Schizophrenia is characterized by the following thought disorders. Violation of thinking. Types of thought disorders in schizophrenia

Among mental illnesses, it belongs to the group of psychoses, that is, it is a mental disorder, which is characterized by a gross violation of contact with the surrounding reality. At the same time, the condition may be accompanied by inappropriate behavior, various hallucinations and delusions. When the internal unity between feelings, will breaks up, including, there is a violation of thinking. In this regard, the patient cannot adapt to the social environment. It is known that disorders of thinking, as well as emotional and volitional spheres, make the patient's behavior special, although the patient's memory is preserved, formal intellectual functions function.

There are many scientific views on thought disorders caused by schizophrenia. Etiology and pathogenesis differ in that the symptoms are highly variable, different types of course, manifestations of diseases are very individual. As for thinking disorders, taking into account the existing form of schizophrenia, the picture differs significantly. Now there are many works that are aimed at studying various disorders of thinking in this disease, however, this phenomenon has not been fully studied, and the mental activity of patients is largely a mystery. There are a number of features in the application of various diagnostic methods that make it possible to more accurately determine the presence of a thinking disorder.

Scientists conducted research aimed at identifying the specifics of thought disorders, which was identified on the basis of neuropsychological and pathopsychological studies of patients suffering from simple schizophrenia and paranoid form. In addition to the main goal, scientists were interested in how negative and positive symptoms manifest themselves in impaired thinking in schizophrenia of various forms. It was required to find out the presence of features of the brain organization and to find out if there are differences in right-hemispheric and left-hemispheric symptoms due to various forms of schizophrenia. The study revealed patterns inherent in various degrees of impaired thinking.

In the course of research, scientists have found that thinking disorders are more pronounced in those patients who suffer from a paranoid form, and this primarily concerns disorders related to the motivational sphere. For example, if in a simple form pseudo-abstract answers are more often observed, which can be attributed to violations of generalization, then in a paranoid form, inadequate answers consist of resonant and diverse judgments. In particular, patients with paranoid schizophrenia have more disorders related to the logical course of thinking. When tested, the following was revealed: patients with the paranoid form gave twenty-five percent of inadequate answers, and with the simple form, this figure increased to forty-five percent.

In addition, there was a statistically significant difference regarding both left-sided symptoms and right-sided neuropsychological symptoms. For example, patients with a simple form experienced difficulties with tasks that required spatial thinking, the need to understand the emotional content. Modern authors attribute these functions to the activity of the right hemisphere. Based on this, it can be concluded that the functions of the right hemisphere in such patients were in a depressed state, if compared with the left hemisphere. In patients suffering from paranoid schizophrenia, impaired thinking indicated mainly a hyperactive right hemisphere, and this was evidenced by tests for spatial thinking, synthesis, production of images and associations.

Currently, it is believed that mental processes suffer when the convexital parts of the frontal lobes are affected. There is a violation of thinking and the arbitrary subordination of behavior and mental processes to various programs suffers. In this case, the left hemisphere is most associated with voluntary control, this is due to the connection with speech processes. The right hemisphere in this case is responsible for the emotional forms that regulate behavior. Such regulation occurs in patients who are in a state of decompensation, and the behavior is explained by the structure of delusions and hallucinatory syndrome.

Thought disorders that are considered typical in schizophrenia are described multiple times and are expressed in a variety of terms. But the main thing to pay attention to is the loss of associative links. In this regard, the patient loses the ability to focus on a specific mental task. Extraneous thoughts, which are completely unnecessary, are an obstacle to the patient's concentration of attention, thinking becomes vague, as a result, a stream of purely personal mental material is formed, which is the source of a large number of strange and unusual thoughts. It should be noted that some patients experience difficulty in generating the thought process.

Thought disorders in schizophrenia have been described by psychiatric clinicians and psychologists. For the thinking of patients with schizophrenia, it is characteristic that a violation at the level of concepts does not exclude the relative preservation of formal logical connections. What is happening is not the disintegration of concepts, but a distortion of the process of generalization, when a lot of random, undirected associations arise in patients, reflecting extremely general connections.

Yu. F. Polyakov in patients with schizophrenia notes a violation of the actualization of information from past experience. According to the experiment, in comparison with healthy patients, patients better recognize those stimuli that are less expected, and worse - stimuli that are more expected. As a result, vagueness, whimsical thinking of patients is noted, which leads to a violation of mental activity in schizophrenia.

These patients do not single out significant significant connections between objects and phenomena, however, they do not operate, like oligophrenics, with secondary specific situational signs, but actualize excessively general, often weak, random, formal signs that do not reflect reality.

When carrying out the "exclusion of objects", "classification of objects" techniques, patients often generalize based on personal taste, random signs, offering several solutions, while not giving preference to any of them. In this case, we can talk about the diversity of thinking, when the judgment about some phenomenon proceeds in different planes.

The initial stage of thinking disorders earlier than in other methods is revealed in pictograms. Here, disorders of analytical and synthetic activity are found (correlation of abstract semantic and subject-specific components). Patients can choose an image that is inadequate to the content of the concept, they can offer an empty, emasculated, meaningless set of objects, pseudo-abstract images, devoid of content in themselves, or a part, a fragment of some situation, etc.

During the associative experiment, associations are noted atactic, echololic, refusing, according to consonance.

The distortion of the generalization process occurs in combination with violations of the sequence and criticality of thinking. For example, looking at H. Bidstrup's drawings, patients do not understand humor, humor is transferred to other, inadequate objects.

During the implementation of many techniques, patients are marked by reasoning. Reasoning in schizophrenia is characterized by emasculation of associations, loss of focus, slippage, pretentious and evaluative position, a tendency to large generalizations about relatively insignificant objects of judgment.

Slipping is manifested in the fact that patients, while reasoning adequately, suddenly stray from the correct train of thought to a false association, then again they can reason consistently without correcting mistakes. The inconsistency of judgments does not depend on exhaustion, the complexity of tasks.

Thus, in schizophrenia, attention and memory impairments can be detected. However, in the absence of organic changes in the brain, these disorders are the consequences of impaired thinking. Therefore, the psychologist should focus on the study of thinking.

1. Blockage of thinking, often with a subjective sense of loss of control over thoughts (sperrung)
2. Neologisms- new, own language
3. Blurred thinking– lack of clear conceptual boundaries
4. reasoning- the chain of reasoning eludes the patient
5. slipping- sudden change of topic of conversation
6. Verbigerations- mechanical repetition of words and phrases (especially common in chronic forms)
7. Own logic
8. Difficulties in generalizing and understanding similarities and differences
9. Difficulties in separating the major from the minor and discarding the non-essential
10. Combining phenomena, concepts and objects according to insignificant features

It happens: the clinical method (psychiatrist) does not reveal disorders, he asks the psychologist: look carefully if there are thought disorders. The psychologist begins to lay out the cards and highlight the thinking disorders. Psychologists who will work in clinical psychology are of great help to psychiatrists in the early diagnosis of mental disorders.

4. Decrease in mental activity (“reduction of energy potential” according to K. Konrad (or “broken wing syndrome”))

Lost "steel" and "rubber" in the individual. There are problems with learning, with work, it becomes difficult to read books, watch TV, learn new knowledge. The condition improves after physical work. He does it with pleasure and does not get tired. "Steel" is purposefulness, striving for achievements. "Rubber" is flexibility, the ability to adapt to the environment (Gannushkin).

P. Janet - mental strength - determines the ability of an individual to implement any mental functions; psychic tension is the ability of an individual to use his psychic power.

A balance is needed between psychic strength and psychic tension.

The extreme expression of a decrease in mental activity is abulia.

Apato-abulic syndrome.

It often happens: there is psychic strength, but there is no tension. In everyday life, we call this laziness. There are opportunities, but you don't want to use them. A schizophrenic patient cannot use his psychic power. "Broken wing syndrome" - you have to force, give the command. Otherwise, nothing will be done, a push from the outside is needed.

5. Disharmony of the mental make-up of the personality - schism - splitting

The coherence between the main mental processes is violated: perceptions, feelings, thoughts and actions (the unity of the personality is lost).

5. 1.Schisis in thinking:

Diversity of thinking (both essential and non-essential confessions are used at the same time. Honesty is a category of reasonable relations reflected in mathematics, physics and psychiatry - the definition of a patient)

Fragmentation of thinking (the patient tells the psychiatrist that he has a somatic disease, and why is he being treated by a psychiatrist? Because there was a queue for the therapist ...)

schizophasia

How to distinguish schisis from Kandinsky-Clerambault syndrome? We understand schism as a negative disorder. Some psychiatrists consider Kandinsky-Clerambault to be a manifestation of schism. But this is a productive disorder.

5. 2. Schism in the emotional sphere:

According to E. Kretschmer, the psychesthetic proportion is “wood and glass” (emotional dullness + fragility, sensitivity of mental organization). He does not cry at the funeral of a loved one, but at the sight of an abandoned kitten, he begins to sob over him.

