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UDC 616.895.8-07
CLINICAL AND DYNAMIC MECHANISMS OF THE INITIAL PERIOD OF SCHIZOPHRENIA SUBTYPE WITH A LEADING NEGATIVE SYMPTOM COMPLEX
1 Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of
Sciences, Tomsk
2 Siberian State Medical University, Tomsk
N.A. Bokhan12, A.V. Semke12, E.G. Kornetova12, A.N. Kornetov2, A.A. Goncharova1, Yu.L. Maltseva1
The systematization of the manifestations of the initial period of simple schizophrenia as a subtype with a leading negative symptom complex with the determination of the clinical-dynamical mechanisms of the formation of each clinical pattern, taking into account its duration, was carried out. The aim was the systematization of clinical-dynamic mechanisms of the initial period of the schizophrenia subtype with a leading negative symptom complex. Material and methods: 168 patients with simple schizophrenia were examined, 128 (76.2%) men, 40 (23.8%) women. The average age of the sample was 28.1+1.4 years. A structured diagnostic interview was used, anamnestic information was collected on premorbid, initial period and the manifestation of the disease. Standardization was carried out using the ICD symptom checklist and the ICD-10 symptom glossary for mental disorders. Statistical processing was carried out using the Mann-Whitney criterion, the Spearman correlation coefficient and the Fisher criterion. Results: the initial period with prevalence of pseudo-neurotic disorders was noted in 73 patients (43.5%), in women it was significantly more frequent (p <0.05). Behavioral disturbances prevailed in 70 patients (41.7%). Prodrome by the type of the "simplex"-syndrome proper was observed in 25 patients (14.8%). In most patients (75.6%), a gradual initial period prevailed. Subacute and acute prodrome was in 17.3% and 7.1%, respectively. There were no statistically significant differences in the frequency of occurrence of its types in terms of duration depending on gender. Discussion: clinical-dynamical mechanisms of the prodromal stage of the disorder were distinguished, differing in the prevalence of certain clinical manifestations, as well as in its duration. Conclusion: by simple schizophrenia, in most cases (75.6%), the initial period occurred with a gradual increase in pseudo-neurotic and behavioral disturbances, as well as manifestations of the "simplex"-syndrome. This trend is typical for both sexes, but in women, pseudo-neurotic disturbances (57.5%) were met statistically significantly more frequently (p <0.05). The transition of the initial period to the debut of simple schizophrenia proceeded smoothly. Key words: schizophrenia, symptom complex, diagnostics.
In recent decades, the clinical picture of schizophrenia is considered mainly in a dichotomous model, in which the opposite poles occupy positive and negative symptom complexes, represented, respectively, by delusions and hallucinations - on the one hand, and emotional indifference and lack of will (abulia) on the other [1-2]. In the classical division of schizophrenia into subtypes, only two of them are fully manifested by the clinical picture, in which negative symptoms play a leading role - simple and residual. Residual schizophrenia is the outcome of paranoid, hebephrenic, catatonic and disorganized schizophrenia, and is usually fixed after several episodes of exacerbation of the subtypes listed. The focus of this work is simple schizophrenia as the only one of the negative pole subtypes that has an initial (prodromal) period.
The concept of ICD-10 [3] treats simple schizophrenia as an infrequent disorder difficult to diagnose. Its main features include the progressive development of oddities in behavior and the inability to meet the requirements of society. Characterized by the flattening of the affect, the loss of impulses without prior pronounced psychotic symptoms.
The disorder is not as distinctly psychotic as other subtypes of schizophrenia. In general, individual subtypes in recent years act as objects of study less and less often due to the gradual change of the categorical paradigm in psychiatry to the dimensional one [4], and the simple form has practically dropped out of the research space due to the narrowing of the diagnostic boundaries of schizophrenia in the latest systematics of the DSM [5 -8], based in this section on first-rank symptoms described by K. Schneider [9]. At the same time, studies of recent years show the importance of scientific research in this direction [10-11], especially since in DSM-5 [8] there is still an indication of the need for further study of simple schizophrenia, which in this systematics is called "fuzzy psychosis syndrome. "
The initial period of schizophrenia, as a rule, remains out of sight of psychiatrists due to the low appealability of specialized care at this stage, however, even by appealing, arises a problem conditioned by difficulties of diagnosis, which leads to complications in the choice of therapy. Adequate treatment is more effective if it begins even before the manifestation of the schizophrenic pro-
cess. At the same time, it is necessary to clarify the diagnostic criteria and classify the initial period of schizophrenia, especially with its protracted variants [12].
