Mosaic schizophrenia

Mosaic - translated from French means a motley mixture, in a broader sense - something consisting of heterogeneous elements. In medicine, this term refers to diseases that have signs of different forms that cannot be attributed to any one type of disease. In modern classifiers, such pathological conditions are preferred to be called mixed (English version - mixed), completely getting rid of the metaphorical definition.

Mosaic polymorphic psychopathy was still distinguished in the previous version of the disease classifier (ICD-9), and mosaic schizophrenia has not been mentioned in authoritative sources for a long time. This term is found mainly in articles that somehow mention the biography of Friedrich Nietzsche and the disease that was apparently called that at the end of the 19th century. In modern versions of classifiers, serious books and articles on psychiatry, the definition of "mosaic" in relation to schizophrenia is no longer found, although in everyday life you can still encounter such a formulation.

What is this?

Former psychopathies, and now severe personality disorders, since they often bring a lot of inconvenience and suffering to the subject himself and his environment, can lead to isolation and social disintegration. But, at the same time, a psychopath cannot be classified as sick, because his characteristics are not associated with organic damage to the brain and are not manifestations of diseases. At least at the current level of diagnostics, painful changes in the body cannot be detected, although there is clearly something wrong with the subject's psyche. ICD-10 distinguishes dependent, hysterical anxious, paranoid, schizoid, sociopath and others, a total of eight main types and six more classified as others. So, mosaic psychopathy does not fit the description of any of the types listed in the classifier. Mosaicity or mixing is manifested in the fact that one character has symptoms of several disorders at once, sometimes absolutely polar. They are so mixed that it is impossible to isolate the core syndrome. However, despite the possible progressive social isolation of the psychopath due to his inadequate character traits, the patient’s intellect (mental abilities) remain intact.

If we are talking about schizophrenia, then in the modern interpretation, it is a severe progressive disease, resulting in mental retardation. Mosaic schizophrenia, in relation to the example of Nietzsche, is, first of all, an obsession with an overvalued idea. Psychiatrists note that not only schizophrenics are prone to the emergence of overvalued ideas and their fanatical promotion, but also psychopaths, who have a mixture of symptoms of the schizoid and psychasthenic types, and who are also prone to radicalism.

Psychopaths, unlike schizophrenics, are sane and perfectly aware of their actions, so they bear criminal responsibility for committing illegal acts equally with everyone else. Nevertheless, a whole group of personality disorders are classified among mental illnesses, since their manifestations differ significantly from the generally accepted norms in society and cause significant anxiety to the subject himself and the people around him. Often, the behavior of a psychopath is simply socially dangerous.

Epidemiology

Statistics also do not have exact figures. Psychopaths, in general, come to the attention of researchers only after committing crimes and being sentenced. The frequency of occurrence of psychopathies of all types is estimated as follows - every twentieth inhabitant of the planet can be a psychopath, every tenth has individual psychopathic character traits, but is still not a psychopath in the full sense of the word. The overwhelming majority of psychopaths belong to the strong half of humanity - their share is estimated at 80%.

Causes mosaic schizophrenia

A person acquires psychopathic personality traits under the influence of many factors. It is assumed that the formation of pathological character traits occurs mainly at a very early age. It is the influence of unfavorable external stimuli in the first three years, when complex behavioral skills are formed that facilitate adaptation in society, and even on a child with a hereditary predisposition, that is considered the most destructive. In older children, according to experts, susceptibility to unfavorable external influences becomes lower, however, if the effect of negative stress factors continues, then behavioral characteristics increasingly deviate from the norm.

The development of genetics has made it possible to discover a specific type of genes, the carriers of which are naturally distinguished by cruelty, selfishness, lack of empathy for the suffering of others, and aggressive behavior. The MAO-A gene (the warrior gene, the aggression gene) encodes monoamine oxidase A in a certain way, influencing biochemical reactions involving neurotransmitters that regulate mood and behavior - dopamine, serotonin, norepinephrine, melatonin, histamine. The carrier of this gene will not necessarily grow up to be a psychopath; the atmosphere surrounding him from early childhood is of great importance. A friendly and warm atmosphere in the family, combined with control over the child's behavior and certain restrictions, contribute to his socialization.

