How to recognize low-grade schizophrenia? Sluggish schizophrenia: symptoms and treatment methods How to identify low-grade schizophrenia.

Sluggish schizophrenia is a type characterized by weak progress; the disease is characterized only by indirect specific manifestations. Synonyms for the term are “low-progressive schizophrenia” or “schizopathic disorder.”

When sluggish schizophrenia occurs, biochemical disturbances in the brain's neurotransmitters are observed: excessive secretion of dopamine, stimulation of their receptors. Pathology in the limbic system is also revealed, inconsistency in the functioning of the hemispheres and a malfunction of the functions of the fronto-cerebellar connections are traced.

The main factors in the development of personal changes include:

• genetic predisposition is the most common reason;
• severe stress;
• previous infectious diseases and brain injuries;
• negative family environment.

There is no connection between the occurrence of schizopathic disorder and gender, but in men the course of the pathology is more severe than in women. It has been proven that residents of megacities and vulnerable social groups get sick more often.

Symptoms

Symptoms of sluggish schizophrenia can be noticed even during puberty, when the disease debuts. But it clearly manifests itself in adulthood. The line between ordinary neurotic and schizoid disorders is very thin; differentiating them is sometimes difficult due to the multiform manifestations of the pathology. The course of the disease is characterized by gradual, shallow personality changes.

Stages

Sluggish schizophrenia develops and proceeds in stages:

• Latent period. They are distinguished by blurred symptoms, sometimes even loved ones do not understand that the person is sick. The manifestations are characterized by prolonged hypomania (elevated mood followed by apathy), irritability, abstract or philosophical reasoning that is of no value. Sometimes somatized depression and persistent emotional outbursts (affects) are observed. Sometimes a teenager stops communicating, refuses to leave the apartment or go to the exam.
• Manifest stage. At this stage, there is an increase in clinical manifestations, when oddities begin to bother loved ones. They do not always turn to a specialist during this period, since there is no delusion or hallucinations. The condition is attributed to character traits. At this time, the patient experiences fear or panic attacks, hypochondria, paranoid syndrome, hysteria or obsessive states.
• Stabilization. After some time, the manifestations of the pathology subside, the condition returns to normal, and the person behaves normally.

The last stage can last a long time, sometimes stretching for years.

Forms

General clinical signs of low-grade schizophrenia appear in various forms:

• Sensopathic disorders. This type is characterized by unpleasant sensations, pain inside the body or on the skin, but there is no pathological process. Sometimes the patient complains of a feeling that is unusual for the organ, for example, a burning sensation in the head. It is impossible to convince him otherwise.
• Depersonalization. At this time, a person seems to lose his own self, ceases to perceive himself as a person, he loses his will and emotions, it seems to him that someone is controlling him.
• Dysmorphophobia. The syndrome is expressed in exaggerating or inventing flaws in appearance, usually manifests itself in adolescents. Often the defects are pretentious in nature, for example, the patient is sure that one eye is larger than the other.
• Hysteria. The desire to be the center of attention. If this does not happen, hysteria begins with screams and sobs. Sometimes the mood changes sharply, laughter gives way to crying.
• The asthenic form is considered mild. The patient experiences rapid fatigue from normal work, household chores, and communication. Moreover, he does not have any somatic or chronic illnesses. Often a person communicates with asocial subjects and enthusiastically collects collections.
• The obsessive form is similar to obsessive-compulsive neurosis, but psychogenesis and personality conflict do not occur. Sometimes the patient performs a meaningless ritual before the action.
• Hypochondria manifests itself during periods of hormonal changes. It seems to a person that he is sick with a dangerous illness.
• The psychopathic form is expressed in mannered behavior or foolishness, and possible manifestations of delusions or hallucinations.
• Affective disorder. Here, sluggish schizophrenia occurs in two variants. In the first case, the patient plunges into depression, engaged in personality analysis. In another form, the condition resembles hypomania, when unreasonably active activity is replaced by apathy.
• Latent form. Symptoms resemble the debut and do not progress to the manifest stage. The mildest expression of schizoid disorder.
• Unproductive disorders. Although they manifest negative symptoms, they do not affect the psyche.

Slowly, but sluggish schizophrenia progresses, and over the years the symptoms become brighter. Due to mental disorders, thinking, will, and emotional sphere suffer. Personality undergoes changes and defects develop.

Defects

With any type of flaccid or latent schizophrenia, mental defects develop over time. They appear individually or in combination, their specificity is determined by the symptoms of the disease:

• Verschreuben. The defect manifests itself through austic activity and is accompanied by pretentious actions that do not comply with generally accepted norms. The patient is unable to evaluate himself in relation to other people and his own future. He does not understand that he is behaving strangely; when he finds out that he is considered eccentric, he is very surprised. His home is unkempt and cluttered with unnecessary items. The person himself looks unkempt, dresses strangely, and neglects the rules of personal hygiene. Movements lose their plasticity, are angular, facial expressions are mannered. The patient gradually loses family feelings, becomes emotionally coarse, loses his sense of tact, often falls into euphoria, makes inappropriate jokes, and is prone to complacency and inappropriate speech pathos. At the same time, he retains mental and physical functions.
• Pseudopsychopathization. The condition manifests itself in emotional elation and activity, and sometimes a hysterical component may be present. The patient simply gushes with absurd ideas, calling on everyone to help him realize them. Naturally, he never achieves a concrete result.
• The reduction in energy potential is expressed in limited contacts. The person does not want to work, feels comfortable at home, and often uses alcohol or drugs. Alcohol in small quantities improves the condition, severe intoxication causes aggressiveness, and behavior becomes uncontrollable.

Treatment

Treatment of low-grade schizophrenia includes a biosocial approach. Not only drug therapy is important, but a separate aspect is psychotherapy and social adaptation of the patient. Without a complex of measures, it is impossible to achieve stable remission.

It is preferable to start drug therapy before the manifestation stage appears. To treat the indolent form, a reduced dosage of drugs is used compared to malignant manifestations of the disease. A drug is prescribed that can effectively relieve symptoms. What drugs are used:

• Typical neuroleptics. Antipsychotics are used to block the sensitivity of neurotransmitter systems. Highly patented drugs are characterized by a higher level of connection with dopamine receptors, so they are prescribed for active manifestations (mainly Haloperidol, also Trifluperidol, Pimozide). For mild symptoms, low-patent medications can be used: Perphenazine, Periciazine.
• Atypical neuroleptics. New generation drugs affect dopamine as well as seratonin receptors.
• Anxiolytics work to eliminate feelings of anxiety and melancholy.
• Normotimics stabilize mood.
• Antidepressants reduce feelings of melancholy, apathy, and irritability.
• Nootropics. Neurometabolic stimulants have a specific effect on the functional component of the brain.
• Psychotropics activate the mental and physical (to a lesser extent) activity of the body. Psychostimulants improve brain activity, relieve apathy, increase muscle tone and coordination of movements.

Prescription of drugs and dosage are purely individual, depending on the characteristics of the course of sluggish schizophrenia, symptoms and side effects. Typical antipsychotics have different effects on patients and can cause extrapyramidal syndrome, so they are carefully selected.

Oral administration of medications is recommended; intramuscular or intravenous administration of medications is used for urgent relief of psychomotor agitation. A course of drugs to eliminate symptoms is 2 months. The duration of the stabilization process is up to six months. During this period, the dosage is reduced, but the medication cannot be completely abandoned.

Social adaptation

For low-grade schizophrenia, treatment includes measures to preserve the patient’s full personality as a part of society. A special role here belongs to the professionalism of the psychiatrist, his ability to find contact with the patient so that he does not perceive treatment as an encroachment on freedom.

The task of relatives is to support a person during a period of remission, help him restore previous connections, not let him get hung up on his experiences, and withdraw into himself. Joint visits to public events, exhibitions, returning to work - all this helps to restore the taste for a full life, simple human joys. If the patient becomes indifferent, it is important to interest him in new hobbies and find an interesting hobby. You should not be too protective of the patient: he will become irritated and withdraw.

Sluggish schizophrenia does not lead to a complete personality defect. Typically, complex treatment allows the patient to restrain the onset of the manifestation and gives the opportunity to fully live life in the stabilization stage.

Sluggish schizophrenia, or low progression schizophrenia, - a type of schizophrenia in which the disease progresses weakly, the productive symptoms characteristic of schizophrenic psychoses are absent, most often only indirect clinical manifestations are observed (neurosis-like, psychopath-like, affective, overvalued, hypochondriacal, etc.) and shallow personality changes. In the modern international classification of diseases (ICD-10) there is no such diagnosis.

Slightly progressive (sluggish) schizophrenia is used as a synonym for schizotypal disorder by many authors.

“Schizotypal personality disorder” in the Russian classification also corresponds to sluggish schizophrenia and coincides with it according to the diagnostic criteria accepted in Russian psychiatry.

The first descriptions of sluggish schizophrenia are often associated with the name of the Soviet psychiatrist A.V. Snezhnevsky. Its diagnostic boundaries, adopted by Snezhnevsky and his followers, were significantly expanded in comparison with the criteria for schizophrenia adopted in the West; the diagnosis of sluggish schizophrenia found application in the practice of repressive psychiatry in the USSR and was used more often than other clinical diagnoses to justify the insanity of dissidents.

The opinion has been repeatedly expressed that the diagnosis of sluggish schizophrenia was received or could be received not only by dissidents, but also by ordinary patients in the absence of schizophrenia and the presence only of neurotic disorders, depressive, anxiety or personality disorders.

The concept of sluggish schizophrenia became widespread only in the USSR and some other Eastern European countries. This concept has not been recognized by the international psychiatric community and the World Health Organization, and the use of diagnostic criteria for low-grade schizophrenia in relation to dissidents has been condemned internationally.

History of diagnosis: the concept of latent schizophrenia since Bleuler

There is an opinion that the authorship of the concept of sluggish schizophrenia is erroneously attributed to Snezhnevsky, since similar disorders were discussed under different names in the works of psychiatrists in different countries. It is also noted that it is in the works of Snezhnevsky and his colleagues that sluggish schizophrenia acts as an independent form and describes various options for its course.

The concept of “latent schizophrenia” was first used by Eugen Bleuler in 1911 (its criteria were not clearly defined by him):

These simple schizophrenics make up the majority of all “brains on one side” (reformers, philosophers, artists, degenerates, eccentrics). There is also latent schizophrenia, and I actually think these are the most common cases.

According to Bleuler, the diagnosis of latent schizophrenia can be made by studying the patient's condition retrospectively: when studying the past of persons with schizophrenia in whom the disease has become obvious, prodromes of the latent form can be detected.

E. Bleuler proposed considering a number of cases of psychasthenia, hysteria, and neurasthenia as manifestations of unrecognized schizophrenia. According to E. Bleuler, schizophrenia, which is most characterized by a peculiar splitting of the unity of the personality, more often occurs “in latent forms with mild symptoms than in obvious forms with complete symptomatology...”.

Subsequently, descriptions of relatively favorable forms corresponding to the concept of sluggish schizophrenia became widespread under various names in studies of national psychiatric schools in Europe, the USA, Japan, etc. The most famous of these names are “mild schizophrenia”, “microprocessual”, “micropsychotic”, “rudimentary” "", "sanatorium", "amortized", "abortive", "prephase of schizophrenia", "slow", "subclinical", "pre-schizophrenia", "non-regressive", "latent", "pseudo-neurotic schizophrenia", "schizophrenia with obsessive-compulsive disorders”, slowly developing schizophrenia with “creeping” progression.

In Soviet psychiatry, the description of similar forms of disorders has a long tradition: for example, A. Rosenstein and A. Kronfeld in 1932 proposed the term “mild schizophrenia”, which is similar in content; in this regard, we can mention the works of B. D. Friedman (1933), N. P. Brukhansky (1934), G. E. Sukhareva (1959), O. V. Kerbikov (1971), D. E. Melekhov (1963 ) and etc.

The author of the monograph “History of Schizophrenia,” French psychiatrist J. Garrabe, notes that in the period before World War II, the criteria for “schizophrenia without schizophrenic symptoms” underwent changes, being expanded to include a number of atypical, borderline conditions: in particular, Zilberg wrote about “outpatient schizophrenia " Often, studies dealt with so-called prepsychotic or pre-schizophrenic conditions - occurring in the period before the onset of psychosis, which, however, most often did not occur in this case.

The problem of “pseudoneurotic schizophrenia” was developed in American psychiatry throughout the 1950s and 60s, in particular by P. Hoch and P. Polatin, who proposed this term in 1949. According to J. Garrabe, in this case it would be more accurate to talk not about mental illness itself, which is characterized by processual (progressive) development, but about personality disorders (psychopathy), in particular about “borderline”, Russian. borderline personality disorder. The clinical and genetic study of schizophrenia spectrum disorders led to the interest of American researchers in the problem of pseudoneurotic schizophrenia in the next decade and a half (the concept of “borderline schizophrenia” by D. Rosenthal, S. Kety, P. Wender, 1968).

The broad interpretation of the concept of “schizophrenia” that prevailed in American psychiatry (the concept of “pseudo-neurotic schizophrenia”) was formed under the influence of the ideas of Bleuler, who considered schizophrenia mainly a psychological disorder - perhaps with a psychogenic basis - rather than a pathological state of the nervous system, and significantly expanded the boundaries of this concept in comparison with Emil Kraepelin. As a result, in the United States, the diagnosis of schizophrenia was extended to those patients who in Europe would have been diagnosed with depressive or manic psychosis, or even considered as suffering from a neurotic or personality disorder rather than a psychotic one. Patients were diagnosed with schizophrenia based on a wide range of neurotic symptoms, such as phobias or obsessions.

In 1972, a joint UK-US diagnostic project found that the diagnosis of schizophrenia was much more common in the US than in the UK. After this, the idea spread that standardized methods of diagnosis were needed. In the last quarter of the twentieth century, several diagnostic schemes were developed and continue to be widely used. These systems (particularly ICD-10 and DSM-IV) require clear evidence of current or past psychosis and that emotional symptoms are not predominant.

The concept of sluggish schizophrenia was proposed by Professor A.V. Snezhnevsky, according to some sources, in 1969. However, a report on latent schizophrenia (this concept was literally translated into English as “sluggish course”) was read by him back in 1966 in Madrid at the IV World Congress of Psychiatrists). Snezhnevsky's concept of sluggish schizophrenia was based on Bleuler's model of latent schizophrenia. Western psychiatrists considered this concept as unacceptable, since it led to an even greater expansion of the already expanded (including in English-speaking schools) diagnostic criteria for schizophrenia.

J. Garrabe notes that, according to the views of Snezhnevsky, expressed by him in 1966, latent (“torpid”, “flaccid”) schizophrenia means “chronic lesions that develop neither in the direction of deterioration nor in the direction of recovery.” Unlike Bleuler's latent schizophrenia, Snezhnevsky's concept of sluggish schizophrenia did not imply a mandatory development that would lead to the emergence of schizophrenic symptoms proper, but was limited only to latent (pseudo-neurotic or pseudo-psychopathic) manifestations.

