First attack of schizophrenia. Periodic schizophrenia

Schizophrenia translated from Greek means “splitting of the psyche” - loss of the unity of mental activity. In other words, schizophrenia leads to splitting of thinking, reduction, and sometimes distortion of emotional and volitional manifestations. These are the changes that this disease makes to the patient’s personality. There is reliable data on the significance of hereditary predisposition in the disease of schizophrenia, but the cause of its occurrence is still unknown.

In a forensic psychiatric clinic, about half of the subjects declared insane are patients with schizophrenia. This indicates its great forensic psychiatric significance.

The disease most often begins between the ages of 15 and 25 years, which gave the right to initially call it “dementia praecox.” At the same time, it can occur in persons under 15 years of age (childhood and adolescent schizophrenia) or in adulthood and old age (late, senile schizophrenia).

Schizophrenia has a variety of clinical manifestations. Among the disorders and additional factors characteristic of it, the main ones are the type of course of the disease and the characteristics of the symptoms characterizing the disease. These indicators are largely interrelated. Their precise determination helps to resolve both treatment problems and social prognosis. The latter also includes resolving issues within the competence of forensic psychiatry. Typically, there are three main forms of schizophrenia: continuous, paroxysmal-progressive and periodic (recurrent).

Continuous schizophrenia. Depending on the degree of severity (progressivity), they distinguish between sluggish, moderately progressive and malignant schizophrenia.

Sluggish schizophrenia. Acute psychotic states are not observed in persons with a sluggish course of schizophrenia. At the onset of the disease, neurosis-like disorders, vague somatic complaints, unmotivated mood swings that occur without objective reasons, and a feeling of fatigue are noted. The slow development of the disease allows patients to maintain social adaptation for a long time. Patients with neurosis-like disorders (hysterical manifestations, obsessions, asthenia) rarely commit illegal actions. The question is different in cases where low-grade schizophrenia is accompanied by clearly psychopathic-like manifestations. The presence of symptoms such as excitability, irritability, anger, brutality, mood instability, a tendency to dysphoria, suggestibility, combined with emotional and volitional decline, is a fertile ground for committing various antisocial actions. The criminality of these patients increases under the influence of external additional hazards, primarily the use of alcoholic beverages and drugs. In a state of drug and alcohol intoxication, patients can commit a wide variety of acts, including grave socially dangerous acts. A special place among patients with sluggish schizophrenia with psychopathic-like disorders is occupied by persons with severe disorders in the sphere of desires, the so-called heboids. These patients are introverted, inaccessible, have superficial contacts with others, an oppositional attitude towards them (including family members), and oppositionality and negativism take on a grotesque, exaggerated character; behavior is inappropriate and usually includes elements of foolishness. Thinking is amorphous, sometimes paralogical. The behavior of patients with heboid disorders is characterized by disinhibition (including sexual), perversion of drives, often impulsiveness, desire for aimless pastime, and passivity. Infantile and suggestible patients easily enter into antisocial environments and are usually prone to alcohol and drug abuse, vagrancy, and promiscuous sexual relations. In this regard, they were previously classified as the so-called morally insane. Such patients commit rape, hooliganism and theft, i.e. pose an increased social danger to society.

Moderately progressive schizophrenia (delusional, paranoid) begins at the age of 25-30 years. It develops gradually, gradually, especially in the first years. This form is usually characterized by delusional disorders. The occurrence of typical delusions is preceded by an initial period, during which patients may experience obsessions and other neurosis-like disorders (suspicion, anxiety). This period can last several years. Then comes the paranoid stage of the disease. Gradually, unique complexes of pathological overvalued and delusional ideas of various contents (poisoning, relationships, persecution, jealousy, hypochondriacal, love, etc.) are formed.

The paranoid stage lasts from 2-3 to 15-20 years. The subsequent stage of the disease is determined by the addition of hallucinations and symptoms of mental automatism (Kandinsky-Clerambault syndrome) to delirium. The complication of the disease occurs with severe anxiety, fear, distinct confusion, a sense of impending danger, and sometimes catatonic symptoms. Subsequently, the symptoms of exacerbation are smoothed out, and either manifestations of mental automatism come to the fore, primarily pseudohallucinations (hallucinatory version of paranoid schizophrenia), or various delusional ideas (persecution, jealousy, etc.), and mental automatisms remain undeveloped (delusional version of paranoid schizophrenia ).

Typically, illegal actions are committed against the background of exacerbation of symptoms of psychosis during the transition of the disease to the second stage. Subsequently, the clinical picture of the disease may become more complicated and delusions of grandeur may appear. At the same time, the content of delusional and hallucinatory disorders becomes fantastic (paraphrenic stage of the disease). The previous delusional system begins to disintegrate, mental automatisms increase in intensity and become more diverse. Socially dangerous actions can be performed during these remote periods of illness. The disease can stabilize at any stage.

The initial conditions of paranoid schizophrenia are less severe than those of malignant schizophrenia. Many patients with paranoid schizophrenia can live at home after treatment if they receive ongoing supportive therapy. Often they partially retain their ability to work.

Malignant schizophrenia most often begins in adolescence in the form of increasing personality changes. At the same time, former attachments gradually disappear, acquaintances and friends are lost. Against the background of gradually increasing indifference, reactions of irritation, hostility, and rudeness arise towards loved ones, often combined with manifestations of brutality. Sometimes patients talk about their parents as if they were their worst enemies. Gradually, patients lose interest in their surroundings, the curiosity inherent in adolescents. Lethargy and passivity appear, which leads to a sharp decline in school performance. The desire of a number of patients to compensate for the lack of mental productivity by hard work does not yield success. Often during these periods, patients develop interests that are unusual for them. They begin to selectively read philosophical or religious books from time to time, and develop their own methods of physical or spiritual improvement.

Against the background of primary personality changes, further complication of the disease occurs, usually occurring from one to five years after its onset. Affective, hallucinatory, delusional and catatonic disorders appear. They are characterized by one main feature: they are not developed and, layering on top of each other during their development, often make it difficult to determine which of all the disorders is predominant. Two to four years usually constitute the duration of the manifest period of the disease, after which a slightly variable final state occurs, determined by emotional dullness, a sharp decrease in the focus of volitional impulses and residual positive symptoms. Socially dangerous acts are committed by patients both at the initial stage and during the period of the appearance of actual psychotic disorders - delusions, hallucinations, etc. Often, the basis for committing socially dangerous actions are pronounced changes in their personality and impulsive actions.

