Psychiatry - H.T. Sonnyk 2003

Schizophrenia

Schizophrenia (from the Ancient Greek schizein meaning "to split" and phren meaning "mind") is a chronic, progressive mental disorder characterized by both primary negative (deficit) symptoms—such as apathy, autism, and the dissociation of mental activity—and secondary positive (productive, formative) symptoms, including delusions, illusions, hallucinations, as well as affective and psychomotor disturbances.

Due to its profound social impact, schizophrenia remains a central issue in psychiatry. According to H.I. Kaplan and B.J. Sadock, the United States spends approximately 100 billion dollars annually on the care and Treatment of patients with schizophrenia.

Historical Background

The symptoms of schizophrenia were first detailed in 1857 by the French psychiatrist B. Morel; however, the primary credit for establishing schizophrenia as an independent nosological entity belongs to E. Kraepelin (1893). He grouped previously described conditions—paranoid dementia, catatonia, and hebephrenia—under the term "dementia praecox." He based this Classification on the unfavorable prognosis common to all three forms and the progressive decline in mental activity ultimately resulting in dementia. Later, influenced by the works of O. Diem (1903), the simple form of the disease was also included in this category.

The term "schizophrenia" itself was coined in 1911 by the Swiss psychiatrist E. Bleuler. He convincingly argued the point, slightly earlier proposed by Claude (1909), that in this pathology it is more accurate to speak of "dissociation" or the splitting of the psyche rather than dementia (hence the name). He also revised the understanding of The Nature of the disease—which E. Kraepelin termed a "regular biological process"—by proposing a psychoanalytic interpretation of it.

Since then, several conceptual frameworks for studying schizophrenia have emerged. French psychiatry tended to decisively separate early dementia in Kraepelin's description from E. Bleuler's concept of schizophrenia. In Germany, K. Kleist (1953) and K. Leonhard (1957) held a distinct position. In the United States, the dominant view considers schizophrenia as a manifestation of personality reactions with a psychoanalytic interpretation, while clinical Diagnosis remains overtly eclectic, based on scoring a percentage from a standard scale of 10–12 symptoms where paranoia, hallucinosis, abusive voices, associative disorders, and other features carry equal weight. Soviet psychiatry also developed several approaches to understanding schizophrenia. A.L. Epstein, A.S. Chistovich, and P.E. Vishnevsky did not recognize the nosological independence of schizophrenia, proposing instead that it was the result of an unfavorable outcome in protracted infectious psychoses. The St. Petersburg school, represented by P.A. Ostankov, V.P. Osipov, and I.F. Sluchevsky, interpreted schizophrenia through Kraepelin's clinical-biological framework, whereas A.V. Snezhnevsky's school prioritized the transformation of Psychopathological Syndromes in diagnosis.

Epidemiology

Schizophrenia is the most common psychosis, with a population prevalence estimated at 1–1.5%, regardless of sex. Approximately two million new cases are diagnosed worldwide each year.

While schizophrenia can manifest at any age, the peak incidence (50% of cases) occurs between the ages of 16 and 25.

Etiology AND Pathogenesis

Investigations into the etiology and pathogenesis of schizophrenia began long before it was classified as an independent disorder. It was initially studied within the framework of disorders later consolidated under METABOLISM/2.html">THE CONCEPT OF dementia praecox. Perspectives on the disease evolved across a broad spectrum—from psychodynamic and anthropological to physiological, anatomical, and genetic.

The "psychist" school viewed schizophrenia as a consequence of psychological trauma in early childhood or the Influence of other microsocial psychogenic factors. Conversely, the "somatic" school sought to explain The Development of schizophrenic psychoses through biological disruptions across various Organs and systems, including the Brain, Liver, gastrointestinal tract, and Endocrine glands.

The debate concerning the relative contributions of psychological and biological factors to the pathogenesis of this disorder remains highly relevant today.

I. Psychogenic Theories. Theories regarding the psychogenesis of schizophrenia retain adherents today who continue to investigate The Role of various psychogenic and social factors in the onset and progression of the disease.

