Progressive schizophrenia

There are many theories about this mental illness and discussions among psychiatrists of different schools and directions are ongoing. However, the progression of true schizophrenia seems indisputable to representatives of the American and European psychiatric schools. Schizophreniform symptoms without a progressive weakening of mental activity, according to most psychiatrists, cast doubt on the diagnosis of schizophrenia itself and are interpreted as schizophrenia spectrum disorders. Therefore, the very name "progressive schizophrenia" is reminiscent of "butter", since in psychiatric manuals in the very definition of the disease it is interpreted as a progressive endogenous mental pathology. In the latest edition of the manual on diagnostics of mental disorders DSM-5, and also - presumably, in the future ICD-11, schizophrenia includes the most severe forms of the disease, the duration of the corresponding symptoms in this case should be observed in the patient for at least six months. [ 1 ]

It has probably already become clear that progression is an increase in symptoms, a progression of the disease. It can be continuous (type I) and increasing from attack to attack (type II) with a circular, that is, periodic type of disease progression. The progression of schizophrenia concerns not so much the severity and frequency of affective attacks as personality changes. Autism increases - the patient becomes increasingly apathetic, his speech and emotional reactions become poorer, interest in the surrounding reality is lost. Although timely and adequate treatment can stabilize the patient's condition and push the last stage of the disease far enough. It is possible to achieve remission, equivalent to recovery. After schizophrenia began to be treated with neuroleptics in the 50s of the last century, the proportion of the most severe cases of progressive schizophrenia decreased from 15 to 6%. [ 2 ]

Epidemiology

The statistics of the prevalence of the disease are not unambiguous, due to the difference in the diagnostic approach and the registration of patients. In general, approximately 1% of the world's population has a diagnosis of schizophrenia, among them there is an approximate gender balance. The greatest number of onsets of the disease occurs between the ages of 20 and 29. As for the forms, the most common are paroxysmal-progressive, which affects 3-4 people out of 1000, and low-progressive - every third out of 1000. The most severe malignant continuous schizophrenia affects much fewer people - about one person out of 2000 of the population. For male patients, the continuous course of the disease is more typical, for women - paroxysmal. [ 3 ], [ 4 ], [ 5 ]

Causes progressive schizophrenia

More than a hundred years of studying the disease have generated many hypotheses about the nature of schizophrenia and the causes that cause it. However, the WHO fact sheet states that studies have not yet identified a single factor that reliably provokes the development of the disease. However, the risk factors for developing schizophrenia are quite obvious, although none of them are mandatory. Hereditary predisposition to the disease has proven etiological significance, but the transmission of genetic information is complex. The interaction of several genes is assumed, and its hypothetical result may be a bouquet of neuropathologies that cause symptoms that fit into the clinical picture of schizophrenia. However, so far, both the genes found in studies of schizophrenics and the structural abnormalities of the brain, as well as disorders of neurobiological processes are nonspecific and can increase the likelihood of developing not only schizophrenia, but also other psychotic effects. Modern neuroimaging methods have not been able to detect specific changes inherent only to the brain of schizophrenics. Geneticists have also not yet identified any one genetically mediated mechanism for the development of the disease. [ 6 ], [ 7 ]

Environmental influences such as early childhood living conditions, psychological and social interactions are environmental stressors and, in combination with innate predisposition, increase the risk of developing the disease to a critical level.

Currently, schizophrenia is considered a polyetiological mental disorder, the pathogenesis of which may be triggered by prenatal factors: prenatal infections, the use of toxic substances by the mother during pregnancy, environmental disasters.

Psychosocial risk factors for the development of the disease are very diverse. People suffering from schizophrenia were often subjected to mental and/or physical abuse, inadequate treatment, and did not feel the support of loved ones in childhood. The risk of developing the disease is higher in residents of large cities, in people with low social status, living in uncomfortable conditions, and uncommunicative. A repeated psychotraumatic situation similar to one that occurred in early childhood can provoke the development of the disease. Moreover, this does not necessarily require such serious stress as beating or rape; sometimes a move or hospitalization is enough for schizophreniform symptoms to begin to develop. [ 8 ]

The use of psychoactive substances is closely related to schizophrenia, but it is not always possible to trace what was primary: the disease or the destructive addiction. Alcohol and drugs can provoke the manifestation or another attack of schizophrenia, aggravate its course, and contribute to the development of resistance to therapy. At the same time, schizophrenics are prone to the use of psychedelics, the most accessible of which is alcohol. They quickly develop psychological dependence (experts believe that dopamine hunger is the cause), however, if it is not known for sure that a person suffered from schizophrenia before starting to use toxic substances, then he is diagnosed with alcohol/drug psychosis.

