CC BY
6
УДК 616.895.8
Azimova G.A. assistant Agranovsky M.L., MD professor Dalimova S.A.
assistant Muminov R.K. senior lecturer department of psychiatry and narcology Andijan State Medical Institute
TYPOLOGY OF ASTHENIC DISORDERS IN REMISSION OF PAROXYSMAL-PROGREDIENT SCHIZOPHRENIA
Abstract: The relevance of this study is determined by the lack of clear differential diagnostic criteria for endogenous asthenia in modern taxonomies and classifications of mental diseases, which significantly complicates the adequate qualification, diagnostic and prognostic assessment and affects the choice of therapy for these conditions.
Key words: asthenia, typology, schizophrenia, remission, disorders.
Relevance. The problem of identifying, diagnosing and treating asthenic and asthen-like conditions remains one of the most complex and controversial in modern psychiatry. This is explained both by the extreme prevalence of these disorders, which ranges from 10% to 45% in psychiatric practice, and by the fact that asthenic symptoms are the least nosologically specific, "basic" in relation to many mental disorders and are included in the structure of the most diverse psychopathological symptom-o-complexes [4].
The lack of specificity of asthenic syndrome makes it difficult to make a nosological diagnosis, since this symptom occurs not only in mental diseases, but also in various somatic pathologies [9].
Taking into account the clinical variability of asthenia manifestations, attempts to systematize various asthenic symptoms have been made repeatedly. Despite this, until now, in modern classifications of mental diseases, the criteria by which asthenia can be diagnosed are extremely vague and, as a rule, include only two main signs: exhaustion and weakness, which increase with physical and intellectual exertion.
Additional signs include irritable weakness, hyperesthesia, headache and muscle pain, dizziness, sleep disorders, autonomic disorders [5]. Despite the fact that many publications are devoted to the description of schizoasthenia, there are still no clear definitions, classification, criteria for the syndromic assessment of asthenic disorders in schizophrenia and endogenous depressive states, which often leads to diagnostic errors.
In particular, asthenia is considered to be in the framework of a positive [7]. It should be noted that asthenia in schizophrenia, as a rule, is continuous, an asthenic symptom complex of varying degrees of severity is observed both in the prodromal period [3], in the debut of the painful process [1], at the manifest stage [8], and in remission [5], in the period of stabilization (residual states with the so-called asthenic defect) [11]. At the final stages of the endogenous process, asthenia manifests itself with a number of symptoms: cognitive disorders, changes in the general feeling of the body [6], a persistent decrease in the ability to work, which is associated with a decrease in the volume of mental and physical activity [2]. In addition, asthenia, in this case, can take the form of "somatopsychic fragility" [4,9] and be combined with hypochondriac ideas and/or with affective (subdepressive) disorders [3]. Asthenia in schizophrenia largely correlates with the progrediency of the disease and, to a certain extent, serves as a kind of "marker" of negative symptoms, at the same time, not being its analog [7].
According to a number of modern researchers, significant difficulties are caused by distinguishing the primary negative symptoms with the picture of asthenia from phenomenologically similar pictures caused by affective (depressive) pathology or persistent productive psychotic symptoms, side effects of antipsychotics, the phenomena of hospitalism [10]. These provisions are closely related to the problem of psychopharmacotherapy of negative, including asthenic, disorders in schizophrenia, the effectiveness of which, at this stage of the development of psychopharmacology, is assessed as clearly insufficient [6]. According to modern concepts, the immune system is actively involved in the pathological process in endogenous mental diseases [8].
The analysis of the role of biological, including immune, mechanisms in the pathogenesis of mental disorders, the development and nature of the course of mental diseases and the use of these indicators both to clarify the diagnosis and to assess the effectiveness of treatment is one of the innovative approaches at the present stage of the development of psychiatry [2]. In addition, there are practically no clinical and biological studies of patients with schizophrenia that would allow objectifying and expanding the idea of the severity and structure of asthenic symptoms. From the above, it follows that it is expedient to identify biomarkers for differential diagnosis and evaluation of the effectiveness of therapy for asthenic disorders in remissions of schizophrenia, which has not been attempted so far.
Thus, the unresolved issues of systematics, clinical psychopathological and nosological assessment of asthenic disorders, as well as the lack of pathogenetically based algorithms for the treatment of these conditions determine the relevance of this work.
The purpose of the study. The aim was clinical and psychopathological differentiation and identification of immunological features of asthenic disorders in patients with schizophrenia in remission, as well as optimization of therapy for these conditions based on the data obtained.
