Psychiatry - O. K. Napryeyenko 2001

Clinical Psychiatry
Schizophrenia

Schizophrenia (from the Greek schizein meaning 'to split' and phren meaning 'mind') is an endogenous progressive (process) mental disorder that typically debuts at a young age (16–30 years). It is characterized by both primary (negative) deficit symptoms—such as apathy, autism, and dissociation of mental activity—and secondary (positive) symptoms, including delusions, illusions, hallucinations, motor-volitional disturbances, and depressive features.

The term "schizophrenia" was coined by the Swiss psychiatrist Eugen Bleuler in 1911; consequently, the group of psychoses encompassed by this concept is sometimes referred to as Bleuler's disease. Depending on the diagnostic criteria applied, its prevalence is estimated at 3 to 20 cases per 1,000 population, averaging 1–2%.

Etiology AND Pathogenesis

No specific etiological factor for schizophrenia has been identified. According to WHO data, the Causes and Mechanisms of its development are best understood through a multifactorial approach.

A significant role is attributed to genetic predisposition. For instance, the concordance rate for schizophrenia reaches up to 90% in monozygotic twins and 15% in dizygotic twins. Children born to two parents with schizophrenia develop the disorder in 15–40% of cases, compared to 12% if only one parent is affected. The predisposition is inherited primarily in a recessive manner and is accompanied by a decline in energetic processes, autointoxication, and autoimmunization. This is manifested by non-specific alterations in nitrogen, protein, and Amino acid METABOLISM, as well as changes in neurohormone levels coupled with the blockade and subsequent degeneration of adrenergic receptors.

These abnormalities result in distinct pathophysiological factors, notably hypnoid states—an intensification of inhibitory processes within the Cerebral Cortex—a functional imbalance between the cortex and subcortical structures, and inertia or paradoxical reactivity of The Nervous system.

Attempts to explain THE ORIGIN OF these alterations and their role in the pathogenesis of schizophrenic disorders are based on the dopamine, noradrenaline, and serotonin hypotheses, as well as theories involving gamma-aminobutyric acid (GABA) metabolism, the generation of endogenous hallucinogens, slow viral infections, and others.

Clinical presentation

One of the most prominent manifestations of schizophrenia is thought disorder, which is clearly evident in 84% of patients.

Thought Disorders in schizophrenia vary in severity and form, ranging from mild incoherence—with subtle impairments in the conceptualization of Abstract notions—to profound dementia.

Seeking to penetrate The Essence of these impairments, E. Bleuler characterized schizophrenic thinking broadly as autistic, meaning detached from reality. In such thinking, judgments are formed solely in accordance with the patient's affective needs, without regard for logic or factual reality. According to Storch, the thinking of these patients is regressive and archaic. Kraepelin, Hoppe, E. Bleuler, and Bumke compared schizophrenic thought to the thinking of a healthy person on the verge of falling asleep. Kleist regarded schizophrenic thinking as paralogous, characterized primarily by a lack of logic and causal relationships between judgments.

Addressing the general state of cognitive mental processes, it should be noted that perception in schizophrenia is imprecise and blurred. To a large extent, it is disrupted As a result of the patient's diminished general activity and affectivity. Nevertheless, it is striking that some patients retain various pieces of information concerning real-life events, hospital occurrences, and the like, which they perceive despite their autistic state, mutistic stupor, and other phenomena typical of schizophrenia. Attention, particularly active attention, is frequently impaired. Passive attention, however, is "often preserved. It is precisely due to the preservation of passive concentration that patients with schizophrenia sometimes perceive quite accurately various events that would seemingly not concern their interests.

Memory in schizophrenia is not impaired, at least not to the point of amnesia. Occasionally, distortions of memory occur—paramnesias, misinterpretations of events (confabulations), or temporal displacement of memories (pseudoreminiscences). It is possible that these memory disorders should be considered, in part, a consequence of the disrupted sense of self, which is characteristic of schizophrenia. Under this aberration, a patient may believe, for instance, that two warring personalities inhabit their body. Sometimes the patient speaks in the third person, referring to themselves as "he" or "she". Paramnesias in these cases may be psychogenic in nature and based on mechanisms of repression, whereby memories unpleasant to the patient are distorted under The Influence of specific affective attitudes.

Regarding thought disorders in the strict sense of the term, they are most pronounced in the terminal Stages of the illness, during so-called end-state schizophrenic dementia.

Characteristic features include severe personal neglect, a narrowing of interests coupled with decreased activity, and emotional blunting.

Although schizophrenia leads to profound personality alterations, Gruhle and other authors argue that it is not characterized by intellectual destruction in the form of true dementia, and that one can legitimately speak only of peculiar modifications of thought. The validity of this assertion is supported by the fact that schizophrenic patients with profound dissociation of mental activity who have spent many years in psychiatric hospitals can still, with a skillful approach, retain The ability to analyze and draw Conclusions. Yet these same patients, having just correctly performed a complex arithmetic calculation, may moments later make errors in the simplest mathematical operations. Such intellectual changes undoubtedly differ from dementia. Consequently, many authors have concluded that the intellectual impairment in schizophrenia manifests not as a deficit in individual intellectual capacities, but rather as an inability to utilize them.

As Gruhle colorfully put it, in schizophrenia "...the machine is intact, but entirely or insufficiently serviced." The intellect of such patients has also been compared to a bookcase filled with interesting and meaningful books, the owner of which cannot make use of them because they cannot find the key to the door. Gruhle and Beringer attributed this phenomenon to a "deficiency of the intentional arc in the thinking of the schizophrenic patient." In this state, guiding concepts—the so-called determinative tendencies that shape thought and determine its direction—are lacking. Thus, as a result of pathological changes in thought, the schizophrenic intellectual disorder essentially reduces to a disorder of intellectual initiative and intellectual productivity.

A characteristic and specific thought disorder in schizophrenia is the disruption of the flow of representations and their connections, known as "schizophrenic loosening of associations" (or schizophrenic thought fragmentation).

The thinking of such a patient appears fragmented, much like Other Aspects of mental activity. Elements that should be combined in normal thinking appear disconnected in schizophrenia. At the same time, various ideas that have no logical connection become fused together in schizophrenic thought.

E. Bleuler described schizophrenic thought fragmentation as follows: associations lose their coherence, and the illness severs, unevenly, several or most of the threads guiding our thoughts. Consequently, the products of thought acquire a bizarre and sometimes illogical character: "Two accidentally encountered representations merge into a single concept," or "fragments of ideas are improperly joined to form a new idea."

Among the Characteristic Features of schizophrenic thinking are the following: 1) conceptual agglutination; 2) symbolic thinking; 3) ambivalence of thought; 4) thought derailment (slipping); 5) thought blocking (Sperrung); 6) stagnation of thought; 7) intrusion of thoughts (mentism); 8) accessory ideas; 9) banality of thought; 10) tendency to circumstantiality and over-elaboration (rezernerstvo). Speech exists in unity with thought; therefore, the verbal output of these patients formally reflects the peculiarities of their thinking. Above all, schizophrenic speech fragmentation is characteristic, differing formally from the speech incoherence observed in acute delirium states. The sole distinction is that in schizophrenia, the majority of patients preserve the internal grammatical Structure of speech against a Background of disrupted content. However, in severe cases, the patient's speech becomes completely chaotic, sometimes turning into a word salad devoid of both internal logical connection and external grammatical form. In such instances, one speaks of "schizophasia" or "verbal salad." Distinguishing this fragmentation from incoherence can often be difficult.

