Dementia and defect in schizophrenia. simple form of schizophrenia simple form of schizophrenia profound dementia

According to the classification of O. V. Kerbikov, it belongs to dementia, in which there are no deep organic changes. According to I. F. Sluchevsky, it belongs to transient dementia. On this subject, he wrote:

Patients with schizophrenia may show deep dementia for many years, and then unexpectedly for those around them, including doctors, to discover relatively well-preserved intellect, memory and sensory sphere.

There has been some debate as to whether dementia in schizophrenia can be considered dementia proper. So, Kurt Schneider believed that in these cases, strictly speaking, dementia, dementia are not observed, since “general judgments and memory, and so on, which can be attributed to intelligence, do not undergo direct changes,” but only some violations of thinking are observed. A. K. Anufriev noted that a patient suffering from schizophrenia can simultaneously appear in the course of a conversation with him to be both feeble-minded and not feeble-minded, and that the term "schizophrenic dementia" is quite justifiably taken in quotation marks. According to G. V. Grule, the disorder of intellect in schizophrenia depends on the characteristics of mental activity that do not directly affect the intellect and are volitional disorders like apato-aboulia and thinking disorders. Therefore, one cannot speak of changes in intelligence in schizophrenia as classical dementia. In schizophrenic dementia, it is not the intellect that suffers, but the ability to use it. As the same G. V. Grule said:

the machine is intact, but not fully or sufficiently serviced.

Other authors compare intelligence in schizophrenia to a bookcase full of interesting, clever, and useful books to which the key has been lost. According to M. I. Weisfeld (1936), schizophrenic dementia is caused by “distraction” (delusions and hallucinations), “insufficient activity” of the personality before the illness, “the influence of acute psychotic states” and “non-exercise”. On the latter occasion, he quotes the words of the great figure of the Renaissance, Leonardo da Vinci, who claimed that the razor becomes rusty through disuse:

the same happens to those minds that, having ceased the exercise, indulge in idleness. Such, like the aforementioned razor, lose their cutting fineness, and the rust of ignorance corrodes their appearance.

Criticizing the idea of ​​the outcome of mental illness in dementia, N. N. Pukhovsky notes that the phenomena attributed to "schizophrenic dementia" are closely related to toxic-allergic complications in case of inadequate tactics of active treatment of psychoses (including neuroleptic, ECT, insulin-comatose therapy, pyrotherapy), with the remnants of the system of constraint in psychiatric hospitals and the phenomena of hospitalism, desocialization, coercion, separation and isolation, domestic discomfort. He also links "schizophrenic dementia" to a defense mechanism of regression and repression (parapraxis).

Nevertheless, nevertheless, the discrepancy between intellectual reactions and stimuli indicates the presence of dementia in patients with schizophrenia, albeit in a peculiar version of it.

Story

Special dementia in patients with schizophrenia 4 years after the creation of the very concept of the disease by E. Bleiler was described by the Russian psychiatrist A. N. Bernshtein in 1912 in Clinical Lectures on Mental Illness.

Classification

According to the classification of A. O. Edelstein, based on the degree of disintegration of the personality, there are:

1. Syndrome of "apathetic" dementia ("dementia of impulses");
2. "Organic" type of dementia - according to the type of organic disease, such as Alzheimer's disease;
3. Syndrome of "ruining" with the onset of insanity;
4. Syndrome of "personal disintegration".

Pathogenesis

The pathogenesis of schizophrenic dementia, like schizophrenia itself, is not fully known. However, some of its aspects are described. The Austrian psychiatrist Josef Berze in 1914 considered schizophrenic dementia "hypotension of consciousness." It is noteworthy that in the future many other scientists agreed with him: prominent researchers of schizophrenia K. Schneider, A. S. Kronfeld and O. K. E. Bumke. The Soviet physiologist IP Pavlov also considered schizophrenia to be a chronic hypnotic state. However, this is not enough to understand the pathogenesis of schizophrenic dementia. In schizophrenia, with the preservation of the elements of the intellect, its structure is disturbed. In this regard, the main clinic of the condition appears. According to V. A. Vnukov, expressed back in 1934, the basis of schizophrenic dementia is the splitting of the intellect and perceptions, paralogical thinking and flattened affect.

Clinical picture

Perceptual disorders

Deep perceptual disturbances in schizophrenia, in the first place - symbolism, derealization and depersonalization affect the intellect negatively.

Thinking disorders

Thinking in schizophrenic dementia is atactic, with elements of pretentiousness, symbolism, formality, mannerism, mosaicism. At one time, even E. Kraepelin, exploring “dementia praecox”, noted “driving”, “slipping”, “pulling apart” thoughts. So-called atactic thinking arises, outwardly manifested by speech disorders, more often in the form of schizophasia, when sentences are grammatically correct, but their content is meaningless, slippage from the topic occurs, neologisms, contamination occur, symbolic understanding occurs, perseveration, embolophrasia, paralogicality, combination of incongruous and separation indivisible.

Memory disorders

Memory in schizophrenic dementia, as in schizophrenia in general, is preserved for a long time. Such patients are well oriented in their own personality, space and time. According to E. Bleiler, the phenomenon when patients with schizophrenia, along with psychotic ones, have preserved some aspects of intelligence, is figuratively called "double bookkeeping".

Forecast

Since schizophrenia is a chronic and progressive disease, the prognosis for recovery from such dementia, if it has already occurred, is usually uncertain. However, since this dementia is transient, if the course of the disease itself has been stopped, the prognosis can be relatively favorable. In other cases, an extremely unfavorable outcome is possible. There comes either an extreme increase in negative symptoms in the form of complete apathy, abulia and autism, which manifests itself in absolute indifference, untidiness, the breakdown of social ties and the absence of speech, or with elements of the former clinical form of schizophrenia: hebephrenia defect, residual catatonia, rudiments of delirium in paranoid form. Nevertheless, the prognosis for life is favorable, and for working capacity - relatively favorable with successful treatment.

Literature

• O. V. Kerbikov, M. V. Korkina, R. A. Nadzharov, A. V. Snezhnevsky. Psychiatry. - 2nd, revised. - Moscow: Medicine, 1968. - 448 p. - 75,000 copies;
• O. K. Naprenko, I. J. Vloch, O. Z. Golubkov. Psychiatry = Psychiatry / Ed. O. K. Naprenko. - Kiev: Zdorov "ya, 2001. - S. 325-326. - 584 p. - 5000 copies - ISBN 5-311-01239-0 .;
• Yu. A. Antropov, A. Yu. Antropov, N. G. Neznanov. Intellect and its pathology // Fundamentals of the diagnosis of mental disorders. - 2nd, revised. - Moscow: GEOTAR-Media, 2010. - S. 257. - 448 p. - 1500 copies. - ISBN 978-5-9704-1292-3.;
• N. N. Pukhovsky. Therapy of mental disorders, or Other psychiatry: A textbook for students of higher educational institutions. - Moscow: Academic project, 2003. - 240 p. - (Gaudeamus). - ISBN 5-8291-0224-2.

Dementia - a total change and devastation of the personality, gross thinking disorders, apathetic or disorganized behavior in the absence of criticism of one's condition.

Specificity of schizophrenic dementia.

