Is schizophrenia completely curable or not? Principles and methods of treatment of schizophrenia - treatment at different periods of the disease, choice of drugs, alternative methods, features of the treatment of schizophrenia in children, prognosis. About the possibility of treatment

Amnestic (Korsakovsky) syndrome is a condition in which clinical picture a memory disorder for events of the present predominates, while it is preserved for events of the past. Clinically, this disorder is manifested by a triad of symptoms: 1) fixation amnesia, retrograde amnesia (from the moment of development of fixation amnesia; 2) amnestic disorientation in time and place (due to the inability to remember the place of stay and the current date); 3) confabulations (false memories) and pseudo-reminiscences (displacement in memory of the time of real incidents).

This condition was first described by S. S. Korsakov in his dissertation “On alcoholic paralysis”:

Mental disorder (with alcohol paralysis) was expressed either in the form of irritable weakness, then in the form of confusion, or in the form of a characteristic memory disorder... It was to varying degrees and unequal in its manifestation: in some cases it was limited only to pronounced irritable weakness of the mental sphere, in in others, it took on the character of confusion of consciousness with hallucinations or illusions; in others, finally, it took on the character of a peculiar weakening of mental abilities without pronounced confusion, but with a particularly noticeable loss of memory

Korsakoff's syndrome is often an integral part of Wernicke's encephalopathy. One of the manifestations of encephalopathy is nystagmus, which occurs as a result of damage to the brain stem at the level of the nucleus of the abducens and oculomotor nerves, which impairs oculomotor function. Also with this disease there is damage to the cerebellum, which is manifested by ataxia. In this case, patients often experience confusion. This triad of symptoms is reversible, however, against the background of their regression, fixation amnesia may come to the fore, which means the onset of Korsakoff's syndrome

Some authors describe the anamnestic syndrome as a chronic form of Wernicke encephalopathy. This is partly true, but only if we are talking about Korsakov psychosis, which is a consequence of alcoholism. Korsakoff syndrome can manifest itself for a variety of reasons (deficiency nutrients and some diets; fasting - in persons suffering from anorexia nervosa, schizophrenia, terminal cancer, as well as in prisoners of war; malignant tumors of the stomach, inflammatory diseases intestines; systemic diseases - malignant tumors, disseminated tuberculosis, acquired immunodeficiency syndrome (AIDS), uremia, stem cell transplantation, etc.).

Etiology and pathogenesis

S.S. Korsakov himself believed that the main cause of this disease was a disorder of the associative apparatus. Memorization process new information occurs due to the ability to connect new information with existing information through the construction of associative connections. But what if the building of these connections is incomplete or completely broken? Perhaps this is precisely the reason for the occurrence of fixation and retrograde amnesia, and this also explains the preservation of memory for past events.

According to modern concepts, the main role in the pathogenesis of anamnestic syndrome is assigned to vitamin B1 (also known as thiamine). It is its deficiency that leads to disruption of metabolic processes in brain cells, because thiamine is a cofactor that is involved in essential biochemical processes. As a result of these processes, brain cells, through the utilization of glucose, receive the required amount of energy in the form of ATP. Due to a lack of energy (with a decrease in thiamine concentration), the activity of alpha-ketoglutarate dehydrogenase decreases, which in turn leads to the accumulation of glutamate. IN large quantities This neurotransmitter has a toxic effect on brain cells.

The cause of Korsakoff's syndrome is damage to the limbic system of the brain, in particular the so-called “Pipetz circle”. The medial structures of the thalamus, hippocampus, and amygdala are affected, and the connections between them are damaged. The limbic system performs a motivational-emotional function that allows us to satisfy our biological needs. Memory and emotions are very important to perform this function. Emotions teach us to distinguish bad from good, and memory protects us from mistakes. It is thanks to the limbic system that short-term memory is able to transform into long-term memory.

Clinical manifestations

To better understand the clinical picture of Korsakoff's syndrome, below I will present examples of two clinical cases described by British neurologist Oliver Sacks.