In the chapter of the “Manual of Psychiatry” written by R. Ya. Nadzharov, A. B. Smulevich, which was published in 1983 under the editorship of Snezhnevsky, it is argued that, contrary to the traditional idea of ​​“sluggish schizophrenia” as an atypical variant of the disorder (i.e. . about deviation from the natural, more unfavorable development of the disease), low-progressive schizophrenia is not a protracted stage preceding major psychosis, but an independent variant of the endogenous process. In some cases, its characteristic signs determine the clinical picture throughout the entire course of the mental disorder and are subject to their own developmental patterns.

It is also worth noting that there were significant differences between the “mild schizophrenia” of A. Kronfeld, whose works were not republished during the 1960-80s, and the “sluggish schizophrenia” of A. V. Snezhnevsky. Thus, at the II All-Union Congress of Psychiatrists in 1936, Kronfeld made an explanation that the “mild schizophrenia” he identified is a variant of the overt schizophrenic process: this form always begins with a phase of acute psychosis and for many years retains this symptomatology, which, however, patients compensate so much that they remain socially safe. He noted the “exorbitant expansion” of his original concept of “mild schizophrenia” by Moscow authors, which led to its unjustified diagnosis in cases where we are talking about supposedly initial, rather than reliably residual symptoms and when these symptoms are not manifest. According to Kronfeld, the use of this concept in recent years has often been unfounded and due to fundamental clinicopathological errors.

Clinical manifestations and symptoms

As in the case of “ordinary” schizophrenia, the clinical criteria identified by proponents of the concept of low-grade schizophrenia are grouped into two main registers:

• pathologically productive disorders (“positive psychopathological symptoms”);
• negative disorders (manifestations of deficit, psychopathological defect).

In the clinical picture of sluggish schizophrenia, variants with a predominance of either productive disorders (obsessive-phobic, hysterical, depersonalization, etc.) or with a predominance of negative disorders (“sluggish simple schizophrenia”) are distinguished.

Accordingly, the following variants of sluggish schizophrenia are distinguished:

• with symptoms of obsession, or with obsessive-phobic disorders;
• with phenomena of depersonalization;
• hypochondriacal;
• with hysterical (hysteria-like) manifestations;
• poor (simple, sluggish) schizophrenia - with a predominance of negative disorders.

According to A. B. Smulevich, the following stages of development of low-progressive schizophrenia are distinguished:

1. Latent a stage that does not show clear signs of progression.
2. Active(with a continuous course, in the form of an attack or a series of attacks), or the period of full development of the disease.
3. Stabilization period with a reduction in productive disorders, personal changes coming to the fore, and signs of compensation emerging in the future.

Latent period. The clinical picture of this stage (and the so-called latent schizophrenia, which means a favorable form of sluggish schizophrenia, manifested only by symptoms of the latent period) is most often limited to a range of psychopathic and affective disorders, obsessions, and phenomena of reactive lability. Among psychopathic disorders, schizoid traits predominate, often combined with features reminiscent of hysterical, psychasthenic or paranoid personality disorder. Affective disorders in most cases manifest themselves as erased neurotic or somatized depression, prolonged hypomania with persistent and monotonous affect. In some cases, clinical manifestations of the initial (latent) stage of sluggish schizophrenia may be limited to special forms of response to external harm, often repeated in the form of a series of 2-3 or more psychogenic and somatogenic reactions (depressive, hysterical-depressive, depressive-hypochondriacal, less often - delusional or litigious).

According to A. B. Smulevich, mental disorders in the latent period are not very specific and can often manifest themselves only at the behavioral level; Children and adolescents are characterized by reactions of refusal (from taking exams, from leaving the house), avoidance (especially in cases of social phobia), and well-known states of youthful failure.

Active period and stabilization period. A distinctive feature of the development of most forms of low-progressive schizophrenia is considered to be a combination of attacks with a sluggish continuous course. Symptoms sluggish schizophrenia with obsessive-phobic disorders characterized by a wide range of anxiety-phobic manifestations and obsessions: panic attacks that are atypical in nature; rituals that take on the character of complex, fanciful habits, actions, mental operations (repetition of certain words, sounds, obsessive counting, etc.); fear of an external threat, accompanied by protective actions, “rituals” (fear of toxic substances, pathogenic bacteria, sharp objects, etc. entering the body); phobias of contrasting content, fear of madness, loss of control over oneself, fear of causing harm to oneself or others; constant obsessive doubts about the completeness of one’s actions, accompanied by rituals and double-checks (doubts about the purity of one’s body, clothes, surrounding objects); fear of heights, darkness, being alone, thunderstorms, fires, fear of blushing in public; and so on.

Sluggish schizophrenia with symptoms of depersonalization characterized primarily by the phenomena of alienation, extending to the sphere of the autopsyche (consciousness of changes in the inner world, mental impoverishment), and a decrease in vitality, initiative and activity. A detached perception of objective reality, a lack of a sense of appropriation and personification, and a feeling of loss of flexibility and sharpness of intellect may prevail. In cases of prolonged depression, the phenomena of painful anesthesia come to the fore: loss of emotional resonance, lack of subtle shades of feelings, the ability to feel pleasure and displeasure. As the disease progresses, a “feeling of incompleteness” may arise, extending both to the sphere of emotional life and to self-awareness in general; patients recognize themselves as changed, dull, primitive, and note that they have lost their former spiritual subtlety.

Clinical picture sluggish hypochondriacal schizophrenia consists of senestopathies and anxiety-phobic disorders of hypochondriacal content. There is non-delusional hypochondria (which is characterized by phobias and fears of hypochondriacal content: cardiophobia, cancerophobia, fears of some rare or unrecognized infection; obsessive observations and fixation on the slightest somatic sensations; constant visits to doctors; episodes of anxiety-vegetative disorders; hysterical, conversion symptoms ; senestopathies; overvalued desire to overcome the disease) and senestopathic schizophrenia (characterized by diffuse, varied, changeable, fanciful senestopathic sensations).

At sluggish schizophrenia with hysterical manifestations the symptoms take on grotesque, exaggerated forms: rude, stereotyped hysterical reactions, hypertrophied demonstrativeness, affectation and flirtatiousness with traits of mannerism, etc.; hysterical disorders appear in complex comorbid relationships with phobias, obsessive drives, vivid mastering ideas and senesto-hypochondriacal symptom complexes. Characteristic is the development of prolonged psychoses, the clinical picture of which is dominated by generalized hysterical disorders: confusion, hallucinations of the imagination with mystical visions and voices, motor agitation or stupor, convulsive hysterical paroxysms. At later stages of the disease (stabilization period), gross psychopathic disorders (deceit, adventurism, vagrancy) and negative disorders become more and more pronounced; Over the years, patients take on the appearance of lonely eccentrics, degraded but loudly dressed women who abuse cosmetics.

For sluggish simple schizophrenia characteristic phenomena of autochthonous asthenia with impaired self-awareness of activity; disorders of the anergic pole with extreme poverty, fragmentation and monotony of manifestations; depressive disorders related to the circle of negative affectivity (apathetic, asthenic depression with poor symptoms and an undramatic clinical picture); in phase disorders - increased mental and physical asthenia, depressed, gloomy mood, anhedonia, alienation phenomena, senesthesia and local senestopathy. Slowness, passivity, rigidity, mental fatigue, complaints of difficulty concentrating, etc. gradually increase.

According to a number of Russian authors (M. Ya. Tsutsulkovskaya, L. G. Pekunova, 1978; “Manual of Psychiatry” by A. S. Tiganov, A. V. Snezhnevsky, D. D. Orlovskaya, 1999), in many or even in most cases, patients with sluggish schizophrenia achieve compensation and full social and professional adaptation. According to Professor D. R. Luntz, the disease can theoretically be present even if it is not clinically demonstrable, and even in cases where there are no personality changes. R. A. Nadzharov and co-authors (chapter of the “Manual of Psychiatry” edited by G. V. Morozov, 1988) believed that this type of schizophrenia “due to the low severity of personality changes and the predominance of syndromes uncharacteristic for “major schizophrenia” presents significant difficulties for distinctions from psychopathy and neuroses.”

Sluggish schizophrenia and international classifications

In 1999, Russia switched to the ICD-10 classification of diseases, which has been used in WHO member countries since 1994. The concept of “sluggish schizophrenia” is absent in the ICD-10 classification, but it is mentioned in the Russian, adapted version, prepared by the Ministry of Health of the Russian Federation. In this version "forms that in the domestic version ICD-9 qualified as low-progressive or sluggish schizophrenia", classified under the heading “schizotypal disorder” (with the indication that their diagnosis requires additional signs). However, in the previous, also adapted version of the ICD-9 classification, used in the USSR since 1982, low-grade schizophrenia was included in the heading of another nosological unit - latent schizophrenia.

Many Russian authors use the terms “schizotypal disorder” and “sluggish schizophrenia” (“low-progressive schizophrenia”) as synonyms. On the other hand, there is also an opinion that schizotypal disorder represents only some of the clinical variants of sluggish schizophrenia, mainly pseudoneurotic (neurosis-like) schizophrenia and pseudopsychopathic schizophrenia. A. B. Smulevich writes about “the desirability of isolating sluggish schizophrenia from the polymorphic group of schizophrenia spectrum disorders, united by the concepts of “schizotypal disorder” or “schizotypal personality disorder”, considering it as an independent form of the pathological process. Some authors have stated the need to consider forms with neurosis-like (obsessive-compulsive) disorders within the framework of schizophrenia.

“Sluggish schizophrenia” in the Russian-Soviet classification is also identified with the diagnosis of “schizotypal personality disorder”, sometimes with borderline personality disorder or cyclothymia.

The opinion was also expressed that certain forms of sluggish schizophrenia in adolescents correspond to such concepts within the framework of the ICD-10 and DSM-III classifications as schizoid, impulsive, dissocial (asocial), histrionic (hysterical) personality disorders, residual schizophrenia, hypochondriacal syndrome ( hypochondria), social phobia, anorexia nervosa and bulimia, obsessive-compulsive disorder, depersonalization-derealization syndrome.

Practice of using diagnosis in the USSR

In 1966, the Soviet Union participated, among nine countries, in an international pilot study on schizophrenia organized by WHO. The study demonstrated that the diagnosis of “schizophrenia” was especially often made at the A. V. Snezhnevsky Center in Moscow; American researchers also adhered to an expanded diagnostic framework. 18% of patients diagnosed with schizophrenia were classified by the Moscow research center as having low-grade schizophrenia, a diagnosis that, however, was not registered in any of the other eight centers. This diagnosis was established in cases where computer processing reliably determined the presence of manic disorder, depressive psychosis, or, much more often, depressive neurosis in patients. The diagnosis of latent schizophrenia (a rubric not recommended by ICD-9 for widespread use) was also used by 4 of the 8 other study centers; it was exhibited by a total of less than 6% of the patients who took part in the study.

Sluggish schizophrenia was systematically diagnosed to ideological opponents of the political regime that existed in the USSR with the aim of their forced isolation from society. When diagnosing dissidents, they used, in particular, criteria such as originality, fear and suspicion, religiosity, depression, ambivalence, guilt, internal conflicts, disorganized behavior, insufficient adaptation to the social environment, change of interests, and reformism.

There are no exact statistics on the abuse of psychiatry for political purposes, however, according to various data, thousands of people became victims of political abuse of psychiatry in the USSR. In particular, according to R. van Voren, secretary general of the Global Initiative in Psychiatry, which deals with the problem of abuse in psychiatry and reforms of the mental health care system, in the Soviet Union about a third of political prisoners were placed in psychiatric hospitals. In addition to dissidents, the diagnosis of sluggish schizophrenia was also received, for example, by army evaders and tramps.

Individuals diagnosed with this condition were subject to severe discrimination and limited opportunities to participate in society. They were deprived of the right to drive a car, enter many higher educational institutions, and became “restricted from traveling abroad.” Before each holiday or state event, persons with this diagnosis were involuntarily hospitalized for the duration of the event in a psychiatric hospital. A person diagnosed with “sluggish schizophrenia” could easily get a “SO” (socially dangerous) stamp in his medical history - for example, when trying to resist during hospitalization or in the case when he became a participant in a family or street fight.

Patients who were diagnosed with “sluggish schizophrenia” by representatives of the Moscow school of psychiatry were not considered schizophrenics by psychiatrists in Western countries on the basis of the diagnostic criteria adopted there, soon officially enshrined in ICD-9. Supporters of other trends in Soviet psychiatry (especially representatives of the Kyiv and Leningrad schools) for a long time strongly opposed Snezhnevsky’s concept and the related concept of overdiagnosis of schizophrenia. Throughout the 1950s and 60s, representatives of the Leningrad school of psychiatry refused to recognize dissidents who were diagnosed with sluggish schizophrenia in Moscow as schizophrenics, and only by the late 1960s and early 1970s did Snezhnevsky’s concept finally prevail in Leningrad.

In the early 1970s, reports of the unnecessary hospitalization of political and religious dissidents in psychiatric hospitals reached the West. In 1989, a delegation of American psychiatrists visiting the USSR re-examined 27 suspected victims of abuse, whose names were provided to the delegation by various human rights organizations, the US Helsinki Commission and the State Department; clinical diagnosis was carried out in accordance with American (DSM-III-R) and international (ICD-10, draft) criteria. The delegation members also conducted surveys of patients' family members. The delegation concluded that in 17 of the 27 cases there was no clinical basis for exculpation; in 14 cases there were no signs of mental disorders. A review of all cases demonstrated a high incidence of schizophrenia diagnosis: 24 out of 27 cases. The report presented by the delegation noted that some of the symptoms included in the Soviet diagnostic criteria for mild (“sluggish”) schizophrenia and moderate (“paranoid”) schizophrenia are unacceptable for making this diagnosis according to American and international diagnostic criteria: in particular, Soviet psychiatrists attributed “ideas of reformism,” “increased self-esteem,” “increased self-esteem,” etc. to painful manifestations.

Apparently, this group of patients interviewed is a representative sample of the many hundreds of other political and religious dissidents declared insane in the USSR, mainly during the 1970s and 80s.

Famous examples of diagnosing dissidents

Viktor Nekipelov, accused under Article 190-1 of the Criminal Code of the RSFSR (“dissemination of deliberately false fabrications discrediting the Soviet political system”), was sent for examination to the Serbsky Institute with the following conclusion made by the expert commission of the city of Vladimir: “Excessive, excessive temper, arrogance... a tendency towards truth-seeking, reformism, as well as reactions from the opposition. Diagnosis: low-grade schizophrenia or psychopathy". He was declared mentally healthy at the Institute. Serbsky, served his time in a criminal camp.

Eliyahu Rips, accused under Article 65 of the Criminal Code of the Latvian SSR, corresponding to Art. 70 of the Criminal Code of the RSFSR (anti-Soviet agitation and propaganda), who attempted self-immolation in protest against the entry of Soviet troops into Czechoslovakia, was subjected to forced treatment in a “special type of mental hospital” with the same diagnosis.

