First episode of schizophrenia. Periodic schizophrenia

Schizophrenia in Greek means "splitting of the psyche" - the loss of the unity of mental activity. In other words, schizophrenia leads to a splitting of thinking, a decrease, and sometimes a perversion of emotional and volitional manifestations. These are the changes that this disease brings to the personality of the patient. There are reliable data on the significance of hereditary predisposition in 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 testifies to its great forensic psychiatric significance.

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

Schizophrenia is characterized by a variety of clinical manifestations. Among the disorders and additional factors inherent in it, the main ones are the type of the course of the disease and the characteristics of the symptoms characterizing the disease. These indicators are largely interconnected. Their precise definition contributes to the resolution of both problems of treatment and social prognosis. The latter also includes the solution of issues related to the competence of forensic psychiatry. Usually there are three main forms of schizophrenia: continuous, paroxysmal-progressive and periodic (recurrent).

Continuous schizophrenia. Depending on the degree of severity (progression), sluggish, moderately progressive and malignant schizophrenia are distinguished.

Sluggish schizophrenia. Persons with a sluggish course of schizophrenia do not have acute psychotic states. At the onset of the disease, neurosis-like disorders, vague complaints of a somatic nature, 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 acts. The question is different in cases where sluggish schizophrenia is accompanied by distinctly psychopathic manifestations. The presence of symptoms such as excitability, irritability, malice, brutality, mood instability, a tendency to dysphoria, suggestibility, combined with emotional and volitional decline, is fertile ground for various antisocial actions. The criminality of these patients is enhanced 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 variety of, including serious socially dangerous acts. A special place among patients with sluggish schizophrenia with psychopathic disorders is occupied by persons with severe disorders in the sphere of drives, the so-called heboids. These patients are introverted, inaccessible, have superficial contacts with others, an oppositional attitude towards them (including family members), and opposition, negativism take on a grotesque, exaggerated character; behavior is inappropriate, usually includes elements of foolishness. Thinking is amorphous, sometimes paralogical. In the behavior of patients with heboid disorders, disinhibition (including sexual), perversion of drives, often impulsiveness, desire for aimless pastime, and passivity are noted. Infantile and suggestible patients easily enter into an antisocial environment, they are usually prone to the abuse of alcoholic beverages and drugs, vagrancy, and promiscuity. In this regard, they were previously referred to the group of so-called morally insane. Such patients commit rape, hooliganism and theft, i.e. represent 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 early years. This form is usually characterized by delusional disorders. The emergence of a typical delirium is preceded by an initial period, during which patients may experience obsessions and other neurosis-like disorders (suspicion, anxiety). This period may last for several years. Then comes the paranoid stage of the disease. Gradually, peculiar complexes of pathological overvalued and delusional ideas of various content are formed (poisoning, relationships, persecution, jealousy, hypochondriacal, love, etc.),

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 to the delirium (Kandinsky-Clerambault syndrome). The complication of the disease proceeds with severe anxiety, fear, distinct confusion, a sense of imminent danger, and sometimes catatonic symptoms. In the future, the symptoms of exacerbation are smoothed out, and either manifestations of mental automatism come to the fore, primarily pseudohallucinations (hallucinatory variant of paranoid schizophrenia), or various crazy ideas (persecution, jealousy, etc.), and mental automatisms remain undeveloped (delusional variant of paranoid schizophrenia). ).

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

Initial conditions in paranoid schizophrenia are less severe than in malignant schizophrenia. Many people with paranoid schizophrenia can live at home after treatment if they receive ongoing supportive care. Often they partially retain their ability to work.

Malignant schizophrenia begins most often in adolescence in the form of progressive 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, rudeness occur to relatives, often combined with the manifestation of brutality. Sometimes patients speak of their parents as their worst enemies. Gradually, patients lose interest in the environment, the curiosity inherent in adolescents. Lethargy, passivity appear, which leads to a sharp decrease in school performance. The desire of a number of patients to compensate for the lack of mental productivity by hard work does not give success. Often during these periods, patients have interests that are unusual for them. They begin to selectively read philosophical or religious books from time to time, develop their own methods of physical or spiritual improvement.

