Progressive schizophrenia

There are many theories about this mental illness, and there is an ongoing discussion among psychiatrists of different schools and directions. However, the progression of true schizophrenia is seen by representatives of the American and European schools of psychiatry as unquestionable. Schizophreniform symptomatology without progressive weakening of mental activity, in the opinion of most psychiatrists, casts doubt on the very diagnosis of schizophrenia and is interpreted as schizophrenic spectrum disorders. Therefore, the very name "progredient schizophrenia" resembles "butter in the oil", since psychiatry manuals in the very definition of the disease treat it as a progredient endogenous psychiatric pathology. In the latest edition of the DSM-5 manual for the diagnosis of mental disorders, and presumably in the future ICD-11, schizophrenia refers to the most severe forms of the disease, and the duration of the corresponding symptomatology should be observed in the patient for at least six months. [1]

It has probably already become clear that progression is an increase in symptomatology, progression of the disease. It can be continuous (type I) and increasing from attack to attack (type II) in the circular, i.e., periodic type of the disease course. The progression of schizophrenia concerns not so much the severity and frequency of affective attacks, but rather personality changes. Autization increases - the patient becomes more and more apathetic, his speech and emotional reactions become poorer, his interest in the surrounding reality is lost. Although timely prescribed adequate treatment can stabilize the patient's condition and push back the last stage of the disease far enough. It is possible to achieve remission, equating 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

Statistics on the prevalence of the disease are not unambiguous, the difference in diagnostic approach and patient records has an impact. In general, about 1% of the world's inhabitants are diagnosed with schizophrenia, among them an approximate gender balance. The greatest number of debuts of the disease occurs between the ages of 20 and 29 years. As for the forms, the most common are attack-progressive, which affects 3-4 people out of 1000, and low-progressive - one in three out of 1000. The most severe malignant continuous schizophrenia affects far fewer people - about one person in 2,000 of the population. Male patients are more characterized by a continuous course of the disease, while female patients are more characterized by a seizure-like course. [3], [4], [5]

Causes of the progressive schizophrenia

More than a hundred years of studying the disorder have generated many hypotheses about the nature of schizophrenia and the causes that trigger it. However, the WHO newsletter states that research has not yet identified a single factor that reliably provokes the development of the disease. However, the risk factors for schizophrenia are fairly obvious, although not one of them is certain. Proven etiologic significance has a hereditary predisposition to the disease, but the transmission of genetic information is complex. The interaction of several genes has been suggested, and its hypothesized result could be a bouquet of neuropathologies that cause symptoms that fit into the clinical picture of schizophrenia. However, so far, both genes found in studies of schizophrenics and structural abnormalities of the brain, as well as disorders of neurobiological processes are non-specific and can increase the likelihood of development, not only schizophrenia, but also other psychotic effects. Modern methods of neuroimaging have not been able to detect specific changes inherent only in the brain of schizophrenics. Nor have geneticists yet identified a single 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 when combined with an innate predisposition, increase the risk of developing the disease to a critical level.

Schizophrenia is currently considered a polyethiologic psychiatric disorder, the pathogenesis of which may be triggered by prenatal factors: prenatal infections, 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 in childhood to mental and/or physical abuse, inadequate treatment, lack of support from loved ones. The risk of developing the disease is higher in residents of large cities, people with low social status, living in uncomfortable conditions, uncommunicative. Repeated psychotraumatic situation, similar to what happened in early childhood, can provoke the development of the disease. And it is not necessarily such a serious stress as a beating or rape, sometimes a move or hospitalization is enough to start developing schizophreniform symptoms. [8]

Substance use is closely associated with schizophrenia, but it is not always possible to trace the primary cause: the illness or the destructive addiction. Alcohol and drugs can provoke the manifestation or another attack of schizophrenia, exacerbate its course, contribute to the development of resistance to therapy. At the same time, schizophrenics are prone to the use of psychedelics, the most available of which is alcohol. They quickly become psychologically dependent (experts believe this is caused by dopamine starvation), but if it is not known that a person had schizophrenia before using toxic substances, he or she 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 include a tendency to jump to conclusions and prolonged anxiety about negative actions or statements about oneself, increased attention to perceived threats, high sensitivity to stressful events, personality externalities (internalities), etc. The presence of certain personality traits is also a factor that increases the likelihood of developing the disease. [9]