Analyzing the verbal activity in schizophrenia, Lebedinsky noted a characteristic feature: the wave-like fading or exhaustion of speech. For example, during a conversation with a patient, speech may initially appear relatively coherent, but then the relevance of individual words to the overarching meaning gradually diminishes. In other words, over the course of a conversation, a progressive loss of word meaning can be observed. Frequently, schizophrenic patients refuse contact altogether. This phenomenon, known as mutism, is a particularly characteristic symptom of the catatonic form of schizophrenia. The causes of mutism are highly diverse; one of the most common is patient negativism. Occasionally, mutism results from thought blocking.

In some cases, a patient becomes mute due to diminished activity and blunting of affect. They lack the stimulus to speak and take no interest in their surroundings; thus, the patient may remain silent simply because there is nothing to talk about. In such instances, mutism serves as an expression of the patient's autistic stance toward the environment.

During certain phases of schizophrenia, verbal agitation may occur. Due to a profusion of verbal associations, speech comes to resemble that of manic patients. However, this does not represent true "flight of ideas" characteristic of a manic state. Rather, schizophrenic verbal agitation exhibits an automatic stringing together of words devoid of internal meaning, driven purely by superficial verbal associations such as rhyme, assonance, or identical word endings. Occasionally, patients also utilize associations based on internal meaning, yet this is accompanied by a mechanical listing of words associated merely through contiguity.

The speech of many patients is particularly mannered, featuring bizarre turns of phrase. The patient speaks with a distinctive accent and peculiar intonations, and many words are distorted. Neologisms are characteristic, sometimes built upon wordplay or phonetic manipulation. In certain cases, patients employ newly coined words to explain their own bizarre delusional and hallucinatory experiences, which cannot be expressed through ordinary language.

A characteristic feature of schizophrenic speech is the stereotyped repetition of specific words and expressions. This can manifest as verbigeration, where the same words and phrases are monotonously repeated over a certain period. Echolalia—the automatic repetition of questions or words spoken in the patient's presence—is also observed. All of these speech disorders are typical of the catatonic form of schizophrenia and are part of the catatonia symptom complex. However, these linguistic features may also occur in Other forms of schizophrenia, namely paranoid and hebephrenic.

Speech disorders in schizophrenia are unstable. For example, verbal agitation may suddenly give way to mutism, or speech may become coherent. However, as the disease progresses, transitions to organized speech are observed less and less frequently, and eventually incoherence may become permanent.

Special attention is paid to psychosensory disorders. These phenomena accompany schizophrenia, but they can also be observed in other conditions.

Psychosensory disorders refer to alterations in the perception of the external world and one's own body, arising from impaired synthesis of elementary gnostic Functions associated with specific receptors, as well as changes in proprioceptive functions, such as vestibular ones. Due to the disintegration of these functions in schizophrenia, disturbances in the body schema are observed (manifesting as Changes in the shape, size, or mass of individual body parts, the disappearance of certain parts, or their displacement and detachment from one another). Such disorders may present as partial disturbances of the body schema, but total forms also occur (such as the enlargement, reduction, or alteration of one's body mass and shape). These include experiences of bodily bifurcation and the feeling of a double, or the complete disappearance of the body. Spatial perception disorders are also observed; objects may appear to recede, approach, or multiply. This category also includes micropsia (where the patient sees objects as reduced in size), macropsia (objects appearing excessively large), and metamorphopsia (distortions of objects in the imagination). Disorders of time perception are diagnosed as well, where something seen for the first time is perceived as already familiar (déjà vu) or, conversely, something seen many times is perceived as unfamiliar, never seen before (jamais vu). There may be disturbances in the perception of stillness or movement in the environment—meaning everything around the patient may seem dead, frozen, and motionless, or conversely, in a state of continuous motion. Sometimes the patient imagines that everything is collapsing, walls are falling on them, and a terrible catastrophe is unfolding.

Hallucinations, and particularly pseudohallucinations, are a quite frequent occurrence in schizophrenia. Auditory hallucinations are predominant. They may be elementary in nature (noise, crackling, gunshots—so-called akoasms). Most commonly, the patient hears "voices" of the most diverse character: loud and distinct, or quiet (whispers) and indistinct, indefinite. Occasionally, it feels as though someone is calling the patient by name. Complaints about the repetition and prompting of thoughts are significantly rarer. Sometimes the patient gets the impression that their thoughts are known to others, i.e., that their "thoughts are being stolen." It is possible that this latter experience is associated with a subjective sensation of delayed thinking.

Many patients exhibit kinesthetic and tactile hallucinations. Patients complain of paresthesia: burning sensations, pain, feelings of Touch, or physical influence such as electric currents, radio waves, mysterious rays, hypnosis, and the like. Sometimes patients get the impression that they are turning over in the air, or that earthquakes are occurring (hallucinations of general sensation).

Gustatory and olfactory hallucinations are quite common. For example, the patient may perceive the smell of mice, poisonous gases, etc. As for visual hallucinations, they are rare in schizophrenia and occur mainly during periods of exacerbation. Pseudohallucinations also predominate here: visual images are faint, and the patient "sees" them "in their imagination" or "behind their back."

Alongside hallucinations, illusions are sometimes observed.

Often, even in the face of a flood of hallucinations, clear consciousness is preserved. Not infrequently, patients conceal or dissimulate their hallucinatory experiences and refuse to talk about them. The issue of the genesis of hallucinations and pseudohallucinations in schizophrenia remains debatable. According to Gruhle, they should be considered primary symptoms directly caused by the organic process. E. Bleuler, on the other hand, classified them as additional, secondary, i.e., psychogenic phenomena. Schneider is also inclined to view hallucinations as a secondary phenomenon arising from thought disorders. A specific property of schizophrenic hallucinations is considered to be the patient's perception of them as something intrusive and alien to their ego.

Delusional ideas are a frequent, though not constant, occurrence in schizophrenia.

Delusions are typically absurd, unstable, and contradictory. They reflect the characteristic schizophrenic disorders manifested as a disruption in The Unity of the personality and its splitting. The thought disorders inherent in schizophrenia are also reflected in the delusions.

Most common are delusions of reference and influence, which are frequently components of persecutory delusions that, in schizophrenia, tend to be fragmentary and symbolic. Like hallucinations, delusions may be concealed (dissimulated) by patients.

Hypochondriacal delusions are characteristic. They are sometimes connected with the aforementioned types of delusional ideas. It is believed that hypochondriacal delusions may be triggered by peculiar bodily sensations—"cenesthesias." Delusions of grandeur are also observed, which are more often devoid of reality and concrete meaning. In these cases, the patient connects their persona with abstract concepts of the cosmos, humanity, destiny, etc. Mystical inventions, of which the patient considers themselves the author, frequently figure in delusions of grandeur; such cases are referred to as delusions of invention.

