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Prognosis of the course of schizophrenia. How to achieve sustainable remission in schizophrenia and how long does it last? What do schizophrenics feel during remission?

Remission in schizophrenia is not a sign of complete recovery or cure from the disease. This is a period of time during which a person with schizophrenia feels well and does not show symptoms. To understand when and under what conditions remission is possible, it is necessary to understand the preceding stages.

Stage one is acute. It is characterized by symptoms such as delusions, auditory and visual hallucinations, which the patient initially tries to keep silent about. The speed of thinking and reaction decreases. Fears escalate. There may be feelings of external surveillance and persecution. In the acute stage, apathy, refusal to care for oneself, passivity may be present, and memory deteriorates. Patients often express strange, idiosyncratic views on how the world works. This stage lasts about one and a half to two months.

Then the patient enters the stage of stabilization of the process, when the symptoms of the acute stage of psychosis are smoothed out and expressed much weaker. Deterioration in the areas of thinking, memory, and perception may increase. This phase can last from six months or longer.

What does remission mean in schizophrenia?

This phase does not mean that the person has recovered from schizophrenia. But if there are no signs of the disease for 6 months, we can talk about entering remission. Provided that the first psychotic episode (i.e., the first occurrence of schizophrenia) is treated promptly and fully, the likelihood of remission is much higher.

The remaining 40 percent of patients are those whose illness is severe, robbing them of the ability to adapt socially, to resume work/school, and to live independently. The quality of life in these cases suffers and decreases. In such situations, doctors, as a rule, insist that the patient receive a disability group, constant medication support, and regular hospitalizations in order to maintain the condition.

How do you know when remission has ended and a relapse has begun?

The level of anxiety and irritability increases. The patient ceases to cope with stress in the simplest situations.

attacks of inexplicable melancholy arise again, apathy reappears, interest in usual activities is lost. The patient again “falls into hibernation” - this is exactly what it looks like from the outside.

It should be noted that if after the first episode treatment continued, as did psychotherapy, then the chance of relapse is only 25-30 percent. If treatment for schizophrenia is ignored, then relapse is almost inevitable - its probability will be more than 70 percent. But the prognosis, after the second and subsequent acute episodes, worsens and the option of remission gets further and further each time.

Remission, or reversal of the sentence.

Schizophrenia is not only a disease. Often, schizophrenia is a death sentence. Persons who are diagnosed with this condition are deprived of their rights, they are not allowed to perform certain types of work, they will not be allowed to drive anything more powerful than a bicycle, in some cases they are deprived of their legal capacity, and often end up in a boarding school for psychochronic patients. However, the progression of the disease is not always so dire, and sometimes we see patients returning to a full life, and this is happiness for both them and us. Today I want to talk about one of them.

Vladimir was from a large Siberian city, the youngest beloved son, the pride of his parents. The disease overtook him after graduating from the local medical institute. Hospitalizations followed one after another, the productive symptoms did not really change, within two years he was forced to register a 2nd group of disability, he was deprived of legal capacity, his mother took guardianship over him. Vladimir spent several years, with short breaks, in a psychiatric ward, the doctors shrugged, the disease progressed, despite all their efforts. And then his parents die. Of all Vladimir’s relatives, only his aunt remains, living with her family in Tolyatti. She takes him to her place, but Vladimir’s condition is so grave that he cannot live in a family. His aunt, who transferred guardianship to herself, is forced to put him on the waiting list for a boarding school for psychochronic patients. And here the dark streak in Vladimir’s life ends, fortunately for him there are no free places in the boarding school and they are offered to wait for several years, they say, as soon as possible, but for now, sorry, not at all. There is nothing to do, Vladimir stays at home with his aunt, takes medications for some time, then it turns out that there is no particular need for them - he sleeps and eats well, does not talk about obvious delirium, and no otherworldly voices are noted either. They left him with some nonsense from the appointments for safety reasons, and told him to come to the appointment regularly in order to monitor his condition. Further, Volodya began to show interest in the reality around him, began to go out, and even combed his hair before going out, took on some of the household chores, and, surprisingly, coped with them quite well. My aunt was happy, we were with her, Volodya was on the mend. About a year later, he began to be interested in how he could make a contribution to the family budget, since he can’t all sit on his aunt’s neck. Based on the results of a forensic psychiatric examination, the court restored his rights, and VTEK, with some surprise, changed the second, already life-long group, to the third. Volodya returned to medical practice. Since it was about twenty years ago, I no longer remember exactly what job he got, either as a physiotherapist, or as a doctor in a massage room in a sanatorium, something like that. He did his job well, and the nurses hovered around the prominent young doctor. With one of them he started a family. A few years later, the disability group was finally removed from him, he and his wife raised two children, and no one, when communicating with him, except professional psychiatrists, would have suspected any traces of the disease. You never know how many original people there are among us. With great pleasure, I removed him from psychiatric observation, fully aware that there was no merit in this, Vladimir was just lucky - the disease receded, and there were no places in the boarding school in time.

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Stages of schizophrenia

A functional diagnosis as the basis for a work prognosis can only be established by correctly determining the stage of the disease and, above all, by resolving the main question: is there still an active process in the acute or subacute period, or has the process ended or stopped and an inactive stage has begun (remission, residual period, post-processual state, etc.).

The main criteria for delimiting the stages (periods) of the disease in expert practice are signs of intensity, severity of symptoms of the active process, and after its completion, or the stage of remission, the presence or absence of manifestations of the defect, the type and possibilities of its compensation. This distinction depends on the general physiological pattern in the characteristics of nervous processes at different stages of the course: in the stages of the active process, diffuse, diffuse disturbances of nervous processes, diffuse unconditional inhibition and extreme inertia of the irritable process suppress compensatory mechanisms; on the contrary, in the residual, post-processual, post-destructive stages, when the process has ended or stopped, a defect is identified in the form of persistent loss or dissociation of functions and the release of compensatory mechanisms characteristic of the central nervous system “to the highest degree” (I. P. Pavlov).

In the prodromal and initial periods of schizophrenia, everything is subordinated to the task of timely diagnosis and therapy; loss of ability to work can only be temporary during the period of exacerbation and therapy. In the acute and subacute stages, the intensity and generalization of symptoms lead to loss of ability to work, and the expert most often states the disability of these patients in absentia, according to reports from medical institutions. The question of the nature of this disability (temporary - sick leave or permanent loss of ability to work - disability) is decided depending on the type of course of the disease process, the duration of the acute and subacute condition, the presence or absence of a tendency to remission, etc. On the contrary, as acute and subacute symptoms subside Subacute symptoms of an active process will be characterized by the characteristics of remission, post-process or residual defective state, and the possibility of its compensation. During the period of recovery and convalescence, all examination issues are subordinated to the tasks of restorative therapy and social rehabilitation.

We can talk about clinical recovery only in rare cases, since even with complete cessation of the symptoms of the active process and stabilization of the condition, there remains a predisposition to new attacks of the disease and reduced resistance to harmful factors. This condition is practically very difficult to distinguish from remission, since the possibility of developing a new attack of the disease can never be ruled out. Recovery from a defect is always the subject of the expert’s competence: the issue of ability to work is decided depending on the type, structure and degree of compensation of the defect. The stage of the initial or final state in psychiatry has controversial content. Conventionally, the term “initial state” defines two types of states: a) the state of stabilization of the process in the psychotic phase of malignant and continuously ongoing processes (the so-called long-term forms), when in this long-term psychotic state negative symptoms, symptoms of a pronounced defect or dementia are already clearly visible or another type. Patients with these severe, chronic psychotic conditions are most often treated and monitored in psychiatric hospitals. The possibility of late remissions is determined by the level of development of therapy; b) a state of initial dementia, when in the structure of the Status negative symptoms, symptoms of loss (personality changes, thinking disorders in the absence of a critical attitude) occupy the main place. In such cases, correct determination of the type of dementia will be important for the selection of measures for the social rehabilitation of patients.

The concept of “remission” literally means only temporary relief, a decrease in the manifestations of the disease. It speaks of a way out of a psychotic state and the possibility of social readaptation. However, in its content it is very broad and, from the point of view of the prognosis of working capacity, very uncertain: even in-hospital improvement is called remission. The practice of studying the effectiveness of active therapy made it possible to create a quantitative (A, B, C and D) and syndromological classification of remissions in schizophrenia (asthenic, paranoid, hypertensive, hypochondriacal). For the practice of VTE, where during the period of remission it is necessary to resolve the issue not only about the disability group, but also about professional suitability, work recommendations and rehabilitation measures, it is necessary not only to quantify the degree of remission and not only syndromological characteristics, but also knowledge of its structure and dynamics .

In the structure of remission to predict working capacity, it is necessary to distinguish between 4 components: remaining symptoms of the active process, preserved personality traits and social and labor attitudes, manifestations of the defect and compensatory formations. Remaining symptoms of an active process may require long-term maintenance therapy, and compensatory formations are a reflection of how the relationships and interactions of preserved personality traits and manifestations of the defect are formed and changed in the process of rehabilitation therapy and work activity. The entire sum of treatment, rehabilitation and social measures is the most important factor that forms the structure of remission after patients emerge from the acute or subacute period. Here the preventive and rehabilitative value of expert opinions is fully realized.

In the practice of VTE, combining the characteristics of the statics and dynamics of remissions, it is necessary to distinguish between complete and incomplete remissions, as well as the degree of stability of remission and, depending on this, diagnose: a) complete and persistent remissions bordering on recovery (or intermission), when we can talk about recovery the patient’s ability to work in his main profession with minor restrictions (remission A according to the accepted classification of M. Ya. Sereisky); b) persistent remissions with a defect, when the issue of ability to work is decided depending on the type and structure of the existing defect and the degree of its compensation. Therefore, for the practice of VTE, the systematics of these remissions with a defect coincides with the systematics of defective states (see Dynamics of defective states); c) incomplete and unstable remissions with subsided symptoms of the active process, when the ability to work is determined by the severity and degree of affective intensity of these symptoms (delusions, hallucinations, senestopathies, affective fluctuations, etc.) and their influence on the patient’s behavior. Diagnosis of remissions in these cases should be supplemented by the definition of “incomplete” or “in the stage of stabilization.” The patient's professional ability to work has often not yet been restored.

