The necessity of developing a two-stage qualification in ICD-11.

In the International Classification of Diseases, 10th Revision (ICD-10) two opposing principles are combined and mixed: atheoreticity that is necessary for the natural classification and commitment to nosology. Implementation of these principles requires a two-stage qualification. The first stage should be narrative detailed syndromological qualifications with identification of psychotic level of disorders. As for the second stage, the qualification should be nosological, based on complete clinical analysis, which is far from being possible to realize at once. ICD-10, specifically brought to nosological certainty, may remain the natural foundation for nosological qualification. Implementation of the syndromic qualification at the first stage will allow to consider nosological features of each syndrome at the second stage and to expand the list of criteria in different clusters. Such a suggestion opens the prospect for subsequent revisions of the ICD and allows to direct our efforts and those of practitioners to the unified channel, where the statistical goals would not be implemented at the expense of the research ones.

[A differential approach to the improvement of prevention and correction of neuroleptic side extrapyramidal disorders with pantogam activ in patients with schizophrenia]. / Differentsirovannyi podkhod k usovershenstvovaniyu metodov preduprezhdeniya i korrektsii neirolepticheskikh pobochnykh ekstrapiramidnykh rasstroistv preparatom pantogam aktiv u bol'nykh shizofreniei.

AIM: To assess the efficacy and safety of pantogam active (PA) in prevention and correction of neurological side-effects during the course neuroleptic treatment of acute endogenous psychoses. MATERIAL AND METHODS: Eighty schizophrenic patients (mean age 33 years) with acute psychosis were examined. All patients received 28-day course treatment with typical and atypical neuroleptics. Two equal groups were studied: patients of the first group were treated with trihexyphenidyl (THP) in dose of 0,002-0,012 mg and patients of the second group received in addition PA in dose 0,9 mg/day. Clinical-observation, psychometric scales (PANSS, CGI-S, UKU) were administered at baseline and in 1st,3rd,7th, 14th, 21st, 28st day. RESULTS: PA in the combination with THP improved tolerability to neuroleptic therapy in whole and exerted the better correction effect on neuroleptic extrapyramidal disorders (EPD) compared to THP monotherapy. The number of patients with ERD was reduced by 1.5 times and prevention of EPD was observed 3 times more frequent in the group treated with PA. In the THP group, other adverse effects (AE) were 1,7 times more frequent and the total AE score was 2,5 times greater compared to the PA group (131 vs 50). Correction and preventive effects of the combined treatment on the clinically severe symptoms of EPD (akathisia, muscle dystonia) were more frequent in patients treated with typical neuroleptics. A less amount of THP (by 1,2 times) was used to stop EPD in the PA group. CONCLUSION: PA in the combination with THP has demonstrated the clear neuroprotective effect on the development, frequency and clinical presentations of neurological side-effects. The РА can be recommended as a drug of choice for correction and prevention of neuroleptic side-effects, it promotes their tolerability and improves quality of life during the course treatment.

[Clinical and immunological correlations in endogenous depression].

OBJECTIVE: To study the possibility of using immunological parameters for the evaluation of the activity of endogenous process in depression and quality of response to psychopharmacotherapy. MATERIAL AND METHODS: Authors examined 42 patients, aged 20-55 years, with the prevalence of anxiety (n = 22) or apathy (n = 20) in the clinical picture of depression. The following immunological parameters were measured in the blood of the patients: degranulation activity of leukocyte elastase (LE), functional activity of alpha-1-proteinase inhibitor (alpha-1-PI); the level of autoantibodies to neuroantigen S-100B and myelin basic protein. RESULTS AND CONCLUSION: The involvement of inflammatory and autoimmune responses in the pathophysiology of endogenous depression was confirmed. Depression associated with increased levels of autoantibodies to brain neuroantigens (an autoimmune component) had a more complicated structure and showed the tendency to prolonged course and resistance to the therapy. The results suggest that some immunological parameters may be used as markers of patient's clinical status and quality and completeness of psychopathological symptom reduction.

[The pathomorphosis of schizophrenia]. / K voprosu o patomorfoze pri shizofrenii.

The author considers the problem of pathomorphosis, i.e. the changes in clinical presentation of endogenous mental diseases (schizophrenia, depression), since the time of its classical description. There is a general trend towards the development of forms with more favorable course in schizophrenia and the domination of prolonged and masked variants in depression. These changes are discussed in aspects of true (natural) pathomorphosis and therapeutic (induced) pathomorphosis. The relative character of this stratification and insufficient understanding of the problem in psychiatry in general are emphasized.

[Some variants of premanifesting disorders in attack-like schizophrenia].

