Delusional schizophrenia

Delirium is almost always present in schizophrenics, even in rapidly progressing malignant forms in the initial period, disappearing as they "withdraw into themselves" and become increasingly dull. The author of the symptoms of first-rank schizophrenia, Kurt Schneider, called it a delusional disease in the fullest sense of the word. Systematized 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 classical typical form of schizophrenia that the productive symptoms are most clearly expressed - delirium and hallucinations. The first symptom, as a rule, is a delusional conviction of something that does not correspond to reality. It can be based on real facts or arise in the form of a ready-made plot. At first, delirium is relatively understandable and represents a chain of logically connected conclusions, sometimes even very plausibly interpreting the situation. Later, as the disease develops and thinking is clearly disintegrating, auditory hallucinations usually appear. Inner voices sounding in the head, other parts of the body, suggested "foreign" thoughts and forced statements, sensations 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 expressed to a much lesser degree or are not noticeable at all, however, many clinicians believe that delusional perception of internal and external events is typical for a schizophrenic. The hidden "delusional work" of the sick brain does not always result in obvious psychosis, but is the underlying cause of increasing pessimism, anxiety, a sense of hostility in the environment and inevitable disaster, forcing the patient to withdraw into himself and isolate himself from the world.

Affective-paranoid syndrome is characterized by depression, delusional ideas of persecution, self-accusations and hallucinations with a vivid accusatory character. In addition, this syndrome can be characterized by a combination of mania of grandeur, noble origin and hallucinations of a laudatory, glorifying and approving nature.

Epidemiology

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

Causes delusional schizophrenia

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

Risk factors

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

Modern diagnostic equipment has made it possible to detect structural disorders in parts of the brain in schizophrenics during their lifetime, also non-specific. Similar anomalies, expressed to a lesser degree, are often detected in close relatives of patients.

Schizoid personality traits (anxiety, 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 unfavorable psychosocial environmental stressors can become a trigger for the development of the disease. Childhood spent in a family where the cult of violence prevailed, low social status, loneliness, frequent moves, lack of understanding and support from loved ones, even the rhythm of life in a metropolis can provoke the development of schizophreniform symptoms.

Age crises associated with changes in hormonal and psychosocial status are recognized as periods of increased risk of onset and exacerbation of schizophrenia: adolescence, pregnancy and childbirth, menopause, retirement.

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

Neuroendocrinological hypotheses are earlier. The basis 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 period of fading sexual function, and frequently encountered endocrine pathologies in schizophrenics.

Proponents of the neuroendocrine hypothesis assumed that mental pathology developed under the influence of internal (autointoxication due to dysfunction of the endocrine glands) and unfavorable external factors, the susceptibility to which was predisposed by the weakness of the endocrine system. However, no disorders of the endocrine organs specific to schizophrenia have been identified, although a certain role of hormonal shifts in pathogenesis is recognized by most researchers. [ 2 ]

In patients with schizophrenia, changes in cellular and humoral immunity are observed, which served as the basis for the development of neuroimmunological theories; some authors developed the theory of the viral origin of schizophrenia; however, at present, none of the proposed versions is fully capable of explaining the pathogenesis of the disease.

One of the main manifestations of psychosis in schizophrenia is delirium. It, or at least a delusional perception of the surrounding world, is found in 4/5 patients diagnosed with schizophrenia. This phenomenon of thought disorder is most clearly expressed in the paranoid form of the disease.

Pathogenesis

The pathogenesis of delirium in schizophrenia is also explained differently by representatives of different psychiatric schools and trends. According to some, it grows out of the patient's life experience, interpreted with some special meaning in connection with a change in the awareness of the surrounding world. For example, pathologies of the gastrointestinal tract that the patient had in his anamnesis can result in delusions of poisoning. According to others, delusional ideas are weakly dependent on real events and personal characteristics of the patient. First, there is a split in consciousness, against the background of which the schizophrenic's existence is transformed, and then delusional perception (abnormal sensations) appears, from which the delirium itself grows as an attempt to explain these sensations, their origin, and the explanations can be the most incredible.

It is currently believed that in order to trigger the mechanism of delusional development, a certain personality type and the presence of pathology of the cerebral cortex are necessary, in particular, its frontal lobes, 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 delusional ideas is considered extremely important and, to date, proven.

Symptoms delusional schizophrenia

The delusional form of schizophrenia manifests itself in the statements and behavior of the patient, who defends his false beliefs with indisputable persistence. The most characteristic feature of this disease is the stage-developing chronic delirium. [ 3 ]

German psychiatrist K. Conrad identified several stages in the dynamics of the formation of schizophrenic delirium. The first signs of its development (trema phase) are characterized by such symptoms 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 understandable, which causes tension and a feeling of fear. Depending on the plot of the first delusional thoughts, a feeling of guilt may appear, against the background of which suicidal thoughts arise. Much less often, patients in this phase experience an elevated mood. [ 4 ]

The next, second stage of development of delusional formation is (apophenia), delusional "enlightenment". Crystallization of delusion begins - the patient's delusional ideas become more specific, he finds himself in their captivity. At the same time, the situation becomes more definite for him, doubts disappear, confusion and tension weakens. Patients at this stage often feel themselves to be the "center of the universe", the only ones possessing true knowledge. Delusion at this stage is usually logical and quite plausible.

