Schizophrenia

This term also has other meanings, see Schizophrenia (values).This article is about a psychotic disorder (or a group of disorders). For his erased forms, see schizotypic disorder; about personality disorder, see schizoid personality disorder.

Schizophrenia (from other Greek, "split" - "mind, thinking, thought"), previously Lat. dementia praecox ("premature dementia") is an endogenous polymorphic mental disorder or a group of mental disorders associated with the disintegration of the processes of thinking and emotional reactions. Schizophrenic disorders generally differ in characteristic fundamental disorders of thinking and perception, as well as inadequate or decreased affect. The most frequent manifestations of the disease are auditory hallucinations, paranoid or fantastic delusions or disorganization of speech and thinking against a background of significant social dysfunction and disability.

A variety of symptoms has given rise to a debate about whether schizophrenia is a single disease or is a diagnosis behind which lies a number of individual syndromes. This ambiguity was reflected in the choice of the name: Bleuler used the plural, calling the disease schizophrenia.

The etymology of the word, from the "cleavage of the mind," causes confusion - in a popular culture the disease is mixed with a "split personality" - an inaccurate name for a dissociative identity disorder. The first known mistaken use of the term is noted in the article of the poet TS Eliot, published in 1933.

The overall risk of the disease, according to research, is 0.4-0.6% (4-6 cases per 1000 people). Men and women fall ill about equally often, but women tend to have a later onset of the disease.

In the treatment of schizophrenia, medication with antipsychotics (such as amisulpride, olanzapine, risperidone, quetiapine) is the main one, along with cognitive-behavioral psychotherapy, family psychotherapy, occupational therapy, social rehabilitation. It remains unclear which of the antipsychotics are more effective, typical or atypical, yet the latter are more modern and have fewer side effects. In severe cases and among those who are not helped by other antipsychotics, clozapine is used, which has proven to be the most effective in studies. In the event that it does not help, it is recommended to add to it another antipsychotic (eg, amisulpride, aripiprazole) or an antidepressant (eg, mirtazapine, fluvoxamine, citalopram).

In patients with schizophrenia, comorbid disorders (concomitant diseases) are most likely to be diagnosed, including depression, anxiety disorders, obsessive-compulsive disorder. Associated somatic diseases, including diabetes, heart and lung diseases, infectious diseases, osteoporosis, hyperlipidemia and hypogonadism are often underestimated and not cured; The risk of alcoholism and drug addiction is about 40%. Frequent social problems, such as long-term unemployment, poverty and homelessness. An increased risk of suicide and health problems lead to a decrease in life expectancy, which in patients is 10-12 years less than in people who are not schizophrenic.Schizophrenia is one of the main causes leading to disability. In a study in 14 countries in 1999, it was shown that the state of active psychosis ranks third in this respect after complete paralysis (quadriplegia) and dementia, exceeding paraplegia and blindness in disabling effects.However, the course of the disease shows considerable diversity and is not associated with the inevitability of chronic development or progressive growth of the defect: 150. The notion (formerly common) that schizophrenia is a constantly progressing disease is currently rejected by specialists and is not supported by neuroimaging methods and by studies of cognitive functions, clinical observations and pathomorphological data. In some cases, recovery is complete or almost complete. Among the factors contributing to a more favorable course are female sex, the predominance of positive (as opposed to negative) symptoms, a greater age at the first episode, a good level of functioning before the illness, acceptance and support from close and familiar, etc.

In case of severe variant of the disease course, if the patient poses a risk to himself and others, involuntary hospitalization may be required. However, in Western Europe, the frequency and length of hospital stay decreased, and the quality of the work of social services improved.

The lack of awareness of the individual that he is ill - anosognosia, can be observed in schizophrenia. Physicians sometimes have to face the denial of the disease not only by the schizophrenic patient himself, but also by his close relatives, which is found even among sufficiently educated people.

Schizoaffective disorder-(other names - recurrent schizophrenia, recurrent schizophrenia, circular schizophrenia, schizoaffective psychosis - an endogenous mental disorder that combines the symptoms of schizophrenia and affective disorder. Characterized by abnormal processes of thinking and deregulated emotions. The diagnosis is usually made when a person has symptoms of both schizophrenia and affective disorder (mood disorder) - both bipolar disorder and depression - but does not strictly match the diagnostic criteria for any one. The bipolar type is characterized by the symptoms of mania, hypomania or a mixed episode. Depressive type only symptoms of depression. Common symptoms of the disorder include auditory hallucinations, paranoid nonsense and disorganized speech and thinking. The onset of symptoms usually begins at a young age of 15 to 20 years, it is now recorded that the symptoms manifest themselves in different periods of life.

In DSM-5 and ICD-10, schizoaffective disorder is in the same diagnostic class as schizophrenia, but not in the same class as mood disorders. The diagnosis was introduced in 1933, and its definition was slightly changed in DSM-5, published in May 2013, as the definition of schizoaffective disorder DSM-IV leads to an excessive misdiagnosis. The changes made to the definition of schizoaffective disorder were designed to make the diagnosis of the DSM-5 more consistent (or reliable) and significantly reduce the use of the diagnosis. In addition, the diagnosis of schizoaffective disorder DSM-5 can no longer be used for the psychosis of the first episode.

History

George Hughes Kirby [en] in 1913 and August Hoch [en] in 1921 described patients with mixed affective and schizophrenic symptoms, and referred them to the manic-depressive group Krepelin. Jacob Kazanin in 1933 introduced the term "schizoaffective state", and considered it a subtype of schizophrenia (according to the criteria of Eigen Bleuler).

Currently, schizoaffective disorders are considered as a borderline group between schizophrenia and affective disorders.

Clinic

Disorders are almost not accompanied by personality changes (in contrast to schizophrenia), affective disorders are longer and more pronounced than productive symptoms of schizophrenia. Seizures can be:

  • depressive-paranoid;
  • manic-paranoid;
  • mixed states.

Diagnostics ICD-10

The diagnosis of F25 is made in accordance with the following groups of criteria:

  • There are signs of affective disorders (F30-F32);
  • Presence of at least one of the following signs for at least 2 weeks:
  • auditory hallucinations in the form of extraneous voices, commenting or leading dialogues;
  • delirium of control and influence, feeling of "made" of thoughts, sensations, movements;
  • sensations of telepathy, that is, the reception or transmission of thoughts at a distance, their openness or withdrawal;
  • broken speech and neologisms;
  • persistent delirium, not characteristic of the patient's subculture;
  • frequent and transient appearance of catatonic symptoms;
  • The symptoms of schizophrenia and affective disorders are presented simultaneously with one aggravation;
  • organic brain damage (F0) and the use of psychoactive substances (F1) are excluded.

Types of schizoaffective disorder

  • F25.0 - Manic type. The diagnosis is made with schizoaffective disorder on a manic background (compliance with the criteria of mania F 30.1.
  • F25.1 Depressive type. The diagnosis is made with schizoaffective disorder on a depressive background (compliance with the criteria of moderate or severe depression F31.3-4).
  • F25.2 The mixed type. The diagnosis is made in schizoaffective disorder, mixed with bipolar affective disorder (compliance with BAP criteria, current episode of mixed character F31.6).
  • F25.8 Other schizoaffective disorders.
  • F25.9 Schizoaffective disorder, unspecified.

One part of the researchers considers the mixed type of schizoaffective disorder as an atypical form of bipolar affective disorder, and the other as a relatively benign form of schizophrenia ("circular schizophrenia").

Epidemiology

The prevalence is estimated at 0.5-0.8%, there is no prevalence over the sex. These data are rather approximate because of theoretically determined differences in diagnostic approaches.

Now the disorder was redefined, but estimates of the prevalence of DSM-IV were less than 1 percent of the population in the range of 0.5 to 0.8 percent.

Etiology

In the questions of the etiology of this disorder, the opinions of scientists are divided. Some researchers consider them as the interaction of genetic burden of schizophrenia and affective disorders on both sides. There are also studies pointing to the genetic independence of schizoaffective disorders. There is also an opinion about the proximity of this type of disorder to epilepsy (periodicity factor + changes in EEG - paroxysmal activity).

Forecast

The outcome of schizoaffective disorder is in an intermediate position: it is less favorable than in bipolar affective disorder, but is more favorable than in schizophrenia. In a mixed type of course, a prognosis similar to bipolar affective disorder, and in a depressive type with a schizophrenia.

A worse outcome can be predicted with hereditary burden of schizophrenia, a low level of adaptation in the period before the onset of the disorder and a continuous course of the disorder.

History

Descriptions of schizophreniform symptoms occur already in the XVII century BC, in the "Book of Hearts", - parts of the ancient Egyptian papyrus Ebers. A study of ancient Greek and Roman sources suggests that, probably, societies of the time were aware of psychotic disorders, but there are no descriptions that would satisfy today's schizophrenia criteria. At the same time, symptoms resembling schizophrenia are noted in Arabic medical and psychological texts dating from the Middle Ages. For example, in the Medical Canon, Avicenna describes a condition somewhat resembling schizophrenia, which he refers to as "junoon mufrith" (heavy madness) and separates from other forms of madness, "junoon" - such as mania, rabies and manic-depressive psychosis.

Although the general concept of insanity has existed for millennia, historically the first description of schizophrenia as an independent nosological unit was put forward by Victor Khrisanfovich Kandinsky under the title "ideophrenia", which was described in detail in his work "On pseudohallucinations" (1890). Then, in 1893, schizophrenia was singled out as an independent emotional disorder by Emil Kraepelin. He was the first to draw the line dividing psychotic disorders into what he then called dementia praecox (literally "early dementia", a syndrome described in 1853 by Benedict Morel, called demence precoce) and manic depression. This dichotomy remains an important concept in modern science.

