for adhra's character
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moonflower77to a considerable extent, the affect-dominant forms of the illness are consistent with the concept of schizoaffective psychoses as an independent nosological unit and with its definition as such. these forms are characterized by affective disturbances combined with non-affective delusions (different varieties of acute sensory delusions, from perceptual delusions to delusions of the imagination). the delusional disorders have to meet at least one of the diagnostic criteria for schizophrenia according to the ICD-10. their manifestations may have a varying clinical significance when it comes to assessing the possible future course and prognosis of the illness. duration-wise, the ratio of delusional and affective disorders within a single episode is, on average, about 1:20.
the illness usually develops in people with schizoid traits that most often amount to an accentuated personality, or, somewhat more rarely, reach the level of a personality disorder. pre-manifestation (prodromal) symptoms appears many years before the first schizoaffective episode. at this stage, usually between the ages of 10-12 years, the patients start to display a reactive emotional lability. psychological trauma, such as certain events that have an emotional significance and/or are difficult to cope with, trigger a depressive reaction. as the years go by, some of the patients begin to have depressions of a mixed reactive and endogenous origin. 2-3 years before the first manifest episode, the affective symptoms begin to increase in severity; the depression deepens, gains a vital (unconditional, inexplicable) quality and becomes more obviously endogenous. the affective disturbances start to come mostly in bipolar phases, which may be doubled. the depression usually comes first and is the deepest in the series, but sometimes, it is the manic phases that are the most prominent. at this point, there are no disturbances in social adaptation or work capacity.
in most cases, the first manifest schizoaffective episode is provoked by an external event, such as psychological trauma or physical illness. more rarely, it arises spontaneously. the stereotypical dynamic of its development includes several clear-cut successive stages: affective disturbances, affective delusions, non-affective delusions, and then again affective disturbances as the episode starts to resolve. the duration of the affective disturbances in the manifest psychotic states may range from 1.5 months to 3 years (more than 6 months on average), and of the delusional disorders from 2 days to 3 weeks (2 weeks on average).
the clinical pattern of the episode may differ depending on the peculiarities of the acute sensory delusions, i.e. whether they are acute perceptual delusions, delusions of the imagination based on visual imagery, or intellectual delusions of the imagination.
if perceptual delusions are predominant:
most of these episodes are triggered by emotional trauma. the actual delusional disturbances usually develop after an apathetic-adynamic depression, or, which is less common, after a classic melancholy depression. it is very rare for them to appear after a classic "joyful" mania. at first, there is a period of "isolated" affective delusions that lasts 1-2 weeks, and the non-affective delusions develop directly afterward. the average duration of these schizoaffective states is 7-8 months.
depending on how far the development of the perceptual delusions progresses, one can distinguish three possible varieties: i) delusional mood, ii) delusions of staging, iii) delusions of symbolic significance.
perceptual delusions that are limited to delusional mood can only appear after a classic melancholy depression. the content of the patients' depressive experience is determined by the traumatic event that had served as a trigger. in 1-2 weeks' time, the patient develops persistent, well-formed depressive delusions, which are replaced at the height of the episode by non-affective delusions that do not have a complete "storyline". instead of depressive feelings, the patients' internal state comes to be dominated by a delusional affect: tension, global suspicion and distrust, a sense of impending danger. this stage is transient and lasts from a few hours to 5 days. the psychotic state ends suddenly, after which the depressive affect returns and is again dominant for the following 2-3 weeks. once it has disappeared, the patients regain a critical attitude to their experience.
only half of the episodes with delusions of staging are precipitated by psychological trauma. these delusions are also preceded by depression, in this case of the apathetic-adynamic variety. in 2 - 3 months' time the depression is complicated by depressive ideas of condemnation and self-blame that continue for 1.5 - 2 weeks. as the non-affective delusions start to surface, the predominant affect switches to that of bewilderment and confusion. one's surroundings and the behavior of other people appear to have been altered: they feel unnatural, artificial, inauthentic, rigged. the patient appears to have fallen victim to a hoax or practical joke. this phenomenon is referred to as delusions of intermetamorphosis. the delusions are fragmented, extremely labile and unfold in a fast, dynamic manner. they last 1-2 weeks and rarely co-exist with the previous affective delusions. the delusional psychosis ends suddenly, but for another 2-3 months, as the episode resolves, the patient may experience short exacerbations in the form of short rudimentary delusions of staging against a depressive background. later, the patient develops a critical attitude toward their experience.