Ambivalence

Paramimia (what worries you? - longing (and at the same time he has a smile on his face)

Paratimia (the funeral of a loved one, everyone is crying, but he rejoices)

Psychological approach to the study of thought disorders in schizophrenia. Psychological research on schizophrenic thinking goes mainly in two directions. The first is characterized by the study of individual variants of schizophrenic thinking, which often have their analogues in the clinical symptoms of schizophrenia (slips, fragmentation, reasoning). The second direction is the search for general patterns of schizophrenic thinking. Such an approach to the study of thought disorders has both practical, differential diagnostic and theoretical significance, since the discovery of the psychological mechanisms of thought disorders in schizophrenia sheds light on the pathogenetic mechanisms of the schizophrenic process itself.

Studying the features of mental processes in patients who had suffered a traumatic brain injury, K. Goldschtein (1939, 1941, 1942, 1946) tried to transfer his data to thought disorders in general, including those observed in schizophrenia. The author put forward a concept about the concreteness of thinking, cognitive deficit in schizophrenia, the loss of the ability of patients with schizophrenia to abstract and form new concepts. The experimental basis of these works was the classification method created by K. Goldschtein and M. Sheerer, in which the main criteria for grouping cards were the color and shape of the geometric figures depicted on them.

Experimental data were interpreted in a similar way by some other researchers, including E. Hanfmann and J. Kasanin (1937, 1942), who studied schizophrenic thinking with the help of their modified method of forming artificial concepts.

L. S. Vygotsky (1933), using a variant of the methodology for the formation of concepts, also considered the experimental data obtained as a manifestation of a decrease in the level of concepts in schizophrenia. However, his work is still of great interest, because it is mainly not about the quantitative side of the decrease in the conceptual level that attracted the followers of K. Goldschtein, but about the qualitative structure of schizophrenic thinking, about the nature of the formation of concepts in patients with schizophrenia. B. V. Zeigarnik (1962), agreeing with L. S. Vygotsky regarding the frequency of changes in the meaning of words found in patients with schizophrenia, believes that in these cases we are not talking about a decrease in the level of conceptual thinking, which happens infrequently with schizophrenia and mainly with a pronounced defect or in the initial states, but about the distortion of the generalization process. Patients with schizophrenia operate with connections that are not specific, but, on the contrary, inadequate to the real situation. Even the concreteness of the judgments of patients with schizophrenia, observed in a number of cases, most often reflects the condensation, the convergence of the concrete and the abstract in their definition of a number of concepts. We have already noted the significance of this phenomenon in the origin of visual-concrete symbolism.

K. Goldschtein's views on the nature of thought disorders in schizophrenia have been criticized. So, D. Rapaport (1945), R. W. Payne, P. Matussek and E. J. George (1959) indicate that the solutions of experimental tasks by patients with schizophrenia, considered by K. Goldschtein and his followers as specific, are in fact unusual, atypical, non-standard . ET Fey (1951), using the Wisconsin method of classifying maps, notes that the low result in patients with schizophrenia is due not to difficulties in the formation of concepts, but to the unusual and even eccentricity of these concepts.

Ideas about a qualitatively different nature of the formation of concepts impressed psychiatrists much more, always emphasizing the unusualness, "otherness" of schizophrenic thinking than the point of view of K. Goldschtein. At the same time, the concept of a violation in schizophrenia of selectivity, selectivity of information came to the fore (N. Cameron, 1938, 1939, 1944, 1947; L. J. Chapman, 1961; R. W. Payne, 1959, etc.). According to researchers in this area, violations of the selectivity of information in the thinking of patients with schizophrenia are closely related to the expansion of the range of features of objects and phenomena involved in solving mental problems. Patients with schizophrenia use criteria that do not have real significance as relevant. The selection of unusual features of objects and phenomena in the process of thinking and ignoring their specific features is considered as a manifestation of excessive “semantic freedom” (L. S. McGaughran, 1957). A. Borst (1977) refers to this increased capacity for unexpected associations as hyperassociativity.

The concepts of over-generalization, or over-inclusion (N. Cameron, 1938) have become the most widespread for designating the psychological nature of the thinking of patients with schizophrenia. Overinclusion is understood as the impossibility for the patient to stay within certain given semantic boundaries, as a result of expanding the conditions of the mental task.

Unanimous in putting forward the concept of the role of impaired information selectivity in the origin of schizophrenic thinking, various researchers differ in their views on the causes of overinclusion. Some (R. W. Payne, P. Matussek, E. J. George, 1959) attribute the leading role to violations of the supposed filtering mechanism, which does not provide differentiation of essential features from non-essential, divorced from reality, not significant in this problem situation. Other researchers (A. Angyal, 1946, M. A. White, 1949) attach great importance in the formation of overinclusion to the fact that in schizophrenia the creation of the necessary inhibitory attitudes suffers and the attitude is not developed, without which differentiation of signs, characteristic of normal thinking, is impossible. N. Cameron (1938, 1939) considers overinclusion as a manifestation of the autistic personality position of patients with schizophrenia, their non-conformity, deliberate ignorance of generally accepted standards and patterns.

In the studies of Yu. F. Polyakov (1961, 1969, 1972, 1974) and his collaborators T. K. Meleshko (1966, 1967, 1971, 1972), V. P. Kritskaya (1966, 1971) and others, the obtained experimental data are consistent with the results of studies by N. Cameron, L. J. Chapmann, P. Matussek, R. W. Payne and others. However, according to Yu. sufficient explanation of their nature. The issues of violation of the selectivity of information in schizophrenic thinking are studied by Yu. F. Polyakov in a different aspect, in connection with the peculiarities of actualizing knowledge based on past experience inherent in patients with schizophrenia.

Features of the use of past experience by patients with schizophrenia are of interest to psychiatrists. So, A. I. Molochek (1938) attached great importance in the structure of schizophrenic thinking to the presence of adynamic, not participating in the mediation of the new material of past experience, new judgments grow without relying on past experience, regardless of the general state of thinking. At the same time, A. I. Molochek proceeds from the opinion of N. W. Gruhle (1932) that knowledge (a treasury of experience) is untouched in schizophrenia. Ya. P. Frumkin and S. M. Livshits (1976), on the basis of their observations, on the contrary, show the role of past experience in the formation of the clinical picture according to the mechanism of pathological revival of trace reactions.

Yu. F. Polyakov and his collaborators used two series of methods. The first includes methods, the performance of tasks for which is based on updating the knowledge of past experience (methods of comparing objects, subject classification, exclusion). The researcher's instruction on these methods was "deaf", it did not indicate to the patient the direction of mental activity. The second series of methods included tasks with minimal updating of past experience (tasks for comparison on a given basis, classification of geometric shapes that differ in shape, color and size). Additionally, more complex methods were used, the performance of tasks for which is associated with creative thinking - the nature of the problem situation requires an unbanal solution. The only correct solution of the problem turns out to be "disguised", latent. An example of such a task is the Szekely problem. The subject is offered several objects and asked to balance them on the scales so that the cups of the latter, after a while, themselves become unbalanced. Among the items offered is a candle. The correct solution of the problem is that a burning candle is placed on the scales, which after a while will decrease significantly and the scales will go out of balance. Data were obtained indicating that specific differences between patients and healthy people were found mainly when performing tasks according to the methods of the first group. For patients with schizophrenia, it turned out to be characteristic to highlight non-standard (weak, latent) signs.

It was found that the less the patient's activity is determined by the researcher's instructions, the more possible solutions are possible. As in the studies of N. Cameron, L. J. Chapmann and others, the expansion of the range of features involved in the performance of the experimental task occurs due to the actualization of the latent properties of objects and phenomena. The difference between the results in patients and healthy people is determined by the extent to which the conditions for completing the task allow for the ambiguity of the solution.

Thus, Yu. F. Polyakov in the information selection mechanism attaches importance to such factors as the degree of determinism of the solution by the condition of the task, the requirements of the task, the course of its analysis, and the past experience of the subject. In patients with schizophrenia, the probabilities of actualization of standard and non-standard signs are equalized, which, according to Yu. F. Polyakov, is largely based on the actualization of knowledge based on past human experience.

Our observations show that the expansion of the range of signs involved in solving mental problems turns out to be different when comparing the results using different methods, which, according to Yu. F. Polyakov, are all based on past experience, for example, when studying patients with schizophrenia using classification and exclusion methods. This difference depends on the difference in the degree of determination of the solution to the task by its condition, the greater or lesser certainty of the instruction, the volume and duration of mental activity in the experimental situation. Classification and exclusion methods differ significantly from each other. The classification technique in its subject variant allows for a much larger number of possible solutions, the process of putting forward certain decisions and their correction is longer, the instruction with it is less certain than in the subject variant of the exclusion technique.

We compared the results of the experimental psychological study with the clinical qualifications of the examined patients with schizophrenia. The greatest number of erroneous solutions to the task according to the schizophrenic type (distortion of generalization, slippage, diversity) in the initial manifestations of the disease was noted in the study according to the classification method, while these patients mostly performed the tasks for exclusion correctly. In the presence of a pronounced schizophrenic defect, the effectiveness of using both methods to detect schizophrenic thinking disorders was leveled off. This allows us to speak about the different validity of these methods in the initial stage of the schizophrenic process. The same circumstance calls into question the predominant importance of actualizing past experience.