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Definition of remission in schizophrenia

(Based on materials from the 10th winter session of the seminar on schizophrenia. Davos, 2006)

Remission concept
Remission in schizophrenia is an achievable goal. It was this idea that was the basis of all messages at the symposium, held as part of the 10th winter session on schizophrenia in Davos, Switzerland. The recently introduced system of agreed upon working criteria for clinical remission in schizophrenia creates a favorable basis for achieving and maintaining treatment results and meeting the expectations of the patient and his relatives. The urgent need is to change the attitude of doctors towards the treatment of schizophrenia, to align patients, caregivers and doctors to achieve positive treatment results and positive outcomes. The main topic of the seminar was the introduction of new remission criteria into clinical practice. Seminar participants also discussed methods of using long-acting injectable medications necessary to achieve and maintain stable remission.
Symposium participants noted that despite significant progress in research and treatment, schizophrenia is generally considered a chronically relapsing disease for which cure is unlikely or impossible, and treatment is ineffective. Doctors more often accept the course of the disease with periodic relapses and hospitalization as normal rather than as unacceptable treatment failure. Patients diagnosed with schizophrenia can go into remission, a difficult but important concept for both patients and doctors. The concept expands treatment options and requires consistent operational criteria for clinical remission in schizophrenia to translate it into clinical trials and clinical practice.
Remission has long been an important clinical goal in the treatment of depression and anxiety disorders, but schizophrenia is characterized by extreme variability and duration of disease progression and variable disease outcomes. The concept of standard remission criteria needs to be implemented taking these features into account. Schizophrenia in many patients is associated with violations of the treatment regimen, which usually leads to relapse, often with serious consequences. Sometimes it takes more than a year for the patient to return to the previous level of social activity, and with each subsequent relapse the condition may worsen to such an extent that it becomes impossible to achieve the previous level of somatic and functional state.

Criteria for remission in schizophrenia
The Schizophrenia Remission Working Group at a conference in 2003 proposed standard criteria for remission based on diagnostic criteria reflecting the characteristic signs and symptoms of the disease.
This consensus document defines remission as “a state in which patients experience relief from the major signs and symptoms of the disease, do not exhibit conduct disorder, and do not meet sufficient criteria to support the initial diagnosis of schizophrenia.” Professor John Kane, who chaired the symposium, said: “This means that a patient presenting to see a doctor cannot be diagnosed with schizophrenia based on the signs and symptoms present.” Remission does not mean recovery, which is more difficult to achieve and which includes other indicators of professional and social rehabilitation, necessitating a high level of functional usefulness. However, during remission, signs and symptoms typical of schizophrenia are absent, and the patient has achieved an acceptable psychosocial level. Patients in remission have significantly improved quality of life (QoL) as assessed by the SF-36 scale.
The criteria are based on eight PANSS (Positive and Negative Symptom Scale) scores for the initial diagnosis of schizophrenia:
rave
thought disorder
hallucinatory behavior
unusual content of thoughts
mannerisms and posing
dulled affect
social isolation
impaired spontaneity and fluency of speech
To be diagnosed as in remission, a patient must have all these symptoms completely absent or very mild (level 1–3 on the PANSS scale) for at least 6 months. Thus, this model uses clear thresholds to define improvement as opposed to criteria for change. Therefore, the comparison of the original score and the improvement expressed as a percentage can be replaced by a standard criterion and used in clinical practice and research.

Goal of remission: achieving change
The introduction of remission criteria is endorsed by EUFAMI (European Federation of Family Associations of Mental Illness) as an important concept for developing new strategies in psychiatry. The European Patient Advocacy Group works with 44 organizations in 28 countries. The group supports patients and their families by influencing decision-makers and the media at local and national level in all cases involving mental health issues. EUFAMI calls on health authorities to include the concept as a separate topic in the future Green Article of the European Commission “Improving the mental health of the population. Toward a strategy in psychiatry for the European Union countries.”

Treatment adherence: the starting point
Incomplete adherence to treatment is common in schizophrenia, although difficult to assess. A recent publication identifies medication failure as a major factor leading to disease progression, increased mortality, and increased health care costs in many diseases. It is well known that many patients with schizophrenia do not take medications as prescribed by the doctor, the treatment regimen is violated from time to time by at least 50% of patients with schizophrenia. Atypical oral antipsychotics have complemented treatment options and are more effective than conventional antipsychotics in relieving symptoms and reducing relapse rates. However, treatment failure still remains a major problem. The development of atypical long-acting injectables that combine the effectiveness of an atypical agent with the convenience and reliability of once-every-2-week administration has significantly improved adherence to treatment regimens. Compliance with the treatment regimen is the result of a combination of several favorable factors:
predictable, stable and long-lasting levels of drug concentrations in the blood plasma;
reduced maximum plasma concentrations with minimal fluctuations;
lack of metabolism in the liver after absorption in the gastrointestinal tract;
a quick way to identify missed injections (violation of the treatment regimen).
Risperidone is the first long-acting atypical antipsychotic. Data confirm that the drug can achieve and maintain remission in many previously “stable” patients who are not prone to relapse. To test the clinical significance of the proposed remission criteria, a retrospective assessment of data obtained in the 6-month open-label phase of the clinical trial was carried out.
The purpose of the study was to compare the effectiveness of risperidone and a control drug (StoRMi). Patients were prescribed risperidone extended-release injection (RLAI) after oral medications or long-acting antipsychotics. Of the 715 patients, only 29% met PANSS criteria at study entry, but this proportion increased to 60% by the end of the study. Treatment with extended-release risperidone injection resulted in statistically significant and long-lasting improvements in mental and physical status. 74% of patients completed the six-month study, indicating a very high level of adherence to the RPDI treatment regimen. This should help patients meet and maintain remission criteria.

Putting the concept into practice
L. Helldin, Deputy Chief Psychiatrist at NU Health Care in Trollhättan, Sweden, emphasized the importance of introducing the concept of remission criteria into daily practice. The CATIE trial (Comparing the Effectiveness of Antipsychotics in Patients with Schizophrenia) was the first study conducted in a real-life clinical setting. The researchers conducted an objective comparison of several antipsychotic drugs and took into account the outcome of the disease for the patient and his relatives. To assess the lifestyle of specific patients, it is necessary to study the characteristics of one institution or locality. L. Helldin described a study conducted in Sweden of an area with a population of 253,000 people, of whom 670 suffered from schizophrenia. The screening examination identified 243 patients who could be included in the study. A wide range of situational factors were assessed, including work capacity, social activity, education, family burden, quality of life and awareness of illness.
To determine the status of patients, criteria for remission and its degrees were used. Of the 243 patients, 93 (38%) were assigned to the remission group; 3 points on the PANSS scale was taken as the cutoff criterion. This value was considered acceptable, since at a cut-off level of 2 points only 11% of patients met the criteria for remission, at a cut-off level of 4 points - 74% of patients. Patients assigned to the remission group have better functional capacity as measured by the number of daily activities scores (Camberwell Needs Assessment Scale), and have a greater chance of improving their ability to work and a greater degree of independence. Their educational and social status is higher, and the burden on the family is less. In addition, such patients were less likely to need hospitalization or a long hospital stay, and the chances of independent daily life were higher. Patients in remission had better quality of life and illness awareness, and they reported less cognitive impairment and greater satisfaction with treatment.

Observation tool used by doctors
A standardized monitoring tool for all European health care systems is a starting point for assessing the effectiveness of the concept of remission in the treatment program for patients with schizophrenia. This will help develop reliable criteria for assessing the conduct and results of clinical trials and facilitate mutual understanding among all participants in treatment: patients, relatives, doctors and other interested parties.
The criteria for remission described by the Expert Working Group are included in the interactive observation tool to assist clinicians in using scales developed for the assessment of schizophrenia in assessing remission and treatment effectiveness. This tool is a user-friendly, visual aid that automatically summarizes all assessments and reports on the patient's status and progress. Once the history and examination data have been entered, clear step-by-step guidance guides you through the stages of assessment and characterization of the patient. Each stage includes theoretical justification and recommendations. In addition to helping the clinician assess the situation, the tool helps patients and families document progress and focus on future achievements.