Pathogenesis

The complex of the above causes triggers the pathogenesis of schizophrenia. Modern hardware methods make it possible to trace functional differences in the nature of activation of cerebral processes in the brain of schizophrenics, as well as to identify certain features of structural units of the brain. They concern the reduction of its total volume, in particular, gray matter in the frontal and temporal lobes, as well as in the hippocampus, thickening of the occipital lobes of the cerebral cortex, and enlargement of the ventricles. In schizophrenic patients, blood supply to the prefrontal and frontal lobes of the cerebral cortex is reduced. Structural changes are present at the beginning of the disease and may 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 separate the effects of any particular factor. [10]

The first and best known is the dopamine hypothesis of the origin of schizophrenia (in several variants), which emerged after the successful introduction of typical neuroleptics into therapeutic practice. Essentially, these were the first effective drugs to control the productive symptomatology of psychosis, and it was presumably caused by increased activity of the dopaminergic system. Especially since many schizophrenics were found to have increased dopamine neurotransmission. Now this hypothesis seems untenable to most specialists; subsequent neurochemical theories (serotonin, kynurenine, etc.) also failed to sufficiently explain the variety of clinical manifestations of schizophrenia. [11]

Symptoms of the progressive schizophrenia

The most noticeable manifestation is in the form of acute psychosis, before the appearance of which often no one noticed any special behavioral abnormalities. Such an acute manifestation of the disease is considered to be prognostically favorable, because it promotes active diagnosis and the rapid initiation of treatment. However, this is not always the case. The disease may develop slowly, gradually, without pronounced psychotic components.

The debut of many cases of the disease, especially in males, coincides with adolescence and young adulthood, which makes early diagnosis difficult. The first signs of schizophrenia may resemble the behavior of many adolescents, who in the period of adulthood declines in academic performance, changes in the circle of friends and interests, signs of neurosis - irritability, anxiety, sleep problems. The child becomes more withdrawn, less frank with parents, reacts aggressively to advice and rejects authoritative opinions, may change hairstyle, insert an earring in the ear, change the style of dress, become less neat. However, none of this is a direct indication that the disease is developing. In most children, teenage escapades pass without a trace. Until there are signs of disintegration of thinking, it is too early to talk about schizophrenia.

Violation of the unity of the thought process, its detachment from reality, paralogy 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. The initial stages are characterized by such phenomena as sperrung and mentism, the emergence of so-called symbolic thinking, which manifests itself as the substitution of real concepts by symbols understood only by the patient, resonerism - verbose, empty, leading to nothing reasoning with the loss of the original theme.

In addition, the very thinking of a sick person lacks clarity, its purpose and motivation are not traceable. The schizophrenic's thoughts are devoid of subjectivism, they are uncontrollable, alien, inserted from the outside, which is what patients complain about. They are also confident in the availability of their forcibly inserted thoughts to others - they can be stolen, read, replaced by others (the phenomenon of "openness of thoughts"). Schizophrenics are also characterized by ambivalent thinking - they are capable of thinking about mutually exclusive things at the same time. Disorganized thinking and behavior in a mild form can be manifested already in the prodromal period.

The progressive course of schizophrenia means the progress of the disease. In some people it comes roughly and quickly (in juvenile malignant forms), in others slowly and not too noticeably. Progress is manifested, for example, in schizophasia ("disconnected" thinking) - verbally it is the appearance in speech verbal "okroshka", meaningless combination of completely unrelated associations. It is impossible to catch the meaning of such statements from the outside: the patients' statements completely lose their meaning, although the sentences are often grammatically correct and the patients are in clear consciousness, fully preserving all types of orientation.

In addition to disorganized thinking, the big symptoms of schizophrenia also include delusions (untrue beliefs) and hallucinations (false sensations).

