Biological Therapy for Schizophrenia

Schizophrenia is a disease that has a biological nature, its manifestations that eliminate the effects on the metabolism of biologically active substances in the brain.
Since the discovery of the first psychotropic drug aminazine in the 50s of the 20th century, there has been a revolution in the treatment of mental disorders, especially schizophrenia. Until that time, the most popular methods for treating schizophrenia were insulin therapy, electroconvulsive therapy and lobotomy. Drug treatment to a greater extent was symptomatic and usually included sedative drugs.

With the advent of neuroleptics, the possibility of chemical exposure to it and the elimination of symptoms appeared, whereas before such patients had to be isolated from society in anticipation of short-term spontaneous remissions.

Modern pharmacology, including in the open air. These drugs are called “neuroleptics” or “antipsychotics.” They have one thing in common – they all, first of all, eliminate the manifestations of psychosis: delusions, hallucinations, psychomotor agitation. The mechanism of their action is the blockade of receptors to the mediator – a biologically active substance of the brain – dopamine, thanks to this and the appearance of the antipsychotic effect of drugs. In addition, they have affinity for other receptors (for acetylcholine, adrenaline, serotonin, histamine), which explains a fairly wide range of their actions, including the occurrence of some side effects. There are many classes of neuroleptics that differ in chemical structure, which means that they affect the body in different ways, to a greater or lesser extent, affect the various manifestations of schizophrenia.

Action of neuroleptics

The actual antipsychotic action of neuroleptics is distinguished: the general effect on all manifestations of psychosis and the prevention of further development of the disease, and the selective effect on the productive symptoms (delusions, hallucinations, obsessive states, catatonia). Due to the sedative (retarding) action, antipsychotics are effective in various types of psychomotor agitation and insomnia. Some neuroleptics, on the contrary, have an activating effect, it is used in the treatment of negative symptoms (apathy, catatonic stupor, autism).
Cognitropic action is an effect on higher cortical functions (memory, attention, thinking, perception). Neuroleptics also have a neurological effect – they are associated with dopamine receptors, which are located in the centers of regulation of movements, which cause such side effects as muscle stiffness, restlessness, trembling limbs . These adverse events are eliminated by the appointment of correctors, such as cyclodol or akineton.

Neuroleptics also affect the autonomic nervous system and the endocrine system, which can manifest dry mouth, delayed urination, lowered blood pressure, decreased sexual desire, menstrual disorders, weight gain. In different groups of neuroleptics, the listed effects are expressed in varying degrees, and the use of a particular class of drugs depends on the form of schizophrenia and the characteristics of its course.

Recently, preference is given to the modern class of neuroleptics, which appeared in the 90s of the 20th century, the so-called “atypical” neuroleptics. They are atypical because, unlike previous generations of drugs, they practically do not have a neurological effect, i.e. do not cause side effects associated with movement disorders, which is a very valuable quality, because Movement disorders usually deliver great discomfort to patients and require the appointment of additional drugs-proofreaders. At the same time, modern antipsychotics are as effective in eliminating the symptoms of schizophrenia as the old drugs. Another advantage of atypical neuroleptics is their positive effect on cognitive function (cognitotropic action), which was not the case with drugs from previous years; due to binding to serotonin receptors in the brain, atypical antipsychotics also have an antidepressant effect.

Modern drugs are easy to use – the characteristics of their distribution in the body are such that they can be taken only once a day. With regular intake, the drugs begin to fully operate in 2-3 weeks, so they need to continue to be taken, even if at first glance there is no expected effect. However, at the peak of the drug’s action, not all symptoms of the disease can be immediately eliminated, for a complete reduction of symptoms and for the prevention of recurrence of the disease, medicines should be drunk on average for two years.

For the convenience of long-term use of drugs released prolonged forms of neuroleptics in the form of injections  – one such injection lasts for 2-4 weeks. In addition to the elimination of specific schizophrenic symptoms, it is useful to have a general strengthening treatment, since the disease is usually accompanied by general disorders of the nervous system. For this purpose, drugs that improve metabolism in the nervous tissue are used: picamilon, mexidol, cerebrolysin, milgam, mildranate, gliatillin, nootropil.

Drug-resistant Schizophrenia Therapy

The main problem that may arise during the treatment of schizophrenia is drug resistance (resistance). This phenomenon is rare, however, it can occur in certain forms of schizophrenia, metabolic features of the patient, or prolonged and inadequate treatment with psychotropic drugs. In such cases, as well as to break the acute attacks of schizophrenia with delusions and catatonia, electro-convulsive therapy (ECT), insulin-comatose therapy, hemosorption and plasma exchange, laser irradiation of blood are used.

Electroconvulsive therapy sessions are performed in the intensive care unit under general anesthesia to minimize the risk of complications. Electrodes are applied to the patient’s head and artificially cause a convulsive fit. The treatment includes 4-8 sessions of ECT, patients completely forget seizures, and the effectiveness of this method can be quite significant. Another method of shock therapy for schizophrenia is insulin therapy. This technique is based on the introduction of insulin doses to achieve a hypoglycemic coma (loss of consciousness due to a decrease in blood sugar), 10-20 minutes after reaching the coma, the patient is removed from it by intravenous administration of a glucose solution. In order to break the attack of psychosis requires 10-20 sessions.

Sometimes it is effective to use detoxification (purification from toxins) of an organism using hemosorption or plasmapheresis. The blood of the patient is driven through a special apparatus, where it is cleaned of toxins, immune complexes, in the case of long-term drug therapy – of drugs. This can help both to reduce the manifestations of productive schizophrenic symptoms and to overcome drug resistance due to the “cleansing” of receptors. Similar exposure has blood irradiation with a laser.

The listed methods of the so-called “non-medicinal” therapy are used in extreme cases of intolerance, drug resistance, or for the termination of acute psychosis. In all other cases, there is enough drug therapy. Also, for greater efficacy, a combination of drug therapy with non-drug therapies is possible.

With the modern development of psychiatry, when it is possible to conduct therapy with modern drugs, with timely access to a doctor (no later than 2 years after the first symptoms of the disease appear), with prescribing adequate drug therapy and following the regimen of drugs, it is possible to conduct effective treatment with a minimum of side effects elimination of schizophrenic symptoms and defects that the disease managed to cause the patient’s personality. With a long-term disease it is possible to achieve a significant improvement in the condition and prevent further development of the disease process.

At the same time, a single biological therapy for effective treatment of schizophrenia is clearly insufficient and requires mandatory psychotherapy (individual, group, family), psychological correction of memory disorders, attention, thinking, as well as a set of social measures aimed at rehabilitating a person suffering from this disease.

Pregnancy during schizophrenia: complications and recommendations to relatives

Pregnancy during schizophrenia

In recent years, women with schizophrenia are not afraid to have children and successfully perform the functions of mothers . This is due to the new principles of treatment and care for such patients, as well as the use of atypical antipsychotics.

It is difficult for a psychiatrist to lead such pregnant women, it is also difficult for gynecologists. There is a risk of complications for the mother and fetus, and it is caused both by the possibility of recurrence of schizophrenia, and the effect of psychotropic drugs on the fetus.

It is known that for the first fifteen years after the onset of schizophrenia, a woman leads an active social and sex life. And pregnancy does not protect and does not protect against exacerbation of the disease. A woman may refuse to take psychotropic drugs, but the risk of relapse is great.

Schizophrenia can begin during pregnancy, but such cases are rare. Most often there are personality disorders. But if schizophrenia occurs during pregnancy, then the further development of psychosis will be unfavorable. In such patients, preterm labor is more often recorded, and the child has a low body weight.

Schizophrenia can cause congenital abnormalities and perinatal mortality. Patients with schizophrenia are advised to become pregnant one year after the onset of this disease. Hormones can be a means of contraception ( depomeroxyprogesterone ), but against the background of their administration, relapses of schizophrenia or depression are possible.

Oral contraceptives can interact with nicotine and psychotropic drugs ( clonazepine ), increasing the level of their concentration in serum. The use of first-generation antipsychotics, such as haloperidol , is considered safer than taking atypical antipsychotics.

The abolition of antipsychotics in the first 6-10 weeks of pregnancy can be practiced only in patients with mild forms of schizophrenia. Antipsychotics should be used in the minimum effective dose, while controlling the level of the drug in the blood. When treated with olanzapine and clozapine, CYP 1A2 activity of cytochrome P450 decreases during pregnancy.

Hallucinations and delusions as the symptoms schizophrenia

Hallucinations and   rave   – This is one of the main signs of acute mental disorders. Wrong to call them   only signs of schizophrenia , since they can accompany and   other mental illnesses . That is why in the treatment of a patient with similar symptoms, it is imperative that a thorough medical examination   differentiated diagnosis.

But   here we   Consider these phenomena precisely in   within this disease, where they are positive ( productive) symptoms of schizophrenia. Thats   there is   picture of the disease appears   what is not   maybe u   man in   norm

Let’s start with   that hallucinations and   delirium in schizophrenia   These are signs of acute psychosis that require immediate treatment.   qualified psychiatric care . Need to remember that on   further course of the disease affects   how timely and   its acute manifestation was stopped. The faster the patient’s relatives take care of   rendering assistance, the more favorable the prognosis. A gross mistake is   what   for some reason, relatives expect that the symptoms of schizophrenia will disappear   yourself, or about   there is simply no one to take care of the patient, and   then the acute psychotic state continues to progress. Naturally in   In this case, it is becoming increasingly difficult to stop it.

Hallucinations at schizophrenia

When diagnosing schizophrenia, auditory hallucinations are most often detected when a person hears those   or other sounds or voices that are not in   objective reality. Voices most often first comment on a person’s actions, then they can begin to criticize him, threaten him, and   by   as psychosis unfolds, even ordering to commit those   or other actions. It is very dangerous, in   first of all, for the patient himself, since he   can harm itself or people surrounding it, trying, for example, to be protected from   not   existing objectively but   available in   his distorted picture of the world, danger.

Signs of hallucinations :

  • the man suddenly becomes silent, starts to to listen to anything
  • talking to myself (here, naturally not   include man’s thinking out loud or comments on   about anything he   perceives or experiences in   currently in   reality, for example, “Where   did this book disappear … “) ,
  • sudden , causeless laughter,
  • increasing closure, inability to focus on

Crazy disorder at schizophrenia

Rave   – one more of   acute signs of schizophrenia. These are certain beliefs of a person or his conclusions that are not   match what surrounds it in   reality. This is the most inconsistency of reality   – one of   The first signs that an idea, a belief are delusional. The second feature of delirium   – her   sustainability and   the fact that no third-party reasonable counterargument given ideas   give in

According to statistics, order   80% of people with schizophrenia? suffer from various kinds of delusions.

By   Crazy ideas can be different in their content. So, classified:

  • Delusion of relationship (observed most often). The person feels like the center of all the phenomena around him and   events: the actions of all, even completely unfamiliar and   randomly passing people expressing them   persons driving past cars and   other things.
  • Brad of pursuit when the patient is sure that certain people / people / organizations intend to cause him some damage, are watching or are already causing some harm (neighbors are poisoned by gas, relatives pour in   food poison   and   other).
  • Nonsense effects (mental or physical), when a person is convinced that his thoughts, actions, experiences are not connected with   his inner personal motives as well   are the result of the influence of some external force: witchcraft, hypnosis, cosmic rays.

Less common but   So   other types of nonsense can occur.

The productive symptoms of schizophrenia may increase gradually or appear suddenly. Regardless   the rate of unfolding of such an acute condition in schizophrenia, you must immediately apply for   medical care. Remember: a person with such manifestations of the disease is often not   able to ask about   aid because the picture of the world and   perception of his own state for him is very much distorted. Especially if this is the first attack, the manifestation of schizophrenia.

High-quality relief of such conditions is impossible outside the hospital. The sooner assistance is provided, the more favorable the further forecast will be.

Recommendations relatives the sick schizophrenia

what to do if a loved human schizophrenia

What should be the sequence of your actions if   whom   Something   of   do people close to you have schizophrenia? Talk to   an experienced doctor. Remember that timeframes play an important role and   in   largely determine the success of therapy. The most common treatment for schizophrenia is to start at   hospital, it should include   making an accurate diagnosis, since there are quite a few options for the manifestation of schizophrenia. It is desirable that the situation around the patient with schizophrenia should be calm (one or two local chambers), so that the doctor who assists should master modern methods of psychotherapy. It is unacceptable to provide the patient with schizophrenia to himself, to exclude that   activity that was interesting to him. Schizophrenic activity should be encouraged by qualified personnel who know not   only medicine but   and   psychology. AT   In some cases, it is important to strengthen the strength of the patient with schizophrenia, choosing a good nutrition for him, adequate physical therapy, massage , physiotherapy and   balneotherapy Around a schizophrenic patient should not be   only experienced doctors but   and   specially trained psychologists, social workers.

how to lead yourself with the sick schizophrenia

It is known that the course of schizophrenia is chronic, i.e. stretched in time. Despite the ongoing treatment (even with modern drugs), mental and behavioral disorders in schizophrenia are marked for a long time. Proper treatment of the patient by his close environment has a significant impact on the outcome of therapy.   Below is a list of some techniques available to everyone that facilitate rehabilitation .

Do not rush. The process of restoring health can be lengthy.

  • Keep calm. Excessive enthusiasm is normal, however, try to temper it. Dissent is also common. Try to take it easy.
  • Explain easier. Say what you want to say clearly, calmly and confidently.
  • Set limits. Everyone should know the rules. A few simple rules will help put everything in its place.
  • Follow the doctor’s instructions. It is necessary to take medications as he prescribed, and only those that he prescribed.
  • No drugs and alcoholic drinks to the patient.   schizophrenia! They aggravate the symptoms diseases .
  • Pay attention to all changes in well-being. If possible, write down and report them to the consulting physician.
  • Solve problems step by step. Make changes gradually. Work on one thing.
  • Let’s rest each other. Everyone needs a break. You are tired of something – it happens. Fine also sometimes to say “no.”
  • Do not think about what you can not change. Something needs to be left as it is. but not leave without attention manifestations cruelty .
  • Do all your business as usual. Restore the usual order of housework. Support connection with by their relatives and friends .
  • Temporarily lower your expectations. Use your own impressions, comparing the results of treatment (rehabilitation) of the current month with the previous one.

