for adhra's character
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moonflower77schizodominant forms of schizoaffective psychosis are the least consistent with its definition as a separate nosological unit, if understood in the stricter sense of these words. their clinical and psychopathological manifestations also depend on the peculiarities of the delusional syndromes present during a schizoaffective episode. however, the delusions are formed through mixed mechanisms. a common feature that unites all the schizodominant varieties is the combination of acute sensory delusions with a tendency to create ideational delusional constructs. here, it is a deeper (paranoid) psychopathological register that is prevalent; at the peak of the psychotic state, the patient develops acute kandinsky - clérambault syndrome [described by v.i. dikaya (1985) and i.y. nikiforova (1991)]. as the schizoaffective episode develops, there is no clear sequencing of affective disturbances, affective delusions and delusions proper; in fact, they often overlap, are "layered" over each other, as it were, and co-exist simultaneously. as a result, the psychopathological structure of the schizoaffective episodes is multi-faceted, with manifold features.
compared to affect-dominant forms, the affective disturbances as such are present for a much shorter while (no more than 1-3 weeks), while the pure delusional state lasts much longer (over 3-4 weeks). schizophrenic symptoms are more numerous and pronounced and have to meet at least two of the obligatory diagnostic criteria for schizophrenia according to the ICD-10. the total duration of the schizoaffective episode is 4-6 months. the average ratio of affective and schizophrenic (delusional) disturbances in the schizoaffective state is about 1,5:1.
this type of schizoaffective disorder develops in individuals who have a schizoid personality characterized by a mosaic structure, a certain emotional deficit and so-called "exemplary", "obedient" or "straightlaced" traits. more often, they are regarded as having schizoid personality disorder or a pseudo-disorder that mimics it.
during the pre-manifestation (prodromal) period, from puberty onward, the patients' premorbid traits start to sharpen against the background of bipolar affective disturbances that manifest in atypical ways. during the depressions there is a loss of drive and incentive, a growing inertia and sluggishness, while the mania is accompanied only by an increase in general activity without any feelings of joy or mirth. the phases are prolonged (up to 6 months in duration). 1,5-2 years before the first manifest episode, the severity of the affective disturbances increases. the depression becomes more vital and includes transient ideas of low self-worth or worthlessness, obsessive thoughts of a hypochondriac nature and an inclination toward alcohol abuse. the mania is dominated by sociopathic-like behavior, euphoria, disinhibition of and/or loss of control over one's instincts, and traces of silly, childish behavior.
shortly before the onset of psychosis, there is a marked increase in the depth and severity of the affective disturbances. sometimes, there is an increase in inertia and motor inhibition (for depression) or quasi-sociopathic behavior (for mania). at the height of mania, there may be occasional obsessive ideas, transient and undeveloped affective delusions, spells of depersonalization, separate associative automatisms. if one analyses the general structure of the affective disturbances, one can detect individual ideas of reference, paranoid inclusions, bouts of anxiety, "hails" (auditory illusions where the patient seems to hear somebody calling out to them). double or triple phases are common, as is their continual alternation.
as a rule, the first manifest schizoaffective episode is spontaneous (autochthonous). more rarely, it develops after a physical illness. the patient develops a paranoid psychosis (acute kandinsky - clérambault syndrome) that can have several varieties, depending on the mechanism through which the delusional syndromes are formed: defined by acute perceptual delusions with elements of interpretive delusions; defined by delusions based in on visual images with elements of interpretation; defined by acute (unsystematic) interpretive delusions with elements of sensory delusions. the peculiarities of the delusional disturbances detetmine both the clinical presentation of the episode and the prognosis (possible outcome).
