Treatment of schizophrenic personality defect

In the scientific community, schizophrenia refers to a complex personality disorder at the psychological level, leading to disturbances in emotional reflexes and mental abilities. According to official statistics, 1% of people suffer from this disease, not counting those who are not aware of the problem. Treatment of schizophrenia is aimed at relieving acute symptoms, which gives the person a chance to return to normal life. But most people treat such patients with prejudice and negativity, which has given rise to many myths in this direction. They are baseless, but firmly rooted in the consciousness of the people.

Schizophrenics are dangerous to society due to cruelty and aggressiveness

This is also partly a myth. Many people have the impression that people with schizophrenia pose a threat to others. Mostly this is the negative influence of media and films. In fact, people with schizophrenia are as harmless as children. On the contrary, they themselves often become targets of criminal attacks.

A different scenario happens in the absence of proper treatment. Then, in the acute stage of the disease, a person is prone to violence under the influence of visions and delusional thoughts. It’s more scary when there are hallucinations of an auditory nature in the form of a call for specific hostile actions.

For example, in 2015, one resident of Nizhny Novgorod, during an exacerbation of schizophrenia, killed his own family (six children, wife and mother). He explained the action by saying that he heard an order to act in this way. Belov suffered from schizophrenia for a long time and repeatedly showed aggression towards his wife. Relatives tried to keep it a secret and did not seek help from doctors.

No less dangerous are delusional states associated with persecution mania. A person sees everyone and everything around him as a threat to himself. To protect himself, he often begins to defend himself from supposedly attacking people. Therefore, during an exacerbation of schizophrenia, relatives close to the patient are at greater risk.

Material and methods

The study included 170 patients suffering from schizophrenia and schizophrenia spectrum disorders, 63 men and 107 women, whose average age was 41±15 years, and the average duration of the disease was 22.3±5.4 years.

The sample was formed from the number of patients (112 observations) hospitalized at the Scientific Center for Mental Health (director - Prof. T.P. Klyushnik) during 2016-2018. and examined at the clinic of the Department for the Study of Borderline Mental Pathology and Psychosomatic Disorders (headed by RAS Academician A.B. Smulevich) and in the psychotherapeutic department of the University Clinical Hospital No. 3 of the First Moscow State Medical University. THEM. Sechenov (rector - RAS academician P.V. Glybochko). Along with the patients of this group, the study included observations (68 patients) previously presented in published works carried out in the Department for the Study of Borderline Mental Pathology and Psychosomatic Disorders [20, 21, 47, 54].

Inclusion criteria

patients in the study were as follows: compliance of the mental status and stereotype of the disease with the diagnosis of “schizophrenia” (simple - F20.6, residual - F20.5 according to ICD-10) or “schizotypal disorder” (F21);
the duration of the disease is at least 10 years, allowing verification of the clinical characteristics of the defect; abnormal structure of premorbid constitutional make-up, represented by any types of RL; the ability to collect objective information about patients who have reached adulthood from at least one of their capable parents; informed consent of patients to participate in the study .
Exclusion criteria were severe concomitant somatic or neurological pathology that prevented the study.

The main research methods were psychopathological and psychometric. In addition, a psychological examination of the patients was carried out, which included an assessment of the general cognitive profile and personality structure over time, taking into account its premorbid makeup and its changes during the course of the disease.

A number of scales were used for psychometric evaluation. Thus, to determine the profile of negative symptoms, the SANS​7​᠎, PANSS​8​᠎ and MFI-20​9​᠎ scales were used, to diagnose the personality profile in dynamics - the OCHH-B​10​᠎, SCL-90-R scales ​11​᠎, SPQ-A​12​᠎.

Statistical processing was carried out using standard methods of the Statistica 10.0 program (Mann-Whitney test, Spearman correlation analysis with Bonferroni correction when estimating the p

; Data clustering was carried out using the k-means method).

Schizophrenia can develop due to flaws in upbringing

One of the causes of schizophrenia is considered to be improper upbringing. In particular, we are talking about a lack of attention from the mother. In fact, blaming parents in this matter is baseless. No matter how coldly they treat their own child, this cannot provoke illness years later. Schizophrenia is a serious mental disorder, the development of which is caused by a whole complex of negative factors. Here are some of them:

• predisposition at the genetic level;
• head injuries;
• frequent stressful situations;
• brain dysfunction and so on.

There are still many questions in this regard to which scientists have not received accurate answers.

The relevance of considering the current state of the problem of schizophrenic defect is determined by the underestimation of the importance of negative disorders in the diagnosis and treatment of schizophrenia. Thus, a formalized assessment of the results of psychopharmacotherapy (using operational criteria1​᠎), aimed at establishing and improving the quality of remission in schizophrenia, takes into account the contribution of negative disorders insufficiently. Thus, of the eight points of the PANSS scale, the reduction of which is taken into account when qualifying the state of remission, only three relate to negative symptoms (N1 - dulled affect; N4 - passive-apathetic social withdrawal; N6 - impaired spontaneity and fluency of speech). At the same time, the frequency of negative disorders in schizophrenia is significant and depends on the duration and type of course of the disease. According to domestic authors [3, 4], this frequency (excluding outpatient forms and schizophrenia spectrum disorders) for continuous (excluding paranoid) schizophrenia is 40%, for fur-like schizophrenia - 31%, for recurrent - 29%. With a follow-up period of 12 months from the onset of the disease [5, 6], negative disorders are diagnosed in 16–35% of cases and subsequently persist, which correlates with the same indicator (35%) 2 years after the first hospitalization [7]. In out-of-hospital settings, one or more negative symptoms are observed in 52.5% of patients with schizophrenia [8].