The main theme of the delusional disorder is that the patient is influenced by external forces to act, feel and/or think in a certain way, to do things that are not his or her own. The patient is convinced that the fulfillment of orders is controlled and he cannot disobey them. Schizophrenics are also characterized by delusions of attitude, persecution, there may be persistent delusions of another kind, not acceptable in this society. Delusions are usually bizarre and unrealistic.

Also a symptom of schizophrenia is the presence of pathological supervalue ideas, affectively charged, absorbing all personal manifestations of the patient, perceived as the only true. Such ideas eventually become the basis of delusions.

A schizophrenic is characterized by delusional perception - any signals from the outside: remarks, sneers, newspaper articles, lines from songs and others are taken at their own expense and in a negative way.

The appearance of delirium can be noticed by the following changes in the patient's behavior: he became withdrawn, secretive, began to treat relatives and good acquaintances with inexplicable hostility, suspicion; periodically makes it clear that he is being persecuted, discriminated, threatened; shows unreasonable fear, expresses concerns, checks food, hangs extra locks on doors and windows, plugs ventilation holes. The patient may make pithy hints about his great mission, about some secret knowledge, about merits before mankind. He may be tormented by a sense of invented guilt. There are many manifestations, most of them implausible and mysterious, but it happens that the statements and actions of the patient are quite real - he complains about neighbors, suspects his spouse of cheating, employees - in bribing.

Another "big" symptom of schizophrenia is hallucinations, more often auditory hallucinations. The patient hears voices. They comment on his actions, insult him, give orders, engage in dialog. Voices sound in the head, sometimes their source is different parts of the body. There may be other types of persistent hallucinations - tactile, olfactory, visual.

Signs of hallucinations can be dialogues with an invisible interlocutor, when the patient throws lines as if in response to comments, argues or answers questions, suddenly laughs or gets upset for no reason, has an anxious look, can not concentrate during the conversation, as if someone distracts him. An outside observer usually gets the impression that the person in question is feeling something that is only available to him or her.

The manifestations of schizophrenia are diverse. There may be affect disorders - depressive or manic episodes, depersonalization/derealization phenomena, catatonia, hebephrenia. Schizophrenia is characterized, as a rule, 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 movement disorders (catatonic).

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

Formally pre-diseased level of intellect is preserved in schizophrenics for quite a long time, but new knowledge and skills are mastered with difficulty.

To summarize the section, the modern concept of schizophrenia places the symptoms of this illness into the following categories:

• Disorganization - split thinking and associated bizarre speech (incoherent, lacking purposeful speech and activity, incoherent, slipping to complete incoherence) and behavior (infantilism, agitation, bizarre/unkempt appearance);
• positive (productive), which include overproduction of natural functions of the body, their distortion (delusions and hallucinations);
• negative - partial or complete loss of normal mental functions and emotional reactions to events (inexpressive face, scanty speech, lack of interest in any kind of activity and in relationships with people, there may be an increase in activity, meaningless, disorderly, fidgeting);
• cognitive - diminished receptivity, ability to analyze and solve life's tasks (scattered attention, decreased memory and speed of information processing).

It is not at all necessary that all categories of symptoms be present in a single patient. [12]

Forms

The symptoms of the illness differ somewhat between the different types of the illness. The predominant symptomatology in countries using ICD-10 is currently the basis for the classification of schizophrenia.

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

Schizophrenia can also occur circularly, that is, with periodic attacks of affective psychosis. This form of the course of the disease is also called recurrent schizophrenia. Against the background of treatment, affective phases in most patients are quickly enough reduced and there comes a long period of habitual life. True, after each attack, patients experience losses in the emotional-volitional plan. 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 course of the disease is schizophrenia with a seizure-like progression. It has features of both a continuous and recurrent course, and used to be called schizophrenia with a mixed course or Schub-like (from the German word Schub - attack, attack). Schizophrenia with an attack-like-progressive (Schub-like, mixed) course is the most common among the entire reporting population.

