Шизофренія

Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect (restricted range of emotions), cognitive deficits (impaired reasoning and problem solving), and occupational and social dysfunction. The cause is unknown, but evidence for genetic and environmental components is strong. Symptoms usually begin in adolescence or early adulthood. One or more episodes of symptoms must last ≥ 6 months before the diagnosis is made. Treatment consists of drug therapy, cognitive therapy, and psychosocial rehabilitation. Early detection and early treatment improve long-term functioning.

Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate motor behavior (including catatonia) that indicate loss of contact with reality.

Worldwide, the prevalence of schizophrenia is about 1%. The rate is comparable among men and women and relatively constant cross-culturally. Urban living, poverty, childhood trauma, neglect, and prenatal infections are risk factors, and there is a genetic predisposition. The condition starts in late adolescence and lasts a lifetime, typically with poor psychosocial function throughout.

The average age at onset is early to mid 20s in women and somewhat earlier in men; about 40% of males have their first episode before age 20. Onset is rare in childhood; early-adolescent onset or late-life onset (when it is sometimes called paraphrenia) may occur.

Etiology of Schizophrenia

Although its specific causes and mechanisms are unknown, schizophrenia has a biologic basis, as evidenced by

Alterations in brain structure (eg, enlarged cerebral ventricles, thinning of the cortex, decreased size of the anterior hippocampus and other brain regions)

Changes in neurochemistry, especially altered activity in markers of dopamine and glutamate transmission

Some experts suggest that schizophrenia occurs more frequently in people with neurodevelopmental vulnerabilities and that the onset, remission, and recurrence of symptoms are the result of interactions between these enduring vulnerabilities and environmental stressors.

Уразливість нейронів розвитку

Although schizophrenia rarely manifests in early childhood, childhood factors influence disease onset in adulthood. These factors include

Although many people with schizophrenia do not have a family history, genetic factors are strongly implicated. People who have a 1st-degree relative with schizophrenia have about a 10 to 12% risk of developing the disorder, compared with a 1% risk among the general population. Monozygotic twins have a concordance of about 45%.

Neurobiologic and neuropsychiatric tests suggest that aberrant smooth-pursuit eye tracking, impaired cognition and attention, and deficient sensory gating occur more commonly among patients with schizophrenia than among the general population. These findings also can occur among 1st-degree relatives of people with schizophrenia, and indeed in patients with many other psychotic disorders, and may represent an inherited component of vulnerability. The commonality of these findings across psychotic disorders suggests that our conventional diagnostic categories do not reflect underlying biologic distinctions among psychoses (1 Довідковий матеріал щодо етіології Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect. прочитати більше ).

Екологічні стресори

Environmental stressors can trigger the emergence or recurrence of psychotic symptoms in vulnerable people. Stressors may be primarily pharmacologic (eg, substance use Загальні відомості про вживання психоактивних речовин Substance-related disorders involve substances that directly activate the brain’s reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics. прочитати більше , especially marijuana Марихуана (канабіс) Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent. прочитати більше ) or social (eg, becoming unemployed or impoverished, leaving home for college, breaking off a romantic relationship, joining the Armed Forces). There is emerging evidence that environmental events can initiate epigenetic changes that could influence gene transcription and disease onset.

Довідковий матеріал щодо етіології

1. Schizophrenia Working Group of the Psychiatric Genomics Consortium: Biological insights from 108 schizophrenia-associated genetic loci. Nature 511(7510):421-427, 2014. doi: 10.1038/nature13595

Symptoms and Signs of Schizophrenia

Schizophrenia is a chronic illness that may progress through several phases, although duration and patterns of phases can vary. Patients with schizophrenia tend to have had psychotic symptoms an average of 8 to 15 months before presenting for medical care, but the disorder is now often recognized earlier in its course.

Symptoms of schizophrenia typically impair the ability to perform complex and difficult cognitive and motor functions; thus, symptoms often markedly interfere with work, social relationships, and self-care. Unemployment, isolation, deteriorated relationships, and diminished quality of life are common outcomes.

