The symptoms of the disease are somewhat different in different types of the disease. The predominant symptomatology in countries using the ICD-10 is today the basis for the classification of schizophrenia.
In addition, an important diagnostic criterion is the course of the disease. It can be continuous, when painful manifestations are constantly observed at approximately the same level. They are also called "flickering" - the symptoms may intensify and subside somewhat, but there are no periods of complete absence.
Schizophrenia can also have a circular course, that is, with periodic bouts of affective psychosis. This form of the course of the disease is also called recurrent schizophrenia. On the background of treatment, the affective phases in most patients are quickly reduced and a long period of habitual life begins. True, after each attack, patients experience losses in emotional and volitional terms. This is how the progress of the disease manifests itself, which is a criterion for differentiating true schizophrenia from schizoaffective disorder.
The third type of the course of the disease is paroxysmal progressive schizophrenia. It has the features of both a continuous flow and a recurrent one; earlier it was called schizophrenia with a mixed course or fur coat (from the German word Schub - attack, attack). Schizophrenia with paroxysmal-progredient (fur-like, mixed) course is the most common among the entire reporting group of patients.
The continuous progressive course of schizophrenia is characteristic of the types of the disease that manifest in puberty. This is juvenile malignant schizophrenia, the debut of which occurs, on average, at 10-15 years old, and sluggish schizophrenia, the course of which is continuous, however, the progress of this form of the disease is very slow, therefore it is also called low-progressive. It can manifest at any age, and the later the onset of the disease, the less destructive its influence. Up to 40% of cases of early manifestations of the disease are classified as low-progressive schizophrenia (ICD-10 interprets it as a schizotypal disorder).
Progredient schizophrenia in adolescents, in the past - dementia praecox, in turn, is divided into simple, catatonic and hebephrenic. These are the most prognostically unfavorable types of the disease, which are characterized by the development of an acute polymorphic psychotic syndrome, rapid progress and an increase in negative symptoms.
Up to 80% of acute early manifestations of schizophrenia begin, according to some sources, with polymorphic psychosis (“polymorphic fur coat”). The onset is usually sudden, there is no prodromal period, or the presence of some mental discomfort, bad mood, irritability, tearfulness, and disturbances in the process of falling asleep are recalled retrospectively. Sometimes there were complaints of headaches.
The full picture of psychosis unfolds over two or three days. The patient is restless, does not sleep, is very afraid of something, however, he is not able to explain the cause of fear. Then uncontrolled attacks of fear can be replaced by euphoria and hyperexcitation or plaintive lamentations, crying, depression, episodes of extreme exhaustion periodically occur - the patient is apathetic, unable to speak or move.
Usually the patient is oriented in time and space, knows where he is, correctly answers the question about his age, current month and year, but may be confused in the presentation of the sequence of previous events, cannot name the neighbors in the hospital ward. Sometimes the orientation is ambiguous - the patient can answer the question about his whereabouts correctly, and after a few minutes - incorrectly. He may have a broken sense of time - recent events seem far away, and old ones, on the contrary, happened yesterday.
All sorts of psychotic symptoms: various delusions, pseudo- and true hallucinations, illusions, imperative voices, automatisms, dream-like fantasies that do not fit into a certain scheme, one manifestation alternates with another. But still, the most common theme is the idea that others want to harm the patient, for which they make various efforts, trying to distract and deceive him. There may be delusions of grandeur or self-blame.
The delirium is fragmentary and often provoked by the situation: the sight of the ventilation grill leads the patient to the idea of peeping, the radio - to the effect of radio waves, the blood taken for analysis - that it will be pumped out all and thus killed.
Adolescents with polymorphic psychosis often have a derealization syndrome, which manifests itself in the development of staged delusions. He thinks they are putting on a show for him. Doctors and nurses are actors, a hospital is a concentration camp, etc.
Characterized by episodes of depersonalization, oneiroid episodes, individual catatonic and hebephrenic manifestations, ridiculous impulsive actions. Manifestations of impulsive aggression towards others and oneself are quite likely, sudden suicide attempts are possible, the cause of which the patients cannot explain.
The excited state is interspersed with short episodes when the patient suddenly becomes silent, freezes in an unusual position and does not respond to stimuli.
Types of juvenile malignant schizophrenia - simple, catatonic and hebephrenic are distinguished according to the manifestations that are most present in the patient.
With a simple form of schizophrenia, the disease usually develops suddenly, as a rule, in fairly manageable, even in communication and unproblematic adolescents. They change dramatically: they stop studying, become irritable and rude, cold and soulless, abandon their favorite activities, lie or sit for hours, sleep for a long time or roam the streets. They cannot be switched to productive activities; this kind of harassment can cause sharp anger. Patients practically do not have delusions and hallucinations. Sometimes there are episodes of rudimentary hallucinatory manifestations or delusional alertness. Without treatment quickly enough, it takes from three to five years, negative symptoms are growing - emotional impoverishment and a decrease in productive activity, loss of focus and initiative. A cognitive defect specific to schizophrenics grows and the final stage of the disease sets in, as E. Bleiler called it - “the calm of the grave”.
Catatonic schizophrenia (motor disorders predominate) with a continuous course is characterized by a change in stuporous states and excitation without clouding of consciousness.
