Etiology of mental disorders. "Endogenous" and "exogenous". Endogenous psychosis: symptoms and treatment

(Information for patients and their families)

INTRODUCTION

Most people have not only heard, but often used the concept of “schizophrenia” in everyday speech, however, not everyone knows what kind of disease is hidden behind this medical term. The veil of mystery that has accompanied this disease for hundreds of years has not yet been dispelled. Part of human culture is directly in contact with the phenomenon of schizophrenia, and in a broad medical interpretation - endogenous diseases of the schizophrenic spectrum. It is no secret that among the diseases that fall under the diagnostic criteria of this group of diseases, the percentage of talented, outstanding people is quite high, sometimes achieving serious success in various creative fields, art or science (V. Van Gogh, F. Kafka, V. Nizhinsky, M. Vrubel, V. Garshin, D. Kharms, A. Arto, etc.).

Despite the fact that a more or less harmonious concept of endogenous diseases of the schizophrenic spectrum was formulated at the turn of the 19th and 20th centuries, there are still many unclear issues in the picture of these diseases that require careful further study.

Endogenous diseases of the schizophrenic spectrum today are one of the main problems in psychiatry, due to both their high prevalence among the population and significant economic damage associated with social and labor maladjustment and disability of some of these patients.

PREVALENCE OF ENDOGENOUS DISEASES OF SCHIZOPHRENIC SPECTRUM

According to the International Psychiatric Association, about 500 million people worldwide are affected. Of these, at least 60 million suffer from endogenous schizophrenia spectrum diseases. Their prevalence in different countries and regions is always approximately the same and reaches 1% with certain fluctuations in one direction or another. This means that out of every hundred people, one is either already sick or will get sick in the future.

Endogenous diseases of the schizophrenia spectrum usually begin at a young age, but can sometimes develop in childhood. The peak incidence occurs in adolescence and youth (the period from 15 to 25 years). Men and women are affected to the same extent, although in men the signs of the disease usually develop several years earlier. In women, the course of the disease is usually milder, with the dominance of mood disorders, the disease is less reflected in their family life and professional activities. In men, developed and persistent delusional disorders are more often observed, cases of a combination of an endogenous disease with alcoholism, polytoxicomania, and antisocial behavior are not uncommon.

DISCOVERY OF ENDOGENOUS DISEASES OF THE SCHIZOPHRENIC SPECTRUM

It is probably not a big exaggeration to say that the majority of the population considers schizophrenic diseases to be no less dangerous diseases than cancer or AIDS. In reality, the picture looks different: life confronts us with a very wide range of clinical variants of these many-sided diseases, ranging from the rarest severe forms, when the disease flows rapidly and leads to disability in a few years, to the relatively favorable, paroxysmal variants of the disease that prevail in the population and mild, outpatient cases, when the layman would not even suspect illness.

The clinical picture of this "new" disease was first described by the German psychiatrist Emil Kraepelin in 1889 and named by him "dementia praecox". The author observed cases of illness only in a psychiatric hospital and therefore dealt primarily with the most severe patients, which was expressed in the picture of the disease he described. Later, in 1911, the Swiss researcher Eugen Bleiler, who worked for many years in an outpatient clinic, proved that one should speak of a “group of schizophrenic psychoses,” since milder, more favorable forms of the course of the disease that do not lead to dementia often occur here. Rejecting the name of the disease, originally proposed by E. Krepelin, he introduced his own term - schizophrenia. E. Bleuler's studies were so comprehensive and revolutionary that until now the 4 subgroups of schizophrenia identified by him (paranoid, hebephrenic, catatonic and simple) have been preserved in the international classification of diseases (ICD-10), and the disease itself had a second name for a long time - Bleuler's disease.

WHAT IS SCHIZOPHRENIC SPECTRUM DISEASE?

Currently, endogenous diseases of the schizophrenic spectrum are mental illnesses characterized by disharmony and loss of unity of mental functions (thinking, emotions, movements), a long continuous or paroxysmal course and the presence in the clinical picture of the so-called productive symptoms of varying severity (delusions, hallucinations, disorders mood, catatonia, etc.), as well as the so-called negative symptoms - personality changes in the form of autism (loss of contact with the surrounding reality), a decrease in energy potential, emotional impoverishment, an increase in passivity, the appearance of previously unusual traits (irritability, rudeness, quarrelsomeness etc.).

The name of the disease comes from the Greek words "schizo" - split, split and "phren" - soul, mind. With this disease, mental functions seem to be split - memory and previously acquired knowledge are preserved, and other mental activity is disturbed. Splitting does not mean a split personality, as is often not quite understood, but the disorganization of mental functions, the lack of their harmony, which is often manifested in the illogical actions of patients from the point of view of people around them. It is the splitting of mental functions that determines both the originality of the clinical picture of the disease and the peculiarities of behavioral disorders in patients, which are often paradoxically combined with the preservation of intelligence. The term “endogenous diseases of the schizophrenic spectrum” itself, in its broadest sense, means both the loss of the patient’s connection with the surrounding reality, and the discrepancy between the remaining capabilities of the individual and their implementation, and the ability to normal behavioral reactions along with pathological ones.