Paroxysmal-progressive schizophrenia. This type of disease occurs in the form of attacks, but the latter are longer than in periodic schizophrenia. Their difference lies in the fact that in addition to the disorders characteristic of recurrent schizophrenia, syndromes are constantly encountered here, which, during a periodic course, are either absent altogether, or appear in a residual form at distant stages of the disease. Such syndromes are: acute verbal hallucinosis, extensive Kandinsky-Clerambault syndrome, states of acute interpretative delirium, severe and prolonged catatonic disorders without oneiric stupefaction, paraphrenic states. In addition, with paroxysmal-progressive schizophrenia, the disorders that determine the attack occur without any sequence, chaotically. The attacks are followed by periods of painful symptoms (remission). However, from attack to attack, increasingly noticeable personality changes and an increase in dementia are noted. The more complex the attack, the longer it usually lasts. The criminogenicity of patients with recurrent and paroxysmal-progressive schizophrenia during the period of manifest psychosis is relatively low, since in the overwhelming majority of cases they are promptly sent to psychiatric hospitals. The commission of socially dangerous actions by these patients is possible in the very initial period of the disease in the presence of disorders such as confusion, acute sensory delirium, mental automatisms, motor agitation with impulsive actions against a background of anxiety or fear. The overwhelming number of illegal actions are committed by patients with paroxysmal-progressive schizophrenia during periods of remission.

Periodic schizophrenia. Periodic (recurrent) schizophrenia is characterized by the occurrence of acute, relatively short-term, psychotic attacks, interspersed with light intervals (intermissions). With this form of the disease, personality changes increase slowly. Attacks can be determined by a variety of symptoms: affective (depressive, manic), in the form of oneiric catatonia. Typically, the first attacks develop in a certain sequence and in some cases, with repeated returns of the disease, they retain the same structure (the “cliché” type). However, more often repeated attacks occur with a change in symptoms, both in the direction of its complication and in the direction of its flattening (reduction of positive disorders). In the development of attacks of recurrent schizophrenia, a certain sequence of development of psychopathological disorders can be identified. Affective disturbances appear first. Low mood is always combined with anxiety, moodiness, touchiness, and tearfulness. Hypomanic states are accompanied by enthusiasm, tenderness, and a feeling of insight. Affective syndromes that are opposite in structure can replace each other. Over short periods of time, the intensity of affective disorders is subject to significant fluctuations. As the disease deepens, anxiety, fear, or ecstatic states begin to predominate. Motor excitement increases or, on the contrary, inhibition appears. Subsequently, figurative delirium of varying content arises. In its subsequent development, delirium changes towards an increase in fantastic content. It colors the influx of memories of the past, acquired knowledge, and what is happening around. If previously the patient was dominated by motor excitation, now it is increasingly replaced by states of immobility and, finally, at the height of the attack, stupor develops with oneiric stupefaction. An attack of recurrent schizophrenia can stop in its development at any stage. If everything is limited to the appearance of only affective disorders, then they talk about circular schizophrenia. In cases of predominance of depressive disorders and depressive forms of delusions (self-blame, accusations), as well as acute delusions - depressive-paranoid schizophrenia. When an attack with oneiroid develops, oneiroid catatonia is reported. The frequency of attacks varies - from one throughout life to many dozens. The characteristics of remissions depend on many factors, primarily on the frequency and structure of attacks. The more frequent and complex the attacks, the worse the remissions, and vice versa. Typically, personality changes in recurrent schizophrenia occur only after a series of attacks. They are manifested by a decrease in mental activity and a narrowing of the range of interests.

Febrile catatonia (a particularly malignant form). The febrile form of schizophrenia is the most severe malignant type of schizophrenic psychosis. Febrile attacks are possible in both recurrent and paroxysmal-progressive forms of schizophrenia. The clinical picture of a febrile attack looks like pronounced catatonic-oneiric disorders. At the height of a febrile attack, catatonic excitation changes and becomes amentive-like.

Elevated temperature (subfibrillation) usually occurs from the very beginning of the attack, already at the stage of prodromal disorders, followed by a sharp increase during the development of the catatonic state. However, sometimes the temperature rises only at the height of the attack. The total duration of the febrile state is much shorter than the attack (from several weeks to two to three months). The temperature curve is not typical for any somatic or infectious disease. Sometimes the temperature in the morning is higher than in the evening and reaches high numbers (39-40°C). The appearance of patients is typical: feverish shine of the eyes, dry parched lips covered with hemorrhagic crusts, dry red or coated tongue, hyperemia of the skin. Often there are herpes, bruises on the neck, spontaneous nosebleeds, and allergic rashes. Sometimes, on the contrary, at high temperatures there are no indicated febrile symptoms. Pathological reactions of the cardiovascular system are noted: weakening of cardiac activity with a drop in blood pressure, rapid, weak pulse. Blood reactions are nonspecific: leukocytosis, shift to the left, toxic granularity of leukocytes, lymphopenia, increased ESR. In some cases, residual nitrogen, proteins and bilirubin in the blood serum are increased, and the chloride content is changed. Along with this, pronounced changes characteristic of kidney pathology are detected in the urine. Bacteriological blood culture gives negative results. All this indicates toxicosis.

The dynamics of mental disorders occurs as general somatic symptoms increase from acute catatonic-oneiric disorders typical for paroxysmal-progressive schizophrenia (which may be limited) towards amentia-like and even hyperkinetic excitation. With the development of an amentia-like state, excitement becomes disordered and chaotic. Speech becomes completely incoherent (individual sounds, syllables, fragments of phrases).

Currently, with the widespread use of aminazine, deaths are rare, but they do occur. Death from heart failure (sometimes against the background of small focal pneumonia) occurs in the stage of amentia-like or hyperkinetic excitation during their transition to coma.

The reverse development of the attack occurs after the febrile symptoms have passed. In this case, the clinical picture of the disease again takes on a form typical of recurrent or paroxysmal-progressive schizophrenia. The occurrence of a febrile picture does not have a significant impact on the duration of the attack and the further course of the disease.