 

Aggression in Schizophrenia: what to do ?

What to do?

The links that arise between schizophrenia and violence are shown schematically in fig.2. How can these bonds be broken?

It is tempting to draw up some ideal scheme for easing or eliminating violence as a complication of schizophrenia. Of course, ideally, it would be advisable to early identify inadequate education and take measures to eliminate the causes of this in all children, and not only in 0.5–0.8% who may develop schizophrenia. Similarly, problems in interpersonal relationships, behavioral disorders and inadequate performance by parents of their duties would be desirable to consider in childhood in order to eliminate these causes or at least weaken their influence. Some researchers call for the detection of pre-psychotic states and early intervention ( McGorry et al , 2005). But the impact on these complex phenomena goes far beyond our capabilities as doctors, and probably also – until more compelling data is obtained in favor of the effectiveness of early interventions – beyond our ability as scientists to effectively support them. Then what are the clinical implications for everyday practice?

Modified installation

It is time for the psychiatric community to agree that aggressive and antisocial behavior is a possible complication of the current schizophrenic syndrome.With the recognition that the problem of violence is our sphere, it will be possible to take measures to eliminate its causes.As long as the problem of violence is minimized or ignored as “non-disease related,” it is impossible to make any progress in reducing the risk.It is necessary to recognize individuals at high risk, although they make up less than 10% of the population of schizophrenic patients, and give a correspondingly high priority to organizing the treatment of their disease.But how can they be recognized?

Early detection of high-risk patients

Individuals who are at high risk of violence in the future should be identified, avoiding abusive stigma: it is necessary to ensure that the identification process as the primary clinical task is consistent with the mitigation of their risk factors.Risk assessment is not some kind of mysterious technology that requires expensive specialized training.This is a practical work that should be simple, clinical, multidisciplinary and should be systematically carried out.

SimpleThe high-risk group includes a huge number of young men who have a history of childhood behavior disorder, antisocial and aggressive behavior during adolescence, substance abuse , unemployment, and a disorganized lifestyle.

Clinical.The risk increases dramatically with individuals who show anger and suspicion, are unable to understand the essence of what is happening, reject the therapy, threatening and thoughtless.Specific delusional syndromes, especially jealous rage, dramatically increase the risks – just as much as personality traits such as heartlessness and the conviction of the right to impunity.

Multidisciplinary.No professional group has a monopoly on the knowledge necessary for risk assessment, so everyone must make an appropriate contribution.The current behavior in the hospital, social conditions, mental state, assessments of personality traits and level of intelligence, as well as, most of all, a carefully collected history have a certain meaning.

Systematic. The need for risk assessment in psychiatric practice has led to the development of a variety of tools with widely varying accuracy. This is not the place to discuss the quality of the various checklists. It is best to use dynamic as well as static variables, which will allow you to recognize which factors may be targets for their elimination. Their primary appointment for the doctor is to direct attention to the known correlates of aggressive behavior. Evaluation tools allow you to identify risk groups. However, they do not help with an acceptable probability of error to indicate the chances that a particular individual at high risk will be violent. Therefore, they can be considered good tools for assessing needs and bad ones for justifying checks for the purpose of applying punishment. Evaluation tools, such as HCR – 20 ( Webster et al , 1997), which includes a checklist of questions for evaluating psychopathy, allows us to structure the specialist’s approach to risk assessment, while at the same time not going beyond common sense and leaving room for the application of clinical knowledge.

General principles of patient management

Many high-risk patients are young, substance abusers , treatment-rejecting and disorganized.The organization of treatment for these individuals with schizophrenia depends on whether they have managed to achieve complete abstinence over a sufficiently long period from the use of cannabis and other psychoactive substances that patients have abused.There is little point in hospitalizing for several days or even a couple of weeks, since in most cases the patient will still be under the influence of psychoactive substances that he abuses.

Similarly, hospitalization is unlikely to succeed if the patient has the opportunity to regularly leave for a local dealer or receive visitors bringing him drugs.The effectiveness of treatment depends on prolonged hospitalization (4–8 weeks), which may initially involve the patient in a closed ward.After discharge, few individuals in this group will comply with the regimen of medication, they are also unlikely to voluntarily remain in the housing in which they are supervised.Court guidelines for community treatment may help to adhere to the regimen of medication, but where it is possible, preference is given to the depot preparation.

Given the need to minimize side effects, especially akathisia and dysfunction of the frontal lobe, which may accompany the neuroleptic deficiency syndrome, the second generation of atypical antipsychotic drugs should first be prescribed ( Swanson et al , 2004). At present, choice is limited to deporisperidone , at least until the deposited forms of other atypical preparations become available.

Coercion is unlikely to achieve the desired goal in the long run.If you try to deprive these adolescents of the psychoactive substances they use, alcohol, and the only peer group they have known for a long time and impose drugs on them that they do not believe in and consider them unnecessary, then you must provide them with some substantial compensation. .In the short term, in order to provide different types of activities and to structure their lives, they will need improved housing, regular support from specialists, with whom they have developed good relations, and investments that they value.In the medium term, their cooperation can be supported by programs to improve social interaction, improve production skills, provide recreational activities and play sports.The debt o- term plan for these individuals if they are unable to establish a structured and bring joy to the life of (this applies to employment, leisure or group itself (inter) aid) to remain constant risk of relapse of substance abuse, lower social level and the risk of crime .

A minority of high-risk patients will experience systematic paranoid delusions.At first glance, it seems that they are less of a problem, or at least more familiar, since the main mediator of risk are the symptoms of the disease.However, in fact, they are at least equally suspicious and often do not openly follow the healing recommendations.Perhaps because of the sense of superiority divorced from reality, it is more difficult to interest them and they are more undermining the strength of specialists.In addition, these patients need inpatient medical care with rehabilitation, the use of depot preparations and the subsequent persistent observation of a physician, especially when the coverage of delusions is rather slowly losing its strength, if at all.They, like any other disorganized group, should be assisted in the formation of social skills, the development of responsiveness in interpersonal relationships, in developing an ability to manage anger and, most of all, in effective social reintegration .

Organization of events for the provision of social assistance and labor rehabilitation

Patients at high risk who leave the hospital need permanent housing in areas with low crime rates. This elementary and obvious recommendation seems hopelessly idealistic because of resistance to dormitories, “halfway houses” (institution for the rehabilitation of prisoners who have served their sentences, cured drug addicts, alcoholics, the mentally ill – ed .) diseases, not to mention “perpetrators with mental disorders,” in more privileged areas.The community should not continue to push an undesirable individual to the places where the commission of a repeated offense is in fact predetermined.

Individuals with schizophrenia and a high risk of violence upon returning to the community need both a structural and an active supportive lesson.Repeated offenses are committed less frequently due to employment, stable relationships and mixing with non-criminal peers.The formation of work skills in unmotivated, poorly educated individuals with schizophrenia, who have not had experience in the past, is of great importance.And after the closure of hospitals in the 1960s – 1970s, psychiatric services responded adequately to the problem of rehabilitating patients who were long-term in closed psychiatric institutions.Perhaps the time has come to treat the problem of young people with disabilities who belong to a high-risk group with the same seriousness.

Psychological treatments

Disorders in development, hereditary predisposition and the schizophrenic process itself form in some individuals characteristic features and attitudes that can be called criminogenic.Restricting the ability to exercise violence largely depends on the modification of these factors and the forms of behavior that these factors engender.

Under any circumstances, deep skepticism about the effectiveness of treatment of severe personality disorders persists, especially if they are part of the schizophrenic syndrome. This is partly due to the fact that the favorite methods used recently, for example, dynamic psychotherapy techniques, psychotherapeutic communities, individual work with patients and simplified behavioral psychotherapy techniques, were either ineffective or complex statistical methods were required to prove any of their effectiveness. with special justification. Personality disorders as nosological units are usually incurable, but many components of these disorders are open to modification and improvement. In patients with dangerous manifestations of schizophrenia, it is often possible to improve interpersonal skills, control anger, develop a constructive sense of self-confidence, strengthen sympathy for the victim, and eliminate or mitigate cognitive distortions that support destructive behaviors ( Novaco , 1997; Renwick et al , 1997). You cannot form a harmonious strong pro-social personality, but you can reduce the chances of antisocial behavior in the future ( Hollin , 2003; McGuire , 2003).

Substance Abuse

Evaluation of the abuse of alcohol and other psychoactive substances in individuals with schizophrenia willy-nilly becomes the top priority. Currently, in individuals with a high risk of violence, substance abuse is almost a universal phenomenon, therefore, effective control of it will be a necessary (preliminary) condition for any other treatment. This is not the place to analyze or recommend specific approaches to substance abuse , except that it can be repeated that it should be given the same clinical priority both at the place of residence and in hospital conditions, as well as eliminating or alleviating active psychopathological symptoms. In our service at Thomas Hospital Embling we use numerous approaches aimed at obtaining optimal results, considering the patient’s willingness to change and working within the framework of the concept of harm minimization ( Stanton & Shadish , 1997; Sheils & Rolfe , 2000; Mueser et al , 2003). Substance abuse may not be the main driver of violence in individuals with schizophrenia, but as long as it doesn’t decrease or, I dare to hope, it will not stop, no other preventive method will give a chance for success.

Restructuring of therapeutic goals and help systems

Whatever the theory claims, psychiatric services, especially under pressure, focus primarily on controlling the symptoms of the disease.The fact that this is always enough is doubtful, but in high-risk groups this is absolutely not enough.Substance abuse, personality weaknesses, and social conditions necessary to give equal, if not control psychopathology priority, then at least they should be an essential part of the treatment process.In part, this will depend on new resources, but equally it will require a change in the priorities of mental health services and the expectations of doctors.In order for such therapeutic goals to be completely transformed into a sustainable system of medical care, it will need restructuring and retraining of the specialists working in it.

In order to address the issues of criminality and substance abuse in schizophrenia to have a chance of success, not only the introduction of several special programs should be envisaged – the patient must be fully embraced by the desire for change. The main thing for such a system is the active participation of nursing staff working in the department and at the place of residence of the patient. Top nurses should be aware of and participate in their patient programs. All staff in the department and outpatient services who will interact with the patient should be aware of the current goals and methods of patient management in order to reinforce the work performed during individual and group psychotherapy. Psychotherapy sessions should not be a “black box”, a mysterious act. They should be transparent, correspond to the descriptions in the manual, and the questions “why”, “what” and goals should be known not only to the psychotherapist and the patient, but also to all relevant personnel on a daily basis. This approach provides for significant changes in the established order and power. Nursing staff is central to the therapeutic process; psychologists play a much larger role in evaluating and developing programs for specific patients; social workers and occupational therapists (by Standard Occupational Classification System – SOC: they plan, organize and implement programs aimed at restoring the abilities to work, manage the household and everyday life, and also contribute to the overall independence of people who are unable to work for any reason; included in the section “diagnosticians and medical practitioners” – approx. ed .) occupy a more important place, especially in the management of patients by place of residence. Such changes are a challenge for psychiatrists who, succumbing to temptation, will focus only on the symptoms, thinking only about the problems of the disease. However, if the system should work, psychiatrists should play the leading role, and only by making the biopsychosocial ideology of modern psychiatry a reality , such an approach will achieve the goal.

The effectiveness of introducing such a system into our court hospital and community services has been evaluated in the state of Victoria over the past 18 months. This system is already associated with a reduction in cases of violence in wards and a sharp increase in the duration of work of nurses. However, not in forensic psychiatric, but in general psychiatric services, such restructuring should give the greatest dividends for patients and the wider community of people.

FINDINGS

Schizophrenic syndromes are associated with a high incidence of aggressive behavior. Psychiatric services should work to prevent such incidents for the sake of their patients, as well as for the wider public. In most cases, violence among individuals with schizophrenia occurs in relatively small subgroups, which probably constitute no more than 10–15% of the patient population. These high risk subgroups can be recognized well in advance. However, it is important that even in these subgroups only a few ever commit serious acts of violence. This is the basis for applying risk management techniques that complement medical care and treatment of the entire group, rather than justifying the use of coercive methods and disability to individuals. Violence on the part of representatives of high-risk groups is caused not only by active psychopathological symptoms, but also by such factors as personality weaknesses, a change in social status, and concomitant substance abuse .

In order to prevent future violence, approaches aimed at characterizing the criminogenic personality, meeting the need for employment and / or structured activities, at eliminating substance abuse , as well as promoting a network of adequate and supportive social connections and relationships are necessary . It is problematic to continue tolerating the situation when marginalization occurs individuals at highest risk of aggressive behavior or openly rejected by various services. To suggest that they necessarily receive better help only because the likelihood of patient aggressive behavior is higher is problematic to the same extent. However, as soon as we, as mental health professionals, are prepared for the fact that coping with violence is part of the real goals of our work, the problem will become an issue of an adequate level of medical care and treatment for specific violations, and not the best or worst services for any particular individual .

Aggression in Schizophrenia: mediators of agression

Substance Abuse

A great many people, especially in the USA, believe that the main stimulant of crime and violence in individuals, both with and without mental illness, is substance abuse . Epidemiological data on schizophrenia confirm the correlation between substance abuse and criminal activity (Swanson et al , 1990; Steadman et al , 1998; Soyka, 2000; Steele et al , 2003; Wallace et al , 2004).

Individuals with schizophrenia who abuse alcohol and other psychoactive substances are currently responsible for the majority of offenses, and data from some studies suggest that the incidence of violence among individuals with schizophrenia, but without problems associated with the use of psychoactive substances, is not higher. than in control population samples ( Monahan et al , 2001). The authors of the influential MacArthur study even believed that schizophrenia without concomitant substance abuse is a protective factor against aggressive behavior ( Steadman et al , 1998).