Unfavorable living conditions, violence, cruelty, witnessed or participated in by a child, early addiction to alcohol and/or drugs activate the aggression gene.

By origin, psychopathies are divided into congenital and acquired. The nuclear (congenital) form is determined by heredity and the constitution of a person. It manifests itself from childhood and, under unfavorable external conditions in which the child grows, develops into stable antisocial behavior.

Acquired ones are divided into marginal and organic. The latter are considered as behavioral deviations within the framework of some damaging action that caused brain failure, and are not classified as psychopathies.

Marginal ones are acquired at a later age and are associated with an extremely unfavorable environment. They are considered less stable and profound than nuclear ones, and since the formation of pathological personality traits occurs later and only under the influence of a number of unfavorable factors. It is also often impossible to classify their type, so acquired psychopathies are often classified as mixed (mosaic) personality disorders.

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Risk factors

Risk factors for the development of psychopathy, including the mosaic form, include:

• inheritance of a tendency towards aggression – in psychopaths, researchers have found reduced activity in the temporal frontal lobes of the brain, which are responsible for the quality of empathy and the formation of high moral standards;
• pathological pregnancy and childbirth of a psychopath's mother;
• injuries and diseases at an early age that affected the formation of the central nervous system;
• family history of syphilis, alcoholism, drug addiction;
• indifference of parents to their child, including both excessively harsh upbringing and permissiveness;
• bullying, cruelty, violence in the family or among the immediate environment;
• substance abuse;
• periods of age-related crises and hormonal changes.

Modern psychiatry has not yet come to a consensus regarding the mechanism of development of mixed personality disorder, as well as its other forms.

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Pathogenesis

The pathogenesis of psychopathy is considered from the point of view of different theories and none of them gives a complete picture of the mental disorder yet. However, researchers are unanimous in the opinion that the basis of psychopathy is laid in the early period of a child's development, when a negative social factor is superimposed on a hereditary predisposition, and it plays a major role in the development of marginal psychopathies.

The psychodynamic concept, based on the teachings of Z. Freud, considers personality disorder as a defensive reaction to pathological relationships within the family.

Followers of I. P. Pavlov explain the emergence of personality disorders by a pathological imbalance in the excitation and inhibition system, the practical absence of the latter, weakness of higher nervous activity, and uncoordinated work of the cortex and subcortex of the brain.

American neurobiologists studying psychopaths serving time in correctional facilities for committing serious crimes have discovered that the tomogram of their skulls has some peculiarities.

However, there is still no single pathogenetic theory that would provide a comprehensive explanation for such a phenomenon as psychopathy in general, not to mention its types.

Regardless of the type of personality disorder, the psychopathic scenario unfolds as a closed cycle. The individual's personality defects lead to the creation of a conflict situation, as a result of which he develops a psychopathic reaction, which lasts for a more or less long time. Russian and Soviet psychiatrist P.B. Gannushkin, who devoted a significant part of his work to the study of personality disorders, notes that psychopathy is characterized by a certain dynamic. The greatest influence on dynamic processes is exerted by the environment, as a result of which the pathological features of the psychopathic personality are weakened or strengthened. After the end of the next period of decompensation of the disorder, an aggravation of the defective character traits is noted.

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Symptoms mosaic schizophrenia

The character of mosaic psychopaths is accentuated in several directions; it is not possible to choose their belonging to any one type.

Such an individual may combine the traits of a suspicious, suspicious and touchy paranoid person, always right and with an inflated self-esteem, with the fantasies of a schizoid and the impulsiveness of an emotionally unstable type, prone to self-destructive behavior.

Combinations can be varied - a combination of two or more types of disorders, the lack of stability of the core psychopathic syndrome, its variability and is the main clinical sign of mixed personality disorder.

Experts distinguish the main character traits of psychopaths, according to which the individual can be classified into this category - the psychopathic triad.

1. Reckless audacity, fearlessness, lack of a sense of danger, enormous self-confidence and the ability to quickly make decisions allow them to become leaders, prove themselves in extreme situations and earn the respect of others.
2. Egoism combined with a lack of inhibition is an impulsive action aimed at immediate satisfaction of one's own desires, without taking into account anything or anyone, without thinking about the consequences of the actions taken. Psychopaths are always guided, first of all, by their desires.
3. The lack of ability to empathize even with the closest people, emotional dullness, which entails a trail of vile, from the point of view of public morality, actions.