The complexity and versatility of the manifestations of schizophrenic spectrum diseases have led to the fact that psychiatrists from different countries still do not have a unified position regarding the diagnosis of these disorders. In some countries, only the most unfavorable forms of the disease are referred to as schizophrenia itself, in others - all disorders of the "schizophrenia spectrum", and in others - they generally deny these conditions as a disease. In Russia, in recent years, the situation has changed towards a stricter attitude to the diagnosis of these diseases, which is largely due to the introduction of the International Classification of Diseases (ICD-10), which has been used in our country since 1998. From the point of view of domestic psychiatrists, schizophrenia spectrum disorders are quite are reasonably considered a disease, but only from a clinical, medical point of view. At the same time, in the social sense, it would be incorrect to call a person suffering from such disorders sick, that is, inferior. Despite the fact that the manifestations of the disease can also be chronic, the forms of its course are extremely diverse: from a single attack, when the patient suffers only one attack in his life, to a continuous one. Often a person who is currently in remission, that is, out of an attack (psychosis), can be quite capable and even more productive professionally than those around him who are healthy in the generally accepted sense of the word.

MAIN SYMPTOMS OF ENDOGENOUS DISEASES OF SCHIZOPHRENIC SPECTRUM

(positive and negative disorders)

Endogenous diseases of the schizophrenic spectrum have different variants of the course and, accordingly, are distinguished by a variety of clinical forms. The main manifestation of the disease in most cases is a psychotic state (psychosis). Under psychoses understand the brightest and most severe manifestations of the disease, in which the mental activity of the patient does not correspond to the surrounding reality. At the same time, the reflection of the real world in the patient's mind is sharply distorted, which manifests itself in violations of behavior, the ability to correctly perceive reality and give a correct explanation of what is happening. The main manifestations of psychosis in general and in diseases of the schizophrenic spectrum in particular are: hallucinations, delusions, thought and mood disorders, motor (including the so-called catatonic) disorders.

hallucinations (deceptions of perception) are one of the most common symptoms of psychosis in diseases of the schizophrenia spectrum and are disturbances in the sensory perception of the environment - a sensation exists without a real stimulus that causes it. Depending on the sense organs involved, hallucinations can be auditory, visual, olfactory, gustatory, and tactile. In addition, they are simple (ringing, noise, hails) and complex (speech, various scenes). The most common hallucinations are auditory. People suffering from this disorder may occasionally or constantly hear so-called "voices" inside their heads, their own bodies, or from outside. In most cases, the "voices" are perceived so vividly that the patient does not have the slightest doubt about their reality. A number of patients are completely convinced that these "voices" are transmitted to him in one way or another: with the help of a sensor implanted in the brain, a microchip, hypnosis, telepathy, etc. For some patients, "voices" cause severe suffering, they can command the patient, comment on his every action, scold, scoff. Imperative (ordering) "voices" are rightfully considered the most unfavorable, since patients, obeying their instructions, can do things that are dangerous for themselves and others. Sometimes patients mechanically obey the "voices", sometimes answer them or argue with them, occasionally freeze silently, as if listening. In some cases, the content of "voices" (the so-called "inner world of the disease") becomes much more important for the patient than the external, real world, which leads to detachment and indifference to the latter.

Signs of auditory and visual hallucinations:

• Conversations with oneself, reminiscent of a conversation or remarks in response to someone's questions.
• Sudden silence, as if the person is listening to something.
• Unexpected unreasonable laughter.
• Worried, worried look.
• Inability to focus on a topic of conversation or a specific task.
• The impression that your relative hears or sees something that you do not perceive.

How to respond to the behavior of a person suffering from hallucinations:

• Delicately ask if he hears anything now and what exactly.
• Discuss how to help him deal with these experiences or whatever is causing them in the moment.
• Help you feel more secure.
• Carefully express the opinion that what is perceived is perhaps just a symptom of the disease, an apparent phenomenon, and therefore it is worth seeking help from a doctor.

You should not:

• Make fun of the patient or make fun of his feelings.
• Be afraid of his feelings.
• To convince the patient of the unreality or insignificance of what he perceives.
• Engage in a detailed discussion of hallucinations.

crazy ideas- these are persistent beliefs or conclusions that do not correspond to reality, completely seizing the patient's consciousness, arising on a painful basis, not amenable to correction, the influence of reasonable arguments or evidence and are not an inspired opinion that can be learned by a person as a result of appropriate upbringing, education, influence traditions and cultural environment.