Clinical observation. Subject A., 34 years old, is accused of committing hooliganism.

He grew and developed according to age norms. He suffered childhood infections without complications. Graduated from 8th grade of secondary school, sales courses. I studied well. His character was sociable, balanced, and inquisitive. He worked as a salesman, supply agent, and warehouse manager. He showed resourcefulness and efficiency in his work.

At the age of 25, A. developed a depressed mood and a feeling of melancholy for no apparent reason. Soon it gave way to an overexcited mood with excessive mobility and talkativeness. He considered himself a gifted person, told those around him that he knew their thoughts and that he should be sent to intelligence school to prepare for an important mission. During that period, he slept little, was constantly on the move, scattered personal belongings, walked half-naked and barefoot. Periodically I felt fear, “heard” shots, and talked about an impending bombardment. He resisted being admitted to a psychiatric hospital. At first in the hospital he resisted examination and treatment procedures, stubbornly refused to eat, and therefore was fed through a tube. He was tense and angry. From individual statements it was possible to find out that he was scared, that there was “a game going on” all around, “he was being re-educated with the help of special mental influence.” After treatment, his condition improved and he was discharged with a diagnosis of “Schizophrenia, remission with defect.” He was on disability group II for several months, then was transferred to disability group III. He got a job as a train conductor. He occasionally drank alcohol and had casual sex. I decided to continue my studies and entered a technical school. The classes were difficult for him, he had difficulty concentrating, but from time to time “his head worked intensely.”

From the materials of the criminal case it is known that A. came to the dacha plot of citizen K., unknown to him, and began to demand that the dog belonging to K. stop barking. When he was asked to leave, A., using obscene language, beat K. and stabbed him.

During the forensic psychiatric examination, A. noted that his thoughts either switched off or appeared a lot. He was not burdened by his stay in a psychiatric hospital and did not show any concern about his future. He believed that he was placed for examination in connection with the “one hundred percent detection of crime” in order to “deliberately convict.” In fact, he is not to blame for anything. He said that after treatment in a psychiatric hospital, he gained “balance and self-control”, he became “good at self-control, able to correctly evaluate other people and delve into the meaning of current events.”

In the past, A. suffered an attack of psychosis, the structure of which included variable affective disorders (depression was quickly replaced by a manic state and then fear), unsystematized figurative delusions, individual manifestations of mental automatism (a symptom of openness), verbal hallucinations and catatonic symptoms, among which was clearly negativism is expressed. In general, the attack was quite typical for paroxysmal-progressive schizophrenia. The nature of subsequent remission also speaks in favor of this diagnosis. In its structure, psychopathic-like disorders and erased bipolar mood swings were noted. Indications by the patient himself of the appearance of traits of balance in him always indicate one or another degree of emotional decline. This is also evidenced by A.’s indifferent attitude towards his deeds and his fate. The offense was committed by A. during a period of mild mood elevation (in a hypomanic state) and psychopathic-like disorders that intensified during that period. By the conclusion of a forensic psychiatric examination, A. was declared insane and sent for compulsory treatment to a general psychiatric hospital.

Forensic psychiatric assessment. About half of the subjects undergoing forensic psychiatric examination in criminal cases and declared insane suffer from schizophrenia. The recognition of a person suffering from schizophrenia with various types of course as insane or sane depends on a number of factors.

In cases where the clinical picture of psychosis or distinct personality changes during remission (symptoms of a defect in the emotional, volitional and cognitive spheres) do not raise doubts regarding the diagnosis of schizophrenia, the person is declared insane. In this case, we are usually talking about a chronic mental disorder, when even remission (improvement of the condition) is unstable and shallow.

If an offense is committed by patients with schizophrenia, who have suffered a psychotic attack in the past, during a period of stable and deep remission without clear personality changes, in these cases they are usually recognized as sane. This decision is made if the deep remission without noticeable personality changes is long-lasting, the patients are well socially adapted, and their mental state does not deteriorate in a traumatic situation, including those associated with judicial investigations.

If schizophrenia develops after the commission of an offense, during the investigation or after conviction, while in prison, patients are released from serving their sentence (Part 1 of Article 81 of the Criminal Code and Article 362 of the Code of Criminal Procedure), although in relation to the acts accused of them they are recognized as sane. Such patients are sent by court decision to psychiatric hospitals for compulsory treatment.

During a forensic psychiatric examination, patients with schizophrenia sometimes resort to dissimulation of their existing mental disorders. This phenomenon is more often observed in patients with depressive and delusional disorders. These individuals try in every possible way to prove that they are mentally healthy, preferring to be held accountable for the offense committed rather than be recognized as sick.

Great difficulties in recognizing schizophrenia arise in its initial stages, as well as during its sluggish course, when psychopathic-like and neurosis-like disorders predominate. In these cases, the degree of personality changes is often underestimated and the importance of traumatic factors is overestimated. These persons, recognized as sane, can remain in prison for a long time, serve a sentence, and then, as a result of an exacerbation of the disease or personality changes they have, commit repeated socially dangerous acts.

The ability of witnesses and victims suffering from schizophrenia to participate in the judicial investigative process, to correctly perceive the circumstances of the case and give correct testimony about them must necessarily be assessed taking into account the intact aspects of their mental activity, as well as depending on the nature of the analyzed criminal situation in which they are participants. turned out to be. If these principles are observed, the civil rights of mentally ill people - victims and witnesses - will always be respected.

Quite often, patients with schizophrenia undergo a forensic psychiatric examination in civil proceedings, when issues of their legal capacity and the establishment of guardianship over them are being resolved. The need to protect the rights of mentally ill people and issues of preventing socially dangerous actions determine the significance of these examinations. In some cases, there may be a discrepancy between expert indicators of sanity and legal capacity. The issue of capacity is considered as the ability to understand the meaning of one’s actions and direct them. Features of the schizophrenia clinic, the possibility of satisfactory social adaptation of patients and the special requirements imposed on the subject when performing various legal actions (property transactions, marriage relations, raising children) necessitate a differentiated assessment of patients in relation to various legal acts.