Figures scraped on the wall by a patient diagnosed with "dementia praecox". From the archives of the hospital of St. Elizabeth. Early 20th century, Washington.

In 1908, Swiss psychiatrist Eigen Bleuler described schizophrenia as an independent disease that differed from dementia and introduced the term into psychiatry. He proved that the disease does not necessarily occur in young years, but can develop in adulthood. Its main feature is not dementia, but "violation of the unity" of the psyche, including a violation of associative thinking. Bleuler singled out how the diagnostic criteria of "four A": decreased Affect, Autism, violation of Associations and Ambivalence. He considered ambivalence the main sign of schizophrenia, and considered three of its types:

  1. Emotional: simultaneously a positive and negative feeling for a person, an object, an event (for example, with regard to children to parents).
  2. Volitional: endless fluctuations between opposing decisions, the inability to choose between them, often leading to a refusal to make a decision at all.
  3. Intellectual: the alternation or simultaneous existence of contradictory, mutually exclusive ideas in the reasoning of a person.

It is noteworthy that Bleuler attributed to "schizophrenia" not only early dementia, neurotic syndromes and senile senility, but also "the white fever" of alcoholics.

Soon the concept of schizophrenia was officially recognized by all psychiatrists. It remained to find out on what grounds the diagnosis should be made, why the disease occurs and how to treat it. This is what scientists are doing to this day.

In the first half of the XX century schizophrenia was considered a hereditary defect, and in many countries patients became the object of manipulation of eugenic advocates. Hundreds of thousands of people, both by their own consent and without it, were sterilized - primarily in Nazi Germany, the United States and Scandinavian countries. Among other persons with the stigma of "mental unfitness", many patients with schizophrenia fell victim to the Nazi T4 killing program.

Diagnostic descriptions of schizophrenia have undergone changes over time. After an American-British diagnostic study in 1971, it became clear that the diagnosis of schizophrenia in the United States was much more frequent than in Europe. This was partly due to the less formal diagnostic criteria in the US, which then used the diagnostic criteria of the DSM-II, as opposed to Europe, where the ICD-9 classifier was used. This discovery in a number of other factors led to a revision not only of the diagnosis of schizophrenia, but of the entire DSM handbook, followed by the publication of the next version, DSM-IR.

Signs and symptoms of the disease

Currently, the following signs of schizophrenia are distinguished:

  • productive symptoms (most often delirium and hallucinations),
  • negative symptoms (reduced energy potential, apathy, lack of will),
  • Cognitive disorders (disorders of thinking, perception, attention, etc.)

In a person with schizophrenia, disorganization of thinking and speech, their unusualness, auditory hallucinations, delusional ideas can be noted. For a number of reasons, the disease is often accompanied by social isolation, accompanied by a violation of social cognition and paranoid symptoms associated with delusions and hallucinations, as well as negative symptoms: apathy and abulia. In rare cases, the patient can remain silent, freezing in strange postures or, conversely, fall into a state of aimless excitement: these are signs of catatonia. None of the symptoms, taken separately, is sufficient for the diagnosis of schizophrenia, since all of them can accompany other pathological conditions. According to the existing classification of psychoses, the symptoms of schizophrenia-like psychosis should be present for at least a month against a backdrop of a functioning disorder that lasts no less than six months; less long episodes are attributed to schizophreniform disorder.

Most often, schizophrenia begins in late adolescence or in the initial period of adulthood, often causing serious damage to the person's personality at an important stage of social and professional development. In recent years, extensive research has been conducted on the early diagnosis of pre-debut (prodromal) signs of the disease in order to minimize its harmful effects. It is shown that, 30 months before the appearance of obvious symptoms, and in some cases even earlier, the detection of a prodrome is possible. In this period, non-specific signs may appear in future patients - social isolation, irritability and dysphoria. As psychosis approaches, they develop transient (short-term) or limited psychotic symptoms.

One of the most characteristic symptoms of schizophrenia is a frequent or prolonged (for many years) hallucinations. They occur in about half the cases of this disease. At the same time, large-scale epidemiological studies make it possible to understand that the prevalence of hallucinations is much higher than the percentage of people diagnosed with schizophrenia. In the latter case, the prevalence rate for a life span of 1% is usually given. However, according to a large study (Epidemiological Catchment Area Project, USA), about 11-13% experienced hallucinations for their lives. Another study in Holland found that "true" hallucinations were observed in 1.7% of the population, but a further 1.7% experienced hallucinations that were considered to be of no clinical significance, since they were not associated with distress.

Positive and negative symptoms

Symptoms of schizophrenia are often divided into positive (productive) and negative (deficit). To the productive include delirium, auditory hallucinations and thinking disorders - all these are manifestations, usually indicative of the presence of psychosis. In turn, the loss or absence of normal traits and abilities of a person is spoken by negative symptoms: a decrease in the brightness of emotions and emotional reactions experienced - a decrease in affect, poor speech (alogy), inability to have pleasure - anhedonia, loss of motivation. Recent research, however, suggests that, despite the external loss of affect, schizophrenic patients are often capable of emotional experiences at a normal or even elevated level, especially under stressful or negative events. Often a third group of symptoms is isolated from the productive group, the so-called disorganization syndrome, which includes chaotic speech, chaotic thinking and behavior. There are other symptomatic classifications.

There are also secondary negative symptoms, which, unlike the primary one, are caused directly by productive disorders (for example, emotional detachment due to paranoid delusions), side effects of neuroleptics (for example, bradykinesia and sedation) or depression. It is believed that atypical antipsychotics can eliminate these symptoms, but apparently do not eliminate the primary negative symptomatology, which is the key manifestation of the disease.

Schneider's classification

Psychiatrist Kurt Schneider (1887-1967) listed the main forms of psychotic symptoms, which, in his opinion, distinguish schizophrenia from other psychotic disorders. These are the so-called "symptoms of the first rank," or "Schneider's symptoms of the first rank":

  1. delirium of influence from outside forces;
  2. belief in the fact that thoughts are stolen by someone from the head or are invested in it;
  3. "Sounding your own thoughts": the feeling that the content of thoughts becomes available to other people;
  4. voices commenting on the thoughts and actions of a person or talking to each other.

The diagnostic reliability of the symptoms is questioned, but they were taken into account when selecting the criteria used in our time.

Diagnostics

The diagnosis is based on an analysis of the patient's complaints and his behavior. This includes the person's own story about their experiences, with the possible addition of this information by relatives, friends or colleagues, followed by a clinical assessment of the patient by a psychiatrist, social worker, clinical psychologist or other specialist in psychiatry. In psychiatric evaluation, an analysis of mental status and a psychiatric history is usually performed. The developed standard diagnostic criteria take into account the presence of certain signs and symptoms, their severity and duration. Symptoms of psychosis are peculiar not only to schizophrenia. They can manifest themselves in a number of conditions, such as bipolar disorder, major depressive disorder, borderline condition, schizoaffective disorder, drug overdose, drug-induced short psychosis (eg, a stimulant psychosis similar to schizophrenia), schizophreniform disorder. At present, there is no laboratory test for the diagnosis of schizophrenia.

Sometimes, general medical or neurological examinations are performed to diagnose somatic diseases that occasionally lead to psychotic schizophrenic conditions : metabolic disorders, systemic infections, syphilis, HIV, epilepsy and brain damage. It is necessary to exclude delirium, which is distinguished by the presence of visual hallucinations, acute onset, fluctuations in the level of consciousness, and indicating a latent somatic disease.

For differential diagnosis, it is desirable to conduct a full medical examination, including physical examination, a clinical blood test, a biochemical blood test (including liver, kidney and thyroid function tests), urinalysis, an electrocardiogram, a pregnancy test, screening for narcotic substances.

In the diagnosis of schizophrenia, the most widely used are two systems: the Diagnostic and Statistical Manual of Mental Disorders (now DSM-5) published by the American Psychiatric Association, and the International Classification of Diseases established by the World Health Organization (now ICD-10). ICD is commonly used in European countries, including Russia, and DSM in the US and other countries of the world, as well as in most studies. ICD criteria give greater weight to Schneiderian symptoms of the first rank, but in practice, both systems strongly coincide [58]. WHO developed the SCAN toolkit, which can be used to diagnose a number of psychiatric conditions, including schizophrenia.

Criteria ICD-10

Below are the official general criteria for paranoid, gebefrenic, catatonic and undifferentiated schizophrenia (F20.0-F20.3). According to ICD-10, at least one of the following signs should be observed for the diagnosis:

(a)-"Echo" of thoughts (the sound of one's own thoughts), the insertion or withdrawal of thoughts, the openness of thoughts to others.

(b)-The delirium of mastery, influence or passivity that is distinctly related to the body or limbs, thoughts, actions or sensations; delusional perception.

(c)-hallucinatory "voices", commenting on or discussing the patient's behavior; Other types of "voices" coming from different parts of the body.

(d)-Persistent delusions that are culturally inadequate, ridiculous, impossible and / or grandiose in content.

Either at least two of the following "smaller" symptoms should be observed:

(e)-Persistent hallucinations of any kind, if they occur daily for at least one month and are accompanied by delirium (which may be unstable and semi-formalized) without distinctive affective content.

(f)-Neologisms, sperrungs (interruptions in thinking), leading to a discontinuity or incongruity in speech.

(g)-Catatonic behavior, such as agitation, congealing or waxy flexibility, negativism, mutism and stupor.

(h)-"Negative symptoms" (but not caused by depression or pharmacotherapy), usually leading to social exclusion and a decline in social indicators; symptoms that can be expressed:

  • apathy
  • speech depletion or smoothening
  • inadequate emotional reactions

(i)-Credible and consistent changes in the overall quality of behavior, manifested by loss of interest, aimlessness, preoccupation with one's own experiences, social alienation.