A crazy idea arises as a result of a misinterpretation of the surrounding reality generated by the disease and, as a rule, has nothing to do with reality. Therefore, attempts to convince the patient end with the fact that he is even more strengthened in his morbid concept. The content of delusional ideas can be very diverse, but delusions of persecution and influence are most often observed (patients believe that they are being followed, they want to be killed, intrigues are woven around them, conspiracies are organized, they are influenced by psychics, aliens, otherworldly forces or special services with the help of X-ray and laser beams, radiation, "black" energy, witchcraft, damage, etc.). In all their problems, such patients see someone's intrigues, most often close people, neighbors, and they perceive every external event as relating personally to them. Often, patients claim that their thoughts or feelings arise under the influence of some supernatural forces, are controlled from the outside, stolen or broadcast publicly. The patient can complain to various authorities about the intruders, go to the police, move from apartment to apartment, from city to city to no avail, but the “persecution” soon resumes in a new place. The delusions of invention, greatness, reformism, special treatment are also very common (it seems to the patient that everyone around him is mocking him or condemning him). Quite often, hypochondriacal delusions occur, in which the patient is convinced that he is suffering from some kind of terrible and incurable disease, stubbornly proves that his internal organs are affected, and requires surgical intervention. For the elderly, delusions of damage are especially characteristic (a person constantly lives with the idea that neighbors in his absence spoil things belonging to him, put poison in food, rob, want to survive from the apartment).

Crazy ideas are easily recognized even by ignorant people if they are fantastic or obviously ridiculous. For example, the patient declares that he has recently returned from an intergalactic journey, was introduced into the body of an earthling for an experimental purpose, continues to maintain contact with his native planet, and soon must go to the Amazon, where the spaceship that has flown in after him will land. The behavior of such a patient also changes dramatically: he treats his relatives as if they were strangers, communicates with them only on you, while in the hospital, refuses to accept help from them, becomes arrogant with everyone around him.

It is much more difficult to recognize a delusional plot if it is very plausible (for example, the patient claims that former business partners want to settle scores with him, for which they installed listening devices in the apartment, monitor him, take pictures, etc. or the patient expresses a persistent conviction in adultery, as evidenced by numerous household "evidence"). In such cases, people around for a long time may not even suspect that these people have a mental disorder. Especially dangerous are the delusional ideas of self-accusation and sinfulness that arise during depressive-delusional attacks of schizophrenia. It is in this state that extended suicides are often committed, when the patient first (out of good intentions, “so as not to suffer”) kills his entire family, including young children, and then commits suicide.

The appearance of delirium can be recognized by the following signs:

• Changed behavior towards relatives and friends, manifestation of unreasonable hostility or secrecy.
• Direct statements of implausible or dubious content (for example, about persecution, about one's own greatness, about one's guilt.)
• Statements of fear for one's life and well-being, as well as the life and health of loved ones without obvious grounds.
• A clear manifestation of fear, anxiety, protective actions in the form of curtains on windows, locking doors.
• Separate, incomprehensible to others, meaningful statements that add mystery and significance to everyday topics.
• Refusal to eat or carefully check food.
• Active actions of a litigious nature deprived of a real reason (for example, statements to the police, complaints to various authorities about neighbors, etc.).

How to respond to the behavior of a person suffering from delusions

• Do not ask questions that clarify the details of delusional statements and statements.
• Do not argue with the patient, do not try to prove that his beliefs are wrong. Not only does this not work, but it can aggravate existing disorders.
• If the patient is relatively calm and ready to communicate and help, listen carefully to him, calm him down and try to convince him to see a doctor.
• If the delirium is accompanied by strong emotions (fear, anger, anxiety, sadness), try to calm the patient and contact a qualified doctor as soon as possible.

Mood Disorders (1)(affective disorders) in endogenous diseases of the schizophrenic spectrum are manifested by depressive and manic states.

depression (lat. depression- oppression, suppression) - a mental disorder characterized primarily by pathologically low mood, melancholy, depression, motor and intellectual retardation, the disappearance of interests, desires, inclinations and motives, a decrease in energy, a pessimistic assessment of the past, present and future, ideas of low value, self-blame, suicidal thoughts. Almost always, depression is accompanied by somatic disorders: sweating, palpitations, loss of appetite, body weight, insomnia with difficulty falling asleep or painful early awakenings, cessation of menstruation (in women). As a result of depressive disorders, work capacity is sharply reduced, memory and ingenuity are deteriorating, the range of ideas is depleted, self-confidence and the ability to make decisions are lost. As a rule, in the morning, patients feel especially bad, in the afternoon the symptoms may subside in order to return the next morning with renewed vigor. The severity of depression can vary from psychologically understandable sadness to boundless despair, from a slight decrease in activity to the appearance of stupor (extreme lethargy, up to immobility).

Mania (gr. mania- passion, madness, attraction), on the contrary, is a combination of an unreasonably elevated mood, an acceleration in the pace of thinking and physical activity. The intensity of the above symptoms varies over a wide range. The mildest cases are called hypomania. In the perception of many people around, persons suffering from hypomania are very active, cheerful, enterprising, although somewhat cheeky, optional and boastful people. The morbid nature of all these manifestations becomes apparent when hypomania changes into depression or when the symptoms of mania deepen. With a distinct manic state, an excessively elevated mood is combined with an overestimation of the capabilities of one's own personality, the construction of unrealistic, sometimes fantastic plans and projects, the disappearance of the need for sleep, disinhibition of drives, which manifests itself in alcohol abuse, drug use, and promiscuity. As a rule, with the development of mania, the understanding of the morbidity of their condition is very quickly lost, patients commit rash, ridiculous acts, quit their jobs, disappear from home for a long time, squander money, give away things, etc.