The presence of certain personality traits is also a factor that increases the likelihood of developing the disease. These are a tendency to jump to conclusions and long-term worries about negative actions or statements addressed to oneself, increased attention to perceived threats, high sensitivity to stressful events, personal externality (internality), etc. [ 9 ]

Pathogenesis

The complex of the above-mentioned reasons triggers the pathogenesis of schizophrenia. Modern hardware methods allow us to track functional differences in the nature of activation of cerebral processes in the brain of schizophrenics, as well as to identify some features of the structural units of the brain. They concern a decrease in its total volume, in particular, the gray matter in the frontal and temporal lobes, as well as the hippocampus, thickening of the occipital lobes of the cerebral cortex, and expansion of the ventricles. In patients with schizophrenia, the blood supply to the prefrontal and frontal lobes of the cerebral cortex is reduced. Structural changes are present at the onset of the disease and can progress over time. Antipsychotic therapy, hormonal fluctuations, alcohol and drug use, weight gain or loss also contribute to structural and functional changes, and it is not yet possible to clearly separate the effect of any specific factor. [ 10 ]

The first and most well-known is the dopamine hypothesis of the origin of schizophrenia (in several versions), which appeared after the successful introduction of typical neuroleptics into therapeutic practice. In essence, these were the first effective drugs that relieved the productive symptoms of psychosis, and they were presumably caused by increased activity of the dopaminergic system. Moreover, many schizophrenics were found to have increased dopamine neurotransmission. Now this hypothesis seems untenable to most specialists, and subsequent neurochemical theories (serotonin, kynurenic, etc.) also failed to sufficiently explain the diversity of clinical manifestations of schizophrenia. [ 11 ]

Symptoms progressive schizophrenia

The most noticeable manifestation is acute psychosis, before which no one often noticed any particular behavioral deviations. Such an acute manifestation of the disease is considered prognostically favorable, since it facilitates active diagnostics and rapid initiation of treatment. However, this is not always the case. The disease can develop slowly, gradually, without pronounced psychotic components.

The debut of many cases of the disease, especially in the stronger sex, coincides with adolescence and youth, which complicates early diagnosis. The first signs of schizophrenia may resemble the behavioral features of many teenagers, who, during adolescence, experience a decline in academic performance, a change in their circle of friends and interests, and signs of neurosis - irritability, anxiety, sleep problems - appear. The child becomes more withdrawn, less frank with parents, reacts aggressively to advice and rejects authoritative opinions, can change their hairstyle, put an earring in their ear, change their style of clothing, and become less neat. However, all this is not a direct indication of the development of the disease. In most children, teenage escapades pass without a trace. Until signs of disintegration of thinking appear, it is too early to talk about schizophrenia.

Violation of the unity of the thought process, its detachment from reality, paralogism usually occurs in the patient from the very beginning. And this is already a symptom. Such pathology manifests itself in the speech production of the schizophrenic. For the initial stages, such phenomena as sperrung and mentism are characteristic, the appearance of so-called symbolic thinking, manifested as the substitution of real concepts with symbols understandable only to the patient, raisonné - verbose, empty, leading nowhere reasoning with the loss of the original theme.

In addition, the thinking of a sick person lacks clarity, its purpose and motivation are not traced. The thoughts of a schizophrenic lack subjectivity, they are uncontrollable, alien, imposed from the outside, which is what patients complain about. They are also confident in the availability of their thoughts imposed by force to others - they can be stolen, read, replaced with others (the phenomenon of "openness of thoughts"). Schizophrenics are also characterized by ambivalence of thinking - they are able to think about mutually exclusive things at the same time. Disorganized thinking and behavior in a mild form can manifest itself already in the prodromal period.

Progressive course of schizophrenia means progress of the disease. In some people it occurs roughly and quickly (in juvenile malignant forms), in others it is slow and not very noticeable. Progress is manifested, for example, in schizophasia ("disconnectedness" of thinking) - verbally this is the appearance of a verbal "hodgepodge" in speech, a meaningless combination of associations that are absolutely not related to each other. It is impossible to grasp the meaning of such statements from the outside: the statements of patients completely lose their meaning, although the sentences are often constructed grammatically correctly and the patients are in a clear consciousness, fully preserving all types of orientation.