delusions of symbolic significance are preceded by a period of affective delusions, and can evolve with equal frequency after quasi-sociopathic or classic "joyful" manias and after anxious or apathetic-adynamic depressions. half of these states are triggered by somatic illness. the disturbances that come to the fore at the height of the episode are an obviously distorted perception of the real world, whose elements are replaced by various symbols and signs, and a delusional interpretation of one's surroundings. the non-affective delusions acquire a fantastical tinge. the psychotic state subsides gradually, over 2-3 weeks. after the delusions of symbolic significance are gone, the affective delusions and affective disturbances once again become dominant. the patients' critical attitude is formed slowly over time.
the course of affect-dominant forms defined by perceptual delusions is close to the phase-based one (that of the affective psychoses). later, during the subsequent episodes, the delusional symptoms tend to simpliy. they begin to arise spontaneously (in an autochtonous manner), become more transient and are sometimes limited to signs of fear or anxiety or impulsive behavior without any clearly defined "storyline".
the purely affective and schizoaffective episodes occur with more or less the same frequency throughout the course of the illness (one episode in three years). the affective disturbances remain primarily bipolar, with unipolar depression being more rare. for most patients, the illness becomes purely affective with time. in remission, there is just a temporary asthenia and a sharpening of their premorbid hypersensitive traits; often, the reactive emotional lability they had before the first psychotic break is retained. indicators of social and work adaptation are usually high, even at the remote stages of the illness, and the professional and educational level of the patients tends to increase.
if delusions of the imagination based on visual images are predominant:
the episode is usually triggered by an external event, which, in most cases, is a somatic illness. in the overwhelming majority of cases, it begins with mania (mania with quasi-sociopathic behavior, classic "joyful" mania or mania accompanied by confused, fragmented ideation).
as a rule, acute delusions of the imagination develop against the background of the affective disturbances, along with the manic delusions. they are dynamic, variable and unfold in a rapid, abrupt fashion. vivid, fantastical mental images (usually visual) start to surface in the patient's mind. they are unstable, changeable, each limited to a single "storyline" of its own, and have a three-dimensional, bright, almost tangible quality. the delusional events are fragmented, scene-like, or, less commonly, daydream-like, incomplete from the psychopathological perspective. they are not subject to any single, more specific interpretation. circular affective disturbances are an integral component of such episodes.
the acute delusional state ends more or less suddenly and is typically over within 1-2 weeks. at the same time, the affective delusions also become less pronounced, and so do the persisting affective (manic) disturbances. the patients' critical attitude toward their experience is fairly complete, though often accompanied by an unfounded optimism regarding the possibility of relapse.
the further course of the illness is relatively favorable, and can be seen as intermediate between phase-based (as with the affective disorders) and recurrent episodic (as with periodic non-progressive schizophrenia). after the first psychotic episode, the following schizoaffective episodes are strictly spontaneous (autochthonous) in origin and share the same structure (course with clichéd episodes). they develop against the background of mania or a mixed state. the subsequent affective and schizoaffective episodes occur virtually with the same frequency (one episode in 2 years). for more than half of the patients, the illness is regressive, and eventually acquires a purely affective character. bipolar affect is dominant, but the manic affect becomes more and more prominent as time goes by. in remission, there are some noticeable personality changes: the patients' premorbid hysterical-schizoid traits are sharpened, and they become exceedingly dry and rational. in over a third of the cases, there is some impairment in social and work adaptation: the educational level of many patients increases, but their professional level usually drops. however, the majority retain their capacity to work over the entire course of the illness.
if intellectual delusions of the imagination are predominant:
there are warning signals early on during the pre-manifestation (prodromal) period. from childhood onwards, at critucal ages, many patients display certain symptoms: bouts of night terrors, undeveloped mental automatisms and ideas of persecution, a sense of change to their "self". bipolar affective swings appear spontaneously (in an autochthonous manner) and take the form of double phases at once. as a rule, the first is a mania with quasi-sociopathic behavior, which prevails over the asthenic-adynamic subdepression. however, 2-3 years before the manifestation of the schizoaffective psychosis, there is a further increase in the severity of the mania, and the affective phases begin to alternate continuously or as come as repeated unipolar manias that follow one another in rapid succession. at the same time, the mania is complicated by the appearance of heteronomous inclusions, such as the occasional undeveloped ideatory automatisms and rudimentary ideas of influence/control or erotic claims/harrassment, which do not require hospitalization and disappear in a mattter of days.
