Clinical characteristics of schizophrenia. Comparative psychopathological characteristics of patients with paranoid schizophrenia who committed and did not commit socially dangerous actions

Schizophrenia is included in the group of endogenous and endogenous-limiting mental diseases. This group includes diseases, the cause of which has not yet been established, although the available data indicate the pathology of internal processes in the body, leading to mental disorders. It is also known that schizophrenia (and in general all endogenous diseases) is often observed in persons with a hereditary burden of the disease. Even the risk of schizophrenia was determined depending on the degree of relationship.

With schizophrenia, patients become withdrawn, lose social contacts, they have a depletion of emotional reactions. At the same time, various degrees of severity of disorders of sensations, thinking, perception and motor-volitional disorders are observed.

The psychopathological manifestations of schizophrenia are very diverse. According to their characteristics, they are divided into negative and productive. Negative ones reflect the loss or perversion of functions, productive - the identification of specific symptoms, namely:

hallucinations, delusions, affective tension and others. Their ratio and representation in the mental state of the patient depend on the severity and form of the disease.

For schizophrenia, the most characteristic are peculiar disorders that characterize changes in the patient's personality. These changes relate to all the mental properties of the individual, and the severity of the changes reflects the malignancy of the disease process. The most typical are intellectual and emotional disturbances.

Let us briefly consider each of the typical disorders in schizophrenia:

Intellectual disorders. They manifest themselves in various ways of thinking disorders: patients complain of an uncontrollable flow of thoughts, their blockage, and others. It is difficult for them to comprehend the meaning of the text they read. There is a tendency to capture a special meaning in individual sentences, words, to create new words. Thinking is often vague, in statements there is, as it were, slipping from one topic to another without a visible logical connection. In a number of patients, the logical sequence acquires the character of speech discontinuity (schizophasia).

Emotional disorders. They begin with the loss of moral and ethical properties, feelings of affection and compassion for loved ones, and sometimes this is accompanied by acute hostility and malice. In some cases, there is emotional ambivalence, that is, the simultaneous existence of two conflicting feelings. Emotional dissociations occur when, for example, tragic events cause joy. Emotional dullness is characteristic - impoverishment of emotional manifestations up to their complete loss.

Disorders of behavior, or violations of volitional activity. Most often they are the result of emotional disturbances. It decreases, and over time, interest in your favorite business disappears altogether. Patients become slovenly, do not observe elementary hygienic personal care. The extreme form of such disorders is the so-called abulic-akinetic syndrome, characterized by the absence of any volitional or behavioral impulses and complete immobility.

Perceptual disorders. They are manifested mainly by auditory hallucinations and often by various pseudo-hallucinations of various sense organs: visual, auditory, olfactory.

There are three forms of schizophrenia: continuous, periodic and paroxysmal-progredient, - “the systematics of forms of schizophrenia, which is based on a fundamentally different nature of their course with the unity of symptomology and trends in the dynamics of the pathological process, the stereotype of the development of the disease. There are continuous, recurrent and paroxysmal - progressive schizophrenia. Each of these forms includes different clinical variants.”

The table shows a comparison between the two groups of patients by age (at the time of the survey), some social indicators. reflecting the picture social adaptation patients, as well as the duration and degree of malignancy of the course of the schizophrenic process.

As can be seen from the table, there was no significant difference in the age of the patients between the two groups ( average age within 32-33 years).

A different picture is observed when comparing social indicators. Thus, almost half of the patients in the second (control) group had families and, despite their relatively young age, most of them (80%) received secondary and higher education. At the same time, more than half (52%) of patients were not working or studying at the time of the examination. In this regard, we can talk about their rapid social maladjustment. A large proportion (56%) of persons with disabilities due to mental illness confirms this.

Other social indicators characterize the patients of the main group. Most of them did not have a family and acquired only primary education (17 and 15 people, respectively, i.e. 68 and 60%). However, the number of employed patients is relatively high (68% worked or studied). At the same time, the vast majority of patients (23 out of 25) did not have a disability, and only one was a disabled person of the second group due to mental illness.

Thus, when comparing the two groups of patients, the difference in social indicators attracts attention. It should be noted that a lower educational level and worse family adaptation among patients with schizophrenia who committed socially dangerous acts were found in epidemiological studies by N.M. Zharikov et al. (1965) and V.M. Shumakov (1974). However, statistical analysis does not provide a clear explanation for this fact. There is an assumption that the difference in the level of social adaptation is associated with features in the clinic of schizophrenia. When analyzing the clinical features, first of all, a difference in the degree of progression of the schizophrenic process and the duration of the disease is revealed.

So, in patients of the control group, the disease began on average at the age of 22-23 years. Apparently, this circumstance is associated with a relatively higher educational level of these patients and the possibility of better family adaptation. At the same time, the rate of development of the process was in most cases fast and moderately progressive (92%). These data, compared with average duration diseases in this group at the time of the survey (10.5 years) and the indicator of disability (14 mentally ill patients, including 12 disabled people of the 1st and 2nd groups) indicate a significant severity of the schizophrenic process.

In the clinical picture of the disease in patients of the control group, there were psychopathological features characteristic of malignant types of schizophrenia.

The structure of the paranoid syndrome was dominated by polythematic delusions, accompanied, as a rule, by pronounced affective fluctuations and abnormal behavior of patients. The latter contributed to the timely detection of mental illness and hospitalization.

The delusional syndrome in these patients had the character of a widespread and vague delusion of persecution. Usually delusional ideas were non-specific. Patients suspected that “someone is harming” them, “pursuing, but it is not known who”, stated that they feel “some effect”. In most cases, there was no persistence of the topic of delirium. Paranoid ideas of various content quickly replaced one another. The polythematic nature and frequent change of one topic of delirium to another led to the fact that delirium, remaining all the time leading in the clinical picture of the disease, did not represent significant relevance for the patient. At the same time, his behavior, although often due to delusional experiences, was, on the one hand, very changeable, non-purposeful, and on the other hand, so unusual that it led to emergency intervention by psychiatrists and placement in a psychiatric hospital.

It should be emphasized that usually delusional syndrome occurred during exacerbations of the condition and was accompanied by affective disorders.

As an example, we cite one of the exacerbations of the schizophrenic process in patient K., who, being at home, became excitable, angry, sometimes shouted out separate words incoherently, stripped himself, tore his clothes. On the 3rd day of this state, he unexpectedly announced that his wife was "connected with fascist intelligence", cut the telephone cord and locked himself in his room. Upon the doctor's arrival, he willingly went to the hospital, declaring that "it's dangerous at home." In the psychiatric ward, the patient refused to eat, stating that medical workers they want to poison him, but he willingly took the writing from the hands of his wife who visited him.

In this observation, first of all, a significant acuteness of the condition is traced, accompanied by changes in efficiency, separate catatonic inclusions, fragmentary delusions of persecution with an ambivalent attitude towards the object of the delusional theme (wife - "persecutor"). Attention is drawn to the ease of the patient's consent to hospitalization, reminiscent of the pathological motivation of behavior according to the type of "delusional defense" (II. Shipkovensky, 1973).

In other cases, one could also talk about the polymorphism of psychopathological symptoms. At the same time, psychopathological phenomena, including the leading delusional syndrome, bore the features of either a significant severity of the condition, or were combined with defect-symptoms, and the clinical picture approached the “big syndrome” according to A.V. Snezhnevsky with his characteristic mosaic of symptoms. So, in the structure of the paranoid syndrome, delusional ideas were combined with dysmorphophobic disorders, elements of the Kandinsky syndrome, false recognition, catatonic symptoms were observed, sometimes even elements of oneiroid.

On the other hand, this group of observations was characterized by the rapid formation of a schizophrenic personality defect. Lethargy, spontaneousness, ambivalence, and intellectual disturbances sometimes deprived patients of the ability to purposefully aggressive delusional behavior, even in cases where specific persons were included in the delusion (in our observations, these were relatives of the patient or medical workers in psychiatric institutions). Thus, sick S. believed that the district psychiatrist "treated him badly." However, when visiting his doctor at home, he passively obeyed the examination, since he was "too lazy to object."

In several observations of this group, the focus of dangerous actions on oneself was noted. So, one patient, fearing poisoning, was starving, bringing himself to exhaustion. Another, convinced that others consider him "bad", made several suicidal attempts.

Thus, it can be said that the general characteristic features were, on the one hand, a rapid increase in the schizophrenic defect, which by the time the delusional syndrome appeared had already reached considerable depth, and, on the other hand, the vagueness, fuzziness of the paranoid syndrome and the lack of specificity of delusional ideas.

Other clinical features were observed in patients of the main group who committed socially dangerous acts.

First of all, the duration of the disease was significantly longer (14.2 years), and the rate of development was generally slower (32% of patients with a low degree of progression compared to 8% in the 2nd group). Thus, taking into account the equality of the age of the patients in the two groups, it can be seen that in the 1st group, schizophrenia began earlier, which, apparently, explains the lack of education. At the same time, the slow development of the disease allowed patients to stay longer in life and maintain their ability to work. This is confirmed by the indicators of employment in labor and disability.

However, the most significant clinical difference between patients of the 1st and 2nd groups was that the delusional ideas that arose in the conditions of a slow, long-term development of the disease were specific, monothematic, directed at certain individuals, clearly defined and, as a rule, very relevant. for the sick. Systematized delusions of persecution often developed over the years, gradually subordinating all the activities of the patient. At the same time, defective symptoms appeared relatively late, which allowed patients to successfully hide and dissimulate painful experiences and maintain relatively correct behavior for a long time. Long-term preservation of outwardly correct behavior with significant relevance of delusional experiences and their concreteness allowed patients to secretly prepare for "defense" from imaginary persecutors or for "revenge" on them. A characteristic feature of some of these patients was the outward deliberation of a socially dangerous act.

So, sick B. married a "pursuer", with the aim of cracking down on her. For several years he secretly prepared for "revenge", and then killed his wife. Patient O., while studying at school, was convinced that the teachers treated him badly and persecuted him, but for many years he hid this; 5 years after graduation, set fire to her "out of revenge" teachers.