In addition to disorganized thinking, major symptoms of schizophrenia also include delusions (beliefs that do not correspond to reality) and hallucinations (false sensations).

The main theme of delusional disorder is that the patient is influenced by external forces, forcing them to act, feel and/or think in a certain way, to commit acts that are not typical for them. The patient is convinced that the execution of orders is controlled, and they cannot disobey. Schizophrenics are also characterized by delusions of reference, persecution, and may have persistent delusional ideas of a different kind, unacceptable in a given society. Delusions are usually bizarre and unrealistic.

Another symptom of schizophrenia is the presence of pathological overvalued ideas, affectively charged, absorbing all the patient's personal manifestations, perceived as the only true ones. Such ideas eventually become the basis for delusional formation.

A schizophrenic is characterized by delusional perception - any signals from the outside: comments, smirks, newspaper articles, lines from songs and others are perceived as personal and in a negative way.

The onset of delirium can be noticed by the following changes in the patient's behavior: he has become withdrawn, secretive, has begun to treat relatives and good friends with inexplicable hostility and suspicion; periodically makes it clear that he is being persecuted, discriminated against, threatened; shows unreasonable fear, expresses concerns, checks food, hangs additional locks on doors and windows, plugs up ventilation openings. The patient can make meaningful hints about his great mission, about some secret knowledge, about his services to humanity. He may be tormented by a feeling of imaginary guilt. There are many manifestations, most of them are implausible and mysterious, but it happens that the patient's statements and actions are quite real - he complains about neighbors, suspects his spouse of cheating, employees - of undermining.

Another "big" symptom of schizophrenia is hallucinations, most often auditory. The patient hears voices. They comment on his actions, insult him, give orders, enter into a dialogue. The voices sound in the head, sometimes their source is different parts of the body. Other types of persistent hallucinations can also occur - tactile, olfactory, visual.

Signs of hallucinations may include dialogues with an invisible interlocutor, when the patient makes remarks as if in response to comments, argues or answers questions, suddenly laughs or gets upset for no reason, looks anxious, cannot concentrate during a conversation, as if someone is distracting him. An outside observer usually gets the impression that his vis-à-vis feels something that only he can sense.

The manifestations of schizophrenia are varied. There may be disturbances of affect – depressive or manic episodes, depersonalization/derealization phenomena, catatonia, hebephrenia. Schizophrenia is usually characterized by complex symptom complexes of mood disorders, including not only depressed or abnormally elevated mood, but also hallucinatory-delusional experiences, disorganized thinking and behavior, and in severe cases – pronounced motor disorders (catatonic).

Progressive schizophrenia occurs with the appearance and increase of cognitive impairment and negative symptoms - a gradual loss of motivation, volitional manifestations and emotional component.

Formally, the pre-morbid level of intelligence is preserved in schizophrenics for quite a long time, but new knowledge and skills are acquired with difficulty.

To summarize this section, it should be noted that the modern concept of schizophrenia classifies the symptoms of this disease into the following categories:

• disorganizational - split thinking and associated bizarre speech (incoherent, purposeless speech and activity, inconsistency, slippage to the point of complete incomprehensibility) and behavior (infantilism, agitation, bizarre/unkempt appearance);
• positive (productive), which include overproduction of the body's natural functions, their distortion (delusions and hallucinations);
• negative – partial or complete loss of normal mental functions and emotional reactions to events (expressionless face, poor speech, lack of interest in any kind of activity and in relationships with people, there may also be increased activity, meaningless, disorderly, fussiness);
• cognitive – decreased sensitivity, ability to analyze and solve life’s problems (scattered attention, decreased memory and speed of information processing).

It is not at all necessary for one patient to have all categories of symptoms. [ 12 ]

Forms

The symptoms of the disease vary slightly in different types of the disease. The predominant symptoms in countries using ICD-10 are currently the basis for the classification of schizophrenia.

In addition, an important diagnostic criterion is the course of the disease. It can be continuous, when painful manifestations are observed constantly at approximately the same level. They are also called "flickering" - the symptoms can intensify and subside somewhat, but there are no periods of complete absence.

Schizophrenia can also proceed circularly, that is, with periodic attacks of affective psychosis. This form of the disease is also called recurrent schizophrenia. During treatment, affective phases in most patients are reduced quite quickly and a long period of normal life begins. True, after each attack, patients experience losses in emotional and volitional terms. This is how the progress of the disease manifests itself, which is a criterion for differentiating true schizophrenia from schizoaffective disorder.