Фази шизофренії

In the prodromal phase, individuals may show no symptoms or may have impaired social competence, mild cognitive disorganization or perceptual distortion, a diminished capacity to experience pleasure (anhedonia), and other general coping deficiencies. Such traits may be mild and recognized only in retrospect or may be more noticeable, with impairment of social, academic, and vocational functioning.

In the advanced prodromal phase, subclinical symptoms may emerge; they include withdrawal or isolation, irritability, suspiciousness, unusual thoughts, perceptual distortions, and disorganization (1 Довідкові матеріали щодо симптомів Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect. прочитати більше ). Onset of overt schizophrenia (delusions and hallucinations) may be sudden (over days or weeks) or slow and insidious (over years). But, even in an advanced prodromal phase, only a fraction ( 40%) tend to convert to full schizophrenia.

In the early psychosis phase, symptoms are active and often at their worst.

In the middle phase, symptomatic periods may be episodic (with identifiable exacerbations and remissions) or continuous; functional deficits tend to worsen.

In the late illness phase, the illness pattern may become established but there is considerable variability; disability may stabilize, worsen, or even diminish.

Категорії симптомів при шизофренії

Generally, symptoms are categorized as

Patients may have symptoms from one or all categories.

Positive symptoms can be further categorized as

Delusions are erroneous beliefs that are maintained despite clear contradictory evidence. There are several types of delusions:

Delusions of reference: Patients believe that passages from books, newspapers, song lyrics, or other environmental cues are directed at them.

Delusions of thought withdrawal or thought insertion: Patients believe that others can read their mind, that their thoughts are being transmitted to others, or that thoughts and impulses are being imposed on them by outside forces

Delusions in schizophrenia tend to be bizarre—ie, clearly implausible and not derived from ordinary life experiences (eg, believing that someone removed their internal organs without leaving a scar).

Hallucinations are sensory perceptions that are not perceived by anyone else. They may be auditory, visual, olfactory, gustatory, or tactile, but auditory hallucinations are the most common. Patients may hear voices commenting on their behavior, conversing with one another, or making critical and abusive comments. Delusions and hallucinations may be extremely vexing to patients.

Negative (deficit) symptoms include

Blunted affect: The patient’s face appears immobile, with poor eye contact and lack of expressiveness.

Poverty of speech: The patient speaks little and gives terse replies to questions, creating the impression of inner emptiness

Negative symptoms often lead to poor motivation and a diminished sense of purpose and goals.

Disorganized symptoms, which can be considered a type of positive symptom, involve

Thinking is disorganized, with rambling, non–goal-directed speech that shifts from one topic to another. Speech can range from mildly disorganized to incoherent and incomprehensible. Bizarre behavior may include childlike silliness, agitation, and inappropriate appearance, hygiene, or conduct. Catatonia is an extreme example of bizarre behavior, which can include maintaining a rigid posture and resisting efforts to be moved or engaging in purposeless and unstimulated motor activity.

Cognitive deficits include impairment in the following:

The patient’s thinking may be inflexible, and the ability to problem solve, understand the viewpoints of other people, and learn from experience may be diminished. Severity of cognitive impairment is a major determinant of overall disability.

Підвиди шизофренії

Some experts classify schizophrenia into deficit and nondeficit subtypes based on the presence and severity of negative symptoms, such as blunted affect, lack of motivation, and diminished sense of purpose.

Patients with the deficit subtype have prominent negative symptoms unaccounted for by other factors (eg, depression, anxiety, an understimulating environment, drug adverse effects).

Those with the nondeficit subtype may have delusions, hallucinations, and thought disorders but are relatively free of negative symptoms.

The previously recognized subtypes of schizophrenia (paranoid, disorganized, catatonic, residual, undifferentiated) have not proved valid or reliable and are no longer used.

Суїцид

About 5 to 6% of patients with schizophrenia commit suicide Суїцидальна поведінка Suicide is death caused by an act of self-harm that is intended to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors to completed. прочитати більше , and about 20% attempt it; many more have significant suicidal ideation. Suicide is the major cause of premature death among people with schizophrenia and explains, in part, why on average the disorder reduces life span by 10 years.

