Continuously ongoing and paroxysmal-progressive schizophrenia. Moderately progressive schizophrenia Schizophrenia paroxysmal progressive course

Paroxysmal-progressive schizophrenia

Continuous schizophrenia

Malignant,

Progressive (delusional variant, hallucinatory variant),

Low-progressive (sluggish),

Malignant

Progressive (schizoaffective)

Low-progressive (sluggish)

Continuous schizophrenia is characterized by a non-remission course, while malignant (nuclear) forms (simple, catatonic, hebephrenic and juvenile paranoid) are accompanied by the rapid development of apathetic dementia; The continuous paranoid form of schizophrenia, which begins in adulthood, has a lower progression (the degree of increase in negative symptoms). The most favorable in relation to the increase in schizophrenic personality changes is sluggish schizophrenia.

Paroxysmal-progressive (fur-like)

schizophrenia is characterized by a continuous, sluggish course, against the background of which acute affective, affective-delusional and delusional attacks develop, after each of which schizophrenic personality changes deepen and at the same time a relatively high level of work ability is maintained for a long time. In this variant, the disease occurs with remissions—the complete disappearance or weakening of productive psychopathological symptoms.

Recurrent (periodic) flow– the most favorable variant of schizophrenia, in which, after acute affective or affective-delusional attacks, remissions of good quality occur, with the complete disappearance of productive (psychopathological) symptoms and a slight change in personality.

As already mentioned, the division of schizophrenia into forms is quite arbitrary, because in the course of the disease some syndromes can be replaced by others and, thus, one form can be transformed into another. Schizophrenia is characterized by a certain dynamics of changing syndromes.

The simple form refers to the so-called nuclear, or malignant, schizophrenia. Beginning gradually at puberty or adolescence, the process then takes on a continuous course and relatively quickly leads to a schizophrenic defect. With this form, it is often not possible to establish the exact timing of the onset of the disease. A teenager or young man gradually becomes lethargic, loses his previous interests, leaves school, and stops communicating with friends. There is a decrease in his mental activity, and rudeness towards loved ones appears. The patient, who previously had a warm and caring attitude towards his mother and father, begins to reproach them for their bad attitude towards him, reacts with irritation to any comments from his relatives or manifestations of concern for him, even to the point of aggression, becomes completely indifferent to the events happening around him (in the family , school), cold, selfish.

During this period, a teenager may leave home, wander aimlessly through the streets, sometimes fall into bad company, start smoking, and abuse alcohol. The picture of the disease may resemble an exaggerated pubertal crisis, but the severity and deepening of personality changes make one suspect the beginning of the process. At the same time, the patient may develop interests that were not previously characteristic of him. Having no stock of knowledge, he begins to deal with various complex issues, for example, philosophical problems, questions of the origin of the Universe, complex problems of astronomy (the so-called “metaphysical intoxication”). He develops a tendency to reasoning, endless empty introspection, and influxes and interruptions of thoughts arise. Unstable auditory hallucinations, fragmentary delusional ideas of relationship, persecution, and hypochondriacal experiences may occur. Emotional and volitional disorders are becoming increasingly apparent.

Patients completely stop doing anything, can lie in bed all day long, covering their heads with a blanket, become sloppy, do not wash, and stop caring for themselves. With relative preservation of formal abilities, such patients often become deeply disabled due to pronounced emotional-volitional disorders and peculiar thinking disorders (schizophrenic or apathetic dementia). In some cases, the defect grows more slowly, and there is no deep disintegration of the psyche.

Hebephrenic form also refers to unfavorable juvenile nuclear schizophrenia, has a continuously progressive course and relatively quickly leads to dementia. It can start in the same way as a simple form. At the same time, the leading factors in the clinical picture, along with personality changes, are absurdity of behavior and statements, a tendency to grimace, and foolishness. Sometimes the mood is dominated by empty, unproductive euphoria, but anger and anger may also predominate. Periodically, attacks of motor agitation may occur, accompanied by speech incoherence, shouting of neologisms, antics, inappropriate laughter, somersaults, a sudden attack on others, throwing objects, and the desire to tear clothes. Such patients cynically curse, dance, spin around in place, destroy everything that comes to hand, and reveal negativistic tendencies. The disease often leads to an increase in apathetic dementia.

Example. Patient T., 33 years old. Heredity is burdened. Early development is correct. I studied well at school. From the age of 19, he began to exhibit strange behavior: he grimaced, shouted out individual words, laughed inappropriately, at home he jumped up and down in one place, strangely tilted his body forward, walked barefoot, sometimes walked sideways, hiding his face. While eating he made strange sounds, spat, his movements were impetuous, he suddenly jumped up and told his mother that he had to run. At times he refused to eat, was aggressive towards his mother, and did not take food from her. Sometimes he listened to something, smiled, and answered something. He was admitted to a psychiatric hospital. Behavior was characterized by features of foolishness, mannerisms, grimacing, and sometimes impulsiveness. He could lie in bed for hours, was unkempt, masturbated in front of the staff, grimaced, laughed inappropriately, sang loudly, stuck out his tongue, gesticulated, suddenly jumped out of bed, rushed to the window, and then lay down again.

Catatonic form As a rule, it begins somewhat later than the previous two, at the age of 20-25 years. It has a continuously progressive course and an unfavorable outcome. The onset may be gradual or acute. With an acute onset, in the midst of complete health, catatonic agitation or a stuporous state may develop, which are leading in the clinical picture. In the catatonic form of schizophrenia, lucid catatonia occurs (against the background of clear consciousness). This is very important to take into account, since the combination of catatonic syndrome with oneiric (catatonic-oneiric attack) indicates a favorable course of schizophrenia (periodic). Catatonic symptoms can join the process that occurs with paranoid experiences (secondary catatonia), in these cases it indicates a worsening of the disease. The catatonic form usually ends in apathetic dementia.

The paranoid form most often begins in adulthood, but can also occur in adolescence. The prevailing symptoms are various delusional ideas that develop acutely or gradually. The most common are various delusional ideas of persecution (delusions of relationship, poisoning, special meaning, influence, persecution itself), but delusions can also have other contents (delusions of invention, jealousy, high origin, love, hypochondriacal, physical disability). Delirium is often accompanied by various hallucinations, most often auditory. In the paranoid form, Kandinsky-Clerambault syndrome often develops. With a long course of the disease, the appearance of paraphrenic syndrome is quite typical.