Olga Iofe was accused under Article 70 of the Criminal Code of the RSFSR that she took an active part in the production of leaflets with anti-Soviet content, storage and distribution of documents with anti-Soviet content, seized from her during a search. Preliminary examination carried out by the Institute named after. Serbsky (Professor Morozov, Doctor of Medical Sciences D.R. Lunts, doctors Felinskaya, Martynenko), declared O. Iofe insane with a diagnosis of “sluggish schizophrenia, simple form.”

Many more examples can be given. They tried to make this diagnosis to V. Bukovsky, but the commission, which consisted mainly of opponents of the theory of sluggish schizophrenia, eventually declared him sane. This diagnosis was also made to Zhores Medvedev, Valeria Novodvorskaya, Vyacheslav Igrunov, who distributed the “Gulag Archipelago”, Leonid Plyushch, accused of anti-Soviet propaganda, Natalya Gorbanevskaya, charged under Article 190.1 of the Criminal Code of the RSFSR for the famous demonstration on Red Square against the entry of Soviet troops into Czechoslovakia - according to the conclusion of Professor Luntz, “the possibility of sluggish schizophrenia cannot be excluded”, “should be declared insane and placed for compulsory treatment in a special type of psychiatric hospital.”

Using the example of an examination carried out on April 6, 1970 in relation to Natalya Gorbanevskaya, the French historian of psychiatry J. Garrabe concludes about the low quality of forensic medical examinations carried out in relation to dissidents: the absence in the clinical description of changes in thinking, emotions and the ability to criticize, characteristic of schizophrenia; the absence of any expertly established connection between the action giving rise to the charge and the mental illness that could explain it; indication in the clinical description only of depressive symptoms that do not require hospitalization in a psychiatric hospital.

Condemnation of the practice of using diagnosis in the USSR by the international psychiatric community

In 1977, at a congress in Honolulu, the World Psychiatric Association adopted a declaration condemning the use of psychiatry for the purposes of political repression in the USSR. She also came to the conclusion that it was necessary to create a committee, later called the Committee of Inquiry. Review Committee) or more precisely - the WPA Committee on the Investigation of Abuse of Psychiatry (eng. WPA Committee to Review the Abuse of Psychiatry), which, according to its competence, must investigate any alleged cases of the use of psychiatry for political purposes. This committee is still active today.

Condemnation of the practice of using the diagnosis “sluggish schizophrenia” in the USSR led to the fact that in 1977, at the same congress, the World Psychiatric Association recommended that psychiatric associations in various countries adopt classifications of mental illnesses that are compatible with the international classification in order to be able to compare the concepts of different national schools. This recommendation was followed only by the American Psychiatric Association: in 1980 it adopted the DSM-III (Diagnostic and Statistical Manual of Mental Disorders), which excluded diseases without obvious psychiatric signs and recommended for what was previously called “latent”, “borderline”, “ "sluggish" or "simple" schizophrenia, make a diagnosis of a personality disorder, for example, schizotypal personality.

The All-Union Scientific Society of Neuropathologists and Psychiatrists of the USSR, refusing to acknowledge the facts of abuse, chose to leave the WPA in 1983, along with the psychiatric associations of other countries of the Soviet bloc. In 1989, at the IX Congress of the WPA in Athens, in connection with perestroika, it was again admitted to the World Psychiatric Association, pledging to rehabilitate the victims of “political psychiatry.” Victims of “political psychiatry” who were subjected to repression in the form of forced placement in psychiatric institutions and rehabilitated in accordance with the established procedure should be paid monetary compensation by the state. Thus, the facts of the use of psychiatry for political purposes were recognized.

According to data published by the International Society for Human Rights in the White Book of Russia, in the country as a whole, the diagnosis of low-grade schizophrenia resulted in the recognition of about two million people as mentally ill. They began to be gradually discharged from psychiatric hospitals and removed from psychiatric registration in psychoneurological dispensaries only in 1989 in order to achieve admission of the All-Union Scientific Society of Neuropathologists and Psychiatrists of the USSR to the World Psychiatric Association, which it was forced to leave at the VII Congress in 1983. In 1988-1989, at the request of Western psychiatrists, as one of the conditions for the admission of Soviet psychiatrists to the WPA, about two million people were removed from psychiatric registration.

Modern Russian psychiatry relies heavily on the works of A.V. Snezhnevsky: for example, in A.B. Smulevich’s book “Low-progressive schizophrenia and borderline states,” a number of neurotic, asthenic and psychopathic conditions are classified as low-progressive schizophrenia. J. Garrabe in the monograph “History of Schizophrenia” notes:

Harold Merskey, Bronislava Shafran, who devoted a review to “sluggish schizophrenia” in the British Journal of Psychiatry, find no less than 19 publications on this issue in the S. S. Korsakov Journal of Neuropathology and Psychiatry between 1980 and 1984, of which 13 were signed by Soviet authors, Moreover, these articles do not bring anything new in comparison with the report on this by A.V. Snezhnevsky. This loyalty of the Moscow school to a controversial concept at the very moment when it is attracting such criticism from the scientific community is surprising.

Overdiagnosis of schizophrenia also occurs in post-Soviet times. Thus, systematic studies show that the diagnosis of the entire group of affective pathology in modern Russian psychiatry is negligibly small and relates to schizophrenia in a factor of 1:100. This completely contradicts 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 still continue to use the version of this manual adapted for Russia, which is similar to the version of ICD-9 adapted for the USSR. It is also noted that patients with severe and long-term panic disorder or obsessive-compulsive disorder are often unfoundedly diagnosed with sluggish schizophrenia and prescribed antipsychotic therapy.

Views and assessments

On the broad scope of diagnosis and prerequisites for its use for non-medical purposes

The opinion is often expressed that it was the broad diagnostic criteria for sluggish schizophrenia, promoted by Snezhnevsky and other representatives of the Moscow school, that led to the use of this diagnosis for repressive purposes. Western, as well as modern Russian psychiatrists and human rights activists note that the diagnostic criteria of the disease, which included erased, unexpressed symptoms, made it possible to diagnose it for anyone whose behavior and thinking went beyond social norms.

Canadian psychiatrist Harold Merskey and neurologist Bronislava Shafran in 1986, after analyzing a number of publications in the S.S. Korsakov Journal of Neurology and Psychiatry, came to the conclusion that “the concept of sluggish schizophrenia is obviously very flexible , is diverse and includes much more than our ideas about simple schizophrenia or a residual defective state. Many mental conditions that in other countries would most likely be diagnosed as depressive disorders, anxiety neuroses, hypochondria or personality disorders, according to Snezhnevsky’s theory, invariably fall under the concept of sluggish schizophrenia.”

Russian psychiatrist Nikolai Pukhovsky calls the concept of mild (sluggish, slow and imperceptible) schizophrenia mythologized and points out that the fascination of Russian psychiatrists with it coincided with a legal deficiency that allowed the state to use this diagnosis for the purposes of political repression. He notes the absurdity of such formulations as “the reason for the difficulty of recognizing schizophrenia with a slow, sluggish onset is the absence of any pronounced disturbances in mental activity in the initial period” And “outpatient treatment is also carried out for patients with a sluggish, slow and imperceptible type of schizophrenia, not accompanied by noticeable personality changes”, and indicates that the fascination with the theory of mild schizophrenia, as well as the idea of ​​the inferiority of the mentally ill and the supposedly inevitable outcome of mental illness into dementia, was associated with manifestations of overprotection, systematic disregard of the interests of patients and actual evasion of the idea of ​​service, the idea of ​​therapy; the psychiatrist, in fact, acted as an adherent of dubious esoteric knowledge.

The famous Ukrainian psychiatrist, human rights activist, executive secretary of the Association of Psychiatrists of Ukraine Semyon Gluzman notes that in the 1960s, the diversity of Soviet psychiatric schools and directions was replaced by the dictates of the school of Academician Snezhnevsky, which gradually became absolute: alternative diagnostics were persecuted. This factor - as well as the peculiarities of the legal field in the USSR (the absence of legal acts at the legislative level regulating the practice of compulsory treatment), as well as the “iron curtain” that separated Soviet psychiatrists from their Western colleagues and prevented regular scientific contacts - contributed to massive abuses in psychiatry , the frequent use in judicial and extrajudicial psychiatric practice of the diagnosis “sluggish schizophrenia” and its presentation to political dissidents.

In the “Manual on Psychiatry for Dissenters,” published in the “Chronicle of the Defense of Rights in the USSR” (New York, 1975, issue 13), V. Bukovsky and S. Gluzman express the opinion that the diagnosis of sluggish schizophrenia in mentally healthy people is socially adapted and prone to creative and professional growth, could determine the presence of such characterological features as isolation, a tendency to introspection, lack of communication, and inflexibility of beliefs; with objectively existing surveillance and wiretapping of telephone conversations, a dissident could be revealed to have “suspicion” and “delusions of persecution.” V. Bukovsky and S. Gluzman cite the words of an experienced expert, Professor Timofeev, who wrote that “dissent can be caused by a brain disease, when the pathological process develops very slowly, gently, and its other signs remain for the time being (sometimes until the commission of a criminal act) invisible”, who mentioned the difficulties of diagnosing “mild and erased forms of schizophrenia” and the debatability of their very existence.

Ukrainian forensic psychiatrist, Candidate of Medical Sciences Ada Korotenko points out that the school of A.V. Snezhnevsky and his colleagues, who developed a diagnostic system in the 1960s, including the concept of sluggish schizophrenia, was supported by F.V. Kondratiev, S.F. Semenov , Ya. P. Frumkin and others. Vague diagnostic criteria, according to A. I. Korotenko, made it possible to fit individual personal manifestations into the framework of the disease and recognize healthy people as mentally ill. Korotenko notes that the establishment of mental pathology in free-thinking and “dissident” citizens was facilitated by the lack of diagnostic standards and the USSR’s own classification of forms of schizophrenia: diagnostic approaches of the concept of sluggish schizophrenia and paranoid states with delusions of reformism were used only in the USSR and some Eastern European countries.

St. Petersburg psychiatrist Doctor of Medical Sciences Professor Yuri Nuller notes that the concept of the Snezhnevsky school allows, for example, to consider schizoid psychopathy or schizoidness as early, slowly developing stages of an inevitable progressive process, and not as personality traits of an individual, which do not necessarily have to develop along the way schizophrenic process. From here, according to Yu. L. Nuller, comes the extreme expansion of the diagnosis of sluggish schizophrenia and the harm that it brought. Y. L. Nuller adds that within the framework of the concept of sluggish schizophrenia, any deviation from the norm (according to the doctor’s assessment) can be considered schizophrenia, with all the ensuing consequences for the person being examined, which creates a wide opportunity for voluntary and involuntary abuse of psychiatry. However, neither A.V. Snezhnevsky nor his followers, according to Nuller, found the civil and scientific courage to reconsider their concept, which had clearly reached a dead end.

In the book “Sociodynamic Psychiatry,” Doctor of Medical Sciences, Professor T. P. Korolenko and Doctor of Psychological Sciences N. V. Dmitrieva note that the clinical description of sluggish schizophrenia according to Smulevich is extremely elusive and includes almost all possible changes in the mental state, as well as partially conditions that occur in a person without mental pathology: euphoria, hyperactivity, unreasonable optimism and irritability, explosiveness, sensitivity, inadequacy and emotional deficit, hysterical reactions with conversion and dissociative symptoms, infantility, obsessive-phobic states, stubbornness.

The President of the Independent Psychiatric Association, Yu. S. Savenko, wrote that the complete distortion of the phenomenological approach in conditions of total ideologization and politicization led to an unprecedented scale of overdiagnosis of schizophrenia. He noted that Snezhnevsky and his followers considered any processuality, that is, the progression of the disease, as a specific pattern of schizophrenia, and not a general psychopathological, general medical characteristic; hence the desire to diagnose schizophrenia in any syndromic picture and any type of course, although in reality the differential diagnosis of erased, outpatient forms of schizophrenia with other endogenous disorders requires careful individualization. Ultimately, this led to the inevitable attribution of many neurosis-like and paranoid states to schizophrenia, often even in the absence of procedurality. According to Yu. S. Savenko, the clear delineation of the diagnostic framework of Kronfeld’s “mild schizophrenia” turned out to be replaced in the 1960-80s by “a continuous continuum of quantitative differences from the healthy norm.” Yu. S. Savenko pointed out that the academic approach of Snezhnevsky and his followers is characterized by “refined sophistication, not suitable, even contraindicated, for widespread use, divorced from taking into account the social aspect: the possibilities of real practice, social compensation, the social consequences of such diagnostics.”

American psychiatrist Walter Reich (lecturer of psychiatry at Yale University, head of the program of medical and biological sciences at the Washington School of Psychiatry) noted that due to the nature of political life in the Soviet Union and the social stereotypes formed by this life, nonconformist behavior there really seemed strange and that in connection with the nature of Snezhnevsky’s diagnostic system, this oddity in some cases began to be perceived as schizophrenia. According to Reich, in many and perhaps most cases where such a diagnosis was made, not only the KGB and other responsible persons, but also the psychiatrists themselves actually believed that the dissidents were sick. Discussing during a personal meeting with Snezhnevsky in the early 1980s a program to study borderline states planned for the Scientific Center for Mental Health, Reich came to the conclusion that there is no significant difference between these borderline states and some “mild” forms of schizophrenia, especially low-grade schizophrenia. : It is possible that many or even most people whose behavioral characteristics meet Snezhnevsky’s criteria for this disorder do not actually suffer from it, since these behavioral manifestations should be considered within the framework of a neurotic disorder, character abnormalities, or simply qualified as normal behavior.

On the creation of the concept of low-grade schizophrenia

Different points of view have been expressed regarding the question of whether the concept of low-grade schizophrenia was created specifically to combat dissent.

Walter Reich noted that Snezhnevsky's concepts were formed under the influence of a number of his teachers and acquired their final form long before the placement of dissidents in psychiatric hospitals acquired any noticeable proportions; thus, these views arose independently of their supposed usefulness in diagnosing dissenters. However, it was precisely the errors contained in these theories that made them easy to apply to dissidents. The presence of these concepts, according to Reich, was only one of the reasons why dissidents in the USSR were diagnosed with mental illness, but a very important reason.

Vladimir Bukovsky, who was diagnosed with “sluggish schizophrenia” by Snezhnevsky in 1962, spoke as follows:

I don’t think that Snezhnevsky created his theory of sluggish schizophrenia specifically for the needs of the KGB, but it was unusually suitable for the needs of Khrushchev’s communism. According to the theory, this socially dangerous disease could develop extremely slowly, without manifesting itself or weakening the patient’s intelligence, and only Snezhnevsky himself or his students could determine it. Naturally, the KGB tried to ensure that Snezhnevsky’s students more often became experts on political affairs.

The French scientist J. Garrabe shares Bukovsky's opinion on this matter and comes to the conclusion that the repressive apparatus penetrated into a theoretical weak point, and it was not the Moscow school of psychiatry that deliberately committed scientific forgery in order to make it possible to use psychiatry for repression against dissidents. According to Garrabe, Snezhnevsky alone should not be held responsible for psychiatric abuses; Perhaps some of his students shared Snezhnevsky's views on sluggish schizophrenia quite sincerely, while other experts, disapproving of these views, may have been wary of criticizing them publicly. Nevertheless, Garrabe emphasizes that condemnation of the abuses of psychiatry that took place in the USSR should be based not only on ethical considerations, but also on scientific criticism of the concept of “sluggish schizophrenia.”

