Delusional schizophrenia

Delirium is almost always present in schizophrenics, even with rapidly progressive malignant forms in the initial period, disappearing as they “go into themselves” and increase mental dullness. The author of the symptoms of schizophrenia of the first rank Kurt Schneider called her a delusional disease in the fullest sense of the word. A systematic chronic delirium (verbal, based on an incorrect interpretation of real facts) is characteristic of the most common form of the disease - paranoid, which more than others fits the definition of "delusional schizophrenia."

It is in the classic typical form of schizophrenia that the most productive symptoms are most pronounced - delirium and hallucinations. The first symptom, as a rule, is precisely delusional belief in something that is not true. It can be based on real facts or arise in the form of a finished plot. At first, the nonsense is relatively understandable and is a chain of logically related conclusions, sometimes even very plausibly interpreting the situation. Later, with the development of the disease and a pronounced breakdown of thinking, auditory hallucinations usually appear. The inner voices that sound in the head, other parts of the body, inspired by “alien” thoughts and forced expressions, feelings of stolen thoughts in patients with schizophrenia are transformed into hallucinatory delirium, and delusional chaos begins.

In other forms of the disease, productive symptoms are much less pronounced or completely invisible, however, many clinicians believe that a schizophrenic is typically delusional perception of internal and external events. The hidden "delusional work" of a sick brain does not always translate into obvious psychosis, but it is the background of growing pessimism, anxiety, a feeling of hostility to the environment and inevitable disaster, forcing the patient to lock himself in and shut himself off from the world.

Affective paranoid syndrome - characterized by depression, delusions of persecution, self-accusations and hallucinations with a bright accusatory character. In addition, this syndrome can be characterized by a combination of megalomania, of noble origin and hallucinations of laudatory, glorifying and approving nature.

Epidemiology

Delusional or paranoid schizophrenia, which affects approximately 70% of patients with this diagnosis, is considered the most favorable relative to other forms of this disease. Statistics records the largest number of manifestations of classical schizophrenia in the age group of 25 to 35 years. It happens that the first episode of the disease occurs at a later, even advanced age.

Causes of the delusional schizophrenia

The World Health Organization in the newsletter about this mental illness indicates that the available research data (and subject to schizophrenia has been studied for more than a hundred years) do not reliably confirm any mandatory etiological factors. However, there are many hypotheses about the possible causes of schizophrenia. Most researchers are inclined to the assumption that the development of the disease occurs in individuals predisposed to it under the influence of several internal and external factors, superimposed on each other, that is, modern psychiatry considers it as a polyetiological mental pathology. [1]

Risk factors

Risk factors relate to different areas. A very important reason is heredity. It is among patients with a paranoid form of schizophrenia that there is a rather high frequency of burdened family history. True, gene mutations specific for schizophrenia have not been found; they can also occur in other mental pathologies.

Modern diagnostic equipment made it possible to identify in vivo in schizophrenics the presence of structural disorders in the brain, also not specific. Such anomalies, expressed to a lesser extent, are often detected in close relatives of patients.

Schizoid personality traits of an individual (anxiety, a tendency to get stuck, suspiciousness, suspicion, isolation, sensitivity to criticism) are characteristic not only of the patient, but also of his relatives. According to some geneticists, they are also hereditarily determined. The presence of such accentuations in combination with adverse psychosocial environmental stressors can become a trigger factor in the development of the disease. Children's years spent in a family dominated by a cult of violence, low social status, loneliness, frequent moving, lack of understanding and support from loved ones, even the rhythm of a megalopolis’s life can provoke the development of schizophreniform symptoms.

Periods of increased risk of debut and exacerbations of schizophrenia are recognized as age-related crises associated with changes in hormonal and psychosocial status - adolescence, pregnancy and childbirth, menopause, retirement.