OBJECTIVE: To investigate a spectrum of disorders preceding the development of manifesting psychosis in the aspect of their topology and possible prognostic value. MATERIAL AND METHODS: Authors examined 60 outpatients, 21 women and 39 men, aged from 22 to 34 years. All patients were diagnosed with attack-like progressive schizophrenia. The retrospective evaluation of disease history and determination of the psychopathological structure and dynamics of manifesting episode and premanifesting symptom clustering were carried out. RESULTS AND CONCLUSION: It was identified 4 variants of premanifesting disorders: affective (n=15), affective with neurotic-like symptoms (n=17), affective with hallucinatory/paranoid symptoms (n=21) and affective with deficit symptoms (n=7). These disorders determine not only the transparent symptomatics but project in the manifesting episode structure and has a prognostic value thus reflecting a trend towards the continuous course of schizophrenia already at the premanifesting stage.

[The typology of oneiroid-catatonic states in schizophrenia].

OBJECTIVE: To determine the types of oneiroid-catatonic states characteristic of corresponding schizophrenia attacks and their treatment-related changes. MATERIAL AND METHODS: We examined 68 outpatients, 25 men and 43 women, aged from 18 to 54 years, using psychopathological and follow-up methods. Results and conclusion. Two groups of oneiroid states were described. Oneiroid-catatonic states with the predominance of visual (optical) component derangement of consciousness were characteristic of the first group and oneiroid states with the prevalence of sensory component of derangement of consciousness were described in the second group. The second group was divided into two subgroups by the severity of the visual component (minimal and mixed). The types of oneiroid-catatonic states determined the dynamics of the attack in whole and were related to treatment (drug-induced pathomorphosis). These results are significant for differential diagnosis, treatment, and prognosis of the disease.

[Controversial problems of clinical psychiatry].

Current existing problems of clinical psychiatry are considered in the aspect of most urgent and unresolved issues in the field of schizophrenia. Special attention is drawn to the differences in existing approaches to the classification of schizophrenia. In this connection, the author emphasizes the importance of the classification developed by A.V. Snezhnevsky and his school for theoretical and practical psychiatry. In view of this classification, the problem of clinical heterogeneity of schizophrenia related with the conception of different disease forms is considered. Difficulties of diagnosis of some forms and psychopathological evaluation of psychotic attacks developed in the continuous course of schizophrenia well as insufficient understanding of the problem of negative (deficit) symptoms and remission classification are discussed.

[EEG-correlates and possible predictors of efficacy of treatment of endogenous depression].

An analysis of EEG spectral power values and of quantitative clinical scores of depressive conditions has been carried out in dynamics of treatment in 40 patients with endogenous depression with the main goal to study neurophysiologic correlates and to search possible predictors of therapeutic outcome. The reduction of depressive symptoms by the end of the treatment course was associated with EEG signs of improvement of brain functional state. Significant correlations have been revealed between the EEG narrow-band spectral power values and clinical scores. As well, significant correlations have been revealed between some initial (before beginning of treatment) EEG parameters and quantitative clinical scores at the stage of remission establishing. The values of EEG beta-1 and beta-2 spectral power appeared to be such predictors, while initially larger values of EEG beta activity spectral power were associated with higher pronounce of residual depressive symptoms after the treatment course. The data obtained allow to justify basic views on brain mechanisms of various aspects of depressive disorders, and to reveal possible neurophysiological predictors of efficacy of treatment of endogenous depression.

[Age-related aspects of depressive states].

The significant variety of psychopathological presentations of depression causes difficulties in its diagnosis. Depression of middle age is subdivided depending on the predomination of one or another disorder in the clinical picture. There are simple depression and complicated depression with additional psychopathological symptoms. The most difficult is to diagnose depression with onset in early childhood, including infant's age, when the psychopathological presentations depend on the consequences of the perinatal CNS lesion, maternal deprivation and other factors. In children, the clinical picture of depression differs by syndromologic incompleteness, peculiarity of phenomenological presentations and polymorphism of disorders. In adolescence, depression is characterized by the predominance of behavioral disorders, marked psychopathic-like disorders, suicidal attempts, higher frequency of bipolar forms. Depression with late age at onset differs by the abundance of somatic and hypochondriac complaints, anxiety and depressive delusion accompanied by the transitory aggravation of cognitive impairment (depressive pseudodementia).

[Genomic instability in the brain: etiology, pathogenesis and new biological markers of psychiatric disorders].

The latest advances in molecular medicine, medical genetics and neurobiology have provided for a new look at processes occurring in cells of the brain and have allowed to discover previously unknown phenomena associated with mental traits and to propose new biomedical direction which include genomics, psychiatry and neurobiology - brain genomics. The application of modern molecular and cellular technologies of genome analysis in the brain in common psychiatric disorders (autism, schizophrenia and Alzheimer's disease) has shown that genomic instability is a phathogenetic mechanism of central nervous system abnormalities and plays a role in the brain development. Genomic disbalance alters neural homeostasis leads to cell death and is an important biological marker of psychiatric disorders which determine genomic pathways. These alterations lead to synaptic disfunction and neurodegeneration. In the present review, the main advances of brain genomics and potential application in diagnostic, clinical and therapeutic practice.