The third type of the disease course is paroxysmal-progressive schizophrenia. It has features of both continuous and recurrent course, earlier it was called schizophrenia with mixed course or fur coat (from the German word Schub - attack, seizure). Schizophrenia with paroxysmal-progressive (fur coat, mixed) course is the most common among the entire accountable contingent of patients.

Continuously progressive course of schizophrenia is typical for the types of disease that manifest in puberty. This is juvenile malignant schizophrenia, the debut of which occurs, on average, at 10-15 years and sluggish schizophrenia, the course of which is continuous, however, the progress of this form of the disease is very slow, therefore it is also called low-progressive. It can manifest at any age, and the later the onset of the disease, the less destructive its impact. Up to 40% of cases of early manifestations of the disease are classified as low-progressive schizophrenia (ICD-10 interprets it as a schizotypal disorder).

Progressive schizophrenia in adolescents, previously early dementia, in turn is divided into simple, catatonic and hebephrenic. These are the most prognostically unfavorable types of the disease, which are characterized by the development of acute polymorphic psychotic syndrome, rapid progression and increase in negative symptoms.

According to some data, up to 80% of acute early manifestations of schizophrenia begin with polymorphic psychosis ("polymorphic fur coat"). The onset is usually sudden, there is no prodromal period, or retrospectively, some mental discomfort, bad mood, irritability, tearfulness, and sleep disturbances are remembered. Sometimes there were complaints of headaches.

The full picture of psychosis unfolds over the course of two or three days. The patient is restless, does not sleep, is very afraid of something, but is unable to explain the cause of the fear. Then uncontrollable attacks of fear can be replaced by euphoria and hyper-excitation or plaintive lamentations, crying, depression, and periodically there are episodes of extreme exhaustion - the patient is apathetic, unable to speak or move.

Usually the patient is oriented in time and space, knows where he is, correctly answers the question about his age, the current month and year, but may be confused in describing the sequence of previous events, cannot name neighbors in the hospital ward. Sometimes orientation is ambiguous - the patient can answer the question about his whereabouts correctly, and a few minutes later - incorrectly. His sense of time may be impaired - recent events seem distant, and old ones, on the contrary, as if they happened yesterday.

Psychotic symptoms are of all kinds: various deliriums, pseudo- and true hallucinations, illusions, imperative voices, automatisms, dream-like fantasies that do not fit into a certain pattern, one manifestation alternates with another. But still, the most frequent theme is the idea that those around the patient want to harm him, for which they make various efforts, trying to distract and deceive him. Delusions of grandeur or self-accusation may occur.

The delirium is fragmentary and often provoked by the situation: the sight of a ventilation grate leads the patient to think about peeping, a radio – about exposure to radio waves, blood taken for analysis – about the fact that it will be pumped out and thus killed.

Teenagers with polymorphic psychosis often have derealization syndrome, which manifests itself in the development of delusions of staging. He believes that a play is being performed for him. Doctors and nurses are actors, the hospital is a concentration camp, etc.

Characteristic episodes of depersonalization, oneiroid episodes, individual catatonic and hebephrenic manifestations, absurd impulsive actions. Manifestations of impulsive aggression towards others and oneself are quite probable, sudden suicide attempts are possible, the reason for which the patients cannot explain.

The excited state alternates with short episodes when the patient suddenly becomes silent, freezes in an unusual position and does not respond to stimuli.

Types of juvenile malignant schizophrenia - simple, catatonic and hebephrenic - are distinguished according to the manifestations that are most present in the patient.

In the simple form of schizophrenia, the disease usually develops suddenly, as a rule, in fairly manageable, smooth-going and unreproachable teenagers. They change abruptly: they stop studying, become irritable and rude, cold and heartless, abandon their favorite activities, lie or sit for hours, sleep for a long time or wander the streets. It is impossible to switch them to productive activity, harassment of this kind can cause severe anger. Patients practically do not have delusions and hallucinations. Sometimes there are episodes of rudimentary hallucinatory manifestations or delusional alertness. Without treatment, negative symptoms increase quite quickly, it takes from three to five years, - emotional impoverishment and a decrease in productive activity, loss of purposefulness and initiative. A cognitive defect specific to schizophrenics increases and the final stage of the disease sets in, as E. Bleuler called it - "the tranquility of the grave."