Loss or sharp decrease in spontaneity and initiative;

Profound violation of intellectual activity (a sharp decrease in the ability to embarrass, judge, generalize, understand the situation - the complete loss of all intellectual baggage, the entire stock of knowledge, the destruction of any interests.

All this creates a “ruining syndrome” (described by A.O. Edelstein in the 30s).

Ruining syndrome is observed in 15% - 22% of cases of schizophrenia. Its formation is difficult to associate with any form of schizophrenia, but more often with catatonic and hebephrenic forms.

Clinic: complete indifference and indifference, a frozen smile, misunderstanding of elementary questions, answers like schizophasia, indifference when meeting with relatives, lack of the slightest concern for the family, voracity, slovenliness (when eating, they often do not use a spoon).

Defect - in contrast to dementia, it is a relatively mild form of partial weakening of mental activity. Patients in the stage of stable remission tend to restore to some extent a critical attitude to the manifestations of the defect.

A defect is a primary negative symptom, i.e. reflecting persistent deficient personality changes. They must be distinguished from secondary negative ones associated with the current exacerbation of psychosis, depression, and neurolepsy.

It is impossible to determine the depth and type of negative/deficit disorder at the active stage of the process. During an exacerbation or in the stage of incomplete remission, both primary and secondary negative disorders are present in the clinic.

Primary negative disorders (consequences of the disease itself) are extremely difficult to distinguish from the side effects of drugs, hospitalism, loss of social status, lowering the level of expectations on the part of relatives and doctors, getting used to the role of "chronically ill", loss of motivation, hope.

Typology of the defect in schizophrenia.

When assessing the nature and severity of the defect, the prognosis of the condition, two provisions of D.E. Melekhov (1963) should be remembered.

1) signs of an increase in the severity of the defect or the appearance of new symptoms in its structure - indicate the continuing activity of the process;

2) even pronounced manifestations of a defect are available for compensation if the process has stopped in its development, passes into the stage of stable remission, a post-process (residual) state and takes a long, slow, sluggish course without frequent exacerbations.

Defect typology.

1) Asthenic - or non-specific "clean" defect (Huber), "decrease in energy potential" (Conrad K.), "dynamic devastation" (Janzarik W), "primary adynamia" (Weitbrecht) - this is a decrease in energy potential and spontaneous activity, as well as the level of purposeful thinking and emotional responsiveness (Huber).

"Decrease in energy potential" according to Conrad K. (1958) is characterized by a decrease in the strength of mental tension, will, intensity of desires, interests, level of motives, dynamic activity in achieving the goal;

"Dynamic devastation" according to Janzarik W (1954, 1974) - includes a decrease in emotional tension, concentration, intentional impulsivity, readiness for action, which is manifested by emotional coldness, lack of interest, lack of interest, lack of initiative.

The structure of the asthenic defect is intellectual and emotional impoverishment, unsharply expressed thinking disorders, narrowing of the circle of interests. The behavior of patients is outwardly ordered. Household and uncomplicated professional skills are preserved, selective attachment to one of the relatives or medical staff, a sense of one's own change is preserved.

2) Vershroben (acquired deficient or expansive schizoidia according to Smulevich A.B., 1988).

Structure - autism in the form of pretentiousness, absurdity of actions with a separation from reality and life experience. Decreased sensitivity and vulnerability, the disappearance of a tendency to internal conflict, the extinction of related feelings. The sense of tact, humor, distance disappears. In general - a decrease in criticality and emotional coarsening. Lost (reduced) former creative abilities. Cognitive activity is reduced to the use of insignificant, latent properties and relations of objects, their consideration in unusual aspects and connections, the use of rare words, neologisms, a tendency to pretentious expressions. "Pathological autistic activity" - comes down to pretentious actions, divorced from reality and past life experience. There are no clear plans and intentions for the future. The lack of criticism is manifested by a disorder in the evaluation of one's "I", in the form of awareness of one's own individuality through comparison with others. In everyday life, oddities - the clutter of the home, neglect, neglect of hygiene, contrast with the pretentiousness of the hairstyle and details of the toilet. Mimicry is unnatural, ianern, motility is dysplastic, movements are angular. Emotional coarsening is manifested by the reduction of sensitivity and vulnerability, the disappearance of the tendency to internal conflict, the extinction of related feelings. The sense of distance and tact is grossly violated. Often - euphoric, out of place jokes, complacency, empty pathos, regressive syntonicity.

3) Psychopathic (pseudopsychopathy) - typologically comparable to constitutional personality anomalies (psychopathies).

This type of defect is predisposed to - a) the confinement of active (manifest periods of the disease to age-related crises, b) a low progression course, c) the presence in the initial period of schizophrenia of affinity for disorders of the psychopathic circle.

Pseudopsychopathies in the clinic of paroxysmal progredient schizophrenia are described in the idea of ​​2 variants of post-processual personality development (Smulevich A.B., 1999).

1. "Idealists alien to the world" according to E. Kretschmer (1930) - with a new approach to reality, hermits, unsociable eccentrics, indifferent to the fate of relatives, with a worldview subordinate to the ideas of spiritual self-improvement, detached from vain affairs, with autistic hobbies. This also includes personality changes of the “second life” type (Vie J., 1939) with a radical break with the entire system of premorbid social, professional and family ties. Change of occupation, formation of a new family.

2. residual states according to the type of dependent personalities (psychasthenic remissions according to V.M. Morozov, R.A. Nadzharov). Doubts for any reason, a drop in initiative, the need for constant motivation, passive obedience, the position of "grown-up children" in the family. In production conditions, they are lost with minor deviations from their usual activities; in non-standard situations, they take a passive position with avoidant behavior and reactions of refusal.

4) Syndrome of monotonous activity and rigidity of affect (D.E. Melekhov, 1963).

Patients are distinguished by good performance, enthusiasm, tirelessness, invention, rationalization, professional erudition in stereotyping the working day and planning. The range of interests is preserved, but with the possibility of one attraction. Along with this, there is a lack of emotional resonance, a decrease in sympathy and empathy, dryness and restraint of emotional manifestations, external sociability and breadth of contacts in the absence of truly close people, inflexibility and elimination from solving family problems. There is resistance to frustration, lack of reactive lability, high self-esteem, not always adequate optimism, lack of critical attitude and rationalization in explaining the causes of the attack.

5) Pseudo-organic - is formed during the development of schizophrenia on organically altered soil.

It is characterized by a drop in mental activity and productivity, intellectual decline, rigidity of mental functions, leveling of personality traits, narrowing of contacts and range of interests (a simple deficiency type defect (Ey H., 1985), autochthonous asthenia (Glatzel J., 1978)). It is formed more often against the background of a family predisposition to schizoid psychopathy.

5) Syndrome of infantilism and juvenilism - more often formed with atypical seizures suffered in puberty and adolescence with heboid, pseudoneurotic, atypical depressive, dysmorphophobic disorders or overvalued formations such as metaphysical intoxication. "Juvenileism" is reflected in the manner of dressing, behaving in a team, in the choice of hobbies, friends, profession and worldview.

Neurocognitive deficit in schizophrenia.

