Characteristic signs of sluggish schizophrenia. What is low-grade schizophrenia? Simple low-grade schizophrenia

The international classifier does not include the diagnosis of “sluggish schizophrenia”; instead, the category “schizotypal disorder” is used, coded as F21. Another, quite often used name is latent schizophrenia. This discrepancy in terms is due to the fact that the disease borders on neuroses, psychopathic disorders, hypochondria and similar mild mental disorders that make a person strange and eccentric, but allow him to remain in society and family.

In the psychiatric literature, sluggish schizophrenia is designated by the terms: micropsychotic, mild, sanatorium, rudimentary, poorly progressive, subclinical, non-regressive, preschizophrenia, outpatient, torpid and the like.

The main difference of this form is the absence of progression or processuality, instead of which personality disorders of the schizoid spectrum come to the fore. Under the influence of illness, the personality undergoes changes, changing once and forever. The condition does not lead to the development of dementia, but the resulting changes cannot be reduced. In psychiatry, the disease is sometimes referred to as the schizophrenic phenotype.

Professor Snezhnevsky proposed to designate the process as sluggish; he also has an exhaustive definition: “Chronic lesions that develop neither in the direction of deterioration nor in the direction of recovery.” This is a separate option that has its own logic of existence.

Sluggish schizophrenia: causes

The highest frequency of the disorder is observed in blood relatives of patients being treated in a psychiatric hospital. Psychiatrists say that the hospital patient himself is only a marker of the disorders that exist in the family.

The leading cause of low-grade schizophrenia is genetic. Up to 3% of the total population is affected, men are much more likely to suffer from it. A cause other than hereditary is difficult to detect.

Signs and symptoms of low-grade schizophrenia

Symptoms of low-grade schizophrenia are quite characteristic:

There is never a split personality characteristic of other forms of schizophrenia. Symptoms are included in the personality structure, changing it. To establish a diagnosis, any 4 signs are sufficient, but they must exist for at least 2 years.

Stages and forms of sluggish schizophrenia

Experts distinguish 3 forms of such a disease as sluggish schizophrenia:

• hidden or latent, when the first signs appear that can be attributed to various manifestations of the neurosis- or psychopath-like spectrum;
• active, when all the symptoms and signs of sluggish schizophrenia are fully manifested;
• stabilization, when illusions and images subside, but fully manifest themselves personality disorders, remaining until the end of life.

Until a certain age - usually up to 20 years - a schizophrenic does not manifest himself in any way, studies and works, and even grows professionally.

However, already in the latent period, selfishness, communication difficulties, paradoxicality, sometimes demonstrativeness, suspicion and almost always inflated self-esteem and a sense of superiority appear.

Mood fluctuations are different from normal, reminiscent of depression or hypomania. Characterized by tireless activity, often one-sided, unfounded optimism, the emergence of rituals, fears, vegetative crises, and various pain symptoms.

The active period is characterized by either a dramatic change in personality or a condition reminiscent of an exacerbation of schizophrenia. Manifestations largely depend on age. Adolescents and young people are characterized by senestopathic disorders (unusual body sensations - gurgling, transfusion, movement - coupled with hypochondria), and for people of mature and older age - litigious ideas and suspicions that are close to delusions of jealousy, but do not reach their severity.

Almost always in the active period there are obsessions - attractions, thoughts, fear of going crazy, blasphemous. The affective coloring of these experiences is weak; over time, the person accepts them as natural, without even trying to resist.

The stabilization period is protracted, lasting almost the rest of your life. This is a lull when a person becomes apathetic, loses all initiative, and life incentives fade away. The intellect loses its sharpness and flexibility, the sense of pleasure is lost, and the person feels dull.

Diagnosis and differential diagnosis

One of the most difficult diagnostic tasks, since it is necessary to distinguish between an endogenous process and personality disorders, which are also of a hereditary nature.

There are 3 criteria in favor of the schizophrenic process:

How to recognize signs of schizophrenia in a teenager

This is difficult because the symptoms of the disease are superimposed on the character changes characteristic of puberty.

The following signs should alert you:

• detachment and isolation;
• silence, loss of liveliness of communication;
• mood swings when it is without apparent reason changes several times a day;
• difficulties in contacting peers, gradual isolation from them;
• isolation from others, lack of understanding of “truths.”

Teenagers are generally difficult people, but sometimes they still manage to reach healthy people. With affection, care and tenderness, one can ensure that at some point they reveal their experiences and discuss at least some of the issues that concern them with adults. Another thing is a sick teenager. He closes himself off forever, and not because he doesn’t trust adults, but due to personal changes - he simply has nothing to tell.

The following personality changes occur:

Treatment of low-grade schizophrenia

Quite a difficult task, some improvement is possible in the active period. During stabilization, when deficiency symptoms become dominant, coupled with personality changes, only minimal improvements are possible. Treatment of sluggish schizophrenia should be carried out almost throughout life, but patients do not have psychosis and therefore rarely end up in a hospital. Eccentric behavior and oddities are perceived by others as a given, and as a result, patients are not treated at all.

Drug treatment

Traditional antipsychotics and atypical neuroleptics are used, other groups of drugs are added occasionally.

Traditional drugs block dopamine receptors, thereby achieving a general antipsychotic effect. These are Haloperiodol, Chlorpromazine, Thioridazine and the like.

Atypical antipsychotics act on both dopamine and serotonin receptors. They have significantly fewer side effects, and their use does not interfere with family life or work. These are Risperidone, Olanzapine, Clozapine, Quetiapine and the like.