It should be noted that depression and mania are simple and complex. The latter include a number of additional symptoms. For diseases of the schizophrenic spectrum, it is most often characterized by complex affective symptom complexes, which include, in addition to depressed mood, hallucinatory experiences, delusions, various thought disorders, and in severe forms, catatonic symptoms.

In this case, we are talking only about painful mood changes; psychologically understandable reactions of grief, depression, for example, after the loss of a loved one, bankruptcy, due to "unhappy love", etc. are not considered here. or,on the contrary, an upbeat, euphoric mood after a successful session, marriage, and other joyful events. Movement disorders (or, as they are also called, "catatonic") are a symptomatic complex of mental disorders, manifested either in the form of stupor (immobility) or in the form of arousal. With catatonic stupor, an increased muscle tone is noted, often accompanied by the patient's ability to maintain a forced position given to his members (“wax flexibility”) for a long time. With stupor, the patient freezes in one position, becomes inactive, stops answering questions, looks in one direction for a long time, refuses to eat. In addition, passive obedience is often observed: the patient has no resistance to changing the position of his limbs and posture. In some cases, the opposite disorder can also be observed - negativism, which manifests itself as an unmotivated, senseless opposition of the patient to the words and especially the actions of the person entering into communication with him. In a broad sense, negativism is a negative attitude towards the influences of the external environment, fencing off external impressions and counteracting stimuli coming from outside. Speech negativity manifests itself mutism(from the Latin "mutus" - mute), which is understood as a violation of the volitional sphere, manifested in the absence of a response and arbitrary speech in the patient, while maintaining the ability to speak and understand the speech addressed to him.

Catatonic excitation, on the contrary, is characterized by the fact that patients are constantly on the move, they speak incessantly, grimace, mimic the interlocutor, they are distinguished by foolishness, aggressiveness and impulsiveness. The actions of patients are unnatural, inconsistent, often unmotivated and sudden; they have a lot of monotony, repetition of gestures, movements and postures of others. The speech of patients is usually incoherent, contains symbolic statements, rhyming, refrains of the same phrases or statements. Continuous speech pressure can be replaced by complete silence. Catatonic excitement is accompanied by various emotional reactions - pathos, ecstasy, anger, rage, at times indifference and indifference.

Although any verbal communication is practically impossible during catatonic excitement, and the patient's motor activity can only be reduced with the help of medications, nevertheless, the patient should not be left in isolation, because. he has impaired elementary self-service skills (using the toilet, dishes, eating, etc.) and unexpected life-threatening actions for the patient and those around him are possible. Naturally, in this case we are talking about the need for emergency medical care and, most likely, hospitalization.

The difficulty in caring for a patient who is in a state of excitement is largely due to the fact that the exacerbation of the disease often begins unexpectedly, usually at night, and often reaches its highest development within a few hours. In this regard, relatives of patients should act in such a way as to exclude the possibility of dangerous actions of patients in these "unadapted conditions". Relatives of the patient, his friends or neighbors do not always correctly assess the possible consequences of the state of excitement that has arisen. The patient (a person who is well known to them with established relationships) is usually not expected to be in serious danger. Sometimes, on the contrary, an acutely ill person causes unjustified fear and panic among others.

Actions of relatives in case of development of psychomotor agitation in a patient:

• Assess the degree of danger of the patient to yourself or others and urgently call a psychiatrist to resolve the issue of hospitalization (the phone number of the psychiatrist on duty in Moscow is 925-3101).
• Create conditions for assistance, eliminate, if possible, the atmosphere of confusion and panic.
• If you see that you are in immediate danger, try to isolate the patient in a windowless room and call the police.
• Remove piercing and other objects that the patient can use as a weapon of attack or suicide.
• Talk to the patient calmly, without raising your voice, avoid sudden movements, keep the maximum possible physical distance.
• Remove from the room where the patient is, all strangers, leaving only those who can be useful.
• Try to calm the patient by asking abstract questions, in no case argue with him and do not enter into an argument.
• If you have already been in a similar situation, remember the recommendations of your doctor on the use of drugs that can reduce or remove arousal.

Thinking disorders(cognitive impairments), characteristic of schizophrenia spectrum diseases, are associated with the loss of focus, consistency, and logic of mental activity. Such violations of thinking are called formal, since they do not concern the content of thoughts, but the thought process itself. First of all, this affects the logical connection between thoughts, in addition, the figurativeness of thinking disappears, the tendency to abstraction and symbolism prevails, there are breaks in thoughts, a general impoverishment of thinking or its unusualness with the originality of associations, up to ridiculous. In the later stages of the disease, the connection between thoughts is lost even within the same phrase. This manifests itself in broken speech, which turns into a chaotic set of fragments of phrases that are absolutely unrelated to each other.