However, in most schizophrenic case histories, the relationship between a particular exogenous factor and the manifestation of the disease is not clearly traced.
In the presence of a congenital predisposition, the development of schizophrenia can trigger intrauterine infections, living in adverse environmental conditions, the use of psychoactive substances by the expectant mother. Studies by neurophysiologists find that at the time of the manifestation of schizophrenia, there are already anomalies in cerebral structures that develop immediately after birth and do not change at a later age. This suggests that the lesion occurs at the very early stage of the development of the brain, and as the disease progresses, an increasing number of neurochemical components are involved in the pathological process. The consequence of this is the pathological interactions of the main neurotransmitters, there is a simultaneous violation of several functional and metabolic processes in various neurotransmitter systems, which leads to changes in patient behavior that fit into schizophrenia-like symptoms. The most modern neurogenesis theories of the pathogenesis of schizophrenia arose relatively recently, when it became possible for intravital non-invasive study of the electrophysiological activity of the brain and visualization of its structures.

Earlier are neuroendocrinological hypotheses. The reason for their appearance was the debut of the disease noted by psychiatrists mainly in adolescence and youth, relapses in women during pregnancy and immediately after childbirth, exacerbations during the decay of sexual function, frequent endocrine pathologies in schizophrenics.

Apologists for the neuroendocrine hypothesis suggested the development of mental pathology under the influence of internal (auto-toxicity due to disruption of the endocrine glands) and unfavorable external factors, to the susceptibility of which the weakness of the endocrine system predisposed. Nevertheless, no endocrine disruption specific for schizophrenia has been identified, although a certain role of hormonal changes in pathogenesis is recognized by most researchers. [2]

In patients with schizophrenia, changes in cellular and humoral immunity are noted, which served as the basis for the advancement of neuroimmunological theories, some authors have developed a theory of the viral origin of schizophrenia, however, at present, none of the proposed versions can fully explain the pathogenesis of the disease.

One of the main manifestations of psychosis in schizophrenia is delirium. His or at least delusional perception of the world is found in 4/5 of patients with a diagnosis of schizophrenia. This phenomenon of thinking disorder is most pronounced in the paranoid form of the disease.

Pathogenesis

The pathogenesis of delirium with schizophrenia, representatives of different psychiatric schools and areas also explain in different ways. According to some, he grows out of the patient’s life experience, interpreted with some special meaning in connection with a change in awareness of the world around him. For example, a patient’s history of a gastrointestinal tract pathology could result in poisoning delirium. According to others, delusions are weakly dependent on real events and personal characteristics of the patient. First, there is a splitting of consciousness, against which the being of the schizophrenic is transformed, and then delusions (abnormal sensations) already appear, from which delirium itself grows as an attempt to explain these sensations, their origin, and the explanations are most unbelievable.

Currently, it is believed that a certain type of personality and pathology of the cerebral cortex, in particular, its frontal lobes, are required to start the mechanism of development of delirium, the pronounced atrophy of the cortical neurons of which contributes to the distortion of the processes of perception of various sensations. The role of impaired perception in the formation of delusions is considered extremely important and, to date, proven.

Symptoms of the delusional schizophrenia

The delusional form of schizophrenia is manifested in the statements and behavior of the patient, who defends his false beliefs with unquestioned tenacity. The most characteristic for this disease is a staged developing chronic delirium. [3]

The German psychiatrist K. Konrad singled out several stages in the dynamics of schizophrenic delirium formation. The first signs of its development (trema phase) are characterized by symptoms such as confusion and anxiety of the patient. He learns to live with a new altered consciousness, he is filled with new inexplicable sensations, not always clear, which causes tension and a sense of fear. Depending on the plot of the first delusional thoughts, a feeling of guilt may appear, against which suicidal thoughts arise. Elevated mood is much less common in patients in this phase. [4]

The next, second stage in the development of delirium formation is (apofenia), delusional "insight". The crystallization of delirium begins - the patient concretizes his delusional ideas, he finds himself in captivity. At the same time, the situation for him becomes more definite, doubts disappear, confusion and tension subside. Patients at this stage often feel like "the center of the universe", the only ones with true knowledge. Delirium at this stage is usually logical and quite believable.

The phase of the disaster or apocalyptic is characterized by incoherent hallucinatory delirium. This stage does not occur at all. It is characterized by a serious disorganization of thinking, speech disorders, the occurrence of irreversible negative symptoms.

Not always the occurrence of delirium occurs in stages. It can manifest itself in the form of an acute paranoid outbreak or grow out of an overvalued idea based on real life facts, from which the patient draws his conclusions that contradict practical experience. Delirium has the character of a belief; the patient does not require evidence of his innocence. He is convinced of it.