The advancement of this perspective has led to the formulation of several etiological models of schizophrenia:

1. The psychodynamic model attributes the development of schizophrenia to profound disruptions in interpersonal relationships. A variant of this model, stemming from Freudian theory, posits a subconscious reaction to an intrapsychic conflict originating in early childhood.

2. The phenomenological-existential model views alterations in the patient's "essence" and inner world as the driving factors in the psychogenic development of schizophrenia.

According to this perspective, the illness itself represents a unique mode of existence for the individual.

All theories regarding the psychogenesis of schizophrenia are largely interpretative and insufficiently supported by empirical observation. Numerous attempts by proponents of these approaches to apply corresponding therapeutic interventions (such as psychotherapy) have proven largely ineffective.

II. Autointoxication Theories. These theories stem from the detection of various physiologically active (toxic) substances—including Proteins and low-molecular-weight compounds—in the bodies of patients with schizophrenia, which elicit neurotropic effects.

Over the past 20 to 30 years, laboratories worldwide have isolated various functionally active "toxic" compounds from the Blood, urine, and CEREBROSPINAL FLUID of schizophrenia patients.

While the presence of toxic factors in the biological fluids of schizophrenia patients is undisputed, it remains unclear to what extent these anomalous substances are involved in the specific mechanisms underlying the pathogenesis of the disease.

III. Biochemical Hypotheses

1. Catecholamine hypotheses examine the potential role of norepinephrine and dopamine dysfunctions in disrupting neurobiological processes within the brains of patients with schizophrenia.

2. The indolatamine hypothesis group proposes that serotonin, its metabolites, and other indole derivatives participate in the mechanisms of mental activity. Disruption in these pathways can impair mental Functions and lead to the development of schizophrenic symptoms.

These hypotheses are closely related to concepts suggesting that the development of schizophrenia is associated with the dysfunction of enzymatic systems involved in biogenic amine metabolism. Particular attention is paid to such Enzymes as monoamine oxidase (MAO), catechol-O-methyltransferase (COMT), dopamine beta-hydroxylase (DBH), and others.

IV. Immunological hypotheses. Immunological hypotheses of schizophrenia are based on the concept of autoimmune processes, i.e., the Organism's ability to produce Antibodies against its own tissue Antigens.

The Mechanism of disease development in this case is associated with the synthesis in patients' bodies of antibodies against brain antigens (antibrain antibodies), which can damage brain tissue.

Evidence for the existence of so-called antibrain antibodies in the blood and cerebrospinal fluid in schizophrenia has been obtained by numerous authors.

V. Among the biological hypotheses of schizophrenia, the genetic one currently appears to be the most convincing.

The Study of hereditary factors in schizophrenia has been conducted for decades in various countries around the world. Numerous data on twin concordance (genetic similarity) regarding schizophrenia strongly support the essential role of hereditary factors in the pathogenesis of the disease.

The most compelling evidence regarding the role of genetic factors in the development of schizophrenia was obtained from studies of groups of children whose parents suffered from schizophrenia, but who were separated from their biological parents at birth and adopted into "healthy" families. In psychiatric literature, this approach is known as the "adopted children strategy".

It turned out that raising children in "healthy" families did not reduce the frequency of the disease developing in children if their biological parents suffered from schizophrenia. In other words, a favorable microsocial environment does not decrease the incidence of schizophrenia in children with a hereditary predisposition.

In some cases, the symptoms and course of schizophrenia can be very similar to the mental illness picture of one of the patient's relatives. In other cases, genetic factors determine an excessively heightened sensitivity to any stress, even minor ones. Such vulnerability and heightened sensitivity lead to the gradual development of a defense mechanism in the patient, which becomes the basis for the psychopathological symptoms that comprise the clinical picture of the disease.

Stemming from this reaction are the 3 main symptoms of schizophrenia: autism, abulia, and emotional flattening.

Autism is a withdrawal from reality, manifested in A wide variety of forms that nevertheless form a similar clinical picture.

