From Big Medical Encyclopedia

ShIZOFRENYYa. Contents:

History.............. 411

Classification.......... 4 I

Aetiology, pathogeny and pathomorphologic characteristic of schizophrenia................ 412

Clinical picture....... 415

Diagnosis.............. 425

Treatment.............. 426

Rehabilitation........... 428

Forecast............... 429

Labour examination........ 4 30

Forensic-psychiatric examination............... 430

Schizophrenia (schizophrenia; Greek schizo to split, divide - j-phren mind, reason; synonym: Bleylera a disease, dementia praecox, psychosis of the disco rdantny, weak-mindedness early) — the endogenous mental disease with a continuous or pristupoobrazny current which is shown changes of the personality in the form of schizophrenic defect (decrease in mental activity, emotional impoverishment, autism, loss of unity of mental processes, disturbance of thinking) at safety of so-called formal abilities of intelligence (memory, the acquired knowledge, etc.), and also various positive frustration (nonsense, hallucinations, disturbance of affect, a catatonia, etc.). There is a point of view that Sh. represents group related endogenous procedural (having property to develop and become complicated) diseases.

Highway is considered the most widespread mental disease. According to a number of foreign authors, Sh. meets in 0,8 — 0,9% of all population. V. Maier-Gross considered that among the population at the age of 16 — 50 years there are 0,5% of patients with schizophrenia. The Swedish psychiatrists at mass inspection of the population of fishing settlements with structure of the population, constant during a lineage, established that incidence of ill. in them reaches 1%.

Heterogeneity of the reported data on Sh.'s incidence is connected not so much with the valid deviations in its prevalence how many with various criteria of diagnosis of this disease at psychiatrists of different schools. Prevalence Shch., as well as many other mental diseases, is determined by data of primary negotiability and number of the patients staying on the registry and therefore does not reflect true incidence. Undoubtedly sick Sh.' number during all life never addresses the psychiatrist. People around do not consider them patients, they have a reputation only for people strange, odd fellows. Thus, exact data on Sh.'s distribution do not exist. The data which are available in a crust, time are extremely approximate and contradictory.


the Modern concept «schizophrenia» developed gradually. The fr. psychiatrist B. Morel in 1857 gave the first description of one of forms Sh. (a simple form). He treated it as nosologically an independent disease, a cut called «dementia praecox» (early weak-mindedness). In 1871 E. Hecker on an initiative and under the leadership of K. Kalbaum for the first time described a wedge, a picture of youthful insanity, or a hebephrenia; he considered it also as an independent disease. In 1874, K. Kalbaum allocated the catatonia (see, the Catatonic syndrome) recognized further as one of forms of schizophrenia. In 1888 Manyan described the chronic hallucinatory-dilision psychosis called by it chronic nonsense with system development (chronic nonsense of Manyan) as nosological unit.

The aspiration of psychiatrists of the end 19 — the beginnings of 20 century to a research of diseases on the basis of the nosological principle allowed them to overcome limitation of the former syndromologic description of separate mental disorders. So, in 1882

X. Kandinsky combined related group psikhopatol. symptom complexes in uniform nosological unit — the idiofreniya matching to a certain extent modern understanding of schizophrenia. S. S. Korsakov in 1891 on the basis of association of a row amental (in understanding of that time) syndromes allocated a disease — diznoyyu * This concept was wider, than the concept «early weak-mindedness» described by E. Krepelip and included a number of forms Sh. (in modern understanding of this disease).

Consistently carrying out the nosological principle in a research of mental diseases, E. Krepelin in 1898 finally allocated early weak-mindedness (early weak-mindedness of Krepelin) as independent nosological unit. It included early weak-mindedness of Morel, Kalbaum's catatonia, Gekker's hebephrenia and chronic nonsense of Manyan as forms. Further researches of a number of psychiatrists, e.g. in Russia —

S. A. Sukhanova, P. B. Gannushkina, abroad — E. Stransky, was confirmed nosological independence of III. also studying its wedge, pictures is deepened. In 1911 E. Bleyler published the research about psychopathology and clinic of early weak-mindedness, in Krom proved association of early weak-mindedness with nek-ry borderline cases and offered more corresponding it psikhopatol. to the nature (absence actually weak-mindednesses, splitting of mental activity) name «schizophrenia». This name emphasized the main quality inherent in all its wedge, to forms — splitting of mentality (but not weak-mindedness). The concept «schizophrenia» gained bystry distribution in the world literature.

Further researches showed that a wedge, manifestations, a current and Sh.'s outcomes are extremely various, and in some cases it is difficult to delimit it from maniac-depressive psychosis (see), neurosises (see), psychopathies (see), organic and symptomatic psychoses (see the Pathopsyhosis, Symptomatic psychoses). Still there are only kliniko-psychopathological criteria of nosological independence of Sh., and reliable data about its nature are absent; it serves as the reason of uncountable attempts of its partition on a number of independent diseases, narrowings of its nosological borders. E. Regis tried to divide Sh. into early weak-mindedness and a hebephrenia, Shaslen (Ph. Chaslin) — ■ on the early weak-mindedness and an independent disease causing disorder of coordination of mental activity (discordance). Claude (N. of Claude, 1925) distinguished early weak-mindedness, schizophrenia and a shizomaniya. Langfeldt (G. Langfeldt, 1956) allocated true schizophrenia and exogenous schizophrenia, the Shot glass (H. Page of Riimke) — true Sh. and schizophrenic reactions. Bumke and Krish (O., Bumke, of H. Krisch) considered that IIL as an independent disease does not exist, and there are schizophrenic reactions of a brain to various harmful factors. Kleyst and Leongard (To. Kleist, To. Leonhard) instead of Sh. and maniac-depressive psychosis allocated apprx. 30 independent, in their opinion, diseases., Hey (N. Eu, 1959), distinguishing a number of forms in Sh., allocated independent acute crazy and degenerative psychoses. Conrad (To. Conrad, 1959) developed the idea of unitary endogenous psychosis (see a unitary psychosis).

Sh.'s CLASSIFICATION differs big a wedge, polymorphism. In this regard its classification is very important for the correct recognition of Sh., the choice of therapeutic tactics, and also for timely definition of the clinical and social forecast. To a crust, time in the international psychiatry does not exist uniform standard klassi-fikashchsh IIL as distinctions between national and separate schools of sciences in delimitation of this disease and, therefore. its forms are still big.

To a crust, time many psychiatrists use initial classification of early weak-mindedness of Krenelin. the including catatonia, a hebephrenia. a paranoid form (see. A paranoid syndrome), or the chronic nonsense of Manyan, and also the simple form (attached a bit later), allocated generally by the principle of the leading syndrome. Later classification of Krepelin, in a cut a number of additional forms was allocated (depressivnoparanoidny, etc.), was not widely adopted as well as attempts to allocate from early weak-mindedness separate nosological unit — a paraphrenia (see P arafrenny syndrome).

In Vleyler's classification which was generally corresponding to Krepelin's classification the special form — latent schizophrenia was allocated. proceeding favorably with dominance of neurosis-like frustration. However, in E. Bleyler's understanding. the outcome in weak-mindedness was not the defining her Sh. Techeniye's sign can be more or less progreduated, up to latent.

In it. psychiatry classification of early weak-mindedness of Krepelin generally remains. Schneider (To. Schneider) combined a hebephrenia with a simple form, however other researchers, e.g. J. H. Weitbrecht, keep a hebephrenia in the systematics offered by them. In classification Leon-garda atypical «regional» schizoaffective psychoses are allocated; this classification is not standard in it. psychiatry.

In fr. psychiatry of Sh. is considered as hron. psychosis with acute or subacute episodes.

In an amer. allocate to psychiatry the following types of schizophrenic frustration; disorganized (corresponds to a hebephrenic form), catatonic, paranoid, undifferentiated and residual Shch. V separate group, outside Sh. schizoaffective disorders are taken out; in former an amer. classifications they joined in a framework of IH. as one of its types. Boundary Sh. (latent and neurosis-like forms) is removed in a class of frustration of the personality. N. Petrilowitsch, proceeding from features of manifestation and a current of III., allocated the following its versions — polymorphic, monomorphic and amorphous.

Classification of ill. in the International classification of diseases of the ninth review it is eclectic and represents the compromise allowing to obtain a little comparable data. Usually in the certain countries this classification is followed by special comments. In the International classification of diseases of the ninth review in group of schizophrenic psychoses allocate simple, hebephrenic, catatonic, paranoid types, an acute schizophrenic episode, latent schizophrenia, residual schizophrenia and schizoaffective type.

In the USSR Sh.'s classification developed in All-Union scientific center of mental health of the USSR Academy of Medical Sciences on the basis of long clinical, kliniko-kata-mnesticheskikh and kliniko-epidemiological researches is standard. This classification based on unity of psychopathology and Sh.'s current helps the doctor to establish the diagnosis and to predict a further current and an outcome of the disease. Allocate the following forms Sh. and their subspecies, or types.

1. Nepreryvnotekushchy schizophrenia: slow (nevrozopodob

Nye and psychopatholike); progreduated; malignant (nuclear).

2. Pristupoobrazno-progrediyent-naya (shuboobrazny): maloprogredn-entny shuboobrazny with rather sluggish rate of a progrediyentnost (with the attacks combining affective and neurosis-like frustration or affective and crazy frustration); progreduated (with a progreduated current, affective and crazy and gallyutsinatornobredovy attacks); malignant (with heavy, polymorphic attacks and an outcome in the expressed defective states or transition to a continuous current).

3. Periodic, or recurrent (with affective, affektivnobredovy and oneiric attacks and an insignificant progre-diyentnost). Option of periodic schizophrenia is schizoaffective schizophrenia.

As this classification considerably differs from Sh.'s classification in the International classification of diseases of the ninth review, methodical materials on adaptation of the last to domestic psychiatry are developed.



of the Research of an etiology and pathogeny of III. began long before its allocation in an independent disease. From the point of view of psikhodiia-michesky hypotheses of III. considered as a result of a mental injury at early children's age or influences of other microsocial and psychogenic factors. Contrary to it supporters of the somatic direction tried to explain mechanisms of development of Sh. by disturbances biol. processes in various bodies and systems of an organism. The ratio of mental and biological factors in Sh.'s pathogeny to a crust, time is not found out.

Biol. researches III. are directed to studying of an etiology and pathogeny of a disease in general and its separate manifestations. Researches are based on achievements of biochemistry, immunology, genetics, neurophysiology, neuromorphology, etc.

Biol. hypotheses of a pathogeny of III. are traditionally opposed to models of psychogenic development of Sh. (psychodynamic model, pheno-menologicheski-existential model, etc.). However the latest data on mechanisms of action of external, stressful factors (including psychogenic) the environment on neyrotransmitterny, including neuropeptide, systems of a brain open new opportunities in studying biol. bases of interaction of external and internal (genetic) factors at schizophrenia.

In a crust, time real bases for essentially new approaches to studying of a pathogeny of Highway appeared. They are connected with opening neuro transmitternykh and medicinal receptors, their endogenous ligands (see Receptors), with establishment of the sequence of nucleotides in molecules DNA, release of antigens, specific to tissue of a brain, and emergence of the gibridomny technology allowing to receive monoclones (see the Hybridoma, t. 20, additional materials) that opens ample opportunities for biochemical, immunological, genetic and neyromorfo logical researches. The most convincing represent genetic hypotheses of a pathogeny of schizophrenia.

Genetic features of schizophrenia. The question of a role of heredity in development of mental disturbances was discussed throughout all history of psychiatry. However only at the beginning of 20 century there were real premises for scientific research of this problem. The first 60 years of genetic studying of Sh. (since 1911) are the period of accumulation of the data received genealogical and twin by methods (see. Twin method, Genealogical method). Already the early family (genealogical) studies found explicit discrepancy of empirical data on the frequency of cases of Sh. among the immediate family of the patient - pro-gang (see the Proband) with theoretical number of patients, a cut would have to take place if Sh. is a classical monogenic disease. So, for group of sib-owls (brothers, sisters of a proband) the observed frequency of a disease of Sh. was much lower (5 — 8%) expected (25%) in case of simple recessive inheritance in families where both parents of a proband are healthy.

Along with development of these researches in the late twenties began 20 century studying of the twins sick with Sh. Vpervye a special research of concordance (existence of a disease at both twins) in couples identical, or monozygotic. twins were spent by Lyuksen-burger (H. Luxenburger, 1928). In the next years these researches consisted in comparative analysis of indicators of concordance in couples monozygotic and dizygotic, or nonidentical, twins that allowed to judge a ratio of the genetic and environmental factors defining development of a disease, apparently. Practically all researches of the twins having endogenous psychoses steadily found considerable exceeding (by 2 — 4 times) degrees of concordance according to Sh. of monozygotic twins in comparison with dizygotic twins. These results again indirectly confirmed the importance of genetic factors in an etiology and a pathogeny of a disease, but did not allow to define a quantitative contribution of hereditary and environmental factors.

Nek-ry researchers believed that the concept «schizophrenia» combines genetically different diseases, to-rye at the expense of a community of substrate of defeat — mental processes — are characterized at the remote levels of phenotypical manifestation of genes defined a wedge, similarity. However convincing proofs were not got also in it a referral as by means of the traditional methods of the genetic analysis oriented to monogenic signs preferential somatoiyevro logical character it was impossible to reveal structure of genetic heterogeneity of so irregular shapes of mental pathology.

Ambiguity and the incomplete nature of generalizations on genetics of III. resulted in need in the 60th 20 century again to estimate a contribution of genetic and environmental factors to development of the mental disorders combined under the general name «schizophrenia». Comparative analysis of repeated cases of III was for this purpose carried out. in families: among blood and adoptive relatives of probands (adopted children) and among half-sibs in posterity of monozygotic twins, dis-kordantny on III. In both cases the evidence of the bigger importance in Sh.'s development of hereditary factors, than environmental was obtained. During this period significant progress in development of nonconventional methods of the applied genetiko-mathematical analysis allowing to study diseases was observed, predisposition to the Crimea is determined not by one, but several (perhaps many) genes. At the same time the following main requirements to planning of a genetic research of these diseases were formulated: 1) standardization a wedge, descriptions on the basis of criteria of quantitative assessment a wedge. displays of a disease; 2) epidemiol. orientation in accumulation family populyatsi-onnykh materials that provides a genetic representativeness and statistical stability of required characteristics of the studied genetic models of inheritance of pathology; 3) a comprehensive approach to studying of a pathogeny of a disease for the purpose of detection pathogenetic significant markers of hereditary predisposition; 4) wide use of modern methods of analytical genetics of the person using the COMPUTER.

