Treatment of schizoaffective disorder in accordance with international standards

Schizoaffective disorder is a disorder in the functioning of the nervous system of the brain that involves a combination of schizophrenia and affective psychosis. This disorder is not often diagnosed in people with mental disorders. An in-depth study of the causes of this disorder and the nature of its manifestation is still ongoing. But it is reliably known that an important motivating factor in the development of the problem is genetics. If a first- or second-degree relative has previously been diagnosed with schizophrenia, the risk of developing schizoaffective disorder increases.

According to statistics, lonely people who are not surrounded by attention and care are susceptible to this mental illness. Drug and alcohol abuse may be a motivating factor.

Let us highlight several factors noted by experts regarding predisposition to the development of schizoaffective disorder:

- Women are susceptible to this mental disorder more often than men; — Until adulthood, the disease practically does not occur; — Single residents of large cities have a higher risk factor, unlike residents of villages.

Causes of schizoaffective disorder

The prevalence in the population reaches 0.8%; according to some data, men and women are equally susceptible to the disease; according to others, the incidence in women is slightly higher. Schizoaffective disorder is believed to be more severe in men than in women. This is a chronic disease, currently considered incurable, however, its treatment, like the treatment of mental disorders in general, allows you to control symptoms and maintain an acceptable quality of life.

As with many other mental illnesses, the causes of schizoaffective disorder are still not clearly established. Experts call the immediate cause of the development of schizoaffective disorder a disturbance in the metabolism of neurotransmitters - substances through which nerve impulses are transmitted by cells of the nervous system to each other or to other cells of the body.

Just as in the case of schizophrenia, a hereditary predisposition is assumed - often in patients suffering from schizoaffective disorder, family history reveals indications of similar cases among close and distant relatives.

The influence of external factors may also be important - social ill-being (lack or insufficiency of social connections), severe one-time or chronic stress, and also, presumably, some viral infections.

Schizoid disorder

In ordinary life, people often use the word “schizoid” to describe the behavior of a particular person. As a rule, in such cases some mental abnormalities are attributed to him. However, schizoid is a personality type that is used by psychiatrists and psychologists to identify certain patterns necessary when working with clients and patients.

Schizoid personality disorder is no longer a characteristic of a person or his behavior, but a pathological condition included in the ICD-10 classification. It describes an emotionally cold and aloof person who tends to become deeply immersed in his fantasies.

This disorder occurs in approximately 3-5% of people. Scientists have been studying it for a long time and have given various definitions, including or excluding it from the spectrum of schizophrenic disorders.

There was a time when these two phenomena were considered in the context of one disease. Indeed, there is a connection between them, but today the term “schizoid disorder” is used exclusively to describe the syndrome, and therefore is not identified with schizophrenia.

Prognosis for schizoaffective disorder

The prognosis directly depends on whether schizoaffective disorder is treated, and if so, how adequately it is. Overall, the prognosis is better than that of schizophrenia, but worse than that of mood disorders in terms of adjustment and functioning. The patient, especially if he receives therapy, usually manages to remain socially adapted, and sometimes manages to maintain his ability to work. Without treatment, patients, especially those with a long history of illness, lose social connections and become disabled.

New methods of treating schizoaffective disorder abroad

Before treatment for schizoaffective disorder begins abroad, a thorough diagnosis is carried out, which is quite complex, and therefore should be carried out by a specialist with experience in working with similar diseases. Establishing a correct diagnosis is important, first of all, in order to choose the right treatment strategy, as well as for prognosis. The problem is that often the diagnosis cannot be established immediately, since the manifestation of schizoaffective disorder (usually acute) is similar to either schizophrenia or bipolar affective disorder, and after the acute condition subsides, in remission, the disease may not have pronounced symptoms. Usually, to make a diagnosis of schizoaffective disorder, it is necessary to observe the patient over time.

It is necessary to differentiate schizoaffective disorder, first of all, from schizophrenia and bipolar affective disorder (manic-depressive psychosis). What is common with schizophrenia may be the presence of delusions, hallucinations, loss of socialization, negative symptoms; with bipolar affective disorder – the presence of depression (often) and hypomania (less often), as well as mixed conditions.

Depending on the predominance of certain symptoms, the following types of schizoaffective disorders are distinguished:

• Depressive-delusional (depressive-paranoid syndrome);
• Manic-delusional (manic-paranoid syndrome);
• Mixed.

The disorder has a chronic course with pronounced periods of exacerbation and remission. The diagnosis is made based on the presence of symptoms of schizophrenia (especially negative ones), manifested against the background of bipolar disorder (especially depression), which have been present for at least two weeks.