These observations testify to the particular danger of a long-term developing delusional syndrome in patients with a relatively slow development of defective symptoms. It should be emphasized that the commission of dangerous actions in most cases was preceded by an increase in affective tension. At the same time, in contrast to the control group, it was due to the exacerbation of paranoid symptoms, the actualization of delusional ideas. In the structure of the paranoid syndrome, in addition to affectively saturated delusional ideas of a specific content, other psychopathological symptoms were observed extremely rarely. The clinical “harmness” of the delusional syndrome was therefore “not disturbed” in any way and there were no conditions, as in patients of the 2nd group, to reduce the relevance of pathological ideas and a gross violation of the pattern of behavior. Therefore, in all our observations in the 1st group, the actions of patients when they committed socially dangerous actions were not chaotic, disorderly, but purposeful and prepared. So, sick L., preparing to defend himself from the "persecutors", drew diagrams of the human body, marking the most vulnerable places. The patient called this occupation "working out a retaliatory strike." During the exacerbation of delirium, he inflicted a knife wound on his "pursuer" in exactly the same place.

In another case, sick P. left a highly paid job and entered an institution as a watchman in order to have a gun; from this gun, the patient soon killed his brother - the "pursuer".

Thus, despite the similarity of the studied groups of patients with continuously ongoing paranoid schizophrenia, there are significant differences between them in the duration, rate of development and degree of progression of the disease, which largely determine the social danger. One can come to the conclusion about the greater potential danger of more "safe" patients, the motivation of whose behavior is associated with the existing delusional structure. These data need further clarification, but the already existing observations allow us to express certain considerations for the prevention of dangerous behavior in such patients.

First of all, it is natural early detection patients with schizophrenia. Wherein Special attention in connection with the potential danger, patients with a relatively slow development of the process, the gradual formation of a delusional structure should be involved. At the same time, even when a diagnosis of schizophrenia is established in these cases, before committing illegal acts, it often remains difficult to decide on the hospitalization of such patients, since the external preservation of correct behavior and a tendency to dissimulate prevent their timely placement in a psychiatric hospital.

Apparently, the provisions of the Instruction of the Ministry of Health of the USSR dated 26/VIII, 1971 on the urgent hospitalization of mentally ill persons representing a public danger should be more widely applied here.

Unfortunately, the diagnosis of schizophrenia was belated in a significant proportion of the patients followed up; the diagnosis was established only during a forensic psychiatric examination. In these cases, the prevention of repeated socially dangerous actions and the rational choice of medical measures are important. The long-term latent formation of a delusional structure, the intellectual safety of patients, the tendency to dissimulate, the relevance of delusional experiences and the subordination of the entire behavior of the patient to pathological ideas dictate the need to place them in special psychiatric hospitals in accordance with Art. 58 of the Criminal Code of the RSFSR. M.F. came to the same conclusion. Talze (1965) in the analysis of patients with low-progressive paranoid schizophrenia. This recommendation allows you to more fully isolate the patient from the object of delirium, to carry out the necessary treatment and readaptation measures, the implementation of which may be difficult in psychiatric hospitals. general type because of the desire of such patients to hide their experiences, their tendency to escape and repeated antisocial actions due to the delusional motivation of behavior.

These patients were examined in the Moscow City Psychiatric Hospital No. Solovyov.

Thanks

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases should be carried out under the supervision of a specialist. All drugs have contraindications. Expert advice is required!

General characteristics of schizophrenia

At its core, this is chronic illness, in which a disorder of thinking and perception of any phenomena of the surrounding world develops against the background of a preserved level of intelligence. That is, a person with schizophrenia is not necessarily mentally retarded, his intelligence, like that of all other people, can be low, medium, high, and even very high. Moreover, in history there are many examples of brilliant people who suffered from schizophrenia, for example, Bobby Fischer - world chess champion, mathematician John Nash, who received Nobel Prize etc. The story of John Nash's life and illness was brilliantly told in A Beautiful Mind.

That is, schizophrenia is not dementia and a simple abnormality, but a specific, very special disorder of thinking and perception. The term "schizophrenia" itself consists of two words: schizo - split and phrenia - mind, reason. The final translation of the term into Russian may sound like "split consciousness" or "split consciousness". That is, schizophrenia is when a person has a normal memory and intellect, all his senses (vision, hearing, smell, taste and touch) work correctly, even the brain perceives all information about environment the way it should be, but the consciousness (the cerebral cortex) processes all this data incorrectly.

For example, human eyes see the green leaves of trees. This picture is transmitted to the brain, assimilated by it and transmitted to the cortex, where the process of comprehending the received information takes place. As a result, a normal person, having received information about green leaves on a tree, comprehends it and concludes that the tree is alive, it is summer outside, there is a shadow under the crown, etc. And with schizophrenia, a person is not able to comprehend information about green leaves on a tree, in accordance with the normal laws inherent in our world. This means that when he sees green leaves, he will think that someone is painting them, or that this is some kind of signal for aliens, or that he needs to pick them all, etc. Thus, it is obvious that in schizophrenia there is a disorder of consciousness, which is not able to form an objective picture from the available information based on the laws of our world. As a result, a person has a distorted picture of the world, created precisely by his consciousness from the initially correct signals received by the brain from the senses.

It is because of such a specific disturbance of consciousness, when a person has both knowledge, and ideas, and correct information from the senses, but the final conclusion is made with the chaotic use of their functionals, the disease was called schizophrenia, that is, the splitting of consciousness.

Schizophrenia - symptoms and signs

First, you should know that schizophrenia is characterized by symptoms and signs. Symptoms are understood as strictly defined manifestations characteristic of the disease, such as delirium, hallucinations, etc. And signs of schizophrenia are four areas of human brain activity in which there are violations.

Signs of schizophrenia

Associative defect - is expressed in the absence of logical thinking in the direction of any ultimate goal of reasoning or dialogue, as well as in the resulting poverty of speech, in which there are no additional, spontaneous components. Currently, this effect is called briefly - alogia. Let's consider this effect with an example in order to clearly understand what psychiatrists mean by this term.

So, imagine that a woman is riding a trolley bus and her friend enters at one of the stops. A conversation ensues. One of the women asks the other: "Where are you going?" The second replies: "I want to visit my sister, she is a little sick, I'm going to visit her." This is an example of a response normal person not suffering from schizophrenia. In this case, in the response of the second woman, the phrases “I want to visit my sister” and “she is a little sick” are examples of additional spontaneous speech components that were said in accordance with the logic of the discussion. That is, the only answer to the question of where she is going is the "to her sister" part. But the woman, logically thinking of other questions of the discussion, immediately answers why she is going to her sister (“I want to visit because she is sick”).

If the second woman to whom the question was addressed was a schizophrenic, then the dialogue would be as follows:
- Where are you driving?
- To Sister.
- Why?
- I want to visit.
Did something happen to her or just like that?
- It happened.
- What happened? Something serious?
- Got sick.

Such a dialogue with monosyllabic and non-expanded answers is typical for the participants in the discussion, among whom one is ill with schizophrenia. That is, with schizophrenia, a person does not think out the following possible questions in accordance with the logic of the discussion and does not answer them immediately in one sentence, as if ahead of them, but gives monosyllabic answers that require further numerous clarifications.

Autism- is expressed in distraction from the real world around and immersion in one's inner world. A person's interests are sharply limited, he performs the same actions and does not respond to various stimuli from the outside world. In addition, a person does not interact with others and is not able to build normal communication.

Ambivalence - is expressed in the presence of completely opposite opinions, experiences and feelings regarding the same object or object. For example, in schizophrenia, a person may simultaneously love and hate ice cream, running, etc.

Depending on the nature of ambivalence, there are three types of it - emotional, volitional and intellectual. So, emotional ambivalence is expressed in the simultaneous presence of opposite feelings towards people, events or objects (for example, parents can love and hate children, etc.). Volitional ambivalence is expressed in the presence of endless hesitation when it is necessary to make a choice. Intellectual ambivalence consists in the presence of diametrically opposed and mutually exclusive ideas.

affective inadequacy - is expressed in a completely inadequate reaction to various events and actions. For example, when a person sees a drowning person, he laughs, and when he receives some kind of good news, he cries, etc. In general, affect is an external expression of an internal experience of mood. Accordingly, affective disorders are external manifestations that do not correspond to internal sensory experiences (fear, joy, sadness, pain, happiness, etc.), such as: laughter in response to the experience of fear, fun in grief, etc.

These pathological effects are signs of schizophrenia and cause changes in the personality of a person who becomes unsociable, withdrawn, loses interest in objects or events that previously worried him, commits ridiculous acts, etc. In addition, a person may have new hobbies that were previously completely atypical for him. As a rule, philosophical or orthodox religious teachings, fanaticism in following an idea (for example, vegetarianism, etc.) become such new hobbies in schizophrenia. As a result of the restructuring of a person's personality, the working capacity and the degree of his socialization are significantly reduced.

In addition to these signs, there are also symptoms of schizophrenia, which include single manifestations of the disease. The whole set of symptoms of schizophrenia is divided into the following large groups:

• Positive (productive) symptoms;
• Negative (deficiency) symptoms;
• Disorganized (cognitive) symptoms;
• Affective (mood) symptoms.

Positive symptoms of schizophrenia

Positive symptoms of schizophrenia include:

• Rave;
• hallucinations;
• Illusions;
• A state of arousal;
• Inappropriate behaviour.

Hallucinations are a violation of the perception of the surrounding reality with the help of the senses. That is, hallucinations are understood as certain sensations that do not exist in reality. Hallucinations are divided into auditory, visual, olfactory, tactile and gustatory depending on which sense organ they affect. In addition, hallucinations can be simple (individual sounds, noise, phrases, flashes, etc.) or complex (coherent speech, certain scenes, etc.).

The most common are auditory hallucinations, when a person hears voices in his head or in the world around him, sometimes it seems to him that the thoughts were not produced by him, but put into the brain, etc. Voices and thoughts can give commands, advise something, discuss events, speak vulgarities, make you laugh, etc.

Visual hallucinations develop less frequently and, as a rule, in combination with hallucinations of other types - tactile, gustatory, etc. It is the combination of several types of hallucinations that gives a person a substrate for their subsequent delusional interpretation. Yes, some discomfort in the genital area are interpreted as a sign of rape, pregnancy or disease.

It should be understood that for a patient with schizophrenia, his hallucinations are not a figment of the imagination, but he really feels it all. That is, he sees aliens, atmospheric control threads, smells of roses from the cat litter and other non-existent things.

Rave is a collection of certain beliefs, conclusions or conclusions that are completely untrue. Delusions can be independent or provoked by hallucinations. Depending on the nature of beliefs, delusions of persecution, influence, power, greatness or attitude are distinguished.

The most common delusion of persecution develops, in which it seems to a person that someone is pursuing him, for example, aliens, parents, children, policemen, etc. Every minor event in the surrounding space seems to be a sign of surveillance, for example, tree branches swaying in the wind are perceived as a sign of observers sitting in ambush. The met person in glasses is perceived as a messenger who goes to report on all his movements, etc.