acute paranoid psychosis (kandinsky - clérambault syndrome) defined by acute sensory delusions with elements of interpretive delusions:
this form of the illness was described by a.a. mukhin (1985). the psychotic state develops gradually, usually after a physical illness. in most cases, this happens during an asthenic-adynamic depression, or, less commonly, at the moment when depression switches to mania. during the subsequent episodes, the circular affect is retained during the initial stages of the paranoid psychosis. in the very beginning, against the background of the affective disturbances, there already are some rudimentary signs of a delusional mood, such as diffuse suspicion and elements that hint at delusions of significance. within 1-2 weeks, the circular affect is completely replaced by a delusional one that includes anxiety, general tension and a delusional wariness. the delusions are formed in full over the following few days. the patients notice the "intent" gazes of passers-by, see a "special significance" in their actions and so on. the delusional "plot" is usually concerned with moral damage to the patient, rather than a threat to their physical existence (life). there may be separate instances of false recognition. the mechanism is mixed and includes elements of both sensory and interpretive delusions.
the further development of the psychosis may take two directions. in some cases, it is limited to the development of the acute kandinsky - clérambault syndrome. its symptoms appear already within 3-5 days since the onset of the delusional psychosis, and are comprised largely by delusions of influence/control and mental automatisms of the associative variety. the delusions of persecution remain specific and retain a realistic plot. the delusions of influence or control also combine the properties of perceptual and interpretive delusions, occur simultaneously with the mental automatisms and often serve as their delusional "explanation". there is no clear notion about the specific method or source of the external control/influence. associative mental automatisms are usually limited to mind-reading or the internal openness of thought. senestopathic and kinesthetic automatisms are primitive. the patients are not pro-active and do not show any desire to contact other people and resolve the delusional situation. on the whole, the delusions are specific, unsystematic and share a single theme.
in other cases, not only does the patient develop the acute kandinsky - clérambault syndrome, but their delusions are modified and acquire a fantastical flavor. as the kandinsky - clérambault syndrome deepens, the disturbances become generalized and display a greater syndromal polymorphism. the delusional "plot" remains specific and mundane, but the patients start to see certain events and actions of other people as strange, unusual, extraordinary. as they formulate assumptions as to who might be persecuting them and why, they soon lose touch with the real situation; as a result, the ideas of persecution grow in scale and become more global. false recognitions cease to be concrete and definite. as the severity of the psychosis increases, the patients may show occasional signs of confusion against the background of the persecution-related "plot", which is still retained; the content of the latter becomes less and less specific and is extended in a diffuse manner to the entirety of one's surroundings (which are perceived as "altered", "changed", "a theater performance", "an experiment", "a test from god", "a laboratory", "a model city", "a movie studio" etc.). over the next 1-2 days the delusions continue to become more global, and, at the same time, more fragmented. the patients' affect becomes labile, and sometimes there can be fast, sudden transitions from fear to exaltation. the delusional "plot" becomes polymorphic; along with ideas of persecution and control/influence, the patients express ideas of condemnation and elements of so-called manichean delusions. there may be separate, rudimentary olfactory hallucinations, ideas of poisoning, illusory or genuine verbal hallucinations or catatonic inclusions, but without the transition to an oneiroid state. among the perceptual delusions, delusions of staging or symbolic significance often remain the most prominent, but are not developed any further. the content of the fantastical delusional experiences is limited to "mundane" or "trivial" topics and are usually connected to moral issues. the schizoaffective state is made even more complex by undeveloped delusions of condemnation and guilt (for depression) or self-aggrandisement (for mania); these correspond to the preceding circular affect, though the latter is no longer present (at that point, the patients no longer complain of it) and has been replaced by delusional affect. at the height of the psychosis, the behavior of the patients is delusional.
usually, the patients emerge from the psychotic state gradually. once the delusional disturbances have subsided, for another 1-1,5 months the affective disturbances once again become prevalent. as a rule, they are identical to the ones the patient had before the onset of the delusional schizodominant psychosis. post-episode depression and mania may become protracted.
the structure of the subsequent episodes does not change, but the symptoms of the schizoaffective psychosis may be reduced while the episodes themselves become more prolonged (though without any overt signs of progression). as the illness runs its course, the patients' premorbid traits, such as their emotional deficit and psychological passivity, become more and more pronounced. there is no marked decline in social and work adaptation or any obvious signs of disability, but there is no rise in creative activity or professional growth either. many patients eventually start to work from home.