Drug therapy for schizoaffective disorder should also be combined, it consists of the use of antipsychotics and mood stabilizers; in the presence of depression, antidepressants are added to the main therapy. For sleep disorders, sleeping pills may be indicated, usually in a short course. Outside of exacerbations, the patient takes maintenance therapy. Also, after the acute condition has been relieved, rehabilitation measures are carried out, the same ones that include the treatment of schizophrenia - mainly psychotherapy aimed at restoring socialization.

Clinical picture

Schizoaffective disorder develops at a young age and has no sexual preference. It combines features of schizophrenia and altered affect. In this case, the disease almost always begins with affective disorders, then schizophrenic symptoms appear.

From schizophrenia, the disease causes strange, illogical behavior, sometimes of a frightening nature. Actions may become aimed at one type of activity, for example, take the form of sexual perversions. Usually a manifestation of inappropriate emotions: they cry when everyone is laughing, and vice versa.

Emotional disturbances are manifested by coldness and meager feelings. Changes occur in the logical structure of mental activity, up to dementia. The patient's speech is filled with neologisms and is characterized by raggedness and incoherence.

Typical schizophrenic disorders are hallucinations and delusions.

An affective disorder is a disorder that exaggerates these emotions in one direction or another. Affect is the manifestation of a person’s internal subjective feelings through emotions outward.

During the course of the disease, the following forms are distinguished:

• depressed;
• manic;
• mixed.

The depressive stage of the disease is accompanied by:

• sharply depressed mood;
• loss of appetite, body weight;
• increased appetite, body weight;
• low self-esteem, feelings of guilt;
• insomnia or increased sleepiness;
• fatigue, decreased vitality;
• loss of interest in previously significant things;
• feeling of hopelessness;
• loss of concentration;
• suicidal thoughts.

The developed depression is accompanied by stupor and depressive oneiroid. The hallucinations that accompany this state are imperative - they are commanding in nature. The syndrome of openness of thoughts appears - the patient thinks that his thoughts are accessible to others.

In the depressive form of the disorder, Cotard's delusion can be traced. The patient complains of decomposition, rotting of parts of the body, the whole organism, he believes that a foul odor emanates from him.

The syndrome includes destructive delusions, ideas of one’s own or someone else’s malicious behavior. Within this stage, delusions of sinfulness and hypochondria were traced.

The manic form of the disease includes:

• unbridled joy;
• fast flow of thoughts;
• accelerated rate of speech;
• increased self-esteem;
• absentmindedness;
• enhanced performance;
• sexual liberation;
• uncontrollable, gambling behavior - countless sexual relationships, driving at high speed without rules, alcohol abuse;
• inflated self-esteem;
• little need for sleep.

To all this is added the delirium of grandeur, the ability to influence other people's thoughts, to suppress the will. The perception of the passage of time is disrupted, and magical considerations are formed.

Often the disease is present in a mixed form. As part of this course, depression alternates with mania or hypomania. Delusions and hallucinations are of an ambivalent (bifurcated) nature. Pathological ideas and impaired perception are based on the struggle between good and evil.

The acute phase of psychosis usually lasts more than two weeks.

How is schizoaffective disorder treated in Israel?

In Israel, treatment of schizoaffective disorder, depending on the severity of the patient's condition, can be carried out in a hospital, on an outpatient basis or in a day hospital. Hospitalization is necessary only in the acute phase of the disease, with which in most cases schizoaffective disorder manifests itself. If the treatment is chosen correctly, and if the patient adheres to medical prescriptions without stopping maintenance therapy, then re-hospitalization, as a rule, is not required.

The treatment approach is combined - it includes treatment of anxiety disorder, mainly with mood stabilizers, treatment of the schizophrenic component with antipsychotics, and treatment of depression with antidepressants. If antidepressants are ineffective, antipsychotic drugs (neuroleptics) can be used. The therapeutic effect is provided by lithium preparations, azaleptin, monoamine oxidase inhibitors, tricyclic antidepressants and their combinations.

Since the disease is accompanied by negative symptoms, i.e., a certain weakness, loss of socialization, much attention is paid to social rehabilitation. This is especially important for patients with schizoaffective disorder, since they have every chance of maintaining, albeit not fully, social adaptation.

The Renaissance Clinic in Israel provides assistance in the treatment of mental disorders in accordance with the achievements of world psychiatry. An individual approach to the patient is practiced, when therapy is compiled taking into account all the existing characteristics of the patient, concomitant diseases, etc. Patients receive comprehensive care in a comfortable environment - drug treatment, psychotherapy, rehabilitation. The goal is to restore and maintain mental health at an acceptable level as fully as possible, and maintain all social functions, including work. People suffering from schizoaffective disorder, receiving maintenance therapy, can perform, among other things, intellectual work, for example, work in scientific institutions in professorial positions, i.e., retain their functions fully.

