The concept of schizophrenia. Main points
Schizophrenia or schizophrenia (from Greek schizo - cleavage, phren - soul) refers to a group of similar mental disorders of unclear origin (etiology), which probably have common endogenous pathogenetic mechanisms in development in form of hereditary anomaly, which do not manifest until a certain period of life. Without treatment, a continuously progressing or seizure-like course is characteristic, usually culminating in a single-type picture of personality change (defect) with disorganization of mental functions (thinking, emotions, psychomotor skills - the behavior as a whole) while preserving memory and previously acquired knowledge.
The prevalence of schizophrenia is 1% of the population. Age maximum morbidity is 15-25 years for men and 25-35 years for women. The higher number of schizophrenia patients is among low socio-economic strata. There is also a correlation with population density (in cities with more than one million inhabitants the probability of the disease is higher). There is a hypothesis about the existence of "schizophrenogenic" cultures, such as Japanese culture. There is also evidence that a person who lives in the countryside will live longer after recovery than a person who has recovered in the city and is less likely to relapse.
A number of signs associated with the course of the disease can give a more or less positive prognosis about the future prospects of a particular patient. A negative prognosis is indicated by early onset, non-acute onset, autism of the patient, lack of immediate stressors, negative symptoms, and poor social adjustment. A positive prognosis is indicated by the presence of depression or mania, late onset, acute onset, presence of immediate stressors, positive symptoms, and close social connections.
This mental disorder as a single disease was isolated at the end of the XIX century by the famous German psychiatrist Emil Kraepelin under the name "early dementia" (lat. dementia praecox), that is developing in the youth or young years. Prior to that, various forms of schizophrenia were considered to be independent mental illnesses. In 1911, the Swiss psychiatrist Eugen Bleuler designated this disease by the neologism "schisophrenia.
History of schizophrenia
The great clinical polymorphism of schizophrenia in its modern scope has its historical roots. The main clinical variants of this disease were singled out as early as in the prenosological period of psychiatry development. The main forms that served as "material" for Kraepelin's synthesis at the end of the 19th century were far from homogeneous; each of them had its own history and different clinical and psychological evaluation at different stages of psychiatry development and in different national schools.
The term "psychosis" was first used in 1845 by Baron Ernst von Feuchtersleben, dean of the medical faculty of the University of Vienna, in his "Textbook of Medical Psychology" to denote manifestations of mental illness. Whereas the term "neurosis" referred to lesions of the central nervous system. It had to wait for the works of Jean Martin Charcot and Sigmund Freud and the transition to the 20th century for the meaning of the term "neurosis" (introduced by the Scottish doctor William Cullen in 1776) to change completely and begin to mean on the contrary psychopathological states without an organic lesion of the nervous system.
The first steps in the description of the future nosological unit concerned its "nuclear" (in the later understanding) adolescent adverse current form. Separate descriptions of such patients can be found in Heinroth, Pinel, Moreau de Tours, Esquirol, Gottlen, P. Malinowski, P. Butkovsky. These were cases of sudden "fading" of mental faculties in young people, previously quite complete or even gifted, the development of dementia or lunacy.
Long period of XIX century is characterized by the domination of two concepts in psychiatry - the concept of unified psychosis (Zeller, Neumann, Griesinger) in explanation of variability of the disease pattern, and the concept of degeneration (Morel, Magnan) in explanation of etiology and psychopathology features for a significant group of mental disorders, including modern schizophrenia, its continuous current and seizure-like forms.
Throughout the 19th century, psychiatrists were faced with a fundamental question: whether there was a single psychosis or whether it was possible to distinguish between different types of psychosis. The German psychiatrist Wilhelm Griesinger introduced and developed the ideas of the famous German psychiatrists Heinrich Neumann and Ernst Albert Zeller, which later got the name of the "single psychosis concept". This concept generally rejected the existence of independent mental illnesses (nosological units). Mental disorders, caused by various reasons, pass through two basic stages, reflecting primary and secondary affection. According to W. Griesinger's views, psychosis is a process where in the first stage there are no brain changes, they are still reversible, while in the second stage there are brain changes that cannot be cured. The clinical expression of this concept was W. Grisinger's classification (1845), which respectively distinguished melancholia (a state of mental depression), mania (a state of agitation) and a state of mental weakness, including delirium, confusion and idiocy. Since that time, this classic triad of stages (melancholia, mania, dementia) has been repeated in many works of psychiatrists of the time. In spite of the antinosological character of the concept of a single psychosis, it is necessary to note the progressive aspects of such an approach. First of all, it concerns the assertion that there are general regularities of current mental illness, i.e., that there is a certain sequence of mental disorders. Secondly, this approach was a step forward compared to symptomological classification attempts based on a purely psychological principle.
