Depressive symptoms occur in about a quarter of patients with schizophrenia. Due to the high frequency of symptoms, there is debate as to whether they should be considered part of the symptom profile of schizophrenia. Recognizing and diagnosing depressive episodes or symptoms in patients with schizophrenia is sometimes difficult due to overlap with negative symptoms. However, identifying symptoms of depression early is very important because this disorder associated with risk of suicide, poorer quality of life, and decreased performance medicines. In a recent study by G. Van Rooigen et al. considered possible ways treatment of depressive episodes and symptoms of schizophrenia.
Having studied scientific works on PubMed, they came to the following conclusions. In the acute phase of psychosis, it is recommended to treat depressive symptoms, primarily with antipsychotics only, since depressive symptoms may improve or disappear with remission of psychosis. For example, if patients suffer from significant positive symptoms (such as delusions and hallucinations), they can lead to social isolation and, as a result, cause symptoms of depression. Therefore, treating psychotic symptoms with D2 receptor antagonists may improve symptoms of depression.
At the same time, a number of studies have found that excessive blocking of dopamine receptors (increased doses of antipsychotics or increased binding) leads to a deterioration in self-awareness and/or dysphoria. If depressive symptoms persist, you should investigate whether this is due to excessive blocking of dopamine receptors. If this is the case, it is advisable to reduce the dosage of antipsychotics or switch to an antipsychotic with less dopamine D2 receptor binding. Other studies suggest that sulpiride, clozapine, olanzapine, aripiprazole, quetiapine, lurasidone, and amisulpride are slightly better than other drugs in improving depressive symptoms in patients with schizophrenia.
In addition, if you are depressed, it is recommended to exercise exercise, since they generally have a beneficial effect on the patient’s condition. If depressive symptoms continue to persist, consider moving to either cognitive behavioral therapy or adding an antidepressant (eg, selective serotonin reuptake inhibitors). Additional studies have demonstrated that antidepressants, incl. SSRIs are only effective when patients meet criteria for a depressive episode. Future high-quality studies are needed to confirm these results.
Tolerability of antidepressants also has great importance, since patients diagnosed with schizophrenia usually already receive antipsychotic drugs and there may be associated side effects. Thus, patients receiving additional antidepressants had significantly more complaints of abdominal pain, constipation, dizziness and dry mouth, which are common side effects antidepressants.
Material prepared as part of the project ProSchizophrenia- a specialized section of the official website Russian Society Psychiatrists dedicated to schizophrenia, modern approaches to its diagnosis and treatment.
Editor: Kasyanov E.D.
Sources:
- Geeske van Rooijen, Jentien Marloes Vermeulen, Henricus Gerardus Ruhé, and Lieuwe de Haan. Treating depressive episodes or symptoms in patients with schizophrenia. Cambridge University Press 2017 doi:10.1017/S1092852917000554
- Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull. 2008; 34(3): 523–537
- Dauwan M, Begemann MJ, Heringa SM, Sommer IE. Exercise improves clinical symptoms, quality of life, global functioning, and depression in schizophrenia: a systematic review and meta-analysis. Schizophr Bull. 2016; 42(3): 588–599.
Treatment with potent drugs finally gave results. For the second month, my husband (daughter, uncle, father...) has no hallucinations and his interest in life has gradually begun to awaken. The family just breathed a sigh of relief and thought about magic word“remission”, like one nasty morning former patient psychoneurological dispensary again spoke about the frailty of existence. Don’t rush to jump to conclusions about relapse Dementia praecox . Approximately 30% of patients with schizophrenia, during the period of remission, are diagnosed with a depressive episode, which is a direct consequence of this disease. In the early 80s this mental disorder was allocated to a separate section of the ICD, where it was assigned code F.20.4 and given the definition of “post-schizophrenic depression” (PSD).
Post-schizophrenic depression. Mechanisms of development and causes of occurrence
Doctors, when asked about the pathogenesis of PSD, shrug their shoulders in bewilderment. They don't have clear answers, but there are several plausible theories:
- Theory 1. The disorder is the result of the action of neuroleptics, in particular, aminazine. The side effects of this drug indicate that it can cause depression and neuroleptic syndrome. Why do they continue to appoint him? It’s just that chlorpromazine, in terms of its sedative effect, is considered the most powerful antipsychotic, which also has the widest therapeutic range.