Not infrequently, delusional ideas—as well as other manifestations of schizophrenia—clearly exhibit ambivalence, along with the contradictory Nature of the patient's thoughts, affects, and inclinations. For instance, the same patient may simultaneously consider themselves a tsar, a military commander, and a revolutionary. A female patient might call herself an empress's wife while simultaneously claiming to be a physical education teacher. Symbolism is frequently observed in the content of the delusions. Patients exhibit a greater or lesser degree of indifference toward the absurd ideas they express. A patient's behavior rarely corresponds to the content of the delusions. In the Cytology/cytology/16.html">Early stages of the illness, delusions—being unilaterally affect-laden—influence the patient's actions and social attitudes. With the further Development of the pathological process, delusional ideas become increasingly fragmentary and obscure.

The genesis of delusions is also insufficiently understood. E. Bleuler regarded them as secondary psychogenic phenomena. In his view, Affective Disorders—primarily in the form of a unidirectional orientation of affects—play a significant role in The formation of delusions. According to Gruhle, delusions in these patients are primary and organically determined.

Distorders of self-awareness also play a crucial role in the formation of delusions in schizophrenia. The patient projects their experiences onto the external world, identifying themselves with other people and objects. A certain role is also played by the sensation of a bizarre change within oneself and the environment, stemming from the aforementioned depersonalization disorders experienced by the patient. These experiences frequently lead to The Emergence of the delusion that mysterious forces alien to their personality are exerting an influence through hypnosis, rays, and other factors that the patient is typically unable to comprehend or explain. Due to the inability to verbally structure these incomprehensible experiences, the patient interprets the delusion in a peculiar (bizarre) manner, formulating their thoughts unusually.

Emotional disorders are considered by the majority of researchers to be among the earliest impairments in schizophrenia. They play a significant role in the symptomatology of this illness. Characteristic features include the contradictory nature of affective manifestations, with constant fluctuations of emotions between the poles of hypersensitivity (sensitivities) and indifference (apathy). Kretschmer termed these properties of schizophrenic affectivity the "psychaesthetic proportion." At the onset of the disease, heightened sensitivity (emotional hyperesthesia) is more frequently observed. Later, as the pathological process develops, affective blunting progresses, reaching complete affective-emotional dullness in the final stages of the illness. In the early periods of schizophrenia, states of melancholy and subconscious fear may occur, sometimes leading to suicide. Occasionally, the patient reacts excessively to minor insults and life problems. Subsequently, manifestations of schizophrenic dementia increase. Patients become indifferent, showing no interest in relatives and loved ones, and remaining unconcerned with real-life troubles that at one time could have deeply touched their feelings. They also become indifferent toward themselves and their own future.

Affective blunting, gradually deepening, leads to the complete decay of the patient's emotional life and pronounced affective immobility.

Kraepelin, considering affective dullness to be the most characteristic symptom of schizophrenia, asserted that it is one of the earliest signs of this illness. However, Gruhle rightly objected to the traditional interpretation of the emotional sphere of a schizophrenia patient as one of "dull indifference." The latter indeed most frequently occurs at the terminal stages of the disease development. In the initial stages, affective indifference—which often manifests as "antipathy toward people"—may be merely superficial. In reality, what one observes is not so much affective dullness as emotional experiences directed inward, against the background of a loss of interest in the surroundings. In the early stages of the disease, patients exhibit emotional hyperesthesia rather than an indifferent attitude toward, say, their hallucinatory and delusional experiences. Nevertheless, even when the capacity for deep affective experiences is preserved, the patients' emotions remain poorly understood. Strictly speaking, it is more appropriate here to speak of a splitting of affectivity.

The splitting of mental activity in this case consists of a disruption in the adequacy of affects—that is, their coordination—and their connection with other aspects of the personality's activity. Thus, emotional inadequacy may manifest as a mismatch between affects and the patient's other internal experiences. For instance, something that causes joy in a healthy person may upset a schizophrenia patient, and vice versa (paramimia). Alternatively, affects may fail to correspond to the patient's words, facial expressions (paramimia), gestures, and actions. Not infrequently in schizophrenia, one can notice poorly motivated and incomprehensible sudden explosions of affect. Sometimes, alongside emotional devastation, there are peculiar, purely external manifestations of emotions that have an unnatural, theatrical character. In these cases, the patients laugh or cry with unmotivated mannerisms. Occasionally, they demonstrate unmotivated hatred toward parents and relatives, even though they treated them wonderfully before the onset of the illness. Emotional ambivalence, manifested as a peculiar contradictory duality of affects, is also a characteristic sign of affective splitting in schizophrenia. Any experience of the patient may be perceived by them simultaneously as pleasant and unpleasant, cheerful and sad.

A phenomenon related to ambivalence, termed ambitendence, is also observed. This is a duality of desires in which the patient cannot decide on their direction.

All of this pathological emotional symptomatology is unified under THE CONCEPT OF "apathy," which can be characterized as the loss of emotional vividness and variety, as well as of life-work perspective, accompanied by the appearance of paradoxical emotions.

In schizophrenia, extraordinary importance is attributed to autism. It consists of the patient's withdrawal and the loss of their natural connections with the real world. The patient becomes inaccessible and loses contact with their environment.

Autism is a phenomenon of likely secondary character. A certain role in The Development of autism may be played by impaired self-awareness, accompanied by the experience of something terrifying and unusual both within oneself and in the surrounding environment. Depersonalization phenomena give rise to a subjective feeling of alienation and loneliness, which generates an oppositional stance toward the external world in the patient and leads to the loss of contact with people.

Alongside this, the affective disturbances described above play a significant role in the genesis of autism. These two phenomena are interconnected, since the core of autism in schizophrenia is the loss of the patient's adequate affective response to the environment, resulting in withdrawal. In the early stages of the disease, the patient's extreme sensitivity may prompt a desire to shield themselves from unpleasant contact with objective reality. Subsequently, autism is facilitated by the patient's gradual affective blunting, causing their surroundings to cease interesting them. E. Bleuler, considering autism one of the primary and mandatory symptoms of schizophrenia, was inclined to broaden the concept of autism by classifying it within the sphere of thinking. There is reason to believe that autistic thinking in this disorder is largely a manifestation of impaired concept formation, specifically their concretization.

In schizophrenia, disturbances of drives and instincts are quite common. Sexual drive is most frequently diminished. Increased libido, when it occasionally occurs, often manifests as an irresistible urge to masturbate due to autistic detachment. As affective blunting develops, patients may masturbate openly, without any regard for those present.

Distortions of sexual drive also occur, sometimes revealing inclinations toward homosexuality. Frequently, a diminished sex drive is accompanied by other signs of sexual dysfunction.

Appetite disturbances may present as either an increased food drive with gluttony, or a decrease leading to anorexia, with prolonged and complete refusal to eat, and rarely—coprophagia and others.

Schizophrenia is also frequently marked by a compromised instinct of self-preservation, which leads to diminished protective responses and, at times, a propensity for suicide. Suicidal tendencies are often observed at the onset of the disease. Suicide attempts are sometimes the result of experiencing profound alterations in one's own ego, which can be accompanied by severe anguish and dread. Occasionally, suicide is driven by persecutory delusions, stemming from an urge to escape the terror of dying at the hands of imaginary enemies. Suicidal attempts can occasionally be impulsive, unmotivated, and sometimes obsessive in nature.

At times, alongside suicidal ideation, patients with schizophrenia exhibit a tendency toward self-mutilation. For instance, patients may inflict various injuries upon themselves, scratching their Skin or pulling out their Hair. Cases of ocular self-enucleation, biting off PARTS OF THE Tongue, and similar acts are also documented. Such self-harm is linked to delusional and hallucinatory experiences against the backdrop of a diminished instinct of self-preservation.