Patients from abroad, having undergone treatment in Israel, have the opportunity to maintain remote communication with their attending physician, receiving timely help and support, and thereby maintaining long-term remission.

The following factors support seeking help in Israel, at the Renaissance Clinic:

• reasonable prices for the treatment of schizoaffective disorder;
• treatment methods that comply with international best practices;
• individual approach to each patient;
• focusing efforts not just on eliminating the symptoms of the disease, but on maximum social rehabilitation of the patient;
• complete confidentiality.

Application of psychotherapy

Psychotherapy for patients with such a diagnosis is an auxiliary method of providing assistance; it accelerates the effect that can be achieved by precise selection of medications, consolidates the result, prolongs remission, and adapts the person to a society of healthy people. Talk therapy is often used for schizoaffective disorder. It allows you to better understand your condition, understand your own feelings and reduce their influence, identify negative attitudes that provoke destructive behavior, and replace them with constructive thoughts and actions. For this purpose, cognitive-behavioral techniques are used for individual lessons and work in groups. If the cause of the disease is psychotrauma at a young age, psychodynamic therapy is used.

If the patient is unable to express all his problems, art therapy is of great help. Taking part in art, music, or dance can help you express yourself and cope with current triggers for your attacks. Family therapy plays a leading role in the treatment of schizoaffective disorder, which allows one to influence the home environment. Thanks to the participation of loved ones in the treatment process, they can understand:

• the feelings that the patient experiences;
• what actions on their part help or hinder recovery;
• what needs to be done to make positive changes.

Many relatives behave incorrectly towards a mentally ill person. With their hypertrophied care, they cause or strengthen his feeling of inferiority. Understanding his problem, but at the same time constantly recognizing himself as weak and incompetent, the patient only aggravates his difficult situation. Thanks to family psychotherapy, a person understands how his condition and signs of the disease can affect those who live nearby. After treatment, all family members begin to act together, directing their efforts to eliminate existing difficulties and problems, and work on a strategy to prevent the next exacerbation of the pathology.

A person who has been diagnosed with schizoaffective disorder, if he contacts Dr. Isaev’s clinic in a timely manner, has the opportunity to completely get rid of the manifestations of the disease. Qualified specialists help a person with this diagnosis reduce the number of attacks and increase the time of remission for a long time.

Psychotherapeutic techniques aim to remove not only causative factors, but also reduce the likelihood of stressful effects. Work with a specialist begins after the acute attack has stopped, otherwise the doctor will not be able to achieve full contact and awareness of the problem. In general, the prognosis for this disease is favorable, but the outcome depends on the timeliness of the start of treatment and the characteristics of affective and schizophrenic manifestations.

The use of psychotherapy significantly increases the effectiveness of drug treatment. The specialist’s job is to detect hidden factors that provoke attacks, eliminate them or reduce their impact. A person is aware of the reasons for the development of deviations and understands their destructiveness. Family psychotherapy also plays a significant role, thanks to which mutual understanding between the patient and close relatives improves.

What methods are used to treat schizoaffective disorder in Moscow?

Patients can receive treatment for schizoaffective disorder in Moscow in public or private psychiatric hospitals. Currently, it is possible to obtain therapy for this disease that meets international standards, and therefore is the most effective. This opportunity is provided by the Moscow branch of the Israeli Renaissance Clinic, which specializes in the treatment of various types of addiction and other mental disorders.

It should be noted that people suffering from schizoaffective disorder, as well as other mental illnesses associated with mood disorders, are especially susceptible to alcohol and drug addiction. This is due to attempts at self-medication. Traditionally in Russia there is a negative attitude towards people suffering from mental illnesses, so they often do not consult a doctor for a long time with their problem. Instead, they “treat” themselves, trying to drown out the symptoms of ill health with the help of various psychotropic substances. Experts consider such dependence as a complication of the underlying disease, and note that it is necessary to simultaneously treat it too, since otherwise therapy for schizoaffective disorder will not be effective.

When contacting the Moscow department of the Renaissance Rehabilitation Center, patients receive assistance in the volume and type that are provided for by world practice, among other things, confidentiality is guaranteed.

An important point is that prices for treatment of schizoaffective disorder in Moscow at the Renaissance clinic correspond to prices for treatment in other private Moscow clinics.