Against the background of primary personality changes, a further complication of the disease occurs, usually occurring from one to five years after its onset. Appear affective, hallucinatory, delusional and catatonic disorders. They are characterized by one main feature: they are not deployed and, layering on each other during their development, often make it difficult to determine which of all the disorders is predominant. Two to four years usually make up the duration of the manifest period of the disease, after which there comes a little-changing final state, determined by emotional dullness, a sharp decrease in the purposefulness of volitional impulses, and residual positive symptoms. Socially dangerous acts are committed by patients both at the initial stage and during the period when psychotic disorders proper appear - delirium, hallucinations, etc. Often, the basis of the commission of socially dangerous actions are pronounced changes in their personality and impulsive actions.

Paroxysmal-progredient schizophrenia. This type of disease occurs in the form of seizures, 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, there are constantly such syndromes that, during a periodic course, are either absent altogether, or appear in a residual form at the remote stages of the disease. Such syndromes are: acute verbal hallucinosis, extended Kandinsky-Clerambault syndrome, states of acute interpretive delirium, pronounced and prolonged catatonic disorders without oneiroid stupefaction, paraphrenic states. In addition, in paroxysmal-progressive schizophrenia, the disorders that determine the attack occur without any sequence, chaotically. Attacks are followed by periods of painful symptoms (remissions). However, from attack to attack, more and more noticeable personality changes and an increase in dementia are noted. The more difficult the attack, the longer it usually takes. The criminality of patients with recurrent and paroxysmal-progredient schizophrenia during the period of overt psychosis is relatively low, since in the vast majority of cases they are sent to psychiatric hospitals in a timely manner. The commission of socially dangerous actions by these patients is possible in the very initial period of the disease in the presence of such disorders as confusion, acute sensory delirium, mental automatisms, motor excitation with impulsive actions against the background of anxiety or fear. The vast majority of illegal actions are committed by patients with paroxysmal progredient 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 course of the disease, personality changes increase slowly. Attacks can be determined by a variety of symptoms: affective (depressive, manic), in the form of oneiroid catatonia. Usually, 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. First there are affective disturbances. Low mood is always combined with anxiety, capriciousness, resentment, tearfulness. Hypomanic states are accompanied by enthusiasm, tenderness, a sense of insight. Opposite in structure affective syndromes can replace each other. Over short periods of time, the intensity of affective disorders is subject to significant fluctuations. With the deepening of the disease, anxiety, fear, or rapturous-ecstatic states begin to predominate. Motor excitation increases or, on the contrary, inhibition appears. In the future, figurative nonsense of a different content arises. In its subsequent development, the delirium changes in the direction of increasing fantastic content. It colors the influx of memories of the past, acquired knowledge, 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, a stupor develops with oneiroid 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 speak of circular schizophrenia. In cases of predominance of depressive disorders and depressive forms of delusions (self-accusation, accusations), as well as acute delusions - about depressive-paranoid schizophrenia. With the development of an attack with oneiroid - about oneiroid catatonia. The frequency of seizures is different - from one throughout life to many dozens. Features of remissions depend on many factors, primarily on the frequency and structure of seizures. The attacks are more frequent and more difficult, the remissions are worse, 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 circle of interests.

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

Elevated temperature (subfibrillation) usually occurs from the very beginning of an attack, already at the stage of prodromal disorders, followed by a sharp increase during the deployment of a 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 characteristic of any somatic or infectious disease. Sometimes the temperature in the morning is higher than in the evening and reaches high numbers (39-40°C). Typical appearance of patients: feverish gleam of the eyes, dry parched lips, covered with hemorrhagic crusts, dry red or furred tongue, hyperemia of the skin. Often there is herpes, bruising on the neck, spontaneous nosebleeds, allergic rashes. Sometimes, on the contrary, at a high temperature there are no such febrile symptoms. Pathological reactions of the cardiovascular system are noted: a weakening of cardiac activity with a drop in blood pressure, an accelerated 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 of blood serum are increased, the content of chlorides is changed. Along with this, pronounced changes characteristic of kidney pathology are found in the urine. Bacteriological blood cultures are negative. All this points to toxicosis.

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

Currently, with the widespread use of chlorpromazine, deaths are rare, but still happen. Death from heart failure (sometimes against the background of small-focal pneumonia) occurs in the stage of amental-like or hyperkinetic excitation during their transition to a coma.

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

clinical observation. Subject A., 34 years old, is accused of committing hooligan acts.

He grew and developed according to the age norm. He survived childhood infections without complications. He graduated from the 8th grade of a comprehensive school, courses for salespeople. Studied well. By nature, he was formed sociable, balanced, inquisitive. He worked as a salesman, supply agent, warehouse manager. In his work, he showed resourcefulness and agility.