Delusions of influence are also very common and are characterized by the idea that a person is being affected by some negative or positive effect, for example, DNA rearrangement, radiation, suppression of the will by psychotropic weapons, medical experiments, etc. In addition, with this form of delusion, a person is sure that someone controls his internal organs, body and thoughts, putting them directly into the head. However, the delirium of influence may not have such vivid forms, but disguise itself as forms that are quite similar to reality. For example, a person each time gives a piece of cut sausage to a cat or dog, because he is sure that they want to poison him.

The delusion of dysmorphophobia is a strong belief in the presence of shortcomings that need to be corrected, for example, to straighten protruding ribs, etc. The delusion of reformism is the constant invention of some new powerful devices or systems of relationships that in reality are not viable.

Inappropriate behavior represents either naive stupidity, or strong agitation, or inappropriate manners and appearance. Typical variants of inappropriate behavior include depersonalization and derealization. Depersonalization is a blurring of the boundaries between self and non-self, as a result of which one’s own thoughts, internal organs and body parts seem to a person not their own, but brought from outside, random people are perceived by relatives, etc. Derealization is characterized by an increased perception of any minor details, colors, smells, sounds, etc. Because of this perception, it seems to a person that everything is not happening for real, and people, like in a theater, play roles.

The most severe variant of inappropriate behavior is catatonia, in which a person takes awkward postures or randomly moves. Clumsy poses are usually taken by a person in a stupor and hold them for a very long time. Any attempt to change his position is useless, because he has a resistance that is almost impossible to overcome, because schizophrenics have incredible muscle strength. A special case of awkward postures is wax flexibility, which is characterized by holding any part of the body in one position for a long time. When excited, a person begins to jump, run, dance and make other meaningless movements.
Also referred to as inappropriate behavior hebephrenia- excessive foolishness, laughter, etc. A person laughs, jumps, laughs and performs other similar actions, regardless of the situation and location.

Negative symptoms of schizophrenia

In general, the negative symptoms of schizophrenia are described as loss of energy and motivation, reduced activity, lack of initiative, poverty of thought and speech, physical passivity, emotional poverty, and narrowing of interests. A patient with schizophrenia appears passive, indifferent to what is happening, taciturn, motionless, etc.

However, with a more accurate selection of symptoms, the following are considered negative:

• Passivity;
• Loss of will;
• Complete indifference to the outside world (apathy);
• Autism;
• Minimal expression of emotions;
• Flattened affect;
• Inhibited, sluggish and mean movements;
• Speech disorders;
• Disorders of thought;
• Inability to make decisions;
• Inability to maintain a normal coherent dialogue;
• Low ability to concentrate;
• Rapid exhaustion;
• Lack of motivation and lack of initiative;
• mood swings;
• Difficulty in constructing an algorithm for sequential actions;
• Difficulty in finding a solution to the problem;
• Poor self-control;
• Difficulty switching from one activity to another;
• Ahedonism (inability to experience pleasure).

The speech of a person suffering from schizophrenia is characterized by the following features:

• Constant jumping on various topics;
• The use of new, invented words that are understandable only to the person himself;
• Repetition of words, phrases or sentences;
• Rhyming - speaking in meaningless rhyming words;
• Incomplete or jerky responses to questions;
• Sudden silences due to blockage of thoughts (sperrung);
• The influx of thoughts (mentism), expressed in rapid incoherent speech.

Autism is a detachment of a person from the outside world and immersion in his own little world. In this state, the schizophrenic seeks to withdraw from contact with other people and live in solitude.

Various disorders of will, motivation, initiative, memory and attention are collectively referred to as depletion of energy potential , since a person quickly gets tired, cannot perceive a new one, analyzes the totality of events poorly, etc. All this leads to a sharp decrease in the productivity of his activity, as a result of which, as a rule, his ability to work is lost. In some cases, a super-valuable idea is formed in a person, which consists in the need to preserve strength, and manifests itself in a very careful attitude towards one's own person.

Emotions in schizophrenia become weakly expressed, and their spectrum is very poor, which is usually called flattened affect . First, a person loses responsiveness, compassion and the ability to empathize, as a result of which the schizophrenic becomes selfish, indifferent and cruel. In response to various life situations a person can react in a completely atypical and incongruous way, for example, be completely indifferent to the death of a child or take offense at an insignificant action, word, look, etc. Very often, a person can experience deep affection and obey any one close person.

With the progression of schizophrenia, a flattened affect can take on peculiar forms. For example, a person can become eccentric, explosive, unrestrained, conflict, angry and aggressive, or, on the contrary, acquire complaisance, euphoric high spirits, stupidity, uncriticality to actions, etc. With any variant of a flattened affect, a person becomes sloppy and prone to gluttony and masturbation.

Violations of thinking are manifested by illogical reasoning, incorrect interpretation of everyday things. Descriptions and reasoning are characterized by the so-called symbolism, in which real concepts are replaced by completely different ones. However, in the understanding of patients with schizophrenia, it is these concepts that do not correspond to reality that are symbols of some real things. For example, a person walks naked, but explains it this way - nudity is needed to remove a person’s stupid thoughts. That is, in his thinking and consciousness, nudity is a symbol of liberation from stupid thoughts.

A special variant of thought disorder is reasoning, which consists in constant empty reasoning on abstract topics. Moreover, the ultimate goal of reasoning is completely absent, which makes them meaningless. In severe schizophrenia, it can develop schizophasia, representing the pronunciation of unrelated words. Often these words are combined by patients into sentences, observing the correctness of cases, but they do not have any lexical (semantic) connection.

With the predominance of negative symptoms of depression of the will, the schizophrenic easily falls under the influence of various sects, criminal groups, asocial elements, obeying their leaders implicitly. However, a person may retain a will that allows him to perform some senseless action to the detriment of normal work and social intercourse. For example, a schizophrenic can draw up a detailed plan of a cemetery with the designation of each grave, count the number of any letters in a particular literary work, etc.

Anhedonia represents the loss of the ability to enjoy anything. So, a person cannot eat with pleasure, take a walk in the park, etc. That is, against the background of anhedonia, a schizophrenic, in principle, cannot enjoy even those actions, objects or events that previously gave him it.

Disorganized symptoms

affective symptoms

Typical syndromes characteristic of schizophrenia

So, The typical positive syndromes of schizophrenia include the following:

• hallucinatory-paranoid syndrome - characterized by a combination of unsystematic delusions (most often persecution), verbal hallucinations and mental automatism (repetitive actions, a feeling that someone controls thoughts and body parts, that everything is not real, etc.). All symptoms are perceived by the patient as something real. There is no sense of artificiality.
• Kandinsky-Clerambault Syndrome - refers to a variety of hallucinatory-paranoid syndrome and is characterized by the feeling that all visions and disorders of a person are violent, that someone created them for him (for example, aliens, Gods, etc.). That is, it seems to a person that thoughts are put into his head, internal organs, actions, words and other things are controlled. Periodically there are episodes of mentism (an influx of thoughts), alternating with periods of withdrawal of thoughts. As a rule, there is a completely systematized delusion of persecution and influence, in which a person explains with complete conviction why he was chosen, what they want to do to him, etc. A schizophrenic with the Kandinsky-Clerambault syndrome believes that he does not control himself, but is a puppet in the hands of persecutors and evil forces.
• paraphrenic syndrome - characterized by a combination of delusions of persecution, hallucinations, affective disorders and the Kandinsky-Clerambault syndrome. Along with the ideas of persecution, a person has a clear conviction of his own power and power over the world, as a result of which he considers himself the ruler of all the Gods, the solar system, etc. Under the influence of his own delusional ideas, a person can tell others that he will create a paradise, change the climate, transfer humanity to another planet, etc. The schizophrenic himself feels himself in the center of grandiose, supposedly ongoing events. An affective disorder consists in a constantly high mood up to a manic state.
• Capgras syndrome- is characterized by the delusional idea that people can change their appearance to achieve any goals.
• Affective paranoid syndrome - characterized by depression, delusional ideas of persecution, self-accusations and hallucinations with a vivid accusatory character. In addition, this syndrome can be characterized by a combination of megalomania, noble birth and hallucinations of a laudatory, glorifying and approving character.
• catatonic syndrome - characterized by freezing in a certain position (catalepsy), giving parts of the body some uncomfortable position and maintaining it for a long time (waxy mobility), as well as strong resistance to any attempts to change the adopted position. Mutism can also be noted - dumbness with a preserved speech apparatus. Any external factors, such as cold, humidity, hunger, thirst and others, cannot force a person to change the absent facial expression with almost completely absent facial expressions. In contrast to being frozen in a certain position, arousal may appear, characterized by impulsive, senseless, frivolous and campy movements.
• hebephrenic syndrome - characterized by foolish behavior, laughter, mannerisms, making faces, lisping, impulsive actions and paradoxical emotional reactions. Perhaps a combination with hallucinatory-paranoid and catatonic syndromes.
• Depersonalization-derealization syndrome - is characterized by feelings of painful and extremely unpleasant experience about changes in one's own personality and the behavior of the surrounding world, which the patient cannot explain.

Typical negative syndromes schizophrenia are as follows:

• Thinking Disorder Syndrome - manifested by diversity, fragmentation, symbolism, blockage of thinking and reasoning. The diversity of thinking is manifested by the fact that insignificant features of things and events are perceived by a person as the most important. At the same time, the speech is detailed with a description of the details, but vague and unclear in relation to the general main idea of ​​the patient's monologue. The fragmentation of speech is manifested by the fact that a person builds sentences from words and phrases that are unrelated in meaning, which, however, are grammatically connected by correct cases, prepositions, etc. A person cannot complete a thought, because he constantly deviates from a given topic by associations, jumps to other topics, or begins to compare something incomparable. In severe cases, the fragmentation of thinking is manifested by a stream of unrelated words (verbal okroshka). Symbolism is the use of a term as a symbolic designation of a completely different concept, thing or event. For example, with the word stool, the patient symbolically denotes his legs, etc. Blockage of thinking is a sharp break in the thread of thought or loss of the topic of conversation. In speech, this is manifested by the fact that a person begins to say something, but abruptly stops, without even finishing a sentence or phrase. Reasoning is fruitless, lengthy, empty, but numerous reasoning. In speech, a patient with schizophrenia can use his own invented words.
• Syndrome of emotional disorders - characterized by the extinction of reactions and coldness, as well as the appearance of ambivalence. People lose emotional ties with loved ones, losing compassion, pity and other similar manifestations, becoming cold, cruel and insensitive. Gradually, as the disease develops, emotions disappear completely. However, not always in a patient with schizophrenia, who does not show emotions in any way, those are completely absent. In some cases, a person has a rich emotional spectrum and is extremely burdened by the fact that he is not able to express it fully. Ambivalence is the simultaneous presence of opposite thoughts and emotions in relation to the same object. The consequence of ambivalence is the inability to make a final decision and make a choice from the possible options.
• Will disorder syndrome (aboulia or hypobulia) - characterized by apathy, lethargy and lack of energy. Such disorders of the will cause a person to be fenced off from the outside world and become isolated in himself. With strong violations of the will, a person becomes passive, indifferent, without initiative, etc. Most often, will disorders are combined with those in the emotional sphere, so they are often combined into one group and called emotional-volitional disorders. In each individual person, volitional or emotional disturbances may predominate in the clinical picture of schizophrenia.
• Personality Change Syndrome is the result of the progression and deepening of all negative symptoms. A person becomes mannered, absurd, cold, withdrawn, uncommunicative and paradoxical.

