The initial stage of schizophrenia

Schizophrenia is attributed to mental disorders that have preliminary signs that can signal the development of this disease. The set of early symptoms and the entire period of their manifestation are considered the prodromal or prepsychotic phase, which is defined by such terms as initial schizophrenia, risk syndrome for psychosis, and prodrome schizophrenia. The duration of this period is individual for each case and varies from several months to several years. [1]

Epidemiology

The prevalence of schizophrenia among the population as a whole is 0.7-1.1%; according to other information, 3-4 cases of schizophrenia and 3.3 cases of prodrome, that is, initial schizophrenia, are detected for every thousand people.

The proportion of people diagnosed with schizophrenia is 0.29% of the total population, varying from 0.2 to 0.45% in different countries. [2]

According to WHO 2016, more than 21 million people worldwide suffered from this severe chronic mental disorder. 70-90% of patients had a prodromal stage.

If the initial stage of schizophrenia in men usually manifests between 15-25 years, then the initial stage of schizophrenia in women is detected later - at 25-30 years old, moreover, almost one and a half times less than in men (according to other sources, the number of men and women with schizophrenia is about the same). [3]

In children and people after 45 years, schizophrenia is rarely diagnosed.

Causes of the initial schizophrenia

At present, the exact causes of schizophrenia continue to be studied, and often in psychiatry there is a very vague definition of the etiology of this disease, as a result of the complex interaction of genetically determined factors with the environment.

So, risk factors for the initial stage of schizophrenia exist and, it seems, partially contribute to its occurrence and subsequent transition to the stage of manifestation (in 35% of cases - after two years). [4]

Versions and theories regarding the causes of this disease include:

• inheritance of genetic mutations (schizophrenia is often observed in close relatives, although it does not belong to the hereditary diseases themselves, but, as the researchers suggest, it can develop in cases of unbalanced genomic imprinting);
• impaired brain function due to an imbalance of biogenic amines acting on nerve cells - neurotransmitters dopamine, serotonin, norepinephrine, glutamic acid (N-methyl-D-aspartate-glutamate) and GABA (gamma-aminobutyric acid);
• the presence of communication and interaction problems between individual cerebral regions and structures due to abnormalities of the brain cells themselves, especially glial ones that surround the central nervous system neurons;
• shifts of an immunological nature - increased activation of the immune system of an inflammatory or autoimmune genesis;
• the effect of a viral infection (Morbillivirus, Varicella Zoster, Rubella virus, genital Herpes simplex virus type II, Bornavirus) or toxins on the embryo or newborn;
• perinatal damage to the central nervous system with hypoxia and / or cerebral ischemia;
• chronic stress (including mothers during pregnancy) and psychosocial factors;
• the use of psychotropic (psychoactive) substances.

Is it possible to claim the presence of a seasonal factor is not yet clear, however, studies have shown that those born in winter or early spring (when the body lacks vitamin D) are more likely to develop schizophrenia. [5]

Pathogenesis

Many experts see the pathogenesis of schizophrenia as impaired transmission of nerve impulses mediated by the neurotransmitter dopamine. Read more about the so-called dopamine theory in the publication -  Schizophrenia .

Current studies of the mechanisms involved in the development of this mental disorder give reason to assume the leading role of disturbances in the connections between the functional structures of the brain that perceive sensory signals and form the corresponding responses: the associative region in the frontal part of the prefrontal cortex, the auditory cortex of the temporal lobes, and the associative regions of the cerebral cortex lower parietal lobe, etc.

Perhaps the pathological change in the relationships and interactions of the associative zones of the brain is the result of an increasing decrease in the number of membrane calyrin outgrowths on the processes of cortical pyramidal neurons - dendritic spines. [6]

On the other hand, studies of geneticists have shown that chromosomal micro-rearrangements - non-allelic homologous recombination of neurotransmitter genes and their receptors with molecular damage in the form of the loss of microscopic chromosomal fragments (deletions) or are directly related to the mechanism of development of sporadic schizophrenia (in the absence of cases of this disease in the genus) their segmental doubling (duplication). [7]

Symptoms of the initial schizophrenia

In fact, with the development of this disorder in the human psyche, changes take place that lead him into the inner world, unknown and incomprehensible to others.