The continuous-progressive course of schizophrenia is characteristic of the types of illness that manifest in puberty. These are juvenile malignant schizophrenia, which debuts at an average age of 10-15 years, and sluggish schizophrenia, which has a continuous course; however, the progression of this form of the disease is very slow, which is why it is also called low-progressive. It can manifest at any age, and the later the onset of the disease, the less devastating its effects. Up to 40% of early onset cases are classified as low-progressive schizophrenia (ICD-10 defines it as schizotypal disorder).

Progressive schizophrenia in adolescents, in the past - early dementia, in turn is subdivided into simple, catatonic and hebephrenic. These are the most prognostically unfavorable types of the disease, which are characterized by the development of an acute polymorphic psychotic syndrome, rapid progress and increasing negative symptoms.

Up to 80% of acute early manifestations of schizophrenia begin, according to some reports, precisely with polymorphic psychosis ("polymorphic coat"). The onset is usually sudden, there is no prodromal period or retrospectively recalled presence of some mental discomfort, bad mood, irritability, tearfulness, disturbances in the process of falling asleep. Sometimes there were complaints of headache.

The full picture of psychosis unfolds over two or three days. The patient is restless, awake, afraid of something, but is unable to explain the cause of the fear. Then uncontrollable attacks of fear may be replaced by euphoria and hyperexcitement, or pitiful lamentations, crying, depression, periodically there are episodes of extreme exhaustion - the patient is apathetic, unable to talk or move.

Usually the patient is oriented in time and space, knows where he/she is, correctly answers the question about his/her age, current month and year, but may be confused about the sequence of previous events, cannot name neighbors in the hospital room. Sometimes orientation is ambivalent - the patient may answer a question about his location correctly, but a few minutes later - incorrectly. The patient's sense of time may be disturbed - recent events seem distant, while old events, on the contrary, seem to have occurred yesterday.

The psychotic symptoms are diverse: various delusions, pseudo- and true hallucinations, illusions, peremptory voices, automatisms, dream-like fantasies that do not fit into a certain pattern, one manifestation alternating with another. But still the most frequent theme is the idea that the patient wants to harm the people around him, for which they make various efforts, trying to distract and deceive him. Delusions of grandeur or self-recrimination may occur.

The delirium is fragmentary and often provoked by the situation: the sight of a ventilating grille leads the patient to think of peeping, a radio - of exposure to radio waves, blood taken for analysis - of being pumped out all of it and thus killed.

Adolescents with polymorphic psychosis often have a derealization syndrome, manifested by the development of delusions of staging. He believes that a play is being staged for him. Doctors and nurses are actors, the hospital is a concentration camp, etc.

Episodes of depersonalization, oneiroid episodes, some catatonic and hebephrenic manifestations, ridiculous impulsive actions are characteristic. Impulsive aggression to others and to oneself is quite probable; sudden suicide attempts are possible, the cause of which patients cannot explain.

The agitated state is interspersed with brief episodes when the patient suddenly falls silent, stiffens in an unusual posture and does not respond to stimuli.

Types of juvenile malignant schizophrenia - simple, catatonic and hebephrenic are distinguished by the manifestations maximally present in the patient.

In the simple form of schizophrenia, the disease usually develops suddenly, usually in fairly manageable, even-tempered and non-addictive adolescents. They change dramatically: stop learning, become irritable and rude, cold and callous, abandon their favorite activities, lie or sit for hours, sleep for long periods of time or wander the streets. They can not be switched to productive activities, molestation of this kind can cause sharp anger. Patients practically do not have delusions and hallucinations. Occasionally there are episodes of rudimentary hallucinatory manifestations or delusional alertness. Without treatment quickly enough, it takes from three to five years, negative symptomatology increases - emotional impairment and a decrease in productive activity, loss of focus and initiative. The cognitive defect specific to schizophrenics increases, and the final stage of the disease comes, as E. Bleuler called it - "the calm of the grave".

Catatonic schizophrenia (motor disorders predominate) with a continuous course is characterized by alternating stupor and agitation without mental confusion.