A crucial manifestation of schizophrenia is the impairment of volitional qualities, the intentional (from Latin intentio — striving, purpose) Properties of the personality, and a reduction in motivational drive. Together with blunted affect, these form the fundamental backdrop upon which schizophrenic dementia develops.

Motor disturbances are also common, manifesting as an impoverishment of movement resulting from decreased patient activity. Movements are restricted and awkward. The lack of harmony and expressiveness in movement, along with a mismatch between facial expressions and gestures relative to actual emotions, creates an impression of fragmentation within motor behavior, mirroring the disruption seen across all mental activity.

Motor symptoms characteristic of schizophrenia, particularly its catatonic form, include phenomena grouped under the concept of "catatonic syndrome."

Catatonic excitement. Against a background of unmotivated anxiety, the patient experiences unpleasant, threatening, and imperative auditory hallucinations. Fear sets in, and the patient becomes agitated. This agitation is senseless in character and plays out within a confined space (a bed, a corner of the ward, etc.). Speech is halting. The dissociation of mental activity manifests through bizarre combinations of pathological resistance and compliance. Stereotypical repetitions of others' actions (echopraxia), facial expressions (echomimia), and heard phrases (echolalia) are observed. Simultaneously, the patient resists attempts to feed, dress, or wash them. Gradually, the catatonic excitement transitions into stupor.

Catatonic stupor may be purely motor in nature, unaccompanied by any inhibition of intellectual functions. Despite being immobile, the patient still perceives their surroundings; evidence of this is that, in the event of a fire, for instance, a patient may suddenly break their stupor and flee. Furthermore, upon emerging from the stupor, they can accurately describe what was happening around them at the time. Occasionally, stupor is accompanied by a complete arrest of thinking. During catatonic stupor, complete immobility and physical rigidity are observed, and the patient may become incontinent. In some cases, the closed eyelids of the patient tremble. At other times, the eyes are wide open with the gaze fixed on a single point. Muscles may be flaccid, or a pronounced rigidity of all muscles, particularly the limbs, may be observed.

The opposite of automatic obedience is negativism. This symptom is characteristic not only of catatonic schizophrenia but of other forms as well. Negativism manifests as an unmotivated reluctance to follow any instructions. Sometimes it serves as an oppositional stance adopted by the patient toward their environment. Most frequently, it has an automatic character, entirely detached from the patient's specific psychological experiences. Evidence for this is seen when a patient attempts to carry out commands—such as performing movements suggested by others—yet these attempts fail due to an intense internal resistance felt by the patient.

Negativism is distinguished as passive and active. A demonstrative manifestation of passive negativism is the patient's complete unresponsiveness to requests, whereas in active negativism, the patient does the exact opposite.

During catatonic stupor, patients may remain in stereotypical postures for extended periods. These include the "embryo position": the chin pressed against the chest, arms pulled tight to the torso, and knees drawn up to the abdomen.

The "air pillow position" (or Dupré's sign): the patient lies supine with the HEAD, neck, and shoulder girdle elevated. The "hood position": the patient pulls their shirt, blanket, or similar item over their head and peers out from beneath it.

In this type of stupor, symptoms of waxy flexibility and catalepsy can be detected, where the patient freezes in whatever posture they are placed. Mutism—pathological silence—is also characteristic.

Catatonic manifestations also encompass impulsive actions. These are sudden and seemingly reflex-like in nature. Occasionally, such a patient makes an impulsive attempt at suicide or self-mutilation.

In schizophrenia, a range of purely neurological symptoms can be observed that are independent of the patient's mental state. These serve as manifestations of dynamic functional-organic disruptions of cerebral functions, the Specificity of which regarding this disease has not been conclusively proven. We are referring to "soft" (non-localized) neurological signs, potential Anomalies of the corpus callosum and Cerebellum, enlargement of the cerebral ventricles, and other symptoms.

Among endocrine disorders, thyroid dysfunctions with symptoms of hyper- or hypothyroidism are frequently observed. In some cases, enlargement or reduction of The Thyroid Gland is detected, occasionally accompanied by exophthalmos and tremor. Disturbances in Adrenal gland function have also been noted, which may potentially account for the asthenia and various skin pigmentation disorders observed in schizophrenia. Gonadal dysfunctions are quite common in schizophrenia, predominantly manifesting as diminished function, and infantilism is frequently present. Amenorrhea and other menstrual irregularities are also indicative of impaired gonadal activity.

TYPES OF SCHIZOPHRENIA ONSET

The initial manifestations of schizophrenia are extraordinarily diverse in their Clinical Features, which frequently creates significant diagnostic challenges. Despite the polymorphism of the onset of schizophrenia, typical symptoms can often be identified even in the earliest stages. Although initially subtle, these symptoms eventually allow for a more or less precise Diagnosis of the developing pathological process.

Several types of onset are most commonly observed.

I. Types of gradual disease progression

Gradual development type characterized by affective-volitional personality impoverishment

In the presence of pre-psychotic vulnerability during Puberty (ages 13–14) in an individual with a burdened hereditary background—who has exhibited a general deficiency in psychosomatic development since childhood—activity and interest in the surroundings gradually begin to decline.

Gradual development type of affective-volitional impoverishment in a pre-psychotically healthy personality. A young person who exhibited no deviations from the norm prior to illness and performed well in primary school becomes lazy and inattentive during puberty or adolescence. They begin to lag behind in their studies, lose interest in academics as well as everything else, and become excessively daydreamy. Outbursts of irritation occasionally occur, sometimes against the backdrop of an incipient emotional blunting. Such mental disturbances during the transitional period warrant a detailed clinical analysis by a physician.

Gradually developing characterological changes with antisocial tendencies

This type of onset is most commonly observed in young adults. It typically begins with emotional disturbances and personality shifts. Relationships with parents and loved ones deteriorate into groundless hostility, accompanied by rudeness and irritability. At times, patients leave home and remain missing for days. In its behavioral manifestations, this state resembles the psychopathic conditions with antisocial tendencies seen in children with chronic epidemic encephalitis.

Gradually developing characterological changes with mannered and eccentric features. The patient loses interest in studies and abandons routine activities, becoming withdrawn. New, unusual interests emerge that lie entirely outside their previous pursuits. Speech becomes elaborate and pretentious. Negativism is frequently observed, manifested as a refusal to acknowledge generally accepted authorities, and behavior becomes increasingly inappropriate.

Psychasthenic onset type

A distinct type of schizophrenia onset occurs around the age of 20–25, characterized by the emergence of obsessive ideas and phobias. Tormented by vague, compulsive fears, patients express a dread of losing their mind. Their indecision and doubts serve as manifestations of ambivalence. Thought blocking, autism, and the weakening of social ties are also characteristic features.

Neurasthenic (astheno-hypochondriacal) onset type

This type is characterized by asthenia accompanied by rapid fatigue, painful sensations in various parts of the body, and a subjective conviction of suffering from an incurable disease. The patient becomes withdrawn, inactive, and unkempt. Days are spent in idleness, absorbed in analyzing bodily sensations while showing no interest in family or the outside world. Unlike this condition, patients suffering from true neurasthenia remain alert and highly motivated to rid themselves of their painful symptoms.