Given the authority of Steadman and his co-authors, this judgment has become generally accepted. However, as mentioned, amending the mediating factor actually amends the effect of schizophrenia. Moreover, you can conclude that the very substance abuse is a causative factor only after excluding the possibility that violence, and substance abuse are mediated – wholly or partly – a common third factor torus.

The most likely candidates for such a third factor are personality traits. and / or social conditions.

The McArthur study concluded that individuals with schizophrenia who did not abuse psychoactive substances were no more aggressive than other members of society, was refuted by research results that explored larger groups of individuals who did not abuse psychoactive substances (Vevera et al , 2005).

For example, a study of 2,861 individuals with schizophrenia, consistent with the population control group and first hospitalized over a 25-year period, showed that although during these years the incidence of known cases of substance abuse among patients increased from 8 to 27%, the conviction rate for violence increased only moderately (from 6 to 10%), which corresponds to an increase in the control group (from 1 to 3%) ( Wallace et al , 2004). In this article, it has been suggested that over the past 30 years, more and more people with schizophrenia who are prone to violence have begun to abuse psychoactive substances, and not that the incidence of violence manifested by schizophrenic patients has increased in accordance with the increase in the level of substance abuse . This explanation is supported by the results of a study conducted by two groups: Tengström and his colleagues. (2004), as well as Vevera and his colleagues (2005).

Reducing the incidence of substance abuse among individuals with schizophrenia is an important therapeutic goal, essential for improving both the control of symptoms of the disease and the quality of life. Although this will almost certainly contribute to reducing the number of cases of antisocial behavior, this is far from a panacea for violent inclinations.

Deinstitutionalization

If you believe the popular press and some politicians, the root of the problem of crime among people with severe mental disorders is in deinstitutionalization and in the insolvency of community health care. In a single study that examined the problem of crime among individuals with schizophrenia during the period of deinstitutionalization and the introduction of community health care, there was no evidence for an increase in the number of offenses compared to their frequency in the general population ( Mullen et al , 2000; Wallace et al , 2004). True, it must be admitted that this took place in the locality in which adequate funding was provided for the transition period, and during the study it remained an integrated service rationally provided with sufficient resources. Studying a less organized and worse funded deinstitutionalization process could have other results. However, this illustrates only that ineffective assistance – at the place of residence or in a psychiatric hospital – gives unfavorable results. There is currently no scientific basis for attributing to the deinstitutionalization any increase in crime. Those of us who have worked in large psychiatric hospitals know that their strong point was the strict formation of institutionalized groups and not representing the risk of incapacitated, rather than antisocial and aggressive patients, who then, as now, often ended up in prison.

Active psychopathological symptoms

Considerable clinical experience and numerous literature data confirm the link between active psychopathological symptoms and antisocial behavior, although not all studies support the role of such specific manifestations as delusions and hallucinations ( Hafner & Boker , 1982; Taylor , 1985; Appelbaum et al , 2000; Arsenault et al , 2000). Negative symptoms can perform the protection function even hydrochloric (Swanson et al , 2006).

The assessment of the role of active psychopathology in the manifestation of violence in individuals with schizophrenia, in my opinion, is overstated, but the fact that it plays a certain role is beyond doubt. For example, evidence of a link between jealous rage and assaults against a partner is fully proven, and persecutory delirium, hallucinations, and nonspecific psychotic arousal sometimes provoke violence ( Mullen , 1996; Foley et al , 2005).

A model of two types of violence in schizophrenia is gaining increasing support ( Steinert et al , 1998; Gje et al , 2003). Individuals who demonstrate the first type of violence usually have a systematized nonsense associated with violence, they do not have clear anamnestic data on behavior disorder or offenses during the period of adulthood, they usually commit the first violent crime after admission to treatment, almost always attack a person who assists them or cares for them, or for a friend, and – perhaps most importantly – they are “similar ” to the sick.

Individuals with the second type of violence usually have disorganized clinical syndromes, a history of behavioral disorder, early onset of substance abuse , and, as a rule, they commit violent and non-violent offenses before diagnosing mental disorder, resorting to violence in the family and outside the home and “Similar” to criminal offenders. Most cases of violence among individuals with schizophrenia can be attributed to the second type, although it is possible that the first type of violence is over-represented among the killers.

Consequences of psychopathological symptoms in schizophrenia

Some disorders that make up the schizophrenic syndrome are found from an early age. Schizophrenia can affect the risk of aggressive behavior through three types of vulnerability.

  • the types of vulnerability that precede the development of active psychopathological symptoms;
  • types of vulnerability acquired due to the active course of the disease;
  • types of vulnerability imposed by the results of ongoing treatment and management.

Of the examples listed in Box 1, attention should be paid to the early onset of substance abuse , since one of the most common clinical errors is the diagnosis of psychosis caused by these substances in individuals with schizophrenia, in whom the abuse was preceded by the appearance of overt psychotic symptoms.

Development factors

Violent individuals with schizophrenia are more likely to develop than those who do not manifest themselves and those in the general population.

As a result, in childhood and younger adolescence, the former are at a disadvantage. They are more likely to come from disadvantaged with e- Mei, which have been deprived of parental care, they observed growth retardation, there were problems in school and poor peer relationships in childhood and adolescence, criminal histories from family members (Schanda et al , 1992; Tiihonen et al , 1997; Fresan et al , 2004).

Childhood disorder (according to anamnesis), which probably partly reflects the sequence of such factors, is much more often diagnosed in people with schizophrenia who will be violent, and serves as a powerful predictor of such behavior ( Hodgins et al , 2005). Yet such a strong connection seems to be that it uses both ways: individuals with a behavioral disorder and delinquency of juveniles have a history of increased risk of developing schizophrenia in later life ( Gosden et al , 2005).

Box 1. Vulnerabilities that can predispose to violence in schizophrenia

The types of vulnerability that precede the development of active psychopathological symptoms:

  • developmental disorders;
  • asocial traits of character;
  • insufficient education;
  • increased frequency of behavior disorder;
  • non-socialized delinquency ;
  • early onset of substance abuse .

Types of vulnerability acquired due to the active course of the disease:

  • active psychopathological symptoms;
  • degradation of the individual;
  • change in social status;
  • substance abuse ;
  • unemployment.

Vulnerabilities caused by:

  • side effects of drugs, especially akathisia and neuroleptic deficiency syndrome;
  • excessive insulation;
  • loss of social skills;
  • imprisonment.

Current social context

Individuals with schizophrenia often do not form the working skills and social roles of an adult individual even before diagnosing their disorder. Once established, schizophrenia is associated with unemployment, which usually leads to a precarious financial situation and a decline in social status. This usually leads to marginal existence, characterized by poor living conditions, if not homelessness, in socially disorganized neighborhoods where substance abuse, interpersonal conflicts and crimes are common. The risk of violence in individuals with severe mental disorders appears to increase dramatically in those who are discharged from hospital to areas with a high crime rate (Silver, 2000; Logdberg et al, 2004).

Personal factors

Currently, strong evidence has been obtained that personality traits serve as mediating factors for criminal activities in schizophrenia (Moran et al, 2003; Nolan et al, 1999; Moran & Hodgins, 2004; Tengström et al, 2004). In part, the connection is incomprehensible because of the terminology used to describe the weaknesses of the personality of individuals with schizophrenia, unlike those of offenders.

The psychopathic traits of a repeat offender-offender are vividly described as follows: lack of remorse and remorse, search for novelty, impulsivity and heartlessness. On the contrary, to describe the personality disorders observed in schizophrenia, the following expressions are used: flattened affect, lack of empathy, lack of realistic long-term goals, irresponsibility, excessively high self-esteem and hypersensitivity.

In fact, representatives of both groups show irritability, tendency to asocial actions, indifference (or blindness) to the feelings and interests of other people, suspicion and negativity, express ideas of greatness, unrealistic beliefs about their rights and inability to learn from experience. The main thing for the emergence of manifestations of violence are both the type of personality, against which the psychosis manifests, and the negative effects of the schizophrenic process on the person.

SCHIZOPHRENIA AND AGGRESSION: STATISTICAL CORRELATIONS

Individuals with schizophrenia make a significant contribution to violence in our communities and often destroy their own lives. Approximately 10% of those who will become perpetrators and commit the majority of serious aggressive actions can be identified in advance. A structured program that deliberately influences the criminogenic personality and behavioral factors on the abuse of psychoactive The substance so you, as well as a change in social status along with active psychopathology disorders, would help prevent violence. Such a system of medical care would significantly reduce the number of violent crimes and cases of murder, reduce the number of schizophrenic patients who are in prison, stop the increase in the number of forensic psychiatric beds and, most importantly, improve the lives of many mentally ill, most troubled people. and disadvantaged.

In this article, I intend to continue the discussion of schizophrenia and violence in order to find out what exactly mediates this connection and, more importantly, how to prevent violence. First, I will provide current data in support of the essential and clinically significant connection between schizophrenia and violence. Then I will review the research on the factors that serve as a link between the presence of schizophrenic syndrome and antisocial behavior. Finally, I will describe possible ways of modifying modern clinical practice and making additional changes to it in order to break the connection between the presence of schizophrenia and aggressive behavior.

Correlations

There is a correlation between the presence of schizophrenic syndrome and more frequent manifestations of antisocial behavior in general and violence in particular ( Hodgins , 1992; Hodgins et al , 1996; Wallace et al , 1998; Angermeyer , 2000; Arsenault et al , 2000; Walsh et al , 2001). Currently, there is a huge amount of evidence that such correlations are significant not only statistically, but also clinically and socially ( Hodgins & Müller-Isberner , 2004).

Why is this connection, if it is so obvious, not widely recognized among doctors and service organizers? Equally puzzling, and why so many researchers and experts in this field (sometimes I) either made it difficult or minimized the significance of correlations in fact to nothing to do with the case?

Research results show that in prisons in all Western countries, 5–10% of people awaiting trial for murder suffer from schizophrenic disorder . The true incidence of schizophrenia among murderers seems to be closer to high swing rates, since almost all studies have systematic errors that underestimate the degree of connection. Taylor and Gunn (1984 a , b ) in their study, which remains one of the most methodologically robust, concluded that 11% of murderers and 9% found guilty of non- lethal violence suffered from schizophrenia. The results of follow-up studies using large samples of people suffering from schizophrenia confirm high rates of violent crime ( Soyka et al , 2004; Wallace et al , 2004; Vevera et al , 2005; Swanson et al , 2006).

On the contrary, doctors may never meet at their reception a patient who committed murder or brutal violence against other people. Up to 10% of murderers suffer from schizophrenia, but the annual risk that a schizophrenic individual will commit a murder is about 1 in 10,000, and the risk that he will be convicted of using violence is one out of 150 ( Wallace et al , 2004). There is an obvious paradox, because the manifestations of extreme aggressiveness, especially the murder, are much less common in our community than most people realize. The annual frequency of homicides in the UK is about 1 per 100,000 population, so even a tenfold increase in risk among individuals with schizophrenia will not necessarily impress the individual doctor, although it will most likely affect society as a whole.

People with schizophrenia often resort to minor verbal abuse and threats of physical violence or try to strike or threaten to do so (5–15% per year), but doctors often do not present this as manifestations of the disease, but as situational, due to personality characteristics or provoked by intoxication. The problems caused by antisocial behavior remain hidden from doctors in the future, because many of those who have committed an offense turn out to be invisible behind prison walls. In prisons, the frequency of schizophrenia is 10 times higher than the average ( Fazel & Danesh , 2002). Hopefully, thanks to the reforms recently carried out in the UK, which will attract outpatient psychiatric teams to prisons, these lost patients will once again be in the field of vision of services.

So, everyday experience tells the doctor one thing, epidemiology is something else. Time to listen to our science – or, as it were, the researchers said in concert, not to mention in unison.

It is more difficult to explain the minimization of the correlation between the presence of schizophrenia and the violence of researchers and scientists, or the rejection of it. This is partly due to good, but inappropriate intentions. Many of us have begun to conduct research in this area, trying to demonstrate that the public’s fear of violence from individuals with mental disorders is not fully justified. To a certain extent, they are exaggerated, but not quite, as it turned out, groundless. The desire to comprehend increased aggressiveness in the appropriate context too often slips unnoticed into denial, reducing its value.

Another problem in evaluating research related to this area is the confusion of fundamental methods. For example, which variables should be corrected before a correlation is calculated between the presence of schizophrenia and violence. Distorting factors create an apparent correlation, establishing a positive, but independent connection with both schizophrenia and aggressive behavior. Mediating factors are a product or consequence of a schizophrenic state that directly or indirectly exacerbates violence.

It may be logical to correct for distorting factors, but amending for mediating factors will weaken or hide statistically significant links. It is not easy to differentiate between distorting and mediating factors in advance. This is partly due to the fact that many factors of interest to us, such as substance abuse , socioeconomic status and even personality traits, can be both distorting and mediating. Therefore, in practice, it is necessary to take a sensible approach to the calculations of the full correlation, and then to ask the question why it exists.

Top 8 myths about schizophrenia in which not worth it believe

Neither   one thing disease not   shrouded in so mysterious and   mystical halo as schizophrenia . TO   Unfortunately, this generates unimaginable quantity wild delusions . Well   but   we   offer discover truth : first , it interesting as well   secondly , speculation complicate a life themselves sick , interfere them   socialize and   make hesitate his diseases

Myth number   1. The main sign schizophrenia   splitting personalities

Title diseases translated as ” splitting of reason, “and   behind   by this not necessary worth it split exactly personality . Thats   there is not   everything schizophrenics hear vote or become receptacle for a few personalities .

it split can touch to   example , emotions : man can hate anything throughout soul as well   after 5   minutes change anger on   mercy. Or mourn dead aquarium fish, but   stay indifferent at of death close person.

