Acute paranoid. Alcohol paranoid: signs, symptoms, types and treatment
Acute alcoholic paranoid is manifested by sensual (unsystematized, fragmentary) delusions of persecution, anxious-depressive affect, ideas of special significance, physical impact. Acute alcoholic paranoid, together with a delusional interpretation of the environment, is characterized by illusory perception. For example, in conversations, patients hear threats addressed to them, an emphasized negative attitude, etc. The affect of dust prevails; aggressive actions are possible against imaginary pursuers.
There are abortive, acute and prolonged alcoholic paranoids with schizophrenia-like inclusions.
Abortive alcoholic paranoid most often develops against the background of binge drinking, in a state of intoxication. The clinical picture is similar to acute alcoholic paranoid; however, the duration of such psychosis is determined by several hours.
In acute alcoholic paranoid, prodromal phenomena last 3-5 days and develop in patients during withdrawal disorders; characterized by depressed mood, malaise, anxious-fearful affect, sleep and appetite disturbances; autonomic disorders (tremor, sweating, palpitations, etc.), worsening in the evening and at night. Psychosis itself develops against the background of withdrawal syndrome, usually after complete insomnia, in the evening or at night. The state of confusion in patients changes to acute fear and motor restlessness. At the same time, delusions of special significance arise, elementary auditory deceptions in the form of knocking, rustling, coughing, sounds of footsteps, etc., they are quickly joined by fragmentary verbal hallucinations with delusions of persecution. Delusions of special significance are transformed into diffuse-sensual delusions of persecution - simple in content, often addressed to everyday topics or specific situations. The complication of the plot of delusion depends on illusory-hallucinatory disorders: on their basis, delusions of poisoning, physical influence, and jealousy develop. In the structure of the paranoid syndrome, along with delusions of physical influence, individual phenomena of mental automatism arise; monophabulism, fragmentation, and extreme instability are characteristic. Auditory pseudohallucinations are often observed; their content is simple and specific.
In all cases of acute alcoholic paranoid, short-term impulsive actions are noted; patients suddenly rush to run, leave the transport while running, ask for help, etc. Nevertheless, it should be emphasized that they rarely commit aggressive actions towards imaginary pursuers.
In the evening and at night, patients experience elementary visual illusions and hallucinations. The clinical picture of psychosis remains extensive and full of psychopathological symptoms for an average of 10-24 days. The reverse development of psychosis occurs much more slowly, regression of psychopathological symptoms sometimes drags on for up to 1-1.5 months. First, the affect of fear weakens, mental automatisms, auditory deceptions, and then delusional ideas disappear. According to the clinical features, acute alcoholic paranoid is similar to paranoid of the “external environment”. These clinical variants of psychotic states are brought together by the development of alcoholic paranoid in a “road situation.” Restoration of a critical attitude towards psychosis does not occur immediately; it is accompanied by long-term residual phenomena, post-intoxication asthenia and symptoms of a psychoorganic personality defect.
Prolonged alcoholic paranoid is evidenced by the transformation of affect and delusions. The affect of fear becomes less intense, and an anxious-low mood begins to predominate. The sensory-illusory component of delusion is also reduced, and its certain systematization is noted: for example, the patient begins to suspect not everyone in a row of the assassination attempt, but only certain, specific individuals. The motives for persecution also become more specific and defined. Outwardly, the behavior seems orderly, but the patient’s suspicion, mistrust, and low availability remain. Sometimes it is difficult to distinguish residual delusions from prolonged paranoid and the latter is favored by the presence of altered affect. Repeated alcoholic excesses aggravate the course of paranoia, and psychosis in this case can become recurrent. The duration of psychosis is several months.
Paranoid is a disease that manifests itself in a delusional state, phenomena of mental automatism, verbal hallucinations, false ideas and pseudohallucinations. This pathology is considered a more severe condition than paranoia and at the same time a milder disease than delusional disorder, paraphrenia. The syndrome in question is more often observed in pathologies with organic etiology, toxic and somatogenic psychoses. It also, in combination with pseudohallucinosis, accompanies schizophrenia. Paranoid symptoms can rarely be observed in isolation.
Involutionary paranoid
Acute alcoholic paranoid is manifested by the occurrence. The onset of the disease is directly related to prolonged consumption of alcohol-containing drinks (binge drinking) or. The patient begins to feel that he is being persecuted, that he is in serious danger, that they want to poison him. Delusional ideas determine all the patient's behavior. He begins to suspect that everyone around him, including his closest relatives, friends and doctors, is trying to harm him, wants to kill him. In any conversation, persons suffering from this form of paranoia find a hidden meaning that indicates a conspiracy against them. Sometimes illusions appear that confirm the idea of a conspiracy to kill them.
Patients with acute alcoholic paranoid try to find any confirmation of their own suspicions in all occurring events. They interpret things, objects and environments around them as certain symbols that confirm their ideas. So, for example, a knife forgotten on the table can serve as evidence that the wife wanted to stab her husband, but something distracted her. Patients suffering from this form of the disease may begin to fear the dark, they are afraid to go outside, they are afraid to communicate with people. Often they may feel that danger comes from certain people, for example, from those with whom they are in conflict or to whom they owe money. Also, such patients are characterized by a pronounced feeling that does not go away even within the walls of their own home, in safe conditions. Often, patients may develop frightening visual hallucinations, against the background of which the feeling of fear and affect of anxiety significantly intensifies. Patients may behave unnaturally, for example, having accidentally met a supposed enemy, they run away in the opposite direction or home for help.
Alcoholic paranoid treatment is not carried out at home, since patients require constant medical supervision and hospitalization in a psychiatric hospital. For the treatment of alcoholic paranoid, drug treatment is used in combination with vitamin therapy. As drug therapy, preference is given to antipsychotics and tranquilizers, less often to antidepressants and nootropics. After the manifestations of alcoholic paranoid have been relieved, complex therapy for alcoholism is recommended, which uses a number of psychotherapy techniques, in particular group therapy.
Prevention of the development of alcoholic paranoid is to prevent the development of alcohol dependence in persons prone to psychopathy.
Reactive paranoid
Clinical medicine is divided into:
- acute reaction to stress;
- hysterical psychoses;
One of the most common types of psychogenic reactions is psychogenic depression.
Two main groups of reactive depressive states can be distinguished: acute and prolonged depressive reactions. Acute forms are characterized by excessive intensity of affective manifestations, which are expressed in the form of outbreaks. Protracted forms are a slowly developing depressive state, the clinical manifestations of which become most pronounced only after a certain period of time has passed after the onset of a traumatic situation.
One of the rarest forms of psychogenic reactions is psychogenic mania. At the beginning of the development of this form of pathology, symptoms of fussiness and agitation predominate, against the background of insignificant manifestations of vital disturbances - the affect of joy, pleasure, disinhibition of aspirations. A combination of opposites, for example, grief and inspiration, is typical.
Psychogenic paranoid occurs in approximately 0.8% of cases. Three forms of psychogenic paranoid can be distinguished: acute, subacute and protracted.