In recent years, in psychiatry, the paradigm of the biological basis of mental disorders has received intensive development, within its framework - the concept of neurocognitive deficit in schizophrenia.

The neurobiological model of schizophrenia suggests a violation of the formation of the central nervous system, in the form of a decrease in the volume of gray matter, a decrease in the level of metabolism, membrane synthesis and regional blood flow of the prefrontal cortex, a decrease in delta sleep on the EEG. But evidence of damage to any specific area of ​​\u200b\u200bthe brain has not been received. Violations occur at the synaptic level, although there are data on structural violations in the literature.

Neurocognitive deficit is a form of information processing disorder, insufficiency of cognitive function: memory, attention, learning, executive function. It is observed in 97% of patients with schizophrenia and only in 7% in the healthy population. Cognitive decline is also observed in relatives of patients with schizophrenia. The main intellectual decline occurs in the first 2 years of the disease.

Neurocognitive deficits are regarded as the "third key group of symptoms" in schizophrenia, along with negative and productive disorders.

Intellectual functioning in patients with schizophrenia is relatively unaffected (IQ is only 10% lower than in healthy people). But at the same time, a “deficiency” of memory, attention, information processing speed, executive functions is revealed. This affects the social, professional viability and quality of life of patients with schizophrenia.

Memory disorders - relate to verbal and auditory modality, deficiency of working memory (working memory - the ability to capture information for use in subsequent activities). The deficit of working memory is manifested in a violation of storing information for a short period during which it is processed and coordinated with other long-term mental operations, which ultimately leads to the development of a response. The ability to concentrate is an indicator of solvency in solving problems and acquiring skills.

Attention impairment - auditory and visual modality, difficulty maintaining attention for a long time, sensitivity to distractions.

Insufficiency in schizophrenia of the executive function (drawing up and implementing plans, solving new problems that require the involvement of new knowledge. The state of the executive function - determines the ability to live in society) - a weak ability to plan, regulate behavior and set goals.

"Cognitive profile" of patients with schizophrenia (according to the results of averaged neurocognitive tests).

Normal or near-normal reading test result;

The lower limit of tests assessing simple sensory, speech and motor functions;

decrease by 10 points in IQ according to the Wechsler test;

1.5 to 3 standard deviations reduction in memory scores and more complex motor, spatial, and linguistic tasks;

Extremely low scores on tests of attention (especially attention span) and tests of problem-solving behavior.

AFFECTIVE MOOD DISORDERS.

Affective disorders are a group of mental disorders with various course options, the main clinical manifestation of which is a pathological decrease or increase in mood, accompanied by a violation of various areas of mental activity (motivation of activity, drives, voluntary control of behavior, cognitive functions) and somatic changes (vegetative, endocrine regulation, trophic, etc.)..

Antique period -Hippocrates "melancholy", "black bile"

1686 Theophile Bonet: "manico-melancolicus"

1854 J. Falret and Baillarger: "circular insanity"

1904 Emil Kraepelin "manic-depressive psychosis" .

Symptomatology - polar, phase affective oscillations

depressive phase.

Emotions - melancholy, depression, sadness, hopelessness, worthlessness, a sense of twin, the meaninglessness of existence; anxiety, fears, anxiety; pessimism; loss of interest in family, friends, work, sex; inability to have fun, have fun - anhedonia

Thinking - slowness of thinking, difficulty concentrating, making decisions; thoughts of failure, low self-esteem, inability to switch from negative thoughts; loss of a sense of reality, the appearance of hallucinations and delusions of depressive content is possible; suicidal thoughts (about 15% of untreated patients with affective disorders commit suicide).

Physical condition - changes in appetite and weight (70% lose weight, others gain); sometimes an excessive craving for sweets develops; sleep disturbances: although insomnia is a common complaint, about 15-30% feel an increased need for sleep, and they do not feel rested even after 12-14 hours of sleep; loss of energy, weakness, drowsiness; various pain sensations (headaches, muscle pains; bitter taste in the mouth, blurred vision, indigestion, constipation; agitation and anxiety.

Behavior - slow speech, movements, general "retardation"; excessive tearfulness or, conversely, the absence of tears, even if you want to cry; alcohol and/or drug abuse.

Typology of depressive syndromes: Melancholic depression; depression with anxiety; Anesthetic depression; adynamic depression; Depression with apathy; Dysphoric depression; Smiling (or ironic) depression; Tearful depression; Masked depression (“depression without depression”, somatization of depression) Somatization is a manifestation of a mental disorder in the form of physical suffering.

Manic phase.

The main symptom of mania is increased elation. As a rule, this mood grows in a certain dynamic sequence, which includes a successive change of the following phases:

Elevation of mood within the normal range: happiness, joy, fun (hyperthymia);

Moderate lifting: increased self-esteem, increased work capacity, activity, reduced need for sleep (hypomania);

Actually mania: manic symptoms increase and begin to disrupt the normal social activity of the patient;

- "delusional" or psychotic mania: excessive hyperactivity, irritability, hostility, possible aggression, delusions of grandeur and hallucinations

Emotions - elevated mood, feeling of uplift, euphoria, ecstasy.

But possible: irritability, malice, overreaction to ordinary things, lability, a quick change of mood: a feeling of happiness and after a minute anger for no apparent reason, hostility.

Thinking - increased self-esteem, ideas of greatness, one's own power; misinterpretation of events, bringing their own meaning to the comments of the usual content; distractibility, lack of concentration; jump of ideas, flight of thoughts, jumping from one topic to another; insufficiency of criticism to one's condition; loss of a sense of reality, the appearance of hallucinations and delusions is possible.

Physical state - increased energy, shortening of sleep - sometimes only 2 hours of sleep is enough, sharpening of perception of all senses - especially colors and light.

Behavior - involvement in adventures and grandiose plans. involuntary uncontrollable desire to communicate: can call friends on the phone many times at any time of the night to discuss their plans, excessive spending of money, often just giving away money, pointless multiple purchases, jumping from one activity to another, laughter, jokes, singing, dancing. Possible: malice and exactingness. Loquacity, speech is fast and loud. The emergence of a new interest in collecting something, increased sexual activity.

In the ICD-10 classification - grouped under heading F3 "MOOD DISORDERS"

According to modern concepts, painful episodes of mood disorders are a combination of symptoms (manic or depressive) that make up the dominant affective state.

Etiology: predominantly hereditary, autochthonous course.

The first episodes of the disease are often preceded by mental trauma (mental and physical overexertion), physiological changes (pregnancy, childbirth), exogenous factors (TBI, intoxication, somatic diseases), and subsequently their significance weakens.

Episode types

1. Depressive

2. Manic

3. Mixed

TYPES OF MOOD DISORDERS (according to ICD-10, DSM-1V classification).

1. Depressive disorders

depressive episode

Recurrent depression (Great depression)

Dysthymia

Other depressive disorder

2. Bipolar disorders:

first type

second type

Cyclothymia

Other Bipolar Disorders

3.Other affective disorders:

recurrent depression(Great depression according to DSM-1V)

Epidemiology: prevalence: men 2-4%, women 5-9% (men: women = 1:2), mean age of onset: ~30 years

Etiopathogenesis.