Symptoms of schizophrenia in men, women, children and adolescents

The first symptoms of schizophrenia (initial, early)

• Speech disorders. As a rule, a person begins to answer any questions in monosyllables, even those where a detailed answer is required. In other cases, it cannot exhaustively answer the question posed. It is rare that a person is able to answer a question in full, but he speaks slowly at the same time.
• Anhedonia- the inability to enjoy any activities that previously fascinated a person. For example, before the onset of schizophrenia, a person liked to embroider, but after the onset of the disease, this activity does not fascinate him at all and does not give pleasure.
• weak expression or complete absence emotions. The person does not look into the eyes of the interlocutor, the face is expressionless, it does not reflect any emotions and feelings.
• Failure to complete any task because the person does not see the point in it. For example, a schizophrenic does not brush his teeth because he does not see the point in it, because they will get dirty again, etc.
• Weak focus on any subject.

Symptoms of different types of schizophrenia

Paranoid (paranoid) schizophrenia

Catatonic schizophrenia

Hebephrenic schizophrenia

Simple (mild) schizophrenia

Undifferentiated schizophrenia

Residual schizophrenia

Post-schizophrenic depression

In addition to the above, some doctors additionally distinguish manic schizophrenia.

Manic schizophrenia (manic-depressive psychosis)

Depending on the nature of the course, continuous and paroxysmal-progressive forms of schizophrenia are distinguished. In addition, in modern Russia and former USSR isolated recurrent and sluggish types of schizophrenia, which in modern classifications correspond to the terms schizoaffective disorder and schizotypal disorder. Consider the symptoms of acute (stage of psychosis paroxysmal-progredient form), continuous and sluggish schizophrenia.

Acute schizophrenia (attacks of schizophrenia) - symptoms

An attack of acute schizophrenia can occur in the form of psychosis or oneiroid. Psychosis is characterized by vivid hallucinations and delusions, a complete detachment from reality, persecution mania or depressive detachment and self-absorption. Any mood swings cause changes in the nature of hallucinations and delusions.

Oneiroid is characterized by unlimited and very vivid hallucinations and delusions, which concern not only the surrounding world, but also oneself. Thus, a person imagines himself as some other object, for example, pockets, a disc player, a dinosaur, a machine that is at war with people, etc. That is, a person experiences complete depersonalization and derealization. At the same time, within the framework of the delusional-illusory representation of oneself as someone or something that has arisen in the head, whole scenes from the life or activity of that with which the person has identified himself are played out. Experienced images cause motor activity, which can be excessive or, on the contrary, catatonic.

Continuous schizophrenia

Sluggish (hidden) schizophrenia

Sluggish schizophrenia has the following stages:

• Debut- proceeds inconspicuously, as a rule, at puberty;
• Manifest period - characterized by clinical manifestations, the intensity of which never reaches the level of psychosis with delusions and hallucinations;
• Stabilization- complete elimination of manifest symptoms for a long period of time.

Neurosis-like schizophrenia

Alcoholic schizophrenia - symptoms

Alcoholic psychosis can occur in three ways:

• Delirium (delirium tremens) - occurs after the cessation of consumption of alcoholic beverages and is expressed in the fact that a person sees devils, animals, insects and other objects or living beings. In addition, a person does not understand where he is and what is happening to him.
• Hallucinosis- occurs during drinking. A person is disturbed by auditory hallucinations of a threatening or accusatory nature.
• delusional psychosis- occurs with prolonged, regular and fairly moderate alcohol consumption. It is expressed by delusions of jealousy with persecution, attempts at poisoning, etc.

Symptoms of hebephrenic, paranoid, catatonic and other types of schizophrenia - video

Schizophrenia: causes and predisposing factors, signs, symptoms and manifestations of the disease - video

Causes and symptoms of schizophrenia - video

Signs of schizophrenia (how to recognize the disease, diagnosis of schizophrenia) - video

Schizophrenia is a mental illness of a continuous or paroxysmal course, begins mainly at a young age, is accompanied by characteristic personality changes (autization, emotional-volitional disorders, inappropriate behavior), mental disorders and various psychotic manifestations. Frequency- 0.5% of the population. 50% of beds in psychiatric hospitals are occupied by patients with schizophrenia.

Code by international classification ICD-10 diseases:

The reasons

Genetic Aspects. A priori, polygenic inheritance seems to be the most probable. The unscientific application of a broader definition of schizophrenia leads to an increase in the estimate of the population frequency to 3%. Several loci have been proven or suspected to contribute to the development of schizophrenia (.SCZD1, 181510, 5q11.2‑q13.3; .amyloid b A4 precursor protein, AAA, CVAP, AD1, 104760, 21q21.3‑q22.05; .DRD3 , 126451, 3q13.3; SCZD3, 600511, 6p23; SCZD4, 600850, 22q11‑q13; EMX2, 600035, 10q26.1.

Symptoms (signs)

CLINICAL PICTURE

Clinical manifestations of schizophrenia are polymorphic. Various combinations of symptoms and syndromes are observed.

Negative symptoms. In psychiatry, the term "negative" means the absence of certain manifestations inherent in a healthy person, i.e. loss or perversion of mental functions (for example, depletion of emotional reactions). Negative symptoms - - decisive in the diagnosis.

Thinking disorders. People with schizophrenia rarely have only one type of impaired thinking; usually a combination different types thinking disorders.. Diversity. Minor features of ordinary things seem to be more significant than the subject as a whole or the general situation. Manifested by ambiguity, vagueness, thoroughness of speech .. Fragmentation. There is no semantic connection between concepts while maintaining the grammatical structure of speech. Speech loses its communication properties, ceases to be a means of communication between people, retaining only its external form. Characterized by a gradual or sudden deviation in the thought process towards random associations, a tendency to symbolic thinking, characterized by the coexistence of the direct and figurative meaning of concepts. There are sudden and incomprehensible transitions from one topic to another, a comparison of the incomparable. In expressed cases, speech is devoid of semantic meaning and is inaccessible to understanding with its outwardly correct construction. In pronounced cases of broken thinking, the patient spews out a sequence of completely unrelated words, and pronounces them as one sentence (verbal okroshka). The disorder occurs with a clear mind, which is different from an absence. The patient starts his thought or answer and stops suddenly, often in the middle of a sentence. .. Reasoning - thinking with a predominance of ornate, little content, empty and fruitless reasoning, devoid of cognitive meaning .. Neologisms - new words invented by the patient, often by combining syllables taken from different words; the meaning of neologisms is clear only to the patient himself (for example, the neologism "tabushka" is created from the words "stool" and "wardrobe"). For the listener, they sound like absolute nonsense, but for the speaker, these neologisms are a kind of reaction to the inability to find the right words.

Emotional disorders. Emotional disorders in schizophrenia are manifested primarily by the extinction of emotional reactions, emotional coldness. Patients, due to a decrease in emotionality, lose a sense of attachment and compassion for loved ones. Patients become unable to express any emotions. This makes it difficult to communicate with patients, leading them to withdraw even more into themselves. In patients at a later stage of schizophrenia, strong emotions are absent; if they appear, one should doubt whether the diagnosis of schizophrenia was correctly made. Emotional coldness first of all and to the greatest extent manifests itself in feelings for parents (usually the patient responds to the care of the parents with irritation; the warmer the attitude of the parents, the more obvious the patient's hostility towards them). As the disease progresses, such a dulling or atrophy of emotions becomes more and more noticeable: patients become indifferent and indifferent to their surroundings. great care. Patients with schizophrenia show both positive and negative emotions, although not as strongly as healthy people. Some people with schizophrenia who appear to be emotionless actually live rich emotional inner lives and take their inability to express emotions hard. Ambivalence. The coexistence of two opposite tendencies (thoughts, emotions, actions) in relation to the same object in the same person at the same time. It is manifested by the inability to complete certain actions, to make a decision.

Volitional disorders. Emotional disorders are often associated with decreased activity, apathy, lethargy and lack of energy. A similar picture is often observed in patients suffering from schizophrenia for many years. Pronounced volitional disturbances lead to unconscious removal from the outside world, preference for the world of one's own thoughts and fantasies, divorced from reality (autism). Patients with severe volitional disorders look inactive, passive, lack of initiative. As a rule, emotional and volitional disorders are combined with each other, they are designated by one term "emotional-volitional disorders". For each patient, the ratio of emotional and volitional disorders in the clinical picture is individual. The severity of emotional-volitional disorders correlates with the progression of the disease.

Personality changes are the result of the progression of negative symptoms. Manifested in pretentiousness, mannerisms, absurdity of behavior and actions, emotional coldness, paradoxicality, lack of sociability.

Positive (psychotic) manifestations. The term "positive" ("productive") in psychiatry means the appearance of states that are not characteristic of a healthy psyche (for example, hallucinations, delusions). Positive symptoms are not specific for schizophrenia because occur in other psychotic conditions (eg, organic psychosis, temporal lobe epilepsy). The predominance of positive symptoms in the clinical picture indicates an exacerbation of the disease.

Hallucinatory - paranoid syndrome is manifested by a combination of poorly systematized, inconsistent delusional ideas, more often persecution, with a syndrome of mental automatism and / or verbal hallucinations .. For the patient, apparent images are as real as objectively existing ones. Patients really see, hear, smell, and do not imagine. For patients, their subjective sensory sensations are just as real as those coming from the objective world. The behavior of a patient experiencing hallucinations seems insane only from the point of view of an outside observer; The most important and common symptoms of schizophrenia, however, one symptom is not enough to diagnose this disease. Many patients with schizophrenia with a whole range of other symptoms, such as thought disorders, emotional and volitional disorders, have never observed either delusions or hallucinations. It must also be remembered that delusions and hallucinations are inherent not only in schizophrenia, but also in other mental illnesses, so their presence does not necessarily indicate that the patient has schizophrenia.