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

Catatonic and hebephrenic schizophrenia may be seizure-progressive (mixed course). In this case, for all the severity of these forms of the disease, the clinical picture in the post-attack period is somewhat milder. Although the disease progresses, the schizophrenic defect in patients is less pronounced than in the continuous form of the course.

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

Manic seizures occur with pronounced symptoms of agitation. The patient has an elevated mood, a feeling of uplift and vigor. There may be a surge of ideas, it is impossible to have a coherent conversation with the patient. The patient's thoughts take a violent character (alien, embedded), motor excitement also increases. Quite quickly, delusions of impact, persecution, special meaning, "openness of thoughts" and other symptoms characteristic of schizophrenia join. In some cases, the attack takes on the character of oneiroid catatonia.

Depressive attacks begin with despondency, anhedonia, apathy, sleep disturbance, anxiety, fears. The patient is preoccupied, expecting some kind of misfortune. Later he develops delirium, characteristic of schizophrenia. A clinical picture of melancholic paraphrenia with self-accusation and attempts to settle scores with life, or oneiroids with illusory-fantastic experiences of "world catastrophes" may develop. The patient may fall into stupor with fascination, confusion.

Against the background of treatment, such attacks often pass quickly enough, first of all hallucinatory and delusional experiences are reduced, and lastly depression disappears.

The patient comes out of the affective phase with some loss of his mental qualities and impoverishment 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 hardly noticeable. In the initial stage it resembles a neurosis. Later, obsessions develop, more obscure, insurmountable than in ordinary neurotics. Bizarre defense rituals quickly appear. Fears are often too ridiculous - 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 have a decrease in mental activity, sometimes they become incapable of work, because the performance of ritual actions takes all day. They have a very narrowing circle of interests, increasing lethargy and fatigue. With timely treatment, such patients can achieve a fairly rapid and prolonged remission.

Paranoid schizophrenia can be of either type, either continuous or episodic, or it can be episodic-progressive. It is the latter type of course that is most common and best described. Manifestation of paranoid schizophrenia occurs between 20 and 30 years of age. Development is slow, the personality structure changes gradually - the patient becomes distrustful, suspicious, secretive. At first, a paranoid interpretive delusion appears - the patient thinks that everyone is talking about him, he is being watched, he is being harmed, and certain organizations are behind it. Then auditory hallucinations join - voices giving orders, commenting, judging. Other symptoms inherent in schizophrenia appear (secondary catatonia, delusional depersonalization), psychic automatisms appear (Kandinsky-Clerambault syndrome). Often it is in this paranoid stage that it becomes clear that it is not eccentricities, but a disease. The more fantastical the delusion, the more significant the personality defect.

The attack-like-progressive course of paranoid schizophrenia develops at first, as in the continuous type. Personality changes occur, then the picture of delusional disorder with symptoms inherent in schizophrenia unfolds, paranoid delirium with components of affective disorder may develop. But such an attack is quickly enough completed and there comes a period of long remission, when the patient returns to the usual rhythm of life. Some losses are also present - the circle of friends narrows, restraint and secrecy increases.

The remission period is long, averaging four to five years. Then there is a new attack of the disease, structurally more complex, for example, an attack of verbal hallucinosis or psychosis with manifestations of all kinds of psychic automatisms accompanied by symptoms of affective disorder (depression or mania). It lasts much longer than the first one - five to seven months (this is similar to the continuous course). After the attack is resolved with the restoration of almost all personality traits, but at a somewhat reduced level, several more quiet years pass. Then the attack recurs again.

Seizures become more frequent and periods of remission shorter. Emotional, volitional, and intellectual losses become more marked. However, the personality deficits are less significant compared with the continuous course of the disease. Before the era of neuroleptics, patients usually experienced four seizures followed by the end stage of the disease. Nowadays, with treatment, the remission period can be extended indefinitely and the patient can live a normal life in the family, although in time he will become more fatigued, do only simpler work, become somewhat estranged from his relatives, etc.