In official psychiatry, the initial stage of delirium formation is called paranoid. At this stage, delirium is not yet accompanied by hallucinations and is logically structured. The patient interprets the events and behavior of the people around him quite plausibly. Often at this stage the symptoms of delirium have not yet reached a significant height and are not particularly noticeable. Those around them interpret them as oddities of character. The patient sometimes goes to the doctor, but not to the psychiatrist, but to the therapist, neurologist, cardiologist complaining of a loss of strength, headache or heartache, difficulty falling asleep, unusual sensations in different parts of the body. He may have some eccentricities, obsessions, irritability, poor concentration, forgetfulness amid anxiety or, less often, an overly joyful mood, but at the initial stage of a patient’s complaints, they are usually diagnosed with vegetovascular disorders, neurosis, or manifestations of osteochondrosis. And with certainty, a psychiatrist will still not be able to diagnose schizophrenia in the initial stage with the developing process of delirium formation. For this, long-term monitoring of the patient is necessary.

Psychiatrists also know the so-called Kandinsky symptom, which is characteristic of the initial stage of schizophrenia and is presumably caused by disorders of the vestibular apparatus and the autonomic nervous system. Patients complain of bouts of severe myrrh-like headache, against which they hardly maintain coordination in space, there is a feeling of weightlessness, and the patient just leaves the soil under his feet, he feels “like Armstrong on the moon.”

A brighter debut is acute psychosis. It is manifested by a sudden and rapid increase in symptoms. In addition to the obvious disorganization of thinking, in most cases, the patient can be abnormally excited, aggressive, prone to destructive actions, or, less commonly, overly enthusiastic and obsessed with an idea of often global proportions. He develops psychomotor agitation and requires urgent hospitalization in a psychiatric hospital. The patient is under the supervision of specialists and he is more likely to start treatment in a timely manner.

The gradual development of delirium formation leads to constant not too noticeable changes in the patient's behavior. He is less and less concerned about life realities, family and work problems. He removes himself from them, becoming more and more self-contained. Nevertheless, against the background of general detachment, the patient shows ingenuity and activity, trying to realize his ideas: writes letters to various authorities, tracks down rivals, tries to expose ill-wishers or to realize himself as a reformer. He cannot be convinced of wrongness by any logical arguments and proofs or his energy can be redirected to another, more real direction. [5]

A typical symptom of schizophrenic delirium is aimless philosophies or schizophasia. The patient cannot be stopped, he speaks incessantly, and moreover coherently, without using parasitic words. However, the meaning in his monologue is simply absent.

The paranoid stage may persist for a long time, but it is schizophrenia, in contrast to schizotypal disorders, that is a progressive disease, and over time, disorganization of the systematic structure of delirium, more often monotemic, and an increase in deficit changes are observed to a greater or lesser extent.

Paranoid delirium is gradually transforming into paranoid - new topics appear, multidirectional, devoid of reality, delirium becomes more and more chaotic. The patient has broken thinking, which is manifested by speech disorders: sudden stops, abrupt change of subject, inconsistency, mentism, abstract statements that make speech noticeably meaningless. The vocabulary is also reduced, it often does not use prepositions and / or conjunctions, does not take initiative in the conversation, answering briefly and not in essence, but hooking on a favorite topic, it cannot stop. Speech is replete with repetitions, not always understood by neologisms, and the loss of grammatical structure. The presence of all these symptoms is not necessary, they appear depending on the depth of the psyche lesion.

Psychiatrists, based on observations of patients, note the following features of delirium with schizophrenia: it practically does not reflect the benign personality traits of the patient, since completely new personality traits appear under the influence of the pathological process (A.Z. Rosenberg), this is confirmed by O.V. Kerbikov calling this phenomenon a delirium of rebirth. Psychiatrists also note a slow systematization of delusional judgments, pretentiousness, full of abstractions and symbolism, a big gap from reality.