- Theory 2. Post-schizophrenic depression is endogenous. It is assumed that emotional disorder personality was present even before it was masked by the delusions and hallucinations of schizophrenia. When acute psychosis retreated, then depression came to the fore.
- Theory 3. PSD is a transitional stage of remission, which is generally characterized by positive dynamics. Residual signs of psychosis are caused by stress due to the transition to outpatient treatment, job search, and change of daily routine.
Circumstances contributing to the development of the disease:
- Social insecurity and stigma (label “schizophrenic”).
- Hereditary predisposition to depression.
- Tense situation in the family circle. The patient's relatives feel anger, helplessness, guilt, and ostracism from friends and neighbors. Part of this moral burden is voluntarily or involuntarily transferred to the shoulders of the patient with PSD.
- In the “risk zone” are young men 25-30 years old and women 50-55 years old (menopause).
Symptoms of the disease
PSD occurs after the most severe symptoms schizophrenia (delusions, hallucinations, thinking disorders...) cease to dominate clinical picture, but some of the signs of the disease continue to persist. It could be:
- Eccentric behavior that does not correspond to generally accepted norms.
- Incoherent and fragmentary speech. A person is not able to create associations and gets confused in individual concepts and images.
- The circle of communication is limited to 2-3 people - most often these are the patient’s relatives who are accustomed to his style of communication. Emotional coldness may manifest towards strangers, even to the point of aggression. The lack of communication is compensated by conversations with imaginary people or with oneself.
- Low physical activity, loss of interest in life, apathy. The condition worsens in the morning or before bed.
- Increased anxiety, suicidal thoughts.
- Depersonalization and derealization.
PSD can present as one or a combination of symptoms. Depending on their “set,” the disease can occur in an anxious, hypochondriacal, depressive-apathetic, asthenic-depressive or depressive-dysthymic variant. Treatment is selected according to the clinical picture.
About diagnostics
The diagnosis of “post-schizophrenic depression” can only be considered if at least one of the symptoms of a depressive episode has been present in the patient’s behavior for the last two weeks (see “Symptoms”). The initial prodromal period of schizophrenia and PSD are very similar to each other, and only a qualified specialist can distinguish between them. It is not difficult to cope with depression, while schizophrenic delusions and hallucinations tend to “grow” into a person over time and it becomes much more difficult to treat them.
Examination of a patient with PSD includes the following steps:
- Consultation with a psychotherapist. If necessary, conversations with a therapist and neurologist are scheduled.
- Fluorography, general analysis blood, urine test.
- To exclude concomitant somatic or neurological disease are appointed additional research: cardiogram, electroencephalography, CT scan of the brain.
- Held clinical trial, which includes collecting anamnesis, observations and conversations with the patient.
Based on the diagnostic results, a decision is made on hospitalization. A hospital is an extreme case, where a patient is sent if he becomes dangerous to others or shows suicidal tendencies. PSD is mainly treated at home or on an outpatient basis.
Treatments for a depressive episode
Therapy can last from a month to two, depending on the patient's resistance to medications and social factors.
Drug therapy
- Antidepressants (AD):
Amitriptyline. Popular new generation AD. Increases the level of serotonin, norepinephrine. Has a powerful sedative and analgesic effect. Contraindicated in many heart diseases. Concomitant use of amitriptyline and MAO inhibitors can lead to the death of the patient.
Imipramine, milnacipran. Used for the treatment of PSD of the depressive-apathetic type.
- fluvoxamine. It has both antidepressant and stimulating effects. Well tolerated, has significantly fewer side effects than the above mentioned ADs.
- Tranquilizers:
Diazepam, sibazon, relium. Reduce stress and fears, help with insomnia.
- Neuroleptics
Haloperidol, triftazine, risperidone. “Classics” of psychotropic drugs. Prevents hallucinations, strong antiemetic. Appointed when severe forms PSD.
Physiotherapy
- Zigzag technique. For several days in a row, the patient is given the maximum permissible dose of antidepressants (AD), and then their use is abruptly stopped. Used to overcome resistance to psychotropic drugs.