Patient 0., 34 years old. The father suffers from schizophrenia. He grew and developed correctly. He was moderately sociable and active. I went to school at the age of seven. I studied well. Oddities in behavior were noted for the first time. When analyzing the history of the disease, you should pay attention to the fact that the patient comes from a hereditarily burdened family. The disease began gradually in adolescence with an increase in negative disorders, later, against the background of depression, the paranoid Kandinsky Clerambault syndrome formed, in addition, ideas of greatness took place. We are talking about a juvenile paranoid form of schizophrenia, which has a malignant course, with a steady increase in schizophrenic personality changes.

Circular shape along with catatonic-oneiroid, it refers to recurrent (periodic) schizophrenia. The disease in such cases proceeds paroxysmally, personality changes characteristic of schizophrenia increase relatively slowly, patients have a fairly high level of social and labor adaptation, attacks are depressive or manic in nature. This form of schizophrenia should not be confused with manic-depressive psychosis. The main differential criterion is the nature of the interictal period. If with manic-depressive psychosis a person is practically healthy in the interictal periods, then with schizophrenia, after each attack, the personality changes characteristic of this disease deepen.

Special forms of schizophrenia include febrile, or hypertoxic, form. In these cases, the disease begins quite acutely, the clinical picture is characterized by a catatonic-oneiric state, and sharp psychomotor agitation with delirium, hallucinations, and fear is accompanied by severe intoxication, a significant increase in temperature, and somatic disorders. Before neuroleptics became widely used to treat schizophrenia, such conditions were often fatal (fatal catatonia). Usually, after relief of the acute condition, a stable, good-quality remission occurs, and patients are kept alive.

In recent years (which is apparently due to the widespread use of neuroleptics in psychiatric practice), the clinical picture of schizophrenia has often become blurred; we often encounter so-called sluggish, slow-flowing forms. Despite the continuity of the flow, the defect grows rather slowly. Such patients are usually treated differentially, taking into account the characteristics of the clinic and the course of the disease. Today, psychopharmacotherapy is most actively used, in particular drugs such as chlorpromazine (chlorpromazine), on average up to 300-600 mg per day; nozinane (levomepromazine, tizercin), 150-200 mg; stelazine (triftazine), 50-70 mg per day; mazeptil, 50-70 mg per day; haloperidol, 10-17 am outpatient and require constant attention. In these forms of the disease, the clinical picture is dominated by neurosis-like, psychopathic-like or paranoid disorders, and affective instability. The dosage of antipsychotics and the duration of treatment depend on the patient's condition. After a course of treatment, it is recommended to carry out long-term maintenance therapy (small doses of the same drug) necessary to consolidate remission and prevent exacerbation of the process. Maintenance therapy (as well as primary therapy) should be carried out by monitoring the composition of the blood and urine. If it worsens, you can slightly increase the dose of the medicine, and if there is a long-term good remission, you can reduce it. To avoid the development of neuroleptic syndrome during psychopharmacotherapy, “correctors” are prescribed - antiparkinsonian drugs: cyclodol, akinetone, triphen, tremblex. In some cases, other methods of active therapy are indicated - insulin, electroconvulsive therapy, pyrotherapy. Insulin therapy is indicated for acute psychotic states and in the absence of pronounced personality changes. There are a number of contraindications associated with somatic problems (endocrine pathology, severe diseases of parenchymal organs, the cardiovascular system, cancer). Before starting insulin therapy, it is extremely important to give the patient a sugar load (normally, within two hours the amount of sugar in the blood returns to its original value). Insulin is administered on an empty stomach. Starting with 4 units and increasing the daily dose by 2-4 units, they reach a certain dose that can cause a coma within three hours (the so-called shock dose). The course of treatment consists of 25-30 hypoglycemic doses. The patient is kept in a comatose state for no more than 30 minutes, after which he is brought out of the coma with 20-30 ml of 40% glucose intravenously, then given a calorie-rich breakfast. If the patient is poorly fed, he may develop repeated shock (this often happens in the evening, at night; it is stopped in the usual way). A separate room is allocated for insulin therapy. It is important that the staff is well trained and knows the specifics of patient care and measures to combat complications. Repeating the course of insulin therapy is possible no earlier than six months later. The technique of intravenous drip administration of insulin has been introduced into clinical practice to limit the course of treatment to the rapid achievement of a hypoglycemic coma (almost from the first injection). If there are clinical indications and there are no contraindications from a somatic condition, electroconvulsive therapy can be performed. The main indication for the use of electroconvulsive therapy is prolonged depression. Treatment is carried out in a hospital, where the necessary emergency care can be provided. Bitemporally, electrodes are applied to the patient and a current of 80-120 V is passed with an exposure of 0.3-0.8 s, after which an epileptic seizure develops with complete amnesia of the existing condition. No more than 10 sessions are recommended per course. During the session, complications are possible in the form of fractures of tubular bones, vertebrae, dislocation of the lower jaw. In order to prevent side effects, muscle relaxants (distyline, listenone) are used. Along with drug therapy, it is extremely important to conduct psychotherapy and occupational therapy, which is an important link in the complex treatment of the schizophrenic process and helps to implement the social readaptation of the patient.

Fur-like schizophrenia is the most common among all forms of schizophrenia. The essence of the paroxysmal-progressive type of dynamics of schizophrenia lies in the combination of two variants of the course - continuous and periodic.

In the initial period, negative personality changes typical of schizophrenia appear and gradually progress, and in some cases, productive symptoms in the form of obsessions, depersonalization, overvalued or paranoid ideas. Next, manifest and subsequent attacks occur in the form of transient, qualitatively new disorders in relation to the permanent symptoms.

Attacks of fur coat-like schizophrenia are distinguished by particular clinical diversity. There are acute paranoid, acute paranoid, catatonic-hebephrenic, catatonic-depressive, depressive-hallucinatory, depressive-obsessive and other attacks. Each attack is accompanied by a personality shift, a deepening of negative personality changes and an increase in permanent productive impairments.

In some patients with fur-like schizophrenia, negative personality changes and chronic productive disorders progress slowly and in the intervals between attacks.