At the age of 25, A. for no apparent reason developed a depressed mood, a feeling of melancholy. Soon it was replaced by a high-excited mood with excessive mobility, talkativeness. He considered himself a gifted person, told others that he would recognize their thoughts and that he should be sent to an intelligence school to prepare for an important task. During that period, he slept little, was always on the move, scattered personal belongings, walked half-dressed and barefoot. From time to time he felt fear, “heard” shots, spoke about the impending bombardment. When hospitalized in a psychiatric hospital, he resisted. In the hospital, for the first time, he resisted examination and medical procedures, stubbornly refused to eat, and therefore he was fed through a tube. He was tense, angry. From individual statements, it was possible to find out that he was scared, that there was a game going on around him, that he was being re-educated with the help of special mental influence. After the treatment, his condition improved, he was discharged with a diagnosis of Schizophrenia, remission with a defect. For several months he was on a disability of the II group, then he was transferred to the III group of disability. He got a job as a train conductor. Occasionally drank alcohol, engaged in casual sex. I decided to continue my studies and entered a technical school. Classes were given to him hard, he had difficulty concentrating, but from time to time "the head worked intensively."

It is known from the materials of the criminal case that A. came to the summer cottage of a 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 foul language, beat K. and stabbed him.

During the passage of a forensic psychiatric examination, A. noted that his thoughts either turned off, or a lot of them appeared. Staying in a psychiatric hospital was not burdensome, did not show 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 condemn." In fact, he is not to blame for anything. He said that after treatment in a psychiatric hospital he had "poise and self-control", he became "well in control of himself, able to correctly assess other people and delve into the meaning of current events."

In the past, A. suffered an attack of psychosis, in the structure of which there were changeable affective disorders (depression was quickly replaced by a manic state, and then fear), unsystematized figurative delirium, individual manifestations of mental automatism (a symptom of openness), verbal hallucinations and catatonic symptoms, among which was clearly expressed negativity. In general, the attack was quite typical for paroxysmal-progressive schizophrenia. The nature of the subsequent remission also speaks in favor of this diagnosis. In its structure, psychopathic disorders and erased bipolar mood swings were noted. The indications of the patient himself about the appearance of balance traits in him always indicate one degree or another of emotional decline. This is also evidenced by the indifferent attitude of A. to the deed and his fate. The offense was committed by A. during a period of mild mood elevation (in a hypomanic state) and psychopathic disorders that intensified during that period. According to the conclusion of the 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 a forensic psychiatric examination in criminal cases and declared insane suffer from schizophrenia. The recognition of a person suffering from schizophrenia with a different type of course, insane or sane depends on a number of factors.

In cases where the clinical picture of psychosis or distinct personality changes during the period of 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) is unstable and shallow.

If the offense is committed by patients with schizophrenia who have experienced a psychotic attack in the past, during a period of persistent and deep remission without distinct personality changes, in these cases they are usually recognized as sane. This decision is made in the event that deep remission without noticeable personality changes is long, the patients are well socially adapted, and they do not experience a deterioration in their mental state in a psycho-traumatic situation, including those associated with forensic investigative proceedings.

With the development of schizophrenia after the commission of an offense, during the investigation or after conviction, while in places of deprivation of liberty, 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 incriminated to them they are recognized as sane. Such patients, by a court decision, are sent to psychiatric hospitals for compulsory treatment.

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

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

The ability of witnesses and victims suffering from schizophrenia to participate in the judicial and investigative process, 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. Subject to these principles, the civil rights of the mentally ill - victims and witnesses - will always be respected.

Quite often, patients with schizophrenia undergo a forensic psychiatric examination in a civil process, when issues of their legal capacity and the establishment of guardianship over them are resolved. The need to protect the rights of the mentally ill and the prevention of 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 legal capacity is considered as the ability to understand the meaning of one's actions and manage them. Features of the clinic of schizophrenia, the possibility of satisfactory social adaptation of patients and the special requirements for the subject when performing various legal actions (property transactions, marriage, 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 is different - 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 seizures characteristic of recurrent schizophrenia. These include oneiroid-catatonic, depressive-paranoid and affective seizures. It is not possible to single out one or another variant of recurrent schizophrenia depending on the nature of the seizures due to the fact that most patients experience seizures of various psychopathological structures during their lives. Attacks as a whole are characterized by bright affectivity, one or another type of sensual delirium, catatonic disorders quite easily arise. Remissions are of high quality. The absence of changes in the patient's personality after the first attacks allows us to speak of intermissions. Gradually, after repeated attacks, patients experience personality changes, which are characterized by the following manifestations: asthenic, hypersthenic, with an increase in working capacity, but with a decrease in creative efficiency and a slight impoverishment of emotional manifestations. Usually these changes are observed after the third - fourth attack. Then the activity of the process decreases: seizures become less frequent, personality changes, as it were, 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 transferred psychotic state and they clearly distinguish between the state of 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, which manifests itself in productive and growing negative symptoms.