- Laser therapy. The flow of quanta, affecting the neurovascular bundles and the patient’s brain, has a sedative effect, relieves increased anxiety, has an anticonvulsant effect.
- Plasmapheresis is a plasma replacement procedure. Used to detoxify the body after taking antipsychotics. Drug therapy stops for this period.
- Electroconvulsive therapy or electroshock treatment. A painless procedure (anesthesia is used), which is carried out in comfortable conditions. Despite its fearsome reputation, it produces surprisingly good results with affective disorders, which include PSD.
Psychotherapy
- Group therapy. Includes cognitive and behavioral psychotherapy. Helps a patient with PSD understand the relationship between his disease and problems that arise in communication. A person stops feeling lonely when he understands that everyone has difficulties, and they can be solved.
- Family. Many psychoneurological dispensaries offer courses (trainings) to train relatives of patients. Here they are taught correct behavior, given full information about his illness.
- Individual. The psychotherapist, using the arguments of logic, consistently forms the patient’s understanding of his condition, helps to rebuild his value system and views on the world around him.
Leaving this mental disorder untreated means not only dooming the patient to suffer from symptoms of depression, but also greatly increasing the risk of suicide. Take care of your loved ones, and the disease will recede before your persistence, because as E. Remarque wrote:
«… and it’s good that people still have many important little things that chain them to life and protect them from it. But loneliness—real loneliness, without any illusions—comes before madness or suicide.”
Often, not only amateurs, but also non-psychiatrists confuse depression and schizophrenia: after all, these completely “independent” diseases can be closely intertwined. At the same time, depression is by no means a sign or symptom of schizophrenia, but schizophrenia is often accompanied by depression.
It is important to remember that depressive states in schizophrenia not only significantly increase the suffering of patients, but also represent a kind of warning signal for others, since they often precede the schizophrenic’s attempts to commit suicide.
Depressive conditions can be divided into several categories.
Acute anxiety depression. She is characterized by decreased mood, confusion, and confusion in her thoughts. Delusional ideas, for example, persecution mania and thoughts of suicide are intertwined with ideas of self-blame and self-destruction.
Stuporous depression. Its main feature is motor retardation. At the same time, patients begin to feel sad and worry about the supposed imminent death of their loved ones. Their melancholy is intensified by feelings of their own inferiority and self-recrimination.
Suicidal tendencies in this form of the disorder do not always occur, but if it does appear, patients can spend hours developing options for ending their lives.
Erased depression. At the beginning of schizophrenia and during its sluggish course depressive syndrome often appears unclear and erased. The patients themselves are not even aware of their depression. They do not have any painful experiences about hypothetical losses, there are no complaints about their condition. Therefore, they usually have a negative attitude towards the prospect of treatment for depression. Erased disorders can be combined with ideas of sexual inferiority and unfinished suicide attempts.
Anesthetic depression. All the patient’s feelings seem to be frozen, including feelings of melancholy and anxiety. Patients are lethargic, apathetic, no one interests them.
The main symptoms of schizophrenia are considered to be apathy, lack of will, withdrawal, strange behavior associated with experienced hallucinations, crazy ideas. However, these symptoms may accompany others. mental states, which are important to correctly differentiate for successful treatment.
Symptoms of schizophrenia - danger in diagnosis
Unfortunately, full diagnostics can only be carried out by experienced and highly qualified doctors. This requires not only academic knowledge, but also extensive practical experience. Symptoms of schizophrenia are often confused with symptoms organic diseases brain, toxic and infectious lesions of the nervous system.
Unfortunately, specialists at the Preobrazhenie Clinic often encounter diagnostic errors. Treatment is often carried out in the wrong direction, so the main symptoms of schizophrenia not only do not go away, but often begin to increase, and the person’s condition worsens.
Schizophrenia as a disease was discovered only two centuries ago. It was then that doctors began to describe the main symptoms of schizophrenia and select treatment methods.
And previously it was considered a vice, the possession of demons, and other supernatural explanations were also found.
The symptoms of schizophrenia, with a detailed picture of the disease, are noticeable even to an inexperienced person in medicine.