Specifics of treatment of schizoaffective disorder in St. Petersburg

State and private psychiatric clinics also provide treatment for schizoaffective disorder in St. Petersburg. For the most part, patients in the acute phase of the disease go to one of the state psychiatric hospitals, where they receive assistance to the extent necessary to relieve acute symptoms. As for further, supportive treatment and subsequent rehabilitation, things are more complicated, since doctors are often guided by somewhat outdated approaches adopted back in Soviet times.

As for the cost of treatment for schizoaffective disorder in St. Petersburg, in state clinics assistance to Russian citizens is provided free of charge, which is a big plus, unfortunately, often the only one.

We recommend that patients from St. Petersburg with a similar disease contact the Renaissance Clinic - in Israel or Moscow. Despite the fact that Moscow is closer, treatment in Israel has the additional advantage of a change of environment, which produces an additional therapeutic effect. For religious patients, this effect can be especially strong (meaning that the patient is traveling to a place that is sacred to him).

Previously (before 1983) in Russian psychiatry, attacks of a schizoaffective structure were considered as a favorable (undifferentiated) course of paroxysmal-progressive schizophrenia [5]. In ICD-10 [4], adopted for use in the practice of domestic psychiatry, schizoaffective disorder (SAD) is allocated to a separate diagnostic heading - F25, but retains its place in the section “Schizophrenia, schizotypal and delusional disorders” (F2).

Depending on the dominant affect in the structure of the attack, taking into account schizophrenic symptoms, SAD is divided into manic, depressive and mixed types. The depressive type of schizoaffective disorder (F25.1) includes primarily depression with the presence of at least two of the three characteristic (typical) depressive symptoms (low mood, loss of interests and ability to enjoy, severe fatigue, even with little effort - F32) or concomitant behavioral disorders within a depressive episode. Along with severe depression, at least one (preferably two) typical symptom of schizophrenia from the list “a-d” (F.20) must be present. In DSM-IV-TR [15], similarly to ICD-10, a psychotic state with the simultaneous presence of depressive, manic or mixed affective disorder and symptoms of schizophrenia is accepted as the main symptom of SAD. At the same time, in the clinic of schizoaffective disorder of the depressive type, the severity of depression must meet the criteria for a depressive episode. The presence of hallucinations and delusions is recognized as possible (for at least 2 weeks).

The purpose of this study was to study the psychopathological structure of the first manifest attacks of SAD, taking into account the characteristics of the pre-manifest period.

Material and methods

A group of patients of 48 people, 34 women and 14 men, diagnosed with the depressive variant of SAD according to ICD-10 (F25.1) was studied. The larger number of women in the present study was due to the fact that the collection of material was mainly carried out in the women's department of the regional clinical psychiatric hospital No. 1 (although the predominance of women was also noted in the literature [1]).

The criteria for inclusion in the study were the manifest (first) attack of SAD with the presence of depressive symptoms and one or more schizophrenic symptoms from the list “a-d” (F20) with a duration of the psychotic state of at least 1 month. Notable is the fact that the plot of hallucinations and/or delusions corresponds (congruently) to depressive affect in the structure of the attack. The exclusion criteria corresponded to ICD-10 in category F25 with special attention to the presence of delusional symptoms at the pre-manifest stage, including those interspersed with “purely” affective disorders. Patients with productive symptoms without concomitant depressive disorders at the active stage of the attack were also excluded.

The vast majority (89.6%) of patients had secondary specialized or incomplete higher and higher education. Before the manifest attack, 43.8% continued to work, 10.4% were on maternity leave; the number of university students, less often college and school students, was 14.6%; 31.2% stopped working at the pre-manifest stage. Of those employed, the majority worked in the service sector or performed the duties of skilled workers; much less often they were engaged in teaching or entrepreneurial activities, or worked as employees or scientists. 20 (41.6%) patients were married, 5 (10.4%) were divorced, 1 (2.1%) were widowed. More than half (52.1%) had children: one child - 14 patients (29.3%), two - 9 (18.7%), three - 2 (4.1%).

All patients were in the hospital during the examination period. The onset of the manifest depressive variant of SAD in the majority (77.1%) of patients occurred in adulthood (after 20 years), in 22.9% - during adolescence (from 17 to 20 years).

The average age of patients at the time of manifestation of an attack of SAD was 30.5±1.5 years. The duration of the active course of the attack was less than 1 month in 11 (22.9%) patients, 2 months in 16 (33.3%), 3 months in 5 (10.5%) and more than 3 months in 16 (33.3%) ).

A psychopathological analysis of premorbid personality characteristics and pre-manifest manifestations of psychosis was carried out, and the mental status of patients at the time of the attack and the immediate postpsychotic period was assessed. The database consisted of 65 features.

