Progressive schizophrenia

Forms of schizophrenia and course

Treatment of schizophrenia - we use soft hospital replacement techniques without the use of psychotropic drugs.

Schizophrenia is a group of diseases characterized by disharmony and loss of unity of mental functions (thinking, emotions, motor skills), a combination of productive (delusions, hallucinations, etc.) and negative (decreased volitional activity, emotional impoverishment, increased introversion, etc.) symptoms, long-term and progressive course, united by a common development mechanism and the same outcome of the disease (development of the so-called schizophrenic defect).

The term schizophrenia has been used since 1911, after E. Bleuler combined the previously observed dementia praecox, hebephrenia, catatonia and chronic delusional psychoses into one disease. Schizophrenia is diagnosed in approximately 1% of the population, with approximately equal prevalence in men and women. This disease affects approximately 45 million people in the world, and it is diagnosed in 4.5 million people every year. In Russia, the incidence and prevalence of schizophrenia are at the world average.

Forms of schizophrenia

• in the form of psychoses with severe mental disorders in the form of delusions, hallucinations, aggressive behavior, freezing;
• in the form of non-rough, so-called borderline disorders (the appearance of obsessive thoughts, mood changes, the appearance of unpleasant sensations in various parts of the body, etc.),
• and also under the guise of subtle personality changes (loss of previous interests, increasing isolation, passion for “occult” knowledge, etc.).

Variants of the course of schizophrenia

• unfavorable forms of schizophrenia, in which the disease, after its onset, proceeds only with progression and leads to the disintegration of personality in a short time (several years)
• a continuous course in which the symptoms of the disease do not stop, there are no temporary lulls.
• paroxysmal course, in which attacks of the disease can be replaced by more or less long periods without painful disorders (remission). Moreover, there are people who have suffered only one attack in their entire lives.
• paroxysmal-progressive course, there is a kind of intermediate type of course, in which increasing personality changes are observed between attacks.

PsyAndNeuro.ru

Bipolar affective disorder (BD) is a phenomenologically heterogeneous entity, and within a diagnostic category, individuals with BD may have very different symptom profiles. Therefore, despite different diagnostic categories, bipolar disorder has significant overlap with schizophrenia at both the clinical and genetic levels.

Delusions and hallucinations are quite common in bipolar disorder, and in about a third of cases, psychotic symptoms are incongruent with affect. Such symptoms are associated with a poor prognosis and poor response to lithium. In addition, they are qualitatively similar to symptoms of schizophrenia, suggesting that psychotic bipolar disorder, especially with affect-incongruent hallucinations and delusions, has a close etiological relationship with schizophrenia.

Genome-wide association searches demonstrated the polygenic nature of both schizophrenia and bipolar disorder, with a significant proportion of genetic variance explained by common alleles partially shared by the two disorders. An individual's genetic risk of developing a disease can be calculated using a polygenic risk score (PRS), allowing scientists to examine the genetic basis of symptom domains within given disorders and transdiagnostically with greater power. However, there is a differential separation between the subtypes of bipolar disorder and schizoaffective disorder (an intermediate subtype, which is characterized by a combination of symptoms of schizophrenia and bipolar disorder), which has a relatively greater genetic risk of schizophrenia.

To date, lack of statistical power in well-phenotyped samples has hampered the study of polygenic risk associations for schizophrenia with psychotic symptoms within bipolar disorder.

The new study, published in JAMA Psychiatry, aimed to examine the association between common genetic variants in schizophrenia and bipolar disorder based on the most powerful genome-wide studies yet. This study included 4436 patients with bipolar disorder, 4976 participants with schizophrenia, and 9012 mentally healthy controls. All patients with bipolar disorder were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), a sample of patients with schizophrenia was formed on the basis of the CLOZUK study (treatment-resistant schizophrenia treated with clozapine).

The results showed that the polygenic risk of schizophrenia was higher, surprisingly, in schizoaffective disorder. Further in descending order, schizophrenia had the strongest associations with bipolar disorder type I (full-blown depressive and manic/mixed episodes) with psychotic symptoms incongruent with affect; with bipolar disorder type I with psychotic symptoms congruent with affect; Type I bipolar disorder without psychotic symptoms and, finally, the weakest associations were with type II bipolar disorder (full-blown depressive and hypomanic episodes). All differential associations were statistically significant.

Scientists have shown that there is a clear gradient in the relationship between the polygenic risk of developing schizophrenia and psychotic bipolar disorder, which supports the main hypothesis that incongruent psychotic symptoms within bipolar disorder are more etiologically related to schizophrenia.