Towards an agreement
Delegates questioned the need to score less than 3 on all eight PANSS items over the entire 6-month period. As it was emphasized, to achieve a lasting result and international significance of the concept of remission, it is necessary to apply the criteria for remission without modifications. If one symptom consistently exceeds the threshold, the patient cannot be classified as having achieved remission. The important thing is that this approach helps doctors focus on the “distressing” symptoms, choosing the necessary treatment. D. Kane acknowledged the difficulties of meeting severity criteria, but at the same time emphasized that the concept of remission implies the absence of diagnostic symptoms. This provides information to practitioners about the success achieved and helps explain to patients and their families the reasons for treatment changes and how each stage of treatment addresses a specific problem. If necessary, clinics can apply their own PANSS cutoff criteria and define categories such as “partial remission.” But the standard definition of remission should be uniform - this will allow comparisons across different clinics and different countries. Violation of the treatment regimen, even short-term and for any reason, can lead to relapse. In this case, patients cannot be classified as having achieved remission until the end of the next 6-month period. However, a patient whose condition meets the severity criteria, but does not remain at this level of symptom severity for 6 months, can be classified as “approaching remission.” The six-month period is clinically significant, during which the severity of symptoms decreases to an acceptable degree of severity. A shorter period may not be sufficient to reliably assess long-term and sustained improvement. In addition, the 6-month period corresponds to the period required to diagnose schizophrenia; for other diseases, the criteria for remission imply a period of the same duration.
Terminology to describe the concept of remission should be standardized for ease of use in all European countries. Standardization may include changes in the definition of remission across health care systems. For example, in Croatia, “complete remission” is equated with “cure”, and “partial remission” is used to describe an intermediate stage. D. Kane emphasized that remission is not a cure. Patients may meet the criteria for remission, but they remain susceptible to relapse and are unable to live a full life. Criteria for determining cure have been developed (UCLA criteria). These include 4 areas of marked criteria that must be maintained over a 2 year period.
Reliable remission is important to ensure patients' educational and employment opportunities. Remission may be a ticket to social and civil rights and to the future. It would be useful to establish predictive criteria for remission in risk scores, preferably in cohort studies. If the concept of remission could be incorporated into public policy (patients in remission have a fairly low risk of behavioral abnormalities), public attitudes towards this disease might become more positive.
The fact that remission criteria do not take into account cognitive function will probably be addressed in the near future. Cognitive function can fluctuate widely, and the onset of clinical remission does not necessarily mean improvement in cognitive function. “Currently,” said Prof. D. Kane, - generally accepted testing of cognitive functions does not accurately reflect them; significant fluctuations are noted. However, assessment methods are improving, and I am confident that we will soon include cognitive function in the criteria for remission.”
To summarize, D. Kane once again emphasized the need to develop new promising directions in the treatment of schizophrenia - to fully realize the benefits of improved treatment methods and improve prognosis. The long-term goal of the reconnection program is to restore the connection between the patient and normal life. Achieving remission by introducing remission criteria into routine clinical practice will lay the foundation for this important project throughout Europe.

old.consilium-medicum.com

Remission stage of schizophrenia

Types of schizophrenic defect in remission:

1) Apato-abulic (emotional-volitional) defect. The most common type of defect. It is characterized
emotional impoverishment, sensory dullness, loss of interest in the environment and the need for communication, indifference to what is happening up to one’s own fate, the desire for self-isolation, loss of ability to work and a sharp decline in social status. That is, a person is not interested in anything, a person does not feel anything, he wants to go within four walls and not leave there.

2) Asthenic defect. This is a type of post-processual patients in whom mental asthenia dominates (vulnerability, sensitivity, “exhaustion” without objective signs of exhaustion, reflection, subordination). These patients are dependent individuals, insecure, trying to be close to relatives (with elements of intra-family tyranny). They are distrustful and suspicious of strangers. In their lives they adhere to gentle regimes. Their ability to work is sharply reduced . The person is not confident, he is mentally exhausted, and therefore cannot work for the same reason. Tired of everything, longing for close people.

3) Neurosis-like variant of the defect. Against the background of emotional dullness, mild thinking disorders and shallow intellectual decline, pictures and complaints corresponding to neurotic states, senesthopathy, obsessions, hypochondriacal experiences, non-psychotic phobias and body dysmorphomania predominate. Asthenic disorders are less pronounced. Hypochondriacal experiences can acquire an overvalued character with litigiousness in relation to health workers and medical institutions. Here the person clearly shows signs of neurosis, hypochondria, he believes that he will soon die, and the doctors are bad and do not want to treat. But it usually turns out that the doctor is right and the person is healthy.

4) Psychopathic-like defect Against the background of more dramatic negative changes in the emotional and intellectual spheres, a range of disorders are found that are inherent in almost all types of psychopathy with corresponding behavioral disorders: excitable, hysteroform, unstable, mosaic and, separately, with pronounced “schizoidization” - grotesque and caricaturedly mannered , extravagantly dressed, but completely uncritical of their behavior and appearance. Well, I think I don’t need to explain.

5) Pseudoorganic (paraorganic) defect. This type resembles an excitable psychopathic type, but the disorders are combined with difficulties in memory and thinking (bradypsychia). The main thing is the signs of instinctive disinhibition: hypersexuality, nudity and cynicism, mori-likeness (Greek topa - stupidity) or a “frontal” touch - euphoria, carelessness, mild motor excitement and complete ignorance of the surrounding situation.

6) Thymopathic defect. This is a type of so-called "acquired cyclothymia." In the hypomanic version, the behavior of patients is similar to the previous version, but differs in some “emotionality”. In general, it is characterized by signs of “regressive syntony.” In the subdepressive variant, the passive-apathetic nature of low mood without vital disorders predominates. Monopolar, bipolar and continuum fluctuations of affect are observed.

7) Hypersthenic variant of the defect. This type is characterized by the appearance, after suffering psychosis (fur coat), of previously unusual features - punctuality, strict regulation of the regime, nutrition, work and rest, excessive “correctness” and hypersociality. When a touch of hypomania is included in personal characteristics, social activity can take on a “stormy” character: patients speak at meetings, control the administration, organize circles, societies, “sects”, etc. They begin to study foreign languages, martial arts, and join political organizations. Sometimes new talents appear, and patients go into the world of art, bohemia, etc. Such a case took place in the biography of the artist Paul Gauguin, who became the prototype of the hero of Somerset Maugham’s novel “The Moon and a Penny.” Similar conditions were described by J. Villet under the name “defect of the type of new life.”

8) Autistic variant of the defect. With this type of defect, against the background of emotional insufficiency, typical changes in thinking are noted with the appearance of unusual interests: “metaphysical” intoxication, unusual pseudo-intellectual “hobbies”, pretentious gathering and collecting. Sometimes these disorders are accompanied by a “departure” into fantasy worlds with a separation from reality. The subjective world begins to dominate, it becomes more “real”. Patients are characterized by highly valuable creativity, invention, projectism, “activity for the sake of activity.” Extraordinary abilities may appear (quite early), for example, mathematical ones (Raymond from the wonderful film “Rain Man”). This kind of defect is difficult to distinguish from constitutional autistic abnormalities that arise in childhood and adolescence (Asperger's syndrome). Their appearance is largely compensatory due to the painful predominance of formal logical thinking over emotional (sensual) thinking.

9) Defect with monotonous hyperactivity. In each psychiatric hospital (department) there are 1-2 patients with signs of pronounced emotional impoverishment and intellectual decline, who silently and monotonously, “machine-like” perform a limited range of household work: washing floors, sweeping the yard, cleaning sewers, etc. These patients are always an example of “successful” labor rehabilitation in primitive industries, agricultural work and in medical workshops. They are jealous of their responsibilities, do not entrust them to anyone and conscientiously perform them until the next hallucinatory-delusional or affective-delusional attack of the disease.

Other variants of defects are echoes of persisting irrelevant (residual) psychotic products. Accordingly this is:

10) Hallucinatory defect with irrelevant hallucinatory experiences, a critical attitude towards them, dissimulation, and

11) Paranoid type of defect - a reduced paranoid syndrome with “encapsulated” irrelevant delusions and (contrary to the previous one) a complete lack of a critical attitude towards the disease.

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What does remission mean in schizophrenia?

According to statistics, about 30 percent of patients with schizophrenia are able to return to their normal lifestyle without experiencing any discomfort. Another 30 percent of patients retain some of the symptoms of the disease, may often feel discomfort, and partially retain ideas of persecution. Thinking and memory may decrease, but, nevertheless, they retain the ability to work and lead a moderate social life. Provided that they are regularly monitored by a psychiatrist and take medications in a timely manner, as well as with constant psychotherapeutic support, such patients have a good chance of living without relapse into old age.

How do you know when remission has ended and a relapse has begun?

The level of anxiety and irritability increases. The patient ceases to cope with stress in the simplest situations.

Schizophrenia is an unpredictable mental disorder. Doctors and scientists managed to describe its unpredictability. The number of options is finite. Maybe over the years the patient will become paranoid with a persistent mental defect, maybe he will be completely healed, but in the age of postmodernism something completely original will not happen to him. Since the beginning of the 20th century, when this concept appeared, scientists have already described all variants of pathogenesis. There was enough time. However, this does not deny that the disease occurs according to individual laws. The popular phrase “everyone goes crazy in their own way” is largely true. This individuality is expressed in the fact that everyone has their own life situations, and syndromes tend to be combined.

Cases where the flow of disorder continues continuously are quite rare. At the same time, remission with an undulating course is a rather relative concept. In the vast majority of cases, its quality decreases over the years. During the “light” intervals, patients retain some elements of acute forms in a reduced, residual form. But this residuality will stop more and more. The answer to the question of how long treatment for schizophrenia in a hospital lasts is quite simple - a month or a little less. The reason is quite simple... During this time, the active use of antipsychotics manages to relieve the main symptoms. It is impossible to call this a complete cure, but this does not mean that doctors are discharging untreated patients. No one will ever point out those who are completely cured. Therefore, the criterion for recovery is a decrease in the negativity of symptoms.

One psychiatrist told about this case. The patient was discharged, and he returned immediately to the hospital. The reason is very simple. He went home by bus and was shaking - our roads are bad. It seemed to him that his “brains were shaken,” and he returned in fear to have them “set” back. Of course, this is a subjective human assessment of the situation by the patient himself and is given only as an illustration of the condition that is suitable for discharge and sending the patient for observation at the place of residence. He didn’t run into the forest because the aliens shook his brain. He understood everything and returned to where they could help him.

Remission in schizophrenia is a decrease, but not a recovery. Its course is unpredictable even with complicating factors. There are periods between one hospitalization and another, but this does not mean that all patients suddenly become healthy during the interval.