Attacks in this form of schizophrenia are diverse, characterized by extreme polymorphism and unequal duration (from "transient", lasting minutes, to stretching for many years). However, they are less acute than attacks of recurrent schizophrenia; paranoid and hallucinatory manifestations have a greater proportion in their structure. Sometimes productive symptomatology in paroxysmal progredient schizophrenia is observed not only in attacks, but also in the intercritical period, increasing deficient personality changes, residual (residual) symptoms of an attack are revealed. The structure of seizures in this form of schizophrenia is polymorphic. For example, in a manic attack, a patient often “intersperses” depression in the form of ideas of self-blame, tearfulness, etc. An incomplete critical attitude to the transferred state is characteristic, even in cases where the attack was distinguished 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 age. Depending on the age period in which the disease begins, age-related features are clearly manifested 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 progredient 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.

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

Mental disorders in people have always caused fear and confusion among healthy people. Healers have long tried to figure out where people with strange behavior come from. And only two centuries ago it was possible to describe the attacks of schizophrenia, the 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 seizures 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 the background of stress, infectious diseases, injuries, overvoltage.
3. dopamine- an excess of this hormone affects the work of nerve impulses.
4. Dysontogenetic- the disease is already embedded in the human genes, and due to external factors - trauma, stress, infection, etc., it "floats" out.

How the disease manifests 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 inherent in almost all forms of mental illness.

1. Speech is disturbed, there is delirium, a sharp switch to another, strange topic, tongue-tied.
2. Complete lack of initiative, lack of will, independent actions.
3. Inadequate reaction to actions and statements, lack of emotions.
4. Megalomania, persecution, the constant manifestation of one's own exclusivity.

Seizures in mental disorders

• With an exacerbation of mental illness, first of all, anxiety is observed for no reason.
• The sufferer is subjected to an "attack" of non-existent voices, communicates with ephemeral personalities, beings.
• There is insomnia, the patient often wakes up, walks from corner to corner.
• There is a loss of appetite or vice versa, voracity. In this state, a schizophrenic can eat a portion many times the daily allowance.
• There are outbreaks of aggression, anger, or the sick person hides in a corner, refuses to communicate with loved ones, completely withdraws into himself.
• There is a desire to run away from home.
• The patient becomes distrustful, 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 it is necessary to seek help - call a psychiatric team.

Alcoholic psychosis

Very often, with prolonged alcohol abuse, drug use, psychoses occur, which are confused with the first attack of schizophrenia (manifesto). The symptoms caused by a powerful intoxication of the body are really similar to a mental illness, but there are still distinctive features:

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

The most dangerous is the acute phase of schizophrenia

How long does a schizophrenia attack last?

It is impossible to determine with accuracy how long a schizophrenic seizure lasts. It all depends on the individual indicators of a person, the form of the disease, 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, memory worsens, loss of interest in work, study, and favorite activities is possible. The condition is aggravated by apathy, untidiness, lack of initiative. The patient often has excessive sweating, headache, dizziness, palpitations, anxiety, fears. With timely therapy, the prognosis is favorable, up to a long-term remission.
2. After effective relief of seizures, there is stabilization stage. The process takes more than six months. The patient's symptoms are mild, in rare cases delirium, hallucinations appear. Without medical intervention, the acute phase continues to acquire threatening signs: memory loss occurs, delusional thoughts intensify, the patient hallucinates continuously. As a result, a complete loss of appetite, attacks of aggression with screams, howls are possible. Suicidal tendencies are obsessive.

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 and at the same time call an ambulance for psychiatric help. It is impossible to cope with a mental illness without the intervention of a specialist.