Genetic: 65-75% monozygotic twins, 14-19% dizygotic twins

Biochemical: neurotransmitter dysfunction at the synaptic level (decreased activity of serotonin, norepinephrine, dopamine)

Psychodynamic (low self-esteem matters)

Cognitive (negative thinking matters).

Risk factors - gender: female, age: onset in the age range of 25-50 years; the presence in the family history (heredity) - depression, alcohol abuse, personality disorders.

Anamnesis (especially early) - loss of one of the parents at the age of up to 11 years; negative conditions of education (violence, insufficient attention).

Personality type: suspicious, dependent, with obsessions.

Psychogenia - recent stress/traumatic situations (illness, court, financial difficulties), postpartum trauma, lack of close warm relationships (social isolation).

DYSTHYMIA is a variant of depressive disorders with moderate symptoms and a chronic course (more than 2 years).

Features of reduced mood with dysthymia:

increased sensitivity to the environment, irritability, resentment, angry reactions predominate. Inconsistency of actions and thoughts. Emotional and sensory hyperesthesia. Unstable (often overestimated in a latent form) self-esteem. Lethargy, relaxation. Stuck on insults and failures, the idea of ​​​​the malevolence of others. Preservation of motives with difficulty in their implementation. Increased appetite more often

If syndromic-completed depression develops against the background of dysthymia, "double depression" is diagnosed.

BIPOLAR DISORDER (BR).

Systematics:

Bipolar type 1 disorder is characterized by the presence of 1 or more manic or mixed episodes and at least 1 episode of syndromic-complete depression.

Bipolar type 11 disorder - 1 or more syndromic depressive episodes and at least 1 hypomanic episode.

Etiology.

1) Genetic predisposition - concordance of monozygotic twins 65-85%, dizygotic - 20%, 60-65% of patients with bipolar disorder have a family history of affective disorders

2) Environmental factors contributing to the manifestation of BD - stress, antidepressant therapy, sleep-wake rhythm disturbances, abuse of PA substances.

Prevalence - Lifetime prevalence: 1.3% (3.3 million people in U.S.) Age of onset: adolescence and around 20 years of age

The flow is periodic, in the form of dual phases and continual.

80-90% of patients with bipolar disorder have multiple relapses. The average number of episodes of the disease during a lifetime is 9

The duration of remissions (periods without symptoms of the disease) decreases with age and the number of previous episodes.

Diagnostics. Patients visit an average of 3.3 doctors before a correct diagnosis is made

The median time to a correct diagnosis is 8 years after the first visit to the doctor (60% of patients do not receive treatment during the 6-month period at the initial episode; 35% of patients do not even seek help within 10 years after the onset of the first symptoms of the disease; 34% patients initially receive a diagnosis other than that of bipolar disorder).

The frequency of suicides. 11-19% of patients with bipolar disorder commit suicide. At least 25% attempt suicide. 25-50% of patients have suicidal thoughts in a state of mixed mania

Differentiation between BD and unipolar depression is important.

Family history - Individuals with BD are more likely to have a family history of mood disorders as well as substance abuse.

PD - has a more pronounced hereditary predisposition.

Age of onset – PD is more common in adolescence, and LD is more common after 25 years of age.

The course - BP proceeds in more defined phases (with an abrupt onset and break) and has a more pronounced seasonality in manifestations.

Response to therapy – in PD, antidepressants are less effective and often contribute to the transition to mania.

Cyclothymia is a mild variant of bipolar affective disorder. Often seasonal. There are winter-spring and autumn depressions.

It belongs to transient dementia. On this subject, he wrote:

There has been some debate as to whether dementia in schizophrenia can be considered dementia proper. So, Kurt Schneider believed that in these cases, strictly speaking, there is no dementia, dementia, since “general judgments and memory, and so on, which can be attributed to intelligence, do not undergo direct changes,” but only some violations of thinking are observed. A. K. Anufriev noted that a patient suffering from schizophrenia can simultaneously appear in the course of a conversation with him to be both feeble-minded and not feeble-minded, and that the term "schizophrenic dementia" is quite justifiably taken in quotation marks. According to G. V. Grule (German) Russian, an intellectual disorder in schizophrenia depends on the characteristics of mental activity that do not directly affect the intellect and are volitional disorders such as apato-aboulia and thinking disorders. Therefore, one cannot speak of changes in intelligence in schizophrenia as classical dementia. In schizophrenic dementia, it is not the intellect that suffers, but the ability to use it. As the same G. V. Grule said:

Other authors compare intelligence in schizophrenia to a bookcase full of interesting, clever, and useful books to which the key has been lost. According to M. I. Weisfeld (), schizophrenic dementia is caused by "distraction" (delusions and hallucinations), "insufficient activity" of the personality before the illness, "the influence of acute psychotic states" and "non-exercise". On the latter occasion, he cites the words of the great figure of the Renaissance, Leonardo da Vinci, who claimed that the razor becomes rusty through disuse:

Criticizing the idea of ​​the outcome of mental illness in dementia, N. N. Pukhovsky notes that the phenomena attributed to "schizophrenic dementia" are closely related to toxic-allergic complications with inadequate tactics of active treatment of psychoses (including neuroleptic, ECT, insulin-comatose therapy, pyrotherapy), with the remnants of the system of constraint in psychiatric hospitals and the phenomena of hospitalism, desocialization, coercion, separation and isolation, domestic discomfort. He also links "schizophrenic dementia" to a defense mechanism of regression and repression (parapraxis).

Nevertheless, nevertheless, the discrepancy between intellectual reactions and stimuli indicates the presence of dementia in patients with schizophrenia, albeit in a peculiar version of it.

Story

Special dementia in patients with schizophrenia 4 years after the creation of the very concept of the disease by E. Bleiler was described by the Russian psychiatrist A. N. Bernstein in Clinical Lectures on Mental Illness. Prior to this, in the work of V. Kh. Kandinsky “On Pseudo-hallucinations” (1890), the author pointed out the possibility of an outcome in dementia of the disease of ideophrenia (the modern analogue of which is schizophrenia).

Classification

By classification A. O. Edelstein, based on the degree of disintegration of the personality, distinguish:

Pathogenesis

The pathogenesis of schizophrenic dementia, like schizophrenia itself, is not fully known. However, some of its aspects are described. The Austrian psychiatrist Josef Berze considered schizophrenic dementia to be "hypotension of consciousness". It is noteworthy that in the future many other scientists agreed with him: prominent researchers of schizophrenia K. Schneider, A. S. Kronfeld and O. K. E. Bumke. The Soviet physiologist IP Pavlov also considered schizophrenia to be a chronic hypnotic state. However, this is not enough to understand the pathogenesis of schizophrenic dementia. In schizophrenia, with the preservation of the elements of the intellect, its structure is disturbed. In this regard, the main clinic of the condition appears. According to V. A. Vnukov, expressed back in, the basis of schizophrenic dementia is the splitting of intellect and perceptions, paralogical thinking and flattened affect.

Clinical picture

Perceptual disorders

Memory disorders

Memory in schizophrenic dementia, as in schizophrenia in general, is preserved for a long time. Such patients are well oriented in their own personality, space and time. According to E. Bleiler, the phenomenon when patients with schizophrenia, along with psychotic ones, have preserved some aspects of intelligence, is figuratively called "double bookkeeping".