The degree of progression of fur coat-like schizophrenia and the depth of the developing mental defect vary significantly. In some cases, fur coat-like schizophrenia is close to a malignant form and ultimately ends in a final state (schizophrenic dementia), in others, due to the low severity of progressive tendencies, it is close to sluggish schizophrenia and leads to a shallow personality defect. Most cases of fur coat schizophrenia fall somewhere between these extremes.

Special forms of schizophrenia. The essence of paranoid schizophrenia lies in the emergence and long-term existence of systematized delusions. In some patients, delirium develops acutely - like an insight, in others gradually - on the basis of previous highly valuable ideas. The clinical manifestations of paranoid schizophrenia have significant similarities with the paranoid stage of paranoid schizophrenia described above.

The difference is that with paranoid schizophrenia, the picture of the disease throughout its entire duration is limited to systematized delusions. There is no transition from paranoid to paranoid syndrome.

Paranoid schizophrenia is manifested by delusions of persecution, physical disability, hypochondriacal, inventive, reformist, religious, litigious delusions. In many patients, delirium is monothematic.

Pathological ideas progress extremely slowly. After decades, the delusion may undergo a partial reverse development, remaining in the form of residual or encapsulated (largely lost relevance) delusional ideas. Negative personality changes typical of schizophrenia cannot always be identified.

Febrile schizophrenia (fatal catatonia, hypertoxic schizophrenia) is called acute attacks of oneiric catatonia within the framework of recurrent and paroxysmal-progressive schizophrenia, accompanied by hyperthermia and other somatic disorders. Along with catatonia in the form of stupor or agitation, rises in body temperature up to 38–40 °C occur for up to 2 weeks. The temperature curve does not correspond to typical temperature fluctuations in somatic and infectious diseases. Dry mucous membranes, skin hyperemia, bruising, sometimes bullous rashes, and ulceration of the skin are noted.

In the most severe cases, at the height of the attack, oneiric stupefaction is replaced by amentia-like with deep disorientation, incoherent speech and monotonous motor excitation, limited to the bed. The appearance of choreiform hyperkinesis is possible.

Remission usually occurs after a few weeks. In rare cases, death can occur. Sometimes the patient suffers several attacks of febrile schizophrenia.

Treatment and rehabilitation. In the treatment of patients with schizophrenia, almost all methods of biological therapy and most methods of psychotherapy are used.

Biological therapy. The leading place in the biological treatment of schizophrenia belongs to psychopharmacotherapy. The main classes of psychotropic drugs used are antipsychotics and antidepressants. Drugs of other classes are used less frequently.

For malignant schizophrenia, high doses of the most powerful antipsychotics with a general antipsychotic effect are prescribed in order to stop the progression of the disease and mitigate its manifestations. However, therapy, as a rule, is not effective enough.

For paranoid schizophrenia, neuroleptic antipsychotics (haloperidol, triftazine, rispolept, azaleptin, fluanxol) are used. After improvement of the condition and partial reduction of hallucinatory-delusional disorders, long-term (usually many years) maintenance therapy is carried out, often with the same drugs, but in smaller doses. Injection depot forms of antipsychotics (haloperidol decanoate, moditen-depot, fluanxol-depot) are often used. In the first 2 years after the development of hallucinatory-paranoid disorders, insulin comatose therapy is possible (with the consent of the patient or his relatives). Paranoid syndrome and chronic verbal hallucinosis are particularly resistant to therapy.

Long-term use of antipsychotics often leads to patient intolerance to the drugs, mainly in the form of neurological side effects and complications (neurolepsy, tardive dyskinesia). In these cases, antipsychotics should be used that do not cause or almost do not cause side neurological effects (Leponex, Rispolept, Zyprexa).

In recurrent and paroxysmal-progressive schizophrenia, the choice of drugs is determined by the syndromic structure of the attacks. Patients with depressive attacks are prescribed the most active antidepressants (amitriptyline, melipramine, anafranil), which are usually combined with low doses of antipsychotics that do not have a depressogenic effect (triftazine, etaprazine, rispolept).

In patients with depressive-paranoid conditions, the same combination of drugs is used, but the doses of antipsychotics should be significant or high. If the above antidepressants are ineffective, Zoloft, Paxil or other thymoanaleptics from the group of selective serotonin reuptake inhibitors can be prescribed. Manic episodes are most often treated with haloperidol in combination with hydroxybutyrate or lithium carbonate. The same drugs are used in patients with manic-delusional states. For oneiric catatonia, antipsychotics with an inhibitory effect are prescribed. If antipsychotics are ineffective, electroconvulsive therapy is indicated.

In patients with psychomotor agitation, injectable neuroleptics with inhibitory properties (clopixol-acufaz, aminazine, tizercin, haloperidol, topral) are used in the structure of various attacks.

Treatment of febrile schizophrenia is carried out in intensive care units whenever possible. Active detoxification is used, including hemosorption, hemodez, as well as symptomatic therapy and sometimes chlorpromazine. In cases of particularly severe condition (according to vital indications), ECT is performed.

In interictal intervals, outpatient therapy is carried out to stabilize remission and prevent new attacks. Often the same drugs are used as during attacks, but in smaller doses. When the proportion of affective disorders in the structure of attacks is high, mood stabilizers (lithium carbonate, finlepsin, sodium valproate) are prescribed for a long time.

Drug treatment of sluggish schizophrenia is carried out with a combination of small or medium doses of antipsychotics or neuroleptics with a milder effect (Sonapax, neuleptil) and antidepressants.

In many cases, tranquilizers are also prescribed. For sluggish schizophrenia with a predominance of phobias and obsessions, tranquilizers are prescribed - sedatives (alprazolam, phenazepam, lorazepam, relanium), high doses of antidepressants and moderate doses of antipsychotics.

Psychotherapy. Psychotherapy occupies an essential place in the treatment of patients with schizophrenia.

In the presence of severe psychotic symptoms (paranoid schizophrenia, psychotic attacks of recurrent and fur-like schizophrenia), patients need the participation, encouragement, and support of a doctor. Demonstration of a skeptical attitude towards delusional judgments and attempts to refute them are unproductive and only lead to disruption of contact between the doctor and the patient. Explanations of what statements and forms of behavior of the patient are assessed by others as painful are justified. Family psychotherapy is useful (psychotherapeutic work with the patient’s relatives, aimed at developing the correct attitude towards his painful statements and behavior, at eliminating intra-family conflicts that often arise as a result of painfully changed behavior of a family member).

