Organic schizophrenia. Organic-based schizophrenia, paranoid form, hallucinatory-paranoid syndrome with affective disorders

State Educational Institution of Higher Professional Education OrGMA of Roszdrav

Department of Psychiatry and Medical Psychology

Head department - Doctor of Medical Sciences, Prof. Budza V.G.

Teacher - candidate of medical sciences, ass. Chalaya E.B.

DISEASE HISTORY

Age - 50 years (01/13/1960)

Diagnosis: Schizophrenia on organic grounds (alcoholism, head injury), paranoid form, hallucinatory-paranoid syndrome with affective disorders. It is too early to talk about the course of the disease, since this is the first hospitalization.

Complication - chronic alcoholism stage 2,

Completed by a student of group 517

Faculty of Medicine

Nurguzhina E.E.

PASSPORT DETAILS:

Place of residence - Orenburg

Profession: turner

Date of admission - 09/20/2011

History is subjective and objective.

A) FAMILY HISTORY:

Psychopathological heredity is not burdened.

The patient's husband died in 1990. The son died in the summer of 2011. He suffered from alcoholism.

Before hospitalization, the patient lived with her niece.

ANAMNESIS OF LIFE:

She was born the second child in the family. The age of both parents at the time of the patient’s birth was 26 years. The mother's birth proceeded without complications. Early development without features. I suffered from childhood infections. At the age of 5, she was scared by her cousin and began to stutter. The stuttering continues to this day. At school, she constantly endured ridicule from her peers about her stuttering. She didn’t want to go to class, expressed the idea of ​​suicide to her mother, but did not attempt suicide. I studied well. After school I graduated from college, then worked until retirement at a factory. Made bearings.

She doesn’t remember the timing of her first menstruation. Presumably 14-15 years old. My periods were regular. 3 pregnancies. Two ended in childbirth. One is a medical abortion. Menopause from age 50. It proceeded without any problems. Before her illness, the patient was distinguished by her kindness and responsiveness.

She got married at the age of 25. Relations with my husband were warm. I had a hard time with his death in 1990. I had two sons. The first son, according to the patient, died from complications of the flu. Doesn't remember the date of death.

History of the disease:

According to her daughter, her condition changed about a year ago, when she began to hear “footsteps” in the house, her character changed - she became secretive, irritable, rude, and her memory deteriorated. Unreasonable mood swings appeared, he was irritable, and expressed suicidal thoughts. After 3 months, I began to hear male and female unfamiliar voices emanating from the surrounding space, of an imperative nature. He assures that they are pursuing him. A month before the actual hospitalization, he went to the river at night and swam in his clothes, explaining this by the influence of “voices,” for which he was hospitalized in the Oncology Department (08.2010). After discharge, he did not receive any maintenance treatment. On 08/30/10 in the evening I went out for a “walk” under the influence of “voices” and “got lost.” He wandered around the village for about a day, after which the neighbors called an ambulance. Sent for hospitalization in a psychiatric hospital on a voluntary basis. Upon admission on September 1, 2010, the patient’s consciousness was not impaired. Fully oriented. Answers in terms of what was asked, after a pause, briefly, clarification of the question is constantly required. Speech is quiet, slow and not always understandable. Facial expressions are inexpressive. Slow-paced, sequential thinking. Emotionally inexpressive. Shows no interest in anything. He interprets metaphors correctly. Reported that he heard “voices” that forced him to perform certain actions. The mood is low. The figurative meaning of proverbs is accessible with the help of the interlocutor. I was able to repeat the doctor’s name and patronymic only after repeated repetitions. Denies suicidal thoughts. Quite oriented in matters of everyday life. Criticism of one's condition is formal. Doesn't show any crazy ideas.

Current condition:

SOMATIC CONDITION:

General condition: satisfactory

Body temperature: 36.5 C

Pulse: 74 beats/min

Respiratory rate: 20 per minute

Body type: normosthenic

Skin and visible mucous membranes: the skin is pale pink, there are no rashes, skin moisture is moderate, elasticity is preserved. Visible mucous membranes are pink, shiny, clean, moist.

Subcutaneous fatty tissue: moderately developed, evenly distributed Lymphatic system: lymph nodes are not enlarged

Muscular system: muscle strength is sufficient, tone is normal. Tissue turgor is preserved

Bones and joints: upon examination, no pathological changes were found in the bones of the skull, spine, chest, pelvis, or long tubular bones.

Thyroid gland: not palpable

Respiratory organs: according to examination, palpation, percussion and auscultation of the respiratory system, no pathology was found.

Cardiovascular system: the limits of relative dullness of the heart correspond to the norm. On auscultation, heart sounds are muffled. The pulse is weakly filled and has satisfactory tension. The elasticity of the vessel wall is preserved. BP -130/70 mm RT st.

Digestive organs:

mouth: pink mucosa, moist, teeth, tongue: white coating on the tongue, tonsils: do not extend beyond the edges of the palatine arches

belly: regular shape, in a horizontal position does not protrude beyond the edges of the costal arches. The lower border of the stomach is located 3 cm below the navel. Superficial palpation of the intestine is painless. With deep palpation, pain is noted in the right and left iliac regions. The liver does not extend beyond the edges of the right costal arch, palpation is painless, the edge is smooth and elastic. The pancreas and spleen are not palpable.

Genitourinary system: without features

NERVOUS SYSTEM:

The reaction of the pupils to light is lively, the same on both sides, there is no anisocaria. No nystagmus was detected, convergence was weakened. Fields of view are not narrowed. The range of movements of the eyeballs is full. The patient complains of letters merging before his eyes when reading and sees only large letters. Visual acuity was not determined due to the lack of necessary tables. Mild left-sided hemiparesis. Facial expressions are preserved. The tongue is in the midline, swallowing is not impaired. The range of active and passive movements in all joints is complete, in the joints of the same name the amplitude of movements is the same. Muscle tone is normal. No disturbances in tactile, pain or temperature sensitivity were detected. Tendon and periosteal reflexes are preserved and equally pronounced on both sides. No pathological reflexes or meningeal signs were detected. The patient is stable in the Romberg position; there is a pronounced tremor of the upper extremities of large amplitude. Performs coordination tests (toe-nose and heel-knee) freely. Conclusion: a visual impairment has been identified that requires further detailed examination.

MENTAL CONDITION:

Consciousness.

Consciousness is not upset. Reluctant to engage in communication. The patient's orientation in time, space and personality is preserved. The patient clearly imagines his location, names it correctly, correctly indicates the year, month and date (oriented in calendar time), recognizes the curator during repeated visits. There were no signs of fragmented thinking. There were also no symptoms of switching off consciousness: the patient reacts to stimuli of normal strength, understands questions addressed to him of varying degrees of complexity, and responds to them adequately. No drowsiness. The patient is calm, facial expressions are adequate and unexpressive. Speech is monotonous, connected, consistent, somewhat slow. The mood is smooth and upbeat. In the department he is not active, not sociable, spends more time in bed. He is neat in his clothes. Memory is reduced. Interprets proverbs, sayings and metaphors correctly. Performs arithmetic operations on addition and multiplication without difficulty. Easily lists the days of the week in reverse order. The patient did not have any convulsive or non-convulsive seizures during his life. The patient denies episodes of amnesia.

Conclusion: no disorders of consciousness were identified. Hypomnesia.

Perception.

The patient has no disturbances in the sphere of perception

Attention.

The patient evaluates himself as an inattentive person. Signs of exhaustion of attention are noted (the patient tried to end the conversation as quickly as possible). Some questions needed to be repeated and clarified.

The patient assesses his memory as “average”; his motor and visual memory are better developed. He remembers the events of his childhood and youth well. Basic knowledge is preserved: the patient without hesitation names the name of the mother, father, their age, their date of birth, etc. The patient does not demonstrate pseudoreminiscences or confabulations.

There is no disturbance in the sense of familiarity.

Results of psychological tests for memory research:

Telephone test: the patient easily repeats all the digits of the number after the curator, but after 2 minutes repeats them with difficulty.

Memorizing 10 words.

The following words were presented:

Table River House Dog Face Tree Clock Cheese Garden Flour

Number of words played: 5

Number of attempts 3

After the first presentation, the patient reproduced 3 words, which is significantly below normal levels (from 6 to 7 words).

In addition, when reproducing words, the patient notices sliding associations: remembering the word “flour”, the patient builds her own associative series, adding: “sugar”, “sour cream”, “egg”, considering these words to be present in the presented series. These slippages were noted more than once, and the associations were always of the same type.

Conclusion: memory is reduced (mainly fixation), sliding associations are noted.

