The concept of schizophrenia as a single disease appeared at the beginning of the XX century, when Emil Kraepelin suggested that paranoia, gebefrenia and catatonia are not separate diseases, but manifestations of dementia praecox. He also made a clear distinction between this form of mental illness and manic-depressive psychosis. This became possible after establishing the connection of a significant number of cases of mental illness with syphilis, which allowed to distinguish them from the rest of the group of patients with mental disorders. The discovery of etiology, methods of treatment and prevention of neurosyphilis became one of the main victories of medical science and gave hope that the causes of the main mental disorders will be found.
Eigen Bleuler (1950) proposed a new term for "schizophrenia" instead of the "dementia rheesoch" used earlier, arguing that the fundamental psychopathological phenomenon inherent in this disease was dissociation ("splitting") - both "inside" the thought process, and between thoughts and emotions. The term "schizophrenia" was an expression of this concept and, in turn, had a significant impact on its further development. The classical forms of schizophrenia (for example, gebefrenic, paranoid, catatonic, simple), which were subsequently supplemented with schizoaffective and latent, have so far been desig- nated for descriptive purposes in clinical practice, although there has recently been a trend towards the transformation of psychiatric terminology under the influence of the official American nomenclatures DSM-III and DSM-IV. However, the isolation of individual forms of schizophrenia has proved to be less fruitful, from the point of view of developing differential therapy or studying the etiology and pathogenesis.
ICD-10 mentions such symptoms of schizophrenia: delirium (whimsical, grandeur or persecution), frustrated thinking (intermittent or illogical flow of thoughts or incomprehensible speech), perception disorders (hallucinations, feelings of passivity, relationship ideas), mood disorders, motor disorders catatonia, excitement, stupor), personal decline and decline in the level of functioning.
During the life of schizophrenia, approximately 0.85% of people develop. In childhood, the symptoms of schizophrenia are manifested by the weakening of motivation and emotional reactions. Subsequently, a sense of reality is violated, and perception and thinking deviate significantly from existing norms in a given culture, which is usually manifested by delirium and auditory hallucinations. Often there are also visual and somatic hallucinations, disorganization of thinking and behavior.
Psychosis associated with a violation of the sense of reality, usually manifests in men aged 17-30 years, and in women - 20-40 years. The course and outcome of psychotic disorders are very variable. At the part of patients (about 15-25%) the first psychotic episode ends with complete remission, and in the next 5 years there are no psychotic disorders (however, with subsequent monitoring the proportion of these patients decreases). In other patients (approximately 5-10%), expressed psychotic disorders persist without remissions for many years. Most patients have a partial remission after the first psychotic episode, and subsequently exacerbations of psychotic symptoms are observed periodically.
In general, while the severity of psychotic disorders 5-10 years after the first episode reaches the plateau, the emotional-volitional impoverishment continues for a longer period. Progression of symptoms of schizophrenia is often the result of an increase in primary disorders associated with schizophrenia. These include autism, loss of efficiency, learning ability, low self-esteem and others. As a result, patients remain alone, can not find work, are subject to stress, which can provoke an exacerbation of symptoms and increase their functional defect. In addition, the diagnosis of schizophrenia still generates a negative reaction among the people around, which further limits the patient's possibilities. Although with age, there is a tendency to weaken the symptoms of schizophrenia and often improve functional status, it can not compensate for lost years of life and missed opportunities for the patient.
Connection of criminal action with schizophrenia
Wessely et al. In the course of studying the data of the Camberwell register, tried to answer the question: "Is schizophrenia connected with an increased risk and frequency of committing crimes"? Scientists come to the conclusion that people with schizophrenia, although not generally associated with people with an increased risk of criminal behavior, really are at risk compared with other mental disorders in terms of convictions for violent crimes. It was concluded that there is an increased risk of violence and, consequently, conviction by the court for violence among persons with psychoses, but this relationship is less obvious in the absence of comorbid substance abuse. In the survey of the Office of National Statistics on psychiatric morbidity among prisoners, the prevalence of functional psychoses in the year under review was 7% among convicted men, 10% among unconvicted men in pre-trial detention, and 14% among female prisoners, compared to a clearly comparable figure 0,4% in the general population. The results of this review may require a revision of the above results, since it is almost unbelievable that the difference in the prevalence of mental disorders between the prison population and the general population of this scale could be explained by the tendency of the courts to pass sentences on to mentally ill people. Of course, these results do not in any way indicate a causal relationship between crime and psychosis, they only indicate the existence of an association.
