Despite the numerous studies and the diversity of the concepts of schizophrenic reactions (SR), there is still no unity of views on the clinical boundaries of this concept, and the research criteria for reactive states, the atypia of which is due to the inclusion of procedural manifestations, are still a subject of discussion. The existing disagreements to a certain extent reflect the position of the SR in ICD-10, in which psychogenias of this circle can be classified in the diagnostic sections “Schizotypal disorder” – F21 and “Acute and transient psychotic disorders” – F23. At the same time, in order to classify non-psychotic level SRs to the first of these diagnostic categories, it is not necessary to have a connection with traumatic influences (only in the domestic version of the classification, SRs in this understanding are distinguished by a separate heading – F21.2). At the same time, section F23, which includes, as a priority, the association of psychopathological disorders with stress, does not include disorders whose severity does not reach the degree of acute psychosis (within this category, “Acute polymorphic psychotic disorder” – F23.1; “Acute schizophrenic-like psychotic disorder “- F23.2).
The concepts of the development of psychogenias in schizophrenia, the origin of which dates back to the beginning of the 20th century, were based on the assumption of the existence of a special type of reactive lability, which is formed under the influence of an endogenous process. There was even a separate type – “reactive schizophrenia” [Berze J., 1929], in which, as a result of the impact of mental trauma, a latent schizophrenic process manifests itself as “schizophrenic-psychotic processing of experiences”. Further studies of psychogenias in procedural diseases are based on the idea of the existence of prerequisites in the form of increased readiness for reactions depending on the stage of schizophrenia. It was established that the greatest vulnerability to stressful effects is observed mainly in the initial and post-process periods. In the acute phase of the process, the condition of patients is less affected by psycho-traumatic events [Kantorovich N.V., 1967], while special sensitivity to stress during stabilization can be due to a pathologically altered “soil” with the formation of pseudopsychopathy [Melekhov D.E., 1934] …
As a result of a targeted study of psychogenias in low-grade schizophrenia, A.B. Smulevich (1987), along with SRs that occur simultaneously with the manifestation or entail an exacerbation of the endogenous process, highlighted a variant in which SRs, preferred for patients with residual pseudopsychopathic conditions, are not associated with exacerbation of schizophrenia. According to the author’s observations, this type of SR develops in patients with residual pseudopsychopathic conditions.
It should be emphasized that if the idea of schizophrenia (or schizoidia) as a necessary condition for the formation of SR, which has developed since the time of E. Bleuler , does not cause any particular controversy, then the one put forward in the few works of domestic authors [Melekhov DE, Chernoruk V. G., 1933], not all researchers share the point of view about the possibility of such reactions “on the basis” of personality disorders, not only schizoid, but also of other types.
At the same time, this possibility can be considered in the analysis of modern concepts of schizotypal and borderline personality disorders (PD). Although schizotypal PD largely corresponds to the characteristic of latent schizophrenia in the traditional sense, and borderline one combines deviations, the main features of which are impulsivity with inconstancy of interpersonal relationships, inability to adequately assess reality, affective instability with episodes of dysphoria, irritability, anxiety, tendency to auto-aggressive behavior and disorders drives, their common characteristic is increased vulnerability to psychogenic influences, which is realized by atypical depressive states, obsessive, dissociative disorders and “brief psychotic episodes” or “mini-psychoses” [Kernberg OF, 1967; Gunderson JG, 1975; Paris J., 1999].
This interpretation of SR as clinical structures identified not only by signs of psychogenic provocation and the presence of schizophreniform symptoms contributes to the development of optimal approaches to the treatment of such conditions.
Some of these approaches were developed on the basis of data obtained in the course of a study devoted to the analysis of therapy in patients hospitalized for SR in the clinic of borderline mental pathology and psychosomatic disorders (headed by Academician A.B.Smulevich) of the National Center of the Russian Academy of Medical Sciences.
In the studied patients, a reactive state was verified, which arose against the background of a diagnosis of schizophrenia established in accordance with ICD-10 (“residual” – F20.5, “latent” – F21.1) or PD (“schizotypal personality disorder” – F21.8, ” paranoid personality disorder ”- F60.0,“ borderline type of emotionally unstable personality disorder ”- F60.31). Acute or prolonged mental trauma preceded psychogenesis in the studied sample, in response to which a depression of moderate or mild severity was formed, the content of which was determined by the psychogenic (catatomic) complex. Along with hypotension, other psychopathological disorders (anxiety-obsessive, dissociative, hallucinatory-paranoid) that were heterogeneous with respect to affective ones were also recorded in the clinical picture.
The results of the study allow us to assert that when choosing a method of therapy for SR, it is necessary to take into account, on the one hand, the level of psychopathological disorders (neurotic-psychotic, and on the other hand, interaction with personality (ontogenetically or procedurally determined – psychopathy / pseudopsychopathy) pathology.
Two types of reactions schizophrenic
Depending on the level of psychopathological disorders and comorbid structure constitutional or acquired (residual schizophrenia) personal pathology are two main types of shunt reactor distinguished:
1. SR arising in patients with borderline, schizotypal (including latent schizophrenia) or paranoid RL occurring with the formation of transient psychotic episodes (mini-psychoses) of the type of “outbreaks of hereditary deviants” and are closely interrelated with the psychopathic structure that was formed in the period preceding mental trauma.
2. SRs arising in patients with residual schizophrenia within the framework of a persistent pseudopsychopathic state, proceeding with the formation of psychopathologically homogeneous disorders of a predominantly neurotic level, which are realized within the resources of a personality altered by a progressive endogenous process without the addition of symptoms of more severe registers.