The pre-manifest stage is represented by subclinical changes that affect adaptation opportunities and are manifested by a large number of absenteeism or cessation of studies, persistent changes in interests, prolonged social passivity, estrangement and isolation, prolonged changes in appearance and behavior [13]. Among the behavioral phenomena of the prodrome, suicidal occupies a special place [14-15]. Although it should be emphasized, that sometimes a suicide attempt during the initial period is a consequence of a real stressful situation and should not be considered a manifestation of a schizophrenic process [16], since linear determinism contributes to the erroneous qualification of mental status [17]. On the other hand, a suicide act, carried out in the absence of a traumatic situation or mood disorders can be classified as a part of behavioral disorders [18] or as dissociation of emotional manifestations in schizophrenia [19]. The most complete attempt to systematize the prodromal stage of simple schizophrenia was made by E.D. Kosenko [20], who divided it, depending on the dominant symptoms, into a psychopathic, apathoabulic, neurosis-like and painful sharpening of premorbid pathological character traits, with severe affective disorders, with phenomena of philosophical intoxication.
In accordance with the above, we have systematized the manifestations of the initial period of simple schizophrenia as a subtype with a leading negative symptom complex with the definition of the clinical and dynamic mechanisms of the formation of each clinical pattern, taking into account its duration.
The purpose of the study is to highlight the clinical and dynamic mechanisms of the initial period of a subtype of schizophrenia with a leading negative symptom complex.
Material and methods
The sample included 168 patients with simple schizophrenia, verified in accordance with the criteria for this ICD-10 subtype [3] and who were at the time of the study at the dispensary observation in the city of Tomsk. Among all surveyed, men constituted 128 (76.2%), women - 40 (23.8%), the average age of the sample was 28.1±1.4 years. The study was conducted in compliance with the protocol approved by the local ethical committee of the Mental Health research Institute, Tomsk National Research Medical Center.
Study design. This work is an observational cohort retrospective study, the subject of which are the clinical and dynamic mechanisms of the initial period of simple schizophrenia, manifesting chronic negative disorders. Taking into account the early
age of the onset of schizophrenia, the pronounced manifestations of a decrease in the adaptive potential in the prodromal stage and its duration, the study was based on the clinical-typological [21], static-dynamic assessment [22] adopted for such samples. The survey was conducted using a structured diagnostic psychiatric interview, anamnestic information was collected on premorbid, initial period and disease manifestation. For standardization of clinical data, an estimated list [23] and a glossary of symptoms for mental disorders [24] for ICD-10 were used.
Data processing was carried out using the Statistica 8.0 package. To assess the reliability of differences in quantitative indicators, the criterion of Mann-Whitney was used. To assess the linear dependence of quantitative data, the Spearman correlation coefficient was calculated. Comparison of independent samples for the frequency of occurrence of variants of the initial period was performed using Fisher criterion. The values obtained during the analysis of the correlation were taken as reliable for the values of the correlation coefficient r = 0.5-1.0 with the significance level of differences p <0.05.
Results and discussion
On the basis of the grouping of clinical manifestations, we have combined their polymorphism into three groups of symptom complexes of the initial period of simple schizophrenia: with the predominance of pseudo-neurotic disorders, the predominance of behavioral disorders and the manifestation of the "simplex" syndrome (Table 1).
The initial period with the predominance of pseudo-neurotic disorders was noted in 73 patients (43.5%). Moreover, in women, it occurred significantly more frequently (p <0.05). It was clinically expressed in complaints of weakness, lethargy and feeling unrested. Distraction, disturbance of concentration appeared, there were "runaway" thoughts, "emptiness" in the head, "poverty of thoughts" and "absence" of memory. Along with this, irritability, chilliness of the limbs, hyper-acusia. All this contributed to a decrease in activity, the emergence of subclinical hypochondria with fixation on various bodily sensations, which were of the most diverse nature. There were local or generalized amorphous, painful, sensations difficult to qualify, sometimes imitating somatic or neurological diseases. There was a feeling of change in the self, a sense of impending catastrophe, transient phenomena of auto- and allopsychic dere-alization, alienation of bodily sensations, a sense of the lifelessness of the surroundings. Chronic hypohedia developed. Pseudo-neurotic symptoms could also arise in the form of a somatic sensation, under the "veil" of physical distress. Such patients complained of pain in the area of t he heart, disorders of the gastrointestinal tract. Objectively, there were vegetative-vascular disorders, nasal
bleeding, cardialgia, pseudo-neurotic attacks, reminiscent of panic attacks, but not meeting the criteria for the diagnosis of panic disorder in terms of severity, quantity and temporary factor. Behind the façade of various variants of pseudo-neurotic disorders, transient "influxes" of thoughts, their
"sounding", fancy senestopathies, loss of a sense of continuity and integration of the mental process sometimes appeared. In general, the symptom complex consisted of a combination of hyperstetic disorders and mental exhaustion.
