Sluggish schizophrenia is a type of schizophrenia in which the disease progresses weakly, there are no productive symptoms, only indirect clinical manifestations are characteristic (neurosis, psychosis, affect, overvaluation of ideas, hypochondria), as well as shallow personality changes, very reminiscent of obsessive-compulsive personality disorder.
History of schizophrenia
For the first time in 1896, the famous psychiatrist E. Bleuler described sluggish schizophrenia. Further, sluggish schizophrenia was classified by Professor V.P. Serbsky in 1902 as mild forms of hebephrenia, and in 1905, psychiatrist E.V. Erickson noted sluggish schizophrenia as sluggish dementia praecox.
G. Mayer in 1908, C. Pascal in 1911, and K. Jaspers in 1913 did not remain aloof from this problem. The term itself was first used in the differential diagnosis of childhood, as well as adolescent schizophrenia, in 1933 by psychiatrist G. E. Sukhareva. Further, in 1955, R. A. Nadzharova described sluggish schizophrenia as a separate form of schizophrenia. But this problem was most revealed by Professor A.V. Snezhnevsky in 1969. His publications led to the diagnosis becoming widely used in medical practice.
Signs of low-grade schizophrenia
Sluggish schizophrenia is primarily characterized by alienation, awareness of changes in the inner world, mental impoverishment, decreased vitality, activity and initiative. There may be a detached perception of reality and intellectual acuity. If the signs of sluggish schizophrenia are joined by prolonged depression, then the lack of emotional resonance and shades of feelings, the loss of the ability to feel pleasure comes to the fore. As the disease progresses, there is a feeling of altered consciousness, signs of dullness, primitivism, and a lack of mental subtlety. With sluggish schizophrenia, grotesque and exaggerated rough forms are added to hysterical manifestations in the form of demonstrativeness, affectation, flirtatiousness, mannerisms, and obsessiveness of desires.
For doctors, the diagnosis of schizophrenia is a secret box that contains all diseases that do not fit under other mental illnesses. The problem with sluggish schizophrenia is that the diagnosis is clearly determined at the height of the disease, and the pre-morbid period itself often lasts for years. Observing a person, nothing will betray his incipient illness, except perhaps the eccentricity of his personality. Therefore, it is difficult for doctors to make a correct diagnosis
Symptoms of the disease
During the period of development or exacerbation of pseudoschizophrenia, the patient does not complain of auditory or visual hallucinations. Moreover, he does not suffer from delusional ideas and visually it may seem that the person is absolutely healthy. The main symptoms of mental disorder include:
- aggressive behavior;
- inappropriate behavior in society;
- aggression;
- unreasonable anger.
During the period of exacerbation of the disease, the patient may abuse drugs or alcohol. The condition is accompanied by a deterioration in motor activity, impaired coordination of movements, and a decrease in intellectual abilities. The task of relatives and close friends is to limit alcohol consumption.
A person who has been diagnosed with pseudoschizophrenia begins to gradually withdraw from society. He wants to communicate less and less with friends and relatives. The patient makes plans that bring him emotional satisfaction. However, at the same time, he does not strive to do anything to implement these plans into reality.
Very often, parents associate a teenager’s aggressive or inappropriate behavior with the fact that he is in bad company. While it is necessary to look for the reason elsewhere. Mental disorder can progress and lead to the most tragic consequences. It is necessary to remember to contact a specialist in a timely manner.
Sluggish schizophrenia - symptoms
Symptoms of low-grade schizophrenia often begin to appear in adolescence, but clear manifestations are detected much later.
The long-term, slow development of the disease is accompanied by gradual personality deformations, but many patients manage to maintain the required level of social adaptation throughout their lives.
The line between ordinary and low-grade schizophrenia is quite thin. Sluggish schizophrenia is characterized by a predominance of neurosis-like and psychopathic-like disorders. And in ordinary schizophrenia, disturbances in associative thinking are noted: decreased affect, autism, impaired associations and ambivalence (duality of attitude). Considering ambivalence to be the main symptom of schizophrenia, three types are considered: emotional, volitional, and intellectual.
The emotional sphere includes both positive and negative feelings towards a person or event.
The volitional sphere worries the patient with endless fluctuations between opposing decisions and the inability to choose, so they often refuse to make a decision at all.