According to modern ideas about the relationship between deficit and positive disorders in patients with schizophrenia [7, 9, 10], negative disorders are an independent typologically differentiated psychopathological category

.
Negative disorders have their own pathophysiological basis, as well as a developmental trajectory largely independent of positive symptoms
.

Based on data from domestic [11–14] and foreign literature [15–17], as well as their own research [18, 19], the authors developed a typological taxonomy of defects in schizophrenia and schizophrenia spectrum disorders, which is given below. This taxonomy, being syndromic, is comparable in some respects to the symptomatic classification of negative changes, based on research data using the psychometric scales PANSS, BPRS, SAPS/SANS. It includes three main types of defect (I-III).

Type I defect - pseudopsychopathy

, the formation of which occurs by overlapping dimensions characteristic of personality disorders (PD) and negative disorders already at the initial stages (or premorbid) of the disease2​᠎. This type is comparable to descriptions of negative disorders such as the “preceding deficit paradox” [15], “premobid negative symptoms” [16], “schizophrenia proneness” syndrome [20], “precursors of negative disorders” [17], “prepsychotic vulnerability” [21], “attenuated negative - pseudo-adaptive psychobehavioral phenomena” [22]. This interpretation is confirmed by the results of genetic studies by A. Jorgensen and J. Parnas [23], who consider the comorbid relationship between the manifestations of schizoid premorbid and deficit changes as an indicator of the contribution of genetic factors to the formation of negative disorders3​᠎. At the same time, in the structure of most variants of a psychopathic-like defect there are changes of the Ferschroben type, associated with schizoid (deficient schizoids [13]), paranoid [26], hyperthymic, excitable [14], hysterical (defective hysteria/dissociation), anankastic [13, 27, 28] dimensions.

Type II defect - pseudoorganic (asthenic, oligophrenic-like, pseudobradyphrenia, etc.),

formed at different stages of the endogenous process.

III type of defect - psychopathic (acquired psychopathy of the type of “new” life, not associated with premorbid pathocharacterological characteristics of the personality), with the formation of an endogenous process in the later stages.

Before moving on to the analysis of the current state of the problem, let us turn to the historical background of the doctrine of the schizophrenic defect and consider the stages of its development. First of all, it is necessary to dwell on the data indicating the existence of negative disorders dating back to the pre-nosological period of psychiatry, i.e., anticipating the “discovery” of dementia praecox

as an independent disease - the first stage. “Idiocy” has been described in insanity [29], thymic deficiency [30], “weakening of the brain and decline”, when “the thinking ability has no energy, is devoid of direction” [31], extinction of mental functions [32], “acquired idiocy of young "[33]. The key concept at this stage is the concept of H. Jackson [34], who, in accordance with the data of a number of publications [35-38], is credited with introducing the term “negative symptoms” into the scientific lexicon4​᠎. At the same time, he emphasized the priority of negative (over positive) disorders in terms of pathogenetic connection with the disease process.

The second stage in the development of the doctrine of negative disorders in schizophrenia was marked by the identification of dementia praecox

[47], the main clinical characteristics of which include the formation of a defect. According to E. Kraepelin: “the most important symptom of early dementia is emotional dullness - indifference to previous objects of attachment, fading of feelings for relatives and friends, loss of satisfaction from work and leisure, which is often the very first and most frightening symptom of the onset of the disease.” The concept of dichotomous division of schizophrenia symptoms into primary and secondary psychopathological formations proposed by E. Bleuler​5​᠎ [48] seems to be key in terms of the problems considered in this study. It must be emphasized that the primary symptom complexes of E. Bleuler​6​᠎ (abnormality of associative processes, ambivalence, affective incongruence, autism) are in fact the prototype of currently identified negative disorders (persistent negative symptoms) [7, 10]: alogia, apathy/abulia , flattened affect, asociality [50]. In this aspect, the clinicopathogenetic assessment of primary symptom complexes, which, in accordance with the concept of E. Bleuler, act as basic psychopathological formations that determine the essence of the disease, acquires paramount importance.

At the subsequent third, post-Kraepelin/post-Bleiler stage, the concept of deficiency states of the endogenous circle developed within the framework of two polar models. On the one hand, we are talking about models of “clinical unity” of negative/positive disorders, on the other hand, about a model that interprets positive and negative symptom complexes as “heterogeneous psychopathological categories.”

Models of obligate overlap of positive and negative disorders (“clinical unity”) are based on the concept of dissolution by H. Jackson (1831), according to which, as negative disorders increase due to damage to phylogenetically “younger” structures of the psyche, the functions of which drop out, naturally become more actualized. ancient” (deep) formations, the consequence of which is positive symptoms, which are inseparable from negative ones with this approach. Most psychiatrists of the post-Kraepelin/post-Bleiler period approached the construction of a psychopathological model of schizophrenia in the light of the Jacksonian hierarchy and, accordingly, considered positive and negative symptom complexes within a single clinical space. Thus, H. Ey [51], pointing to the unity of negative and positive symptom complexes, analyzed the vector of interaction of these disorders within the framework of two interrelated processes: negative symptom complexes reflect the disintegration of intrapsychic structures directly related to the organic process, while positive disorders represent a mechanism of restitution (restoration) of healthy areas of the brain. Significant contribution to the development of the teachings of A.V. Snezhnevsky introduced the concept of H. Jackson [52] about the simultaneous increase in the severity of positive and negative disorders as the endogenous process progresses (Fig. 1). The tendency to combine positive and negative symptom complexes within a single syndrome clearly appears even when describing the final states of schizophrenia - paranoid/catatonic dementia [51, 53], in which, it would seem, manifestations of the defect should dominate.