But a mental glitch that divides a person’s personality into several is called a dysociative personality disorder and this is a completely different violation.

In the mind of a schizophrenic patient, logical connections are broken, so thoughts and ideas in the head easily coexist and contradict each other.

Myth number   2. Schizophrenia   – rare disease

On   really her   sick about 1   % of the population that is not   so   and   few. Take to   example, hemophilia, which have   of many on   hearing. Her   hemophilia most common   A striking one of   five   000 or even 10   000   men. AT   case with   schizophrenia on   every 1   000 people have to about 5   cases diseases .
 

Myth number   3 People with   schizophrenia is unpredictable, making them   dangerous to society

Schizophrenics are NOT violent and generally safe. They predominantly indecisive and passive . it associated with mentioned above violations logical connections . To the patient to man complicated line up even short plan aggression .

Some schizophrenics have antisocial behavior, but   it is normalized with   using drugs

From schizophrenics can expect unpredictable action and outbreaks rage . But more often Total this associated with related disorders, in particular, deep mental injuries or abuse alcohol , drugs .

Myth number   four. The most terrible at schizophrenia   hallucinations and   rave

Yes, it is hallucinations and   false conclusions (nonsense) most often cause strange human behavior and   appeals to   to a psychiatrist.

But   hallucinations in   our time is treated relatively easily due to the large selection of effective drugs   – antipsychotics. The main problem for patients is   symptoms that are called negative: a decrease in any activity, unwillingness to communicate, lack of emotion and   vegetative disorders. because of of them to man complicated contact with   people support friendship and   to work .

Myth number   five. Only schizophrenics hear vote

If you   sometimes hear voices in   head, it is normal, such auditory hallucinations are visited from   five   before   15   % of adults and   maybe   more since some don’t   recognized in   this because of the fear that their   recognize crazy. Special often this it happens at overwork , stress and   before waste to   sleep.

Myth number   6 Schizophrenia   it is sentence on   the whole a life

Of course, there people who disease completely knocks out of   life, though on   treatment but   such minority . According to statistics, 25   % (but   because it is very much) patients survive the first and   only episode of psychosis, and   then all life live without recurrence and   them   not even   need to take medicine.

Other to patients have to sit on   tablets, but   but they can to count on   remission long in   decades and   live ordinary life to do work and   family .

Have   third is always will be be observed lungs disorder that also especially not   will be influence on   quality of life .

Myth number   7 Schizophrenics are brilliant . AND   in general, they at all not   sick as well   simply other

Helps   whether schizophrenia in   creativity ? Here can answer and   yes and   no. WITH   one hand, and   any disease , schizophrenia can reduce quality of life person ( but   not   always like we   have understood of   previous paragraph ).

WITH   On the other hand, there really is a similarity between the thought processes of schizophrenic patients and   creative people   – at   them in   thalamus has few dopamine receptors, which reduces the degree of filtering of signals that come from   thalamus to   cerebral cortex. it can provoke flashes creativity .

Even if a this and   so,   schizophrenia   – it is disease and   as any disease her   not   need to romanticize.

Myth number   eight. Schizophrenia quickly is progressing

The disease progresses slowly, and   this is not immediately   notice. The first signs often look quite innocent: difficulties in   study and   on   work, problems with   communication and   concentration. Similar ” symptoms ” may notice y   myself practically everybody . Then person can to begin hear voices as well   rather , barely distinguishable whisper. Exactly on   this stage disease it is better Total amenable to treatment .

Have   small quantities the sick schizophrenia is progressing swiftly after first episode .

5 early signs of schizophrenia that are helpful to keep in mind

Let’s start with the main thing : schizophrenia is a serious mental disorder that requires special analysis before confirming or, on the contrary, refuting it. And because the list presented below, in no case should not be taken as the ultimate truth, but only as a way to see the changes happening to you or someone close to in time to ask for help.

Excluding the age factor, schizophrenia affects all population groups, regardless of gender, race, or social status . A mental disorder that is characterized by distorted thinking and perception usually begins between 16 and 30 years .

Although the exact cause of the disorder is unknown, it is generally accepted that genetic and environmental factors are most often the catalysts . Unfortunately, there is no way to prevent schizophrenia, but earlier treatment, psychiatrists agree, will have a positive effect on the patient’s condition in both the short and long term. Medical Daily talked about the five initial signs of schizophrenia that are important to keep in mind .

Social isolation

A person at risk may begin to avoid social interaction with family and friends, spending most of his time in isolation. Gradually, this affects the person’s schedule, so that he can also begin to miss training, work, or other social activities, even if nothing like that had been noticed before him. This also includes the loss of interest in things that previously did not leave a person indifferent – a hobby, favorite TV shows and delicious food .

Hygiene problems

Problems with personal hygiene are considered one of the earliest signs of depression and schizophrenia. This is because when this kind of mental disorders, even primitive and very easy from the point of view of a healthy person, is extremely difficult. Doctors say that everything usually begins with the fact that the patient begins to take a very slow bath, brush teeth or wash face, gradually increasing the intervals between these actions. This behavior is usually associated with internal factors, such as apathy, emotional burnout and self-oblivion, but may also depend on the degree of social exclusion.

Obsession with religion

Or – another option – mysticism, esoteric , supernatural . Medical literature has revealed a significant connection between religion and various aspects of schizophrenia. “Patients with schizophrenia are prone to religious extremes and hallucinations. In addition, there is some evidence that religion is related to the level of psychopathology, ”the authors write a review published in 2014 in Indian Journal of Psychological Medicine .

This connection, experts believe, is due to paranoia and an ever-increasing separation from reality. And while at the first stage a person can be only slightly removed from real life, with time he is able to completely immerse himself in thoughts of evil spirits, magical powers and mystical creatures.

Sharp movements

Certain movements or expressions, usually involuntary, were observed in the early stages in almost all patients with schizophrenia. Among them: too active mimicry, twitching of the corners of the mouth, slow blinking. Here it is important to understand that if active facial expressions were always peculiar to a person, then there is no problem. Only those cases are important when this facial expression suddenly became more active than ever before. Other physical manifestations, to which experts advise to pay attention, are the decrease in motor skills, the need for constant external stimulation and twitching of the limbs, resembling a tremor.

Auditory hallucinations

Hallucinations in schizophrenics can affect any of the five senses, but auditory hallucinations are the most common. In particular, more than 70% of patients with diagnosed schizophrenia talked about hearing voices. Such violations, doctors add, can lead to confused thoughts, loss of concentration and memory problems. Another symptom associated with hallucinations is the discontinuity of thinking, when it seems to a person that not all the thoughts that are present in his head belong to him

How to live with bipolar disorder

In bipolar disorder, manic and depressive phases alternate, which, by many indications, are opposite to each other. Therefore, in the diagnosis of the disorder, two scales of symptoms are used. A person should be expressed in different periods of those and other signs.

Typical symptoms of mania ( hypomania )

  • Heightened mood, from uplifted to feelings of elation and euphoria. High mood is not associated with external events, even very unpleasant incidents can not spoil it.
  • High energy. The patient feels full of strength and ready for any achievements. Talented people in a state of easy mania can work around the clock, and with good results.
  • Raising energy causes a flash of turbulent activity. This is noticeable in all human behavior: he moves quickly, actively gesticulates, fusses, hurries somewhere.
  • Speech fast. Until recently, man was laconic, and now it flows in a continuous stream. He speaks with confidence, with pressure. At the same time, it is easy to distract him from the main idea, and he instantly switches from one topic to another.
  • Grand ideas. The “manic” brain works at higher speeds: it generates new ideas, finds harmony and meaning in everything. A “leap of ideas” appears: when a person cannot concentrate on one topic, images in his brain are replaced at a breakneck pace, and those around him with all their desire can no longer see the logic in his statements.
  • The extreme manifestation of such a state is a bullshit of greatness. In mania, it may seem to a person that he is brilliant, his ideas are perfect, and he is on the verge of a great discovery.
  • Sleep disturbance. The need for sleep is dramatically reduced. People can sleep for 2-3 hours and not feel tired.
  • Hypersexuality . In mania, a person feels particularly attractive. He begins to flirt inappropriately, dress defiantly, look for new connections, without worrying about the consequences.
  • Rasters of large sums of money. In a maniacal rise, people can gain credits, spend all their savings on entertainment, and consider it an excellent solution.
  • Lack of self-criticism. In a strong mania, man is unable to adequately assess his behavior and control it.
  • Aggressiveness, irritability. Surrounding people in this state seem stupid and slow, their attempts to reason with a person with BAR cause a strong protest.

Typical symptoms of depression

  • Low mood without external reasons. A person is depressed, even if everything goes well in his life, constantly experiencing anguish, hopelessness, helplessness.
  • The patient believes that it is he who is to blame for problems at home and at work, he feels himself a burden for his relatives.
  • Suicidal thoughts and plans. If such a state is delayed, the person begins to think about the meaninglessness of his life, which brings only pain and frustration. These are not just complaints: suicide attempts during a depression are very common.
  • Fatigue, fatigue. A person experiences constant overwork and gets tired of even the easiest work. Some patients sleep all day, others can not sleep because of internal tension and anxiety. In severe depression, the patient completely loses working capacity. His strength may not even be enough to take care of himself.
  • Loss of interest in matters that used to be liked ( anhedonia – loss of ability to have fun). A person becomes indifferent to his surroundings, his close people annoy and tire him. In this state, patients often withdraw into themselves and isolate themselves from society.
  • Inhibition of thinking, speech, movements.
  • High anxiety. A depressed person constantly expects the worst: in his life, in his family’s life, in business, and is afraid of any changes.
  • Exacerbation of health problems. The physical well-being of a person is also deteriorating. The most common somatic signs of depression are dry mouth, stomach pain, palpitations, headaches, muscle aches, shortness of breath, and frequent urination.

how to distinguish schizophrenia from manic depressive psychosis ?

Despite the fact that today the clinical picture of the development of schizophrenia at the physiological and psychological level is described in sufficient detail, the symptoms of mental disorders are a moving phenomenon. Therefore, in some cases, a consolidated opinion of a single specialist, patient monitoring for several weeks and an extensive history (preliminary data collection), which, besides previous examinations and appointments, would include general information about the patient’s personal life, his social activity, the first episodes of the disease, etc.

Most often, both in the public consciousness and individual specialists, they confuse schizophrenia with bipolar disorder, also known as manic-depressive psychosis (an outdated and unaccepted designation to date). Indeed, both diseases have similar features in the clinical picture:

for example, both schizophrenia and bipolar disorder are endogenous, that is, genetic, hereditary ;

  • both diseases are accompanied by both depressive episodes and psychotic episodes (impulsive, spontaneous, chaotic activity),
  • and in both cases, characteristic changes are observed at the organic level – primarily in the structure and metabolism in the cerebral cortex.

But these are just common features. In essence, schizophrenia and manic-depressive psychosis are two different diseases. And although none of them can be called preferable or easy, the correct pharmacological support and the content of the course of psychotherapy depend on the exact statement of the diagnosis.

At the Matzpen clinic , a psychiatrist and a psychotherapist simultaneously work with a patient whose diagnosis is subject to doubt, and the final diagnosis is made at a general consultation of specialists. It is fair to note that the diagnosis that the patient or his relatives are counting on is not always confirmed . However, a complete and independent examination in any case will help to clarify the clinical picture of the patient and the optimal program of his treatment.

In particularly controversial cases, during the collection of anamnesis, special psychological tests can be assigned to shed light on the dynamics of his personality structure and internal conflicts, and particular thinking, which in turn is important for the subsequent psychotherapy of the disorder.

Rules of life

If you bipolar upset you have to to master new ones regulations of life .

In this even there is their pros : you have Now there is serious cause to begin new life more healthy and informed .

Much depends on from medication and adequacy physician, but without your his own active of participation Effect from treatment will be much weaker . So that if pills you are taking not the first month and improvement everything not comes , you worth it think about your own an image life : everything whether you do right ?

Daily regime

This is really important. Mood fluctuations are strongly associated with the change of seasons, time of day, hours of sleep. And to make the mood smoother, the mode should be as stable as possible.

The activity and anxiety of mania make it difficult to sleep, and in the morning you are completely exhausted. With depression, you feel tired all the time. Often the strength and motivation are not enough even for the most simple case -n rochitat mail, make breakfast.

To get out of this circle, first of all you need to normalize your sleep.

This means that it matters to you:

  • go to bed every night at the same time;
  • waking up at the same time;
  • sleep at least 8 hours;
  • do not allow yourself to sleep during the day;
  • refuse to hang on a computer, TV or smartphone at least an hour before bedtime;
  • practice meditation, breathing exercises or a very light physical exercise (walk, Pilates exercises ) at night .

In hypomania really want to walk all night long. But you have to make a choice: one tumultuous party can turn into a whole week of depressive or anxious “hangover”.

Remember that a sudden change of work or sleep mode can cause deterioration. For example, a flight to another country, and then a few days of lack of sleep can cause mania.

In depression I want to sleep more, because you can afford 12 hours in bed, but do not lie down for a day without leaving the house. It will only get worse. When you are alone with yourself, you will become more and more immersed in depressive thoughts.

Physical activity

When you constantly feel tired, sport is the last thing that attracts you. But if you still have enough perseverance, health will soon change for the better.

Physical activity contributes to the development of hormones of good mood, it will ease the depression. After a load, it will be easier for you to fall asleep, which guarantees a better state of health the next day. Exercise stimulates mental abilities. Statistics show: people who exercise regularly, 25% less likely to suffer from depression.

But exercises help only if they are regular: at least three times a week for 30 minutes. If you are too tired, start with simple and slow exercises, with time you will have more energy. Or just go for a walk in the park – exercise in the fresh air is especially helpful.

Come to the sun often! It improves mood and gives a surge of strength. Solar radiation promotes the absorption of vitamin D , which is necessary for the brain to function.