Periodic (recurrent) schizophrenia

The recurrent form of schizophrenia occurs in the form of attacks with a wide variety of durations (from several weeks to several years). The number of attacks in patients during their lives varies - from 1-2 to 10 or more. In some patients, each attack is provoked by an exogenous moment (symptomatic lability). There are three types of attacks characteristic of recurrent schizophrenia. These include oneiric-catatonic, depressive-paranoid and affective attacks. It is not possible to single out one or another variant of recurrent schizophrenia depending on the nature of the attacks due to the fact that most patients experience attacks of different psychopathological structures throughout their lives. The attacks are generally characterized by intense affectivity; one or another type of sensory delirium and catatonic disorders occur quite easily. Remissions are of high quality. The absence of changes in the patient's personality after the first attacks allows us to talk about intermissions. Gradually, after repeated attacks, patients experience personality changes, which are characterized by the following manifestations: asthenic, hypersthenic, with an increase in performance, but with a decrease in creative efficiency and a slight impoverishment of emotional manifestations. Usually these changes are observed after the third or fourth attack. Then the activity of the process decreases: attacks become less and less frequent, personality changes seem to freeze at the same level. One of the important features of patients suffering from recurrent schizophrenia is that they always have a critical attitude towards the psychotic state they have suffered and they clearly distinguish between health and illness.

The performance of such patients usually does not decrease, with the exception of a slight drop in patients with asthenic personality changes. The prognosis for recurrent schizophrenia is quite favorable, but it should be borne in mind that in such patients, against the background of severe depression, suicidal thoughts and attempts are noted. These patients require special monitoring.

Paroxysmal schizophrenia

This form is characterized by recurring attacks against the background of a continuously ongoing process, manifested in productive and increasing negative symptoms.

Attacks in this form of schizophrenia are varied, characterized by extreme polymorphism and unequal duration (from “transient”, lasting minutes, to lasting for many years). However, they are less acute than attacks of recurrent schizophrenia; in their structure, paranoid and hallucinatory manifestations have a greater share. Sometimes productive symptoms in paroxysmal progressive schizophrenia are noted not only during attacks, but also in the inter-attack period; increasing deficit personality changes and residual symptoms of an attack are detected. The structure of attacks in this form of schizophrenia is polymorphic. For example, during a manic attack, the patient often “intersperses” depression in the form of ideas of self-blame, tearfulness, etc. An incomplete critical attitude towards the transferred state is typical, even in cases where the attack was characterized by severe and massive psychotic symptoms, and sometimes it is completely absent .

The age of onset of paroxysmal-progressive schizophrenia also varies. It can begin in childhood, adulthood and late life. Depending on the age period in which the disease begins, age-related features are clearly evident in the clinical picture. For example, the presence of infantilism in a patient allows us to speak with a high degree of confidence about the onset of the disease in childhood. The prognosis for paroxysmal-progressive schizophrenia is varied and depends primarily on the age of onset of the disease, the severity of the process and the degree of personality changes.

A mental disorder is necessarily manifested by external signs. Attacks of schizophrenia can be different in nature and course. They indicate the form and severity of the disease. Having studied their manifestations, the specialist prescribes appropriate treatment.

Mental disorders in people have always caused fear and confusion among healthy people. Doctors have long tried to figure out where people with strange behavior come from. And only two centuries ago it was possible to describe attacks of schizophrenia, symptoms, and in the 20th century doctors identified the types, forms and stages of the disease, its causes.

The course of schizophrenia involves the development of attacks from time to time

According to the findings of a number of scientists who have been working to identify the causes of the disease for many years, there are a number of factors that provoke mental disorders.

1. Heredity- transmission of the disease at the genetic level from parents, grandparents, etc.
2. Psychoanalytic. The disease occurs against a background of stress, infectious diseases, injuries, and overexertion.
3. Dopamine— an excess of this hormone affects the functioning of nerve impulses.
4. Dysontogenetic- the disease is already embedded in a person’s genes, and due to external factors - trauma, stress, infection, etc., it “pops up” to the outside.

How does the disease manifest itself?

Seizures of schizophrenia have a different character, it all depends on the type and form of the disease. But there are common symptoms that are common to almost all forms of mental illness.

1. Speech is impaired, there is delirium, sudden switching to another, strange topic, and tongue-tiedness.
2. Complete lack of initiative, lack of will and independent actions.
3. Inappropriate reaction to actions and statements, lack of emotions.
4. Delusions of grandeur, persecution, constant manifestation of one's own exclusivity.

Seizures in mental disorders

• When mental illness worsens, the first thing that occurs is anxiety for no reason.
• The sufferer is “attacked” by non-existent voices and communicates with ephemeral personalities and creatures.
• Insomnia occurs, the patient often wakes up and walks from corner to corner.
• There is a loss of appetite or, on the contrary, gluttony. In this state, a schizophrenic can eat a portion many times greater than the daily norm.
• There are outbreaks of aggression, anger, or the sick person hides in a corner, refuses to communicate with loved ones, and completely withdraws into himself.
• There is a desire to run away from home.
• The patient becomes distrustful and may stop recognizing a loved one.

A person during an attack begins to worry for no reason

Important: the listed attacks in medicine are called psychosis. They require urgent relief, for which you need to seek help - call a psychiatric team.

Alcohol psychosis

Very often, with prolonged abuse of alcoholic beverages and drug use, psychosis occurs, which is confused with the first attack of schizophrenia (manifestation). The symptoms caused by severe intoxication of the body are indeed similar to mental illness, but there are still distinctive features:

1. Delirium tremens. Due to withdrawal from alcohol and drugs, the patient sees phantom creatures: devils, goblin, spiders, flies, etc., and tries to catch them. A common hallucination is the head of a dog, which the sufferer may talk to or be afraid of. The characteristic signs of behavior of a mentally ill person who has an attack of schizophrenia are reflected in the video, of which there are a huge number on the Internet.
2. Hallucinations. Voices are heard that can threaten, order, criticize. In such cases, patients are sure that others also hear non-existent sounds.
3. Rave. It occurs against the background of prolonged alcohol intoxication and is characterized by persecution mania and fear of being poisoned.
4. With prolonged consumption of alcohol, brain cells are affected, causing encephalopathy. An alcoholic develops symptoms of schizophrenia: delusions, hallucinations, attacks of aggression, anger, and he becomes uncontrollable. In severe cases, hospitalization in a specific institution is required.