A condition in which individuals form false views and conclusions associated with a specific traumatic situation is called reactive paranoid or reactive delusional psychosis. At first, ideas may have super-value for an individual, be psychologically understandable and arise from real-life events. At first, such ideas are amenable to corrective action, but as the disease develops, they transform into delusional ones. They are accompanied by incorrect behavior. In addition, individuals suffering from this form of paranoid show a lack of criticality towards their own actions and condition.
Reactive paranoid is a group of psychoses, as a result of which it has a rich symptomatology that arises as a result of mental trauma (for example, being in an alien environment, under conditions of serious stress). The main symptoms of this form of paranoid are overvalued or delusional ideas. In addition, hallucinations are possible. Patients are characterized by increased anxiety and suspicion. They are in stable psychological tension. Often with reactive paranoid a depressive component is detected in varying degrees of severity. This form of the disease is diagnosed based on medical history and clinical symptoms.
Treatment of paranoid, first of all, involves eliminating the traumatic situation. In addition, some psychotherapeutic techniques and drug therapy have successfully proven themselves, which are used only after the elimination of psychotic-level disorders.
The condition in question can occur during isolation, for example, in conditions of linguistic isolation. You can also identify a number of factors that predispose to the development of paranoid:
- misunderstanding of other people's customs or speech;
— environmental stress (for example, military conditions);
- overwork;
- alcoholism;
- state weakened by insomnia;
- malnutrition.
At first, patients experience fear and excessive suspicion, then thoughts of persecution appear, which develop into a fear of possible murder. Against the background of this condition, deceptions of perception often occur, manifested in auditory hallucinations (patients hear the voices of loved ones or the crying of children). This condition is more often observed among prisoners who are serving a sentence for a crime in solitary confinement - they hear the voices of relatives, close friends, and the crying of children.
Typically, recognizing reactive paranoids is not difficult. The main criteria for diagnosis are:
- situational conditionality of the disease state;
- connection with a traumatic situation;
- reversibility of symptoms when the external environment changes.
In addition, some mental disorders, for example, inflationary paranoid or other paranoid phenomena, can be identified using the Szondi test.
Inflationary paranoid is a wary and delusional perception of the environment as hostile. Paranoid phenomena are delusional judgments that are based on deception.
Alcoholism stage 3
2. Patient 36 years old. He entered a drug treatment clinic at the insistence of his wife; he does not consider himself an alcoholic. Has been abusing alcohol for 15 years. Tolerance up to 1.5 liters of moonshine. The hangover syndrome is persistent; it can be drunk with up to 0.5 liters of vodka. The nature of drinking is binge drinking. The gag reflex due to an alcohol overdose disappeared 3 years ago. He had not previously been treated for alcoholism.
2. Your medical tactics
Alcoholism stage 2
3. Patient, 50 years old, had a childhood head injury with loss of consciousness. He has been abusing alcohol since the age of 18. Lately, he has been drinking alcohol daily in small doses. He suffered from syphilis and was cured. Severe memory disorders are revealed, he does not remember anything, he has amnesized most of the events of his own life and public historical events. Not oriented in time, does not find his room, his bed. The Wasserman reaction in the blood is negative. Complains of pain in the legs.
1. Identify the symptoms of the disease
2. Your medical tactics
Korsakov psychosis
4. The patient is 45 years old, has been abusing alcohol for many years, drank up to 2 liters. vodka, lately he gets drunk from 1 glass of vodka. Uses alcohol substitutes. He was admitted to a psychiatric clinic due to the fact that his orientation was disturbed; the night before he saw how the room was filled with rats and mice that climbed on him and bit him. It was scary. He grabbed an ax and fought them off, ran around the house, trying to hide. When he ran out into the street screaming, neighbors called an ambulance.
The next morning in the department he is not accessible to contact, is not calm in bed, feels his clothes, grabs them, pulls them off, fingers them. Pronounces individual words, interjections, syllables. Body temperature is 40 degrees, neurological status shows symptoms of oral automatism, nystagmus, ptosis, hyperhidrosis, dysarthria. After recovery, he remembers nothing about the painful period.
1) Identify the symptoms of the disease
2) Your medical tactics
Alcohol delirium
5. A 20-year-old patient, who recently suffered from a severe form of pneumonia followed by asthenia, drank 0.5 liters at a friend’s wedding. vodka, he quickly became drunk, his speech became dysarthric, his gait was unsteady. Then he seemed to sober up, got up from the table and confidently walked out of the room into the kitchen. Without answering the hostess’s question about what he needed, he grabbed a knife and quickly returned to the table, where he began screaming loudly and waving the knife, not understanding the words addressed to him. He attacked guests, threatening to kill him, and showed strong resistance to those holding him. The face was pale, the pupils were dilated. After 15-20 minutes he calmed down and fell asleep on the sofa in the next room. The next morning I didn’t remember anything about what happened.
1. Identify the symptoms of the disease
2. Your medical tactics
Pathological intoxication
6. Patient 32 years old. For a month I vacationed with relatives in the Caucasus, drinking up to 3-4 liters of wine every day. in a day. Returning home to Siberia, he noticed that his fellow travelers in the compartment were behaving strangely, looking at him somehow ominously, for some reason they took out a knife and began to cut bread, but he realized that they were showing him how to deal with him. He was very scared, ran out of the compartment and asked the conductor to hide him. When the train arrived at the station, I saw people running towards the station. He realized that they were running after him and that death awaited him. As he walked, he jumped out of the car and shouted: “Help, save!” ran away from the station.
i. Identify the symptoms of the disease
ii. Your medical tactics
Acute alcoholic paranoid
7. A 39-year-old patient has been abusing alcohol for 10 years, has a hangover, and has a tolerance of 1.5 liters. vodka. He hasn't been sleeping well the last few days, he hears cars making noise in the garden, he goes out of the house to check it out, but doesn't see anything suspicious. In the noise of water and the ticking of a clock, she hears swearing at herself, and began to hear “voices” from the street and the next room. There were many “voices”, all the conversations were about the patient, some scolded her, insulted her, threatened her with violence, others defended her, encouraged her, gave advice, and promised to help. She looked out the window, but didn't see anything. This is the first time such violations have appeared. Anxiety appeared and my mood dropped.
1 Identify the symptoms of the disease
2.Your medical tactics
This is a relatively rare form of reactive psychosis. The clinical picture is characterized by relative simplicity, elementaryness, imagery, and affective saturation of paranoid experiences. Most patients have ideas of persecution and relationships. The plot of delirium reflects traumatic circumstances (directly or in the form of objections). Auditory hallucinations often develop, and visual hallucinations rarely develop. In the acute period of behavior, the reactions of patients have psychopathological manifestations and often result in auto- or hetero-aggression, leading to suicidal acts. Acute psychopathological symptoms usually regress within a few days, but within 2-4 weeks. a trail of described symptoms remains, most often evening and night terrors.
The following forms of reactive paranoids are distinguished.
1. Paranoid - delusional ideas are unstable, reflect a traumatic situation and are formed against the background of outwardly ordered behavior, without hallucinations.
2. Hypochondriacal - develops as a result of some somatic disease. Patients express opinions about an incurable disease, usually in combination with ideas of attitude, impact, and sometimes body dysmorphic disorder.