Its possibilities are limited due to the fact that deficiency disorders are the outcome of the disease, its result.

All a psychotherapist can do is try to teach a sick person how to interact correctly with the outside world. This happens during cognitive behavioral therapy. However, an obstacle to psychotherapeutic work is the fact that the patient does not consider himself sick. It is difficult to argue with him, especially if the person has never been hospitalized.

Changes in character and lifestyle are visible to others, but are not at all obvious to the patient himself. It’s much easier with those who have been in the hospital at least once. They were initially well treated, and had the opportunity to contact someone who received disability due to mental illness. Naturally, they strive to avoid such a fate.

Rehabilitation

Psychoeducational programs have the greatest effect when relatives and other persons in contact with the patient are informed in detail about the characteristics of the disease. Separate classes are devoted to how to behave correctly with a sick person and respond to his not always adequate behavior. Relatives trained in soft correction techniques create with the patient emotional connections on a new level.

Forecast and prevention of attacks of low-grade schizophrenia

The prognosis is generally favorable, especially if work activity matches the patient's personality characteristics. Simple, but at the same time in-demand professions are available: repairman, upholsterer, sorter, carpenter, postman, marker, seamstress, bookbinder, engraver, marker, gardener and the like.

There is psychiatry, psychiatric problems arise - psychoses and other disorders. This is the case when the concept of “deterioration in quality of life” acquires such features that it becomes noticeable during a routine visual examination of the patient. It is enough to look at him to understand the situation. In the majority of patients with serious disorders, this quality simply cannot help but deteriorate. At the same time, the lives of those around him change for the worse.

Symptoms of low-grade schizophrenia do not appear immediately

Everything should be simple: if there is psychosis - psychiatry, but if there is no - somewhere else...

The patient may persist, declare that he is completely healthy and that some kind of arbitrariness is being done to him. Only, if behind this person the actions are strange and full of a complex of aggression and protest, then it will be better for everyone if the application of an adequate treatment regimen nevertheless begins. The scales of diagnosis weigh the degree of suffering. And the forecast, in general, should be made in relation to this degree - its increase or decrease.

The bad thing is that some antipsychotics, along with a decrease in mental activity, also significantly reduce mental and physical abilities, but they are prescribed when, the day before the start of therapy, the patient has a large gas key from the pipes evil spirits kicked out or threw feces at passing trains, following the instructions of the voices in his head.

Everything is clear here. There is suffering, and there is at least some method of escape. Neuroleptics are not candy, but in real, selected and obvious cases of psychiatry they are necessary. Nearby there is another layer of existence. This is a world of unconventional personalities, autistic thinkers, ambivalent connoisseurs of the beautiful and the ugly, strange behavior, magic and mysticism, avant-garde art and a desire to reform society. Psychiatric intervention is possible, sometimes also necessary, but the criteria themselves cannot be the same as in the case of overt paranoid schizophrenia. We are talking not only about diagnostic criteria, but about the very principle of initializing the process and approach to it. It is impossible to say that the signs of sluggish schizophrenia in men and women do not deserve the attention of psychologists in general, including representatives of religious teachings. It is clear that psychotherapists will have something to work with. Not to treat something, but to work with something...

Latent schizophrenia, what is it...

Why and why did the WHO, which manages the process of revisions of the ICD, include the diagnosis of “latent schizophrenia” in class V? It is understood that the patient himself assesses his condition as negative, experiences suffering and seeks help. A doctor cannot provide it just like that, neither in Germany, nor in the USA, nor in Russia. We need a diagnosis. But, fortunately, it is far from block F20. Then block F21 “Schizotypal disorder” was created. There are two types of “similarities” that fall into this category. These are diagnoses starting with “pseudo” - pseudoneurotic and pseudopsychopathic schizophrenia, as well as latent, “poor in symptoms”, schizotypal personality disorder and a special schizophrenic reaction.

Latent schizophrenia symptoms have an exclusively non-psychotic profile. Differentiating it with schizotypal personality disorder is almost impossible in practice. Offhand, you can name five diagnoses from completely different categories, which can also be suitable for some individual case.

The disorder was once designated and is sometimes still designated by the concept of “sluggish schizophrenia.” It is connected with two facts. This is the use of an approach to imprison in the PND all those disliked by the authorities and with the search for a prodrome of the usual paranoid schizophrenia in some milder forms.

Sluggish schizophrenia not associated with schizotypal disorder

It is quite possible that this prodrome exists. But only in order to develop the correct attitude to the situation, you need to finally understand what “splitting consciousness” is, and then develop actions. It is necessary to apply some kind of therapy to people with a serious disconnect from reality now. In other cases, haste is far from related to the construction of an adequate treatment regimen.

The presence of psychosis is not so difficult to establish

Let us outline the picture as it seems correct from the practical side. This is a quick diagnostic that is carried out from the very beginning. Let's imagine a completely peaceful situation. We will omit the “combat” path, with bindings, injections right in the ambulance, screaming, handing over patients to a special brigade by police officers, because then the situation speaks for itself.

Let it be a local psychiatrist and a person who came himself. What does the doctor ask first? A standard set of questions is used, and the answers show a person’s ability to assess the situation, the situation, and identify himself. The presence of hallucinations, pseudohallucinations and delusions is established. If possible, information received from the alleged patient is supplemented with information from relatives. While in cursory mode, this is not yet a detailed history of life and condition, but simply clarification of the very nature of the case. The psychiatrist will also inquire about head injuries, other possible reasons the appearance of some organic changes.