Rice. 1. The ratio of positive and negative symptoms of schizophrenia according to the concept of A.V. Snezhnevsky.

However, a number of publications dating back to the mid-20th century, formally conceptualized within the framework of the “clinical unity” model, actually postulate the primacy of positive disorders, that is, the dominance of positive symptoms. In this regard, the minimization of the criteria for negative disorders in the diagnostic models of schizophrenia by G. Langfeldt [54] and K. Schneider [55], which aim to clarify (limit) the boundaries of schizophrenia and form the basis of the diagnostic criteria for schizophrenia in ICD-10, DSM-III and DSM-IV. Thus, the positive symptoms cited by the authors as such are developed in detail and combine delusions of passivity (openness of thoughts, external control over movements, statements, impulses, feelings, will [54]) and delusional perception (withdrawal/investment, openness of thoughts, feeling that actions controlled, committed under external influence [55]), co-anesthesiopathy (somatic hallucinations [54, 55]), auditory hallucinations (the sound of one’s own thoughts, “voices” talking about the patient, commenting on his actions [55]), allo-/autopsychic depersonalization [54]. In turn, negative disorders that are deprived of the status of an independent psychopathological phenomenon are not included in the list of diagnostic criteria for schizophrenia. Accordingly, the role of negative disorders as differentiating markers is minimized.

This trend continues at the beginning of the 21st century. According to some adherents of extreme positions [2], it seems reasonable and appropriate to exclude negative symptoms from the criteria for remission in schizophrenia “as a diagnostically insignificant and low-specific” group of symptoms with low expert reliability.

In the article “Century” (“One Hundred Years”), dedicated to the anniversary of the publication of E. Bleuler’s monograph “Dementia Praecox oder Gruppe Der Schizophrenie” (1911), W. Carpenter [56] points out these significant shortcomings of the diagnostic system proposed at the post-Bleuler stage of research and delimitation of schizophrenia. Among them, the author focuses on disturbances in the perception of reality (i.e., positive disorders - A.S.

) and underestimation as diagnostic criteria, identified by E. Bleuler, of primary symptoms - directly related to the endogenous process (i.e. psychopathological manifestations of the negative series -
A.S.
) symptoms. Indications of the shortcomings of the diagnostic system of G. Langfeldt and K. Schneider, which essentially levels out the role of negative disorders, are also contained in a number of modern publications [57].

At the end of the 20th and beginning of the 21st centuries, the concept of negative schizophrenia [36, 50, 58-62], a polar model of the unity of positive and negative disorders, which dramatically changed the direction of research on deficiency states and, accordingly, signified a break with Jacksonian traditions in psychiatry, became fundamental.

The fundamental idea that determined the direction of research on deficiency disorders at this stage is the dichotomous division of manifestations of the endogenous process (negative/positive schizophrenia). The framework of positive schizophrenia includes psychopathological formations corresponding to the symptoms of the first rank by K. Schneider, and negative - primary according to E. Bleuler or basic according to G. Huber [63] negative symptom complexes.

The concept of negative schizophrenia in its modern modification is based on the identification of this category as an independent clinical entity that reveals its own clinical and pathogenetic correlates and developmental stereotype [36, 37, 50, 58-62]. In terms of further development of this area of ​​research, the concept of primary persistent negative symptoms is advocated [7, 10. 38]​7​᠎. The latter include two types of clinically heterogeneous phenomena, differing both in their underlying pathophysiological mechanisms and in functional outcome: motivational deficiency

— abulia, or “avolition” (anhedonia, apathy, asociality), and
expressive deficit
, or “expressive deficits” (flattened affect, impoverished speech, alogia) [65, 66]. In this case, expressive deficit is considered as a core group of schizophrenic defect [67].

The stability of primary negative disorders formed within 1 year after the first episode is low; As evidenced by the materials of follow-up studies, in subsequent years the prevalence of negative symptom complexes increases significantly. Thus, according to W. Chang et al. [5], the prevalence of primary persistent negative disorders within 1 year after the first attack of the disease is 6.5% and increases over the next 2-3 years to 23.7%.

However, as evidenced by our own observations and data from a number of studies, the spectrum of process-based deficit disorders is not limited to the psychopathological manifestations appearing in the clinical space of negative schizophrenia. The same applies to the trajectory of development of psychopathological symptom complexes: negative schizophrenia (a mode of multidirectional dynamics in relation to positive dimensions is only one of the options for overlapping negative and positive disorders in diseases of the endogenous circle).

The dynamics of negative disorders have different trajectories, and the possibilities of overlap with positive symptom complexes are correspondingly diverse. Based on literature data and our own research, three variants of development trajectories of negative/positive symptoms that are realized during the course of an endogenous disease were identified: 1) simultaneous-progressive

;
2) multidirectional
(polar vectors);
3) simultaneous phase
with overlapping negative/positive disorders at the level of general symptoms.

With immutable-progressive dynamics

characterized by the fact that negative and positive disorders at the stage of the active course of the endogenous disease grow together.
Subsequently, at the stage of stabilization of the disease process, with their complicity, either final/initial states
(overlapping symptom complexes of a pseudo-organic defect and residual - subpsychotic - symptoms of the positive circle) [53, 55, 68, 69] or
post-process borderline states of a binary structure
. The latter are remissions of the second/new life type [70-72], the structure of which is determined by psychopathic-like changes that form on the basis of negative changes (asthenic, pseudo-organic defect with phenomena of reduction in energy potential). Such “acquired psychopathy” are personalized phenomena that duplicate in a reduced form the manifestations of psychosis (hypoparanoia, dyskinetopathy, Ferschroben-type changes [18, 72-74]. (Fig. 2).