The anastrophic or apocalyptic phase is characterized by incoherent hallucinatory delirium. This stage does not occur in everyone. It is characterized by serious disorganization of thinking, speech disorders, and the emergence of irreversible negative symptoms.

Delirium does not always develop in stages. It can manifest itself as an acute paranoid outburst or grow out of an overvalued idea based on real life facts, from which the patient draws his own conclusions that contradict practical experience. Delirium has the character of a belief; the patient does not need proof of his rightness. He is convinced of it.

In official psychiatry, the initial stage of delusional development is called paranoid. At this stage, delusions are not yet accompanied by hallucinations and are logically structured. The patient interprets events and behavior of people around him quite plausibly. Often at this stage, the symptoms of delusion have not yet reached a significant height and are not particularly noticeable. People around them interpret them as character quirks. The patient sometimes consults a doctor, but not a psychiatrist, but a therapist, neurologist, cardiologist with complaints of loss of strength, headache or heart pain, difficulty falling asleep, unusual sensations in different parts of the body. He may have some eccentricities, obsessions, irritability, poor concentration, forgetfulness against the background of anxiety or, less often, an overly joyful mood, but at the initial stage, the patient's complaints are usually diagnosed as vegetative-vascular disorders, neurosis, or manifestations of osteochondrosis. And even a psychiatrist will not be able to confidently diagnose schizophrenia at an early stage with the developing process of delusional formation. This requires long-term observation of the patient.

Psychiatrists are also familiar with 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 attacks of severe myrgen-like headaches, against which they have difficulty maintaining spatial coordination, a feeling of weightlessness sets in, and the patient simply loses the ground from under his feet, he feels like "Armstrong on the Moon."

A more striking debut is acute psychosis. It manifests itself in a sudden and rapid increase in symptoms. In addition to obvious disorganization of thinking, in most cases, the patient may be abnormally excited, aggressive, prone to destructive actions or, less often, overly enthusiastic and obsessed with some idea, often of a global scale. He develops psychomotor agitation and requires urgent hospitalization in a psychiatric hospital. The patient is under the supervision of specialists and has a better chance of starting treatment in a timely manner.

The gradual development of delusional formation leads to constant, not very noticeable changes in the patient's behavior. He is less and less concerned with the realities of life, family and work problems. He withdraws from them, becoming more and more withdrawn. Nevertheless, against the background of general detachment, the patient shows ingenuity and activity, trying to implement his ideas: he writes letters to various authorities, tracks down rivals, tries to expose ill-wishers or realize himself as a reformer. No logical arguments and evidence can convince him of his wrongness or redirect his energy in another, more realistic direction. [ 5 ]

A typical symptom of schizophrenic delirium is aimless philosophizing or schizophasia. The patient cannot be stopped, he talks incessantly, and coherently, without using filler words. However, there is simply no meaning in his monologue.

The paranoid stage can persist for a long time, but schizophrenia, unlike schizotypal disorders, is a progressive disease, and over time, to a greater or lesser extent, disorganization of the systematized structure of delusions, often monothematic, and an increase in deficit changes are observed.

Paranoid delirium gradually transforms into paranoid — new topics appear, multidirectional, devoid of reality, delirium becomes increasingly chaotic. The patient has a fragmented thinking, which is manifested by speech disorders: sudden stops, abrupt changes of topic, inconsistency, mentalism, abstract statements that make speech noticeably meaningless. The vocabulary also decreases, he often does not use prepositions and/or conjunctions, does not take the initiative in conversation, answers briefly and irrelevantly, but having touched on a favorite topic, he cannot stop. The speech is full of repetitions, not always understandable neologisms, loss of grammatical structure. The presence of all the listed symptoms is not necessary, they manifest themselves depending on the depth of the psyche's damage.

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

In the paranoid stage, pseudo- and true hallucinations join the delirium - an involuntary perception of objects that are absent in reality. Schizophrenics often experience pseudo-hallucinations, the patient understands their unreality, but is unable to show a critical attitude towards them. He unquestioningly obeys and believes the voices that he hears with his "inner ear". In delusional schizophrenia, patients mainly experience auditory hallucinations, and the most typical are voices giving orders, accusing, threatening, or simply intrusive sounds (howling wind, pouring or dripping water, creaking, whistling, stomping) without verbalization. Other types of hallucinations (visual, olfactory, tactile) may also be present, but they do not occupy a major place in the clinical picture. After the appearance of hallucinations, the delirium “crystallizes”, becomes clearer, its content becomes more complex and takes on a fantastic color.