Catatonic schizophrenia (predominantly movement disorders) with a continuous course is characterized by alternating stuporous states and excitement without clouding of consciousness.

Hebephrenic - characterized by hypertrophied silliness. With continuous progression and without treatment, the disease quickly (up to two years) enters the final stage.

Catatonic and hebephrenic schizophrenia may proceed in an attack-progressive manner (mixed course). In this case, despite the severity of these forms of the disease, the clinical picture in the post-attack period is somewhat more mitigated. And although the disease progresses, the schizophrenic defect in patients is expressed to a lesser degree than in the continuous form of the course.

Recurrent schizophrenia occurs with the development of manic or depressive affective attacks, in the interictal period the patient returns to his normal life. This is the so-called periodic schizophrenia. It has a fairly favorable prognosis, there are cases when patients have experienced only one attack in their entire life.

Manic attacks occur with pronounced symptoms of excitement. The patient has an elevated mood, a feeling of elation and vivacity. A jump of ideas is possible, it is impossible to have a consistent conversation with the patient. The patient's thoughts take on a violent character (foreign, embedded), motor excitement also increases. Delirium quickly joins in - influence, persecution, special meaning, "openness of thoughts" and other symptoms characteristic of schizophrenia. In some cases, the attack takes on the character of oneiroid catatonia.

Depressive attacks begin with despondency, anhedonia, apathy, sleep disorders, anxiety, fears. The patient is preoccupied, expects some misfortune. Later, he develops delirium, characteristic of schizophrenia. A clinical picture of melancholic paraphrenia with self-accusation and attempts to commit suicide, or oneiroid with illusory-fantastic experiences of "world catastrophes" may develop. The patient may fall into a stupor with enchantment, confusion.

With treatment, such attacks often pass quite quickly; first of all, hallucinatory-delusional experiences are reduced, and last of all, depression disappears.

The patient emerges from the affective phase with some loss of his mental qualities and depletion of the emotional-volitional component. He becomes more reserved, cold, less sociable and proactive.

Sluggish schizophrenia usually has a continuous course, but it is so slow and gradual that progress is almost unnoticeable. In the initial stage, it resembles neurosis. Later, obsessions develop, more incomprehensible, irresistible than in ordinary neurotics. Bizarre protective rituals quickly appear. Fears are often too absurd - patients are afraid of objects of a certain shape or color, some words, obsessions are also inexplicable and not associated with any event. Over time, such patients' mental activity decreases, sometimes they become incapable of work, since performing ritual actions takes up the entire day. Their range of interests narrows significantly, lethargy and fatigue increase. With timely treatment, such patients can achieve a fairly quick and long-term remission.

Paranoid schizophrenia can proceed according to any type, both continuously and paroxysmally, and also – paroxysmal-progressive course is possible. It is the latter type of course that is the most widespread and best described. Manifestation of paranoid schizophrenia occurs from 20 to 30 years. Development is slow, personality structure changes gradually – the patient becomes distrustful, suspicious, secretive. At first, paranoid interpretive delirium appears – the patient thinks that everyone is talking about him, he is being watched, he is being harmed, and certain organizations are behind this. Then auditory hallucinations join in – voices giving orders, commenting, condemning. Other symptoms inherent in schizophrenia appear (secondary catatonia, delusional depersonalization), mental automatisms appear (Kandinsky-Clerambault syndrome). Often, it is at this paranoid stage that it becomes clear that these are not eccentricities, but a disease. The more fantastic the plot of the delirium, the more significant the personality defect.

The paroxysmal-progressive course of paranoid schizophrenia develops at first, as in the continuous type. Personality changes occur, then a picture of delusional disorder with symptoms inherent in schizophrenia unfolds, paranoid delirium with components of affective disorder may develop. But such an attack ends quite quickly and a period of long-term remission begins, when the patient returns to the normal rhythm of life. Some losses are also present - the circle of friends narrows, restraint and secrecy increase.

The period of remission is long, on average four to five years. Then a new attack of the disease occurs, structurally more complex, for example, an attack of verbal hallucinosis or psychosis with manifestations of all types of mental automatisms accompanied by symptoms of an affective disorder (depression or mania). It lasts much longer than the first - five to seven months (this is similar to a continuous course). After the resolution of the attack with the restoration of almost all personal qualities, but at a slightly reduced level, several more calm years pass. Then the attack repeats again.