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

It is necessary to influence the brain cells, the patient's behavior with neuroleptic, nootropic drugs. The acute phase can carry a risk to life, both the patient and others. Often in a state of seizure, persons suffering from schizophrenia attacked people, maimed, committed violence. For those who are faced with the diagnosis of "schizophrenia" for the first time, a video of an attack will tell you in detail what a sick person looks like, what characteristic facial features and behaviors are manifested. Thanks to this, it is possible to determine the disease without a doubt and turn to the right medical structure.

Schizophrenic attacks 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 seizures

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

The development of schizophrenia is signaled by the isolation of a person who by all means tries to protect himself from the outside world. His regime is disturbed, sleep becomes restless, such a person often suffers from insomnia.

Regular headaches, migraines, sudden changes in mood, behavior - all this is also possible. Inadequate 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 rises, the patient imagines that someone is chasing him. There is an overwhelming fear of death. Logical thinking is turned off, and mental abilities are reduced to a minimum.

The patient can begin to speak in a childish voice, lisp, continuously repeat some incomprehensible and incomprehensible phrases, elevate himself above others, and after that completely move away from everything that happens around him.

In some cases, a clear consciousness is preserved, but the pathology covers motor reflexes. Patients may experience schizophrenic seizures, complete stupor, or an unusual level of activity.

Attacks can occur continuously or in periods with long light intervals when a person feels healthy. Such attacks occur 1 time in 2-3 years. Attack-like schizophrenia also goes through periods that either change 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 will help to cope with an attack, so a person must be taken to a medical facility where he will be assisted. With the patient, you need to behave gently, he should not feel pressure, as if he were being driven into a trap. Speech should be slow, but not condescending, so that the patient cannot suspect anything.

To calm the patient in the clinic, various antipsychotics are used, 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 an agent is determined by the condition of the patient.

If the attack does not go away, hypnotics can be added to neuroleptics. A person who has had an attack of schizophrenia should be under the inhibitory effect of medication 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 pronounced: anxiety or depression.

How to prevent a second attack?

In order to prevent a recurrence of a schizophrenic type seizure, it is necessary to seek the help of a specialist.

It goes through several stages. The first phase is the intake of medications that affect the patient's brain. Depending on the type of disease and symptoms, the doctor prescribes a drug 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 to understand the sources that influenced the onset of schizophrenia, and find out the factors that can provoke a second attack.

There are several guidelines to follow at home. It is necessary to completely exclude alcohol-containing drinks and narcotic substances from the life of the patient. 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 head of the patient. With the support of close people, he will not need to create an imaginary world.

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

Schizophrenia(schizophrenia; Greek schizō split, split + phrēn mind, mind; synonymous with Bleuler's disease) is a mental illness with a long chronic progressive course, accompanied by dissociation of mental processes, motor skills and increasing personality changes. The mismatch 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 the 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, senestohypochondriac, psychopathic neurosis-like, affective.
At the same time, positive disorders differ significantly from psychogenic, somatogenic and organic mental disorders.

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

ETIOLOGY, PATHOGENESIS AND PATHOMORPHOLOGICAL CHARACTERISTICS schizophrenia. Schizophrenia belongs to a group of diseases with hereditary predisposition. This is evidenced by the accumulation of cases of this disease in the families of patients with schizophrenia, as well as the high concordance of identical twins for 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 deficiency of brain tissue cells, changes in autoimmune reactions), accompanied by the production of antibodies in the body of a schizophrenic patient that can damage brain tissue.

Along with biological hypotheses, concepts of the psycho- and sociogenesis of schizophrenia are also put forward, based on behavioral, 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 psychoanalytic and psychodynamic positions, schizophrenia is considered as one of the forms of personality maladjustment, as a result of its special development, which was triggered by early interpersonal conflicts.

Pathological anatomical 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 prolapse of cytoarchitectonics of the cerebral cortex, as well as pigmentary sclerosis of neurons, microglia unresponsiveness are observed.

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

Continuous schizophrenia is characterized by chronic, progressive, without deep remissions, the development of the pathological process. The weakening of the progredient 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 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 have thinking disorders, their ability to concentrate is impaired. Despite the efforts expended on the preparation of educational tasks, children's academic performance drops sharply. If brilliant abilities were previously revealed, now patients are forced to stay for the second year, and sometimes stop training. As emotional changes deepen, alienation from relatives grows, often combined with irritability and even aggressiveness.