The intellectual sphere consists of the alternation and simultaneous contradiction of judgments and mutually exclusive ideas.
The following combinations of sluggish schizophrenia are distinguished:
• obsessive-compulsive disorder or obsessive-compulsive disorder with phobic disorders;
• depersonalization of personality;
• hypochondriacal;
• hysterical manifestations;
• predominance of negative violations.
A. V. Smulevich identifies the following stages of development of sluggish schizophrenia: latent stage, active stage, stabilization period.
The latent period includes psychopathic and affective disorders, obsessions, and reactive lability. The predominant features of schizoidia, hysteria, psychasthenic and paranoid personality disorder.
A. B. Smulevich believes that mental disorders during the latent period manifest themselves only at the behavioral level. For example, teenagers’ refusal to take exams, leave the house, avoidance of society (social phobia).
Active period, as well as stabilization period.
In the active period, a feature of the development of sluggish schizophrenia is considered to be a combination of vivid attacks with a sluggish course.
The symptoms of the disease are combined with obsessive-phobic disorders and are characterized by anxiety-phobic manifestations and obsessions such as rituals, panic attacks, fanciful habits, actions, mental operations, fear of external threat, fear of madness and loss of control, phobias of contrasting content, fears for harm to oneself and others, obsessive doubts, rituals with double-checks, fear of heights, being alone, darkness, thunderstorms, fires, fear of blushing in public, fires
Features of treatment
In rare cases, pseudoschizophrenia will require inpatient treatment using new generation antipsychotics. Today, the majority of treatment is individual psychotherapy.
However, it should be remembered that if pseudoschizophrenia is accompanied, for example, by alcohol or drug addiction, then the first thing that needs to be done is to remove the breakdown products of alcohol or drugs from the body.
Individual psychotherapy will allow the patient to develop a trusting relationship with a specialist. Such conversations help the patient rethink his behavior. And the doctor, in turn, will be able to develop a treatment plan for pseudoschizophrenia that is suitable for a particular patient.
If the patient's condition does not improve after psychotherapy, the specialist may decide to use medications. In the treatment of mental disorders of this type, the following are used: antidepressants, antipsychotics and tranquilizers. Only after a thorough examination and study of the patient’s card, the doctor can prescribe drug therapy.
Differential diagnosis
When collecting all the necessary data, it is necessary to clearly understand whether we are talking about neurosis-like schizophrenia or neurosis.
To distinguish, the diagnostician uses the following criteria:
In 90% of cases, a client with a neurotic disorder is aware that he has an illness, although he tries not to seek help from a doctor for a long time.- The schizophrenic ignores deviations and the need for medical assistance.
- Neurosis does not destroy a person’s personality and appears due to an identifiable cause.
- Schizoneurosis produces obvious changes in character and affects cognitive abilities. The clinical picture of the disorder develops without any obvious prerequisites.
Neurotic manifestations can be completely cured if the treatment process is properly organized and carried out. Neurosis-like schizophrenia, even in the case of successful therapy, leaves an imprint on personality traits. The disease may recur.
Similarities with psychopathy
In the psychopathic form of sluggish schizophrenia, according to A. E. Lichko, similarities with schizoid, unstable, less often hysterical or epileptoid psychopathy (according to the classification of psychopathy by P. B. Gannushkin) may be found [1]. However, this is outdated data, using the old classification of both psychopathy and the name psychopathic-like schizophrenia. The term “sluggish schizophrenia” disappeared from psychiatric use with the transition to ICD-10 in Russia in 1997. There is no correspondence in ICD-10 for unstable and epileptoid psychopathy.
Classification
In the International Classification of Diseases, 9th revision (ICD-9), psychopathic schizophrenia was classified under category 295.5295.5 - latent (sluggish, low-progressive) schizophrenia. 295.51 - sluggish schizophrenia with neurosis-like and psychopath-like symptoms[3].
In ICD-10, pseudopsychopathic (psychopathic-like) schizophrenia is classified as a subtype of schizotypal disorder, its code in the classification adapted for use in the Russian Federation is F21.4 [4]. The diagnosis F21.4 also includes “borderline schizophrenia.”
Pseudopsychopathic schizophrenia: the main manifestation is antisocial psychopathic behavior!
Pseudopsychopathic schizophrenia is a type of schizotypal disorder characterized by psychopathic-like symptoms.