The attempt of nosological understanding of the described group belongs to the French psychiatrist Benedict Augustin Morel, whose name is associated with both the isolation and the first attempt of etiological and pathogenetic analysis of the group of debilitating psychoses of adolescence, different from idiocy and secondary dementia. Morel points out the high frequency of such observations and introduces the term "early dementia" in his Treatise on Mental Disorders, 1860. He was interested in the systematics of mental diseases, a general concept that could explain the variety of mental anomalies. Morel created the first etiological classification of mental diseases, including 6 groups. The first group (hereditary psychoses) describes the early dementia he singled out. The single concept, which, in his opinion, was supposed to link all the groups he described, was the concept of degeneration. In his famous Treatise on the Physical, Mental, and Spiritual Degenerations of the Human Race, 1859, he describes progressive mental changes, increasing from generation to generation, from character anomalies to dementia. He classifies early dementia as the fourth (final) stage of degeneration. A follower of Morel's ideas also French psychiatrist Jacques Joseph Valentin Magnan considered that psychoses are divided into two main groups: simple (accidental) and complex (degenerative), developing in individuals with hereditary or acquired disposition. In degenerates, mental disorders are characterized by a complex and irregular form. The concept of degeneracy is now of only historical interest as one of the first attempts at an evolutionary-biological approach to understanding mental illness, but it dominated the minds of psychiatrists until the end of the 19th century and imprinted the views of not only French, but also German, Italian, and Russian researchers.
Morel's ideas were also adopted by a number of major German psychiatrists (Griesinger W., 1872; Krafft-Ebing R., 1869). The concept of a single psychosis was also subjected to revision. First of all, it was shown that it was possible to develop primary delirium without preliminary stages of melancholy and mania. Thus the doctrine of primary delirium and paranoia, the doctrine of delirium with chronic evolution Magnan (1891) emerged.
The attention of Magnan and his contemporaries in France and Germany was drawn to another problem - primary delusional psychoses. It was from this time that intensive clinical development and attempts to systematize future paranoid forms began. Allocation of delusional psychoses into a special class is connected with the name of the great French psychiatrist Jean Etienne Dominique Esquirol, who described them in the group of "intellectual monomania". Subsequent development of the concept of delusional psychosis led to the definition of a special form of delusional psychosis, characterized by a chronic evolution. This type of delirium was singled out and described in 1852 by French neuropathologist and psychiatrist Ernst-Charles Lasigue - persecutory delirium (persecution delirium). Further the concept of delusional psychosis was developed by Legrand du Saulle, Falret, Magnan and others. The main distinction of this form is the dominance in the clinical picture of delirium, which undergoes a certain development over time.
Further progress in the study of malignant forms occurred under the influence of the works of German psychiatrists Kalbaum and Hecker. The isolation of catatonia and hebephrenia is associated with their name.
Carl Ludwig Kalbaum defended his dissertation "Classification of Mental Diseases" in 1863. In his classification he proposed to distinguish a special class of psychoses associated with a particular phase of physiological development and to designate them as "paraphrenia." "Dementia praecox" here naturally finds its place as pubertal paraphrenia, and senile (senile) dementia as senile paraphrenia, thus preserving the age of manifestation of dementia, which is one of the essential points of Morel's description, as an important distinguishing criteria for these nosological units. Later on, in the course of history, Kraepelin and then Freud would give or rather try to give the term "paraphrenia" a completely different meaning, which would not be successful, but would make us forget the original and basic meaning.
Edward Hecker, a student of Kalbaum, published a monograph in 1871 in which he made a clinical description of "hebephrenic paraphrenia. He gives as the main characteristics of this new nosological unit "its occurrence at the time of puberty... its rapid outcome into a state of mental weakness and a special form of terminal dullness, the signs of which could be recognized in the first stages of the disease. Thus, at first glance, nothing has changed from Morel's first description as far as the age of manifestation and the terminal condition are concerned. The etymology of the neologism coined to denote this disease well underscores the importance given to the first point, because Geba is the goddess of youth.
For E. Hecker this disease is the disease of youth, it occurs "between the ages of 18 and 23, at a time when the renewal and psychological restructuring of the self (W. Griesinger), which takes place during puberty, is barely completed under normal conditions. The novelty lies in the fact that the mental debility which completes the course of the disease is expressed in the precursory symptoms which can be observed from the first stages of the disease and above all in the very nature of these symptoms: the anomaly of syntactic construction, changing several times while composing long phrases, but without interrupting the thread of thought; the inability to formulate this thought in concise form... The patient finds the tendency to remain fixed on one subject and, to use Hamlet's words, to "pursue to death". Finally, "a pronounced tendency to deviate from normal verbal and written forms, to change the manner of speaking, and to use incomprehensible jargon in speech and writing." According to Gecker's descriptions, hebephrenia is characterized by a rapid progression to dementia.