The group of the Soviet researchers which had the extensive semeynoepidemiologichesky materials which are saved up in clinics and laboratories of scientific research institute of clinical psychiatry of All-Union scientific center of mental health of the USSR Academy of Medical Sciences, having used new methods of the genetic analysis (the genetiko-dispersive and multiple parameter segregatsionny analysis), and the group of foreign researchers leaning on total empirical materials of many researchers, using a bit different approach to the analysis of materials (the causal analysis of Wright) came to essentially coinciding conclusions. It turned out that to 60 — 70% of all etiopatogenetichesky displays of this pathology is defined by hereditary factors. At the same time were significant as well systematic all-family environmental factors, respectively 10 — 20% fall to the share to-rykh. It was for the first time revealed that exists specific twin a component of exposure (apprx. '10% of all factors), and it serves as the accurate instruction on a certain limitation of a twin method. At last, establishment of that fact that at a disease of III was extremely important. the positive phenotypical expert-sortativnost of marriages, i.e. nonrandom selection of the persons marrying is of great importance. Nonrandom selection of spouses leads to increase in posterity of the average level of exposure to Sh.'s disease due to increase in homozygosity on the genes defining hereditary predisposition to this disease and by that to earlier and heavier display of a disease in a lineage (a phenomenon of an antitsipation).

In a crust, time the concept «schizophrenia» serves for designation of group of mental diseases of the multi-factorial nature, i.e. diseases, manifestation to-rykh is defined by specific interaction of various environmental factors and a complex system of genes, one of to-rykh prove as «main» (almost independent of the others), and others — only in interaction with a part of other genes or in total with influence of environmental factors. At the same time a miscellaneous a wedge, to forms of endogenous psychoses there correspond different genotypic combinations. These genotypic combinations initially define only nek-ry deviations in development of the highest levels morfo-fiziol. organizations of a brain as substrate of mental processes. Such deviations are found quicker and more often in the conditions of increased requirements to an organism. Evolutionary determined and periodically happening over certain critical periods of ontogenesis (pubertal and involutional) metabolic reorganizations of an organism just also create conditions for development of endogenous psychoses. Such autokhtonny, i.e. without the explicit visible reason, Sh.'s development is characteristic generally of the heaviest a wedge, forms (malignant), observable at youthful age. It is obvious also that in other cases start patol. process can occur under the influence of the external factors influencing on individuals, genotypes to-rykh are characterized by a reduced threshold of reaction.

Biochemical changes. The first hypotheses of disturbance of biochemical processes in sick Sh.' organism were based on detection of their toxic action biol. liquids (blood, urine, etc.) on various test objects, and also on structural similarity of psychotomimetics (see. Psychodisleptic substances) with noradrenaline and dopamine (autotoksichesky hypotheses).

During 60 — the 80th there are 20 century in various laboratories of the world from blood, urine and cerebrospinal liquid of patients of III. toxic connections, or abnormal substances, different in activity, were allocated. However remains not clear as far as they are involved in specific mechanisms of a pathogeny of Sh. whether they are primary elements of biochemical disturbances or a consequence of disturbance of mechanisms of regulation of a metabolism. Existence of toxic connections in biol. sick Sh.' liquids it is hereditarily caused what points detection them in biol to. liquids of relatives of patients with schizophrenia.

A number of hypotheses of a pathogeny of Sh. is based on the assumption that at this disease specific links of a metabolism, in particular biogenic amines are broken (see Catecholamines). It is possible to distinguish group from these hypotheses with catechols - new and group of indolamine hypotheses. They are adjoined by concepts, according to the Crimea Sh.'s development is connected with disturbance of the enzymatic systems participating in exchange of biogenic amines. Carry hypotheses of O-methylation to number of catechol-minovykh of hypotheses and dopamine. According to a hypothesis of O-methylation change of processes of transmethylation of biogenic amines is supposed (strengthening of a way of O-methylation in comparison with N-methylation and accumulation of metilirovanny products of exchange of amines).

The dopamine hypothesis of Sh. appeared as a result of studying of mechanisms of action psikhofarmakol. means, including psychotomimetics. The role of dopamine (see Catecholamines) in antipsychotic action of neuroleptics was established in 1963 by A. Carisson and Lindkvist (M. to Lindqvist). Besides, it was revealed that the chemical substances capable to increase activity of dopamine and noradrenaline (e.g., amphetamine) can cause the psychotic states a little different from Sh. Sut of a dopamine hypothesis consists that in tissue of a brain of sick Sh. the excess amount of dopamine is formed (as a result of the strengthened its synthesis or imperfection of the mechanisms regulating its catabolism), there is a hypersensitivity of dopamine receptors and activity of dofaminer-gichesky structures of a brain increases. Though nek-ry manifestations of III. it is possible to explain with change of function of dofaminergichesky structures of a brain (nigrostriarny and mezentsefalno-cortical, and also mezentsefalno-limbic), the direct evidence of reliability of a dopamine hypothesis it is not obtained; in cerebrospinal liquid and a brain decrease of the activity of a dofamin-R-gidroksilazy was not revealed, edges are metabolized by dopamine, and also changes of maintenance of a key product of exchange of dopamine — gomovanilny to - you. The hypersensitivity of dopamine receptors (increase in their number) established in nek-ry researches can be caused by long introduction psikhofarmakol. means.

Indolamine hypotheses explain Sh.'s development by disturbance of exchange of serotonin and its metabolites (see Serotonin), and also other indolovy connections.

In a crust, time attempts to combine a dopamine hypothesis of UL with modern ideas of endorphines are made (see Opiates endogenous). Considering communication of dopamine and endorphin systems of a brain, assumed that endorphines in the course of information transfer through dopamine synapses on pre-and postsynaptic level play the modulating role. In the light of these assumptions the hyperactivity of dofaminergichesky neurons postulated at Sh. can be not primary, but secondary. Primary disturbances can be connected with disturbances in endorphin system of a brain.

The main obstacle for the proof of the existing hypotheses of a pathogeny of Sh. is unavailability of tissues of brain of the person to direct studying for the purpose of detection of the corresponding defects of exchange. Besides, assessment of the importance of alleged disturbances was complicated by opening of neyronalny transmitterny receptors: end reaction of a brain depends not only on concentration of mediators, but also on a functional condition and number of neyronalny receptors. In this regard in a crust, time of a biochemical research of a pathogeny of Sh. are directed generally to studying of receptors of nervous cells.

Immunological features.

One of the most important patterns of Sh. is sufficient expressiveness of the autoimmune reactions which are characterized by emergence in blood of brain antigens and antibodies to tissue of a brain. In a crust, time proteins are emitted brain, including mozgospetsifichesky. By means of mozgospetsifichesky antigens it was succeeded to find distinctions between Sh. and nek-ry nevrol. diseases. Such selective activity of blood serum of sick Sh. and nervous diseases allows to approach identification of the antigens participating in autoimmune reactions at schizophrenia.

Studying of cellular immunity (see) at Sh. allowed to establish decrease in proliferative activity of T lymphocytes (see. Immunocompetent cells) in response to nesiyetsifichesky stimulators and presence at blood serum of sick Sh. of the factor inhibiting a proliferative lymphocyte activity of healthy people. It was shown that changes of T lymphocytes can be connected with influence of antibrain antibodies, to-rye are capable to block and eliminirovat a part of such cells and to break their function. It is established also that blood serum of sick Sh. has antithymocyte activity, edges it is more expressed within the first years of a disease. In a crust, time draws attention of researchers the system of histocompatability (HLA system) playing a role of barriers of a tissue incompatibility and defining predisposition to a nek-eye to diseases.

Immunol. the system at Sh. changes under influence psikhofarmakol. means: fenotiazinovy drugs can change immunol. reactivity of an organism and function of immunocompetent cells; antibodies to psikhofarmakol are formed. to means; lymphocytes bear medicinal receptors on the surface. Main assumptions of development immunol. reactions at Sh. it is possible to formulate as follows: emergence of antithymocyte antibodies leads to disturbance of permeability of cellular membranes of tissue of brain (in connection with availability of the general antigens in tissues of a brain and a thymus) that promotes an exit in a blood channel of brain antigen. As a result of interaction of antigen and an adenoid tissue antibodies to tissue of a brain are formed, to-rye, interacting with antigens of a brain and thymus, can cause an exit of new portions of antigen. This scheme allows to arrange the collected facts and to understand interrelation of the corresponding processes giving to immunopato l. to shifts, about to-rykh more correct to speak as about immunol. components of a pathogeny of schizophrenia.

Disturbances of higher nervous activity. Neyrofiziol. researches Sh. originate from I. P. Pavlov's works, to-ry for the first time tried to apply fiziol. analysis psikhopatol. the phenomena from positions of the theory of higher nervous activity. Such works which became classical as «Psychiatry as the helper of physiology of big hemispheres», «The trial excursion of the physiologist in the field of psychiatry» and some other, laid the foundation of new approach to a research of mechanisms of mental diseases, and in particular schizophrenia. The concept about the second alarm system as extraordinary and «a specific increase» by century of N of of the person had significant effect on the subsequent works devoted to studying of disturbances of mental activity in clinic. As a result of researches of century of N of and its disturbances at III. such basic facts as disturbance of switching function, the selection information transfer in the second alarm system, processes of internal inhibition and some others. were determined. These researches expanded understanding of disturbances of mental activity at III. Also distinctiveness of disturbance of processes of century of N of was established at III. maniac-depressive psychosis and neurosises.

Early studies of electric activity of a brain at III. were carried out still by Berger (N. Berger, 1924 — 1929); ond were based on scientific premises. having nothing in common with Pavlov's theory about higher nervous activity. Began with I. I. Laptev (1941) and M. N. Livanov (1945) works systematic elektrofi-ziol. researches of a brain. M. N. Livanov put forward the idea that the interrelation of electric processes can reflect interrelation fiziol. processes of a brain. Early studies of so-called space synchronization of electric processes of different morfofunktsionalny areas of a brain showed that at Sh. disturbance of interrelation of the brain processes tested elektrografichesk comes to light. In one cases increase in number of bonds in comparison with norm, in others — reduction comes to light. Such changes had also the preferential localization on the surface of bark of big hemispheres of patients. On the basis of these researches it is possible to make the conclusion: at Sh. the system organization of electric processes and respectively — physiological is broken. And, if in initial stages of a disease the system of brain processes is broken, desintegrated, then at the expressed psychosis, or at its long current there is a new system differing according to the characteristics from system of brain processes of the healthy person. There is «stable morbid condition» (across Bekhtereva); it is connected with specific manifestations of mental activity and corresponds to the concepts «sick point» or «patodinamichesky structure» (io Pavlova).

In a number of researches the great value is attached to a ratio of functions of the right and left hemispheres. The role of this or that hemisphere in Sh.'s pathogeny needs to be considered in connection with specific symptomatology psikhopatol. states.

At III. all functional systems of a brain and an organism in general are in a varying degree involved in patol. process. It is not possible to allocate the leading link in this process, but it is undoubted that deep structures of a brain, in particular limbic system, take part in it.

Apparently, clinically revealed pathology forms as a result of disturbances of integration in various links biol. processes. The received results of studying of the system organization of brain processes at Sh. allowed to create new understanding of disturbances of mechanisms of mental activity, and in clinic — to use neyrofiziol. given for control of efficiency of psychoheadlights-makol. means in the course of therapy of mentally sick.

Pathomorphologic characteristic of schizophrenia. Patol. P.E. Snesarev (1937, 1961) defined the process in a brain characterizing schizophrenia as encephalopathy of toksiko-hypoxemic character. Such encephalopathy can be caused by disbolism in an organism or in the most nervous system. Disturbances are probably implemented on the basis of special predisposition — the increased «fragility», «fragility» morfol. structures and functional systems of a brain. This «fragility» can be caused by genetic predisposition.

At a macroscopic research of a brain at Sh. any idiosyncrasies do not come to light. At microscopic examination in the most typical cases chronic and rather acute changes of cells can be found. Hron. changes are characterized by reduction of amount of neurons, their atrophy and wrinkling, increase in content of lipofuscin in them (see); rather acute — swelling of cells, emergence of cells shadows, hypostasis, etc. Also the mikroochagovost of defeat of nervous tissue when groups of the changed cells or the centers of their loss are located among not changed cellular elements is inherent to schizophrenia. The centers of loss of neurons (emptiness) at Sh. are not connected with pathology of vessels. A microscopic picture of a brain at III. it is characterized by decrease in reactivity of a neuroglia (especially microglias), i.e. lack of a replaceable gliosis that is peculiar to much patol. prto otsessa in a nervous system. At an electronic mikrosko-picheskom a research ultrastructural features of the wrinkled (hyperchromic) neurons are established, reversibility (functional character) of corresponding changes at a certain stage of their development, and also close connection and some kind of community of processes of wrinkling and swelling of neurons is shown (signs of both phenomena in one cell, their close localization).

Changes of a brain at Sh. vary depending on a form, * a stage and duration of disease. Therefore Sh. belongs to those diseases, at to-rykh the pathoanatomical diagnosis formulate with reference to a wedge, the diagnosis. It belongs also to a febrile catatonia, at a cut hypostasis and swelling of a brain, a plethora of vessels, a hyperemia, dot hemorrhages is noted. Microscopically at the same time swelling of neurons and other cells, a chromatolysis, karioliz, vacuolation of cells, ischemic changes, and also perivascular hemorrhages, hypostasis, etc., developing quite often against the background of hron comes to light. changes of cells. It is essential that any certain pathology of internals in these cases does not manage to reveal.

In morfol. picture III. big changes are made by long treatment psikhofarmakol. means. Observed at the same time medicinal pathomorphism (see) is that even at long disease with dominance in a wedge, a picture of negative frustration extensive fields of losses of nervous cells can not be found.


the progressing general change of the personality consisting in alienation from people and isolation (autism), the oppositional attitude towards people around, unmotivated and strange acts, oddity is most characteristic Of Sh. Patients become more and more unavailable, cold-chymi, lose ability to directly perceive people and the world, to communicate easy with people around, the affective otklikayemost (an emotional resonance), sincere flexibility disappears, mental activity decreases, or the energy potential falls [Conrad (To. Conrad), 1959]. Patients become passionless and passive observers of the world surrounding them. This emotional coldness is sometimes combined with the increased vulnerability, the fragility which is excessively developed by the reflection (raised by tendency to introspection); about similar changes speak as about a combination of «a tree and glass» in images. In far come cases of III. excessive frankness of patients is sometimes observed, up to disclosure of intimate aspects of life («autism inside out», «regressive synthon-nost»). At patients the feeling of constant internal discontent, hostility to surrounding is often noted.

The fear in various form and different intensity belongs to the earliest continuous manifestations of Sh. In some cases the fear is shown in the form of feeling of the danger which is concealed everywhere, unaccountable alarm concerning the approaching death up to physically felt its approach. At other patients sensation of fear accepts more trope in the form of constantly expected attack, the approaching accident, death. Intensity of fear fluctuates from causeless alarm, feeling of the approaching danger to suddenly arising squall of pointless panic.