In cases where the disease is limited to predominantly negative disorders (progressive emotional impoverishment, loss of interests, lethargy, intellectual unproductiveness), 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.
So, in some cases, the phenomena of foolish excitement prevail (hebephrenic form of schizophrenia) - clowning, grimacing, rudeness, malice and sudden mood swings; at the same time, phenomena of regression of behavior may come to the fore - slovenliness in food and clothing, a tendency to ridiculous actions. In other cases of malignant schizophrenia, delusional and hallucinatory disorders are expressed (non-systematized delusions of persecution, poisoning, grandeur, phenomena of mental automatism, pseudohallucinations).

The most malignant course of schizophrenia is noted with the early appearance, and later the 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 in the form of hyperkinesia with impulsivity, outbursts of aggression, senseless stereotyped movements, repetition of words and movements of others (catatonic arousal).

Progredient (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. In the development of paranoid schizophrenia, three stages are distinguished - paranoid, paranoid, paraphrenic. At the first stage, delusional ideas of ordinary content arise (nonsense of jealousy, invention, reformism, etc.), which, in the course of the development of the disease, are gradually systematized and take the form of delusions of persecution.

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

At the paraphrenic stage, delirium dominates with ideas of greatness, high origin, false, fictional memories (confabulation). In the clinical picture, the delusion of grandeur, which is formed against the background of an altered, usually increased affect, is combined with delusions of persecution, as well as auditory hallucinations and phenomena of mental automatism.

Sluggish schizophrenia often debuts in adolescence. However, distinct 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 disorders in the clinical picture. In the first case, asthenic conditions are noted with a polar change in painful manifestations (for example, hyperesthesia - hypesthesia); hysterical states with the 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 former affective coloring; hypochondriacal states, characterized by a transition from neurotic and overvalued hypochondria to senestohypochondria (see Senestopathy); depersonalization states with a persistent modification of the consciousness of "I", the phenomena of autopsychic depersonalization (alienation of higher emotions, consciousness of one's own mental change).

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 supervaluable formations; at the same time, the following dynamics in the clinical picture is noted: overvalued ideas - overvalued nonsense - systematized paranoid nonsense with a plot divorced from reality.

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

Recurrent schizophrenia occurs in the form of acute prolonged or transient seizures with a predominance of affective disorders (schizoaffective psychoses). Attacks are separated by persistent and deep, without pronounced negative disorders, remissions, in the clinical picture of which recurring erased hypomanic and subdepressive states are more often noted. The following types of attacks are characteristic of recurrent Sh. A oneiroid-catatonic attack is determined by a clouding of consciousness, a fantastic content of experiences (planetary flights, world catastrophes, etc.). The picture of a depressive-paranoid attack is dominated by sensual, poorly systematized delirium with vivid ideas reflecting the unusual, staged everything that happens 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. Seizures occur with a violation of the perception of the environment: with elevated-ecstatic affect, reality is perceived brightly, colorfully, with anxiously suppressed - gloomy, as a harbinger of trouble.

In a number of cases of recurrent and paroxysmal-progredient schizophrenia, continuous tireless motor excitation 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 established on the basis of anamnesis and clinical picture.

Differential diagnosis is carried out primarily with borderline conditions (psychopathies, psychogenies).

In contrast to psychogenies and psychopathy, schizophrenia is dominated by autochthonous disorders not associated with external influences. With psychogenic provocation of schizophrenia, a discrepancy between the severity of clinical manifestations and the strength of mental influence is characteristic. With further development, a close dependence of symptoms on external hazards is not detected, and the content of painful manifestations gradually loses its connection with the traumatic situation. With the development of schizophrenia, not only an exacerbation of premorbid features is noted, which is also characteristic of psychopathy, but also a complication of the clinical picture due to the appearance of new, previously undetectable psychopathic properties and symptoms that are not typical for psychopathy decompensations (suddenly arising unmotivated anxiety, acute depersonalization disorders, false positives, etc.).

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

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

Considerable difficulties are presented by the recognition of incipient schizophrenia, the manifestations of which are similar to the picture of a pathologically proceeding puberty. In these cases, the diagnosis of schizophrenia is facilitated by severe thought disorders and gross heboid manifestations, accompanied by a persistent drop in mental activity and performance.

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

To stop 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 (chlorpromazine, tizercin, haloperidol), as well as tranquilizers (elenium, relanium, phenazepam).