An article published in the Independent Psychiatric Journal on the occasion of the 100th anniversary of A.V. Snezhnevsky mentions the expanded diagnosis of schizophrenia (three times the international one) used for non-medical purposes. But the same article cites the opinion of Yu. I. Polishchuk, who worked for many years under the leadership of A.V. Snezhnevsky, who wrote that the basis for the abuse of psychiatry was created by the totalitarian regime, and not by the concept of sluggish schizophrenia, which served only as a convenient excuse for them. According to the editors, the extensive diagnosis of schizophrenia in different eras could acquire different meanings: in 1917-1935, concepts such as “mild schizophrenia” by L. M. Rosenstein and “schizophrenia without schizophrenia” by P. B. Gannushkin saved from execution, in In the 1960s and 70s, an overly broad diagnostic framework, on the contrary, served to discredit and suppress the human rights movement.

American psychiatrist Elena Lavretsky believes that the weakness of the democratic tradition in Russia, the totalitarian regime, repression and the “extermination” of the best psychiatrists between 1930 and 1950 paved the way for the abuse of psychiatry and the Soviet concept of schizophrenia.

On the other hand, according to R. van Voren, most experts are of the opinion that the psychiatrists who developed the concept of sluggish schizophrenia did this on the instructions of the party and the State Security Committee, understanding very well what they were doing, but at the same time believing that this concept logically explains a person's willingness to sacrifice well-being for an idea or belief that is so different from what most people believed or forced themselves to believe.

A similar opinion was expressed by the famous human rights activist Leonard Ternovsky: according to his assumption, the diagnosis “sluggish schizophrenia” was invented by the staff of the Serbsky Institute, Academician A.V. Snezhnevsky, G.V. Morozov and D.R. Lunts specifically for the needs of punitive psychiatry.

Western researchers of the political abuses of psychiatry in the USSR, political scientist P. Reddaway and psychiatrist S. Bloch, consider Snezhnevsky one of the key figures who led the use of psychiatry to suppress free thought in the Soviet Union, noting that Snezhnevsky introduced a new interpretation of the disease, which created the possibility of viewing ideological dissent as a symptom of a severe mental disorder.

Sluggish schizophrenia in art

• “Sluggish schizophrenia” is the title of an album of songs by Alexander Rosenbaum, released in December 1994.
• “It flows sluggishly, like the Moscow River, my dear has schizophrenia” - a line from the song “Steppen Wolf” (album “Mythology”) by the rock group “Crematorium”

Literature

• Snezhnevsky A.V. Schizophrenia and problems of general pathology. Bulletin of the USSR Academy of Medical Sciences, Medicine, 1969.
• Schizophrenia. Multidisciplinary research / Ed. A. V. Snezhnevsky, M., 1972.
• Endogenous mental illnesses. Edited by Tiganov A.S.
• Panteleeva G. P., Tsutsulkovskaya M. Ya., Belyaev B. S. Heboid schizophrenia. M., 1986.
• Bashina V. M. Early childhood schizophrenia, M., 1989.
• Lichko A. E. Schizophrenia in adolescents, L., 1989.
• Smulevich A. B. Low-progressive schizophrenia and borderline states, M., 1987.

In the 60-70s. In the 20th century in Russia, dozens of convicted dissidents were given a diagnosis during trials that no one had even heard of before—sluggish schizophrenia. This concept was introduced by the Soviet psychiatrist A.V. Snezhnevsky, who is believed to have done this on the political order of the USSR Government. The International Psychiatric Society and WHO did not recognize the concept he described. In addition, all such processes related to the trials of dissidents and protesters against communism and Soviet society were condemned at the international level.

Since then, this concept has been used in Russian psychiatry and a number of Eastern European countries, but not in the West. In 1999, Russia switched to ICD-10, which does not include this diagnosis. But the Ministry of Health of the Russian Federation adapted the classification and included the disease under the heading “schizotypal disorder,” although previously it belonged to latent schizophrenia.

What it is

The definition given by Snezhnevsky: sluggish schizophrenia is a form of personality and behavior disorder that is characterized by weak progress and is not expressed by a bright, productive clinical picture. Only indirect signs (neuroses, psychopathy, states of passion, hypochondria) and minor personality changes can be observed. Synonyms: low-progressive schizophrenia and schizotypal disorder.

Recently, due to the high informatization of society through the Internet, many have begun to apply this diagnosis to themselves, their friends and even famous people. In this case, an unprofessional substitution of concepts often occurs: a single outbreak of psychosis or prolonged neurosis is already considered signs of sluggish schizophrenia. Everything that does not fit into the framework becomes a mental disorder: rallies of opposition politicians, provocative speeches by various feminist groups, public protests - all this is lumped together.

The problem is quite relevant and requires, at a minimum, a revision of the description of this disease and clearer symptoms.

Causes

The causes of low-grade schizophrenia are not discussed in detail in scientific works. Most often they talk about heredity and genetic predisposition.

Recently, it has often been said that life circumstances can also act as provoking factors:

• mental trauma received at any age;
• drug addiction, alcoholism;
• vagrancy, seclusion;
• severe stress;
• traumatic brain injuries;
• prolonged and uncontrolled use of powerful psychotropic drugs;
• , the so-called “star fever”, when a person begins to consider himself an exceptional person capable of changing this world.

However, in most cases, heredity is still the main reason.

Symptoms

Sluggish schizophrenia is not recognized internationally due to the vagueness of its clinical picture. The signs of the disease are not clearly defined and seem to be pulled out of various psychiatric diagnoses, so differentiating it from other disorders is quite difficult. Some experts (both foreign and domestic) note that some symptoms are observed even in healthy people.

Today, the following symptoms are taken into account to make a diagnosis:

1. Inadequacy of mood and emotions in relation to what is happening, detachment and disappointment.
2. The desire to stand out from the crowd with inappropriate behavior and non-standard appearance.
3. The desire for loneliness, sociopathy, reluctance to make contact with others.
4. Zealous defense of one's beliefs, which may be contrary to generally accepted ones. So-called magical thinking, when the patient believes that his thoughts are the only true ones.
5. Pretentious, unusual, florid speech. However, it maintains the logic of presentation and the beauty of style. A commanding, mentoring tone that does not accept objections.
6. Mild paranoia, aggressiveness, suspicion, hypochondria.
7. Involuntary thinking, lack of control over one’s own thoughts, which take over the patient.

Of these 7 signs, 4 are usually sufficient to make a diagnosis, provided that they have been present for at least 2 years. However, the disease is not limited to them. The patient may experience other symptoms:

• pseudopsychopathy - unhealthy emotional agitation;
• Verschreuben - the inability to take into account one’s past life experiences and mistakes, expressed in stupid actions, repetition of the same behavioral patterns;
• defect in reduction of energy potential - limited circle of communication, fixation on one idea;
• getting stuck on details - a person does not understand global problems because his thinking suffers from excessive detail, amorphism, and thoroughness;
• hallucinations - derealization and depersonalization, body illusions;
• depression;
• hysteria;
• constant obsessive fears, phobias.

The clinical picture at many points overlaps with other mental personality disorders, from which it is sometimes difficult to separate it. However, there is one striking difference from all other forms of such diseases - the absence of split personality.

Stages

A. B. Smulevich (Russian psychiatrist, professor, psychopharmacologist, doctor of medical sciences, academician of the Russian Academy of Medical Sciences) described in detail the three stages of sluggish schizophrenia. Each of them has a special clinical picture.

Latent stage (debut)

At the very beginning, the disease does not manifest itself in any way and proceeds hidden, although during an appointment with a psychiatrist, serious underlying personality disorders are discovered:

• psychopathic and affective disorders;
• obsessions;
• schizoidia;
• hysteria;
• paranoia;
• autism;
• overly emotional reactions to certain situations;
• erased neurotic and somatized depressive states;
• prolonged hypomania.

The latent stage most often begins in adolescence. The disease can be suspected by the deviant behavior of children: belonging to various informal groups, demonstrative reactions of refusal (from food, lessons, exams, etc.).

Active stage (manifestation)

Seizures begin, which may lead others to suspect a personality and behavior disorder:

• panic attacks with hallucinations, when the patient thinks that someone is hunting or watching him;
• obsessive doubts about your own actions (did you turn off the iron when leaving the house; is there a hole in your clothes in a visible place, etc.);
• numerous phobias (heights, darkness, loneliness, thunderstorms, closed spaces, etc.), which had not manifested themselves in any way before;
• demonstrating and imposing your crazy ideas on everyone;
• open opposition to generally accepted principles (rules and traditions of society), the dominant political regime without fear of punishment;
• prolonged depressive states, accompanied by hysterics, screams, and tears.

However, such attacks are predominantly isolated. Then schizophrenia again flows into a sluggish, latent state until the next outbreak. Their frequency is different for everyone - from once a week to once every six months.

Stable stage

A reduction in productive disorders is observed, personal changes come to the fore, and signs of compensation are subsequently formed. As a rule, those around him who have known a person with sluggish schizophrenia for a long time already get used to his eccentricity by this period and adapt to his vision of the world. They cannot even suspect that he is sick. Moreover: according to psychotherapists, the stable stage is characterized by the fact that patients with such a diagnosis make a career (they are even respected for their irreconcilable views and loyalty to one idea), arrange their personal lives, and adapt socially.

Pathological personality changes characteristic of the stable stage and formed at the previous stage:

• senestopathy - impaired perception of reality (he may consider everyone around him to be spies);
• depersonalization - loss of one’s own “I” (in actions and behavior one is guided only by one’s obsession);
• dysmorphophobia - rejection of oneself (may consider oneself too fat, stupid, or have achieved nothing in life);
• hysteria (when he doesn’t get what he wanted, mental attacks begin with screams and demonstrative sobbing).

The stable stage of the disease lasts until the end of life. Some experts believe that at this stage, personality degradation is inevitable.

Kinds

Depending on how sluggish schizophrenia manifests itself, there are several forms.

Sluggish neurosis-like schizophrenia (obsessive-compulsive):

• obsessive images, thoughts, desires, fears;
• panic attacks;
• passion for delusional ideas;
• unhealthy tendency towards mysticism and religiosity;
• doubts about one's own actions;
• excessive cleanliness;
• various phobias;
• senseless repetition of the same actions.

Sluggish schizophrenia with senestopathy (hypochondriacal):

• constant worry about your health;
• complaints of poor health;
• regular visits to doctors;
• perception of any of your sensations as painful and abnormal;
• hysterics about imminent death;
• ignoring doctors;
• tendency to self-medicate.

Depersonalized:

• partial or complete disappearance of personality traits;
• erasing “subtle emotions”;
• lack of emotional connection with relatives;
• dulled color perception;
• lack of thoughts;
• memory loss;
• lack of mood;
• the feeling of one’s own body as an automaton that performs an action according to a predetermined algorithm, and not the way the person himself wants it.

Sluggish psychopathic-like schizophrenia (hysterical):

• obsessive desire to lead in society;
• unhealthy desire for admiration and surprise from others;
• shocking, vulgar, noisy behavior to attract everyone's attention;
• frequent and sudden mood swings;
• hand tremors, dizziness, fainting due to excessive worries;
• hysterical attacks with screaming, sobbing, self-harm.

Some experts identify several more forms of sluggish schizophrenia:

• asthenic - friendship with asocial individuals, collecting strange things;
• affective - depression, delusional and unhealthy self-analysis, hypomania, apathy, physical weakness;
• unproductive - deviant behavior, violation of laws, tendency to crime (but without an open threat to society).

As a rule, none of the forms of sluggish schizophrenia exists in its pure form: clinical pictures of different personality and behavior disorders can coexist in one patient.

Peculiarities

Symptoms may vary depending on gender.

Features of the disease in women:

• heavy, defiant makeup;
• vulgar, bright clothes;
• untidiness, sloppiness, unkemptness;
• “Plyushkin syndrome”: storing unnecessary rubbish at home;
• Vivid hysterics, sudden mood swings.

In women, the psychopathic (hysterical) form of the disease is most often diagnosed.

Characteristic signs of the disease in men:

• emotional coldness, lack of initiative, apathy;
• eccentric behavior;
• numerous phobias;
• obsessions;
• alcoholism.

Sluggish schizophrenia in men manifests itself at an earlier age than in women. Progresses quickly, longer treatment is required. The most common form is with senestopathy (hypochondriacal).

Despite all these differences, the treatment methods are the same for everyone.

Diagnostics

The patient who applies for the first time is registered. Since schizophrenia is sluggish, he is observed for 2 years. With an active form of the disease, hospitalization is possible. However, the final diagnosis is made only after a specified period of time, if during these two years the person has clearly demonstrated 4 of the 7 main symptoms (see them above).

Some experts believe that 3 criteria are sufficient to make a diagnosis:

1. A drastic change in life, radically opposite to how a person lived before.
2. Negative symptoms are growing like a snowball.
3. The constant dominance of one delusional idea that captures all a person’s thoughts.

Foreign psychiatrists can always challenge the diagnosis, since the concept of sluggish schizophrenia does not exist in the international classification of diseases.

Differentiation

The difference between sluggish schizophrenia and the simple form of schizophrenia:

• slow development of the disease (over several years, throughout life);
• inappropriate actions and hysterical attacks are isolated;
• beyond the limits of exacerbation, a person is perceived by others as eccentric, but within the norm, that is, not as sick;
• does not pose a danger to others.

In addition, with sluggish schizophrenia, driving a car is allowed; this does not prevent such people from occupying responsible positions and positions, or speaking publicly (they have beautiful speech, a well-developed articulatory apparatus). They may be prohibited from doing this only during exacerbations and for the period of treatment.

With a simple form of the disease, this is impossible, since deep-seated personality disorders are also accompanied by psychosomatics and numerous physiological pathologies (distracted attention, inability to concentrate, hypertension, muscle atony, etc.).

How to distinguish neurosis from sluggish schizophrenia?

Treatment

Complex treatment of sluggish schizophrenia is usually prescribed once a year for prevention or during periods of exacerbation.

Medications:

• traditional antipsychotics: Molindone, Chlorpromazine, Thioridazine, Thiotixene, Fluphenazine decanoate, Haloperidol, Decanoate;
• II generation neuroleptics: Risperidone, Olanzapine, Quetiapine, Clozapine, Aripiprazole, Ziprasidone (side effects include obesity and diabetes mellitus);
• mood stabilizers: lithium salts, Carbazepine, valproate, Lamotrigine;
• anxiolytics (tranquilizers): Adaptol, Alprazolam, Bellataminal, Hypnogen, Imovan, Reslip, Fesipam, etc.;
• psychostimulants, nootropics, antidepressants.

Other treatments:

• social support: psychosocial skills training, vocational rehabilitation programs;
• family psychotherapy sessions: help and understanding from loved ones and relatives;
• art therapy;
• trips;
• active physical activity (work, sports).