Syndrome of mental automatism (Kandinsky-Clerambault syndrome) is the most typical variety of hallucinatory-paranoid syndrome for schizophrenia. The essence of the syndrome is a feeling of the violent origin of disorders, their "made" .. Alienation or loss of belonging to one's "I" of one's own mental processes (thoughts, emotions, physiological functions organism, movements and actions performed), the experience of their involuntariness, doneness, imposition from the outside. Symptoms of openness, withdrawal of thoughts and mentism (an involuntary influx of thoughts) are characteristic. impact. Patients no longer belong to themselves - they are at the mercy of their persecutors, they are puppets, toys in their hands (feeling of mastery), they are constantly under the influence of organizations, agents, research institutes, etc.

Paraphrenic syndrome is a combination of expansive delusions with delusions of persecution, auditory hallucinations and (or) mental automatisms. In this state, along with complaints about persecution and influence, the patient expresses ideas about his world power, cosmic power, calls himself the god of all gods, the ruler of the Earth; promises a paradise on earth, the transformation of the laws of nature, a radical climate change. Delusional statements are distinguished by absurdity, grotesqueness, statements are given without evidence. The patient is always in the center of unusual, and sometimes grandiose events. Observe various manifestations of mental automatism, verbal hallucinosis. Affective disorders manifest themselves in the form of elevated mood, capable of reaching the degree of a manic state. Paraphrenic syndrome, as a rule, indicates the prescription of the onset of schizophrenia.

Capgras Syndrome (delusional belief that people around them are able to change their appearance for a specific purpose).

Affectively - paranoid syndrome.

Catatonic syndrome. Catatonic stupor. Characterized by increased muscle tone, catalepsy (freezing for a long time in a certain position), negativism (unreasonable refusal, resistance, opposition to any outside influence), mutism (lack of speech with a intact speech apparatus). Cold, uncomfortable posture, wet bed, thirst, hunger, danger (for example, a fire in a hospital) are not reflected in any way on their frozen, amimic face. Patients remain in the same position for a long time; all their muscles are tense. A transition from catatonic stupor to excitation and vice versa is possible. Catatonic excitation. Characterized by an acute onset, suddenness, randomness, lack of focus, impulsiveness of movements and actions, senseless pretentiousness and mannerisms of movements, ridiculous unmotivated exaltation, aggression.

hebephrenic syndrome. Foolish, ridiculous behavior, mannerisms, grimacing, lisping speech, paradoxical emotions, impulsive actions are characteristic. May be accompanied by hallucinatory - paranoid and catatonic syndromes.

The depersonalization-derealization syndrome is characterized by a painful experience of a change in one's own personality and the surrounding world, which cannot be described.

depression in schizophrenia

Depressive symptoms in schizophrenia (both during exacerbation and in remission) are often observed. Depression is one of the most common causes suicidal behavior in patients with schizophrenia. It should be remembered that 50% of patients with schizophrenia commit suicide attempts (15% are fatal). In most cases, depression is due to three causes.

Depressive symptoms can be an integral part of the schizophrenic process (for example, with the predominance of a depressive paranoid syndrome in the clinical picture).

Depression can be caused by awareness of the severity of one's illness and social problems faced by patients (narrowing the circle of communication, misunderstanding on the part of relatives, labeling "psycho", labor maladaptation, etc.). In this case, depression is a normal reaction of a person to a serious illness.

Depression often occurs as side effect neuroleptics.

CLASSIFICATION

The division of schizophrenia according to its clinical forms is carried out according to the predominance of one or another syndrome in the clinical picture. Such a division is conditional, because only a small number of patients can be confidently assigned to one type or another. Significant changes are characteristic of patients with schizophrenia clinical picture in the course of the disease, for example, at the beginning of the disease, the patient has a catatonic form, and after a few years he also has symptoms of the hebephrenic form.

Forms of schizophrenia

. simple form characterized by a predominance of negative symptoms without psychotic episodes. A simple form of schizophrenia begins with the loss of previous motivations for life and interests, idle and meaningless behavior, isolation from real events. It slowly progresses, and the negative manifestations of the disease gradually deepen: decreased activity, emotional flatness, poverty of speech and other means of communication (facial expressions, eye contact, gestures). Efficiency in study and work decreases until their complete cessation. Hallucinations and delusions are absent or occupy a small place in the picture of the disease.

. paranoid form- the most common form; the clinical picture is dominated by hallucinatory-paranoid syndrome and mental automatism syndrome. The paranoid form is characterized by the predominance of delusional and hallucinatory disorders in the picture of the disease, forming paranoid, paranoid syndromes, the Kandinsky-Clerambault syndrome of mental automatism and paraphrenic syndrome. At first, a tendency to systematize nonsense is noted, but in the future it becomes more and more fragmentary, absurd and fantastic. As the disease develops, negative symptoms appear and intensify, forming a picture of an emotional-volitional defect.

. hebephrenic form characterized by the predominance of hebephrenic syndrome. This form differs from the simple greater mobility of patients, fussiness with a touch of foolishness and mannerism, instability of mood is characteristic. Patients are verbose, prone to reasoning, stereotyped statements, their thinking is poor and monotonous. Hallucinatory and delusional experiences are fragmentary and startling in their absurdity. According to E. Kraepelin, only 8% of patients have favorable remissions, but in general the course of the disease is malignant.

. Catatonic form is characterized by the predominance of the catatonic syndrome in the clinical picture of the disease. This form manifests itself as a catatonic stupor or excitation. These two states can alternate with each other. Catatonic disorders are usually combined with hallucinatory-delusional syndrome, and in the case of an acute paroxysmal course of the disease - with oneiroid syndrome.

Flow and types of flow

There are continuous and paroxysmal - progredient types of schizophrenia. Before the appearance of the ICD-10 in domestic psychiatry, there were two more types of flow: recurrent and sluggish. The ICD-10 (as well as the DSM-IV) does not include the diagnoses of recurrent schizophrenia and indolent schizophrenia. Currently, these disorders are distinguished as separate nosological units - schizoaffective disorder and schizotypal disorder, respectively (see Schizoaffective disorder, Schizotypal disorder).

The continuous type of course is characterized by the absence of clear remissions during treatment, the steady progression of negative symptoms. Spontaneous (without treatment) remissions are not observed in this type of course. In the future, the severity of productive symptoms decreases, while negative symptoms become more pronounced, and in the absence of the effect of treatment, it comes to the complete disappearance of positive symptoms and pronounced negative symptoms. The continuous type of flow is observed in all forms of schizophrenia, but it is exceptional for simple and hebephrenic forms.

The paroxysmal - progredient type of the course is characterized by complete remissions between attacks of the disease against the background of the progression of negative symptoms. This type of schizophrenia in adulthood is the most common (according to various authors, it is observed in 54-72% of patients). Acute attacks, clinical manifestations and durations vary. The appearance of delusions and hallucinations is preceded by a period with severe affective disorders - depressive or manic, often replacing each other. Mood swings are reflected in the content of hallucinations and delusions. With each subsequent attack, the intervals between attacks become shorter and the negative symptoms worsen. In the period of incomplete remission, patients remain anxious, suspicious, tend to delusionally interpret any actions of others, hallucinations occasionally occur. Particularly characteristic are persistent subdepressive states with reduced activity, a hypochondriacal orientation of experiences.

Diagnostics

Research methods. There is no effective test to diagnose schizophrenia. All studies are directed mainly to the exclusion of an organic factor that could cause the disorder. Laboratory methods studies: .. KLA and OAM .. biochemical analysis blood test.. thyroid function test.. blood test for vitamin B 12 and folic acid content.. blood test for heavy metals, drugs, psychoactive drugs, alcohol. Special Methods.. CT and MRI: rule out intracranial hypertension, brain tumors.. EEG: exclude temporal lobe epilepsy. Psychological methods (personality questionnaires, tests [for example, Rorschach tests, MMPI]).

Differential Diagnosis

Psychotic disorders caused by somatic and neurological diseases. Symptoms similar to those of schizophrenia are observed in many neurological and somatic diseases. Mental disorders in these diseases appear, as a rule, at the onset of the disease and precede the development of other symptoms. Patients with neurological disorders tend to be more critical of their illness and more concerned about the onset of symptoms of mental illness than those with schizophrenia. When examining a patient with psychotic symptoms, an organic etiological factor is always ruled out, especially if the patient has unusual or rare symptoms. The possibility of a superimposed organic disease should always be kept in mind, especially when the schizophrenic patient has been in remission for a long time or when the quality of the symptoms changes.

Simulation. Schizophrenic symptoms can be invented by patients or for the purpose of obtaining a "secondary benefit" (simulation). Schizophrenia can be feigned because the diagnosis is largely based on the statements of the patient. Patients who really suffer from schizophrenia sometimes make false complaints about their alleged symptoms in order to receive some kind of benefits (for example, transfer from the 3rd disability group to the 2nd).

Mood disorder. Psychotic symptoms are observed in both manic and depressive states. If the mood disorder is accompanied by hallucinations and delusions, their development occurs after pathological mood changes occur, and they are not stable.

Schizoaffective disorder. In some patients, the symptoms of a mood disorder and the symptoms of schizophrenia develop simultaneously, are expressed in the same way; therefore, it is extremely difficult to determine which disorder is primary - schizophrenia or a mood disorder. In these cases, a diagnosis of schizoaffective disorder is made.

Chronic delusional disorder. The diagnosis of a delusional disorder is justified in case of systematized delusions of non-bizarre content lasting at least 6 months, with the preservation of normal, relatively high functioning of the personality without severe hallucinations, mood disorders and the absence of negative symptoms. The disorder occurs in adulthood and old age.

Personality disorders. Personality disorders can be combined with manifestations characteristic of schizophrenia. Personality Disorders- stable features that determine behavior; the time of their onset is more difficult to determine than the onset of schizophrenia. As a rule, psychotic symptoms are absent, and if they are, they are transient and unexpressed.

Reactive psychosis (brief psychotic disorder). Symptoms persist for less than 1 month and occur after a well-defined stressful situation.

Treatment

TREATMENT

Social - psychological support in combination with drug therapy can reduce the frequency of exacerbations by 25-30% compared with the results of treatment with neuroleptics alone. Psychotherapy for schizophrenia is ineffective, so this method of treatment is rarely used.