Hysteroid onset type

This mode of onset is predominantly observed in young women, though it may also occur in men. The initial signs of the pathological process include emotional lability, alongside episodes of motiveless sadness and weeping, often accompanied by various hysterical (conversion) seizures. Gradually, ambivalence sets in, behavior becomes inconsistent, and the hallmark reduction in activity associated with schizophrenia becomes apparent.

Hallucinatory-paranoid onset type

The disorder may manifest initially through hallucinatory and delusional phenomena, accompanied by psychosensory disturbances. Frequently, these are compounded by calling voices, fully formed auditory hallucinations, or other pseudo-hallucinatory experiences. Delusions of reference, persecution, and outside influence gradually take shape.

II. Types of acute onset

Maniac-like onset type

The onset of schizophrenia is frequently expressed as sudden maniac-like agitation. The patient becomes excessively restless and talkative, with a thought process reminiscent of a "flight of ideas." However, this agitation is often superseded by inertia, and mood remains unstable, with a predominance of irritability.

Depressive onset type

The illness begins acutely with depression. The patient becomes hypokinetic, frequently exhibits mutism, refuses food, and sometimes displays impulsive suicidal ideation. Behavior appears unnatural and inconsistent, accompanied by paramimias.

Acute delirious onset type

Schizophrenia may present as an acute illness resembling exogenous toxic-infectious psychosis. Elevated body Temperature triggers a state of acute agitation accompanied by confusion, delirious manifestations, and occasionally meningeal-like symptoms. One of the key indicators of a schizophrenic debut is the presence of catatonic and, at times, hebephrenic symptoms. Such an onset of the schizophrenic process must be differentiated from schizophreniform syndromes of exogenous etiology.

Epileptiform onset type

In A number of cases, schizophrenia begins with the appearance of epileptiform or twilight-state seizures. Against a background of generalized lethargy and inertia, the patient experiences periodic paroxysms.

It should be noted that in the early stages of schizophrenia, the aforementioned debut manifestations may occur in combination. These initial disorders may subside only to recur, gradually or abruptly culminating in the distinct clinical picture of a schizophrenic psychosis.

Clinical forms of SCHIZOPHRENIA

Classifying schizophrenia into subtypes is complicated by the polymorphism of its manifestations. Nevertheless, to navigate the clinical landscape of the disease, it is essential to distinguish the primary, prototypical forms classically described first by E. Kraepelin and subsequently by E. Bleuler. The majority of authors agree on identifying hebephrenic, catatonic, paranoid, and simple clinical forms (types) of schizophrenia.

Hebephrenic schizophrenia typically debuts during adolescence, frequently around the period of puberty. Onset later in life is less common, and early childhood onset remains exceptional.

This variant of schizophrenia most often develops gradually. However, hebephrenic episodes can occasionally emerge as an acute psychosis characterized by maniac-like, anxious, or confusional agitation. The pathological condition unfolds quite rapidly—either continuously or through a series of prolonged exacerbations followed by brief, indistinct remissions. As a rule, this process rather quickly leads to a personality defect marked by significant emotional blunting and dementia.

The main symptoms of hebephrenia include marked incoherence of thought, impaired conceptual generalization, emotional blunting, and silly, clownish behavior (grimacing). Alongside these, particularly in acute stages, symptoms typical of other forms of schizophrenia—especially catatonic—may appear. A mixed hebephreno-catatonic clinical picture is frequently observed. Sometimes patients maintain conscious accessibility and even exhibit warmth toward others. Gradually, however, they become increasingly withdrawn, indifferent, and apathetic.

The catatonic form of the disorder most frequently begins with acute agitation accompanied by numerous psychotic and motor symptoms. Occasionally, the condition develops subacutely, starting with a depressive state, hypochondriacal ideas, auditory hallucinations, and fears. Catatonia typically debuts between the ages of 20 and 30, sometimes earlier, but rarely later. Following a relatively brief acute stage, a period of remission often ensues. Much less commonly, directly following an acute flare-up, the process assumes a chronic progressive course. Most characteristically, catatonia manifests as recurrent acute episodes repeating irregularly and interspersed with rare remissions until The final stage is reached. This endpoint is characterized by a high prevalence of motor symptoms, yet a less pronounced personality disintegration than that seen in the terminal states of hebephrenia. Stuporous akinesia, marked by deceleration, sluggishness, stiffness, or Muscle rigidity, may unexpectedly give way to catatonic excitement with hyperkinesias, stereotyped automatic movements, verbigeration, echolalia, echomimia, and echopraxia against a background of negativism. Catatonic excitement is usually short-lived, whereas catatonic stupor can persist for years. Alongside catatonic phenomena, patients occasionally exhibit neurological signs, notably anisocoria (pupillary Asymmetry). Autonomic nervous system disturbances are often quite pronounced.

Paranoid schizophrenia, unlike the first two forms, predominantly debuts in adulthood, frequently after the age of 30. It has a relatively slow course, with the disease process developing gradually. Spontaneous remissions are comparatively rare.

Paranoid schizophrenia is characterized by a relative preservation of behavioral comprehension, some retention of emotionality, and comparatively milder impairments in thought sequencing, particularly at the onset of the illness. However, a progressively crystallizing delusional worldview soon emerges, marked by the gradual development—initially of delusions of reference, followed later or simultaneously by delusions of persecution, influence, hypochondriacal delusions, and occasionally delusions of grandeur. Over time, the patient's focus becomes increasingly concentrated on their own hallucinatory-delusional experiences, leading to a complete loss of interest in real life.

Terminal states in paranoid schizophrenia develop relatively slowly. They are characterized by affective blunting, fragmented thinking, and impaired conceptual generalization. Behavior frequently becomes eccentric, bearing a catatonic imprint. Alongside progressive personality degradation, autism becomes increasingly pronounced, accompanied by a total loss of interest in the external world.

Simple schizophrenia is one of the most frequent forms of this disease. It typically begins during puberty. Developing gradually—sometimes over the course of decades—it results in a greater or lesser degree of personality defect. Remissions in this form of schizophrenia are rare.

Simple schizophrenia is characterized by progressively increasing personal neglect, apathy, and a slow decline in activity. Hallucinations, delusions, and catatonic symptoms are absent. The predominant feature is a peculiar form of dementia that develops progressively over decades. Most frequently, this occurs against the background of a premorbid schizoid psychopathic personality structure. Only in isolated mild cases do psychological deviations remain at the level of schizoid personality disorder.

Atypical forms of schizophrenia include: circular, schizoaffective, and remitting forms; presentations of schizophrenia featuring clouded consciousness, or with exogenous or other heterogeneous organic admixtures; combinations of schizophrenia with Epilepsy; schizophrenia with obsessive-compulsive features; sluggishly progressive forms of schizophrenia; febrile schizophrenia; and childhood-onset schizophrenia.

The circular form of schizophrenia encompasses schizophrenic states with a distinct circular course, presenting as periodic depressive and manic episodes accompanied by a constellation of symptoms characteristic, on the one hand, of schizophrenia, and on the other, of manic-depressive psychosis.

The remitting form of schizophrenia is observed quite frequently. It is primarily characterized by a peculiar intermittent course. The schizophrenic process unfolds through separate, intermittent episodes and alterations, followed by periods of remission. These episodes last from several days to several weeks, and occasionally months, though they are most often short-lived. Remissions are frequently so complete that one may even speak of practical recovery; following an episode, patients return to normal life without noticeable psychological deficits.