The patient’s main type of thinking is concrete: in a conversation, the patient tries to reduce all answers to questions to specific objects, things, actions. There is a disorder of thinking in terms of tempo: it is slow. The patient’s speech is impoverished, slow, answers to questions are monosyllabic, formal, after a long pause. The same type of answers predominate, such as “everything is fine... everything is fine..”. After establishing contact, the patient began to respond to questions more animatedly, the answers to questions became more detailed and complete, but the slowness of thinking remained. No pathological thoroughness, reasoning, or perseverations were noted in speech. The depth of judgments expressed by patients in conversation is insufficient. The Patient's judgments relate mainly to everyday problems, the affairs he is involved in in the department, and his relationship with his mother. The patient conducts these simple reasoning correctly, without expressing paralogical ideas. When talking, the patient speaks in a calm, normal voice. Results of psychological tests to assess thinking:

The patient correctly excludes the fourth unnecessary thing and correctly explains why he excludes this particular concept.

Comparison of concepts.

When asked what is common and what is the difference between a dog and a cat, the patient answered that a cat is a pet, affectionate, drinks milk, has green and shiny eyes, and a dog is man’s friend.

To the question “what do an apple and a pear have in common?” the patient answered that “the apple is round, green, yellow, red, the pear is oblong, yellow, green.”

The patient sees the differences between a bird and an airplane in the fact that “the airplane is metal, but the bird is alive.” Based on the results of this study, it can be concluded that the patient retains the ability to identify features of objects on the basis of which their comparison is made.

Understanding the meaning of proverbs and metaphors. The patient explains the meaning of the expression “golden hands”, “shirt-guy” correctly. When asked what the proverb “strike while the iron is hot” means, the patient replied: “until one thing is finished, you should not start another.” Conclusion: disorders of thinking in terms of tempo (slowdown) are noted.

Intelligence.

When collecting anamnesis, the patient did not use general and professional concepts; his judgments and conclusions related only to everyday, domestic problems, were superficial, without attempts to analyze situations. Only relatively simple questions were easily understood, and simple, superficial, specific answers were given. Complexly formulated questions concerning individual details were difficult to understand and had to be repeated or simplified. The patient's stock of general knowledge is sufficient: he named a lot of names of cities, rivers, states (for example, the rivers Lena, Volga, Sakmara, Indus, etc.) were named. He knows the name of the current president of Russia, but is not aware of the political situation in the world (although he claims to be interested in politics and watches news programs).

Conclusion: the level of intelligence is sufficient.

The patient assesses his mood at the moment as having a cold. The patient is subject to mood swings, takes everything “too close to heart”, in conflict situations does not try to defend himself, but remains silent, and less often responds with rudeness. He is not vindictive, easily forgives an insult, and defines his character as “kind, flexible.” The patient does not notice any mood swings depending on the time of day. Doesn't show suicidal thoughts. The patient's facial expressions are inexpressive, and there are practically no gestures. The patient always takes the same position: sitting with his elbows on the table. Emotions are weakly expressed and mostly adequate to the subject of the conversation, but sometimes the patient laughs for no reason when answering any question.

Conclusion: There are episodes of emotional inadequacy. It is currently not possible to identify delusions and hallucinations. Criticism of the disease, the condition as a whole, is formal.

Motor-volitional sphere.

The patient is neat in his hair and clothes. He participates passively in the conversation, mostly answers the questions posed, does not ask counter questions, does not show interest in the conversation, and does not try to find out anything about his illness. He is mostly alone in the department, rarely communicates with patients, and spends most of his time aimlessly in bed. He often mentions that he should be discharged soon and that he really wants to go home. The patient's behavior during the conversation is somewhat constrained.

Conclusion: disturbances in the motor-volitional sphere in the form of hypobulia (he is indifferent to his present situation, the future, has no desires, does not make plans).

Behavior.

When observing a patient outside of a supervision situation, it was noted that the patient spends more time in bed, communicates little with other patients, and more often sits alone or walks along the corridor. The patient's attitude towards work is positive. He treats his painful experiences (pseudohallucinations) uncritically.

Conclusion: the patient’s behavior showed signs of autism.

Entered for the first time. Repeatedly hospitalized in the emergency department due to chronic alcoholism.

Data from instrumental examination methods:

Fluorography: emphysema, diffuse pneumosclerosis, roots are asymmetrically compacted, non-structural. The left dome of the diaphragm is pressed upward by the colon swollen with gas. The aorta is compacted.

Data from laboratory examination methods:

Biochemical blood test from 2.09.10

Total bilirubin 13.0 µmol/l

Glucose 4.5 mmol/l

OAM 2.09.2010:

Density 1004

Protein 0.015

Chest X-ray 09/03/10

Slight pneumosclerosis, roots and aorta thickened. The right dome of the diaphragm is partially relaxed. The heart is ordinary.

Electroencephalography 8.09.10

Moderate changes in brain biopotentials are recorded. The cortical rhythm is slowed down to 8.2 Hz, better expressed in the caudal leads, where its slight asymmetry is noted - slightly less on the right than on the left, paroxysmal. Paroxysmal beta1 activity, prone to hypersynchronization, was enhanced in all leads. Bilaterally synchronous waves are recorded in a slow alpha rhythm, above the background amplitude with a variable accent in the anterior leads, then in the caudal leads, indicating dysfunction of the brain stem structures. When testing with FS, there is no increase in FS rhythms. The GV test somewhat enhances interhemispheric asymmetry and emphasizes the signs of dysfunction. There are no typical forms of epiactivity.

CONSULTATIONS OF SPECIALISTS

Neuropathologist:

Encephalopathy of mixed origin. Mild left-sided hemiparesis.

Therapist:

Myocardial dystrophy stage II. HF 0-1, Chronic bronchitis, emphysema, pneumosclerosis, DN stage 1, Hypertension II degree, HRV

In the process of studying the patient’s mental status based on conversation, observation, and testing, the following was revealed:

Symptoms:

amorphous and unproductive thinking

hypothymia

sad affect

mental and physical inhibition

hypobulia

verbal true hallucinations

delusions of persecution

emotional inadequacy

Syndromes:

Depressive syndrome (exogenous depression)

Apato-abulic syndrome

Hallucinatory-paranoid syndrome

Probable etiology: organic brain damage of mixed origin (repeated head injuries, chronic alcoholism).

Nosological diagnosis:

Diagnosis

Organic-based schizophrenia (alcoholism, head injury), paranoid form, hallucinatory-paranoid syndrome with affective disorders. It is too early to talk about the course of the disease, since this is the first hospitalization.

Complication - chronic alcoholism stage 2,

Rationale:

Based on the patient’s complaints that he hears male and female unfamiliar voices emanating from the surrounding space, imperative in nature, which haunt the patient from his words, constant bad mood, attacks of melancholy, motor and mental retardation; reduced performance; decreased interests and desires to do something; indifference; sleep disturbance.

Based on his life history: Repeatedly suffered a head injury; he has been drinking alcohol since he was 18-19 years old. About 10 years ago I began to become an alcoholic more often, drinking heavily for about six months. Tolerance up to 1500 ml of moonshine. I didn’t come out of binge drinking on my own. Reports that he has not consumed alcohol for the last 4 years, and has been coded several times in OKPB No. 1, OND.

Based on the history of the disease, the condition changed about a year ago, when he began to hear “footsteps” in the house, his character changed - he became secretive, irritable, rude, and his memory deteriorated. Unreasonable mood swings appeared, he was irritable, and expressed suicidal thoughts. After 3 months, I began to hear male and female unfamiliar voices emanating from the surrounding space, of an imperative nature. A month before the actual hospitalization, he went to the river at night and swam in his clothes, explaining this by the influence of “voices,” for which he was hospitalized in the Oncology Department (08.2010). After discharge, he did not receive any maintenance treatment. On 08/30/10 in the evening I went out for a “walk” under the influence of “voices” and “got lost.” He wandered around the village for about a day, after which the neighbors called an ambulance

And also based on objective and instrumental data that revealed personality changes of the schizophrenic type, the presence of procedural disturbances in thinking, and a decrease in the expression of emotional manifestations, a diagnosis of “Schizophrenia” is likely.

Paranoid type: there are delusions and hallucinations, but there are no thought disorders, behavioral disorganization, and affective flattening.

Differential diagnosis

delusional hallucination disorder thinking

A differential diagnosis must be made with organic psychoses of a traumatic and intoxication nature, since the history contains indications that the patient has repeatedly suffered traumatic brain injuries and consumed alcohol.

Among the symptoms characteristic of hallucinatory-delusional psychosis of a traumatic nature, the patient has signs of asthenic syndrome (sleep disturbances, anxiety), hallucinations and delusions, emotional disorders in the form of episodes of anxiety and fear.