Diagnostic instructions

In this case, these symptoms should be observed for at least a month. Conditions meeting these criteria but continuing for less than a month are classified as acute schizophreniform psychotic disorder (F23.2 with an additional fourth sign indicating the nature of the disorder), and if they subsequently last more than a month, the diagnosis is changed (recoded) to the appropriate form of schizophrenia.

With the development of symptoms of schizophrenia, along with the expressed symptoms of other disorders (affective: manic or depressive episodes, epileptic, in other brain diseases, with alcohol or drug intoxication or with withdrawal syndrome), the diagnosis of schizophrenia is not exposed and the appropriate diagnostic categories and codes are applied. The diagnosis of schizophrenia is made if the case meets the criteria of the manic episode F30- or depressive episode (F32-), but the above general criteria are revealed before the development of a mood disorder.

Symptom (i) in the above list refers only to the diagnosis of "simple type of schizophrenia" (F20.6), and the duration of observation of symptoms by a psychiatrist for at least one year is required.

DSM Criteria

According to DSM IV-TR and DSM-5, the diagnosis of schizophrenia is made when the following diagnostic criteria are met:

(A) Symptoms: Two or more of the following, each present for most of the month (or less if treatment interrupted symptoms:

  • crazy ideas
  • hallucinations
  • disorganized speech (eg frequent slippage or inconsistency, abstract content of speech). See mental disorders.
  • severely disorganized (eg, inappropriate clothing choices, frequent crying) or catatonic behavior negative symptoms, including the plane of affect (absence or decrease in the brightness of emotional reactions), alology (silence or impoverishment of speech) or aviolation (reduced or absent motivation).
Note: If crazy ideas are considered fantastic, or hallucinations are a single voice, commenting on the current actions of the patient or two or more conversations with each other, it is enough to have only one of these symptoms from all of the above. The criterion of speech disorganization is sufficient only when it radically disrupts communication with the patient.

(B) Social / professional dysfunction: For a significant part of the time from the onset of the disorder, the level of achievement in work, relationships or care of self is much lower than before the disease, and if the disease began in childhood - the inability to reach the expected level in the field relations between people, work or study.

(C) Duration: Symptoms last at least six months. From this half-year for at least one month, the symptoms satisfy the criterion (A) (active phase), and at the rest of the time (the residual and prodromal phase), there are negative symptoms or at least two of the symptoms of the criterion (A) persist in the erased , weakened form (for example, strange beliefs or an unusual sensory experience).

(D) Schizoaffective disorder and depressive or bipolar disorder with psychotic symptoms are excluded. Or phases of depressive, manic or mixed episodes are not active, or their duration is small in comparison with the total duration of the active and residual phases.

(E) The reason is not in taking drugs or drugs and not in some kind of somatic illness.

(F) If the patient has suffered from autism or other developmental abnormalities, it is necessary for the diagnosis of schizophrenia to have expressed delusions or hallucinations lasting at least a month (or less if successful).

Subtypes

Historically, in Western countries, there has been a division of schizophrenia into simple, catatonic, hebephrenic (then disorganized), and paranoid.

DSM

Previously, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-IV-TR) contained five schizophrenia subtypes:

  • Paranoid type: Delusional ideas and hallucinations are present, but there are no thinking disorders, disorganization of behavior, and affective flattening (ICD-9 code 295.3, ICD-10 code F20.0).
  • Disorganized type: in the ICD is called "gebefrenic schizophrenia." A combination of mental disorders and flattening of affect is characteristic (ICD-9 295.1, ICD-10 F20.1).

Catatonic type:

  • conspicuous psychomotor disorders.
  • Symptoms may include catatonic stupor and waxy flexibility (ICD-9 295.2, ICD-10 F20.2).

Undifferentiated type:

  • psychotic symptoms are present, but paranoid, disorganized or catatonic type criteria are not met (ICD-9 295.9, ICD-10 F20.3).

Residual type:

  • there are positive symptoms, but they are mild (ICD-9 295.6, ICD-10 F20.5).
  • In the fifth edition (DSM-5), the American Psychiatric Association removed all schizophrenia subtypes because of their "limited diagnostic stability, low reliability and poor validity" In DSM-IV, the subtypes of schizophrenia existed "due to strong clinical traditions". According to the authors of DSM, the studies conducted since that time failed to confirm the "usefulness" of isolating the forms of schizophrenia. A review of 24 studies with 38 "analyzes" based on the study of 28 cohorts of patients did not confirm the concept of the presence of classical forms of schizophrenia. Researchers also found no difference in response to therapy and differences in flow characteristics when comparing schizophrenia subtypes. Instead of dividing into forms, the DSM-5 introduced "psychopathological dimensions", which, in the opinion of the authors, should better describe the heterogeneity of schizophrenia and are more useful clinically.

ICD

In the ICD, in addition to the paranoid, gebefrenic, catatonic, undifferentiated, residual (residual), subtypes are distinguished :

Post-schizophrenic depression: a depressive episode that occurs after the reduction of schizophrenic symptoms, with the possible presence of some symptoms of schizophrenia in a weakened form (ICD-10 F20.4).

Simple schizophrenia: developing gradually negative symptoms, gradually taking a heavy shape, in the absence of a history of psychotic episodes (ICD-9 295.0, ICD-10 F20.6).

Another type of schizophrenia: includes senestopatic schizophrenia and schizophreniform disorder / psychosis of the OBD (ICD-10 F20.8) [66]. However, the descriptions of the senestopatic schizophrenia in ICD-10 are not given. In a version of the ICD-10 adapted for use in the Russian Federation, another type of schizophrenia (F20.8) includes hypochondriacal schizophrenia (ICD-10 F20.8xx1), schizophrenia (ICD-10 F20.8xx2), schizophrenia (ICD- 9 299.91, ICD-10 F20.8xx3), atypical forms of schizophrenia (ICD-9 295.81, ICD-10 F20.8xx4), schizophrenia of other established types (ICD-9 295.8, ICD-10 F20.8xx8). But all of these diagnostic units, except for senestopatic schizophrenia, are not available in the World Health Organization version of ICD-10 in 2016 [66] and are present only in the ICD-10 version modified for use in the Russian Federation.

In the ICD-10 are considered subtypes of schizotypic disorder (codes of subheadings are present only in the adapted version for the RF version):

  • Latent schizophrenia (ICD-10 F21.1). Prepsychotic schizophrenia and prodromal schizophrenia are included.
  • Schizophrenic reaction (ICD-10 F21.2).
  • Pseudoneurotic schizophrenia (ICD-10 F21.3).
  • Pseudopsychopathic schizophrenia (ICD-10 F21.4). Enables borderline schizophrenia.
  • "Poor symptoms" of schizophrenia (ICD-10 F21.5). It is mainly negative symptoms.

Also, in the adapted version of the ICD-10 for the Russian Federation, there is a paranoia of schizophrenia (F22.82), in which there may be querulous, soviet, love (erotomaniac) delirium, delusion of invention or reformism, and a delusional form of dysmorphophobia. Paranoiac schizophrenia with a sensitive relationship delusion is code F22.03. They are classified as delusional disorders (F22). However, in the original version of ICD-10, submitted by WHO in 2016, these concepts are not available.

In the beta version of ICD-11, following the American Psychiatric Association and DSM-5, all schizophrenia subtypes were removed.

In the beta version of ICD-11 there are:

  • 6A20.0 Schizophrenia, the first episode
  • 6A20.1 Schizophrenia, several episodes
  • 6A20.2 Schizophrenia, continuous
  • 6A20.Y Other specified schizophrenia
  • 6A20.Z Schizophrenia, unspecified

Disease prevalence

Schizophrenia affects both sexes equally, but men usually start earlier, with a peak incidence of 20-28 years compared with 26-32 years in women. Much less often schizophrenia occurs in early childhood, cases of late (early onset of middle age) and very late (in old age) schizophrenia are also rare. The prevalence for the period of life is usually indicated as 1%, however, a systematic review of studies conducted in 2002 gave a result of 0.55%. Contrary to the popular belief that the spread of schizophrenia is uniform throughout the world, variation in incidence across the globe, within individual countries, and at lower levels, up to urban areas is found. One of the most persistent findings is an increased incidence of schizophrenia in urban settings: the correlation persists even when controlling possible confounding factors, such as drug addiction, ethnic differences and the size of social groups. According to most anthropologists, schizophrenia is not common among traditional societies and is a disease of civilization. J. Devereaux called schizophrenia "ethnic psychosis of the Western world".

Etiology (causes of the disease)

The causes and mechanisms of the development of schizophrenia, previously completely unknown [76], have recently begun to unfold [77] thanks to the achievements of neurobiology, but still remain unclear and confused. Important pathogenic factors, according to the alleged data obtained in the studies, are genetic predisposition, living conditions in early childhood, neurobiological disorders, psychological and social interactions. Currently, the neurobiological mechanisms of the disease are actively being studied, but a single organic cause has not yet been established.

Although low reliability of diagnostics presents problems in calculating the relative contribution of genetic variations and environmental influences (for example, severe bipolar disorder may overlap in symptoms with clinical depression), evidence has been obtained that the disease can be caused by a combination of these two groups of factors [78]. These data suggest that the diagnosis is largely due to heredity, but the onset of the disease is significantly dependent on environmental factors and stressors [79]. The idea, which presupposes the presence of an innate predisposition ("diathesis"), which manifests itself under the influence of biological, psychological or environmental stressors, was called the "stress-diathesis model" [80]. The notion of the importance of biological, psychological and social factors was embodied in the notion of a "biopsychosocial model".