3. paranoid of external circumstances (S. Zhislin, 1940) have several varieties:
a) wartime paranoid. The plot of the delusion correlates with the situation. Patients are afraid of being captured, perceive all people as enemies, etc. Paranoid unfolds against the background of the affect of fear and is accompanied by impulsive actions, such as flight;
b) “railway” Paranoid - develops during long, uncertain travel, in a hurry, in an unusual environment, in a state of exhaustion. The plot of delusion - persecution and relationships - is also determined by general circumstances. Patients “notice” that everyone is looking at them in a special way, whispering, making signs to each other, planning murder, etc.;
c) prison paranoids. The plot of delirium reflects the situation associated with arrest and imprisonment. Usually the patient develops hallucinations, often auditory: accusations, threats or comments on actions.
Induced paranoid psychosis. Develops in individuals who have long and close contact with mentally ill people. Usually these are people with a low intellectual and cultural level. In terms of content, the psychopathological phenomena of the recipient are similar to those of the inductor. Most often these are delusions of persecution, relationships, quarrels or erotic ones.
Nonsense of the slow-witted. (Close in pathogenesis is also delirium in a foreign language environment.) First, there is a pathological interpretation of the speech of people surrounding the patient, and then, against the background of deepening affects of fear and anxiety, the interpretation of gestures, facial expressions, postures and actions. Delusional thoughts of relationship and persecution are formed, and auditory hallucinations and illusions often appear.
differential diagnosis
The basis for the differential diagnosis of reactive psychoses is the Jaspers criteria. In clinical practice, very often reactive states have to be differentiated from endogenous (depression, schizophrenia) and exogenous (alcohol, etc.) psychoses. Of primary importance for the diagnosis of reactive psychoses is the condition of patients after leaving the psychotic state. Most often, reactive psychoses end with complete recovery of the patient after a short period of asthenia. But sometimes residual mental disorders or personality changes remain (psychotic personality). If complete recovery does not occur, premorbid obligate, facultative or latent characterological traits become aggravated. In particular, after hysterical psychoses, a pronounced hysterical-exciting accentuation is formed. After prolonged reactive depression, stable hypothymia is established. Asthenic conditions, often with elements of psychoorganic syndrome, are long-lasting and difficult to differentiate during the pislearacic period. To define these conditions, G. Huber (1968) introduced the term “asthenic defect”.
Age characteristics, pathomorphosis and consequences of reactive psychoses
Most often, reactive psychoses occur between the ages of 20 and 40 years. In young patients, they are usually short-term, fragmentary and are mainly in the form of episodes of affectively narrowed or twilight changes in consciousness without psychopathological components. With age, the clinical picture of reactive psychoses is dominated by depressive syndrome with ideas of self-accusation and self-abasement, and hypochondriacal delusions.
The clinical pathomorphosis of reactive psychoses in recent years has been manifested by an insignificant severity of psychopathological symptoms. In rare cases, pseudodementia and puerilism are observed. A rare phenomenon is Ganser syndrome. Depressive-paranoid symptom complexes predominate. The structure of disturbances of consciousness has forms that are not characteristic of reactive psychoses: delirious, amental. After reactive psychoses, in many cases a critical attitude towards the environment is completely restored or short-term trace asthenia remains. The consequence of protracted psychoses with a non-progressive course is a lytic state with prolonged trace asthenia.
Transforming, prolonged psychoses gradually disappear, but psychopathological syndromes remain and relapses develop, followed by an unexpressed defect. In the case of a progressive course, elements of the Kandinsky-Clerambault syndrome appear in the clinical picture, and an apatico-abulic type defect is formed.
treatment
Therapeutic tactics are determined by the severity and clinical form of reactive psychosis. In acute forms with a predominance of impaired consciousness and psychomotor agitation, patients need emergency care. Sometimes the patient is immobilized. Parenteral antipsychotic drugs: chlorpromazine (up to 500 mg per day), haloperidol (up to 40 mg per day), tizercin (up to 400 mg per day), clopixol (up to 400 mg per day) with action correction by parkopan, cyclodol, etc. After relief During the acute period, it is possible to switch to benzodiazepine tranquilizers (diazepam, chlordiazepoxide - up to 40-60 mg per day, tranxene - 50-100 mg each) followed by oral use of these or others (memory medaze - 20-30 mg, nitrazepam - 5-10 mg) tranquilizers.
In the treatment of reactive symptoms, thymoleptics play an important role; if necessary, they are prescribed in combination with neuroleptics and tranquilizers. For monomorphic depression with a predominance of motor and ideational retardation, imipramine (up to 75-100 mg) and Prozac (60 mg per day) are indicated. For polymorphic depression, the clinical picture of which is psychopathic-like disorders (usually of a hysteroid nature), broad-spectrum antidepressants with a sedative component are prescribed (amitriptyline - up to 100 mg, cipramil - up to 60 mg, Zofolt - 25-200 mg, thoracisine - up to 150 mg). mg, pyrazidol - up to 150 mg, insidon - up to 50 mg per day).
The basis of treatment for protracted reactive psychoses is tranquilizers. Parenteral administration of diazepam (up to 80 mg per day), phenazepam (up to 5 mg per day), rudotel (30 mg per day), tranxene (50-80 mg) is indicated. In severe cases, when symptoms of a dissociative nature predominate (hallucinations, stupor, paranoid thoughts), a combination of tranquilizers, antipsychotics (Stelazine, Chlorprothixene, and Fluanxol, Zyprexa, Rispolept, Solian) and behavior correctors (Meleril, Sonapax) in average therapeutic doses is used. In the treatment of pseudodementia symptom complex, amytal-caffeine disinhibition has not lost its importance.
After relief of the acute psychotic state, rehabilitation measures are carried out, and psychotherapeutic measures are carried out against the background of general restorative treatment. The objectives of psychotherapy are to eliminate the pathological fixation that has arisen due to psychotraumatic situations, with the subsequent activation of the individual, the actualization of positive social, work and family attitudes.
forecast
With adequate treatment and rehabilitation, in most cases the prognosis is favorable: patients recover. In a small number of patients, a neurotic or psychopathic type of personality development is formed, which significantly worsens the prognosis of social adaptation. Depressive disorders are expressed, accompanied by suicidal tendencies, life-threatening.
expertise
Medical and social examination of neurotic disorders. Loss of performance most often is partial and temporary during the acute period of the disease. It is possible to temporarily transfer patients to another part-time job. Temporary transfer to disability is practiced quite rarely: only for particularly severe forms of neuroses, neurotic personality development, frequent occurrence of hysterical paroxysms, in the case of motor and sensory disorders, a combination of obsession with depression.
RESI, endless rituals. When assessing the performance of hysterical personalities, one must take into account their ability to be demonstrative, and sometimes to have rental tendencies.
Forensic psychiatric examination of neurotic disorders. Patients with neuroses are recognized as sane and capable, since their state is conscious and they are able to control their actions. The development of neurosis after an offense, at the stage of investigation and trial, is usually not an obstacle to serving a sentence in prison. The diagnosis of neurosis most often appears in terms of differential diagnosis with other mental illnesses.