Then the paraphrenic stage of the disease may occur. It is characterized by the so-called "pathological intellectual creativity" (M.I. Rybalsky). The peculiarities of paraphrenic delirium are inconstancy and variability, first of individual components of the plot, then of some events, which ends with a change in the entire plot. At this stage, the patient feels better, begins to "remember" his past life, it seems to him that the disease is retreating. The mood of a patient with paraphrenic syndrome is usually elevated, speech is emotional, systematized. They are charismatic and can be convincing, especially in cases where the plot of the delirium is quite real. But in most cases, delirium in paraphrenia is distinguished by fantastic absurd content. The patient often develops megalomania. He feels like a messiah, capable of changing the history of mankind, appropriates great discoveries, contacts 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 "small-scale" delusions are typical - elderly schizophrenics are mainly convinced that imaginary ill-wishers (often relatives or neighbors) oppress them, do not love them, want to get rid of them, try to deceive and harm them (poison, injure, deprive them of housing). Even in the presence of delusions of grandeur, it is pessimistic: underestimated, ill-wishers are all around "putting spokes in the wheels", etc. [ 6 ]

Deep pathological changes in the structure of the psyche at the paranoid or paraphrenic stage are characterized not only by hallucinations, but also by mental automatisms. They are divided into motor - the patient claims that he moves not of his own free will, but following orders from the outside; ideational, concerning the thought process (thoughts are transmitted from the outside, replacing his own with them); sensory - external imposition of sensations. The sources of external influence, according to patients, are the most fantastic - foreign intelligence services, aliens, witches, and 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 outlet or a transmitter built into an electric bulb. Mental automatisms together with delusions of influence are described in psychiatry as the Kandinsky-Clerambault syndrome, most often encountered in the symptom complex of developed schizophrenia.

In the general clinical picture of schizophrenia, along with delirium, there are various emotional disturbances: depressed state of mind, manic episodes, panic attacks, bouts of apathy or aggression.

True schizophrenia must progress and lead to the emergence of a specific schizophrenic defect, otherwise the disease is diagnosed as a schizotypal personality disorder. The development of negative symptoms can be slowed down by properly prescribed treatment, a sluggish course of the disease. In general, paranoid delusional schizophrenia is not characterized by such pronounced manifestations as incoherent speech, inadequacy of associations, impoverishment of emotions, flattening of feelings, catatonic disorders, striking disorganization of behavior. Nevertheless, negative symptoms, although not very pronounced, appear over a long period of the disease or each attack ends with some losses - a narrowing of the circle of communication, interests, a decrease in motor activity.

Complications and consequences

Delusions in schizophrenia already imply a disorder of the perception and thinking process. Even in the initial stage of the disease, the presence of delusional ideas prevents a person from building communications, solving family and work problems. With schizophrenia, attention and memory suffer, speech and motor skills are impaired, emotional and intellectual deficits slowly but steadily increase. [ 7 ]

The most common comorbid disorder in schizophrenia is depression. Depressive mood often accompanies schizophrenics from the prodromal phase. And at the initial stage 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. Depression that develops within six months after the first episode of psychosis is especially dangerous in this regard.

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

Panic attacks, according to research, develop in approximately a third of patients; their symptoms can appear in the prodromal period, during psychotic episodes and after them.

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

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 this is not caused by schizophrenia itself (some patients live very long), but by addiction to bad habits and suicidal tendencies.

Diagnostics delusional schizophrenia

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

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

Examination of the patient's somatic health includes laboratory tests and a full cardiological examination. Laboratory diagnostics are not able to confirm the diagnosis of schizophrenia, such analysis does not yet exist, but it gives an idea of the patient's general health and allows to prevent diagnostic errors and distinguish the manifestations of schizophrenia from symptoms resembling it, developing in endocrine pathologies, collagenoses, neuroinfections, diseases with manifestations of neurodegeneration, etc.

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

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

European psychiatrists are guided by the diagnostic criteria set out in ICD-10. The diagnosis of delusional schizophrenia is made if the patient has a pronounced delusional syndrome. Symptoms of delusion of a specific content (influence, possession, relationship, persecution, openness of thoughts) must be present for a long time, at least a month, regardless of 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 observations of the patient reveal signs of qualitative changes in behavior - narrowing of interests, social circle, increasing passivity, isolation, indifference to appearance.