Attacks become more frequent, and remission periods become shorter. Emotional-volitional and intellectual losses are becoming more noticeable. However, the personality defect is less significant compared to the continuous course of the disease. Before the era of neuroleptics, patients usually experienced four attacks, after which the final stage of the disease occurred. At present, with the help of treatment, the remission period can be extended indefinitely and the patient can live his normal life in the family, although over time he will tire more quickly, perform only simpler work, become somewhat distant from loved ones, etc.

The type of schizophrenia is not of great importance for the prescription of antipsychotic therapy, so some countries have already abandoned such classification, considering the identification of the type of schizophrenia inappropriate. The new edition of the ICD-11 disease classifier also proposes to move away from classifying schizophrenia by type.

For example, American psychiatrists recognize the division of schizophrenia into two types: deficit, when negative symptoms are predominant, and non-deficit, with a predominance of hallucinatory-delusional components. In addition, the diagnostic criterion is the duration of clinical manifestations. For true schizophrenia, it is more than six months.

Complications and consequences

Progressive schizophrenia over time leads, at a minimum, to the loss of flexibility of thinking, sociability, and the ability to solve life problems facing the individual. The patient ceases to understand and accept the point of view of others, even the closest and like-minded people. Although the intellect is formally preserved, new knowledge and experience are not absorbed. The severity of increasing cognitive losses is the main factor that leads to the loss of independence, desocialization, and disability.

Schizophrenics have a high probability of committing suicide, both during periods of acute psychosis and during periods of remission, when they realize that they are terminally ill.

The danger to society is considered greatly exaggerated, however, it does exist. Most often, everything ends with threats and aggression, but there are cases when, under the influence of imperative delirium, patients commit crimes against the individual. This does not happen often, but it does not make it any easier for the victims.

The course of the disease is aggravated by addiction to psychoactive substance abuse; half of the patients have this problem. As a result, patients ignore the recommendations of the doctor and relatives, violate the treatment regimen, which leads to rapid progression of negative symptoms, and also increases the likelihood of desocialization and premature death.

Diagnostics progressive schizophrenia

Only a specialist in psychiatry can diagnose schizophrenia. There are no tests or hardware studies that would confirm or refute the presence of the disease. Diagnosis is made based on the patient's medical history and symptoms identified during observation in the hospital. Both the patient and people living near him and knowing him well - relatives, friends, teachers and colleagues at work - are interviewed.

There must be two or more symptoms of the first rank according to K. Schneider or one of the major symptoms: specific delirium, hallucinations, disorganized speech. In addition to positive symptoms, negative personality changes must be expressed, it is also taken into account that in some deficit types of schizophrenia there are no positive symptoms at all.

Symptoms similar to schizophrenia are also present in other mental disorders: delusional, schizophreniform, schizoaffective, and others. Psychosis can also manifest itself in brain tumors, intoxication with psychoactive substances, and head injuries. Differential diagnostics are carried out with these conditions. It is for differentiation that laboratory tests and neuroimaging methods are used, allowing one to see organic lesions of the brain and determine the level of toxic substances in the body. Schizotypal personality disorders are usually easier than true schizophrenia (less pronounced and often do not lead to full-blown psychosis), and most importantly, the patient emerges from them without a specific cognitive deficit. [ 13 ]

Treatment progressive schizophrenia

The best results are achieved with timely therapy, that is, when it begins during the first episode that meets the criteria for schizophrenia. The main drugs are neuroleptics, the intake should be long-term, about a year or two, even if the patient has had a debut of the disease. Otherwise, the risk of relapse is very high, and within the first year. If the episode is not the first, then drug treatment must be taken for many years. [ 14 ]

Taking neuroleptics is necessary to reduce the severity of psychotic symptoms, prevent relapses and worsening of the patient's general condition. In addition to drug therapy, rehabilitation measures are carried out - patients are taught self-control skills, group and individual sessions with a psychotherapist are held.

For the treatment of schizophrenia, first-generation drugs are mainly used at the beginning of treatment, typical neuroleptics, the action of which is realized through the blockade of dopamine receptors. According to the strength of action, they are divided into three groups:

• strong (haloperidol, mazheptin, trifluoperazine) – have a high affinity for dopamine receptors and low affinity for α-adrenergic and muscarinic receptors, have a pronounced antipsychotic effect, their main side effect is forced movement disorders;
• medium and weak (chlorpromazine, sonapax, tizercin, teralen, chlorprothixene) - the affinity of which to dopamine receptors is less pronounced, and to other types: α-adrenergic muscarinic and histamine - is higher; they have mainly a sedative, rather than an antipsychotic effect and less often than strong ones cause extrapyramidal disorders.