But with organic psychosis of traumatic origin, mental disorders are accompanied by disturbances of consciousness in the form of clouding, psychosis develops following the influence of additional harmful factors on the body (somatic troubles, intoxication, alcohol, surgery, etc.), which is not observed in this patient. Organic traumatic hallucinatory-delusional psychosis most often debuts with twilight or delirious stupefaction, which was also not noted in this patient. Among organic psychoses of intoxication origin, the patient’s condition should be differentiated from chronic verbal hallucinosis with delusions, which occurs during alcoholism.

Elements of similarity with this pathology in the patient are verbal auditory hallucinations. In addition, the patient has components of apathetic syndrome, which is also characteristic of verbal hallucinosis.

But this patient has disturbances in thinking in the form of slowness. There are disorders of the emotional sphere (emotional inadequacy, decreased emotional activity), disturbances of the motor-volitional sphere (hypobulia), elements of autism in behavior, which is more typical of schizophrenia and is an obligate symptomatology for it.

Schizoaffective disorders. The group of schizoaffective disorders includes conditions in which affective and schizophrenic symptoms are detected simultaneously for at least several days. In this clinical case, a diagnosis of depressive type of schizoaffective disorder is likely. In this disease, at least one typical schizophrenic symptom is detected simultaneously with the presence of at least two characteristic depressive symptoms in the second. At the moment, the patient does not have any other symptom of depression other than a slightly reduced mood (there is no slowdown in the flow of ideas, speech-motor retardation, characteristic disturbances of perception - hypoesthesia, illusory, derealization, depersonalization phenomena, etc.). The state of anxiety cannot be considered a sign of depression, since it is caused by delusional-hallucinatory phenomena. Mental disorders due to exogenous lesions. There is no history of trauma, infectious diseases with damage to nervous tissue, somatic diseases with endocrine disorders, etc. However, asthenic syndrome, present in the mental status of the patient, can be observed in this group of diseases. As part of the asthenic syndrome, the patient did not exhibit such characteristic (but not specific) symptoms that occur with organic lesions of the central nervous system such as sleep disturbance, heat intolerance, bending work, and anticipation of weather changes. Neurological symptoms are very scarce and are limited only to a decrease in muscle tone. No encephalopathic changes were detected: memory was preserved, there was no thoroughness of thinking, no pattern of incontinence of affect was observed. To completely exclude this pathology, sophisticated laboratory and instrumental research methods, including computed tomography of the brain, should be performed.

REHABILITATION

Medical.

A patient in the clinic has a hallucinatory-delusional syndrome, in which treatment with neuroleptics with a predominantly inhibitory effect in rapidly increasing dosages is recommended: aminazine - 250-400 mg/day, tizercin - 250-400 mg/day, etc. In parallel, neuroleptics with antipsychotic effects are prescribed : haloperidol - 15-20 mg/day, trisedyl - 2-5 mg/day, triftazine - 40-60 mg/day, etc. Other psychotropic drugs, including long-acting drugs, are also indicated. The complex also includes correctors: cyclodol, artan, parkopan, romparkin, norakin, etc. Often, during long-term treatment in patients with schizophrenia, resistance of the pathological process to the therapy is discovered. The disease takes a long-term chronic course without a tendency to relapse. To overcome therapeutic resistance, the following is indicated: - intravenous or intramuscular administration of melipramine until a temporary exacerbation of symptoms - administration of mannitol, urea, lidase, hemodez, diuretics (furosemide, veroshpiron)

administration of immunosuppressants (cyclophosphamide)

application of a method for quickly changing the dosage of antipsychotics (“zigzag”, immediate drug withdrawal)

the use of electroconvulsive therapy and insulin comatose treatment during periods of complete drug withdrawal

administration of drugs from the group of nootropics (aminalon, nootropil, encephabol) After achieving a therapeutic effect, it is necessary to continue treatment aimed at preventing relapses. Psychotropic drugs are prescribed, preferably long-acting (motiden-depot, fluspirilene).

Therapist's appointments:

Riboxin 1 t * 3 times a day No. 2

Asparkam 1 t* 3 times a day No. 20

Bromhexine 125 mg * 3 times/day

blood pressure control 2 times/day

Social.

Considering that the patient’s disease is prognostically favorable, especially against the background of prophylactic prescription of psychotropic drugs of the neuroleptic series, family therapy should be carried out and an attempt should be made to improve the microsocial environment. To improve the patient’s social status, it is possible to recommend employment (for a simple job) or work on a relaxed schedule in a medical treatment facility.

CLINICAL AND SOCIAL AND LABOR PROGNOSIS

Clinical prognosis: doubtful, since persistent personality changes in the emotional and motor-volitional spheres are possible.

Social and labor prognosis: assessed as favorable, since the possibility of rehabilitation after discharge from the hospital is preserved, simple professional activity is also possible.

Supervision diaries

The patient constantly lies in bed, looks at one point, and is reluctant to engage in conversation. The questions are answered in monosyllables: yes or no; many clarifying questions are required. Complains of a runny nose and headache. He is not active in the department, communicates with other patients only when he goes to smoke. Depressed mood.

The patient constantly lies in bed, looks at one point, is reluctant to enter into conversation, his speech is tongue-tied, and requires many clarifying questions. He is not active in the department, communicates with other patients only when he goes to smoke. Depressed mood. He will recognize the curator.

The patient was sent home under the responsibility of his son.

The patient in the department is inactive and reluctant to engage in conversation. The speech is monotonous, requires a lot of clarifying questions, questions have to be repeated. Depressed mood. He does not complain of headaches and considers himself healthy. In the department he played cards with other patients.

The patient lies in bed, refuses to communicate.

The patient in the department is inactive, reluctant to engage in conversation, speech is unexpressive, monotonous, questions need to be repeated, usually answers yes or no to questions. Depressed mood. He does not complain about headaches and wants to quickly go to the ward.

The patient in the department is inactive, usually spends the whole day in bed, and is reluctant to engage in conversation. Unexpressive speech requires clarifying questions. The mood is depressed and stable. He has no complaints of headaches.

The patient refuses to communicate, citing the fact that he is tired.

BIBLIOGRAPHY

1. Kirpichenko A.A. "Psychiatry". Minsk, “Higher School”, 1984.

Zharikov N.M., Ursova L.G., Khritinin D.F. “Psychiatry” Moscow, “Medicine”, 1989.

. "Manual of Psychiatry" ed. A.V. Snezhnevsky

Thinking of patients with schizophrenia and organic. damage to the brain using the Pictogram technique.

In the work of a clinical psychologist, it is often necessary to make a diagnosis between organic brain disease and schizophrenia. In the differential diagnosis of schizophrenia and mental disorders of organic origin, the thinking characteristics of patients are of great importance. There are many methods aimed at diagnosing this cognitive process: Excluding objects, Comparing concepts, Finding similarities and others.

As is known, the experimental pictogram technique is aimed at studying indirect memorization. In addition, this test procedure is widely used in pathopsychology specifically for the study of thinking. It also allows you to obtain information concerning not only visual-figurative thinking, but also the characteristics of the emotional-volitional sphere, the orientation of the patients’ consciousness, and personal properties. The essence of the technique is to convey any verbally designated concept through its image.

To conduct it, you need to have a blank piece of paper, not a notebook, a pencil and a set of words proposed for memorization. Words offered for memorization should be named in the order in which they are offered:

1) Happy holiday

2) Hard work

The instructions are read only once. Repeated announcement of instructions is allowed in response to a direct request. Instructions: “Now I’ll test your memory. I will tell you words and phrases that you need to remember. To make it easier for you to memorize, draw a picture for each word, but in such a way that this picture helps you remember the right word. The quality of the drawing doesn't matter, it just needs to help you remember. Words and letters are prohibited from being written.” After some time - 30-40 minutes, the subject is asked to reproduce words and phrases from the pictures.

Using this technique, an attempt was made to subject to psychological analysis those features of thinking that in psychiatry are designated as “bizarreness”, and sometimes even as “discontinuity” of associations.

The thinking of patients with organic brain damage (52 people) without a severe intellectual defect and a diagnosis of schizophrenia without acute psychopathological symptoms (62 people) was studied in the conditions of outpatient admission of patients with OPND.

The study of the characteristics of the mental activity of patients consisted of a thorough analysis of the content of the selections of images for memorization.

The analysis took into account such factors as abstractness-concreteness, individual significance, standardity-originality, adequacy, and the content of the choice.

Among the types of choices obtained in patients diagnosed with schizophrenia, it was noted 26% adequate in content and 64% of inadequate elections. The criterion for dividing the images chosen by patients into adequate and inadequate could not, of course, be subjective. There were, however, no convincing formal grounds for such a division.

With this approach, the psychological analysis of the selected images itself becomes proof of inadequacy. Thus, the patient draws a square to the phrase “hard work,” explaining it this way: “A square has all sides equal. If the work is distributed evenly, it will be hard”; to the concept of “disease” I drew small circles inside a large circle, since these are microbes under a microscope, and they are the cause of illnesses and diseases; I presented the word “love” as an infinity sign with exclamation marks next to it, because it is a big, infinite, very strong feeling.

