducing brain excitation and eliminating positive symptoms such as delusions, hallucinations, and psychomotor agitation. Examples of such neuroleptics include aminazine (chlorpromazine), haloperidol, trifluoperazine, etc. However, a drastic reduction in dopamine production led to hypofunction of the brain's dopaminergic system, resulting in the progression of negative symptoms and the development of side effect syndromes such as neuroleptic-induced depression and extrapyramidal disorders. Today, a new Class of "atypical" neuroleptics is undergoing intensive development. By acting not only on dopamine receptors but also on other receptors, such as serotonin receptors, they do not simply decrease dopamine levels, but rather normalize them. Therefore, atypical neuroleptics facilitate the reduction of both positive and negative symptoms. These include azaleptin (clozapine), risperdal, olanzapine, seroquel, and solian (amisulpride).

Atypical neuroleptics become indispensable for maintenance therapy—the prolonged use of psychotropic agents over many months and years to sustain remission and prevent relapse. As a rule, the same medication that achieved remission is used, but at a reduced dose.

Rehabilitation is a set of measures aimed at preserving or, if lost, at least partially restoring a patient's social status, including their working capacity, family relationships, and active life in society. Prolonged stay in a psychiatric hospital leads to institutionalism—the loss of independent living skills and social competencies. Therefore, hospitalization should be kept to a minimum. This is what the entire medical world strives for today, forming the foundation of the humanistic approach in psychiatry. In addition to maintenance pharmacotherapy, rehabilitation measures include psychotherapy (individual, group, and family). The role of the family physician in rehabilitation efforts for patients with schizophrenia cannot be overstated.

Concept of Forensic Psychiatric Examination

Forensic psychiatric examination is a specialized and very common type of expert evaluation conducted in criminal or civil proceedings, aimed at establishing:

— the sanity of the perpetrator of unlawful acts (suspect, accused);

— the legal capacity of an individual;

— the mental state of a victim or witness.

A forensic psychiatric examination is conducted by a commission of expert psychiatrists either on an outpatient or inpatient basis (sometimes in the courtroom, where the expert is summoned). Separate types of forensic psychiatric examinations include posthumous and absentia evaluations.

Let us examine the Key Concepts of forensic psychiatric examination.

Sanity is a criminal-law concept that characterizes the perpetrator of a crime. It is provided for by Article 19 of the Criminal Code of Ukraine and implies that a person who has committed an offense is capable of understanding The Significance of their actions and (or) controlling them. Sanity comprises two criteria: legal (psychological) and medical (biological). The former consists precisely of understanding the significance of one's actions (the intellectual component of the criterion) and the ability to control them (the volitional component). The second criterion concerns the mental state of the perpetrator from the perspective of diagnosing a particular mental or behavioral disorder in accordance with the country's applicable classification of diseases and other health disorders (i.e., ICD-10). A person who has committed unlawful acts but is unable to understand their significance and (or) control them due to a permanent or temporary mental disorder (or mental defect) is recognized by the court as insane and is exempt from liability. Instead, such a person is deemed in need of compulsory treatment. The duration, Location, and Nature of the treatment (outpatient or inpatient) are determined by the court, which, based on the submission of the forensic psychiatric expert commission, reviews the necessity of its continuation or termination every six months.

Nor can individuals be punished if they committed a crime while sane but fell ill with a mental disorder during the investigation. They also require compulsory treatment, but upon recovery, they may be subject to punishment.

As we can see, even the presence of such an undeniable mental disorder as schizophrenia in a perpetrator does not automatically determine their insanity if the patient was in remission at the time of the offense, was able to correctly understand the unlawful nature of their actions, and could control them. More frequently, such cases involve the concept of diminished (effectively reduced) responsibility (Article 20 of the Criminal Code of Ukraine). Diminished responsibility does not exempt a person from liability before the law, but is considered by the court as a mitigating circumstance.

It should be noted that, according to Article 21 of the Criminal Code of Ukraine, a state of alcoholic, narcotic, or substance-induced intoxication does not exempt a person from liability for unlawful acts committed. On the contrary, the court may recognize such a state as an aggravating circumstance.

The core principle of forensic psychiatric examination in civil proceedings is the Protection of the economic interests of the mentally ill.

Civil proceedings address the issue of legal capacity, i.e., an individual's ability to understand their civil rights and obligations and consciously enter into property relations with the state or other persons.

The following types of legal capacity are distinguished:

— partial civil capacity of children under 14 years of age;

— incomplete civil capacity for individuals aged 14–18;

— full civil capacity.

Individuals who, due to a mental disorder or cognitive impairment (e.g., dementia), are unable to understand the significance of their actions and/or control them are recognized as legally incapacitated (Articles 39–41 of the Civil Code of Ukraine). Guardianship is established over such persons. The guardian steps in for the individual declared legally incapacitated in property and other relations.

Individuals (starting from the age of 14) suffering from a mental disorder that significantly affects their ability to understand the significance of their actions and/or control them are recognized as having limited legal capacity (Articles 36–37 of the Civil Code of Ukraine). Curatorship is established over such persons.

A court may restrict an individual's civil capacity if they abuse psychoactive substances (e.g., alcoholic beverages), thereby placing themselves, their family, or dependents whom they are legally bound to support in severe financial hardship.

Let us consider a clinical example.

Patient O., a 27-year-old unmarried female with schizophrenia residing in Odesa in an apartment purchased for her by her parents, is prone to substance abuse. She was detained on the territory of Ukraine while committing a crime—smuggling codeine and other narcotic substances from neighboring Moldova.

During the investigation, she confessed that she had acted consciously for financial gain as part of a criminal group that specifically entrusted her with transporting narcotic substances, believing that, as a sick person, she would not bear criminal responsibility.

At the time of committing the unlawful acts, she was in a state of remission and was found sane by a forensic psychiatric examination. While in a pre-trial detention center, she experienced an exacerbation of her mental illness. A repeat forensic psychiatric examination was conducted, as a result of which patient O. was found legally insane and, consequently, incapable of undergoing further investigative proceedings and standing trial. The court committed the patient to compulsory medical treatment, despite which full remission could not be achieved. Thus, patient O. could not be held criminally liable and continued to undergo compulsory treatment.

The patient's parents filed a lawsuit in court to declare her legally incapacitated. However, according to the forensic psychiatric examination, O. could only be recognized as having limited legal capacity; that is, she could freely dispose of a portion of her pension, while surrendering the remaining portion to her parents for the maintenance of her minor child. Furthermore, O. did not have the right to sell her apartment or get married (i.e., bring another person into this apartment) without her parents' consent. At the same time, she was not deprived of her right to vote in civil elections. Three years later, the court revoked the compulsory treatment and replaced it with treatment on a general basis. Shortly thereafter, O. was discharged home. Given the instability of her remission state, the court did not hand down a sentence regarding O.'s punishment, despite the fact that she was found sane at the time the crime was committed.

This example demonstrates the complexity and humane focus of forensic psychiatric examination as an integral part of the Ukrainian judicial system.