When statistically assessing the results, we used the non-parametric χ2 test with Yates correction (nominal, binary data) [6], Fisher’s test (if the expected frequency is less than 5) [7]. In order to determine the influence of risk factors on the formation of a clinical group, linear discriminant analysis was used. The calculation was carried out using the Statistica 6.0 program (“Stat Soft”).

Results and discussion

Based on a retrospective analysis of the pre-manifest stage of depressive SAD, the vast majority of patients - 79.2% - were diagnosed with affective disorders. Depressive states were

place in 23 (47.9%) patients. It turned out that in these cases, psychogenic provocation was noted quite often - in 16 (69.6%) patients ( p

<0.028). Bipolar disorders developed more rarely than depressive patients at the pre-manifest stage of SAD - in 12 (25.0%) patients, and hypomania, even more rarely - in 3 (6.3%). In the last two cases, the disorders arose autochthonously. According to N.D. Lakosina et al. [3], affective disorders in the form of hypomania or subdepression are detected in 59.6% of patients with SAD.

In this study, there was no dependence of the occurrence of an attack of BAD on the season, although there was a tendency for depressive BAD to develop more often in the fall compared to spring and summer.

Let us draw attention to the fact that the active manifestation of depressive BAD was immediately preceded by provoked or autochthonous affective disorders. Moreover, with a high degree of confidence ( p

<0.0001) the absence of an interval between pre-manifest disorders and the attack predominated, and pre-manifest affective disorders delayed from the manifest attack for a period of 1 month to 1 year or more were significantly less common. The presence of pre-manifest affective disorders indicates premorbid stress vulnerability of some patients with manifest depressive MAD. Attention was also drawn to the fact that there was no seeking medical help at the pre-manifest stage.

In 15 (31.3%) patients at the pre-manifest stage, pathological interests and hobbies were identified in the structure of non-psychotic affective disorders. Their content varied somewhat depending on the valence of the affect. So, in the case of a depressed state, this could be a passion for computer games (online games) and immersion in them, attempts at spiritual self-improvement in the knowledge of philosophical teachings, many hours of listening to hard rock, interest in “health-improving” literature and attending relevant courses. During the period of hypomania, a sudden love arose, including through the Internet, a passion for astrology, palmistry in order to find out one’s future, a craving for artistic creativity (for example, an active performance as a dancer in an erotic bar); attending expensive courses with the goal of “getting to know yourself as a person, learning to make the right decision and avoiding wrong ones, improving relationships with others and loved ones”, intensifying participation in business with the attitude of “making more profit” to the detriment of all other interests, including caring for the family ( “even children are not interested”). The significant frequency (51.2%) of the occurrence of pathological interests and hobbies in SAD (mixed and manic types were studied) has already been noted in the works of domestic authors [8].

Assessment of the severity of depression at the active stage of the course of depressive SAD was carried out from the perspective of ICD-10 criteria (F32-F34)[]. Half of the patients - 25 (52.2%) were diagnosed with an intermediate degree of severity - between severe and moderate depressive episode (DE). The basis for this was the presence in the patient of all three typical symptoms of depression mentioned above and from two to three of its other manifestations from the ICD-10 list; in one observation, a combination of two typical and six additional symptoms of depression was classified as an intermediate degree of severity of DE. In foreign literature [16], there are indications of the possibility of identifying an intermediate (transitional) severity degree of major depression or major DE.

In other cases, patients had mild (16.6%), severe (12.5%) and moderate (8.3%) severity of DE. The presence of subdiagnostic manifestations of DE was noted in 5 (10.4%) cases.

A significant frequency of individual subdiagnostic manifestations of generalized anxiety disorder (GAD) associated with diagnostically delineated depression was revealed. In this case, DSM-IV criteria were used. It was not possible to use the diagnostic rubric for GAD in ICD-10 (F41.1) due to the confusion of the criteria for GAD and non-fabular (floating) anxiety. Such manifestations of GAD as sleep disturbance (83.3%), fatigue (66.6%), and difficulty concentrating (52.1%) overlap with the manifestations of depression itself. The symptom of muscle tension is not typical for patients with the depressive variant of SAD. The accumulation of manifestations of autonomic hyperactivity in patients also turned out to be uncharacteristic. Thus, individual manifestations of vegetative anxiety were noted in 38 patients, and in 16 of them - in the form of one symptom.

At the onset of the attack, a significant place could be occupied by motor excitement (restlessness), when the patient, according to relatives, rushes around the room or spends days in meaningless movement around the apartment. At the height of the attack, psychomotor retardation was clearly manifested, which was accompanied by complaints about thinking disorders: “I can’t quickly formulate a thought,” “thoughts flow slowly,” “it takes me a long time to think.” The patients' voice was quiet, their answers were monosyllabic with long pauses; patients rarely changed their body position during conversation. With such psychomotor slowness, especially at the height of the attack, patients complained of a “sad, melancholy mood”, said that they “have no desires, don’t want anything”, “decreased mood”.