To simplify the identification, the whole set of symptoms of this mental disorder, including the initial symptoms of schizophrenia, is divided into subgroups: positive (psychotic symptoms appearing), negative (lost abilities), emotional (affective) and cognitive (cognitive). [8]

According to psychiatrists, at the same time, all the symptoms in one patient never appear, and many can be observed temporarily and very briefly; however, some of the signs of the disease are persistent and cannot be treated. [9]

Earlier than others - often unnoticed in the prodrome stage - negative symptoms that reduce the ability to adapt appear, which are associated with loss of motivation, decreased perception and expression of emotions, loss of feelings of pleasure and enjoyment, reduced self-care, and limitation of verbal communication (in this case, speech becomes monotonous, and there is no eye contact during a conversation). Among the positive symptoms are noted:

• fixed false (delusional) beliefs, often paranoid in nature, that have no real reason; a person with distorted thinking and perception of reality becomes incredulous and more suspicious, avoiding contact with people (up to complete isolation);
• auditory or  imperative hallucinations  (during which patients often talk to themselves or listen to loud music to drown out “voices in the head”);
• disorganization of the processes of thinking and verbal communication (inconsistency, illegibility and incoherence of speech);
• behavioral disorganization - from causeless anxiety, agitation, and increased motor activity (aimless and useless) to a state of absolute immobility (catatonia).

For a family and loved ones, in the first place, these symptoms of the initial stage of schizophrenia become apparent.

The affective symptoms of initial schizophrenia include a depressive state and a sense of strangeness around the world. And cognitive symptoms include decreased attention, the ability to remember new information and establish logical connections, as well as plan and organize your actions.

Distinguish the symptoms of the prodromal and psychotic stages of schizophrenia according to the intensity and duration of its manifestation, as well as increasing progression.

Initial signs of schizophrenia in adolescents

The prodrome of schizophrenia often manifests itself precisely in adolescence, which, according to psychiatrists, makes it difficult to identify due to some similarities with the behavior patterns of many teenagers. [10]

In principle, the initial signs of schizophrenia in adolescents are nonspecific and can be both in  depression in adolescents and prodromal signs of mood disorder, bipolar or anxiety disorder.

Symptoms of initial schizophrenia in a teenager are close to the symptoms of adults and are manifested in estrangement from family and friends, separation from reality, problems with sleep, irritability and apathy, decreased stress resistance, general motivation and academic performance, loss of interest in past hobbies, neglect of personal hygiene rules. Dull or inappropriate emotions, memory impairment, causeless hostility to others are also observed, but delusions are rare, and hallucinations are mostly visual.

Complications and consequences

Without treatment for schizophrenia at the stage of prodromal symptoms, it can lead to its transformation into explicit psychosis and the appearance of problems that affect all areas of life. Complications include self-harm, suicidal thoughts and suicide attempts (relative risk is estimated at 12.6%), obsessive-compulsive disorder, alcohol or drug abuse, social exclusion. [11]

Throughout the world, schizophrenia is associated with significant disabilities and can adversely affect education and professional activities.

Diagnostics of the initial schizophrenia

Despite the non-specificity of the symptoms of initial schizophrenia, in psychiatry there are criteria according to which the diagnosis of this disorder is carried out by means of a survey, anamnesis, analysis of symptoms and a complete psychiatric evaluation of the patient. [12]

Specialists currently use: the Prodromal Symptom Scale (SOPS), the Prodromal Symptom Rating Scale (Brief Psychiatric Rating Scale) based on the Comprehensive Assessment of Symptoms and History criteria, and the Comprehensive Assessment of Mental State at Risk (CAARMS) ) [13], [14]

See also -  Diagnosis of cognitive impairment

Differential diagnosis

Differential diagnosis is carried out by similar methods and allows to distinguish prodromal schizophrenia from psychotic forms of depression, schizoaffective or bipolar disorder.

In cases with adolescents, the psychiatrist communicates with their parents | / guardians |, clarifying complaints, explaining the principles for determining the diagnosis, treatment methods, the effect of prescribed drugs, and also answers their questions. For example, sleepwalking is the initial stage of schizophrenia? No,  sleepwalking or walking in a dream  is a manifestation of a neurosis (neurotic reaction) and refers to sleep disorders that are associated with the work of the brain.