most often, the first manifest schizoaffective episode is spontaneous (autochthonous) and develops only against the background of a manic effect. after the mania has unfolded to the utmost, most patients start to develop atypical manic delusions. at first, these resemble ideatory constructs of a confabulatory variety, but later, as the illness continues, they are modified and replaced by so-called "delusional speculations" or "delusional guesses" [term coined by anufriev a.k., 1992]. the patient, with the ideational component of their imagination pathologically enhanced, seems to gain "intuitive" insight into the meaning of current events. this is followed by "creative development" and the subsequent construction of fantasmagorical theories or the formulation of "genius" discoveries united by a common storyline. the psychopathological phenomena observed in such cases lack an eidetic component. on occasion, there are separate elements of delusional retrospective flashbacks. on the whole, the delusional psychosis is characterized by a sudden, rapid onset, reversibility, and variable manifestations that change easily and fast. its constituent syndromes are incomplete.
as a rule, the delusional psychosis abates gradually, within 2-3 weeks, after a period of manic delusions and non-delusional manic affect. the reverse development of the affective disturbances is protracted and may take up to 3-5 months, which is quite a long while. the patients' critical attitude toward the acute psychosis is often incomplete, with attempts to find a "rational" explanation for their symptoms (for example, ascribing them to psychological causes).
the course of the illness is episodic and progressive. bipolar affect is dominant, but the manic phases are more prominent than the depressive ones, and the phases tend to alternate a la continua. as the time passes, there is a significant reduction in the thymic (mood-related) component of the affective disturbances; the mania is complicated by dysphoric inclusions, self-aggrandizing ideas of a non-delusional nature, and, finally, by heterogeneous inclusions in the form of non-affective delusions. at the same time, the depression becomes milder and often manifests in an atypical way, only as difficulties in concentrating / focussing one's attention. the episodes are fairly frequent (one episode per year on average) and frequently become protracted. the illness itself tends to become chronic.
throughout the entire course of the illness, during the subsequent schizoaffective episodes, the delusional disturbances retain the same clichéd structure. transition to a purely affective level is very rare and the illness often takes on a continuous character. when remissions do occur, they reveal negative changes in the patients' personality, such as emotional deficit, loss of productivity and residual thought disorders. for the vast majority of the patients, social and work adaptation deteriorates with time; their professional level drops and they tend to go on disability benefits.
the outcome of this variety is unfavorable, and it is debatable whether it should be categorized as schizoaffective disorder.
from: A. S. Tiganov (ed.) "Endogenous psychiatric disorders", chapter 3: G. P. Panteleyeva, V. I. Dikaya "Schizoaffective psychoses"
the illness usually develops in people with schizoid traits that most often amount to an accentuated personality, or, somewhat more rarely, reach the level of a personality disorder. pre-manifestation (prodromal) symptoms appears many years before the first schizoaffective episode. at this stage, usually between the ages of 10-12 years, the patients start to display a reactive emotional lability. psychological trauma, such as certain events that have an emotional significance and/or are difficult to cope with, trigger a depressive reaction. as the years go by, some of the patients begin to have depressions of a mixed reactive and endogenous origin. 2-3 years before the first manifest episode, the affective symptoms begin to increase in severity; the depression deepens, gains a vital (unconditional, inexplicable) quality and becomes more obviously endogenous. the affective disturbances start to come mostly in bipolar phases, which may be doubled. the depression usually comes first and is the deepest in the series, but sometimes, it is the manic phases that are the most prominent. at this point, there are no disturbances in social adaptation or work capacity.
in most cases, the first manifest schizoaffective episode is provoked by an external event, such as psychological trauma or physical illness. more rarely, it arises spontaneously. the stereotypical dynamic of its development includes several clear-cut successive stages: affective disturbances, affective delusions, non-affective delusions, and then again affective disturbances as the episode starts to resolve. the duration of the affective disturbances in the manifest psychotic states may range from 1.5 months to 3 years (more than 6 months on average), and of the delusional disorders from 2 days to 3 weeks (2 weeks on average).
the clinical pattern of the episode may differ depending on the peculiarities of the acute sensory delusions, i.e. whether they are acute perceptual delusions, delusions of the imagination based on visual imagery, or intellectual delusions of the imagination.
if perceptual delusions are predominant:
most of these episodes are triggered by emotional trauma. the actual delusional disturbances usually develop after an apathetic-adynamic depression, or, which is less common, after a classic melancholy depression. it is very rare for them to appear after a classic "joyful" mania. at first, there is a period of "isolated" affective delusions that lasts 1-2 weeks, and the non-affective delusions develop directly afterward. the average duration of these schizoaffective states is 7-8 months.