In 1874, Kalbaum in turn published a monograph on another disease manifested by catatonia. This "tension dementia" is characterized by disorders of voluntary motor activity. Kalbaum drew attention to special muscular disorders that had not previously attracted the attention of researchers. He suggested the picture of a disease during which, following mania or melancholia, waxing flexible or negativistic with tense muscles or stereotyped movements and postures, he called strain psychosis or catatonic desease. Kalbaum described in detail the classic catatonic symptoms: negativism, mutism, verbiguration, waxing flexible, rigidity, stereotypy, catalepsy, flamboyance of movements, grimacing, etc.
In the fourth edition of his Manual of Psychiatry (1893), Emile Kraepelin identifies groups of mental decay processes-catatatonia, hebefrenia, paranoid dementia. In the fifth edition (1896), he already fully formulates his concept and outlines the broader boundaries of the early dementia he singled out. Early dementia (dementia praecox) E. Kraepelin originally defined early dementia as a debilitating disease process and based its continuous course and unfavorable outcome on its distinction from manic-depressive psychosis, for which he considered a phase course and favorable outcome to be characteristic. Subsequently, however, among cases of the disease with a continuous course he began to allocate a variant characterized not so much by a malignant weakening process, but by progredient. It concerned first of all seizure forms to which E. Kraepelin referred to circular, depressive-paranoid, agitated periodic forms, as well as diseases with systematized delirium, which he described in the group of paraphrenias. Later E. Kraepelin in the eighth edition of the manual (1913) significantly changed his views on other clinical features of early dementia as well. This concerned primarily the early onset of the disease, which determined the name of the disease. In addition to the early onset and its characteristic catatonic and hebephrenic pictures, he began to suggest the development of delusional psychoses in later ages. He suggested that delusional forms should be subdivided into more severe - with unsystematized delirium and catatonic disorders ending in dementia - and milder ones occupying an intermediate place between severe forms and paraphrenia.
Along with the indisputable merit of E. Kraepelin in the creation of the nosological concept, the latter had weaknesses, which include its static character and syndromic principle underlying the systematics of the disease forms. Therefore, E. Kraepelin, despite its wide distribution, especially in German psychiatry, caused a wide discussion. For example, A. Hoche (1912) believed that E. Kraepelin unjustifiably extended the scope of early dementia. Considering his concept to be erroneous, he opined that only a small group of diseases with early onset leading to severe outcomes could be classified as early dementia. A similar point of view was held by his student O. Bumke (1924), who believed that the disease isolated by E. Kraepelin, can be attributed only really malignant current diseases, constituting as if a core (nuclear forms), around which concentrated similar to the clinical picture of the disease, representing symptom complexes of exogenous origin.
Further development of the doctrine of schizophrenia is associated with the name of Eugene Bleuler (1911), who gave this name to the disease (schizophrenia, Bleuler's disease). If E. Kraepelin based early dementia on the principles of course and outcome, E. Bleuler considered the primary diagnostic criterion for schizophrenia to be the occurrence of a primary, "main" disorder - a thinking disorder. He considered delirium, hallucinations, etc. to be secondary phenomena. Studying the psychopathology of schizophrenia, E. Bleuler described such disorders as autism, ambivalence, peculiarity of affective disorders. E. Bleuler was reticent to distinguish forms of schizophrenia's course.
Later on, the conceptions of schizophrenia continued to change: they began to speak not so much of dementia, but rather of mental defect, not so much of a debilitating process, but of the progredient nature of its course, schizophrenia was presented as a disease process, manifesting both malignant and fairly benign, mild forms.
J. Berze (1910), E. Stransky (1914), and H. Gruhle (1922) concentrated their efforts on studying the characteristic disorder of schizophrenia. In this connection the concepts of "intrapsychic ataxia" and "hypotonia of consciousness" appeared.
Subsequently, K. Schneider (1925) introduced the notion of first-rank schizophrenia-specific symptoms, to which he referred phenomena of mental automatism and deficit disorders, K. Conrad (1959) wrote of "reduction of energy potential", W. Janzarik (1957) of "dynamic desolation", G. Huber (1964) of "pure asthenic defect".
French researchers have embraced the nosological concept of E. Kraepelin's nosological concept was generally perceived negatively. Attempts by some French psychiatrists to attribute acute and delusional psychoses to early dementia did not find support. E. Dupre (1910) and P. Chaslin (1912) continued to insist on the necessity of maintaining the independence of chronic hallucinatory-paranoid psychoses. At the same time, there was a tendency to refer to early dementia in B. Morel (as a degenerative process) catatonic-gebephrenic states and delusional schizophrenia. Subsequently H. Claude (1923, 1925), referring to early dementia, stressed that it should include only cases of primary mental insufficiency of adolescence manifested by progressive weakening of intellectual capacities (it should be noted that Claude considered early dementia an organic disease of infectious origin in the brain). Subsequent classification of A. Ey (1954, 1959) was different in that it was based not only on the principle of predominance in the picture of a particular syndrome, but also on the principle of course. The author distinguished severe, moderately severe forms of delusional psychoses, distinguished from systematized delusional, acute, cycloid and schizoaffective forms.