acute paranoid psychosis (kandinsky - clérambault syndrome) defined by delusions based on visual imagery with elements of interpretation:
in most cases, the episode develops spontaneously (in an autochthonous manner), within 2-3 days after the switch from a depressive phase to a manic one. as ideational agitation increases, the patient's mood gains prideful overtones; they overstate their own importance, entertain ideas of a special mission and show signs of a self-esteem that is obviously too high. at the same time, the patients develop delusions of persecution where they attribute a special meaning to their surroundings and have some non-persistent ideas of staging.
during the initial stages of the episode, the circular affective disturbances, affective (manic) delusions and non-affective delusions are, as it were, combined, overlayed upon each other, and the disturbances in general are polymorphic. the patients' delusional experiences soon become divorced from the real situation and start to be perceived as incomprehensible, after which the patients develop acute kandinsky - clérambault syndrome. there is an undifferentiated sense of being subjected to influence or control from outside, which is interpreted in unusual ways. associative mental automatisms are accompanied by forced influxes of thoughts, deluges of vivid, image-laden "dreams", hallucinations of the imagination; yet, at the same time, the patient attempts to analyze the logic of the delusional events. as the psychosis deepens, mental automatism is experienced as a total openness of thought, ideas of persecution and influence/control reach a megalomanic and paraphrenic scale and are accompanied by a delusional depersonalization that has a fantastical quality. the delusional "storyline" is expanded through "epiphanies" or "sudden insights" with elements of delusional retrospection and an involuntary "unravelling of memories," which have a vivid, image-rich quality.
this close connection between the delusional disturbances and the circular affect and mania-induced ideas is retained throughout the episode. there is no inversion of affect, but at the height of the psychosis, the circular affect is transformed; for a short while, it acquires a distinct psychotic tinge, turning into exaltation, intense excitement, ecstasy, a sense of having gained a special insight into various events.
the psychotic state subsides slowly, in a matter of 1-2 weeks. the delusions gradually lose their relevance and the patients' condition comes to be dominated by manic affect with rudimentary manifestations of mental automatism. the patients' critical attitude is not restored at once, and largely concerns the acute period of the illness. the reverse development of the episode usually takes no more than a month.
the subsequent episodes arise spontaneously (in an autochthonous manner). the structure of the psychosis remains the same, but its manifestations become more reduced, rudimentary; the delusional disturbances grow poorer in imagery, and are increasingly dominated by interpretations. the psychotic episodes themselves become more prolonged and the affective disturbances start to come continuously. in remission, against the background of atypical affective disturbances, there are bouts of mental automatisms, depersonalization and anxiety. transition to a purely affective level is exceptionally rare.
within a year since the end of the first psychotic episode, there is a distinct shift in the patients' personality. they begin to display negative symptoms such as excessive rationality, psychological rigidity, inert behavior, fruitless and illogical philosophizing, a decline in efficiency and productivity. these symptoms may intensify after the second or third relapse and be accompanied by a significant loss of work capacity.
acute paranoid psychosis (kandinsky - clérambault syndome) defined by acute (unsystematic) interpretive delusions with elements of sensory delusions:
this form of the illness was described by s.y. tsirkin (1980). the episode usually arises in a spontaneous (autochthonous) manner. the first signs of the delusional psychosis typically appear at the moment when the affective pole is switching from mania to depression or from depression to mania. along with the circular affect, there appears a delusional affect of anxiety and diffuse suspicion; at the same time, the patient starts to develop affect-related delusions (delusions of sin and condemnation for depression and delusions of erotic claims or harrassment for mania)..