The consciousness falls apart (consciousness «I»), there is a feeling of alienation of separate mental acts, affects, feeling of change spiritual «I», its bifurcation, loss of unity of the life and life of the real world. Quite often there are various phenomena of a derealization (see). In judgments, emotions and impulses to action constantly arise dual vzaimoprotivopo false, mutually exclusive tendencies (ambivalence, or an ambitendentnost).

The thinking at Sh. becomes autistic — torn off from reality. Depending on features of a current, weight of the arising disturbances at Sh. also other types of disorder of thinking are observed: disruptiveness, atacticity of thinking, at a cut unity of maintenance of a thought breaks up, two accidentally arisen associations merge together, diverse contents — in one concept, fragments of thoughts — in one new thought. Such frustration does thinking paralogistic, lishennsh to focus.

Leu the ler explained such thinking of E. B with «a loosening of associative bonds». Unsharp expressiveness of «a loosening of associative communication» leads to sliding of thinking — logically not to the connected transition from one concept or judgment to another. The current of associations is sometimes broken by a sudden stop, a failure, «obstruction of a thought». Subjectively it is endured as otnyaty, a break of a thought. Along with it stereotype — monotony of associations, reproduction of the same contents in different variations is inherent to thinking at sick Sh. Reasoning — the unproductive reasonings of banal contents which are quite often stated grandiloquently belongs to characteristic disorder of thinking. At patients the tendency to symbolical thinking — replacement of concepts with images is observed; philosophic (metaphysical) intoxication (sterile reflection over the most abstract questions of life, problems of the Universe); addiction to a fantasy and mysticism. Many researchers compare feature of disorder of thinking at Sh. to thinking of the sleeping person; in such cases speak about snopodobny frustration of associations.

Sick Sh.' speech it becomes frequent florid, with unusual expressions, strange turns, special intonation (airs and graces of the speech). The use of neologisms — the new, elaborate words resulting from replacement of concepts with symbols is often observed. Also special type of disruptiveness of the speech is noted, at a cut senseless contents is stated in grammatical correct form (shizofaziya). At speech excitement along with an inkogerention (an incoherent mere verbiage) verbigeration — uniform repetition of the same words or phrases is possible. At III. the echolalia (repetition of the separate words and phrases said by attendees), and also a mutism (silence), quite often long failure from the speech are observed. Along with it at sick Sh. also the increased garrulity («an impact of the speech») arising usually without a situation can be noted.

Pretentious are also actions, behavior of patients. The movements lose them smoothness, rotundity, ease, become angular, sometimes elaborate. The person — intense, its expression does not change, unnatural grimaces sometimes appear. In hard cases nek-ry patients have an excitement, teatralnopatetichesky, pretentious and foolish, chaotic; at others — the immobilization reaching degree of a stupor with muscular tension (see. Catatonic syndrome). Acts of patients often of a nemotivi-rovana, are unusual, impulsive, can sometimes be socially dangerous. Sudden antisocial actions (disorderly conduct, drawings mutilations, murder) made by persons with earlier irreproachable social behavior can become the first external manifestation by III., before by developing it is hidden. In the initial period of development of Sh., usually as a result of heavy changes of affect («the main schizophrenic mood») or also suicide of patients is impulsive, possible. It can be made also at later stage of a course of a disease at depressive change of affect.

The most frequent frustration at Sh. is the nonsense. As a rule, the persecution complex, physical impact coexisting with the various phenomena of mental automatism meets (see Kandinsky — Klerambo a syndrome).

The interpretive paranoiac nonsense of the most various contents is quite often observed (nonsense of jealousy, invention, hypochiondrial nonsense, etc.). Along with the called forms of interpretive nonsense at Sh. there are different types of figurative fantastic nonsense, both acute, and chronic (see Nonsense). In many cases initial inertly proceeding III. various types of persistence — sterile sophistication, persuasive doubts, phobias, etc. are noted (see. Persuasive states). Persuasive actions like rituals early join them. In the initial period of Sh. patients with a time have a constant aspiration to consider itself in a mirror (a so-called symptom of a mirror).

Among hallucinatory frustration acoustical verbal pseudohallucinations are especially characteristic of Sh., at to-rykh the patient hears sounding of own thoughts, various «voices» (see Hallucinations). In acute cases of Sh. there are true verbal hallucinations, but they quickly enough pass into pseudohallucinations. True visual hallucinations are not characteristic of Sh.; generally visual pseudohallucinations meet. Olfactory true hallucinations, and especially pseudohallucinations (the «made» smells) are quite frequent. As a rule, verbal and visual pseudohallucinations are combined with nonsense. At the first stages of a course of a disease, sometimes long enough, the maintenance of nonsense and pseudohallucinations can not match. At this time hallucinations of the commenting contents are frequent. Further, usually during development fantastic hron. nonsense, the unity of content of both frustration is established.

For III. senesthopathias (see) — extremely burdensome various physical feelings, and also the «made» feelings are especially characteristic. Synesthesias in the form of suddenly arising persuasive representations, crazy thoughts, the pseudohallucinations which are followed by burdensome, unusual physical feelings can be observed.

Dysmnesias at Sh. do not arise. The false memoirs, or confabulations developing in some cases (see Konfabulez), are not followed by amnesia and belong to konfabulyatorny nonsense (nonsense of imagination of Dyupre). Under the influence of nonsense distortion of memoirs in the form of crazy interpretation of the past is possible. Also pseudo-hallucinatory memoirs are possible (see Kandinsky — Klerambo a syndrome).

The disorders of intelligence inherent to organic lesions of a brain (e.g., at a general paralysis, atherosclerosis, senile dementia, etc.), at Sh. are not noted. Even in far come Sh.'s cases there can be correct conclusions, judgments. Also the stock of the acquired knowledge remains. In this regard nek-ry researchers consider that at Sh. not the intelligence, but ability to use it that disorder of mental activity at Sh. is characterized not by disintegration, but paradoxical activity, dissociation, splitting, discordance, etc. suffers.

The arising frustration at Sh. a number of researchers explain narusheniyekhm preferential spheres of consciousness (see Depersonalization), final formation a cut comes to the end late enough (during puberty).

Inherent Sh. of frustration, namely disorders of thinking, consciousness (depersonalization), inadequacy of affect (parathimia), arise in the most various combinations and happen different degree of manifestation. However, despite a big wedge, Sh.'s polymorphism, syndromes inherent to it are rather outlined. Manifestations numerous a wedge, forms Sh. are limited to the following syndromes: asthenic (see. An asthenic syndrome), hysterical, a syndrome of persuasive states (see. Persuasive states), depersonalizatsion-ny, senestopathetic, hypochiondrial (see. A hypochiondrial syndrome), depressive (see. Depressive syndromes) and maniacal (see. Maniacal syndromes), hallucinatory (see Hallucinations), paranoiac (see. A paranoiac syndrome), hallucinatory paranoid (Kandinsky's syndrome — Klerambo), paraphrenic (see. A paraphrenic syndrome), oneiric (see. A oneiric syndrome), catatonic (see. Catatonic syndrome). Highways are not inherent syndromes of stupefaction, epileptic seizures and other paroxysms, anamnestic states, manifestations of a psychoorganic syndrome.

Inherent Sh. syndromes arise not chaotically, and in a certain sequence, forming a wedge, a stereotype of development of various options of a current (forms) of a disease. In process of Sh.'s progressing initial simple (small) syndromes become harder and harder (big). So, the asthenic or hysterical syndrome becomes complicated persuasive states, depersonalization, senesthopathias or hypochiondrial frustration; the depressive syndrome becomes depressive and alarming and then depressive and crazy; paranoiac — paranoid and hallucinatory

and, at last, paraphrenic. In process of increase of attacks of recurrent (periodic) Sh. their difficult the wedge, the picture consisting of affective, catatonic and oneiric and crazy frustration even more becomes complicated accession of the frustration relating to Kandinsky's syndrome — Klerambo. Remissions become less deep. Long catatonic states become complicated developing of persistent pseudo-hallucinosis, fantastic nonsense, depersonalization. In turn, hallucinatory-dilision states become complicated emergence of affective catatonic frustration and the phenomena of a shizofaziya. Complexity a wedge, pictures Sh. depends also on the disease of a combination arising from the very beginning patol. positive frustration (the listed above syndromes) with negative (slowly accruing change, defect of the personality, or schizophrenic defect). In a wedge, the picture of asthenic or other neurotic syndrome of a reference schizophrenic state can find, sometimes with great difficulty, the increasing isolation, coldness, alienation from people around, loss of an emotional resonance, loss of mental activity, loss of former interests. The changes of all mental warehouse of the patient amplifying further leave a mark and on other positive frustration, complicating thereby a wedge, displays of a disease.

It is especially difficult a wedge, a picture of so-called final conditions of Sh., to-rye represent a result of schizophrenic process. It consists of the expressed decrease of the activity, emotional impoverishment, autism, loss of unity of mental processes, a reduction of mental potential, weakening of motives, unproductiveness and splitting of thinking, reasoning. In more mild cases easing of interests, decrease in inclinations, instability of aspirations, isolation, strangenesses in behavior, automatic under-chinyaemost, slackness, the suppressed mood, lines of negativism, airs and graces, stereotypies are observed; in the expressed cases — inadequate pretentious impulsive actions, the expressed negativism, a paramimia, by the speech (see Ganzer a syndrome), airs and graces of the speech; in even more hard cases — ridiculous stupid negative behavior, airs and graces, apathy, quite often auditory hallucinations and catatonic symptoms. A special rare kind of a reference state — the expressed speech disruptiveness in the form of a shizofaziya at safety of the correct behavior.

The characteristic of a current of various forms of schizophrenia

of Nepreryvnotekushchaya schizophrenia

is characterized hron. a forward current with aggravations without clear attacks, including with affective rasstroystvakhm. Changes of the personality at this form usually precede manifestation (to the period expressed a wedge, manifestations) Sh. of N accrue in process of disease, reaching at an adverse current of the most expressed degree up to development of schizophrenic defect. In some cases stabilization of symptomatology or its gradual reduction is possible. However deep remissions are not observed. At this form the productive symptomatology is presented by the broad range of syndromes — from neurosis-like and psychopatholike to crazy and katatonogebefrenichesky; syndromes of affective frustration extremely re d at tsiro in An y.

Depending on degree of a progre-diyentnost of a disease (weighting and complication a wedge, pictures) allocate slow, progreduated (paranoid) and malignant (nuclear) Sh.

Vyalotekushchaya shizo

the freniya develops rather slowly, inertly, does not lead to deep emotional impoverishment. The productive symptomatology is generally limited neurosis-like and psychopatholike to syndromes.

Depending on character prevailing in a wedge, the picture «axial» of symptomatology allocate the following options slow to III.: 1) with the phenomena of persistence; 2) with the phenomena of depersonalization; 3) with hypochiondrial and senestopaticheskii-m manifestations; 4) with hysterical manifestations. As a special form of slow Sh. allocate low-progreduated schizophrenia.

At slow Sh. with the phenomena of persistence phobias, or persuasive fears prevail (see. Persuasive states), various contents or in the form of a monosymptom, or combined with persuasive actions (rituals). Phobias are deprived of bright emotional coloring, they quickly «turn pale», are forced out by system of rituals. It is poorly expressed, and afterwards in general the component of fight against them (overcoming navyazchivost) disappears. The criticism is also insufficient. The disease stretches for decades and leads to typical changes of the personality: to emotional depletion, strengthening of autism, emergence of stereotype of behavioural reactions, disturbance of thinking. Signs about-grediyentnosti process are found first of all in expansion of a circle of persuasive frustration, gradual throughout a row of years. At the same time tendency to some kind of «systematization», i.e. group of multiple secondary persuasive educations around primary persistence, or obsession comes to light. The phenomena of persistence lose former affective coloring, become more and more inert, uniform, and their contents — more and more ridiculous.

Slow III. with the phenomena of depersonalization, as a rule, arises at youthful age and it is characterized by a combination of the deperso-nalizatsionny phenomena to psychopatholike frustration. At the remote stages of a disease during stabilization of process into the forefront psychopatholike changes act: rigidity, an egocentrism, callousness, rationalism, emotional depletion, is found also decrease in mental activity. Along with it patients show the increased care of the health (develop the whole system of the measures directed to strengthening of health).

At slow Sh. with hypochiondrial and senestopathetic manifestations the supervaluable ideas of hypochiondrial contents dominate (e.g., a sifilomaniye, the resident of Kan-romaniya) or resistant unusual elaborate senesthopathias (see) various localization prevail. Also monosimptomny states are noted, at to-rykh there can be expressed feelings of pain. At the same time typical changes of the personality develop (e.g., emotional impoverishment).

At slow Sh. with hysterical manifestations the rough hysteriform phenomena — paresis, paralyzes, disorders of consciousness, patol are observed. imagination, morbid depression, hysterics, etc., and also hysterical forms of behavior (see Hysteria). Along with it disorders of thinking, the separate crazy (unsystematized) ideas, the accruing emotional impoverishment are noted.

Low-progreduated III. the wedge, pictures and satisfactory social adaptation of patients differs slow, within miogy years, in weighting. Are characteristic long stage of latency with the subsequent activation of a disease at its remote stages of it; a tendency to gradual modification of symptomatology from the nosological specificity which is least differentiated in sense (in stage of latency) to characteristic of an endogenous disease (at an active stage); combination of the frustration typical for sluggish development of process (neurosis-like, psychopatholike, supervaluable and paranoiac), with the autokhtonny (spontaneous) affective attacks, simple on structure, which are quite often gaining tendency to a continuous (continual) current at later stages of process. Most accurately the tendency to a pristupoobrazny current (the outlined attack with the subsequent permanent remission) is shown at so-called odnopristupny maloprogre-diyentny Sh., for a cut are characteristic development of an attack within one of age crises, its big duration with slow development and so gradation in remission and in most cases age coloring psikhopatol. pictures. Wedge, picture of attacks at youthful age decides by an adynamic or hypochiondrial depression on disturbances of thinking, geboidny states, depersonalization and the supervaluable ideas, most often in the form of philosophic (metaphysical) intoxication and dysmorphophobia (see). In the attacks arising at mature age psychopatholike or paranoiac frustration (preferential supervaluable and crazy ideas of jealousy and barratry) can prevail affective (an alarming depression).

Progreduated schizophrenia develops at persons 25 years, however perhaps and earlier (at youthful age) the beginning are more senior. Throughout a disease crazy frustration in the form of paranoiac, paranoid or paraphrenic syndromes dominate. At a progreduated current they replace each other though stabilization at this or that stage is possible. At this form III. there are no clear attacks of a disease, only its aggravations are noted, the expressed depressive or maniacal affective frustration are not observed. The nonsense, as a rule, has the systematized character.