For the development of ideas about schizophrenia the works of K. Kleist (1913, 1919, 1942, 1953) and K. Leonhard (1936, 1957, 1960). In their works, schizophrenia was divided into a group of progredient systemic forms ("systematic schizophrenia") and a group of periodic and phase psychoses, to which they included cycloidal psychoses and "nonsystematic schizophrenia". K. Leonhard referred periodic catatonia and affectively saturated paraphrenia to the latter form, which has an attack-progressive course. He insisted on clear boundaries between the forms described, but clinically this did not always look convincing. The absence of rigid boundaries between malignant forms and seizure-like course with a favorable prognosis allowed W. Janzarik (1957, 1968) to talk about difficulties in nosological differentiation of endogenous psychoses. K. Conrad (1959) defended the point of view about the possibility of typological, but not nosological division of endogenous psychoses.
The tendency to exclude intermittent forms from the modern classification of schizophrenia (Bleuler M., 1962; Weitbrecht J., 1963) should also be noted.
Irrespective of the affiliation of psychiatrists to one or another national school, a clear desire to distinguish true schizophrenia (close to "early dementia", according to E. Kraepelin) from "pseudo schizophrenia", when it is a clinical picture similar to schizophrenia, having a different genesis, is constantly traced in psychiatry.
Some directions and studies of schizophrenia are as if on the sidelines of clinical understanding of this disease. It is an attempt of purely psychological treatment of it. So, K. Conrad (1959) considers schizophrenia from the position of Gestalt psychology, N. Petrilowitsch (1996) - from the standpoint of structural psychology. Attempts have also been made to understand the essence of the illness from the standpoint of psychoanalytic and psychodynamic concepts as well as from the standpoint of existentialist philosophy. For example, L. Binswanger (1963) considered schizophrenia a special kind of human existence (existentialism). Close to this position, anthropological psychiatry aims to investigate the role of schizophrenic psychosis in the transformation of the patient's personality and its changes, in the process of his or her relationship with the surrounding world. The listed directions cannot be evaluated unequivocally, since some of them should be opposed to clinical approaches to schizophrenia, while others almost merge with some classical clinical studies, reflecting unconventional views of its manifestations.
American psychiatry, which developed relatively independently of European psychiatry, deserves separate consideration. American psychiatry, until the 1930s, was not noted for its original approach to the problem of schizophrenia.
After that, psychoanalytic and psychodynamic concepts, according to which schizophrenia was considered as "personality reaction" (catatonic, simple, schizoaffective, pseudoneurotic), became especially widespread in the USA. Since the 1970s, the fascination with psychoanalysis and psychodynamic concepts in American psychiatry has declined, giving way to neurobiological concepts.
In recent decades, the range of diagnostic approaches to schizophrenia in various countries remains quite wide. In Germany, thanks to the work of K. Conrad (1958, 1959); J. Glatzel (1968); H. Helmchen (1988) the boundaries of schizophrenia are quite clearly delineated. In Britain, however, the criteria for schizophrenia are not clear, although S. Frangon and R Murray (1996), in their recent synthesis of the biological and clinical study of schizophrenia, have a fairly clear presentation of what they consider to be typical disorders of that illness. For the rada of psychiatric schools in France is characterized by a tendency to expand the diagnosis of this disease (Pichot P., 1992). Schizophrenia is also widely diagnosed in the United States. This is evidenced by the latest classification of mental disorders adopted by the American Psychiatric Association - DSM-IV. The group of schizophrenia includes paranoid, catatonic, residual forms, as well as schizophrenia with disorganization of speech, behavior and inadequate affect. The simple form and various variants of low-progressive schizophrenia are excluded from the group of schizophrenic disorders and classified as "personality disorders.
In domestic psychiatry the nosological principle was immediately accepted by the majority of psychiatrists [Serbsky V.P., 1902; Sukhanov S.A., 1905; Bernstein A.N., 1912]. Similarly to O. Bumke allocated nuclear ("true") schizophrenia, which was distinguished from symptomatic schizophrenia [Ostankov P.A., 1928; Kannabikh Y.V., 1933]. The benign forms or so-called mild schizophrenia have also been studied [Kameneva E.N., 1933; Rosenstein L.M., 1933; Friedman B.D., 1933]. The systematics of schizophrenia forms was devoted to the research of A.A. Molokhov (1948, 1960) and M.Y. Seriysky (1954). Subdivision of childhood and adolescent schizophrenia into sluggish (unfavorable) and acute (favorable) was carried out by G.E. Sukhareva (1933, 1937).
The works of D.E. Melekhov (1958, 1963), who singled out certain types of its course rather than forms, were of great importance for the development of the doctrine of schizophrenia. He described types of continuous flowing and attack-like developing schizophrenia. In the first group Melekhov distinguished malignant, slowly progredient and actively progredient forms with a protracted course. He admitted the possibility of changing the degree of progredient and the rate of the process at certain stages of the course of the illness.