The most dangerous phase is considered to be the acute phase of schizophrenia.

How long does a schizophrenia attack last?

It is impossible to determine with accuracy how long a schizophrenic attack lasts. It all depends on the individual’s characteristics, the form of the disease, and aggravating circumstances. According to general data, there are several phases and each of them takes a certain period of time

1. Acute (first) phase. The exacerbation lasts up to two months. The patient's thinking and memory deteriorate, and there may be a loss of interest in work, study, and favorite activities. The condition is aggravated by apathy, untidiness, and lack of initiative. The patient often experiences excessive sweating, headache, dizziness, rapid heartbeat, anxiety, and fears. With timely therapy, the prognosis is favorable, up to long-term remission.
2. After effective relief of attacks, stabilization stage. The process takes more than six months. The patient's symptoms are mild; in rare cases, delusions and hallucinations occur. Without medical intervention, the acute phase continues to acquire threatening signs: memory loss occurs, delusional thoughts intensify, and the patient hallucinates continuously. As a result, complete loss of appetite and attacks of aggression with screaming and howling are possible. Suicidal tendencies are obsessive in nature.

An attack of schizophrenia: what to do

The main thing is not to bring a person’s condition to acute phases. It is important to pay attention to the first signs of the disease and seek qualified help. If the process is started, you should calm the patient down and at the same time call an ambulance for psychiatric help. It is impossible to cope with mental illness without the intervention of a specialist.

During the acute phase, the patient can be dangerous to others

It is necessary to influence the brain cells and the patient’s behavior with antipsychotic and nootropic drugs. The acute phase can pose a risk to the life of both the patient and those around him. Often, during a seizure, people suffering from schizophrenia attacked people, caused injuries, and committed violence. For those who are first faced with a diagnosis of schizophrenia, a video of an attack will tell you in detail what the sick person looks like, what characteristic facial features and behavior appear. Thanks to this, you can without a doubt identify the disease and contact the right medical structure.

Attacks of schizophrenia are a consequence of a functional disorder of the brain. There are several causes and predisposing factors for this disease, such as heredity, emotional shock, brain injury, etc.

Symptoms and frequency of attacks

The first signs of the disease include a sharp change in color preferences and a strange change in behavior.

The development of schizophrenia is signaled by the isolation of a person who tries in every way to protect himself from the outside world. His routine is disrupted, his sleep becomes restless, such a person often suffers from insomnia.

Regular headaches, migraines, sudden changes in mood, behavior patterns - all this is also a possibility. Inappropriate obsessions come to the patient's head, he suffers from hallucinations and delusions. A person becomes suspicious, he considers everything around him suspicious.

The level of sensitivity increases, the patient imagines that someone is following him. An insurmountable fear of death appears. Logical thinking is turned off, and mental abilities are reduced to a minimum.

The patient may begin to speak in a childish voice, lisp, continuously repeat some incomprehensible and unintelligible phrases, elevate himself above those around him, and then completely withdraw from everything that is happening around him.

In some cases, clear consciousness is maintained, but the pathology affects motor reflexes. Patients may experience seizures in schizophrenia, complete stupor, or unusual levels of activity.

Attacks can occur continuously or in periods with long light intervals when the person feels healthy. Such attacks occur once every 2-3 years. Paroxysmal schizophrenia also goes through periods that either change the personality or pass without a trace.

What to do during an attack?

When the patient is in an agitated or aggressive state, it is necessary to try to calm him down and make him harmless to others, and also try to prevent suicide attempts, if any. Only a specialist can help cope with an attack, so the person must be taken to a medical facility where he will receive assistance. You need to behave gently with the patient; he should not feel pressure, as if he was being driven into a trap. Speech should be slow, but not condescending, so that the patient cannot suspect anything

To calm the patient, the clinic uses various antipsychotics, for example: Haloperidol, Triftazin, Truxal, Rispolept. Such drugs have an inhibitory effect on the brain, are suitable for parenteral administration (i.e., bypassing the gastrointestinal tract), they act for 10-12 hours and do not cause an adverse reaction. The dosage of such a drug is determined by the patient's condition.

If the attack does not go away, hypnotics can be added to the antipsychotics. A person who is having an attack of schizophrenia should be kept under the inhibitory influence of medications until he completely calms down.

If the attack manifests itself in the form of a depressive state, then the specialist may prescribe antidepressants, for example, Fluvoxamine, Paroxetine. The dosage depends on the patient’s condition and which symptoms are more severe: anxiety or depression.

How to prevent a second attack?

In order to prevent a recurrent schizophrenic-type attack, you need to seek help from a specialist.

It takes place in several stages. The first phase is taking medications that affect the patient’s brain. Depending on the type of disease and symptoms, the doctor prescribes a medicine according to an individual program.

The next step is to understand the cause of the disease. This may be a manifestation of neurosis, a consequence of a head injury, an emotional shock experienced, the result of alcohol or drug addiction, etc. The doctor will help you understand the sources that influenced the onset of schizophrenia and find out the factors that can provoke a second attack.

There are several recommendations that need to be followed at home. It is necessary to completely eliminate alcohol-containing drinks and narcotic substances from the patient’s life. A person should not feel like an outcast, so he should not be allowed to be isolated from society. The process of socialization will not allow the formation of one’s own reality in the patient’s head. With the support of loved ones, he will not need to create an imaginary world.

Negative experiences should be minimized or completely prevented. It is recommended to throw out all the negativity in the gym or creative expression. Such a hobby will help distract the patient from his fears. A person must be busy with something all the time, then he will not have time to immerse himself in the world of fantasies and hallucinations. Also, the patient will be more tired physically, his sleep will become calmer.