The choice of drug depends on many factors and is determined by the activity in relation to certain neurotransmitter receptors, the unfavorable side effect profile, the preferred route of administration (drugs are available in different forms), and the patient's previous sensitivity are also taken into account. [ 15 ]

During acute psychosis, active pharmacotherapy with high doses of drugs is used; after achieving a therapeutic effect, the dose is reduced to a maintenance dose.

Second-generation or atypical neuroleptics [ 16 ], [ 17 ], [ 18 ] (leponex, olanzapine) are considered more effective drugs, although many studies do not confirm this. They have both a strong antipsychotic effect and affect negative symptoms. Their use reduces the likelihood of side effects such as extrapyramidal disorders, however, the risk of obesity, hypertension, and insulin resistance increases.

Some drugs of both generations (haloperidol, thioridazine, risperidone, olanzapine) increase the risk of developing heart rhythm disturbances, including fatal arrhythmia.

In cases where patients refuse treatment and are unable to take the daily dose of the drug, depot neuroleptics are used, for example, aripiprazole - prolonged-release intramuscular injections or risperidone in microgranules, which help ensure compliance with the prescribed treatment regimen.

Treatment of schizophrenia is carried out in stages. First, acute psychotic symptoms are relieved - psychomotor agitation, delusional and hallucinatory syndromes, automatisms, etc. As a rule, the patient at this stage is in a psychiatric hospital for one to three months. Both typical and atypical antipsychotics (neuroleptics) are used. Different psychiatric schools prefer different therapeutic schemes.

In the post-Soviet space, the drug of choice remains classical neuroleptics, in cases where their use is not contraindicated for the patient. The criterion for choosing a specific drug is the structure of psychotic symptoms.

When the patient has predominantly psychomotor agitation, threatening behavior, rage, aggression, drugs with dominant sedation are used: tizercin from 100 to 600 mg per day; aminazine - from 150 to 800 mg; chlorproxiten - from 60 to 300 mg.

If productive paranoid symptoms prevail, the drugs of choice are strong first-generation neuroleptics: haloperidol - from 10 to 100 mg per day; trifluoperazine - from 15 to 100 mg. They provide powerful anti-delusional and anti-hallucinatory effects.

For polymorphic psychotic disorder with hebephrenic and/or catatonic elements, mazheptil is prescribed - from 20 to 60 mg or piportil - from 60 to 120 mg per day, drugs with a broad spectrum of antipsychotic action.

American standardized treatment protocols give preference to second-generation antipsychotics. Classical drugs are used only when it is necessary to suppress attacks of psychomotor agitation, rage, violence, and also if there is precise information about the patient that he tolerates typical antipsychotics well or he needs an injectable form of the drug.

English psychiatrists use atypical neuroleptics in the first episode of schizophrenia or when there are contraindications to the use of first-generation drugs. In all other cases, the drug of choice is a strong typical antipsychotic.

When treating, it is not recommended to prescribe several antipsychotic drugs at the same time. This is possible only for a very short period of time in case of hallucinatory-delusional disorder against the background of strong agitation.

If side effects are observed during treatment with typical antipsychotics [ 19 ], correctors are prescribed - Akineton, Mydocalm, Cyclodol; the dosage is adjusted or the latest generation of drugs is switched to.

Neuroleptics are used in combination with other psychotropic drugs. The American standardized treatment protocol recommends that in cases of fits of rage and violence on the part of the patient, valproates be prescribed in addition to powerful neuroleptics; in cases of difficulty falling asleep, weak antipsychotics are combined with benzodiazepine medications; in cases of dysphoria and suicidal manifestations, as well as post-schizophrenic depression, antipsychotics are prescribed simultaneously with selective serotonin reuptake inhibitors.

For patients with negative symptoms, therapy with atypical antipsychotics is recommended.

If there is a high probability of developing side effects:

• cardiac arrhythmia – daily doses of phenothiazines or haloperidol should not exceed 20 mg;
• other cardiovascular effects - risperidone is preferred;
• abnormally strong thirst of a psychogenic nature - clozapine is recommended.

It is necessary to take into account that the highest risks of obesity develop in patients taking clozapine and olanzapine; low risks – trifluoperazine and haloperidol. Aminazine, risperidone and thioridazine have a moderate ability to promote weight gain.