Whether the person himself came to a specialist, or whether relatives persuaded him, or lured him by deception, but in 30 minutes you can establish the very essence: whether there is psychosis or not. What it is, how it proceeds, what needs to be excluded, what to add - this is all determined during long-term observation. No psychosis? Shouldn't you go to a psychotherapist? It heals the soul and is relatively inexpensive.

Now let's imagine a situation with various vague oddities.

• Doctor, sometimes strange thoughts come into my head. It seems to me that the world has turned against me.
• I think that I did something terrible at some point in the past, and now I will inevitably face retribution.
• I can't stay alone. I feel terrible, like the walls are trying to crush me. What should I do?

All these statements may hide a variety of diagnoses. Here’s what he said about the world’s militia against him - it’s possible that if we let him talk more, he’ll start telling things that we’ll see obvious signs delusions of persecution and influence. But, again, in the interpretations of a psychiatrist. Or maybe he doesn’t even have depression, he’s completely healthy and there’s no question of any diagnosis here.

Therefore, psychosis is identified according to criteria that clearly indicate its presence.

Diagnosing a disorder without psychotic symptoms is even easier

During the years of the USSR, it was enough to see a guy with an earring in his ear, long hair and torn jeans. Symptoms of “sluggish” schizophrenia within the framework of psychosis may not be detected. Therefore, a diagnosis can be made to anyone, even if the person tries to cheat and is laconic.

Scientists, doctors and members of the public who work at WHO have added a separate block to the ICD for diagnosing all sorts of oddities, not out of malicious intent. This is only an attempt to regulate the activities of psychiatrists and psychotherapists in cases where help is needed or desired. Psychiatry is a special kind medical practice. Diagnosis follows treatment. All haloperidol passions that are related to paranoid schizophrenia are almost always, in almost all cases, justified by the situation itself. By at least, we know that voices are not a joke, and they do not seem, but are part of the “reality” of the patient’s psyche. And measures need to be taken... Those that can reduce the degree of damage from the disorder.

If desired, symptoms of low-grade schizophrenia can be found in anyone - so you cannot make a diagnosis yourself

But these things, when some kind of moderate schizophrenia occurs, do not give such confidence in the justification of psychiatric intervention.

Signs of low-grade schizophrenia allow anyone to be diagnosed. Differential diagnosis of “sluggish” schizophrenia is possible only in terms of separating it from organic disorders and more serious syndromes associated with malignancy. From everything else, including normal condition, it is either very difficult or impossible to separate. The only difference between “sluggish” schizophrenia and the simple form of schizophrenia is that these are two controversial diagnoses, but the simple form is found at the age of 14-20 years, and the “sluggish” form is found in any person.

For you, personally, you can make a diagnosis in 20 minutes, and justify it in 10. It cannot be ruled out that if it doesn’t work out, then the examination period can be increased to 40 minutes. But in an hour you will not be left without a diagnosis. Tough? What did you want if psychotic symptoms are excluded in fact? What then are they considering? This is the main secret... Diagnosis reveals prepsychotic and prodromal schizophrenia. Until the premiere, all persons diagnosed with paranoid schizophrenia were normal. They were given a license to drive vehicles, enlisted in the army and government agencies, they were ordinary, no different from other citizens. But somehow all this developed in them... This non-difference is “pre”, “prod”... It is enough to look at the norm from a different angle, and it will become a special sluggish, light, soft and some kind of schizophrenia.

This does not deny the existence of the problem itself, but it does indicate that approaches to its consideration are controversial.

At the same time, strange as it may seem, everything said above is not an attempt to deny the existence of the problem of schizophrenia itself without its main symptoms. A pure prodromal state, if noticed by the patient himself and assessed as a source of discomfort, is a consequence of a general integral disorder. It concerns metabolism, energy-informational metabolism, it is associated with the initial diathesis, it also indicates that the information exchange has been disrupted, and this is somehow connected with

• activity of the higher nervous system;
• work of the psyche;
• features of thinking.

The moment when the patient managed to notice the prodrome just indicates that his thinking has “broken.” The “mechanism” itself... Sometimes in Orthodoxy the mind is called the “eye” of the soul. So the person felt that the “eye” began to “see” worse. Everyone expresses this differently. It was not by chance that Bleuler described this latency; it was not by chance that he spoke about the prodrome latent form. And in fact, all this can lead to hallucinations. But you can only treat them differently.

Hallucinations and delusions are a way for the unconscious to establish contact with consciousness. This is a defensive reaction and, at the same time, a way for the psyche to self-heal. What is “fixed” at the moment of activation of hallucinations is precisely the ability of thinking to interpret and compile information. The unconscious splashes out into consciousness the constructive elements of its language, even if they have the appearance of devils - these are the images that it is rich in, it has no others, but their role is much more positive than it might seem. Of course, consciousness interprets elements of the unconscious as some kind of phenomena - voices, alien lizards and the like. But this is all in the case of the paranoid form. Symptoms and signs of “sluggish” schizophrenia are softer things, some kind of imperceptible transactions of information from the unconscious to consciousness. This does not change the general principle. The process of mental self-regulation began, and once it began, it did not happen out of nowhere. Treatment of “sluggish” schizophrenia is a real attempt to block the action immune system the body itself.

Weaknesses of psychiatry

One of the weakest points of psychiatry is that it presents the consequence of something in the form of the disorder itself, and by treatment they mean the elimination of the consequences. This is the same as treating a boil by applying the tightest bandage - as long as not a drop of pus gets on the sheet. Why do they talk so much about behavior in these “sluggish” and other “mild” forms? Because something obvious is needed... It is absolutely wrong to consider the behavior of all supposed patients to be non-standard in external terms. Let's put it this way - more often than others, you notice individuals who are original, communicate differently, dress differently, see the world differently and talk about it. Autistic people hid in their own holes, and no one knows about them. In fact, there are many more autistic people than there are eccentrics and public performers.