At rather slow rate of a course of a disease the paranoiac crazy syndrome prevails for a long time (paranoiac III.) in the form of the systematized nonsense of invention, a reformatorstvo, love nonsense (an expansive form) or nonsense of the relation, prosecution, poisoning (a persekutorny form). Both forms of nonsense can be combined. In these cases against the background of an expansive delirium there are either episodes, or the states with a persecution complex existing a long time. At more progreduated current with persekutorny nonsense transition of paranoiac frustration to a paranoid stage is possible. Paranoiac III. it is possible to allocate as the progreduated Sh.'s subspecies more favorable on the current, close to slow III., but it is possible to consider and as an initial stage of progreduated schizophrenia.

In typical cases progreduated Sh. begins gradually (cases with an acute debut are rare). The initial stage of a disease is more often characterized by the separate phenomena of persistence, morbid depression, the unstable, incidental, but further repeating and gradually fixed crazy ideas (nonsense of the relation, jealousy, etc.). During this period changes of the personality (isolation, rigidity, loss of affective flexibility, narrowing of emotional reactions) appear. The focus of interest, contacts is limited. Patients become reticent, gloomy; from time to time there are short-term episodes of alarm. Duration of this initial stage fluctuates from 5 — 6 to 20 years. The occurred changes are not evident since in a premorbidal state patients differ in schizoid traits of character.

Further there is Sh.'s manifestation to emergence of a crazy or hallucinatory-dilision syndrome. The disease develops gradually with consecutive change of crazy and hallucinatory (pseudo-hallucinatory) syndromes. However the forward current is interrupted by aggravations, especially upon transition of one syndrome to another.

At a crazy syndrome in the manifest period separate crazy episodes are succeeded by the systematized nonsense which is not followed by hallucinations and the phenomena of mental automatism. If the state is not stabilized during this period (as at paranoiac Sh.), the nonsense of physical impact and the phenomenon of mental automatism appears. At the subsequent progressing of a disease the nonsense gains fantastic character (a paraphrenic syndrome). What more clearly expressed paranoiac frustration in an initial stage, big systematization of nonsense is noted that during the subsequent periods.

The most adverse are progreduated Sh.'s cases, ir to-rykh considerable changes of the personality and psychopatholike frustration precede emergence of the unsystematized crazy ideas. At these patients by the time of manifestation of a disease social disadaptation because of the expressed defect of mentality (disintegration of a family, loss of professional working capacity, alcoholic excesses, contradictory actions) already comes to light. The paranoiac syndrome at them proceeds without accurate systematization of nonsense, and the subsequent manifestation of crazy psychosis is characterized by considerable polymorphism. Along with nonsense of physical impact also pseudohallucinations are noted. Adversity of a current is expressed also in frequent accession of secondary catatonic frustration, in rather bystry fantastic complication of paranoid nonsense by paraphrenic nonsense, in particular nonsense of greatness (see. Paraphrenic syndrome). The phenomena of the expressed crazy depersonalization, accession of crazy confabulations are frequent. Final states at these patients are characterized by rough defect in the emotional sphere, a disintegration of thought and speeches (shizofazi-chesky frustration), airs and graces, separate catatonic frustration, sketchy paraphrenic nonsense.

At a hallucinatory-dilision syndrome against the background of unsystematized nonsense of the relations, jealousy, prosecution or the neurosis-like phenomena there are verbal illusions which are combined with crazy interpretation (reference to themselves) someone else's speech, and in the subsequent elementary hallucinations — noise, whistle, calls, separate words. After this there are true verbal hallucinations hostile for sick contents. This period proceeds short time (till 1 year) and quickly is replaced by pseudo-hallucinosis — Kandinsky's syndrome — Klerambo with dominance of pseudo-hallucinatory frustration develops. There is a nonsense containing the pseudo-hallucinatory information connected with prosecution, influence, jealousy (hallucinatory nonsense). Such state can last 6 — 10 years. In the subsequent the hallucinatory paraphrenia develops. The secondary catatonic phenomena join seldom. The hallucinatory-dilision syndrome differs in a smaller progrediyentnost, than crazy.

Zlokaches of TV unlimited (I the turf I) schizophrenia arises, as a rule, at teenage and youthful age. At this form of a disease negative frustration precede positive (crazy, hallucinatory paranoid, katatonogebefrenny); polymorphism of positive frustration has no syndromal completeness; considerable resistance to therapy otkhmechatsya; quickly there comes the serious final condition.

The initial stage of a disease is characterized by falling of mental activity, the accruing emotional impoverishment and the distorted manifestations of the pubertal period. Than more slowly process develops, especially psychopatholike pubertal frustration — emotional instability, the oppositional attitude towards relatives, special interests, geboid-ny manifestations are expressed (see the Geboidny syndrome). The zlokachestvenny process, the is more distinct decrease in mental activity and the general coarsening of the personality.

The manifest period is usually preceded by emergence of the sketchy crazy ideas of prosecution, poisoning, sexual influence. The manifest period is characterized by expansion of «big psychosis» with polymorphic, but not completed a wedge, a picture sindromalno, in a cut affective, crazy, hallucinatory and pseudo-hallucinatory disorders, the phenomena of mental automatism, katatonogebefrenny and catatonic frustration are combined. General stereotype of development psikhopatol. disturbances (from affective to crazy and further to catatonic frustration) remains. It happens rather quickly to simultaneous increase of negative frustration. At a rapid progreduated current separate syndromes are not divided, accumulate at each other, creating polymorphism a wedge, pictures. The specified features allow to distinguish conditionally the following a wedge, options malignant to III.: paranoid option (drift is relative), a malignant catatonia (a catastrophic current) and the most rare option (a so-called simple form of schizophrenia) which is characterized by poverty and a rudiment a rnost of positive frustration with catatonic and crazy symptoms against the background of rough schizophrenic defect. At paranoid option of malignant Sh. in the period of the developed mental disorders crazy frustration, to-rye, though in a rudimentary form prevail longer, undergo dynamics, characteristic of crazy syndromes: from paranoid to Kandinsky's syndrome — Klerambo and further to an incomplete paraphrenic state against the background of schizophrenic defect. Catatonic and katatonogebefrenny frustration are fragmentary and arise later, than at a malignant catatonia. Final states at paranoid option develop in 2 — 4 after the manifest period and are characterized by symptomatology of the «foolish», «muttering», «pretentious» weak-mindedness.

The malignant catatonia differs in lack of stupefaction, a combination of catatonic frustration with crazy and hallucinatory; at it more often than at other options, ge-befrenny frustration in the form of inclusions in structure of psychosis are observed. Before use of psychopharmacological means (see) quite serious and long struporous and substruporous conditions as well as long conditions of catatonic and katatonogebe-frenny excitement were observed. In a crust, time catatonic frustration meet in more rudimentary form — «a catatonic mimicry», nek-paradise constraint of movements, unsharply expressed echolalia, an ekhomi-miya, an ekhopraksiya, lines of silliness in behavior, episodes of catatonic impulsive excitement (see. Catatonic syndrome). In general this form represents hron. the katatonoparanoidny state, for to-rogo is characteristic a combination of catatonic frustration to an unsystematized persecution complex and poisonings, the phenomena of mental automatism, pseudohallucinations and fragmentary paraphrenic disturbances (sketchy fantastic nonsense). Remissions, hl. obr. therapeutic, are noted usually only at the beginning of the manifest period. In 1 — 1V2 years after developing of psychosis, as a rule, there is a stabilization of process; there comes the final state. At a malignant catatonia the heaviest signs of mental degradation with devastation of the personality are observed. The earlier there are catatonic frustration after manifestation of psychosis, the it is heavier final states (like stupid or negativi-stichesky weak-mindedness, according to E. Kre-pelin).

Pristupoobrazno - progreduated (shuboobrazny) schizophrenia is characterized by a combination of the syndromes inherent to nepreryvnotekushchy Sh. to rather outlined attack, or to fur coats, later to-rogo nablas changes of the personality or residual isikhopatol yudatsya. frustration. Attacks include affective components (depressive and .maniakalny». not characteristic of aggravations of nepreryvnotekushchy ILL This form differs in big polymorphism of both attacks, and mezhpristupny states.

Character of a progrediyentnost is also various — from bystry increase of schizophrenic defect from an attack to an attack before its slow formation which is not reaching heavy degree. Would allocate the following type y p rice that on ra zno-p rogrediyent-ache (shuboobrazny) III.: low-pro-grediyentnaya shuboobrazny, progreduated shuboobrazny, malignant shuboobrazny.

The m and l about progredy in N of t of N and I sh at about about r and z in N and I schizophrenia is in most cases characterized by the frustration erased on the wedge, to manifestations observed long before the first developed attack (usually in the pubertal period). Further there are affective attacks, same or polymorphic, is more often than depressive character (a depression in combination with navyazchivost, dysmorphophobia, morbid depression, the ideas of jealousy, etc.) * At remissions at patients superficial, but rather clear changes of the personality come to light: autism, alienation from

relatives, aspiration to creation of the rezonersky world outlook schemes which are torn off from reality, tendency to morbid depression. At the same time considerable decrease in mental activity or social disadaptation, as a rule, is not found.

Progreduated shuboobrazny sh and z about f r in e-N and I am characterized by dominance in attacks of crazy frustration over affective. The following main types of attacks are observed: acute paranoiac, acute hallucinosis, acute paranoid (hallucinatory option of a syndrome of Kandinsky — Klerambo), acute paraphrenic. At a bad paranoiac attack gradual development of nonsense of specific contents, hl is noted. obr. hypochiondrial, nonsense of jealousy, prosecution. Crazy frustration arise against the background of vigilance, concern. Development of the crazy ideas is connected with the extending crazy interpretation of the taking place events and the facts of antecedents. The monothematic or on-litematichesky plot of nonsense is possible. In the situations which are not mentioning the crazy concept, the behavior of patients significantly does not change. This stage of development of an attack can proceed from 2 — 3 months to 1 — 2 years then the state worsens — the fear, alarm increases, there is a presentiment of death. At this time there are not developed elements of nonsense of value, a performance, and also separate illusions. Despite duration of disease state, a clear depression on escaping of an attack and the subsequent formation of remission confirm the pristupoobrazny course of psychosis. As a rule, at this type of disease already in the first remission clear signs of schizophrenic defect of the personality come to light.

Acute hallucinosis (bad hallucinatory attack) is characterized by dominance in a wedge, a picture of verbal hallucinosis (see Hallucinations). In an initial stage of an attack, along with alarm, vigilance, the separate interpretive crazy ideas (prosecutions, jealousy), there are verbal illusions, calls and the phenomena of crazy interpretation of the foreign speech. Further true verbal hallucinations, contents develop to-rykh corresponds to a plot interpretive, or primary, nonsense (see). At a heavy current true hallucinosis gains the nature of pseudo-hallucinosis. Sharply developed attack can proceed with a picture of the acute paranoid accompanied with verbal hallucinosis. In process of involution of an attack there are clearer affective disorders of depressive character. The remissions forming after bad hallucinatory attacks are characterized by incomplete criticism concerning the postponed psychosis, schizophrenic defect and quite often residual hallucinatory frustration of a rudimentarnykhma like functional hallucinations (see Hallucinations).

The bad paranoid attack (hallucinatory option of a syndrome of Kandinsky — Klerambo) is shown by expansion against the background of interpretive nonsense of mental avtomatizm that is followed by change of a plot of nonsense (emergence of nonsense of physical impact). Though in a wedge, a picture of an attack crazy frustration prevail, come to light also af

dummy disturbances in the form of high spirits, soprovozh

given loquacity, or gloomy depression. Bad paranoid attacks

rather seldom appear the first; they follow a thicket acute paranoiac.

The bad paraphrenic attack

in the form of a fantastic or hallucinatory paraphrenia arising at progreduated shuboobrazny Sh. reflects deep disorder of mental activity. As a rule, in such cases it is about transformation of the attacks following for acute paranoid.

Thus, structure of attacks at progreduated shuboobrazny III. in process of disease changes according to the patterns of change of syndromes characteristic of nepreryvnotekushchy Sh. Odnako unlike nepreryvnotekushchy Sh. at pristuioobrazno-pro-grediyentnoy III. the tendency to alternation of acute states with remissions (a pristupoobrazny current) remains what tell considerable fluctuations about (as spontaneous, and under the influence of treatment) psi-hopatol. phenomena.

The manifest period is preceded, as a rule, by superficial changes of the personality, to-rye in essence are the erased attacks. Besides, there are atypical depressions (gloom, slackness, ideatorny frustration or the erased depressions with the dysmorphophobia which is combined with the ideas of the relation), the easy hypomaniacal states which are followed by psychopatholike frustration are more rare. In a wedge, a picture of the repeated erased attacks the sketchy interpretive ideas of the special relation, separate verbal hallucinations quite often are shown.

After manifestation in one cases psychosis is limited to one attack with the subsequent increase of schizophrenic defect, in others — there is a progressing course of a disease to repeated heavier attacks and deterioration of remission as a result of deepening of schizophrenic defect and increase of residual crazy frustration. In some cases the disease gets a continuous current, and it is difficult to distinguish such patients from nepreryvnotekushchy progreduated (paranoid) Sh. Nakonets's patients, suspension of process at any stage is possible; at the same time the subsequent attacks do not become complicated (cliche type) and schizophrenic defect almost does not accrue.

Malignant shuboobrazny schizophrenia on a wedge, to manifestation and the nature of schizophrenic defect approaches nepreryvnotekushchy malignant (nuclear) schizophrenia. The disease in comparison with other types of shuboobrazny Sh. begins at earlier age (And — 15 years). Initial manifestations of Sh. are characterized by falling of mental activity (falloff of progress, loss of former interests, isolation, bezdeya-telyyust, alienation). On this background extremely rudimentary and non-constant separate catatonic symptoms, persuasive actions, paranoiac, dismorfo-phobic and depersonalizatsionny frustration, and also atypical affective disturbances come to light: hypomanias without the increased mood with psychopatholike behavior, tendency to with and d istiches Kim to acts; frustration of inclinations (vagrancy, alcoholic excesses); episodes of foolish excitement with somersaults, grimacing (gebefrenny crises); depression with irritability, malignancy, change of motive block by impulsive aggression, sometimes with impulsive suicide attempts, catatonic inclusions (stereotypies, grimacing, inadequate laughter).