In milder cases, there is an illogical transition from one thought to another. ("slipping") which the patient himself does not notice. Thinking disorders are also expressed in the appearance of new pretentious words that are understandable only to the patient himself (“neologisms”), in fruitless reasoning on abstract topics, in philosophizing ("reasoning") and in the disorder of the process of generalization, which is based on non-essential features . In addition, there are such violations as an uncontrolled stream or two parallel current streams of thoughts.

It should be emphasized that formally the level of intelligence (IQ) in persons suffering from diseases of the schizophrenic spectrum differs only slightly from the IQ level of healthy people, i.e. intellectual functioning in this disease remains quite intact for a long time, in contrast to specific damage to cognitive functions, such as attention, the ability to plan one's actions, etc. Less often, patients suffer from the ability to solve problems and problems that require the involvement of new knowledge. Patients select words according to their formal characteristics, without caring about the meaning of the phrase, they skip one question, but answer another. Some thinking disorders appear only during the period of exacerbation (psychosis) and disappear when the condition stabilizes. Others, more persistent, remain in remission, creating the so-called. cognitive deficit.

Thus, the range of schizophrenia spectrum disorders is quite wide. Depending on the severity of the disease, they can be expressed in different ways: from subtle features that are accessible only to the eye of an experienced specialist, to sharply defined disorders, indicating a severe pathology of mental activity.

With the exception of thinking disorders (1), all of the above manifestations of schizophrenia spectrum diseases belong to the circle positive disorders(from lat. positivus - positive). Their name means that the pathological signs or symptoms acquired during the course of the disease are, as it were, added to the state of the patient's psyche, which was before the disease.

Thinking disorders can refer to both positive symptoms (if observed at the height of psychosis), and negative ones, if they appear during remission.

Negative Disorders(from lat. negativus - negative), so called because in patients, due to the weakening of the integrative activity of the central nervous system, there may be a “falling out” of powerful layers of the psyche due to the painful process, expressed in a change in character and personal properties. At the same time, patients become lethargic, low-initiative, passive (“decreased energy tone”), their desires, urges, aspirations disappear, emotional deficit increases, isolation from others appears, avoidance of any social contacts. Responsiveness, sincerity, delicacy are replaced in these cases by irritability, rudeness, quarrelsomeness, aggressiveness. In addition, in more severe cases, the above-mentioned mental disorders appear in patients, which becomes unfocused, amorphous, empty. Patients can lose their previous work skills so much that they have to register a disability group.

One of the most important elements of the psychopathology of schizophrenia spectrum diseases is the progressive impoverishment of emotional reactions, as well as their inadequacy and paradoxicality. At the same time, even at the beginning of the disease, higher emotions can change - emotional responsiveness, compassion, altruism. As the emotional decline, patients are less and less interested in events in the family, at work, they break old friendships, lose their former feelings for loved ones. Some patients observe the coexistence of two opposite emotions (for example, love and hate, interest and disgust), as well as the duality of aspirations, actions, tendencies. Much less often, progressive emotional devastation can lead to a state of emotional dullness, apathy.

Along with emotional decline, patients may also experience violations volitional activity more often manifested only in severe cases of the course of the disease. It may be about abulia - partial or complete absence of motives for activity, loss of desires, complete indifference and inactivity, cessation of communication with others. Sick all day, silently and indifferently, lie in bed or sit in one position, do not wash, stop serving themselves. In especially severe cases, abulia can be combined with apathy and immobility.

Another volitional disorder that can develop in schizophrenia spectrum diseases is autism (a disorder characterized by a separation of the patient's personality from the surrounding reality with the emergence of a special inner world that dominates his mental activity). In the early stages of the disease, a person can also be autistic, formally in contact with others, but not allowing anyone into his inner world, including those closest to him. In the future, the patient closes in himself, in personal experiences. Judgments, positions, views, ethical assessments of patients become extremely subjective. Often, a peculiar idea of ​​the life around them takes on the character of a special worldview, sometimes autistic fantasizing occurs.

Another characteristic feature of schizophrenia is decreased mental activity . It becomes more difficult for patients to study and work. Any activity, especially mental, requires more and more tension from them; extremely difficult to concentrate. All this leads to difficulties in the perception of new information, the use of a stock of knowledge, which in turn causes a decrease in working capacity, and sometimes complete professional failure with the formally preserved functions of the intellect.

Thus, negative disorders include disorders of the emotional and volitional spheres, disorders of mental activity, thinking and behavioral reactions.

Positive disorders, due to their unusualness, are noticeable even to non-specialists, therefore they are detected relatively easily, while negative disorders can exist for quite a long time without paying much attention to themselves. Symptoms such as indifference, apathy, inability to express feelings, lack of interest in life, loss of initiative and self-confidence, impoverishment of vocabulary, and some others may be perceived by others as character traits or as side effects of antipsychotic therapy, and not the result of a disease state. . In addition, positive symptoms can mask negative disorders. But, despite this, it is negative symptoms that most affect the future of the patient, his ability to exist in society. Negative disorders are also significantly more resistant to drug therapy than positive ones. Only with the advent of new psychotropic drugs at the end of the 20th century - atypical antipsychotics (rispolepta, zyprexa, seroquel, zeldox, abilify, serdolect) did doctors have the opportunity to influence negative disorders.