According to the picture of the psychotic attack, patients with manifest depressive SAD could be divided into two groups: 1st - with a monomorphic attack structure - in 14 (29.2%) patients, 2nd - with a polymorphic clinical attack structure - in 34 (70, 8%) patients. The monomorphic clinical structure of the attack in 10 cases was limited to verbal hallucinosis (true or pseudohallucinatory variants), one of the schizophrenic symptoms necessary for diagnosing SAD from the ICD-10 list; in 1 case there was functional verbal hallucinosis, in 3 cases the delusional register of psychotic symptoms predominated (acute sensory delirium or delusional somatopsychic depersonalization syndrome). In the case of the polymorphic structure of manifest depressive SAD, in most cases - in 27 (79.4%) patients, the mental status was determined by verbal hallucinosis - its true and pseudohallucinatory variants (35.3 and 44.1%, respectively); in isolated observations there was verbal functional hallucinosis (2.9%). A feature of the polymorphic structure of the attack is the combination of manifestations of verbal hallucinosis in the form of the main syndrome with the episodic occurrence at the onset and during the active stage of the attack of episodes of acute sensory delirium (delusional mood, symbolic meaning, intermetamorphoses, acute paranoid, delirium of staging), visual-figurative delirium of the imagination, individual manifestations of mental automatism syndrome or delusional episodes with the plot of damage, damage, imaginary pregnancy, confabulatory delusions. Among the optional syndromes, along with verbal hallucinosis, which determines the clinical picture of the attack, episodic occurrence of visual and olfactory hallucinations, hallucinations of the imagination, and in a single observation - visceral hallucinations were identified. Much less frequently (3 patients), the main clinical manifestations of polymorphic structural depressive disorder were determined by the delusional register of disorders. There was a clear syndromological phasing in the formation of delusions of staging, combined manifestations of delusions of corruption with misomania; hypochondriacal delusions with hallucinations of the imagination. In 2 observations, with a polymorphic structure of manifest depressive PAR, there was an oriented oneiroid with the presence of verbal pseudohallucinosis or mental automatism syndrome.

For individual disorders, significant statistical differences were noted between the group of patients with a mono- and polymorphic clinical picture. In group 1 of patients, schizoid (sensitive variant) premorbid personality traits were significantly more common (χ2=4.58, df=1, p

=0.03), stress-provoked affective disorders at the pre-manifest stage (χ2=7.2, df=1,
p
=0.007), while the latter were more often represented by depressive disorder (χ2=5.8, df=1,
p
=0.016) and in the form of a single depressive episode (χ2=7.8, df=1,
p
=0.005).
On the contrary, in patients with a polymorphic attack structure, bipolar affective disorder occurred significantly more often at the pre-manifest stage (χ2 = 3.98, df = 1, p
= 0.046) in the form of dual affective phases (
p
= 0.04).
Features of pre-manifest affective symptoms depending on the monomorphic or polymorphic structure of the manifest depressive mental disorder are presented in Table.
1 and 2 .

Comparative syndromological characteristics of manifest depressive SAD, depending on the mono- or polymorphic structure, are given in Table. 3

.

Let us dwell on some of the features of verbal hallucinosis that occurred in the patients we observed. We are talking about the “symptom of openness” or, rather, the consciousness of the openness of one’s thoughts according to the mechanism of inference [11]. Patients, for example, said: “the neighbors voiced my thoughts - whatever I think about, they already know and answer me” or “the voices of my husband’s relatives behind the wall know my thoughts - I just think about it, and they already tell me in advance what will happen "

Episodes of delusional mood as initial manifestations of delirium of the imagination [11] during a depressive manifest attack of SAD with a polymorphic clinical picture were characterized by a “premonition of bad things,” or the patient “caught” the condemning glances of others on himself—“they don’t look at me like that.” Otherwise, it is a feeling that relatives in the family can harm a child just brought from the maternity hospital; as if “the furnishings in grandma’s apartment have changed: the mirror hangs in a different place than before; The furniture is not placed where it usually is”; upon returning to her apartment, the patient could not recognize the front door - “its shape and color of the door had changed.” Delusions of symbolic meaning in the structure of the polymorphic clinical picture of the manifest depressive variant of SAD, as well as all the types of delusions mentioned above, were an episode.