It can be seen that the images that the patients came up with to remember the proposed concepts were very far from the content of the given concept.

Looking at the pictures in the pictogram of patients with organic brain damage, one notices the abundance of adequate (59%) and specific (63%) images To the concept of “hard work” - a man with a shovel is depicted (“When you dig with a shovel, it is very hard”); a drawing depicting two lovers shows the word love”; the concept of “illness” is a person in bed, because the patient is lying down, because of the illness he cannot get up and go to the doctor.

For example, the sign “+” denotes the concepts of “friendship”, because it is a positive principle, and the word “justice”, since it is a positive factor”; and the sign “-” denotes the concept of “Enmity”, since it is negative, I do not like enmity, I deny it. Their drawings were dominated by original (47%) and abstract images (48%). For them, one symbol (arrows, geometric shapes, some icons) is enough to explain the concept and compose a story based on it. To the word “development” they draw a spiral going downward, since development cannot be eternal, someday it will end, and the death of man and the end of the world will come, and then there are rational arguments about the inevitable demise of humanity.

When studying the pictogram technique in patients with schizophrenia, disorders in the correlation of abstract-semantic and objective-specific components of analytical-synthetic activity are discovered. For mediation, an image is chosen that is devoid of any content in itself, but is based on the actualization of a sensory impression (by the word “deception” it depicts a woman, since she stands deceived by me. I am bad, and she is in despair, and our thoughts are running).

Subjects with brain damage, as a rule, are fixated on a lot of minor details of the picture, which makes it difficult to retain stimulus words in memory. Sometimes patients were unable to focus on any specific drawing, since not a single drawing could, from their point of view, accurately and completely convey the specific meaning of the word.

They are characterized by difficulties in abstracting from specific details, a tendency to excessively detail associations, which lead to the impossibility of identifying significant features of concepts. The phrase “delicious dinner” refers to a table with a lot of dishes, food and drinks depicted on it, and the concept of “feat” depicts an athlete on a podium with a cup in his hands and a medal around his neck and judges in the background.

The pictogram of patients with schizophrenia often contains pseudo-abstract images. These include empty, meaningless, and sketchy. Schematization sometimes reaches the point of complete absurdity in drawings. The concept of a “happy holiday” is depicted as a triangle, “happiness” as wavy lines, and “sadness” as a circle in a square. The drawing loses the boundary of convention to such an extent that essentially nothing remains of the desired concept in it. Images by consonance. In these cases, when choosing an image to help remember, patients were guided by the sound composition of the word and chose a picture whose name included the same syllable as the given word. (For the concept of “despair” - a drawing of a teapot, “deception” - semolina, etc.).

Table No. 1. Comparative characteristics of pictogram images of patients with schizophrenia and with mental disorders of organic origin.

Mental disorders of organic origin

Source:
Thinking of patients with schizophrenia and organic
Thinking of patients with schizophrenia and organic. damage to the brain using the Pictogram technique. In the work of a clinical psychologist, it is often necessary to make a diagnosis between organic
http://www.b17.ru/article/10847/

Organic schizophrenia

PSYCHIATRY(from the Greek psyche - soul and iatreia - treatment), a branch of medicine that studies the causes, manifestations and treatment of mental illness. The history of this medical specialty is fundamentally different from the history of therapy or surgery. The history of psychiatry, from the distant past to almost the present, is a history of human drama and strong passions, fanatical prejudices and cruel persecutions. Only in recent decades has psychiatry emerged as a modern, respected science. The reasons that it developed in ways other than therapy or surgery, and for so long won the status of a legalized branch of medicine in the public and professional consciousness, lie primarily in the special nature of mental illnesses themselves.

We now know that in both of these cases (as in many others) innocent people suffering from mental illness were executed. From the descriptions of hallucinations and other symptoms contained in old chronicles, we can get an idea of ​​the diseases that determined the behavior of numerous “sorcerers” and “witches” condemned in those days. Most of the “witches” and their “assistants” who were burned at the stake suffered from schizophrenia, some from hysteria or dementia; Among them there were also neurotic individuals or simply dissidents. Schizophrenia is still the most serious mental illness today. The vast majority of psychiatric patients requiring hospitalization are people suffering from schizophrenia or related conditions.

Many people today are ashamed that they themselves or their relatives have a mental illness. A visit to a psychiatrist or psychotherapist is often kept secret and can cause, at least in some people, a contemptuous attitude, expressed in such commonly used words as “nuts”, “crazy”, “crazy”, etc. Such attitudes show that being diagnosed with mental illness still remains a stigma, and reflects the hostility of the “healthy” and “normal” towards those considered “abnormal” and “crazy”. In this regard, further educational work is needed to explain the nature of mental illness and the nature of modern psychiatry.

Addiction to other substances, such as drugs, hallucinogens, narcotics, or tobacco, can also be caused by a combination of psychological and social factors. The dangers associated with addiction and the severity of toxic complications depend on the chemical nature of the substances used. When using most of these drugs, there is a tendency to form mental dependence, i.e. habits only to the pleasure received, and not to the physical need for the drug. see also ADDICTION.

(from the Greek schizein - splitting and phren - mind) - one of the “big” mental disorders. It is usually a chronic and gradually developing disease that often begins in adolescence or young adulthood. It has a wide variety of symptoms that gradually progress, increasingly limiting the patient’s capabilities until they finally affect his entire personality, affecting behavior, emotional reactions, thinking and life. see also SCHIZOPHRENIA.

Paranoia (delusional disorder) - This condition was previously defined as a syndrome associated with schizophrenia, but paranoia is now considered as an independent type of mental disorder, which is characterized by a tendency to blame people and attribute malice to them. In many cases, unfounded suspicion, mistrust, jealousy and envy, suspiciousness, fear of persecution and ideas of grandeur prevail. These symptoms are often combined into a kind of delusional system. see also PARANOIA.

– deep mental disorders caused by one or another damage to brain tissue. Both rapidly developing acute and quite severe mental disorders and chronic protracted disorders are possible. The differences between acute and chronic organic psychoses concern not only the nature, but also the prognosis, as well as treatment.

The causes of organic psychoses can be infectious diseases, poisoning, hallucinogenic states (alcoholism or drug addiction), metabolic disorders, neurosyphilis, tumors and other brain diseases, and hormonal pathologies. These organic causes cause pronounced changes in the structure and function of brain tissue. Such changes, accompanied by damage to the blood vessels of the brain, can lead to mental disorders, which often resemble mental illnesses caused by psychological factors. Meanwhile, these two types of psychoses differ both in their origin and in the clinical picture of disease progression.

Of course, it is necessary to take into account the entire complex of psychological factors operating during the formation of personality: the influence of not only the mother, but also the father, brothers and sisters, other family members, social and economic status, situational conflicts, school, cultural factors, profession, internal and external pressure, i.e. frustrations of various types, originating from all kinds of sources. Thus, each mental disorder is a purely individual problem that can only be understood by revealing its deep dynamic sources. This procedure is difficult, and to find the causes of the disease, one must delve deeply into the life history and personality structure. see also PSYCHOANALYSIS.

Certain types of psychiatric patients, especially those with strong antisocial tendencies, may benefit from group therapy. The group itself forms a special type of therapeutic community, of which each patient becomes an integral part. By participating in group therapy, patients not only overcome tendencies toward self-isolation and withdrawal, but also realize that others have the same difficulties and problems. This understanding, as well as the experience of communication in a favorable therapeutic environment and an atmosphere of mutual support, helps to improve the mental state of patients. When, thanks to group therapy, the patient feels more confident, he can be recommended individual psychotherapy, which provides not so much support as a deeper understanding of unconscious conflicts and driving forces. see also PSYCHOTHERAPY; GROUP PSYCHOTHERAPY.

In cases where these measures do not bring success and the patient’s condition continues to progressively deteriorate, psychosurgery is resorted to as a last resort. Instead of the previously used prefrontal lobotomy (in which nerve fibers in the frontal lobe were crossed), more targeted operations on the deep structures of the brain are now used. These operations are performed only in a very small part of cases - if patients, despite all therapeutic efforts, remain aggressive, destructive tendencies and excessive excitement.

The importance of the problems facing modern psychiatry is easier to understand in the light of statistical data. In US psychiatric hospitals, the number of patients accounts for approximately a third of all hospitalized patients. However, this is only a small proportion of people with some kind of mental illness. The total number of mental patients in the United States reaches 8–9 million. Of these, 1.5 million suffer from severe, disabling forms of psychosis and neuroses.