Medical and social examination of reactive psychoses. Temporary incapacity for work is established for the period of psychotic symptoms. Prolonged loss of ability to work is said to occur in protracted reactive psychoses with a tendency to stable fixation and relapses. In this case, other parameters of the patients’ vital functioning are also assessed differentially.
Forensic psychiatric examination of reactive psychoses. Often, reactive psychoses develop after the commission of illegal actions, as a result of a certain situation, namely: arrest, investigation, search, etc. In such cases, the examination is not aimed at establishing sanity or insanity at the time of the offense, but at the ability of the subject to participate in the investigation, trial and serve the sentence. As a result of the reverse nature of acute reactive psychoses, forensic investigative actions are suspended only during their development. Prolonged reactive psychoses necessitate compulsory treatment, followed by trial and serving a sentence. A particularly severe course with a tendency to become chronic can be assessed according to the criteria that apply to an endogenous disease and the corresponding recommendation for compulsory treatment.
Military examination of neurotic disorders and reactive psychoses. In the case of pronounced persistent painful manifestations, all contingents of conscripts and military personnel with neurotic disorders and reactive psychoses are declared unfit for military service and excluded from military registration. The same applies to moderately expressed long-term or repeated manifestations of the disease (except for officers, warrant officers, midshipmen and female military personnel, whose suitability for military service is determined individually). In the case of moderately expressed, short-term painful manifestations with the transition to mild asthenia, all contingents of military personnel and conscripts are considered temporarily unfit. they are granted leave or released from service. With mild and short-term manifestations of the disease, resulting in recovery, military personnel are recognized as fit for service in the army and navy, and the suitability for service of officers, warrant officers, midshipmen, female military personnel in the Airborne Forces, sailors, marines, special structures and submarines is determined individually.
ACADEMY OF MEDICAL SCIENCES
ALL-UNION RESEARCH CENTER FOR MENTAL HEALTH
Acute paranoid syndrome in schizophrenia
(issues of psychopathology, clinic and prognosis)
Performer: Mukhin Andrey Alekseevich
Scientific supervisor: Dr. G. P. Panteleeva
UDC 616.895.87
14.00.18 - "Psychiatry"
Moscow, 1985
GENERAL DESCRIPTION OF WORK
THE RELEVANCE OF RESEARCH.
The acute paranoid syndrome in schizophrenia remains poorly understood to date. The observed connection with provoking exogenous factors, the specificity of the content of delusional experiences, their affective intensity and relative transient nature, the absence of pronounced personality changes after psychosis has passed allowed a number of authors to evaluate the acute paranoid syndrome as uncharacteristic of schizophrenia and consider it mainly within the framework of various a kind of exogenous psychoses: reactive (psychogenic) paranoids (V.A. Gilyarovsky, 1946; K .L. Immerman, 1955; N.I.Felinskaya, 1968; M. McCabe , 1975), alcoholic paranoids (I.V. Strelchuk, 1949; A.G. Goffman, 1961; S.V. Pozdnyakova, 1978), somatogenic psychoses (S.M. Moefes, 1974; U. H. Peters , 1967). Recognizing the possibility of an endogenous origin of acute paranoids, most foreign authors nevertheless did not classify them as manifestations of “true” schizophrenia and described them as manifestations of the so-called. "schizophrenic reactions" (E. Popper, 1920; K. Sohr , 1961), "reactive schizophrenia" ( J. Berze , 1928), "phasophrenia" ( K. Kleist , 1953), "pseudoschizophrenia" ( H. C. Rumke , 1958), "atypical psychoses" ( H. Mitsuda, 1974; V. Pauleikhoff ,1974), “non-systematic schizophrenia” ( K. Leonhard .,1966), “borderline schizophrenic psychoses” ( M. Roth&H. MoCllaand ,1979). Psychiatrists of the French school traditionally distinguished acute paranoids from schizophrenia, separating them into an independent nosological category of “transient delusional states” (P. Pichot, 1982). Scandinavian psychiatrists still include most acute delusional states in their widely interpreted reactive psychoses or in the intermediate group of the so-called. "schizophreniform" psychoses ( E. Stromgren, 1965, N. Retterstol 1968, 1983). According to the views of American authors, reflected in DSM-III (1980), psychoses with a picture of acute paranoid are taken beyond the scope of schizophrenic ones and are considered under the headings “acute paranoid disorder” and “transient reactive psychosis.”
At the same time, mainly in the domestic literature, information is accumulating that acute paranonda syndrome can exhaust the picture of acutely developed schizophrenic psychosis (L.R. Luria, 1937; S.G. Zhislin, 1940; O.V. Kerbikov, 1949; V.A. Kontsevoy, 1965; L.M. Savchenko, 1974; I.V. Morkovkina, 1983, etc.). However, psychoses, defined by the picture of acute paranoia in schizophrenia, as a rule, were not studied as an independent category. They were described in different forms of the disease (paranoid, paroxysmal-progressive, recurrent, low-progressive, latent) and were assessed as one of the types of acute paranoid states (V.A. Kontsevoy, 1971; L.N. Vid- Manova, 1979; V.M. Nikolaev, 1984), as a variant of transient psychosis (V.A. Kontsevoy, 1965; L.M. Savchenko, 1974; K.E. Borisova, 1983), as paranoid reactions (I .V.Morkovkina, 1983). The features of their pre-manifest period, the subsequent course of the disease, as well as the role of exogenous harm in the occurrence of acute paranoid in schizophrenia remained poorly studied. All this, along with the lack of an adequate typology of such acute delusional psychoses, created difficulties in differential diagnosis with exogenous psychoses, made it difficult to assess the place of acute paranoids in the taxonomy of schizophrenia and to judge their prognostic significance.
PURPOSE AND OBJECTIVES OF THE STUDY.
The purpose of the work was to study the clinical features and course of schizophrenia, which for the first time manifests itself as acute paranoid syndrome. Based on the set goal, the following tasks were consistently solved:
1. To develop a typology of acute paranoids in schizophrenia based on the study of the phenomenology and dynamics of such schizophrenic psychoses.
2. To study the features of the long course of schizophrenia, which for the first time manifests itself as acute paranoid syndrome.
3. To clarify the conditions for the occurrence of acute paranoids in schizophrenia.
4. Determine the prognostic value of acute paranoid syndrome during the manifestation of schizophrenia for the further course of the disease.
MATERIALS AND METHODS OF RESEARCH.
The study material included 80 patients with schizophrenia (43 women and 37 men), who first manifested acute paranoid syndrome in adulthood (from 18 to 54 years). 50 patients were examined in the clinics of the Institute of Clinical Psychiatry of the All-Russian Research Center of Clinical Psychiatry of the USSR Academy of Medical Sciences and in the departments of the Moscow Clinical Psychiatric Hospital No. 1 named after. P.P. Kashchenko directly during the period of the first manifest psychosis using the clinical-psychopathological method. Some of these patients (27 patients) were subsequently followed up for 2-3 years. In addition, another 30 patients with schizophrenia, whose disease manifested itself as acute paranoid syndrome at least 10 years ago, were selected from among patients with schizophrenia registered at the Psycho-neurological dispensary No. 10 of the Proletarsky district of Moscow and examined using clinical follow-up method. The duration of follow-up in these 30 patients ranged from 10 to 40 years and averaged 19 years.