From the very beginning, patients become withdrawn, taciturn, and strive to minimize communication with others. During forced communication, they maintain a formal, cold demeanor, avoiding eye contact with the interlocutor (gaze negativism), looking down or away; when greeting, they either do not offer a hand or offer a limp hand without returning a handshake. Conversation is restricted to a narrow circle of purely business-like topics necessary for the situation; patients avoid discussing other matters or give vague Answers to them.

Patients frequently resort to a peculiar camouflage: they wear large dark glasses, wide-brimmed hats pulled down over their eyes, and grow long Hair and beards. In more pronounced cases, patients inexplicably quit their studies or jobs, gradually stop going outside, curtain their windows, or even spend all day lying in bed with a blanket pulled over their heads. In other instances, they leave the city, hiding in the forest, mountains, or caves.

Some patients attempt to somehow compensate for their autism by changing jobs and choosing professions that do not require human interaction (night watchman, hunter, forester, etc.). Their inner experiences become more important to them than the real circumstances of the surrounding reality. They are immersed in their dreams, thoughts, and desires, which seem to them already fulfilled, leading to bizarre judgments about their surroundings—in particular, patients imagine themselves at the center of surrounding events.

Abulia translates as "lack of will". It manifests as reduced activity, inactivity, loss of initiative, and loss of interest in the surroundings. In severe cases, patients even fail to perform basic self-care, do not wash, suffer from Urinary Incontinence, and spend the entire day in bed or sitting in a motionless posture. This symptom begins with patients abandoning everyday tasks, quitting their studies and work. All the above-mentioned symptoms are associated with a "drop in the energy radical" of the psyche.

Emotional blunting manifests at the onset of the disease. Patients gradually lose normal, lively human feelings and interests, becoming cold toward their loved ones and relatives. Subsequently, this coldness intensifies, turning within a few years into complete indifference to everything except the patient's delusional ideas.

Despite the wide variety of disease manifestations in individuals, the main symptoms of schizophrenia in combination often create a similar picture. Most patients are fully and correctly oriented in their environment, time, and personal identity; however, in some cases, "double orientation" occurs, where the patient, while maintaining correct orientation, simultaneously insists that they are actually another person living in a different place and time, reflecting The phenomenon of psychological splitting.

In the initial stage of schizophrenia, most patients at least partially retain a critical attitude toward themselves; they feel that they are ill, that a shift has occurred in their condition, and many openly state that they have "lost their minds". Consequently, they frequently begin reading psychiatric literature and visit a psychiatrist on their own initiative.

However, as the disease progresses further, this critical attitude is gradually lost, and patients fail to notice impairments in their mental state, often refusing treatment As a result.

CLASSIFICATION.

Types of the course of schizophrenia:

1) continuously progressive (process schizophrenia) — develops gradually over many years and ultimately leads to specific dementia. A malignant variant of the continuous type is sometimes observed.

2) attack-like progressive (schub-like) — manifestations of the disease take the form of acute attacks, which may be followed by remission or sometimes even a halt in further development. The outcome of the disease is a personality defect, progressing with each attack.

3) periodic (recurrent) — a chronic course with punctuated flare-ups, predominantly in the form of atypical, manic, or depressive phases, each followed by a period of remission. Thought Disorders are of secondary importance. The personality defect is minimally expressed. In this course, disease progression is manifested primarily by a gradual shortening of remission periods and an increase in the duration of flare-ups.

CLINICAL PICTURE.

Simple form. It typically debuts in adolescence or early adulthood. Its 2 main features are a gradual, subtle onset and a slow, yet continuously progressive course without remissions.

Patients gradually develop the following characteristic behavioral changes: social withdrawal, a cold or even hostile attitude toward parents, unexpected, impulsive, and paradoxical actions, negativity toward others, loss of usual interests, and The Emergence of new, unusual hobbies. Such patients become indifferent to their appearance, unkempt, or sometimes, conversely, dress overly fashionably and grotesquely. Gradually, they distance themselves more and more from those around them. In most cases, the diagnosis of mental illness is made with a significant delay, because, as a result of the slow and subtle development of psychopathological symptoms at the beginning of the disease, others usually consider them difficult people or victims of poor upbringing. Furthermore, this form of schizophrenia lacks delusions and hallucinations, which dictates its name. 3 to 5 years (sometimes more) after the onset of the disease, an apathetic-abulic or psychopathic-type mental defect develops.