Rice.
2. Simultaneously progressive development of negative/positive disorders in the form of final/initial states (1) or post-process borderline states of a binary structure (remissions of the second/new life type) (2). Multidirectional dynamics

psychopathological symptom complexes are represented by trajectories of negative/positive disorders that have polar development vectors. At the same time, variants of dynamics with dominance throughout the entire course of the disease of either negative disorders (negative schizophrenia, see above) or positive symptoms are identified.

In negative schizophrenia, the formation of positive disorders is completed at the initial stages of the process, and the entire clinical space of the disease belongs to deficiency symptom complexes, due to the deepening of which the progressive movement of the process is realized.

In the polar version of the multidirectional development of psychopathological disorders at the initial stages, the formation of not positive symptoms, but a defect (“schizophrenia stopped at the very beginning” [75]) is completed. Note that indications of a variation in the dynamics of psychopathic-like disorders with increasing accentuation of schizotypal traits and manifestations of the Verschroben type over the years, which can be considered as indicators of a very slow progression, are found in a limited number of observations [76].

Clinical manifestations and their further dynamics throughout the course of the disease are realized due to positive endoform disorders (hypochondriacal symptom complexes with phenomena of bodily autism, subsyndromal affective phases of the “acquired cyclothymia” type, etc.), formed on the basis of the primary ones - at the level of pseudopsychopathy (see above ) and negative changes of the “second disease” type [19]) (Fig. 3).

Rice. 3. Multidirectional (polar vectors) course of negative/positive disorders in negative schizophrenia (1) and “schizophrenia stopped at the very beginning” (2).

Simultaneous-phase flow

is realized at the level of two polar models of overlapping negative/positive disorders, accompanied by the formation of common symptoms. At the same time, the vector of comorbid relationships between negative and positive disorders is ambiguous and is determined by the heterogeneity of the structure of deficiency symptoms.

With a psychopathic-like defect

Deficient changes that have already reached the level of completed clinical formations represent a vector of attraction for depressive symptom complexes (G. Gross model of transitional syndromes [77]). In these cases, the symptoms of affective registers acquire the properties of a psychopathological formation, “superimposed” on the manifestations of the main non-affective disease (“superimposed on ... nonaffective psychiatric disorders” [78]). Affinity for negative disorders in these cases is primarily revealed by depression, which occurs with a predominance of neurotic, conversion and dissociative (compartment dissociation) symptoms.

Within the second model - phase defect

[16, 79])​8​᠎ the vector of attraction takes on the opposite direction: the manifestation of recurrent depressive phases is accompanied by the exacerbation of previously latent deficiency symptoms.

Affinity for affective disorders in these cases reveals a defect of the avolition type (apathy, anhedonia, anergy). Deficient changes located at the level of subsyndromal formations, overlapping with depressive symptoms (psychopathological complex of negative affectivity), reach the level of completed clinical formations, and upon completion of the affective phase are reduced (Fig. 4).

Rice. 4. Simultaneous-phase course of negative/positive disorders (overlap at the level of general symptoms).

Therapy of negative symptom complexes, the formation of which in schizophrenia and schizophrenia spectrum disorders significantly affects the depth (symptomatic/syndromic) and duration of remissions, the level of social adaptation of the patient and his functional recovery [81], is associated with the need for the maximum possible medicinal effect.

Despite the variety of clinical types of defect/negative symptom complexes (transient, phase defects, defects that have completed formation already at the onset of the disease, psychopathic, persistent - asthenic, pseudo-organic [16], as well as secondary), one of the main principles of therapy for deficiency disorders is the use of drugs with distinct “anti-negative” properties

. Such possibilities are inherent in the mechanisms of action of atypical antipsychotics, primarily risperidone, clozapine, amisulpiride, and olanzapine [82].

The drug cariprazine (a piperazine/piperidine derivative), which, judging by the data of foreign publications[83, 84], has pronounced anti-deficiency activity, is highly effective in the treatment of schizophrenia, which occurs with a predominance of negative disorders.

The main goals of “anti-negative” drug effects are considered to be 1) prevention
(
or at least slowing down) of the transformation of latent deficiency changes to the level of persistent syndromic completed deficiency structures;
2) correction of already formed negative disorders
.

Tasks aimed at preventing the progressive development of deficiency symptoms are located in the area of ​​early, before the manifestation of the disease, identification of distinct signs of the disease (at the level of precursors of negative disorders [85], manifestations of premorbid negative [16] and subclinical negative symptoms, signs of disorganization [86]) and medicinal influence primarily with the help of antipsychotics.

The advisability of starting treatment at the prodromal stages of the disease is convincingly demonstrated by data from a number of studies [87, 88], which make it possible to establish the benefits of early psychopharmacological intervention [89, 90]. In this case, indicators such as the duration of the untreated disease

(DUI - Duration of Untreated Illness), which determines the time passed from the appearance of the first psychopathological symptom to the start of adequate psychopharmacotherapy, and
the duration of untreated psychosis
(DUP - Duration of Untreated Psychosis), the end point of which coincides with the definition of DUI, and the beginning is counted from the manifestation of manifestations psychosis (Fig. 5). Thus, D. Perkins et al. [91] found that a shorter DUP is associated with a better response to treatment with antipsychotics, which is manifested by a decrease in the severity of psychopathological, including negative disorders, and an improvement in the clinical prognosis and social functioning of the patient.