Mental disorders play an important role in the development of drug addiction, alcoholism, juvenile delinquency and other types of crime. In the United States, approximately 6 million people currently use cocaine, the vast majority of them under the age of 25. Cocaine addiction occurs in all levels of society. Its consequences are especially tragic for young and talented people. Alcoholism is also common among people of all social standings and all socioeconomic groups. There are approximately 9 million alcoholics in the United States, and millions more are close to becoming alcoholics. see also ADDICTION.

The risk of developing schizophrenia is 1%, and the incidence is 1 case per 1000 population per year. The risk of developing schizophrenia increases in consanguineous marriages, when the family is burdened with the disease among first-degree relatives (mother, father, brothers, sisters). The ratio of women to men is the same, although the detection rate of the disease is higher in men. The birth and death rates of patients do not differ from the population average. The risk of developing the disease is highest for those aged 14-35 years.

What causes Schizophrenia:

(A) The most recognized is the genetic nature of schizophrenia, which is substantiated by studies of the risk of developing the disease in mono- and dizygotic twins, siblings, parents and children, as well as by studying adopted children from parents suffering from schizophrenia. However, there is equally compelling evidence that schizophrenia is caused by a single gene (monogenic theory) with variable expressivity and incomplete penetrance, a small number of genes (oligogenic theory), many genes (polygenic theory), or multiple mutations. Hopes rest on studies of translocations in chromosome 5 and the pseudoautosomal region of the X chromosome. Therefore, the most popular hypothesis is the genetic heterogeneity of schizophrenia, in which, among others, there may also be sex-linked variants. It is likely that patients with schizophrenia have a number of advantages in natural selection, in particular, they are more resistant to pain, temperature and histamine shock, as well as radiation. In addition, the average intelligence of healthy children of parents with schizophrenia is higher than the general intelligence of similar ages. Probably, the basis of schizophrenia is a schizotype - a carrier of markers of schizotaxy, which, being a neutral integrative defect, manifests itself under the influence of environmental factors as a pathological process. One of the markers of schizotaxy is a violation of slow eye movements when observing a pendulum, as well as special forms of evoked potentials of the brain.

(B) Constitutional factors take part in shaping the degree of severity and reactivity of the process. Thus, in women and male gynecomorphs, schizophrenia progresses more favorably and tends to be periodic; after the age of 40, the course of the disease is also more favorable. In men with an asthenic constitution, the disease occurs more often continuously, and in women with a pyknic constitution, it is more often periodic. However, the constitution itself does not determine susceptibility to disease. Morphological dysplasia usually indicates a possible atypia of the process, and such patients are less responsive to treatment.

(B) According to neurogenetic theories, the productive symptoms of the disease are caused by dysfunction of the caudate nucleus of the brain, the limbic system. A mismatch in the functioning of the hemispheres and dysfunction of the fronto-cerebellar connections are detected. CT scan can detect expansion of the anterior and lateral horns of the ventricular system. In nuclear forms of the disease, the EEG shows reduced voltage from the frontal leads.

(D) Rather, attempts to connect schizophrenia with infectious (streptococcus, staphylococcus, tuberculosis, E. coli) and viral (slow infections) pathology are of historical interest. However, in patients with schizophrenia, there is a clear distortion in immune responses during the development of infectious pathology.

(E) Biochemical studies have linked schizophrenia to excess dopamine. Blocking dopamine during productive symptoms with antipsychotics promotes patient relaxation. However, with a defect, there is a deficiency of not only dopamine, but also other neurohormones (norepinephrine, serotonin), and with productive symptoms, not only the amount of dopamine increases, but also cholecystokinin, somatostatin, and vasopressin. Various changes are observed in carbohydrate and protein metabolism, as well as in lipoprotein metabolism. Indirect evidence of metabolic disorders in schizophrenia is the presence of a specific odor in nuclear forms of the disease, chondrolysis (destruction and deformation due to a defect in the cartilage of the auricle), earlier puberty with a rapid increase in loss of libido.

(E) Theories of psychology explain the development of the disease from the point of view of the revival of archaic (Paleolithic, mythopoetic) thinking, the impact of a deprivation situation, selectively split information, which causes semantic aphasia. Pathopsychologists discover in patients: a) diversity and ambivalence of judgments, b) egocentric fixation, in which judgments are made on the basis of their own motives, c) “latent” signs in judgments.

(G) Psychoanalytic theories explain the disease by childhood events: exposure to a schizophrenogenic, emotionally cold and cruel mother, a situation of emotional dissociation in the family, fixation or regression to narcissism, or latent homosexuality.

(3) Ecological theories explain the fact that patients with schizophrenia are predominantly born in the cold season due to the effects of prenatal vitamin deficiency and mutagenic effects during the spring conception of a child.

(I) Evolutionary theories consider the genesis of schizophrenia within the framework of the evolutionary process either as a “payment” for an increase in the average intelligence of a population and technological progress, or as a “hidden potential” of progress that has not yet found its niche. The biological model of the disease is the freeze-flight response. Patients suffering from the disease have a number of selective advantages; they are more resistant to radiation, pain, and temperature shock. The average intelligence of healthy children of parents with schizophrenia is higher.

Symptoms of Schizophrenia:

The diagnostic group as a whole is characterized by a combination of disorders of thinking, perception and emotional-volitional disorders that last for at least a month, but a more accurate diagnosis can be established only within 6 months. observations. Typically, the first stage is a diagnosis of acute transient psychotic disorder with symptoms of schizophrenia or schizophrenia-like disorder.

Stages of the disease: initial, manifest, remission, recurrent psychosis, deficiency. In 10% of cases, spontaneous recovery and long-term (up to 10 years) remission are possible. The reasons for differences in prognosis are predominantly endogenous. In particular, the prognosis is better in women with a pyknic physique, high intelligence, living in a two-parent family, as well as with a short (less than 1 month) initial period, a short manifest period (less than 2 weeks), the absence of an abnormal premorbid background, the absence of dysplasia, low resistance to psychotropic drugs.

According to E. Bleuler, the axial disorders of schizophrenia include thinking disorders (fragmentation, reasoning, paralogism, autism, symbolic thinking, narrowing of concepts and manticism, perseveration and poverty of thoughts) and specific emotional-volitional disorders (dullness of affect, coldness, parathymia, hypertrophy of emotions, ambivalence and ambition, apathy and abulia). M. Bleuler believed that axial disorders should be delineated by the presence of manifest manifestations, the absence of syndromes of exogenous type reactions (amentia, delirium, quantitative changes in consciousness, seizures, amnesia), the presence of fragmented thinking, splitting in the sphere of emotions, facial expressions, motor skills, depersonalization, mental automatisms, catatonia and hallucinations. V. Mayer-Gross considered the primary symptoms to be thought disorders, passivity with a feeling of influence, primary delirium with ideas of relationship, emotional flattening, sounding of thoughts and catatonic behavior.

The most recognized in diagnosis are the first rank symptoms according to K. Schneider, which include: the sound of one’s own thoughts, auditory contradictory and mutually exclusive hallucinations, auditory commentary hallucinations, somatic hallucinations, influence on thoughts, influence on feelings, influence on impulses, influence on actions, a symptom of openness of thoughts, sperrung and delusional perception, close to acute sensory delirium. Symptoms of the second rank include catatonia, pathological expression in speech, emotions and experiences. Most of these symptoms are taken into account in the modern classification thanks to the International Study of Schizophrenia in 9 countries.

According to ICD 10, at least one of the following signs must be observed:

• 1. “Echo of thoughts” (the sound of one’s own thoughts), putting or taking away thoughts, openness of thoughts.
• 2. Delusional influence, motor, sensory, ideational automatisms, delusional perception. This combination in domestic psychiatry is referred to as Kandinsky-Clerambault syndrome.
• 3. Auditory commentary on true and pseudohallucinations and somatic hallucinations.
• 4. Delusional ideas that are culturally inadequate, ridiculous and grandiose in content.

Or at least two of the following signs:

• 1. Chronic (more than a month) hallucinations with delusions, but without pronounced affect.
• 2. Neologisms, sperrungs, broken speech.
• 3. Catatonic behavior.
• 4. Negative symptoms, including apathy, abulia, impoverished speech, emotional inadequacy, including coldness.
• 5. Qualitative changes in behavior with loss of interests, lack of focus, autism.

The prognosis for schizophrenia depends on a set of factors that are listed in the table.

Prognosis factors for schizophrenia

The course of schizophrenia can be established already in the period of manifestation, but more precisely - after the third attack. With a tendency towards remissions of good quality, the attacks are usually polymorphic and include an affect of anxiety and fear. Highlight continuous course, which means the absence of remission for more than a year, episodic with increasing defect, when negative symptoms increase progressively (continuously) between psychotic episodes, episodic with a stable defect, when persistent negative symptoms occur between psychotic episodes. The episodic course corresponds to the paroxysmal course of symptoms accepted in Russian psychiatry. Episodic relapsing, when complete remissions are observed between episodes. This variant of the course corresponds to the symptoms of a periodic course accepted in Russian psychiatry. After an attack it is also possible incomplete remission. Previously, in domestic psychiatry, this concept corresponded to remissions “B” and “C” according to M.Ya. Sereisky, in which behavioral disorders, affect disorders, encapsulated psychosis or neurotic symptoms are detected in the remission clinic. Complete remission corresponds to remission “A” according to M.Ya. Sereisky.