Forecast

Since schizophrenia is a chronic and progressive disease, the prognosis for recovery from such dementia, if it has already occurred, is generally uncertain. However, since this dementia is transient, if the course of the disease itself has been stopped, the prognosis can be relatively favorable. In other cases, an extremely unfavorable outcome is possible. Either an extreme increase in negative symptoms occurs in the form of a complete

Dementia is an irreversible progressive degradation of the intellect. When there is a disorder of the intellect, as if passing, depending on the state of the person. Proper adequate treatment can improve the patient's condition.

Dementia in schizophrenia occurs periodically. At the same time, dementia itself is unstable, and a patient with schizophrenia, who was considered demented, suddenly shows a good memory and thinking. For this reason, schizophrenic dementia is called transient (transient).

Symptoms

The period of exacerbation begins against the background of anxiety or depression, as a result of the formation of psychosis. Some typical features of behavior can be identified.

• Patients with schizophrenia begin to be afraid of something, they may begin to hide or climb certain objects. Emotions of fear are associated with the presence of hallucinations with vivid images of a fantastic nature.
• Usually there are problems of orientation in space, patients may forget how to use ordinary household appliances.
• The behavior of adults resembles that of a child. For example, when asked about the number of fingers, a person begins to count them, gets embarrassed and loses count. Manipulations with clothes can often be simply comical and at first glance seem to be feigned, until it becomes clear that a person is not pretending or making faces, but really confuses the purpose of toilet items.
• Performing neurological diagnostic exercises, the patient can take out the earlobe instead of the tip of the nose, and according to the instruction “show your teeth”, lifts his lips with his hands.
• In behavior, one can observe imitation of animals: they bark, crawl on all fours, lap up soup from a plate.
• The phenomenon of echolalia may appear: mirror answers follow the questions. Patients may forget the names of objects. Instead, explain the meaning. Sometimes there is a long speech from sentences that are literate in structure, but absolutely meaningless.
• In behavior, there is a change in periods of excitation and inhibition. After fuss and activity, one can observe complete immobility and lethargy.

Orientation in space and time is gradually restored, anxiety disappears, patients become adequate and move on to communication. The period of psychosis is forgotten.

In schizophrenia, memory is preserved, and the patient retains the ability to think abstractly for a long time. However, there is a change in focus, that is, thinking is not productive and symbolic. Man is prone to meaningless philosophizing. There is thinking, but it becomes far from real life. At the same time, the knowledge base is slowly decreasing, and skills, including vital ones, are being lost. There are also problems with concentration.

Along with intellectual disabilities, there is a loss of the desire to communicate, and autism develops.

In the severe stage, patients do not lose the ability to move, but are almost immobile, cannot eat on their own, cease to control physiological needs, and do not answer questions.

Disorders of mental processes

• Perception. In schizophrenia, first of all, symbolism and is observed. The perception of the external world is deprived of reality, which negatively affects the intellect as a whole.
• Disorder of thought. Schizophrenic dementia is characterized by pretentiousness, symbolism, mannerisms, mosaic, formality. Thoughts, as it were, "disperse" in different directions. There is a speech disorder, often in the form when the forms are correct, and the meaning of what was said is completely lost.
• Memory disorder. Memory in schizophrenic dementia remains intact, but the patient cannot use its reserves, and is oriented only in his own personality, is not able to create logical space-time connections. At the same time, some preserved aspects and logical conclusions can be observed, which confuses others who cannot understand the sanity of a person.

Since it is an irreversible disease, the prognosis of dementia treatment is doubtful. But, given the transience of the condition, when establishing the diagnosis of the disease itself, the prognosis can be favorable.

these terms are often used to this day; however, they are not used in ICD-10 as not well-defined.

In 1911, the Swiss psychiatrist E. Bleuler proposed a new term for the name of this disease - "schizophrenia" (from the Greek schiso - splitting and phren - soul). The term "dementia praecox" did not correspond to the essence of the disease, since it often not only did not end with dementia, but even a practical recovery was occasionally observed. The possibility of such an outcome in dementia praecox was also noted by E. Kraepelin.

E. Bleiler believed that the most important symptom of the disease is not a kind of dementia, but a special discordance, splitting of mental processes ("schism") and a specific modification of the personality as a result of the development of a disease process. They were identified primary and secondary signs of the disease. The primary ones include the patient's loss of social contacts and increasing isolation (autism), impoverishment of emotionality (apathy), special thinking disorders (reasoning, fragmentation, paralogy, symbolism) and the splitting of the psyche - schism (dissociation between various mental manifestations, ambivalence). In English-speaking countries, these disorders are often described as "four A "Bleuler: Autism, decrease in Affect (emotional impoverishment), violation of harmony of Associations, Ambivalence. In the Russian tradition, these mental disorders are classified as personality changes of the schizophrenic type (see section 13.3.1). Basically, the symptoms described are negative disorders. They play a decisive role in the diagnosis of schizophrenia.

Other mental disorders, defined by E. Bleuler as secondary, additional, are manifested by senestopathies, illusions and hallucinations, delusions, catatonia, atypical affective seizures (mania and depression). He did not consider these disorders to be the main ones in the diagnosis of the disease, since they also occur in other diseases, although some of them may be typical of schizophrenia. Essentially, these disorders are productive or positive symptoms.

Although productive symptoms are not mandatory for schizophrenia, it should be recognized that there are very characteristic (especially for some forms of the disease) syndromes. In 1925, K. Schneider described the most typical variants of delusions, which he designated as "syndromes of the first rank", including ideas of influence with a feeling of interference in the process of thinking, transmitting thoughts at a distance, reading and taking away thoughts, breaks in thinking, putting in and taking away feelings and actions. In the Russian psyche

atria, these disorders are considered as the Kandinsky-Clerambault syndrome of mental automatism (see section 5.3). The syndrome of mental automatism is observed in schizophrenia quite often (up to 55% of cases), but does not serve as an obligatory manifestation of the disease. Automatism is a typical example of schizism (splitting) in schizophrenia, since the mental acts inherent in the patient in his mind are divided (split) into those that belong and do not belong to him.

Works of many authoritative Russian and foreign psychiatrists are devoted to the study of schizophrenia [Kleist K., 1913, 1953; Leonhard K., 1936, 1960; Kerbikov O.V., 1949; Hey A., 1954; Konrad K., 1958; Snezhnevsky A.V., 1960, 1972; Nadzharov R.A., 1964, 1972; Smulevich A.B., 1980, etc.]. In the XX century. managed to obtain a lot of new information about the genetics, biochemistry, pathological anatomy of this disease. However, until now, the classic works of E. Kraepelin, E. Bleuler and K. Schneider are the basis of the modern classification and diagnosis of the disease, which is reflected in the structure of the ICD-10 (see section 14.3).