The patient is explained the nature of the disease, calmed down, discussed with him his problems. The patient is trying to form an adequate attitude to the disease and treatment, the skills of timely recognition of signs of an impending relapse. An excessive emotional reaction of the patient's relatives to his disease leads to frequent stressful situations in the family, provokes an exacerbation of the disease. Therefore, the patient's relatives should be explained the nature of the disease, methods of treatment and side effects (side effects of antipsychotics often frighten relatives).

Basic principles drug therapy

Drugs, doses, duration of treatment are selected individually, strictly according to the indications, depending on the symptoms, the severity of the disorder and the stage of the disease.

Preference should be given to a drug that has previously been effective in this patient.

Treatment usually begins with the appointment of small doses of drugs, gradually increasing them until the optimal effect is obtained. In case of acute development of an attack with severe psychomotor agitation, the drug is administered parenterally; if necessary, the injections are repeated until the excitation is completely relieved, and in the future, the treatment method is determined by the dynamics of the psychopathological syndrome.

The most common mistake is prescribing more neuroleptics to patients than necessary. Studies have shown that smaller amounts of antipsychotics generally produce the same effect. When the clinic increases the daily dose of antipsychotic drugs to the patient, giving the impression that in this way they increase the treatment and reduce psychotic symptoms, in fact this effect depends only on the time of exposure to the drug. Long-term administration of high doses of neuroleptics often leads to the development of side effects.

Subjective severe sensations after the first dose of the drug (often associated with side effects) increase the risk of a negative result of treatment and patient avoidance of treatment. In such cases, it is necessary to think about changing the drug.

The duration of treatment is 4-6 weeks, then, if there is no effect, a change in the treatment regimen.

When an incomplete and unstable remission occurs, the doses of drugs are reduced to a level that ensures the maintenance of remission, but does not cause depression of mental activity and pronounced side effects. Such maintenance therapy is prescribed for a long time on an outpatient basis.

Basic drugs

Antipsychotics - chlorpromazine, levomepromazine, clozapine, haloperidol, trifluoperazine, flupentixol, pipothiazine, zuclopenthixol, sulpiride, quetiapine, risperidone, olanzapine.

Antidepressants and tranquilizers are prescribed for depressive and anxiety states, respectively. When a depressive effect is combined with anxiety and restlessness, antidepressants with a sedative effect, such as amitriptyline, are used. For depression with lethargy and reduced energy of behavior, antidepressants are used that have a stimulating effect, such as imipramine, or without a sedative effect, such as fluoxetine, paroxetine, citalopram. Tranquilizers (eg, diazepam,zepine) are used short-term to treat anxiety.

Complications in the treatment of neuroleptics

Long-term therapy with neuroleptics can lead to the development of persistent complications. Therefore, it is important to avoid unnecessary treatment by changing doses depending on the patient's condition. Anticholinergic drugs prescribed for relief of side extrapyramidal symptoms, with long-term constant use, increase the risk of tardive dyskinesia. That's why anticholinergic drugs are not used constantly and for prophylactic purposes, and are prescribed only in case of side extrapyramidal symptoms.

Akineto - hypertensive syndrome .. Clinical picture: masked face, rare blinking, stiffness of movements .. Treatment: trihexyphenidyl, biperiden.

Hyperkinetic - hypertensive syndrome .. Clinical picture: akathisia (restlessness, restlessness in the legs), tasikinesia (restlessness, desire to constantly move, change position), hyperkinesis (choreiform, athetoid, oral) .. Treatment: trihexyphenidyl, biperiden.

Dyskinetic syndrome .. Clinical picture: oral dyskinesias (tension of masticatory, swallowing muscles, muscles of the tongue, an irresistible desire to stick out the tongue), oculogiric crises (painful rolling of the eyes) .. Treatment: trihexyphenidyl (6-12 mg / day), 20% r - r caffeine 2 ml s / c, chlorpromazine 25-50 mg / m.

Chronic dyskinetic syndrome .. Clinical picture: hypokinesia, increased muscle tone, hypomimia in combination with local hyperkinesias (complex oral automatisms, tics), decreased urges and activity, akairiya (annoyance), emotional instability .. Treatment: nootropics (piracetam 1200-2400 mg / day for 2-3 months), multivitamins, tranquilizers.

Malignant neuroleptic syndrome.. Clinical picture: dryness skin, acrocyanosis, sebaceous hyperemic face, forced posture - on the back, oliguria, increased blood clotting time, increased residual nitrogen in the blood, kidney failure, lowering blood pressure, fever .. Treatment: infusion therapy (rheopolyglucin, hemodez, crystalloids), parenteral nutrition(proteins, carbohydrates).

Intoxication delirium develops more often in men over 40 years of age (with a combination of chlorpromazine, haloperidol, amitriptyline. Treatment is detoxification.

Forecast for 20 years: recovery - 25%, improvement - 30%, care and / or hospitalization required - 20%. 50% of patients with schizophrenia commit suicide attempts (15% with a fatal outcome). The older the age of onset, the better the prognosis. The more pronounced the affective component of the disorder, the more acute and shorter the attack, the better it can be treated, the more likely it is to achieve a complete and stable remission.

Synonyms. Bleuler's disease, Dementia praecox, Discordant psychosis, Early dementia

ICD-10 . F20 Schizophrenia

Notes.

Pfropfschizophrenia (from German Pfropfung - vaccination) - schizophrenia developing in an oligophrenic; oligoschizophrenia; pfropfgebephrenia;

Senestic schizophrenia Huber - schizophrenia with a predominance of senestopathies in the form of sensations of burning, constriction, tearing, turning over, etc.

Schizophrenia-like psychosis (pseudo-schizophrenia) is a psychosis that is similar or identical in clinical presentation to schizophrenia.

schizophrenia-like syndrome common name psychopathological syndromes similar in manifestations to schizophrenia, but arising from other psychoses.

Nuclear schizophrenia (galloping) is the rapid development of emotional devastation with the disintegration of pre-existing positive symptoms (end state).

As can be seen from what has been said, schizophrenia in the proper sense is an endogenous disease based on a hereditary predisposition, usually developing from within without external shocks, characterized by a general change in the entire mental personality with the character of a decrease in tone, with a loss of unity, with outside manifested in isolation, isolation from the outside world, with a tendency to reduce intelligence. Clinical symptoms in this case are extremely diverse. It includes almost everything that was stated in the chapters containing a description of the phenomenology of psychosis in general. On the other hand, in relation to schizophrenia, more than to any other disease, it is true that for the characteristic it is not one symptom that matters, and not even a combination of them, but, so to speak, the features of the internal linkage between them. The manifestations of the disease, both in general, from the introductory changes to the initial dementia, and its individual forms include a very large number of symptoms. But if we were to give a detailed and exhaustive presentation of them, confining them to individual periods and painful forms, then this would only be external description, which would not give an idea not only about the essence of the disease, but even about the clinical characteristics. Here, the most important thing is the relationship between individual symptoms, and even more - their relationship with general personality changes, which should be considered the basis of all changes that occur. Each symptom acquires significance only in connection with an assessment of the general changes that develop in the psyche and change its entire structure. Under such conditions, in order to get acquainted with the essence of schizophrenia, it is precisely the elucidation of these general changes in the entire mental personality, the change in the entire mental appearance, in other words, the study of the psychology of schizophrenia, that acquires special significance. Familiarization with its features and differences both from a healthy psyche in general, and from what the patient represented before the disease, can most of all give an understanding of this disease. Penetration into the psyche of a patient with schizophrenia is the only thing that can give the key to understanding both individual symptoms and their totality and the behavior of the patient as a whole.

At the center of the schizophrenic psyche lies a peculiar change in the consciousness of the “I” itself and the entire personality with a violation of normal attitudes towards the environment. First of all, it is characterized by more and more prominent isolation in itself, alienation from everything else. In the presence of this autism, the patient's personality acquires more and more the meaning of something self-sufficient, finding in itself everything that is needed to maintain a certain balance, and not needing any excitations from the outside. From the outside, this autism is expressed in isolation, in increasing alienation from the environment with some active resistance to attempts from the outside to break this isolation and make contact with the patient. According to the internal mechanisms of development, autism stands in connection with other features of the schizophrenic psyche, and above all with the cardinal phenomenon that gave the name to the whole disease - the splitting of the psyche. The latter lies in the fact that the elements of the psyche turn out to be disparate, not united into one harmonious whole, but as if existing separately on their own. This, in turn, is due to the weakening of mental activity, which is reflected in the insufficient activity of synthesis and in the insufficient processing of external impressions.

Fencing off from the outside world finds a direct explanation for itself in the biological changes that are constantly observed in schizophrenia. In this regard, first of all, the absence, or at least a more or less significant weakening of the reflexes of the skin and mucous membranes, which are, as you know, a kind of protective mechanisms, deserves attention, which is typical for schizophrenia. Such features do not represent an isolated phenomenon, but are a partial case of a general weakening of the ability of the schizophrenic brain to respond to external stimuli.

For example common occurrence that schizophrenics have mild reactive phenomena to intoxication and infection. In this regard, with a quite pronounced disease, infections for the most part proceed without delirium. Phenomena of the same order also include the fact that the formation of conditioned reflexes to any stimuli in schizophrenics is given with great difficulty, and already established reflexes fade relatively quickly. All this speaks for the fact that in patients of this kind there are some objective conditions due to which contact with the environment and the liveliness of response to stimuli coming from outside are violated. In part, here we have to reckon with peculiar innate features mental organization, since the phenomena of autism can often be ascertained long before the discovery of the disease, but there is no doubt that with its onset, all previously only outlined signs intensify, in particular autism. In some cases, the development of autism is facilitated by peculiar phenomena of mental hyperesthesia, a special sensitivity that makes close contact with others unpleasant for the patient and makes him especially close and fence off. Naturally, autism and its external expressions - isolation and low sociability of the psyche - represent something much deeper and more persistent than the reluctance of a normal person to communicate with others, caused by emotional moments. The splitting of the psyche is the biological basis not only for autism, but also for other symptoms that are also considered basic for this disease. Due to the disparity of individual elements related to the same phenomenon, but not united by schizophrenic thinking, it happens that all of them, including those that contrast with each other, exist independently, independently of each other. Under normal conditions, each new phenomenon, in relation to which a person must take one position or another, eventually finds a common and unified assessment for itself, which determines the line of behavior in relation to it. In every more or less complex phenomenon there are always many different sides, a lot of signs, diverse in nature and degree of expression. The normal psyche, taking into account all the individual moments, weighs pro and contra, draws a definite conclusion, by which it is guided in its behavior. In a schizophrenic, this unifying thinking is very weak, and the individual elements do not merge into one whole, and each tends to give a reaction that is adequate only to him.