In the paranoid stage, pseudo- and true hallucinations are added to the delirium - involuntary perception of objects that are actually absent. In schizophrenics, pseudo-hallucinations occur more often, the patient understands their unreality, but is not able to show a critical attitude towards them. He unquestioningly obeys and believes in sounding voices that he hears with an “inner ear”. Basically, with delusional schizophrenia, patients experience auditory hallucinations, and the most typical are voices giving orders, accusing, threatening, or simply obsessive sounds (howling wind, pouring or dripping water, creaks, whistles, stomping) without verbal registration. Other types of hallucinations (visual, olfactory, tactile) may also be present, but they do not occupy the main place in the clinical picture. After the appearance of hallucinations, the delirium “crystallizes”, becomes more distinct, its content becomes complicated and takes on a fantastic color.

Then the paraphrenic stage of the disease can occur. It is characterized by the so-called “pathological intellectual creativity” (M. I. Rybalsky). The peculiarities of paraphrenic delirium are the inconstancy and variability of the first individual components of the plot, then of certain events, which ends with a change in the whole plot. The patient at this stage feels better, begins to “remember” his past life, it seems to him that the disease is receding. The mood in a patient with paraphrenic syndrome is usually upbeat, speech is emotional, systematized. They are charismatic and can be persuasive, especially in cases where the plot of the delirium is quite real. But in most cases, paraphrenia delirium is distinguished by its fantastic absurd content. The patient often develops megalomania. He feels himself the messiah, capable of changing the history of mankind, appropriating great discoveries for himself, in contact with aliens or otherworldly forces.

Delusional schizophrenia in elderly patients often begins immediately with paraphrenic syndrome. In this case, a depressive type of its course and delusions of "small scope" are characteristic - elderly schizophrenics are mostly convinced that imaginary ill-wishers (relatives or neighbors often play this role) oppress them, do not like them, want to get rid of them, try to deceive and cause damage (poison, injure, deprive housing). Even in the presence of delusions of grandeur, it is pessimistic in nature: it was underestimated, around it ill-wishers "put sticks in the wheels", etc. [6]

For deep pathological changes in the structure of the psyche in the paranoid or paraphrenic stage, not only hallucinations, but also mental automatisms are characteristic. They are divided into motor ones - the patient claims that he does not move of his own free will, but following orders from the outside; ideational, concerning the thought process (thoughts translate from the outside, replacing them with their own); sensory - external imposition of sensations. According to patients, the most fantastic sources of external influence are foreign intelligence services, aliens, witches, often in the person of an old acquaintance, colleague or neighbor. Influence on the patient can be carried out, according to his ideas, by means of wave radiation, for example, through a radio stream or a transmitter built into an electric bulb. Mental automatisms, coupled with delusions of exposure, are described in psychiatry as Kandinsky-Clerambo syndrome, the most common in the symptom complex of developed schizophrenia.

In the general clinical picture of schizophrenia, along with delusions, various emotional disturbances take place: depressed mood, manic episodes, panic attacks, attacks of apathy or aggression.

True schizophrenia should progress and lead to the appearance of a specific schizophrenic defect, otherwise the disease is diagnosed as a schizotypic personality disorder. The development of negative symptoms can inhibit the correct treatment, a sluggish course of the disease. In general, paranoid delusional schizophrenia is not characterized by such pronounced manifestations as incoherent speech, inadequate associations, impoverishment of emotions, flattening of feelings, catatonic disorders, striking disorganization of behavior. Nevertheless, negative symptoms, although not too pronounced, manifest themselves over a long period of the disease or each of its attacks ends with some losses - a narrowing of the circle of communication, interests, and a decrease in motor activity.

Complications and consequences

Delirium with schizophrenia already suggests a disturbance in the process of perception and thinking. Even in the initial stage of the disease, the presence of delusions prevents a person from building communications, solving family and work problems. With schizophrenia, attention and memory suffer, speech and motor skills are impaired, and an emotional and intellectual deficit is slowly but steadily increasing. [7]

The most common comorbid disorder for schizophrenia is depression. A depressive mood accompanies schizophrenics often from the prodromal phase. And at the initial stage of the development of the disease, increased anxiety caused by persistent disorders of perception, become the cause of suicidal intentions and attempts. Schizophrenia is generally considered a disease with a high risk of suicide. Particularly dangerous in this regard is depression, which develops within six months after the first episode of psychosis.

Schizophrenics are prone to abuse of alcohol and other psychoactive substances, which leads to an atypical course, frequent relapses and pharmacoresistance. Alcoholism or drug addiction in schizophrenics quickly becomes permanent. Patients stop working, shy away from treatment and lead an antisocial lifestyle, often breaking the law.