Rice.
5. Models of therapy for schizophrenia. The use of psychotropic drugs in these cases is aimed at both a course strategy (reversing negative changes) and a preventive (preventing/slowing down the progressive dynamics of negative disorders) effect, which involves the continuation of psychopharmacotherapy even in conditions of complete reduction of positive disorders (in the process of preventive therapy the risk of exacerbation is also minimized positive symptoms). An obligatory component of drug prescriptions in these cases are atypical antipsychotics (aripiprazole, risperidone, etc.), prescribed in minimal, individually tolerable doses.

Assessment of the possibilities of drug intervention (in terms of further development and improvement of methods for overcoming resistance) in the psychopharmacological correction of subdomains of negative disorders is based on the modern clinical model of the schizophrenic defect. In accordance with it, negative disorders are considered as a multidimensional structure based on heterogeneous pathophysiological mechanisms [92], and not as a single psychopathological construct. Accordingly, psychopharmacological correction is carried out with drugs that have selective activity against conditionally reversible components of negative disorders and manifestations of the defect associated with positive symptoms. In the first case, the objects of drug intervention are relatively isolated negative manifestations - circumscript manifestations of the defect. These may include impulsivity with a risk of aggression and self-harm; paranoia with ideas of relationship; primary autistic activity - pathological overvalued hobbies, etc.; syndrome of overopenness and fetishization of the defect—autism inside out [93].

Among the manifestations of the defect associated with positive psychopathological disorders, autochthonous asthenia with symptoms of somatopsychic fragility can be considered as target symptoms of psychopharmacotherapy [11]; sensoroipochondria [94]; apathetic defect (such as avolition), overlapping (within the framework of general symptoms) with the phenomena of dysthymia (phase defect [16, 79]); defective mania; defective hysteria [95, 96]; deficit changes such as social withdrawal, combined with anxiety-phobic disorders (panic attacks, agoraphobia).

Schizophrenic reactions (for example, refusal reactions [97, 98], postponement [99, 100], juvenile asthenic failure [101], etc.) as manifestations of the dynamics (psychogenically/situationally/somatogenically provoked) of defective states also act as the object of drug intervention (psychopathic-like defect of the pseudo-acquired psychopathy type).

Returning to the general principles of treatment of negative disorders, it is necessary to emphasize the following. The above data on the structure of the defect and associated psychopathological disorders indicate the need to use a wide range of psychotropic drugs for their correction: along with the mandatory prescribed atypical/traditional antipsychotics, the treatment regimen includes drugs of other psychopharmacological classes - antidepressants, anticonvulsants (pregabalin), nootropics (nootropil, Cerebrolysin, Pantogam active), tranquilizers.

The study was carried out with financial support from the Russian Foundation for Basic Research within the framework of scientific project No. 16−07−00997.

The authors declare no conflict of interest.

The formalized criteria for remission in schizophrenia proposed by the American and European working groups [1, 2] combine two components: a symptomatic criterion, including core symptoms of schizophrenia (scores of 3 or less on the eight most diagnostically significant PANSS items), and a temporary criterion (duration more than 6 months).

The qualification of all pathocharacterological changes that appear in the prodrome of a procedural disease as negative disorders can only be considered within the framework of a psychopathological hypothesis and requires further clinical verification.

Research by M. Dominguez et al. also points to genetic vulnerability as one of the factors influencing the development trajectory of negative disorders. [24] and M. Janssens et al. [25].

According to research in the history of psychiatry [39], the identification and description of “negative symptoms” was also carried out by H. Jackson’s predecessors [40–44]. Among them, first of all, it is necessary to highlight J. Reynolds [45], to whom the author referred in his work of 1875 [46].

The concept of E. Bleuler, who identified primary and secondary symptoms in the psychopathological space of schizophrenia, laid the foundations for the subsequent paradigm shift of schizophrenia from categorical to dimensional.

The concept of the primacy of negative disorders in relation to positive ones raises a number of objections, since it turns out to be inapplicable to some conditions. For example, in cases of primary (primordial according to W. Griesinger [49]) delirium, positive symptoms clearly cannot be considered as secondary.

The term “primary persistent negative disorders” defines a broader concept in relation to the model of negative disorders; negative symptoms of increasing severity should determine the clinical picture for at least 6 consecutive months. The presence of secondary negative disorders is excluded [64].

Depression, which forms common symptoms with negative disorders, defined in modern literature within the framework of a defect such as avolition, as V.M. points out. Morozov [80], in prognostic terms act as “heraldic signs” of a progressive endogenous process.

Cariprazine exhibits high (in vivo) affinity for dopamine receptors of the D3 and D2 types (with a predominant effect on D3 receptors), as well as partial agonism to 5-HTIA receptors. The use of the drug in clinical institutions of the Russian Federation has not yet been approved.

If one of the parents suffers from schizophrenia, the child cannot avoid a similar fate

It is believed that parents with schizophrenia give birth to a mentally ill child. This statement is fundamentally incorrect. Heredity cannot be ruled out, but it is not the disease that is transmitted, but the tendency to it. Therefore, it is wrong to give up on a child whose mother and father or one of them suffers from schizophrenia.

The theoretical probability of inheriting the disease is estimated at 67-88%. But in reality the numbers are not so scary:

• in identical twins (even those with a genetic predisposition) - 45-47%;
• Mom or dad is sick - 14%, both - 45%;
• the diagnosis was made to close relatives – about 5%.