the non-affective delusions stem from long-standing obsessive ideas of a varied content, which had already been present during the prodromal period. at this point, they intensify and undergo a delusional modification. as for the affective delusions mentioned above, they acquire a persecutory shade in the beginning of the psychosis, and the scale of their "storyline" tends to expand. at first, it is comprised by guesses or conjecture and is consistent with the affect, as well as with the affective disturbances themselves. however, due to the surfacing of new delusional ideas that have a different theme, among them some undeveloped vestiges of perceptual delusions, these delusions change and gain a new quality. little by little, the patient enters a delusional state typical for the kandinsky - clérambault syndrome. delusions of persecution are still unstructured and interpretive in nature, but a connection begins to emerge between them and the delusions of influence/control, which do tend to become more systematic (though no more than that - the patients cannot explain how they are being controlled/influenced in a clearer or more coherent way, cannot tell for certain who is doing this to them or why). apart from the delusions of influence or control, the most developed of all the components of the kandinsky - clérambault syndrome in this case are the mental automatisms, which are, for the greatest part, associative. the sensory component, wich is somewhat less pronounced, is usually connected to the sexual sphere. if there are any pseudo-hallucinations, they are, as a rule, soundless.
later, the schizoaffective state remains polymorphic and consists of multiple syndromes. that is to say, the rudimentary perceptual delusions do not deepen or become more general, and remain fragmented even at the height of the psychosis; only the delusions of special significance, which contain some elements of interpretation, are more or less well-formed and stand out among the others. the patients' delusional behavior is determined by the symptoms of the kandinsky - clérambault syndrome and the prevailing delusional affect. in some cases, the delusions acquire a paraphrenic quality.
the boundaries of the psychosis are blurred, in the sense that it is often protracted (up to 3-6 months) and both its development and resolution are gradual. as the signs of psychosis abate, the affect often switches to the opposite of that which was observed in the beginning, when it was just starting to develop. the final affective state usually includes residual delusional and hallucinatory phenomena, often with fragments of mental automatisms. after the psychosis, the patients' critical attitide even toward the acute period remains incomplete.
the further course of the illness is usually characterized by episodes of the same "cliched" type; sometimes their clinical pattern may be simplified, but the paranoid register is still very prominent. in each of the episodes, the depression and mania remaim atypical, and it is not uncommon for them to alternate continuously. though the illness on the whole is episodic, as times goes by, the signs of its progression become more apparent. the patients' mental activity decreases, their emotions become more flat and dulled-down; their social circle becomes narrower, more limited, they spend less time communicating with others. their work capacity is also reduced, sometimes to the point of becoming disabled.
from: a.s. tiganov (ed.) "endogenous psychiatric disorders", chapter 3: g.p. panteleyeva, v.i. dikaya "schizoaffective psychoses"
compared to affect-dominant forms, the affective disturbances as such are present for a much shorter while (no more than 1-3 weeks), while the pure delusional state lasts much longer (over 3-4 weeks). schizophrenic symptoms are more numerous and pronounced and have to meet at least two of the obligatory diagnostic criteria for schizophrenia according to the ICD-10. the total duration of the schizoaffective episode is 4-6 months. the average ratio of affective and schizophrenic (delusional) disturbances in the schizoaffective state is about 1,5:1.
this type of schizoaffective disorder develops in individuals who have a schizoid personality characterized by a mosaic structure, a certain emotional deficit and so-called "exemplary", "obedient" or "straightlaced" traits. more often, they are regarded as having schizoid personality disorder or a pseudo-disorder that mimics it.
during the pre-manifestation (prodromal) period, from puberty onward, the patients' premorbid traits start to sharpen against the background of bipolar affective disturbances that manifest in atypical ways. during the depressions there is a loss of drive and incentive, a growing inertia and sluggishness, while the mania is accompanied only by an increase in general activity without any feelings of joy or mirth. the phases are prolonged (up to 6 months in duration). 1,5-2 years before the first manifest episode, the severity of the affective disturbances increases. the depression becomes more vital and includes transient ideas of low self-worth or worthlessness, obsessive thoughts of a hypochondriac nature and an inclination toward alcohol abuse. the mania is dominated by sociopathic-like behavior, euphoria, disinhibition of and/or loss of control over one's instincts, and traces of silly, childish behavior.