The majority of typical schizophrenic psychoses occur against the backdrop of relatively clear consciousness. However, in isolated schizophrenic episodes, particularly during acute flare-ups of the illness, the patient's awareness of the surrounding world may become clouded.

Schizophrenia may occasionally present atypical psychotic pictures depending on the influence of exogenous, toxico-infectious, or traumatic factors, as well as concurrent somatic or neurological diseases. Of particular practical importance is mixed schizophrenia combined with alcoholism. Not infrequently, an ordinary bout of delirium tremens assumes a protracted character and transitions into the debut picture of schizophrenia. Such forms of schizophrenia with an alcoholic debut were first described by Greeter and are therefore termed Greeter's schizophrenia. In such cases, one is dealing with provoked schizophrenia—or more precisely, schizophrenia unmasked by chronic exogenous alcohol intoxication.

Sluggishly progressive forms of schizophrenia predominantly feature "neurosis-like" manifestations and are close in character to simple schizophrenia. These neurosis-like disorders are viewed either as a prodromal stage of more severe forms of schizophrenia, as rudimentary forms thereof (neurosis-like schizophrenia), or, in some cases, as a post-psychotic state following acute disease flare-ups.

This form of schizophrenia is characterized principally by disturbances of the emotional sphere and general personal activity. Concurrently, irritability, withdrawal, suspiciousness, and lethargy are observed. Hypochondriacal preoccupations are quite frequently noted, featuring stereotyped complaints of "nervousness" against a backdrop of so-called affective emptiness. This form is most commonly encountered in out-patient clinical practice.

The febrile (hypertoxic) form of schizophrenia is rarely observed. Its course is marked by pyrexia (fever), with body temperature reaching 40 °C or higher and persisting

anywhere from several days to 3–4 months. Concurrently, no signs of infectious somatic pathology can be detected. In such instances, the illness follows a severe course, frequently threatening the patient's life and overall condition. Such patients require urgent intensive care measures.

Among the sluggishly progressive forms of schizophrenia, psychopathic-like (hebephroid) schizophrenia is distinguished; its clinical picture approximates schizoid, hysteroid, epileptoid, or labile (mosaic) psychopathy (personality disorder).

Paranoia (classified in ICD-10 as "delusional disorder"). Some authors consider this disorder a distinct condition belonging to the group of schizophrenic psychoses, while others view it as the so-called paranoiac form of schizophrenia. It debuts between the ages of 30 and 40, frequently following psychological trauma. To a monothematic array of delusions there gradually are added persecutory delusions, grandiose ideas, and occasionally threatening illusory experiences driven by the delusions. During periods of exacerbation, patients become dangerous and capable of homicide, demonstrative suicide, etc.

Most frequently, schizophrenia debuts during the aforementioned age periods. However, cases of schizophrenia developing at an earlier age are also observed.

The history of The Doctrine of childhood schizophrenia originates with cases described by G. Heller as dementia infantilis. The disease can afflict children aged 3 to 5 years. While the majority of authors classify this condition as schizophrenia, some consider its clinical manifestations to be the sequelae of an encephalitis with a peculiar course, or a state belonging to cerebral heredodegenerations (hereditarily determined conditions).

TYPES OF SCHIZOPHRENIC COURSE

I. Continuous progressive chronic course, or continuous-progredient type. It develops gradually over many years and ultimately leads to a specific dementia. A malignant variant of the continuous-progredient type is sometimes observed, most frequently in adolescence and youth.

II. Episodic-progredient (shub-like) type. The manifestations of the illness take the form of acute attacks, which may be followed by remission or occasionally even an arrest of further disease progression. The outcome of the disorder is a personality defect, which progresses with each subsequent attack.

III. Recurrent (episodic) type. A chronic course characterized by periodic flare-ups, predominantly in the form of atypical manic or depressive phases, each followed by a period of remission. The personality defect is minimally expressed. In this type of schizoaffective psychosis, disease progression manifests principally as a gradual shortening of remission periods and an increase in the duration of flare-ups.

The course of the illness may worsen in any form of schizophrenia. However, instances occur where it remains unchanged for decades—these are the so-called stationary forms of schizophrenia. Improvements, i.e., remissions, may occur at any stage of schizophrenic development.

TYPES OF REMISSION IN SCHIZOPHRENIA

Depending on the reduction of psychopathological symptoms, the presence of a mental defect, and the dynamics of patients' functioning levels, the following types of remission are distinguished:

Complete (Remission A) — the complete disappearance of productive psychotic symptoms, while some patients retain mildly expressed apathetic-dissociative symptoms that do not significantly impair their quality of life (capacity for self-care, orientation, behavioral control, communication, mobility, and work ability).

Incomplete (Remission B) — a significant decrease in productive psychopathological symptoms, accompanied by persistently moderate negative psychotic disorders and a decline in functioning criteria (such as limited work capacity).

Incomplete (Remission C) — noticeable reduction and encapsulation of productive psychopathological manifestations, a well-defined personality defect, and a significantly reduced level of functioning (including complete loss of work capacity).

Partial (Remission D) — a decrease in the acute severity of the illness, with a certain deactivation of psychotic and other symptoms. Patients require the continuation of the main course of Treatment (inpatient improvement).

Classification, types of course, and remissions of schizophrenia, schizotypal, and delusional disorders:

According to ICD-10 F20 Schizophrenia

F 20.0 Paranoid schizophrenia

F 20.1 Hebephrenic schizophrenia

F 20.2 Catatonic schizophrenia

F 20.3 Undifferentiated schizophrenia

F 20.4 Post-schizophrenic depression

F 20.5 Residual schizophrenia

F 20.6 Simple schizophrenia

F 20.8 Other forms of schizophrenia

F 20.9 Schizophrenia, unspecified

Types of course:

F 20. x 0 Continuous

F 20. x 1 Episodic with progressive deficit

F 20. x 2 Episodic with stable deficit

F 20. x 3 Episodic remitting Types of remission:

F 20. x 4 Incomplete

F 20. x 5 Complete

F 20. x 7 Other

F 20. x 9 Observation period up to one year

F 21 Schizotypal disorder (bizarre or eccentric behavior, social withdrawal, apparent emotional coldness, suspiciousness, tendency to ruminative thinking, paranoid ideas, possible illusions, depersonalization or derealization, transient episodes of auditory or other hallucinations and delusions; absence of the symptom complex characteristic of schizophrenia)

F 22 Persistent delusional disorders

F 22.0 Delusional disorder

F 22.8 Other persistent delusional disorders

F 22.9 Persistent delusional disorder, unspecified

F 23 Acute and transient psychotic disorders

F 23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia

F 23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia

F 23.2 Acute schizophrenia-like psychotic disorder

F 23.8 Other acute and transient psychotic disorders

F 23.9 Acute and transient psychotic disorder, unspecified

F 24 Induced delusional disorder

F 25 Schizoaffective disorder

F 25.0 Schizoaffective disorder, manic type

F 25.1 Schizoaffective psychosis

F 25.2 Schizoaffective disorder, mixed type

F 25.8 Other schizoaffective disorders

F 25.9 Schizoaffective disorder, unspecified

F 28 Other nonorganic psychotic disorders

F 29 Unspecified nonorganic psychosis

Classification and course types of schizophrenia and other psychotic disorders:

Per DSM-IV 295. Schizophrenia

295.30 Paranoid schizophrenia

295.10 Disorganized schizophrenia

295.20 Catatonic schizophrenia

295.90 Undifferentiated schizophrenia

295.60 Residual schizophrenia

295.40 Schizophreniform disorder

297.1 Delusional disorder

298.8 Brief psychotic disorder

297.3 Shared psychotic disorder

293. ... Psychotic disorder due to another medical condition (specify somatic or neurological condition)

293.81 With delirium

293.82 With delusions

289.9 Unspecified mental disorder

Diagnosis

Thus, schizophrenia is characterized by a wide range of clinical manifestations. For this reason, its diagnosis, particularly in the early Selection/3.html">Stages of development, is difficult. The diagnosis of schizophrenia is based on identifying the Progressive development of specific negative symptoms and a characteristic personality defect. The disorder is marked by emotional flattening, the presence of the aforementioned thought and perception disorders, and interpersonal difficulties. The primary goal of diagnosis is to provide a clear clinical justification for the disorder, thereby establishing the prerequisites for preventing dangerous behavior by the patient and mitigating progressive personality deterioration.

Differential diagnosis should primarily be conducted with exogenous and affective psychoses, as well as with neurotic disorders and personality disorders.

Unlike schizophrenia, the onset of exogenous psychoses is associated with adverse external factors such as intoxications, infections, Various Forms of radiation, etc. Furthermore, the clinical picture is dominated by hallucinations (most commonly visual), frequently against the background of impaired consciousness. Personality deterioration develops following a so-called organic pattern.

Affective psychoses are characterized by a phasic course and the absence of marked personality deterioration. There is no progressive complexification of initial symptoms. In schizophrenia, however, episodes of affective disorders in the course of the disease can transform into affective-paranoid, catatonic-oneiroid states, etc.

In neuroses and personality disorders, noticeable psychopathological manifestations appear immediately following intra- and interpersonal conflicts. Patients retain critical insight into their distressing experiences. The typical course of neurosis follows this trajectory: neurotic reactions – persistent neurotic state – neurotic development.

In schizophrenia, what stands out is a lack of critical insight (or purely formal insight), along with a schizophrenic pattern of personality alteration.

Treatment

Traditionally, the treatment of schizophrenia consists of primary and maintenance courses, which involve biological therapy (psychopharmacological, convulsive, and other Shock Methods), psychotherapy, general strengthening measures, and social rehabilitation strategies for patients.

The primary course aims at the remission of acute mental disorders. It is most often conducted in inpatient settings, less frequently in day hospitals, and occasionally on an outpatient basis. Maintenance therapy is prescribed to consolidate and build upon the positive progress achieved during the primary treatment course, as well as to prevent relapses and complications.

Biological therapy primarily involves the administration of psychotropic and other medications, taking into account the leading pathological syndrome (clinical form of the disease), the stage of the schizophrenic process, its specific course, and the patient's general health status.

For paranoid schizophrenia, manifested by hallucinatory and delusional states, antipsychotics such as trifluoperazine (stelazine), haloperidol (haldol, sulpiride), are used. If these are insufficiently effective, mazindol / methiothepin variants / thiopropazate / thioproperazine (majeptil, cephalin), trisedyl (triperidol, trifluperidol), clopixol, fluanxol, risperidone (rispolent), or zyprexa are prescribed. If motor symptoms predominate, chlorpromazine (aminazine, megaphen) and levomepromazine (tisercin) are more effective. A combination of chlorpromazine with trifluoperazine or haloperidol is also indicated. When paranoia is accompanied by depressive syndrome, antidepressants such as amitriptyline (amizol, novotryptin, elivel), zoloft, pyrazidol (pirlindole), cipramil, prozac, etc., are included in the treatment regimen, or neuroleptic drugs with an antidepressant effect (carbidine, chlorprothixene) are prescribed. For co-occurring anxious-depressive mood with hypochondriacal concerns, melitracen / thioridazine (melleril, sonapax) can be recommended. When hallucinosis and ideational automatisms predominate, high doses of perphenazine (etaperazine) are indicated. In chronic schizophrenia, leponex (azalentin, clozapine), zyprexa, and risperidone are effective, as they do not cause severe extrapyramidal side effects. For prolonged hallucinatory-paranoid syndrome with psychomotor retardation, frenolone (metofenazate) is indicated. With further chronicity of these symptoms, targeted combined neuroleptic therapy is appropriate: haloperidol – trifluoperazine, majeptil – haloperidol, etc. It should be emphasized that when using high doses of the aforementioned drugs, the prescription of so-called correctors (parkopan, cyclodol, yumex, memantine, ricinol, etc.) is mandatory to prevent the development of neuroleptic malignant syndrome. In cases of special sensitivity to neuroleptics and a propensity for extrapyramidal disorders, leponex (clozapine) is used. Atypical antipsychotics (zyprexa, risperidone, solian) practically do not require correctors, as they rarely induce neuroleptic syndrome. Convenient and effective options within the primary treatment course include long-acting antipsychotics such as clopixol-depot, fluanxol-depot, moditen-depot, and haloperidol decanoate. They are administered once or twice a month.

For simple schizophrenia, activating neuroleptics are most effective – frenolone, semap (penfluridol), and small doses of trifluoperazine.

In sluggishly progressive (sluggish) schizophrenia, when obsessive-compulsive states predominate, tranquilizers are prescribed – diazepam (seduxen), phenazepam, relanium, elenium, etc., along with small doses of neuroleptics such as haloperidol and stelazine. When systematized obsessive ideas emerge, long-acting neuroleptics are advisable – moditen-depot, fluanxol-depot, clopixol-depot, fluspirilene (IMAP), etc. For astheno-hypochondriacal experiences and hysteriform symptoms, tranquilizers are used – seduxen, raderorm, tazepam (nozepam), oxazepam (or low-dose neuroleptics), and their combinations with antidepressants: seduxen – petilil, trifluoperazine-amitriptyline. With escalating signs of schizoidization and other psychopathy-like disorders, penfluridol / periciazine (neuleptil), zyprexa, risperidone, fluphenazine (moditen/liogen), trifluoperazine, and haloperidol are prescribed.

Patients with hebefrenic schizophrenia are prescribed haloperidol, mazetil, and trisedyl. Catatonic excitement is managed with chlorpromazine and haloperidol. For oneiroid catatonia, tisercin is administered. When depersonalization is predominant, a combination of neuroleptics—such as perphenazine, thioridazine (or alimemazine)—and antidepressants like amitriptyline, citalopram, and prozac is used.

Treatment for patients with hypertoxic (febrile) schizophrenia is preferably carried out in an intensive care unit or the resuscitation ward of a psychiatric hospital. Chlorpromazine is prescribed. If no positive dynamics are observed, some authors recommend combining it with electroconvulsive therapy. In cases of prolonged hyperthermia, injections of amidopyrine or other antipyretic drugs, regional hypothermia (ice packs on vascular bundles) are prescribed. If There is a risk of Brain edema, aminophylline, lasix, urea, a drip-lytic mixture (500 ml of isotonic sodium chloride solution, 0_{5 % novocaine — 50 ml, 1 % diphenhydramine — 2 ml, 5 % ascorbic acid — 10 ml), mannitol, prednisolone or dexamethasone intravenously via drip, mesatone (phenylephrine), noradrenaline, etc., are administered. Antibiotics are prescribed to prevent corresponding complications.