Hebephrenic form (from the Ancient Greek «hebephrenia» — «youthful mind») — like the simple form, it generally arises in adolescence or early adulthood. Alongside the same symptoms present in the simple form, behavioral features such as persistent foolishness and aggressiveness come to the fore here. In their behavior, such patients are mannered, make bizarre movements, act like clowns, fool around, mock others, annoy those around them, cause them various petty nuisances, and make fun of the elderly. Often, they display excessive callousness and, with malicious glee, may commit murder or inflict severe bodily injuries. This form of schizophrenia is very rare, and its course is characterized by a lack of remissions and high malignancy. It is not diagnosed immediately (because patients are long mistaken for ill-mannered teenagers or troublemakers) and leads to a pronounced psychopathic-type mental defect.

Catatonic form. This form of schizophrenia used to be much more common than it is now. It is characterized by a combination of mental disorders inherent to schizophrenia with changes in Muscle tone, which is reflected in the name («catatonic» — with altered tone). It can occur at any age. Patients exhibit an alternation of catatonic stupor and catatonic excitement (for symptomatology, see the chapter «Disorders of the Effector-Volitional Sphere»).

Catatonic stupor can last from several weeks to several years. After emerging from stupor, when patients enter into adequate verbal contact, it becomes clear that throughout this entire state they were fully oriented to their surroundings and well remember all the details of conversations and events that took place around them at that time.

In the catatonic form, oneiroid syndrome may occur, in which patients plunge into a world of fantastic experiences, finding themselves in an imaginary Setting and situation: «in heaven, in hell, taking a flight into space,» and so on. At the same time, they do not make contact or answer questions, but while lying in bed, they observe imaginary scenes with an expression of pleasure or fascination on their faces.

The state of catatonic stupor is dangerous due to the potential development of pressure sores and persistent refusal to eat, which can cause patients to die from exhaustion. In addition, catatonic stupor can suddenly and unexpectedly transition into catatonic excitement: patients stormily and impulsively jump out of bed and perform continuous, monotonous movements — stomping, waving their arms, shaking their heads, etc. These movements can continue without any signs of fatigue for several days. Establishing verbal contact with such patients is impossible; they do not answer questions. Catatonic excitement can end abruptly, either returning to catatonic stupor or culminating in remission.

Paranoid (or hallucinatory-paranoid) form. This is the most widespread form of schizophrenia. It can occur at any age, but most commonly between 16 and 30 years of age. The main manifestation that determines the name («paranoid» — from Ancient Greek for delusions) and content of this form is paranoid (delusional) syndrome. It is characterized by delusions of special significance, reference, persecution, physical influence, etc.

The disease develops gradually, but externally it may appear to manifest suddenly. The classical development of paranoid syndrome occurs in several stages: first, delusions of special significance appear with a symbolic interpretation of the surrounding environment, followed by delusions of reference, which gradually acquire concrete embodiment in delusions of persecution.

However, patients quite often develop delusions of persecution right away. In some cases, delusions are combined with auditory, visual, gustatory, olfactory, and tactile pseudohallucinations (hallucinatory-paranoid syndrome). In others, delusional ideas occur without hallucinations.

A characteristic feature of this form of schizophrenia is the Kandinsky-Clérambault syndrome — a combination of psychic automatism, pseudohallucinations, delusions of influence, and thought broadcasting.

Sometimes the clinical picture shows symptoms that form part of paraphrenic syndrome — systematized delusions starting with ideas of reference, influence, persecution, and poisoning, which expand to grandiose proportions (encounters with aliens, extraordinary power allowing one to control the entire Universe, etc.) and end with The formation of delusions of grandeur.

In cases of a favorable course, a state of remission sets in after a few months — patients return to work and family with comparatively adequate behavior. The psychotic attack may never repeat.

In other, more severe cases, psychotic episodes may recur repeatedly throughout life.

In the majority of patients, however, the disease follows an episodic-progressive course, where a psychotic attack after remission is followed by another attack of approximately the same form. Such attacks recur repeatedly over many years. Furthermore, after each psychotic episode, the mental defect deepens further.