Persistent negative symptoms during the period of remission (defect) include in its clinic erased symptoms of productive symptoms (encapsulation), behavioral disorders, depressed mood against the background of apathetic-abulsic syndrome, loss of communication, decreased energy potential, autism and isolation, loss of understanding, instinctive regression.

In childhood, this diagnosis can be made quite accurately only after 2 years; from 2 to 10 years, nuclear forms predominate, which manifest themselves in a slightly different form. Paranoid forms have been described since the age of 9 years. Characteristic symptoms of childhood schizophrenia are regression, in particular regression of speech, behavior (symptom of manege, ballet walking, choice of non-playing objects, neophobia), emotional-volitional disorders and developmental delay. Overvalued fears and delusional fantasies act as equivalents of delirium.

Paranoid (F20.0).

The premorbid background is often unremarkable. The initial period is short - from several days to several months. In the clinic of this period there are symptoms of anxiety, confusion, individual hallucinatory inclusions (calls), and disturbances in concentration. The onset may also be of the type of reactive paranoid or acute sensory delusion, which is initially considered as an acute transient psychotic disorder with symptoms of schizophrenia or schizophrenia-like. The manifest period is from 16 to 45 years of age.

Variants of paranoid schizophrenia are: paraphrenic with symptoms of predominantly systematized paraphrenia; hypochondriacal variant, in which delusions of infection are clearly associated with the content of auditory, olfactory, and somatic hallucinations; hallucinatory-paranoid variant, occurring with Kandinsky-Clerambault syndrome. Special variants of paranoid schizophrenia are affective-delusional variants, characteristic of a remitting course. These include depressive-paranoid and expansive-paranoid variants. The depressive-paranoid variant usually begins as a hypochondriacal delusion, which grows to the point of enormity; the depressive affect is secondary. The expansive-paranoid variant occurs with the clinic of expansive paraphrenia, but the expansion continues less than the ideas of greatness. Classic paranoid schizophrenia is accompanied by polythematic delusions in which it is difficult to separate the ideas of persecution, relationships, and meaning.

With paranoid schizophrenia, all variants of the course are possible (continuous, episodic and remitting), and negative disorders during the period of remission include sharpening of characterological traits, fixation of apathetic-abulic symptoms, “encapsulation”, in which individual symptoms of hallucinations and delusions are detected in the clinic of remission.

Clinical example: Patient O., 33 years old. Premorbid without any features. After graduating from school and serving in the army, he entered and successfully graduated from law school and worked as an investigator in a coastal city. He was distinguished by his official zeal and highly appreciated the attention of his superiors. Married and has a child. During the period of active work to investigate a banal domestic crime, he noticed that he was being watched in the toilet and in the bathroom. When he bathes, they “release special gases” that make him fall asleep, and under this pretext they steal official documentation. Trying to connect the events, I realized that this was beneficial to one of the bosses in order to hide his “deeds.”

He himself began to follow him, but “it turned out that nothing could oppose the “high patronage.” As a result, “bugs” were installed in his apartment, including on the TV, which controlled his thoughts and turned on his desires. Thanks to such “operational work”, his every action and thought became the property of the Main Directorate. I wrote a report “to the top”, but was not understood, “since everyone is connected to each other.” In turn, he began to install listening equipment in the boss’s office, was detained at that moment and subjected to a special investigation. In psychomotor agitation he was taken to a psychiatric clinic. During hospitalization he was silent, and later he said that he could not speak due to the constant monitoring of speech by equipment. After recovering from psychosis, 10 days later, he was discharged and got a job as a legal consultant, but still felt surveillance and control of thoughts. He became indifferent to his loved ones, and usually did nothing at home, spending hours constructing anti-surveillance equipment. He came out wearing a special beret, into which he embedded microcircuits for a “thought screen.” He hears the voice of his pursuer, who sometimes continues to expose him and his family to radiation using special methods.

Diagnostics

In the manifest period and the further course of the disease, the following are characteristic:

1. Delusions of persecution, relationship, significance, high origin, special purpose or absurd delusions of jealousy, delusions of influence.

2. Auditory true and pseudohallucinations of a commentary, contradictory, condemning and imperative nature

3. Olfactory, gustatory and somatic, including sexual, hallucinations.

The classical logic of the development of delusions, described by V. Magnan, corresponds to the sequence: paranoid (monothematic delusions without hallucinations) - paranoid (polythematic delusions with the addition of auditory hallucinations) - paraphrenic. However, this logic is not always observed; the development of acute paraphrenia and the absence of a paranoid stage are possible.

Differential diagnosis

At the first stages it is necessary to differentiate with acute transient psychotic disorders, and then with chronic delusional and schizoaffective disorders, as well as organic delusional disorders.

Acute transient psychotic disorders can occur with productive and negative symptoms of schizophrenia, however, these conditions are short-lived and limited to a period of about two weeks with a high probability of spontaneous release and good sensitivity to antipsychotics. This section, meanwhile, can be considered as “cosmetic” at the stage of manifest psychosis in paranoid schizophrenia.

Chronic delusional disorders include monothematic delusions; if auditory hallucinations occur, they are more often true. This group includes those variants of delusions that were commonly called paranoid (delusions of love, delusions of reformation, invention, persecution).

At schizoaffective disorders delusional disorders are secondary to affect, and affect (manic, expansive, depressive) lasts longer than the delusion.

At organic delusional disorders exogenous symptoms are often present, and neurologically, neuropsychologically and with the help of objective research methods it is possible to identify the underlying organic disease of the brain. In addition, personality changes in such disorders have a specific organic coloring.

Therapy

Until now, it is believed that the treatment of acute manifest psychosis in paranoid schizophrenia is best started with detoxification therapy, as well as antipsychotics. The presence of depressive affect in the structure of psychosis forces the use of antidepressants, but expansive affect can be stopped not only by tisercin, but also by both carbamazepine and beta-blockers (propranolol, inderal). The onset of paranoid schizophrenia in adolescence is usually accompanied by an unfavorable course, so the increase in negative disorders can be prevented by insulin comatose therapy, small doses of rispolept (up to 2 mg) and other antipsychotic drugs. In acute psychosis, the dose of rispolept is increased to 8 mg. Neuroleptics - prolongs - are used as maintenance therapy, and if there is affect in the structure of psychosis, lithium carbonate is used. Therapy is based either on the principle of influencing the leading syndrome, which is chosen as the “target” of therapy, or on the principle of a complex effect on the sum of symptoms. Initiation of therapy should be careful to avoid dyskinetic complications. In case of resistance to antipsychotic therapy, monolateral ECT is used, and the application of electrodes depends on the structure of the leading syndrome. Maintenance therapy is carried out depending on the clinical features of the attack, either with prolong antipsychotics (haloperidol depot, lioradin depot) or with antipsychotics in combination with lithium carbonate.

Hebephrenic (F20.1).

Behavioral disorders are common in premorbid patients: anti-disciplinary, antisocial and criminal behavior. Dissociative personality traits, early puberty, and homosexual excesses are common. This is often perceived as a distortion of pubertal crisis. The onset most often occurs between the ages of 14 and 18 years, although later hebephrenia can also manifest. Subsequently, in the manifest period, a triad is characteristic, including the phenomenon of inaction of thoughts, unproductive euphoria and grimacing, reminiscent of uncontrollable tics. The style of behavior is characterized by regression in speech (obscene speech), sexuality (casual and abnormal sexual relations) and in other instinctive forms of behavior (eating inedible things, aimless dromomania, sloppiness).

Clinical example: Patient L., 20 years old. In adolescence, he was distinguished by obnoxious behavior. Suddenly and for no apparent reason he came into conflict with friends and parents, spent the night in basements, drank hashish and alcohol, and began to steal. After finishing the 9th grade with difficulty, he transferred to college, which he was unable to graduate from because he was put on trial for hooliganism. After returning home, I decided to come to my senses and went to work. But his attention was attracted by a certain girl, to whom he began to show strange signs of attention. She worked in a large supermarket, and L. began to visit her in the evenings. When he met her, he spoke loudly and used obscene expressions, spat and thereby compromised her, but when she pointed this out to him, he broke the window and scattered goods in the store. In addition, he became sloppy and did not wash at all, spoke a lot, but without any meaning and without a central idea, his speech was interspersed with tirades of “fashionable expressions” that he drew from the “new Russians.” He asked the policeman to accompany him to the restaurant for security, and when he refused, he got into a fight. He abandoned his job and lived in a landfill not far from his beloved’s store. But this did not bother him at all, since he was in constant euphoria. During this time, he committed several thefts, and was caught when he stole a bag of candy from a child. During hospitalization, he laughed foolishly, grimaced, and in his speech- thematic slippage.