In most cases, the plot of episodes with visual-figurative delusions of imagination in the clinic of depressive SAD, which was polymorphic in clinical structure, had a dramatic but ordinary content. In the domestic literature [2] there are indications of the possibility of the emergence, along with megalomanic and everyday content, of delusions of imagination. This could be a short-term, transient “feeling of being in a cemetery” (funeral of a mother, daughter-in-law), accompanied by a feeling of cold, wind, while the patient saw trees around her, heard the crying of others, or this “feeling of darkness around her and dead relatives nearby” with a request for close people to turn on the light, otherwise, it’s a feeling of being buried alive - “it’s cold, they’re throwing earth at me” with a request for help from others; drowning - “I feel like I’m dead, I feel water around me, I can’t take a breath - water gets into my mouth”; dying - “it seemed like I was dying, I saw a picture in my head: a corridor with a bright light.” These could be flashes of flame in the evening hours (“fire all around”) with double orientation - the feeling that the patient is on the street and at the same time understands that she is in the apartment. The scale of psychotic experiences in the case of diagnostically outlined visual-figurative delusions of the imagination (oriented oneiroid) included “the expectation of war and disaster”, “the struggle of world powers for human resources, energy and land”; the patient found himself in the center of these events with the need to choose someone's side in the conflict. This could be a reincarnation with the loss of her physical “I”, reincarnation and return to her physical body, while the patient did not completely lose orientation in the environment, for example, she made demands on the medical staff - “do something with me, I have become different."

Episodes of delirium with a plot of damage reflected a pathoplastic family or professional conflict situation, as well as pronounced asthenia as one of the manifestations of depression (“I didn’t do anything, but was already tired after 15 minutes”) and in none of the observations did they exhaust the clinical picture of acute polymorphic in structure depressive schizoaffective attack. The determining factor in these cases was verbal hallucinosis without any continuity in the content of the voices in relation to the delusional plot of damage. Transient ideas of damage arose, for example, in the context of the beginning of the privatization of a house and land (“the neighbors are rearranging pegs, limiting the area of ​​​​my plot, doing this at night, covering my house with garbage”) and existed with verbal hallucinosis commenting on the patient’s behavior, or arose during emerging from an attack with a complex polymorphic structure (“my son is in cahoots with his sister - they decided to put me in the hospital in order to take possession of the apartment”). The delusion of intermetamorphosis was represented by the phenomenon of a negative double, and it could, as it were, precede the development of an acute attack or be the final one at the exit from it, and also arise in the structure of an episode with the plot of the delusion of a staging. The latter occurred both at the hospital stage and during the stay in the department.

Among our observations there was also a small group - 7 (20.6%) patients with the presence of subcatatonic symptoms in the structure of a polymorphic attack. In this case, transient subcatatonic episodes occurred at the onset of the attack. According to relatives, these were short-term episodes of immobility for several minutes (“freezing”), for example, in one position with a lack of reaction to external stimuli, or episodes of freezing in one position were replaced by motor excitement. Otherwise, these were more extensive episodes in the form of freezing while eating, washing dishes, or holding the lower limb raised and bent at the knee joint in one position. In isolated cases, subcatatonic symptoms were included in the clinical picture of delineated oriented oneiroid. The inclusion of these observations in the category of depressive SAD, from our point of view, was possible due to the distinct depression in the structure of the attack and the correspondence of the content of the visual-figurative delusions of the imagination to the dominant affect.

The general group of patients was also analyzed in relation to the presence or absence of mixed affective disorders at various stages of the attack. These types of attacks occurred in 25 (52.1%) and 23 (47.9%) patients, respectively. In 4 cases, there was a sudden replacement of the depressive component of psychosis by an episode of elevated mood with possible appropriate and productive activity. Thus, one patient began to actively participate in the preparation and holding of a charity evening for several days in order to raise money for an orphanage; another - for several days, experiencing “euphoria”, became active in everyday life, expressed a desire to relax at the dacha; in the third case, a depressive state was observed in the morning and during the day, which in the evening was replaced by mild hypomenia with the need for vigorous activity (“general cleaning of the apartment”), which corresponds to the concept of “conditional bipolarity” [10]. In the fourth case, the patient, according to relatives, for a short time became smiling, cheerful, and tried to hum and dance to the music. In a larger number of observations (9), hypomania (including the type of conditioned bipolarity) occurred at the end of an attack, immediately after the reduction of depressive and productive symptoms. Moreover, in 4 patients, after recovery from an attack or in the immediate post-psychotic period, bipolar affective disorders were noted. Along with mixed affective disorders in the form of a bipolar variant, the presence of mixed affective symptoms proper was revealed. This was mixed depression [12-14] at the height of the attack or mixed depression at the height of the attack and an alternating variant [9] at the stage of reduction of depressive and productive symptoms (2 observations), an alternating variant at the onset of an attack (1 case) and at the end of it (3 patients), but without concomitant productive symptoms.