In 1975, a certain Jimmy G., forty-nine years old, approached Dr. Sachs; he had accompanying papers with him, in which the doctor discovered a “mysterious note”: “Helplessness, dementia, confusion and disorientation.” Jimmy said hello, said his first and last name, place of birth, year of birth, described his hometown, even drew a map showing the houses where his family lived. He mentioned that he was interested in mathematics and natural sciences. He spoke with particular enthusiasm about his service in the navy. Jimmy's story was so vivid and complete the smallest details, which gave the impression that he was not talking about the distant, albeit very pleasant past, but about the events that were happening to him right now. Of course, this transition from the past tense (when the patient talked about school) to the present tense (to the story about serving in the navy) did not escape the doctor, and he had a suspicion:

– What year is it now, Mr. G.?

Of course, forty-five, but what?

And you, Jimmy, how old are you then?...

Like nineteen. Next year there will be twenty...

Here,” he handed him the mirror. “Take a look and tell me what you see...

- Lord, what's going on? What's wrong with me?...Is this a dream, a nightmare? I'm out of my mind? It's a joke?

Jimmy was very excited by what he saw in the mirror and scared, but he immediately forgot about it as soon as the doctor diverted his attention.

This case is a clear manifestation of fixation and retrograde amnesia. The cause of this condition, as Dr. Sachs later learned, turned out to be alcoholism:

“Serving in the Navy, my brother believed, gave him a foundation in life, and problems began after he was discharged ashore in 1965.”

This manifestation of Korsakov’s syndrome fits one of Sergei Sergeevich’s descriptions presented above: “... took on the character of a peculiar weakening of mental abilities without pronounced confusion, but with a particularly noticeable decline in memory.”

Jimmy finds himself trapped in his own past. His memory seemed to be in a loop, locked in a time loop; there are no new impressions, no new information, and all he can do is replay the same memories over and over again, which is probably why these memories are so vivid.

Thanks to his past, Jimmy still remained a full-fledged person; the disease did not destroy his personality, but rather froze it. Since the construction of associative connections was disrupted, Jimmy had to find another path to reality and he found it:

“I saw that Jimmy had found himself and connected with reality in the fullness of spiritual attention and an act of faith.”

Another case is very different from the one described above. This time the anamnestic syndrome will be dominated by confusion, it will be difficult to talk about any specific type of amnesia, because, as Oliver Sacks writes, “memory ... is completely destroyed.”

Mr. Thompson, a patient of Dr. Sachs, upon meeting, does not recognize the attending physician at all; he attributes many personalities to Dr. Sachs, but never remembers him. He is also completely unoriented in either space or time:

“Within five minutes, Mr. Thompson mistakes me for a dozen different people. Guess gives way to hypotheses, hypotheses to confidence, and all this is lightning fast, without a single hitch, without the slightest hesitation. He has no idea who I am, he doesn’t even know who he is or where he is. The fact that he is a former grocer with severe Korsakoff's syndrome and is being held in a neurological facility is not available to him."

Mr. Thompson, unlike Jimmy, does not have any clear memories, his memory does not record the present and he does not have a past to cling to. Deprived of his own history, he seems to compensate for this with his “desperate verbosity.” His stories are always bright and lively, but there is not a word of truth in them: fictional people, places, events (confabulation)

“He never stops... like he’s chasing something and can’t catch up.” This phrase quite accurately describes Mr. Thompson's condition.

His stories help him imagine himself as someone, feel like a whole person, he is like an actor who can’t stop playing and changes roles one after another. Mr. Thompson has no choice but to chase himself.

Restoring memory functions

I would also like to mention that Korsakoff's syndrome is not an incurable disease; there are many described cases of recovery. The recovery process is also not without interesting aspects. With the onset of the disorder, complete memory loss is described, but during the recovery process it is noted that memory is restored unevenly. The ability to remember time takes the longest to recover. These patients already remember faces, conversations, places, but they cannot remember what happened when, or the sequence of events. Korsakov also wrote that during the recovery process, patients recalled events that occurred during the illness, the very events that were not recorded in memory. He believed that the matter was in the so-called “traces of impressions”:

“First of all, what is striking is that although the patient is not at all aware that he still has traces of the impressions that he receives, nevertheless these traces remain and in one way or another influence the course of ideas, albeit in unconscious mental activity.”