It seems to patients that one or the other side of any phenomenon is important, and therefore they often change their attitude to it many times over. This is most clearly expressed in the presence of two sides opposite in nature, one of which attracts, and the other repels. For example, when greeting a doctor, such a patient alternately stretches out his hand, then immediately takes it back, and so on many times; entering the study room, he stops, then takes a step forward, then steps back, and so on ad infinitum. Naturally, for such simple acts as shaking hands and visiting an office, many different motives can be imagined for both positive and negative solutions to the issue. The usual reaction for healthy people and for most patients is - without hesitation to offer a hand and accept the invitation. Psychologically understandable would be a consistently negative reaction in a patient with delusions of persecution in relation to the doctor or with delusional attitudes towards others in general. But in this case, there is both a positive and a negative assessment of the same phenomenon and at the same time opposite tendencies - to reach out, enter the office and do just the opposite. This phenomenon is called ambivalence and ambivalence, with the first name referring to the characteristics of intellectual components, and the second - the impulses to action associated with them. To a greater or lesser extent, this ambivalence is characteristic of all schizophrenics. Although in such a sharp form as in the examples given, it does not appear very often, nevertheless, it must be seen as the reason that the whole behavior of the schizophrenic turns out to be devoid of unity, consisting of disparate and often contradictory acts; even more often it is revealed in the fact that the schizophrenic, not being able to make the final choice among the solutions presented, remains inert, inactive, completely passive in his attitude to the environment.

Schizophrenic ambivalence and ambivalence differ in essential features from the uncertainty in one's actions and indecisiveness, characteristic of psychasthenics and neurotics in general. From the side of internal experiences, the indecision of psychasthenics is characterized by great emotionality and a completely different attitude towards it by the patient himself: he is aware of its absurdity, is tormented by it, strives to overcome it, but cannot; the schizophrenic is passively carried away by those ideas that are currently dominant. From the outside, the manifestations of ambivalence and ambivalence are more rude, persistent, manifesting themselves not only in complex actions, in relation to which there may be doubts about the correctness of one or another approach, but also in the most elementary motor acts, the fulfillment or non-fulfillment of which even to the smallest extent. cannot interfere with the patient's interests in any way. The behavior of an ambivalent schizophrenic can sometimes give the impression of complete absurdity and dementia, but the latter in the proper sense is not here. The possibility of a correct understanding of phenomena and adequate behavior is not excluded, but it is not revealed due to some internal reasons. This latter can sometimes be interpreted as a phenomenon of inhibition, close to what is called by this name among physiologists. Not without reason IP Pavlov brings together some clinical phenomena with inhibition. Undoubtedly, however, that in its main basis, the phenomena in schizophrenia are much more complicated. It must be considered that the German psychiatrist Beringer, who speaks of the weakening of the intentional arc in the thinking of the Schizophrenic, is closer to the truth, and Berze, according to which the most significant thing in schizophrenia is a general decrease in mental activity, due to which the possibilities that are available are not revealed, and more highly standing mental forces are affected. , in other words, higher mental abilities. It is precisely because of the lowering of psychic activity concerning higher processes that the phenomena that characterize the life of the lower aspirations and instinctual drives that are suppressed in the ordinary state are predominated. However, the state of affairs cannot be imagined in such a simplified way that we are talking about the disinhibition of impulses coming from the subcortical zone due to the disinhibition of the cortex, with the activity that is usually associated with higher mental processes. Undoubtedly there are deeper changes in the whole psychic personality. The latter seems to the schizophrenic connected with the surrounding by some special relationship. There is some analogy in this with the thinking of primitive man, as Levi Bruhl describes it. Everything around is perceived by the schizophrenic as having a certain relation to him, is perceived in a special symbolic way, from the point of view of some mysterious connections with the environment, some magical influences, the object of which is he and his body. The thinking of a schizophrenic in this way is not adequate to the thinking of a normal person, which is why it is often called paralogical, going according to its own laws, different from all the laws that can be seen in the thinking of a healthy person. They also talk about abstraction”; the abstractness of the schizophrenic's thinking, which stands in connection with his detachment from the external real world and his inner aspiration, introvertedness in Jung's terminology.

The splitting of the psyche usually concerns such formations that are the most durable, in particular, the consciousness of the patient's "I" itself. The latter in a normal state is characterized by a number of signs, which include activity, unity, continuity and consciousness that these experiences belong to the subject, are his personal, the “I” of the schizophrenic is deprived of all these properties and, above all, unity. It seems completely different, substituted, devoid of its usual properties. Related to this is the fact that schizophrenics sometimes refer to themselves in the third person. This affirms, first of all, the presence of deep changes in the consciousness of one's "I" and, moreover, with a clear splitting off of some elements of the personality from others: the "I" observing - the central part - receives the meaning of something independent and independent of the "I" acting. This can be seen already manifestations of the most significant schizophrenic symptom - splitting of the personality, sometimes leading to the idea that two, as it were, separate people live in the patient, who are in a certain antagonism: one acts, the other criticizes, condemns or defends. Sometimes the patient himself identifies himself with one of these two personalities, sometimes they seem to exist completely independently of him. Going even further, splitting can turn the personality into a disorderly collection of scattered fragments, and the result is a complete disintegration of the personality, in which it is difficult to catch hints of the former structure. Due to the fact that the experiences of the patient lose the character of something personal, belonging to him, individual ideas or groups of them begin to seem like something alien, extraneous, inspired from the outside.

The described changes in the personality of schizophrenics are in some respects reminiscent of the depersonalization of melancholics, to whom their "I" also seems changed, completely different, lifeless and insensitive. In this case, however, there is no violation of the unity of the personality: and its continuity: the melancholic does not think about the existence of some other person, but expresses his conviction that his own personality has changed, and he blames this change. Meanwhile, in a schizophrenic, all phenomena are much more crude, they have the character of complete splitting, disintegration. To a certain extent, a change in organic sensations is common, which is quite profound in melancholics. Although it has a different character there, nevertheless, the main differences are not in emotional experiences, but in intellectual disorders that come to the fore in schizophrenia, are accompanied by a profound violation of the mental structure, while the personality of the melancholic in its essence is completely unchanged, which is especially clear. performs after the attack of the disease; after an illness, the personality of a melancholic comes out the same, not damaged in its basic properties.

A change in sensations associated with the activity of the organs of the body is a constant and essential sign that has great importance for the genesis of many phenomena characteristic of the psychology of schizophrenics. In relation to schizophrenia, more than in relation to any other psychosis, the general position holds that psychosis is a disease of the whole organism, and not just of the brain. Naturally, therefore, the appearance in the mind of a schizophrenic of new, abnormal sensations, acting on well-being and emanating from internal organs. But it must be borne in mind that with this disease, changes in the subcortical zone and, in particular, in the centers of the autonomic nervous system, are very frequent. As a result of deep vegetative disorders associated with changes in the corresponding parts of the central nervous system, schizophrenics have a large number of various sensations of a usually unpleasant nature, paresthesia, sensations of sorting, pulsation, passage of electric current, sometimes quite pronounced pain. According to the statistics of the psychiatric clinic II MMI, out of 65 cases of schizophrenia, 52 had sharp headaches, and the rest had a feeling of heaviness and tension. Bleuler pointed out the frequency of headaches in schizophrenia. In many cases they are of a special nature, resembling similar phenomena in migraine, partly in brain tumors. Headaches are undoubtedly associated with vasomotor and secretory disorders, sometimes with those changes that are known under the name of cerebral swelling (Hirnschwellung) and are very often ascertained in the autopsy of schizophrenics.

Most patients complain not so much of pain as of a feeling of fullness, swelling of the brain. It seems to them that the brain grows, swells, enlarges, fills the entire skull, presses on the bones ready, they protrude, unclench, diverge. Patients feel that the head is under some kind of pressure, that at any moment it can burst, tear; from within, something presses on the eyes, on the superciliary arches, as a result, the eyes, according to the expression of the patients, roll out, the superciliary arches and temples protrude. One of the patients at the moment severe pain wraps a towel around the head to keep the bones in place in this way. Pain is always felt to come from within. The very brain hurts, an abscess is definitely brewing in it, which pulsates, presses and presses.

Against the background of various sensations, which are very frequent in schizophrenia, illusions develop in large numbers, which, together with hallucinations, play a large role in the pathology of this disease. It seems to the patient that someone is touching him, someone is lying behind his back on the same bed with him. Illusions of a general feeling should include such sensations, as if inside, in abdominal cavity, in the chest, in general in the body there is something extraneous, alive. Hallucinations are much more important. Inclination to them, some psychiatrists are among the main signs of schizophrenia. Especially often observed, and, moreover, in a characteristic form, olfactory and auditory hallucinations. Partly here we have to reckon with the phenomena of hyperesthesia, which are the same signs of irritation as the above-described unpleasant and pain. If we recall that, for example, Halban (Halban) stated in pregnant women a significant increase in the acuity of perception of mainly olfactory and gustatory sensations, then something similar can take place here. In any case, schizophrenics have very frequent hallucinations in the proper sense. The patient is haunted by various smells, mostly of an unpleasant nature: the smell of burning, rotten eggs, carrion, the smells of some unknown poisons, the smell of sweat, urine and feces. Often it seems to the patient that the bad smell comes from himself.

Taste hallucinations are most often in such a form that some strange taste of something metallic, some kind of poison seems to be in the food; the meat in the soup has a taste of carrion, some kind of rot. Auditory hallucinations are most often observed in the form of voices, which are either single or numerous and are heard from all sides. The voices are either loud, real and heard so clearly that you can indicate the direction from which they are coming, then almost silent, heard in the form of a whisper. Sometimes the patient cannot tell where the voices come from, in some cases the voice or voices are heard inside the patient himself, in the chest, especially often in the head. The so-called inner voices and "opinions" are especially characteristic. It seems to the patient that, although he does not hear anything, someone is talking directly into his head. Typical for this disease are those phenomena that are known under the name of pseudo-hallucinations or mental hallucinations, as well as the fact that his thoughts and individual words seem to be repeated loudly by someone (Gedankenlautwerden). Sometimes patients talk about the telephone, wireless telegraph, radio.