Risk may be especially high for young men with schizophrenia and a substance use disorder Розлади, пов’язані із вживанням психоактивних речовин Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance. прочитати більше . Risk is also increased in patients who have depressive symptoms or feelings of hopelessness, who are unemployed, or who have just had a psychotic episode or been discharged from the hospital.

Patients who have late onset and good premorbid functioning—the very patients with the best prognosis for recovery—are also at the greatest risk of suicide. Because these patients retain the capacity for grief and anguish, they may be more prone to act in despair based on a realistic recognition of the effect of their disorder.

Насильство

Schizophrenia is a surprisingly modest risk factor for violent behavior. Threats of violence and aggressive outbursts are more common than seriously dangerous behavior. Indeed, people with schizophrenia are overall less violent than people without schizophrenia.

Patients more likely to engage in significant violence include those with substance use disorders Розлади, пов’язані із вживанням психоактивних речовин Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance. прочитати більше , persecutory delusions, or command hallucinations and those who do not take their prescribed drugs. A very few severely depressed, isolated, paranoid patients attack or murder someone whom they perceive as the single source of their difficulties (eg, an authority, a celebrity, their spouse).

Довідкові матеріали щодо симптомів

1. Tsuang MT, Van Os J, Tandon R, et al: Attenuated psychosis syndrome in DSM-5. Schizophr Res 150(1):31–35, 2013. doi: 10.1016/j.schres.2013.05.004

Diagnosis of Schizophrenia

The earlier the diagnosis is made and treated, the better the outcome.

No definitive test for schizophrenia exists. Diagnosis is based on a comprehensive assessment of history, symptoms, and signs. Information from collateral sources, such as family members, friends, teachers, and coworkers, is often important.

According to the DSM-5, the diagnosis of schizophrenia requires both of the following:

≥ 2 characteristic symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) for a significant portion of a 6-month period (symptoms must include at least one of the first 3)

Prodromal or attenuated signs of illness with social, occupational, or self-care impairments evident for a 6-month period that includes 1 month of active symptoms

Диференційний діагноз

Other mental disorders with similar symptoms include several that are related to schizophrenia:

Neuropsychologic tests, brain imaging, electroencephalogram, and other tests of brain function (eg, eye-tracking) do not help to distinguish among major psychotic disorders. However, early research (1 Довідковий матеріал щодо діагностики Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect. прочитати більше ) suggests that results of such tests can be used to group patients into 3 distinct psychosis biotypes that do not correspond to current clinical diagnostic categories.

Certain personality disorders (especially schizotypal) cause symptoms similar to those of schizophrenia, although they are usually milder and do not involve psychosis.

Довідковий матеріал щодо діагностики

1.Clementz BA, Sweeney JA, Hamm JP, et al: Identification of distinct psychosis biotypes using brain-based biomarkers. Am J Psychiatry 173(4): 373-384, 2016. doi: 10.1176/appi.ajp.2015.14091200

Prognosis for Schizophrenia

During the first 5 years after onset of symptoms, functioning may deteriorate and social and work skills may decline, with progressive neglect of self-care. Negative symptoms may increase in severity, and cognitive functioning may decline. Thereafter, the level of disability tends to plateau. Some evidence suggests that severity of illness may lessen in later life, particularly among women. Spontaneous movement disorders may develop in patients who have severe negative symptoms and cognitive dysfunction, even when antipsychotics are not used.

For the first year after diagnosis, prognosis is closely related to adherence to prescribed psychoactive drugs and avoiding recreational drug use.

Overall, one third of patients achieve significant and lasting improvement; one third improve somewhat but have intermittent relapses and residual disability; and one third remain severely incapacitated. Only about 15% of all patients fully return to their pre-illness level of functioning.

Factors associated with a good prognosis include

Factors associated with a poor prognosis include

Men have poorer outcomes than women; women respond better to treatment with antipsychotic drugs.