The studies of V.A. Gilyarovsky (1932, 1936), O.V. Kerbikov (1949), S.G. Zhislin (1958, 1963), D.S. Ozeretskovsky (1962), L.L. Rokhlin (1970), G.V. Morozov (1975, 1977), N.N. Timofeev, T.T. Nevzorova (1988), S.F. Kozlov (1988) and others have undoubted significance for the study of psychopathology and the clinical picture of schizophrenia. Nevzorova, S.F. Semenov (1977).
In the 1960s and 1980s, the problems of psychopathology and the clinical picture of schizophrenia were studied in particular detail in the teams headed by A.V. Snezhnevsky. A distinctive feature of these studies was the multidisciplinary approach. The clinical picture of the disease was studied in combination with psychological, neurophysiological, biochemical, genetic, epidemiological, and other studies. Finally, the concepts of pathos and nosos of schizophrenia emerged in a theoretical synthesis. Continuous malignant forms of schizophrenia [Aleksanyants R.A., 1957; Morozova T.N., 1957], paranoid schizophrenia [Sotsevich G.N., 1957; Elgazina L.M., 1958; Shumsky N.G., 1958; Gratsiansky A.A, 1959], seizure-like [Favorina V.N., 1956; Ilyon G.Y., 1957; Tiganov AC, 1963, 1966, 1969; Panteleeva GL, Sokolova B.V., 1966] sluggish [Najarov R.A., 1964, 1972; Smulevich A.B., 1987], seizure-progredient [Vidmanova L.N, 1963; Dikaya V.I., 1986; Kontsevoi V.A., Panteleeva GL, 1989] variants of a course; the features of disease depending on age are described [Vrono M.S., 1972, 1983; Panteleeva G.P., Sternberg E.Ya, 1972, 1983; Tsutsulkovskaya M.Y., 1986], and also features of acute, dangerous for life attacks [Tiganov A.S., 1982] and transient forms of endogenous process [Kontsevoi V.A., 1965; Savchenko L.M., 1974].
Diagnosis
Schizophrenia is characterized by a wide range of clinical manifestations, and in some cases, its diagnosis is very difficult. Diagnostic criteria are based on so-called negative disorders or peculiar changes in the personality of the patient. This includes impoverishment of emotional manifestations, impaired thinking and interpersonal disorders. Schizophrenia also has a specific set of syndromes.
In diagnosing schizophrenia, it is important to differentiate the clinical picture of schizophrenia from exogenous psychopathologies, affective psychoses (in particular, from MDP), and also from neuroses and psychopathias. Exogenous psychoses begin in connection with certain harms (toxic, infectious, and other exogenous factors). At them, specific changes of the personality (of an organic type) are observed, and psychopathological manifestations proceed with the prevalence of hallucinatory and visual disorders. In affective psychoses, personality changes typical of schizophrenia are not observed. Psychopathological manifestations are limited mainly to affective disorders. In the dynamics of the illness, no complication of syndromes is observed, whereas in schizophrenia, there is a tendency for complication of attacks. And in case of a sluggish, inactive course of schizophrenic process, differential diagnostics of schizophrenia with neuroses and psychopathies is necessary. It should be noted that the dynamics of schizophrenia are always distinct from the dynamics of other nosological units, although sometimes they may be indistinguishable in cases of unscrupulous or incompetent attitude to the diagnostic process. Such cases are not uncommon, which has contributed to the emergence of a special section (or discipline) in science studying errors in diagnostic and general clinical practice.
In schizophrenia, it is impossible to single out a single symptom that is specific to the disease. Nevertheless, there are several symptoms that are most typical of schizophrenia, and also, the pathogenesis of the disease in dynamics has differences from all other mental illnesses, although not always self-evident and sometimes difficult to discern even with careful examination.
For example, Bleuler believed that the loss of associative thinking was central to the disease's symptomatology. Kurt Schneider proposed a list of symptoms he called "first-rank symptoms. The presence of one or more of these directly indicates that the patient has schizophrenia. The following symptoms were included in this list:
- Auditory hallucinations, in which "voices" speak the patient's thoughts aloud,
- Auditory hallucinations in which two "voices" argue with each other,
- Auditory hallucinations in which "voices" comment on the patient's actions,
- Tactile hallucinations, where the patient feels the touch of something extraneous,
- "Taking" thoughts out of the patient's head,
- "Putting" thoughts into the patient's head by outsiders,
- The belief that the patient's thoughts are transmitted to others (as by radio), or from others are received by the patient,
- "Putting" the feelings of others into the patient's mind,
- "Putting" bystanders into the patient's consciousness of irresistible impulses,
- The feeling that all the patient's actions are carried out under someone else's control, automatically,
- Normal events are systematically given some special, hidden meaning.