Less stress

Strong stress is your main enemy. The psyche of a person with bipolar disorder is much less stable and resistant to stress. It is easy to unbalance, and it is stress that can trigger another mania or depression.

Just take it for granted and do not demand heroic deeds from yourself. It is possible that tests really harden someone and make them stronger, but this is definitely not about manic-depressive people.

You, probably, noticed that during the periods of deterioration you are especially injured, even a trifle can ruin you or bring you to tears. If you do not take care of yourself in such moments, you can get to a nervous breakdown, to overcome the consequences of which it will take weeks in the hospital.

This should not be forgotten when you undertake a difficult job or another matter that requires great effort and responsibility.

In hypomania, it is very easy to gain a lot of projects that simply crush you with their weight when the depression begins.

This does not mean that you should not take responsibility for your family and work. This means that you need to soberly assess your strength, and do it during remission. Then provide for the possibility of regular rest and assistance in case of deterioration. Whatever you feel now, they will, sooner or later. It is better not to take on tasks that require constant stress: for example, when you are the only earner in the family or an indispensable specialist in the company.

Healthy food

Proper nutrition is also very important for keeping fit. There are products that will improve your condition and even reduce protrebnost in medicines, and there are those that can seriously harm.

Especially useful for the bipolar :

  • Omega-3 acids
  • Numerous studies have shown that Omega-3 fatty acids, which are abundant in fish and fish oil, alleviate symptoms . If you are a vegetarian, then try to eat more eggs and nuts, they also contain them.
  • Vitamin B12

Vitamin B12 is necessary for the functioning of nerve cells and blood cells, it is he who ensures the normal functioning of the brain. Eat plenty of red meat, chicken, liver, fish, eggs, milk. Or pick the appropriate vitamins.

Magnesium
This microelement is found in whole grains, legumes, and dark green vegetables, such as spinach. Magnesium is a natural mood stabilizer, it soothes, like lithium, the most famous medicine for BAR.

Water
W To feel energetic, you must provide themselves with water in abundance. That means 8-10 glasses of fluid a day. With exercise, you need to drink even more.

And, on the contrary, are harmful:

  • Excess sugar
  • Increasing the level of sugar in the blood can make your unstable mood even more chaotic, and sugar can also enhance the depressive phase. If you really need something sweet, eat fruits – natural sugars do not cause sudden jumps in blood glucose.
  • Simple carbohydrates

 

Major depressive disorder: Symptoms and signs

Major depressive disorder (MDD) is a mental disorder characterized by severe and persistent bad mood, which is accompanied by low self-esteem, loss of interest or pleasure from previously enjoyable activities. The concept of “depression” is used in various cases. It is often used to define this syndrome, but may also be related to other mood disorders or simply to a bad mood. Major depressive disorder adversely affects family life, professional or school life, sleep, eating habits, and general health. In the United States, about 3.4% of people with major depressive disorder commit suicide, and up to 60% of people who committed suicide suffered from depression or another mood disorder.

Other names: clinical depression, major depression, unipolar depression or recurrent depression in case of repeated manifestations. The diagnosis of major depressive disorder is based on the patient’s own experiences, behavior reported by relatives or friends, as well as during the study of the mental state. There is no laboratory testing to determine clinical depression, although doctors usually conduct physical tests that may show similar symptoms.

The most common age of onset of the disorder is the age from 20 to 30 years, a slightly lower probability of its manifestation falls on the range between 30 and 40 years. As a rule, people who are treated with antidepressants, in many cases receive special counseling, in particular, undergo cognitive behavioral therapy (CPT). Medications seem to be effective, but the effect is significant only in cases of extremely severe depression. Hospitalization may be necessary in cases involving self-neglect or a significant risk of harm to yourself or others. A small proportion of patients are treated with electroconvulsive therapy (ECT). Of course, a disorder can vary widely in its manifestations, ranging from a one-time manifestation over a period of several weeks to a disorder that lasts a lifetime, on the basis of major depression. Persons with depression have a shorter lifespan compared to those who do not suffer from depression; this is partly due to greater susceptibility to illness and suicide. It is not clear whether drugs affect suicide risk. Current and former patients may be stigmatized (hanging social labels). The understanding of the nature and causes of depression has been recognized for centuries, although this understanding is incomplete and there are still many aspects of depression that are the subject of discussion and research. The alleged causes are psychological, socio-psychological, hereditary, evolutionary and biological factors. Long-term use of appropriate drugs can cause or worsen the symptoms of depression. Psychological treatments are based on theories of personality, interpersonal communication and learning. Most biological theories focus on monoamine chemicals, namely serotonin, norepinephrine and dopamine, which are naturally present in the brain and provide communication between nerve cells. This symptom complex (syndrome) was named, described and classified as a mood disorder in the 1980 Psychological Association’s Diagnostic Aids publication.

Symptoms and signs

Major depression significantly affects family life and personal relationships, professional or school life, sleep and eating habits, as well as general health. Its effect on good general well-being is comparable to the effects of chronic diseases such as diabetes. A person who has manifestations of major depression usually complains of a bad mood, which permeates all aspects of life, as well as the inability to experience pleasure from those activities that previously brought satisfaction. Depressed people can be preoccupied with their problems, reflect on them, have thoughts of their own inferiority, feel guilty, regret, helplessness, hopelessness and self-loathing.

In severe cases, people with depression may show symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually of an unpleasant nature. Other symptoms of depression include poor concentration and memory (usually in persons with metabolic and or psychotic symptoms , non-participation in social activities, low sexual desire, and thoughts of death or suicide.

Insomnia is often manifested in people prone to depression. Usually, the person wakes up oche Hb early and can not fall asleep then s. Hypersomnia or excess sleep may also occur. Some antidepressants can cause insomnia due to their stimulating effect. A person in depression may report several physical symptoms, including fatigue, headaches, problems with digestion; somatic complaints are the most common problems in developing countries, according to the criteria of depression of the World Health Organization. Appetite is often reduced, leading to weight loss, although increased appetite and weight gain can also occur. Family members and friends may notice that the person is either very nervous or sluggish. In older people with depression, cognitive symptoms may appear, such as forgetfulness and more noticeable slowing of movements.

Depression in older people often coexists with physical disorders, such as stroke, other cardiovascular diseases, Parkinson’s disease, and chronic obstructive pulmonary disease. Children with depression may experience irritable (not depressed) moods; symptoms may vary depending on age and situation. Most lose interest in school, they show a decrease in performance. Diagnostics may be delayed or missed if symptoms are treated as a usual capriciousness. Depression can also coexist with attention deficit hyperactivity disorder (ADHD), which makes it difficult to diagnose and treat both disorders.

Accompanying illnesses

Major depression often occurs in conjunction with other mental disorders. A 1990-1992 national survey of comorbidities showed that 51% of people suffering from depression are also subject to persistent anxiety. Symptoms of anxiety can have a significant impact on the course of depressive diseases, reducing the likelihood of recovery, increasing the risk of relapse and contributing to disability and suicide attempts.

American neuroendocrinologist Robert Sapolski argues that the relationship between stress, anxiety and depression can be measured and demonstrated biologically. There are elevated rates of alcohol or drug abuse, in particular, there is a manifestation of dependence; at about one third of individuals diagnosed with ADHD develop concomitant depression. Post-traumatic stress and depression are often combined in their manifestation. Depression and pain also often occur together. One or more pain symptoms occur in 65% of patients with depression, and from 5 to 85% of patients with pain syndromes experience depression, depending on the underlying disease; There is a low prevalence in general practice and a higher prevalence in specialized clinics. Diagnosing depression is often delayed or skipped altogether, making the condition worse.

The result may also worsen if the depression was identified, but its causes were not understood. Depression is often associated with a 1.5–2 fold increase in the risk of cardiovascular diseases that are not dependent on other risk factors; they themselves are directly or indirectly associated with risk factors, such as smoking or obesity. People with major depression rarely follow the doctor’s recommendations regarding the treatment and prevention of cardiovascular diseases, which ultimately increases the risks of complications. In addition, cardiologists may not reveal depression, which complicates the course of cardiovascular diseases.

Bipolar disorder

Bipolar disorder, also known as manic-depressive psychosis, is a mental illness characterized by atypical mood changes, energy swings and the ability to function. Unlike normal mood changes, with their ups and downs that are common to everyone, the symptoms of bipolar disorder can lead to very serious consequences. They are able to destroy personal relationships, affect the quality of work or school performance, and even lead to suicide. Fortunately for us, bipolar disorder still gives in to treatment, and patients with this disease are able to lead a full and productive life.

Every year1 about 5.7 million adult Americans, or 2.6% of the population aged 18 and over, are diagnosed with “bipolar disorder.” Bipolar disorder is usually manifested in late adolescence or in early adulthood. However, in some cases, the first symptoms appear already in childhood, and in others – the symptomatology is revealed only at later stages of life. Quite often bipolar disorder can not be diagnosed, and people have to suffer for years before they are properly diagnosed and begin the necessary course of treatment. As well as diabetes or cardiovascular diseases, bipolar disorder is a chronic disease that must be closely monitored throughout life.

“Manic depression breaks the normal course of moods and thoughts, provokes inadequate behavior, undermines the foundations of rational thinking and quite often destroys the will and will to live. This disease, organic by its nature, in practice proceeds as a psychological disorder; it is unique in its ability to enthrall and bring pleasure, but the consequences of it bring unbearable suffering and often lead to suicide.

“I am happy that I managed to avoid death from this disease, I am happy that I was able to get the best medical help, as possible, I am happy that I have such friends, colleagues and, of course, my family.”

Kay Redfield Jamison, Ph.D. An Unquiet Mind, 1995, p. 6. (Published with permission of the publishing house “Alfred A. Knopf”, branch “Random House, Inc.”).

Symptoms of bipolar disorder

Bipolar disorder is the cause of a sudden change of mood – from extremely excited and / or irritable, to minor and hopelessly helpless, with a subsequent return to the original state and often with periods of normal mood in between. Such alternations of moods are often accompanied by significant changes in energy and behavior. The periods of the excited state and the passive state are called “episodes of mania and depression.”

Signs and symptoms of mania (or manic episode):

  • Increased energy, activity and anxiety
  • Incredible excitement, overly elated, euphoric mood
  • Increased irritability
  • The confusion of thoughts and the rapid pace of conversation, jumping from one idea to another
  • Distraction, inability to concentrate
  • Decreased need for sleep
  • Unreasonable confidence in their own abilities and abilities.
  • Inadequate assessment of the situation
  • Wastefulness, wretchedness
  • A long period when behavior is very different from normal
  • Increased sexual activity
  • Drug use, especially cocaine, alcohol and drugs for insomnia
  • Provocative, intrusive or aggressive behavior
  • Denial of the fact that something is wrong

A manic episode becomes a diagnosis if an excited condition, accompanied by three or more symptoms, lasts for most of the day, almost every day for a week or longer. For the final diagnosis of irritation, four additional symptoms are necessary.

Signs and symptoms of depression (or depressive episode):

  • A prolonged state of sadness, anxiety or emptiness.
  • Feeling of hopelessness or pessimism.
  • Feeling guilty, feeling worthless or helpless.
  • Loss of interest or pleasure from activities that used to be fun, including sex.
  • A lowered level of energy, a feeling of constant fatigue or “inhibition”.
  • Problems with concentration, difficulties with memorization or decision making.
  • Anxiety or irritability.
  • Increased drowsiness or insomnia.
  • Changes in appetite or / and unintended loss or weight gain.
  • Chronic pain or other persistent symptoms of poor health, not a result of physical illness or injury.
  • Thoughts of death or suicide, suicide attempts.

A depressive episode becomes a diagnosis if five or more symptoms manifest themselves throughout most of the day, almost every day for two or more weeks.

Hypomania is a weakened or moderately mild form of mania. A patient with signs of hypomania is able to feel good and even feel satisfaction from his own increased productivity and efficiency. Therefore, even if a family or friends are able to recognize that a bipolar disorder may be hidden behind a mood change, then the patient himself does not consider his condition abnormal. However, in the absence of proper treatment, hypomania is able to move into a heavier form of mania, and in some individuals may end with depression.

In some cases, a severe form of mania or depression is accompanied by symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (sound, visual or other sensations of the presence of things, which are not really present at the moment) and delusions (distorted, unconditionally believed representations that are not based on any logical grounds and are not based on a person’s cultural experience). In bipolar disorder, psychotic symptoms tend to reflect the extreme condition of the patient at a given time. For example, in the manic phase, delirium can be observed when a person is sure that he / she is a president or a person with power or wealth. During the period of depression, there can be delusions of guilt or worthlessness, when a person is convinced of his economic collapse and lack of money, or committing a serious crime. With this symptomatology, patients suffering from bipolar disorder can erroneously diagnose schizophrenia – another severe mental illness. The phases of bipolar disorder can be imagined in the form of a spectrum or a continuous scale. At one end of this scale – a severe form of depression, above it is a depression of moderate severity. Then follows the state of depression, which, in case of its short duration, many are called “melancholy”, but which is professionally defined as “dysthymia” if it becomes chronic.

Then comes a normal or balanced mood, followed by hypomania (a weak or moderate-moderate form of mania), and at the end – a severe form of mania.

However, in some patients, the symptoms of mania and depression can be observed simultaneously. This condition is called mixed bipolar disorder. With this type of bipolar disorder, the symptomatology often includes excitement, sleep disturbance, significant changes in appetite, psychosis, suicidal thoughts.

The patient is in a state of sadness and hopelessness, but at the same time feels an extraordinary burst of energy.

Bipolar disorder is not always associated with a mental illness, its causes can be the abuse of alcohol or drugs, poor academic progress or failures at work, strained personal relationships. All these problems, in fact, can be signs of a latent illness of disturbed mood.