These traits are characteristic of all forms of psychopathies, psychopaths always act this way - both excitable and asthenic, inhibited, first of all, they look after their own interests. It is ruthlessness and selfishness with a complete lack of remorse, sometimes well disguised, that distinguish a psychopathic personality from an ordinary person, who also sometimes acts selfishly, can deceive and be mean, and then worries and tries to justify himself and make amends. Psychopaths are brilliant manipulators and ruthless exploiters, to achieve their goals they perfectly use the empathy of others, and can react to insubordination with harsh aggression. Moreover, these people are always confident in their rightness, are pleased with themselves, show a complete lack of principles and are prone to sadism, physical and moral.

The first signs of nuclear mosaic psychopathy can be noticed already in childhood. Basically, parents pay attention to cruelty towards peers and/or other living beings, the desire to dominate, to command not only other children but also adults, to try to use force against those who disagree, not paying attention even to the physical superiority of the opponent. Aggression is characterized by great rage and persistence. Anyone can show such inclinations, but ordinary children respond to explanations and admonitions, and little psychopaths do not give in to any persuasion. They are characterized by a visible lack of remorse, a complete lack of understanding of their own guilt (there is always another culprit) and, most importantly, such children are not afraid of punishment. Obedience can be achieved from them only by promising them the reward they are interested in.

It is worth thinking about if small children constantly offend their friends and adults, snap, not responding to admonitions and punishments, take other people's things without asking, try to dominate in any environment. Teenagers generally become uncontrollable, they cannot be intimidated by any threats or convinced logically. Not wanting to obey, they often run away from home, get into bad company and commit illegal acts. The feelings of others, even the closest ones, are of no interest to psychopaths at any age.

However, not everything is so gloomy. Upbringing in a benevolent atmosphere smooths out pathological character traits to a certain extent. Socialized psychopaths assimilate well into society, make a good career, sometimes reach great heights (V.I. Lenin, I.V. Stalin, A.G. Lukashenko are considered mosaic psychopaths). They have families and a circle of friends who rate them quite positively, although they also note their recklessness and fearlessness, a tendency to unusual, often shocking actions, egoism and the ability to achieve their goals without taking into account the interests of others.

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Forms

Mosaic psychopathy is realized in active, passive and mixed forms. Active, in particular, include the already mentioned political leaders, big business tycoons. Experts claim that psychopaths in the population are about 1%, but among managers of various levels there are more than 5%. As a favorite job or, rather, the most frequently held position, they name "chairmen of the board".

The ICD-10 identifies the following specific personality spectrum disorders:

• paranoid - these are suspicious, touchy and very suspicious people with high self-esteem, distinguished by a persistent sense of their own rightness and convinced of the intentions of others to deceive their trust, which in fact they do not have in anyone (a typical example is jealous people);
• schizoid - withdrawn, prone to introspection, fantasies, anhedonia, not needing emotional attachment or even a minimal social circle;
• dissocial - sociopaths are distinguished by a significant discrepancy between their behavior and the basic norms accepted in society, the psychopathic triad in this case is expressed to the maximum, and the fear of punishment does not stop them, they easily fall into rage and can commit any acts of violence;
• emotionally unstable or excitable - easily become excited and are unable to control their behavior;
• hysterical - also easily excited, but their excitability is superficial in nature, more like a theatrical performance aimed at attracting attention;
• anankastic - insecure, meticulous and scrupulous, cautious, but very stubborn, overcome by obsessive ideas, actions that, however, do not reach the heights of mania;
• anxious - prone to exaggerating impending dangers, suspecting others of underestimating them, hypersensitive to criticism and rejection;
• dependent - cannot stand loneliness, such people need to obey someone from their relatives and/or friends, they are not able to make independent decisions even in small matters, their behavior directly depends on the chosen idol;
• Among others, there are also narcissists, eccentrics, disinhibited, infantile, passive-aggressive and psychoneurotics.

Mosaic psychopaths combine at least two types, and sometimes more, of the listed disorders in their behavior, and the manifestations are so unstable that they cannot be attributed to any type. Mixed personality disorder complicates the subject's adaptation in society, and it is also difficult for others to adapt to coexistence with such a person. P.B. Gannushkin called mosaic psychopaths constitutionally stupid, although, looking back at historical examples, it is difficult to agree with this.