For non-psychotic levels of disorders (remission of paroxysmal schizophrenia, sluggish schizophrenia), systematic psychotherapy, mainly rational (cognitive) and behavioral, is indicated.

Techniques of stimulating and distracting psychotherapy are used. Special techniques are used aimed at eliminating certain disorders, for example, functional training for transport phobias.

Methods such as hypnosuggestive psychotherapy, autogenic training, and psychoanalytic psychotherapy are used in patients with schizophrenia to a limited extent due to the risk of worsening the patient’s condition and low effectiveness.

Social rehabilitation is indicated for almost all patients with schizophrenia (the exception is patients with preserved ability to work and sufficient social adaptation).

Even with chronic psychotic symptoms, a deep personality defect with complete disability, the systematic use of social rehabilitation measures in combination with pharmacotherapy and psychotherapy allows a number of patients to partially restore basic self-care skills and involve patients in simple work activities.

In such cases, the process of social rehabilitation is multi-stage in nature. It often begins during the hospitalization period with the involvement of patients in performing simple household tasks.

Next, patients systematically perform simple work in the department, and then in occupational therapy workshops at the hospital. After discharge from the hospital, they continue to work in occupational therapy workshops, moving on to increasingly complex operations.

With a successful rehabilitation process, it is possible to return to work that does not require high qualifications, in special enterprises for the mentally ill, or even in general production conditions. To do this, patients have to be taught new work skills that are accessible to their mental state.

In cases of sluggish schizophrenia, recurrent schizophrenia with rare attacks, properly organized social rehabilitation in combination with treatment often makes it possible to maintain or restore pre-morbid professional, family and social status.

Its only option is paranoid or paranoid schizophrenia. The disease is characterized by:

continuously progressive course. During the course of the disease, periods of both exacerbation (exacerbation) and relative mitigation of existing symptoms may occur, which, however, are neither attacks and relapses, nor remissions, since the painful structure does not change significantly;

the beginning of the active period, i.e., the appearance of manifest and typical manifestations of the disease, most often refers to the age of 30–35 years;

the active period of the disease is usually preceded by a long initial period, lasting up to 10 years or more, during which personality disorders and psychopathic behavior, obsessive phenomena, disorders of self-perception, senesto-hypochondriacal disorders, fragmentary deceptions of perception, unstable delusions, often in the form of delusions of attitude, are observed;

Among the productive disorders in the active period, delusions and hallucinations predominate. Its termination may be preceded by the appearance of symptoms of secondary catatonia;

Depending on the predominance of delusional or hallucinatory disorders, it is customary to distinguish between delusional and hallucinatory variants of paranoid schizophrenia. The delusional version of paranoid schizophrenia in typical cases occurs in several stages: the paranoid stage with its characteristic systematized delusions of interpretation of various contents; the paranoid stage, when delusional ideas of influencing the patient and/or the patient’s influence on others come to the fore; paraphrenic stage with expansive or depressive delusional ideas of fantastic content. The duration of each stage is quite uncertain; each of them can last for years, up to 10 years or more.

Apparently, the hallucinatory variant of paranoid schizophrenia is somewhat less favorable. It also occurs in three stages: hallucinatory with a predominance of the phenomena of verbal hallucinosis; paranoid with dominance in the clinical structure of pseudohallucinations, mainly verbal; and paraphrenic, when the content of pseudohallucinations takes on a fantastic character. Hallucinations and pseudohallucinations are accompanied by delusions of the corresponding content. The duration of each stage can reach a number of years, but in general the change of stages occurs more quickly than with the paranoid variant;

Deficiency disorders, noticeable already in the initial period, increase in the active stage of the disease. The degree of their severity, however, may vary in different patients, from moderate to very pronounced. If the deficiency symptoms are relatively smoothed out, and the duration of any of the stages of the active period is sufficiently long, then each of the stages of the delusional and hallucinatory forms of progressive schizophrenia could qualify as an independent painful form. This is especially true for the delusional version of paranoid schizophrenia. Previously, as is known, some researchers considered paranoia and paraphrenia as independent diseases; ICD-10 distinguishes “chronic delusional disorders”;

in the residual stage of paranoid schizophrenia, the main symptoms are fragmented thinking and schizophasia. In relatively coherent fragments of speech, delusional and hallucinatory disorders that were relevant in the past may be heard.

Paranoid schizophrenia with delusional disorder in ICD-10 is coded G20.00 + G22.0; paranoid schizophrenia with chronic delusional disorder - G20.00 + G22; paranoid schizophrenia, hallucinatory variant - G20.00 + G28; the final state is G20.54, as well as G20.5 (adapted version of ICD-10).

In the treatment of progressive schizophrenia, neuroleptics with antipsychotic action are mainly used in high doses (mazeptil, haloperidol, stelazine, azaleptin, rispolept, Zyprex) and often in different combinations, long-acting antipsychotics (haloperidol-decanoate, moditene-depot, clopixol-depot, fluanxol -depot). If the prescribed course of therapy does not lead to improvement within one and a half months, it should be replaced by another.

In cases of resistance to therapy, tests show very low concentrations of drugs in plasma. To overcome resistance to treatment, in addition to changing medications, lithium drugs, anaprilin, benzodiazepines, carbamazepine, electric shocks, insulin shocks, sulfosine therapy, as well as immunomodulators, in particular levomisol (150 mg in two doses for one and a half months), can be used. “Therapy of desperation” is a megadose of antipsychotics, fraught with complications (9–10 times higher than usual daily doses), followed by a break in treatment (“zigzag method”). Prescription of nootropics and neurolepsy correctors is mandatory. In cases of severe neurolepsy, hemosorption and plasmapheresis methods are used. After achieving therapeutic remission, you should move on to maintenance and anti-relapse therapy; The most effective way to do this is to use long-acting drugs. Early detection and initiation of therapy is very important. Psychotherapeutic methods do not produce a noticeable effect.