The type of schizophrenia is not important for prescribing antipsychotic therapy, so some countries have already abandoned this classification, considering the identification of the type of schizophrenia to be unnecessary. The new edition of the ICD-11 classification of diseases is also expected to move away from classifying schizophrenia by type.

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

Complications and consequences

Progressive schizophrenia over time leads, at the very least, to a loss of flexibility of thinking, communication skills, and the ability to solve life's problems. The patient ceases to understand and accept the point of view of others, even the closest and most like-minded. While formally the intellect is preserved, new knowledge and experience are not assimilated. The severity of growing cognitive losses is the main factor that leads to loss of independence, desocialization and disability.

Schizophrenics have a high probability of committing suicide, both during acute psychosis and during remission, when he realizes that he is terminally ill.

The danger to society is considered to be greatly exaggerated, but it does exist. Most often everything ends with threats and aggression, but there are cases when under the influence of peremptory delirium, patients commit crimes against the person. This does not happen often, but it does not make the victims feel better.

Adherence to substance abuse aggravates the course of the disease; half of the patients have this problem. As a result, patients ignore the recommendations of the doctor and loved ones, violate the therapy regimen, which leads to rapid progression of negative symptoms, and increases the likelihood of desocialization and premature death.

Diagnostics of the progressive schizophrenia

Schizophrenia can only be diagnosed by a psychiatric specialist. There are no tests and hardware studies that would confirm or deny the presence of the disease. Diagnosis is made on the basis of the patient's medical history and symptoms detected during observation in the hospital. The patient is interviewed, as well as people who live near him or her and know him or her well - relatives, friends, teachers and work colleagues.

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

Similar symptoms to schizophrenia are present in other mental disorders: delusional, schizophreniform, schizoaffective and others. Psychosis may also manifest itself in brain tumors, intoxication with psychoactive substances, head trauma. With these conditions and differential diagnosis is carried out. It is for differentiation used laboratory tests and neuroimaging methods that allow you to see organic lesions of the brain and determine the level of toxic substances in the body. Schizotypal personality disorders are usually milder than true schizophrenia (less pronounced and often do not lead to a full-blown psychosis), and most importantly, the patient emerges from them without specific cognitive deficits. [13]

Treatment of the progressive schizophrenia

The best results are obtained when therapy is administered in a timely manner, that is, when it is started during the first episode that meets the criteria for schizophrenia. The main drugs are neuroleptics, and they should be taken for a long time, about a year or two, even if the patient has had the debut of the disease. Otherwise, there is a very high risk of relapse, and within the first year. If the episode is not the first, then drug treatment should be taken for many years. [14]

Administration of neuroleptics is necessary to reduce the severity of psychotic symptoms, prevent relapses and aggravation 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, typical neuroleptics, whose action is realized through blockade of dopamine receptors, are mainly used at the beginning of treatment. According to the strength of their action, they are divided into three groups:

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

The choice of the drug depends on many factors and is determined by activity against 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 the period of acute psychosis, active pharmacotherapy with high doses of drugs is used, after achieving therapeutic effect, the dose is reduced to a maintenance dose.

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

Some drugs of both generations (haloperidol, thioridazine, risperidone, olanzapine) increase the risk of heart rhythm disturbances up to fatal arrhythmias.

In cases where patients refuse treatment and are unable to take the daily dose, depot neuroleptics, such as aripiprazole in long-acting intramuscular injections or risperidone in microgranules, are used to ensure compliance with the prescribed regimen.

Treatment of schizophrenia is carried out in stages. First, the acute psychotic symptoms - psychomotor agitation, delusional and hallucinatory syndromes, automatisms, etc. - are treated. 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 schools of psychiatry favor different therapeutic regimens.

In the former Soviet Union, classical neuroleptics remain the drug of choice, unless their use is contraindicated. The criterion for choosing a particular drug is the structure of the psychotic symptomatology.

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

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

In polymorphic psychotic disorder with hebephrenic and/or catatonic elements, Majeptil - 20 to 60mg or Piportil - 60 to 120mg daily, drugs with a broad spectrum of antipsychotic action are prescribed.