The most dangerous combination is an antisocial personality with hysterical traits and emotional instability. Such people easily fall under the power of various addictions - they become drug addicts, alcoholics, ludomaniacs (pathological gamblers), sexual perverts and often cross the line of the law.

The presence of polar symptoms in one subject, for example, hyperexcitability combined with psychasthenia, should alert the physician and thoroughly examine the patient for schizophrenia.

Psychopaths with schizoid and psychoasthenic traits most often devote their lives to the implementation of overvalued ideas; some limit themselves to litigation, while others aim to reorganize the world.

If we return to the example of F. Nietzsche, who was diagnosed by his contemporaries with nuclear mosaic schizophrenia, currently interpreted as an obsession, then perhaps now he would be assessed as a mosaic psychopath. And significant personality changes would be attributed to syphilis. After all, if a psychopathic personality by nature becomes infected with an infectious disease or receives a head injury, and this leads to the development of organic cerebral deficiency, then the personality structure is transformed very significantly, and mental degradation occurs.

Obsession with some idea can also overcome schizophrenics. This symptom is additional, but if it is present, it manifests itself at the height of hypomania.

Mosaic or mixed nature is characteristic of different processes – cognition, thinking, feelings. This concept means superficiality, inconsistency, fragmentation. For example, mosaic memory (fragmentation of memories, lack of consistency, inability to form a complete picture) and fragmented, symbolic thinking are more likely symptoms of schizophrenia. Mosaic thinking in this case indicates an advanced stage of the disease and is manifested by schizophasia – “verbal hash”, absolutely meaningless, associatively unconnected speech, when its parts are combined purely mechanically. Patients, however, remain in a clear consciousness, fully retain all types of orientation, and their speech in most cases is grammatically correct. Although such symptoms are also inherent in schizoid psychopaths in the decompensation stage.

Psychopaths can be in two states. Socialized or compensated ones live with us, study, work (often successfully), create families and are not subject to registration, because they do not think that there is anything wrong with them, do not go to doctors and, being law-abiding citizens, do not fall into the field of view of researchers. Staying in the world with society is usually achieved due to the comfortable conditions of existence of a psychopathic personality.

A decompensated state is a pathological psychogenic reaction that occurs as a result of unfavorable external factors. In mosaic psychopaths, reactions can be very different, since the core symptom complex is absent.

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Complications and consequences

Compensated mixed personality disorder does not prevent people from leading a normal life, getting a good education and achieving very significant success in life. If we believe that Lenin and Stalin were mosaic psychopaths, then the consequence of such a disorder was the creation of a state with a fundamentally new social system that existed for 75 years, which should not be underestimated.

Decompensated mosaic psychopathy can be dangerous both for society and for the subject himself. Symptoms of decompensation are an exacerbation of asocial personality traits, and with mixed disorder, the specificity of affective disorders is varied. It is very difficult for such a person to adapt to coexistence with other people, as well as for them to adequately perceive him.

Under various unfavorable life conditions, a completely sociopathic personality can form. Such people do not tolerate failures well, tend to blame others for everything, easily succumb to aggression and commit illegal actions. Among the contingent serving sentences for serious crimes, more than a third are psychopaths.

The consequences of frequent decompensations can be a life of isolation for the subject himself, his suicide or the commission of violent crimes.

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Diagnostics mosaic schizophrenia

People who seek psychiatric help are socially maladapted, for whom decompensated psychopathy prevents them from assimilating into society. Or subjects who have already committed criminal acts come into the field of study.

The main diagnostic tool is various questionnaire tests that allow one to detect a stable combination of personality traits, positive and negative, that characterize a given individual. Based on the results of the survey and the total score, one can conclude whether a given personality is psychopathic. Some tests allow one to determine the form of personality disorder. There is no specific test for mosaic psychopathy, since this form of disorder does not imply a single symptom complex. One can assume the presence of a mixed personality disorder when the testing reveals traits of different personality types.