Original and eccentric does not mean schizophrenic

The obvious strangeness of psychiatry is that not only practicing ordinary doctors, but also scientists allow themselves to think the same way as people on the street. Prodromality is called " a wake-up call“and they believe that if it is recognized in time and treatment is started, then deeper and more serious forms can be avoided. Delusions and hallucinations are perceived as serious, which in reality are a protective and restorative reaction of the psyche and the entire body to the violations occurring in it. Hallucination is a tool of the psyche, not a devil on the broom. By blocking mental activity at the level of influence on neurotransmitter receptors, hallucinations disappear. In some cases, this is necessary. The unconscious - it cannot itself correlate the level of its interference in consciousness. His activity is somewhat reminiscent of the elements. Nevertheless, the entire set of elements of the human device does its job.

1. Due to some problems, the psyche and thinking are transferred to a mode that is most consistent with maintaining vitality in an extreme situation of disruption of energy-information metabolism.
2. The process of self-correction, restructuring, and adjustment to the emerging conditions begins. During this process, the information processing mechanisms of consciousness and the unconscious temporarily merge.
3. With the right attitude to what is happening, attempts not to block neurotransmitter receptors, but to give the body something that will strengthen its immune abilities, the prime minister does not entail the development of a defect. The same is possible in the case of ordinary inaction, but when the person is placed in a gentle environment.

In this context, the question of whether low-grade schizophrenia can be cured seems the most “smart.” Is it possible to block the best, most gentle response of the body and psyche to metabolic disorders, without delusions and hallucinations at all, in the same way as hallucinations are blocked? Yeah. It is possible... It is possible to find such substances and such therapy that a person will not be able to think at all. Everything is quite real.

And about another killer argument. It is believed that about 40% of such patients attempt suicide. Hence the conclusion is that life expectancy in low-grade schizophrenia is low, so something needs to be done urgently. I talked with one supporter of Soviet theories from the time of Snezhnevsky. Authoritatively and powerfully proved the presence of sluggish schizophrenia. And you know, he convinced me. What's the point? He did not equate the term “sluggish” with the concept “latent”. He described 3-4 case histories of the most common paranoid schizophrenia, but without an increase in symptoms, with low progression. Everyone experienced hallucinations, delusions, a decrease in affect and its flattening, but they did not dance naked under the moon, although the patients ended badly. Here is an example of the ornateness of psychiatry terminology in terms of interpretation. It is necessary to prove the presence of a “sluggish” one, then they pass it off as paranoid. The malignancy of the episodes themselves does not bother me at all. Old school of Soviet psychiatry. However, it cannot be denied that paranoid schizophrenia can be sluggish. But this doesn’t make her any different, she’s just paranoid with low progress in pathogenesis.

Instead of output

The problem of thinking disorder exists... It can lead to anything, from autism with elements of agoraphobia to eccentric behavior without a decrease in social activity. However, the only reason for starting treatment in terms of psychiatry is the desire of the patient himself. It makes more sense to make any other diagnosis that contains the word “neurosis.” It is better to abstain from medications as long as possible.

A psychotherapist will help you fight neuroses

It is better to make an exception only for antidepressants if the patient is experiencing depression or something related to anxiety. And in all other respects, psychotherapy is broad, deep and sometimes effective. It’s her methods that you need to rely on.

Psychiatrists are never in a hurry to make a diagnosis of schizophrenia. It can be equated to a sentence. Therefore, you need to know 7 symptoms and signs of sluggish schizophrenia in order to promptly contact a competent specialist for help.

Causes

Currently, the causes of schizophrenia have not been established. Scientists are only putting forward their assumptions. Therefore, this disease is considered multifactorial.

The first factor is based on genetics. Let’s say that if at the birth of a child the parents suffer from schizophrenia, then the risk of transmission is fifty-fifty. If only one of the parents is sick, then the chance of transmitting a (congenital) disease is sharply reduced to almost twelve percent. This indicates the emergence of a predisposition to the disease. Predisposition does not apply to diseases. Pathology may appear after a certain period of time. This time is influenced by factors such as:

1. Parents' health.
2. Drug use.
3. Consumption of alcoholic beverages and many other factors.

The second group is biochemical. It is based on the fact that its factors, in the course of the disease, can cause another disease called psychosis.

Main features

If you start this disease, it is almost impossible to cure it. Currently, there is one opinion that schizophrenia has initial symptoms in the form of hallucinations. But in fact, they can manifest themselves in various forms:

1. Disturbance in the emotional system.
2. A sharp change in life interests.
3. The emergence of fears and so on.

The 7 signs of low-grade schizophrenia include:

1. Gradual decrease in physical and intellectual activity.
2. Self-containment.
3. Mood swings.
4. Impaired perception of the external and internal worlds.
5. There is no logic.
6. Belief in unreal things.
7. Deception of perception.

Symptom groups

Due to the above, all symptoms of low-grade schizophrenia can be divided into two groups:

1. Productive factors.
2. Negative factors.

The most problematic are the negative factors. This group based on problems such as lack of emotions when experiencing extreme situations and interruption in thinking. Some psychologists are able to identify schizophrenia even after communicating with the patient. On this diagnosis he will be faced with disturbances in speech and thinking.

How quickly can a disease be identified?

