Progressive schizophrenia

There are many theories about this mental illness and discussions of psychiatrists of different schools and directions do not stop. However, the progredientity of true schizophrenia is seen by representatives of the American and European psychiatric schools as undoubted. Schizophreniform symptoms without a progressive weakening of mental activity, according to most psychiatrists, cast doubt on the very diagnosis of schizophrenia and are interpreted as disorders of the schizophrenic spectrum. Therefore, the very name "progressive schizophrenia" resembles "butter oil", since in manuals on psychiatry, in the very definition of the disease, it is interpreted as a progressive endogenous mental pathology. In the latest edition of the DSM-5 manual for the diagnosis of mental disorders, and also, presumably, in the future ICD-11, schizophrenia includes the most severe forms of the disease, the duration of the corresponding symptoms should be observed in the patient for at least six months. [1]

It has probably already become clear that progression is an increase in symptoms, the progress of the disease. It can be continuous (type I) and increasing from attack to attack (type II) with a circular, that is, periodic type of course of the disease. The progress of schizophrenia concerns not so much the severity and frequency of affective attacks as personality changes. Autization is growing - the patient becomes more and more apathetic, his speech and emotional reactions become poorer, interest in the surrounding reality is lost. Although timely prescribed adequate treatment can stabilize the patient's condition and push the last stage of the disease far enough. It is possible to achieve remission, equivalent to recovery. After antipsychotics began to treat schizophrenia in the 1950s, the proportion of the most severe cases of progressive schizophrenia decreased from 15 to 6%. [2]

Epidemiology

The statistics of the prevalence of the disease is not unambiguous, the difference in the diagnostic approach and the registration of patients affects. In general, approximately 1% of the world's inhabitants are diagnosed with schizophrenia, among them there is an approximate gender balance. The greatest number of debuts of the disease occurs at the age of 20 to 29 years. As for the forms, the most common are paroxysmal-progressive, which affects 3-4 people out of 1000, and low-progression - every third out of 1000. The most severe malignant continuous schizophrenia suffers from much fewer people - about one person in 2000 of the population. For male patients, a continuous course of the disease is more characteristic, for women it is paroxysmal. [3].  [4]. [5]

Causes of the progredient schizophrenia

More than a hundred years of studying the disease have given rise to many hypotheses about the nature of schizophrenia and the causes that cause it. However, the WHO fact sheet states that studies have not yet identified a single factor that reliably provokes the development of the disease. However, the risk factors for developing schizophrenia are fairly obvious, although none of them is mandatory. The hereditary predisposition to the disease has a proven etiological significance, but the transmission of genetic information is complex. An interaction of several genes is proposed, and its hypothetical result may be a bouquet of neuropathologies that cause symptoms that fit into the clinical picture of schizophrenia. However, so far, both the genes found in studies in schizophrenics and structural anomalies of the brain, as well as disorders of neurobiological processes, are nonspecific and can increase the likelihood of developing not only schizophrenia, but also other psychotic effects. Current neuroimaging techniques have failed to detect specific changes that are unique to the brains of schizophrenics. Also, geneticists have not yet identified any one genetically mediated mechanism for the development of the disease. [6], [7]

Environmental influences such as early childhood living conditions, psychological and social interactions are environmental stressors, and in combination with innate predisposition increase the risk of developing the disease to a critical level.

Currently, schizophrenia is considered a polyetiological mental disorder, the pathogenesis of which may be triggered by prenatal factors: prenatal infections, the use of toxic substances by the mother during pregnancy, environmental disasters.

Psychosocial risk factors for the development of the disease are very diverse. People with schizophrenia were often subjected to mental and/or physical abuse, inadequate treatment, and did not feel the support of loved ones in childhood. The risk of developing the disease is higher in residents of large cities, in people with low social status, living in uncomfortable conditions, uncommunicative. A repeated traumatic situation, similar to that which occurred in early childhood, can provoke the development of the disease. Moreover, this is not necessarily such a serious stress as beating or rape, sometimes moving or hospitalization is enough for schizophreniform symptoms to develop. [8]

The use of psychoactive substances is closely associated with schizophrenia, but it is not always possible to trace what exactly was the primary disease or addiction. Alcohol and drugs can provoke a manifestation or another attack of schizophrenia, aggravate its course, and contribute to the development of resistance to therapy. At the same time, schizophrenics tend to use psychedelics, the most accessible of which is alcohol. They quickly become psychologically addicted (specialists believe that dopamine hunger is the reason for this), however, if it is not known for sure that a person had schizophrenia before starting to use toxic substances, then he is diagnosed with alcohol / drug psychosis.