American psychiatry took a significant step forward in 1980 by adopting a new, substantially revised scheme for diagnosing and systematizing psychiatric disorders, embodied in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). The fourth edition (DSM-IV) was published in 1994. According to it, a diagnosis of schizophrenia can be made only if the following conditions are met:
Symptoms of the disorder have been present for at least six months, as compared to the period preceding the disorder, there is a change in the ability to perform certain activities (work, communication, self-care).
These symptoms are not associated with organic changes in brain tissue or mental retardation.
These symptoms are not associated with manic-depressive psychosis.
Symptoms listed in one of #1, #2, or #3 must be present, as follows:
- At least two of the following symptoms should be present for at least a month: delusions; hallucinations; thought and speech disorders (incoherence or frequent loss of associative connections); largely disorganized or catatonic behavior, "negative" symptoms (dulling of emotions, apathy);
- Strange delusions seen as groundless by members of the same subculture as the patient;
- Explicit auditory hallucinations in the form of one or more "voices" commenting on the patient's actions or arguing with each other.
Symptoms may appear with varying degrees of periodicity, they may be weakly pronounced, and the patient may skillfully conceal some manifestations of his disease. Therefore, it is common practice among professionals to write down in the patient's medical history, "suspected schizophrenia," the first time they see the patient. This means that their diagnosis is in doubt - until the clinical picture becomes clearer.
Psychological features of the schizophrenic patient
Most significant for schizophrenia are peculiar disorders that characterize changes in the personality of the patient. The severity of these changes reflects the malignancy of the disease process. These changes concern all mental properties of personality. However, the most typical are the intellectual and emotional.
Intellectual disorders manifest in different variants of disorders of thinking - patients complain about an uncontrollable stream of thoughts, their clogging and parallelism. Symbolic thinking is also characteristic of schizophrenia when the patient explains certain objects, phenomena according to its meaning which is significant only for him/her. For example, he attributes a cherry pit as his loneliness and an unextinguished cigarette butt as his life on fire. In connection with disruption of the internal inhibition, the patient develops gluing (agglutination) of concepts.
He loses the ability to distinguish one concept from another. The patient picks up a special meaning in words and sentences, and new words - neologisms - appear in his speech. Thinking is often vague and his statements slip from one topic to another without visible logical connection. In a number of patients with far advanced disease changes, logical incoherence in statements acquires a character of verbal discontinuity of thinking in the form of "verbal octopus" (schizophasia). This occurs as a result of loss of unity of mental activity.
Emotional disorders begin with a loss of moral and ethical properties, a sense of affection and compassion for loved ones, and sometimes this is accompanied by resentment and spite. The interest in the thing he or she loves decreases, and with time, disappears completely. Patients become slovenly, and do not observe basic hygienic care for themselves. Significant signs of the disease are also features of the behavior of patients. An early sign of it can be the appearance of autism: withdrawal, aloofness from loved ones, strangeness in behavior (unusual actions, manner of behavior that were not previously characteristic of the person and whose motives cannot be attributed to any circumstances). The patient withdraws into himself, into the world of his own painful experiences. The patient's thinking in this case is based on a perverted reflection of reality in the mind.
During a conversation with a schizophrenic patient, by analyzing their letters, essays it is possible to reveal in a number of cases their tendency to resonating reasoning. Resonance is idle musing, for example, disembodied reasoning of the patient about the design of a desk, about expediency of four legs for chairs, etc.
In the early stages of this disease, emotional changes such as depression, guilt, fear, and frequent mood swings may appear. Later stages are characterized by a decrease in emotional background, in which the patient does not seem to be able to feel any emotions at all. In the early stages of schizophrenia, the symptom of depression is common. The picture of depression can be very distinct, long-lasting and observable, or it can be masked, implicit, signs of which are visible only to a specialist's eye.
The emotional and volitional impairment develops some time after the onset of the process and is clearly expressed at an aggravation of painful symptoms. At the beginning, the disorder can be characterized by dissociation of the patient's sensual sphere. He or she may laugh at sad events and cry at joyful ones. Such a condition changes to emotional dullness, affective indifference to everything around, and especially emotional coldness toward relatives and friends.
Emotional and volitional impoverishment is accompanied by abulia. Patients do not care about anything, have no real plans for the future or talk about them extremely reluctantly, unambiguously, and do not reveal any desire to carry them out. The events of the reality surrounding them hardly attract their attention. They lie idly in bed all day, interested in nothing, doing nothing.
The change in interpretation of the environment associated with the change of perception is especially noticeable in the initial stages of schizophrenia and, judging from some works, can be detected in almost two thirds of all patients. These changes can be expressed both in strengthening of perception (which is more frequent), and in its weakening. More often there are changes connected with visual perception. Colors seem brighter, color shades seem more saturated. There is also a transformation of familiar objects into something else. Perceptual changes distort the outlines of objects, making them threatening. Color shades and material structure can sort of cross over into each other. Perceptual aggravation is closely connected with an overabundance of incoming signals. It is not that the senses become more receptive, but that the brain, which normally filters out most of the incoming signals, for some reason does not do so. This multitude of external signals bombarding the brain makes it difficult for the patient to concentrate and concentrate. According to some reports, more than half of patients with schizophrenia report impaired attention and sense of time.