The series of methods used by Yu. F. Polyakov differed in the degree of their verbalization and abstractness. In this regard, one circumstance, which we discovered earlier, seems significant, which consists in the fact that for patients with schizophrenia, subject and verbal versions of the same methods are unequal. We compared the diagnostic value of the subject and verbal classification and exclusion techniques and concluded that schizophrenic-type thinking disorders are more easily and more consistently detected when subject-based techniques are used. This can be explained by the fact that the subject variants of the classification and exclusion methods are more concrete and visual, the task conditions include more informative features, and the first signal system, along with the second signal system, is more involved in their implementation. Thus, one can think that the different diagnostic significance of the subject and verbal variants of the methods reflects such properties of them as visibility or abstractness. The same property is even more different for two series of Yu. F. Polyakov's methods.

We also consider the following circumstance to be important. In his recent works, Yu. F. Polyakov (1980) considers the phenomena of actualization of past experience and the associated changes in the selectivity of information as "through" features of the psyche of patients with schizophrenia - they are observed outside the acute period of the disease, precede it, and are very often found in relatives of patients. Thus, these features of the psyche are regarded not as manifestations of impaired brain functioning in connection with the disease, but as one of the predisposing characteristics of the anomaly type that constitute the “pathos” of schizophrenia, its constitutionally determined soil, background (A. V. Snezhnevsky, 1972) . The observations of Yu. F. Polyakov and his collaborators, carried out on a large experimental material, explain many questions. So, we observed that whatever the quality of remission, even with its highest clinical assessment, patients experience only a quantitative decrease in the severity of thought disorders.

Disorders of thinking in patients with schizophrenia during the course of the disease do not remain stable in their severity. However difficult it may be to distinguish them by quantitative criterion, it can nevertheless be done in general terms. For example, erroneous decisions detected at the beginning of the disease and qualified as slippages can still be corrected, in the future they become persistent, and when the researcher tries to force the patient to reconsider the correctness of his judgments, he defends them.

The experimental data we obtained on the conformity of the results of the study of the degree of severity of the mental defect were manifested, as already indicated, in the fact that with initial schizophrenia, patients could relatively well perform tasks according to the elimination method, but showed pronounced changes in the study of classifying thinking. At the same time, they showed insufficient purposefulness of thinking, they formed many “parallel” groups, a large number of cards did not belong to any of the existing larger rubrics. Characteristic phenomena of the diversity of judgments were noted - patients were offered several solutions as equivalent, one of which could be correct, but it was not given preference. It was noted that classification was carried out at different levels of generalization - rather generalized and small groups coexisted side by side, individual cards did not belong to any rubric at all.

In the presence of a significant schizophrenic emotional-volitional defect, the validity of these methods seemed to be equalized, the results in them became similar. This circumstance gives grounds for interpreting the observed phenomenon as a result of changes in the emotional-volitional sphere of patients with schizophrenia, primarily due to impaired motivation.

An explanation for the difference in the validity of classification and exclusion methods in patients with initial schizophrenia should be sought in the very structure of the methods and in the features of the experimental situation created in their studies.

Intellectual activity in the process of completing a task is largely determined by intellectual activity, which depends not only on intellectual, but also on extra-intellectual factors. Extra-intellectual factors of mental activity are primarily reduced to motivation.

Motives are understood as such psychological conditions that determine the purposefulness of actions, characterizing a relatively narrow, private and changeable attitude of a person to certain objects and phenomena of the outside world (V. S. Merlin, 1971). A person's motives are closely related to personality traits, first of all, to emotionality.

Thinking is inextricably linked with motivation and its emotional side. L. S. Vygotsky (1934) wrote that there is an affective and volitional tendency behind thought. He talked about the motivational realm of our consciousness, which encompasses drives, needs, interests, drives, affects, and emotions. The same position was developed by M. S. Lebedinsky (1948), who emphasized that normal thinking is a directed, volitional, active process. With regard to schizophrenia, M. S. Lebedinsky believed that with it the direction and stability of thinking suffers, the associative process of patients with schizophrenia is characterized by a lack of focus on the ultimate goal.

Ideas about the insufficiency of the motivational orientation of mental activity in schizophrenia, primarily thinking, have also developed in clinical psychiatry. So, J. Berze (1929), in his distinction between the clinic of procedural and defective states, gave a special role to the factor designated by him as hypotension of consciousness. In the hypotonia of consciousness, the author saw that hypothetical underlying disorder in schizophrenia, which is still in vain, as well as an intermediate link in acute exogenous types of reactions, some psychiatrists are looking for. K-Conrad (1958) put forward a position on the reduction of energy potential observed in schizophrenia, which is a syndrome of profound personality changes. We are talking about the reduction of mental activity and productivity, the inability of the patient to actively use the available life experience. The reduction of the energy potential, according to A.V. Snezhnevsky (1969), covers the spheres of mental activity, productivity and emotionality. G. Huber (1976) considered the pure reduction of the energy potential as the main schizophrenic process syndrome, the organic core of residual schizophrenia, which is the cause of the irreversibility of the initial states.

The reduction of the energy potential is especially pronounced in simple schizophrenia, which is characterized by the absence of productive psychopathological symptoms. A. V. Snezhnevsky (1975) in his scheme of negative psychopathological disorders identifies a circle of energy potential decrease, considering it as more pronounced personality changes of a negative order than personality disharmony, including schizoidization.

The concepts of hypotension of consciousness and reduction of energy potential can be considered clinical equivalents of the decrease in the level of motivation identified by psychologists in patients with schizophrenia.

In the performance of an experimental psychological task, to a certain extent, one can conditionally see manifestations of external and internal motivation. External motivation that affects the activity of the subject is largely related to the nature of the task assigned to him and the clarity of the instructions, which significantly predetermine the results of the task. Intrinsic motivation more reflects the affective-personal properties of the patient and can be considered as a result of mediation in onto- and phylogenesis of a number of external conditions, motives.

Applying the dialectical-materialistic concept of determinism to the analysis of mental phenomena, S. L. Rubinshtein (1957) pointed out that external causes act through internal conditions, which themselves are formed as a result of external influences. Intrinsic motivation in normal and pathological conditions is characterized by an inseparable unity of motivating and meaning-forming functions in a person's mental activity.

Comparison of the results obtained using the methods of classification and exclusion in patients with varying degrees of severity of a mental defect, i.e., differing in the degree of deepening of the reduction of energy potential, shows that in the conditions of performing tasks on the classification of concepts, the role of external motivation is much less than the role of internal motivation. The activity of the patient is less determined by the instructions of the researcher than in the study by the method of exclusion. In addition, when classifying, it encounters a much larger amount of information than when excluding it. This can explain the fact that, according to our observations, in patients with mild clinical manifestations of the schizophrenic process, the study according to the classification method is more diagnostically significant than according to other methods, in which the instruction more clearly defines the results. In the classification thinking of patients with schizophrenia, their motivational bias is clearly detected (B. V. Zeigarnik, 1976), which manifests itself both in low activity, insufficient purposefulness of the thinking process, and in qualitative changes in its course.

The foregoing gives grounds for defining thinking disorders in schizophrenia in the general clinical and psychological aspect as amotivational thinking. O. Mailer (1978) in the clinic of schizophrenia identifies amotivational syndrome, which he assigns a central place in the development of the pathological process, emphasizing, first of all, its genetic conditionality and dependence on the functioning of the reticular formation and hypothalamus. Amotivational syndrome, according to O. Mailer, includes violations of motives, motivation.

Amotivational thinking is a manifestation in the mental activity of patients with schizophrenia of more general pathogenetic mechanisms (reduction of energy potential, amotivational syndrome). Reflecting the essence of schizophrenia as a procedural disease, amotivational thinking is also characterized by procedural progression, which eventually leads to a deep initial state, the disintegration of thinking.

In its pure form, amotivational thinking is most clearly represented in a simple form of schizophrenia. In essence, all the types of schizophrenic thinking identified so far are variants of amotivational thinking, in the description of which researchers have focused on some features of personality disharmony in schizophrenia. So, emphasizing the autistic personal attitudes of the patient, we single out autistic thinking; emphasizing the role of the exaggerated pretentious and evaluative position of some patients with schizophrenia, we are talking about resonant thinking; highlighting the tendency to paralogical constructions, we speak of paralogical thinking, etc. All these clinical, not always differentiated types of schizophrenic thinking are included in the more general concept of amotivational thinking. However, it does not follow from this that the selection of clinical variants included in amotivational thinking is generally unlawful. Amotivational thinking is a negative, unproductive mental disorder, however, a decrease in the level of motivation almost never goes through only a quantitative decrease in function. At the same time, various manifestations of personality disharmony are observed, which determine the presence of clinically distinguished variants of thinking.