The presence of certain personality traits is also a factor that increases the likelihood of developing the disease. This is a tendency to hasty conclusions and long-term worries about negative actions or statements addressed to oneself, increased attention to apparent threats, high sensitivity to stressful events, personal externality (internality), etc. [9]

Pathogenesis

The complex of the above reasons triggers the pathogenesis of schizophrenia. Modern hardware methods make it possible to track functional differences in the nature of activation of cerebral processes in the brain of schizophrenics, as well as to identify some features of the structural units of the brain. They relate to a decrease in its total volume, in particular, gray matter in the frontal and temporal lobes, as well as the hippocampus, thickening of the occipital lobes of the cerebral cortex, and expansion of the ventricles. Patients with schizophrenia have reduced blood supply to the prefrontal and frontal lobes of the cerebral cortex. Structural changes are present at the onset of the disease and may progress over time. Antipsychotic therapy, hormonal fluctuations, alcohol and drug use, weight gain or loss also contribute to structural and functional changes, and it is not yet possible to clearly separate the effect of any specific factor. [10]

The first and most famous is the dopamine hypothesis of the origin of schizophrenia (in several versions), which appeared after the successful introduction of typical antipsychotics into therapeutic practice. In fact, these were the first effective drugs to stop the productive symptoms of psychosis, and it was presumably caused by increased activity of the dopaminergic system. Moreover, in many schizophrenics, an increase in dopamine neurotransmission was found. Now, this hypothesis seems untenable to most specialists; subsequent neurochemical theories (serotonin, kynuren, etc.) also failed to adequately explain the whole variety of clinical manifestations of schizophrenia. [11]

Symptoms of the progredient schizophrenia

The most noticeable manifestation is in the form of acute psychosis, before the appearance of which often no one noticed any special behavioral abnormalities. Such an acute manifestation of the disease is considered to be prognostically favorable, since it contributes to active diagnosis and rapid initiation of treatment. However, this is not always the case. The disease can develop slowly, gradually, without pronounced psychotic components.

The debut of many cases of the disease, especially among the stronger sex, coincides with adolescence and adolescence, which makes early diagnosis difficult. The first signs of schizophrenia may resemble the behavioral characteristics of many adolescents, whose academic performance decreases during the period of growing up, the circle of friends and interests changes, signs of neurosis appear - irritability, anxiety, sleep problems. The child becomes more withdrawn, less frank with parents, reacts aggressively to advice and rejects authoritative opinions, can change her hair, put an earring in her ear, change the style of clothing, become less neat. However, all this is not a direct indication of the development of the disease. For most children, teenage escapades pass without a trace. Until signs of disintegration of thinking appear, it is too early to talk about schizophrenia.

Violation of the unity of the thought process, its isolation from reality, paralogicality usually occurs in the patient from the very beginning. And this is a symptom. Such a pathology manifests itself in the speech production of a schizophrenic. The initial stages are characterized by such phenomena as sperrung and mentism, the emergence of so-called symbolic thinking, which manifests itself as the substitution of real concepts for symbols that are understandable only to the patient, reasoning - verbose, empty, leading to nothing reasoning with the loss of the original topic.

In addition, the very thinking of a sick person is devoid of clarity, his goal and motivation are not traced. The thoughts of a schizophrenic are devoid of subjectivity, they are uncontrollable, alien, embedded from the outside, which patients complain about. They are also confident in the accessibility of their forcibly embedded thoughts to others - they can be stolen, read, replaced by others (the phenomenon of “openness of thoughts”). Schizophrenics are also characterized by ambivalence of thinking - they are able to think simultaneously about mutually exclusive things. Disorganized thinking and behavior in a mild form can manifest itself already in the prodromal period.