Try an experiment. It's not dangerous at all, don't worry. Remove any goals from your mind. Just sit on a chair or armchair and look out the window, not the wall. Don't meditate, don't pray, don't read. Just sit for 10 minutes. And then take a notebook and start writing down all your thoughts. Difficult, of course, but interesting. Just what comes to mind. Stay at least 20 minutes doing this activity, and then close your notebook. Open it every other day and read it. God! This is pure delirium of a madman. Some fragments of associations. The author of these lines catches himself simultaneously thinking about schizophrenia, about this site, about high prices, about back pain, about whether his life was a success, remembers the women with whom he was close, and comes to the conclusion that it's time... Go and make some tea, thereby putting an end to this disgrace.

If you are too lazy to write, then speak out your thoughts and record the sound. Only then immediately erase the files, otherwise someone will see it. And tear up your notebook... No one will go into the intricacies of our experiments.

And this is true for everyone. This is not a criterion for the presence of a delusional disorder, but a feature of the mind. If you set yourself the task of solving a quadratic equation, then a certain percentage of consciousness will begin to get busy - to complete the task. But it is far from a fact that during this process thoughts will not “run away” towards high prices, love relationships and the like. In the mind of a schizophrenic, no “failure” occurs and nothing “splits” more than in other citizens. The existing split is actualized and acquires a phantasmagoric character. Neuroleptics reduce the mental reaction to what is happening in consciousness, but do not change this consciousness. It is generally impossible to change it. Maybe Buddha and some other ascetics managed to change it. Or not to change the mind itself, but to create a different complex of functioning for it.

Outcome of schizophrenia

In connection with all this, it is impossible to indicate the consequences of schizophrenia. If we mean an episode, then it either continues, or the activity of negative factors decreases, or they disappear altogether. Maybe for three days, maybe for seven years, maybe forever. In the classical scheme, the consequences are the phase of the presence of a persistent and pronounced schizoid mental defect. Just don’t ask about what it is, otherwise you’ll have to talk about paranoia, which is different from paranoid schizophrenia.

The goal of psychiatry is to achieve stable remission, which will correspond to the factors of complete healing. Look at the newspaper headlines. Someone was doused with green paint, somewhere a bus was shot at, then a number of media and resources on the Internet were banned, naked women marched, a young man caught Pokemon in a church, and then swore and posted it on the Internet. Who is this healthy person? Where? As soon as you find out that healthy people will be shown on TV, be sure to leave a comment under this article. Let's work together on psychological hygiene and give positive information to society. The goal is achievable in the same way as enlightenment, merging with God, and building a humanistic society of universal happiness are achievable. One can only hope for this, one must believe in it, maybe even dream about it. A schizophrenic who dreams of complete healing on the right path.

There is no need to ask about what the consequences will be if schizophrenia is not treated. Who told you that she needs to be treated? The question is different: what will happen if the symptoms are not stopped? And who could know this? Maybe it will let go on its own, maybe it will be suicide, a crime, an accident, or maybe nothing will happen. If you read somewhere that a schizophrenic definitely needs psychiatric help in the form of treatment, then know that this was written by a person very far from practice, theory, from everything related to the topic. If the subject gets by on his own, let him get by.

Relationships with loved ones show whether a patient with schizophrenia has begun remission

The only exception is his relationship with loved ones. What to do when a patient bullies his family members, throws things out of windows, attacks people, makes noise or threatens? He himself does not want to be treated. Here you can remember one joke...

Are you acting according to the law or according to justice?
Depending on the circumstances.

This is exactly what you need to do...

Get the myths out of your head:

the conditions in the psychiatric hospital are terrible;
psychiatrists mock patients;
all the orderlies are sadists;
the patient will become a “vegetable” after treatment.

A psychiatric clinical hospital is not a sanatorium or a five-star hotel, but in general the conditions for living and treatment are quite suitable. It’s impossible to say for everyone, often it’s easy to become an orderly because there is no work, but some passions arose mainly from art and belong to times long gone. It's the other way around. A “vegetable” can be called not only someone who sits and is silent all his life, but also someone who does not know what he is doing. People leave psychiatric hospitals just when they already know, understand everything and are ready for some kind of life in society.

True, it is extremely difficult to achieve hospitalization without the will of the patient. You will have to collect a lot of signatures, visit everywhere, talk with officials, police, and neighbors. It’s impossible otherwise, if people were simply placed in hospitals, then there would be those who would want to send people they didn’t want there.

Remission problems

Rehabilitation of patients with schizophrenia is quite possible, but what is meant by this is not what is needed. We are used to judging this way: here is a sick person, and here is a recovering person, and this one is already healthy. When applied to such mental disorders, all these terms should be put in quotation marks. Some patients can run around the streets all day long. It seems to them that there are a lot of important and urgent things to do, or there are no things to do, but they are still going somewhere, in a hurry. The majority suffer from autism. There is no point in talking about rehabilitation just like that. What exactly do you need to achieve? It should be borne in mind that we cannot determine exactly what activity or passivity will entail in any particular case. Sometimes it is better not to interfere and leave everyone to their own karma.

Autism can be a completely natural form of self-help, or it can turn into an additional factor in suffering. Here you need to proceed from the patient’s own desires. If he wants everyone to leave him alone, then why pester him with offers to go for a walk? It’s another matter when ambivalence does not allow the patient to build the correct behavioral series; he strives to improve his life, but he fails. This is where you need the help of a psychotherapist.

Schizophrenia in remission also means constant use of antipsychotics. It is necessary to take into account the effect they cause. The main thing is not to set impossible or too difficult tasks for the patient. The patients themselves and those around them must understand that certain deviations are simply inevitable. For example, you don’t need to expect your beloved wife to cook food, clean the apartment, take care of the children and show her emotions the way she did a long time ago. What has happened has passed. Learn to adapt to what is, and not achieve what you would like.

Even in case of remission, patients need a special approach

Statistics and practice

The official statistics of schizophrenia in Russia are not underestimated, but we have many more real schizophrenics than those registered with psychiatrists. The fact is that since the transition of official diagnosis to ICD 10 criteria, and this happened at the very beginning of the 21st century, it has been impossible to diagnose “sluggish” schizophrenia. There is simply no such thing there. During the years of the USSR it was the main one. If you look hard enough, you can find such schizophrenia in almost everyone. As a result, the psychiatrist, to some extent, was a kind of judge and could “deal” everyone.

If those days returned now, and the legislation then allowed forced placement in hospitals, then most likely more than a million people would end up in them. Treatment without consent is still possible, but for this it is necessary that the citizen’s condition meets the following criteria:

poses a threat to society and the safety of other people;
poses a threat to himself;
taken to the hospital in a helpless condition.

These amendments to the legislation were made about five years ago. The bill was considered in the State Duma of the Russian Federation for quite a long time. It is impossible to determine all this simply by visual examination and a short conversation with the prospective patient, therefore short-term hospitalization is allowed to monitor a possibly sick citizen. This is regulated by Article 302 of the Code of Civil Procedure of the Russian Federation.

The number of schizophrenics in our country is much greater than statistics claim

The case must be quite serious. If there are grounds for this, then the psychiatrist has the exclusive right to file an application with the court. If the decision is positive, he will begin treatment on the basis of the court of first instance. This can happen if the patient refuses treatment after three days of examination, and the psychiatrist believes that it is necessary. Even employees of the prosecutor's office are not granted this right. The law requires the psychiatrist to indicate the degree of danger or helplessness and give reasons for this. For example, he attacked his wife with an ax and bit an ambulance paramedic - this is grounds, but contemplating pink elephants while awake is not.

Schizophrenia: statistics and social factors

Schizophrenia in Russia has become quite a big social problem. On the one hand, it is cruel and criminal to send people for compulsory treatment because they have strange ideas. On the other hand, a schizophrenic may not bite anyone or fight with axes. He may file complaints with the courts, the police, call the fire department, and he may imagine terrorists with mines. If he has not previously been treated, it is sometimes very difficult to distinguish an alert citizen from a sick one. Imagine yourself in the place of the person to whom the patient writes a statement that he is a drug dealer and the applicant saw him selling drugs to schoolchildren. The application will be considered without fail. And what will happen next is very difficult to say. Most likely, charges will not arise, but all this will cost labor and worry, and may require the cost of a lawyer. This is all the reality of our days - not the author’s imagination, but quite examples that took place in reality. And there are more and more of them... Even during the relatively prosperous years of 2010-13, the number of officially registered cases of mental confusion grew by 10-12% per year. And this is quite understandable. There is no reactive schizophrenia, but economic difficulties create conditions when the psyche constantly digests negative information, and this is already a provoking “push” state. The same mental metabolism that Anton Kempinski wrote about and which he compared with energy metabolism. And he even boldly used the term “psycho-energetic metabolism.”

This is another difficulty that makes it difficult to solve the almost impossible problems of psychiatry. Schizophrenia in Russia has alarming statistics, but the reasons are not being looked for where they are. They say some strange things about a massive attack on the psyche from the media and art. You'll forget about the movie tomorrow, but you'll remember about your mortgage debt until you pay it off. General statistics are like the average salary of a Russian. Some earn millions in income, others barely scrape together up to 12 thousand, which means our average is somewhere around 2 thousand dollars. Statistics need to be built when analyzing regions, regions, districts, even neighborhoods and villages. If you take a map of our vastness and mark all the problem areas, and then overlay the places with the largest number of recorded cases, they will coincide. Problematic ones are those where the level of economic development is lower, the level of education is lower, it is more difficult to find a job, social pressure is higher and where there is hazardous production. At the same time, the concept of “harmfulness” must be approached broadly. One psychiatrist called the local garment factory a madness factory. Well, he knew very well that 80% of the employees there were sick. Noise, monotonous work, dust, stuffiness. There is nothing useful about this.

The issue of schizophrenia in our country is not only relevant, but also a major social problem

Rehabilitation for schizophrenia depends on factors over which medicine is 100% powerless. The fact that there are constant conflicts at work, the work itself is boring and monotonous, not interesting, does not drive you crazy. But all this provokes a situation where the premiere is more likely to happen. But where will the patient go, who was given the third work group, if he is an employee of the only enterprise in the city, with this aggressive environment? This is where he will return...