shortly before the onset of psychosis, there is a marked increase in the depth and severity of the affective disturbances. sometimes, there is an increase in inertia and motor inhibition (for depression) or quasi-sociopathic behavior (for mania). at the height of mania, there may be occasional obsessive ideas, transient and undeveloped affective delusions, spells of depersonalization, separate associative automatisms. if one analyses the general structure of the affective disturbances, one can detect individual ideas of reference, paranoid inclusions, bouts of anxiety, "hails" (auditory illusions where the patient seems to hear somebody calling out to them). double or triple phases are common, as is their continual alternation.
as a rule, the first manifest schizoaffective episode is spontaneous (autochthonous). more rarely, it develops after a physical illness. the patient develops a paranoid psychosis (acute kandinsky - clérambault syndrome) that can have several varieties, depending on the mechanism through which the delusional syndromes are formed: defined by acute perceptual delusions with elements of interpretive delusions; defined by delusions based in on visual images with elements of interpretation; defined by acute (unsystematic) interpretive delusions with elements of sensory delusions. the peculiarities of the delusional disturbances detetmine both the clinical presentation of the episode and the prognosis (possible outcome).
acute paranoid psychosis (kandinsky - clérambault syndrome) defined by acute sensory delusions with elements of interpretive delusions:
this form of the illness was described by a.a. mukhin (1985). the psychotic state develops gradually, usually after a physical illness. in most cases, this happens during an asthenic-adynamic depression, or, less commonly, at the moment when depression switches to mania. during the subsequent episodes, the circular affect is retained during the initial stages of the paranoid psychosis. in the very beginning, against the background of the affective disturbances, there already are some rudimentary signs of a delusional mood, such as diffuse suspicion and elements that hint at delusions of significance. within 1-2 weeks, the circular affect is completely replaced by a delusional one that includes anxiety, general tension and a delusional wariness. the delusions are formed in full over the following few days. the patients notice the "intent" gazes of passers-by, see a "special significance" in their actions and so on. the delusional "plot" is usually concerned with moral damage to the patient, rather than a threat to their physical existence (life). there may be separate instances of false recognition. the mechanism is mixed and includes elements of both sensory and interpretive delusions.
the further development of the psychosis may take two directions. in some cases, it is limited to the development of the acute kandinsky - clérambault syndrome. its symptoms appear already within 3-5 days since the onset of the delusional psychosis, and are comprised largely by delusions of influence/control and mental automatisms of the associative variety. the delusions of persecution remain specific and retain a realistic plot. the delusions of influence or control also combine the properties of perceptual and interpretive delusions, occur simultaneously with the mental automatisms and often serve as their delusional "explanation". there is no clear notion about the specific method or source of the external control/influence. associative mental automatisms are usually limited to mind-reading or the internal openness of thought. senestopathic and kinesthetic automatisms are primitive. the patients are not pro-active and do not show any desire to contact other people and resolve the delusional situation. on the whole, the delusions are specific, unsystematic and share a single theme.
in other cases, not only does the patient develop the acute kandinsky - clérambault syndrome, but their delusions are modified and acquire a fantastical flavor. as the kandinsky - clérambault syndrome deepens, the disturbances become generalized and display a greater syndromal polymorphism. the delusional "plot" remains specific and mundane, but the patients start to see certain events and actions of other people as strange, unusual, extraordinary. as they formulate assumptions as to who might be persecuting them and why, they soon lose touch with the real situation; as a result, the ideas of persecution grow in scale and become more global. false recognitions cease to be concrete and definite. as the severity of the psychosis increases, the patients may show occasional signs of confusion against the background of the persecution-related "plot", which is still retained; the content of the latter becomes less and less specific and is extended in a diffuse manner to the entirety of one's surroundings (which are perceived as "altered", "changed", "a theater performance", "an experiment", "a test from god", "a laboratory", "a model city", "a movie studio" etc.). over the next 1-2 days the delusions continue to become more global, and, at the same time, more fragmented. the patients' affect becomes labile, and sometimes there can be fast, sudden transitions from fear to exaltation. the delusional "plot" becomes polymorphic; along with ideas of persecution and control/influence, the patients express ideas of condemnation and elements of so-called manichean delusions. there may be separate, rudimentary olfactory hallucinations, ideas of poisoning, illusory or genuine verbal hallucinations or catatonic inclusions, but without the transition to an oneiroid state. among the perceptual delusions, delusions of staging or symbolic significance often remain the most prominent, but are not developed any further. the content of the fantastical delusional experiences is limited to "mundane" or "trivial" topics and are usually connected to moral issues. the schizoaffective state is made even more complex by undeveloped delusions of condemnation and guilt (for depression) or self-aggrandisement (for mania); these correspond to the preceding circular affect, though the latter is no longer present (at that point, the patients no longer complain of it) and has been replaced by delusional affect. at the height of the psychosis, the behavior of the patients is delusional.