Materials and methods of research. 63 male patients aged from 23 to 58 years (average age 41.9 ± 9.46 years) with an attack-progredient form of schizophrenia in remission were examined. The average age of the disease onset was 22.2 ± 4.2 years, the average duration of the disease was 18.9 ± 9.5 years.
The following methods were used in the study: clinical and psychopathological, psychometric (using the PANSS, SANS, CDSS, VAS-A, MFI-20 scales), statistical.
The results of the study. On the basis of clinical and psychopathological examination, all patients were diagnosed with conditions containing signs of asthenia with a predominance of various manifestations, such as weakening or loss of the ability to prolonged mental stress, inability to concentrate on one thing, difficulty in verbal expression of experiences ("I can't find the right words"), decreased mental activity and difficulties in performing elementary types of mental labor, subjective feeling of fatigue and fatigue, complaints about difficulties in concentrating attention and assimilation of information, increased mental fatigue. Along with the exhaustion and unproductivity of intellectual activity, there was an irritable weakness with emotional lability and reactions of discontent.
In 54 patients (85.7%), pronounced vegetative disorders were noted in the picture of the asthenic symptom complex: headache, dizziness, a feeling of heaviness in the head, fluctuations in blood pressure and pulse, dyspepsia, a slight redness or paleness of the skin, a feeling of heat at normal body temperature or, on the contrary, increased chilliness, there was also increased local sweating.
Type I, the so-called affective-asthenic (n = 22; 34.9%), developed within the framework of depression with pronounced asthenic manifestations. The majority of patients objectively had physical exhaustion — 63.6% (14 people), while intellectual load was easier to bear, and mental/mental exhaustion was objectively diagnosed in 36.4% (8 people). Patients complained of asthenic nature: increased fatigue — 86.4% (19 people); a feeling of passivity/ lethargy — 22.7% (5 people); incontinence of affect — 81.8% (18 people); sensitivity and vulnerability — 45.5% (10 people); tearfulness — 27.3% (6 people). Asthenic menthism was noted-40.9% (9 people); assessment of insignificant events as psychotraumatic-77.3% (17 people); difficulty of adaptation in nonstandard conditions-63.6% (14 people).
Type II of endogenous asthenia, called negative-asthenic, was observed in two-thirds of cases (n = 41; 65.1%). Asthenic symptoms also came to the fore in the clinical picture, but a detailed psychopathological examination revealed the predominance of negative disorders of various degrees of severity. These include manifestations of emotional leveling with a rational assessment of the environment (58.5%), increasing autism (90.2%), psychopathic personality changes of the fershroben type (7.3%), apathy (43.9%), abulia (17.1%), and the last three types of disorders were detected in the status, but were not the subject of complaints from patients.
A distinctive feature of endogenous type II asthenia was the dominance of mental / mental exhaustion, which was observed in 82.9% of patients, over physical exhaustion, found in 41.5% of cases. In addition, the decrease in activity in the majority of patients was characterized by a predominance of viscosity, slowness, lack of initiative, lack of independence in 65.9% of cases and in 34.1% of cases was combined with a general monotony of appearance, with stereotyped facial expressions and motor skills — 26.8%, with rigidity of mental functions — 34.1%, while there were no signs of hypo-thymia.
At the same time, during an objective examination (checking the tolerance to physical exertion in the gym), no reliable signs of the predominance of physical asthenia were detected. Even after minor intellectual loads, pronounced thinking disorders came to the fore in the status of patients — slips, single sperrungs, diverse and ornate thinking, a tendency to reasoning, which was not criticized. The feeling of constant fatigue, overwork did not go away in patients even after a long period of rest. They were convinced that even a minimal physical effort would necessarily lead to an aggravation of the feeling of fatigue, the appearance of "colossal fatigue" and an increase in other symptoms (for example, concomitant vegetative disorders). Despite the fact that the patients looked dissatisfied, gloomy, depressed, none of them complained of a low mood.
Conclusion. The results obtained are consistent with other studies and confirm the presence of asthenic symptoms in schizophrenia during remission [6, 7, 9, 16, 17]. At the same time, it is significant and new to identify the heterogeneity of the clinical picture and the connection of asthenic disorders with affective, hypochondriac and negative symptoms. We have not been able to find detailed studies in similar areas in recent years in the literature available to us. The obtained data can be used in further clinical and clinical-biological studies.
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