Various types of research continue to establish the degree of inheritance of schizophrenia. But so far the results are mixed and preliminary. Scientists already know specific genes that can trigger the development of the disease. This is revealed by reading genetic information and carefully studying it.

More precise data were obtained by trying to link this disease to changes in the gene component of several candidates. Thus, the majority of schizophrenics have a polyform type of serotonin, dopamine and COMT genes. But their presence can also be associated with other mental disorders. So, even if there is a complete breakdown of the genotype, it is impossible to give an accurate forecast of whether a person will develop schizophrenia or not.

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Neuroses, phobias

PsyAndNeuro.ru

The relationship between personality pathologies and schizophrenia is one of the central problems of psychiatry. Some personality disorders are considered to be risk factors for the development of schizophrenia and are considered its prerequisites. Thus, some features of borderline disorder also resemble symptoms of schizophrenia. Hierarchical structures and symptom classification systems allow us to look at comorbid pathologies, including personality disorders, differently. Experts often do not pay enough attention to the problem of comorbid disorders and do not consider the treatment of schizophrenia in conjunction with concomitant disorders, since they mistake them for one of the psychotic symptoms or for their side effect.

Personality disorders can prevail both during treatment of the disease and throughout the patient’s life. In this regard, difficulties arise in accurately determining the type of disorder, making a diagnosis and treating it. In a recent review, Simonsen E. and Newton-Howes G. offer the following conclusions.

Clinicians should not forget that psychotic reactions observed during borderline disorders may indicate concomitant affective psychosis, the result of substance abuse, side effects of medications, as well as symptoms preceding schizophrenia.

The incidence of co-occurrence of personality disorders and schizophrenia varies widely, but averages 40%

. At the moment, it is impossible to accurately determine which personality subtype is most susceptible to this risk. One of the hypotheses for the occurrence of comorbid disorders insists that there are certain character traits that increase the likelihood of two diseases occurring at once. The hypothesis cannot be tested using meta-analysis due to lack of data, so the question of the interrelationship of psychopathology, personality traits and hereditary factors remains open.

The best evidence suggests that psychotherapy is the most appropriate first-line treatment for personality disorders, particularly borderline personality disorder. Developing a treatment plan that incorporates elements of personality therapy can be an effective tool for treating symptoms of schizophrenia.

The material was prepared as part of the ProSchizophrenia - a specialized section of the official website of the Russian Society of Psychiatrists, dedicated to schizophrenia, modern approaches to its diagnosis and treatment.

Author of the translation: Korneeva K.K.

Editor: Kasyanov E.D.

Sources:

1. Erik Simonsen and Giles Newton-Howes. Personality Pathology and Schizophrenia. Schizophrenia Bulletin, 04.24.2018 doi:10.1093/schbul/sby053
2. Newton-Howes G, Tyrer P, North B, Yang M. The prevalence of personality disorder in schizophrenia and psychotic disorders: systematic review of rates and explanatory modeling. Psychol Med. 2008;38:1075–1082

Schizophrenia leads to dementia

In life, you can encounter different clinical variants of the development of schizophrenia. Each case is individual. In some, the development of schizophrenia is practically asymptomatic and does not in any way affect mental capabilities. Such patients are still able to think rationally, learn successfully, and do not suffer from memory loss and other manifestations characteristic of schizophrenia.

Other people with a similar diagnosis show obvious deviations at the emotional and mental level. With each new attack, the situation worsens and over time leads to the fact that the person is unable to independently perform basic everyday activities, much less work. There are especially severe forms when the disease progresses rapidly and quickly leads to disability.

No doctor can say for sure what awaits a person with schizophrenia. Despite numerous studies in this direction, science is still powerless. You can compare the state of the brain at different time stages, based on which you can make an approximate forecast.

Cases have been recorded where people suffering from schizophrenia for a long time remain completely adequate and do not lose basic life skills. For example, Nobel laureate D.F. Nash was schizophrenic. But this did not stop him from successfully teaching at the university.

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Personality disorder

Personality changes in schizophrenia manifest themselves quite clearly and leave an imprint on the course and outcome of the disease. At the same time, it remains unclear which features of the premorbid personality are preserved throughout the entire course of the disease, and which ones change under the influence of the process?

According to W. Horan et al. (2005), a person with schizophrenia “actively selects or creates environmental conditions around him in accordance with characteristics of his personality that either enhance or weaken his experiences of events.”

Note that the literature devoted to personality disorders in schizophrenia is relatively small. This fact can partly be explained by the existing negative stereotype regarding the destructive impact of psychosis on a person’s personality.

Research into the personality of a patient with schizophrenia is relevant in relation to the etiopathogenetic model of this mental disorder (“diathesis-stress model”), in which, in addition to the biological predisposition to schizophrenia, stress and the ability to psychologically withstand its load are important. In addition, the idea of ​​the personality of a patient with schizophrenia plays an important role in the prevention of relapse of schizophrenia.

The literature on personality traits in schizophrenia pays considerable attention to environmental stressors and the emotional climate of the family, in particular. Many authors emphasize that these factors have a significant impact on the nature of the course of schizophrenia and the frequency of its relapses (Vaughn C. et al., 1982; Ventura J. et al., 1989). According to Sanderson, Clarcin (2002), personality questionnaires allow you to select the optimal microtherapy option for a patient with schizophrenia, the latter concerns the therapeutic environment, treatment strategy, its forms and methods.

Currently, a number of clinical psychologists are addressing the problem of the relationship between personality and clinical symptoms of psychosis, including the features of its course and relationship with cognitive deficit.