usually, the patients emerge from the psychotic state gradually. once the delusional disturbances have subsided, for another 1-1,5 months the affective disturbances once again become prevalent. as a rule, they are identical to the ones the patient had before the onset of the delusional schizodominant psychosis. post-episode depression and mania may become protracted.
the structure of the subsequent episodes does not change, but the symptoms of the schizoaffective psychosis may be reduced while the episodes themselves become more prolonged (though without any overt signs of progression). as the illness runs its course, the patients' premorbid traits, such as their emotional deficit and psychological passivity, become more and more pronounced. there is no marked decline in social and work adaptation or any obvious signs of disability, but there is no rise in creative activity or professional growth either. many patients eventually start to work from home.
acute paranoid psychosis (kandinsky - clérambault syndrome) defined by delusions based on visual imagery with elements of interpretation:
in most cases, the episode develops spontaneously (in an autochthonous manner), within 2-3 days after the switch from a depressive phase to a manic one. as ideational agitation increases, the patient's mood gains prideful overtones; they overstate their own importance, entertain ideas of a special mission and show signs of a self-esteem that is obviously too high. at the same time, the patients develop delusions of persecution where they attribute a special meaning to their surroundings and have some non-persistent ideas of staging.
during the initial stages of the episode, the circular affective disturbances, affective (manic) delusions and non-affective delusions are, as it were, combined, overlayed upon each other, and the disturbances in general are polymorphic. the patients' delusional experiences soon become divorced from the real situation and start to be perceived as incomprehensible, after which the patients develop acute kandinsky - clérambault syndrome. there is an undifferentiated sense of being subjected to influence or control from outside, which is interpreted in unusual ways. associative mental automatisms are accompanied by forced influxes of thoughts, deluges of vivid, image-laden "dreams", hallucinations of the imagination; yet, at the same time, the patient attempts to analyze the logic of the delusional events. as the psychosis deepens, mental automatism is experienced as a total openness of thought, ideas of persecution and influence/control reach a megalomanic and paraphrenic scale and are accompanied by a delusional depersonalization that has a fantastical quality. the delusional "storyline" is expanded through "epiphanies" or "sudden insights" with elements of delusional retrospection and an involuntary "unravelling of memories," which have a vivid, image-rich quality.
this close connection between the delusional disturbances and the circular affect and mania-induced ideas is retained throughout the episode. there is no inversion of affect, but at the height of the psychosis, the circular affect is transformed; for a short while, it acquires a distinct psychotic tinge, turning into exaltation, intense excitement, ecstasy, a sense of having gained a special insight into various events.
the psychotic state subsides slowly, in a matter of 1-2 weeks. the delusions gradually lose their relevance and the patients' condition comes to be dominated by manic affect with rudimentary manifestations of mental automatism. the patients' critical attitude is not restored at once, and largely concerns the acute period of the illness. the reverse development of the episode usually takes no more than a month.