With constant monitoring by a psychiatrist, low-grade schizophrenia is controlled and kept within normal limits.

Forecasts

Forecasts for the future are contradictory. On the one hand, as mentioned earlier, the majority with this diagnosis live their entire lives like ordinary people. Moreover, they can be public figures, hold leadership positions, and start families.

On the other hand, even rare manifestations of the disease worsen the quality of life and social adaptation. For example, panicking or openly expressing delusional ideas in public gives them a bad reputation. They lose positions, close people, authority. They are considered not only eccentric and otherworldly, but also crazy.

Therefore, such people still need to undergo regular courses of treatment and take care to prevent attacks (lead a healthy lifestyle and avoid stressful and conflict situations).

The diagnosis of sluggish schizophrenia is a stumbling block for foreign and domestic specialists. If a person was given it in Russia, he can always appeal and challenge it in Western countries. In this case, he may be diagnosed with a much more serious disease - schizotypal disorder (symptoms are exactly the same). So experts will have to find a middle ground in this matter.

Sluggish schizophrenia is a variant of the disease characterized by a relatively favorable course, the gradual development of personality changes that do not reach the depth of final states, against the background of which neurosis-like (obsessive, phobic, compulsive, conversion), psychopathic-like, affective and, less often, erased paranoid disorders are found.

The existence of slowly and relatively favorably developing psychoses of an endogenous nature was reflected in the literature long before the dissemination of E. Kraepelin’s concept of dementia praecox.

The study of erased, latent forms of schizophrenia began with the research of E. Bleuler (1911).

Subsequently, descriptions of relatively benign forms corresponding to the concept of low-grade schizophrenia appeared in the literature under various names. The most famous of them are “mild schizophrenia” [Kronfeld A.S., 1928], “microprocessual”, “micropsychotic” [Goldenberg S.I., 1934], “rudimentary”, “sanatorium” [Kannabikh Yu.V., Liozner S.A., 1934], “depreciated”, “abortive”, “prephase of schizophrenia” [Yudin T.I., 1941], “slow-flowing” [Ozeretskovsky D.S., 1950]gj “subclinical”, “preschizophrenia ", "non-regressive", "latent", "pseudo-neurotic schizophrenia" [Kaplan G.I., Sadok B.J., 1994], "schizophrenia with obsessive-compulsive disorders".

V. O. Ackerman (1935) spoke of slowly developing schizophrenia with a “creeping” progression.

In American psychiatry throughout the 50-60s, the problem of “pseudoneurotic schizophrenia” was intensively developed. In the next decade and a half, the attention of researchers to this problem was associated with the clinical and genetic study of schizophrenia spectrum disorders (the concept of “borderline schizophrenia” by D. Rosenthal, S. Kety, P. Wender, 1968).

In domestic psychiatry, the study of favorable, mild forms of schizophrenia has a long tradition. It is enough to point out the studies of L. M. Rosenstein (1933), B. D. Friedman (1933), N. P. Brukhansky (1934), G. E. Sukhareva (1959), O. V. Kerbikov (1971), D. E. Melekhova (1963), etc. In the taxonomy of schizophrenia developed by A-V. Snezhnevsky and his colleagues, sluggish schizophrenia acts as an independent form [Nadzharov R. A., Smulevich A. B., 1983; Smulevich A. B., 1987, 1996].

Conditions corresponding to various variants of sluggish schizophrenia (neurosis-like, psychopathic-like, “poor in symptoms”), in ICD-10, are allocated outside the heading “Schizophrenia” (F20), which unites psychotic forms of the disease, and are considered under the heading “Schizotypal disorder” (F21).

Data on the prevalence of sluggish schizophrenia among the Russian population vary from 1.44 [Gorbatsevich P. A., 1990] to 4.17 per 1000 population [Zharikov N. M., Liberman Yu. I., Levit V. G., 1973] . Patients diagnosed with sluggish schizophrenia range from 16.9-20.4% [Ulanov Yu. I., 1991] to 28.5-34.9% [Yastrebov V. S., 1987] of all registered patients with schizophrenia.

The idea of ​​the biological commonality of sluggish and manifest forms of schizophrenia is based on data on the accumulation in families of probands with sluggish schizophrenia of schizophrenia spectrum disorders - manifest and erased forms, as well as schizoid disorders. A feature of sluggish schizophrenia is the homotopic nature of mental pathology among affected relatives, namely the accumulation of forms similar to the disease of the proband (secondary cases of sluggish schizophrenia) [Dubnitskaya E. B., 1987].

When identifying variants of sluggish schizophrenia based on the predominance of axial disorders in the disease picture - negative (“simple deficit”, according to N. Eu, 1950] or pathologically productive - the features of the “family psychopathic predisposition” are taken into account, the existence of which in the form of a schizoid constitution in families of patients with schizophrenia was first postulated by E. Kahn (1923).

The inherent aggravation of schizophrenia by psychopathy such as schizoidia (“poor schizoids” by T.I. Yudin, “degenerate eccentrics” by L. Binswanger) also extends to sluggish simple schizophrenia. Accordingly, this option, in which the structure of family burden, including psychopathic predisposition, is completely determined by schizophrenia spectrum disorders, is assessed as basic. But low-grade schizophrenia also has a genetic affinity with the range of borderline states. In accordance with this, two other variants are identified, each of which reveals a correspondence between the phenotypic characteristics of the probands’ disease and the preferred type of constitutional mental pathology in families. Thus, in cases of sluggish schizophrenia with obsessive-phobic disorders, there is an accumulation of cases of psychasthenic (anankastic) psychopathy among the close relatives of patients, and in schizophrenia with hysterical disorders - hysterical psychopathy.

In accordance with the presented data, a hypothesis was formulated [Smulevich A.B., Dubnitskaya E.B., 1994], according to which susceptibility to the development of sluggish schizophrenia is determined by two genetically determined axes - procedural (schizophrenic) and constitutional (Fig. 29).

Rice. 29. Structure of family burden in low-grade schizophrenia. 1 - simple schizophrenia (basic variant); 2 - schizophrenia with obsessive-phobic disorders; 3 - schizophrenia with hysterical disorders. The wide line denotes the schizophrenic (procedural) axis, the narrow line the constitutional axis of family burden.

Clinical manifestations. Sluggish schizophrenia, as well as other forms of schizophrenic psychoses, can develop continuously or in the form of attacks. However, the typological division of sluggish schizophrenia according to this principle would not correspond to clinical reality, since a distinctive feature of the development of the disease in most cases is the combination of attacks with a sluggish continuous course.

Subject to the general patterns of the course of endogenous psychoses (latent stage, period of full development of the disease, period of stabilization), sluggish schizophrenia also has its own “logic of development”. The main clinical features of sluggish schizophrenia: 1) a long latent period with subsequent activation of the disease at distant stages of the pathological process; 2) a tendency towards a gradual modification of symptoms from the least differentiated in terms of nosological specificity (in the latent period) to those preferable for the endogenous disease (in the active period, in the stabilization period); 3) invariance series; and psychopathological disorders (axial symptoms), which represent a single chain of disorders, the natural modification of which is closely related to both the signs of generalization of the pathological process and the level of negative changes.

Axial symptoms (obsessions, phobias, overvalued formations, etc.), appearing in combination with defect phenomena, determine the clinical picture and persist (despite the change of syndromes) throughout the entire course of the disease

Within the framework of sluggish schizophrenia, variants with a predominance of pathologically productive ones are distinguished - pseudoneurotic, pseudopsychopathic (obsessive-phobic, hysterical, depersonalization) and negative disorders. The last option - sluggish simple schizophrenia - is one of the symptom-poor forms [Nadzharov R. A., Smulevich A. B., 1983]. It is often determined by the predominance of asthenic disorders (schizoasthenia, according to N. Eu).

Sluggish schizophrenia with obsessive-phobic disorders [obsessive schizophrenia, according to E. Hollander, C. M. Wong (1955), schizophrenia with obsessive-compulsive disorder, according to G. Zohar (1996); schizoobsessive disorder, according to G. Zohar (1998)] includes a wide range of anxiety-phobic manifestations and obsessions. The clinical picture of the latter is characterized by a complex structure of psychopathological syndromes, formed both due to the simultaneous manifestation of several phenomena of the obsessive-phobic series, and due to the addition of ideo-obsessive disorders [Korsakov S. S., 1913; Kraft-Ebing K., 1879], including rudimentary violations of more severe registers. Among such symptom complexes may be dissociative disorders, phenomena of auto- and allopsychic depersonalization, manifesting as part of panic attacks; overvalued and sensory hypochondria, complicating the course of agoraphobia; sensitive ideas of relationship, joining social phobia; delusions of harm and persecution that complicate the picture of mysophobia; catatonic stereotypies, gradually replacing ritual actions.

The progression of the disease in its first stages is manifested by a rapid increase in the frequency, intensity and duration of panic attacks, as well as a reduction in the duration of interictal intervals. Subsequently, one of the most pathognomonic signs of the procedural nature of suffering is the steady increase in manifestations of avoidant behavior, clinically realized in the form of various protective rituals and controlling actions. Gradually displacing the primary component of obsessive disorders - phobias and obsessions, rituals acquire the character of complex, unusual, fanciful habits, actions, mental operations (repetition of certain syllables, words, sounds, obsessive counting, etc.), sometimes very reminiscent of spells.

Among anxiety-phobic disorders, panic attacks most often dominate. A distinctive feature of the dynamics of these pseudoneurotic manifestations acting within the framework of an endogenous disease, which was pointed out by Yu. V. Kannabikh (1935), is the suddenness of manifestation and persistent course. At the same time, the atypicality of panic attacks attracts attention. They are usually protracted and either combined with symptoms of generalized anxiety, fear of loss of control over oneself, insanity, severe dissociative disorders, or occur with a predominance of somatovegetative disorders (like dysaesthetic crises), combined with disturbances in the general sense of the body, a feeling of sudden muscle weakness, senesthesia, senestopathies. The complication of the disease picture is manifested by the rapid addition of agoraphobia, accompanied by a complex system of protective rituals. It is also possible to transform individual phobias (fear of movement in transport or open spaces) into panagoraphobia, when avoidant behavior not only limits movement, but also extends to any situations in which the patient may find himself without help [Kolyutskaya E. V., Gushansky N. E. ., 1998].

Among other phobias in a number of pseudoneurotic disorders, fear of an external (“extracorporeal”) threat is often noted: the penetration into the body of various harmful agents - toxic substances, pathogenic bacteria, sharp objects - needles, glass fragments, etc. Like agoraphobia, phobias of external threat are accompanied by defensive actions (complex, sometimes lasting for hours, manipulations that prevent contact with “contaminated” objects, thorough treatment or even disinfection of clothing that has come into contact with street dust, etc.). “Rituals” of this kind, gradually occupying a leading position in the clinical picture, completely determine the behavior of patients, and sometimes lead to complete isolation from society. Avoiding potential danger (interaction with “harmful” substances or pathogenic agents), patients quit work or school, do not leave the house for months, move away even from their closest relatives and feel safe only within their own room.

Phobias that form within the framework of protracted (from several months to several years) attacks, manifesting together with affective disorders, in contrast to anxiety-phobic disorders that constitute a meaningful (denotative) complex of cyclothymic phases (obsessive ideas of low value, anxious fears of one’s own inadequacy), do not form such close - syndromic connections with depressive symptoms and subsequently manifest their own developmental stereotype, not directly related to the dynamics of affective manifestations [Andryushchenko A.V., 1994]. The structure of phobias that determine the picture of such attacks is polymorphic. When somatized anxiety predominates among the manifestations of depression, the fear of death combined with panic attacks (heart attack phobia, stroke phobia), the fear of being helpless in a dangerous situation, the fear of penetration of pathogenic bacteria, foreign objects, etc. into the body may come to the fore.

In other cases, occurring with a picture of depersonalization and anxious depression, phobias of contrasting content, fear of insanity, loss of control over oneself, fear of causing harm to oneself or others - to commit murder or suicide (stab, throw a child from a balcony, hang oneself, jump out of a window) prevail ). Suicidal and homicidal phobias are usually accompanied by vivid figurative representations of tragic scenes that may follow if alarming fears are realized. As part of the attacks, acute paroxysms of phobias can also be observed, which are characterized by absolute lack of motivation, abstraction, and sometimes metaphysical content.

Obsessions in low-grade schizophrenia often manifest against the background of negative changes that are already forming (oligophrenia-like, pseudo-organic defect, defect of the “Ferschroben” type with autistic isolation and emotional impoverishment). At the same time, abstract obsessions are observed [Snezhnevsky A.V., 1983] of the type of obsessive philosophizing with a tendency to resolve useless or insoluble questions, repeated attempts to reveal the meaning of a particular expression, the etymology of the term, etc. However, most often obsessive doubts are formed in completeness, completeness of actions, which come down to rituals and double-checks. At the same time, patients are forced to repeat the same operations (position objects strictly symmetrically on the desk, turn off the water tap many times, wash their hands, slam the elevator door, etc.).

Obsessive doubts about the cleanliness of one’s own body, clothing, and surrounding objects [Efremova M. E., 1998], as a rule, are accompanied by hours-long ritual actions aimed at “cleansing” from imaginary dirt. Obsessive doubts about the presence of a serious incurable disease (most often cancer) lead to repeated examinations by various specialists, repeated palpating of those parts of the body where the suspected tumor could be localized.

Obsessions that develop or worsen during attacks can occur according to the type of “insanity of doubt” - folie du doute. Against the background of an anxious state with insomnia and ideational agitation, constant doubts appear about actions implemented in the past, the correctness of actions already committed. The picture of attacks can be determined by contrasting obsessions such as doubts about committing violence or murder [Dorozhenok I. Yu., 1998], which manifest themselves at the height of the state in the form of “taking the incredible for reality.” When the state generalizes, fears and hesitations in connection with upcoming actions are also added, reaching the level of ambivalence and even ambition.

As the endogenous process develops, obsessions quickly lose their previous affective coloring and acquire features of inertia and monotony. Their content becomes more and more absurd, losing even external signs of psychological intelligibility. In particular, compulsive disorders in the later stages are close to motor stereotypies and are accompanied in some cases by self-harmful behavior (biting hands, scratching the skin, gouging out the eyes, pulling the larynx). These features of obsessive disorders in low-grade schizophrenia distinguish them from obsessions in borderline states. Negative changes noted at the onset of the disease appear most clearly in its later stages and significantly reduce the social functioning of patients. At the same time, previously unusual psychopath-like manifestations of the anankastic circle are formed - rigidity, conservatism, exaggerated straightforwardness of judgment.

Sluggish schizophrenia with symptoms of depersonalization [Nadzharov R. A., Smulevich A. B., 1983]. The clinical picture of this form of the disease is determined by the phenomena of alienation that appear in various spheres of self-consciousness (auto-, allo- and somatopsychic depersonalization). At the same time, depersonalization extends primarily to higher differentiated emotions, the sphere of the autopsyche (consciousness of changes in the inner world, mental impoverishment) and is accompanied by a decrease in vitality, initiative and activity.