The question of the spread of schizophrenia among the population is an important issue both in scientific and practical terms. Data obtained by different authors may vary somewhat due to differences in diagnostic approaches. The number of identified patients largely depends on the availability of psychiatric care and society's tolerance for the mentally ill. Nevertheless, the available statistical data and the results of epidemiological studies allow us to conclude that the prevalence rates of the most obvious psychotic forms of the disease are similar in all countries and amount to 1-2% of the general population. The initial assumption that schizophrenia is less common in developing countries has not been confirmed. The results of studies specifically conducted in developing countries revealed almost the same incidence of schizophrenia as in Europe. There is only a difference in the clinical manifestations of the disease. So, in patients living in developing countries, acute conditions with clouding of consciousness, catatonic syndromes, etc. are more common. Somewhat more often, cases of the disease are noted in clusters of a migrating population.

Clinical manifestations.

Syndromic forms

Schizophrenia can start at any age. However, the most typical is the young age (20-23 years). However, for certain initial clinical forms of schizophrenia

rhenium has its own "optimal" timing. So, the paranoid form begins more often at the age of over 30 years, variants with neurosis-like symptoms, thought disorders - in adolescence and adolescence. Although the incidence of schizophrenia is the same in men and women, in males the onset of the disease is on average earlier than in women. Symptoms may also differ depending on the gender of the patients. In women, the disease is more acute, in its clinical manifestations, various affective pathologies are more often and more pronounced. Early malignant variants of the disease are more often observed in boys.

Quite often (but not always) it is possible to identify characteristic premorbid personality traits. More typical are isolation, low physical activity, obedience, a tendency to fantasize, an interest in solitary activities (reading, listening to music, collecting). Many patients demonstrate a good ability for abstract thinking, they are easily given the exact sciences (physics, mathematics). In the 20s, E. Kretschmer, after analyzing body types (see section 1.2.3), indicated that the schizoid type is characterized by elongated proportions, poor muscle development (asthenic, or leptosomal, type).

" O debit disease is evidenced by a significant change in the patient's habitual lifestyle. He loses interest in his favorite activities, dramatically changes his attitude towards family and friends. There is an unusual interest in philosophy, religion, ethics, cosmology ("metaphysical intoxication"). Some patients are extremely concerned about their health, show hypochondria, others begin to behave asocially. This process is accompanied by the rupture of former social ties and growing autism.

Symptoms manifest period Schizophrenia is characterized by a variety of clinical manifestations.

Most characteristic of schizophrenia thought disorders. Patients often complain of an uncontrollable stream of thoughts, a stop, a "blockage", a parallelism of thoughts. All these phenomena at times prevent them from understanding the interlocutor, comprehending the meaning of what they read. There is a tendency to capture a special symbolic meaning in individual sentences, words, to create new words (neologisms). Thinking is often vague, in statements there is, as it were, slipping from one topic to another without a visible logical connection. They are characterized by versatility in judgments. Often errors in thinking are explained by the special attention of patients to insignificant features of objects and phenomena. Characterized by a tendency to fruitless sophistication, reasoning

(reasoning). Logical inconsistency in statements in a number of patients with far-reaching painful changes takes on the character of speech discontinuity: although it retains grammatical correctness, it loses its meaning (schizophasia).

Emotional disorders begin with the loss of feelings of affection and compassion for loved ones. Sometimes this is accompanied by hostility and malice towards them. Over time, interest in your favorite business decreases and completely disappears. Patients become sloppy, do not comply with elementary hygiene requirements.

An essential feature of the disease are also the characteristics of the behavior of patients. Closeness develops quite early, relations are broken not only with relatives, but also with former comrades. Patients perform unexpected actions, the manner of speech and facial expressions change. All this happens without connection with any external circumstances and is surprising to people who knew the patient well before.

For schizophrenia, various peculiar senestopathic manifestations are also typical. Senestopathy have a quirky, unusual character. Localization and manifestation of senestopathies do not correspond to the painful sensations that occur with somatic diseases.

Perceptual disturbances are predominantly auditory hallucinations(more often pseudo hallucinations) although tactile, olfactory, and visual deceptions may also occur. Typical manifestations of the disease include various types of bullshit- paranoid, paranoid and paraphrenic. Very characteristic of schizophrenia is the delirium of influence, which is usually combined with pseudohallucinations - Kandinsky-Clerambault syndrome.

Motor-volitional disorders are diverse in their manifestations. They are found in the form of a disorder of voluntary activity and in the form of a pathology of more complex volitional acts. One of the brightest types of violation of voluntary activity is catatonic syndrome, manifested by states of stupor and arousal. The stupor can be interrupted by catatonic excitement and impulsive actions. There are lucid and oneiroid variants of the catatonic syndrome. Lucid catatonia indicates an unfavorable prognosis of the disease and is often observed at a late stage in the development of paranoid schizophrenia. Oneiroid catatonia indicates the severity of the disease process and often ends in remission.

More complex volitional acts, volitional processes also undergo significant changes under the influence of the disease. In patients, sometimes 2 opinions coexist, 2 decisions on the same

the same issue (ambivalence), which prevents them from acting consistently. Typical for schizophrenia is a constant decrease in volitional activity. (energy potential reduction), ending in lethargy and apathy. These symptoms were important for isolating dementia praecox into an independent nosology. Their severity correlates with the progression of the disease. However, in some patients there may be an increase in activity associated with certain painfully conditioned ideas and attitudes. So, for example, in connection with delusional ideas and painful attitudes, patients are able to overcome many difficulties, show initiative and perseverance, and do a lot of work. The content of painful experiences, delusional ideas in patients may be different. At the same time, it reflects the spirit of the time, certain socially significant phenomena.

Although patients with schizophrenia may show a large number of errors in an experimental study of memory and intelligence, these disorders express the lack of necessary attention and emotional interest inherent in these patients. It is believed that in general, memory and intelligence disorders are not characteristic of schizophrenia. The term "schizophrenic dementia" is quite widely used to refer to the outcome of the most malignant forms of the disease, but the nature of such dementia differs significantly from the outcome of typical organic brain diseases (see section 7.2).

forms of schizophrenia. From the moment schizophrenia was singled out as an independent disease, its thorough clinical study and follow-up observations were constantly carried out to identify various forms of schizophrenia and its systematics. The proposed various national classifications were significantly, and sometimes fundamentally different from each other. A compromise between different positions was the return in the ICD-10 to the forms described by E. Kraepelin in the concept of dementia parecox. Below is a more detailed description of them.

paranoid form occurs more frequently than others. Along with the cardinal signs of the disease (autism, disordered thinking, depression and inadequacy of emotions), delirium is the leading symptom in the clinical picture of this form (see section 5.3). The progression of the disease is expressed in a sequential change paranoid(systematized interpretive delusions of persecution without hallucinations), paranoid(in most cases it is represented by a syndrome of mental automatism) and paraphrenic syndromes(crazy ideas of grandeur against the background of euphoria or complacently indifferent mood, often accompanied by

ridiculous fantasies, confabulations and the collapse of the delusional system).

Although the course of the paranoid form can be variable, it is more typical for it to have persistent delusions and pseudohallucinations without noticeable remissions. The onset of the disease in most cases falls on the period of youth and maturity (25-40 years). The emotional defect in most cases increases gradually and allows patients to maintain social ties for a long time. Some patients remain able-bodied for a long time, save their families. With an earlier onset, the disease flows malignantly.

