Schizophrenia

Schizophrenia (general information)

… more than a third of psychiatric hospitalizations in the country are for schizophrenia .



Schizophrenia is a severe mental disorder characterized by severe distortions in thinking, perception and inappropriate emotions and leads to a high level of disability.

Epidemiology . Approximately 1 new case per 1000 population is diagnosed each year. This indicator is stable throughout the world (the incidence does not depend on nationality and race). The median age of onset is 15–25 years for men and 25–35 for women (~90% of all patients are aged 15–54 years). Schizophrenia rarely begins before the age of 10 and later than 50. (!) The risk of getting sick is directly proportional to the degree of relationship and the number of cases in the family.

Etiologyschizophrenia is unknown. Factors that are necessary and sufficient for the onset of the disease have not been established.

Neuromorphological studiesreveal nonspecific degenerative diffuse changes that do not add up to a reproducible structural defect. The anterior limbic regions of the brain and the basal ganglia are more affected. Computed tomography reveals enlargement of the lateral and third ventricles in 5-50% of patients, cortical atrophy, an objective indicator of neuronal loss, in 10-35%. Expansion of the ventricles correlates with the severity of negative symptoms, lower adaptation in premorbid, more pronounced extrapyramidal symptoms in the treatment with antipsychotics. These changes are neither progressive nor reversible, nor are they a consequence of treatment (including ECT).

Clinical signs. In premorbidity, a group of patients with schizophrenia stands out from the population in terms of their personal characteristics (as a rule, schizoid, anxious, paranoid, hysterical, anancaste, and other types of personality are found) and in terms of lower intelligence compared to their peers (more pronounced in men).

With the exception of relatively short episodes of impaired consciousness against the background of an exacerbation of the condition, patients usually completely retain their orientation in the environment and their own personality. Orientation can, however, be distorted in accordance with the content of delusional experiences.

Quite typical, especially for exacerbations, is the absence of consciousness of the disease, which is associated with delusional experiences, manic affect, or psychological defense mechanisms.

The most striking behavioral disorders are catatonic symptoms. Their spectrum ranges from slight mannerisms and quirkiness of individual movements and postures to pronounced excitement, stupor, and stereotypes.

Violation (deceptions) of perception are observed in any sensory modality, more often manifested in the form of auditory hallucinations. Senaesthetic hallucinations are characteristic, often of a bizarre nature in the form of a sensation of an altered state of internal organs, for example, a feeling of heat inside the head, burning of the genitals, penetrating the body with some kind of rays, and pain in the bones. Visual hallucinations and illusions are less common. Olfactory and gustatory hallucinations usually accompany the fear of poisoning in delusions of persecution. (!) The presence of tactile, olfactory and gustatory deceptions should encourage the clinician to rule out organic brain damage.

Violations of the integration of mental processes lead to changes in the perception of one's self, symptoms of depersonalization and derealization. Alien, not belonging to the patient, his body, movements, speech, aspirations can be perceived. The sensory level of perception of the surrounding world decreases.

Violations of the form of thinking include loosening of associations, slippage, semantic inconsistencies, excessive thoroughness, up to verbigerations and verbal okroshka. Disorders of the thought process include an uncontrolled flow and complete interruption of thoughts, vagueness, poverty or quirkiness in the content of speech, paralogy, and a decrease in abstract thinking. Memory impairments are generally less common. The latter are characterized by difficulties in concentrating attention, difficulties in organizing and integrating new experience. Characterized by intense and unproductive focus on esoteric, metaphysical, parapsychological, religious ideas.

Delusional constructions are extremely diverse and may relate to persecution, relationship, special significance, grandeur, love charm. The patient may have an idea that he receives or transmits thoughts at a distance, reads other people's thoughts, or that his own are available to the perception of others. He may believe that his behavior is somehow controlled from the outside, that some sensations and changes in the body are caused from outside, allusions are made to him in the media, or that he can influence what is happening in an unusual way.

Affective (emotional) disorders most often include a lack of emotional involvement during communication, a special inaccessibility of patients in contact, remoteness from the outside world, a decrease in emotional response (impoverishment of affect) or intense and often inadequate, incomprehensible to others, outbursts of anger, anxiety or happiness. The affect may not correspond both to the situation and to the mimic-plastic means of its expression. Affective disorders can be mono- and bipolar. Depressive layers are observed in about 60% of patients. There is ambivalence, a combination of heterogeneous emotions. Impoverishment and inadequacy of affect often accompany autism.

(!) It should be borne in mind that the flattening of affect can be both the primary manifestation of the disease and a parkinsonian side effect of antipsychotics. Depression can also be aggravated by medication.

Psychosis . The prodromal period may precede the onset of psychosis for several weeks or months. Here, asthenic-hypochondriac, psychopathic symptoms, anxiety episodes can be presented. The sharpening of premorbid personality traits, especially schizoid ones, is combined with inadequate affective reactions, decreased motivation and productivity in work or study.

In an attempt to improve their condition, patients often resort to paramedical treatments, frilly diets, and not quite adequate sports. Characterized by fixation on philosophical, metaphysical, religious topics, the appearance of oddities in behavior, pretentiousness or neglect in appearance. The period of manifestation of psychosis can develop acutely or be delayed for weeks or months. This active phase is usually dominated by extensive hallucinatory-paranoid experiences.

The course of the disease. After the first manifestation, the classic course of schizophrenia is considered to be periodic exacerbations, often provoked by social stresses, separated by intervals of remissions, in which residual productive, increasing deficient symptoms and vulnerability to psychosocial stressors more and more clearly appear. An exacerbation is often followed by an episode of post-psychotic depression. On average, after 5-6 years from the manifestation of psychosis, the severity of productive symptoms decreases somewhat and signs of a defect may come to the fore. Quite typical is the non-remission constant course of the disease.

Differences in clinical manifestations allow the division of schizophrenia into separate subtypes :

Paranoid type: the predominance of hallucinatory-paranoid symptoms, a later, compared with other forms, onset, less pronounced deficient symptoms; the typical paranoid patient is tense, suspicious, reserved, often hostile and aggressive; his behavior and thinking in areas not related to psychotic experiences are often intact.

Hebephrenic type : the predominance of primitive, disorganized forms of behavior, disinhibition; thought disorders make contact with reality difficult, appearance corresponds to the disintegration of behavior, facial expressions are inadequate; begins at an early age, usually with emotional flattening, abulic, behavioral disorders, cognitive decline; patients are immersed in themselves, childishly foolishly grimace.

catatonic type: dominated by catatonic motor disorders; agitation and stupor can often replace each other; catatonic symptoms are often combined with oneiric, dreamlike experiences.

Undifferentiated type : in reality, the clinical picture does not always fit into the description of a separate subtype; The subtype of so-called undifferentiated schizophrenia is designed to meet the difficulties of categorization in these cases.

Principles of Treatment . Distinguish active therapy, stopping the manifestations of the disease during its manifestation, attack, exacerbation; maintenance therapy aimed at maintaining the achieved improvement and stabilizing the condition; preventive therapy, the purpose of which is to prevent relapses of the disease and prolong remissions.

In severe psychotic states that disrupt the adaptation of patients and usually require hospitalization, psychotropic drugs (neuroleptics, antidepressants, etc.), as well as shock methods of treatment, are used. Insulin-comatose and electroconvulsive therapy is used both in acute catatonic, affective and affective-delusional, and in some protracted conditions resistant to psychotropic drugs. With a slower development of the process, during the formation of remissions, as well as with a shallow remission, drug treatment is carried out in combination with psychotherapy and occupational therapy.