Genetics

Since it is difficult to separate the contribution of genetic factors from the environment, numerical estimates are usually different, but twin studies indicate a high degree of hereditary disease. Presumably, inheritance is complex, with the possible interaction of several genes, increasing the risk to a critical value or causing several pathological processes forming a single diagnosis. Studies indicate the nonspecificity of detectable genes of schizophrenia risk: they can increase the likelihood of developing other psychotic diseases, such as bipolar disorder. Twin studies have been criticized in connection with a number of methodological problems and errors.

According to recently obtained data, rare deletions and duplications of DNA sequences (see variation in the number of copies) are also associated with an increased risk of developing schizophrenia. There are also data on the possible association of polymorphisms of the RELN gene and the level of its expression with schizophrenia.

In half the cases of genetically determined schizophrenia, random mutations that are absent in the genes of the patient's parents are to blame.

Prenatal factors

It is believed that already at an early stage of neuronal development, including during pregnancy, causative factors can enter into interaction, causing an increased risk of future development of the disease. In this connection, the revealed dependence of the risk of schizophrenia on the birth season is of interest: the disease is more often observed in those born in winter and in spring (at least in the northern hemisphere). Evidence has been obtained that prenatal (prenatal) infections increase the risk, and this is further evidence of the connection of the disease with intrauterine developmental disorders. There is also a hypothesis about the epigenetic predisposition to schizophrenia due to the low level of acylation of certain histone sites and DNA methylation. The possibility of correcting these disorders through epigenetic therapy is discussed.

Social factors

There is a stable correlation of the risk of schizophrenia with the degree of urbanization of the terrain. Another low risk factor is low social status, including poverty and migration due to social tensions, racial discrimination, family unhappiness, unemployment, poor living conditions, social isolation. Childhood-related bullying and traumatic experiences also appear as an incentive for the future development of schizophrenia: studies have shown that people diagnosed with schizophrenia were more likely than others to be physically or emotionally abused, sexually abused, inadequate physical and emotional treatment; many of them survived the loss of parents, abandonment. People with a diagnosis of schizophrenia who survived physical or sexual abuse as a child are more likely than others to have the same diagnosis, commenting voices or visual hallucinations. The role of repeated traumatism in adulthood is also noted: often a trigger for the development of schizophrenic symptoms is a traumatic experience (for example, sexual violence), similar to the traumatic experience experienced in childhood; however, any trauma, including hospitalization or even the experience of psychotic symptoms, can revive painful experiences.

The opinion is expressed that the risk is not influenced by parent education, but broken relationships can be contributing, which are characterized by a lack of support. Nevertheless, there are many studies that examined the relationship between the characteristics of family communication and the emergence of schizophrenia (as well as the risk of relapse). It is shown that such factors as hostility and criticism towards the "patient", imposition of guilt, excessive emotional interference (excessive care and intervention, excessive praise, sacrifice, etc.) play a negative role, anomalous communication (difficulty in trying to understand the general meaning of the conversation ), intolerance, lack of empathy and lack of flexibility in parents. However, it would be superfluous simplification to reduce all these problems to a unidirectional causal model of parents' charges, since the relationship between family communication disorders and the development of the symptoms of the disease is much more complicated. How disrupted communication can be the cause of the onset of symptoms, and vice versa.Loneliness also applies to social risk factors for schizophrenia.

Drug addiction and alcoholism

Schizophrenia and drug addiction are associated with complex relationships that do not allow easy tracking of cause-effect relationships. Convincing evidence suggests that in some people certain drugs can cause illness or provoke another attack. However, it is also possible that patients use psychoactive substances in an attempt to overcome the negative feelings associated with the action of antipsychotics and with the disease itself, the key signs of which are negative emotions, paranoia and anhedonia, because it is known that depression and stress lower the level of dopamine. Amphetamines and alcohol stimulate the release of dopamine, and excessive dopaminergic activity, at least in part, causes psychotic symptoms in schizophrenia. Various studies have shown that amphetamines increase the concentration of dopamine in the synaptic space, enhancing the response of the postsynaptic neuron. An additional argument is the proven fact of exacerbation of symptoms of schizophrenia under the influence of amphetamines. However, with the use of amphetamines, negative symptoms may decrease. In patients with schizophrenia in a state of remission, psychostimulants have a mild stimulating effect (exacerbating psychotic symptoms in schizophrenia only in a psychotic episode). Schizophrenia can provoke excessive use of hallucinogenic and other psychoactive substances. One study suggests a possible role for cannabis in the development of psychosis, but the authors suspect that the proportional effect of this factor is small.

Psychological factors

A number of psychological mechanisms were considered as possible causes of the development of schizophrenia and maintenance of this condition. Cognitive distortions detected in patients and at-risk individuals, especially under the influence of stress or in confusing situations, include excessive attention to possible threats, hasty conclusions, a tendency to external attribution, a distorted perception of the social situation and mental states, difficulties in distinguishing between internal and external speech, and problems with low-level processing of visual information and concentration of attention. Some of these cognitive features may reflect common neurocognitive impairments of memory, attention, problem solving, executive functions, and social cognition, others may be associated with specific problems and experiences. Despite the typical "smoothness of affect," recent studies suggest that many people diagnosed with schizophrenia react emotionally, in particular, to stress and negative stimuli, and that this sensitivity can predispose the symptoms of schizophrenia and the development of the disease itself. There is reason to believe that the content of delusions and psychotic experiences may reflect the emotional causes of the disease, and that the nature of the person's interpretation of these experiences can affect symptomatology. Perhaps the development of "safe habits" in behavior in order to avoid imaginary threats contributes to the persistence of chronic delusions.

The method of obtaining additional information on psychological mechanisms is to monitor the effect of therapy on symptoms.

Neuronal mechanisms

fMRI and other imaging technologies allow one to investigate differences in the character of brain activation in patients with schizophrenia. Neuroimaging with the help of fMRI and PET imaging of the brain in schizophrenia indicates functional differences affecting frontal and temporal lobes, as well as the hippocampus. These differences are associated with neurocognitive impairments, often noted in schizophrenia, but it is difficult to separate the possible contribution to these disorders associated with antipsychotics, which were treated by almost all patients who participated in the studies. In patients with schizophrenia, hypofrontality is also found, a decrease in blood flow to the prefrontal and frontal cortex.

Dopamine hypothesis

Dopamine (aka catecholamine) hypothesis pays particular attention to dopaminergic activity in the mesolimbic pathway of the brain. Studies in this direction were associated with the detection of the antipsychotic effect of the first neuroleptics, the most important pharmacological effect of which was blockade of dopamine receptors. Various studies have shown that in many patients with schizophrenia, the levels of dopamine and serotonin have been elevated in some parts of the brain. These neurotransmitters are part of the so-called "incentive system" and are produced in large numbers during pleasant experiences like sex, drugs, alcohol, and delicious food. Neurobiological experiments confirm that even memories of positive encouragement or its anticipation can increase the level of dopamine that "is used" by the brain for evaluation and motivation, fixing important for survival and continuation of the genus of action.

The so-called "dopamine theory of schizophrenia" or "dopamine hypothesis" was put forward; according to one of its versions, patients with schizophrenia are accustomed to having fun, concentrating on thoughts that cause dopamine secretion and overstrain it with their "encouragement system," which damages the symptoms of the disease. Among the supporters of the "dopamine hypothesis" there are several different currents, but in general, it links the productive symptoms of schizophrenia with impairments in the dopamine systems of the brain. "Dopamine theory" was very popular, but its influence has weakened in our time, now many psychiatrists and schizophrenic researchers do not support this theory, considering it too simplistic and unable to give a full explanation of schizophrenia . This revision was partly facilitated by the appearance of new ("atypical") antipsychotics, which, when compared with old efficacy preparations, have a different spectrum of effects on the neurotransmitter receptors.

The primary defect of dopaminergic transmission in schizophrenia was not established, since in the functional evaluation of the dopaminergic system, researchers received various results. The results of determining the level of dopamine and its metabolites in blood, urine and cerebrospinal fluid were unconvincing due to the large volume of these biological media, which leveled possible changes associated with limited dysfunction of the dopaminergic system.

Kenurenovaya hypothesis

The researchers also attracted the neurotransmitter glutamate and reduced glutamatergic signaling activity of NMDA receptors in schizophrenia. This is primarily indicated by inadequately low levels of glutamate receptors in postmortem brain analysis of patients and the fact that glutamate blocking agents such as phencyclidine and ketamine cause schizophrenia-like symptoms and cognitive impairment. Particular attention was drawn to the endogenous antagonist of NMDA receptors, kynurenic acid, as an increase in its concentration in tick-borne encephalitis causes symptoms similar to those of schizophrenia. The fact that the decrease in glutamatergic activity worsens the indices in tests requiring the activity of the frontal lobes and the hippocampus, and the fact that glutamate is able to influence the dopaminergic system, and both systems are associated with schizophrenia, supports the hypothesis of an important mediating (and possibly conditional ) the role of glutamate signaling pathways in the development of the disease. An additional confirmation of the "kenurenic hypothesis" was preliminary data from clinical trials suggesting the possible efficacy of NMDA receptor coagagonists in mitigating some positive symptoms of schizophrenia.

Other neurochemical hypotheses

There was also a possible role of disorders in GABAergic and in cholinergic neurotransmitter systems, which may be at the cortical level partially responsible for the development of negative symptoms and cognitive deficits. Nevertheless, none of the neurochemical hypotheses can fully explain the diversity of symptoms and the course of schizophrenia.

Structural changes

A number of differences in the structure and size of certain areas of the brain in schizophrenia were observed, beginning with an increase in the ventricles of the brain in patients with the most severe negative symptoms, which shows a significant degradation of gray matter in this disease.