Maintenance Therapy and Rehabilitation

These measures are carried out to increase the duration of remission periods, promote social readjustment, and prevent relapses. To this end, following the main course of treatment, patients are often kept on the same medications that achieved remission for many months or even years. Long-acting neuroleptics (moditen depot, clopixol depot, fluanxol depot, etc.) and atypical antipsychotics (risperidone, zyprexa, solian) are widely used. The dosage is gradually reduced (a sudden, significant decrease in dosage can trigger a return of the psychotic disorder—the withdrawal syndrome).

An auxiliary method of treating schizophrenia is individual psychotherapy, The Role of which increases as the patient emerges from the acute psychotic state. Psychotherapeutic sessions (rational psychotherapy) aimed at calming patients, preventing dangerous actions, convincing them of The Need for treatment, adhering to a certain regimen, instilling confidence in recovery, distracting the patient from painful experiences and ideas, and later fostering a critical attitude toward them.

Behavioral therapy is conducted to develop occupational skills. Group psychotherapy is particularly effective in reducing social isolation, restoring a sense of reality, and so on.

Family psychotherapy plays a significant role. It is conducted to harmonize relationships within the family, help the patient's relatives understand the pathological nature of their behavior and the need for persistent treatment, teach them how to interact with mentally ill individuals, and provide a platform for families to share experiences.

One of the most proven methods of treatment and rehabilitation for schizophrenia is occupational therapy (sociotherapy). It exerts a psychotherapeutic and educational influence on the patient, especially in chronic defect states. Through the systematic use of occupational therapy, it is possible to increase the patient's positive activity, organize their psychomotor functions, and, whenever possible, "draw" them out of their characteristic autism. Thus, on the one hand, work serves as an important element of compensatory influence on mental functions, stimulating general activity, while on the other hand, it distracts the patient from hallucinatory and delusional experiences, facilitating the so-called encapsulation of delusions.

Since schizophrenia reveals functional insufficiency of the Endocrine System, autonomic nervous system disorders, barrier function deficiencies, and defective Blood supply to the entire body and the brain in particular, it is considered advisable to exert a nonspecific influence on patients with the aim of general stimulation and appropriate restructuring of the Organism. For this purpose, treatment methods that activate general metabolism and tone the endocrine system can be used. In this regard, according to many authors, it is useful to prescribe endocrine gland preparations, particularly sex gland extracts. For certain patients with reduced thyroid function, the cautious use of thyroidin is indicated for a certain period.

In 1935, Hungarian psychiatrist L. Meduna first used a method for treating schizophrenia aimed at artificially inducing epileptic seizures. The so-called electroconvulsive, convulsive, or epileptogenic therapy is theoretically justified by the premise, as Meduna argued, that a certain antagonism exists between schizophrenia and epilepsy. For example, epilepsy patients have a well-developed mesenchyme and a tendency toward neuroglia proliferation, whereas schizophrenia is characterized by mesenchyme insufficiency and weak neuroglial reaction.

In 1935, Viennese psychiatrist M. Sakel proposed Insulin therapy. In patients with schizophrenia, the development of hypoglycemic shock is provoked by administering large doses of insulin. However, this method is rarely used today.

Physiotherapy, which has not yet received due attention in the active therapy of mental disorders, has not yet found sufficient application in schizophrenia. The only exception is hydrotherapy—in the form of prolonged warm baths, which, since the time of E. Kraepelin, have been successfully used to treat agitated patients. Among other hydrotherapy Procedures recommended for such states, wet wraps are used in some facilities. Along with these procedures, psychiatrists are beginning to pay attention to other physiotherapeutic methods that favorably influence the course of schizophrenia, such as general light baths.

Treatment with ultrashort waves and ^! roentgenization of the Basal Ganglia has been proposed. The latter two methods are still in the research stage.

Since physiotherapy actively influences the Lymph and Blood Circulation of the Central Nervous System, the permeability of the blood-brain barrier, autonomic functions, and the reticuloendothelial system, there is reason to expect that in the future this treatment method will occupy an important place among the therapies for psychoses in general and schizophrenia in particular.

Debilitated patients are prescribed brewer's Yeast, Liver extract, iron preparations, phytin, and other general fortifying medications. Regarding Nutrition, the appropriateness of a lacto-vegetarian diet should be emphasized. The patient's body has a particular need for Vitamins, especially ascorbic acid and thiamine.

If the patient refuses to eat, appetite is sometimes stimulated with small doses of insulin. However, tube feeding often becomes necessary, sometimes for extended periods.

Prognosis

According to H. Kaplan and B. Sadock (1936), nearly a third of schizophrenia patients lead an overall normal, socially compensated lifestyle without noticing the manifestations of the illness. Another third of such patients experience psychopathological symptoms throughout their lives, yet retain the ability to function fairly normally in society. Only a third of the afflicted require frequent hospitalization due to pronounced mental disorders. Furthermore, nearly 10 % of patients spend extended periods in psychiatric care facilities.

Prevention

Primary prevention. Preventing various negative Physical and Chemical, including ecological, impacts on The Genome of future generations. Warning parents with schizophrenia about the increased risk of this illness occurring in their offspring.

Secondary prevention. Long-term maintenance pharmacotherapy and psychotherapy, followed by anti-relapse therapy (most frequently in spring and autumn). Preventing mental and physical overload, exposure to psychotrauma, intoxications, infections, and other factors that contribute to disease relapses.

Tertiary prevention. Intensive treatment and rehabilitation measures aimed at preventing the progression of mental defects, social maladjustment, and other complications of the illness.

Expert Evaluation

Medical and social expert evaluation is conducted to determine the level of the patient's social functioning based on a set of clinical, psychological, and social indicators. In cases of pronounced mental defects or prolonged treatment-resistant psychotic states, the appropriate disability group is established. A comprehensive rehabilitation and readjustment plan is developed.

Military expert evaluation. Regardless of the course of schizophrenia, the patient is deemed unfit for military service and removed from military registration.

Forensic psychiatric evaluation. In the event of an unlawful act, patients in a psychotic state or during a period of incomplete or partial remission are deemed not responsible for their actions (insane). If a grave crime has been committed and there is a risk of its recurrence, compulsory treatment is ordered by the court. During a period of full remission, the patient is recognized as responsible. The grounds for declaring a patient legally incompetent and placing them under guardianship are their inability to understand the consequences of their own actions due to a prolonged and pronounced psychotic state or as a result of a severe schizophrenic defect.

Review Questions

1. Definition of the concept of "schizophrenia".

2. Etiology, pathogenesis, and Epidemiology of schizophrenia.

3. Main symptoms of schizophrenia (apathy, dissociation, and autism).

4. Features of productive, affective, and catatonic disorders in schizophrenia.

5. Clinical forms of schizophrenia.

6. Types of the course of schizophrenia.

7. Schizoaffective psychoses.

8. Treatment, rehabilitation, and prognosis in schizophrenia.

9. Forensic evaluation in schizophrenia.

10. Age-related Features of the course of schizophrenia.