The main symptoms of schizophrenia are manifestations
Schizophrenia affects almost every area mental activity person:
- The speech contains reasoning, delusional statements and slipping from an important topic to others. Thinking is unconnected, florid and viscous.
- The will suffers greatly, painfully incapable of initiative, independent actions and decision making.
- Emotions are inadequate to the events taking place, facial expressions and pantomime are almost completely absent, the voice is monotonous and devoid of emotional nuances.
- A person loses social skills, communication is reduced to nothing, there is no desire to work, start a family and bring any benefit.
Types and types of symptoms of schizophrenia
- continuous-progradient – the disease flows continuously with a gradually increasing personality defect;
- paroxysmal-progradient - an exacerbation of the disease replaces a period of clinical remission, the destruction of personality increases with the progression of the disease;
- recurrent – attacks of schizophrenia are replaced by states persistent condition peace, personality changes are expressed slightly; A favorable type of disease course in which a person maintains working capacity and social interests for a long time.
Productive and negative core symptoms of schizophrenia
Productive symptoms in schizophrenia include delusions, false perceptions, and strange behavior. Delusional thoughts are most often associated with feelings of special destiny, persecution, jealousy, or fantastic cosmogonies. Pseudohallucinations are usually of a verbal nature, commenting on or criticizing the patient’s actions. Other perceptual deceptions may be in the form of visual hallucinations oneiric character (cosmic dreams), changes in taste, crawling of non-existent insects or worms and a distorted perception of one’s body.
Negative symptoms are expressed as apato-abulic syndrome, i.e. a decrease in the emotional-volitional manifestation of a person. Sooner or later, this leads to a personality defect in schizophrenia - such changes in the patient’s psyche that make it impossible for a person to fulfill his family and social function. Patients with schizophrenia with a severe personality defect are incapable of productive activity. They give up studying, cannot hold down a job, stop caring about their loved ones and taking care of their appearance.
Depressive symptoms of schizophrenia
Depression and mania in patients with schizophrenia are quite common and they have their own characteristics. Affective disorders in schizophrenia occur in a quarter of cases of the disease.
Mania in schizophrenia manifests itself through foolish behavior, elements of anger and frenzy. Unlike affective disorders, manic state in schizophrenia it develops suddenly and disappears just as quickly.
Depressive symptoms of schizophrenia have endogenous features
- seasonality of occurrence - deterioration of the condition in the off-season: spring and autumn;
- mood swings occur without external reasons– there are no visible traumatic situations;
- changes in mood during the day - in the morning the background mood is much worse than in the evening;
- overvalued ideas or delusions of attitude;
- pronounced vital coloring of statements - a strong feeling of melancholy, pronounced depression, pessimism and despondency;
- psychomotor retardation - the patient does not ask for anything, does not strive for anything, sits for a long time in a drooping position.
Schizophrenic depression is usually accompanied by excessive anxiety and internal tension, without mental or physical justification. Anxiety-depressive syndrome in schizophrenia, in the absence of help from a psychiatrist, can lead to suicide. Relapse of depression often leads to new psychosis, so depressive symptoms in schizophrenia are grounds for hospitalization of the patient. Mood disturbances in schizophrenia are always combined with the main symptoms of schizophrenia.
Schizophrenia attack symptoms
During an exacerbation of schizophrenia, the first thing that catches your eye is unreasonable anxiety. This may manifest itself as even more strong care into yourself, or psychomotor agitation. The patient experiences severe mental stress, often hears voices of a threatening nature, becomes uncritical of his delusional thoughts and expresses them out loud.
During this period, a person stops sleeping at night, there is practically no appetite, anxiety and irritability increase. He also makes attempts to protect himself from danger by performing ridiculous actions or rituals, becomes distrustful of loved ones, and may begin to become an alcoholic or run away from home.
During psychosis, it is important to calm the person as much as possible, agree with his ideas and encourage psychiatric team ambulance, or a private psychiatrist.
Aggression as symptoms of schizophrenia
Relapse of schizophrenia may be accompanied by aggressive behavior. The patient is excited, rushes around the apartment, the mood changes sharply from supportive goodwill to violence and frenzy, and back. There is no criticism of one’s condition. Patients cease to realize where they are, get confused in time, and do not understand what is happening around them.