Nevertheless, the pathological nature of these structural changes is unclear; there is no direct evidence and neurotoxicity of psychosis. It is possible that regularly detected structural changes, especially in patients with severe forms of the disease and after a prolonged course, may be associated with secondary processes - for example, due to social isolation and style changes or due to massive pharmacotherapy. Thus, according to some studies, long-term treatment with antipsychotics can introduce unwanted changes in the structure of the brain. It is also shown that the loss of brain volume is facilitated by drinking, smoking, cannabis use, sedentary lifestyle. Structural changes are noted not only in patients with schizophrenia, but also in some individuals suffering from affective disorders (ventricular expansion, flattening of the furrows, indicating a decrease in cortical mass), alcoholism and many other diseases.

It is also suggested that these structural changes may occur as a result of exogenous factors (chronic stress, infections, toxic effects, etc.) and developmental disorders (dysontogenesis), including in the perinatal period: for example, a violation of proliferation and migration of neurons to the cortex of the head brain or natural apoptosis of nerve cells in the process of development.

There is evidence that structural changes in patients with schizophrenia are partially reversible. In particular, physical activity is associated with an increase in the volume of the hippocampus in patients with schizophrenia.

Therapy and support

The chlorpromazine molecule (aminazine) - a remedy that revolutionized the therapy of schizophrenia in the 1950s.

The very concept of cure for schizophrenia remains an object of controversy, since a generally accepted definition of this concept has not been developed, although in recent years rational remission criteria have been proposed that are easily applicable in studies and clinical practice that can become consensus, and there are standardized assessment methods, of which the PANSS scale is generally accepted. Correction of symptoms and increase in the level of functioning seem more realistic goals than complete healing. Revolutionary changes in therapy in the 1950s were associated with the introduction of chlorpromazine. Currently, the recovery model, which emphasizes the hope of improvement, empowerment and social integration, is gaining increasing recognition.

Most patients with schizophrenia can be treated outpatient most of the time. Even in the acute period of the disease, outpatient treatment is often possible. The advantages of outpatient and inpatient treatment should be carefully weighed before a decision is made. Hospitalization may be required for severe episodes of schizophrenia. It can be voluntary or, if local legislation in the field of mental health allows, involuntary (civilian).

In Russia involuntary hospitalization is regulated by the Law on Psychiatric Care. In a number of other countries, deinstitutionalization was carried out, which made it rare for a long stay in the hospital, although it is still possible. Following the placement in the hospital or in its place, support comes in, including open-access centers, district mental health group visits, or assertive home therapy, supported work-based care, and support groups led by the patients themselves.

In many countries outside the Western world, local communities may have the final say in therapy, and treatment may be less formal. In fact, in these countries, the results of therapy may be better than in the West. The reasons for such statistics are unclear, with a view to their elucidation, cross-cultural studies are currently under way.

Medication

The predisposition to schizophrenia is presumably associated with a low level of acetylation of certain histone sites, as well as with DNA methylation. To correct these disorders, preparations based on methyltransferases and histone deacetylase can be used. Even if this technique does not completely cure schizophrenia, epigenetic therapy can significantly improve the quality of life.

According to the dopamine hypothesis, individuals with schizophrenia exhibit increased dopaminergic activity in the mesolimbic pathway and decreased in mesocortical. The main method of treating schizophrenia is the use of antipsychotics (neuroleptics), which can lead to a favorable outcome of the disease [the source is not indicated 109 days] and improve social functioning, acting both on "negative" and acute and " productive "symptoms of psychosis and hindering its further development. When most antipsychotics are taken, the maximum therapeutic effect is achieved within 7-14 days. At the same time, antipsychotics fail to significantly improve negative symptoms and cognitive dysfunction. The effect of antipsychotics is due primarily to the suppression of dopamine activity, despite their significant side effects. The current dosage of antipsychotics is generally lower compared to the first decades of their use.

Despite the widespread prevalence of antipsychotic pharmacotherapy, it is by no means etiopathogenetic, but a symptomatic therapy focused primarily on mildly specific productive symptoms. It is believed that atypical antipsychotics also act on negative symptoms, while "classical" ones are capable of causing deficit symptoms themselves.

Symptoms in varying degrees are amenable to pharmacotherapy. The American Psychiatric Association generally recommends atypical antipsychotics as first-line treatment for most patients, but notes that therapy should be individually optimized for each patient.

There is evidence that clozapine, amisulpride, olanzapine and risperidone are the most effective agents. Further (after stopping psychosis), the use of these antipsychotics reduces the risk of recurrence.

When using antipsychotics, a good response is observed in 40-50% of patients, partial in 30-40%, and in 20% there is a resistance to treatment (lack of satisfactory response to two or three drugs after six weeks of their intake). In such cases, "resistant schizophrenia", patients recommend the administration of clozapine, an agent that is characterized by increased efficacy but carries the risk of potentially fatal side effects, including agranulocytosis and myocarditis in 4% of patients. Clozapine is the only proven medication for resistant schizophrenia (up to 50% efficacy) , for those who did not have a therapeutic response to other antipsychotics. Clozapine may also have an additional advantage, presumably reducing the propensity to alcoholism, drug addiction and suicide in patients with schizophrenia. By suppressing the development of bone marrow, clozapine lowers the level of leukocytes, which can lead to infection, so when using this drug in the first six months, a regular blood test is performed.

There is uncertainty as to how rational the appointment of neuroleptics is at the first signs of schizophrenia. On the one hand, their use in the earliest stages of the disease increases the effectiveness of treatment; but it is associated with an increased risk of side effects. The data available to date do not allow an obvious answer to this question, although practical guidelines in many countries unequivocally recommend drug therapy with antipsychotics for 6-24 months at the first attacks of the disease.

Risperidone, a common representative of atypical antipsychotics

All antipsychotics block dopamine type D2 receptors, the degree of their blockage of other significant neurotransmitter receptors varies. Many of the typical neuroleptics suppress only the D2 receptors, and most atypical ones act simultaneously on a number of neurotransmitter receptors: dopamine, serotonin, histamine and others.

Despite the higher cost, atypical antipsychotics are still preferable to the initial choice of therapy over older, "typical": they are usually more easily tolerated, and their use is less often accompanied by tardive dyskinesia, although they often cause weight gain and diseases associated with obesity, especially risperidone and quetiapine, as well as olanzapine, the use of which is associated with a high risk of diabetes and metabolic syndrome. Also in people receiving atypical antipsychotics, there are cases of increased prolactin levels, galactorrhea and pituitary tumors. It remains unclear whether the transition to newer drugs reduces the chances of developing a malignant neuroleptic syndrome-a rare but severe and potentially fatal neurological disorder that most often arises as a negative response to antipsychotic.

It is believed that both classes of antipsychotics as a whole demonstrate equal effectiveness in suppressing the positive symptoms of the disease. Some researchers have suggested that atypical agents are an added benefit in influencing the negative and cognitive symptoms of schizophrenia, but the clinical significance of these effects has not yet been established. Recent studies have refuted the hypothesis of a reduced frequency of extrapyramidal side effects when using atypical antipsychotics, especially when their old analogues are selected in small doses or low-potency typical antipsychotics are used.

According to prospective longitudinal 15- and 20-year studies (Martin Harrow et al., 2007, 2012), not all patients suffering from schizophrenia are shown lifelong reception of neuroleptics. It was found that patients who stopped taking antipsychotics, in the long term, showed a higher level of neurocognitive skills compared to continued admission. They were also less vulnerable to the occurrence of anxiety disorders and repeated psychoses, demonstrating longer periods of remission. Constant blockade of dopamine receptors D2 can lead to a compensatory increase in their density and affinity, presumably the consequence of these changes is an increased risk of recurrence of psychosis (see Psychoses of hypersensitivity), and larger doses of antipsychotics are required to block the increase in dopamine receptors.

Care should be taken to prescribe high doses of neuroleptics, since excessive blockage of dopamine receptors responsible for good mood can cause depression, which in turn can increase the dependent behavior of patients who sometimes try to compensate for the lack of drug and alcohol effects of dopamine (because amphetamines stimulate the release of dopamine). There is also the problem of non-compliance with the prescription of the doctor: approximately half of outpatients intentionally violate medical instructions. For patients who do not want or do not have the opportunity to take regular tablets, extended forms of drugs have been developed, injections of which are sufficient once every two weeks. In the United States and Australia, legislation allows you to force such injections on patients who refuse to take short-term forms of drugs, but at the same time are in a stable state and do not interfere with the normal life of others.

Decreased doses of antipsychotics during the period of maintenance treatment can reduce the severity of side effects, but increases the risk of exacerbation, as well as their abrupt withdrawal. In patients with the first psychotic episode, short-term use of small doses of neuroleptics is associated with a more favorable prognosis. There is evidence that in the long run, some patients are better off without taking antipsychotics.

One of the most acute problems of modern psychiatry is the unjustifiably frequent use of combinations of neuroleptics (polypharmacy). It is much more effective and much safer to prescribe not two or more neuroleptics, but the combination of neuroleptics with preparations of a different mechanism of action - benzodiazepines or normotimics-anticonvulsants (valproate, lamotrigine, etc.).

Despite encouraging results from early pilot studies, omega-3-unsaturated fatty acids do not lead to symptomatic improvement, according to meta-analysis.

Therapy by additional means

With resistant schizophrenia, it is recommended that clozapine be administered. In case, and this does not help, use the strategy of adding other drugs to clozapine.