Tardive dyskinesia is a complication that develops in one fifth of patients treated with first-generation neuroleptics, and most often occurs in patients who were prescribed aminazine and haloperidol. The lowest risk of its development is in those treated with clozapine and olanzapine.

Anticholinergic side effects occur with the use of strong classical antipsychotics, risperidone, ziprasidone

Clozapine is contraindicated for patients with changes in blood composition; aminazine and haloperidol are not recommended.

Clozapine, olanzapine, risperidone, quetiapine, and ziprasidone were most frequently noted in the development of neuroleptic malignant syndrome.

With significant improvement - disappearance of positive symptoms, restoration of a critical attitude to one's condition and normalization of behavior, the patient is transferred to semi-inpatient or outpatient treatment. The stabilizing therapy phase lasts approximately 6-9 months after the first episode and at least two to three years after the second. The patient continues to take the antipsychotic that was effective in treating the acute attack, but in a reduced dose. It is selected in such a way that the sedative effect gradually decreases and the stimulating effect increases. If psychotic manifestations return, the dose is increased to the previous level. At this stage of treatment, post-psychotic depression may occur, which is dangerous in terms of suicidal attempts. At the first manifestations of depressive mood, the patient is prescribed antidepressants from the SSRI group. It is at this stage that psychosocial work with the patient and his family members, inclusion in the processes of education, work, and resocialization of the patient play a major role.

Then they move on to stopping the negative symptoms, restoring the highest possible level of adaptation in society. Rehabilitation measures require at least another six months. At this stage, atypical neuroleptics are continued in low doses. Second-generation drugs suppress the development of productive symptoms and affect the cognitive function and stabilize the emotional-volitional sphere. This stage of therapy is especially relevant for young patients who need to continue their interrupted studies, and middle-aged patients - successful ones, with a good pre-morbid outlook and level of education. At this and the next stage of treatment, depot neuroleptics are often used. Sometimes the patients themselves choose this method of treatment, injections are made, depending on the chosen drug, once every two (risperidone) to five (moditen) weeks. This method is used when the patient refuses treatment, because they consider themselves already recovered. In addition, some experience difficulties when taking the drug orally.

The final stage of treatment is reduced to the prevention of new attacks of the disease and maintenance of the achieved level of socialization, it can last for a long time, sometimes for life. Low-dose administration of an effective neuroleptic for a given patient is used. According to the standards of American psychiatry, continuous administration of the drug is carried out for a year or a year and two months for the first episode and at least five years for a repeated one. Russian psychiatrists practice, in addition to continuous, an intermittent method of taking neuroleptics - the patient begins the course when the first symptoms of an exacerbation appear or in the prodrome. Continuous administration better prevents exacerbations, but is fraught with the development of side effects of the drug. This method is recommended for patients with a continuous type of disease. The intermittent method of prevention is recommended for people with a clearly expressed paroxysmal type of schizophrenia. Side effects in this case develop much less often.

Prevention

Since the causes of the disease are unknown, it is impossible to determine specific preventive measures. General recommendations that it is necessary to lead a healthy lifestyle and try to minimize the harmful effects on the body that depend on you are quite appropriate. A person should live a full life, find time for physical education and creativity, communicate with friends and like-minded people, since an open lifestyle and a positive outlook on the world increases stress resistance and has a beneficial effect on a person's mental status.

Specific preventive measures are possible only for patients with schizophrenia, and they help them to realize themselves in society to the fullest extent. Medication treatment should be started as early as possible, preferably during the first episode. It is necessary to strictly follow the recommendations of the attending physician, not to interrupt the course of treatment on your own, not to neglect psychotherapeutic help. Psychotherapy helps patients to live consciously and fight their illness, not to violate the regimen of taking medications and to get out of stressful situations more effectively. [ 20 ]

Forecast

Without treatment, the prognosis is unfavorable, and often a specific cognitive defect leading to disability occurs quite quickly, within three to five years. Progressive schizophrenia, aggravated by drug addiction, has a much worse prognosis.

Early treatment of the disease, often during the first episode, leads to long-term and stable remission in about a third of patients, which some specialists interpret as recovery. Another third of patients stabilize their condition as a result of therapy, but the possibility of relapse remains. [ 21 ] They require constant maintenance therapy, some are incapacitated or perform less skilled work than before the disease. The remaining third is resistant to treatment and gradually loses their ability to work.