[Endogenous affective disorders: problems of systematics and typology].

A classification of endogenous affective disorders based on clinical manifestations of a concrete disease is proposed. It reflects one of the stages of investigations into the structure of psychopathological manifestations of depressive and maniacal disorders. Further studies may provide data for the adjustment of the classification to the current diagnostic strategies.

[Paroxysmal and paroxysmal-like conditions during schizophrenia].

The clinical picture of paroxysm-like progredient schizophrenia in 104 patients was characterized by a combination of schizophrenic symptomatology, paroxismal and paroxysm-like disorders. Investigation of their psychopathological structure showed that they differ from that of epileptic paroxysms. The data obtained provide a basis for distinguishing a special variant of endogenous process and developing criteria for typological classification of paroxismal and paroxysm-like disorders.

[Clinical psychiatry and the problem of investigation of new psychopharmacological agents].

Problems of future development of psychopathology and clinical psychopharmacology are discussed. It is shown that the study of efficacious psychopharmacological agents is closely related to the study of the psychopathological structure of psychic disorders, problems of therapeutic resistance and maintenance treatment.

[Current approaches to understanding of autism in childhood].

The authors analyse the trends in the study of childhood autism in the XX century and state of the art in view of nosology, systematics, clinical phenomenology, etiology and pathogenesis of autistic disorders. Mental Health Research Center of Russian Academy of Medical Sciences proposes a new classification of autism in children basing on the study of 500 cases. Each form of autistic disorders is characterized in clinicopsychopathological and pathogenetic aspects. The phenomenon of autism in childhood psychopathology is universal, dependent on peculiarities of ontogenesis of the nervous system, individual development of a child, genetic and environmental factors.

[Clinical psychiatry and problems of novel psychopharmacological medication study]. / Klinicheskaia psikhiatriia i problemy izucheniia novykh psikhofarmakologicheskikh sredstv.

The problems of further development of psychopathology are considered in terms of clinical psychopharmacology. Investigations on efficacy of modern psychopharmacological medications are shown to relate closely to studies of psychopathological structure of mental disorders as well as to problem of treatment resistance and maintenance treatment.

[Current concept of schizophrenia: state of the art]. / Sovremennoe sostoianie ucheniia o shizofrenii.

Approaches to diagnosing schizophrenia are different. There is a distinct tendency either to narrow the limits of the disease or to expand it, which in some cases leads to a disagreement and even a tendency to disputes. The comprehensive studies conducted in the Mental Health Research Center, Russian Academy of Medical Sciences, have provided an overall notion of the disease in terms of its progression and outcome. The clinical picture of schizophrenia is characterized by obligatory specific disorders, such as autism, reduced energy potential, emotional thinking, and behavioral disorders. Personality changes may be seen as the smoothening of specific personality traits and the appearance of the features that are not inherent to the patients in the past. Schizophernia is also characterized by positive psychopathological syndromes: pseudoneurotic, affective, psychopathy-like, hallucinatory-paranoid and catatonic. A study of 7500 patients with schizophrenia demonstrated that there were clear-cut regularities in the development of the disease, which suggest that there are forms and types in its progression. The study identified 3 forms of development: continuous, recurrent, and attack-like progressive with varying degrees and rates of the process (severe, moderate, and mild). Genealogical and clinicogenetic studies demonstrated accumulation of psychoses and abnormal personalities in the families of probands, manifest and slowly progressive forms of schizophrenia and cases of schizoid psychopathy. Among the wide spectrum of pathogenetic concepts, priority should be given to the dopamine hypothesis, whose main point is accumulation of an excessive amount of dopamine in the brain tissue, especially in the nigrostriatal, mesocortical, and mesolimbic systems. This may lead to activation of dopaminergic brain structures with an increase of dopamine receptors. This hypothesis is confirmed by the neuropathological studies demonstrating a significant increase in the numerical density of the dendritic spines and dendritic trunks in the with layer of the prefrontal cortex. The highest index of the numerical density was observed in young patients with prevalent negative disorders. Inasmuch as there is no correlation of this index with the duration of the disease, it can be concluded that the abundance of synaptical connections is a result of disturbed brain development and a factor predisposing to severe progression of schizophrenia. Treatment modalities are determined by the form and rate of progression of and the pattern of the psychopathological syndrome. Of particular importance is the role of age, somatic state, and individual sensitivity to neuroleptic drugs. Another important factor in the treatment of schizophrenia is a simultaneous or consecutive impact on the psychopathological syndrome and the disease as a whole.