Of antipsychotics, clozapine is combined with amisulpride, risperidone, and with negative symptoms with aripiprazole. Of antidepressants, clozapine is supplemented with citalopram, fluvoxamine, mirtazapine, with them clozapine acts on negative symptoms of schizophrenia, which are considered to be the most difficult to treat. Of anticonvulsants use lamotrigine, topiramate, valproic acid. And also giving a significant improvement, statistically confirmed, memantine.

Other antipsychotics with negative symptoms are also used together with fluoxetine, mirtazapine, Omega-3, serine. With global symptoms, together with donepezil, sarcosine. When aggression of antipsychotics together with S-adenosylmethionine. The addition of rivastigmine improves memory in patients with schizophrenia, selective attention and integration of information with knowledge and their context, and galantamine attention and memory, and may have an auxiliary therapeutic effect, including negative symptoms and apathy among patients with chronic schizophrenia and residual symptoms.

Psychological and social therapy

Psychotherapy is also widely recommended and is used in schizophrenia, although the possibilities of therapy are sometimes limited by pharmacology because of problems with funding or inadequate training of staff. In addition to treating the disease itself, it (psychotherapy) is also aimed at social and professional rehabilitation of patients. Only antipsychotic drugs alone do not allow to restore the patient's condition to a premorbid level of functioning in society, and psychotherapy, family and individual, allowing to influence social factors and patient adaptation, can largely predetermine the outcome of the disease.

Cognitive-behavioral therapy (CBT) is used to alleviate symptoms and improve the related aspects - self-esteem, social functioning and awareness of their condition; Reduction of distress experienced by patients suffering from psychosis and improving their quality of life. CPT in psychoses is not so much aimed at eliminating psychotic symptoms, but rather as helping patients develop a system of psychotic experiences that would allow them to avoid serious suffering. Although early trials did not produce a clear result, subsequent reviews indicate the possible efficacy of CBT in influencing the symptoms of schizophrenia. There is a meta-analysis showing the efficacy of CBT in individuals diagnosed with schizophrenia; according to the conclusions drawn from the results of the meta-analysis, CBT should be offered as an element of the usual treatment for patients. Some studies have demonstrated the superiority of CBT over supportive psychotherapy in psychoses . In addition, it was concluded that CBT allows a little decrease in the frequency of relapses in patients.

Data on psychoanalytic methods of treating schizophrenia are contradictory, the effectiveness of these methods is one of the most controversial topics in psychiatry. Many specialists take a position of total rejection of the use of psychoanalysis in persons with schizophrenia. There are data both in favor of psychoanalytic therapy in comparison with drug therapy, and against; a number of reviews concluded that there is too little data on the effectiveness of psychoanalysis. Nevertheless, one meta-analysis showed that both psychoanalytic therapy and cognitive-behavioral, even when any of these treatments are used without medication, are as effective as traditional antipsychotics. This gives hope that psychotherapy, applied alone, without medication, can be a suitable treatment for those patients who are not helped by antipsychotics, or those who refuse to take them, or those who are treated by a doctor who chooses to use medication only in small amounts or not at all.

One of the arguments against individual psychotherapy (both cognitive-behavioral and psychoanalytic) is its high cost. Nevertheless, according to the supporters of the use of psychotherapy in psychoses, the total cost of its application is lower than with the use of neuroleptics, since in this case the patient is less permanently treated, operates at a higher level, and his mental problems do not interfere much with finding and to keep working, as the mental problems of those who undergo medical treatment.

Another approach is cognitive remediation therapy, the techniques of which are aimed at combating cognitive impairment, sometimes present in schizophrenia. The first results indicate the cognitive effectiveness of this direction, based on the methods of neuropsychological rehabilitation, and some positive shifts are accompanied by changes in the character of brain activation noted with fMRI scanning. A similar approach, called "cognitive improvement therapy," directed, in addition to the neurocognitive sphere, to social cognition, also showed efficacy.

Family therapy or training, approaches generally directed toward the family system, of which the patient is a part, are generally recognized as useful in studies, at least with long-term intervention. Psychotherapeutic counseling of the patient's family, having a positive impact on family relationships, helps to resolve problems in relationships and thus facilitates the outcome of the disease : 408. Since family relationships are often a risk factor for relapse, family therapy can reduce the risk of relapse because parents are trained in communication and stress management skills, so that criticism, intrusion and hyperopecia are excluded, or the number of contacts between parents and patients is reduced. There are various options for family therapy, such as psychoanalytic family therapy, systemic family therapy, but the treatment program should always be adapted to the needs of a specific family and oriented towards a constructive open dialogue, during which the solution of the tested problems is jointly developed. In addition to the actual therapy, recognition receives a serious impact of the disease on the family and the heavy burden that falls on the shoulders of those who care for the patient, and therefore more self-help books on this subject are published.

Some evidence suggests the benefits of teaching social skills, but there have been significant negative results in this direction. Some works consider the possible benefits of music therapy and other creative forms of therapy, but according to other sources, art therapy has shown ineffective results in the treatment of schizophrenia.

Movements organized by "clients of psychiatric services" have become an integral part of the recovery process in Europe and America; groups such as the Hearing Voices Network and the Paranoia Network have developed self-help techniques aimed at providing support and assistance beyond the traditional medical model adopted by most psychiatrists. By avoiding the consideration of personal experience in terms of mental illness or mental health, they seek to de-stigmatize these experiences and inspire a person to take personal responsibility and gain a positive self-image. Increasingly, partnership relations between hospitals and patient organizations are being established, while the work of doctors facilitates the return of people to society, the development of their social skills and the reduction in the frequency of repeated hospitalizations.

As an alternative to a rigid system of psychiatric institutions, where the attitude towards people is often perceived as authoritarian, unfriendly or cruel, and the treatment is reduced to the regular use of psychiatric (in particular, antipsychotic) means, House-Soterii, named after the first house "Soteria ", Created by Lauren Mosher. House-Soteria or houses modeled after Soteria are currently functioning in Sweden, Finland, Germany, Switzerland, Hungary and some other countries. In his 1999 paper Sotheria and Other Alternatives to Urgent Psychiatric Hospitalization, Lauren Mosher, who developed the Soteria method, described it as "the use of interpersonal phenomenological interventions by unprofessional personnel 24 hours a day, usually without treatment with neuroleptic drugs, in the context of a small, similar home, quiet, supportive, protective and tolerant social environment. The results of research are scarce, but their systematic review in 2008 showed that the program is similar in effectiveness to treatment with neuroleptics in the first and second episodes of schizophrenia.

Other methods

Electroconvulsive therapy (ECT) is not considered for the initial choice of therapy strategy, but can be prescribed if other methods fail. It is more effective in the presence of catatonia symptoms, and NICE rules in the UK recommend the use of ECT in catatonia, if it has already been successfully performed in this patient, but there are no other recommendations for ECT in schizophrenia. Psychosurgery in our time has become a rarity and in schizophrenia is not recommended.

Insulin-co-therapy for the treatment of schizophrenia has been used in the West since its inception in the 30s of the 20th century and until the 1950s, when it was acknowledged that there was no evidence of its effectiveness, although it was significantly more dangerous than ECT. In Russia, insulin-comatose therapy continues to be used, presenting, from the point of view of a number of specialists, a unique method of therapy. Atropinocomatous therapy is also sometimes used.

Forecast

John Nash, an American mathematician who still showed the first symptoms of paranoid schizophrenia in college. Despite the abandonment of medication, Nash continued his research. In 1994, for his early work was awarded the Nobel Prize. The history of Nash's life formed the basis of the biography and feature film "The Mind Games"

Course of the disease

In the framework of the International Study of Schizophrenia (ISoS), coordinated by WHO, a long-term follow-up of 1633 patients from different countries with the diagnosis of "schizophrenia" was carried out. After 10 and 15 years, different results were recorded for both countries and subjects. In general, more than half of the patients available for long-term follow-up have recovered from the point of view of symptomatology (4 on the Bleuler Scale) and more than a third were considered recovered if the level of functioning (above 60 on the GAF scale) was taken into account in addition to symptoms. Around a sixth of them "were found to have reached full recovery, requiring no more therapy in any form", although some still showed some symptoms and decreased ability to work. A significant number had a "late recovery", even after chronic problems and setbacks in the selection of therapy. The findings say that "the results of the ISoS project, following other similar data, help to save patients, caregivers, and clinical workers from the paradigm of the chronic course that dominated the notion of the disease throughout much of the 20th century".

A review of large longitudinal studies carried out in North America also indicates a great variation in the results, as well as that the course of the disease can be mild, moderate or severe. The clinical outcome was on average worse than with other psychotic and psychiatric disorders, but between 21% and 57% of patients, depending on the severity of the criteria, showed good results. Progressive deterioration was observed "in a small number of cases," although there was a marked risk of suicide and early mortality. The authors note that "the most important is the evidence that in a moderate number of cases, patients show complete remission of symptoms without subsequent relapse, at least for a long time, and that some of these patients do not require supportive drug therapy".

A clinical study with severe recovery criteria (simultaneous remission of positive and negative symptoms with adequate social and professional functioning for two years) suggests a 14% recovery in the first five years. In another study that took into account patients living in the same area, 62% of the subjects had a general improvement in the composite index of symptoms, clinical and functional indicators. Another longitudinal study, which lasted more than 20 years, showed that at least half of the 1,300 people with schizophrenia achieved "a recovery or a significant improvement in the condition":

In analyzing WHO data, another important regularity has been found: people diagnosed with schizophrenia living in "developing countries" (India, Colombia, Nigeria) show better long-term performance than patients from "developed countries" (USA, UK, Ireland , Denmark, Czech Republic, Slovakia, Japan, Russia) [247], despite the fact that antipsychotic medications are generally less available in poor countries.