For example, as Korsakov describes, you come to a patient for the first time, he offers his hand, says hello, then you leave for two minutes, returns, and the patient no longer greets you, although he claims that he is seeing you for the first time. Obviously, such cases are examples of implicit (hidden) memory. An analogy can be drawn with intuition. The human brain perceives a huge amount of different information and not all of it reaches our consciousness, but some of it is still remembered, and certain associations can snatch these memories from the depths of information; when this happens, we talk about intuition. In patients with Korsakoff's syndrome, as mentioned above, associative connections are not built, so nothing can “awaken” these memories. However, in many patients with fixation and retrograde amnesia, emotional memory remains intact. They don't remember people they've met for the first time, but they do remember the impression they made on them. When meeting the same people, they immediately develop sympathy for some and antipathy for others. Perhaps it is precisely thanks to the preservation of emotional memory that patients with Korsakov syndrome have a chance of recovery and the opportunity to return to reality.

Prepared by: Ashirova V.G.

Sources:

1) S.S. Korsakov “General psychopathology” – ed. Bean, 2003, p. 480
2) Oliver Sacks “The Man Who Mistook His Wife for a Hat” – ed. AST, 2015, p. 352
3) T.B. Dmitrieva, V.N. Krasnov, N.G. Neznanov, V.Ya. Semke, A.S. Tiganov “Psychiatry: national manual” – ed. GEOTAR-Media, 2009, p. 1000
4) Wernicke-Korsakoff Syndrome – Glen L Xiong, MD; Chief Editor: David Bienenfeld, MD; Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento County Mental Health Treatment Center (Updated: Apr 18, 2016).
5) E.D. Chomsky “Neuropsychology” – ed. Peter, 2005, p. 496
6) V.V. Shulgovsky “Fundamentals of Neurophysiology” – published by Aspect Press, 2000, p. 2777) A.A. Skoromets, A.P. Skoromets, T.A. Skoromets “Nervous diseases” – ed. MEDpress-inform, 2010, p. 560

One of the most common anomalies in psychiatric practice is Korsakov's amnestic syndrome. Korsakoff's syndrome occurs as a result of a clear deficiency of thiamine - vitamin B1.

This psychopathological complex is a set of symptoms, the main triad of which is:

loss of memory for events and facts of the present with relative preservation of memories of past events, so-called fixation amnesia;
violation of allopsychic orientation;
vicarious confabulations - the appearance of false memories.

In modern psychiatry, the term “Korsakoff psychosis” is used exclusively to refer to pathological conditions that have developed due to chronic alcoholism. At the same time, the name “Korsakoff syndrome” can be used for anomalies that started for other reasons. Also, these conditions have a pronounced difference: Korsakov’s psychosis is characterized by a gradual aggravation of disorders of mnestic function, while with Korsakov’s syndrome there is an abrupt onset of pathology.

Korsakov's syndrome: causes of the disorder

The leading reason leading to the onset of Korsakoff's syndrome is a pronounced deficiency in the body of thiamine - vitamin B1. The main culprit of this deficiency is chronic alcoholism.

Long-term alcoholism and regular intoxication of the body with ethanol breakdown products lead to impaired absorption of thiamine. Since thiamine is a water-soluble compound, it is not stored in the body. The presence of ethanol in the blood inhibits the mechanisms of thiamine phosphorylation, which is necessary for the production of active coenzyme forms of vitamin B1. This, in turn, causes a significant decrease in the concentration of the active form of thiamine. Since thiamine is essential in the metabolism of carbohydrates, fats and proteins, its deficiency causes fatal neurological disorders.

A person who abuses alcohol develops acute or subacute damage to the midbrain and hypothalamus, called Gaye-Wernicke syndrome.