Atypical forms of schizophrenia. These include the circular, schizoaffective, and remitting forms, as well as sluggishly progressing schizophrenia, and the hypochondriacal, neurosis-like, and febrile forms of schizophrenia.

Circular form. This form manifests as manic and depressive episodes that follow one another or are interspersed with remissions of varying duration. After each psychotic attack, the mental defect deepens. Overall, this form of schizophrenia has a relatively favorable course with a fairly positive prognosis; patients can maintain their ability to work and Other Aspects of social functioning for many years.

Hypochondriacal form. In this form of schizophrenia, patients are convinced that they are suffering from a severe somatic illness. In some cases, this conviction is expressed through hypochondriacal delusions: patients insist that they have tuberculosis, Syphilis, Cancer, or some other disease. Moreover, they arrive at this conviction suddenly, as if through an «epiphany.»

Patients find signs of one disease or another, seek medical help, demand treatment, and — distrusting doctors' Conclusions that they are healthy — move from one medical facility to another, demanding endless tests and courses of treatment. They accuse doctors of deception and of hiding the true diagnosis, spending years trying to convince those around them that they are right.

In other, more frequent cases, There is a firm conviction of having some non-specific «illness,» which is based on numerous distressing, painful, and unpleasant sensations throughout the body. Patients describe these sensations using bizarre, unusual Complaints: «the HEAD is burning» and simultaneously «the legs are turning cold,» «needles» or «waves» are crawling over the body, in The Heart region there is «emptiness,» «heart Valves are clicking,» «hot blood is running through the vessels,» «bubbling,» and much more.

Pronounced phenomena of depersonalization are present: the head feels soft and half-empty, with cracks, fissures, depressions, or bumps on it; the face is yellow-green; the hands have «dried out,» etc.

All patients with hypochondriacal schizophrenia usually look gloomy and upset. They declare that something is «weighing them down.» Elementary hallucinations can frequently be detected: visual ones such as «circles» or «balls» before the eyes; auditory ones such as «crackling» in the head, noise, or ringing in the ears; olfactory ones, most often the smell of rot or a rotten egg from the Mouth; and tactile ones, such as something crawling under the Skin, etc.

The disease most often begins and develops gradually, typically around the age of 25–40 years. In some cases, it may begin suddenly as an attack of heat, trembling, or weakness, and then transition into a gradual course.

Following years of unsuccessful treatment by doctors of various specialties, patients turn to self-treatment. They develop a special diet for themselves, constantly wear a warm hat on their heads and pads on various parts of their body. Gradually, they distance themselves more and more from others and lose interest in everything except the state of their health and the search for ever-new remedies.

Some patients behave passively, spending time at home, mostly in bed. Others display litigious activity, applying to various authorities with complaints against doctors and demanding more qualified medical care. Usually, it is only after many years that patients come to the attention of psychiatrists. At this stage of the illness, alongside the hypochondriacal syndrome, emotional flattening and mental autization are clearly pronounced.

The course of the disease in this form of schizophrenia is slow, sluggish, and unaccompanied by remissions. Patients are admitted for treatment at late Stages of the disease, which renders therapy largely ineffective in many cases.

Sluggish schizophrenia. This variant of schizophrenia is distinguished by some researchers based on its clinical course. Psychopathological symptoms are poorly defined, most commonly resembling neurosis or psychopathy.

Such patients may exhibit obsessive thoughts and episodic hallucinations. They often develop their own dietary and hardening regimens, among other practices. A characteristic element is the litigious syndrome (querulous paranoia). For many years, patients wage an active campaign against the infringement of their rights and freedoms—whether real or imagined—and submit numerous complaints to various authorities. This litigation gradually consumes the core of the patient's personality, becoming their primary purpose in life. In terms of its scale and the expenditure of effort and resources, this activity is entirely disproportionate to the stated goal.

Even when their demands are met, their litigious drive simply redirects toward another similar objective, remaining the central focus of their existence. Sluggish schizophrenia features a relatively mild progression regarding the development of a psychic defect, allowing patients to maintain their work capacity and social relationships for a long time. However, years later, psychological impairment eventually develops.