The progressive course of schizophrenia means the progress of the disease. For some, it comes on roughly and quickly (with juvenile malignant forms), for others it is slow and not too noticeable. Progress is manifested, for example, in schizophasia (“discontinuity” of thinking) - verbally, this is the appearance in speech of a verbal “okroshka”, a meaningless combination of associations that are absolutely unrelated to each other. It is impossible to catch the meaning of such statements from the outside: the statements of patients completely lose their meaning, although sentences are often built grammatically correctly and the patients are in a clear mind, completely preserving all types of orientation.

In addition to the disorganization of thinking, the big symptoms of schizophrenia also include delusions (beliefs that do not correspond to reality) and hallucinations (false sensations).

The main theme of a delusional disorder is that the patient is influenced by external forces, forcing him to act, feel and / or think in a certain way, to do things that are not characteristic of him. The patient is convinced that the execution of orders is controlled, and he cannot disobey. For schizophrenics, delusions of attitude, persecution are also characteristic; persistent crazy ideas of a different kind that are not acceptable in this society can be observed. Delusions are usually bizarre and unrealistic.

Also, a symptom of schizophrenia is the presence of pathological overvalued ideas, affectively charged, absorbing all the patient's personal manifestations, perceived as the only true ones. Such ideas eventually become the basis of delusional formation.

A schizophrenic is characterized by delusional perception - any signals from the outside: remarks, grins, newspaper articles, lines from songs and others are perceived at their own expense and in a negative way.

The appearance of delirium can be seen by the following changes in the patient's behavior: he became withdrawn, secretive, began to treat relatives and good friends with inexplicable hostility, suspicion; periodically makes it clear that he is being persecuted, discriminated against, threatened; shows unreasonable fear, expresses concerns, checks food, hangs additional constipation on doors and windows, clogs ventilation openings. The patient can make significant allusions about his great mission, about any secret knowledge, about merits to humanity. He may be tormented by a sense of invented guilt. There are many manifestations, for the most part they are implausible and mysterious, but it happens that the statements and actions of the patient are quite real - he complains about his neighbors, suspects his spouse of treason, employees - of sitting up.

Another "big" symptom of schizophrenia are hallucinations, often auditory. The patient hears voices. They comment on his actions, insult, give orders, enter into a dialogue. Voices are heard in the head, sometimes they come from different parts of the body. There may be other types of persistent hallucinations - tactile, olfactory, visual.

Dialogues with an invisible interlocutor can serve as signs of the onset of hallucinations, when the patient throws remarks as if in response to remarks, argues or answers questions, suddenly laughs or gets upset for no reason, has an alarmed look, cannot concentrate during a conversation, as if someone it distracts. An outside observer usually gets the impression that his counterpart is feeling something that is accessible only to him.

The manifestations of schizophrenia are varied. There may be affective disorders - depressive or manic episodes, depersonalization / derealization phenomena, catatonia, hebephrenia. Schizophrenia is characterized, as a rule, by complex symptom complexes of mood disorders, which include not only depressed or abnormally elevated mood, but hallucinatory-delusional experiences, disorganized thinking and behavior, and in severe cases, severe motor disorders (catatonic).

Progredient schizophrenia occurs with the appearance and increase of cognitive impairment and negative symptoms - a gradual loss of motivation, volitional manifestations and the emotional component.

Formally, the pre-morbid level of intelligence remains in schizophrenics for a long time, but new knowledge and skills are already mastered with difficulty.

Summing up the section, it should be noted that the modern concept of schizophrenia refers the symptoms of this disease to the following categories:

• disorganizational - splitting of thinking and associated bizarre speech (incoherent, purposeless speech and activity, inconsistency, sliding down to complete incomprehensibility) and behavior (infantilism, agitation, bizarre / slovenly appearance);
• positive (productive), which include the overproduction of the natural functions of the body, their distortion (delusions and hallucinations);
• negative - partial or complete loss of normal mental functions and emotional reactions to events (an expressionless face, scarcity of speech, lack of interest in any type of activity and in relationships with people, there may be an increase in activity, senseless, erratic, fussiness);
• cognitive - a decrease in susceptibility, the ability to analyze and solve the tasks set by life (scattered attention, decreased memory and information processing speed).