The definition of schizophrenic thinking as amotivational does not at all diminish the role in the mechanisms of its course of violations of information selectivity, a particular variant of which is the actualization of knowledge of past experience. One might think that the mechanisms of amotivation and violation of information selectivity are closely interrelated. The primary role here is played by the mechanism of reducing the level of motivation, the violation of the selectivity of information is its derivative. OK Tikhomirov (1969) traces this process, which can be represented by 3 links.

The first link is violations of the motivational sphere. They inevitably lead to violations of personal meaning. Personal meaning is what normally creates the partiality of human consciousness and gives a certain significance to phenomena, changes the essence, meaning of these phenomena in the perception of a person (A. N. Leontiev, 1975). The choice of signs of objects and phenomena that are significant for human thinking, i.e., the selectivity of information, is determined by the personal meaning that these objects or phenomena acquire for this or that individual. It is known that in patients with schizophrenia, the personal meaning of objects and phenomena often does not coincide with the generally accepted knowledge of a person about them, which is conditioned by the real situation. Thus, violations of personal meaning in schizophrenia, in which standard and non-standard informative signs are equalized or even the latter are preferred, are the second link in the psychological mechanism of schizophrenic thinking disorders. They inevitably lead to the emergence of the third link - the actual violations of the selectivity of information, which are manifested by violations of the selectivity of information in connection with past experience (Yu. F. Polyakov, 1972) and its probabilistic disorganization (I. M. Feigenberg, 1963, 1977). According to I. M. Feigenberg, the past experience itself and the set of associations inherent in it are stored in the memory of a patient with schizophrenia, the probabilistic possibility of attracting elements of this experience and using them to predict the future is disorganized. With this, I. M. Feigenberg also connects the looseness of associations - it is equally easy for the patient to extract from memory a highly probable or improbable association from past experience, hence the pretentiousness of the speech of patients with schizophrenia, when they use rarely used words by healthy people as easily as frequently used ones.

One might think that such a three-link, or three-factor, idea of ​​the structure of thinking in schizophrenia is the most complete and corresponds to clinical and psychological observations. The primary factor here is the amotivational factor, however, amotivational thinking cannot be entirely reduced to the mechanism of amotivation, its structure includes both violations of personal meaning in patients with schizophrenia and violations of their information selectivity.

Such a structure of the psychological mechanism of thought disorders in schizophrenia corresponds to the ideas of A. R. Luria (1964) on the relationship between the material substrate and clinical symptoms. The mental function as a manifestation of the activity of the material substrate - the brain, its certain functional systems - reacts to pathological processes in it (and now no one considers the schizophrenic process to be purely functional) with characteristic clinical symptoms. Violations of motivation, personal meaning and selectivity of information underlie certain clinical manifestations. On the one hand, this mechanism, at least with its first 2 links, is associated with an increasing emotional decline, on the other hand, changes in thinking of a dissociative type. It can be assumed that, depending on which link is more disturbed, in the clinical picture of schizophrenia, there is a greater severity of one or another type, type of thought disorder. So, for example, with changes in motivation, an apathetic reduction of thinking is predominantly observed. The predominant severity of the violation of personal meaning causes thinking disorders, which are based on a change in the patient's personal position (autistic and resonant thinking). In connection with violations of the selectivity of information, paralogical and symbolic thinking is noted, and in cases where one can think about the additional participation of the factor of catatonic altered psychomotor, we observe fragmented thinking and schizophasia.

With the help of the three-term psychological structure of thinking disorders, the connection between autistic and neological (up to the formation of neoglossia) types of thinking, which is based on a common psychological mechanism, is explained long ago by clinicians (here the special importance of the factor of violation of personal meaning should be emphasized).

Clinical assessment of thinking disorders in schizophrenia. Thinking disorders, according to E. Bleuler (1911), are specific and mandatory (obligate) symptoms of schizophrenia. At the same time, the author clearly distinguished between unproductive thought disorders as a manifestation of the general splitting of the psyche and productive (delusions), which he attributed to additional (optional, accessory) symptoms.

Additional symptoms may predominate in the clinical picture of some forms of schizophrenia, but are not found in all forms of the disease, while unproductive thinking disorders are a symptom inherent in all forms of it.

Recently, there has been a tendency to revise this, until recently generally accepted, provision. So, M. Harrow and D. Quinlan (1977) argue that primary thought disorders are not characteristic of all types of schizophrenia. O. P. Rosin and M. T. Kuznetsov (1979) write that not in every form of schizophrenia, mental disorders are observed: the degree of its disorders and their dynamics, they believe, directly correlate with the form and content of the mental process. There is an undoubted internal contradiction in this statement. The first thesis affirms the possibility of such forms of schizophrenia in which there are no thought disorders at all, while in the second it is already a question of the degree of severity of mental pathology corresponding to the dynamics of the schizophrenic process. And further, the authors say that in hypochondriacal, depressive states and monosyndromes such as overvalued or paranoid ideas of jealousy, self-accusation, dysmorphophobia, which do not affect the structure of the personality as a whole, the symptoms of thinking disorders are little (!) Expressed, and only with the progression of the disease, the pathology of thinking acquires deeper character. And, again, a contradiction, the conclusion follows that thought disorder is not an obligate feature for some of the currently distinguished forms of schizophrenia. Thus, the authors identify the low severity of thought disorders in the initial manifestations of schizophrenia with their absence. It is possible that the statement about the optional nature of unproductive thinking disorders in schizophrenia is a consequence of its broad diagnosis - like schizophrenia, hypochondriacal and paranoid personality developments, dysmorphophobic untreated conditions, etc. are wrongly diagnosed in a number of cases.

Denying the indispensable nature of unproductive thinking disorders in schizophrenia would lead to the loss of an extremely important diagnostic criterion by psychiatrists and an unjustified expansion of the diagnosis of schizophrenia.

This is also contradicted by the data of follow-up studies. Thus, L. Ciompi and Ch. Muller (1976), following the fate of those suffering from schizophrenia in old age, came to the conclusion that for the diagnosis the most important role is played by the symptoms designated by E. Bleuler as primary, including thinking disorders.

Assumptions about the optional thought disorders in schizophrenia are to a certain extent connected with the nature of their qualification, with the difficulties of their identification. O. P. Rosin and M. T. Kuznetsov (1979) rightly speak about the difficulty of psychopathological detection of negative symptoms of thought disorders. These symptoms overlap with brighter, more easily detected and "dramatic", according to H. J. Weitbrecht (1972), productive thought disorders. It is here that pathopsychological research can help the psychiatrist as much as possible. Where mental disorders may not be seen during clinical and psychopathological examination, they are detected psychologically as manifestations of amotivational thinking. With the further course of the process, amotivational thinking as a negative symptom complex becomes more pronounced and can be detected clinically, however, at the initial stages of the disease, a psychological experiment helps to establish the pathology of thinking, involving the patient in a special problem situation, placing an increased burden on his thought processes and establishing a weakness in internal motivation in their course.

In addition to thinking disorders, E. Bleuler also attributed emotional dullness and autism to the constant signs of schizophrenia, hallucinations and catatonic symptoms to additional ones, in addition to delirium.

The concepts of permanent and additional symptoms of schizophrenia are not identical with the concepts of primary and secondary disorders. The criterion of obligatory - optional is empirical and reflects the results of clinical observations, while the category of primary - secondary is a consequence of the concept of schism (splitting) put forward by E. Bleuler and underlying his replacement of the concept of dementia praecox with the concept of schizophrenia. It was a hypothetical underlying disorder that leads to the emergence of psychosis in the schizophrenia group and is inherent in all clinical forms of this group.

EN Kameneva (1970) believes that several main groups of disorders can be distinguished in schizophrenia. Emphasizing the unequal nature of the symptoms of schizophrenia, E. N. Kameneva sees the possibility of combining the most common symptoms in schizophrenia according to their main trends into groups based on more general disorders, which should be considered the main ones. Thus, groups of symptoms are distinguished by the nature of their underlying clinical and psychological tendencies. An example of this is autism, understood by E. N. Kameneva as a procedurally conditioned comprehensive violation of the relationship of the patient with others. The pathologically altered attitude of the patient to society, according to E. N. Kameneva, plays an important role in the formation of delusions (paranoid mood, persecutory nature of delirium), the originality of thinking, its unusualness, pretentiousness, "otherness".

We cannot use the understanding of the primacy of schizophrenic symptoms according to E. Bleuler, which was reduced to their physiogenic nature, while the secondary symptoms of schizophrenia were already considered as a reaction of the personality to the primary ones. Both the so-called primary and secondary symptoms of schizophrenia are caused by a single pathological process. Even sometimes using the concept of major mental disorders according to E. Bleuler, we put a different content into it, linking these disorders with the constancy of their detection in schizophrenia, their diagnostic significance and clinical and psychological orientation. A position is put forward on a group of symptoms that are mandatory for schizophrenia (M. Bleuler, 1972), which includes fragmentation of thinking, splitting of emotionality, facial expressions and motor skills, depersonalization phenomena, mental automatism.