The connection of schizophrenia with violent crimes is usually given more attention than the ties of schizophrenia with other crimes. Taylor in his review of scientific research on this topic concludes that in persons suffering from schizophrenia and convicted of violent crimes, violent acts in the vast majority of cases occur after the onset of the disease. A study of the first episodes of schizophrenia shows that among patients with the first episode of the disease, more than a third a month before admission, there were manifestations of violent behavior, including a potential threat to the lives of others and bizarre sexual behavior. In many cases, prior to the first hospitalizations of these patients, there were appeals to the police, but after hospitalizations, charges were brought only in a small number of cases. Taylor investigated the possibility of schizophrenia in a consistent sample of the population of people in pre-trial detention in Brixton prison. Almost in 9% of cases, one of the forms of psychosis was noted and almost all had active symptoms of schizophrenia; Among those accused of committing a murder, a diagnosis of schizophrenia was present in 8% of cases. According to the report of the National confidential investigation of murders committed by persons suffering from mental illness, 5% of those convicted of murder had symptoms of psychosis. Unlike popular beliefs about people in psychosis, the victim most often becomes not a stranger, but a family member (a more general result obtained for violent behavior in the sample of the community in the study Steadman et al.).
Some specific symptoms of schizophrenia are correlated with violence. So, Virkkunen, when examining in Finland a group of schizophrenic patients guilty of severe episodes of violence, and a group of perpetrators of arsons, found that 1/3 of them committed crimes directly as a result of hallucinations or delusions; The remaining 2/3 committed crimes because of problems caused by stress in the family. The symptoms of threat / loss of control over the situation are directly related to violence. With symptoms that destroy the sense of personal autonomy and the ability to influence the situation, patients can consider their actions to counter the threats related to them ("rationality within irrationality") justified.
Psychotic patients with delusions who commit violent acts by virtue of their ideas are different from patients who do not commit violent acts, by the fact that they are engaged in the search for evidence in defense of their ideas, with the conviction that such evidence is found, as well as affective changes, in particularly depression, anger or fear, associated with their congestion delusions. In the Brixton studies, Taylor et al. With violent actions, the delusional ideas of passivity, religious delusions and delusions of influence were more reliably associated.
The risk associated with active symptoms of schizophrenia, including symptoms of threat / inability to control, increases significantly when substance abuse occurs. The role of the latter factor is emphasized by the data of the study by Steadman et al .: when exposed to this factor, the level of violence among recently discharged psychiatric patients was not higher than the level of violence in the general population. Hallucinations as part of the disease are most often associated with violence in the event that these are imperative hallucinations, or if falsely perceived tastes and smells are interpreted as "evidence" for delusions of control. The role of abnormal personal development in committing crimes by persons suffering from schizophrenia is worse than that (this is a comorbid condition or a consequence of the disease).
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Theories of symptoms of schizophrenia
The original concept of schizophrenia as an early-onset and steadily progressing throughout life neurodegenerative disease (dementia praecox) is currently rejected. Modern hypotheses consider schizophrenia as a neurodevelopmental disease associated with a violation of the development of the nervous system and progressing only in the early years, but not throughout life, which is better consistent with clinical observations. The dysentogenetic theory of schizophrenia makes it possible to understand the role of established etiological factors. Such risk factors for schizophrenia as a birth in winter, a positive family history, a complicated course of pregnancy and childbirth, can disrupt the development of the brain, early forming a predisposition to the disease. Observations of children with a hereditary predisposition, for example, those born by mothers suffering from schizophrenia, revealed a link between the presence of motor, cognitive and affective disorders and the subsequent development of psychosis. The question is debated whether psychosis is the result of the progression of the disease in childhood and adolescence or arises from the fact that the predisposition that emerged in the early years but remained stable appears during the period of growing up, under conditions of increased psychological stress. These theories do not exclude each other, since both suggest an early appearance of mild symptoms and the subsequent development of unfolded psychosis. It should be noted that after the disease has reached a psychotic level, neither the methods of neuroimaging, nor neuropsychological research, nor clinical observation, nor, finally, pathomorphological data indicate further progression of the disease.