Premorbidly, patients exhibit features of borderline (increased impressionability, emotional instability, vivid imagination, affective lability, vulnerability to stress) or schizoid personality disorder (withdrawal, selective sensitivity to internal conflicts, coldness towards others). They are characterized by hypertrophy and instability of the sphere of self-awareness, manifested both in a tendency to reflection, long-term retention of impressions, and in a tendency to form transient depersonalization episodes - deja vu, etc. [Vorobiev V. Yu., 1971; Ilyina N.A., 1998].

At the onset of the disease, the phenomena of neurotic depersonalization predominate - heightened introspection, complaints about the loss of “feeling tone”, the disappearance of brightness and clarity of perception of the environment, which is, according to J. Berze (1926), one of the significant signs of the initial stages of the process. In the paroxysmal course of the disease, disorders of self-awareness usually appear within the affective phases - anxious-apathetic depression according to F. Fanai (1973). Certain depersonalization symptom complexes (a paroxysmal feeling of altered mental functions with fear of loss of self-control) already appear in the structure of acute anxiety attacks (panic attacks). With a shallow level of affective disorders (dysthymia, hysteroid dysphoria), partial anesthetic disorders predominate: detached perception of objective reality, lack of a sense of appropriation and personification, a feeling of loss of flexibility and intellectual acuity [Ilyina NA., 1998]. As depression reverses, there is a tendency toward a reduction in depersonalization disorders, although even in remission, disturbances in self-awareness do not completely disappear. Periodically, due to external influences (overwork) or autochthonously, exacerbation of depersonalization phenomena occurs (perception of one’s own face reflected in the mirror as someone else’s, alienation of the surrounding reality, certain sensory functions).

When generalizing depersonalization disorders within the framework of protracted depression, the phenomena of painful anesthesia (anaesthesia psychica dolorosa) come to the fore. The feeling of numbness manifests itself primarily as a loss of emotional resonance. Patients note that painting and music do not evoke the same emotional response in them, and what they read is perceived as cold, bare phrases - there is no empathy, there are no subtle shades of feelings, the ability to feel pleasure and displeasure is lost. The space seems to be flattened, the surrounding world seems changed, frozen, empty.

The phenomena of autopsychic depersonalization [Vorobiev V. Yu., 1971] can reach the degree of complete alienation, loss of their self. Patients claim that their mental self has gone out: they have lost contact with their past life, they do not know what they were like before, they seem to be does not concern what is happening around. In some cases, the consciousness of the activity of the Self is also disrupted - all actions are perceived as something mechanical, meaningless, alien. The feeling of loss of connection with others, noted even at the onset of the disease, intensifies to a feeling of complete misunderstanding of people’s behavior and the relationships between them. The consciousness of the identity of the Self and the opposition of the consciousness of the Self to the external world are disrupted. The patient ceases to feel himself as a person, looks at himself “from the outside,” experiences a painful dependence on others - he has nothing of his own, his thoughts and actions are mechanically adopted from other people, he only plays out roles, transforms into images that are alien to himself.

As the endogenous process progresses, the phenomena of mental alienation (which are, in principle, reversible) are transformed into the structure of deficiency changes - defective depersonalization. This modification is realized within the framework of the so-called transition syndrome. Symptoms of Depersonalization gradually lose their clarity, physicality, lability and variety of manifestations. The “feeling of incompleteness” comes to the fore, extending both to the sphere of emotional life and to self-awareness in general. Patients recognize themselves as changed, dull, primitive, and note that they have lost their former spiritual subtlety. Alienation of connections with people, which previously appeared in the picture of autopsychic depersonalization, now gives way to true communication difficulties: it is difficult to enter a new team, to grasp the nuances of the situation, to predict the actions of other people. In order to somehow compensate for the feeling of incompleteness of interpersonal contacts, you constantly have to “adjust” to the general mood and follow the interlocutor’s train of thought.

The phenomena of defective depersonalization that develop within the framework of the transition syndrome, along with personality changes characteristic of most patients with schizophrenia (egocentrism, coldness, indifference to the needs of others, even close relatives), are also accompanied by negative manifestations of a special kind, defined in connection with the constant dissatisfaction of patients with their mental activity as "moral hypochondria". Patients concentrate entirely on analyzing the nuances of their mental functioning. Despite the partially restored adaptive capabilities, they strongly emphasize the severity of the damage caused to mental activity. They use all means to demonstrate their mental incompetence: they demand treatment that would lead to a “complete restoration of brain activity”, while showing persistence, seeking various examinations and new medication prescriptions by any means.

For sluggish schizophrenia with hysterical manifestations [Dubnitskaya E. B., 1978] hysterical symptoms take on grotesque, exaggerated forms: rough, stereotyped hysterical reactions, hypertrophied demonstrativeness, affectation and flirtatiousness with mannerisms, contractures lasting for months, hyperkinesis, persistent aphonia, etc. Hysterical disorders, as a rule, act in complex comorbid relationships with phobias, obsessive drives, vivid mastering ideas and senesto-hypochondriacal symptom complexes.

The development of protracted, sometimes lasting more than six months, hysterical psychoses is characteristic. The picture of psychosis is dominated by generalized (mainly dissociative) hysterical disorders: confusion, hallucinations of the imagination with mystical visions and voices, motor agitation or stupor, convulsive hysterical paroxysms. The phenomena of disturbed consciousness usually quickly undergo reverse development, and the remaining signs of psychosis show persistence, unusual for psychogenically caused hysterical symptoms, and a number of features that bring them closer to disorders of more severe registers. For example, deceptions of perception, while maintaining similarities with hallucinations of the imagination (imagery, variability of content), gradually acquire features characteristic of pseudohallucinatory disorders - violence and involuntary occurrence. A tendency toward “magical thinking” appears, hysterical motor disorders lose their demonstrativeness and expressiveness, becoming closer to subcatatonic disorders.

At later stages of the disease (stabilization period), gross psychopathic disorders (deceit, adventurism, vagrancy) and changes typical for schizophrenia (autism, decreased productivity, adaptation difficulties, loss of contacts) appear more and more clearly in the clinical picture. Over the years, patients most often take on the appearance of lonely eccentrics, degraded, but loudly dressed women who abuse cosmetics.

For indolent simple schizophrenia [Nadzharov R. A., 1972] manifestations of the latent period correspond to the debut of negative schizophrenia with a slow deepening of mental deficiency (decreased initiative, activity, emotional leveling). In the active period, the phenomena of autochthonous asthenia with impaired self-awareness of activity predominate. Among other positive symptom complexes, in the foreground are disorders of the anergic pole with extreme poverty, fragmentation and monotony of manifestations. Depressive disorders related to the circle of negative affectivity arise most consistently - apathetic, asthenic depression with poor symptoms and an undramatic clinical picture. Phase affective disorders occur with increased mental and physical asthenia, depressed, gloomy mood, anhedonia and alienation phenomena (a feeling of indifference, detachment from the environment, inability to experience joy, pleasure and interest in life), senesthesia and local senestopathies. As the disease progresses, slowness, passivity, rigidity increase, as well as signs of mental insolvency - mental fatigue, complaints of difficulty concentrating, influxes, confusion and interruptions of thoughts.

During the period of stabilization, a persistent asthenic defect is formed with a tendency to self-sparing, decreased tolerance to stress, when any additional effort leads to disorganization of mental activity and a drop in productivity. Moreover, in contrast to grossly progressive forms of schizophrenia with a similar picture, we are talking about a type of processual changes in which the disease, in the words of F. Mauz (1930), “reduces personality, weakens it, but leads to inactivity only certain of its structures.” Despite the emotional devastation and narrowing of their range of interests, patients show no signs of behavioral regression, are outwardly quite orderly, and possess the necessary practical and simple professional skills.

Diagnosis. The process of diagnosing sluggish schizophrenia requires an integral approach, based not on individual manifestations of the disease, but on the totality of all clinical signs. The diagnostic analysis takes into account information about family history (cases of “familial” schizophrenia), premorbid characteristics, development in childhood, puberty and adolescence. Of great importance for establishing the endogenous-processual nature of painful manifestations are unusual or fanciful hobbies discovered during these periods [Lichko A. E., 1985, 1989], as well as sharp, time-limited characterological shifts with professional “breakdown”, changes in the entire life curve and disorders of social adaptation.

In contrast to borderline conditions, in case of process-related pathology, there is a gradual decrease in working capacity associated with a decrease in intellectual activity and initiative. The signs used as clinical criteria for diagnosing low-grade schizophrenia are grouped into two main registers: pathologically productive disorders (positive psychopathological symptoms) and negative disorders (manifestations of a defect). The latter are not only obligate for recognizing sluggish schizophrenia, but also determine the final diagnosis, which can be established only if there are clear signs of a defect. This provides for the exclusion of conditions that are determined not so much by the influence of an endogenous process (latent, residual), but rather by “personal-environmental interaction.”

When diagnosing sluggish schizophrenia according to the register of pathologically productive disorders, two rows of psychopathological manifestations are simultaneously taken into account: 1st row - disorders that are preferable to the endogenous process from the moment of formation; 2nd row - disorders that have endogenous-processual transformation in dynamics. The 1st row includes subpsychotic manifestations in the picture of episodic exacerbations: verbal deceptions of a commentary, imperative nature, “calling”, “sounding of thoughts”; general sense hallucinations, haptic hallucinations; rudimentary ideas of influence, pursuit of special significance; autochthonous delusional perception. A number of positive disorders that exhibit a dynamic transformation characteristic of the endogenous process include obsessive-phobic states with a consistent modification of ideo-obsessive disorders (“insanity of doubts,” contrasting phobias) in the direction of ideo-obsessive delusions with ambiguous ritual behavior and abstract content of symptoms; depersonalization states with a gradual worsening of disorders of self-awareness from neurotic to defective depersonalization with gross emotional changes and damage in the auto-psychic sphere; hysterical states with transformation of conversion and dissociative manifestations into senesto-hypochondriacal, subcatatonic, pseudohallucinatory.

Ancillary, but, according to modern European psychiatrists, very significant for diagnosis are expression disorders that give the appearance of patients features of strangeness, eccentricity, and eccentricity; neglect of the rules of personal hygiene: “negligence”, sloppiness of clothing; mannerisms, paramimic expression with a characteristic gaze that avoids the interlocutor; angularity, jerkiness, “hinge” movements; pomposity, suggestiveness of speech with poverty, inadequacy of intonation. The combination of these features of the expressive sphere with the nature of unusualness and foreignness is defined by H. C. Rumke (1958) by the concept of “praecoxgeful” (“praecox feeling” in English terminology).

Schizophrenia occurring in the form of an atypical prolonged pubertal attack

This section describes variants of single-attack, relatively favorably developing schizophrenia with syndromes characteristic of adolescence - heboid, special supervaluable formations, dysmorphophobia with psychasthenic-like disorders.

In adolescence, significant changes occur in the reactivity of the body, its neuroendocrine and immunobiological systems, which, of course, cannot but have a profound impact on the occurrence, course and outcome of schizophrenia. In addition, the incompleteness of the evolution of brain systems, immaturity of the psyche and the presence of special crisis pubertal mental manifestations influence the formation of the clinical picture of the disease.

Puberty covers the age range from 11 to 20-23 years. It includes early puberty (adolescence), puberty and late puberty, or adolescence itself, periods. The main characteristics that determine the mental manifestations of the pubertal period: firstly, pronounced instability and inconsistency of individual aspects of the neuropsychic makeup, the leading role of the affective sphere, emotional lability - “pubertal mood lability”; secondly, the desire for independence, independence with doubts and even rejection of previous authorities and especially a negativistic attitude towards the authority of people from the immediate environment - family, teachers, etc. - a period of “denial” [Smirnov V. E., 1929; Busemann A., 1927], “protest against fathers”, “striving for independence”; thirdly, an increased interest in one’s physical and mental self with special sensitivity and vulnerability (about any of one’s shortcomings or failures), leading in some cases to fixation on one’s external data, in others on the problem of self-awareness up to the symptom complex of depersonalization or, on the contrary, to a pronounced desire for self-improvement, creativity in various fields of activity with an orientation of thinking towards abstract problems and signs of maturation of drives - the period of “philosophy”, “metaphysics”.

When schizophrenia debuts in adolescence and especially with its slow, relatively favorable development, the described pubertal crisis manifestations not only persist and have a clear dynamics towards their distortion, but often become decisive for the development of the clinical features of the disease as a whole. We are talking about the formation of special symptom complexes specific to adolescence, among which the most characteristic are heboid, “youthful metaphysical intoxication (special super-valuable formations),” dysmorphophobic and psychasthenic-like [Tsutsulkovskaya M. Ya., Panteleeva G. P., 1986].

Long-term study of juvenile low-progressive schizophrenia [Tsutsulkovskaya M. Ya., 1979; Bilzho A.G., 1987] showed that 10-15 years after the first hospitalization in adolescence, the majority of patients gradually experience compensation for the condition with a reduction in psychopathological phenomena and the identification of only mildly expressed signs of a personality defect, which practically do not interfere with social and labor adaptation . All this indicates the pronounced features of this variant of juvenile schizophrenia, which determine its position in the general taxonomy of forms of the latter. In these cases, there is every reason to talk about atypical protracted pubertal schizophrenic attacks [Nadzharov R. A., 1977] as a variant of the disease close to sluggish schizophrenia.

The form of schizophrenia under consideration has a certain developmental stereotype, the stages of which coincide with the stages of normal maturation.

The period of initial manifestations of the disease begins at the age of 12-15 years. It is characterized by a sharpening of character traits, the appearance of autochthonous atypical bipolar affective disorders, sometimes of a continuous nature, with the presence of a dysphoric shade of depression, dissatisfaction with oneself and others, or signs of agitation with unproductivity, lack of desire for contacts - in hypomania. All this is combined with the appearance of opposition to the environment, the desire for self-affirmation, behavioral disorders, and conflict. It is possible that undeveloped dysmorphophobic ideas of an overvalued nature may appear. Sometimes patients’ attention is fixed on the awareness of changes in their physical and mental “I”, there is a tendency towards introspection and difficulties in contacts with others or a dominance of interests in the field of “abstract” problems.

The next stage, usually corresponding to the age of 16-20 years, is characterized by a rapid increase in mental disorders and their greatest severity. It is during this period that the need for hospitalization in a psychiatric hospital arises. In the status of patients, acute psychotic phenomena are noted, although they are of a transient and rudimentary nature: onirism, agitation, ideational disturbances, mentism, severe sleep disturbances, individual hypnagogic and reflex hallucinations, and individual hallucinations of the imagination. At this stage, heboid, dysmorphophobic, pseudopsychasthenic syndromes and the syndrome of “metaphysical intoxication” appear in their most complete form and completely determine the condition of the patients. But at the same time, in their clinical characteristics, they differ in significant features from outwardly similar manifestations characteristic of pathologically occurring pubertal crises. For a number of years, the condition remains relatively stable, without visible dynamics, characterized by the uniformity of painful manifestations, without a noticeable tendency to complicate psychopathological symptoms and even with periods of their weakening and the preservation of psychopathic, overvalued and affective registers of disorders. When contacting such patients, one sometimes gets the impression that they have pronounced negative changes, a severe schizophrenic defect.