Definition of recovery

Statistical results of studies vary due to the lack of generally accepted strict definitions of remission and recovery. The "Working Group on Remission in Schizophrenia" proposed standardized remission criteria, including "improvement in the main signs and symptoms to a level at which any residual symptoms are so mild that they no longer have a significant effect on behavior and do not reach the threshold determining the primary diagnosis of schizophrenia ". Some researchers propose standardized criteria for recovery, indicating that the definitions of "full return to premorbid (before illness) level of functioning" or "perfect return to full functioning" in DSM-IV are inadequate, not measurable, incompatible with the scope of the variations recognized in society for the norm of psychosocial functioning, and also promote stigmatization and generate a vicious circle of pessimism. Between people diagnosed with schizophrenia, including those in the movements of "consumers of services / victims", and some experts in the field of mental health, there may be quite strong disagreement about the basic attitudes and concepts of recovery. Among the notable limitations inherent in almost all research criteria is a lack of attention to how the subject assesses his condition and feels himself in life. Disease and subsequent recovery often involve long-term frustration in one's own strength, isolation from friends and family, disruption of learning and career and social stigmatization, "experiences that can not simply be turned back or forgotten". The model that determines recovery is gaining weight as a process similar to the gradual "withdrawal from" the problems associated with drugs and alcohol and emphasizing the uniqueness of the path of everyone who has entered this road in search of hope, freedom of choice, new opportunities, inclusion in society, achievements.

Indicators of forecast

Several factors correlate with a more positive overall prognosis: female gender, acute debut (a sharp manifestation of symptoms as opposed to gradual), a greater age in the first episode, a predominance of positive (as opposed to negative) symptoms, a mood disorder, a good level of functioning before the disease, the ability to work well, academic success, social skills, favorable economic conditions, low family cohesion with curative prescriptions. Strengths of character and the presence of internal resources, manifested in decisiveness and "psychological stamina", are also associated with a better prognosis.

Adoption and support from relatives and friends can significantly affect the outcome of the disease. Studies have shown that the negative aspects of the attitudes of others - the number of critical comments, the level of hostility and the disposition to invade and control someone else's life (in aggregate - "expressed emotions", using the terminology of researchers) - all this time and again there is an increased risk of relapse. On the other hand, most of such studies speak only of correlation, and it is often difficult to establish the direction of cause-effect relationships.

Frequent or prolonged (recurrent) hallucinations are closely associated with a negative prognosis, in addition, they have a poor influence on job opportunities for patients, preventing them from returning to normal life.

To an unfavorable prognosis (the formation of residual states) predisposes also the isolation of patients and their long stay in hospitals of the old type, which predetermine the development of hospitalism.

Mortality

When analyzing data on more than 168,000 Swedish citizens receiving psychiatric treatment, the life expectancy of schizophrenic patients was about 80% - 85% of the median. Women diagnosed with schizophrenia lived a little longer than men, and overall the disease was associated with longer life expectancy than alcoholism and drug addiction, personality disorders, heart attacks and strokes. In schizophrenia, there is an increased risk of suicide (according to Soviet data, among patients diagnosed with schizophrenia who were registered in the psychoneurological dispensary, suicidal risk was 32 times higher than in the general population, while in manic-depressive psychosis the same indicator was equal to 48, and with reactive depression - 100); a recent study suggests that 30% of patients attempted at least once in their lives to commit suicide. In another study, during a 20-year period of illness, about 50% of people with schizophrenia attempted suicide, with 10% of them being completed. Another study suggests a 10% mortality rate from suicide in schizophrenia. Additionally, factors such as smoking, poor diet, lack of exercise and negative effects of psychotropic drugs are indicated.

According to studies, the reception of neuroleptics is associated with a higher death rate than in the population, and the relationship between the number of antipsychotics taken and its level is statistically significant (with polytherapy, the risk of premature mortality increases). The use of antipsychotics leads to cardiovascular and pulmonary disorders, which at least partly explains the increased risk of mortality. In a large study (Ray et al., 2001), it was shown that the administration of neuroleptics is associated with an increased risk of sudden cardiac death. Some of the side effects of antipsychotics may cause an increased risk of suicide - for example, DSM-IV notes that "akathisia may be associated with dysphoria, irritability, aggression, or attempted suicide". In placebo-controlled trials, there was a statistically significant increase in the number of completed suicides on the background of active treatment with neuroleptics.

In 2006, the British Journal of Psychiatry published research data, the authors of which (M. Joukamaa, M. Helliovaara, P. Knekt, etc.), having studied the 17-year-old catamnesis of more than 7 thousand patients diagnosed with schizophrenia, found that During this period, of patients who received one, two, three, or more classical (typical) neuroleptics, died 35, 44 and 57 %%, respectively, while among patients with this diagnosis, who did not receive classical antipsychotics, the corresponding figure was only 5 %.

Violence

The link between acts of violence and disease is a topic for controversy. In modern studies, it is said that the percentage of patients with schizophrenia who resort to violence is higher than the percentage of people without any diseases, but at the same time lower than in disorders like alcoholism, and that the difference is smoothed out or completely disappears in case of regional review, taking into account associated with disease factors, primarily socio-demographic variables, alcoholism and drug addiction. Studies show that 5% to 10% of murders in Western countries are carried to people with schizophrenic disorders.

Psychosis in schizophrenia is sometimes associated with an increased risk of acts of violence. Studies of the specific contribution of delusional beliefs and hallucinations do not give an unambiguous picture, primarily paying attention to the delusion of jealousy, a sense of threat and ordering voices. It has been suggested that patients of a certain type are more prone to violence, which are characterized by learning problems, low IQ, behavioral disorders, early alcoholism and drug addiction, violations of the law prior to diagnosis.

Stable evidence suggests that people diagnosed with schizophrenia are more likely to be victims of violent crime - at least 14 times more likely than performers. At that small part of patients that commit violent actions, abuse of psychoactive substances, primarily alcohol, is steadily observed. Aggression, both from patients and directed against them, usually happens in the context of complex social interactions in the family, and is also a problem in the clinic and in the patient's place of residence.

Screening and disease prevention

At present, there are no reliable markers capable of predicting the development of schizophrenia, but studies are under way to evaluate the possibility of determining the future diagnosis of a combination of genetic factors and psychosomatic experiences that do not lead to a decrease in the functional level. People who meet the criteria of the 'ultra high risk state', which presuppose the existence of transient or self-controlled psychotic experiences against the background of the family history of schizophrenia, receive the same diagnosis within a year with a probability of 20-40%. It is shown that various methods of psychotherapy and medicines can reduce the chances of developing true schizophrenia in individuals who meet the criteria of 'high risk'. At the same time, the treatment of people who may never already be ill with schizophrenia is full of controversy because of the risk of side effects when using antipsychotics, especially potentially disruptive effects such as tardive dyskinesia, as well as a rare but sometimes deadly malignant neuroleptic syndrome. The most common form of preventive activity is educational public campaigns that provide information on risk factors for schizophrenia, early diagnosis and treatment options.

Criticism and alternative approaches

Diagnostic problems and disputes

Criticism of the diagnosis of "schizophrenia" is associated with its insufficient scientific validity and reliability and is part of a broader critique aimed at the diagnostic criteria of psychiatry in general. An alternative to the arbitrarily established boundary between the disease and the norm can be the consideration of individual indicators in various diagnostic measurements, suggesting the presence of a spectrum or continuum of conditions as opposed to a single diagnosis. This approach fits well into the research of schizotypy and is consistent with data on high frequency in the general population of psychotic experiences and delusional beliefs that often do not evoke negative emotions.

Experts are increasingly expressing the view that schizophrenia is not a disease, but a syndrome, a consensus nosological unit, the amount of terms that provides communication between general practitioners, psychiatrists and scientific researchers, patients and their relatives. In 2002, in the professional magazine "MGv" (the article "Exposing Schizophrenia"), Peter de Valmnic (Netherlands, Pieter de Valminck) spoke about the harmful consequences of understanding schizophrenia as a disease. In 2003, Jim van Os (Eng.) Russian. during a lecture at the Netherlands Institute of Mental Health and Addictions, argued against the current concept of schizophrenia, in many cases, he claims to be harmful. According to Van Os, the existing diagnostic methods are unnecessarily rude: "There is not one biological criterion that has diagnostic value, and the average differences between the groups are still not diagnostically irrelevant," and it is still impossible to clearly distinguish between patients with schizophrenia and patients with depression. Van Os pointed out that the condition of patients who are diagnosed with schizophrenia, which is essentially a stigmatizing psychiatric label, can be characterized by clusters of symptoms unique to each individual. He proposed to abandon the diagnosis of "schizophrenia" and replace it in DSM-5 with a new diagnosis of "an aberrant importance marking syndrome". However, the diagnosis of "schizophrenia" was not replaced in DSM-5.At the congress on schizophrenia in 2007, during the voting, 62 votes against 61 were in favor of abandoning the term "schizophrenia". Speaker of the last V. Carpenter from the Center for Psychiatric Studies in Maryland (Baltimore) proposed to address the problem of heterogeneity inherent in schizophrenia, and to divide this syndrome into several significant subsyndromes, which will allow to more accurately determine their clearly multiple etiological roots. Several suggestions were made from the audience about alternatives to today's name, in particular "Krepelin-Bleuler syndrome", "hypolaterization syndrome", "deliberately unspecified psychosis"; there were suggestions that whether the replacement of the name stigmatization and misconceptions of the general public would reduce schizophrenia.