Diagnosis of bipolar disorder

Like other mental illnesses, bipolar disorder can not be diagnosed with the help of physiological research methods, such as, for example, a blood test or a brain scan. Thus, the diagnosis of bipolar disorder is made on the basis of a symptomatic picture, a medical history and, if possible, a family history. The criteria for diagnosing bipolar disorder are described in the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders, fourth edition, DSM-IV.

Evidence from patients with bipolar disorder is a valuable source for understanding the various phases of mood swings associated with the disease:

Depression: “I absolutely do not believe in my ability to do anything right. It feels like the course of my thoughts is slowing down and slowing down until eventually it comes to a state of total stupor … [It] haunts … a feeling of complete, desperate helplessness from all this … Someone says it’s , they say, a temporary phenomenon, it will pass and you will get better, but they certainly do not have the faintest idea of ​​what I feel, although they flatter themselves with hope. If I can not feel, move, think or want, then why do I need all this? ”

Hypomania: “At first, when I’m excited, it’s amazing … ideas flicker one by one … as if watching the falling stars in anticipation of seeing the brightest … Shyness removes the hand, the right words and the necessary gestures are right there … uninteresting people and events suddenly acquire an incredible interest. You are overcome by irresistible desires, you want to be seduced and be seduced … You are full of feeling of lightness, strength, omnipotence, euphoria … you are capable of doing anything … but at one point it all ends … ”

Mania: “Thoughts flicker somehow too quickly and they become too much … the clarity of thoughts is replaced by a state of complete loss … you are unable to follow all this, begins to change memory … Your poisonous humor ceases to amuse. It becomes scary for friends … and you do not like everything yourself … everything literally annoys, angers, frightens you, you become uncontrollable and you feel trapped. ”

Suicide

Some patients with bipolar disorder are susceptible to suicide. Any person who thinks about suicide, needs immediate help, preferably a psychiatrist or a therapist. It is necessary to take seriously any person who speaks of suicide. The risk of suicide is much higher in the early stages of the disease. Thus, early diagnosis of bipolar disorder and the definition of effective methods of its treatment can reduce the risk of death from suicide.

The signs and symptoms of suicidal intent:

  • talk about suicidal intent or desire for death
  • feeling hopeless; feeling that nothing will ever change and it will not get better
  • feeling helpless: whatever a person does, nothing can help
  • feeling like a burden to family and friends
  • alcohol or drug abuse
  • bringing affairs to order (putting in order finances, distribution of personal property, ie preparation for death)
  • posthumous memorial
  • the desire to be in danger, to fall into situations in which there is a likelihood of dying

If you have suicidal intentions or you know someone who is in this condition:

  • immediately call a doctor, an ambulance, or “911” for emergency treatment
  • Do not stay alone or leave a person with suicidal intentions of one
  • make sure that there is no access to medicines, weapons or other things that can be used for self-harm

In some cases, suicide is planned thoroughly and in advance, while in others it is an impulsive and ill-conceived act. In any case, the measures proposed in the previous paragraph can be a long-term strategy for patients suffering from bipolar disorder. It should be remembered that suicidal intentions and suicide attempts are symptoms of a disease that can be treated. With proper treatment, you can get rid of suicidal intentions.

How is bipolar disorder?

Episodes of mania and depression usually repeat throughout life. In the intervals between the episodes, most patients with bipolar disorder do not have symptoms, however, about a third of patients have residual symptoms. A small proportion of patients experience chronic continuous bipolar disorder symptoms despite treatment.3

The classical form of this disease, in which episodes of mania and depression regularly recur, was called type I bipolar disorder. Some patients do not have a severe form of mania, but there are mild episodes of hypomania, alternating with depression.

This type of bipolar disorder is called type II bipolar disorder. If within a period of twelve months the patient has four or more episodes, then they speak of a rapidly circulating bipolar disorder. In some patients, episodes are repeated repeatedly for one week or even one day. Rapidly circulating bipolar disorder usually develops at a late stage of the disease and is more common in women than in men.

In case of effective treatment, patients with bipolar disorder are able to live a healthy and productive life. However, without treatment, the natural course of the disease tends to deteriorate. Over time, episodes of mania and depression in the patient become more frequent (faster circulation) and become more severe than at an early stage of the disease.4 But in most cases, proper treatment can reduce the frequency and severity of episodes and help patients with bipolar disorder live a full and happy life.

Is there bipolar disorder in children and adolescents?

Bipolar disorder can be in children and adolescents. Children at greatest risk are those whose parents suffer from this disease.

Unlike adult patients with bipolar disorder, whose episodes are quite clearly delineated, children and adolescents with this disease have an incredibly fast mood change from depression to mania, several times a day. 5 In children, mania often manifests itself in irritability and outbursts of anger, and not in euphoria and excitement, as in adults. Mixed symptoms are also quite common in young people with bipolar disorder. Those who are ill in late adolescence, episodes and symptoms are more classic, inherent in adults, the character.

In children and adolescents, it is difficult to distinguish bipolar disorder from other problems that may occur in this age group. For example, irritability and aggressiveness are characteristic of bipolar disorder, but at the same time they may be symptoms of attention deficit hyperactivity disorder, behavioral disorder, opposition-causing disorders, or other types of serious mental illness more characteristic of adults, such as depression or schizophrenia. Drug abuse also provokes such symptoms.

However, with any disease, the key to success depends on the correct diagnosis. Children and adolescents with emotional or behavioral problems should be checked by a psychiatrist. To every child or adolescent with suicidal tendencies that speaks of suicide or attempts to commit suicide, one must be taken very seriously and immediately provide him / her with professional help from a psychiatrist or psychologist.

Causes of bipolar disorder

On the example of numerous studies, scientists are trying to understand the causes of bipolar disorder. At present, most of them have come to the conclusion that bipolar disorder does not have one single reason. Most likely, many factors play a role here.

Because bipolar disorder tends to repeat in the family, scientists are trying to detect specific genes (microscopic “building blocks” of DNA inside each cell, responsible for the development and growth of the body and psyche) transmitted from generation to generation that can increase the chance of the disease. However, it’s not just the genes. The study of identical twins, having an identical genetic structure, shows that both genes and other factors play an important role in the onset of bipolar disorder. If the cause of bipolar disorder was only in the genetic code, then in the case of a twin disease, the second twin would also always be sick. However, the results of the studies indicate otherwise. Although, if one of the twins develops a bipolar disorder, the chances of a twin from another twin are much higher than those of other siblings.

In addition, it should be noted that the results of genetic studies show that the cause of bipolar disorder, like any other mental illness, is not in one single gene. 7 Apparently, bipolar disorder is the result of joint actions of numerous genes in combination with other individual human factors and environmental factors. Discover these genes, each of which makes its small contribution to the development of predisposition to bipolar disorder, is extremely difficult. But scientists hope that the recently introduced new research methodologies will open this mystery and lead to the development of more effective treatment of bipolar disorder.

Studies of the brain with the use of its images help scientists understand what disruptions in brain activity provoke the development of bipolar disorder and other mental illnesses. 8.9 New technologies allow scientists to obtain images of a live working brain, thus enabling them to study its structure and activity without the need for surgical or any other intervention. These technologies include a magnetic resonance imaging (MRI), positron emission tomography (PET), and a functional magnetic resonance imaging (MRI). There is sufficient evidence obtained on the basis of brain research that the brain of patients with bipolar disorder differs from the brain of a healthy person. In the course of further research, scientists will be able to make a clearer picture of the differences and understand the cause of this disease, which in the end will enable them to find the most effective ways of treatment.

How is bipolar disorder treated?

Due to correctly selected treatment, in most patients with bipolar disorder – even in its most severe forms – it is possible to stabilize mood changes and other symptoms of the disease. Since bipolar disorder occurs with relapses, preventive measures of treatment are not only shown, but are strongly recommended. Treatment combining drugs and psychotherapy is optimal to keep the disease under control.

In most cases, bipolar disorder is controlled much more effectively if the patient does not interrupt treatment, but constantly follows it. But even in these cases, episodes of mood change are quite likely. In such cases, you must always inform the attending physician. A timely change in the doctor’s course of treatment can prevent a full-scale episode.

Treatment will be more effective if you openly discuss with your doctor all doubts and proposed treatment options.

In addition, if the patient and his loved ones fill in the daily schedule of symptoms of mood, medication, sleep patterns, day events, they begin to better understand the disease. Such graphics also help the treating physician to monitor the progress of the disease and treatment more effectively.

Medications

Drugs for the treatment of bipolar disorder are prescribed by certified psychiatrists-MDs (MD), specialists in the diagnosis and treatment of mental illness. Although the therapist can also prescribe medication, nevertheless the patient with bipolar disorder is strongly recommended to be observed and treated by a psychiatrist.

In bipolar disorder, as a rule, prescribe the so-called “mood stabilizers.” 10 There are several types. Usually patients with bipolar disorder continue to take mood stabilizers for a long period of time (years). Other drugs are administered additionally as needed, usually for a shorter period of time, to relieve episodes of mania or depression that may occur periodically, even with mood stabilizers.

  • Lithium is the first of mood-stabilizing drugs allowed by the US Food and Drug Administration (FDA) to treat mania. This medicine is an effective means of controlling mania or preventing relapses of both manic and depressive episodes
  • Anticonvulsants such as valproate (Depakote®) or carbamazepine (Tegretol®) also have a mood stabilizing effect and can be used in particularly difficult to treat cases of bipolar disorder. The FDA authorized the use of valproate for the treatment of mania in 1995
  • New anticonvulsants, such as lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate (Topamax®), are under study to determine how well they affect the stabilization of mood cycles
  • To achieve maximum effect, several anticonvulsants can be prescribed at once or they can be used in combination with lithium
  • Children and adolescents with bipolar disorder are usually treated with lithium, but valproate and carbamazepine are also used. Scientists find out the safety and effectiveness of the use of these and other psychotropic drugs for children and adolescents. According to studies, valproate can lead to hormonal changes in adolescent girls and polycystic ovary syndrome in young women who started taking this drug before the age of 13. 13 Therefore, young patients taking valproate should certainly be under close medical supervision .
  • Patients with bipolar disorder who want to become pregnant or are already pregnant face a difficult choice, as mood stabilizers can have a negative effect on the fetus or on a breast-fed baby.14 Thus, before taking a responsible decision, it is necessary to discuss with the expert all the pros and cons “Against” all possible ways of treatment. Currently, at the testing stage are new drugs that significantly reduce the risk during pregnancy or lactation.

Treatment of bipolar disorder

According to the results of the study, patients with bipolar disorder undergoing treatment with antidepressants are at risk of developing mania, hypomania or a rapidly circulating form of the disease. 15 In order to protect patients with bipolar disorder from such effects, it is usually necessary to use mood-stabilizing drugs, either in combination with antidepressants, or by themselves. At present, lithium and valproate are the most common drugs that stabilize the mood. Nevertheless, experiments are continuing to evaluate the effectiveness of the use of new medications for mood stabilization.

  • Atypical antipsychotics, including clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Rispendal®), quetipine (Seroquel®), and ziprasidone (Geodon®) are being studied for possible use in the treatment of bipolar disorder. There is reason to believe that the use of clozapine can help patients who do not respond to lithium or anticonvulsant drugs.

Other studies have confirmed that olanzapine is effective in acute mania, and has recently been approved for use in this capacity by the FDA. Olanzapine also helps in the treatment of psychotic depression.

  • Aripiprazole (Abilify®) is another atypical antipsychotic drug used to treat the symptoms of schizophrenia and manic or mixed (manic and depressive) episodes of type I bipolar disorder. It is available in tablets and in liquid form. Injections are used to treat symptoms of excitement in schizophrenia and manic or mixed episodes of type I bipolar disorder.
  • If there is a problem of insomnia, high-performance benzodiazepine drugs, such as clonazepam (Klonopin®) or lorazepam (Ativan®), can help. However, since these drugs are addictive, they are prescribed only for a short time. Instead, in some cases, they are prescribed soothing, such as zolpidem (Ambien®).
  • During the course of treatment of bipolar disorder, it is necessary to repeatedly change medicines for the purpose of the most effective treatment. All drug changes and changes in drug doses should occur according to the prescription of the treating psychiatrist.
  • Do not forget to tell your psychiatrist about all your medications, including over-the-counter medications, homeopathic remedies, vitamins and other supplements. This is very important, as some drugs and supplements are incompatible and can cause adverse reactions.
  • To avoid relapse or a new episode, you must strictly adhere to the treatment plan. Discuss with the attending physician all the questions about the medicines.

Thyroid function

In patients with bipolar disorder, thyroid dysfunction is often observed. Increased or decreased levels of thyroid hormones in itself can affect mood changes and energy levels. Therefore, it is very important that the thyroid parameters are under constant monitoring by the attending physician.

The rapidly circulating form of bipolar disorder is often accompanied by diseases of the thyroid gland. In such cases, along with medications for bipolar disorder, it is necessary to take medications to treat the thyroid gland. It should also be borne in mind that in some patients, lithium can cause a decrease in thyroid activity. In this case, in the course of treatment, it is necessary to introduce medications to regulate thyroid function.

Side effects of drugs

Before you start taking new medications, always consult a treating psychiatrist and / or a pharmacist about possible side effects. Depending on the drug, side effects can be expressed in the addition of weight, nausea, tremor, decreased sexual activity or possibility, anxiety, hair loss, difficult movements and dry mouth. Be sure to tell your doctor about all side effects that occurred during the taking of a medicine. To remove or reduce side effects, the doctor can change the dosage of the drug or change it to another. Do not change medication or stop taking them without consulting a psychiatrist.

Psychosocial methods

Along with medical treatment, the use of psychosocial methods is recommended, including certain forms of psychotherapy (or “colloquial” therapy). Such methods help patients with bipolar disorder and their families understand the specificity of the disease and obtain the necessary information. The results of the research showed that psychosocial therapy helps to stabilize the mood, reduce the number of hospitalizations and improve the vital activity in various spheres of human activity.12 As a rule, licensed psychologists and social workers are engaged in such therapy, coordinating their actions with the attending psychiatrist and jointly monitoring the progress in state of health of the patient. The number of sessions, their frequency and duration depend on the individual needs of each patient.