The content of hallucinations is mostly unpleasant for the patient; he hears abuse, threats addressed to him, he is accused of various crimes in his service, in a bad attitude towards his family, in debauchery. Sometimes he hears long discussions in which a large number of people take part, the whole past life of the patient is discussed, and it is found that he has always been a bad person, a thief, an onanist, a state criminal, a spy. Sometimes voices are heard that stand up for him. Sometimes dialogue is heard; two voices arguing among themselves, and both are localized inside the head of the patient. Most often, the speakers do not address the patient directly, but, as it were, talk about him among themselves, calling him by name or simply “he”. Quite typical of schizophrenia are auditory hallucinations of this kind that a voice belonging to an invisible person registers everything that the patient does, mocking and scolding, for example: “Now he undresses and goes to bed, now he will sleep,” etc. In some cases, the hallucinatory experiences of schizophrenics generally take on the picture of Clerambault's mental automatism. Most of the voices belong to strangers, less often to familiar people whom the patient does not see. Sometimes it seems to the patient that the voices he hears belong to those around him, passers-by on the street, random companions in the tram.

Less common are visual hallucinations, which are also varied. feature visual hallucinations schizophrenics can be considered that they are mostly deprived of brightness and vitality. Hallucinatory images are somehow incorporeal, unreal, give the impression of painted pictures, and not creatures of flesh and blood. Sometimes the figures move like in a movie. Similarly to auditory deceptions of the senses, pseudohallucinations often occur here too - certain images are seen somehow mentally and appear to lie somewhere outside the field of vision, sometimes in the head.

Acquaintance with the content of the hallucinations of schizophrenics, even the very proof of their presence, presents great difficulties due to the autistic attitudes of such patients, low sociability, and even a tendency to hide their experiences due to the tendency to dissimulate. In such cases, it is necessary to take into account the assessment general behavior patients and the so-called objective signs of hallucinations: staring at one point, turning the head, making one think that the patient is listening to something, pinching his nose, plugging his ears, etc. (Fig. 39).

Rice. 39. Plugging the ears of a schizophrenic with auditory hallucinations.

Sometimes the presence of hallucinations can be judged by unexpected quick movements, shouting out answers to someone in space, refusing food.

Among the characteristic phenomena in schizophrenia, delusional ideas should also be attributed. Although they do not represent absolutely permanent feature in this disease, but where there are - and such cases are still the majority - in their structure, in which one can see a clear reflection of the main points of schizophrenic thinking in general, they are a very important ingredient in the clinical picture. The exact clarification of their nature is of great importance for understanding the essence of the disease and for distinguishing it from other diseases. This refers not so much to their content, but to the mechanisms of development, construction and the role that they play in the life of the patient and in relation to others. In the sense of the genesis of delusional ideas, the defining moment is a change in the patient's well-being, the presence of a large number of various new sensations in the body, illusions and hallucinations, as well as disorders in the intellectual sphere. The most characteristic for schizophrenics is, according to the terminology of the psychiatric clinic II MM And cathestic delusions, that is, one where the main role is played by a change in the world of sensations in which the patient lives. Various sensations experienced by him in the body, pain in different places, a feeling of something extraneous, disorders of taste, smell and other sensations - all this in a certain way affects the perception of the environment. In connection with a decrease in critical and combining activity, delusion develops on this basis, which naturally should take the form of a delusion of physical influence. Appeared as a result of biological changes in the body and in particular disorders in the vegetative nervous system sensations, together with illusions and hallucinations, provide material for delusions of poisoning, exposure to electric current, delusions of suggestion, in general various forms physical impact. Experiencing changes throughout the body and not being able to take them critically and evaluate them as a result of the disease, the schizophrenic projects the cause of this change outward and sees it in some influences of other people. The isolation of such patients, together with a violation of contact with others, deprives the patient of the opportunity to become more fully acquainted with all aspects of the phenomenon, which in some initial cases could give a certain correction of the emerging delusional ideas, and at the same time, it is the reason that delusional formation occurs within a vicious circle. autistic experiences of the patient, out of touch with the surrounding real life, why delusion, when detected, strikes with its strangeness, surprise, as if contrived and inconsistency with the real situation. Patients become somehow especially distrustful and suspicious. It seems to them that those around them have begun to treat them differently, shun the patient, whisper among themselves, laugh at him; on the street and in the tram one and the same suspicious faces constantly come across, some strange taste is noticed in the food. For some time, the matter is limited only to alertness and, as it were, keeping an eye on what is happening around, and we can talk about special period incubation, during which delusional ideas seem to be hatched; then the patient has a certain conviction that his suspicions are well founded. Due to the isolation of schizophrenics and suspicion towards everyone around them, fully mature crazy ideas, as a rule, are not expressed for a very long time, they even stubbornly hide. In the presence of a well-defined delirium to direct questions about the patient's attitude towards persons woven into this delirium, evasive or even negative answers are usually obtained. With a strong tendency to dissimulate, the patient very often stubbornly and with great skill hides his delusional attitude towards imaginary enemies and behaves towards them in such a way that the latter may not suspect anything for a long time. This can happen even to the people closest to the sick person who constantly live with him and it would seem that they should know his psychology. So in one case, a schizophrenic, in connection with the development of a delusion of jealousy in him at the beginning of his illness, made an unexpected attack on his wife, which almost ended in a serious misfortune, although before that he had not shown any hostile attitude towards her.

A very common form of delusions of persecution in schizophrenics is delusions of suggestion, influence. It seems to the patient that he is completely subordinate to some people unknown to him, in the power of some special force, that all his thoughts and actions are not his, but inspired by others. He himself is just an automaton, a toy of some mysterious forces. Interpreting the nature of this influence, the patient sometimes speaks of hypnosis, suggestion at a distance, reading his thoughts and suggestion of desires unusual for him, impulses for this or that action, about the action of special rays, about radio, about some special machines. The peculiarities of the delusional concepts of schizophrenics include the fact that the delusion of persecution is very often associated not with people around him and generally known to him, but with some suspicious, unknown personalities. This feature is especially pronounced when the delusions are extensive, complex and, as often happens, tend to add up to a whole system. In such cases, some special mysterious organizations often appear, a gang of intruders, the mafia, masons, counter-revolutionaries. The patient does not know any of these intruders either by sight or by name, but is convinced of their existence, as he constantly feels their influence on himself. The nature of the effects seems so peculiar to the patient that often he cannot define it in generally accepted terms, but must invent special names, sometimes not stopping before inventing new words.

Delusions of grandeur are not so common, but if there is, in its structure it represents all the features of schizophrenic psychology. The content of delirium, as is characteristic of it in general, varies depending on the characteristics of the time experienced, on social status and the education received. From the outside, it is often as if there is a great resemblance to progressive paralysis, since the same ideas of high position, possession of various talents appear, but the inner meaning and psychogenesis are completely different. The schizophrenic's delusions of grandeur lack concreteness and reality; he does not consider himself simply Napoleon, a high commissioner, a famous artist, but characterizes his difference from ordinary people in a special, often vague and not always understandable way. For example, he begins to think that he is a genius who has never had an equal; he is called upon to carry out great reforms, to make all people happy, he invented a special system, massage, which will immediately open the eyes of all people and teach them how to live, so that everyone feels that they do not know sorrow.

It is characteristic that a schizophrenic, when creating crazy systems that seem to be aimed at the benefit of others, always has in mind not specific people close to him and those around him in general, but some abstract person, all of humanity. In this, too, he differs from a paralytic patient who distributes his imaginary wealth to those around him and tries to make happy, first of all, those who have rendered him some service. In self-exaltation, schizophrenia sees the realization of some higher will, the predestination of some mysterious forces. In this regard, it is very typical of the delusions of grandeur of schizophrenics that they often imagine themselves to be prophets, leaders, reformers, destined to show mankind new ways. Very often you can discover in the construction of delirium a tendency towards something mystical, mysterious, towards something special that cannot be measured by an ordinary arshin.

In many cases, delusional ideas of grandeur are observed in a schizophrenic simultaneously with delusions of persecution, sometimes entering the same system, with some ideas representing, as it were, the logical development of others; the patient is persecuted because they envy him, they want to take away his high position from him, to appropriate and pass off as his own inventions, etc.

The delusional ideas of schizophrenics are also characterized by the fact that, being in an organic connection with the foundations of his thinking, they are persistent, not amenable to dissuasion, and to a greater extent are reflected in his behavior. The schizophrenic, despite the fact that he has long retained the formal abilities of the intellect and a store of information, can never be convinced that his suspicions are unfounded or that his claims to high position are absurd. On the contrary, contradictions and objections make patients especially stubborn and force, strengthening their argumentation, to develop delusional concepts more and more. We can further talk about a very large sequence of the patient's behavior from the point of view of his delusional ideas. They determine social attitudes, attitudes towards others, such as the final withdrawal from other people and the creation of complete isolation, as well as the protective measures that the patient takes and attacks on others. In the future, as dementia grows, the delusional concepts lose their integrity and unity, and even further, along with the disintegration of the psyche, they turn into separate fragments, and the expressed fragmentary delusional ideas seem completely meaningless and no longer have any effect on the patient's behavior.

The features of delirium characteristic of schizophrenia come out with particular clarity not when the delirium is generally poorly developed, and comes down, as often happens, to 2-3 more or less interconnected thoughts. They need to be studied in those cases where the development of the delusion leads to the creation of especially magnificent pictures. Particularly interesting from the point of view of influencing behavior are those cases in which insane thoughts and desires arising from delusional fantasies are more or less fully realized in life, without encountering obstacles due to the exceptional position of the patient. In this respect, the history of the disease of the Bavarian king Ludwig, who came from a very degenerate Wittelsbach family, deserves attention.

He suffered from schizophrenia for a number of years with a lot of delusional ideas of greatness and persecution, which did not prevent him from remaining on the throne for some time.

The delirium of persecution and the fear of people led him to spend whole months alone, or at least without seeing a single face. Food was served to him on a table that, with the help of a special mechanism, was pulled out from under the floor. Approximate, being to his reception, had to wear masks. When he visited the court theater, then in the latter there should not have been other spectators except him. He himself sat in a closed box, and it was not visible from the stage or from the spectator shaft whether the king was in his box or not. Artists had to play in an empty theater without being sure that they had at least one audience. For the schizophrenic king, a secluded castle was built according to his instructions, on the lead roof of which a lake was built, an artificial swan floated on it, on which the king, who imagined himself to be Lohengrin, sat down. Such sharp disturbances, however, did not prevent the patient from maintaining sufficient orientation and even cunning. This is evident from the fact that he, having committed suicide under insufficiently clarified circumstances (apparently, drowned in the lake), killed his life physician, the famous psychiatrist Gudden, along with him.