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

Differential diagnosis

Differentiating delusional schizophrenia from other mental disorders with a pronounced delusional component is quite difficult. Long-term observation 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 thinking processes and emotional state are excluded, especially pituitary tumors, lesions of the frontal structures of the brain, vascular malformations, abscesses, cysts, hematomas. Past and chronic neuroinfections - herpes, neurosyphilis, tuberculosis, HIV, other viruses, consequences of collagenoses, craniocerebral injuries, neurodegeneration, metabolic disorders (pernicious anemia, folate deficiency, metachromatic leukodystrophy, hepatocerebral dystrophy, sphingomyelinosis). In case of obvious disease of the central nervous system, infectious or intoxication, including alcohol, drug damage to the brain, schizophrenia is not diagnosed, unless it is precisely established that its symptoms preceded the infectious disease, injury or abuse of psychoactive substances. [ 9 ]

The duration of the schizophrenia-like condition is taken into account in the diagnosis. In cases where the symptoms are observed for less than one month and are self-limited or relieved by medication, the patient's condition is classified (according to ICD-10) as schizotypal or schizoaffective psychotic disorders.

An isolated delusional syndrome in itself, even with manifestations of delusions specific to schizophrenia (persecution, relationships, interaction), indicates only a pathology of the central nervous system and is not an absolute diagnostic criterion. Although with complete identity of the delusional structure and plots, some features are still present. In epilepsy, neurosyphilis, encephalitis after severe infections, atherosclerotic lesions complicated by somatogenic intoxication, depression, post-traumatic, alcoholic and drug psychoses, delirium is usually simpler and more specific. In addition, it has been noted that patients with epidemic encephalitis express a desire to cure their disease and even "pester" medical personnel about it, epileptics and depressive patients are delirious in states of twilight consciousness, while in schizophrenics, changes in consciousness are not observed. Their delirium and delirious statements are distinguished by pretentiousness and complexity. Moreover, in schizophrenia, delirium concerns not so much the physical impact as the subjective experiences of the patient, reflecting the invasion and capture of his volitional sphere and thinking. [ 10 ]

Schizophrenia and delusional disorders are also differentiated, in which mono- or polythematic chronic delusions develop, identical in structure and plot to schizophrenic ones. The same themes - persecution, jealousy, one's own ugliness, querulantism, grandeur with periodic episodes of depression, olfactory and tactile hallucinations, and in elderly patients auditory hallucinations are also allowed, which are part of the clinical picture of schizophrenia, are also observed in delusional disorder. Some suffer from it all their lives, however, such patients never have chronic imperative voices, constant delusions of influence, or even weakly expressed negative symptoms. In addition to behavior 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 ]

Thus, in 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 of a personal nature and continue not only during periods of affective disorders, but also outside of them. There should be no delusions of influence, transmission and openness of thoughts, rare transient auditory hallucinations are allowed. There should also be no signs of organic brain damage of any genesis.

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

Treatment delusional schizophrenia

Read this article for detailed treatment of delusional schizophrenia.

Prevention

Hereditary burden cannot be changed, but it is not the only risk factor for the development of the disease; external conditions are also necessary, and efforts must be made to minimize them.

If there is a genetic predisposition, it is better to plan pregnancy. Even before its onset, it is necessary to undergo examination and treat existing pathologies in order to avoid drug effects on the fetus. It is important that the expectant mother's weight is normal, and she was able to give up bad habits before pregnancy, and during the period of gestation - not smoke or drink. A balanced diet, moderate physical activity, stable and calm relationships in the family are factors that predispose 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 up as healthy as possible and minimize the risk of developing delusional schizophrenia.

During adolescence, excessive emotional expression should be avoided, the child's behavior, activities, and circle of acquaintances should be controlled, observing the "golden" mean in order to avoid both excessive dependence and lack of control. If a depressive mood or other changes in affect occur, the child can visit a psychotherapist, special trainings that help to form internal mechanisms for combating the influence of stress factors.

At any age, important preventive steps that prevent the development of mental disorders are considered to be the ability to accept oneself, communicate with others and find those who can help; the ability to "speak out"; physical activity, with group activities being preferable; the ability to manage reactions to stressors; reducing, or better yet, completely giving up alcohol and other psychoactive substances; acquiring new skills, creative and spiritual activities, participating in social life, having good friends and a strong family.

Forecast

The question of the existence of schizophrenia as a single disease remains open, the diagnostic criteria for this disease also differ significantly among psychiatric schools in different countries. But in general, delusional schizophrenia, no matter what it is called, still belongs to severe and incurable diseases. Nevertheless, a good prognosis is increased by early treatment, its continuity and the absence of stigmatization. In the conducted studies, it was found that stigma led to more pronounced symptoms of schizophrenia compared to those patients who were treated without knowing their diagnosis.

A good prognosis is the achievement of a long-term therapeutic effect, sometimes patients are even stopped taking medications. Success depends entirely on the adequacy of the prescribed treatment and the individual resources of the patient's personality. Modern psychiatry, with a comprehensive approach to treatment, has a large arsenal of tools to stabilize the patient's condition.