Paroxysmal-progressive (fur-like) schizophrenia

There are three forms: malignant, paranoid or progressive and schizoaffective.

1. Malignant fur coat-like schizophrenia. According to its clinical structure, it borders on manifestations of malignant juvenile schizophrenia. Making this distinction is quite difficult in some cases. It manifests itself in attacks with severe symptoms and duration of up to a year or more, as well as relatively short inter-attack intervals, in which a rapid accumulation of deficiency symptoms is revealed and very serious productive symptoms persist, albeit in a rudimentary form.

In the initial period, against the background of atypical hypomanic and subdepressive states with psychopathic symptoms, undeveloped productive disorders of almost the entire spectrum, including catatonic ones, are observed. Significant deficit disorders are also detected, primarily impoverishment of emotions and decreased activity. The duration of this period is 2–2.5 years.

The active period of the disease is characterized by manifest attacks with extremely polymorphic (from senestopathy to catatonia), changeable and usually undeveloped productive symptoms; however, persistent dominance of catatonia, usually substupor, is possible. The active period consists of several attacks (up to 3–4), the first of which usually occurs at the age of 12–14 years.

In the residual period of the disease, a gross schizophrenic defect is revealed. Nevertheless, patients retain the ability to perform simple labor operations and, with outside help, adapt to life in society. The consequences of the disease are not always so fatal. A.S. Tiganov testifies that “persistent and long-term remissions with varying degrees of personality changes” occur.

In ICD-10 it is coded with the following codes: 20.21 + 20.11 (catatonic and hebephrenic symptoms predominate); 20.01 (paranoid symptoms predominate); 20.31 (polymorphic or “undifferentiated” symptoms are observed).

2. Fur-like paranoid schizophrenia Me or a paranoid variant of fur coat-like schizophrenia. It is distinguished by a variety of attacks, in which, however, delusions and hallucinations predominate, as well as wide variability in the quality of remissions after attacks and the severity of residual disorders in general; the duration of attacks ranges from several weeks to a number of months and even years; in the latter case, the picture of the disease approaches paranoid schizophrenia, and only the presence of distinct affective disorders can clarify the essence of the matter.

In the initial period of the disease, slowly increasing personality changes are observed (from the leveling of individual qualities to the actualization of previously hidden personality traits), emotional impoverishment, and decreased activity; against this background, atypical affective shifts with psychopathic behavior may occur, as well as paranoid structures with varying degrees of systematization. In other words, the appearance of erased affective-delusional disorders is possible already in the initial period. This circumstance complicates the determination of the duration of the initial period and the time of transition of the latter to the active stage of the disease.

The active period of the disease in typical cases is characterized by acute psychotic attacks with interpretive delusions and episodes of sensory delirium (delusional variant of the disease) or verbal hallucinosis (hallucinatory variant of the disease), attacks with delusional and hallucinatory variants of Kandinsky-Clerambault syndrome, as well as delusional and hallucinatory variants of acute paraphrenia . The sequence of development of attacks, if we keep in mind their clinical structure, is identical to the scenario of the dynamics of paranoid schizophrenia: in the first attack the paranoid syndrome or the syndrome of verbal hallucinosis dominates, in the second - the syndrome of mental automatism, in the third - the paraphrenic syndrome. Thus, there should be only three attacks in total.

Reality, however, does not always obey this theory. As for affective disorders, in the first attack, against the background of a somewhat depressed mood, a delusional mood predominates; in the second attack, depressive or manic disorders are clearly presented, in the third, paraphrenic, an elevated mood background predominates. The presence of an affective radical in this form of the disease poses the difficult task of distinguishing it from schizoaffective disorder (which currently exists in a hypothesis) and schizoaffective schizophrenia, designated in the current domestic nomenclature. A.S. Tiganov in the “Manual of Psychiatry” (1999) limits himself to only pointing out that schizoaffective schizophrenia manifests itself in attacks with depressive-delusional, depressive-catatonic, as well as manic-delusional and manic-catatonic symptoms, ultimately ending in “acquired” cyclothymia.

In the residual period of this form of the disease, incomplete remission or a stable defect of varying severity is observed with deficiency and, apparently, some residual productive disorders.

In addition to what is close to paranoid, there is, as A.S. Tiganov points out, also fur-like schizophrenia, “close to sluggish”, in this case, disorders associated with the continuous course of the process are represented by pathology of self-perception, hypochondria, senestopathies, and hysterical symptoms. The manifestation of the disease may be preceded by cyclothyme-like disorders. The attacks themselves are usually affective - more often they are depression than mania.

At the same time, the violations that existed before the attack recede into the background. If the affective radical in attacks is expressed in an erased form, aggravated interictal disorders come to the fore. Sometimes double affective attacks develop (depression, and then immediately mania or mania and immediately followed by depression). Cliché-type attacks occur, but they can also become more complicated with the development of sensory delirium. There can be one manifest attack, more often there are several attacks, the duration of which is months and, less often, years. After the end of the attacks, a residual period begins with persistent personality changes and residual neurosis-like symptoms.

To the problems of distinguishing fur coat-like schizophrenia from related painful forms (fur coat-like paranoid and schizoaffective schizophrenia, schizoaffective disorder) are added a number of others, no less important. This applies, for example, to the nature of fur coats. Thus, patients may experience attacks of oneiric catatonia, which are supposedly not characteristic of fur-like schizophrenia. If such attacks do not lead to further regression of the personality, they are not actually fur coats and, therefore, indicate a tendency towards the transition of fur coat-like schizophrenia to recurrent, in any case, they require some kind of meaningful assessment. Here, by the way, another problem is visible - the problem of the relationship between the clinical structure of attacks and interictal intervals.

Based on data about the latter, it turns out that it is impossible to predict whether there will be another attack, when it may occur and what disorders it will present. In the same way, based on the nature of the attack itself, it is very difficult to predict how long it can last, what consequences it will lead to, whether it will turn out to be the next or final episode. The pattern of attacks itself is fraught with many surprises, in which mutually exclusive disorders can be combined, for example, high spirits with delusions of grandeur coexist with painful senestopathies and hypochondriacal delusions. In one patient, it is as if two sick personalities coexist, or even three, if the patient outwardly behaves in a completely orderly manner and does not lose touch with reality.