These include pathological desires, mood lability with outbursts of rage, and the emergence of unusual interests. Once the disease is identified and treatment is selected, its course is well controlled.
The prognosis is favorable due to the high effectiveness of therapy and the slow progression of the disease.
Causes
The development of a psychopathic-like form of schizophrenia is observed against a background of causes similar to those of the main disorder. Experts highlight the presence of a genetic predisposition in patients. Apparently, changes in the mental sphere arise from an imbalance of neurotransmitters in the brain. Negative environmental impacts are also important:
- low social status of a person, accompanied by poverty and discrimination in society;
- traumatic experiences and bullying from peers and adults in childhood, including sexual abuse;
- excessive consumption of alcoholic beverages and drugs;
- lack or limitation of positive contacts with others in adolescence and adulthood.
It is important to note that pseudopsychopathic schizophrenia can cause the development of the classical form of pathology in the absence of treatment, being a borderline disorder.
Clinical manifestations
The symptoms are mild and may not be noticed by others for a long time. There are no positive symptoms (delusions, auditory and visual hallucinations). Main features:
- causeless attacks of aggression and rage;
- lack of pity for surrounding animals and people;
- constant anger, which periodically manifests itself in outbursts of rage;
- tendency to antisocial behavior: a person tries to harm others by uttering unpleasant words; a child can deliberately break toys, household items and devices;
- drug and alcohol use.
Patients, starting in adolescence, begin to lose social connections. They withdraw socially from friends and family members, showing a tendency to contact strangers. When communicating with a person, a large number of plans are revealed, most of which are impracticable.
Against this background, the patient is not able to perform simple tasks during the day, as he is focused on “big” goals. The emotional sphere is characterized by impoverishment - the patient is cold and does not react to the events of the surrounding world.
Gradually he becomes more and more tired and loses interest in anything.
Sluggish psychopath-like schizophrenia manifests itself in childhood. The child gradually moves away from his parents and begins to conflict with them. He develops strange hobbies.
When trying to exert negative influence - “house arrest”, shouting, the situation begins to worsen. It is important to note that such pedagogical measures are not effective and asociality increases.
A positive effect is possible only with complex therapy using medications and psychotherapy.
On topic: Childhood schizophrenia
Syndromes developing during the disease
Psychiatrist A.E. Lichko described several variants of the clinical picture in patients with psychopathic-like schizophrenia:
- hysteroid syndrome;
- epileptoid syndrome;
- unstable behavior syndrome;
- syndrome of increasing schizoidization.
The last syndrome is the most common. It is characterized by increasing isolation and avoidance of conflicts with loved ones. As a result, communication with relatives and friends is disrupted.
The degree of personality disorder increases over time and a schizoid type of psyche is formed. In addition to unsociability, there is a tendency to unusual activities, as described above.
Hobbies appear that are not typical for healthy people - collecting garbage, etc.
Epileptoid syndrome is characterized by a number of symptoms: cruelty, perversion of sexual desire, hypochondria with pronounced suspicion of doctors and medical institutions.
The disease often manifests itself with attacks of cold cruelty, which can cause serious harm to the health of others.
Patients themselves are not aware of their aggressiveness and note that others begin to treat them poorly.
Hysteroid syndrome is more often detected in girls during adolescence. Patients strive to attract the attention of others. Their behavior is theatrical and pretentious. Patients are deceitful, but, realizing this, they continue to invent stories about themselves and lie to loved ones. The emotional sphere is impoverished - rough antics and increased gesticulation predominate.
The syndrome of unstable behavior is similar to the heboid syndrome described in the 19th century. An important difference is the absence of gross personality changes. However, patients are prone to idleness and idleness.
They do not go to work, study, and try to avoid any labor. Teenagers tend to engage in antisocial habits: drinking alcohol, drug addiction and sexual promiscuity.
Often, under the influence of other people, they can participate in fights, thefts and other illegal activities.
Diagnosis of the disease
It is possible to identify pseudopsychopathic schizophrenia through a comprehensive examination by a psychiatrist. The specialist talks with the person, learns about the peculiarities of his life and talks with relatives and friends.
The latter indicate changes in the patient’s character, the appearance of indifference, cruelty and antisocial behavior.
At this stage, it is important to exclude organic brain damage - traumatic brain injury, tumor diseases, and drug addiction.