depending on how far the development of the perceptual delusions progresses, one can distinguish three possible varieties: i) delusional mood, ii) delusions of staging, iii) delusions of symbolic significance.
perceptual delusions that are limited to delusional mood can only appear after a classic melancholy depression. the content of the patients' depressive experience is determined by the traumatic event that had served as a trigger. in 1-2 weeks' time, the patient develops persistent, well-formed depressive delusions, which are replaced at the height of the episode by non-affective delusions that do not have a complete "storyline". instead of depressive feelings, the patients' internal state comes to be dominated by a delusional affect: tension, global suspicion and distrust, a sense of impending danger. this stage is transient and lasts from a few hours to 5 days. the psychotic state ends suddenly, after which the depressive affect returns and is again dominant for the following 2-3 weeks. once it has disappeared, the patients regain a critical attitude to their experience.
only half of the episodes with delusions of staging are precipitated by psychological trauma. these delusions are also preceded by depression, in this case of the apathetic-adynamic variety. in 2 - 3 months' time the depression is complicated by depressive ideas of condemnation and self-blame that continue for 1.5 - 2 weeks. as the non-affective delusions start to surface, the predominant affect switches to that of bewilderment and confusion. one's surroundings and the behavior of other people appear to have been altered: they feel unnatural, artificial, inauthentic, rigged. the patient appears to have fallen victim to a hoax or practical joke. this phenomenon is referred to as delusions of intermetamorphosis. the delusions are fragmented, extremely labile and unfold in a fast, dynamic manner. they last 1-2 weeks and rarely co-exist with the previous affective delusions. the delusional psychosis ends suddenly, but for another 2-3 months, as the episode resolves, the patient may experience short exacerbations in the form of short rudimentary delusions of staging against a depressive background. later, the patient develops a critical attitude toward their experience.
delusions of symbolic significance are preceded by a period of affective delusions, and can evolve with equal frequency after quasi-sociopathic or classic "joyful" manias and after anxious or apathetic-adynamic depressions. half of these states are triggered by somatic illness. the disturbances that come to the fore at the height of the episode are an obviously distorted perception of the real world, whose elements are replaced by various symbols and signs, and a delusional interpretation of one's surroundings. the non-affective delusions acquire a fantastical tinge. the psychotic state subsides gradually, over 2-3 weeks. after the delusions of symbolic significance are gone, the affective delusions and affective disturbances once again become dominant. the patients' critical attitude is formed slowly over time.
the course of affect-dominant forms defined by perceptual delusions is close to the phase-based one (that of the affective psychoses). later, during the subsequent episodes, the delusional symptoms tend to simpliy. they begin to arise spontaneously (in an autochtonous manner), become more transient and are sometimes limited to signs of fear or anxiety or impulsive behavior without any clearly defined "storyline".
the purely affective and schizoaffective episodes occur with more or less the same frequency throughout the course of the illness (one episode in three years). the affective disturbances remain primarily bipolar, with unipolar depression being more rare. for most patients, the illness becomes purely affective with time. in remission, there is just a temporary asthenia and a sharpening of their premorbid hypersensitive traits; often, the reactive emotional lability they had before the first psychotic break is retained. indicators of social and work adaptation are usually high, even at the remote stages of the illness, and the professional and educational level of the patients tends to increase.
if delusions of the imagination based on visual images are predominant:
the episode is usually triggered by an external event, which, in most cases, is a somatic illness. in the overwhelming majority of cases, it begins with mania (mania with quasi-sociopathic behavior, classic "joyful" mania or mania accompanied by confused, fragmented ideation).
as a rule, acute delusions of the imagination develop against the background of the affective disturbances, along with the manic delusions. they are dynamic, variable and unfold in a rapid, abrupt fashion. vivid, fantastical mental images (usually visual) start to surface in the patient's mind. they are unstable, changeable, each limited to a single "storyline" of its own, and have a three-dimensional, bright, almost tangible quality. the delusional events are fragmented, scene-like, or, less commonly, daydream-like, incomplete from the psychopathological perspective. they are not subject to any single, more specific interpretation. circular affective disturbances are an integral component of such episodes.
the acute delusional state ends more or less suddenly and is typically over within 1-2 weeks. at the same time, the affective delusions also become less pronounced, and so do the persisting affective (manic) disturbances. the patients' critical attitude toward their experience is fairly complete, though often accompanied by an unfounded optimism regarding the possibility of relapse.