The designation of such an attack as paraphrenic is clearly one-sided and in this sense not entirely accurate. It is not very clear which attacks are most characteristic of furious schizophrenia: those that are closer to continuous schizophrenia, or those that indicate similarities with recurrent schizophrenia? For now, we can definitely only talk about a continuum with two poles, filled with various kinds of transitional structures. Finally, with fur-like schizophrenia, febrile attacks can also occur, the time of onset of which is impossible to predict, just as it is impossible to foresee what awaits such a patient ahead.

Additional difficulties arise when coding fur coat-like schizophrenia according to ICD-10, where the disease is generally defined as schizophrenia, an episodic course with an increasing defect (G20.x1), but according to the codes it is presented as categorical, hebephrenic, paranoid schizophrenia, and other acute psychotic disorders , undifferentiated schizophrenia, then like other acute delusional psychotic disorders. If we add to this possible coding errors, then the statistics will actually turn out to be a fiction, which, however, is already quite often the case.

The diversity of the clinical structure of attacks and interictal intervals requires a careful, thoughtful, individualized approach to the treatment of patients. Let us limit ourselves here only to the fact that during treatment various tasks arise: relief of acute conditions, impact on psychotic symptoms, elimination of affective disorders, impact on neurosis-like symptoms, reduction of negative disorders, prevention of subsequent attacks, social rehabilitation in interictal intervals and in the residual period of the disease. Thus, a very wide range of psychotropic drugs is used in various combinations and with constant correction of treatment measures. Psychotherapy also becomes of great importance, especially in the intervals between attacks and in the residual period of the disease.

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Based on the clinical assessment of the initial stages of the disease, the main part of the paroxysmal processes remaining until old age was classified as a paroxysmal-progressive form of the disease (159 observations).
When assigning patients to the group under consideration, the following selection principles were observed: onset of the disease before the age of 40 years, age during the examination period over 60 years, and the course of the disease throughout its entire duration in the form of repeated defined attacks. Nevertheless, the clinical manifestations and course of the disease turned out to be very diverse in patients selected based on these characteristics. Significant differences were revealed, for example, in the severity of the formed defect and the dynamics of its development, in the frequency of attacks observed throughout the disease (from 2 to 40), in their distribution by age, as well as in the syndromic characteristics and clinical types of psychotic attacks. It turned out that all these clinical parameters of the paroxysmal-progressive course, each of which in itself reflects a certain aspect of the activity of the disease process, are not always combined with each other and correlate with each other. This property of paroxysmal schizophrenia did not allow us to analyze the patterns of its dynamics in one plane, which we could, for example, allow when interpreting the dynamics of continuously occurring forms as a cycle of successively developing and replacing each other stages. In accordance with the observed clinical facts, the path of separate analysis of the above parameters of the paroxysmal course and only a subsequent attempt at their integration and discussion turned out to be more adequate.
The main indicator of the progression of the schizophrenic process is, as is known, the degree of severity and dynamics of the deficit changes that form as a result of the disease. Such changes were detected quite clearly in remissions, but in the majority of patients in this group they reached only a moderate degree, despite the duration of the disease and the significant number of attacks suffered by many patients. Thus, with a general assessment of the progression of the disease, based on taking into account only the severity of deficiency symptoms, schizophrenia in the group of patients with an attack-like course of the disease should be regarded as a process with a relatively small progression. In patients with attacks that continued into old age, rather significant residual productive disorders were often observed in remission, the presence of which made it difficult to assess the true extent of the defect. In the period after the completion of the next attack, the majority of patients showed generally sufficient mental integrity and a satisfactory degree of adaptation to the demands of everyday life. The previous skills, previously characteristic forms of behavior and relationships with others that existed before the attack were restored, so the patients could fully integrate into their previous life.
Thus, an increase in the number of attacks in later life, as a rule, was not accompanied by a further deepening of negative symptoms.
Personality changes in these patients were characterized mainly by mildly expressed autism, rigidity of mental processes and emotional decline. Most of them showed a lack of desire to communicate with other people and a certain alienation even within the family. Some patients lived in old age completely alone. Their behavior was characterized by regularity, some monotony and a desire for strict regulation of the daily routine and activities. Consistency in observing strict restrictions, the monotony of a regime that spared their health, excessive seriousness in relation to little things with the dullness of emotional reactions, the lack of spontaneity and liveliness gave the patients’ behavior traits of curious pedantry. The majority of patients did not show signs of any significant decrease in mental activity, many of them retained limited or even full working capacity until retirement age and later. Some retained their previous interests (collecting, visiting theaters, exhibitions, etc.). Consciousness of the disease, as a rule, was preserved. The patients recalled their previous hospital stays with some reconciliation and at the same time spoke with satisfaction about their present life in old age, often showing optimism and making various plans for the future. Observed in remissions, especially at their beginning and in cases with frequent attacks, productive disorders were usually limited to affective and neurotic manifestations. Only occasionally was diffuse paranoia detected without the formation of persistent delusional disorders.
More pronounced personality changes in remission were found only in 1/5 of the total number of patients in this group: first of all, there were clear signs of a decrease in general mental activity with loss of motivation, slowness, a certain helplessness, limited interests, emotional dullness and traits of mental immaturity.
Often more severe (episodic) residual disorders were noted - paranoid, hallucinatory-paranoid and rudimentary catatonic.
In terms of the main question discussed here about the patterns of dynamics of paroxysmal-progressive schizophrenia, it is important to note the following. In a retrospective analysis of long periods of the course of paroxysmal-progressive schizophrenia, as in studies conducted by Bleuler (1911), G. Huber (1979), it was found that the appearance of the schizophrenic defect and its deepening occurred mainly in the initial stages of the disease. In 86% of observations, the formation of the defect, regardless of the degree of its severity, was completed after the 1st-3rd attack of psychosis, and in the future this defect did not increase significantly. The duration of the period of increase in negative symptoms turned out to be different.
In most cases, even with the appearance of negative disorders before the first manifest attack of psychosis and the final formation of the schizophrenic defect already in the first remission, the duration of this period was 3-7 years.
In other cases, in which the defect continued to deepen after the 2nd or 3rd attack, the duration of the increase in procedural deficit manifestations was longer and depended on the duration of the interictal intervals. However, the formation of the schizophrenic defect was completed in all our patients, mainly in young and middle age.
In approximately 65% ​​of patients, the final formation of the schizophrenic defect was completed before the age of 40; at a later age, the development of negative changes ended in 25% of patients, and at the age of over 50, their further deepening was noted in only 8.6% of patients.
In later age periods, compared with interictal intervals at a younger age (along with the indicated stabilization of negative symptoms), in many patients, especially with a small depth of the defect, even an improvement in the quality of remission could be observed. Previously observed asthenic phenomena decreased or disappeared, and residual productive symptoms that occurred in previous remissions were smoothed out. If, for example, in early remissions general lethargy and declines in mood prevailed, then in late interictal periods sthenicity, cheerfulness, and optimism often appeared, compensatory capabilities increased, and social adaptation improved. The same improvement in the quality of remissions and compensatory capabilities was also observed during long-term remissions that occurred after the attenuation of attacks.
Another indicator of progression or the degree of activity of the paroxysmal-progressive process is the duration of attacks of psychosis and the frequency of their occurrence at successive stages of the disease.
As we indicated, in the recurrent and paroxysmal-progressive form of the disease, the duration of psychotic attacks is characterized by relative stability. It was shown that, regardless of the total number of attacks occurring throughout the disease or changes in their frequency in certain age periods (decrease at the age of 40-49 years, increase after 50 years), attacks of short duration (1-6 months) clearly predominated at all stages of the disease ). The duration of individual psychotic attacks was not significantly influenced by the various trends in the modification of productive symptoms observed during paroxysmal schizophrenia (complication or simplification of the psychopathological structure of attacks). From the presented data it follows that in cases of a true paroxysmal course of schizophrenia, the duration of attacks repeated throughout the disease is quite stable and cannot be considered as a reflection of the activity of the developing process. Considering the fact that we have established that in paroxysmal forms that turn into chronic psychoses, long-term and “extra-long-term” attacks are significantly more common, we can assume that this indicator to a certain extent correlates with the general trend in the development of the paroxysmal process.
More important data for understanding the patterns of the course of paroxysmal-progressive schizophrenia were obtained by analyzing the relationships between the distribution of attacks by age and the dynamics of deficit symptoms. It was when comparing these two clinical parameters that the presence of certain divergent tendencies in the dynamics of manifestations of the paroxysmal schizophrenic process was revealed, which are, apparently, the most specific feature of this form.
Characteristic of schizophrenia, which occurs with delineated psychotic attacks throughout its entire duration, is the uneven distribution of attacks across age periods. Most of the psychotic attacks - 57.2% of the total number of attacks (1592) - were observed over the age of 50 years, while at the age of under 40 there were 23.1%, and at the age of under 49 - 19.7 %. If we compare these data with the established patterns of the dynamics of negative manifestations of the disease, then the results obtained are difficult to interpret in the light of traditional ideas about the step-like development of paroxysmal-progressive schizophrenia. As is known, the development of this form of schizophrenia is associated with a model of the dynamics of disorders, according to which the sequential occurrence of furious attacks is inevitably accompanied by a stepwise deepening of deficiency symptoms.