Treatment of the initial schizophrenia

Effective treatment of schizophrenia in the initial stage - based on an integrated therapeutic approach to this mental disorder - should be carried out according to an individual plan drawn up by a psychiatrist for each patient. This is psychotherapy (individual or group) and psychosocial treatment, which includes psychological education, family therapy, social skills training, vocational rehabilitation, cognitive-behavioral therapy and rehabilitation.

Comprehensive  treatment for schizophrenia  is aimed at reducing the likelihood of prolonged disability, which people with this disorder often face, and helps them live a normal life.

Modern psychosocial methods should be combined with drug therapy, which uses drugs from pharmacological groups to correct the symptoms of initial schizophrenia, such as:

• antidepressants ;
• anxiolytics:  Adaptol  (Mebikar),  Zolomax , Olanzapine (other trade names are  Zolafren , Olaneks, Parnasan, Normiton);
• antipsychotics or antipsychotics : Risperidone (other trade names are Rispolept, Rileptide, Ridonex, Rilept, Leptinorm),  Azaleptin  (Clozapine), Aripiprazole (Ariprizol, Amdoal, Zilaxer).

For example, the use of the antidepressant Paroxetine (Paroxin,  Paxil , Adepress), which can be prescribed from the age of 15, can be accompanied by side effects in the form of nausea and loss of appetite, weakness and drowsiness, insomnia and somnambulism, headache and dizziness, increased intracranial pressure and muscle spasms (including orofacial), tachycardia and instability of blood pressure, problems with urination and excessive sweating.

Despite the impressive list of side effects, with schizophrenia, the antipsychotic Risperidone is very often prescribed (the dose is determined by the attending physician). It is not used in the treatment of patients under 15 years of age, as well as in the presence of a history of severe heart diseases, problems with blood circulation in the brain, kidney and liver dysfunction, a decrease in BCC, diabetes mellitus, and epilepsy. The list of its side effects includes: sleep disorders, increased irritability and impaired attention, anxiety and anxiety, headache and abdominal pain, increased blood pressure and increased heart rate, seizures, dyspepsia, menstrual cycle disorders in women and erectile dysfunction in men.

An antipsychotic, Azaleptin, given in an individually prescribed dosage, can cause increased drowsiness, headache and dizziness, blurred vision, tremors, nausea, vomiting, dry mouth, constipation, heart rhythm disturbance, increased blood pressure, decreased white blood cell count, involuntary urination obesity. The drug is contraindicated for heart problems, hypertension, epilepsy, diseases of the intestines, blood and bone marrow.

Aripiprazole is contraindicated in cardiovascular diseases and before the age of 18 years. It can also cause side effects, including: sleep disturbances and psychomotor agitation; salivation and cramps; shortness of breath from nose; atrial fibrillation, myocardial infarction, and cerebral hemorrhage; decreased memory and confusion. [15]

Prevention

There is no reliable way to prevent initial schizophrenia, but following a treatment plan can help prevent the progression of symptoms.

Secondary prevention of schizophrenia is most likely to be possible when risk factors and the causes of its development are studied more deeply.

Until then, only early detection of the prodromal phase and intervention can change the course of the disease and help minimize disability.

According to a study on Recovering from an Initial Episode of Schizophrenia (RAISE), published in the 2015 goal in the American Journal of Psychiatry, rapid detection and treatment of people with schizophrenia prodrome increases their chances of a full life.

Forecast

Prediction of the course and outcome of mental disorders related to chronic diseases is based on the existing symptoms, the intensity of its manifestation and the patient's response to the therapy. And this, according to experts, is possible only in 10-20% of cases.

Schizophrenia is often episodic, so the longer the periods of remission, the more favorable the prognosis for this patient. In addition, some people with this diagnosis - with the right psychotherapeutic and medical support and the development of self-help strategies - are able to manage their symptoms.

However, it should be borne in mind that people with schizophrenia die at a younger age than healthy people. And the main cause of premature death is suicide: according to some estimates, 10–13% of patients resort to suicide because of severe depression and psychosis, which develop if untreated.