To assess the mental sphere, instrumental methods are used, for example, a neurophysiological test system or neurotest. Laboratory tests and consultations with medical specialists are necessary to identify concomitant diseases.
Differential diagnosis is carried out with other types of schizophrenia and with organic diseases of the central nervous system. To do this, the patient undergoes magnetic resonance imaging, angiography and other studies as indicated. Only a doctor should interpret the results obtained.
Treatment approaches
Treatment of psychopathic-like schizophrenia is aimed at stabilizing the condition, eliminating symptoms of the disease and social rehabilitation. In this case, therapy is divided into 3 successive stages:
- Stopping treatment to relieve acute symptoms, for example, an attack of rage and aggressiveness.
- Stabilizing therapy to stabilize the patient’s condition and prevent the progression of acute disorders, if any.
- Anti-relapse treatment aimed at preventing exacerbations after the end of primary therapy.
Therapeutic measures should begin immediately after the manifestation of the disease. Acute mental changes can progress rapidly, leading to social maladaptation, decreased quality of life and divergent behavior.
There are several approaches to treatment: the use of drugs, the use of cell therapy, psychotherapy and detoxification of the body. Patients with pseudopsychopathic schizophrenia are recommended to be hospitalized during the acute period, when they pose a threat to their own health and the health of others.
After stabilization of the condition, it is possible to receive outpatient care with an annual examination by a psychiatrist.
The average duration of therapy is 9 months. It takes 3-6 weeks to relieve acute psychosis. Subsequent treatment allows you to normalize the psyche and prevent relapses in the future. The patient must undergo social and labor rehabilitation.
Choice of medicines
Medications are the “gold standard” for treating any type of schizophrenia. The drugs of choice are antipsychotics, which are usually divided into traditional and atypical.
Traditional drugs (Haloperidol, etc.
) have a pronounced therapeutic effect, however, they have a wide range of side effects and are recommended for use in patients with a standard course of the disease.
Atypical antipsychotics can be used in most patients. They are prescribed immediately after diagnosis. The most commonly used antipsychotics are:
- Olanzapine reduces the desire for antisocial behavior and stabilizes the patient’s mental sphere;
- Risperidone and Amisulpride are recommended for outbursts of rage, inappropriate behavior, etc.
Neuroleptics can reduce somatovegetative manifestations, including hysteria. If the patient has severe asthenia and other negative changes in the psyche, Fluanxol, Stelazin, Rispolept, etc. can be used.
Drugs from the group of tranquilizers are prescribed to patients with panic attacks. Clonazepam and Alprazolam are the most effective. They must be used during the period of remission, when the patient still has individual phobias.
This helps prevent relapse.
If a patient develops depression associated with the development of schizophrenic disorders, it is possible to use antidepressants:
- serotonin reuptake inhibitors - Venlafaxine, Fluoxetine, etc. (drugs reduce anxiety and help eliminate the depressive component of the disease);
- tricyclic antidepressants (Amitriptyline, Melipramine) are active against any type of depression.
In case of pronounced manic and antisocial behavior, mood stabilizers are prescribed. A lasting effect is observed with the use of Depakine and Valprocom. Lamotrigine has a similar effect.
During the period of maintenance therapy, it is recommended to continue the use of atypical antipsychotics. Their dosage is gradually reduced - this reduces the risk of developing undesirable effects while maintaining high efficiency.
It is believed that in case of a single case of exacerbation, therapy should continue for 2 years. In case of relapse, the duration of treatment is increased to 5 years.
In case of three or more acute periods of the disease, medications are continued for life.
Read more about the medications used for schizophrenia and treatment regimens in a separate article.
Non-drug therapy
In addition to medications, non-drug approaches are used in therapy:
- photo and physical therapy, which involves applying light or weak electric current to a specific area of the retina or body, respectively (treatment reduces anxiety, phobias and other negative symptoms of pseudopsychopathic schizophrenia);
- transcranial stimulation with direct current or magnetic field;
- plant-based immunomodulatory agents.
An important treatment method is psychosocial therapy aimed at rehabilitating the patient in society.
In this case, family psychotherapy is recommended, since people close to the patient are often close to him and come into contact. There should be a calm environment in the house.
You should not try to limit the patient's movement and speech, as this stimulates the progression of the acute disorder.