Meanwhile, the results of the analysis allowed us to conclude that the dynamics of disorders considered typical for paroxysmal-progressive schizophrenia - the deepening of negative symptoms as attacks of psychosis recur - are observed only in the first stages of the disease, i.e., mainly in patients in their youth. and middle age. Most of the attacks that occur only in the later stages of the disease do not entail an increase in the schizophrenic defect. In other words, at a later age, the activity of the attack-like schizophrenic process continues to manifest itself and manifests itself even more intensely only in the formation of attacks, while the “destructive tendency” of the disease process remains stable or even weakens and can be compensated. It follows from this that the model of a step-like course, developed on the basis of observations of young and middle-aged patients with schizophrenia or short follow-ups, cannot serve as a characteristic of the course throughout the entire course of the disease.
The analysis of long periods of the disease made it possible to more fully imagine the patterns of development of paroxysmal-progressive schizophrenia and identify two main stages in the development of the disease, which are quite clearly visible in the majority of patients. The first stage, coinciding with the young and middle age of patients, is the stage of a truly paroxysmal-progressive course in the form of furnace attacks characteristic of this form, i.e. attacks that mark a deepening of deficiency symptoms (their formation was completed in 65.8% of 159 patients under the age of 40 years). The second stage - the stage of partial stabilization of the progression of the process - occurs in the majority of patients (in 2/3 of patients aged 40-49 years, and in the rest - after 50 years).
The formation of the process in 65.8% of 159 patients was completed before the age of 40, only 25.6% of these 159 patients completed the formation of the defect at the age of 40-49 years and in 8.6% over 50 years. At this stage, the diverging trends in the dynamics of processual manifestations described above are most fully revealed: on the one hand, an increase in the activity of the seizure formation mechanism, and on the other, a weakening, stabilization and partial compensation of deficiency changes. The dynamics of clinical manifestations of the paroxysmal schizophrenic process in the later stages of its course is not limited to the two diverging trends described.
At the stage of partial stabilization of the progression of the attack-like process, a kind of dissociation is often observed between increased attack formation and the changing severity of psychotic disorders observed during attacks.
A special study by L. O. Sudareva was devoted to this aspect of the long course of paroxysmal-progressive schizophrenia, i.e., the question of the dynamics of productive disorders in the clinical picture of repeated attacks. The author found that often the clinical picture of psychotic attacks changes significantly in later age periods. At the same time, at distant stages of the course of the disease, a variety of trends in the dynamics of psychopathological disorders are revealed, including a tendency towards their simplification or complication. In 20% of patients with paroxysmal-progressive schizophrenia (159 people), the disease proceeded in the form of attacks, the psychopathological structure of which was the same throughout the entire schizophrenic process (course of the “cliché” type in the form of the same type of depressive-hallucinatory, depressive-paranoid attacks, acute attacks paraphrenia, etc.). In 49% of late-life patients, at long-term stages of the disease, there was a gradual reduction in the clinical manifestations of attacks; and in 31%, the clinical picture of attacks occurring at a later age became more complex.
In other cases, the complication of the pattern of attacks occurred due to the appearance and further increase of disorders of another register - paranoid or hallucinatory-paranoid symptoms; At the same time, the overall structure of the attacks became more complicated. The listed changes in the intensity of the development of psychosis or a more complex restructuring of the psychopathological structure of attacks were observed, as a rule, only in the involutionary period, i.e., against the background of an already established and stable schizophrenic defect.
Thus, as already noted, at distant stages of the course of paroxysmal-progressive schizophrenia, the activity of the process may remain in the form of recurrence of psychotic attacks and without phenomena of increasing defect. Moreover, another feature of the course of the disease process, which continues into old age, was revealed: frequent recurrence of attacks was combined in most cases with a simplification of their clinical picture. In other words, there was a known dissociation between the increasing occurrence of attacks and the predominance of regredient tendencies of symptom and syndrome formation in attacks, expressed in the reduction of the clinical picture of attacks to the level of affective disorders.
Concluding the analysis of the patterns of development identified during the study of the longest periods of the course of paroxysmal-progressive schizophrenia, let us dwell on the most important, from our point of view, provisions.
The main conclusion arising from the data obtained is that the progression of this form of schizophrenia in terms of its main indicator - the formation of a defect, as in other forms of the disease, is limited both in the degree of its severity and in the duration of the period of its increase. Therefore, in the paroxysmal-progressive course of schizophrenia, we can conditionally distinguish separate stages of its development - the stage of active growth of process changes and the stage of obvious weakening and stabilization of these changes. The stabilization of process dynamics with the recurrence of attacks continuing throughout the entire course of the disease is not, naturally, as complete and complete as in continuously ongoing forms of schizophrenia. It manifests itself only in the cessation of the growth of the schizophrenic defect and, in some cases, also in the weakening of the psychopathological disorders that arise during attacks, and in accordance with this in the transformation of the initially occurring furious attacks into purely affective phases.
Of particular importance for understanding the patterns of the attack-like course of the disease should be attached to the fact that against the background of a stabilized defect, the mechanism of attack formation not only does not stop or weaken, but, on the contrary, clearly intensifies. Such complex and to a certain extent opposite dynamics of clinical disorders prevents consideration of the patterns of paroxysmal-progressive course of schizophrenia in the form of a single, linearly developing cycle. This fact, indicating a certain independence of the manifestations of paroxysmal-progressive schizophrenia in its dynamics, requires a more in-depth study at the biological level.
However, it should be taken into account not only in current and future biological studies, but also in the prognostic assessment of paroxysmal schizophrenic processes or in solving a number of therapeutic and social issues.