Between 20 and 25 years (in some patients later, in others earlier) gradual compensation of the condition occurs with a noticeable reduction or complete disappearance of the described disorders and restoration of social and labor adaptation. As a rule, at this stage there are no longer any signs of progression of the disease process, in particular its repeated exacerbations. Social compensation and professional growth have also increased over the years.

A feature of the long-term period of the disease, regardless of the predominant syndrome at the previous stage of the disease, is the relatively shallow degree of negative changes. If during the period of full-blown disorders the impression of a deep mental defect was created - emotional flattening, moral dullness, gross manifestations of infantilism, a pronounced drop in energy capabilities, then as productive disorders were reduced, personality changes usually turned out to be not so pronounced, limited only in some patients to a loss of breadth of interests, a decrease mental activity, the emergence of a purely rational attitude towards loved ones, with the need for care, and some isolation in the family circle. In some patients, signs of infantilism came to the fore, manifested in impracticality, dependence on loved ones, emotional immaturity, weakness of desires with a good level of mental productivity; in others, schizoid personality traits prevailed with traits of autism and eccentricity, which, however, did not interfere with a high level of professional growth and social adaptation.

Studies of premorbid patients, the characteristics of their early development, the study of childhood crisis periods, and personality traits in childhood made it possible to discover a high frequency of abnormal personality traits with phenomena of dysontogenesis [Pekunova L. G., 1974]. Analysis of the family background showed that in families of patients there is a significant accumulation of sluggish and attack-like forms of schizophrenia in parents and siblings [Shenderova V.L., 1975]. Relatives of patients often also had similarities with the patients in their premorbid personality.

Thus, the form of schizophrenia in the form of prolonged atypical pubertal attacks should be classified as a special group in the taxonomy of forms of schizophrenia, in the genesis of which, with the dominant role of pubertal crisis mechanisms, constitutional genetic factors are of great importance. There is reason to believe that we are talking not only about the pathoplastic, but also about the pathogenetic role of puberty in the genesis of these atypical pubertal forms.

In view of the possibility of significant compensation for the condition of patients after puberty, with a high level of their professional growth, social and labor adaptation, issues that limit the subsequent social growth of patients (transfer to disability, restrictions on admission to a university, expulsion from a university, etc.) .). The possibility of a high level of compensation for these atypical pubertal attacks requires a special discussion of the social aspects of their clinical diagnosis, since these patients socially should not fit into the general group of patients with schizophrenia along with patients with severe progressive forms.

Among the atypical pubertal schizophrenic attacks, the following 3 types are distinguished: heboid, with the syndrome of “youthful metaphysical intoxication,” with dysmorphophobic and psychasthenic-like disorders.

Conditions corresponding to different variants of schizophrenia with a course in the form of an atypical protracted pubertal attack are taken out of the ICD-10 section “Schizophrenia” (F20), which unites psychotic forms of the disease, and are considered in the section “Schizotypal disorder” (F21). In this case, it is possible to indicate the corresponding syndrome with the second code: F21, F60.2 (heboid); F21, F60.0 (“metaphysical intoxication”); F21, F45.2 (dysmorphophobic); F21, F60.6 (psychasthenic-like).

In the Recommendations of the Ministry of Health of the Russian Federation for the use of ICD-10 in Russia, atypical protracted pubertal seizures are highlighted in the section “Schizotypal disorder” (F21) as a psychopathic variant of sluggish schizophrenia (F21.4) using the above second code to highlight the corresponding clinical syndrome that dominates the picture of protracted pubertal attack. Thus, the heboid variant is coded as F21.4, F60.2; option with “metaphysical intoxication” - F21.4, F60.0; dysmorphophobic variant -F21.4, F45.2; psychasthenic variant - F21.4, F60.6.

Heboid attack should be defined as a mental disorder that occurs in adolescence, characterized by a pathological exaggeration and modification to a psychotic level of psychological pubertal properties with a predominance of affective-volitional disorders, including drives, leading to behavior contrary to generally accepted norms and pronounced maladaptation in society [Panteleeva G. P. ., 1973, 1986].

The first (initial) stage in the development of the heboid state, in which the disease debuts, occurs mainly in the first half of puberty - the age of 11-15 years. The duration of this stage in most patients is 1-3 years.

Initial signs of the disease: the appearance in patients of previously unusual psychopathic features of the schizoid and excitable circle, perverted emotional reactions and drives. Signs of “flawed” personality of the schizophrenic type also develop.

In some cases, an exaggeratedly skeptical attitude towards the environment prevails, combined with crude cynicism in judgments about life, a desire for originality, and farce. The behavior of patients begins to be dominated by idleness, separation from common interests with peers, one-sided passions for modern music such as “punk rock”, “heavy metal”, “rap”, etc. Others tend to walk aimlessly along the streets. Patients completely ignore the opinion of relatives on this or that issue, the convenience of the family, and react indifferently even to the death of people close to them. All this indicates that the leading features in the behavior of such patients are weakening self-control and increasing lack of will. In other cases, the clinical picture of the initial stage of the disease is dominated by features of increased irritability, rudeness and lack of harmony with others, which was previously unusual for patients. The stubbornness exhibited by patients is alarming due to its lack of motivation. Patients, despite requests, convictions and even orders, stop cutting their hair, changing their linen, refuse to wash, enter into unnecessary arguments, and argue unnecessarily for hours. In reactions to the environment, inadequate anger, often accompanied by aggression, becomes more and more noticeable. During study sessions, patients become increasingly laziness and absent-mindedness. It is also noteworthy that the patients seem to stop in their mental development: they again begin to be interested in fairy tales, as well as military and “spy” themes of books and films, they get special pleasure from describing scenes of various atrocities, torments, various scandalous stories, become deceitful, etc.

Simultaneously with the described changes, atypical, erased bipolar affective disorders are revealed. They more often appear in the form of dysthymia with a predominance of dissatisfaction with oneself, a desire for loneliness, and an unwillingness to do anything. Sometimes hypomanic states also occur, which in these cases are characterized by periods of unexpected rudeness and conflict against a background of carelessness.

The second stage in the dynamics of heboid manifestations is characterized by the manifestation of the heboid state and develops in most cases at the age of 15-17 years. During this period, a psychopathic-like development of pubertal disorders occurs, leading to complete decompensation of the condition. The behavior of patients amazes those around them with rudeness, inadequacy and low motivation of actions. The conflict and brutality of the behavior of patients with senseless opposition and total negativism to the generally accepted way of life, elevating everything negative to authority takes on exaggerated features. Ugly and caricatured forms of imitation of style in clothing and manners also appear, which, as a rule, lead to boundless eccentricity and pretentiousness of appearance and behavior in general, deliberate looseness, empty posing and clowning. In some cases, behavior is dominated by a negativistic attitude towards close relatives with unmotivated hostility and hatred towards them, persistent terrorization of them with unfounded claims, sophisticated cruelty and causeless aggression. Quite typical are the persistent desire to resolve abstract problems in the absence of appropriate knowledge and understanding of them, while simultaneously moving away from any really significant, useful activity. Increasing irritability is often accompanied by grotesque, monotonous hysterical reactions, which in their manifestations often approach unmotivated impulsive outbursts of rage and aggression.

Despite the preservation of intellectual abilities at this stage of development of the heboid state, most patients, due to a sharp decline in academic performance, leave school or in the first years of college and lead an idle lifestyle for several years; in some cases, without hesitation, they go to other cities to “experience life”, easily fall under the influence of antisocial personalities and commit offenses, join various religious sects (mainly of a “satanic” orientation).

Often, patients experience disinhibition of sexual desire, excessive consumption of alcoholic beverages and drugs, and gambling. The attraction to any type of activity is determined by perverted emotional reactions, and then the nature of the activity approaches in its content to perverse drives. For example, patients are drawn to descriptions of cruelty, adventurous actions, depict in drawings various unpleasant situations, drunkenness, human deformities, etc.

Since manifestations of the heboid state can imitate negative disorders, it is difficult to judge the true severity of personality changes during this period. Nevertheless, the “schizophrenic” coloring of the behavior of patients in general appears very clearly in the form of inadequacy of actions, their lack of motivation, incomprehensibility, strangeness, monotony, as well as pretentiousness and absurdity. In the picture of the heboid state, pronounced schizoid features coexist with hysterical elements of panache and demonstrativeness, symptoms of pathological fantasy - with traits of rigidity, manifestations of increased excitability and affective instability - with neurotic and phobic symptoms, disturbances of desire - with disorders of the psychasthenic circle (self-doubt, loss feelings of ease during communication, increased reflection, etc.), phenomena of dysmorphophobia of an obsessive or overvalued nature, with erased senestopathies, unformed ideas of relationship.

Affective disorders during the period under review are of a bipolar phase nature and arise autochthonously. At the same time, they are, as a rule, atypical and the actual thymic component in their structure appears in an extremely erased form. Affective states are characterized by a significant extension over time (from 2-3 months to 2-3 years) and often succeed each other in a continua manner.

Against the background of the described disturbances, in some cases, suspicion occasionally arises with the feeling that something is afoot around, states of pointless fear, sleep disturbances in the form of insomnia or nightmares, and rudimentary phenomena of oneirism. There are episodes of sound and influx of thoughts, a transient feeling of possessing hypnotic power, guessing other people's thoughts with a feeling of involuntary thinking, memories, unusual brightness and illusory perception of the environment, mystical penetration, episodes of depersonalization and derealization, hypnagogic visual representations. All these symptoms in the structure of the heboid state are rudimentary in nature, lasting from several hours to 1-2 days.

The third stage of the heboid state is characterized by a weakening tendency towards further complication of symptoms and stabilization of the condition at the level of the previous stage. From the age of 17-20 years, over the next 2-7 years, the clinical picture and behavior of patients become monotonous, regardless of changes in real conditions and external influences. In these cases, patients remain deaf to those situations that arose as a result of their incorrect behavior (brought to the police, hospitalization, expulsion from an educational institution, dismissal from work, etc.). Their tendency to use alcohol and drugs is also persistent, despite the absence of an irresistible attraction to them (the patients are not amenable to correction, administrative influences, or drug treatment). They easily fall under the influence of antisocial individuals, participate in crimes and antisocial initiatives organized by the latter, and are detained by the police for “hooliganism” and other acts. Signs of mental retardation also become more noticeable (the latter seems to stop at the teenage level, patients “do not grow up”).

During this period, the largest number of hospitalizations due to improper behavior of patients is noted. Treatment in a hospital, in particular the use of antipsychotics, can relieve the heboid condition, but after cessation of treatment, the patients’ condition quickly deteriorates again.

During the third stage, regardless of any external factors, many patients may spontaneously experience an improvement in their mental state, which can last from several days or weeks to one and (less often) several months. During these periods, patients, in the words of their relatives, become almost “as before.” They start studying, catching up on neglected material, or working. It often seems that signs of emotional dullness disappear. But then the state changes again and heboid disorders of the previous psychopathological structure arise.

The fourth stage in the dynamics of the heboid state is characterized by its gradual reverse development. It lasts on average 1-2 years and occurs at the age of 20-24 years (ranges from 18 to 26 years). At this stage, the polymorphism of heboid disorders gradually decreases, behavioral disorders, unmotivated hostility towards relatives, a tendency to use alcohol and drugs, and unusual hobbies and interests are smoothed out; The “pubertal worldview” loses its clearly oppositional orientation, and then gradually fades away. Signs of weakening self-control remain much longer, which is reflected in episodic alcohol, drug and sexual excesses. Productive symptoms (neurosis-like, dysmorphophobia, etc.) gradually disappear and only a tendency to mild autochthonous mood changes remains.

The social and labor adaptation of patients is significantly improved. They often resume interrupted studies and even begin to master a profession.

As heboid disorders are reduced, it becomes possible to assess personality changes. As a rule, they are not as deep as one might expect. They were limited only by the loss of breadth of interests, a decrease in mental activity, the emergence of a purely rational attitude towards close people with the need for their care, and some isolation in the family circle.

Thus, the fourth stage is the formation of stable remission. Two main types of the latter can be distinguished. The first is characterized by the fact that mental infantilism (or juvenileism) in combination with schizothymic manifestations comes to the fore, the second is determined by pronounced schizoid personality traits with traits of autism and eccentricity.

Attack with symptoms of “metaphysical intoxication” is a condition that develops in adolescence, characterized by the dominance in the mental life of the subject of affectively charged one-sided intellectual activity (usually abstract content) and leading to various forms of social and labor maladjustment.

The actual “metaphysical” content of the ideational activity of patients, which determined the name of the syndrome, is not mandatory. The manifestations of this phenomenon are significantly diverse. Some patients really devote themselves to the search for metaphysical or philosophical “truths,” while others are obsessed with ideas of spiritual or physical self-improvement, which they elevate to the rank of a worldview; still others spend a lot of time and energy on the invention of a “perpetual” or “supportless” engine, solving currently unsolvable mathematical or physical problems; still others turn to Christianity, Buddhism, and Hinduism, becoming religious fanatics and members of various sects.

Qualifying the state of “metaphysical intoxication” as a purely age-related (youthful) symptom complex, L. B. Dubnitsky (1977) identified 2 obligatory psychopathological signs in its structure: the presence of an extremely valuable education, which determines the pronounced affective charge of patients in accordance with their views or ideas and their dominant significance in the entire mental life of an individual; one-sided increased attraction to cognitive activity - so-called spiritual attractions. Depending on the predominance of the first or second sign, different clinical variants of the type of attack under consideration are distinguished.

The affective version of “metaphysical intoxication” is more common, i.e., with a predominance of the first sign - overvalued formations of an affective nature. In these cases, the most intense affective saturation of the state predominates, the actual ideational developments take a secondary place, and the interpretative side of the patients’ intellectual activity is reduced to a minimum. Patients usually borrow generally popular ideas or other people's views, but defend them with an indestructible affective charge. There is a dominant feeling of conviction in the special significance and correctness of one’s own activities. The content of these ideas most often includes religious views, parapsychology, and the occult. Evidence of the predominance of affect over idea is a shade of ecstasy in the state: patients declare a mystical insight into the essence of the issues of existence, knowledge of the meaning of life during the period of “inspiration,” “insight,” etc. The formation of such a “worldview” usually occurs quickly according to the “ crystallization,” and its content is often in direct contradiction with the patients’ past life experiences, their previous interests, and personal attitudes. The presence of phase affective disorders gives these conditions a special coloring. With depressive affect, patients who have been involved in issues of philosophy or religion come to idealism, metaphysics, mysticism or accept the views of “nihilists”, “superfluous people”, “beatniks”. However, even after depression has passed, the interests of patients, as well as their activities, are determined by a selective range of issues that dominate the consciousness to the detriment of real interests and activities. During periods of exacerbation of the condition, the “obsession” of patients reaches the level of so-called overvalued delirium [Smulevich A. B., 1972; Birnbaum K., 1915]. At the same time, numerous (albeit episodic) subpsychotic symptoms are noted. Characteristic is a distortion of the sleep-wakefulness rhythm, sometimes persistent insomnia, short-term oneiric disorders, individual hypnagogic hallucinations and hallucinations of the imagination, corresponding to the content of “metaphysical intoxication.” Less common are acute transient disturbances in thinking, interpreted by patients from the standpoint of their own “worldview.”