It is not necessary for one patient to have all categories of symptoms. [12]

Forms

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.

Complications and consequences

Progressive schizophrenia over time leads, at a minimum, to the loss of flexibility of thinking, communication skills, and the ability to solve the life tasks facing the individual. The patient ceases to understand and accept the point of view of others, even the closest and like-minded people. Despite the fact that the intellect is formally preserved, new knowledge and experience are not assimilated. The severity of increasing cognitive losses is the main factor that leads to loss of independence, desocialization and disability.

Schizophrenics are highly likely to commit suicide, both during the period of acute psychosis and during remission, when he realizes that he is terminally ill.

The danger to society is considered greatly exaggerated, however, it exists. Most often, everything ends with threats and aggression, but there are cases when, under the influence of imperative delirium, patients commit crimes against a person. It doesn't happen often, but it doesn't make it any easier for the victims.

Aggravates the course of the disease adherence to the abuse of psychoactive substances, half of the patients have this problem. As a result, patients ignore the recommendations of the doctor and relatives, violate the therapy regimen, which leads to the rapid progress of negative symptoms, and also increases the likelihood of desocialization and premature death.

Diagnostics of the progredient schizophrenia

The diagnosis of schizophrenia can only be made by a specialist in the field of psychiatry. Analyzes and hardware studies that would confirm or deny the presence of the disease do not yet exist. Diagnosis is based on the data of the medical history and symptoms identified during observation in the hospital. They interview both the patient himself and people living next to him and knowing him well - relatives, friends, teachers and work colleagues.

There must be two or more symptoms of the first rank according to K. Schneider or one of the major symptoms: specific delirium, hallucinations, disorganized speech. In addition to positive symptoms, negative personality changes should be expressed, it is also taken into account that in some deficient types of schizophrenia, there are no positive symptoms at all.

Symptoms similar to schizophrenia are also present in other mental disorders: delusional, schizophreniform, schizoaffective and others. Psychosis can also manifest itself in brain tumors, intoxication with psychoactive substances, and head injuries. With these conditions, differential diagnosis is carried out. It is for differentiation that laboratory tests and neuroimaging methods are used to see organic brain lesions and determine the level of toxic substances in the body. Schizotypal personality disorders usually proceed more easily than true schizophrenia (less pronounced and often do not lead to full-blown psychosis), and most importantly, the patient comes out of them without a specific cognitive deficit. [13]

Treatment of the progredient schizophrenia

The best results are achieved when the therapy is timely prescribed, that is, when it is started during the first episode that meets the criteria for schizophrenia. The main drugs are antipsychotics, the intake should be long, about a year or two, even if the patient had a debut of the disease. Otherwise, the risk of relapse is very high, and during the first year. If the episode is not the first, then drug treatment must be carried out for many years. [14]

Taking antipsychotics is necessary to reduce the severity of psychotic symptoms, prevent relapses and aggravate the general condition of the patient. In addition to drug therapy, rehabilitation activities are carried out - patients are taught self-control skills, group and individual sessions are held with a psychotherapist.

For the treatment of schizophrenia, first-generation drugs are mainly used at the beginning of treatment, typical antipsychotics, the action of which is realized through the blockade of dopamine receptors. According to the strength of their action, they are divided into three groups:

• strong (haloperidol, mazheptin, trifluoperazine) - have a high affinity for dopamine receptors and low for α-adrenergic and muscarinic receptors, have a pronounced antipsychotic effect, their main side effect is forced movement disorders;
• medium and weak (chlorpromazine, sonapax, tizercin, teralen, chlorprothixene) - the affinity of which for dopamine receptors is less pronounced, and for other types: α-adrenergic muscarinic and histamine - is higher; they have mainly a sedative rather than an antipsychotic effect and are less likely than strong ones to cause extrapyramidal disorders.

The choice of drug depends on many factors and is determined by activity against certain neurotransmitter receptors, the unfavorable side effect profile, the preferred route of administration (drugs are available in different forms), and the patient's previous sensitivity are also taken into account. [15]

In the period of acute psychosis, active pharmacotherapy with high doses of drugs is used, after achieving a therapeutic effect, the dose is reduced to maintenance.