Febrile (hypertoxic) form is rarely observed. Its course is characterized by high fever (hyperpyrexia), with body Temperature reaching 40°C or higher and persisting from several days to 3–4 months. Notably, no signs of infectious pathology can be detected. In such cases, the disease takes a severe course, frequently resulting in fatal outcomes. These conditions require urgent, intensive care interventions.

Symptoms of schizophrenia in dental practice.

Considering that this textbook has been written in accordance with the psychiatry curriculum for students of dental faculties in higher medical educational institutions, we find it necessary to examine in greater detail certain symptoms and syndromes of schizophrenia that a dentist may frequently encounter in clinical practice.

These are predominantly dysmorphomanic disorders, such as a patient's pathological conviction of having a physical deformity (usually a facial defect). Pathological symptoms may also manifest as a belief that they emit unpleasant odors, or as unusual sensations in the Oral Cavity (senesthesias).

Within THE SPECTRUM OF schizophrenia, dysmorphomania (dysmorphophobia) and the pathological conviction regarding unpleasant body odors typically emerge between the ages of 13 and 20. These morbid symptoms develop gradually and imperceptibly, taking the form of delusions or overvalued ideas, and rather rarely manifest as obsessions. As a rule, these symptoms are characteristic of continuous schizophrenia and are combined with neurosis-like, psychopath-like, and hypochondriacal disorders. Dysmorphomanic disorders generally begin with a sense of self-doubt, interpersonal difficulties, and a conviction of personal inferiority, which usually lacks any substantial grounds.

During the initial period, the dysmorphomanic syndrome may occupy a central place in the clinical picture. Characteristic features include a depressed mood and ideas of reference. As the pathological process progresses, dysmorphomanic disorders gradually recede or transform into other schizophrenic symptoms. In such cases, the ideas of physical deformity and unpleasant odors become, as it were, the thematic core of paranoid delusions.

In unfavorable courses of schizophrenia, these complaints quickly assume an overtly bizarre character. The drive to correct a physical defect is poorly expressed in patients with continuous schizophrenia, while abulic manifestations come to the fore in the affective sphere.

Ideas of "active correction of deformity" are most pronounced in patients with periodic (attack-like) schizophrenia. In some cases, this may be accompanied by suicidal ideation. Corrective plastic surgery is not recommended for patients with schizophrenia, as unpleasant sensations in surgical scars can serve as a trigger for the further development of psychopathological symptoms.

The condition of the oral cavity in patients with schizophrenia.

The condition of the Oral Cavity and the masticatory apparatus is inextricably linked to the general Functions of the organism. In schizophrenia, as a result of progressive abulia, patients cease to care for their Teeth and fail to seek timely dental care. Consequently, such patients frequently suffer from digestive disorders and intoxications. It is also well established that protein and Mineral Metabolism are disrupted in schizophrenia. All these factors deserve the dentist's close attention.

Reports indicate that dental diseases occur much more frequently in patients with schizophrenia than in healthy individuals. According to A.A. Nechaeva, dental caries was observed in 86.6% of schizophrenia patients, and periodontal disease in 55.2% of all examined subjects. Furthermore, periodontal manifestations were found to be directly correlated with the duration of the disease and were most frequently encountered in the catatonic form of schizophrenia (62.2%).

Prosthetic treatment in patients with schizophrenia presents significant challenges, particularly in those with apathetic-abulic disorders and a prolonged psychopathological process. All of the above underscores the necessity of organizing systematic dental care for this patient population.

Remissions in schizophrenia.

As noted above, schizophrenia may follow a continuous course—characteristic of the simple, hebephrenic, and hypochondriacal forms—or manifest as attacks followed by remissions, as seen in the catatonic, paranoid, and circular forms.

Remissions are categorized into four types based on their duration and quality:

Type A is characterized by the disappearance of psychopathological symptoms along with a critical insight into the past psychotic episode. This type of remission features virtually complete recovery.