Table 1
Clinical characteristics of the initial period of simple schizophrenia
Gender
Initial period Male Female Both
Abs. % Abs. % Abs. %
1. Pseudoneurotic disorders 50 39,1 23* 57,5 73 43,5
2. Behavioral disorders 54 42,2 16 40,0 70 41,7
3. «Simplex» syndrome 24 18,7 1 2,5 25 14,8
Total 128 100,0 40 100,0 168 100,0
Note: * denotes data with a significance level of p <0.05
Behavioral disorders prevailed in 70 patients (41.7%). They were manifested by disinhibition, abandonment of generally accepted forms of behavior, oppositional attitude towards the nearest environment, non-motivated outbursts of rage, gloominess, inactivity. Patients became alienated, inaccessible, treated their relatives with open hatred, became cold and callous. Since the debut of the disease in most cases was observed in the adolescent period, parents often viewed this behavior as part of a "transitional" age or as a defect in upbringing. The behavior was marked by pronounced asociality, penchant for the criminogenic groups. Sometimes, in the foreground there was disinhibition, hyperexcitability and fussiness. Due to the emotional coldness of the external affective discharges, actions, behavior were particularly ridiculous and brutal. Many patients were prone to dromemania, not having a specific range. They were incomprehensible and inexplicable to others. The weakness of volitional delays led to socially dangerous actions. The vague sense of change, "mental" discomfort and disorder of mental activity determined the emergence of craving for alcohol. In drunkenness, behavioral deviations and emotional-volitional disorders were even more pronounced.
The initial period, proceeding according to the type of the "simplex" syndrome itself, was observed in 25 patients (14.8%). For them, the characteristic was a decrease in mental productivity, the emergence of an opposition to relatives, heightened sensitivity or lethargy, laziness, gloominess, isolation, alienation. The patients felt their own "change", which was manifested by undiscovered ideas of the relationship and a sense of "catastrophe". Thinking became blurry, fuzzy. Appeared more or less pronounced phenomena of metaphysical intoxication. Against the background of de-
pressed mood, there were occasionally "influxes", "delays", "breaks" of thoughts.
There was noted an unproductive tendency to analyze actions, abstract problems. The increasing thread of allopsychic emotional resonance with autopsychic orientation and the destruction of interpersonal relations passed through the red thread through all the initial simplex symptoms. Patients lost weight, closed, dropped out of school, work. The development of these disorders, as a rule, was gradual.
The mechanism of the formation of symptom complexes from the first signs of prodrome to manifestation is also determined by the length of the initial period. We estimated its duration to three months as the acute onset of the disease; from three months to one year as subacute and over one year as gradual. In the majority of patients examined - 75.6%, a gradual initial period prevailed (Table 2).
Subacute and acute prodrome occurred much less frequently - 17.3% and 7.1%, respectively. There were no statistically significant differences in the frequency of occurrence of its types in duration depending on gender.
In contrast to the subtypes of schizophrenia, characterized by episodic course, especially with the predominant positive symptom complex, with a simple form, with its "erased" onset and chronic nature, the allocation of the initial period is quite a difficult task. In the present study, the clinical and dynamic mechanisms of the prodromal stage of the disorder were distinguished, which differed in the prevalence of certain clinical manifestations, as well as its duration.