the further course of the illness is relatively favorable, and can be seen as intermediate between phase-based (as with the affective disorders) and recurrent episodic (as with periodic non-progressive schizophrenia). after the first psychotic episode, the following schizoaffective episodes are strictly spontaneous (autochthonous) in origin and share the same structure (course with clichéd episodes). they develop against the background of mania or a mixed state. the subsequent affective and schizoaffective episodes occur virtually with the same frequency (one episode in 2 years). for more than half of the patients, the illness is regressive, and eventually acquires a purely affective character. bipolar affect is dominant, but the manic affect becomes more and more prominent as time goes by. in remission, there are some noticeable personality changes: the patients' premorbid hysterical-schizoid traits are sharpened, and they become exceedingly dry and rational. in over a third of the cases, there is some impairment in social and work adaptation: the educational level of many patients increases, but their professional level usually drops. however, the majority retain their capacity to work over the entire course of the illness.
if intellectual delusions of the imagination are predominant:
there are warning signals early on during the pre-manifestation (prodromal) period. from childhood onwards, at critucal ages, many patients display certain symptoms: bouts of night terrors, undeveloped mental automatisms and ideas of persecution, a sense of change to their "self". bipolar affective swings appear spontaneously (in an autochthonous manner) and take the form of double phases at once. as a rule, the first is a mania with quasi-sociopathic behavior, which prevails over the asthenic-adynamic subdepression. however, 2-3 years before the manifestation of the schizoaffective psychosis, there is a further increase in the severity of the mania, and the affective phases begin to alternate continuously or as come as repeated unipolar manias that follow one another in rapid succession. at the same time, the mania is complicated by the appearance of heteronomous inclusions, such as the occasional undeveloped ideatory automatisms and rudimentary ideas of influence/control or erotic claims/harrassment, which do not require hospitalization and disappear in a mattter of days.
most often, the first manifest schizoaffective episode is spontaneous (autochthonous) and develops only against the background of a manic effect. after the mania has unfolded to the utmost, most patients start to develop atypical manic delusions. at first, these resemble ideatory constructs of a confabulatory variety, but later, as the illness continues, they are modified and replaced by so-called "delusional speculations" or "delusional guesses" [term coined by anufriev a.k., 1992]. the patient, with the ideational component of their imagination pathologically enhanced, seems to gain "intuitive" insight into the meaning of current events. this is followed by "creative development" and the subsequent construction of fantasmagorical theories or the formulation of "genius" discoveries united by a common storyline. the psychopathological phenomena observed in such cases lack an eidetic component. on occasion, there are separate elements of delusional retrospective flashbacks. on the whole, the delusional psychosis is characterized by a sudden, rapid onset, reversibility, and variable manifestations that change easily and fast. its constituent syndromes are incomplete.
as a rule, the delusional psychosis abates gradually, within 2-3 weeks, after a period of manic delusions and non-delusional manic affect. the reverse development of the affective disturbances is protracted and may take up to 3-5 months, which is quite a long while. the patients' critical attitude toward the acute psychosis is often incomplete, with attempts to find a "rational" explanation for their symptoms (for example, ascribing them to psychological causes).
the course of the illness is episodic and progressive. bipolar affect is dominant, but the manic phases are more prominent than the depressive ones, and the phases tend to alternate a la continua. as the time passes, there is a significant reduction in the thymic (mood-related) component of the affective disturbances; the mania is complicated by dysphoric inclusions, self-aggrandizing ideas of a non-delusional nature, and, finally, by heterogeneous inclusions in the form of non-affective delusions. at the same time, the depression becomes milder and often manifests in an atypical way, only as difficulties in concentrating / focussing one's attention. the episodes are fairly frequent (one episode per year on average) and frequently become protracted. the illness itself tends to become chronic.
throughout the entire course of the illness, during the subsequent schizoaffective episodes, the delusional disturbances retain the same clichéd structure. transition to a purely affective level is very rare and the illness often takes on a continuous character. when remissions do occur, they reveal negative changes in the patients' personality, such as emotional deficit, loss of productivity and residual thought disorders. for the vast majority of the patients, social and work adaptation deteriorates with time; their professional level drops and they tend to go on disability benefits.
the outcome of this variety is unfavorable, and it is debatable whether it should be categorized as schizoaffective disorder.
from: A. S. Tiganov (ed.) "Endogenous psychiatric disorders", chapter 3: G. P. Panteleyeva, V. I. Dikaya "Schizoaffective psychoses"