Among the psychosocial methods used in bipolar disorder include cognitive behavioral therapy, psychological education, family therapy and a new technique – interpersonal and socio-rhythmic therapy. Researchers at the National Institute for Mental Health (NIMH) study and compare the effectiveness of these methods in combination with various drugs for the treatment of bipolar disorder:

  • Cognitive-behavioral therapy helps patients with bipolar disorder understand and change negative or distorted patterns of thinking and behavior associated with the disease.
  • Psychological education introduces patients to information about the disease and methods of its treatment, and also helps to learn to recognize the signs of relapse, which allows you to seek help in advance and prevent the onset of a full-scale episode. Mental education is also useful for family members of the patient.
  • Family therapy uses a strategy of lowering the level of tension in the family, which can aggravate the symptoms of the disease or caused them.
  • Interpersonal and socio-rhythmic therapy helps patients with bipolar disorder improve interpersonal relationships and organize their daily routine. A regular schedule and an orderly sleep regime help prevent manic episodes.
  • As with medical treatment, in order to achieve successful results of psychosocial therapy, it is necessary to strictly follow the prescribed course of treatment.

Other treatments

  • Electroconvulsive therapy (ECT / ECT) is used when medication, psychosocial therapy, or a combination of these drugs do not have the desired effect or are too slow to stop serious symptoms such as psychosis or suicidal manifestations. The use of ECT can also help during acute episodes when the physical condition of the patient (including pregnancy) does not allow the use of medications. ECT is a highly effective treatment for severe depression, manic and / or mixed episodes. The possibility of long-term memory problems resulting from ECT, which until recently was a serious cause for concern, has now been significantly reduced by the latest ECT methods.

Nevertheless, it is necessary to discuss in advance all the pros and cons of using ECT and other alternative therapies with the patient himself, and, if necessary, with family members or friends.

  • Medicinal herbs and natural supplements, such as Hypericum perforatum (Hypericum perforatum), have not been studied enough, and the specialists have little information about their effect on bipolar disorder. Since FDA regulation rules do not apply to such products, different manufacturers of these additives use different amounts of active ingredients. Before you start taking herbs or natural supplements, you should consult your doctor. There is evidence that St. John’s wort can lower the effectiveness of certain drugs (see: www.nimh.nih.gov/events/stjohnwort.cfm) leaving the OMH site. 20 In addition, like prescription antidepressants, in some patients with bipolar disorder, St. John’s wort may provoke mania, especially in cases where the patient does not take mood stabilizers.
  • Studies are under way on the effectiveness of use in the treatment of bipolar disorder Omega-3 (contained in fish oil fatty acids) in combination with traditional medicines or separately.

Chronic disease, which is treated very effectively

Although episodes of mania and depression are in the habit of appearing and disappearing, it must always be remembered that bipolar disorder is a chronic disease that is not currently cured. The only way to keep this disease under control is to constantly take medication, even during periods when you are feeling well. Only in this case it is possible to reduce the chance of relapse and deterioration of the condition.

Accompanying illnesses

Among patients with bipolar disorder, alcoholism and drug addiction are very common. Studies have shown that there are a number of reasons for this, including self-medication, a change in mood from alcohol or drug abuse, and risk factors that affect both the development of bipolar disorder and drug dependence. 23 Treatment of alcoholism or drug addiction is an important part of the overall course of treatment.

Anxiety disorders, such as post-traumatic stress or obsessive-compulsive disorder (obsessive-compulsive disorder), are also common in bipolar disorder. 24, 25 Concomitant anxiety disorders can sometimes be controlled by the same means as bipolar disorder, but in some cases special treatment is required. For detailed information on anxiety disorders, contact NIMH (see below).

Helping patients with bipolar disorder and their families

Patients with bipolar disorder should lead an experienced psychiatrist, specializing in the diagnosis and treatment of this disease. Psychologists, social psychiatric service workers and nurses of psychiatric clinics help to provide various aspects of treatment and care for patients and their families.

You can get help in the following places:

  • Treatment programs at universities or medical institutes
  • In psychiatric departments of hospitals
  • In private psychiatric offices and clinics
  • In health care organizations (HMOs)
  • In the offices of district or children’s doctors
  • In community mental health centers

Patients with bipolar disorder may need help to get help

  • Patients with bipolar disorder often do not realize how sick they are, or they see the cause of their illnesses not in a mental disorder, but in something else.
  • To seek help from a doctor, patients with bipolar disorder may need encouragement and support from the family and friends. The therapist can play an important role, insisting on consultation with a psychiatrist.
  • Sometimes it is necessary that a family member or friend accompany a patient with bipolar disorder to see a doctor and be treated.
  • Sometimes a patient who is in a stage of acute attack should be hospitalized for his / her own safety and to provide the necessary treatment. In some cases it is necessary to hospitalize the patient against his / her will and without consent.
  • It is necessary to constantly support and encourage the patient, after the start of treatment, because in some cases it may take quite a long time to find the right course of treatment.
  • In some cases, patients with bipolar disorder during the period of remission can specify a plan of action in the event of a future manic or depressive relapse.
  • Like other serious diseases, bipolar disorder severely affects spouses, family members, friends and employers.
  • Family members of a patient with bipolar disorder often have to deal with serious problems in their behavior, such as unrestrained waste of money during episodes of mania, or withdrawal into themselves during depression, and the long-term consequences of such behavior.
  • Many supportive bipolar disorders are supported by support groups supported by various organizations, such as the National Association for the Study of Depressive and Manic-Depressive Disorders (NDMDA), the National Alliance for the Treatment of the Mind Indigent (NAMI), and the National Association for Mental Health (NMHA). Such support groups also help families and friends of patients with bipolar disorder. The coordinates of these organizations can be found in the “Useful Information” section of our brochure.

Clinical studies on bipolar disorder

Some patients with bipolar disorder receive medication and / or psychosocial therapy if they agree to participate in clinical trials (clinical trials). During these tests, scientific studies of the disease and the ways of its treatment involving people are conducted. Clinical trials in psychiatry provide information on the effectiveness of a drug or a combination of several drugs, the benefits of behavioral therapy or psychotherapy, the reliability of a diagnostic procedure, or the success of a preventive method. Clinical trials help scientists to follow the course of the disease: how it starts, progresses, goes on recession, how it affects the body and mind. Thanks to information obtained during clinical trials, millions of Americans with mental illness today live a normal and productive life. However, not everyone can take part in such trials. Before deciding to participate in the study, each person should weigh the pros and cons.

In recent years, the NIMH has introduced a new generation of clinical trials, so-called real-world research. They received their name for several reasons. Unlike traditional clinical trials, they offer many different types of treatment and treatment combinations. In addition, they try to involve as many mentally ill people from different regions of the United States and treated in various health facilities as possible. To participate in these trials, they try to attract patients suffering from several mental illnesses simultaneously, as well as those who have concomitant physical ailments. The main objective of research in the real world is to improve the methods and improve the results of treatment for all those suffering from mental disorders. Apart from the fact that these studies record the dynamics of the symptoms of the disease, they also collect information on how treatment affects other important aspects of the “real world”, such as the quality of life, the ability to work and function in society. In the course of research, the effectiveness of costs for different types of treatment is also studied and factors that affect how patients adhere to the prescribed course of treatment are analyzed.

Quetiapine (seroquel) and biopsychosocial approach in schizophrenia

Schizophrenia as a biopsychosocial phenomenon requires long-term combined drug and psychosocial treatment. With adequate care, the clinical and functional outcome of schizophrenia is no less favorable than in a number of diseases requiring conservative or surgical treatment (arthroplasty, coronary bypass) [2]. Psychopharmacotherapy is an integral part of the biopsychosocial treatment of a patient with schizophrenia. The clinical efficacy (in daily practice) of typical neuroleptics (TN) and atypical antipsychotics (AA) is composed of interrelated safety indicators (individual tolerability), satisfaction with treatment, compliance of patients. A scientifically justified choice of VT or AA is determined by the best risk ratio (early and delayed adverse effects) / benefit (clinical effect) of therapy and the preferences of the patient and his loved ones. The choice of the drug is dominated by a precautionary principle: minimizing the risk of unwanted actions, taking into account the patient’s suspected sensitivity and in the context of his professional and daily activities (for example, small finger tremor is a tragedy for a musician). The effect of a TH or AA is predicted by the doctor, based on the experience of treating the patient or his blood relatives (incidentally, their awareness of the details of treatment and the need for information is revealed). The selling price of AA (seroquel) is two orders of magnitude higher than the TN in terms of the daily dose, but pharmacoeconomic studies indicate that the former has an illusory-objective value in formulating the form and choosing a doctor. After all, the cost of antibiotics and immunosuppressants is not less, but priority in financing health care. The resource-saving potential of AA manifests itself fully in their rational choice and application [2]. The position of the national clinical guidelines [6] is consistent with the recommendations for the treatment of schizophrenia in a number of European countries: AA is shown in the absence of the expected (acceptable for the doctor, patient, his loved ones) clinical response and / or high risk or development of undetectable undesirable effects of TN in a minimal therapeutic dose , causing significant distress in the patient and reducing his social functioning and quality of life. This step-by-step approach is a proven cost-effective strategy in the face of a scarcity of medical resources [2]. The criterion for deciding on the choice of AA was the ethical principle of justice – a non-discriminatory, reasonable, differentiated distribution of limited medical resources for the treatment of certain groups of patients with limited therapeutic options in comparison with the population of schizophrenia. The success of the treatment is facilitated by the productive union of the patient, his relatives with the doctor-adviser (members of the multidisciplinary team), joint planning of treatment for the consistent resolution of the patient’s personally significant problems (from getting rid of blasphemous “voices” before returning to the profession), forming the responsibility of the patient and his relatives for the result of treatment. The strategic goal of biopsychosocial treatment is unchanged: improving the clinical and functional outcomes of schizophrenia, alleviating its multiple burdens for the patient and his loved ones, psychiatric and general medical services, society as a whole. However, the tasks of therapy change in connection with the phase of the disorder [6, 9, 25, 26].

Acute (stop) treatment of patients in the first episode, relapse or exacerbation of schizophrenia is aimed at the early stabilization of psychotic disorders; identification of individual psychosocial triggers of an acute condition; prevention of prolonged social disadaptation of the patient. The purpose of treatment of paroxysmal forms: the achievement of the deepest remission, continuous forms – compensation of psychotic disorders within the framework of therapeutic remission. Explanatory work with the patient (the meaning of treatment to alleviate the most disturbing symptoms, an individual prognosis, preferably in an optimistic manner) strengthens the setting for treatment during the “latent” period of the drug. Education of close, active participants in the process of therapy is important in the formation of a protective and protective environment. It is important to “imprints” (imprinting) positive events in acute treatment, and negative impressions result in the rejection of subsequent treatment, distress. When hospitalization should be avoided whenever possible physically constraining the patient, prolonged isolation in the monitoring room. Disturbance of patients, lack of exercise and lack of employment, roughness, internal conflicts of personnel are risk factors for the patient’s aggression in the hospital department even against the background of “good medicine”. It is preferable to take drugs inside and only if necessary to resort to parenteral administration. However, some physicians are inclined to start acute treatment with intramuscular forms of VT, or, more rarely, AA, unreasonably believing that this method is more effective [2].

However, no more than 10% of patients require parenteral administration of the drug in connection with the rejection of tableted forms. A number of patients perceive injections as a repressive measure, evidence of a particular danger of their condition. In addition, injections are painful (especially for patients with a reduced pain threshold), are costly and fraught with complications (respiratory depression, infiltrates).

Seroquel in connection with its safety can be appointed until the results of laboratory tests are obtained; in urgent cases, when the patient resists examination (but not taking the medicine) – until a complete medical examination. Probably a trial 48-hour treatment with trial doses of seroquel (50-100 mg) to identify the individual sensitivity of the patient with an assessment of his subjective reaction [16]. Seroquel less often than TN, causes dysphoria, emotional indifference. Such an unpleasant and memorable early symptomatology, which outstrips the therapeutic effect, often leads to the rejection of further treatment. Hypotension (it is important to prevent the patient, especially the elderly, not to stand up sharply, avoid dehydration, especially in summer) and dry mouth (good rinse, chewing gum without sugar) are usually reduced as they adapt to seroquel, like most of the early “general toxic” actions of neuroleptics [ 1].

In psychogerontological practice, the risk of orthostatic hypotension (to prevent abrupt rising from bed) and dizziness
(with possible falls), tachycardia in the initial stage of treatment (the initial dose of seroquel should not be more than 25 mg, the slower the dose, the better the drug is tolerated). The risk of ventricular tachyarrhythmia in the treatment with seroquel (10%) corresponds to that in the treatment with tableted haloperidol and 1.5 times less than when treated with risperidone [22]. In acute treatment, the speed of the drug is important. Olanzapine inside (including the resorption form) requires 5-8 hours for its concentration in the blood plasma to peak, oral haloperidol – 4 hours, risperidone and seroquel – 2 hours. It is possible to increase the dose of quetiapine to 800-1000 mg for a 3- 5 days (200 mg / day) with asymmetric two-time appointment of most of the drug at night, if necessary in combination with high-potency tranquilizers (lorazepam, phenazepam). The non-specific calming effect of seroquel without hypersedition (the need for tranquilizers is reduced) is useful for prompt, within 5-7 days, arresting the agitation and hostility of patients [8], is positively perceived by patients, does not interfere with detailed somatoneurological evaluation and early psychosocial interventions. While the risk / benefit ratio of quetiapine is above the recommended threshold, little is known about it, but within the therapeutic range, with the selection of seroquel (up to 750 mg / day), psychotic anxiety decreases within a week [12].