(paranoid, delusional) usually occurs in middle age - about 30 years, but often much later. The first symptoms are often gradually and imperceptibly emerging delusions of relationship, jealousy, poisoning, and hypochondriacal nature, which gradually become systematized and take the form of delusions of persecution (see). In other cases, obsessions, hysterical or psychopathic disorders are noted, which are later joined by various delusional ideas with a persecutory nature. The existence of a fairly systematized delusion is indicated by the appearance in patients of the “persecuted - persecutor” symptom - personal or written complaints from patients to government authorities, the appearance on their part of aggressive actions towards imaginary persecutors. The period of paranoid schizophrenia, determined only by delusional disorders, is called.

Personality changes usually become noticeable several years after the onset of the disease and are manifested by isolation, touchiness, narrowing of the circle of interests, and loss of the ability to empathize. The initial period lasts from 2-3 to 20 years or more. Subsequently, the disease proceeds in the form of a hallucinatory-delusional state, in which either delusional or hallucinatory disorders may predominate. The latter most often manifest themselves as Kandinsky-Clerambault mental automatism syndrome (see). Initially, its appearance is accompanied for a short time by anxiety, fear, confusion, symptoms of acute delirium, speech and motor agitation, and individual and unstable catatonic symptoms. This stage of the disease is called paranoid.

Subsequently, delusional and hallucinatory disorders acquire fantastic content. During this period, delusions of grandeur begin to dominate. The paraphrenic stage of paranoid schizophrenia develops. In a number of cases, this stage gradually turns into a state that is unchanged in its manifestations, in which phenomena of speech discontinuity (schizophasia) are often observed - grammatically correctly constructed phrases consist of words that are not related to each other in meaning.

In the delusional type of continuously ongoing progressive schizophrenia, disorders of the delusional circle predominate throughout the entire course of the disease from the moment of manifestation.

In the most typical cases with a gradual onset, mainly in middle age, a continuously progressive course is clinically expressed in a sequential change of paranoid, paranoid, paraphrenic syndromes.

Paranoid syndrome is characterized by interpretive delusions of various contents (persecution, jealousy, hypochondriacal, invention, love, etc.). There are no hallucinations or pseudohallucinations. The prognosis is most unfavorable in cases where personality changes occur from the very beginning - general coarsening, paradoxical thinking and speech, autism. Usually in these cases the delirium is less systematized and fragmentary. The transition to the next - paranoid - stage occurs either gradually, or (more often) with an exacerbation of the clinical picture, the appearance of anxiety, agitation, and individual catatonic symptoms. Subsequently, the leading place begins to be occupied by the Kandinsky-Clerambault syndrome, and, in contrast to the hallucinatory type, it is not pseudohallucinations that predominate, but delusions of physical influence and gross disturbances of thinking.

During this period, patients usually lose their ability to work and are treated in the hospital for a long time. During the transition to the next - paraphrenic - stage, delirium acquires a figurative, fantastic, dream-like character, including ideas of greatness. In some cases, paraphrenic delusions of grandeur acquire the character of a grandiose, in others - confabulatory.

In final states, pronounced phenomena of speech discontinuity with neologisms (schizophasia) are not uncommon. In contrast to speech disorders observed in acute conditions, with schizophasia, an incoherent set of words from the mud of “word salad” is dressed in a grammatically correct form of sentences, and there is a desire for speech contact (“monologue symptom”). It should be noted that a suspension of the process can be observed at any of the described stages of paranoid schizophrenia.

When paranoid schizophrenia occurs at a young age, the course of the disease is more malignant. Personality changes are detected early, stages change faster, catatonic and hebephrenic inclusions are frequent, which makes the clinical picture more complex and polymorphic.

At a later age, there is also a more rapid transition to the paraphrenic stage, often the erotic content of delirium, and the vivid sensual nature of automatisms.