A significant group of symptoms in the diagnosis of early schizophrenia are disorders associated with difficulty or inability to interpret incoming signals from the external world. Auditory, visual and kinesthetic contacts with the environment cease to be understandable for the patient, forcing him to adapt to the surrounding reality in new ways. This can be reflected both in his speech and in his actions. Under such disorders, the information arriving to the patient ceases to be integral for him and very often appears in the form of fragmented, divided elements. For example, when watching TV programs, the patient cannot look and listen at the same time and sees and hears as two separate entities. Vision of everyday objects and concepts - words, objects, semantic features of what is going on - is impaired.
Also typical of schizophrenia are various peculiar senestopathic manifestations: unpleasant sensations in the head and other parts of the body. Senestopathies have a flamboyant character: patients complain of a feeling of tumescence of one hemisphere in the head, dryness of the stomach, etc. The localization of the senestopathic manifestations does not correspond to the painful sensations that may be present in somatic diseases.
The delirium and hallucinations of a schizophrenic patient make the strongest impression on others and on culture in general, which has been expressed even in dozens of works on this subject. Delirium and hallucinations are the most well-known symptoms of mental illness and, in particular, schizophrenia. Of course, it should be remembered that delirium and hallucinations do not necessarily indicate schizophrenia and schizophrenic nosology. In some cases, these symptoms do not even reflect general psychotic nosology, being a consequence, for example, of acute poisoning, severe alcohol intoxication and some other painful conditions.
Delusion is a false judgment (inference) that arises without an appropriate reason. It does not lend itself to dissuasion, despite the fact that it contradicts reality and all previous experience of the patient. Delusion opposes any strongest argument, which distinguishes it from simple errors of judgment. In terms of content, a distinction is made between delusions of grandeur (wealth, special origin, invention, reformation, genius, love), delusions of persecution (poisoning, accusation, robbery, jealousy) and delusions of self-abasement (sinfulness, self-accusation, illness, destruction of internal organs).
It is also necessary to distinguish between unsystematized and systematized delirium. In the first case, we are talking, as a rule, about such an acute and intensive course of illness that the patient does not even have time to explain for himself what is going on. In the second case, however, it must be remembered that delusions, while being self-evident to the patient, can masquerade for years as some socially questionable theories and communications. Hallucinations are considered a typical phenomenon in schizophrenia, and they close the spectrum of symptoms based on altered perception. While illusions are erroneous perceptions of something that actually exists, hallucinations are imaginary perceptions, perceptions without an object.
Hallucinations are a form of perception disorder of the world around us. In these cases, perceptions occur without a real stimulus, a real object, have sensory brightness and are indistinguishable from objects that exist in reality. Visual, auditory, olfactory, gustatory and tactile hallucinations are encountered. Patients at this time really see, hear, smell, but do not imagine, do not imagine.
The hallucinating person hears voices that do not exist and sees people (objects, phenomena) that do not exist. At the same time he has a complete belief in the reality of perception. It is the auditory hallucinations that are most typical in schizophrenia. They are so characteristic of the disease that a primary diagnosis of schizophrenia can be made based on their presence. The occurrence of hallucinations is indicative of the considerable severity of the mental disorders. Hallucinations, which are rather frequent in psychoses, never occur in patients with neurosis. Observing the dynamics of hallucinations, it is possible to establish more precisely their belonging to this or that nosological form. For example, in alcoholic hallucinosis, "voices" speak about the patient in the third person, and in schizophrenic hallucinosis, they more often address the patient, comment on his or her actions or order him or her to do something. It is especially important to pay attention to the fact that it is possible to learn about the presence of hallucinations not only from the patient's stories, but also from his or her behavior. This is necessary when the patient hides the hallucinations from others.
Closely related to delirium and hallucinations is another group of symptoms common to many schizophrenic patients. While a healthy person clearly perceives his body, knows precisely where it begins and where it ends, and is well aware of his self, the typical symptomatology of schizophrenia is distorted and irrational perceptions. These perceptions of the patient can fluctuate in a very wide range - from small somato-psychic disorders of self-perception to a complete inability to distinguish oneself from another person or from some other object of the external world. Impaired perception of oneself and one's self can lead to the patient ceasing to distinguish oneself from another person. He may begin to believe that, in fact, he is of the opposite sex. And what happens in the external world may rhyme with the patient's bodily functions (rain is his urine, etc.).
A change in the patient's general mental picture of the world inevitably leads to a change in his motor activity. Even if the patient carefully conceals the pathological symptomatology (hallucinations, visions, delusions, etc.), it is still possible to detect the appearance of the illness by changes in his movements, walking, manipulating objects and in many other cases.