Hebephrenic - characterized by hypertrophied foolishness. With a continuous course and without treatment, the disease quickly (up to two years) enters the final stage.
Catatonic and hebephrenic schizophrenia can proceed paroxysmal-progredient (mixed course). In this case, with all the severity of these forms of the disease, the clinical picture in the post-attack period is somewhat more mitigated. And although the disease progresses, the schizophrenic defect in patients is less pronounced than in the continuous form of the course.
Recurrent schizophrenia occurs with the development of manic or depressive affective attacks, in the interictal period the patient returns to his normal life. This is the so-called periodic schizophrenia. It has a fairly favorable prognosis, there are cases when patients have experienced only one attack in their entire lives.
Manic attacks occur with severe symptoms of arousal. The patient has an elevated mood, a feeling of uplift and cheerfulness. A jump of ideas is possible, it is impossible to have a consistent conversation with the patient. The patient's thoughts take on a violent character (foreign, nested), motor excitation also increases. Quite quickly, delusions join - influence, persecution, special significance, "openness of thoughts" and other symptoms characteristic of schizophrenia. In some cases, the attack takes on the character of oneiroid catatonia.
Depressive attacks begin with despondency, anhedonia, apathy, sleep disorders, anxiety, fears. The patient is preoccupied, expecting some misfortune. He later develops a delusion characteristic of schizophrenia. A clinical picture of melancholic paraphrenia with self-accusation and attempts to commit suicide, or a oneiroid with illusory-fantastic experiences of "world catastrophes" may develop. The patient may fall into a stupor with fascination, confusion.
Against the background of treatment, such attacks often pass quite quickly, hallucinatory-delusional experiences are reduced first of all, and depression disappears last.
The patient leaves the affective phase with some loss of his mental qualities and depletion of the emotional-volitional component. He becomes more restrained, coldish, less sociable and proactive.
Sluggish schizophrenia usually has a continuous course, but it is so slow and gradual that progress is almost not noticeable. In the initial stage, it resembles a neurosis. Later, obsessions develop that are more incomprehensible, more irresistible than in ordinary neurotics. Bizarre protective rituals quickly emerge. Fears are often too ridiculous - patients are afraid of objects of a certain shape or color, any words, obsessions are also inexplicable and not associated with any event. Over time, mental activity decreases in such patients, sometimes they become unable to work, since the performance of ritual actions takes the whole day. Their circle of interests is greatly narrowed, lethargy and fatigue are increasing. With timely treatment, such patients can achieve a fairly quick and long-term remission.
Paranoid schizophrenia can proceed according to any type, both continuously and paroxysmal, as well as a paroxysmal-progressive course. It is the latter type of flow that is most common and best described. Manifestation of paranoid schizophrenia occurs from 20 to 30 years. Development is slow, the personality structure changes gradually - the patient becomes distrustful, suspicious, secretive. First, paranoid interpretive delusions appear - the patient thinks that everyone is talking about him, watching him, harming him, and certain organizations are behind this. Then auditory hallucinations join in - voices giving orders, commenting, condemning. There are other symptoms inherent in schizophrenia (secondary catatonia, delusional depersonalization), mental automatisms appear (Kandinsky-Clerambault syndrome). Often it is in this paranoid stage that it becomes clear that this is not an eccentricity, but a disease. The more fantastic the plot of the delusion, the more significant the personality defect.
The paroxysmal-progressive course of paranoid schizophrenia develops first, as in the continuous type. Personality changes occur, then a picture of a delusional disorder with symptoms inherent in schizophrenia unfolds, paranoid delusions with components of an affective disorder may develop. But such an attack ends quickly enough and a period of long-term remission begins, when the patient returns to the normal rhythm of life. Some losses are also present at the same time - the circle of friends is narrowing, restraint and secrecy are growing.
The remission period is long, averaging four to five years. Then a new attack of the disease occurs, structurally more complex, for example, an attack of verbal hallucinosis or psychosis with manifestations of all types of mental automatisms, accompanied by symptoms of an affective disorder (depression or mania). It has been going on for much longer than the first one - five to seven months (this is similar to a continuous flow). After the resolution of the attack with the restoration of almost all personal qualities, but at a slightly reduced level, several more calm years pass. Then the attack is repeated again.
Attacks become more frequent, and periods of remission become shorter. Emotional-volitional and intellectual losses are becoming more noticeable. Nevertheless, the personality defect is less significant compared to the continuous course of the disease. Prior to the era of antipsychotics, patients typically experienced four attacks, after which the final stage of the disease occurred. Currently, against the background of treatment, the remission period can be extended indefinitely and the patient can live his normal life in the family, although over time he will get tired faster, perform only simpler work, move away from loved ones, etc.
For the purpose of antipsychotic therapy, the type of schizophrenia is not of great importance, therefore, in some countries, such a classification has already been abandoned, considering the identification of the type of schizophrenia as impractical. The new edition of the ICD-11 Classification of Diseases is also expected to move away from the classification of schizophrenia by type.
For example, American psychiatrists recognize the division of schizophrenia into two types: deficient, when negative symptoms are predominant, and non-deficient, with a predominance of hallucinatory-delusional components. In addition, the diagnostic criterion is the duration of clinical manifestations. For true schizophrenia, it is more than six months.