It must be emphasized, however, that firstly, Type A remission is rarely observed, and secondly, even these patients exhibit certain, albeit mild, personality changes following the psychotic episode. With Type A, patients remain employable and can continue their previous work, except in cases where their occupation involves individual responsibility for the life, health, and safety of others (e.g., drivers, dispatchers, firefighters, surgeons).

Type B is characterized by the disappearance of psychopathological symptoms, yet without a critical insight into the experienced psychosis. Personality changes in such cases are more pronounced, and a residual psychic defect remains. Patients with Type B are also capable of working, but the range of available occupations is narrower than in Type A. Specifically, managerial positions are contraindicated for them.

Type C features a significant reduction in psychopathological symptoms, though some psychiatric impairments persist. Patients with Type C may be discharged from the inpatient facility and perform uncomplicated work.

Type D. This type involves in-hospital improvement, where psychopathological symptoms persist, but patients become calm, with an absence of affective tension and aggressiveness. Patients with Type D either remain in the hospital for further treatment or may be discharged provided they are under family supervision; they are unable to work.

Psychic defects in schizophrenia.

Typically, a psychological defect develops after the very first episode of schizophrenia. With each subsequent attack, it deepens, manifesting as blunted emotions and volition, as well as distinct thought disorders. Patients become untidy, apathetic, and withdraw from social life. This condition stabilizes over time, allowing clinicians to speak of a defective stage of schizophrenia. Against the backdrop of emotional and volitional deficits, various other persistent mental disorders may arise, enabling the identification of 6 distinct types of defect states:

I. The asthenic type of defect is characterized by lethargy, increased fatigability, aversion to any activity, and social withdrawal.

This type of defect is most commonly observed in the simple, catatonic, and hypochondriacal forms of schizophrenia. Such patients usually maintain critical insight into their condition and may remain employed, albeit with a reduced workload.

II. The psychopath-like type of defect can occur across all forms of schizophrenia. Patients are impulsive, eccentric, tactless, embittered, and prone to frequent conflicts with others.

They may be employed in isolated, individual work environments.

III. The paranoid type of defect. Patients behave secretively, guardedly, and with an air of superiority. Their thinking is overly detailed, with inordinate significance attributed to every minute detail; they are distrustful and suspicious of others, which severely hinders communication. This type of defect corresponds to the paranoid form of schizophrenia. Patients may be employed in individual work environments.

IV. The hypomanic type of defect is relatively rare and occurs primarily in the hebephrenic and circular forms of schizophrenia. Patients maintain a persistently elevated mood, are talkative and fidgety, and show a drive for active engagement, yet they easily abandon tasks they have started.

In mild cases of the hypomanic defect, patients are able to work satisfactorily. In instances of deeper mental deterioration, their activity becomes chaotic and uncontrollable, resulting in a complete loss of working capacity.

V. The anathemo-abulic type of defect is found in all forms of schizophrenia, most frequently in the simple and hypochondriacal variants. Patients with this type of defect are apathetic, inactive, emotionally flattened, and devoid of any interests or occupations. They either refuse food or overeat. Such patients are entirely unable to work.

VI. Mixed types of defect incorporate features of several defective manifestations. The prognosis regarding employability is unfavorable.

TREATMENT.

The mainstay of schizophrenia treatment involves The Use of psychotropic medications, Shock therapy, and psychotherapeutic interventions aimed at the social readjustment of patients. At the present stage, pharmacotherapy with neuroleptics (antipsychotics) occupies a central place among these Methods.

Indications for neuroleptic use depend on the predominance of their sedative or antipsychotic activity. Consequently, they are often prescribed in combination.

Agents such as chlorpromazine, levomepromazine, chlorprothixene, and perphenazine possess a broad spectrum of calming and antipsychotic effects. They can be combined with neuroleptics that have a targeted antipsychotic action. Combining neuroleptics with similar Mechanisms of action is generally inadvisable.

For instance, trifluoperazine, haloperidol, and pimozide exhibit a pronounced selective effect on delusions and hallucinations and can be combined with other neuroleptics for treating patients with paranoid schizophrenia. Meanwhile, thioproperazine and fluphenazine are effective in cases of catatonia.