SCIENTIFIC NOVELTY OF THE WORK.
1. For the first time, a psychopathological analysis of various types of acute delusional states with a picture of acute paranoid in schizophrenia was carried out and their clinically substantiated variants were identified, based on the structural features and dynamics of delusional persecutory disorders that constitute the main content of the acute paranoid syndrome.
2. For the first time, general patterns of development of the process have been established during a long-term (at least 10 years) course of schizophrenia, manifesting as acute paranoid, and its varieties have been described, which have made it possible to determine the place of these psychoses in the taxonomy of schizophrenia.
3. The pathogenetic role of clinical features of the pre-manifest period and exogenous harms in the occurrence of acute paranoids in schizophrenia is substantiated.
4. Based on the data obtained, criteria for predicting the further course of schizophrenia, first manifesting as acute paranoid syndrome, were determined.
PRACTICAL SIGNIFICANCE OF THE WORK.
Clarification of the psychopathological features and dynamics of acute paranoid syndrome in schizophrenia, development of its typology allows for a differentiated approach to assessing the status of patients and the dynamics of the disease as a whole. Criteria for the prognosis of schizophrenia, which first manifests itself as acute paranoid syndrome, have been developed; variants of the subsequent dynamics of the disease, differing in the nature of psychopathological manifestations, course and prognosis, have been identified. The criteria for the differential diagnosis of acute schizophrenic paranoids with structurally similar psychoses of an exogenous nature have been clarified. Recommendations for psychopharmacotherapy of acute paranoids in schizophrenia have been developed, taking into account their typology, the form of the disease, differentiated recommendations for secondary prevention of relapses of the disease and rehabilitation of patients have been determined. The data obtained in the study have found application in the practical work of the Moscow Clinical Psychiatric Hospital No. I them. P.P. Kashchenko and Psycho-neurological dispensary No. 6 of the Sverdlovsk district of Moscow.
PUBLICATION OF RESEARCH RESULTS
The materials of the work are reflected in 4 scientific articles, a list of which is given at the end of the abstract.
SCOPE AND STRUCTURE OF WORK
The dissertation is presented on 178 pages of typewritten text (the main text is 159 pages) and consists of an introduction, 5 chapters (literature review, general characteristics of the material, 3 clinical chapters outlining their own research results), conclusions and conclusions. The bibliographic index contains 202 sources (103 works by domestic authors, 99 works by foreign authors).
RESEARCH RESULTS
A clinical study of psychoses with a picture of acute paranoid in examined patients with schizophrenia found that, along with general features that give them a certain similarity to each other: acute onset, dominance of sensory delusions of persecution, as a rule, specific, close to reality content against the background the affect of fear, anxiety or confusion (A.V. Snezhnevsky, 1983), there are a number of significant differences that relate to the qualitative features of delusional persecutory disorders and the structure of psychosis as a whole. Depending on these differences, the following variants of acute paranoid in schizophrenia were identified: paranoid with a dominance of acute sensory delusions ( I II variant) and paranoid with a tendency towards a fantastic modification of delirium ( III option). The differences between the selected options also lie in the dynamics of psychosis, the nature of affective disorders that accompany delusional disorders, the nature of behavioral disturbances in patients with psychosis, the duration of psychosis, and the characteristics of recovery from it.
Ioption. Paranoid with dominance acutesensual delirium. TO I 23 observations were classified as variant (5 women and 18 men). Delusional psychosis here arose acutely, developed over several hours, was completely exhausted by the sensory delirium of persecution with an affect of fear and, in its clinical manifestations, revealed similarities with the “paranoid of the external situation” by S.G. Zhislina (1940). In all patients, the development of psychosis was immediately preceded by exogenous harm. In most cases (in 16 observations), these states developed under conditions of a change in the usual environment - during a long trip by train, bus, boat, and in the remaining 7 observations - after psychogenically traumatic events. Delusional psychosis began with anxious tension. At the same time, patients noticed a group of people whose behavior and appearance seemed suspicious to them. These people attracted the attention of patients by being unkemptly dressed, playing cards, and drinking. These individuals were immediately perceived by patients as “criminals.” The patients began to observe these people and very quickly “noticed” that the “bandits” were “circling” around them, “looking” in their direction. The anxious tension was replaced within 1-2 hours by a vital fear for life. The patients “understood” without any hesitation that they were being robbed and killed, that they had lost at cards, etc. In the noise of voices, in the conversations of the pursuers, the patients began to “hear” individual words and phrases of a threatening nature, which they attributed to themselves. Despite the night time and the previous forced insomnia, the patients could not fall asleep, their behavior was completely determined by delusional experiences and the affect of fear: they tried to hide from their pursuers, ran, hid in other cars, etc. It is characteristic that almost all patients sought protection from law enforcement officers. As psychosis developed, the circle of persecutors expanded, which involved all the people with whom the patients had to deal: police officers, and later the staff of the psychiatric department where the patients were admitted.
The duration of acute delusional psychosis with this variant of acute paranoid was from 1-2 days to a week. Productive symptoms, simultaneously with the affect of fear, disappeared almost critically, already on the 1-2 day of treatment, and sometimes spontaneously when the situation changed. Despite the short duration of these delusional states, criticism of them either did not appear at all, or arose only after 1. 5-2 months and was extremely formal. Despite emerging from psychosis, the patients remained inaccessible, were not interested in contacting the doctor, and only formally agreed that they were sick.
Thus, the psychopathological structure of acute paranoid in this variant is quite simple: the affect was exhausted by the experience of vital fear, the main structural element of delusion was delusional perception with the direct experience of specific persecution. Delusional ideas arose on the basis of an instant delusional assessment of events occurring around them, as a direct reflection of the delusional meaning of what was happening. The plot of delirium was extremely visual, ordinary, concrete, retained a monothematic character throughout the psychosis and boiled down to persecution with a threat to the physical existence of the patients. The content of delirium, as a rule, reflected psychogenic (situational) aspects. The behavior of the patients was clearly delusional in nature and reflected the content of their persecutory experiences. As a rule, delusional disorders were accompanied by disturbances in perception (mainly with the participation of an illusory component) in the form of auditory deceptions such as verbal illusions, illusory hallucinosis, and individual auditory hallucinations, often of a functional nature.
II . Paranoid with elements interpretative delirium. II a variant of acute paranoid was observed in 37 of the examined patients (23 women and 14 men). Psychopathological structure of psychosis compared with I option, was much more complex both in terms of the variety of psychopathological phenomena and in the presence, along with acute sensory delirium, of components of interpretive delirium.