Diagnostics

The structure of hebephrenic syndrome reveals:

1. Motor-volitional changes in the form of grimacing, foolishness, regression of instincts, unmotivated euphoria, aimlessness and lack of focus.

2. Emotional inadequacy.

3. Formal paralogical thinking disorders - reasoning and fragmentation.

4. Undeveloped delusions and hallucinations that do not come to the fore and are in the nature of inclusions.

The course is often continuous or episodic with an increasing defect. The structure of the defect includes the formation of dissocial and schizoid personality traits.

Differential diagnosis

Hebephrenic schizophrenia should be differentiated from tumors of the frontal lobes and dementias in Pick's disease and Huntington's disease. At tumors General cerebral symptoms, changes in the fundus, EEG and CT can be detected. Pick's disease is noted at a much later age, and when Huntington's disease hyperkinesis of thinking, facial expressions, gestures, and posture is specific. On CT scans in patients with schizophrenia who have been taking antipsychotics for a long time, there may be changes similar to Huntington's disease.

Therapy

Treatment includes the use of insulin therapy, hypervitamin therapy, tranquilizers and major neuroleptics (aminazine, mazeptil, trisedil, haloperidol, Zeprexa, rispolept in doses of about 4 mg per day). Maintenance therapy is carried out with combinations of antipsychotic prolongs and lithium carbonate, which help control impulses, in particular aggression.

Catatonic (F20.2).

The premorbid background is characterized by schizoid personality disorder, although development is possible on a premorbidly unchanged background. In the initial period, depressive episodes, simplex syndrome with isolation, loss of initiative and interests. Manifestation is likely to be of the type of acute reactive stupor, after traumatic brain injury, or influenza, although more often psychosis develops for no apparent reason.

Classic catatonic schizophrenia occurs in the form of lucid catatonia, catatonic-paranoid states and oneiric catatonia, as well as febrile catatonia. The motor component of catatonia is expressed in the form of stupor and agitation. Currently, classical catatonia has been replaced by microcatatonic states.

Catatonic stupor includes mutism, negativism, catalepsy, rigidity, freezing, automatic subordination. Usually noted in stupor Pavlov's symptom(the patient responds to whispered speech, but does not respond to normal speech), gear wheel symptom(when flexing and extending the arm, a jerk-like resistance is observed), airbag symptom(the head remains raised after removing the pillow), hood symptom(the patient tries to cover his head or covers his head with clothes).

Catatonic agitation proceeds with the phenomena of chaos, lack of focus, perseverations and fragmented thinking. The entire clinical picture can be expressed either in a change of excitement and stupor, or in the form of repeated stupors (excitement).

At lucid catatonia purely motor psychosis is noted, and behind the façade of movement disorders no productive disorders are noted. Catatonic-paranoid option suggests that delirium lies behind the catatonia. Often such productive disorders can be indirectly identified as a result of observing the patient’s facial expressions: he moves his gaze, his facial expression changes, regardless of the context of the doctor’s questions. At oneiric catatonia behind the façade of catatonia there is an influx of fantastic visual images of a cosmic, apocalyptic nature. The patient visits other worlds, heaven and hell. There is no amnesia after exiting this state. Febrile catatonia as a variant of catatonic schizophrenia is recognized only by some psychiatrists; the majority believes that the addition of temperature to stupor is due to either additional somatic pathology, or unrecognized brainstem encephalitis, or neuroleptic malignant syndrome. In the clinic, there are discrepancies in the pulse rate and temperature, a petechial rash appears on the lower extremities, a gray film appears on the mucous membrane of the lips, and muscle tone gradually increases.

To the signs microcatatonia include increased tone of the muscles of the shoulder girdle, increased activity of the oral zone, stereotyping of facial expressions, posture, gesture, gait, speech stereotypies, mutism, stereotypical finger play, hypokinesia of posture, reduced mobility of the hand with increased finger activity, lack of blinking. Sometimes catatonic stupor manifests itself only in the form of mutism.

All flow options are possible. The defect is usually expressed in apathetic-abulic states.

Clinical example: Patient P., 28 years old. Premorbidly active and alive. After graduating from the Agricultural Institute, he was assigned to forestry and got married. Over the course of a year, my wife noticed changes in behavior: he became withdrawn and answered questions in monosyllables. One day he did not return from work on time, his wife found him sitting on a bench - he was mindlessly looking into space and did not answer questions. In the department, being presented to himself, he looks into space and resists changing his posture. There is no catalepsy. Mutism and negativism remain persistent and the only symptoms over the next two weeks. After prescribing small doses of antipsychotics (risperidone and haloperidol), he came out of his stupor. He couldn’t explain his condition, “I didn’t know how to speak,” “I didn’t want to answer questions.” For two years there were no psychopathological disorders, he continued to work. I became acutely ill again and for no apparent reason. Accelerated and broken speech and psychomotor agitation appeared, which gave way to stupor. However, in the clinic of stupor, along with mutism and negativism, catalepsy was noted. At the station he stood silently in the center of the hall for several hours, such unusual behavior was noticed by the police, and he was taken to the clinic. Coming out of the stupor took longer.

Diagnostics

Diagnosis is based on identifying:

1) stupor;

2) chaotic, unfocused excitement;

3) catalepsy and negativism;

4) rigidity;

5) subordination and stereotypy (perseveration).

Differential diagnosis

Catatonic schizophrenia should be distinguished from organic catatonic disorders resulting from epilepsy, systemic diseases, tumors, encephalitis, and from depressive stupor.

At organic catatonia atypical movement disorders are noticeable. For example, against the background of catalepsy - tremor of the fingers, choreoathetoid movements, difference in symptoms of rigidity and catalepsy in the upper and lower extremities, muscle hypotonia. Data from CT, EEG and neurological examination help clarify the diagnosis.

Depressive stupor accompanied by a characteristic facial expression of depression with a Veragut fold. Depression is identified in the anamnesis.

Symptoms of microcatatonia resemble both signs of neuroleptic intoxication and behavioral signs of a defect in schizophrenia, such as apathetic-abulic. In the latter case, they speak of secondary catatonia. For a differential diagnosis, it is useful to prescribe detoxification therapy, Tremblex, Parkopan, Cyclodol or Akineton. The use of this course usually reduces the signs of neuroleptic intoxication.

Catatonic mutism should be distinguished from selective (selective) mutism in children and adults with schizoid personality disorders.

Therapy

Medium and large doses of antipsychotic drugs for catatonia can lead to fixation of symptoms and their transformation into a chronic course. Therefore, for stupor, therapy should be prescribed with intravenous administration of tranquilizers in increasing doses, sodium hydroxybutyrate, droperidol, nootropics, with careful monitoring of the patient’s somatic condition. 5-6 sessions of ECT with bilateral application of electrodes give a good effect. The occurrence of a febrile state in the absence of contraindications forces ECT or transfer to the intensive care unit. Catatonic agitation can be stopped with chlorpromazine, haloperidol, tizercin.

Undifferentiated (F20.3).

Clinic

The clinical picture includes signs of paranoid, catatonic and hebephrenic schizophrenia in a state of psychosis. Such high polymorphism within one psychosis usually suggests an episodic relapsing course. However, with the development of symptoms from one typology to another in a sequential chain of psychoses, the course can be continuous, for example, when in dynamics there is a transition from paranoid to nuclear syndromes. The lack of differentiation of symptoms is sometimes due to the fact that the disease occurs against the background of drug or alcohol addiction, against the background of immediate and long-term consequences of traumatic brain injury.

Diagnostics

The diagnosis is based on identifying symptoms of paranoid, catatonic and hebephrenic schizophrenia.

Differential diagnosis

High polymorphism of psychosis is also characteristic of schizoaffective disorders, however, with them, affective disorders last longer than those characteristic of schizophrenia.

Therapy

The complexity of therapy lies in the choice of the “target” of influence and the complex of supportive therapy. For this purpose, it is important to select axial symptoms, which are almost always visible in the dynamics of the disease.

Post-schizophrenic depression (F20.4).

Clinic

After a previously experienced typical episode with productive and negative symptoms of schizophrenia, a protracted depressive episode develops, which can be considered a consequence of schizophrenic psychosis. Typically, such an episode is characterized by atypia. That is, there is no typical daily dynamics of mood disorders, for example, the mood worsens in the evening, similar to asthenic depression. Complex senestopathies, apathy, reduction in energy potential, and aggressiveness may be present. Some patients interpret their condition as a result of psychosis. If the level of depression corresponds to a mild and moderate depressive episode, it can be considered as a special clinical remission, and if negative disorders predominate, it can be considered as a dynamic defect.