The active stage of the disease with the dominance of the phenomena of “metaphysical intoxication”, as well as in heboid conditions, is limited to the period of adolescence, beyond which there occurs a pronounced reduction of all positive disorders, smoothing and compensation of personal changes, good, steadily increasing social and labor growth, i.e. e. a state of stable remission such as practical recovery [Bilzho A. G., 1987].

With this type of attack, there is also a phasic pattern in the development of clinical manifestations, coinciding with the stages of the pubertal period.

The disease develops more often in men. The initial period of the disease refers to adolescence (12-14 years). The phase of adolescence is marked by the intensification of highly valuable activities of various content: computer activities (with an emphasis on gaming programs and virtual communication via the Internet), poetry, sports, chemical experiments, photography, music, etc. Such hobbies are usually short-lived, patients quickly “cool down” and “ switch" to new activities. A significant place in the mechanism of overvalued activity belongs to fantasy. The content of overvalued activity is directly dependent on affect. This is especially evident in cases of depression accompanied by “philosophical quests.” When depression disappears, patients experience a “painful anticipation of happiness.” Simultaneously with the emergence of various forms of overvalued activity, the isolation of patients from others increases, which they experience as an “inferiority complex.”

At the stage of the active course of the disease (15-16 years), all patients show dominance of unilateral activity and a pronounced affective intensity of the state. Becoming adherents of the philosophy of existentialism, the views of Kant or Nietzsche, accepting the ideas of Christianity or Buddhism, engaging in physical exercises or Einstein’s theory of relativity, patients do not for a minute doubt the truth and extreme significance of the views they defend, and indulge in their favorite activities with extraordinary tenacity and passion. “Immersed” in new interests, patients begin to skip classes at school, shirk household errands, sharply limit contacts, and show indifference to loved ones.

Typical for these cases is a distortion of the sleep-wake cycle: patients, studying in the evenings and staying up at books past midnight, have difficulty getting out of bed in the morning, experiencing a feeling of weakness and lethargy. The emergence of a religious or philosophical “worldview” is usually preceded by a characteristic change in mood: “transferring” their mood to the surrounding world, nature, art, patients seem to be constantly in a state of anticipation of extraordinary events, the upcoming “release” of new ideas of philosophical or religious content or inventions . These new ideas are perceived as “insight,” the knowledge of a new meaning in life with a “reassessment of values.” A philosophical worldview can take on the character of “overvalued delusional ideas.” The affective intensity of their ideas always gives the impression of fanaticism.

The described states are accompanied by various, albeit isolated, sensory phenomena. Sleep disturbances develop (often persistent insomnia), episodic hypnagogic hallucinations, isolated short-term oneiric disorders (often in a drowsy state), reflex hallucinations, and hallucinations of the imagination appear. Hypnagogic hallucinations that arise autochthonously or reactively throughout the entire phase of adolescence are often interpreted by patients in ideological terms. Some patients experience acute transient thinking disorders that are particularly pretentious and have a mystical interpretation.

By the age of 17-22 years, all the patients’ activities and their entire lifestyle are determined by “metaphysical intoxication” and altered affect. By this age, phase affective disorders (often bipolar), combined with intellectual activity, become especially clear. Despite this activity, signs of social maladaptation of patients are found. They usually leave their studies in the first years of higher education or are expelled due to academic failure. The performance of patients in the subsequent period remains uneven in this sense. By the age of 20-21, their inability to adapt to life, dependence on parents, and age-inappropriate naivety of judgment become more and more evident; one-sided intellectual development, as well as decreased sexual desire and signs of physical infantilism.

The postpubertal period (22 years - 25 years) is accompanied in these patients by a gradual “fading away” of supervaluable activity while maintaining erased cyclothyme-like affective phases and the emergence of opportunities for social adaptation. Patients return to school and begin to work. At the same time, in comparison with the premorbid, certain personality changes can be detected here: autism, a tendency to adhere to established routines and ways of life, elements of reasoning, insufficient self-criticism, distinct signs of mental and sometimes physical juvenileism. The remaining extremely valuable education still influences the preference of interests and activities of patients, most often becoming the content of their professional activity.

As a rule, these patients are subsequently distinguished by a relatively high level of professional productivity.

Attack with dysmorphophobic and psychasthenic-like disorders characterized primarily by a condition that in the literature since the time of E. Morselli (1886) has been defined by the concept of body dysmorphophobia - a painful disorder dominated by the idea of ​​an imaginary physical defect (form or function). Dysmorphophobia, as indicated by many researchers on the basis of epidemiological data, is a symptom complex that occurs mainly in adolescence and adolescence and represents one of the aspects of the manifestations of pubertal crises [Nadzharov R. A., Sternberg E. Ya., 1975; Shmaonova L. M., Liberman Yu. And Vrono M. Sh., 1980].

P. V. Morozov (1977) and D. A. Pozharitskaya (1993) found that this age includes not only the predominant frequency of these pictures, but also their certain age-related features, in particular their close combination with the so-called youthful psychasthenic-like symptom complex [Panteleeva G.P., 1965]. By disorders of the psychasthenic type we mean manifestations that resemble the personality characteristics characteristic of psychasthenic psychopaths. Here, in the clinical picture, the most common symptoms are the appearance of previously unusual indecision and uncertainty in one’s actions and actions, difficulties in dealing with feelings of constraint and tension in public, heightened reflection, a feeling of change in one’s personality and detachment from the real (“loss of the sense of the real” ), leading to disruption of adaptation to environmental living conditions. When this variant of an atypical pubertal attack manifests itself, dysmorphophobia prevails in some cases, and psychasthenic-like disorders prevail in others.

The described phenomena of dysmorphophobia and psychasthenic-like disorders are usually preceded by the emergence or intensification of schizoid features at the age of 11-13 years. Sometimes erased productive disorders are simultaneously observed: phobias, unstable sensitive ideas of relationships, subclinical bipolar affective phases. Later (12-14 years), ideas about a physical disability usually arise, which at first are practically no different from the teenager’s usual over-valued interest and concern about his own appearance. Fearing ridicule, teenagers disguise their imaginary physical disabilities with clothes or shoes and are embarrassed to undress in public. Some of them do intense physical exercise, others only follow a certain diet “in order to correct physical deficiencies.”

The manifest stage of the disease develops at the age of 15-18 years. Its onset is determined by the complication of the topic of dysmorphophobia: along with concerns about excess body weight, the presence of juvenile acne, patients begin to worry about the shape of the nose, impending baldness, subtle birthmarks, etc. The behavior of patients also changes sharply: they are completely overwhelmed by thoughts about the acne they have. “defects”, they leave school, quit work, do not go out, hide from friends and guests. While self-medicating, they constantly monitor their appearance with the help of a mirror - the “mirror” symptom. Patients persistently turn to cosmetologists and are ready to do anything to correct the defect. They often give pronounced affective reactions with hysterical features. In some cases, when patients develop definite depressive disorders, overvalued ideas of a physical disability acquire a polythematic character, approaching depressive delusions of self-blame; in others, dysmorphophobia remains monothematic: depressive affect is determined with great difficulty, and overvalued ideas of a physical disability develop into an uncorrectable system of beliefs, approaching delusions of a paranoid type. These patients often exhibit ideas of attitude, verbal illusions, and they declare that their ugliness is “openly” mocked everywhere. During this period, patients are usually hospitalized several times.

In cases with the presence of psychasthenic disorders, dysmorphophobic and hypochondriacal ideas of polymorphic content, sensitive ideas of attitude, and reflection like “moral hypochondria” are added to difficulties in contacts, tension and stiffness in public, fear of blushing, and doubts about the correctness of one’s actions. Affective disorders throughout this stage are bipolar, continuous in nature. There are also undulations in the severity of psychasthenic-like disorders, fluctuations in the level of dysmorphophobic and hypochondriacal ideas and sensitive ideas of attitude from the overvalued to the delusional register (bypassing the obsessive level), correlating with changes in the poles of affect and the severity of affective disorders. In states of depression, in addition to the actualization of dysmorphophobic ideas, subjectively more severe depersonalization-derealization disorders, phenomena of somatopsychic depersonalization, and episodes of acute depersonalization are noted. Despite the severity of clinical symptoms and the rapid onset of social and labor disadaptation, the level of negative changes is shallow. The condition of patients remains stable for a long time according to the same manifestations within adolescence.

By the age of 22-23 (for some a little earlier, for others later), a reduction in the ideas of physical disability gradually occurs, and psychasthenic-like disorders lose the character of a single symptom complex. They are fragmented into individual symptoms that do not have an affective component. Their relevance for patients is gradually lost.

By the age of 25, patients retain only erased affective disorders in the form of autochthonous subdepressive phases and short-term subdepressive reactions, in the clinical picture of which, however, some psychasthenic-like features appear (the predominance of anxious fears, fear of failure, causing trouble for others) or somewhat exaggerated taking care of your appearance. Sometimes there remain traits of isolation, isolation, superficiality, immaturity of judgments and interests, increased suggestibility; egocentrism and insufficient emotional attachment to loved ones are combined with a subordinate position in the family. Some patients are irritable and easily give affective reactions on minor occasions, subsequently citing increased fatigue and lack of restraint. Moreover, they allow themselves such reactions only at home.

After the described manifestations have passed, all patients work and cope with their studies quite well. They reach, as a rule, a relatively high professional level, although in some cases there is low initiative and productivity.

Sluggish schizophrenia is also called low-progressive, non-psychotic, microprocessual, rudimentary, hidden, larved, etc. The main feature of this form is slow progress, with indirect manifestations of the clinical picture. Pathology is not characterized by productive symptoms; the clinical picture is based on neurotic disorders, partially negative signs with shallow personality changes.

Stages of the pathology

As a rule, sluggish schizophrenia begins its debut in adolescence, but since its signs are weakly expressed, it is possible to recognize the pathology after a considerable time.

This type of schizophrenia is characterized by stages in the manifestation of symptoms. Pathology is conventionally divided into three periods:

• debut or latent period;
• manifest or active phase;
• stabilization.

The onset is unnoticeable, the symptoms are relative. Depressive states may occur, accompanied by isolation and a person’s withdrawal into his own invented world. Various ideas begin to arise, the patient is prone to abstract thinking, philosophizing, which has no values.

The debut gives way to the manifest; during this period, the symptoms of the disease clearly begin to appear and, as a rule, a diagnosis is established. During this period, absurd fears often arise, for example, a person dressed in a uniform or a purple jacket can cause an unbearable state of horror and a desire to run away. Symptoms such as isolation become more pronounced, it can reach the state of autism, the patient is exhausted, often experiences insomnia, and his range of interests is narrowed.

The manifestation can occur with different clinical signs; neuroses, paranoia, hysteria, obsessive-compulsive disorder, hypochondria, and others may predominate. Also, low-grade schizophrenia has a history of one or two of the following defects:

• Verschreuben, the main sign of this defect is strange behavior, pronounced foolishness, eccentricity, eccentricity. This behavior is expressed in sloppiness, awkwardness in appearance, for example, a patient can wear shorts with a down jacket in the summer, etc. His movements are uncertain, angular, reminiscent of a small child, but he does it all with a serious look. Changes are also observed in speech, it is full of all sorts of pretentious turns of phrase, the patient speaks quickly and not to the point, dangling thoughts are often observed, he begins his story with one thing, forgetting what he was talking about at the beginning, jumps to another topic of conversation. At the same time, everything remains, mental and physical activity is preserved;
• pseudopsychopathy - this defect is expressed in a large number of different ideas in the patient, which he considers extremely valuable and does not tolerate any criticism on this matter. The patient is emotionally excited and involves everyone around him to implement his brilliant ideas. Naturally, the result of such actions is negligible or non-existent;
• a reduction in energy potential manifests itself in depression, self-isolation, lack of any motivation to do anything, a desire to spend time alone, and isolate from society.

The stabilization stage is the main goal pursued when treating patients. In fact, this is a remission with partial or complete disappearance of symptoms characteristic of the manifest period. Unfortunately, stable and long-term stabilization is not always possible to achieve, but even without treatment the situation will only worsen, leading the patient to an irreversible personality defect.

General clinical picture

In addition to the three conditions described, low-grade schizophrenia can manifest itself with various symptoms, for example:

Low-progressive schizophrenia and its forms

Sluggish schizophrenia can occur in the following forms:

Personality defect

The most difficult and often irreversible consequence of a long course of schizophrenia is the development of a personality defect. In this case, all human qualities suffer: emotions, will, thinking and intellect.

A personality or schizophrenic defect consists of the following manifestations:

• autism;
• speech disorder;
• impoverishment of the emotional sphere;
• inability to adapt to society;
• thinking disorder.

All these signs steadily develop in any form of schizophrenia; the sluggish process, unfortunately, is no exception, with the only difference being that such symptoms arise later than in other types of pathology.

Therapy

For the most favorable outcome of schizophrenia, it is important to begin treatment before the onset of the manifest stage. A distinctive feature in the treatment of a sluggish form is the use of drugs in relatively small doses compared to other more malignant types of pathology.

For treatment, one drug is determined that is best able to relieve the symptoms of the disease and lead to remission. Slightly progressive schizophrenia is a chronic disease and requires continued treatment even during a period of stabilization and even complete remission. As a rule, they leave the same drug that was used and during the manifestation period they only reduce the dosage to the minimum. The main groups of drugs for schizophrenia are as follows:

• neuroleptics of new and old generation;
• anxiolytics;
• normomitics;
• antidepressants;
• nootropic drugs;
• psychostimulants.

The main drug for the sluggish form of schizophrenia is considered to be a new generation antipsychotic - haloperidol. Less commonly prescribed are classic, typical, or previous generation antipsychotics. Their disadvantage is a large number of side effects. Basically, drugs are prescribed orally; medications are administered intravenously or intramuscularly only when it is urgently necessary to stop psychomotor agitation.

Sluggish schizophrenia is treated in most cases on an outpatient basis; less often, during the period of manifestation, the patient may be in a hospital setting. Hospitalization may be indicated in the following cases:

• refusal to eat for more than a week;
• loss of body weight by more than 20%;
• aggressive conditions;
• psychomotor agitation;
• suicide attempts.

In addition to drug treatment, psycho-emotional support from relatives and doctors is important. Group sessions with a psychotherapist, which involve patients with the same diagnosis, are encouraged. It is important not to criticize the patient’s behavior, but to create psychologically favorable conditions for life.

The prognosis for indolent schizophrenia is more favorable compared to other forms. Treatment requires smaller doses of medications, and the personality defect occurs slowly and is not pronounced. The main goal in the treatment of pathology is based on achieving high-quality and long-term remission, preferably without repetitions of manifest periods.

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