The manifest period at malignant shuboobrazny Sh. arises at the age of 14 — 16 years; it is characterized by a combination of affective, crazy and catatonic disturbances. Often it begins with an atypical mania with silliness, uniform stereotipizirovan-ache activity and the rudimentary ideas of greatness and a reformatorstvo. At increase of excitement hebephrenic silliness or monotonous motive excitement with stereotypies, grimacing, impulsiveness prevail. In the manifest period the sketchy ideas of prosecution, influence, a special origin, and also not developed, sketchy nonsense of a performance, imperative pseudohallucinations come to light. After the first attack signs of schizophrenic defect sharply accrue, during remissions rudimentary catatonic symptoms are found. At the subsequent attacks there is an increase of catatonic symptomatology, at first in the form of alternation of excitement to a stupor, and further in the form of dominance of struporous frustration like lyutsidny catatonia (see. Catatonic syndrome) with pseudohallucinations. Affective frustration become more atypical, erased and gain character of dysphorias. After 2 — 3 attacks mental activity sharply falls. Malignant shuboobrazny Sh. is not separated by a clear boundary from malignant (nuclear) Sh. Perekhodnymi it is possible to consider those forms, at to-rykh later 2 — 3 attacks disease becomes continuous (only waviness remains), and a wedge, a picture difficult of an otlichim from typical malignant (nuclear) 411. At the same time, as it in general is peculiar to all types of pristupoobrazno-progreduated Sh., even at its most adverse current the termination of progressing of a disease after one or several attacks with stabilization of a state and establishment of rather permanent remission is possible.

Periodic, or recurrent, schizophrenia zashshat extreme situation among other

forms 111., as in its wedge, manifestations and a current there are signs both schizophrenic (dissociative), and the affective frustration observed at maniac-depressive psychosis. Existence of clear affective frustration, W. h bipolar (alternation of opposite affective frustration, napr, depressions and manias), and favorable development (pristupoobrazny, and sometimes and phase) pull together recurrent Sh. with maniac-depressive psychosis. However because in klnn. to a picture of this psychosis the important place is taken by schizophrenic frustration, many researchers consider it as a separate form Sh.

Are characteristic of periodic Sh. single, but the repeating accurately outlined polymorphic attacks are more often. Their range fluctuates from purely affective to oney-roidno-catatonic. The same patient can have same attacks (cliche type) or various on structure. Existence in structure of attacks of various crazy, hallucinatory and pseudo-hallucinatory phenomena distinguishes these attacks from typical affective phases of maniac-depressive psychosis.

The initial stage in the form of repeated soft (opaque) depressions or the erased hypomaniacal states can be short (weeks, months) or longer. Sometimes similar phases come to light in the anamnesis of patients several years prior to the manifest period, to-ry arises most often at youthful age. It is preceded by a stage of somatic (preferential vegetative) frustration and affective disturbances or a stage of somatopsychic depersonalization with affective disturbances. Snowballing of psychosis is followed by emergence of fear, alarm, a crazy mood with characteristic feeling of change «I» and surrounding, with confusion, crazy command. In dalneyshekhm there are phenomena of an affective and crazy derealization and depersonalization with development of nonsense of a performance (intermetamorfoz), false recognitions, with associative, or ideatorny, the avtomatizm (see Kandinsky — Klerambo a syndrome) which are followed by strengthening of imagination, involuntary crazy imagination. There is an acute paraphrenic modification of nonsense. All symptoms of the previous stage (mental avtomatizm, nonsense of special value, a performance, false recognitions) acquire the fantastic contents, the fantastic sense is given to memoirs and former knowledge, occurring around and to feelings in a body. The subsequent development of an attack brings to cards tannins of a oneiric catatonia. Against the background of the substupor sometimes interrupted by excitement snovidny stupefaction with grezopodobny fantastic nonsense, deep depersonalization, full detachment from surrounding develops. The described sequence is inherent to full and acute development of an attack. However suspension of development of an attack at one of its early stages is possible. In this case in its wedge, a picture can prevail affective (monopo-lyarny and bipolar), affektivnobredovy or oneiric katatoni-cheskiye manifestations.

In addition typical for periodic Shch. currents, exist two other options. The first of them is characterized short-term (duration of several days to 2 weeks) by tranzitorny attacks of katatonooneyroidny, depressive and paranoid character or a picture of acute paranoid. At the second the disease since the period of manifestation for years flows continuously with change of attacks, various on structure, without accurate remissions (continua type). Most often such rather adverse type of disease is observed at youthful age. Changes of the personality at periodic III., usually arising in the first years of the manifest period (after the first attacks), are characterized by the phenomena of special mental weakness (lines of easy astenisation of mentality) — a nek-eye decrease of the activity, initiatives, interests, and also restriction of contacts. At separate stages of a current the wedge, a picture of attacks is usually exhausted by affective frustration. The considerable number of patients transfers only one developed attack for all life. Practically regardless of the frequency of attacks of deep schizophrenic defect at this form does not arise. It also defines great opportunities for social and labor adaptation of this group of patients.

More rough changes of the personality (decrease in mental activity in combination with psychopatholike rasstroystvakhm) are observed at periodic Sh.'s debut at youthful age and dominance in a wedge, a picture of attacks of crazy frustration or at tendency of a disease from the very beginning to a continuous current. Such cases should be regarded as transitional between periodic and pristupoob - different and progreduated schizophrenia. At nek-ry patients, on the contrary, despite typical schizoaffective attacks, clear change of the personality is not noted. In these cases periodic Sh. can be delimited from maniac-depressive psychosis only on a wedge, a picture of an attack. Similar disease, and also purely affective attacks indistinguishable from phases of maniac-depressive psychosis, but leading to schizophrenic changes of the personality assume existence of transitional, intermediate forms between two main endogenous diseases (schizophrenia and maniac-depressive psychosis).

Remissions at periodic Sh. often are followed by tsiklotimo-like frustration, to-rye prevail, especially when subclinical (lungs) disturbances of affect were noted also in the domanifestny period.

Schizoaffective schizophrenia is intermediate between pristupoobrazno-pro-grediyentnoy and periodic forms of schizophrenia. It is characterized by bad affective and paranoid, affective and hallucinatory, galyutsinatorno-paranoid and paraphrenic attacks, remissions with clear changes of the personality and insignificant residual frustration. In structure of attacks affective frustration take the most important place. Attacks differ in big sharpness, polymorphism of psychopathological manifestations. The crazy ideas do not reach considerable systematization. Hallucinations are figurative, quite often stsenopodobna. The maintenance of nonsense and hallucinations entirely depends on the nature of affect. The tendency to fantastic modification of nonsense is expressed quite clearly. At affective and paranoid attacks the expressed depressive or maniacal states are combined with interpretive low-system-tizirovannym nonsense. The jealousy, prosecution, etc. become the maintenance of nonsense most often. Throughout all attack signs of crazy mood remain. At height of an attack there is an expansion of nonsense to elements of crazy perception of a situation and strengthening of figurativeness and sensuality of nonsense. At maniacal affect

the ideas of a reformatorstvo, invention prevail. They usually arise as «inspiration». The real systematization, detailing of the crazy ideas are absent. At

progreduated development to a prist

of a pas the picture of a melancholic or fantastic grezo-like acute paraphrenia is developed. The reduction of psychosis passes through a stage of tsiklotimopodobny frustration — a monopolar or bipolar

form (see. Maniac-depressive psychosis).

At affective and hallucinatory attacks the picture of a depression with hallucinosis, as a rule, develops. True verbal hallucinations have depressive contents, stsenopodobny hallucinations (a scene of court, preparation for an execution) are sometimes observed. The nonsense is generally hallucinatory, however the figurative nonsense of value, a performance is possible. At height of an attack the depressive and paranoid state with the fantastic maintenance of hallucinosis and separate catatonic symptoms can develop. Hallucinosis and hallucinatory nonsense remain the main frustration in an attack; the specified attacks differ in it from attacks, externally similar to them, at periodic Sh.

Ostro the developing Kandinsky's syndrome — Klerambo at schizoaffective Sh. is also developed against the background of a depression or a mania. In process of development of this syndrome the nonsense of mental and physical impact extends to all areas of interest and activity of the patient. Depending on the changing nature of affect the crazy ideas of physical impact have the benevolent, hostile or mixed character. At expansion and fantastic modification of crazy frustration the attack gains lines of a fantastic or hallucinatory fantastic paraphrenia. Involution of an attack happens through affective (often long) stage to tsiklotimopodobny affective frustration.

At remissions, in addition to deepenings of autism, emergence of slackness and passivity, considerable decrease in criticism both by the acute period of psychosis, and to a disease in general is noted. Sometimes during remission there are rudimentary manifestations of a syndrome of Kandinsky — Klerambo, senesthopathias, etc. Further disease variously. The manifest attack can be the only thing during life, the repeated attacks repeating a picture of the first (a current as «cliche»), or lengthening of the subsequent attacks with simultaneous simplification of their picture are possible.

At shizoaffekgivny Sh., just as at periodic III., there can be «febrile» (with rise in body temperature) psychotic attacks (a febrile catatonia). The «febrile» attack, as a rule, happens the first; it can sometimes follow for usual (without rise in temperature) an attack. Possibly and emergence of several (to three) «febrile» attacks with gradual from an attack to an attack fading of a «febrile» component. It is difficult to determine any consistent patterns in emergence of «febrile» attacks. It is only possible to draw a conclusion that the temperature reaction in a wedge, a picture at least one attack which is not connected with certain somatic reasons demonstrates possible development of a febrile catatonia. Subfebrile temperature usually happens already at a stage of prodromal frustration, and during expansion of a catatonic state it sharply raises. Duration of a feverish state is much shorter than an attack. The temperature curve differs from a temperature curve at any somatic or infectious disease; sometimes body temperature in the morning above, than in the evening, can reach high figures (39 — 40 °). Outward of patients is typical: feverish gloss of eyes, the dry lips covered with the baked crusts, a dry red or coated tongue, a dermahemia. Quite often there are herpes, and also bruises and spontaneous nasal bleedings, allergic rashes. Sometimes at high temperature the specified signs are not observed. Weakening of cordial activity with the falling of the ABP which is speeded up by a low pulse is noted. In blood the leukocytosis, a deviation to the left, the lymphopenia accelerated by ROE, existence of toxic granularity in leukocytes come to light. In some cases the content of residual nitrogen, protein and bilirubin in blood serum increases, and also the content of chlorides changes. In urine protein, erythrocytes, gialts-new or granular cylinders is found. Bakteriol. crops of blood yield a negative take.

Dynamics of mental disturbances occurs in process of increase of somatic symptoms from typical for pristupoobrazno-progredi-entnoy Sh. acute oneiric kata - tonic frustration (it can be limited to them) before the amentivnopodob-ny and even hyperkinetic excitement which is interrupted by substu-porous and struporous episodes. Excitement amplifies in the evening and at night. Tell about the oneiric and catatonic nature of these states, in addition to catatonic episodes, elements fantastic (though sketchy) nonsense. The greatest temperature increase is observed during amentivnopodob-ny and hyperkinetic excitement. Involution of an attack occurs after decrease in temperature; since this period the wedge, a picture becomes typical for schizoaffective schizophrenia.

Features of schizophrenia at children's and pubertal age

the Concept «children's schizophrenia» appeared after the description of dementia praecocissima de Sanctis (S. of de Sanctis, 1908). Children's Sh.'s existence admits in a crust, time many researchers. One researchers believe that Sh. can begin only on reaching an organism of a certain level of a maturity; others, recognizing children's Sh.'s existence, deny its unity with schizophrenia of adults and consider as an independent disease.

Supporters of the psychological direction in psychiatry connect children's Sh.'s originality with specific reactions of children's age, to-rye are interpreted from psychoanalytic and psychodynamic positions. Special significance at the same time is attached to disturbances of the intra family relations, and first of all bonds between mother and the child. According to biol. the point of view organic lesion of c is the cornerstone of children's Sh. N of page — inborn encephalopathy, according to Bender (L. Bender, 1966), or «the minimum brain dysfunction» (the concept which was widely adopted in a crust, time). At the same time carry any psychotic, pseudo-neurotic, psevdopsikhopa-tichesky, pseudo-moronic and other states at children to children's Sh.

Most of psychiatrists in the USSR consider Sh. at children and adults as a uniform disease (one nosological form), edges can begin at any age, including the earliest. Sh.'s unity at children and adults is confirmed by a community of the main psychopathological symptoms, patterns of a current and an outcome of a disease, and also similarity of hereditary (genealogical) indicators. In modern medical literature there are enough data, including the @-tamnestichesky, confirming the beginning Sh. at children's age, a feedforward of Sh. for children and teenagers with Sh. at adults. However Sh. at children's and pubertal age has the features connected with age (an age pathomorphism). Influence of an age factor on a wedge, picture of a disease needs to be studied proceeding from features of the specific age periods. In psychiatry distinguish children's age (0 — 9 years), in Krom allocate the period of early age (0 — 4 years), prepubertatny (10 — 12 years), pubertal, or teenage (13 — 15 years), and youthful (16 — 18 years). The manifest period and aggravations occur during the periods of age crises, especially in pubertal more often. JI. M. Shmaonova, 10. I. Liberman, M. Sh. Vrono (1980) showed that at the age of

0 — 11 years the disease begins in 7,9% of cases, at the age of 12 — 17 years — in 23,4%. And among patients males, and this dominance of subjects vyra-zhenny prevail, than the age of patients is less.

At children's and pubertal age positive frustration change. The syndromes typical for Sh. of any age, gain the features inherent to their age from children and teenagers. Besides, there are preferential syndromes which are found is almost exclusive at children and teenagers.

Age features of psychopathological frustration at children are expressed to those more considerably, than the child is younger. Syndromes, typical for Sh., differ at children's age rudimentarnostyo, incompleteness separate a component in and a syndrome in general, and also variability and a tranzitornost. Despite it, at children's age and furthermore in pubertal, polymorphism of symptomatology, characteristic of Sh., rather clearly is shown. Carry children's fears, special motor and speech stereotypies to preferential syndromes of children's age, patol. imagination; to preferential syndromes of pubertal age — anorexia nervosa (see Anorexia), dysmorphophobia (see), metaphysical intoxication, a geboidny syndrome (see) and a hypochiondrial syndrome (see).

One of features of III., begun at children's and pubertal age, consists in a combination of symptoms of actually schizophrenic defect of the personality to symptoms of disturbance of the physiological development caused by schizophrenic process. At malignant schizophrenia especially heavy defect of the personality with the phenomena of a deep arrest of development forms (an oli-gofrenichesky component of defect, on T. P. Simeon). At low-pro-grediyentnoy schizophrenia at children's age disturbances of development with its delay in the form of «disgarmonichesky infantility» or «partial defect», according to G. E. Sukhareva, combined with changes of the identity of the fershro-bin type are noted (somewhat eccentric, strange). As manifestations, preferential for children's and pubertal age, it is possible to call also regress of the speech and behavior, an arrest of development, mental infantr the lizm and other disturbances of development caused by schizophrenic process.