The term "splitting" itself was introduced by E. Bleuler (1911), who understood it as a violation of the associative process, loosening of associations. Subsequently, the author somewhat expanded the concept of splitting, referring to it the disintegration of feelings and drives, the insufficiency of the combined activity of individual mental functions. Thus, the concept of splitting in the understanding of E. Bleuler came close to the concept of intrapsychic ataxia, the essence of which E. Stransky (1905, 1912, 1914) saw in the dissociation between the intellectual and affective spheres. Splitting should be understood as a general dissociative tendency inherent in all manifestations of the schizophrenic psyche.

Dissociation in schizophrenia captures mental activity as a whole and cannot, in the strict sense, be localized within any one mental function. Even in the fragmentation of thinking, we see manifestations of emotional decline and catatonic mental-speech automatisms (a symptom of a monologue).

In a number of cases in the clinic there is a dissociation of the combined activity of several mental functions, an example of which is the paradoxical emotionality of patients with schizophrenia, in which the emotional side of thinking does not correspond to its content. Parapraxia also belongs to the same type of schizophrenic dissociation, to which A. A. Perelman (1963) attributed all the oddities and inadequacies of forms of behavior (inadequate, mannered and impulsive actions, negativism, ambitiousness, paramimia, passing speech, a symptom of the last word, inadequate manner of speech ). In the discrepancy between mental activity and external stimuli, A. A. Perelman saw a manifestation of violations of the unity, integrity of the psyche, its splitting, and attached great importance to the occurrence of this very specific symptom of schizophrenia, in his opinion, to the presence of an ultraparadoxical phase.

Paradoxical symptoms of this kind, it can be considered, are always an expression of dissociation in the activity of several mental functions, of which one is necessarily the function of thinking. Paradoxical actions, like paradoxical emotions, do not correspond to the mental plan of action arising from the situation. It is also possible to clarify their pathophysiological mechanism. The ultraparadoxical phase explains the very fact of the paradoxical nature of the efferent link of the conditioned reflex, but not the absence of a tendency on the part of the patient to make adjustments to behavioral acts that contradict reality. P. K. Anokhin (1972), considering the mechanism of intellectual activity, attached particular importance to the acceptor of the results of an action, which, at the highest level, carries out, according to I. P. Pavlov, a predictive, “preventive” component of activity inherent in any conditioned reflex act. The pathophysiological mechanism of paradoxical psychopathological manifestations should be understood as the result of a combination of the ultraparadoxical phase and dysfunction of the acceptor of the results of the action.

It seems to us that disturbances in the functioning of the acceptor of the results of action are an integral part of the pathophysiological mechanism underlying the majority of schizophrenic symptoms, and primarily thought disorders.

Of great diagnostic importance is the primacy of schizophrenic delirium. The concept of primary delirium was developed by K. Jaspers (1913). Subsequently, H. W. Gruhle (1932) considered the primary delusion as true, specific to schizophrenia. K. Jaspers divided all delusional manifestations into 2 classes. To the first he attributed the primary inexplicable, psychologically inferred delusional experiences, to the second - delusional ideas, logically arising from disturbances of affect, consciousness, hallucinations. Currently, a number of authors designate secondary delusional ideas as delusional, and only primary delusional ideas are understood as delusions (G. Huber, G. Gross, 1977). In the primary delirium, K. Jaspers distinguished three options - delusional perception, delusional representation and delusional awareness.

Delusional perception is a delusional interpretation of adequately perceived things. The object or phenomenon is perceived by the patient correctly, but it is given an inadequate, delusional meaning. This new perception of the meaning of things is absolutely immutable, inaccessible to critical rethinking. The range of manifestations of delusional perception is from the unclear, still incomprehensible to the patient, the significance of things (the patient notices the unusual look of the person he met, the features of his clothes, manner of speech, etc.) to delusional ideas of relation, meaning.

A delusional idea is characterized by a retrospective rethinking of real memories or sudden influxes, “insights” that do not follow from previous reflections and arise completely unexpectedly. A peculiar intuitive thinking is characteristic, which is often found in patients with schizophrenia and is associated with a split personality (M. Bleuler, 1972).

Delusional awareness (awareness) is characterized by the emergence in the patient of knowledge about events of world importance, although he had never thought about these problems before.

These types of primary delusions are essentially reduced to the initial manifestations of the pathology of thinking, on the basis of which a delusional system arises, psychologically incomprehensible, as K. Jaspers believed, in its origins and understandable only internally, that is, in the interconnection of individual painful experiences.

In the development of primary delirium, 3 periods are distinguished.

1. The period of precursors (primary delusional mood, according to K. Jaspers) is observed most often in the onset of schizophrenia and is characterized by extremely painful experiences for the patient of changes in the real world, everything around the patient acquires a new, essential meaning for him. The patient correlates with himself completely independent of him and objectively existing manifestations of reality. Typical signs such as incredulity, suspicion, confusion of patients, their tendency to all sorts of unfounded guesses and assumptions.

2. The period of "crystallization" (according to M.I. Balinsky, 1858) of delirium and its systematization. Primary delirium manifests acutely, often the patient experiences subjective relief, when delusional knowledge replaces extremely painful suspicions and expectations. For the patient, everything falls into place. An active rethinking of real events begins in terms of delusional experiences. At the same time, the circle of delusionally interpreted events and phenomena is expanding, and connections between them that are understandable only to the patient are established. A delusional system arises, in which its core, axis can be distinguished. It is around this axis that interrelated delusional experiences are grouped.

3. The period of regression of delirium is characterized by the disintegration of the delusional system, the growth of gross defective symptoms. Crazy ideas lose their emotional charge. In some cases, they talk about the encapsulation of delusions - delusional ideas in a reduced form and less personally significant ones are preserved, but they no longer determine the patient's behavior.

To a certain extent, the degree of manifestation of delusional conviction is associated with the stages of delusion formation (G. Huber, G. Gross, 1977). Initially, during the period of delusional mood, there are fluctuations in the degree of confidence of the patient that his delusional experiences correspond to reality (preliminary emotional stage). This is followed by the stage of primary delusional conviction, followed by the stage of positive or negative judgments about the reality of the delusion. G. Huber and G. Gross write that the intensity of delusional conviction may decrease in the final stage. This is confirmed by E. Ya. Shternberg (1980), who observed the appearance of doubts or even negative judgments about the reality of delusional ideas at the final stages of delusion.

Primary delirium is especially closely related to the personality of the patient. Clinical observations do not give grounds for isolating premorbidly in patients with schizophrenia any constitutional and personal features that could be considered as signs of a predisposition to delusional formation. Schizoid personality traits before illness are also observed in patients in cases where schizophrenia proceeds as a simple or catatonic form. The formation of schizophrenic delirium, as a rule, is accompanied by total personality changes. Not only the character of the personality changes, but also the whole existence of the patient, the whole system of relations of the personality - to himself, to his relatives, to the events of the surrounding reality. Personality changes in schizophrenic delirium occur with pronounced phenomena of depersonalization. V. I. Ackerman (1936) singled out two sides of schizophrenic depersonalization. The first is characterized by the phenomenon of appropriation, when there is a forced attribution by the patient to himself of objective connections of reality independent of him, which are then given a special, symbolic meaning. Proceeding from the ideas about the generality of the primary schizophrenic delirium with the entire corresponding structure of the psyche, with the semantic lability of thinking, V. I. Akkerman considered semantic meanings to be the object of delusional appropriation. The phenomenon of alienation, which is polar in relation to appropriation, comes down to attributing a role to someone else's influence in the implementation of the mental activity of the patient. V. I. Akkerman considered these two phenomena in unity, as a kind of psychopathological proportion.

For primary schizophrenic delusions, it is characteristic that the patient is never, as, for example, with oneiroid, only a witness, an observer, he is always at the center of painful experiences. Delusional experiences always have a direct or indirect relation to his vital interests, and thus, one can speak of a kind of delusional egocentrism. K. Kolle (1931) characterized the content of primary delusions as egocentric, visual and painted in an unpleasant sensual tone.

K. Jaspers and his followers were characterized by the understanding of primary delirium as inexplicable, not psychologically deducible and not reducible, in contrast to secondary delirium, to disorders of consciousness, efficiency, and perception. The same point of view is shared by K. Schneider (1962), who introduced the concepts of delusional insight and delusional perception. Delusional insight, including delusional representation and delusional awareness of K. Jaspers, involves a sudden, intuitive actualization of a delusional thought. With delusional perception "primarily" normal perception is subjected to "secondary" delusional comprehension.

Primary delirium is usually opposed to secondary, closely related in its occurrence to other psychopathological disorders, for example, residual delirium in patients with epilepsy with frequent twilight disorders of consciousness or after delirium, holothymic delirium in depressive and manic states.

Such a contrast between primary and secondary delusions in terms of the mechanisms of their formation is schematic and unreasonable. No type of delusion is limited to the realm of thought disorders. Delusion is always the result of the defeat of all mental activity, it captures its various spheres, primarily affective-personal and perceptual. Nevertheless, the pathology of judgments and uncritical thinking are the leading mechanisms in the formation of delusions. V. P. Serbsky (1906), criticizing contemporary ideas about primary, primordial delirium, pointed out that the origin of delirium is inextricably linked with “thoughtlessness, weakening of critical ability”, and at the same time, in the occurrence of delirium, he attached great importance to the presence of painful sensations , changes in self-perception.