If in the family in which the child grew up there were constantly scandals or some kind of conflict, then the cause of schizophrenia could even be, for example, the loss of a job. Symptoms of low-grade schizophrenia appear a few days after the incident. The first sign is an immediate change in a person’s behavior.

Stages

The progression of flaccid schizophrenia occurs in stages. The following stages are distinguished:

1. Debut (or latent stage) – has blurred and mild symptoms, and therefore the course may go unnoticed even by the patient’s closest people. The following manifestations are typical:

• persistent affects;
• prolonged hypomania;
• somatized depression.

This stage often occurs during puberty. Among teenagers, attempts to avoid communication and refusal to leave the house are possible.

1. The manifest (or active) stage is characterized by an increase in the clinical symptoms of the disease. During this stage, oddities in human behavior become noticeable. However, they are not yet perceived by others as signs of illness, due to the absence of hallucinations and delusions. Meanwhile, the patient begins to experience panic attacks, and various phobias arise. In order to overcome them, a person begins to resort to certain rituals and double-checks (cleanliness of the body, clothes, etc.).
2. Stabilization – all clinical symptoms that appeared in the previous stage fade away. The patient's behavior becomes completely normal. The duration of this stage can be very long.

Kinds

If we take into account the stage of the disease, as well as some of its manifestations, then we can distinguish two types of sluggish schizophrenia.

1. Neurosis-like.
2. Psychopathic.

The difference between these two types is that for the neurosis-like type, phobic disorders are more characteristic. They manifest themselves in obsessive fears caused by a variety of factors, and often completely unfounded. This is especially often manifested in the fear of being in society and the desire to constantly be at home. Such patients are very afraid various infections Therefore, they most often isolate themselves from any society. The process itself occurs gradually and often unnoticed by others and the patient himself.

In another type of sluggish schizophrenia - psychopath-like - the most striking symptom is not fear, but depression - that is, a stable negative emotional background over a long period of time, as well as a gradually developing depersonalization of his personality. This entire set of symptoms is usually called flattening of affect. The patient stops striving to contact other people; he looks at himself as if from the outside, constantly evaluating his actions and talking to himself. He ceases to recognize himself as the person he is. This, for example, manifests itself in the fact that he ceases to recognize his reflection in the mirror, proving that this is a completely different person.

The theory of human substitution often appears in this issue. Such people lack any emotional reaction to the surrounding situation, and over time they begin to lead an almost vegetal lifestyle in emotional terms. Also, this variety may be characterized by a desire for wandering and gathering, a particularly strong love for animals, with which such people seek to replace their need for contact with people.

Diagnostics

Diagnosing the low-grade form of schizophrenia is a very difficult task, which often requires very long observations that can last indefinitely. And even in this case, one should not rush to a final diagnosis.

There are two types of deviations from which it is difficult to distinguish sluggish schizophrenia: borderline states - various types of psychopathy, neurotic deviations and similar diseases. Manifestations of progressive schizophrenia (neurosis-like and psychopath-like) are also possible. As already mentioned, the disease is very difficult to diagnose. If it is impossible to make an indisputable diagnosis in this situation, then it is better to give preference to something that is different from this disease and begin treatment of the patient without stopping monitoring him. There have been cases when a patient was treated for neurosis for 4-8 years and only after that time received a diagnosis of “sluggish schizophrenia.”

The same applies to doubts in differential diagnosis with other types of schizophrenia. In this case, it is better to give preference to other types of this disease and apply the necessary treatment methods.

Treatment

The goal of treatment for a diagnosis of sluggish schizophrenia is to achieve stable remission, with constant maintenance therapy. Treatment consists of taking medications. The medication prescribed by your doctor should be taken regularly. Only with strict adherence to the treatment regimen is it possible to achieve positive results. The following types of drug treatment are distinguished:

• Traditional antipsychotics.

The action is carried out by blocking dopamine receptors. The choice of drug is based on the patient’s condition, level of severity side effects, and also depends on the route of administration. These drugs include the following drugs: Haloperidol, Chlorpromazine, Thiotixene, etc.

• Second generation neuroleptics.

They affect the activity of dopamine and serotonin receptors. The advantage of these drugs is that they have less side effects. The highest effectiveness in relation to the symptoms of the disease remains an open question. These include drugs: Olanzapine, Ziprasidone, Risperidone, Aripiprazole, etc. When taking drugs from this group, there is a need to monitor the patient’s body weight, as well as to monitor the appearance of signs of type 2 diabetes.

Social support

In addition to drug therapy, there is a great need for sick people to provide social support. It is mandatory to attend various trainings and programs whose objectives are aimed at rehabilitation. Such activities allow patients:

• provide independent self-care;
• feel comfortable in society;
• continue work activities.

Collaboration

In the treatment of sluggish schizophrenia, an integrated approach is very important. The help of a psychologist, psychotherapist and social workers is required. Also, close people should provide proper support, without ignoring the patient’s problems. Hospitalization may be necessary at the manifest stage of the disease. Do not neglect this doctor's prescription. Involvement in creativity, visiting various art therapy sessions and cultural places also has a beneficial effect on the condition of patients. It is not recommended to interfere with the self-realization of the patient if he shows interest in creativity. A person with a disease should not be hidden from society or embarrassed about it.

Features of sluggish schizophrenia in women and men

Today, medicine knows the main features of schizophrenia, which are the same in both men and women.

• A decrease in a person’s emotionality and the appearance of indifference to the world around him.
• The desire to close yourself off from the people around you and isolate yourself from the world in any way.
• An indifferent attitude towards one’s former interests and concentration of attention on only one narrow area.
• Inability to adapt to the environment and its changes.