The first type of SR
In the first type of SR, reactive states, although they have the basic signs of true psychogeny, i.e. arise in connection with objectively significant stressful influences (death of loved ones, betrayal, divorce, loss of work), and the psychogenic complex remains relevant throughout the reactive state, differ in a number of significant features.
The clinical picture of reactive states of this type is determined by the combination of a shallow (hysterically dysphoric or anxious) depression of psychogenic content with patho-characteristic (impulsiveness, demonstrativeness, explosiveness) and polymorphic subpsychotic disorders. A characteristic feature of the latter part of the cases is the coexistence of dissociative disorders (pseudodementia, magical thinking, delusional fantasizing), catatimically charged imagery and hallucinations of the imagination, reflecting a traumatic situation, and psychologically irreducible deceptions of perception (calls, haptic, olfactory hallucinations). In other cases (in individuals of a paranoid warehouse with an unshakable conviction of their own rightness, perseverance, determination to achieve a goal, uncompromisingness), in the process of developing psychogeny, the homonymous to obligate properties of the RL are unstable, unsystematized delusions overlap with the anxiety-obsessive form polar with respect to the structure of the RL “Madness of doubt.”
Such reactions are reversible, do not show a tendency to a protracted course (their duration does not exceed several months) and are not accompanied by an exacerbation of the endogenous process with an increase in negative changes in the schizophrenic type.
Therapeutic approaches for type I SR The
therapeutic approaches for this type of SR correspond to the characteristics of both psychopathological disorders that determine the structure of the reaction as a whole (affective – reactive depression), and optional subpsychotic formations.
As a rule, combined therapy is carried out (antidepressants in combination with antipsychotics), and due to the fact that in the clinical picture throughout the pathological reaction the most stable component is hypotension, the main place in the treatment regimen is given to antidepressants, which is consistent with data from other authors. Preferred drugs of the group of selective serotonin reuptake inhibitors (SSRIs), prescribed in high doses (fluoxetine 60-80 mg / day; fluvoxamine 300 mg / day). The appropriateness of using SSRIs is explained in the literature [Coccaro EF, 1996; Paris J., 1999] not only with a favorable tolerance profile and a wide therapeutic range of doses for this group, but also with high lethal doses, which ensures their safety in patients with a risk of impulsive suicidal behavior.
Given the affective instability, the propensity of patients with this type of reaction to repeated depressive conditions, the use of normotimics (carbamazepine, lithium carbonate) is justified.
Subpsychotic manifestations in the picture of psychogenicity are stopped by neuroleptics. At the same time, the corrective effect of the agent of this class on pathocharacterological disorders is also used. Traditional antipsychotics are prescribed taking into account the transient nature of the hallucinatory-paranoid register disorders and the flotating nature of anxiety-obsessive manifestations in low doses (a series of controlled studies have shown the effectiveness of non-injection forms of chlorpromazine [Leon NF, 1982] and haloperidol [Sebran G., Siegel S., 1984]). However, our own observations confirm that given in the modern literature [Khousam HR, Donnely NJ, 1997; Szygethy EM, Schulz SC, 1997] information on the preference of atypical antipsychotics (risperidone 4-6 mg, quetiapine 150-400 mg).
In a number of cases (with the predominance of psychopathic and / or paranoid symptoms over affective ones), monotherapy with neuroleptics of a new generation, which is not inferior in effectiveness to combined treatment, can be carried out.
The second type of SR
With SR of the second type (as opposed to the first), the acquired reactive lability inherent in patients ensures the pathogenicity of even objectively insignificant traumatic events. A pathological reaction is characterized by a dissociation between the minimum force of stress (minor office conflict, family troubles, problems with passing exams or paperwork) and the severity of the response to it. The reactive formations formed at the same time are characterized by relative simplicity, stereotype and a small range of psychopathological manifestations, limited mainly by disorders of the affective and neurotic levels.
Corresponding in the psychological understanding to “refusal reactions” or avoidance, SR according to clinical manifestations can be classified as hysterical, hypochondriacal, asthenic and anxious, which are based on doubts about the ability to cope with habitual activities, associated with real failure.
Shallow psychogenically caused psychopathological disorders are accompanied by the actualization of litigious tendencies, diffuse ideas of attitudes aimed at the “offenders”, “troublemakers”. In some cases, such conditions can persist for months, while in others they can be transient and undergo reduction within a few days even without medication.
Psychopharmacotherapy in type 2 SR
The role of psychopharmacotherapy in this type of SR is relatively small in comparison with type 1 psychogenias. Therapeutic tactics are based on the clinical picture of the reactive state, taking into account the comorbid manifestations of the schizophrenic defect. The main means of stopping psychogenic formations, accompanied, as is typical of “refusal reactions”, confusion in front of everyday difficulties, fear of being left unattended and unsupervised, painful fears and anxiety symptoms, are tranquilizers. At the same time, the treatment adapts to the clinical features of SR: to influence asthenic symptoms, it is necessary to add nootropics and / or small doses of neuroleptics with activating properties (trifluoperazine 3-5 mg, sulpiride 100-200 mg); in cases where the clinical picture of psychogenia is characterized by hysterical or hypochondriacal (neurotic hypochondria) disorders, the effect of tranquilizers can be enhanced with neuleptil in daily doses of 5-10 mg.
Social measures aimed at changing or resolving the situation that contributed to the emergence of a reactive state also have a healing effect. The psychotherapeutic effect of this type of SR is achieved even by the fact of hospitalization, which helps isolate the patient from the traumatic situation.