Of interest are the views of W. Mayer-Gross (1932) on the mechanism of formation of primary schizophrenic delirium. He emphasized that it is difficult to separate primary delusions from hallucinations, thought disorders, disorders of the "I" and, above all, from anomalies of an affective nature. The decisive factor in the emergence of primary delirium W. Mayer-Gross considered the awareness of significance, the primary motivating connection without any external motives in the sense of an erroneous ratio (a concept close to the appropriation phenomenon of V. I. Ackerman).

There are two approaches to the question of the legitimacy of the division of nonsense into primary and secondary. The first approach is pathogenic. One should agree with the point of view of A. A. Perelman (1957), O. P. Rosin and M. T. Kuznetsov (1979), according to which all types of delusions by origin should be considered as secondary. Both in the so-called primary and secondary delusions, a combination of factors is involved in its pathogenesis - disorders of thinking, efficiency, consciousness, perception. This is a disorder of generalizing thinking, and the practical orientation of the cognitive process, and the corrective role of the criterion of practice (O. V. Kerbikov, 1965). In relation to schizophrenia, such factors of paramount importance in the formation of delusions as specific pathological features of thinking, its subjective symbolism, autistic break with reality, paralogical judgments, loss of the criterion of practice and the necessary correlation with personal life experience are distinguished. Equally important in the formation of delusions are, as already noted, disorders of the affective sphere and perception.

The second approach is clinical and phenomenological. Psychopathological observations show that the division of delusions into primary and secondary is a clinical reality. And this circumstance has an important diagnostic value; it is not for nothing that most psychiatrists characterize schizophrenic delusions as primary (true, autochthonous). The difference, obviously, lies in the fact that in the case of primary delirium, mental disorders that precede its manifestation are visible - they proceed latently, without clinically manifesting noticeable behavioral disorders. Therefore, the primary delirium gives the impression of acutely emerging. However, in a pathopsychological study in patients with initial manifestations of paranoid schizophrenia, we always find unproductive thinking disorders characteristic of this disease. Delusion can be represented as a neoplasm in mental activity, sometimes prepared by long-term disorders of affective and cognitive activity. The acute onset of delirium is an abrupt transition from an increase in the quantitative indicators of these changes to the emergence of a new quality of mental processes.

Thus, both primary and secondary delusions in their development are associated with unproductive thinking disorders, affective disorders and perceptual disorders. Both the mental disorders preceding delirium and the delirium in schizophrenia itself cannot be considered as fundamentally different psychopathological categories - they are all manifestations of the same complex pathological process, the mechanism of which can only be understood when considering them in the development of the disease.

EN Kameneva (1970) in the genesis of primary schizophrenic delirium pays considerable attention to violations of instinctiveness. More definite and very promising, from our point of view, for further development is the hypothesis put forward by V. Ivanov (1978) about the role of unconscious mechanisms of mental activity in primary schizophrenic delusion formation. Considering the formation of delirium as a pathologically complex conditioned reflex from the standpoint of the pathophysiology of higher nervous activity, V. Ivanov notes that this formation can occur at different levels, with different degrees of participation of consciousness. In cases where only the “end result” of the resulting pathological reflexes is realized, delirium may seem unexpected, incomprehensible, that is, a picture of delusional insight arises according to K. Schneider. Conscious and unconscious simultaneously participate in the mechanisms of delusion formation as variants of higher nervous activity. V. Ivanov's hypothesis corresponds to clinical observations regarding the occurrence of primary schizophrenic delusions, and provides a pathophysiological explanation of its genesis.

K-Schneider purely empirically singled out a group of symptoms of rank I in the clinical picture of schizophrenia. Important diagnostic value of symptoms of the I rank is emphasized by N. J. Weitbrecht (1973), N. A. Fox (1978), K. G. Koehler (1979). These symptoms can also be observed in other mental illnesses, for example, in acute exogenous (somatically conditioned) psychoses, they are not pathognomonic only for schizophrenia. However, their presence in the clinical picture has, according to N. J. Weitbrecht, a positive diagnostic value. This takes into account other symptoms included in the picture of the disease, and the characteristics of the course of psychosis. In particular, K-Schneider and N. J. Weitbrecht put forward the position that the symptoms of rank I indicate the legitimacy of diagnosing schizophrenia if they occur with clear consciousness, while with impaired consciousness they occur in the clinic of acute exogenous psychoses. The symptoms of rank I have nothing to do with the primary symptoms of schizophrenia identified by E. Bleuler, or with the main schizophrenic disorder, since they were singled out for a specific diagnostic purpose, and not in theoretical terms.

K. Schneider divided all psychopathological symptoms into manifestations of pathological expression (impaired speech, efficiency, behavior) and pathological experiences (delusions and hallucinations). Symptoms of the 1st rank include pathological experiences: the sounding of one's own thoughts, auditory hallucinations of a contradictory and mutually exclusive, as well as commentary nature: somatic hallucinations; external influence on thoughts; influence on feelings, motives, actions; symptom of openness; breaks of thoughts (sperrings); delusional perceptions (the real perception of something seems to the patient to be done, irrational, having a special relation to him).

K. Schneider attributed other deceptions of perception, delusional insights, confusion, as well as manifestations of pathological expression - depressive or hyperthymic disorders, emotional impoverishment, etc. to the symptoms of rank II.

Confident diagnosis of schizophrenia, according to K. Schneider, is possible in the presence of all symptoms of rank I and in the absence of signs of organic damage to the central nervous system, impaired consciousness. However, the author did not deny the diagnostic value of symptoms of the II rank, if they are sufficiently pronounced and constant.

Of interest is the modification of the phenomenology of symptoms of the first rank, undertaken by K. G. Koehler (1979), who divided them into 3 groups of symptoms (continuums). Within the continuum, the symptoms are arranged in accordance with the nature of the development, course.

1. The continuum of perceptual delusions consists of pseudo-hallucinatory "voices" and the sound of one's own thoughts; true auditory hallucinations, including "voices" repeating the thoughts of the patient.

2. The delusional continuum includes delusional mood; delusions associated with perception or provoked by them; delusional perceptions.

3. The continuum of exposure, alienation, mastery (ie, a group of depersonalization symptoms) includes a sense of mastery; general sense of impact; specific sense of impact; a sense of one's own change under the influence of external influences; experiencing the impact on oneself with a feeling of replacing one's own thoughts with others', i.e., there is not only an impact from the outside on the thoughts and feelings of the patient, but also their substitution by "ersatz thoughts", "ersatz feelings"; experiencing the impact on oneself with the loss of one's own thoughts and feelings, the influence from outside the patient, as it were, is deprived of mental functions; similar to the above experiences of external influence with the experience of dissolving the thoughts and feelings of the patient in the outside world.

It should be noted that in the modification of K.G. Koehler depersonalization - derealization continuum in the diagnosis of schizophrenia is given special importance, which corresponds to the views of G. Langfeldt (1956) and B. Bleuler (1972).

Despite the purely empirical nature of the allocation of symptoms of the first rank in schizophrenia, emphasized by K. Schneider himself, I. A. Polishchuk (1976) characterized them as physiogenic, primary, psychologically irreducible, and in this he saw their essential diagnostic value. It should only be added that the symptoms of the first rank are not mandatory, obligate. They are predominantly observed in paranoid schizophrenia. Rank I symptoms are diagnostically significant in cases where they are present in the clinical picture, but their absence does not contradict the possibility of diagnosing schizophrenia. It was in this regard that the diagnostic value of rank I symptoms in schizophrenia was confirmed based on the follow-up materials for 40 years (K. G. Koehler, F. Steigerwald, 1977). The authors consider rank I symptoms as a manifestation of "nuclear" schizophrenic disorders.

Delusional syndromes in schizophrenia are most often observed in its paranoid form. According to the classification of the forms of schizophrenia according to the types of its course (AV Snezhnevsky, 1969), paranoid (progredient) refers to continuously ongoing schizophrenia. Delusion can also be observed in other types of the course of the disease, however, in progredient schizophrenia, it prevails in the clinical picture and determines it.

With the course of the schizophrenic process, delusional syndromes in typical cases undergo a characteristic transformation, described for the first time by V. Magnan (1891) when he singled out chronic delusional psychoses. Transformation, the stereotype of the development of delusional syndromes in paranoid schizophrenia are in the nature of a successive change of paranoid, paranoid and paraphrenic syndromes (SV Kurashov, 1955).

The stage of paranoid delirium is determined by the picture of a systematized delusional symptom complex, which usually proceeds without hallucinations. Delusion in its clinical manifestations is primary in nature, it cannot be derived from the life situation and personal characteristics of the patient. This stage is replaced by paranoid delusions. Brad is deprived of a single system. In the clinical picture, along with delusional experiences, auditory pseudo-and true hallucinations are most often noted. R. A. Nadzharov (1969, 1972) defines this stage as hallucinatory-paranoid, Kandinsky-Clerambault syndrome. With the growth of a mental defect, delusional ideas become absurd, fantastic, the events of a past life are reproduced in them in an increasingly distorted form, the thinking of patients is confabulatory. As a rule, paraphrenic delusions are characterized by a gross emotional defect, pronounced dissociative disorders, and impaired critical thinking, when patients do not even try to give their delusional experiences any credibility. K. Kleist (1936) defined this type of schizophrenic defect as fantasyophrenia.