In fact, a disease such as schizophrenia can actually be treated with the use of modern medications, and a person, with some support, can lead a completely full life. At the same time, it should be immediately noted that such a severe mental illness cannot be completely cured, since the areas of brain damage present in this disease remain with the person forever.

Despite the fact that schizophrenia is an incurable disease, patients and their families should never give up and let things take their course, as this will only make things worse. The thing is that even leading experts cannot give an accurate answer to the question of whether schizophrenia can be cured now and whether this will be possible in the future, but at the same time, there are far from isolated cases when people, after long-term drug and psychotherapeutic treatment, have more did not suffer from exacerbations, being in remission until the end of life.

Stable remission

Less than a century ago, a diagnosis such as schizophrenia was a real sentence, which meant that a person would gradually lose his ability to work, sobriety of thought and any connection with reality and would end his life, most likely in a specialized institution, completely losing his personality. At present, methods have not yet been found to completely cure schizophrenia, but modern medications can significantly stop or at least greatly slow down the development of the pathological process.

In addition, with the correct selection of medications and the patient’s compliance with all the doctor’s instructions, a stable and long-term remission can be achieved, that is, the person will stop feeling all the hardships of this serious mental illness and will be able to lead a completely full life. Despite the fact that some traditional healers from time to time claim that schizophrenia is curable, in reality, without targeted drug treatment in the acute period, and then supportive socialization therapy, the consequences can be very sad.

However, despite the fact that the answer to the question of whether schizophrenia is curable or not is still clearly negative, not everything is as bad as it might seem at first glance. The thing is that modern drug and physiotherapeutic treatment regimens are extremely effective. According to statistics, people who, after an acute period of the disease, completed a full course of drug treatment in a hospital and then did not take maintenance doses of drugs at home, in 60-80% of cases in the first year again required therapy in a medical institution. At the same time, those who took medications in maintenance doses apply in the first year only in 20% of cases. If maintenance therapy continued after 1 year from the onset of the disease, the risk of developing the acute phase is reduced to 10%,

Difficulties in treatment

In cases of severe schizophrenia, combined with other mental disorders, it is often very difficult to achieve high-quality dynamics. Such severe cases account for no more than 2-5% of all patients with schizophrenia.

In addition, despite the good results of drug therapy, it should be taken into account that psychotropic drugs used to treat schizophrenia have a number of side effects. This is often the reason that a person loses faith in improving his condition and stops taking the medications he needs. Currently, many people suffering from schizophrenia continue treatment with medications at home and indicate that most side effects caused by taking the drugs gradually disappear.

Doctors associate this phenomenon with the gradual adaptation of the body of people suffering from schizophrenia to these drugs, but at the same time, the effectiveness of taking the drugs does not change significantly. Thus, a person who has been given such a terrible diagnosis as schizophrenia should remember that modern methods of treating this disease are quite effective, and one should be patient in order to return to a full life as a person confident in himself and his abilities.

In addition, it is important to consider that schizophrenia is a progressive mental illness, the development of which can only be stopped by drug therapy. If you refuse to take the necessary medications, the cases of deterioration and relapse of the acute phases of the disease will increase significantly, which will ultimately lead to a person losing the ability to think normally and perceive the surrounding reality. Thus, despite the fact that it is impossible to cure schizophrenia, it is still possible and necessary to treat this condition, since only this gives a chance that a person will later become a full-fledged member of society and will not experience unpleasant symptoms.

Considering that the risk of transmitting schizophrenia to a child is only 5-10%, many women suffering from this mental illness decide to create a full-fledged family and have their own children. However, in order for pregnancy and childbirth to be as painless as possible, a woman must undergo a full course of treatment and achieve stable remission, since taking medications at this time can negatively affect the condition of the developing fetus.

Help with exacerbations

The main direction of treatment for schizophrenia is drug suppression of existing symptomatic manifestations and stabilization of a person’s brain function during an exacerbation, and then supporting the patient’s condition to prevent deterioration. Until relatively recently, treatment of schizophrenia was carried out using electroconvulsive therapy and other methods of influence that were no less painful for humans. However, several generations of special psychotropic drugs have now appeared, thanks to which complete elimination of symptoms can occur.

It is worth noting that first-generation psychotropic drugs, previously widely used to treat patients with schizophrenia with severe manifestations of delusions, hallucinations and other symptoms, are currently fading into the background, since such drugs have too many side effects. Such 1st generation psychotropic drugs include:

Haloperidol.
Cyclodol.
Amitriptyline.
Melipramine.

These drugs are currently used mainly within the walls of psychiatric clinics, and in very short courses, when it is necessary to stabilize the patient’s condition.

A long course of taking such drugs is rarely prescribed, since similar effects from their use
significantly reduce the patient's quality of life.

The best option is the use of so-called atypical antipsychotics, that is, new generation drugs, which include:

Olanzepin.
Trisedyl.
Majeptyl.
Quentiapin.
Rispiridone.
Amisulpiride et al.

This group of antipsychotics helps eliminate not only delusions and hallucinations, but also normalizes the general state of mental health, including the elimination of isolation, poverty of thinking, negative attitude towards life, lack of initiative and other phenomena inherent in a condition such as schizophrenia. Development of a drug to treat schizophrenia is still underway. Intensive drug therapy for paranoid and other types of schizophrenia, accompanied by delusions and hallucinations, is usually supplemented with drugs that have a metabolic effect on brain tissue, which include:

Berlition.
Mildranath.
Mexidol.
Milgama
Cerebrolysin.

Additional medications may also be prescribed to improve the patient’s condition. Currently, drugs belonging to the group of nootropics, tranquilizers, and sleeping pills are widely used. Among other things, vitamin complexes and physical therapy may be prescribed. With sluggish schizophrenia, the patient does not have to undergo treatment in an inpatient psychiatric hospital. Moreover, with this variant of the course of the disease, milder antipsychotics and additional drugs are usually used so as not to provoke a worsening of the condition.

In the acute course of forms of schizophrenia, accompanied by severe symptoms, it usually takes about 2-3 weeks to relieve the acute phase in a hospital setting, after which the attending physician selects medications in a maintenance dose. With the correct selection of new types of antipsychotic drugs, there should be no pronounced side effects, and a person can lead a completely full life, no different from those around him.

Residual effects

Even during a period of remission, a person needs to take prescribed medications and continue treatment with a psychotherapist to maintain a normal state. Only understanding on the part of the doctor and close relatives can eliminate the remaining manifestations. The thing is that for a long time after an exacerbation, patients experience an increased level of anxiety, fear and suspicion. Often, the complication of relationships with relatives and doctors is a consequence of a lack of understanding of the patient’s problems and ridicule of them.

The psychotherapist must, if possible, explain the nature of the person’s manifestations and conditions and try to treat the patient’s problems with understanding. Over time, with the right medication support, a person suffering from schizophrenia, which occurs with exacerbations, learns to cope with stress and build relationships with loved ones. A person suffering from schizophrenia must know absolutely everything about his illness.

Among other things, social rehabilitation is a necessary measure. First of all, it is necessary to encourage the patient to perform actions aimed at self-care and simple physical work.

Prevention measures

Considering that many treatment regimens and maintenance therapy have now been developed in the post-remission period for women and men suffering from schizophrenia, repeated attacks of psychosis are not observed, but this does not mean that the person has been cured of this mental illness. In order to maintain normal mental health, the patient himself and his relatives must make certain efforts. First of all, the patient needs to try to avoid stress and lead a normal life, that is, try to go to bed at the same time, and also eat and exercise on a schedule. Sleep duration should be at least 8 hours.

Proper rest allows the brain to recover faster from stress, which plays a significant role in maintaining the normal state of a person suffering from schizophrenia. Among other things, a necessary measure is a proper diet, which should be as varied as possible and include a large amount of vegetables and fruits. Meat, fish and dairy products should also be fully represented in the diet of a person suffering from schizophrenia.

Types of remission in schizophrenia

Depending on the reduction of psychopathological symptoms, the presence of a mental defect and the dynamics of manifestations of the level of vitality in patients, the following types of remissions are distinguished:

Complete (remission A) - the complete disappearance of a productive psychotic clinic for the preservation of slightly expressed apathetic-dissociative symptoms in some patients does not significantly reduce the quality of life (the ability to self-care, orientation, behavior control, communication, movement, performance).

Incomplete (remission B) - a significant decrease in the manifestation of productive psychopathological symptoms for the preservation of moderately severe negative psychotic disorders and deterioration of criteria for the level of vital activity (limited performance, etc.).

Incomplete (remission C). Noticeable reduction, encapsulation of productive psychopathological manifestations, well-defined personality defect, significantly reduced level of vital activity (including complete loss of ability to work).