Schizophrenia(schizophrenia; Greek schizō split, divide + phrēn mind, mind; synonym Bleuler's disease) is a mental illness with a long-term chronic progressive course, accompanied by dissociation of mental processes, motor skills and increasing personality changes. The inconsistency of the entire mental life in schizophrenia allows us to designate it with the concept of “discordant psychosis.” A characteristic feature of schizophrenia is the early appearance of signs of a personality defect. The cardinal signs are autism (the patient’s isolation from reality with loss of emotional connections and fixation on internal experiences, ideas, fantasies), ambivalence (duality in the affective sphere, thinking, behavior), disorders of associative activity, emotional impoverishment, as well as those noted at different stages of the disease positive disorders - delusional, hallucinatory, catatonic, hebephrenic, senestohypochondriacal, neurosis-like psychopathies, affective.
At the same time, positive disorders differ significantly from psychogenic, somatogenic and organic mental disorders.

Negative disorders in schizophrenia include manifestations of pseudoorganic (rigidity of thinking, intellectual decline), asthenic (decreased mental activity, or reduction of energy potential) and psychopathic-like defect (mainly schizoid personality changes).

ETIOLOGY, PATHOGENESIS AND PATHOMORPHOLOGICAL CHARACTERISTICS schizophrenia. Schizophrenia belongs to a group of diseases with a hereditary predisposition. This is evidenced by the accumulation of cases of this disease in families of patients with schizophrenia, as well as the high concordance of identical twins with schizophrenia. There are several hypotheses for the pathogenesis of schizophrenia. Thus, the biochemical hypothesis assumes, first of all, disturbances in the metabolism of biogenic amines or the functions of their enzymatic systems. The immunological hypothesis is based on a number of biological abnormalities (membrane insufficiency of brain tissue cells, changes in autoimmune reactions), accompanied by the production in the body of a patient with schizophrenia of antibodies that can damage brain tissue.

Along with biological hypotheses, concepts of the psycho- and sociogenesis of schizophrenia are also put forward, based on behaviorist, psychological and other theories (for example, the theory of communication, filters, excessive inclusion), which have not received wide recognition due to insufficient scientific validity of a number of provisions.

From a psychoanalytic and psychodynamic perspective, schizophrenia is considered as one of the forms of personality disadaptation, as a result of its special development, the impetus for which was early interpersonal conflicts.

A pathological examination of the brain of patients with schizophrenia revealed pronounced encephalopathic changes of a toxic-hypoxic nature.
In cases of a malignant, protracted course of schizophrenia, shrinkage of pyramidal nerve cells and their disappearance with the formation of foci of loss of cytoarchitecture of the cerebral cortex, as well as pigmented sclerosis of neurons, and areactivity of microglia are observed.

CLINICAL PICTURE
There are continuous, paroxysmal-progressive and recurrent types of schizophrenia.

Continuous schizophrenia is characterized by chronic, progressive development of the pathological process without deep remissions. The weakening of progressive dynamics is accompanied only by a relative stabilization of psychopathological manifestations with a slight reduction in both positive and negative disorders. Depending on the degree of progression of the process, malignant (nuclear), progressive and sluggish schizophrenia are distinguished. According to the characteristics of psychopathological manifestations, within each of them, separate forms of schizophrenia are distinguished.

Malignant schizophrenia most often develops in childhood or adolescence.
Among the manifestations of the disease, a decrease in mental activity, increasing emotional changes and signs of a distorted puberty predominate. At the initial stages of malignant schizophrenia, patients already experience thinking disorders and their ability to concentrate is impaired. Despite the efforts spent on preparing school assignments, children's academic performance drops sharply. If previously brilliant abilities were discovered, now patients are forced to stay for a second year, and sometimes stop studying. As emotional changes deepen, alienation from relatives increases, often combined with irritability and even aggressiveness.

In cases where the disease is limited primarily to negative disorders (progressive emotional impoverishment, loss of interests, lethargy, intellectual unproductivity), a simple form of schizophrenia is diagnosed.

With the development of the clinical picture of psychosis, positive disorders observed along with negative ones are polymorphic, sometimes undeveloped.
Thus, in some cases, phenomena of silly excitement (hebephrenic form of schizophrenia) prevail - clowning, grimacing, rudeness, malice and sudden mood swings; at the same time, phenomena of behavioral regression may come to the fore - sloppiness in food and clothing, a tendency to ridiculous actions. In other cases of malignant schizophrenia, delusional and hallucinatory disorders are expressed (unsystematized delusions of persecution, poisoning, grandeur, phenomena of mental automatism, pseudohallucinations).

The most malignant course of schizophrenia is observed with the early appearance and subsequent predominance in the clinical picture of catatonic disorders (catatonic form of schizophrenia), which can be either in the form of akinetic manifestations with increased muscle tone, phenomena of waxy flexibility, negativism (catatonic stupor), or the form of hyperkinesia with impulsiveness, outbursts of aggression, meaningless stereotypical movements, repetition of words and movements of others (catatonic excitement).

Progressive (paranoid) schizophrenia develops in people over 25 years of age; occurs with a predominance of delusional disorders. The initial stage of the disease is characterized by neurosis- and psychopath-like disorders and unstable delusional ideas. The manifestation of the process is manifested by the formation of delusional or hallucinatory disorders. There are three stages in the development of paranoid schizophrenia - paranoid, paranoid, paraphrenic. At the first stage, delusional ideas of ordinary content arise (delusions of jealousy, invention, reform, etc.), which, as the disease develops, are gradually systematized and take the form of delusions of persecution.

At the paranoid stage, manifested by the phenomena of anxious-fearful arousal, there is a change in the delirium of physical influence to the phenomena of mental automatism, when the patient seems that his thoughts and movements are controlled from the outside, influencing his feelings and functions of internal organs.

At the paraphrenic stage, delusions with ideas of greatness, high origin, false, fictitious memories (confabulation) dominate. In the clinical picture, delusions of grandeur, which form against the background of altered, usually increased affect, are combined with delusions of persecution, as well as auditory hallucinations and phenomena of mental automatism.

Sluggish schizophrenia often debuts in adolescence. However, clear manifestations may be detected later. The slow, long-term development of the disease is accompanied by gradually increasing personality changes. Sluggish schizophrenia is characterized by a predominance of neurosis-like or psychopathic-like disorders in the clinical picture. In the first case, asthenic conditions are noted with a polar change in painful manifestations (for example, hyperesthesia - hypoesthesia); hysterical states with transformation of hysterical manifestations in the bodily sphere (hysteralgia, spasms, tremors, etc.); obsessive-phobic states, in which there is a consistent modification of phobias or obsessive fears (from simple to generalized), accompanied by ritual behavior that loses its previous affective coloring; hypochondriacal conditions, characterized by a transition from neurotic and overvalued hypochondria to senestohypochondria (see Senestopathies); depersonalization states with a persistent modification of the consciousness of the “I”, the phenomena of autopsychic depersonalization (alienation of higher emotions, awareness of one’s own mental alteration).