Sluggish schizophrenia in men greatly reduces the emotional response to events or phenomena occurring in their lives.

In some cases, a person may begin to utter completely incoherent nonsense or will see hallucinations. There are also significant increases in speech, speech becomes incoherent and illogical.

The signs of low-grade schizophrenia in women are similar to those in men, but there are some other features. A patient with schizophrenia may experience rapid mood swings to the opposite, as well as a desire to bring absolutely unnecessary things into her home. There is also a strong change in the choice of clothing and makeup. A woman can wear very bright makeup or, on the contrary, become unkempt.

Schizophrenia is a mental illness that is associated with impaired mental and emotional functioning. Such a state leads to the destruction of a person’s mental sphere, to his disorganization and, ultimately, to the complete disintegration of the personality. The disease is replete with a variety of symptoms, which are divided into 2 large groups: positive and negative symptoms.

As with any mental disorder, the signs of schizophrenia are often ambiguous, so it can sometimes be difficult to identify. However, this disease requires careful and timely diagnosis, as this is the key to successful treatment.

Schizophrenia and its causes

The first mention of schizophrenia, or schizophrenia as it was called, dates back to the 17th century BC. But, naturally, a clear, clear definition of the disease was not given then.

This concept was introduced into psychiatry in 1908 by the Swiss psychiatrist Eugen Bleuler. He clearly limited this concept from other mental disorders and defined it as a separate disease.

Literally, from Greek, the disease is translated as “split of the mind.” But this concept should not be compared with a split personality. It is also impossible to draw parallels between this term and dementia. The basis of schizophrenia is a violation of the coordinated functioning of the psyche, a breakdown of connections between its components: perception, thinking, attention, emotions. As a result of this, it cannot work as a single mechanism, causing all kinds of failures.

The reasons for the development of such a disorder have not been precisely and definitively established. To date, there are only theories of the occurrence of such a condition:

1. Heredity.
2. Risk factors during pregnancy. It is believed that the likelihood of developing the disease increases in people born in the winter and spring months. Prenatal infections and gene mutations also play a role.
3. Social status. It has been established that the development of schizophrenia is influenced by such criteria as low material level, racial persecution, lack of work, family problems, isolation from society, and loneliness.
4. Childhood traumatization. Manifestations of the disease in adulthood are provoked by traumatic factors suffered by a person in childhood: sexual and physical violence, loss of parents, lack of proper upbringing and care.
5. Psychological conditions. Increased emotionality, reduced stress resistance.
6. Excess dopamine. Excessive release of the neurotransmitter dopamine in the brain leads to constant stimulation of the “reward system”, which causes most of the symptoms. However, this hypothesis is increasingly fading into the background.
7. Addiction.
8. Changes in some brain structures. For example, enlargement of the ventricles and decrease in gray matter.

Symptoms

The most “favorite” age for schizophrenia is from 16 to 30 years. The disease affects both men and women. As a rule, it is preceded by warning symptoms in the form of irritability, social withdrawal and frequent mood swings. Detection of the prodromal period is possible two and a half years before the onset of progression of the disorder.

Main diagnostic criteria schizophrenia are manifestations of productive and negative symptoms.

Productive symptoms are signs that indicate overwork psyche, the so-called “reflection without an object.” These include:

In addition, people suffering from schizophrenia have a strong belief that someone is stealing their thoughts, or that other people are hearing them, or, conversely, that they are being implanted in the patient’s head. Chaotic speech, incoherent thinking and behavioral reactions are also common.

Negative symptoms in schizophrenia

Negative symptoms in the development of schizophrenia are called complete or partial loss of normal mental reactions. It includes a wide range of manifestations:

• smoothness of affect. Affect is the internal perception and outward manifestation of emotions. In schizophrenia, this process is very scarce, characterized by a poverty of emotions or their absence in principle. Such a person is not able to understand the feelings of others. This disorder is manifested by depression, mood lability, guilt, and fear. This leads to social maladaptation and isolation, since it is very difficult to establish contact with the patient. He begins to avoid people because he finds himself misunderstood;
• alogia – paucity of speech. She becomes poor and uninformative. If such patients are asked a question, the answer is usually short and concise. A woman suffering from the disease said that it was so difficult for her to speak that she was physically unable to explain her condition to her loved ones;
• Anhedonia is the inability to derive pleasure and enjoyment from activities that previously caused positive emotions. Lack of motivation and activity to achieve it;
• sleep disturbance – problems falling asleep, insomnia, interrupted sleep;
• physical sensations – headaches and dizziness, malaise. Vestibular disorders are manifested by an unsteady gait, the person becomes clumsy. Characteristic symptom– stupor, as well as muscle hyper- or hypotonicity, small twitching.

Cognitive impairments are observed, which are sometimes also classified as negative symptoms. These are thinking disorders that manifest themselves as decreased attention and memory, lack of logic and the ability to reason.

The perception of sounds is distorted, the surrounding world seems blurry. The patient's anxiety worsens and he becomes withdrawn.

Obligate symptom of schizophrenia

One of the obligatory negative symptoms of schizophrenic disorder is abulia - lack of willpower. Characterized by a loss of desire and motivation for any kind of activity that previously aroused interest. Such people are passive and lack initiative.

As the disease progresses, abulia develops into apato-abulia syndrome, an extreme degree of volitional disorder. A typical picture: a person is constantly alone, sitting or lying down, he can watch TV all day, but does not grasp the meaning of what he is watching. He refuses to take a shower, perform morning daily procedures, get a haircut, sleeps without changing clothes, and defecates anywhere.