Schizophrenic delusions have no equivalent in pathopsychological data. Our experience shows that in a psychological study in patients with paranoid schizophrenia, only disorders of thinking and affective-personal sphere characteristic of schizophrenia are found. The identification in a verbal experiment of non-indifferent, affective-significant and reflecting the patient's delusional experiences of irritant words cannot be considered a sufficiently reliable criterion.

The only exception is data obtained using the MMPI questionnaire.

In the study of the MMPI questionnaire, the personality profile of a patient with paranoid schizophrenia is characterized by an increase in indicators on the scales 8, 6 and 4 .

The MMPI questionnaire can also be useful for identifying delusional dissimulation. In these cases, there is a high negative value of the difference in the F-K indicators, as well as a significant decrease in the indicators on the "psychotic" scales.

In some cases, in the study of dissimulating patients, a significant number of statements are noted that the patients left without evaluation at all. Accounting for these statements, which cause dissimulating patient fears of exposure, statements gives a completely different personality profile curve (J. Bartoszewski, K. Godarowski, 1969).

Compulsive states occur mainly at the beginning of the schizophrenic process. This circumstance served as the basis for highlighting even a peculiar psychasthenic form of schizophrenia according to the characteristics of the debut (C. Pascal, 1911). Currently, cases of schizophrenia with obsessional symptoms are classified as a sluggish neurosis-like type of disease.

Already at the very beginning of the disease, both polymorphic and monothematic obsessive-compulsive states are found. Most often it is the fear of going crazy, obsessive thoughts and fears associated with changes in self-perception, sometimes reaching the severity of senestopathies. Such obsessive fears and fears are close to hypochondriacal symptoms.

Obsessions at the beginning of the schizophrenic process can be of a twofold nature - a manifestation of the schizophrenic process itself (in these cases, there are no premorbid character traits of the anxious and suspicious type) or, being constitutionally conditioned, already precede the onset of schizophrenia (S. I. Konstorum, S. Yu. Barzak, E. G. Okuneva, 1936). Particularly pronounced in the syndrome of obsessive-compulsive disorder within the framework of schizophrenia are the phenomena of self-doubt, indecision, doubts, which A. A. Perelman (1944) considers as manifestations of ambivalence.

The distinction between schizophrenic obsessions and obsessive-compulsive neurosis presents great difficulties in a number of cases. Put forward by N. P. Tatarenko (1976), the criterion of insufficient criticality of a patient with schizophrenia to obsessions, even with the formal recognition of their morbid nature, seems to us to be very subjective. Such a position of the patient in relation to obsessions may be the result of the suggestive nature of the questioning. An even less acceptable criterion is the loss of social adaptation by patients, since severe and long-term cases of obsessive-compulsive disorder are known, which completely disable patients. And vice versa, schizophrenia with obsessions can proceed relatively favorably ("stationary schizophrenia", according to Yu. V. Kannabikh, 1934) with long-term, at least partial, preservation of the patient's ability to work.

In the differential diagnosis of obsessive-compulsive disorders in schizophrenia, the identification of obligatory negative schizophrenic symptoms on the part of thinking and emotional decline plays a paramount role. Due to emotional decline, obsessions and fears are not affectively saturated enough. Ambivalence and ambivalence are revealed. The patient is never fully aware of the absurdity of his obsessions. Ritual actions appear exceptionally early, bearing an absurdly symbolic character. Explanation to patients of the ritual actions observed in him is often pretentiously resonant, and sometimes delusional.

In the later stages of schizophrenia, obsessive rituals take on the character of elementary motor stereotypes, completely divorced from obsessive thoughts or fears. Thus, the patient we observed covered entire notebooks with wavy lines, and only by analyzing the picture of the onset of the disease could it be possible to establish the ritual nature of these stereotypical actions.

R. A. Nadzharov (1972) draws attention to the exceptional inertness of the syndrome of obsessions in schizophrenia, its tendency to systematize due to the early addition of monotonous motor and ideation rituals, a weakly expressed component of the struggle, the proximity of obsessions during periods of exacerbations to mental automatism and hypochondriacal delirium.

The most significant criterion for the differential diagnosis of obsessive-compulsive states of schizophrenic and neurotic genesis is the presence or absence of a specifically schizophrenic progressive mental defect, which is detected both clinically and during pathopsychological examination.

Until now, despite a significant number of works devoted to the study of defective and initial states in schizophrenia, the question of schizophrenic dementia remains debatable. They argue both about the legitimacy of diagnosing dementia in the clinic of schizophrenia, and about its nature.

E. Kraepelin, who singled out this disease for the first time, called it dementia praecox (dementia praecox), thus emphasizing the importance of dementia in its course and outcome. He considered recovery with a defect and dementia to be the most frequent outcomes of the disease. In the typology of schizophrenic dementia developed by E. Kraepelin, as A. G. Ambrumova (1962) notes, its unequal forms are distinguished, reflecting different stages of the disease.

H. W. Gruhle (1932) considered that at schizophrenia there is no true dementia. The intellect of a patient with schizophrenia is upset, but, in his opinion, is not subject to destruction. So, patients with schizophrenia with broken thinking sometimes amaze those around them with their well-aimed judgments, conclusions, indicating a formal potential preservation of thinking. In the words of the author, in schizophrenia "the machine (i.e., the intellect) is intact, but it is not serviced at all or is serviced incorrectly." He considered schizophrenic thinking disorders as a pathology of the highest sphere of personality, intellectual initiative, and productivity. H. W. Gruhle (1922) contrasted schizophrenic thinking disorders with true organic dementia, characterizing the former as affective dementia. The same point of view was shared by E. Bleuler (1920), arguing that schizophrenic dementia gets its characteristic stamp primarily in connection with affective disorders. Intellectual deficiency in schizophrenia, according to E. Bleuler, often does not correspond to the degree of difficulty of the task - a patient with schizophrenia cannot add two-digit numbers, but immediately correctly extracts the cube root. He can understand a complex philosophical problem and does not understand that in order to be discharged from the hospital, you must comply with certain norms of behavior.

To a certain extent, disputes about the nature of the insufficiency of thinking in schizophrenia reflect the opposite of opinions about the essence of schizophrenic thinking - that is, whether we are talking about a decrease in the level of thinking or about the “otherness” of the thinking of these patients.

In itself, the unusualness of schizophrenic thinking cannot be considered as dementia, the syndrome is primarily deficient. However, it, as a rule, is observed simultaneously with a decrease in mental productivity, masking the latter to a certain extent. This is the difficulty in isolating the signs of schizophrenic dementia in the procedural stage of the disease (A. O. Edelshtein, 1938; A. A. Perelman, 1944).

One might think that the mental and affective disorders characteristic of schizophrenia not only mask dementia, but also give it a certain peculiarity. The picture of schizophrenic dementia is a peculiar combination of intellectual decline with thinking disorders, which are found in the distortions of the generalization process and are associated with changes in the motivational component of mental activity, thus indirectly reflecting the initial manifestations of schizophrenic dementia.

Schizophrenic dementia is usually associated with the stage of the initial state of the process, which in turn is distinguished from the defect. A schizophrenic defect is a manifestation of the procedural stage of the course of schizophrenia. It can be detected very early, after the first attack of the disease. A schizophrenic defect is a dynamic concept, it can also tend to the opposite, within certain limits, development, while the initial state is characterized by minimal dynamism, it is stable.

A. G. Ambrumova (1962) distinguishes between compensated and decompensated stabilized residual-defective states. In the former, along with the destructive core, there are accompanying functional-dynamic formations that play an important role in the design of the clinical picture. Conditions characterized by complete decompensation correspond to the idea of ​​the original ones. This point of view coincides with the position of A. N. Zalmanzon (1936), who considered schizophrenic dementia as organically destructive in its genesis.

The typology of syndromes of schizophrenic dementia in relation to the initial states was developed by A. O. Edelshtein (1938). He distinguishes 3 variants of schizophrenic dementia. In some cases, extra-intellectual factors come to the fore, but this dementia syndrome is based on the intellectual core. Such cases are defined as apathetic dementia. Sometimes the organic nature of dementia is noted - a disorder of criticism, banality and primitiveness of judgments, poverty of thinking, exhaustion of mental processes. The most severe disorders of the intellect are found in the syndrome of ruin - there is a total disintegration of the personality and intellect, only the lower mental functions remain intact. With the ruining syndrome, it is impossible to perform simple counting operations, simple tests for combinatorics, etc.