The clinical picture of schizophrenia with a predominance of psychopathic disorders resembles manifestations of psychopathy.

A special place is occupied by schizophrenia, which occurs with highly valuable formations; At the same time, the following dynamics in the clinical picture are noted: overvalued ideas - overvalued delirium - systematized paranoid delirium with a plot divorced from reality.

Paroxysmal-progressive (fur coat) schizophrenia is characterized by delineated attacks (fur coats) separated by remissions. The disease may be limited to one attack, and with progressive development it manifests itself in repeated, more severe attacks with a deterioration (due to the deepening of the personality defect and the expansion of the range of residual disorders) in the quality of remissions. The attacks are varied; in the initial period, neurosis-like, paranoid, paranoid, hallucinatory, catatonic-hebephrenic disorders may be observed. The attack is characterized by acute variability, polymorphism of symptoms, and severity of affective disorders. There are acute affective-delusional, affective-hallucinatory attacks, acute paraphrenia, and attacks with a predominance of mental automatism.

Recurrent schizophrenia occurs in the form of acute, prolonged or transient attacks with a predominance of affective disorders (schizoaffective psychoses). The attacks are separated by persistent and deep remissions, without pronounced negative disorders, in the clinical picture of which recurrent, erased hypomanic and subdepressive states are more often noted. The following types of attacks are characteristic of recurrent Sh. Oneiric-catatonic attack is determined by clouding of consciousness, fantastic content of experiences (planetary flights, world catastrophes, etc.). The picture of a depressive-paranoid attack is dominated by sensual, unsystematized delirium with vivid ideas that reflect the unusual, staged nature of everything that is happening around, the clash of antagonistic, opposing forces. Affective attacks are defined by manic, depressive and mixed states, interrupted by delusional episodes and short periods of dream-altered consciousness. The attacks occur with a disturbance in the perception of the surroundings: with elated-ecstatic affect, reality is perceived brightly, colorfully, with anxious-suppressed affect - gloomily, as a harbinger of trouble.

In some cases of recurrent and paroxysmal-progressive schizophrenia, continuous, tireless motor agitation and confusion are noted, accompanied by high body temperature, acrocyanosis, subcutaneous hemorrhages, the development of exhaustion and coma (hypertoxic, or febrile, schizophrenia).

DIAGNOSIS Schizophrenia is diagnosed based on history and clinical picture.

Differential diagnosis is carried out primarily with borderline conditions (psychopathy, psychogenia).

In contrast to psychogenies and psychopathy, in schizophrenia autochthonous disorders not associated with external influences predominate. Psychogenic provocation of schizophrenia is characterized by a discrepancy between the severity of clinical manifestations and the strength of the mental impact. With further development, the close dependence of symptoms on external hazards is not revealed, and the content of painful manifestations gradually loses connection with the traumatic situation. As schizophrenia develops, there is not only a sharpening of premorbid features, which is also characteristic of psychopathy, but also a complication of the clinical picture due to the appearance of new, previously undetected psychopathic properties and symptoms that are not typical for decompensation of psychopathy (suddenly arising unmotivated anxiety, acute depersonalization disorders, false recognitions, etc.).

In contrast to borderline conditions, with the development of schizophrenia, signs of social maladjustment gradually increase - a weakening, and in some cases a complete severance of ties with the previous environment, an unmotivated change of profession and entire lifestyle.

In outpatient practice, the greatest difficulties are caused by recognizing schizophrenia at the initial stages of the process, as well as during its slow development (sluggish schizophrenia), especially in cases where mental disorders appear under the guise of a somatic illness, and the clinical picture is dominated by somatoform (including hypochondriacal) ) disorders. The assumption of the presence of Sh. arises in connection with polymorphism, stereotypical repetition of somatic sensations, inconsistency of their localization with anatomical formations, as well as a persistent hypochondriacal attitude with a peculiar (elements of paralogical thinking, and sometimes absurdity) interpretation of pathological sensations.

Significant difficulties arise in recognizing incipient schizophrenia, the manifestations of which are similar to the picture of a pathologically occurring puberty. In these cases, the diagnosis of schizophrenia is facilitated by severe thinking disorders and gross heboid manifestations, accompanied by a persistent decline in mental activity and performance.

TREATMENT carried out by psychotropic drugs; If necessary, electroconvulsive therapy and insulin are also used. These treatment methods are combined with psychotherapy and measures for labor and social adaptation. The choice of method and optimal timing of treatment are determined by the clinical picture (primarily the structure of the syndrome), age, somatic condition and individual sensitivity of the patient to certain medications.

To relieve acute psychomotor agitation, the patient is administered hexenal intramuscularly or chloral hydrate in an enema. If necessary, psychotropic drugs are used - intramuscular injections of neuroleptics (aminazine, tizercin, haloperidol), as well as tranquilizers (Elenium, Relanium, phenazepam).

Treatment of patients with malignant and progressive (paranoid) schizophrenia is carried out with antipsychotics with high psychotropic activity (aminazine, stelazine, mazeptil, haloperidol, trisedil, leponex). In severe cases resistant to psychotropic drugs, electroconvulsive and insulin therapy is used.

To relieve attacks of paroxysmal-progressive and recurrent schizophrenia, psychotropic drugs are prescribed, for example, antipsychotics for manic-delusional and oneiric-catatonic attacks. For depressive-paranoid attacks, anxiety, asthenic, hypochondriacal depression, a combination of antidepressants (amitriptyline, anafranil, melipramine, ludiomil) with neuroleptics and tranquilizers (Relanium, Elenium, phenazepam, tazepam, etc.) is indicated. For affective-delusional attacks that occur with psychomotor agitation, anxiety, and suicidal tendencies in the case of resistance to psychotropic drugs, electroconvulsive therapy is recommended.