At the same time, it is possible to intensify some unconscious instincts: sexual or food. The latter is manifested by uncontrolled absorption of food.

Such patients do not make verbal contact; their speech is poor. They explain their refusal to engage in dialogue by saying that they are tired.

Another distortion of the volitional sphere is parabulia. It is manifested by unfinished activities, impulsiveness and pretentious actions.

The patient is characterized by ambivalence - duality of reasoning and action. For example, he declares himself fat and thin, devil and god.

Another symptom is negativism. The patient performs contradictory actions. If someone hands him an apple, he refuses. But as soon as the fruit is removed, the person asks for it again.

All these negative symptoms can be primary, arising as a consequence of a pathological process, or secondary. They appear under the influence of external factors and often become the negative attitude of others, close people and people towards the patient. long-term treatment in the hospital.

A special role is played by the use of certain medications, in particular antipsychotics. But when they are canceled, the negative symptoms also disappear. This is an indicator by which it can be determined whether the symptoms are progression of the disease, or whether it is side effect treatment.

Types of schizophrenia

Depending on the manifestation of symptoms, the following forms of the disease are distinguished:

1. Paranoid form. In paranoid schizophrenia, productive symptoms prevail over negative symptoms. The main signs of this form are hallucinations and delusions.
2. Catatonic form. Movement disorders are observed - catatonic stupor and agitation. Stupor is characterized by hypertonicity and lack of movement; the person freezes in a bizarre position. At the same time, consciousness is relatively normal. There are no delusions or hallucinations; he perceives information, but is unable to speak or control his body. Catatonia gives way to excitement.
3. Hebephrenic form. Its peculiarity is intellectual disorders and impoverishment in the emotional sphere. Such patients are characterized by incoherent and illogical statements, foolish behavior, and productive symptoms.
4. Circular shape. Productive symptoms, change of depressive and excited states.

But there are other types of disease that are characterized by an atypical course. One of these forms is low-grade schizophrenia.

Sluggish schizophrenia

This type of disease is also called low-progressive schizophrenia or schizotypal disorder and is characterized by a slight progression of the process.

In a less progressive form of the disease, the symptoms are slightly different.

Neurotic disorders predominate, and productive symptoms are often represented by obsessive-phobic, depersonalization, and hysterical disorders.

The disease begins to manifest itself with some minor oddities in behavior. Sometimes loved ones do not focus on this, not even suspecting that they are symptoms of a serious illness:

• apathy and feelings of alienation;
• preference for loneliness and solitude, rejection of strangers;
• the desire to stand out from the crowd. For this purpose, a unique clothing and style is used, inappropriate behavior in the form of loud laughter and speech, antics;
• increased negativism towards others, criticality and suspicion, groundless claims. Such people see enemies everywhere;
• groundless anger and desire for revenge;
• do not accept criticism towards themselves, clear confidence in their rightness;
• pretentious speech and demonstrative behavior.

This is how a girl named Ellis Evans, who acquired the disease at the age of 20, describes the beginning of her pathological history. She walked through the city, and it seemed to her completely deserted and abandoned. The buildings were destroyed and all the people disappeared.

Stages and types of disease

Sluggish schizophrenia has 3 stages of development.

The disease begins with a latent stage, which is characterized by vague symptoms. Personality disorders and disturbances in the emotional sphere are observed. Characterized by depression and mild degree manic disorders. Hysterical and anxious reactions, paranoid episodes are possible.

In adolescence, indicative symptoms are skipping exams, refusing to go out and communicate with other people.

The next stage is active, in which the symptoms “bloom.” It is characterized by alternating attacks of the disease with periods of sluggish progress of the process. During this period, schizophrenia can occur in several ways:

1. Obsessive-phobic reactions, when the patient is visited by obsessions and fears. Characterized by panic attacks, various rituals and protective actions.
2. Depersonalization is a decrease in vital activity, detachment and alienation, loss of mental flexibility, and the ability to quickly switch attention. Emotional scarcity appears, the inability to receive pleasure. Patients themselves note that they grow dull, become primitive and callous.
3. Hypochondriacal reactions manifest themselves either in fears for their health, or in the appearance of pretentious, pathological sensations.
4. Hysterical reactions - mannered behavior. Such individuals are demonstrative, cutesy and flirtatious. Complex and vivid hysterical symptom complexes with impaired consciousness, stupor or agitation, panic fears, visions, and convulsive seizures are possible. Patients are distinguished by deceit and adventurism, many of them eventually become vagabonds, eccentric and attracting attention with their bright appearance.

Sluggish schizophrenia is also characterized by a simple form, which is characterized by negative symptoms. People of this type are characterized by a decrease in energy potential, scarcity of emotions, and depression. Common symptoms are:

• asthenia;
• low mood;
• social isolation;
• inability to experience positive emotions;
• strange and unpleasant sensations in the body and internal organs;
• passive behavior;
• slowness and inhibition of reactions;
• decreased cognitive function.

The third stage is the stabilization of all processes. Pathological symptoms fade away, and the patient returns to normal behavior.

Slightly progressive schizophrenia is capable of “hiding” and not attracting the attention of others for a long time. And only a specialist can identify its signs.

Diagnosis of schizophrenia

The diagnosis of any type of disease is made on the basis of an examination of the patient by a clinical psychologist, social worker and, of course, a psychiatrist. Main role Here the anamnesis, collected from the words of the patient and his immediate environment, plays a role.

Conduct differential diagnosis with other mental disorders.