Forms Sh. at children generally correspond to forms III. at adults. Due to the age features it is advisable to consider features of forms Sh. separately at children's and pubertal age. At children's age nepreryvnotekushchy forms, hl prevail. obr. slow Sh.; at-stupoobrazno-progreduated (shuboobrazny) Sh. is observed rather often; periodic III. meets seldom. At children's age there is a large number of the atypical (transitional) options making a continuous number of intermediate forms.

Malignant Sh. at children's age is characterized by quickly accruing changes of the personality (autism, decrease in mental activity, emotional impoverishment), kat atonopodobny motive and speech frustration, an arrest of development with regress of the speech and behavior. Steady progressing of a disease is followed by aggravations, especially during the periods of age crises. As a rule, in

1 — 2 years after an onset of the illness there occurs relative stabilization of process with dominance of rough schizophrenic defect and an arrest of development (oligofrenopodobny defect).

7 years are aged more senior and especially at prepubertatny age separate cases progreduated III meet., the wedge, manifestations a cut in many respects correspond to a progreduated form at adults (see above).

Slow Sh. — the most common form at children's age (apprx. 50%). It is difficult to establish an onset of the illness because of similarity of its initial manifestations (the erased changes of the personality) to features of the identity of children in a premorbidal state. Personal changes (autism, easing of attachments, decrease in mental activity) are more often observed in combination with such productive symptoms as «abstruse» questions, unusual games and interests, autistic imagination, and also fear, persistence, rudimentary motive frustration, malevolence and suspiciousness. The important place in a wedge, a picture is occupied by the erased affective frustration and patol. inclinations. Despite polymorphism and an atipichnost of manifestations of Sh. at children's age, distinguish neurosis-like and psychopatholike options of slow Sh. with dominance of navyazchivost, autistic imaginations and patol. inclinations. Along with rather favorable options cases meet more expressed progrediyent-nost of process when in a wedge, a picture productive frustration, especially affective, the senestoipokhondrichesena, and also rudimentary hallucinatory paranoid states and even separate catatonic symptoms clearly act.

Pristupoobrazno - progreduated (shuboobrazny) Sh. at children's age differs considerable ati-pichnostyo, connected with a rudimen-tarnost and incompleteness of productive frustration, dominance of syndromes, preferential for children's age, early identification of an arrest of development. Usually the picture of each subsequent attack becomes complicated in connection with accession of heavier symptoms, and the subsequent remissions differ in increase of schizophrenic defect and residual productive symptoms. In process of growth and development of children the wedge, a picture of a disease becomes complicated.

Sharply arising psychotic attacks which are replaced by remissions with minor changes of the personality are characteristic of exceptional cases of periodic Sh. of children's age. Attacks can be provoked by exogenous factors — acute infections, injuries, psychogenias (see). The wedge, picture of an attack is limited to the fear arising preferential at night or before backfilling. The bad attack of periodic Sh. at children's age can proceed in the form of psychomotor excitement, a cut soon accepts-tatonogebefrennye lines. The attacks which are characterized by one affective frustration almost do not meet; affective attacks with the mixed symptomatology prevail. It is difficult to delimit similar cases of periodic Sh. from pristupoobrazno-progredp-entnoy (shuboobrazny) schizophrenia.

At pubertal age it is more form Sh., than at children's age, correspond to forms Sh. at adults. Actually «pubertal» it is usually accepted to designate Sh. beginning sharply, violently and proceeding pristupoobrazno with affective and saturated polymorphic the psychopath of l. symptomatology and somatovegetativny frustration testimonial of a considerable endointoxication. Despite polymorphism of symptomatology, it is possible to allocate attacks with dominance of phase affective frustration and attacks, in to-rykh into the forefront katatonooneyroidny or affective and crazy frustration act. Waviness of a current in the form of a series of short attacks is from the very beginning characteristic of acute Sh. at pubertal age. Further attacks can become long, disease comes nearer to continuous, without remissions. In more opportunities the current in the form of the tranzitorny attacks which are replaced by steady remissions is observed.

Low-progreduated Sh. with syndromes, preferential for this age, is characteristic of pubertal age (see above).

The final condition of Sh. at children's and teenage age in many respects is defined by an onset of the illness (the it earlier, the is heavier a final state) and degree of a progredpent-nost of schizophrenic process. Malignant Sh. is, as a rule, characterized by a serious final condition with social disadaptation. At more favorable current of Sh. at children's and pubertal age steady remissions, conditions of relative stabilization with a social readaptation and even «practical recovery» are possible.

Problems of differential diagnosis of Sh. at children's and pubertal age are defined by age of the beginning of a disease and degree of programs-re of a diyentnost of process. Malignant Sh. is quite often differentiated with oligophrenias (see), for to-rykh the general underdevelopment of mentality with dominance of intellectual insufficiency, and also with dementia infantilis, or Geller's disease is characteristic, for a cut alalias, quickly progressing deep weak-mindedness with regress of the speech and behavior are typical the early acute beginning (in 3 — 4 years) with high temperature and excitement. Other forms Sh. at children's age differentiate with neurosises (with - m), with early children's autism — Kanner and Asperger's syndromes, common features to-rykh is the expressed insufficiency or total absence of need of the child for contact with people around, emotional coldness, fear of novelty and - other (see. Mental dizontogenez). III., proceeding pristupoobrazno, it is necessary to distinguish quite often from organic, reactive and affective psychoses at children and teenagers.

Sh.'s treatment at children's and pubertal age essentially does not differ from Sh.'s treatment at adults.

For children and teenagers medical and pedagogical actions, .mer of a social readaptation and rehabilitation of patients have special value.

The adverse forecast have the forms Sh. which began at children's and pubertal age if on depth and speed of the accruing changes of the personality they differ not in much from malignant schizophrenia.

Features of schizophrenia at late age

of the Research ill. at late age include a problem early of Sh. which began and proceeding to senile age and a problem of the late ILL which began at senile age. By late Sh. in psychiatric literature name Sh. demonstrating after 40 years (nek-ry researchers — after 50 years) as from now on age changes a wedge, pictures of a disease begin to be found. According to epidemiological data, late Sh. occurs at women approximately by 4 times more often than at men.

Observations early of the diseased and the «grown old» sick ILL, and also the retrospective analysis of a course of their disease showed that, as a rule, the main forms Sh. remain steady throughout all life of patients. The age factor influences a wedge, manifestations of III., especially in the involutional (presenile) and senile periods (see Psychiatry). In the involutional period the current of adverse forms Sh. (nuclear and paranoid) almost does not change. Slow ILL, on the contrary, in this period quite often becomes aggravated. At III., proceeding with rare attacks, in the involutional period resuming of attacks, their increase, emergence of series of attacks or their long current is often observed. Attacks and aggravations are characterized by «presenile coloring» of psychopathological symptoms: in the period of an attack of a preoblgive alarming azhitiro - bathing depressive and crazy states, at aggravations of maloprogre-diyentny forms — the paranoiac ideas (e.g., jealousy, damage, poisoning).

At senile age of an aggravation of Sh. are observed much less often; the tendency to a regreduated current is noted. Most of patients with an adverse current of LII. is in an old age in final states, their partial reduction is observed catatonic and and by l of l yutsin ATO rn about - re to in y x with in d r about - m. At slow Sh. neurosis-like and psychopatholike syndromes while paranoiac frustration (including with the supervaluable ideas) and changes of an affective background appear more clearly are reduced. Influence of senile age on a wedge, a picture pristupoobrazno of the proceeding Sh. is rather small, especially when attacks till this time repeated often. Age changes if they come, are characterized at hypomanias by unproductiveness (lack of aspiration to activity), orientation of statements of patients to events of last years, and at depressions — alarming and crazy states and tranzitorny-m the mnestiko-intellectual frustration disappearing after escaping of a depression. At remissions the so-called condition of mental weakness with residual affective disturbances, passivity, uncertainty in itself, ipo-hondrichnostyo is noted. The most typical changes of the identity of patients, such as autism, oddity, airs and graces, mental infantility, are left at senile age almost without changes. At the negative frustration to a lesser extent deforming structure of the identity of the patient { astenisation, decrease in mental activity, fadedness of emotional reactions), influence of age is shown more clearly. At such patients senilnopodobny changes of the personality form: callousness, an egocentrism, avarice, peevishness, rejection new, garrulity owing to what lines of schizophrenic defect are erased. However Sh.'s combination to classical senile and atrophic processes (cm, Alzheimer a disease, Senile dementia) meets seldom. The cases of such combination described in medical literature concern slow and low-pro-grediyentnoy shuboobrazny Sh., at the remote stages of a current to-rykh senile dementia or, more often, Alzheimer's disease was found. Cerebral atherosclerosis, on the contrary, it is quite frequent (approximately in 20 — 25% of cases; it is found in the grown old patients with Sh. Prich the set of transitions from a simple combination of symptomatology of both diseases before their full deleting is observed.

At late Sh. the main forms of this disease are observed. However than at later age there is manifestation of III., is more limited by that than its manifestation: to a pra

crazy, gallyutsinatornobredovy and affective and crazy syndromes possess. Meet pristupoobrazno more often - p ro re d iyentn ye forms, typical distinctions between them are erased. At nepreryvnotekushchy Sh.'s debut at the age of 45 — 65 years the nonsense differs in the small scale and concreteness of a crazy plot. The interpretive nonsense of influence and prosecution, age subject of nonsense — the idea of jealousy, damage, poisoning are characteristic. At the remote stages of disease, and also at debuts of paranoiac nonsense at senile age «the nonsense of imagination» with crazy imagination is observed. Kandinsky's syndrome — Klerambo is presented by preferential touch avtomatizm. Hallucinosis and pseudo-hallucinosis is quite often observed. At manifestation nepreryvnotekushchy III. with hallucinatory-dilision frustration at senile age true hallucinations prevail, it is frequent with episodes of stsenopodobny character. The tendency to bystry formation of a paraphrenic syndrome is found, at Krom the combination of a specific persecution complex with konfabulyatorno-fantas-ticheskimi the ideas of greatness is observed. The maintenance of the expansive crazy ideas often belongs to the past. Kandinsky's syndrome — Klerambo in such cases is expressed is rudimentary. Late III. with a pristupoobrazny current, debuting in the involutional period, it is shown, as a rule, in the form of a depression with «presenile coloring» (alarming azhi-tiro bathing states). At the depressions developing in old age slackness and apathy, or gloom, discontent, irritability in combination with nonsense of condemnation and prosecution is observed.


the Diagnosis is established on the basis of the anamnesis and a clinical picture.

Differential diagnosis is carried out with affective, involutional, alcoholic and epileptic psychoses, organic lesions of c. N of page, somatogenias, and also with borderline cases. Differential diagnosis especially at the initial stages of a disease, when psikhopatol. manifestations of a tranzitorna can be also shown or as a separate outpost symptom (a psychopathological episode, napr, the affective, neurosis-like, observed several years prior to emergence Sh.), or under «someone else's clothes», masking psychogenic or somatic frustration, it is difficult even to the experienced clinical physician. In this regard the integral approach based on set a wedge, signs is reasonable. Also data on features of a premorbidal state, character and level of social adaptation of patients are considered. Diagnosis is facilitated in the presence of data on family burdeness (cases of «family» schizophrenia, across Snezhnevsky).

First of all positive frustration belong to the signs allowing to delimit Sh. from other mental diseases (primary nonsense of the relation, Kandinsky's syndrome — Klerambo, the auditory hallucinations of abstract contents commenting on the hallucinations, «voices» gaining the nature of dialogue, corporal hallucinations, etc.). Existence them is rather reliable differential and diagnostic criterion; according to G. Huber, they meet in 78% of cases of schizophrenia.

To the signs testimonial

of Sh., also katatonogebefrenny manifestations, senesthopathias, disturbances of thinking belong (sudden breaks of thoughts, or shperrung, reasoning and the observed in more mild cases an illegibility of concepts and sliding, negative changes — autism, decrease in mental activity, etc.). Promotes recognition Shch. and the appearance of patients changing over the years consisting of a combination strange, and sometimes would seem incompatible lines, such as pretentious and refined manners, untidiness, psychopathic change-types «фершробен», the exaggerated care of the health, unusual hobbies and other eccentricities. Such, sometimes not giving in to an accurate definition changes, cause the feeling of singularity, extreneity defined to the Shot glass (N. S. Vitke) as Praecox-Gefuhl — feeling of schizophrenia.

The febrile catatonia needs to be differentiated with exogenous (somatogenic) psychoses, especially at manifestation of a disease in a puerperal period or after acute inf. diseases. Unlike the exogenous psychoses proceeding most often with a picture of psychomotor excitement only at height to-rogo there can be separate manifestations of a catatonia, at III. the catatonic symptomatology is more expressed and is observed throughout an attack. While for an attack of III. (a oneiric catatonia) the fantastic plot of experiences is characteristic, at exogenous psychoses prevail though sketchy, but specific representations. At Sh. in intervals between the periods of excitement the slackness which is combined with residual catatonic symptomatology is noted, and at exogenous psychoses — asthenic frustration. Sh.'s attacks in comparison with exogenous psychoses are more long.

The allyutsinatorno-paranoid states arising at patients of III., it is necessary to distinguish from similar but syndromal structure psikhopatol. educations at patients with organic lesions of c. N of page, infectious intoksikatsionnymi and epileptic psychoses (see Intoksikatsionny psychoses, Infectious psychoses, Epilepsy). At such patients psychosis arises most often at late stages of a disease at sufficient expressiveness of the phenomena of an organic psychosyndrome — an adynamy, an incontience or viscosity of affect, permanent dismnestichesky frustration; these changes are not characteristic of III. Essential distinctions are found also in a wedge, manifestations. So, at Sh. change of gallyutsinatornoparanoidny frustration depends on environmental conditions a little and is defined by generally endogennoprotsessualny factors; eventually their sensual character is lost, the tendency to stereotypification, the patient is found accepts a role of the passive observer more often. Contrary to it the symptomatology of exogenous psychoses more labiln, its intensity changes depending on external influences; brightness of painful representations and affective tension remains throughout a long time, and at epileptic psychoses affect gets a dysphoric shade. While deception of perception and nonsense at sick Sh. have mostly abstract character, and episodes of household contents act only in a fancy combination to philosophic-magiche-skoy plot, hallucinatory paranoid frustration at organic and infectious intoksika-tsionnykh psychoses carry ordinary contents. Most often it is necessary to differentiate Sh. with exogenous psychoses of an alcoholic etiology, to-rye arise after long intoxication (see. Alcoholic psychoses). During abstention from alcohol psikhopatol. frustration are reduced.