Partial (remission D) - a decrease in the severity of the disease, a certain de-actualization of psychotic and other symptoms. Patients require continuation of the main course of treatment (in-hospital improvement). Classification, types of course and remissions of schizophrenia, schizo-typic and delusional disorders: According to ICD-10 F 20 Schizophrenia F 20.0 Paranoid schizophrenia F 20.1 Hebephrenic schizophrenia F 20.2 Catatonic schizophrenia F 20.3 Undifferentiated schizophrenia F 20.4 Post-schizophrenic depression F 20.5 Residual al schizophrenia F 20.6 Simple schizophrenia F 20.8 Other forms of schizophrenia F 20.9 Schizophrenia, unspecified Types of course: F 20. x 0 Continuous

F 20. x 1 episodic, with a defect, increasing F 20. x 2 episodic, with a stable defect F 20. x 3 Episodic remitting or remitting type: F 20. x 4 Incomplete F 20. x 5 Complete F 20. x 7 Other

F 20. x 9 Observation period up to a year

F 21 schizotypal disorder (strange behavior, eccentric, social isolation, externally - emotionally cold, suspicious, prone to obsessive thinking, paranoid ideas, possible illusions, depersonalization or derealization, transient-no episodes of auditory and other hallucinations, delusional ideas; characteristic of schizophrenia no complex of symptoms) F 22 Chronic delusional disorder F 22.0 Lighthouse disorder F 22.8 Other chronic delusional disorders F 22.9 Chronic unspecified delusional disorder F 23 Acute and transient psychotic disorders F 23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia

F 23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia

F 23.2 acute schizophrenia-like psychotic disorder F 23.8 Other acute and transient psychotic disorders F 23.9 Acute and transient psychotic disorders, unspecified F 24 Induced delusional disorder F 25 schizoaffective disorder

F 25.0 schizoaffective disorder, manic type F 25.1 schizoaffective psychosis F 25.2 schizoaffective disorder, mixed type F 25.8 Other schizoaffective disorder F 25.9 schizoaffective disorder, unspecified F 28 Other non-organic psychotic disorders F 29 unspecified non-organic psychosis

Classification and types of course of schizophrenia and other psychotic disorders: According to DSM-IV 295. Schizophrenia 295.30 Paranoid schizophrenia 295.10 Disorganized schizophrenia 295.20 Catatonic schizophrenia 295.90 Undifferentiated schizophrenia 295.60 Residual schizophrenia 295.40 Schizophreniform disorders o 297.1 Lighthouse disorder

298.8 Brief psychotic disorder 297.3 Induced mental disorder

293. . Mental disorder caused by (specify the name of somatic or neurological disease)

293.82 3 hallucinations

289.9 Mental disorder, unspecified

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Remission and defect in schizophrenia

The development of a mental defect in schizophrenia is determined by the negative symptoms of the disease, the greatest severity of which is characterized as the “final” state.

The formation of a mental defect, i.e. the increase in negative changes in schizophrenia largely depends on the rate of progression

diseases. Biological (gender, age at onset of the disease) and social factors also have a significant influence. The most severe manifestations of the defect are considered to be the predominance of pseudoorganic disorders. They are usually observed in malignant continuous (nuclear) schizophrenia with a rapid rate of progression, while in cases of slow development of the disease process, negative symptoms may be limited to mild changes (schizoid and asthenic). In men, the onset of symptoms of the defect occurs earlier than in women, and the course of the disease ends more quickly in “final” conditions. The most severe variants of the defect are observed at the onset of the disease in childhood (oligophrenia-like defect with severe intellectual disability), as well as in adolescence and young adulthood (for example, youthful asthenic failure can result in persistent deficiency changes). The risk of developing severe negative changes at the onset of schizophrenia at a later age is reduced. Pronounced negative changes are more often formed in persons with mental retardation and pathocharacterological deviations, with a low level of education, lack of professional skills and social interests.

Research into the manifestations of mental defects continued for many years on a contingent of patients in colonies, psychoneurological boarding schools and hospitals for chronically ill patients, i.e., with protracted, years-long psychotic states that develop in the later stages of unfavorably progressing schizophrenia. The structure of the defect inevitably included positive psychopathological manifestations - paranoid, hallucinatory, catatonic, hebephrenic, which persisted, although in a slightly modified form (stereotyped, devoid of affective coloring, neutral in content), and during the period of relative stabilization of the process. Such complex disorders, combining both negative and positive symptom complexes (they represent, as it were, a frozen “clump” of those psychopathological manifestations that arose at previous stages of the disease), were defined within the framework of final, initial, residual states, the so-called long-term forms, as well as late remissions. An example is the taxonomy of E, based on the prevalence of positive or negative manifestations in the clinical picture. Kraepelin (1913), including 8 types of final states: simple, hallucinatory, paranoid dementia, dementia with “discontinued train of thought,” stupid, foolish, mannered, negativistic dementia. Other classifications were also based on Kraepelin principles [Edelshtein A. O., 1938; Favorina V.N., 1965; Leonhard K., 1957; Schneider K., 1980]. Meanwhile, the observations of V.N. Favorina indicate that even in cases of predominance of negative changes in the structure of the final state, symptoms of psychosis (up to rudimentary catatonic disorders) are always present (albeit in a reduced form). With this approach, the characterization of positive psychopathological disorders involved in the picture of final states pushes aside a detailed analysis of negative changes. In this regard, the position of most modern researchers, who consider schizophrenia, which occurs with a predominance of negative disorders, as the preferred model for the clinical study of the defect [Häfner H., Maurer K., 1993; Strauss J. S. et al., 1974; Andreasen N. S., 1981, 1995; Carpenter W. T. et al., 1985; Zubin G., 1985; Kay S. R., Sevy S., 1990].

In the study of the defect, two main directions can be distinguished, differing in the assessment of the ways of formation and clinical manifestations of negative changes. Works related to the first direction are related to the teachings of J. Jackson (1958) about dissolution of mental activity. According to this theory, negative changes are initially formed in ontogenetically later and, accordingly, higher layers of the psyche and only then spread to more “ancient”, lower mental functions. Examples of the development of the J concept. Jackson in relation to negative changes are the organodynamic theory of N. Eu (1954) and the psychophysiological concept of I. Mazurkiewicz (1980). In a number of clinical studies [Sukhareva G. E., 1933; Edelshtein A. O., 1938; Snezhnevsky A.V., 1969, 1983; Polyakov Yu. F., 1976; Tiganov A.S., 1985; Panteleeva G.P., Tsutsulkovskaya M.Ya., Belyaev B.S., 1986] the formation of a defect is also considered as a sequential chain of negative changes (and in this consonance with the concept of J. Jackson), starting with a subtle deformation of the personal make-up and gradually, as it spreads to deeper layers of mental activity, becoming more severe due to intellectual impairments, thinking disorders, and a general decrease in mental activity. According to the concept of AB. Snezhnevsky, negative disorders in schizophrenia, as they become more severe, go through a number of stages, reflecting the depth of damage to mental activity. The initial signs of the defect include personality disharmony (including schizoidization). Signs of subsequent more severe stages are a decrease in energy potential and personality level.

Representatives of the second direction, whose position is to a certain extent opposed to the previously stated concept, consider the schizophrenic defect in the light of the position of K. Conrad (1958) on the reduction of energy potential. At the clinical level, this concept is most fully developed by G. Huber (1966). The author essentially identifies the concept of reduction of energy potential with the main manifestations of the schizophrenic defect. As negative changes in G. Huber considers only an isolated “loss of tension” comparable to the organic psychosyndrome, in which the tone of behavior and all actions, aspiration towards the goal are lost, a decrease in motivation occurs, and a narrowing of the range of interests occurs. In accordance with the views of G. Huber, in schizophrenia, as part of negative (irreversible) changes, the parts of higher nervous activity responsible for mental activity (loss of spontaneity, motivation, initiative, decreased vitality and concentration) are affected primarily or even exclusively.

Clinical picture of negative changes. Currently, negative changes that are formed at the personal level are identified - psychopathic defect, and responsible for the decrease in mental activity - pseudoorganic defect. With the relative independence of each of these types of negative disorders, their manifestations are combined [Smulevich A. B., Vorobyov V. Yu., 1988; Smulevich A. B., 1996]. The predominance of psychopathic-like disorders in the structure of the defect is either associated with hypertrophy of individual personality traits due to gross shifts in psycho-aesthetic proportions, an increase in oddities, eccentricities and absurdities in behavior, i.e. a Ferschroben-type defect [Vorobiev V. Yu., Nefed'ev O. P., 1987 ; Birnbaum K., 1906], or manifests itself in the form of increased passivity, lack of initiative, dependence - a defect such as deficit schizoidia [Shenderova V.L., 1974]. With this form of defect, there is a significant decrease in the social standard; patients very quickly give up their previous positions, quit school or work, and become disabled. In cases of predominance of pseudo-organic symptoms, i.e. with a pseudo-organic defect [Vnukov V. A., 1937], signs of a decline in mental activity and productivity, intellectual decline, and rigidity of mental functions come to the fore; There is an increasing leveling of personal characteristics with a narrowing of contacts and range of interests, culminating in a decrease in the level of personality (a simple deficit type defect) [Eu N., 1985] or an asthenic defect (autochthonous asthenia) [Glatzel J., 1978], transforming in severe cases into structure of pseudobradyphrenia. With the development of the latter, a decrease in spontaneity and a slowdown in all mental processes, as well as an increasing inertia of mental functions, come to the fore.

The most characteristic negative changes for schizophrenia are defects of the Ferschroben type and simple deficiency.

Ferschroben type defect . Clinical genetic studies have shown that the typological heterogeneity of the defect (Verschroben type, simple deficiency) in negative schizophrenia correlates with the heterogeneity of constitutional genetic factors in the structure of susceptibility [Lukyanova L. L., 1989]. Predisposition to a defect of the Ferschroben type is associated with relatively broad constitutional and genetic influences (family history of schizoid with a predominance of pathocharacterological anomalies of the group of “active autists” over deficit schizoid, as well as over other psychopathy - paranoid, affective, excitable). The formation of a defect such as a simple deficiency is associated with a predisposition to schizoid psychopathy (mainly with the circle of deficit schizoidia), which exhausts the family burden. One of the main signs of a defect of the Ferschroben type is “pathological autistic activity” (according to E. Minkowsky, 1927), accompanied by pretentious, absurd actions that do not comply with conventional norms, reflecting a complete separation from both reality and past life experience. Orientation to the future also suffers significantly; there are no clear plans and definite intentions. The formation of “pathological autistic activity” is closely related to such changes as the collapse of critical functions. Patients have disorders of self-evaluation (awareness of one's own individuality through comparison with others). Patients do not understand that they are behaving inappropriately; they talk about their strange actions, habits and hobbies as if it were something taken for granted. Knowing that they are considered “eccentrics” and “not of this world” among their loved ones and colleagues, patients consider such ideas to be incorrect and do not understand what they are based on. Features of strangeness and paradox clearly appear not only in the judgments and actions of patients, but also leave an imprint on their life. Their home is cluttered, cluttered with old, unnecessary things. The lack of grooming and neglect of the rules of personal hygiene contrast with the pretentiousness of the hairstyle and details of the toilet. The appearance of patients is complemented by unnaturalness, mannerism of facial expressions, dysplasticity and angularity of motor skills. Emotional coarsening occupies a significant place in the structure of the defect. The traits of sensitivity and vulnerability are almost completely reduced, the tendency to internal conflict disappears, and related feelings fade away. The nuances of interpersonal relationships, the sense of tact and distance are grossly violated. Patients are often euphoric, make inappropriate jokes, and are prone to empty pathos, pathos, and complacency. They develop signs of regressive syntony.