The patient's movements may speed up or slow down without any apparent reason or any more or less coherent way of explaining it. Feelings of clumsiness and confusion in movements are widespread (often unobservable and, therefore, valuable when the patient shares these experiences). The patient may drop things, or constantly bump into objects. Sometimes short "freezes" during walking or other activity are observed. Spontaneous movements (waving of hands while walking, gesturing) may increase, but more often become somewhat unnatural and are restrained because the patient feels that he/she is very clumsy, and tries to minimize these manifestations of his/her awkwardness and clumsiness. Repetitive movements are observed: tremors, tongue or lip movements in the form of sucking, tics and ritualistic movement patterns. The extreme variant of movement disorders is the catatonic state of the patient in schizophrenia when the patient can maintain the same posture for hours or even days, being completely immobile. The catatonic form usually occurs in those stages of the illness when it has been neglected and the patient has not received any treatment for one reason or another.
The catatonic syndrome includes states of catatonic stupor and agitation. The catatonic stupor itself can be of two kinds: lucid and oneiroid.
Lucid catatonia occurs without clouding of consciousness and is expressed as a stupor with negativity or stupor or impulsive agitation. Oneiroid catatonia includes oneiroid mental confusion, catatonic agitation with confusion, or stupor with waxing flexible.
In lucid stupor, the patient retains a basic orientation and assessment of his or her surroundings, whereas in oneroidal stupor, the patient's consciousness is altered. Patients with lucid stupor remember and describe the events surrounding them at the time when they come out of the stupor. Oneuroid patients report fantastic visions and experiences they had during the stupor period. Catatonic agitation is nonsensical, unfocused, and sometimes takes on the character of motor agitation. The patient's movements are monotonous (stereotypy) and are essentially subcortical hyperkinesias; aggression, impulsive actions, negativism are possible; facial expressions often do not correspond to posture (mimic asymmetries may be observed). In severe cases, speech is absent, agitation is mute or the patient growls, moozes, shouts separate words, syllables, pronounces vowels. Some patients have an irrepressible urge to speak. At the same time, speech is pretentious, grandiloquent, and repetition of the same words (perseveration), discontinuity, senseless stringing of one word onto another (verbiguration) are noted. Transitions from catatonic agitation to stupor state and vice versa are possible.
The hebephrenic syndrome is close to the catatonic syndrome both in origin and manifestations. It is characterized by agitation with affectation, pretentiousness of movements and speech, foolishness. The merriment, caricature, and jokes do not infect those around them. Patients tease, grimace, mutilate words and phrases, somersault, dance, and undress. Transitions between catatonia and hebephrenia are observed.
Behavioral changes in schizophrenic patients are usually a reaction to other changes associated with altered perception, impaired ability to interpret incoming information, hallucinations and delusions, and the other symptoms described above. The occurrence of such symptoms forces the patient to change the usual patterns and ways of communication, activity, rest. It is necessary to consider that the patient, as a rule, has an absolute confidence in the correctness of his behavior. Completely absurd, from the point of view of a healthy person, acts have with the patient with schizophrenia a logical explanation and conviction in his rightness. The patient's behavior is not a consequence of his incorrect thinking, but a consequence of mental illness which nowadays can be treated quite effectively with psychopharmacological drugs and corresponding clinical care.
Treatment
Biological methods (shock therapy, psychopharmacotherapy).
Medications are the primary means of treatment for schizophrenia.
Medications:
- psychoanaleptics (antidepressants)
- psycholeptics
- tranquilizers (Used in courses, to relieve exacerbations, outpatient and as maintenance therapy. The choice of medication depends on the structure of the psychopathological syndrome that determines the exacerbation clinic by the time treatment begins)
- insulin therapy
- electroconvulsive therapy
Due to the structural complexity of syndromes, combinations of various psychotropic agents should be used. Aminazin 300-500 mg per day is used in the treatment of progressive ongoing forms. The same is done for febrile seizures. If aminazine is intolerant, intravenous sibasone or stelazine 30-80 mg per day. For catatonic disorders, etaperazine 20-90 mg per day, majeptyl 15-60 mg per day. For delusional and hallucinatory disorders, haloperidol 5-30 mg per day, levomepromazine (tizercine) 150-200 mg per day.
In depressive states, antidepressants with sedative action are used (nosinan, amitriptyline). In sluggish processes and in maintenance therapy, we include librium (elenium), meprotan, valium. In negative disorders - neuroleptics.
Insulin, a course of 15-20 comas is used for periodic forms of schizophrenia, more often in combination with psycholeptics. Insulin-convulsive therapy is also indicated for patients with acute manifestations of schizophrenic process and somatically debilitated patients, while electroconvulsive therapy is indicated for patients who are resistant to therapy by other methods, and for patients with chronic depressive conditions. Due to the widespread use of psychotropic drugs, a significant number of patients are treated as outpatients.