To study personal characteristics, projective techniques (Rorschach inkblots, thematic Apperception Test - TAT, etc.), and various personality questionnaires are most often used.

Research into personality changes that have developed as a result of a pathological process involves, on the one hand, an analysis of activity, motives (needs, the relationship of motives to set goals, the dynamics of motives, their hierarchical structure, criticality, etc.), relationships; on the other hand, the study of the stages of formation of personal characteristics, primarily in the context of relationships that develop in the patient’s immediate environment. Despite the fact that there are methods primarily aimed at studying personality (projective methods, questionnaires), the division of methods into “personal” and “non-personal” remains very conditional (Zeigarnik B.V., 1986).

In recent years, the so-called “five factor model” has gained great popularity in the field of personality assessment in foreign literature. She suggests that personality can be described in general terms of five concepts: neuroticism (emotional), extraversion (interpersonal), openness to experience (experiential), conformity (worldview), conscientiousness (motivational). This model integrates the points of view of different and partly conflicting schools (behaviorism, humanism, psychoanalysis, cognitive development, etc.). Proponents of the model believe that it provides conceptual support for several hundred specific personality factors. However, some important personality characteristics, such as impulsivity, are excluded from the model. Critics of the latter also draw attention to its purely descriptive nature. The most commonly used technique based on the “five-factor model of personality” is the NEO personality questionnaires (NEO-PI, NEO-FF1, NEO PI-R). For example, when studying personality, the superfactors of the revised NEO-PI-R questionnaire are assessed: emotional stability - neuroticism, introversion - extraversion, closedness - openness to new experience, antagonism - goodwill towards other people, lack of concentration - conscientiousness in activity. NEO questionnaires contain statements designed to identify the core components of higher order personality.

The perception of a picture with an uncertain plot helps to understand the dynamics of the motivational sphere of a patient with schizophrenia. So, N.K. Knyashchenko (1965), using pictures, the interpretation of which was based on the physiognomy of the depicted characters (Heckhausen’s “production” TAT), found that patients suffering from a simple form of schizophrenia demonstrate a lack of focus on searching for the correct interpretation. The patients' responses contained a formal statement of the elements of the picture, without expressing any attitude towards the situation.

Personality changes in schizophrenia

• Indifference to performance results
• Difficulty when it comes to identifying the purpose of an activity
• Insufficient activity in the process of achieving the goal, searching for solutions to the problem
• Inadequate assessment of one's capabilities
• Reduced aspirations, weakness of the “regulator of the dynamics of the level of aspirations”
• Lack of interest in personal growth and improvement of performance results
• Lack of orientation to generally accepted social norms
• High level of neuroticism
• Low level of extraversion
• Unfriendly attitude towards people
• Failure to perform duties in good faith.
• Displacement of the meaning-forming function of motives
• Dominance of avoidance motives

Studies aimed at studying the characteristics of the level of aspirations in patients with schizophrenia, suffering from a simple form and a sluggish course of the process, have shown that the choice of task is not influenced by the success of solving previous problems. In this case, the level of aspirations is not formed; adequate self-esteem of one’s capabilities is impaired. At the same time, the patients’ statements do not have an emotional connotation, even when the experimenter emphasizes their mistakes (Bezhanishvili B.I., 1967).

The results of research by A.B. are of interest. Kholmogorova (1972), aimed at studying the characteristics of the level of aspirations depending on the leading syndrome of schizophrenia (neurosis-like, psychopath-like, paranoid). It turned out that in the group of patients with neurosis-like symptoms, the long-term goal is static, not future-oriented (the plan is only to achieve a previously obtained best result). The patients seemed to lack a “regulator of the dynamics of the level of aspirations, stimulating an increase in achievements.” There was also no orientation of achievements towards the “social norm”. In the dynamics of the level of aspirations, avoidance motivation dominated, and defensive forms of behavior were expressed. In psychopathic-like syndrome, a decrease in orientation to the level of achievement was observed. The long-term goal was built without taking into account real achievements and their dynamics and was inadequate. Two trends were revealed here: patients either completely ignored the “social norm” of fulfillment, or set the task of achieving it immediately, without intermediate stages. With paranoid syndrome, orientation towards the level of achievements decreased, the “social norm” and the dynamics of achievements were not taken into account. Patients could not fully accept the experimental situation, distorting the picture of the dynamics.

N.S. Kurek (1982), using various methodological techniques, revealed the connection between “adynamia of the level of aspirations” and a decrease in the activity of patients with schizophrenia and an increase in the “schizophrenic defect”.

The mechanisms of altered meaning formation in low-grade schizophrenia were studied by M.M. Kochenov (1978). It turned out that the behavior of patients with schizophrenia in the situation of experimental psychological research has its own characteristics: they did not have an orientation stage, they did not choose “winning” tasks and at the same time took on clearly impossible ones. The displacement of the meaning-forming function of motives, the splitting off of the effective function from the “known” one disrupted the activity of patients and, possibly, was the reason for changes in their behavior and personality. According to the author, the reduction of motives led to impoverished activity.

In studies devoted to the study of the personality of patients with schizophrenia, it was shown that the latter are more neurotic and at the same time more introverted than healthy people. This fact is observed both during the acute phase of the disease and during the long period of its remission and affects the quality of life of a patient with schizophrenia. At the same time, it is known that high levels of neuroticism and introversion are considered psychological factors that increase the risk of schizophrenia. A high level of extraversion, on the contrary, significantly reduces the likelihood of this mental disorder.