According to studies, panic attacks develop in about a third of patients, their symptoms can appear in the prodromal period, during and after psychotic episodes.

More often than in the general population, many somatic pathologies are found among schizophrenics, especially obesity and pathologies of the cardiovascular system.

Schizophrenia often causes disability, and the life expectancy of patients with this diagnosis is shorter by an average of 10-15 years. It is believed that schizophrenia itself does not lead to this (some patients live very long), but a commitment to bad habits and a tendency to suicide.

Diagnostics of the delusional schizophrenia

The question of clear clinical criteria for schizophrenia and, in general, many psychiatrists do not consider it an independent mental illness, is still open. The approach to this issue in different countries is also not the same.

If schizophrenia is suspected, the initial diagnosis of the disease requires the collection of a complete somato-neurological history of the patient. The doctor must talk not only with the patient, but also with his relatives.

Examination of the patient's somatic state of health includes laboratory tests and a complete cardiological examination. Laboratory diagnosis is not able to confirm the diagnosis of schizophrenia, such an analysis does not yet exist, but it gives an idea of the patient’s general state of health and helps to prevent diagnostic errors and to distinguish the manifestations of schizophrenia from symptoms resembling it, developing with endocrine pathologies, collagenoses, neuroinfections, diseases with manifestations of neurodegeneration and so forth

The patient is prescribed various tests from a general blood and urine test to determine the level of glucose, thyroid hormones and the pituitary gland, corticosteroid and reproductive, plasma electrolytes, C-reactive protein, urea, calcium, phosphorus, and biochemical tests. Tests for the presence of drugs and HIV infection, the Wasserman reaction, the study of spinal cerebrospinal fluid.

Instrumental diagnostics is prescribed in a variety of ways, allowing you to make a conclusion about the work of all systems in the body. Neurophysiological examination is mandatory, which includes electroencephalography, duplex angioscanning, magnetic resonance imaging. Although hardware studies reveal the presence of morphological and neurodegenerative cerebral disorders, they also cannot exactly confirm the diagnosis of schizophrenia. [8]

European psychiatrists are guided by the diagnostic criteria outlined in ICD-10. The diagnosis of the delusional form of schizophrenia is made if the patient has a pronounced delusional syndrome. Symptoms of delusions of a specific content (exposure, mastery, attitude, persecution, openness of thoughts) should be available for a long time, at least a month, and regardless, whether the patient was treated during this period. Delusional or hallucinatory delusional symptoms should not be caused by any kind of intoxication or neurological pathology, and in the observation of the patient there are signs of qualitative changes in behavior - narrowing of interests, social circle, increase in passivity, isolation, indifference to appearance.

Deficit changes related to neurocognitive (attention, imagination, memory, speech) and executive functions are determined using various pathopsychological and neuropsychological tests.

Differential diagnosis

It is quite difficult to differentiate delusional schizophrenia from other mental disorders with a pronounced delusional component. Long-term follow-up of the patient is recommended - at least six months before diagnosing him with schizophrenia.

First of all, organic pathologies in the brain structures responsible for the processes of thinking and the emotional state, especially pituitary tumors, lesions of the frontal structures of the brain, vascular malformations, abscesses, cysts, hematomas, are excluded. Postponed and chronic neuroinfections - herpetic, neurosyphilis, tuberculosis, HIV, other viruses, the effects of collagenoses, traumatic brain injuries, neurodegeneration, metabolic disorders (pernicious anemia, folate deficiency, metachromatic leukodystrophy, hepatocerebral dystrophinosis). With a clear disease of the central nervous system, infectious or intoxication, including alcohol, drug damage to the brain, schizophrenia is not diagnosed, unless it is clearly established that its symptoms preceded an infectious disease, trauma or abuse of psychoactive substances. [9]

The duration of the schizophrenic state is taken into account in the diagnosis. In cases where the symptomatology is observed for less than one month and is self-stopping or stopping medication, the patient's condition is classified (according to ICD-10) as schizotypic or schizoaffective psychotic disorders.