The standardized multifactorial personality test (originally the Minnesota Multifaceted Personality Test) allows one to identify the closeness of the test subject to a certain type of psychopathy (paranoid, asthenic, schizoid), to establish the degree of anxiety and tendency to antisocial actions, the presence or absence of sexual perversions. The test also has additional scales that allow one to assess the degree of sincerity of the test subject, as well as to make adjustments to his unreliable answers. An entire scale (the fourth) is devoted to the tendency to antisocial behavior. High scores, which are used to evaluate the answers of this scale, indicate the impossibility of socialization in society.

When a subject scores high on personality traits that belong to different types of psychopathies and it is impossible to isolate any one type, he is diagnosed with mixed personality disorder. These are the only criteria for the diagnosis of "mosaic psychopathy."

The R. Hare test is also used, which is accompanied by an interview-autobiography. This test was intended for people who committed illegal acts, so the facts from the biography of the subject had to be confirmed by documents, since psychopaths are not distinguished by sincerity.

There are other assessment methods for self-assessment of the patient, or a survey is conducted and points are given by a specialist. A comprehensive approach is often used. The quality of the individual's relationships with other people is studied, his ability to learn new things, the level of perception, attention, memory are examined.

Various studies are used – the general level of health is assessed using the latest laboratory and instrumental studies. If an individual is found to have any mental illnesses, organic damage to brain structures or somatic pathologies, then the diagnosis is made based on the underlying disease.

A person can be recognized as a psychopath according to the following criteria (according to Gannushkin): psychopathic traits are stable, total, always manifest themselves and make social adaptation difficult, and in advanced cases make it completely impossible.

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Differential diagnosis

Mixed personality disorder in the psychiatric hierarchy in terms of severity of disorders follows the extreme variant of the norm - accentuation of character, corresponding to forms of psychopathy. Stable mosaic anomalies of character also manifest themselves in accentuations, however, the main diagnostic criterion for distinguishing is the severity of these features. In accentuated personalities, their features are not an obstacle to assimilation in society, they do not reach the height of pathology. The differences are clearly quantitative in nature.

The leading pathological features determine the type of personality disorder and, if it cannot be identified, a mosaic form is diagnosed.

Mosaic psychopathy is differentiated from psychopathic-like post-traumatic disorders, consequences of infectious diseases, poisoning, endocrinopathies and other pathologies accompanied by damage to the central nervous system, establishing the fact of completely normal development before the appearance of psychopathic-like symptoms.

There are also constitutional (nuclear) psychopathies with acquired, arising at any age under the influence of psychological trauma. They are distinguished from congenital by a clear beginning and connection with a psychotraumatic event. Signs of nuclear psychopathies are noted already in early childhood.

Nuclear schizophrenia is differentiated from mosaic psychopathy. The conditions have much in common. American psychiatrists have already stopped classifying schizophrenia by types, and ICD-11 also suggests not to distinguish its types, since the disease is characterized by a variety of symptoms and its type does not matter for treatment. Its nuclear form manifests itself early, already in puberty, the formed pathology is observed in early youth (by 18-20 years). Schizophrenic dementia develops quite quickly, has a continuous malignant course. For psychopathy, the development of dementia is not characteristic at all.

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Treatment mosaic schizophrenia

People live with psychopathy all their lives, the compensated state does not require intervention, but the stage of decompensation is always accompanied by difficulties in the social and personal plan. It is during this period that the need arises to provide assistance to the patient to compensate for abnormal characterological deviations.

Psychotherapy comes to the forefront. It is difficult to work with such patients, since their deceitfulness and ability to manipulative actions can reverse the entire program of classes, especially group classes. Therefore, preference is given first of all to individual programs. The patient's personal attitudes are corrected in terms of developing concepts about the need to comply with moral norms and rules in relationships with other people. The emphasis is on the fact that such a position is beneficial, first of all, to the patient himself. Awareness of the need for rational attitudes and aspirations for productive activity is activated. Classes are held in the form of explanations and discussions; if necessary, family members can be involved in the classes.

Medication is used in emergency cases when agitation or depression prevent the patient from thinking and acting rationally; in severe and deep decompensated psychopathies, there may be a need for constant medication correction with psychotropic drugs. There are no specific medications for mosaic psychopathy. Medications are selected individually, taking into account the predominant symptoms of the disorder and their selective action:

• including braking function;
• predominantly inhibitory with a moderate stimulating effect;
• having only a stimulating effect;
• mainly stimulants with moderate inhibitory effect;
• having a general or selective antipsychotic effect.