A. G. Ambrumova (1962) believes that schizophrenic dementia can be diagnosed only if there is a ruining syndrome. One cannot agree with this point of view. It should be said that the syndrome of apathetic dementia has long been distinguished as part of the organic pathology of the brain in Pick's disease, due to traumatic brain injury, and in some forms of encephalitis. The organic (or pseudo-organic) type of schizophrenic dementia also has a right to exist. In clinical practice, we often see patients in the initial state of schizophrenia, so indistinguishable from those suffering from organic brain lesions with dementia that diagnostic issues in these cases are often resolved on the basis of anamnesis and the detection of some residual fragments of schizophrenic thought disorders in the clinic.

A decrease in the level of generalization and distraction is more often observed with a long prescription of the schizophrenic process. In the initial states, they often prevail over the thinking disorders characteristic of schizophrenia. This is confirmed by our studies of patients with hypochondriacal-paranoid schizophrenia. As the mental defect intensified and due to the duration of the disease (given that the group of examined patients was relatively homogeneous in clinical terms), an increase in the number of lower speech reactions was noted in the associative experiment, the results became similar to those in organic dementia.

AV Snezhnevsky (1970) noted that at present it is still impossible to give a single definition of schizophrenic dementia. We can say that schizophrenic dementia is characterized by damage to the highest levels of human brain activity. Therefore, its first manifestation is the fall of creative activity.

Considering schizophrenic dementia as a dynamic symptom formation, we cannot be content with putting an equal sign between the concepts of dementia and the initial state. The initial state is the end result of the schizophrenic process, but we should be interested in the initial manifestations of schizophrenic dementia. This is a problem that needs special development. At present, it can be considered that the first irreversible signs of a schizophrenic defect in mental activity are already the beginning of developing dementia.

In the dynamics of schizophrenic dementia, stages can be distinguished. On the initial stage of development of schizophrenic dementia, in our opinion, we can talk about the detection of signs of a defect, even unsharply expressed. At this stage, the insufficiency of cognitive processes in patients with schizophrenia is due to predominantly extra-intellectual factors. This stage of insufficiency, unproductive thinking can be designated as functional, or affective (taking into account the role of the loss of the motivational component of thinking), dementia, however, the initial manifestations of the destructive process are already visible in it. Affective dementia is only a stage in the development of true dementia. And in this regard, the syndromes of initial states in schizophrenia, identified by A. O. Edelstein, can also be considered as stages in the formation of dementia - from apathetic to ruining syndrome (a picture of total dementia).

An important criterion for differentiating the stages of schizophrenic dementia is the degree of reversibility of thinking disorders in the process of onset of therapeutic or spontaneous remission.

This type of formation of dementia - from the stage, which is characterized by the defeat of predominantly extra-intellectual mechanisms of mental activity, to the stage of true dementia, is observed not only in schizophrenia, but also in the clinic of organic diseases of the brain. It is characterized by the development of the cerebral-focal psychosyndrome isolated by M. Bleuler (1943) into an organic psychosyndrome. For the cerebral-focal psychosyndrome, originally described in the clinical picture of epidemic (lethargic) encephalitis, and then in other organic diseases of the brain with stem or frontal localization of the lesion, first of all, drive disorders are typical. With the progression of the organic process, the symptoms of focal-cerebral psychosyndrome, defined as subcortical dementia, are replaced by pictures of cortical dementia, characteristic of organic psychosyndrome. Thus, we are talking about some similarity of pathogenetic mechanisms in schizophrenia and the type of organic pathology of the brain, which is characterized by the development of a focal-cerebral, subcortical psychosyndrome into an organic, cortical one. On the one hand, this is one of the proofs of the possible organic nature of schizophrenic dementia, and on the other hand, it can be considered as the cause of the known frequency of schizoform clinical manifestations in the framework of this kind of organic brain damage, primarily encephalitis.

Violations of thought processes in schizophrenia consist of several processes. Purpose disorder.

Violation of purposefulness is one of the defining features of the entire mental life of patients with schizophrenia, being traced both in the emotional-volitional sphere and in the sphere of thinking. The main symptom in which this is most clearly seen is reasoning. Reasoning, or fruitless sophistication- reasoning that does not have a final goal, in which the patient strings words one on top of the other, not coming to anything in the end. This trend is most clearly visible in the so-called. schizophasia, when the patient builds a grammatically correct phrase from words that are completely unrelated in meaning. Decreased volitional activity, which underlies the violation of the purposefulness of thinking, can lead, when strengthened, to a loss of comprehension, simplification of associative processes, up to the acquisition of a primitive, formal, concrete character by thinking, the loss of the ability to understand the abstract meaning of statements, for example, when interpreting proverbs and sayings. The next trend is a violation of the associative process. In schizophrenia, we are dealing with a tendency to form associations, connections between concepts based on the so-called. latent (weak, not obvious, not basic) signs. As a result, thinking acquires a strange, difficult to understand character. Such thinking is called paralogical. Thus, the patient's reasoning becomes difficult to understand, not only because he himself often does not know where he is moving and whether he is moving somewhere at all, but this movement is carried out along obscure paths. One of the possible options in this case is the predominant use in thinking of the symbolic "figurative" meaning of words and concepts. Such thinking is called symbolic. The tendency to form new connections, associations between concepts also finds its expression in the merging of several concepts into one and the formation of new words to denote such concepts. This trend leads to the formation of the so-called. neologisms. The extreme form of paralogical thinking, in which the violation of the associative process is pronounced, total, is called atactic thinking or schizophrenic incoherence. The combination of negativism in the volitional sphere, violations of purposefulness and paralogicality finds its expression in the so-called. slips or answers not in terms of the question, when the patient, in response to a question, begins to talk about something that is not related to the question at all or has little relation to it.

As noted by B.V. Zeigarnik, thinking disorders are one of the most common symptoms in mental illness. In addition, there is no single principle for the analysis of thinking disorders, since different researchers are based on different thinking models. Psychological research on schizophrenic thinking goes mainly in two directions. The first is characterized by the study of individual variants of schizophrenic thinking, often having their analogues in the clinical symptoms of schizophrenia (slips, fragmentation, reasoning), the second is the search for general patterns of schizophrenic thinking.

Primary thinking disorders are not characteristic of all types of schizophrenia. O. P. Rosin and M. T. Kuznetsov write that not in every form of schizophrenia, mental disorders are observed: the degree of its disorders and their dynamics, they believe, directly correlate with the form and content of the mental process.

The author associated violations of the boundaries between the ego and the outside world with the difficulties of separating the figure and the ground.

To explain the peculiarities of thinking of patients with schizophrenia, the concepts of "overgeneralization", "overinclusion" were put forward, which was considered as an expression of the inability to stay within the given semantic boundaries, an expansion of the conditions of the task. Among the reasons for over-inclusion were: violations of the proposed filtering mechanism, which does not ensure the differentiation of essential features from non-essential ones, divorced from reality, not significant in a given problem situation; violation of the creation of the necessary inhibitory installations and the inability to develop installations, without which the differentiation of signs characteristic of normal thinking is impossible.

L.S. Vygotsky suggested that the functions of concept formation in patients with schizophrenia were disintegrating – the latter are reduced to the level of complexes, i.e. specific meaning formations - which is based on a change in the meanings of words. As noted by B.V. Zeigarnik, a decrease in the conceptual level is noted only in a number of cases in the initial state (defect). The basis of such a violation is not a decrease, but an inadequacy to specific life relations (real), indicating a thickening of their individual aspects and properties due to the loss of focus on the objective content of phenomena and objects. M. S. Lebedinsky believed that in schizophrenia the direction and stability of thinking suffers, the associative process of patients with schizophrenia is characterized by a lack of focus on the ultimate goal. OK. Tikhomirov traced three links in the psychological mechanism of impaired thinking in schizophrenia:

The first link is a violation of the motivational sphere, which leads to violations of personal meaning. For patients with schizophrenia, the personal meaning of objects and phenomena often does not coincide with the generally accepted knowledge of a person about them, which is conditioned by the real situation. At the same time, standard and non-standard informative features are equalized.

The second link is giving non-standard informative features more importance than standard ones.

The third link is violations of the selectivity of information, which are manifested by violations of the selectivity of information in connection with past experience and its probabilistic disorganization.

indicates V.M. Bleicher, such a structure of the psychological mechanism of thought disorders in schizophrenia corresponds to the ideas of A. R. Luria about the relationship between the material substrate and clinical symptoms. Violations of motivation, personal meaning and selectivity of information underlie certain clinical manifestations: on the one hand, this mechanism (the first two links) is associated with an increasing emotional decline, on the other hand, changes in dissociative type thinking. It can be assumed that, depending on which link is more disturbed, in the clinical picture of schizophrenia, there is a greater severity of one or another type, type of thought disorder. The first classification scheme for the pathology of thinking in psychopathology was proposed by Gresinger. He distinguished two types of thinking anomalies: painful ideas about the form of thinking (slowdown / acceleration) and anomalies of ideas about their false content (false content of thoughts - delirium). Disorders of the content of thinking (productive) are characterized by an inadequate reflection of the essential qualities, aspects, relationships and patterns of objective reality due to the diseased state of the brain. They are divided into obsessive, overvalued and delusional ideas. Disorders of the form of the associative process are represented by violations of the pace, mobility, purposefulness of thinking and the grammatical structure of speech.