An isolated delusional syndrome per se, even with manifestations of schizophrenia-specific delirium (persecution, relationships, interactions), indicates only the pathology of the central nervous system and is not an absolute diagnostic criterion. Although with the complete identity of the delusional structure and plot, some features are still there. With epilepsy, neurosyphilis, encephalitis after severe infections, atherosclerotic lesions complicated by somatogenic intoxication, depression, post-traumatic, alcoholic and narcotic psychoses, delirium is usually simpler and more specific. In addition, it has been observed that patients with epidemic encephalitis express a desire to cure their disease and even “stick” with this to the medical staff, epileptics and depressed patients rave in twilight states, while in schizophrenics there is no change in consciousness. Their delusions and delusions are distinguished by pretentiousness and complexity. In addition, with schizophrenia, delirium concerns not so much the physical impact as the subjective experiences of the patient, reflects the invasion and capture of his volitional sphere and thinking. [10]

Schizophrenia and delusional disorders are also differentiated, in which mono- or polythematic chronic delirium develops, which is identical in structure and plot to schizophrenic. The same topics - persecution, jealousy, personal ugliness, clericalism, greatness with periodic episodes of depression, olfactory and tactile hallucinations, and in elderly patients, auditory ones, which are part of the clinical picture of schizophrenia, are also observed in delusional disorder. Some have been ill with them all their lives, however, such patients never have chronic peremptory voices, constant delirium of exposure, and even mild negative symptoms. In addition to behavior that is directly related to delirium, the mood, speech and actions of patients with delusional disorder are quite adequate to the situation and do not go beyond the norm. [11]

So, with delusional personality disorder, delirium is the only or most striking symptom. It is quite logical, realistic and often provoked by life situations, and should also be observed for three months or more, be personal in character and continue not only during periods of affect disorders, but also outside them. There should be no delirium of influence, transmission and openness of thoughts, rare transient auditory hallucinations are allowed. There should also be no signs of organic damage to the brain of any genesis.

The main diagnostic criterion for schizophrenia remains the presence of a progressive nature of the weakening of mental activity.

Treatment of the delusional schizophrenia

For a detailed treatment of delusional schizophrenia, read this article .

Prevention

The hereditary burden cannot be changed, but it is not the only risk factor for the development of the disease, external conditions are still necessary, to minimize which efforts must be made.

With a genetic predisposition, pregnancy is best planned. Even before its onset, it is necessary to examine and treat the available pathologies in order to avoid drug exposure to the fetus. It is important that the weight of the expectant mother is in line with the norm, and she was able to abandon bad habits before pregnancy, during the period of gestation she did not smoke or drink. A balanced diet, moderate physical activity, stable and calm family relationships are factors predisposing to the birth of a healthy child. Caring for his physical and mental health, positive emotional support, a healthy lifestyle cultivated in the family will allow him to grow as healthy as possible and minimize the risk of developing delusional schizophrenia.

In the adolescent period, excessive emotional expression should be avoided, the child’s behavior, activities and circle of acquaintances should be controlled, observing the “middle ground” in order to avoid both excessive dependence and lack of control. In the event of a depressive mood or other changes in affect, the child can attend a psychotherapist, special trainings that help to form internal mechanisms to combat the influence of stressful factors.

At any age, the ability to accept oneself, to communicate with others and to find those who can provide assistance are considered important preventive steps to prevent the development of a mental disorder; the opportunity to "talk"; physical activity, with group exercises preferred; ability to manage the reaction stressors; a decrease, or better, a complete rejection of alcohol and other psychoactive substances; the acquisition of new skills, creative and spiritual activities, participation in the social life of life, the presence of good friends and a strong family.

Forecast

The question of the existence of schizophrenia as a single disease remains open, the criteria for diagnosing this disease also differ significantly in psychiatric schools in different countries. But in general, delusional schizophrenia, as if it were not called, so far refers to serious and incurable diseases. Nevertheless, a good prognosis increases the earlier start of treatment, its continuity and lack of stigma. The studies revealed that stigma led to more pronounced symptoms of schizophrenia compared with those patients who were treated without knowing their diagnosis.

A long-term therapeutic effect is considered a good prognosis, sometimes patients are even canceled taking drugs. Success depends entirely on the adequacy of the prescribed treatment and the individual resources of the patient’s personality. Modern psychiatry with an integrated approach to treatment has a large arsenal of means to stabilize the patient's condition.