In most patients, the negative symptoms of schizophrenia persist throughout life, and growing social maladjustment can be a consequence of the relationship between the sick individual and society. This can be explained at a very elementary level, for example, if we consider the employment problem. After a psychotic episode, it is difficult for a patient to return to his former life and his former occupation. Even in the absence of any symptoms, employers, co-workers, friends and relatives do not consider him a capable person. The unemployment rate among schizophrenic patients reaches 80%, although a large part of them remain functional. The importance of this factor is well shown in studies of socio-centric cultures in developing countries, where schizophrenic patients can maintain their social and professional status in a much less stressful environment. In these countries, the disease is more benign. A detailed discussion of the issues of the etiology and neurobiological basis of schizophrenia is made by Carpenter and Buchanan, Waddington.
It has long been noted that patients with schizophrenia are very heterogeneous in relation to the nature of the onset of the disease, the leading symptoms, the course, the effectiveness of treatment, the outcome. In 1974, an alternative hypothesis was proposed (Strauss et al., 1974), based on the data of transverse and prolonged clinical observations, which indicate a relative independence between positive psychotic symptoms, negative symptoms and impaired interpersonal relationships. The essence of the hypothesis is that these groups of symptoms have an independent psychopathological basis, and do not represent a single unified pathophysiological process. During the observation period there was a high correlation between the severity of the psychopathological symptoms belonging to one group and, conversely, there was no correlation between the severity of the symptoms belonging to different groups. These data have been confirmed in numerous studies, but with one addition. It turned out that hallucinations and delusions are closely related, but do not correlate with other positive symptoms (for example, disorganization of thinking and behavior). It is now generally accepted that the key manifestations of schizophrenia include distortion of the sense of reality, disorganization of thinking and behavior, negative symptoms and cognitive impairment. Negative symptoms of schizophrenia include a weakening of emotional reactions and their external manifestations, poor speech, reduced social motivation. Earlier Kraepelin described these manifestations as "the drying of the source of will." Differences between groups of symptoms are extremely important in the appointment of pharmacotherapy. Other clinical manifestations that are important from a therapeutic point of view include depression, anxiety, aggression and hostility, suicidal behavior.
For many years, the effect of drugs in schizophrenia has been estimated mainly because of their effect on psychotic symptoms or associated indicators, such as the length of hospitalization or remission. With the identification of the relative independence of different groups of symptoms, a comprehensive assessment of the effect of therapy on each of these groups has become standard. It turned out that standard antipsychotic therapy has virtually no effect on cognitive impairment and negative symptoms of schizophrenia. Meanwhile, these two groups of symptoms can have a decisive influence on the severity of the patient's condition and the quality of his life. Awareness of the limitations of the possibilities of traditional pharmacotherapy became the impetus for the development of new agents for the treatment of these manifestations of schizophrenia.
Schizophrenia is a chronic disease that can progress through several exacerbations, although the duration and characteristics of exacerbations may vary. Among patients with schizophrenia, there is a tendency to develop psychotic symptoms 12-24 months before seeking medical help. In the premorbid period, the patient may not be disturbed or the social competence may be violated, slight cognitive disorganization or distortion of perception is observed, the ability to experience pleasure (anhedonia) decreases and other general problems of coping with problems are present. Such symptoms of schizophrenia can be subtle and can only be recognized retrospectively or may be more noticeable with a violation of social, educational and professional functioning. In the prodromal period, subclinical symptoms can occur, including detachment or isolation, irritability, suspiciousness, unusual thoughts, distortions of perception and disorganization. The onset of the disease (delirium and hallucinations) can be sudden (days or weeks) or slow and gradual (over years). The type of schizophrenia can be episodic (with obvious exacerbations and remissions) or continuous; there is a tendency to increase the functional deficit. In the late phase of the disease, the patterns of the disease can be stable, the degree of disability can be stabilized and even diminished.