These changes are comparable to the phenomena of bradyphrenia that develop in organic brain diseases, but not identical to them, and therefore can be defined as pseudobradyphrenia.

In patients with a defect such as a simple deficiency a reduction in the volume of mental activity is combined with the phenomena of “asthenic autism” [Snezhnevsky A.V., 1983; Gorchakova L.P., 1988]. An integral sign of this type of defect appears to be intellectual decline. Patients experience difficulties in the formation of concepts and in their verbalization, a decrease in the level of generalizations and the ability for logical analysis, a violation of the actualization of their own experience and probabilistic forecasting. Their judgments are clichéd and banal. The impoverishment of associative connections and slowness significantly complicate professional activity and limit overall activity. An increase in such pseudo-organic disorders as a decrease in motivation with loss of spontaneity in all its manifestations is also characteristic, which is associated with disruption of contacts with others. The desire for communication disappears, previous interests, determination, and ambition are lost. Patients become passive and uninitiative. Referring to a “loss of strength”, a constant feeling of fatigue, they avoid previous companies, meet with acquaintances and friends less and less, citing the need to save energy; limit interpersonal connections to the narrow framework of family relationships. There is also a disorder from a number of pseudo-organic ones, such as mental vulnerability: any change in the life pattern causes disorganization of mental activity, manifested by increased thinking disorders, anxiety, inactivity, and emotional incontinence. When faced with the slightest difficulties, they experience reactions of avoidance and refusal; they give up their previous positions in life with amazing ease - they give up classes in higher educational institutions, work, and without hesitation agree with the status of a disabled person. However, such phenomena are accompanied not only by a feeling of helplessness, as is the case with changes associated with organic brain damage. In a number of cases, egocentrism comes to the fore, marking both the disappearance of former attachments and former sympathies, and the emergence of a new, no longer emotional, but rational structure of relationships with people, which leads to special forms of symbiotic coexistence. At the same time, some patients become ruthless egoists, exploiting and torturing relatives, while others turn into obedient and submissive to the will of others. However, most of them are deprived of true feelings, sincerity, and the ability to directly empathize. If they sometimes worry, showing signs of care and participation when their parents or other relatives are unwell, it is only out of fear of being left without support and care in the event of illness or death of those caring for them.

Dynamics of negative changes. Negative changes that form within schizophrenia are subject to significant dynamic shifts and cannot be considered as frozen and completely irreversible or as progressive, that is, inevitably leading to dementia. At least two types of dynamics can be specified as alternatives - reduction of negative changes And post-processual personality development .

Reverse trend can be observed in deficiency disorders that determine the picture of protracted affective and asthenic states characteristic of the course of negative schizophrenia. Such reversible negative changes are considered within the framework of transitional syndromes [Drobizhev M. Yu., 1991; Gross G., 1989], psychopathological manifestations of which can only potentially be transformed into the structure of the defect, but do not actually relate to it. As remission occurs, such negative disorders undergo partial and sometimes complete reduction. The possibility of reducing negative manifestations remains at the stage of attenuation of active manifestations of the disease, during the period when consolidation of the defect has not yet occurred [Melekhov D. E., 1963; Mauz R, 1921]. At this time, there are favorable opportunities to restore work skills and social attitudes.

Compensatory processes are also observed in persistent, severe manifestations of the defect, accompanied by behavioral regression. Most often, readaptation processes are observed in cases of a defect with phenomena of monotonous activity [Morozov V. M., 1953; Smulevich A. B., Yastrebov V. S., Izmailova L.G., 1976]. With this type of deficiency disorder, it is possible not only to learn the basic rules of self-care, but also to restore skills for certain types of work. In some cases, while maintaining the autistic nature of their activities, patients even acquire new professional skills that do not coincide with the qualifications received before the illness, and learn crafts. However, the implementation of compensatory possibilities (encapsulation of painful ideas formed in the active stage of the pathological process, and restoration of real ideas about reality, reduction of the phenomena of autism, indifference to the environment, reduction of thinking disorders, orderliness of behavior) in these cases is carried out subject to targeted pharmacotherapeutic, psychocorrectional and psychosocial influences [Mauz F., 1929].

Dynamics according to the type of post-process development, as a rule, is observed with relatively shallow negative changes (outpatient final states according to L. M. Shmaonova (1968) and is usually considered within the framework of late remissions or residual schizophrenia [Nadzharov R. A., Tiganov A. S., Smulevich A. B. . et al., 1988]. Being, on the one hand, the final stage of the course of schizophrenia, these conditions in subsequent development do not have a clear connection with the pathological process (there are no signs of a deepening of pathocharacterological disorders caused by the endogenous disease or an increase in negative changes in the dynamics). Age-related, environmental and social influences begin to play. The modification of psychopath-like manifestations that occurs in the process of post-processual development is not limited to the distortion and leveling of individual personality traits, but occurs according to the type of personality shift, accompanied by a total restructuring of characterological properties. In extreme, complete variants, the formation of something different occurs. albeit largely flawed, of the “new personality” type [Sabler V.F., 1858]. Variants of post-processual development are known (asthenic, hysterical, hypochondriacal, hyperthymic, development with the formation of overvalued ideas).

In terms of the dynamics of the actual pathocharacterological manifestations and, accordingly, the mode of adaptation in residual schizophrenia, two variants of post-process development (autistic, psychasthenic), representing the extreme poles of a wide range of personal changes, appear most clearly.

Autistic development- autistic type of remission (according to G.V. Zenevich, 1964) - is characterized by impaired contact with reality, a gradual departure from the usual environment, a detached attitude towards the past and reconciliation with one’s new situation. The worldview that is formed in these cases (ideas of spiritual self-improvement, detachment from “vanity matters”), as well as autistic hobbies correspond to the mental™ of “idealists alien to the world” [Kretschmer E., 1930; Maksimov V.I., 1987] and define a new approach to reality. Patients live as hermits, unsociable eccentrics, strive to work in isolation from the team, do not participate in social events, interrupt previous acquaintances, regard the help offered to them as attempts to interfere in their affairs, show complete indifference to the fate of relatives, and distance themselves from loved ones. One of the variants of autistic development includes changes of the “second life” type [Yastrebov V. C., 1977; Vie J., 1939] with a radical break with the entire system of premorbid social, professional and family ties, a change in occupation, and the formation of a new family.

At psychasthenic development- psychasthenic type of remission (according to V.M. Morozov, R.A. Nadzharov, 1956) growing indecision, self-doubt, an emerging consciousness of helplessness and the need to rely on others come to the fore. V.I. Maksimov (1987), G. E. Vaillant, J. Ch. Perry (1980) designated such states as residual according to the type of dependent personalities. Doubts arising for any reason, loss of initiative, and the need for constant encouragement to activity prevent patients from living independently; in everyday life they are passive, subordinate, in the position of “adult children”, obediently carrying out assigned tasks and giving relatives the right to solve all pressing problems. In production conditions, they are lost even with minor deviations from the usual sequence of labor processes. Patients strive to avoid conflict situations, do not dare to contradict others, protect themselves from new acquaintances, unusual, exciting impressions; Fearing liability, they limit their work activities to performing simple operations. In non-standard situations, a passive position with avoiding behavior and refusal reactions also dominates.

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Chapter 22. Dementias, defects, remissions and prognosis in schizophrenia

In conclusion of the part of the summary that is devoted to the textbook clinical psychopathology of schizophrenia, I would like to define the concepts of “dementia” and “defect” in this disease. In other words, we will mainly talk about conditions (syndromes) that are considered “final polymorphic”. Among other things, it is necessary to weigh the reality of prognostic assessments of a process disease.

Dementia (Latin de - denial of something and mentis - reason) - this concept refers to forms of acquired persistent dementia. Calling congenital types of dementia, for example, mental retardation, “dementia” is considered incorrect. Another cardinal characteristic of dementia is its persistent nature, i.e. lack of any dynamics.

These conceptual rules also apply to the term “dementia.” In this sense, the use of the phrase “partially reversible dementia” by the St. Petersburg school of psychiatrists, used to designate certain types of deficit-dynamic states in organic psychoses (P.G. Smetannikov), seems unsuccessful.

For all types of dementia with a “reversible” character, it is preferable to use the concept of “pseudo-dementia” or “stupidity” (English: stupidity). For example, “insulin stupor” is a transient condition with a touch of intellectual defect of varying depth after a course of insulin-shock therapy.

As stated, one of the main characteristics of dementia or dementia states is the absence of any dynamics. Therefore, the concept of “moderate” dementia (dementia) with its supposed transition to “sharply expressed” can also be considered unsuccessful, although well-established and acceptable. The same considerations apply to the concept of “partial” (but not “lacunar”) dementia in connection with the possible prospect of its “total” variant.