In these cases, there was not such a clear dependence of the onset of psychosis on external hazards: in 6 patients, psychosis arose autochthonously, and in 31 cases it was provoked exogenously (mainly psychogenically). In 8 cases, several months or years before the development of acute psychosis, monothematic ideas of jealousy, relationship, persecution, or a diffuse “paranoid mood” took place. Paranoid in this group of patients, as well as in I variant, it arose acutely, sometimes against a background of delusional alertness caused by previous traumatic events, but developed more slowly, usually within several days, less often - several hours. The predominant affect from the very beginning of psychosis was anxiety, against the background of which patients instantly, without ideational development, began to delusionally evaluate people’s behavior, objects and events accessible to direct sensory perception: they noticed the “intense” glances of passers-by, “conventional signs” with which they allegedly exchanged, “understood” that interference during telephone conversations indicated wiretapping, etc. The persecutory plot was also specific and ordinary in content. It arose immediately and became a schema for everything perceived in the future, all new delusional perceptions. The delusion of persecution here, in its content, rather related to aspects of moral damage and did not carry, as in I option, a direct threat to the physical existence of patients. They believed that they were being checked because... they are suspected of theft, they follow them in order to collect incriminating materials and then put them on trial, etc. The delusional assessment covered almost all aspects of the patients’ lives: “surveillance” was carried out at home, on the street, in public transport, at work, both directly by the persecuting persons, and indirectly, with the help of listening devices, “hidden cameras”. In a number of cases, false recognitions were observed that were isolated and specific in nature: patients “recognized” their pursuers, whom they had already “seen” the day before. Unlike I variant, delusional ideas were more persistent and did not show such a close dependence on directly perceived events, although the main source supporting delusional experiences still remained delusional perception. The difference also lay in the fact that here there was a more pronounced tendency towards consistency in the development of the plot, towards the ideational development of delirium. The patients tried to analyze the “facts”, generalized them, and interpreted the events of the past in a delusional way.
However, a logically developed delusional system was never created.
In general, the clinical picture of psychosis here was more polymorphic than in I option. The plot of delirium often went beyond the theme of persecution. At the height of psychosis, in a number of observations, ideas of poisoning arose, and less often - influence. With a depressive change in affect, ideas of condemnation and guilt appeared. There could also be elements of larger, less commonplace ideas, such as espionage. Perception disorders were more diverse than with I option. In addition to verbal ones, there were visual and olfactory hallucinations, hallucinations of taste, while the illusory nature of perception was slightly expressed. In the majority of patients, despite the affect of anxiety and current delusions of persecution, their behavior was outwardly orderly, which allowed them to remain in society for quite a long time. If, for delusional reasons, they tried not to go out on the street, quit their jobs, etc., they did this without revealing the true delusional reasons for their behavior, citing everyday circumstances. Duration of acute paranoid II In its version, from its beginning to the moment of hospitalization was 1.5-2 months. Placement in a psychiatric hospital was usually associated with the appearance of an affect of fear, delusional excitement, or suicidal attempts. In a psychiatric hospital, despite active treatment and a change of environment, signs of psychosis persisted for about another month on average. Recovery from it was gradual, lytic, over 1-3 weeks. During the period of reverse dynamics, short-term rudimentary episodes of exacerbation of delusional disorders often occurred. Criticism of the transferred state did not appear immediately after the productive disorders had passed, but only after 1-2 months and was incomplete. The patients did not show any concern about the psychosis they had suffered and tried to avoid conversations on this topic. In some patients, criticism did not appear at all. There were signs of emotional deficiency, a tendency to reasoning, and formalism in thinking.
III variant. Paranoid with a tendency to fantastic modification of delirium. To the group with III The acute paranoid variant included 20 patients (15 women and 5 men). Only in 3 observations did the delusional state develop autochthonously; in most cases, the onset of acute paranoid was preceded by exogenous harm. The acute delirious state here proceeded in two stages. At the first stage, it was determined by the picture of acute paranoid, the manifestations of which remained dominant throughout almost the entire duration of psychosis, which determined the classification of psychosis as a whole as a variant of acute paranoid. Only at the height of the state were signs of a fantastic modification of delirium revealed (stage 2), which, however, were observed in the clinical picture for a short time.
The psychotic state in these patients arose acutely and was characterized by an affect of anxiety, less often by episodes of fear. The formation of delusions was of a mixed nature, including components of both sensory and interpretive delusions, with a clear predominance of the former. The persecutory plot, which existed from the very beginning of psychosis, was mainly based on a delusional perception of the environment. At the same time, some actions of people and events were perceived from the very beginning as incomprehensible and unusual. Regarding the participants and goals of the persecution, the patients had various assumptions, which quickly lost touch with the real situation, and the scale of the ideas of persecution appeared. If false recognitions were noted in the picture of the delusional state, then they were devoid of concreteness and certainty. The behavior of the patients at this stage was outwardly correct. This condition lasted about 2-3 weeks. As psychosis developed, with an increase in its severity, confusion appeared, and in some cases began to dominate, which marked the beginning of stage 2 of psychosis. The plot of the persecution was generally preserved, but the content of the delusional perception became less specific and diffusely spread to everything around. The surroundings began to be perceived as somehow “changed”. The patients took everything that happened around them personally. In most cases, within 1-2 days, the fragmentation of painful experiences, the scale of delirium increased, and lability of affect appeared with a rapid transition from fear to delight. The symptom of staging, which was not observed in the first two variants of acute paranoid, became more formalized: the environment began to be perceived as a performance being played out, the theme of the experiment sounded. Orientation in the surroundings became fantastic, the situation was assessed as a laboratory, a model of a city. False recognitions also took on a distinctly fantastic character. The plot of delirium became polymorphic; along with ideas of persecution, ideas of condemnation, influence, power, and elements of Manichaean delirium appeared. In a number of cases, delusions of symbolic meaning became dominant. The polymorphism of the clinical picture was complemented by olfactory hallucinations and ideas of poisoning, true verbal hallucinations and individual mental automatisms. The behavior of patients at the height of psychosis outwardly looked ridiculous. As a rule, within the first few hours after the onset of confusion, patients were hospitalized. During treatment, confusion, affective disorders (fear, anxiety), and productive symptoms practically disappeared by 4-5 days. In some cases, events in psychosis were partially amnesic. Memories were fragmentary, presented by patients as unreal and reflected partial clouding of consciousness at the height of psychosis. Criticism appeared after 2-3 weeks and often only at the most acute fantastic stage of delusional psychosis.
The given pictures of variants of acute paranoid in schizophrenia differ in the mechanism of delusion formation, reflect the different level of generalization of disorders in psychosis and the features of their dynamics. On the other hand, the above typology of acute paranoids in schizophrenia reflects varying degrees of their similarity both with purely psychogenic conditions and with endogenous schizophrenic psychoses. If I the variant of acute paranoid is, in terms of the conditions for the formation of delusions, in its psychopathological structure, most similar to purely psychogenic psychoses, then II and III variants have a more typical picture for endogenous conditions, because contain symptoms that are uncharacteristic of exogenous psychoses: elements of interpretative delusion, a symptom of staging, delusions of symbolic meaning, etc.
The given descriptions reflect not only the psychopathological originality of the identified variants of acute paranoid in schizophrenia, but, mainly, carry information about general trends in the development of delusional psychoses.
The conducted clinical follow-up study made it possible to establish a number of general patterns inherent in the course of schizophrenia, which first manifests itself as acute paranoid syndrome. It turned out that the further course of the disease can take various forms with varying degrees of progression of the process. In accordance with the data of the follow-up study, it was possible to talk about 5 types of the course of schizophrenia, which first manifests itself as acute paranoid syndrome: 1. a continuous course, 2. a paroxysmal (fur-coat-like) course with a pronounced progression and a tendency to transition to continuous, 3 . paroxysmal (coat-like) course with an average degree of progression, 4. paroxysmal course, close to recurrent, and 5. course similar to the dynamics of latent schizophrenia.