In nek-ry cases of periodic Sh. there is a need to carry out differential diagnosis with maniac-depressive psychosis (see), at Krom atypical affective frustration are not noted, there are no complex structure of attacks, and also the negative frustration accruing from an attack to an attack.

Depressive and paranoid attacks of the periodic Sh. demonstrating at late age quite often remind a picture of involutional melancholy (see the 11th redstarchesky psychoses). Differential diagnosis in these cases is based on bigger lability a wedge, manifestations at sick Sh., and also on a prevalence at them the crazy ideas of fantastic contents, physical impact, special value, a metamorphosis at a nevyra-zhennost of affect of alarm inherent to involutional psychoses, alarming and hypochiondrial pictures, nigilistic nonsense (see the Pen a syndrome).

Psychogenias (see) it is rather simple to exclude when the injuring situation played a role of the initial (starting) mechanism, and a wedge, a picture in dalneyshekhm gained the lines inherent to Sh. Neobkhodimost's attack in differentiation can arise when almost throughout Sh. the situational maintenance of nonsense remains. At Sh.'s differentiation with psychogenias it is necessary to consider that at Sh. discrepancy of expressiveness a wedge, manifestations of rather small pathogenicity of the previous mental injury, the long nature of psychosis, and also emergence psikhopatol is observed. frustration, though rudimentary, but preferable to Sh. Nesvoystvenna to psychogenias chaotic change of the affective states, opposite on a sign, proceeding without the expressed vegetative disturbances, frustration of a dream and appetite and the inadequacy of emotional reactions (the external coldness and a plaque of reasoning imposing in the beginning as restraint and self-control concerning the psychoinjuring situation) which is found along with it. Bad attacks of Sh. differ from the crazy reactions arising at a psychogenia in the fact that at Sh. the tendency to generalization and expansion of nonsense, two-planned character of perception surrounding, allowing coexistence of crazy interpretations with real assessment of the situation has paramount value. To a big variety of the crazy ideas, incomprehensibility, and sometimes and absurdity of the false conclusions inherent to the patient of III., resist simplicity of paranoid frustration at a psychogenia, concreteness of their contents which is directly following from the psychoinjuring situation. Even at a full reduction of psychopathological manifestations at Sh. unlike psychogenias of a complete recovery of criticism does not occur. In some cases establishment of nosological borders perhaps only after end of psychosis. At the same time the instruction on III. not only slackness, apathy, the increasing isolation (contrary to an adynamy after heavy psychogenias), but also the sharp, occurred after an attack change of a way of life, disappearance of former interests, attachments and aspirations, and sometimes and new vocational guidance can serve.


by the Main methods of treatment III. are therapy psychopharmacological means (see), and also treatment by insulin and electroconvulsive therapy (see), combined with psychotherapy (see), first of all with labor therapy (see).

The choice of an adequate method and optimum terms of therapy are defined by a form of a current, to rates and a stage of a course of a disease, structure of a syndrome, and also some other factors, napr, age, a somatic state, individual sensitivity to these or those drugs.

Stopping of acute crazy and hallucinatory states is carried out by means of neuroleptics (see) broad spectrum of activity — aliphatic derivatives of a fenotiazin (aminazine, Tisercinum), steles and Zine and, a haloperidol, leponexum. If necessary resort to parenteral administration of drugs. For nepreryvnotekushchy Sh.'s treatment derivatives of a fenotiazin (Stelazinum, etapera-zin in daily doses respectively 40 — 80 and 60 — 120 mg), and in cases of dominance of hallucinatory frustration and Kandinsky's syndrome — Klerambo — derivatives of phenyl propyl ketone (a haloperidol of 20 — 50 mg and трт^седил 2 — 6 mg) use alkyl-piperazinilpropilnye. It is effective also, especially at emergence of signs of resistance, a combination of neuroleptics (leponexum — 100 — 400 mg in a combination to Stelazinum or a haloperidol). Hron. the hallucinosis finding stability to psikhofarmakol. to means, is the indication to carrying out an atropinic coma (see Atropine).

Most rezistentna to therapy sick malignant Highway. In this regard at catatonic and ~ the tatonoparanoidny states most of which often are observed at this form of a disease neuroleptics with high psychotropic activity (leponexum of 300 — 400 mg, majeptil of 60 — 80 mg, high doses of aminazine, Stelazinum, a haloperidol) are shown. Though in most cases malignant III. treatment does not lead to a full reduction of positive frustration, systematic use of neuroleptics, as a rule, prevents emergence of heavier mental disorders. In cases, especially heavy, resistant to neuroleptics, increase in efficiency of therapy their single-step cancellation, and also use of the methods increasing reactivity of an organism (see), e.g. pyrotherapies (see), electroconvulsive therapy, atropinic whom, etc. sometimes promotes.

At pristupoobrazno-progreduated Sh.'s treatment are effective psikhofarmakol. means, electroconvulsive therapy and insulinotera-iiya. Electroconvulsive therapy is shown at resistant to drug treatment heavy, proceeding with the phenomena of psychomotor excitement, alarm, suicide tendencies depressive, depressive and hypochiondrial and - pressivno-paranoid states. Purpose of an insulin therapy is reasonable at the first attacks of a disease, is preferential when a wedge, the picture is defined by a katatonooneyroidny or depressive and paranoid syndrome.

Therapy of the attacks proceeding with dominance of depressive symptomatology, psikhofarmakol. by means it is carried out by means of tricyclic antidepressants (amitriptyline, Melipraminum); also ludiomil and Pyrazidolum are shown.

At treatment of alarming, hypochiondrial, persuasive (anankastiches-ky), anestetichesky, hysterical and crazy depressions the combination therapy is carried out: Sochi

a taniye of antidepressants with tranquilizers (Elenium, Seduxenum, Tazepamum, Phenazepamum) or neuroleptics (etapera-ziny, Frenolonum, Stelazinum, Theralenum, sonapaksy, chlorprothixene). The slow reduction of affective frustration at a deep water of a depression is the indication to parenteral administration psikhofarmakol. means.

Therapy of an oyaeyroidny catatonia, maniakalny and maniacal and crazy attacks it is carried out by neuroleptics. Hypomanias sometimes manage to be stopped salts of lithium (see).

Among the neuroleptics used at treatment of a febrile catatonia aminazine is most effective. If, despite an intensive care, the state continues to worsen, electroconvulsive therapy is carried out. Also symptomatic therapy directed to correction of somatic disturbances is shown.

At dominance in structure of attacks and remissions of affective frustration prolonged preventive use of salts of lithium is shown.

At medicinal treatment of small and progreduated Sh. use drugs different psikhofarmakol. groups — tranquilizers, antidepressants, nootropic means (see), neuroleptics, including and the prolonged action (mo-diten-depot).

Use psikhofarmakol. means for treatment of long persuasive states whether-zatsionnykh a depersona, senestoipokhondriche-sky, isterokonversionny frustration (see Hysteria) effectively in most cases only at an intensive care, the cut is a basic element course intravenous drop administration psikhofarmakol. means (Seduxenum, Elenium, Theralenum, amitriptyline, Melipraminum, piracetam, etc.). At resistance to them appoint an atropinic coma.

Sick Sh.' treatment at late age is carried out psikhofarmakol. means in doses, components 2/2 — / z the average dose recommended for patients at mature age. It is not necessary to use drugs of the prolonged action. Side effects psikhofarmakol. means arise usually at rather low dosages and are characterized by dominance of hyperkinesias over parkinsonopodobny frustration, and also relative frequency of exogenous psychotic episodes at treatment by antidepressants. At treatment of Sh. complicated by cerebral atherosclerosis use of nootropic means is recommended.

The psychotherapy (see), napr, hypnotherapy, rational, collective, group psychotherapy, is shown at low-progreduated to Highway. At more malignant forms psychotherapy ispolzuyetoya hl. obr. during stabilization (remissions, including also the period of their formation, and also post-procedural states with rather superficial schizophrenic defect).

Treatment by insulin (insulin therapy, insulinoshokovy therapy) from the middle of the 30th of 20 century and before emergence psikhofarmakol. means was the most effective method of treatment of schizophrenia. In the USSR Sh.'s treatment by insulin was for the first time applied in 1936. A.S. Kronfeld and E. Ya. Shternberg. With the advent of neuroleptics treatment by insulin became method of the choice at nek-ry forms of schizophrenia. The mechanism to lay down. effects of insulin at psychoses remains not clear. It is established what to lay down. the effect is connected not with direct effect of insulin on c. N of page, and with the hypoglycemia caused by it (see) since in the doses applied to treatment, insulin almost does not get through a blood-brain barrier. Recovery iod begins action of insulin therapy at Sh. with improvement of an emotional background. These changes are a basis for the subsequent elimination of other mental disturbances. It is suggested that the crucial role in emotional reorganization is played by change of the dominating influences on a cerebral cortex from deep structures of a brain, especially activation during a hypoglycemia phylogenetic of ancient perednegi-potalamichesky regulatory system.

The greatest to lay down. the effect is reached at sick Sh. with prescription of a disease till 1 year, at patients with an acute paranoid and hallucinatory paranoid syndrome, including g with Kandinsky's syndrome — Klerambo and depressive and paranoid frustration, not treated psikhofarmakol. means of group of a fenotia-zin. At prescription of a disease before half a year good long-term remissions needlessly in a maintenance therapy are observed approximately in 65% of cases, on the second half of the year of a disease the percent of remissions decreases to 35%. Psychopatholike and neurosis-like options of a slow form Sh. will badly respond to treatment insulin. At a hebephrenic syndrome therapy by insulin quite often leads to an aggravation of symptoms.

Before a course of treatment insulin comprehensive clinical laboratory inspection of the patient is necessary. Insulin is entered daily in the morning on an empty stomach subcutaneously, less often intramusculary or intravenously. The course is begun with development of an individual coma dose; for this purpose in the first day to the patient enter 4 — 8 PIECES of insulin, in 4 hours give a breakfast and 100 g of sugar. Daily add from 2 to 4 PIECES, soporous also coma will not develop yet (see Devocalization, Côme). Usually coma dose makes 60 — 150 PIECES. Slow increase in a dose causes adaptation to insulin and it can be recommended only in the presence of relative contraindications (to the weakened patients, old men, women during a climax, to teenagers with vegetative lability). Too bystry increase in a dose leads to cumulation of insulin and threatens with complications. During the definition of a coma dose of insulin it is necessary to be guided by consistently developing main signs of a hypoglycemic syndrome: an initial vegetative syndrome (feeling of hunger and weakness, the increased sweating, tachycardia, increase in the pulse ABP due to decrease in diastolic pressure, etc.), a somnolen-tion (drowsiness), a lung, and then deep devocalization.

The soporous state at administration of insulin is characterized by loss of ability to fix a look on the shown subject, to follow simple instructions; at the same time remain mimic, voice, vegetative reaction to a call by name, a blink reflex. With disappearance of reflexes there comes the coma. The first two-three coma it is aware of treatment it is necessary to interrupt right at the beginning. Too deep coma (loss of a corneal reflex, a cerebrate rigidity) does not give sufficient to lay down. effect it is also dangerous. The hypoglycemia is interrupted with an intravenous injection of 40% of solution of glucose (20 — 40 ml, at a coma — to 60 — 80 ml). For prevention of a repeated hypoglycemia the patient is given 100 — 200 g of sugar in solution and a breakfast, carbohydrate-rich. During a course of treatment to whom cause to 20 — 30 eaz; if remission occurs after the first yacha of a coma, the number a lump is reduced, at slow improvement of a condition of the patient to whom cause up to 40 times.

Several modifications of insulinoshokovy therapy are offered: intravenous administration of insulin; a combination of insulin to gangliobloki-ruyushchy means (see) type of bin-zogeksoniya, with sulfanamide and nt d news agency etiches Kimi and r ep and r and that mi,

napr, Butamidum, and also in combination with psikhofarmakol. means (e.g., aminazine, Melipraminum). At intravenous administration of insulin development of a coma accelerates, are eliminated hypoglycemic psychomotor excitement and repeated a hypoglycemia, however convulsive reactions become frequent, complications in the form of aseptic thrombophlebitises are frequent and development of anaphylactic reaction is possible. At treatment by insulin in combination with ganklioblokator development of a coma also accelerates, heavy complications are possible. At treatment by insulin in combination with sulfanamide anti-diabetic drugs psychomotor excitement decreases, but are possible repeated a hypoglycemia. A combination of insulin with such psikhofarmakol. means as Tisercinum, the haloperidol, Triphtazinum, amitriptyline, is transferred well, and at a combination to aminazine, Melipraminum and a librium complications are possible.

Apprx. 10% of sick Sh. find resistance to insulin (introduction to 200 PIECES of drug does not cause in them a coma). In the course of a course it can be observed both adaptation, and a sensitization to insulin in this connection coma doses change. During a hypoglycemia quite often there is a psychomotor excitement: early (against the background of clear consciousness) and later (against the background of devocalization and a sopor), and also clonic spasms and epileptic seizures. Early psychomotor excitement is eliminated with introduction to the patient of Tisercinum (25 mg intramusculary), late psychomotor excitement and clonic spasms are stopped by a haloperidol (5 — 10 mg intramusculary) or barbamyl (3 — 6 ml of 5% of solution intravenously). During the developing of an epileptic seizure intravenous administration of 60 — 80 ml of 40% of solution of glucose is shown; for its prevention use phenobarbital (0.1 — 0,2 g in the morning before an injection of insulin). Heavy complication is long (not stopped by glucose) the insulin coma. Repeated dangers do not represent a hypoglycemia in evening and night hours, but are subject to immediate stopping. At the beginning of a course of treatment insulin sometimes observes Sh.'s activation (strengthening of hallucinations, crazy tension, deepening of a depression, etc.).

Absolute contraindication to treatment by insulin are heart diseases (dekompensirovanny mitral, aortal), the expressed cardiosclerosis, stenocardia, a myocardial infarction (in the anamnesis), an idiopathic hypertensia of the III stage, the chronic often becoming aggravated pneumonia, a peptic ulcer, diseases of a liver and kidneys, heavy endocrinopathies, a diabetes mellitus, sharp exhaustion, diseases of bone system, acute inf. diseases, and also impassability of the nasal courses for the probe (at impossibility to enter glucose intravenously it enter via the probe), etc. A relative contraindication are the compensated mitral defect, an idiopathic hypertensia of the I—II stage, an active pulmonary tuberculosis, a peptic ulcer in the absence of aggravations for several years, hron. pyelitis, cystitis and cholecystitis.

See also Hormonal therapy.


Rehabilitation actions begin at early stages of a disease and are held in a uniform complex with therapy. The volume and methods of rehabilitation are differentiated depending on a form Sh. and a stage of its development, like remission, residual conditions and some other factors.