Antipsychotics of the second generation or atypical  [16],  (leponex [17],  [18] olanzapine) are considered more effective drugs, although many studies do not support this. They have both a strong antipsychotic effect and affect negative symptoms. Their use reduces the likelihood of side effects such as extrapyramidal disorders, however, the risk of developing obesity, hypertension, and insulin resistance increases.

Some drugs of both generations (haloperidol, thioridazine, risperidone, olanzapine) increase the risk of developing heart rhythm disturbances up to fatal arrhythmias.

In cases where patients refuse treatment, are not able to take a daily dose of the drug, deposited neuroleptics, for example, aripiprazole - intramuscular injections of prolonged action or risperidone in microgranules, are used to ensure adherence to the prescribed therapy regimen.

Treatment of schizophrenia is carried out in stages. First, acute psychotic symptoms are stopped - psychomotor agitation, delusional and hallucinatory syndromes, automatisms, etc. As a rule, the patient at this stage is in a psychiatric hospital for one to three months. Both typical and atypical antipsychotics (neuroleptics) are used. Different schools of psychiatry favor different therapeutic regimens.

In the post-Soviet space, classical antipsychotics remain the drug of choice, in cases where their use is not contraindicated for the patient. The criterion for choosing a particular remedy is the structure of psychotic symptoms.

When the patient is dominated by psychomotor agitation, threatening behavior, rage, aggression, drugs with dominant sedation are used: tizercin from 100 to 600 mg per day; chlorpromazine - from 150 to 800 mg; chlorproxyten - from 60 to 300 mg.

If productive paranoid symptoms prevail, strong antipsychotics of the first generation become the drugs of choice: haloperidol - from 10 to 100 mg per day; trifluoperazine - from 15 to 100 mg. They provide powerful anti-delusional and anti-hallucinatory effects. 

In polymorphic psychotic disorder with hebephrenic and / or catatonic elements, mazheptil is prescribed - from 20 to 60 mg or piportil - from 60 to 120 mg per day, drugs with a wide spectrum of antipsychotic action.

American standardized treatment protocols favor second-generation antipsychotics. Classical drugs are used exclusively when it is necessary to suppress attacks of psychomotor agitation, rage, violence, and also if there is accurate information about the patient that he tolerates typical antipsychotics well or he needs an injectable form of the drug.

English psychiatrists use atypical antipsychotics in the first episode of schizophrenia or when there are contraindications to the use of first-generation drugs. In all other cases, the drug of choice is a strong typical antipsychotic.

When treating, it is not recommended to prescribe several antipsychotic drugs at the same time. This is possible only for a very short time with a hallucinatory-delusional disorder against the background of strong arousal.

If  [19] side effects are observed during treatment with typical antipsychotics, correctors are prescribed - akineton, midokalm, cyclodol; adjust the dosage or switch to the latest generation of drugs.

Antipsychotics are used in combination with other psychotropic drugs. The American Standardized Treatment Protocol recommends that in cases of fits of rage and violence on the part of the patient, in addition to powerful antipsychotics, prescribe valproates; for difficulty falling asleep, weak antipsychotics are combined with benzodiazepine drugs; in a state of dysphoria and suicidal manifestations, as well as post-schizophrenic depression, antipsychotics are prescribed simultaneously with selective serotonin reuptake inhibitors.

Patients with negative symptoms are recommended therapy with atypical antipsychotics.

With a high likelihood of developing side effects:

• heart rhythm disturbances - daily doses of phenothiazines or haloperidol should not exceed 20 mg;
• other cardiovascular effects - risperidone is preferred;
• unnaturally strong thirst of a psychogenic nature - clozapine is recommended.

It must be taken into account that the highest risks of obesity develop in patients taking clozapine and olanzapine; low - trifluoperazine and haloperidol. Aminazine, risperidone and thioridazine have a moderate ability to promote weight gain.

Tardive dyskinesia, a complication that develops in a fifth of patients treated with first-generation neuroleptics, most often occurs in patients who have been prescribed chlorpromazine and haloperidol. The lowest risk of its development in those treated with clozapine and olanzapine.