In general, the symptoms of schizophrenia as such can be divided into positive, negative, cognitive and disorganization symptoms. Positive symptoms are characterized by immoderate or distorted normal functions; negative symptoms - decrease or loss of normal functions. Symptoms of disorganization include thinking disorders and inadequate behavior. Cognitive symptoms are violations of information processing and difficulties in solving problems. The clinical picture may include symptoms from either one or all of these categories.
Positive symptoms of schizophrenia can be divided into delusions and hallucinations or thinking disorders and inadequate behavior. Delusion is a false belief. In the delusion of persecution, the patient believes that he is annoyed, followed, deceived. In the delusion of the relationship, the patient believes that episodes from books, newspapers, lyrics or other external hints are relevant to him. In the delusions of insight or thought-taking, the patient believes that other people can read his thoughts, that his thoughts are transmitted by others, or that thoughts and motivations are invested in him by external forces. Hallucinations can be auditory, visual, olfactory, gustatory or tactile, but auditory hallucinations are by far the most common. The patient can hear voices commenting on his behavior, talking with each other or making critical and offensive remarks. Delusions and hallucinations can be extremely unpleasant for the patient.
Thinking disorders include disorganized thinking with incoherent, non-purposeful speech, with constant transitions from one topic to another. Violations of speech can range from mild disorganization to incoherence and meaninglessness. Inadequate behavior can be manifested childishly naive foolishness, agitation, not appropriate to the situation appearance and manners. Catatonia is an extreme variant of behavioral disorders, which may include maintaining a rigid posture and persistent resistance to movement, or aimless spontaneous locomotor activity.
Negative (deficit) manifestations of the disease are expressed in a form and include flattened affect, poor speech, anhedonia and unsociability. With flattened affect the patient's face looks hypomimous, with poor eye contact and lack of expressiveness. Poverty of speech is manifested by a decline in speech production, monosyllabic answers to questions that create the impression of an inner emptiness. An- donia can be a reflection of a lack of interest in activities and an increase in aimless activity. Unfairness manifests itself in a lack of interest in relationships with people. Negative symptoms often lead to poor motivation and a decrease in the focus of behavior.
Cognitive deficits include violations of attention, speech processing, working memory, abstract thinking, the difficulty of solving problems and understanding social interactions. The patient's thinking can become inflexible, the ability to solve problems, to understand other people's points of view and to learn from experience is reduced. Symptoms of schizophrenia usually disrupt the ability to function and significantly interfere with work, social relationships and self-care. The frequent result is unemployment, isolation, broken relationships and a decline in the quality of life. The severity of cognitive impairment largely determines the degree of general disability.
About 10% of patients with schizophrenia commit suicide. Suicide is the main cause of premature death among schizophrenic patients, this partly explains why among people with schizophrenia, life expectancy is on average reduced by 10 years. Patients with a paranoid form of schizophrenia, late onset of the disease, and a sufficient level of functioning before the disease, who have the best prognosis, are also more susceptible to suicide. Since these patients retain the ability to respond to grief and suffering, they may be more likely to act desperately, based on a realistic understanding of the consequences of their illness.
Schizophrenia is a relatively small risk factor for behavior accompanied by violence. Threats of violence and small aggressive outbreaks are much more frequent than really dangerous behavior. Patients who are more prone to acts of violence include those who abuse drugs and alcohol, have delusions of persecution or imperative hallucinations, as well as those who do not take prescribed treatment. Very rarely, heavy-depressive paranoid patients who feel isolation, attack or kill those they consider to be the only source of their problems (for example, an authoritative, famous person, a spouse). Patients with schizophrenia can go to emergency departments with threats of violence or in order to get food, shelter and the necessary care.