The material was prepared as part of the ProSchizophrenia - a specialized section of the official website of the Russian Society of Psychiatrists, dedicated to schizophrenia, modern approaches to its diagnosis and treatment.

Prepared by: Kasyanov E.D.

Source: Judith Allardyce et al. Association Between Schizophrenia-Related Polygenic Liability and the Occurrence and Level of Mood-Incongruent Psychotic Symptoms in Bipolar Disorder. JAMA Psychiatry. 2018;75(1):28-35. doi:10.1001/jamapsychiatry.2017.3485

Main forms of schizophrenia

Diagnosis of forms of schizophrenia, even in cases of severe painful disorders in the form of psychoses with seemingly obvious schizophrenic symptoms, requires caution. Not all psychoses with delusions, hallucinations and catatonic symptoms (freezing, agitation) are manifestations of schizophrenia. Below are the most specific psychotic symptoms for schizophrenia (the so-called first-rank symptoms).

Openness of thoughts – the feeling that thoughts can be heard from a distance. Feeling of alienation is the feeling that thoughts, feelings, intentions and actions come from external sources and do not belong to the patient.

Feeling influenced - the feeling that thoughts, feelings and actions are imposed by some external forces that must be passively obeyed.

Delusional perception is the organization of real perceptions into a special system, often leading to false ideas and conflict with reality.

Auditory hallucinations are clearly audible voices emanating from inside the head (pseudohallucinations), commenting on the actions or pronouncing the patient’s thoughts.

Differential diagnosis

In cases of acute illness, a doctor can assume schizophrenia based on an examination, conversation with the patient, information from loved ones about how behavioral disorders developed, how the patient behaved. Accurate diagnosis of the form of schizophrenia, especially in cases where the disease is not severe, sometimes requires hospitalization. Modern scientists consider it necessary to monitor the patient for at least a month in order for the diagnosis to be accurate. In these cases, in addition to assessing the history of the disease and the patient’s condition upon admission, the doctor observes the patient’s behavior in the hospital (or day hospital), and also carries out various diagnostic manipulations to exclude other causes of mental disorders.

One of the diagnostically valuable types of examinations is a pathopsychological examination, during which higher mental functions are assessed:

• memory
• attention
• thinking
• intelligence
• emotional sphere
• volitional characteristics
• personal characteristics, etc.

Depending on the manifestations of the disease and its course, several forms of schizophrenia are distinguished:

Paranoid form of schizophrenia

The most common form of the disease. It manifests itself as a relatively stable, usually systematized delusion (persistent false conclusions that cannot be dissuaded), often accompanied by hallucinations, especially auditory ones, as well as other perceptual disturbances. The most common symptoms of paranoid schizophrenia include:

• delusions of persecution, relationship and significance, high origin, special purpose, bodily changes, or jealousy;
• hallucinatory voices of a threatening or commanding nature or auditory hallucinations without verbal expression, such as whistling, humming, laughter, etc.;
• olfactory or taste hallucinations, sexual or other bodily sensations.

Visual hallucinations may also occur. In the acute stages of paranoid schizophrenia, the behavior of patients is grossly disturbed and is determined by the content of painful experiences. So, for example, with delusions of persecution, the sick person either tries to hide, escape from imaginary pursuers, or attack and try to defend himself. With auditory hallucinations of a commanding nature, patients can carry out these “commands”, for example, throw things out of the house, swear, grimace, etc.

Hebephrenic form of schizophrenia

More often, the disease begins in adolescence or young adulthood with a change in character, the appearance of a superficial and mannered passion for philosophy, religion, the occult and other abstract theories. Behavior becomes unpredictable and irresponsible, patients look infantile and foolish (they make ridiculous faces, grimace, giggle), and often strive for isolation. The most common symptoms of hebephrenic schizophrenia include:

• distinct emotional flatness or inadequacy;
• behavior characterized by goofiness, mannerisms, grimaces (often with giggles, smugness, self-absorbed smiles, grand manners);
• distinct thinking disorders in the form of broken speech (violation of logical connections, jumping thoughts, connection of heterogeneous elements not related in meaning);
• hallucinations and delusions may not be present.

To diagnose the hebephrenic form of schizophrenia, it is necessary to monitor the patient for 2-3 months, during which the above-described behavior persists.

Catatonic form of schizophrenia

In this form of the disease, movement disorders predominate, which can vary in extremes from freezing to hyperactivity, or from automatic submission to senseless resistance, the patient’s unmotivated refusal to perform any movement, action or resistance to its implementation with the help of another person. Episodes of aggressive behavior may occur.