With a continuous course, the disease developed according to the laws of continuous paranoid schizophrenia and was characterized by the predominance throughout the entire course of hallucinatory-paranoid symptoms with a pronounced progression of the process and persistent disability of patients. Unlike typical cases of paranoid schizophrenia, which are most characterized by a gradual onset with a consistent complication of delusional disorders, here there was an acute manifestation of the disease immediately with a picture of acute paranoid. However, the further stages of the disease in the form of a change from paranoid disorders to paraphrenic ones remained. One of the characteristic features of the course of the disease in these cases was its undulation with distinct periods of exacerbation and weakening of the intensity of productive symptoms, but without its complete disappearance. In a furry-like course with a pronounced progression throughout the entire course of the disease, paranoid symptoms also dominated, with the stereotype of complication of delusional disorders, the development of a significant emotional-volitional defect and persistent disability of patients characteristic of continuous paranoid schizophrenia. However, in these observations during the course of the disease, especially in its first stages, there were, although short-term, clear remissions with reverse development and complete reduction of paranoid symptoms, which made it possible to classify such cases as paroxysmal-progressive schizophrenia. The distinctly fur-like course of the disease was distinguished by a lesser degree of progression of the process. This was evidenced by the absence of a noticeable complication of the picture of acute paranoid in repeated attacks, and the rapid onset of relative stabilization of the process with the establishment of long-term (at least 10 years) remission. At the same time, the level of negative disorders here was not as significant as in the first two types of course, and social and professional adaptation was slightly disturbed. The course, close in its features to recurrent schizophrenia, was characterized by a clear recurrence of the disease with the occurrence of clearly defined attacks of the “cliché” type and relatively shallow negative personality changes. The difference from typical cases of recurrent schizophrenia was that the attacks, although they were phasic in nature, were characterized by the dominance of delusional disorders, while affective disorders of a polar nature were practically absent in their picture or were only slightly expressed. Exogenous provocation was also detected, both for the first and some of the repeated psychoses. Negative personality changes were little expressed and did not interfere with the patients’ good social and professional adaptation. In a number of observations, there was clear professional growth; patients graduated from higher educational institutions and were engaged in creative work. Finally, in some cases the disease was characterized by the emergence of acute delusional states with a picture of acute paranoid, developing according to the mechanism of reactions against the background of a long subclinical course of schizophrenia, which made it possible to qualify them within the framework of the dynamics of latent schizophrenia. The mechanism of reactive delusion formation remained in patients in the future. However, over time, the occurrence of repeated psychoses became more and more autochthonous, and their picture revealed features of increasing endogenization. Throughout the illness, the personality traits characteristic of patients in the pre-manifest period were preserved, social and professional adaptation remained good.
The given types of course, as the study has shown, indicate the existence of different trends in the further development of schizophrenia when it manifests itself as a picture of acute paranoid. They showed, therefore, that psychoses with the structure of acute paranoid in schizophrenia have a different clinical essence depending on their place in the taxonomy of schizophrenic conditions and represent, as it were, a chain of transitions between the stage of a continuous process, attacks (fur coats), delusional phases and peculiar reactions in patients with schizophrenia.
When studying the possibility of predicting the long-term course of the disease, it was found that information about the psychopathological structure of manifest psychosis with a picture of acute paranoid has a certain prognostic value. It turned out that continuous (paranoid) schizophrenia and paroxysmal-progressive (with a pronounced and moderate degree of progression) in most cases (100%, 71.4% and 71%, respectively) manifest as psychosis attributed to II variant of acute paranoid. Schizophrenia, close in its characteristics to recurrent, almost exclusively (in 87.5% of cases) manifests itself as acute delusional states with the picture III variant of acute paranoid. And finally, within the framework of the dynamics of latent schizophrenia, the disease, as a rule (in 69.6% of cases) clinically manifests itself as acute paranoid with the structure I option.
The study also revealed significant features of the pathogenesis of psychoses with a picture of acute paranoid in schizophrenia. The study of pathogenetic conditions has shown that the formation of schizophrenia, which first manifests itself as acute paranoid syndrome, is facilitated by such factors as clinical characteristics of the pre-manifest period, exogenous harms, and family background characteristics. As it turned out, clinical features of the pre-manifest period of the disease occupied a significant place among them. Clinical analysis revealed in all patients certain pathological manifestations, which represented a chain of transitions from psychopathic states to states similar to latent schizophrenia and to clearly processual pictures. Only in 9 patients (11.3%) the pre-manifest period was characterized by psychopathic characteristics that could be defined as schizoid. In all patients in this group, the described personality traits remained relatively stable throughout the pre-manifest period. In the majority of patients (60 patients, 75%), the development of acute paranoid was preceded by a long-term, multi-year condition, which could be classified as a latent course of schizophrenia. There were no signs of obvious progression of the disease, but there was a certain endogenous coloring of all psychopathological manifestations and their distinct subclinical dynamics. The clinical picture of the pre-manifest period in these patients was determined by a special abnormal personality type that did not fit into the framework of a certain type of psychopathy, as well as by the phenomena of acquired reactive lability, affective disorders in the form of autochthonous (mainly bipolar) disorders, increased readiness to form highly valuable formations in in the form of ideas of jealousy, attitude and ideas of dysmorphophobic content. Since childhood, all these patients were characterized by a schizoid personality type, along with which some patients clearly manifested traits of deficiency in various spheres of mental activity. In these cases, a certain subclinical dynamics of all the above-mentioned manifestations was characteristic, with a gradual sharpening of personal properties and a shift in emphasis towards an increasing increase in deficiency manifestations. IN II in the remaining cases (13.7%) in the pre-manifest period, one could speak of a low-progressive course of schizophrenia with the development of unsystematized delusional disorders such as monothematic ideas of persecution, relationships, less often jealousy or diffuse readiness for the formation of delusional disorders. Thus, in all the studied cases, the development of acute paranoid was preceded by certain pathological manifestations that can be classified as so-called conditions. "schizophrenic spectrum".