For many years, studying the endogenous diseases of the schizophrenia spectrum, psychiatrists have concentrated their attention mainly on positive symptoms and the search for ways to stop them. Only in recent years has an understanding emerged that specific changes in cognitive (mental) functions are of fundamental importance in the manifestations of schizophrenic spectrum diseases and their prognosis. They mean the ability to mental concentration, to perceive information, to plan one's own activity and predict its results. In addition to this, negative symptoms can also manifest themselves in violation of adequate self-esteem - criticism. This consists, in particular, in the impossibility of some patients to understand that they suffer from mental illness and for this reason need treatment. Criticality to painful disorders is essential for the cooperation of the doctor with the patient. Its violation sometimes leads to such forced measures as involuntary hospitalization and treatment.

THEORIES OF THE ORIGIN OF ENDOGENOUS DISEASES OF THE SCHIZOPHRENIC SPECTRUM

Despite the fact that the nature of most mental illnesses is still largely unclear, schizophrenia spectrum diseases are traditionally referred to as so-called endogenous mental illnesses (“endo” in Greek means “internal”). Unlike the group of exogenous mental illnesses (“exo” - external, external), which are caused by external negative influences (for example, traumatic brain injury, infectious diseases, various intoxications), schizophrenia spectrum diseases do not have such distinct external causes.

According to modern scientific views, schizophrenia is associated with impaired transmission of nerve impulses in the central nervous system (neurotransmitter mechanisms) and a special nature of damage to some brain structures. Although the hereditary factor undoubtedly plays a role in the development of schizophrenia spectrum diseases, it is, however, not decisive. Many researchers believe that, as in the case of cardiovascular disease, cancer, diabetes and other chronic diseases, one can inherit only an increased predisposition to diseases of the schizophrenic spectrum, which can be realized only under certain circumstances. Attacks of the disease are provoked by some kind of mental trauma (in such cases, people say that a person "has gone crazy with grief"), but this is the case when "after does not mean due to." In the clinical picture of diseases of the schizophrenic circle, as a rule, there is no clear connection between the traumatic situation and mental disorders. Usually, mental trauma only provokes a hidden schizophrenic process, which would sooner or later manifest itself even without any external influence. Psychotrauma, stress, infections, intoxication only accelerate the onset of the disease, but are not its cause.

PROGNOSIS FOR ENDOGENOUS DISEASES OF SCHIZOPHRENIC SPECTRUM

Schizophrenia spectrum illnesses are generally not fatal, progressive mental illnesses, often have a relatively benign course, and are amenable to the effects of psychotropic drugs. The prognosis of schizophrenia is more favorable when the disease develops at a relatively mature age and due to any traumatic life events. The same applies to people who are successful in their studies, work, have a high level of education, social activity, ease of adaptation to changing life situations. High professional opportunities and life achievements preceding the onset of the disease make it possible to predict a more successful rehabilitation.

Acute, accompanied by psychomotor agitation, the dramatic development of the disease makes a heavy impression on others, but it is this variant of the development of psychosis that can mean minimal damage to the patient and the possibility of his return to the previous quality of life. Conversely, the gradual, slow development of the first symptoms of the disease and the delayed start of treatment aggravate the course of the disease and worsen its prognosis. The latter can also be determined by the symptoms of the disease: in cases where schizophrenia spectrum disease is manifested mainly by positive disorders (delusions, hallucinations), a more favorable outcome can be predicted than in cases where negative symptoms come first (apathy, isolation, lack of desire and motives, poverty of emotions).

One of the most important factors affecting the prognosis of the disease is the timeliness of the start of active therapy and its intensity in combination with socio-rehabilitation measures.

MAIN TYPES OF ENDOGENOUS DISEASES OF SCHIZOPHRENIC SPECTRUM

The clinical picture of diseases of the schizophrenic spectrum is extremely diverse both in terms of the combination of symptoms and the type of their course. Domestic psychiatrists currently distinguish three main forms of the course of schizophrenia: paroxysmal (including recurrent), paroxysmal-progressive and continuous. Progression inherent in this disease is understood as a steady increase, progression and complication of symptoms. The degree of progression can be different: from a sluggish process to unfavorable forms.

To continuously flowing forms diseases of the schizophrenic spectrum include cases with a gradual progressive development of the disease process, with varying severity of both positive and negative symptoms. With a continuous course of the disease, its symptoms are observed throughout life from the moment of the disease. Moreover, the main manifestations of psychosis are based on two main components: delusions and hallucinations.

These forms of endogenous disease are accompanied by personality changes. A person becomes strange, withdrawn, commits ridiculous, illogical actions from the point of view of others. The range of his interests changes, new, previously unusual hobbies appear. Sometimes these are philosophical or religious teachings of a dubious nature, or fanatical adherence to the canons of traditional religions. At patients working capacity, social adaptation decreases. In severe cases, the occurrence of indifference and passivity, a complete loss of interests, is not excluded.