Gradual build-up of doses (up to 400 mg / day for 5 days) is shown elderly and with liver diseases. Doses of seroquel 450 mg / day, approximately equivalent to 8 mg of haloperidol, are usually sufficient for patients in the first episode of schizophrenia. The efficacy (in RCTs) of acute treatment with seroquel (400-800 mg / day), olanzapine (10-20 mg / day) and risperidone (4-8 mg / day) is similar [3]. The antipsychotic effect of seroquel is most pronounced to the 8th-12th week in 50-85% of patients [15]. Seroquel monotherapy avoids the risk of pharmacokinetic interactions and a complex treatment regimen for the patient and medical staff. A smaller need for anticholinergic correctors (cyclodole), exacerbating and prolonging psychosis, having the potential of dependence and aggravating cognitive frustration of schizophrenia, contributes to the optimization of therapy in the choice of seroquel. The widespread combination of seroquel with VT and other AAs in everyday practice (up to 40%) is associated with the doctor’s impatience , not taking into account the risk of treatment at its rise in price, blurring the clinical picture [2]. In acute treatment, patients prefer seroquel to a number of other AA and TN [7], especially those who avoid taking medication because of increased sensitivity to neurological and metabolic (obesity, hyperprolactinemia) side effects, such as in the first episode of schizophrenia [3] . Thus, weight gain causes no less distress than acute neurological disorders, especially in young girls (at risk), which is important when choosing an antipsychotic to avoid a later break even of successful clinical therapy. The risk of weight gain (in 25% of patients, usually not more than 4 kg for the first 12 weeks with subsequent access to the plateau for a one-year treatment) in seroquel is lower than in a number of AA [3].

Against the background of seroquel, the initially increased weight may even decrease. In everyday practice, however, the majority of patients are treated with a combination of drugs, including a high risk of weight gain (for example, “classical” tricyclic antidepressants, lithium), and the beneficial effect of seroquel against polypharmacy may be lost. Therefore, it is important to teach the patient the skills of a healthy lifestyle (exercise, low-calorie diet). Ineffectiveness of treatment is noted in the absence of positive dynamics in the clinical and functional areas of assessment, including the subjective – the patient himself, within 3-8 weeks after reaching the therapeutic dose of seroquel; with a partial response, treatment should be continued for another 4-10 weeks.

With ineffective treatment, a reassessment of the patient’s mental and physical condition is necessary (revealing hidden organic inferiority, substance abuse, affective disorders, compliance problems, chronic psychosocial distress, increased emotional experience in the family). It is possible to increase the dose of quetiapine after 6-8 weeks of treatment, but ultrahigh doses should be avoided. The practice of premature replacement of quetiapine with another drug or polyneurosis leads to the fact that the cause for improvement of the patient’s condition and undesirable actions remains unclear for the doctor. The transition to seroquel is logical in the case of uncontrolled undesirable phenomena of VT (for example, acute extrapyramidal disorders) or other AA, with the exception of clozapine (for example, obesity). A method of cross-titration that minimizes the risk of symptoms of “ricochet”, sometimes interpreted by a physician, as undesirable actions of a new treatment is desirable (Table 1).

The orderly behavior of the effect of seroquel with the “distancing” of the personality from the remaining psychotic experiences makes it possible to start individual and then group psychosocial interventions (training in management of the disease and its treatment) at the early stages of hospital treatment, continuing at discharge. Therapy includes a number of components:
• detection and prevention of relapse factors, active control of the “early” symptoms of worsening;
• urgent treatment when they are identified by a joint crisis plan worked out jointly with the doctor and close (management of distress, intensification of observation and treatment, strengthening of informal support);
• training in effective coping skills with symptoms and family (family) distress, drawing on the positive experience of group members and behavioral techniques, learning to solve common problems and social skills in the organization of treatment (seeking help, alliance with loved ones and professionals);
• Individual or group family therapy for emotional support, learning to cope with the illness of a loved one through understanding the active role in treatment, reducing excessive emotions as triggers of relapse, and prevention of distress.

As the patient’s condition is stabilized, it is necessary to switch to a treatment that is effective for acute treatment with a drug (seroquel) to prevent early relapses and exacerbations, to strengthen and consolidate the success of therapy. As remission deepens, the patient increasingly acts as a subject of treatment on the principles of partnership. The psychiatrist (social worker, clinical psychologist) focuses on the patient’s problems outside the protected environment of the hospital (day hospital): limits unrealistic expectations and requirements for the functioning of the patient in his family. It is necessary to balance the stimulation of patient responsibility for the result of treatment and the provision of emotional and social protection. It is important to save the patient and his loved ones from the fatalistic expectation of a return of psychosis, orient them to a healthy lifestyle. The management of the patient is focused on evaluating, supporting, explaining, strengthening the sense of reality, changes in his behavior. Relief of psychotic symptoms in the treatment of seroquel allows you to indirectly master (restore) social skills. Group psychosocial therapy is used to develop skills for management of illness and treatment, it is useful to involve the patient and his relatives in the activities of the self-help society in the community (an important part of the treatment plan). Improvement of symptoms outstrips the improvement of social and labor functioning. The nature and extent of disability is a more relevant and real measure of the outcome of schizophrenia treatment than a change in the clinical picture (“target syndrome”). A clear sign of a patient’s social recovery is a return to an occupation appropriate to age. When persistent symptoms need to strengthen psychosocial treatment (cognitive-behavioral therapy).

Pharmaco-dependent remissions with “blurred” symptoms, which are actualized with the abolition or reduction of doses of TN or AA in more than 60% of patients with schizophrenia, determine the continuation of treatment with total (unchanged) doses of quetiapine by the majority of community-acquired patients. The treatment regimen should correspond to the daily functioning of the patient, and it should be simplified, which will improve compliance and facilitate its monitoring by trained relatives. It is advisable to “asymmetric” the reception of most of the seroquel in the evening, since the drug in medium doses is prescribed twice a day, but the clinical effect in patients receiving the drug once a day is similar [13]. When revealing the early symptoms of relapse (the topic of psychoobrazovaniya) may increase the dose of seroquel by 100-200 mg with a temporary attachment of tranquilizers.

Clinical problems in the development of remission. Experiencing a state of “awakening”, that is, a pronounced and rapid clinical improvement in the treatment with seroquel, patients reveal a wide range of reactions (alienation of the disease, reactive depression), disrupt the treatment regimen and therefore require intensive emotional support, since their “I” did not have time to adapt to new ones social problems, and the family of the patient is not always able to perceive with understanding the new role of the patient, more habitual in the inhibited state. The condition is transient, it is possible to appoint tranquilizers for up to a week. Negative disorders, their severity (buildup) is difficult to detect in an acute period. It is necessary to distinguish caused, for example, TH, akinesia, as well as depressive anhedonia, paranoid asociality, impoverishment of speech in thinking disorders from primary negative symptoms. It should be explained to the close nature of the patient’s changes (not “laziness”), cautiously prepare them for the idea that patients may not return to a painful condition, and for improvement, not only medication but psycho-social effects are required. The negative disorders that come to the forefront are the basis for choosing seroquel, if it has not already been assigned, keeping in mind its possible antidecitant and cognitive-impairing effects (at least, it does not exacerbate their undesirable actions), but it’s worthwhile to set up the family not to rely on the fast ” miracle “(to determine the effectiveness of treatment requires at least six months) and call for active cooperation in the case of resocialization of the patient. After all, the “defect” of the patient in many respects is his personal compensatory reaction to the neglect of others, and “learned helplessness” is a consequence of understated requirements in the hospital and community settings. Therefore, the heaviest patients should be sent as soon as possible to the rehabilitation department to develop (restore) social skills, in more light cases – in the day hospital for the continuation of the rehabilitation program or home to the care of relatives with compulsory communication with social services. An unpublished extract from the hospital is fraught with an increase in the burden of schizophrenia for the family and the rapid deterioration of the patient’s condition. Post-schizophrenic depression is possible in 50% of patients, although in the majority (up to 60-80%) of cases active treatment of TN or AA (seroquel) and intensive psychological support in the acute period contribute to resolving depression within the psychosis. In case of depression, the doctor will have to eliminate the previously unrecognized organic disease and schizoaffective disorder, the distress after the previous psychosis, the prolongation of a new episode, treat any concomitant medical illnesses, exclude substance misuse and neurological undesirable actions (akinesia, akathisia can not be ruled out in the treatment of any TN or AA) , to reveal the psychotraumatic situation that is persisting or brought by the illness in the family or at work. A necessary condition for treatment is the information of relatives about the risk of suicidal tendencies in the patient, creating an atmosphere of reasonably weighed optimism. It can be assumed that the harmonious effect of quetiapine on all components of an acute attack will allow for a deeper remission (including a decrease in the frequency of post-schizophrenic depression). With depression in the background of seroquel, treatment with antidepressants of the new generation is shown for at least 6 months [9, 26]. With the difficulty of distinguishing between depressive symptoms and negative, a trial course of antidepressant therapy is shown. The appointment of antidepressants without seroquel can exacerbate psychosis.

Non-compliance with treatment regimens. Good tolerance of seroquel does not guarantee continuation of treatment without systematic psychosocial work with the patient and his relatives, since the main causes of long-term compliance problems are the internal picture of the disease (the patient does not need treatment, he is actively opposed to medicines), an unsatisfactory therapeutic alliance with a doctor , disinterest of the family in the results of treatment. At least 50% of patients lose their relationship with HDPE in the first months after discharge from the hospital. A number of patients, stopping treatment on their own, note that they feel good after 3-4 weeks. It is necessary to take into account the incompletely formed reaction to the acute period, the patient’s vulnerability to psychosocial stresses, possible undesirable actions of therapy, to explain to the patient and his family that the risk of deterioration is high and he is delayed in time, and the path to recovery is long, but “the path will master the going.”

Antiretpressive (maintenance) therapy reduces the risk of recurrences (exacerbations) of schizophrenia and, apparently, slows down the rate of its progression. Treatment is necessary as long as the underlying pathology persists, and does not imply that the risk of relapse is reduced after discontinuation of medication and that in the future it will not need its renewal. Secondary prevention is more important than the risk of unwanted effects of drugs, since most of them are reversible, and the consequences of relapse can be fatal. Adequate pharmacotherapy (“the right medicine for the right patient”) allows to improve, consolidate the achieved therapeutic results with the least risk of undesirable actions. In connection with the unclear prediction of the cessation of activity of the painful process, supportive treatment is indicated to all patients. For patients who have undergone the first episode and are fully remorted within a year, gradual withdrawal of seroquel treatment within one to two years is possible [6, 9, 26]. At least 5 years to be treated in the absence of psychotic symptoms to patients with repeated attacks. Preventive treatment during life is shown by a third of chronic patients, especially dangerous for themselves and others in an acute period (or if repeated psychoses differed in duration and did not respond well to therapy). For many patients, a psychiatrist becomes a general practitioner. He should pay more attention to the state of physical health and well-being of patients, dynamically controlling the possible undesirable effects of prolonged therapy. In this regard, low risk of unwanted effects of seroquel with long-term use [3] is important, for example, tardive dyskinesia, a scourge of maintenance therapy for TH or obesity in the treatment of a number of AA. The choice of seroquel is indicated by the stabilized symptomatically ill, but experiencing these side effects that are not otherwise corrected. Reduction of seroquel dose due to good tolerability and low risk of dose-dependent adverse effects is not useful in patients with pharmacologically dependent remission; in others, it is possible (if the risk / benefit ratio is re-evaluated) not earlier than 6-12 months of stable relief of symptoms of paroxysmal schizophrenia, control. The minimum therapeutic dose of seroquel is determined by physicians after trial and error. With insufficient doses of quetiapine, relapses (exacerbations) may be delayed for several months, and therefore serve as an unreliable indicator. Good tolerability of seroquel in combination with its high antiresidivnoy efficiency contributes to the satisfaction of patients with long-term treatment [11, 14, 17, 21, 24]. However, discontinuation of AA therapy (ziprasidone, quetiapine, olanzapine, risperidone) in chronic patients reaches 75% within 18 months, and is only slightly determined by drug intolerance [18]. Screenings in seroquel treatment are 80% within three years [22], which emphasizes the danger of neglecting psychosocial work to strengthen and control long-term compliance of patients.

So, in the first months of treatment with seroquel, the main efforts are aimed at reducing psychotic symptoms with minimal risk of unwanted effects of therapy. After 3-12 months, the emphasis is shifted to preventing relapses (exacerbations), maintaining and monitoring compliance by the patient, reducing the risk of medical complications of therapy, social and labor engagement and meeting the changing needs of the patient and his family. After a year, the therapy focuses on ensuring an independent and happy life for most patients, regardless of the “length of service” of their disorder.

The symptomatic effect, social functioning and quality of life of a patient with schizophrenia when treated with seroquel will be higher with coordinated interprofessional and interagency interventions (Table 2).

Seroquel opens the locks of early rehabilitation (due to the ordering action); contributes to the establishment of a stable full-fledged remission (antipsychotic and antiresidivnye effects), as the basis of social recovery [4]. A “patient-friendly” seroquel with a close to optimal ratio of risk / benefit therapy is the first choice drug at successive stages of systematic biopsychosocial treatment of schizophrenia.

Literature

1. Gurovich I.Ya. Side effects and complications in neuroleptic therapy / Diss. Doct. honey. sciences. – M., 1971. – 443 p.
2. Gurovich I.Ya., Lyubov E.B. Pharmacoepidemiology and pharmacoeconomics in psychiatry. – M .: Medpraktika, 2003. – 264 p.
3. Gurovich I.Ya., Lyubov E.B. Seroquel in a number of other antipsychotics in the treatment of patients with schizophrenia / / Russian Medical Journal. – 2008. – T. 16, № 12. – С. 1705-1710.
4. Gurovich I.Ya., Lyubov EB, Storozhakova Ya.A. Recovery in schizophrenia: The concept of “recovery” / / Social and clinical psychiatry. – 2008. – Vol. 18. – Issue. 2. – P. 7-14.