Only in case of full compliance of the range of psychotropic action of the drug with the structure of psychopathological symptoms will the therapy be successful. And mosaic psychopathy is characterized by a large variety of manifestations, and this is the difficulty of stopping the decompensated state.

Low doses of neuroleptics are used to treat predominantly excitable psychopathic manifestations. Aminazin, the first drug with a powerful antipsychotic effect and equally impressive side effects, is still used. Its strength of action is the standard and is accepted as a unit of measurement of the antipsychotic effect of the drug. More modern neuroleptics often have a higher aminazine coefficient and fewer side effects in the form of extrapyramidal disorders (stiffness and spasms of muscles, tremors in the body, increased salivation, etc.), which in all such drugs are associated with their ability to change the concentration of dopamine in the synaptic cleft.

For example, Sonapax, which has an antipsychotic effect comparable in strength to Aminazin, but practically does not give extrapyramidal symptoms and does not cause drowsiness. Its antipsychotic effect has an anti-anxiety focus. The drug copes well with obsessions and moderately activates productive activity.

Teralidzhen is one of the latest aliphatic class drugs, characterized by a mild sedative and stimulating effect. It does not stop delusional-hallucinatory states, however, it produces a good anxiolytic effect, helps normalize sleep and eliminates allergic reactions.

The atypical neuroleptic Seroquel exhibits affinity for both dopamine and serotonin receptors. It copes with hallucinations, mania, and paranoia. The power of the antipsychotic action is comparable to Aminazine. Seroquel has an antidepressant and moderate stimulating effect.

Antidepressants are used for severe affective symptoms. Sometimes they are prescribed in combination with antipsychotics if there are fits of rage, delirium and hallucinations.

In case of severe asthenia with depressive moods, Befol can be prescribed. The antidepressant Humoril is preferable for patients with severe inhibition, in addition, it does not have cardiotoxic properties and does not block cholinergic receptors. The reversible monoamine oxidase inhibitor Pirlindol is prescribed to patients with severe anxiety. It can be used to treat patients with heart and vascular diseases, glaucoma and inflammation of the prostate gland. In case of symptoms of "major" depression and severe suicidal intent, the tricyclic antidepressant Melipramine is used, and patients with cardiovascular pathologies are prescribed the serotonin reuptake inhibitor Prozac. It has a noticeable thymonoanaleptic effect, eliminates melancholy, inhibition, and stops bursts of excitement.

Tranquilizers (Lorazepam, Atarax) are also used to relieve fear and related tension. Psychostimulants (Sidnofen, Mesocarb) improve performance and help maintain control over one's behavior. Attacks of mania are relieved by normothymics - lithium salts, Carbamazepine.

When treating with neuroleptics to relieve attacks of drowsiness and lethargy, nootropics – stabilizers of brain activity – can be prescribed as additional drugs.

The medications are dosed individually depending on the identified symptoms and prescribed in short courses to avoid addiction. Treatment is mainly outpatient. Indications for emergency hospitalization in a psychiatric hospital (without the patient's consent) are severe attacks of aggressive behavior, a state of acute psychomotor agitation that pose a danger to others or the psychopath himself.

Nuclear mosaic psychopathy is incurable, however, long-term compensation of the individual's condition is quite possible.

Prevention

Childhood spent in a close-knit family, whose members love and protect each other, is a guarantee that even if the child has psychopathic character traits, he will grow up as a socialized individual. It is especially important to pay attention to the teenage period, when the personality is formed, and the child already feels like an adult and free. Regular sports activities have a good effect - the child is busy, he develops the excitement of being the first.

For both children and adults, folk medicine can be used to prevent decompensated conditions, or a homeopath can be consulted. Phyto- and homeopathic preparations, especially those prescribed by specialists, will help correct behavioral deviations, dispel anxiety and worry, normalize the emotional background, and restore working capacity. In addition, these remedies are free of side effects.

Since decompensation is caused by external factors, one must strive to avoid them, if possible.

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Forecast

Of course, mixed personality disorder is the most complex of all types of psychopathies, however, there are examples, including historical ones, of complete social adaptation and success of mosaic psychopaths. The prognosis depends entirely on the conditions in which an individual with psychopathic character traits will grow and develop.

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