For paroxysmal flow ( recurrent or periodic form of the disease) the occurrence of distinct attacks, combined with a mood disorder, is characteristic, which brings this form of the disease closer to manic-depressive psychosis, especially since mood disorders occupy a significant place in the picture of seizures. In the case of a paroxysmal course of the disease, the manifestations of psychosis are observed in the form of separate episodes, between which there are "bright" intervals of a relatively good mental state (with a high level of social and labor adaptation), which, being sufficiently long, can be accompanied by a complete recovery of working capacity (remission).

An intermediate place between the indicated types of flow is occupied by cases paroxysmal-progredient (fur-like) form of the disease when, in the presence of a continuous course of the disease, the appearance of attacks is noted, the clinical picture of which is determined by syndromes similar to attacks of recurrent schizophrenia.

Forms of endogenous diseases of the schizophrenic spectrum differ in the predominance of the main symptoms: delusions, hallucinations, or personality changes. With the dominance of delusions, we are talking about paranoid schizophrenia . With a combination of delusions and hallucinations, one speaks of its hallucinatory-paranoid variant . If personality changes come to the fore, then this form of the disease is called simple .

A special type of schizophrenia is its low-progressive (sluggish) form- a variant of the disease, characterized by a relatively favorable course, with a gradual and shallow development of personality changes, against which there are no distinct psychotic states, but disorders dominated by neurosis-like (obsessions, phobias, rituals), psychopathic (severe hysterical reactions, deceit, explosiveness, vagrancy), affective and, less often, erased delusional symptoms. Modern European and American psychiatrists have removed this form from the heading of "schizophrenia" into a separate so-called schizotypal disorder. In order to make a diagnosis of sluggish schizophrenia, the doctor draws attention to the personality disorders of patients, giving their appearance features of strangeness, eccentricity, eccentricity, mannerisms, as well as to pomposity and suggestiveness of speech with poverty and inadequacy of intonation.

Diagnosis of this group of conditions is rather complicated and requires a high qualification of the doctor, since, without paying attention to the features described above, an inexperienced doctor may mistakenly diagnose psychopathy, neurosis, affective disorder, which leads to the use of inadequate medical tactics and, as a result, to the untimeliness of therapeutic and social rehabilitation measures.

FIRST SIGNS OF DISEASE

Endogenous diseases of the schizophrenic spectrum most often develop over several years, and sometimes last throughout life. However, in many patients, the rapid development of symptoms can occur only in the first five years from the onset of the disease, after which a relative mitigation of the clinical picture occurs, accompanied by social and labor readaptation.

Experts divide the disease process into several stages.

AT premorbid period most patients do not have signs associated with manifestations of schizophrenia spectrum disorders. In childhood, adolescence and youth, a person who may later develop this pathology is not much different from most people. Only some isolation, slight oddities in behavior, and less often, difficulties associated with learning attract attention. However, it should not be concluded from this that every withdrawn child, as well as all those with learning difficulties, will necessarily suffer from a schizophrenia spectrum disorder. Today, unfortunately, it is impossible to predict whether such a child will develop this disease or not.

AT prodromal (incubation) period the first signs of the disease are already appearing, but so far indistinctly expressed. The most common manifestations of the disease at this level are as follows:

• overvalued hobbies (a teenager or young man begins to devote a lot of time to mystical reflections and various philosophical teachings, sometimes joins a sect or fanatically "leaves" religion);
• episodic changes in perception (elementary illusions, hallucinations);
• decreased ability to any activity (to study, work, creativity);
• a change in personality traits (for example, instead of diligence and punctuality, negligence and absent-mindedness appear);
• weakening of energy, initiative, need for communication, craving for loneliness;
• odd behavior.

The prodromal period of the disease can last from several weeks to several years (on average, two to three years). The manifestations of the disease can increase gradually, as a result of which relatives do not always pay attention to changes in the patient's condition.

If we take into account that many adolescents and young men go through a pronounced age crisis (“transitional age”, “pubertal crisis”), characterized by sudden changes in mood and “strange” behavior, the desire for independence, independence with doubts and even rejection of former authorities and a negative attitude towards people from the immediate environment, it becomes clear why the diagnosis of endogenous diseases of the schizophrenic spectrum is so difficult at this stage.

In the period of early manifestations of the disease, you should seek the advice of a psychiatrist as soon as possible. Often, the adequate begins with a great delay due to the fact that people seek help from non-specialists or turn to the so-called "folk healers" who cannot recognize the disease in time and begin the necessary treatment.