Schizophrenic dementia is characterized by the St. Petersburg school of “symptomologists” as “partial-dissociative” due to the loss of internal unity of mental activity, i.e. interactions between mental, emotional and volitional processes with relative preservation of memory and intelligence. Typical symptoms here are ataxic speech confusion (incoherence), sensory dullness with features of inadequacy and loss of the ability for purposeful activity, with its predominance in a perverted form (abulia with parabulia). Formally preserved mnestic and some intellectual functions do not relieve the patient of passivity and helplessness.

“Syndromologists” identify four variants of the initial conditions with schizophrenic dementia:

Apatoabulic option– with a predominance of passivity, deep apathy, lack of will until the decline of instinctive activity.

Dementia c speech confusion: speech in the form of a meaningless set of words, phrases and sentences (while maintaining the grammatical structure). It contains neologisms, fragmentary hallucinatory experiences of a fantastic or mundane nature, as well as unsystematic delusional ideas, without clear tendencies towards their implementation. Patients are mostly apathetic and passive. But periodically they develop states of psychomotor agitation with anger, and less often with aggressiveness.

Pseudo-organic option dementia: patients are in a complacent mood, or they are foolish. Sometimes patients are hyperexcitable and aggressive. Instinctive activity may increase - gluttony, masturbation, active homosexual behavior. Speech is spontaneous, on abstract topics, with slippage and neologisms. Patients are usually unable to provide any information about themselves. They are disinhibited and impulsive. Variants with secondary microcatatonia in the form of stereotypical motor skills and perseverative muttering are observed.

Option c complete ruining psyche: there is total emotional emptiness, complete inactivity. Perversion of instinctive activity may be observed - patients eat excrement, scratch their skin, tear their clothes, etc. Speech in the form of a meaningless set of words (okroshka). Characterized by secondary catatonia in the form of pretentious movements, stilting, grimacing and mild excitement with stereotypies.

While there are more or less adequate definitions for the term “dementia,” there is much more confusion around the concept of “defect.”

Since the time of E. Kraepelin, the idea of four possible outcomes of psychotic states has been established. These are 1) recovery (intermission), 2) weakening (remission), 3) irreversible initial state (dementia) and 4) death.

Three options, 1st, 3rd and 4th, do not require comments. As for the 2nd option - the result of the outcome, weakening or cessation of a psychotic state - here the concepts of “remission” and “defect” are largely identical.

Defect (from Latin defectus - flaw, deficiency) means mental, primarily personal, loss that occurred due to psychosis.

So, dementia and defect arise as a result of the outcome of one or more psychoses. With a continuous process (continuous-psychoproductive and progressive-deficient), the result of the disease is dementia (although in these cases weakening of the process is often observed). But still, defects should be discussed when there is a definite slowdown in the process, or when it stops (remission), which has not reached the initial stages of the disease.

To summarize what has been said, I note that the main characteristic of the defect and its main difference from dementia is that, firstly, it is linked to remission and secondly, it is dynamic.

The second circumstance, i.e. The dynamics of the defect consists either in its increase (progression) or in its weakening (the formation of remission itself), up to compensation and reversibility.

“Positive” characteristics or quality criteria for remission are as follows:

1) Reduction of psychotic symptoms.

2) Relative stabilization of the process.

3) Promotion of protective compensatory mechanisms.

4) Increasing the level of social adaptation of the patient.

In turn, the “negative” characteristics of the defect and the quality of remission are as follows:

1) Severe disorders of the emotional-volitional sphere (apato-abulia, sensory dullness).

2) Thinking disorders (“combination of the incongruous” in logic, reasoning, as well as reasoning).

3) Personal changes, decreased level of mental functioning and adaptation (asthenization, emotional lability, fragility and vulnerability with desocialization).

4) Weakening of the level of critical abilities (intelligence), incl. criticism of the disease and one’s condition.

Thus, the sum of qualitative criteria that favor the formation of a new personality or that impede this (more precisely, their ratio) determines the nature of remission or defect in schizophrenia.

In terms of qualifying the severity of the consequences of psychosis and the possibilities of treatment (compensation) for these consequences, the negative characteristics of the schizophrenic defect (or remission) are of primary importance. In this regard, the following options are highlighted:

Apatoabulic (emotional-volitional) defect. The most common type of defect. It is characterized by emotional impoverishment, sensory dullness, loss of interest in the environment and the need for communication, indifference to what is happening up to one’s own fate, the desire for self-isolation, loss of ability to work and a sharp decline in social status.

Asthenic defect. A type of post-processual patients in whom mental asthenia dominates (vulnerability, sensitivity, “exhaustion” without objective signs of exhaustion, reflection, subordination). These patients are dependent individuals, insecure, trying to be close to relatives (with elements of intra-family tyranny). They are distrustful and suspicious of strangers. In their lives they adhere to gentle regimes. Their ability to work is sharply reduced.

Neurosis-like option defect. Against the background of emotional dullness, mild thinking disorders and shallow intellectual decline, pictures and complaints corresponding to neurotic states prevail - senestopathies, obsessions, hypochondriacal experiences, non-psychotic phobias and body dysmorphomania. Asthenic disorders are less pronounced, so patients strive to maintain their social status and maintain their ability to work. Hypochondriacal experiences sometimes acquire an overvalued character with litigiousness in relation to health workers and medical institutions.

Psychopathic defect. Against the backdrop of more dramatic negative changes in the emotional and intellectual spheres, a range of disorders are found that are inherent in almost all types of psychopathy with corresponding behavioral disorders: excitable, hysteroform, unstable, mosaic and, separately, with pronounced “schizoidization” - grotesque and caricatured mannerisms, extravagantly dressed , but completely uncritical of their behavior and appearance.

Pseudoorganic (paraorganic) defect. This type resembles an excitable psychopath-like type, but the disorders are combined with difficulties in memory and thinking (bradypsychia). The main thing is the signs of instinctive disinhibition: hypersexuality, nudity, cynicism, mori-likeness (Greek moria - stupidity) or a “frontal” touch - euphoria, carelessness, mild motor excitement and complete ignorance of the surrounding situation.

Hypersthenic option defect. The type is characterized by the appearance, after suffering psychosis (fur coat), of previously unusual features - punctuality, strict regulation of the regime, nutrition, work and rest, excessive correctness and hypersociality. When a touch of hypomania is included in the personal characteristics, social activity can take on a “turbulent” character: patients willingly speak at meetings, control the administration, organize circles, easily become involved in religious sects, etc. They study foreign languages, martial arts, and join political organizations. Sometimes new talents appear, and patients go into the world of art, bohemia, etc. Such a case took place in the biography of the artist Paul Gauguin, who became the prototype of the hero of Somerset Maugham’s novel “The Moon and a Penny.” Similar conditions were described by J. Villet under the name “defect of the type of new life.”

Autistic option defect. With this type of defect, against the background of emotional insufficiency, typical changes in thinking are noted with the appearance of unusual interests: “metaphysical” intoxication, unusual pseudo-intellectual hobbies, pretentious gathering and collecting. Sometimes these disorders are accompanied by a “departure” into fantasy worlds with a separation from reality. The subjective world begins to dominate, it becomes more “real”. Patients are characterized by highly valuable creativity, invention, projectism, “activity for the sake of activity.” Unusual abilities may appear (quite early), for example, mathematical ones (Raymond from the wonderful film “Rain Man”). This kind of defect is difficult to distinguish from constitutional autistic abnormalities that arise in childhood and adolescence (Asperger's syndrome). Their appearance is largely compensatory due to the painful predominance of formal-logical thinking over emotional (sensual).

Defect c monotonous hyperactivity. In each psychiatric hospital (department) there are 1 – 2 patients with signs of pronounced emotional impoverishment and intellectual decline, who silently and monotonously, “machine-like” perform a limited range of household work: washing floors, sweeping the yard, cleaning sewers, etc. These patients are always an example of “successful” labor rehabilitation in primitive industries, agricultural work and in medical workshops. They are jealous of their responsibilities, do not entrust them to anyone and conscientiously perform them until the next hallucinatory-delusional or affective-delusional attack of the disease.

Other variants of defects are echoes of persisting residual (residual) and irrelevant psychotic products. Accordingly this is:

Hallucinatory defect with irrelevant hallucinatory experiences, a critical attitude towards them, situational dissimulation, and

Paranoid type defect– reduced paranoid syndrome with encapsulated irrelevant delusions and (contrary to the previous one) the absence of critical assessments of the disease (which, however, does not prevent the patient from performing social functions and maintaining external well-being).

Predictions of the schizophrenic process are rightly considered to be the most thankless part of the psychopathology of the disease. None of them are reliable, which requires very careful promises and recommendations. One should be “philosophical” about “farewells” to patients and relatives of patients in cases of successful relief of acute conditions, because The first episodes of the disease do not always end in its natural remission. You need to be prepared for wishes for a longer treatment “for the second time.” And once again - to the request the most loved ones relatives(with all the “conspiracy”) about the “lethal” injection...

If we talk about the problem in all seriousness, then the connection between external favorable factors and prosperous prognosis of schizophrenic illness relative and is more desirable than mandatory. (Despite the fact that negative factors often provoke relapses of the disease, i.e. they should be avoided). However, micro- and macrosocial stressors are life itself. And schizophrenic patients come into contact with it more often than they remain in isolation. Therefore, prognostic signs and predicates of an unfavorable course of schizophrenia are the following: early onset (before 20 years); hereditary burden of all endogenies; characterological features (closedness and abstract type of thinking); asthenic or dysplastic physique; lack of family and profession; slow, causeless onset and non-remission course of the disease two years after the debut.

In addition, the prognosis of schizophrenia must take into account:

1) in 10–12% of patients it is observed only one attack illness followed by recovery;

2) in 50% of patients there is recurrent flow with frequent exacerbations;

3) 25% of patients need to take medications V flow all life;