Substance use is a significant problem in many people with schizophrenia. There is evidence that use of marijuana Марихуана (канабіс) Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent. прочитати більше or hallucinogens Галюциногени Hallucinogens are a diverse group of drugs that can cause unpredictable, idiosyncratic reactions. Intoxication typically causes hallucinations, with altered perception, impaired judgment, ideas. прочитати більше is highly disruptive for patients with schizophrenia and should be strongly discouraged and treated aggressively if present. Comorbid substance use is a significant predictor of poor outcome and may lead to drug nonadherence, repeated relapse, frequent rehospitalization, declining function, and loss of social support, including homelessness.

Довідковий матеріал щодо прогнозу

1. RAISE: Recovery After an Initial Schizophrenia Episode—A Research Project of the National Institute of Mental Health (NIMH). Accessed 1/14/22.

Treatment of Schizophrenia

The time between onset of psychotic symptoms and first treatment correlates with the rapidity of initial treatment response and quality of treatment response. When treated early, patients respond more quickly and fully. Without ongoing use of antipsychotics after an initial episode, 70 to 80% of patients have a subsequent episode within 12 months. Continuous use of antipsychotics can reduce the 1-year relapse rate to about 30% or lower with long-acting drugs. Drug treatment is continued for at least 1 to 2 years after a first episode. If patients have been ill longer, it is given for many years.

Early detection and multifaceted treatment has transformed care of patients with psychotic disorders like schizophrenia. Coordinated specialty care, which includes resilience training, personal and family therapy, addressing cognitive dysfunction, and supported employment, is an important contribution to psychosocial recovery.

General goals for schizophrenia treatment are to

Antipsychotics, rehabilitation with community support services, and psychotherapy are the major components of treatment. Because schizophrenia is a long-term and recurrent illness, teaching patients illness self-management skills is a significant overall goal. Providing information about the disorder (psychoeducation) to parents of younger patients can reduce the relapse rate (1, 2 Довідкові матеріали щодо загального лікування Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect. прочитати більше ). (See also the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Schizophrenia, 3rd Edition.)

Послуги з реабілітації та підтримки громади

Psychosocial skill training and vocational rehabilitation programs help many patients work, shop, and care for themselves; manage a household; get along with others; and work with mental health care practitioners.

Supported employment, in which patients are placed in a competitive work setting and provided with an on-site job coach to promote adaptation to work, may be particularly valuable. In time, the job coach acts only as a backup for problem solving or for communication with employers.

Support services enable many patients with schizophrenia to reside in the community. Although most can live independently, some require supervised apartments where a staff member is present to ensure drug adherence. Programs provide a graded level of supervision in different residential settings, ranging from 24-hour support to periodic home visits. These programs help promote patient autonomy while providing sufficient care to minimize the likelihood of relapse and need for inpatient hospitalization. Assertive community treatment programs provide services in the patient’s home or other residence and are based on high staff-to-patient ratios; treatment teams directly provide all or nearly all required treatment services.

Hospitalization or crisis care in a hospital alternative may be required during severe relapses, and involuntary hospitalization may be necessary if patients pose a danger to themselves or others. Despite the best rehabilitation and community support services, a small percentage of patients, particularly those with severe cognitive deficits and those poorly responsive to drug therapy, require long-term institutional or other supportive care.

Cognitive remediation therapy helps some patients. This therapy is designed to improve neurocognitive function (eg, attention, working memory, executive functioning) and to help patients learn or relearn how to do tasks. This therapy may enable patients to function better.

Психотерапія

The goal of psychotherapy in schizophrenia is to develop a collaborative relationship between the patients, family members, and physician so that patients can learn to manage their illness, take drugs as prescribed, and handle stress more effectively.

Although individual psychotherapy plus drug therapy is a common approach, few empirical guidelines are available. Psychotherapy that begins by addressing the patient’s basic social service needs, provides support and education regarding the nature of the illness, promotes adaptive activities, and is based on empathy and a sound dynamic understanding of schizophrenia is likely to be most effective. Many patients need empathic psychologic support to adapt to what is often a lifelong illness that can substantially limit functioning.