American standardized treatment protocols favor second-generation antipsychotics. Classic medications are used only when there is a need to suppress psychomotor agitation, rage, violence, and when there is accurate information about the patient's tolerance to typical antipsychotics or when an injectable form of the medication is needed.

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

In treatment, it is not recommended to prescribe several antipsychotic drugs at the same time. This is only possible for a very short period of time in hallucinatory delusional disorder against a background of severe agitation.

If during treatment with typical antipsychotics [19] side effects are observed, prescribe the use of correctors - akinetone, midocalm, cyclodol; adjust the dosage or switch to the latest generation of drugs.

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

Patients with negative symptomatology are recommended therapy with atypical neuroleptics.

If there is a high likelihood of developing side effects:

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

It should be considered that the highest risks of obesity develop in patients taking clozapine and olanzapine; the lowest in trifluoperazine and haloperidol. Aminazine, risperidone and thioridazine have a moderate ability to promote body weight gain.

Late dyskinesia, a complication that develops in one fifth of patients treated with first-generation neuroleptics, occurs most often in patients treated with aminazine and haloperidol. It is least likely to occur in patients treated with clozapine and olanzapine.

Anticholinergic side effects occur against the background of taking strong classical antipsychotics, risperidone, ziprasidone

Clozapine is contraindicated in patients with blood count changes, aminazine and haloperidol are not recommended.

Clozapine, olanzapine, risperidone, quetiapine, and ziprasidone have been most commonly implicated in the development of malignant neuroleptic syndrome.

In case of significant improvement - disappearance of positive symptoms, restoration of critical attitude to his/her 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 episode. The patient continues to take the antipsychotic that was effective during the acute episode, but at a reduced dose. It is selected in such a way that the sedative effect gradually decreases and the stimulant effect increases. When psychotic manifestations return, the dose is raised to the previous level. At this stage of treatment, post-psychotic depression, dangerous in terms of suicide attempts, may occur. At the first manifestations of depressed mood, the patient is prescribed antidepressants from the group of SSRIs. Psychosocial work with the patient and his family members, inclusion in the processes of education, work, and resocialization of the patient plays an important role at this stage.

Then we move on to managing negative symptoms and restoring the highest possible level of adaptation to society. Rehabilitation measures require at least another six months. At this stage, atypical neuroleptics continue to be administered in low doses. Second-generation drugs suppress the development of productive symptomatology and affect cognitive function and stabilize the emotional-volitional sphere. This stage of therapy is particularly relevant for young patients who need to continue their interrupted studies and middle-aged patients who are successful, with a good pre-disease perspective and level of education. Deposited neuroleptics are often used at this and the next stage of treatment. Sometimes the patients themselves choose this method of treatment, injections are given every two (risperidone)-five (Moditen) weeks depending on the drug chosen. This method is resorted to when the patient refuses treatment because they consider themselves already cured. In addition, some people have difficulty taking the medication 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. A low-dose neuroleptic effective for the patient is used. According to the standards of American psychiatry, continuous use 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 repeated episodes. Russian psychiatrists practice, in addition to continuous, intermittent method of taking neuroleptics - the patient begins the course at the appearance of the first symptoms of exacerbation or in 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 course. Intermittent method of prophylaxis is recommended for persons with a clearly expressed attack-like type of schizophrenia. Side effects in this case develop much less frequently.

Prevention

Since the causes of the disease are unknown, specific preventive measures cannot be determined. However, general recommendations that it is necessary to lead a healthy lifestyle and try to minimize the harmful effects on the body depending on you are quite appropriate. A person should live a full life, find time for physical training and creative activities, communicate with friends and like-minded people, as an open lifestyle and a positive outlook on the world increases stress resistance and favorably affects the mental status of a person.

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

Forecast

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

Timely treatment of the disease, more often during the first episode, results in a long and stable remission in about one 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 need constant supportive therapy, some are incapacitated or perform less skilled work than before the disease. The remaining third are resistant to treatment and gradually lose their ability to work.