As the results of the study showed, exogenous harm is also in most cases one of the conditions for the occurrence of acute paranoid in schizophrenia. They directly preceded the development of psychosis in 71 patients (88.7%). Only in 9 patients (11.3%) manifest psychosis occurred autochthonously. According to the data obtained, exogenous influences most often acted in the form of a combination of somatic and psychogenic harm (in 41 cases, 51.3%), somewhat less often only psychogenic (situational) harm occurred (in 27 cases, 33. 8%), somatogenic harmfulness in isolated form preceded manifest psychosis in only 3 observations (3.8%). During the study, it was discovered, however, that the pathogenetic role of exogenous hazards in the formation of manifest psychosis of the type of acute paranoid was different in different observations. In some cases they completely determined the reactive mechanisms of the development of psychosis, in others they played only a provoking role. In all 23 observations related to the dynamics of latent schizophrenia, the content of delusional experiences in the picture of acute paranoid was determined by psychogenic moments almost throughout the entire psychotic state. Psychosis in these cases was regarded as reactive (situational) paranoid in patients with latent schizophrenia. At the same time, exogenous harm was one of the prerequisites for the occurrence of acute paranoid. In the other 48 observations, the content of delusional experiences was not so closely related to psychogenic moments or, as psychosis developed, it lost connection with the content of the traumatic situation. In these cases, it was more legitimate to speak only about the exogenous provocation of an acute delusional state within the framework of paroxysmal-progressive and recurrent forms of schizophrenia or about the provocation of the initial stage of continuous paranoid schizophrenia. The data obtained during the study of the conditions of the pathogenesis of acute paranoids in schizophrenia thus revealed their pathogenetic originality, which distinguishes them from endogenous psychoses typical of schizophrenia. At the same time, the studied psychoses revealed significant similarities with schizophrenia in such a parameter as the nature of hereditary burden. A survey of probands’ closest relatives showed that the frequency of manifest schizophrenic psychoses among them (34.7 cases per 1000 people) is more than 3 times higher than the prevalence of manifest schizophrenia in the general urban population, which may serve as additional evidence the belonging of the studied cases to the schizophrenic range of diseases.
The discovered features of the clinical manifestations and pathogenesis of acute paranoids in schizophrenia made it possible to take a differentiated approach to the development of therapy for these conditions and measures for readaptation of this contingent of patients with schizophrenia. During the study, it was discovered that the features of treatment for syndromatically similar psychoses with a picture of acute paranoid were largely determined by the place of these psychoses in the taxonomy of schizophrenic conditions and their clinical essence. Therapy for acute paranoids developing according to the type of reactions in latent schizophrenia was the simplest and was limited to a relatively short-term (5-10 days) prescription of “sedative” neuroleptics (aminazine) in a hospital setting. Treatment of acute paranoids developing as part of schizophrenic attacks and the initial stage of a continuous process was carried out, as a rule, with a combination of sedative and antipsychotic neuroleptics (aminazine, haloperidol). At the same time, the duration of psychopharmacotherapy increased for psychoses close to recurrent schizophrenia to 1-1.5 months, and for attacks (fur coats) and the initial stage of a continuous process to 2.5-3 months. Such a long-term (up to 3 months) prescription of antipsychotics in these cases was due to a gradual recovery from the psychotic state, as well as possible relapses of acute delirium during the period of remission.
Measures for readaptation of patients with schizophrenia manifesting acute paranoid syndrome were also structured differentially, depending on the form of schizophrenia, taking into account the pathogenetic features of acute delusional psychoses. In continuous-current (paranoid) schizophrenia and similar fur-like schizophrenia with a pronounced degree of progression, almost constantly present paranoid symptoms and a rapidly occurring deep emotional-volitional defect cause a sharp decrease in social and professional adaptation and lead to disability of patients at the level of II groups. In such cases, measures for the rehabilitation of patients were aimed mainly at preventing the development of hospitalism and involving patients in work in occupational therapy workshops. In case of paroxysmal (fur coat-like) schizophrenia with an average degree of progression, the establishment of disability is recommended for patients during the active stage of the disease. With the onset of stable remission, such patients should be actively involved in work at work, they should be oriented towards removing the disability group. However, due to the fact that with this type of disease it is difficult to perform skilled work, such patients need labor reorientation. A different approach to rehabilitation measures was required in cases classified as recurrent and latent schizophrenia. Thus, despite frequent repeated psychoses with delusional symptoms, in these cases negative personality changes were expressed little, the patients, for the most part, remained active at work, the ability to do creative work and did not need to establish a disability group or transfer to a lesser level. qualified work. On the contrary, any professional restrictions here are inappropriate; they can serve as a psychologically traumatic factor and lead to a worsening of the condition. In such cases, it is also necessary to take into account the pathogenetic features of repeated acute delusional states and focus on them when developing measures for secondary prevention. Based on the fact that in most of these cases, both with latent and recurrent schizophrenia; In the pathogenesis of repeated psychotic states, exogenous factors took part; the creation of a gentle lifestyle with the maximum possible exclusion of the influence of various kinds of exogenous hazards acquired particular importance.
CONCLUSIONS
1. Acute paranoid, being a non-specific syndrome for schizophrenia, in some cases can be the leading among the clinical manifestations of schizophrenic psychosis and completely determine its clinical picture.
2. The psychopathological structure of syndromically similar states, determined by the picture of acute paranoid, in schizophrenia is heterogeneous. This heterogeneity is determined mainly by the qualitative features of the structure and dynamics of delusional persecutory disorders, which constitute the main content of the acute paranoid syndrome. Taking into account the differences found, we can distinguish 3 variants of acute paranoids in schizophrenia: paranoid with a dominance of acute sensory delusions ( I option), paranoid with elements of interpretive delusion ( II option) and paranoid with a tendency to fantastic modification of delusions ( III option).
3. Psychoses with a picture of acute paranoid can occur with the manifestation of various forms of schizophrenia: continuous delusional, paroxysmal-progressive, close to recurrent, and can also act within the framework of the dynamics of latent schizophrenia. At the same time, they have a different clinical essence, forming, as it were, a chain of transitions between the stage of a continuous process, an attack (fur coat), a delusional phase and a peculiar reaction.
4. The clinical typology of acute paranoids in schizophrenia reflects not only their psychopathological originality, but mainly carries information about the further dynamics of the disease and has prognostic significance. I a variant of acute paranoid is observed mainly during a course similar to the dynamics of latent schizophrenia, II the variant develops, as a rule, with delusional continuous or with paroxysmal-progressive schizophrenia, III a variant of acute paranoid is characteristic of schizophrenia, close to recurrent.
5. In the pathogenesis of acute paranoid syndrome in schizophrenia, an important role is played by the presence of exogenous harms immediately preceding the development of psychosis and clinical features of the pre-manifest period in the form of pathological manifestations that can be classified as so-called conditions. “schizophrenic spectrum” and represent a chain of transitions from psychopathic states to latent schizophrenic states and to clearly procedural states.
6. Treatment of acute paranoids in schizophrenia is carried out differentiated, taking into account their place in the taxonomy of schizophrenic conditions and their clinical essence. In the treatment of acute paranoids that develop according to the type of reactions within latent schizophrenia, the most effective is the use of antipsychotics with a predominantly sedative effect. In the treatment of acute paranoids as part of schizophrenic attacks, a combination of sedative and antipsychotic neuroleptics is used.
7. Rehabilitation measures for patients with schizophrenia manifesting as acute paranoid should be differentiated depending on the form of the disease. In case of delusional continuous and fur-like schizophrenia with pronounced progression, rehabilitation measures are traditionally aimed at preventing hospitalization and involving patients in work in medical and occupational workshops. In case of paroxysmal (coat-like) schizophrenia of moderate progression, it is mainly necessary to reorient the patients at work. In cases of recurrent and latent schizophrenia, where, despite the predominance of delusional disorders in the structure of psychoses, negative personality changes are expressed insignificantly and patients maintain a high level of work ability for a long time, any professional restrictions are not recommended.
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