In cases of Sh. which is favorably proceeding pristupoobrazno-progre-dnentnoy at the remaining natural adaptation the main objective of rehabilitation — the fastest return to former professional activity and a usual way of life, bystry recovery of social relateds. To this purpose serves the maximum reduction of terms of isolation from society (transfer of patients after manifest displays of psychosis on the mode of open doors, a day hospital).

At pristuioobrazno-irogredi-entnoy III., proceeding with long, sometimes long-term, attacks, ways of rehabilitation are defined by type of remission, its stability and depth of the occurred changes of the personality. The most high level of recovery of professional opportunities manages to be reached by means of short rehabilitation actions at remissions etenichesko-go and the gipertpmichesky types forming at superficial, which are not going beyond personal deviations changes.

The purposes of rehabilitation of patients of slow and periodic Sh. are identical. Slow Sh. even with the big duration of process does not lead in most cases to permanent disability. Despite the periodic aggravations demanding sometimes hospitalization in departments with the facilitated mode, patients continue to study or work, without reducing previous professional level.

At gradually going deep personal changes (the accruing psychopatholike manifestations, emotional depletion, narrowing of a focus of interest) the activation of labor installations which is most considering individual tendencies of patients is shown. At astenisation and emergence of other signs of falling of mental activity measures for simplification of working conditions (work in one change, release from night watches), and also a dignity are necessary. - hens. treatment.

At hypochiondrial, paranoid and nek-ry other remissions (with residual positive frustration), especially when their formation happens against the background of the expressed defect of the personality, need for medical and recovery actions remains throughout a long time after an extract from a hospital. For formation of social and labor installations and employment of patients train in special technological schools, direct to work to special workshops or crews on the general production.

Rehabilitation in nepreryvnotekushchy progreduated Sh.'s cases with big prescription of process and the expressed negative changes is most difficult. Due to big terms of stay in a hospital the expressed phenomena of a hospitalism are found in patients (see), they lose former social relateds and labor skills. For maintenance all links of rehabilitation, since development of skills of self-service and therapy by employment in department are used. The final stage is carried out in the conditions of the industrial enterprise of the general type (industrial rehabilitation); at this stage the rational household device of patients is provided.


the Forecast at Sh. is based on patterns of dynamics of endogenous process and is defined substantially by a form of a disease. At the same time the prediction of further development of painful frustration depends on a possibility of a reduction of positive manifestations and irreversibility of negative.

In each case it is necessary to consider age as predictive criteria, in Krom Sh., an originality of its development in this individual (frequency and duration of attacks, the nature of escaping them, quality and firmness of remissions, etc.), hereditary burdeness, premorbidal properties of the personality, existence of intercurrent diseases began. The expressed personal anomalies of schizoid type, signs of an intellectual underdevelopment, and also existence in the domanifestny period of craniocereberal injuries and other damages of the central nervous system make heavier the forecast.

Ideas of the fatal destiny of sick Sh. which is inevitably coming to the end with heavy weak-mindedness are disproved not only kliniko-katam-nesticheskimi, but also based on big material epidemiol. researches. In sick Sh.' population, according to 10. I. Liberma-na, low-pro-grediyentnoy shuboobrazny Sh.'s patients prevail, the current a cut is characterized by attacks (fur coats) most often with long steady remissions. So, of total number of the diseased with various forms Sh. within a year nearly a half are made by medlennotekushchy Sh.'s patients, and approximately V4 — patients with periodic and close to it pristupo - figurative and progreduated schizophrenia. Thus, the course of a disease which is considered favorable is observed at most of patients; rather small group of cases of malignant Sh. has the adverse forecast; bystry increase of negative changes at this form comes to the end with formation of final states with rough degradation of the personality.

As showed population researches of V. G. Rotstein (1982), at progreduated Sh. the forecast is adverse only in half of cases when formation of final states with fantastic modification of nonsense and catatonic frustration is observed. Only in old age it is possible to expect nek-ry mitigation of these symptoms.

The forecast is much better at Sh. with paranoiac frustration and when manifestation of crazy symptomatology is preceded by a long initial stage. The disease in many years can come to the end with encapsulation of nonsense (development of crazy system stops, the nonsense influences behavior of patients less and less) or its combination to psychopatholike frustration. Formation of such residual states does not interfere with social adaptation.

Periodic Sh.'s forecast in most cases favorable. Changes of the personality accrue slowly — only after repeated attacks, the negative symptomatology is limited to an asthenic syndrome. Best of all the forecast at psikhogenno or somatogenno provoked acute the attacks which are quickly reaching the culmination, and also at in the same way repeating symptomatology within the next aggravation of process (cliche type). At a prevalence in attacks of affective frustration the forecast concerning an urezheniye or a full reduction of the subsequent attacks improves in connection with prolonged preventive use of salts of lithium. At often repeating attacks when the current accepts continuous character, and a wedge, the picture becomes complicated due to dominance of katatonogebef-renny frustration, a failure.

The forecast at pristupoobrazno-progreduated III. it is ambiguous. To signs, allowing to assume comparative high quality of disease process, the full reduction of positive frustration coming after their end, sthenic or hyperthymic type of remissions, their big duration and which is closely connected with these a wedge, parameters the insignificant, not interfering social and labor adaptation reduction of mental activity belongs along with sharpness p short duration of attacks. For definition of the forecast pristupoobrazno-progreduated III. the fact that at most of patients throughout life the limited number of attacks is observed is of great importance. So, according to L. M. Shma-onova and Yu. I. Liberman, at 29.7% of population of patients with schizophrenia one attack, at 25,1% — two attacks is noted. The probability of repetition of psychosis considerably decreases if duration of remission exceeds 5 years. At certain stages of development of Sh. (is more often after one or several attacks) the forecast in connection with the occurring stabilization of process can change to the best. Superficial changes (tsiklotimopodobny or psychopatholike) do not interfere in these cases of full social and labor adaptation.

The optimum forecast is possible at patients slow Highway. In most cases thanks to use psikhofarmakol. means of a possibility of adaptation of patients with this form III. considerably extended. Despite the long, long-term course of process, signs of considerable intellectual and social decrease are not found in them. In nek-ry cases the forecast worsens in an after-life in connection with emergence during the involutional period of signs of an aggravation before that latent schizophrenic process.

As important predictive criterion the nature of hereditary burdeness can be considered. The analysis of a family background allows to assume not only a form of a course of a disease at a proband, but in nek-ry cases to predict also its specific manifestations. similar to those at relatives (through symptoms). Identification among his immediate blood family of patients with favorably proceeding psychoses (periodic Sh., maniac-depressive psychosis, involutional melancholy, situational depressions), and also persons with anomalies of character of cycloid type (see Psychopathies) the N taking suicide actions allows to predict the favorable course of psychosis at a proband. Absence of psychoses at close relatives or existence of severe progreduated forms Sh. on a sideline of relationship, and also detection of anomalies of character with the expressed emotional changes give the grounds to consider that the disease at a proband can accept malignant character.

During the definition of the labor forecast degree of a progre-diyentnost, type and depth of schizophrenic defect, and also some other clinical and social factors are considered. So, as the sign favorable for recovery of working capacity, rather high level of education and existence in a premorbidal condition of permanent labor installations in any sphere of activity is considered. Due to the remaining compensatory opportunities success at rehabilitation actions can be reached even at severe forms of a disease.

A lethality directly from III. it is exclusively small. She is possible only in extremely exceptional cases of a febrile catatonia. Slightly more often patients perish as a result of the suicide and accidents caused by disorder of mental activity. The heavy and long current of malignant Sh. with catatonic frustration contributes to a disease of tuberculosis, from to-rogo patients and perish.

At sick Sh.' maintenance in good a dignity. - a gigabyte. conditions, use of modern methods of treatment, broad development of labor therapy and employment life expectancy of sick Sh. same, as well as at all population.


At sick Sh. actually labor skills completely are not lost, but ability to purposeful productive activity in general is broken, adaptation to public production factors is complicated, the relation to production duties is changed. Disturbance of working capacity at them is caused more often by decrease of the activity, disorganization of behavior, loss of intellectual productivity, installation on work, the lack of a critical self-assessment overestimated by the level of claim, not to the corresponding real opportunities, etc. During the definition of extent of decrease in working capacity special attention is paid to changes of the personality — her integrity, plasticity, socially important qualities, world outlook installation, an orientation of interests. At rather favorable in the relation a wedge, the forecast cases after the carried-out treatment the remained ideas of the relation make heavier the labor forecast and complicate professional adaptation.

Many factors, significant for the labor forecast, are defined by a form of a disease. At malignant Sh. extent of social and labor adaptation low, treatment-and-reabilitation measures are ineffective, the available pathology and profound changes of the personality are incompatible with professional activity, compensatory opportunities are minimum. At slow Sh. patients manage to get an education, to master the qualified profession. In this case medical and rehabilitation measures are effective; patients have sufficient compensatory reserves, the remaining frustration roughly do not break behavior, disability comes at late stages of a course of a disease. At nepreryvnotekushchy progreduated Sh. social and labor adaptation steadily decreases that at late stages of disease leads to disability. At pristu-poobrazno-progreduated Sh. conditions of long temporary disability, the periods of decrease, loss and recovery of working capacity are observed. During recovery of working capacity patients, as a rule, manage to gain production skills and an experience that promotes their rehabilitation. Disability at the listed forms of disease comes at different age.

The risk of social and labor disadaptation at Sh. remains still is high. Disability in different terms is noted approximately at 50% of patients. At the same time almost in 70% of cases the II group of disability, in 25% — the III group and in 5% —

the I group is established. As a rule, disability of the I group is established to patients with the malignant form Sh. which began at early children's or youthful age with deep regress of behavior, an intellectual nesostoyata with a lnost, catatonic, gebefrenny frustration, etc. Such patients need permanent foreign care and supervision. Disability of the II group is established at long displays of a disease, incomplete, unstable, poor quality remissions, at tendency to frequent exacerbations of a disease and a recurrence when owing to affective, hallucinatory, catatonic, crazy frustration, changes of the personality, behavior disorders patients are not capable to professional work. Many of them can be involved in work in medical and production, labor workshops (see), the special workshop, work at home or in the specialty in individually created conditions at production. Disability of the III group is established at slow Sh. with insufficiently high quality of remissions in connection with decrease in professional level, impossibility to perform work as a former qualification and to volume, in particular patients, to-rye cannot be returned to a profession of the driver, dispatcher, doctor, teacher, to administrative work, work in harmful conditions, etc. At long attacks with the favorable forecast establish temporary disability, terms a cut can be prolonged up to 6 — 8 months and more.

The sick Sh. suitable for productive professional activity admit able-bodied, at to-rykh display of a disease do not influence performance of production duties.

In the course of examination of working capacity issues not only of group, but also of the reason of disability, terms of its approach, need of re-examination can be resolved, and also recommendations about labor training, the labor device, measures of medical and social rehabilitation, etc. are taken out. Ascertaining of disability is possible only after comprehensive inspection, complex treatment of the patient. Disability at Sh. is not stable. Approximately in 50% of all cases of Sh. positive or negative dynamics comes to light.

The solution of labor examination not only defines position of the patient, but also has the general social and economic meaning. Its purpose to prevent deep social and labor disadaptation of patients, to involve them in different types of feasible labor employment, to return them to the sphere of social production, to keep production shots, valuable to society.



the Main feature of Sh. — the progreduated current, continuous or pristupoobrazny, followed resistant, and is frequent also the accruing changes of the personality. On the basis of these changes in the relation of the persons having this disease the decision on diminished responsibility is passed (see Diminished responsibility).

During the developing of a disease after commission of an offense, during the investigation or stay in the places of detention sick exempt from punishment (Art. 11 of the Criminal code of RSFSR). Such patients would be sent by a court decision to psychiatric.

In definition of a question of sanity or diminished responsibility cases when sick Sh. make npaBOHapyj of a muskmelon evaporated juice during the permanent long-term remission which is not followed by noticeable personal changes occurred after an undoubted attack of III are usually difficult. When deep and long remission is followed by good social adaptation, and in the conditions of legal proceedings at made socially dangerous act there are no frustration inherent to a disease, clear psychogenic frustration (see Psychogenias), these persons admit imputed due to the lack of legal criterion of diminished responsibility. Researches showed that Sh. proceeding in the form of the only attack after the Crimea comes an intermissiya, i.e. practical recovery, is not a rarity. Increase in number of iiter-missions at Sh. is promoted by therapy psikhofarmakol. means and the medicinal pathomorphism connected with it (see. Mental diseases). At the same time practice of judicial psychiatry shows that patients of III., the intermissiya which are in a state, exclusively seldom make offenses.

Difficulties in definition of a question of sanity — diminished responsibility meet also when Sh.'s diagnosis raises doubts. Most often such difficulties arise at the initial stage of Sh. and at its sluggish current when in a wedge, a picture of a disease neurosis-like, psychopatholike or paranoiac frustration prevail. In these cases statement of the wrong diagnosis is quite often promoted by underestimation of the psychoinjuring factors existing at sick personal changes at simultaneous revaluation of value environmental. Such patients, recognized responsible, in some cases after departure of punishment make repeated socially dangerous acts.

Judicial psychiatric expertize (see Examination forensic-psychiatric) is carried out by sick Sh. and in connection with civil cases when issues of their capacity and respectively are resolved of guardianship. Need of protection of the rights of mentally sick person and a problem of prevention of socially dangerous acts define value of such examinations. Usually forensic-psychiatric examination in connection with civil cases is passed by the patients suffering from slow Sh. or the patients who are in a condition of remission. The question of capacity is raised concerning much wider contingent of patients, than a question of sanity. Ability to understand value of the legal actions and to direct them remains in some cases at patients with not expressed schizophrenic defect. Due to the features wedge, pictures III., a possibility of satisfactory social adaptation of patients and special requirements imposed to the subject by different types of legal relationship (education of children, the marriage relations, transactions, etc.), the differentiated assessment of a condition of patients in relation to various legal acts is necessary. At the same time it is necessary to show the maximum care since deprivation of the patient of the legal rights can sharply break his professional and social adaptation and by that to nullify results to lay down. influences.

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A. V. Snezhnevsky (head of group of authors, wedge, picture, history); M. E. Vartanyan (an etiology and a pathogeny), M. Sh. Vrono (features of schizophrenia at

children's and pubertal age),

B. M. Gindilis (gen.), A. E. Lichno (treatment by insulin), E. K. Molchanova (features of schizophrenia at late age), K. K. Monakhov (disturbance of higher nervous activity), G.V. Morozov (sudebnopsikhiatrichesky examination),

R. A. Nadzharov (classification, the characteristic of various forms of schizophrenia), M. S. Rozova (labor examination),

A. B. Smulevich (the diagnosis, the forecast, treatment, rehabilitation).