Anticholinergic side effects occur while taking strong classic antipsychotics, risperidone, ziprasidone

Clozapine is contraindicated in patients with changes in blood composition, chlorpromazine and haloperidol are not recommended.

In the development of neuroleptic malignant syndrome, clozapine, olanzapine, risperidone, quetiapine, ziprasidone were most often seen.

With a significant improvement - the disappearance of positive symptoms, the restoration of a critical attitude towards one's condition and the normalization of behavior, the patient is transferred to semi-inpatient or outpatient treatment. The stabilization therapy phase lasts approximately 6-9 months after the first episode and at least two to three years after the second. The patient continues to take an antipsychotic that has proven effective in the treatment of an acute attack, only at a reduced dose. It is selected in such a way that the sedative effect gradually decreases and the stimulating effect increases. With the return of psychotic manifestations, the dose is raised to the previous level. At this stage of treatment, post-psychotic depression may occur, which is dangerous in terms of suicidal attempts. At the first manifestations of a depressive mood, the patient is prescribed antidepressants from the SSRI group. It is at this stage that psychosocial work with the patient and his family members, inclusion in the processes of learning, work, and resocialization of the patient plays an important role.

Then they move on to stopping negative symptoms, restoring the highest possible level of adaptation in society. Rehabilitation measures require at least another six months. At this stage, atypical antipsychotics are continued in low doses. Second-generation drugs suppress the development of productive symptoms and affect cognitive function and stabilize the emotional-volitional sphere. This stage of therapy is especially relevant for young patients who need to continue their interrupted studies, and for middle-aged patients who are successful, with a good pre-painful prospect and level of education. At this and the next stage of treatment, deposited antipsychotics are often used. Sometimes patients themselves choose this method of treatment, injections are made, depending on the chosen medication, every two (risperidone) to five (moditen) weeks. This method is used when the patient refuses treatment, because they consider themselves already recovered. In addition, some have difficulty taking the drug by mouth.

The final stage of treatment is to prevent new attacks of the disease and maintain the achieved level of socialization, it can last for a long time, sometimes for life. A low-dose intake of an effective antipsychotic for this patient is used. According to the standards of American psychiatry, the drug is taken continuously for a year or a year and two months for the first episode and at least five years for a second one. Russian psychiatrists practice, in addition to the continuous, intermittent method of taking antipsychotics - the patient begins the course when the first symptoms of an exacerbation appear or in the prodrome. Continuous use better prevents exacerbations, but is fraught with the development of side effects of the drug. This method is recommended for patients with a continuous type of disease. The intermittent method of prevention is recommended for persons with a distinct paroxysmal type of schizophrenia. Side effects in this case develop much less frequently.

Prevention

Since the causes of the disease are unknown, specific preventive measures cannot be determined. General recommendations that it is necessary to lead a healthy lifestyle and try to minimize the harmful effects on the body that depend on you are quite appropriate. A person should live a full life, find time for physical culture and creativity, communicate with friends and like-minded people, since an open lifestyle and a positive outlook on the world increase stress resistance and have a positive effect on a person’s mental status.

Specific preventive measures are possible only for patients with schizophrenia, and they help them to fully realize themselves in society. Drug treatment should be started as early as possible, preferably during the first episode. You should strictly follow the recommendations of the attending physician, do not interrupt the course of treatment on your own, do not neglect psychotherapeutic help. Psychotherapy helps patients to live consciously and fight their illness, not to break the regimen of taking medications and to more effectively get out of stressful situations. [20]

Forecast

Without treatment, the prognosis is unfavorable, and often a specific cognitive defect leading to disability occurs quite quickly, within three to five years. Progressive schizophrenia aggravated by drug addiction has a much worse prognosis.

Timely treatment of the disease, more often during the first episode, in about a third of patients leads to a long and stable remission, which some experts interpret as recovery. Another third of patients stabilize their condition as a result of therapy, however, the possibility of relapse remains. [21] They need constant supportive care, some are disabled or perform less skilled work than before the illness. The remaining third is resistant to treatment and gradually loses its capacity.