For example, it is possible to draw a parallel between low-grade schizophrenia and neuroses. In neurosis-like conditions, the appearance of phobias and obsessive thoughts, as in schizophrenia. But these fears do not have an absurd connotation, they are quite understandable and can even be stopped by the person himself through defensive reactions.

Schizophrenia can also be compared to personality disorders. But in this state, oddities in behavior can be traced from childhood and accompany the person constantly. Schizophrenia-like conditions are characterized by development from a certain point when, as before, the patient lived a normal life.

There are two systems used to diagnose schizophrenia: DSM-5 and ICD-10.

In ICD-10, this concept is encrypted under the code F20.0-F20.3. To be assigned this disease to a patient, he must have one of the following symptoms:

• the feeling that a person’s thoughts are heard by everyone around him;
• delusional ideas characterized by inadequacy and absurdity;
• auditory hallucinations that seem to emanate from the head;
• delusional sensations, actions.

Or at least two of the following:

• any hallucinations accompanied by delusions;
• fragmented thinking, creation of new words (parvel - steam locomotive and bicycle);
• catatonia;
• negative signs leading to social isolation;
• changes in behavior leading to a narrowing of the circle of interests, withdrawal into oneself, and detachment from others.

These manifestations should accompany the person for at least a month.

Help with diagnostics

Please note a few characteristic features that accompany the disease at the beginning of its appearance. Perhaps they will help to recognize the disease in time:

1. Social withdrawal. The person loses contact with loved ones. He tries to avoid meeting people, which is why he does not go to school or work. He becomes indifferent to previously loved things and hobbies.
2. Personal hygiene. Problems with hygiene begin with the patient performing all procedures very slowly, gradually this interval increases even more. And over time, he generally stops brushing his teeth, washing himself, etc.
3. Obsession with the supernatural. A person becomes overly interested in mysticism, extrasensory perception, and most often religion. Religious hallucinations are possible. Most likely, this is due to a break with reality.
4. Sudden sharpness and activity in movements and facial expressions.
5. Auditory hallucinations.

These symptoms are almost always present at the beginning of the development of schizophrenia and are important indicators its occurrence.

Treatment of schizophrenia

The question of whether it is possible to recover from schizophrenia is quite controversial. But, definitely, with proper therapy it is possible to achieve stable and long-term remission. The prognosis is especially favorable for the sluggish form.

Proper treatment involves a comprehensive approach. Schizophrenic patients are allowed to outpatient treatment, however, if the process worsens, hospitalization is required. It can also be forced if a person resists.

First of all, it is required drug therapy which must be carried out exactly as prescribed by the doctor. It includes drugs that are classified as antipsychotics and act on both productive and negative signs of the disease.

Antipsychotics block dopamine receptors, thereby reducing the activity of this mediator. Classical antipsychotic drugs affect dopamine receptors, but bypass muscarinic and adrenal receptors. Typical representatives this group Chlorpromazine, Haloperidol, Thioridazine.

It has been established that these drugs can only block positive signs. They do not affect negative reactions and, on the contrary, can lead to their occurrence.

Atypical antipsychotics are more adapted to the treatment of the disease. They affect all types of receptors and eliminate both negative and positive symptoms. These drugs include Olanzapine, Clozapine, Risperidone.

Clozapine is recommended for use in treatment-resistant forms of schizophrenia, when the disease does not respond to treatment with most medications. It is highly effective; in addition, it helps eliminate bad habits, reduces the risk of suicide.

Despite the obvious advantages, the use of atypical antipsychotics has its own adverse reactions. Thus, the use of Olanzapine in the treatment of schizophrenia leads to the development diabetes mellitus and metabolic disorders, and Risperidone causes pathological weight gain.

When treating with antipsychotics, it is important not to deviate from the prescribed treatment regimen and not to adjust the dose yourself. Otherwise, this threatens with a number of dire consequences.

In addition to pharmacotherapy, psychotherapy is necessary in the treatment of schizophrenic illness, namely:

• cognitive-behavioural;
• psychoanalysis;
• family therapy;
• art therapy.

Disease prognosis

As already mentioned, the disease may well have a favorable outcome. This is influenced various factors, including the age of manifestation of the disease, and the severity of symptoms, the state before the disease, and others. An important role belongs to the family and its support.

At the same time, we should not forget that schizophrenia is a rather serious disorder. There are as many cases of sad outcomes as there are positive ones.

Such patients have an increased risk of suicide attempts, which become the most common cause of death. Has its effect Negative influence and taking antipsychotics, causing disturbances in the functioning of the heart and lungs.

Psychoses, which become frequent accompaniments of schizophrenia, lead to antisocial behavior and push patients to commit crimes.

History is rich in examples famous people suffering from this disorder.

Jim Gordon, a phenomenal drummer who worked with such celebrities as John Lennon, Frank Zappa, and Eric Clapton, suffered from a low-grade form of "schiza." He achieved incredible success and coped well with his illness until he killed his mother and ended up in jail. Since then, he has been treated with psychotic drugs.

One of the most popular personalities with schizophrenic disorder is John Forbes Nash. A great mathematician who, at the age of 30, became famous throughout the world for his achievements. The illness did not prevent him from teaching at Princeton University and receiving Nobel Prize in the field of economics.

The owners of the disease were Vincent Van Gogh, Salvador Dali, Veronica Lake, Peter Green.

Schizophrenia is a controversial disease. On the one hand, it causes a lot of trouble and suffering to its bearer, and on the other hand, it can push him to development and creativity. One thing is clear: this disease requires mandatory treatment and cannot be ignored.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Schizophrenia occurring in the form of an atypical prolonged pubertal attack

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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