Treatment of patients with malignant and progredient (paranoid) schizophrenia is carried out with neuroleptics with high psychotropic activity (chlorpromazine, stelazin, mazheptil, haloperidol, trisedil, leponex). In severe cases resistant to psychotropic drugs, electroconvulsive and insulin therapy is used.

To stop attacks of paroxysmal-progredient and recurrent schizophrenia, psychotropic drugs are prescribed, for example, neuroleptics for manic-delusional and oneiroid-catatonic seizures. With depressive-paranoid attacks, anxiety, asthenic, hypochondriacal depression, a combination of antidepressants (amitriptyline, anafranil, melipramine, ludiomil) with antipsychotics and tranquilizers (relanium, elenium, phenazepam, tazepam, etc.) is indicated. With affective-delusional attacks occurring with psychomotor agitation, anxiety, suicidal tendencies in 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 a progressive development of the disease who are not in a state of psychosis, but who also detect 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-hypochondriac, astheno-hypochondriac, depersonalization and erased affective disorders.

Outpatient therapy prevents exacerbation of the process and repeated hospitalizations, helps to 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 pronounced 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 remote stages of the process, antipsychotics (stelazin, etaperazine, frenolon, trisedil) are effective, incl. prolonged action (moditen-depot, imap, haloperidol-decanoate).

The predominance in the clinical picture of gross psychopathic manifestations (heboid disorders, schizoid personality changes in the form of eccentricities and inappropriate behavior) is also an indication for the appointment of neuroleptics (neileptil, stelazin, haloperidol) and tranquilizers.

Therapy of obsessive-phobic and senesto-hypochondriac conditions is carried out with tranquilizers, if necessary, they are combined with mild antipsychotics (chlorprothixen, sonapax, teralen, etaperazine, frenolon) in small doses and antidepressants (anafranil, amitriptyline, ludiomil).

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

In the treatment of affective disorders (often in the form of erased depressive or hypomanic phases), antidepressants (pyrazidol, inkazan, petilil), antipsychotics and tranquilizers are prescribed. Lithium salts (lithium carbonate) and finlepsin, tegretol (carbomazepine) are the most effective as preventive agents.

Children with schizophrenia and adolescents, as well as elderly and senile people, in order to avoid side effects, are provided with smaller 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 shown urgent specialized care in a psychiatric hospital.

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

The implementation of the 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, medical and labor workshops, special workshops).

FORECAST is determined by the type of course of schizophrenia, the tendency to short-term or long-term exacerbations of the process, as well as the severity and rate of development of the personality defect. The influence of a number of other factors is also taken into account (sex, hereditary predisposition, features of premorbid, social status before Sh.'s manifestation, and also 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 in the manifestations of chronic psychosis. With progredient schizophrenia, late long-term remissions can be observed, proceeding according to the type of paranoid, hallucinatory with phenomena of monotonous activity, apathetic, asthenic, etc.

Sluggish schizophrenia often ends with residual states with a predominance of persistent psychopathic, obsessive-phobic, hypochondriacal disorders (pseudopsychopathy, pseudoneurosis). Among the continuous forms of schizophrenia, both the clinical and social prognosis is most favorable with a low progression of the process. The prognosis for paranoid schizophrenia is relatively favorable - only half of the patients have severe end states; in some cases, despite the presence of delusional disorders, patients stay at home for a long time, adapt to the requirements of everyday life, and some even remain able to work. Patients with malignant schizophrenia often become permanent residents of psychiatric hospitals and boarding schools; they retain the opportunity only for nosocomial resocialization. The prognosis of paroxysmal progredient 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 seizures, most patients continue to work.

Forensic psychiatric examination. Distinct manifestations of psychosis or signs of a pronounced personality defect in patients with schizophrenia in a forensic psychiatric assessment indicate insanity, since patients are unable to understand the meaning of their actions and manage them. They are sent for compulsory treatment. The potential for committing socially dangerous acts is greatest during the period of manifestation of psychosis, accompanied by confusion, anxiety, fears of the patient, as well as in delusional patients with ideas of persecution, physical and hypnotic influence. In case of sluggish schizophrenia and post-procedural conditions (the appearance of personality changes after an attack of schizophrenia, primarily psychopathic ones), the expert assessment is strictly individual and is determined by the severity and depth of mental disorders in a particular criminal situation.

In a 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 the commission 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.

With pronounced and persistent mental changes, leading to permanent violations of the adaptation processes and excluding full-fledged social ties, the recognition of incapacity is combined with the imposition of guardianship.