A 40-year-old patient, power engineer. Heredity is not burdened. The father is tough, domineering, the mother is malleable, soft. Older sisters are married, also work as engineers, caring. The patient studied well at school, was a little shy. He graduated from the Moscow Power Engineering Institute and worked in his specialty at a research institute. Promoted quickly in the service, relations with employees developed well. Married at 23. The daughter is healthy and is finishing school.

About a year before the first hospitalization, he noticed an unfriendly attitude towards himself on the part of the employees, became cautious with them, distrustful. Then he drew attention to the fact that on the street people unfamiliar to him, when he appeared, began to smile, spit behind his back, cough and sneeze. He felt especially unpleasant in public transport, because he felt that passengers were deliberately pushing him and shoving a newspaper in his face. He often went on business trips, while at first he did not notice such persecution in other cities. However, shortly before hospitalization, he discovered that the "persecutors" appeared in all settlements. He was so disturbed by this situation that he could not work at all. Relations in the family were broken, he began to drink often, because after taking alcohol he felt somewhat calmer. At the insistence of his wife and sisters, he was hospitalized.

In the clinic, he quite openly talks about his experiences, finds numerous evidence of the non-randomness of any event. In the hospital, he is quite calm, closed, does not communicate with any of the patients. He does not consider himself sick, but he takes medication on his own, without persuasion. Against the background of antipsychotic therapy (triftazine, chlorpromazine and haloperidol), he became more passive, indifferent. In the clinic, he does not notice the persecution, but he cannot agree with the possible painful origin of the “experienced events”.

After being discharged from the clinic, he tried to go to work, but the institute where he had previously worked was closed due to economic difficulties. Didn't try to find a new job. He lived on his wife's money, often drank. Rarely left the house. I began to notice again that the persecution was going on, including at home. He was convinced that the former employees read his thoughts, sometimes he heard incomprehensible whispers, clicks in his head, he considered these phenomena to be signs of "malfunctions in the equipment." Subsequently, he was repeatedly treated in the hospital, but without a significant effect. Was declared disabled. Identified group II disability. At the insistence of his wife, a divorce was filed.

hebephrenic form- one of the most malignant forms of schizophrenia. Its main manifestation is hebephrenic syndrome (see section 9.1). The diagnosis is based on the predominance of childishness and ridiculous, foolish excitement in the manifestations of the disease. The mood is dominated by empty, unproductive euphoria, antics, inadequate laughter, followed by bouts of indignation, aggression, senseless destruction. Speech quickly loses consistency, replete with repetitions and neologisms, often accompanied by cynical abuse. Behavior consists of non-purposeful activity combined with stubbornness and negativism. Against this background, personality changes, a drop in activity, the destruction of emotional ties are catastrophically increasing, indifference and passivity dominate. Patients become unable to solve the simplest practical problems and therefore require constant care and supervision.

The disease begins in adolescence (13-15 years) and then proceeds without remission. Patients become disabled before starting work.

A 27-year-old patient, disabled person of group I.

The patient's older brother suffers from paranoid schizophrenia. The mother is unassembled, anxious, speaks without listening to the interlocutor. Divorced for many years from the patient's father. Father - an engineer, calm, asthenic physique. He does not like to talk to doctors, although he often visits his son in the department. The patient himself from childhood was distinguished by awkwardness, a dysplastic physique (a long hooked nose, deep-set eyes, a pale face with bruises under the eyes, thin, long arms, a sagging stomach). He was very attached to his mother and grandmother, did not like noisy children's company. I studied poorly at school. The question of duplicating classes constantly arose, but the mother begged the teachers and he was given “triples”. At the end of the 8th grade, he entered a vocational school and received the specialty of a confectioner. He was accepted into the factory, but no one took him seriously there. He only did menial work. He cried, declared that he was offended there.

Even at school, the patient had periods when he became capricious. For a long time he did not go to bed at night, pestered his mother and grandmother with ridiculous questions and jokes. If they refused to answer, he began to swear, swear, scatter things. Despite his small stature and asthenic physique, he rushed at his mother and grandmother with his fists, threw heavy objects at them. Laughed when he noticed that he hurt; stuck out his tongue, excitedly asked: “Well, did you get it?”. He was treated in the teenage department of a psychiatric hospital. After treatment, he became calmer. He rejoiced at the arrival of his mother in the hospital, caressed her like a child; cried when she was about to leave. In adolescence and youth, he was treated in the hospital more than 5 times. Since he was treated with disdain at work, in the end he declared that he would not work anymore. I didn’t do anything at home, I didn’t read, I didn’t like to watch TV. Sat in the corner

I watched my mother and grandmother move around the apartment. Laughed if someone stumbled or dropped something. This hospitalization is associated with another attack of aggression.

Upon admission, he first examines doctors with caution, but soon begins to behave quite freely. There is an indistinct grimace on his face: a wrinkled forehead, wide-open eyes, lips folded into an absurd smile. He speaks with a stammer, with a childlike intonation. Often repeats the same statement several times, although he sees that the interlocutor understood him well. Stereotypically asks when he will be discharged; repeats over and over again that he will behave well. Leaving the office, he immediately returns and repeats word for word everything that he had just told the doctors. He pesters nurses and patients with the same questions. Repeats (sometimes with a smile) what he just said, even though other patients get angry at him and threaten to beat him up. He reluctantly agrees to a psychological examination, refuses to show how he writes: “Why is this, I can do it, I studied at school!”. He writes without errors in large children's handwriting. He counts quite well, but such an examination quickly bothers him, and he declares: “Enough!”. Refuses to help the staff in cleaning the premises: "I'm sick!". If the doctor asks what the disease is, he immediately answers: “I am healthy! You promised to write me out!”.

Catatonic form characterized by a predominance of movement disorders (see section 9.1). catatonic stupor differs in that the patient maintains an elaborate, unnatural, often uncomfortable posture for a long time, without feeling tired. For example, lies with his head raised above the pillow ( air bag symptom) covers the head with a sheet or the floors of a dressing gown ( hood symptom) maintains uterine posture. At the same time, muscle tone is sharply increased. This allows you to give the patients any posture that they will continue to maintain ( catalepsy- wax flexibility). Primitive reflexes are often disinhibited (grasping, sucking - proboscis symptom). Patients are characterized negativism(refusing to follow instructions or even doing the opposite of what is required) and mutism(complete lack of speech in the presence of the ability to understand the words of the interlocutor and the team). The immobility of patients can coexist with impulsive acts and attacks of non-purposeful, often stereotyped - catatonic excitement. Other symptoms of catatonia are the desire to copy the movements, facial expressions and statements of the interlocutor ( echopraxia, echomimic, echolalia) mannerisms, pretentiousness of movements and facial expressions, passive (automatic) obedience (lack of spontaneous activity until the patient receives precise instructions).

Catatonic symptoms may be accompanied by clouding of consciousness ( oneiroid catatonia) or arise against the background of a clear consciousness ( lucid catatonia). Lucid catatonia is one of the variants of the malignant course of schizophrenia.

rhenium. Beginning in adolescence, it flows continuously and is accompanied by rapidly growing personality changes, a deep apatico-abulic defect, and early disability. In recent years, this form of schizophrenia has become extremely rare in developed countries.