In the catatonic form of schizophrenia, the following symptoms are observed:

• stupor (a state of mental and motor retardation, reactions to the environment, spontaneous movements and activity decrease) or mutism (lack of verbal communication between the patient and others while the speech apparatus is intact);
• excitement (purposeless motor activity, not subject to external stimuli);
• freezing (voluntary acceptance and retention of an inadequate or pretentious pose);
• negativism (meaningless resistance or movement in the opposite direction in response to all instructions or attempts to change position or move);
• rigidity (holding a pose in response to an attempt to change it);
• “waxy flexibility” (holding body parts in a given position, even uncomfortable and requiring significant muscle tension);
• automatic obedience;
• getting stuck in the mind of one thought or idea with their monotonous repetition in response to newly asked questions that no longer have anything to do with the original ones.

The above symptoms can be combined with a dream-like state, with vivid scene-like hallucinations (oneiroid). Isolated catatonic symptoms can occur in any other form and other mental disorders. For example, after suffering traumatic brain injuries, in case of poisoning with psychoactive substances, etc.

Varieties

The peculiarities of the clinical picture and the degree of progress of the fur-like type of mental illness have necessitated its classification into several subtypes.

Progressive malignant schizophrenia

It has much in common with the teenage type of schizophrenic process, and lies in its continuous course, against the background of which mental crises develop. At the beginning of development, pathology manifests itself in the form of a decrease in energy potential, which is accompanied by inactivity, loss of interests, and increasing emotional deficit.

As the disease progresses, affective disorders increasingly begin to appear, which entail apathetic, subdepressive mood and psychopathic personality disorders. During this period, the patient is characterized by lethargy and aversion to any kind of activity, excessive irritability, and demonstrative rudeness towards others.

Often these symptoms are accompanied by alcohol abuse and spontaneous, impulsive suicide attempts. The patient grimaces, freezes in monotonous poses, and openly ignores any comments about his behavior from the outside.

The onset of malignant progressive schizophrenia is usually observed in adolescence - 12–14 years. Manifest psychoses can be combined with delusional ideas of a paranoid nature and hallucinatory manifestations. Persistent substuporous episodes are replaced by impulsive agitation and foolishness.

After the first attack, the patient exhibits pronounced personality changes.

The periods of remission between exacerbations are short and are accompanied by persistent symptoms of a delusional or catatonic state.

The lack of qualified therapy leads to the fact that after 2-3 exacerbations the patient develops an awareness of changes in himself due to social maladjustment. Individuals with this type of course of the schizophrenic process, depending on the degree of personality changes, can be partially adapted to society and engage in simple types of social activities during periods of remission.

Fur-like schizophrenia of paranoid nature

The first signs of mental abnormalities of this type of schizophrenic psychosis appear, as a rule, in childhood or adolescence, gradually forming a schizoid character structure in the individual. Exacerbations may have a distinct age-related coloration or remain subtle until the onset of obvious manifestation of the disease.

The clinical picture of the formed schizophrenic process includes the following mental disorders:

• various types of depression. This condition is characterized by decreased mood and the inability to receive positive emotions. Such attacks can be limited only by lethargy and decline in activity combined with philosophizing;
• manic attacks. During this period, the patient experiences an increase in the general level of arousal with insufficient activation of intellectual thinking. Elevated mood may be euphoric or irritable;
• attack with dominance of obsessive states. During the period of exacerbation, the patient begins to form and manifest various fears and doubts (phobias), which have an affective connotation;
• depersonalization. The attack occurs against the background of dissatisfaction and irritability associated with the perception of the environment, one’s own “I”, etc. Such attacks often occur in adolescence, and are accompanied by social isolation (asociality);
• attack based on heboid (psychopathic) disorders. The first signs of heboid type schizophrenia appear in adolescence as a result of the pubertal crisis. Along with preserved intellectual abilities, the patient is observed to be excessively rude and negativistic in relation to the surrounding society. The course of heboid schizophrenic processes is accompanied by an increased, unproductive interest in philosophy and religion. The ability to self-control disappears, cases of sexual promiscuity become more frequent, and often during the period of exacerbation, a young man begins to develop alcoholism or drug addiction;
• acute attack of paranoid character. Against the background of depressive disorders, a paranoid syndrome is formed, which is accompanied by delusional states or hallucinosis. The plot of delirium can vary from anxious depressive to affective. Such attacks occur more often in middle-aged men;
• acute Kandinsky-Clerambault syndrome. In an unclouded state of consciousness, mental automatisms are observed in different variants - confusion, delusional states, pseudohallucinations, alienation syndrome, when, in the patient’s opinion, someone or something is controlling him;
• catatonic and catano-hebephrenic types of attacks. They pose a particular danger; they occur severely and over a long period of time. Main signs: stupor alternates with a period of excitement. During the period of stupor, the patient can remain in one position for hours without showing a reaction to the environment. During this time, the schizophrenic may experience hallucinatory visions. Negativism begins to actively manifest itself - non-perception and resistance to any external influence on the patient. In especially severe cases, mutism occurs - while the speech apparatus is intact, speech is completely or partially lost.