For simple and hebephrenic forms, alimemazine or similar behavioral stabilizers are recommended to curb behavioral disorders, earning them the moniker of "behavioral correctors." For circular schizophrenia, chlorpromazine, levomepromazine, and haloperidol are recommended during manic phases, whereas antidepressants (such as imipramine and amitriptyline) are indicated for depressive phases.

In treating the hypochondriacal form, as well as sluggishly progressing schizophrenia, combinations of tranquilizers (such as oxazepam, phenazepam, chlordiazepoxide, and diazepam) and antidepressants are employed.

To exert a more active effect on the brain, neuroleptics can be combined with nootropics, such as piracetam, pyritinol, and memory-enhancing supplements. It should be kept in mind that the prolonged use of high doses of neuroleptics can lead to a range of side effects and complications, including neuroleptic malignant syndrome, parkinsonian syndrome, hypotension progressing to collapse, liver and Kidney damage, and agranulocytosis, among others.

To prevent Parkinson's syndrome—manifested by tremors of the head and hands, muscle rigidity (including the masticatory Muscles), and a mask-like facies—patients are given correctors of neuroleptic therapy (such as trihexyphenidyl or biperiden).

Treatment is conducted under daily blood pressure monitoring. If necessary, patients are prescribed injections of coramine. Following the administration of neuroleptics, they should remain in a recumbent position. Repeat blood and urine tests, as well as liver function assessments, are performed regularly.

Should complications arise, neuroleptic dosages are reduced. In cases where therapeutic resistance to neuroleptics develops, clinicians resort to so-called "zigzags"—wave-like reductions and increases in drug dosages. Toward the end of the treatment course, neuroleptic doses are tapered gradually to prevent a sudden physiological reaction, known as withdrawal syndrome, and disease relapse.

The treatment of hypertoxic (febrile) schizophrenia must be carried out in the intensive care unit of a psychiatric hospital, utilizing high doses of chlorpromazine (up to 400–500 mg per day), corticosteroids, dehydration therapy, Diuretics, Vitamins, and intravenous nutrient mixtures. Some authors recommend Antibiotics to prevent infectious complications. If the aforementioned measures prove ineffective, electroconvulsive therapy is applied.

Following the completion of the main in-hospital course of treatment, schizophrenia patients receive outpatient maintenance therapy consisting of low doses of neuroleptics, particularly long-acting depot formulations (such as haloperidol decanoate, fluphenazine decanoate, penfluridol, or pimozide).

MEDICAL AND Laboratory examination (EXPERT EVALUATION).

Medical-labor evaluation. Patients with simple and hebephrenic forms of schizophrenia, provided the course is continuously progressive, are assigned to disability group III, II, or even I, depending on the severity of the defect. In catatonic and paranoid forms, labor expertise is more variable due to the possibility of spontaneous remissions and a less progressive disease course. The defining criterion in such cases is the depth of remission.

Military Medical Examination. Patients suffering from schizophrenia are deemed unfit for military service and are discharged from military registration.

Forensic Psychiatric Examination. If individuals with schizophrenia commit unlawful acts while in a psychotic state or if the illness develops before the court delivers its verdict, they are declared legally insane and sent for compulsory treatment. Depending on the degree of danger they pose to society, this may involve general psychiatric hospitals or high-security psychiatric facilities. In the latter case, as their public danger diminishes, they are transferred to general psychiatric inpatient units for continued compulsory treatment.

Review Questions.

1. Definition of schizophrenia and The history of its study.

2. Etiological theories of schizophrenia.

3. Classification of schizophrenia.

4. Clinical manifestations of paranoid schizophrenia.

5. Clinical manifestations of simple schizophrenia.

6. Clinical manifestations of catatonic schizophrenia.

7. Clinical manifestations of hebephrenic schizophrenia.

8. Types of course of schizophrenia.

9. Types of remission in schizophrenia.

10. The concept of schizophrenic defect and its types.

11. Pharmacotherapy of schizophrenia.

12. Non-pharmacological treatment of schizophrenia.

13. Psychiatric evaluation of schizophrenia.