In order to confirm the validity of identifying the typology of manifest depressive disorder based on the criterion of the absence or presence of mixed affective disorders in the structure, a linear discriminant analysis procedure was applied with the sequential inclusion and exclusion of features included in the main database. Of the 65 signs, 13 of the most informative ones were identified, allowing one to differentiate the two above-mentioned clinical groups. These signs include manifest schizophrenia in first-degree relatives, the number of mentally healthy relatives; verbal pseudohallucinosis throughout the attack; premorbid features in the form of avoidant (anxious) personality disorder; a number of socio-demographic indicators (presence of children, professional employment, fact of leaving work at the pre-manifest stage); bipolar and depressive disorders at the pre-manifest stage (autochthonous and provoked occurrence), etc. The greatest contribution to the division of clinical groups according to the criterion of the absence or presence of mixed affective disorders is made by the sign “verbal pseudohallucinosis” in the structure of the manifest manifestation of depressive BAD. The quality of discriminant analysis (Wilks' Lambda value was 0.29, F (13.34) = 6.23, p

<0.00001) indicates the correctness of the undertaken separation of patients.

In the clinical structure of the polymorphic depressive variant of SAD with the presence of mixed affective disorders, a number of features of verbal pseudohallucinosis were noted. This refers primarily to its dominance in the psychopathological space of the attack. This refers to the duration of pseudohallucinosis at the active stage of the attack, detailed plot development and systematization of delirium, congruent with the content of auditory hallucinations. Manifestations of verbal pseudohallucinosis may be accompanied by visual pseudohallucinations during a significant period of active psychosis. So, for example, one of the patients has images of influential political, military and religious figures of the past in her head - “I see and hear them in my head, I talk to the images”; Subsequently, the content of pseudohallucinosis acquires a megalomaniac connotation - “the patient must give birth to 16 girls” and at the same time, in accordance with the content of the voices, do not forget to “brush your teeth and wash your face.” In the case of religious and mystical content of auditory hallucinations (voices) or close to megalomaniac content, patients obey their imperative content - “cast out evil spirits, demons from loved ones” by sprinkling with holy water, bringing the icon closer to the face; ready to sacrifice domestic animals; one of the patients, obeying the imperative content of the voices, could hit someone close to her, took a bath in her underwear, broke a telephone, a TV, and ruined a family portrait.

Summarizing the analysis of a non-selected contingent of patients with manifest depressive BD, carried out in everyday psychiatric practice, we can identify a number of options for the structure of attacks: mono- and polymorphic attacks depending on the number of productive (psychotic) symptoms, with the presence or absence of mixed affective symptoms in the form of hypomania , bipolar disorder, mixed depression and an alternating version of mixed affective disorder (without concomitant productive symptoms). Pre-manifest affective disorders were also noted. At the same time, in 47.8% of patients with mixed affective disorders in the structure of manifest depressive MAD, bipolar disorders or isolated episodes of hypomania were detected at the pre-manifest stage. This gives reason to assume that for a certain part of patients with manifest depressive SAD, the tendency towards bipolarity, inherent in the pre-manifest stage, finds its expression at various stages of the course of the attack itself.

[]In the literature [17], a psychometric assessment (PHQ-9 questionnaire) was also used for this purpose.

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Read reviews about the treatment of schizoaffective disorder

“After giving birth, my wife fell ill and was admitted to a psychiatric hospital. They said it was postpartum depression and that she would quickly get back to normal. This turned out not to be the case. It turned out that she had schizoaffective disorder, and although the disease was no longer noticeable after treatment, oddities in behavior remained. They began to look for where to turn, and quickly realized that there was nothing to catch with domestic psychiatry. We found a clinic in Israel and went there. Renaissance Clinic. From there the wife returned as an almost normal person, as they say, they fixed it. She’s taking the pills, and it looks like it’s going to last for a long time, if not forever, but at least she’s the same as before.”

Khvoshchevsky I. P., Taganrog, Russia

“I have been diagnosed with schizoaffective disorder for several years. The disease occurs periodically, the rest of the time I am practically healthy. Nevertheless, attacks do occur, and they are quite painful. For some time they thought it was depression, I took antidepressants, then it was schizophrenia, then we figured it out. I found out that there is an Israeli clinic in Moscow that takes care of such diseases, and I contacted them. Since then there has not been a single attack (10 months have passed), there are good doctors there. I continue treatment, but in a maintenance mode. I’m very pleased.”

Olga Pavelets, Moscow, Russia