Medical practice describes a case of fur coat-like schizophrenia in a 21-year-old boy. For about a year he combined studying at a university and working part-time in an electronics store. After some time, classmates began to notice that their friend’s behavior was changing: he became irritable, suspicious, and his concentration gradually worsened. He began to experience a delusional state, which manifested itself in a mania of persecution by his teachers.

Close friends persuaded him to see a psychiatrist. The specialist did not find the cause of the onset of the disease, but stopped the attack with the help of pharmaceuticals and psychotherapy.

Six months later, the young man stopped taking the medications prescribed to him. After some time, his condition worsened: the guy began to think that the boss had installed video cameras and bugs everywhere at work, which he was trying to find and deactivate.

After another attack of suspicion, the young man began to go into hysterics: he grabbed a chair and broke several televisions, demanding that the director remove all the surveillance systems installed on him. The store management called an ambulance, as a result of which the “rowdy” in an inadequate condition was hospitalized in a psychiatric hospital, where he was placed for inpatient treatment.

Sluggish progressive schizophrenia

This type of schizophrenic psychosis is the most common, and, according to statistics, occurs in 40% of all registered cases of the disease. The clinical picture resembles the onset of a mental disorder and is characterized by abnormalities of thinking, strange behavior of the patient, and emotional inadequacy.

Personality change happens slowly. The attacks are episodic, not clearly expressed, and are usually represented by derealization and depersonalization of the personality, depression, and, less often, affective illusions. Therefore, the prognosis for this type of progressive schizophrenia is most favorable. After the attack, the clinical picture stabilizes and consists of residual symptoms of a neurosis-like nature.

Simple forms of schizophrenia

With this form of schizophrenia, oddities and inappropriate behavior gradually develop, and overall productivity and performance decrease. Delusions and hallucinations are usually not observed. Vagrancy, absolute inactivity, and aimlessness of existence appear. This form is rare. To diagnose a simple form of schizophrenia, the following criteria are needed:

• the presence of progressive development of the disease;
• the presence of characteristic negative symptoms of schizophrenia (apathy, lack of motivation, loss of desires, complete indifference and inactivity, cessation of communication due to loss of responsiveness, emotional and social isolation) without pronounced delusional, hallucinatory and catatonic manifestations;
• significant changes in behavior, manifested by a pronounced loss of interests, inactivity and autism (immersion in the world of subjective experiences with weakening or loss of contact with the surrounding reality).

Residual (residual) schizophrenia

In this form, after psychotic attacks of the disease, only negative schizophrenic symptoms persist and continue for a long time: decreased volitional and emotional activity, autism. The patients’ speech is poor and inexpressive, self-care skills, social and labor productivity are lost, interest in married life and communication with loved ones fades, and indifference to relatives and children appears. Such conditions in psychiatry are usually defined as a schizophrenic defect (or the final state of schizophrenia). Due to the fact that with this form of the disease the ability to work is almost always reduced or lost, and patients often need outside supervision, special commissions determine the disability group for patients.

In the residual form of schizophrenia, the following symptoms are observed:

• distinct negative schizophrenic symptoms, that is, psychomotor slowing, decreased activity, emotional flatness, passivity and lack of initiative; poverty of speech, both in content and quantity; poor facial expressions, eye contact, voice modulation and posture; lack of self-care skills and social productivity;
• the presence in the past of at least one distinct psychotic episode that meets the criteria for schizophrenia;
• the presence of a period, albeit once a year, during which the intensity and frequency of significant symptoms such as delusions and hallucinations would be minimal in the presence of negative schizophrenic symptoms;
• absence of dementia or other brain diseases;
• absence of chronic depression and hospitalization, which could explain the presence of negative disorders.

Continuous flow

In the early stages of schizophrenia, predominantly productive symptoms are observed. First, neurosis-like disorders occur, then delusions and hallucinations are added to the clinical picture of the disease. Subsequently, catatonic disorders may develop. Over time, symptoms progress steadily. Remissions are possible only with appropriate treatment. In the later stages of the disease, negative manifestations predominate: emotional impoverishment, schizis (separation of mental and emotional activity) and volitional disorders.

The severity of certain manifestations at different stages of schizophrenia depends on the form of the disease. The course of schizophrenia that begins in childhood and adolescence is particularly malignant. In this case, pronounced negative symptoms appear very early, and after 1-4 years a pronounced personality defect is formed.