A 17-year-old patient, a collective farmer, was brought to the clinic due to severe motor retardation and inaccessibility. Heredity is not burdened. Born and raised in the village. Parents work on a collective farm (mother is an accountant, father is a tractor driver). In early childhood, he was no different from his peers. I studied at school without much diligence. After graduating from the 8th grade, he decided to work on a farm. Occasionally drank, but never abused alcohol; smokes. He spent his free time with village boys, but in the company of his peers he was never a ringleader.

I started skipping work about 6 months ago. In the morning he refused to get out of bed, lay with his eyes open, did not answer questions. Later he got up, ate with appetite, but silently. For weeks he did not bathe, did not brush his teeth, refused to change his underwear. Once, when his father forcibly pushed him into the bathroom, the patient closed himself and did not leave it for 4 hours, refusing to open the door. The mother took her son to a psychic, because she decided that he had been “damaged”. At the reception, he suddenly jumped up, attacked the psychic, broke the glass door. Then he scolded his mother, accused her of "spoiling everything." The mother decided to take her son to the monastery, but the abbot said that the son was "possessed" and could not be in a holy place. We spent two nights behind the walls of the monastery in prayer. All this time, the son sat in the same position, not answering questions, did not eat anything. At the insistence of the abbot of the monastery, the son was taken to the regional psychiatric hospital. In the hospital, he did not eat and did not answer questions, he lay on the bed for several days without changing his position. The mother insisted on being discharged and took her son to a Moscow clinic.

On objective examination: the patient is tall, asthenic build. On the heels are deep, crusted ulcers (consequences of bedsores from prolonged lying in one position - on the back). Doesn't answer questions when asked. Left to himself, he goes to bed. Doesn't get up to eat does not drink; spits out medicine. Muscle tone is sharply increased; the patient's hand, raised by the doctor, hangs in the air for several minutes.

On the first day, injections of neuroleptics (haloperidol, chlorpromazine) were prescribed. On the 2nd day he began to eat and drink, but refused to take pills. On the 2nd week of stay in the clinic, he began to answer some questions. Managed to switch to oral medication. He was in the clinic for about 2 months, while some stiffness remained. He spoke little, could not explain his lethargy. I did not communicate with patients. After being discharged, he did not return to work. Issued 11 disability group.

simple form manifested almost exclusively by negative symptoms. Unlike other forms, productive disorders (delusions, movement disorders, and affective symptoms) either do not occur at all, or

on loi krappe unsophisticated and reduced. Steadily parasitic anatic-abulic defect is predominant. At the beginning of the disease, there is a refusal to study and work, sk.yunnosp, to vagrancy, a break with the family and 1. ticks. In la.p.meishem, patients become completely indifferent to the events taking place around them. cold. > gopsy; geryakch accumulated stock of knowledge that allows us to create about a kind of paccrpoiicive intellect-ia (intizophrenic dementia-") For ion ((yurmas, the onset is characteristic in adolescence and youthful age: continuous. non-remission course. rapid progression and early disability of zapiya.

Simple schizophrenia. hebephreia and lunar catatonia are the most malignant variants of the disease. With these forms, the disease process debuts in adolescence and youth, before the patient has time to get an education. Such patients, as a rule, do not have a profession and family. Disability is often formalized before reaching working age. Rough personality changes lead to intellectual inactivity. In most cases, the disorders are so pronounced that the diagnosis does not present any difficulties. Most patients are not only unable to work, but also require special care because they cannot take care of themselves, do not wash, do not cook, do not leave the house. Sometimes these forms are combined into the concept juvenile malignant schizophrenia.

Along with malignant variants of the disease, forms of the disease are traditionally described with slowly progressive personality changes and a relatively favorable outcome. The attitude to these psychoses in various psychiatric schools is ambiguous. Therefore, the authors of the ICD-10 tried to separate these controversial variants of the disease from the classical forms.

circular shape distinguished by a number of psychiatrists since the time of Kraepelin. It is characterized by a predominance of vivid emotional disorders (attacks of mania and depression), interspersed with periods of complete reduction of psychosis, combined with a mild, slowly progressive defect in the emotional-volitional sphere. The relatively favorable prognosis of this variant of psychosis makes it difficult to distinguish it from the bipolar type of manic-depressive psychosis (MDP). The ICD-10 recommends classifying such psychosis as a TIR IF31. The condition of patients is assessed somewhat differently if, along with distinct affective disorders (mania or depression), there is a vivid schizophrenic symptomatology in the form of delusions of influence or grandeur, mental automatism, and alertness. oneiric catatonia. Generally

the prognosis for such patients is relatively favorable and they retain their ability to work, however, despite distinct periods of remission, an increase in personality changes is noticeable. In the Russian tradition, this variant of the more shi flow is considered as "recurrent schizophrenia"(See section 1U.1.2). In the ICD-10, such disorders are classified as schizoaffective psychosis .

Senesgopagia (hard to describe extremely unpleasant sensations in the gel) are very characteristic of some variants of schizophrenia. A distinct emotional-volitional defect in such cases does not reach the degree of emotional dullness. Productive symptoms are expressed by senestopathies and hypochondriacal ideas that do not reach the degree of delirium. The foregoing served as the basis for highlighting a special - senestopathic-hypochondriac form of schizophrenia ,

Starting with the works of E. Bleuler, there has been debate about the possibility of a mild personality defect without a previous psychosis. Such mild, latent forms of schizophrenia include cases of strange, eccentric behavior with characteristic violations of the harmony of thinking, supervalue, abundant obsessions of abstract content, artistry, maladaptation. The genetic connection of such disorders with schizophrenia has been confirmed by many studies, however, the non-progression of symptoms, the absence of distinct psychotic episodes, determine the caution in assigning a diagnosis of schizophrenia to such patients. In ICD-10, their condition is defined as schizotypal disorder(see section 19.1.4).

The disadvantage of the proposed classification is the conventionality of the boundaries between its individual forms. Often there is a change in symptoms in the course of the disease. So, catatonic symptoms can be observed in the initial period of the disease or occur with typical paranoid schizophrenia in the final stages ( secondary catatonia). Senestopathies can eventually be replaced by typical delusions of exposure. Therefore, the type of course is often more important for the prognosis of the disease.

course of schizophrenia. Flow types

The course of schizophrenia is defined as chronic, progressive. Some forms, which begin at an early age and proceed continuously, progress rapidly, develop malignantly and within 3-5 years lead to a severe, so-called initial or final state.

The most typical form final state is an apathico-abulic syndrome. Patients are inactive, indifferent; their speech is monotonous. They hardly engage in simple

work. Along with this, there may be other mental disorders (fantastic, unsystematic delusions, hallucinations, peculiar thinking disorders, grammatically correct but meaningless speech - schizophasia), which together create a wide range of initial states.

An unfavorable outcome may also occur with a less malignant variant of schizophrenia, but it occurs at a later date.

Occasionally and with a continuous course of schizophrenia, a relatively favorable outcome is possible. So, at certain stages of the development of the disease, psychopathological symptoms can stabilize, change and weaken. Such changes in the course of the disease are the result of the spontaneous development of the disease process or the result of ongoing treatment. Signs indicating a more or less favorable course of schizophrenia are presented in Table. 19.1.