ACUTE PERIOD OF ILLNESS (HOSPITALIZATION)

Acute period The disease occurs, as a rule, after the condition described above, but it may also be the first sudden manifestation of the disease. Sometimes it is preceded by severe stress factors. At this stage, acute psychotic symptoms appear: auditory and other hallucinations, incoherent and meaningless speech, statements of content that is inadequate to the situation, oddities in behavior, psychomotor agitation with impulsive actions and even aggression, freezing in one position, reduced ability to perceive the outside world as it is exists in reality. When the disease is so pronounced, changes in the behavior of the patient are noticeable even to a non-professional. Therefore, it is at this stage of the disease that the patients themselves, but more often their relatives, turn to the doctor for the first time. Sometimes this acute condition poses a danger to the life of the patient or others, which leads to his hospitalization, but in some cases, patients begin to be treated on an outpatient basis, at home.

They can receive specialized care in a psycho-neurological dispensary (PND) at the place of residence, in psychiatric research institutions, in psychiatric and psychotherapeutic care rooms at general clinics, in psychiatric rooms of departmental polyclinics.

The functions of the PND include:

• Outpatient reception of citizens referred by doctors of general clinics or who applied on their own (diagnosis, treatment, solution of social issues, examination);
• Consultative and dispensary observation of patients;
• Emergency care at home;
• Referral to a psychiatric hospital.

Hospitalization of the patient. Because people suffering from endogenous schizophrenia spectrum disorder often do not realize that they are ill, it is difficult or even impossible to convince them of the need for treatment. If the patient's condition worsens, and you can neither convince nor force him to be treated, then you may have to resort to hospitalization in a psychiatric hospital without his consent. The primary purpose of both involuntary hospitalization and the laws governing it is to ensure the safety of the acutely ill patient and those around him. In addition, the tasks of hospitalization also include ensuring the timely treatment of the patient, even if against his desire. After examining the patient, the district psychiatrist decides under what conditions to carry out treatment: the patient's condition requires urgent hospitalization in a psychiatric hospital, or outpatient treatment can be limited.

Article 29 of the Law of the Russian Federation (1992) "On psychiatric care and guarantees of the rights of citizens in its provision" clearly regulates the grounds for involuntary hospitalization in a psychiatric hospital, namely:

“A person suffering from a mental disorder may be hospitalized in a psychiatric hospital without his consent or without the consent of his legal representative before the decision of the judge, if his examination or treatment is possible only in hospital conditions, and the mental disorder is severe and causes:

a) his immediate danger to himself or others, or

b) his helplessness, that is, his inability to independently satisfy the basic needs of life, or

c) significant harm to his health due to the deterioration of his mental state, if the person is left without psychiatric assistance.

REMISSION PERIOD (maintenance therapy)

During the course of the disease, as a rule, there are several exacerbations (attacks). Between these states, there is an absence of active signs of the disease - a period remissions. During these periods, signs of the disease sometimes disappear or are minimally presented. At the same time, each new "wave" of positive disorders makes it increasingly difficult for the patient to return to normal life, i.e. worsens the quality of remission. During remissions, in some patients, negative symptoms become more noticeable, in particular, a decrease in initiative and desires, isolation, and difficulty in formulating thoughts. In the absence of the help of loved ones, supportive and preventive pharmacotherapy, the patient may find himself in a state of complete inactivity and everyday neglect.

Scientific studies conducted over a number of years have shown that after the first attacks of schizophrenia spectrum diseases, approximately 25% of all patients recover completely, 50% recover partially and continue to need preventive care, and only 25% of patients need constant treatment and medical supervision, sometimes even in a hospital setting.

Supportive care: the course of some forms of schizophrenic spectrum diseases is characterized by duration and a tendency to recurrence. That is why all domestic and foreign psychiatric recommendations regarding the duration of outpatient (supportive, preventive) treatment clearly stipulate its terms. Thus, patients who have had a first episode of psychosis should take small doses of drugs for two years as a preventive therapy. In the event of a repeated exacerbation, this period increases to three to seven years. If the disease shows signs of a transition to a continuous course, the period of maintenance therapy is extended indefinitely. That is why there is a reasonable opinion among practical psychiatrists that for the treatment of those who fall ill for the first time, maximum efforts should be made, conducting the longest possible and full-fledged course of treatment and social rehabilitation. All this will pay off handsomely if it is possible to save the patient from repeated exacerbations and hospitalizations, because after each psychosis, negative disorders grow, which are especially difficult to treat.

Psychiatrists often face the problem of patients refusing to continue taking medication. Sometimes this is due to the lack of criticism in some patients (they simply do not understand that they are sick), sometimes the patient claims that he has already recovered, feels good and no longer needs any medication. At this stage of treatment, it is necessary to convince the patient to take maintenance therapy for the required period. The psychiatrist insists on continuing treatment is not at all out of reinsurance. Practice proves that taking medication can significantly reduce the risk of exacerbation of the disease. The main drugs used to prevent relapse of schizophrenia are antipsychotics (see the section "principles of treatment"), but in some cases additional drugs may be used. For example, lithium salts, valproic acid, carbamazepine, as well as new drugs (lamiktal, topamax), are prescribed to patients with mood disorders prevailing in the picture of an attack of the disease, not only to stop this particular condition, but also to minimize the risk of recurrence of attacks. in future. Even with the continuous course of schizophrenia spectrum diseases, the use of psychotropic drugs helps to achieve a stable remission.

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