Clinical example: Patient V., 30 years old. Doesn't work, does housework. From the anamnesis and medical history, it is known that two years ago she was in the clinic with the following condition. She experienced fears, believed that there were conspiracies around her and that they were making a film about her with the aim of compromising her, setting up strange situations, eavesdropping on conversations, “stealing thoughts,” controlling her voice, which was transferred to another voice. They made a double that always behaves in the opposite way. I was in the clinic for 2 months. A diagnosis of acute transient psychotic disorder with symptoms of schizophrenia was made, and moditene depot was prescribed as maintenance therapy. However, she refused therapy and after discharge returned home without psychotic disorders. Nevertheless, she had difficulty coping with homework and could stay in bed all day, not paying attention to the children. Periodically I felt a transfusion in my stomach, which I explained by the fact that “the medications continue to work.” Sometimes the condition improved in the evening, but more often it changed during the day, becoming fussy and anxious. No delusions or hallucinations were detected. The husband notes that he has to do almost everything at home himself. If she starts washing, she usually doesn’t finish, sometimes she refuses food for the whole day, and he is forced to feed her “almost from his hands.” She was hospitalized again. He explains his condition by “lack of energy,” but is not at all burdened by it. Facial expressions of depression, a pose of submission.

Diagnostics

Diagnosis is based on identifying:

1) a history of an episode of schizophrenic psychosis;

2) depressive symptoms combined with negative symptoms of schizophrenia.

Differential diagnosis

When the disease begins after 50 years, it is necessary to differentiate these disorders from the initial period of Alzheimer's disease, or more precisely from its variant - Lewy body diseases. In this case, additional neuropsychological and neurophysiological studies are needed to differentiate.

Therapy

Treatment includes a combination of tricyclic antidepressants and antipsychotics. It is possible to use disinhibition using nitrous oxide, as well as ECT with the application of electrodes to the non-dominant hemisphere.

Residual (F20.5).

Clinic

This diagnosis can be considered as a delayed (for more than a year after psychosis) diagnosis of a typical defect in the emotional-volitional sphere after suffering psychosis.

Schizophrenia is a mental illness characterized by emotional disorders, inappropriate behavior, thinking disorders and the inability to communicate in society. The peak incidence occurs between 14 and 35 years of age.

Symptoms of the disease

The most pronounced symptoms are emotional-volitional disorders, dysfunctions of perception and thinking, which last for at least a month.

Main symptoms of schizophrenia:

• Apathy, depression, decreased mental and physical activity
• Echo of thoughts - the sound of your own thoughts
• Kandinsky-Clerambault syndrome is a delusion of perception and influence. The patient feels that he is being watched, possessed, influenced in various ways, from magic to atomic energy, laser, etc.
• Auditory hallucinations. The patient hears conflicting voices that affect his thoughts, feelings and actions
• Olfactory, gustatory, somatic hallucinations
• Expressing inappropriate emotions. The patient may cry or laugh inappropriately
• Wrong beliefs of the patient. He may consider himself a great person who rules the world, and think that the most everyday events have great meaning
• The patient's speech is incoherent, rapid, he moves from one topic to another
• Concentration deteriorates
• Patients with schizophrenia often withdraw into seclusion, avoid communication, become lethargic and apathetic, and may neglect personal hygiene.
• The disease can develop either gradually or suddenly.

Causes of the disease

Often the impetus for the development of the disease is overwork, stress or a long-term psychologically traumatic situation. Genetic predisposition is of great importance. However, in some people the disease develops against a background of complete mental well-being.

Diagnostics

At the very beginning of the disease, diagnosis is difficult. Observation of the patient continues for at least 6 months. Typically, the first stage of diagnosis is a diagnosis of “acute transient psychotic disorder with symptoms of schizophrenia” (schizophrenia-like disorder).

At this stage, the psychiatrist communicates with the patient, observes the dynamics and modifications of symptoms. Relatives provide additional information.

General clinical studies are carried out:

• General blood and urine analysis
• Blood chemistry
• Assessment of immune status
• Hormonal profile.

Magnetic resonance therapy is carried out to exclude organic diseases of the brain that can provoke neuropsychiatric symptoms (tumors, abscesses, viral encephalitis).

Electroencephalography (EEG) - shows the electrical activity of the brain. Prescribed for suspected brain diseases or injuries. It is important for differentiating schizophrenia from other mental disorders.

Therapeutic and neurological examination is carried out to exclude diseases that can lead to a schizophrenia-like state.

Psychological tests are helpful in diagnosing schizophrenia in borderline cases. They show disturbances in the functioning of individual brain structures and the ability to remember, perceive, and think.

In addition, there are diagnostic criteria, the presence of at least one of which for more than a month makes it possible to establish a diagnosis of schizophrenia.

Criteria according to ICD-10:

• Echo of thoughts
• Delusion of perception
• Sound hallucinations
• Inadequate, ridiculous, delusional, grandiose ideas.

Complications

• Autism. The patient does not make contact, refuses to interact in society
• Dementia - impaired brain function, memory impairment
• Extrapyramidal disorders (tremor, parkinsonism, tic, dystonia) developing as a result of antipsychotic therapy
• Diseases of the cardiovascular system
• Abdominal obesity
• Risk of developing diabetes
• Suicidal tendencies. About 30% of patients with schizophrenia have attempted suicide at least once in their lives.

Treatment of the disease

Treatment of acute attacks of schizophrenia takes place in a hospital, the rest of the time patients are treated at home.

There is still no radical treatment method, but compliance with the prescribed therapy can reduce the number of hallucinations and delusions, as well as reduce the likelihood of relapse.

Patients are prescribed a range of antipsychotic medications. Social adaptation, communication with the patient, and instilling skills in interacting with other people play an important role in the treatment of the disease.

Risk group

The main risk factor for developing schizophrenia is heredity. In people whose relatives have schizophrenia, the risk of the disease increases 10 times.

Prevention

Primary prevention of schizophrenia involves counseling parents about the possible risk of children developing diseases with a hereditary predisposition. Secondary prevention or prevention of relapses is achieved through constant use of prescribed medications and psychotherapy methods.

Diet and lifestyle

A diet for schizophrenia involves eating healthy, natural foods. Preservatives, dyes, and artificial food additives should be avoided. The main diet should consist of fruits, vegetables, dairy products, and cereals.

Patients should try to lead a healthy lifestyle and spend time outdoors. Relatives should pay as much attention as possible to the sick, communicate with them, and try to evoke positive emotions.

Epidemiology. Delusional syndrome accompanying complex partial convulsive syndromes is more common in women.

Etiology. The etiological factors are organic lesions, especially the parietal and temporal regions of the right hemisphere. The syndrome occurs in temporal lobe epilepsy and sometimes in Huntington's chorea.

Clinic. Delusions appear in the absence of impairment of consciousness, although mild signs of cognitive deficit may be observed. They can be both rudimentary and systematized, their content is varied, although ideas of persecution are more common. The content of ideas may be consonant with personal issues, which may increase the similarity with delusional syndromes of other etiologies. Speech may be incoherent, motor skills may range from adynamia to hyperactivity; often accompanied by a dysphoric mood background. The course depends on the underlying cause; in epilepsy, the syndrome, developing many years after the onset of convulsive manifestations, can persist for years, its severity is often inversely proportional to the frequency of convulsive seizures.

Diagnosis. In addition to meeting the general criteria for F06, the condition is characterized by the following characteristics:
1) the clinical picture is determined by delusional ideas in varying degrees of systematization;
2) consciousness is not impaired, there are no memory impairments.

Convincing evidence of the presence of an organic etiological factor predetermines the formulation of this diagnosis in cases where mental disorders meet the criteria for schizophrenia (F20), persistent (F22) or transient (F23) delusional disorder.

Differential diagnosis. The main differentiation is carried out with delusional states in paranoid schizophrenia. In favor of organic delusional syndrome may be evidenced by the later (after 35 years) appearance in the absence of evidence of schizophrenia in the anamnesis, the predominance of not auditory but visual accompanying hallucinations, greater adequacy of affect and better preservation of thinking and, of course, the identification of an organic etiological factor. The syndrome allows one to distinguish the absence of fluctuations in the level of consciousness from delirium, the absence of global intellectual deficit from dementia, the unconditional predominance of delusional manifestations over hallucinatory ones from organic hallucinosis, and the predominance of delusional symptoms over affective ones from organic affective syndrome. Anamnestic data allow us to differentiate the syndrome from delusional disorders in drug addiction diseases (F1).

Treatment determined by the impact on organic pathology, the approaches described in the treatment of delusional states in schizophrenia are used symptomatically.