In addition to individual psychotherapy, there has been significant development of cognitive behavioral therapy for schizophrenia. For example, this therapy, done in an individual or a group setting, can focus on ways to diminish delusional thoughts.

For patients who live with their families, psychoeducational family interventions can reduce the rate of relapse. Support and advocacy groups, such as the National Alliance on Mental Illness, are often helpful to families.

Довідкові матеріали щодо загального лікування

1. Correll CU, Rubio JM, Inczedy-Farkas G, et al: Efficacy of 42 pharmacologic cotreatment strategies added to antipsychotic monotherapy in schizophrenia: Systematic overview and quality appraisal of the meta-analytic evidence. JAMA Psychiatry 74(7):675-684, 2017. doi: 10.1001/jamapsychiatry.2017.0624

2. Wang SM, Han C, Lee SJ: Investigational dopamine antagonists for the treatment of schizophrenia. Expert Opin Investig Drugs 26(6):687-698, 2017. doi: 10.1080/13543784.2017.1323870

Ключові моменти

Schizophrenia is characterized by psychosis, hallucinations, delusions, disorganized speech and behavior, flattened affect, cognitive deficits, and occupational and social dysfunction.

Threats of violence and minor aggressive outbursts are more common than seriously dangerous behavior, but such behavior may be more common in people with paranoid psychosis who abuse drugs.

Treat with antipsychotic drugs early, basing selection primarily on adverse effect profile, required route of administration, and the patient’s previous response to the drug.

Psychotherapy helps patients understand and manage their illness, take drugs as prescribed, and handle stress more effectively.

With treatment, one third of patients achieve significant and lasting improvement; one third improve somewhat but have intermittent relapses and residual disability; and one third are severely incapacitated.

Додаткова інформація

The following are some English-language resources that may be useful. Please note that The Manual is not responsible for the content of these resources.

American Psychiatric Association (APA), Clinical Practice Guidelines for Schizophrenia, 3rd Edition: Practice guidelines include information on the social determinants of mental health and on effectively using technology (including social media, telepsychiatry, and mental health apps) to provide optimal patient care.

National Alliance on Mental Illness (NAMI), Schizophrenia: NAMI promotes ongoing awareness of schizophrenia, as well as educational and advocacy initiatives to support those who have it, and crisis-response services (including a HelpLine) to assist those in need.

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Що таке оргазм та як зрозуміти, чи відчували ви його

Точка неповернення, перезавантаження всієї нервової системи. Оргазм можна порівняти з перегоранням лампочки, розповіла сексолог Ольга Василенко.

Як визначити оргазм?

Що за м’язи скорочуються? Ті ж м’язи, які ви скорочуєте під час вправ Кегеля + клітор. Спробуйте прямо зараз стиснути вагінальний сфінктер і підтягнути м’язи вгору. Скорочення клітора відчувають не всі жінки, але скорочується він у всіх.

Скороченнями не можна керувати! Не плутайте стадію плато (з усвідомленими м’язовими скороченнями) і оргазм. Плато – це коли дуже добре, але ще не оргазм. На стадії плато ви самі можете напружуватися і стискати м’язи.

Після оргазму переважно з’являється втома

“Дуже добре” – ще не оргазм. Після оргазму дотики до клітора болючі, сексу не хочеться, а кров відливає від геніталій. Виключення – мультіоргазмічність. Можете продовжувати? Не було скорочень? Це ще не оргазм.

Більшість, але не всі, після оргазму відчувають втому. Тому що відбувається перезавантаження нервової системи. Ось чому чоловіки часто хочуть спати після сексу.

“Емоції – не показник. Одна жінка “відлітає в космос”, інша кричить, третя завмирає, четверта плаче. Не орієнтуйтеся на це. Основа – скорочення, якими не можна управляти, стан неповернення і припинення всіх реакцій тіла. Я до 21-22 років думала, що приємні відчуття – це і є оргазм, поки не взяла в руки вібратор”.

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