Treatment of sluggish schizophrenia is carried out with psychotropic drugs (tranquilizers) in combination with antipsychotics and antidepressants, taken in small doses and with the help of psychotherapy.

A significant number of patients with schizophrenia can be treated on an outpatient basis. This contingent includes the majority of patients with sluggish schizophrenia, as well as patients with progressive development of the disease, who are not in a state of psychosis, but who also exhibit relatively isolated delusional (paranoid, residual delusions) and hallucinatory disorders during the period of stabilization of the pathological process (remissions, residual states), as well as psychopathic, obsessive-phobic, senesto-hypochondriacal, astheno-hypochondriacal, depersonalization and erased affective disorders.

Outpatient therapy prevents exacerbation of the process and repeated hospitalizations, helps reduce affective tension and reduce the intensity of painful manifestations, and social readaptation of patients. Treatment on an outpatient basis should not be accompanied by noticeable side effects. The choice of psychotropic drugs, the time of their administration, as well as the distribution of the daily dose are correlated with the patient’s work activity.

In the outpatient treatment of paranoid states, as well as delusional and hallucinatory disorders observed at late stages of the process, antipsychotics (stelazine, etaparazine, frenolone, trisedyl), incl. prolonged action (moditen-depot, imap, haloperidol-decanoate).

The predominance of severe psychopathic-like manifestations in the clinical picture (heboid disorders, schizoid personality changes in the form of eccentricities and inappropriate behavior) is also an indication for the prescription of antipsychotics (neyleptil, stelazine, haloperidol) and tranquilizers.

Treatment of obsessive-phobic and senestohypochondriacal conditions is carried out with tranquilizers; if necessary, they are combined with mild antipsychotics (chlorprothixene, sonapax, teralen, etaprazine, frenolone) in small doses and antidepressants (anafranil, amitriptyline, ludiomil).

For the treatment of depersonalization disorders that are part of the structure of residual states and occur with a feeling of “incompleteness,” intellectual and emotional insufficiency, as well as astheno-hypochondriacal states (lethargy, passivity, decreased initiative and mental activity), psychoactivators (sydnocarb) are used along with neuroleptics and tranquilizers in small doses , nootropil, pyriditol).

When treating affective disorders (usually in the form of erased depressive or hypomanic phases), antidepressants (pirazidol, incasan, petilil), antipsychotics and tranquilizers are prescribed. The most effective preventive agents are lithium salts (lithium carbonate) and finlepsin, tegretol (carbamazepine).

In order to avoid side effects, children and adolescents with schizophrenia, as well as elderly and senile persons, are prescribed lower daily doses of psychotropic drugs, on average 1/2-2/3 of the dose used in middle-aged people.

Persons with suicidal ideas and especially suicidal tendencies are indicated for urgent specialized care in a psychiatric hospital.

Rehabilitation is carried out throughout the course of the disease; in the first stages, it includes both limiting restraint measures (reducing the length of stay in the observation ward, closed department), and active, as psychosis is relieved, involvement in occupational therapy. Medical leave, transfer to light-duty departments, and semi-stationary forms of care (day hospital) are widely practiced. Rehabilitation carried out on an outpatient basis is carried out under the guidance of doctors from psychoneurological dispensaries and specialized offices operating on the basis of enterprises.

The implementation of problems of labor and social adaptation of patients with unfavorable development of schizophrenia and a pronounced personality defect is carried out in special conditions that provide the necessary medical care (for example, occupational therapy workshops, special workshops).

FORECAST is determined by the type of course of schizophrenia, the tendency towards short-term or long-term exacerbations of the process, as well as the degree of severity and rate of development of the personality defect. The influence of a number of other factors is also taken into account (gender, hereditary predisposition, premorbid characteristics, social status before the manifestation of Sh., as well as the age at which the disease manifested itself).

The outcomes of the schizophrenic process are different. In the most severe cases, along with the formation of a pronounced personality defect, there is a gradual, but far from complete (with persistent catatonic, hallucinatory and delusional symptoms) reduction of the manifestations of chronic psychosis. With progressive schizophrenia, late long-term remissions can be observed, occurring as paranoid, hallucinatory with phenomena of monotonous activity, apathetic, asthenic, etc.

Sluggish schizophrenia often ends in residual conditions with a predominance of persistent psychopathic, obsessive-phobic, hypochondriacal disorders (pseudopsychopathy, pseudoneuroses). Among continuous forms of schizophrenia, both the clinical and social prognosis is most favorable when the process develops slowly. The prognosis for paranoid schizophrenia is relatively favorable - only half of the patients experience severe final conditions; in some cases, despite the presence of delusional disorders, patients remain at home for a long time, adapt to the demands of everyday life, and some even remain able to work. Patients with malignant schizophrenia more often become permanent residents of psychiatric hospitals and boarding schools; they retain the possibility only of intra-hospital resocialization. The prognosis of paroxysmal-progressive and recurrent schizophrenia is most favorable with a small number of attacks and long-term remissions. However, even with an increase in the number of attacks, most patients continue to work.

Forensic psychiatric examination. Clear manifestations of psychosis or signs of a pronounced personality defect in patients with schizophrenia during a forensic psychiatric assessment indicate insanity, since patients are not able to understand the meaning of their actions and manage them. They are sent for compulsory treatment. The potential for committing socially dangerous actions is greatest during the period of manifestation of psychosis, accompanied by confusion, anxiety, and fears of the patient, as well as in delusional patients with ideas of persecution, physical and hypnotic influence. In cases of sluggish schizophrenia and post-processual states (the appearance after an attack of schizophrenia of personality changes, primarily psychopathic-like ones), the expert assessment is strictly individual and is determined by the severity and depth of mental disorders in a specific criminal situation.

During the forensic psychiatric examination of schizophrenia in connection with civil cases, the resolution of issues of legal capacity and guardianship is based on determining the mental state at the time of certain legal acts (property transactions, wills, marriages). Patients with sluggish schizophrenia, which occurs with a predominance of neurosis-like disorders without clear signs of progression, more often retain their legal capacity. Patients in a state of psychosis are recognized as incompetent.

In case of pronounced and persistent mental changes, leading to permanent disturbances in the adaptation processes and excluding full-fledged social connections, recognition of incapacity is combined with the imposition of guardianship.