Critics of the diagnosis point to the instability of the criteria, which is especially pronounced when assessing delusional beliefs and thinking disorders. There are opinions that psychotic symptoms are not sufficient grounds for the diagnosis, because "psychosis in psychiatry is like a fever in the rest of medicine is a serious but non-specific indicator". In 1968, British psychologist Don Bannister noted that schizophrenia is diagnosed in a person when "he shows A and B and diagnoses the same disease in another person on the basis of the signs of B, D, and D. Now these two people are united in one category, despite the fact that they do not have a common feature ... Mutually exclusive (disjunctive) categories have too primitive logic for scientific application ".

Studies show that the diagnosis of schizophrenia is relatively unreliable and inconsistent, probably because of the above factors. The famous research carried out in 1972 by David Rosenkhan (see Rosenkhan Experiment), the results of which served as material for an article in the journal Science entitled "About normal people in abnormal places", demonstrated the subjectivity and unreliability of diagnosis - at least at that time. More recent studies have shown that the probability of simultaneous diagnosis of "schizophrenia" by two independent psychiatrists is at best 65%. These data, as well as the results of previous studies demonstrating even less consistency in the analysis of diagnostic reliability, led some critics to demand that the diagnosis of schizophrenia per se be abandoned.

In 2004, the book "Models of Madness" was published, one of whose authors, professor of clinical psychology J. Reed (English) Russian. Using statistical research, he cited evidence that the diagnosis of schizophrenia is neither reliable nor valid. According to the editors of the book by J. Reed, L. Mosher, R. Benthall, the medical model of schizophrenia leads to unreasonable pessimism about the chances of healing and prevents real attempts to understand "what really happened in the lives of these people, their families, and in the society in which they live, "and to provide assistance that would not be reduced to a" chemical or electrical "solution to the problem" ". The authors of the book cite data according to which life circumstances (and in particular children's psychological traumas) play a key role in the onset of psychosis and argue that biological psychiatry can ignore these causes, although preventive programs aimed at improving the quality of life of children, adolescents and their families, would improve the situation.

Doubt is also subjected to attempts to find the genetic basis of schizophrenia. They led to the identification of a number of candidate genes, for example, COMT, NRG1 and DTNBP1, which was announced with great enthusiasm. However, later studies, all without exception, failed to repeat these results. In one of the largest ever published psychiatric genetic studies, the results of which appeared in the American Journal of Psychiatry, there was no correlation between any of the candidate genes and schizophrenia.

In 2002, Japan replaced the term (seishin-bunretzu-be), which denoted schizophrenia and literally translated as "a disease of the split mind", into (togo-sitt?), "integration disorder" [[ 295] [296]. In October 2012, at the 51st annual congress of the Taiwanese Society of Psychiatrists (TSP) in Tainan, a new name for schizophrenia in Chinese was chosen - the whale. trad., exercise., pinyin: si jue shitiao zheng, pall .: sy-tszue-shityao-cheng, literally: "cognitive-perceptual dysfunction". In 2006, the "Campaign for the Disclaimer of the Schizophrenia Label" was launched in the UK with the aim of a similar change in diagnosis and the development of a new approach to therapy and understanding of the symptoms currently associated with schizophrenia.

The practice of using the diagnosis of "schizophrenia" is known not for therapeutic, but for political purposes; in the USSR, a subtype was added to the classification, called "slow-moving schizophrenia." The use of this diagnosis, especially in the RSFSR, against dissidents, was a way to silence them or to abandon their views under the threat of enforced placement in medical institutions. In 2000, the public was alarmed by news of a similar practice, allegedly initiated by the Chinese government and aimed at members of the Falun Gong sect, who were detained and "treated". The Committee on Abuse in Psychiatry APA reacted by adopting a resolution calling on the World Psychiatric Association to investigate the situation in China.

In general, in the USSR there were significant differences in views on the diagnosis of schizophrenia, depending on belonging to a psychiatric school: in 1965, for example, the incidence of schizophrenia in Moscow was 2.6 times higher than in Leningrad, and only in 1996 in 1,4 times.

The overly extensive diagnosis of schizophrenia is also prevalent in post-Soviet times. Thus, systematic studies show that the diagnosis of the entire group of affective pathology in modern Russian psychiatry is negligible and refers to schizophrenia in a multiplicity of 1: 100. This absolutely does not correspond to the data of foreign genetic and epidemiological studies, according to which the ratio of these diseases is 2: 1. This situation is explained, in particular, by the fact that, despite the official introduction of ICD-10 in 1999, Russian doctors continue to use the version of this manual adapted to Russia, similar to the version of ICD-9 adapted to the USSR.

Alternative approaches

At the end of the XX - beginning of the XXI century, the psychological approach to understanding and supporting people with the diagnosis of "schizophrenia", at the center of which the person is located, is becoming increasingly widespread. There has been growing interest in a number of psychological factors that can help to understand the problems of psychosis and expand therapeutic possibilities.

Thus, since the middle of the 20th century, there exists an international public organization ISPS - The International Society for the Psychological Treatments of Schizophrenia and Other Psychoses, which includes groups of specialists working at the national, regional and local levels throughout the world the world.

An extremely radical non-academic approach, widely known as the "antipsychiatry movement", the peak of whose activists came in the 1960s, is opposed to the "orthodox" view of schizophrenia as a disease. According to the prominent participant of this movement, Thomas Szasz, psychiatric patients are not sick, they are more likely to be "with non-standard thoughts and behavior" that cause inconvenience to society. He believes that society violates justice in its desire to control them, classifying their behavior as a "disease" and subjecting them to treatment in an attempt at social control. In his opinion, schizophrenia does not really exist, it is only a social construct based on the ideas of society about the normal and abnormal. "Schizophrenia is given such a vague definition," Szasz writes, "that in fact this term is often applied to almost any kind of behavior that people dislike".

He also denies the existence of biochemical and pathological data on schizophrenia and does not consider the treatment of schizophrenia to be a "scientific activity". Similar views were presented by psychiatrists RD Laing, Silvano Arieti, Theodore Leeds, and Colin Ross who believed that the symptoms of what is commonly called mental illness are responses to the unrealistic demands imposed by social and especially family life on some sensitive of people. In the opinion of these authors, the content of psychotic experiences deserves an interpretation, as opposed to the idea of them as a lack of information significance of the manifestations of a mental disorder. Laing even composed eleven descriptions of schizophrenic patients, proving that the content of their actions and utterances was filled with meaning and logic in the context of their family and life situations. Considering the notion of schizophrenia as an ideological limitation that makes coercive relationships between patients and psychiatrists possible, Laing wrote: "The concept of schizophrenia is the fetters that bind patients and psychiatrists. <...> In order to sit in a cage, we do not always need bars. Certain ideas can also become cells. The doors of psychiatric hospitals are opened because chemical containment is more effective. The doors of our minds are much more difficult to open ".

In Palo Alto in 1956, Gregory Bateson and colleagues Paul Watslavik, Donald Jackson and Jay Haley created a theory of schizophrenia related to Laing's work and suggests a disorder resulting from a person falling into a double message situation in which he receives various or conflicting reports . From this it followed that the symptomatology of schizophrenia is an expression of this desperate situation and is of value as an experience of catharsis and transformation.

Another alternative is put forward: the use in diagnosis of knowledge about specific neurocognitive deficits. Such deficits are manifested in the reduction or violation of basic psychological functions - memory, attention, control functions and the ability to solve problems. It is these abnormalities, and not the bright psychotic symptoms (which in many cases are successfully controlled with the help of antipsychotics) are supposed to cause most of the disabling effect of schizophrenia. However, this trend has developed relatively recently and is unlikely to lead to a radical change in diagnostic techniques in the near future.

The original concept of schizophrenia was suggested by Julian Jaynes. He suggested that prior to the beginning of the historical time, schizophrenia or a similar condition was normal for human consciousness, while the normal state of low affect, suitable for routine actions, was interrupted during the crisis by the appearance of "mysterious voices" giving instructions that was considered "the intervention of the gods". Researchers of shamanism admit that in some cultures schizophrenia or related conditions can predispose a person to choosing the role of shaman; the experience of access to multiple realities is often found in schizophrenia, and is also a key experience in many shamanic traditions.

Psychohistorics, on the other hand, accept psychiatric diagnoses. However, contrary to the current medical model of mental illness, they believe that in pedigree societies the developmental disadvantages of schizoid individuals are caused by deficiencies in upbringing. There is a lot of speculation about the presence of schizophrenia among religious figures of the first magnitude. Paul Kurtz and other commentators find recognition: the idea that the most important religious figures experienced psychosis, heard voices and demonstrated delirium grandeur.

There is an assumption that schizophrenia can be the evolutionary payment of mankind for left-hemispheric specialization associated with the emergence of language, since patients with this diagnosis have less functional asymmetry of the brain hemispheres than in healthy people, and the left hemisphere correction is associated primarily with his linguistic specialization.

Schizophrenia is engaged in a branch of alternative medicine, known as "orthomolecular psychiatry." It is believed that there is a group of diseases - schizophrenia, and the approach to treatment includes conducting diagnostic tests with the subsequent selection of appropriate therapy. In some cases, the appointment of high doses of nicotinic acid (vitamin B3) is considered effective. The adverse reaction of the body to gluten is a source of some alternative theories; supporters of orthomolecular medicine argue that an adverse reaction to gluten is part of the etiology of some cases of the disease. This theory, presented by one author in three British magazines of the 1970s, was not proved. A 2006 review of the literature suggests that gluten can be a pathological factor for patients suffering from celiac disease and for some patients with schizophrenia, but suggests the need for further research to confirm or disprove this assumption. In an Israeli study in 2004, 50 patients with schizophrenia with a control group were measured levels of antibodies to gluten. In both groups, the tests gave a negative result, which led to a conclusion about the doubtfulness of the concept of the relationship between schizophrenia and sensitivity to gluten.

Some researchers suggest that dietary and alimentary therapy in schizophrenia has some prospects.