Researchers from New Zealand found that high levels of neuroticism at age 14 were positively correlated with symptoms of psychosis occurring between ages 18-21. The identified correlations continued to be observed even when control was established for “childhood complicating factors” and comorbid mental disorders (Goodwin R. et al., 2003).

A high level of neuroticism reflects characteristics of the type of “personality organization” that contributes to the formation and fixation of negative cognitive schemes, which, in turn, are the “soil” for the frequent appearance of negative emotions and a feeling of loss of control over the surrounding situation. The latter circumstance increases the risk of developing schizophrenia. In addition, in patients with schizophrenia, indicators of neuroticism correlate with the choice of an inappropriate behavioral strategy (coping strategy), which contributes to substance abuse.

A high level of neuroticism to some extent explains dissatisfaction with drug treatment and refusal to engage in social activities (“social network”), while a high level of extraversion is positively correlated with a higher assessment of physical health and positive emotions. Note that the more pronounced the extraversion, the lower the level of professional functioning of the employee, the more often there are refusals to cooperate and poor quality of work.

The tendency of individuals with high levels of extraversion to seek interpersonal support instead of solving problems, while simultaneously having an elevated level of neuroticism, partly explains why such a personality characteristic negatively affects the professional activity of a patient with schizophrenia.

A low level of extraversion causes a negative attitude towards interpersonal communication (“social interaction”), ultimately weakening the opportunity and worsening the quality of social support. This makes a person predisposed to schizophrenia more susceptible to the effects of stress. According to M. Kentros et al. (1997), pronounced introversion leads to the fact that patients refuse group therapy, but at the same time have a positive attitude towards treatment at home

High levels of neuroticism and low levels of extraversion are nonspecific risk factors, since they predispose to the development of not only schizophrenia, but also a number of other mental disorders, such as depression or tobacco addiction.

According to L. Krabbendam, van J. Os (2005), frequently occurring and strongly expressed negative emotions directly contribute to the development and maintenance of delusions and hallucinations in individuals predisposed to schizophrenia. Somewhat earlier, P. Lysaker et al. (2003) and T. Dinzeo et al. (2004) also found a correlation between the level of neuroticism and the severity of positive symptoms of schizophrenia.

Agreeableness in communication also presupposes modesty and concern for others; its low level is manifested by cynicism, indifference to the problems of others, incompetence and a negative attitude towards any form of cooperation. It has been noted that people with high levels of conscientiousness are prone to obsessive-compulsive disorders, and people with high levels of agreeableness are prone to dependent personality disorder. Low indicators of goodwill and conscientiousness are often simultaneously combined with the presence of antisocial personality disorder, criminal behavior, and aggression. This fact takes on a certain meaning in connection with the fact that among patients with schizophrenia, antisocial behavior and a tendency to use psychoactive substances are more common than among healthy individuals. It has been noted that with an unfavorable course of schizophrenia, hostility towards people increases.

In patients with schizophrenia, strategies for interpersonal relationships and behavioral styles are more oppositional than in patients suffering from some other mental disorders, such as depression (Bagby R. et al., 1997). There is a noticeable increase in hostility towards people in those patients with schizophrenia who begin to use psychoactive substances (Reno R., 2004), and show increasing severity of productive and negative symptoms, emotional instability, insufficient impulse control and hostility (Lysaker P. et.al. , 2003). In a study by M. Kentros et al. (1997) showed that low levels of agreeableness correlate with the severity of negative symptoms (social isolation) and depression.

In most cases, patients with schizophrenia demonstrate a dishonest attitude towards responsibilities. R. Gurrera et al. (2000) provide evidence of a weak correlation between the level of conscientiousness and the age of onset of schizophrenia. Dishonesty is also associated with suicidal tendencies in patients suffering from schizophrenia for more than 5 years (Pillman F. et al., 2003).

Modern studies of the personality of patients with schizophrenia, in particular, conducted on the basis of their self-reports, still demonstrate the preservation (“stability and persistence”) of many of its characteristics, even at the time of exacerbation of the mental disorder. According to H. Berenbaum, F. Fujita (1994), the cognitive process associated with the characteristics of openness to experience (divergent thinking, the ability to find new and creative solutions, etc.) is partly reminiscent of the cognitive process that distinguishes a patient with schizophrenia (unusual associations, distorted perception , whimsical and magical thinking, etc.). Not all researchers adhere to this point of view, especially those who emphasize the connection between a tendency toward esotericism and a distorted perception of reality and the socioeconomic status of patients with schizophrenia (Camissa K. et al., 2005). Apparently, openness to experience is more characteristic of schizotypal disorder than of schizophrenia (Ross S. et al., 2002). The low level of openness to experience probably reflects the characteristics of the disease process, in particular, limited educational success and lack of financial resources typical for patients with schizophrenia. An increased level of openness is usually not combined with severe negative symptoms (Kentros M.b et al., 1997).

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With this diagnosis, you need to take medications for the rest of your life.

So far, the only effective way to combat schizophrenia is medication. During consultation with a psychiatrist, a treatment regimen is developed for each patient based on the use of appropriate psychotropic medications. After completing the prescribed course, the doctor assesses the patient’s condition and may allow a break. If favorable dynamics are observed after this, the doctor stops the medications.

Schizophrenia is a difficult test for a person. For such patients, outside support is important, and the myths that have taken root among people about this disease only complicate everything. Therefore, upon learning of the diagnosis, many become severely depressed and begin to think about suicide. Only professional help will help such patients adequately recognize the problem and set them up for recovery, since schizophrenia is treatable.

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