the subsequent episodes arise spontaneously (in an autochthonous manner). the structure of the psychosis remains the same, but its manifestations become more reduced, rudimentary; the delusional disturbances grow poorer in imagery, and are increasingly dominated by interpretations. the psychotic episodes themselves become more prolonged and the affective disturbances start to come continuously. in remission, against the background of atypical affective disturbances, there are bouts of mental automatisms, depersonalization and anxiety. transition to a purely affective level is exceptionally rare.
within a year since the end of the first psychotic episode, there is a distinct shift in the patients' personality. they begin to display negative symptoms such as excessive rationality, psychological rigidity, inert behavior, fruitless and illogical philosophizing, a decline in efficiency and productivity. these symptoms may intensify after the second or third relapse and be accompanied by a significant loss of work capacity.
acute paranoid psychosis (kandinsky - clérambault syndome) defined by acute (unsystematic) interpretive delusions with elements of sensory delusions:
this form of the illness was described by s.y. tsirkin (1980). the episode usually arises in a spontaneous (autochthonous) manner. the first signs of the delusional psychosis typically appear at the moment when the affective pole is switching from mania to depression or from depression to mania. along with the circular affect, there appears a delusional affect of anxiety and diffuse suspicion; at the same time, the patient starts to develop affect-related delusions (delusions of sin and condemnation for depression and delusions of erotic claims or harrassment for mania)..
the non-affective delusions stem from long-standing obsessive ideas of a varied content, which had already been present during the prodromal period. at this point, they intensify and undergo a delusional modification. as for the affective delusions mentioned above, they acquire a persecutory shade in the beginning of the psychosis, and the scale of their "storyline" tends to expand. at first, it is comprised by guesses or conjecture and is consistent with the affect, as well as with the affective disturbances themselves. however, due to the surfacing of new delusional ideas that have a different theme, among them some undeveloped vestiges of perceptual delusions, these delusions change and gain a new quality. little by little, the patient enters a delusional state typical for the kandinsky - clérambault syndrome. delusions of persecution are still unstructured and interpretive in nature, but a connection begins to emerge between them and the delusions of influence/control, which do tend to become more systematic (though no more than that - the patients cannot explain how they are being controlled/influenced in a clearer or more coherent way, cannot tell for certain who is doing this to them or why). apart from the delusions of influence or control, the most developed of all the components of the kandinsky - clérambault syndrome in this case are the mental automatisms, which are, for the greatest part, associative. the sensory component, wich is somewhat less pronounced, is usually connected to the sexual sphere. if there are any pseudo-hallucinations, they are, as a rule, soundless.
later, the schizoaffective state remains polymorphic and consists of multiple syndromes. that is to say, the rudimentary perceptual delusions do not deepen or become more general, and remain fragmented even at the height of the psychosis; only the delusions of special significance, which contain some elements of interpretation, are more or less well-formed and stand out among the others. the patients' delusional behavior is determined by the symptoms of the kandinsky - clérambault syndrome and the prevailing delusional affect. in some cases, the delusions acquire a paraphrenic quality.
the boundaries of the psychosis are blurred, in the sense that it is often protracted (up to 3-6 months) and both its development and resolution are gradual. as the signs of psychosis abate, the affect often switches to the opposite of that which was observed in the beginning, when it was just starting to develop. the final affective state usually includes residual delusional and hallucinatory phenomena, often with fragments of mental automatisms. after the psychosis, the patients' critical attitide even toward the acute period remains incomplete.
the further course of the illness is usually characterized by episodes of the same "cliched" type; sometimes their clinical pattern may be simplified, but the paranoid register is still very prominent. in each of the episodes, the depression and mania remaim atypical, and it is not uncommon for them to alternate continuously. though the illness on the whole is episodic, as times goes by, the signs of its progression become more apparent. the patients' mental activity decreases, their emotions become more flat and dulled-down; their social circle becomes narrower, more limited, they spend less time communicating with others. their work capacity is also reduced, sometimes to the point of becoming disabled.
from: a.s. tiganov (ed.) "endogenous psychiatric disorders", chapter 3: g.p. panteleyeva, v.i. dikaya "schizoaffective psychoses"