During attacks of aggression, patients can harm both themselves and others. You need to contact a psychiatrist as soon as possible to provide emergency psychiatric care.
Diagnostic symptoms of schizophrenia
The diagnosis of schizophrenia can only be made after long-term observation by doctors within the framework of psychiatric hospital. A group of psychiatrists and other specialists collect the necessary life history, ask the patient and his immediate family about the onset and course of the disease, and conduct all the necessary examinations.
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Schizophrenia is one of the chronic diseases. Thanks to timely diagnosis And with constant supportive treatment, the patient is able to live his entire life without experiencing difficulties, in a state of remission. Therapy is needed on a continuous basis; only in this case is it possible, without causing complications, to ensure a normal existence for the patient.
Schizophrenia manifests itself in different ways, has several types, each of which has its own characteristics of course and treatment. It is for this reason that it does not have general forms treatment.
Among the varieties of schizophrenia, manic-depressive schizophrenia, or as it is also called psychosis or syndrome, occupies a special place.
general characteristics
Manic-depressive syndrome is a more correct name for such a disease, although scientists are clearly divided on this issue. Many psychiatrists define this disease as an independent pathology.
Manic-depressive schizophrenia is characterized by an alternation of two states: depressive and manic. In the intervals between them, a remission may be observed with signs of a normal attitude towards the world and oneself. This condition occurs more often in women than in men. This is due to women’s special susceptibility to stress and physiological characteristics.
The syndrome can be called not very common, since it occurs in a ratio of 7 to 100 thousand (7 cases of the disease per 100 thousand people).
The exact causes of manic-depressive psychosis, like other types of schizophrenia, have not been fully identified. But the vast majority of theories are inclined to believe that the main factor in the onset of the disease is genetic predisposition. One version of this predisposition is the absence of genes responsible for myelin connections.
As stated above, manic-depressive schizophrenia manifests itself in two opposing states.
- Depressive phase. This period occurs more often and lasts longer. The depressive phase is characterized by the following features:
- Motor retardation;
- Speech retardation;
- A depressed state characterized by deep melancholy.
In this state, a person persecutes himself, feeling guilty before the people around him. In this state, suicide attempts are possible. When describing their own condition, patients often use the expression “heaviness in the chest,” meaning that a state of some heaviness is inherent in the entire body, as if a stone had been placed inside a person.
Motor and speech inhibition can reach its apogee, causing complete stupor and immobility. The physical features of this condition are a rapid heartbeat and dilated pupils.
- Manic phase. This period is the opposite depressive state. It consists of the following manifestations:
- hyperactivity, increased excitability, funny mood;
- speech agitation (the patient talks a lot);
- motor excitement;
- accelerated course of mental processes.
At the initial stage of development of the disease, this phase may not look distinct enough, and the symptoms may be erased. But as the disease progresses, the symptoms worsen, becoming more obvious and pronounced.
During this period, the patient becomes fussy, extremely irritable, aggressive, intolerant of criticism and comments regarding his condition.
Other forms of manic-depressive schizophrenia
In addition to the generally accepted periods of illness, there is a mixed form of pathology, in which the symptoms of depression and mania are confused. Against the background of depression, delusions may appear, or a person’s activity may be accompanied by complete apathy. These phenomena are extremely rare, but still occur.
There may also be an erased form in the classic two-phase form. The disease cycle is quite short, and the symptoms are so smooth that the behavior is perceived not as pathology, but as character traits. Patients remain able to work, which makes the disease not obvious to others. The risk of hidden depression in patients is high.
The duration of each phase depends on the person’s condition and the depth of the disease and can vary from 1-2 weeks to several years. Most often, periods of remission appear between phases, but there are cases when a person simply moves from stage to stage without returning to normal existence.
Therapy for manic-depressive schizophrenia
The most important thing that the patient himself and his relatives should know is that the pathology requires constant monitoring by a doctor. Constant course drug treatment will allow achieving relief in conditions in the form of long-term remissions. Medicines are prescribed depending on the stage.