Table 2
The duration of the initial period of simple schizophrenia
Gender
Duration of the initial period Female Female Female
Abs. % Abs. % Abs.. %
1. Acute 10 7,8 2 5 12 7,1
2. Subacute 20 15,6 9 22,5 29 17,3
3. Gradual 98 76,6 29 72,5 127 75,6
Total 128 100,0 40 100,0 168 100,0
"Simplex" syndrome, being the basis for the diagnosis of simple schizophrenia after the manifestation of the process, occurred only in 14.8% of cases in prodrome. The presence of pseudo-neurotic and behavioral disorders in the foreground in the majority of the examined people testifies in favor of the fact, that with this subtype more often in the initial period, non-specific psychopathological precursors of the disease appear, which extremely complicate the diagnosis. The data obtained open up prospects for further research primarily from the perspective of clinical dynamics from the prodromal stage to the completion of the first year of the disease in order to understand the mechanisms of syndrome formation.
The given types of prodromal periods were previously distinguished by other authors in terms of duration [25-26]. With regard to this study, it was necessary to establish the frequency of their occurrence in simple schizophrenia. The results obtained on the prevalence of a gradual initial period correspond to the traditional notions of inconspicuous, gradual onset of simple schizophrenia [27-31], and also give an understanding that the duration of prodrome does not depend on the sex of the patients. In the future, it seems necessary to analyze its relationship with other constitutional factors.
It should be emphasized that in routine clinical practice, a retrospective analysis of the initial period, the development of the disease is important for predicting the clinical manifestations of the disorder and the adaptive capacities of patients, which is evident from the present study and repeatedly emphasized in the psychiatric literature [20, 32-36].
Conclusion
The study showed, that by a simple subtype of schizophrenia, characterized by a predominance of a negative symptom complex in the clinical picture in most cases (75.6%), the initial period proceeded with a gradual increase in pseudo-neurotic and behavioral disorders, as well as manifestations of the "simplex" syndrome. This tendency is characteristic of both sexes, but in women, pseudo-neurotic disorders were statistically significantly more frequent (p <0.05) (57.5%). The transition from the initial period to the debut of simple schizophrenia proceeded smoothly, which in some cases re-
quired additional differential diagnostics to verify the debut of the disease.
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Contacts
Corresponding author: Kornetova Yelena Geor-giyevna, Doctor of medical Sciences, Leading Researcher of the Department of Endogenous Disorders of the Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Consultant Psychiatrist of Clinics of the Federal State Budgetary Educational Institution Siberian State Medical University, Tomsk. 634014, Tomsk, ul. Aleutskaya, 4. Tel.: (3822) 51-33-06. Email: kornetova@sibmail.com
Author information
Bokhan Nikolai Aleksandrovich, Academician of the Russian Academy of Sciences, Honored Scientist of the Russian Federation, Doctor of Medical Sciences, Professor, Head of the Department of Addictive States, Director of the Mental Health Research Institute, Tomsk National Research Medical
Center of the Russian Academy of Sciences, Consultant Psychiatrist of Clinics of the Federal State Budgetary Educational Institution Siberian State Medical University, Tomsk. 634014, Tomsk, ul. Aleutskaya, 4. Tel.: (3822) 51-33-06. Email: bna909@gmail.com
Semke Arkady Valentinovich, Doctor of Medical Sciences, Professor, Deputy Director for Scientific and Medical Work, Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Head of the Department of Endogenous Disorders, Mental Health Research Institute, Tomsk National Research Medical Center. Professor of the Department of Psychiatry, Narcology and Psychotherapy of the Federal State Budgetary Educational Institution Siberian State Medical University, Tomsk. 634014, Tomsk, ul. Aleutskaya, 4. Tel.: (3822) 51-33-06. Email: asemke@mail.ru
Kornetov Aleksandr Nikolayevich, Doctor of Medical Sciences, Head of the Department of Fun-
damental Psychology and Behavioral Medicine of the Federal State Budgetary Educational Institution Siberian State Medical University, Tomsk. 634014, Tomsk, ul. Aleutskaya, 4. Tel.: (3822) 51-33-06. Email: kornetov@mail.tomsknet.ru
Goncharova Anastasiya Aleksandrovna, graduate student of the Department of Endogenous Disorders of the Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk. 634009, Tomsk, per. Kooperativny, 5. Tel.: (3822) 51-33-06. Email: goncharanastasya@gmail.com
Maltseva Yuliya Leonidovna, Head of the Second Clinical Psychiatric Department of the Clinic of the Mental Health Research Institute, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk. 634009, Tomsk, per. Kooperativny, 5. Tel.: (3822) 51-33-06. Email: center@tnimc.ru