In the absence of timely and adequate treatment, Wernicke encephalopathy becomes chronic, transforming into Korsakoff syndrome. At the same time, developing memory impairments and other defects are always severe, so the sick subject may require lifelong care. The prevalence of Korsakoff's syndrome has not been sufficiently studied, but in last years

There is a trend towards a decrease in the number of patients whose disorder is associated with alcoholism. This can be explained by the fact that when performing detoxification measures for acute alcohol disorders, thiamine is always present in the treatment regimen. Korsakoff's syndrome is also present in a wide range of neurological pathologies, visceral diseases and other painful conditions.

Cause of amnestic syndrome:
benign and malignant neoplasms in brain structures;
damage to brain tissue as a result of acute circulatory disorders and the resulting cerebral infarction;
subarachnoid hemorrhage;
contact damage to the soft tissues of the head, cranial structures, brain matter as a result of injuries;
herpetic encephalitis is an acute infectious disease provoked by activation of the herpes simplex virus, which manifests itself in general cerebral and focal symptoms of central nervous system damage;

Amnestic syndrome can develop due to chronic lack of nutrition due to prolonged fasting or prolonged adherence to strict diets. The onset of pathology can be provoked by biliopancreatic shunting - a malabsorptive operation, as a result of which the absorption of nutrients in the gastrointestinal tract is reduced.

Korsakoff syndrome: symptoms

The main manifestation of Korsakov's syndrome is fixation amnesia. Due to existing defects in the mechanism for transferring information from short-term memory to long-term “storage,” memory traces are not strengthened.

If the cause of the anomaly is chronic alcoholism, then the first precursors of Korsakoff syndrome may be noticeable a year before the onset of the disease. A person feels numbness, tingling, “pins and needles”, pain in lower limbs aching character. During a night's rest, cramps in the calf muscles may occur.

Constant headache. Episodes of dizziness are frequent. The mental activity of the subject also undergoes changes. The patient's intellectual level deteriorates and his range of interests decreases. Irrational anxiety, unaccountable fear, and expectations of imminent misfortune arise. Severe sleep problems arise, and the patient is often bothered by nightmares. The onset of Korsakov's syndrome due to alcoholism follows the same scenario as delirium delirium.
The patient's function of consciousness is impaired: he becomes disoriented in time and space. Visual and verbal hallucinations with frightening content often occur. As consciousness becomes clearer, fixation amnesia—the loss of memories for current facts—begins to take first place. Memories of distant events: episodes of youth or childhood are stored in in full. The patient is able to reproduce everything that happened before the illness. The subject is partially able to reproduce existing professional skills.
The person may lose the ability to learn. The patient has a very hard time accepting any changes: he cannot tolerate rearranging the furniture in his home, and cannot tolerate the appearance of new faces in his environment.
The clinical picture of Korsakov's syndrome also includes amnestic disorientation. The patient becomes completely disoriented in space and time. He does not recognize the people around him, does not understand what place he is in, does not know what day it is.
Paramnesia. The patient experiences confabulations—false memories of a fantastic nature. Moreover, the subject is confident in the veracity of his memories, and does not believe in the arguments proving their falsity. There are no contradictions in the individual’s narrative about his past: all stories are supplemented with numerous details.
Cryptomnesia- a phenomenon in which a person believes that what he read about in a book or saw in a film actually happened to him. He is unable to separate his own memories from other people's ideas.
Pseudo-reminiscences are a time displacement of a person’s memories. This is the situation when the subject passes off episodes from the past as current phenomena.

Korsakoff syndrome also manifests itself with other psychotic signs. The patient may have severe anxiety. There are frequent mood swings. The person may be in a state of euphoria and be very fussy. Or, on the contrary, he loses initiative and becomes inactive.

Treatment of Korsakov's syndrome

Treatment of Korsakoff's syndrome, as well as Korsakoff's psychosis, in the acute phase of the disease is carried out in the inpatient department of a psychiatric hospital or drug addiction clinic.

This is necessary, first of all, in order to ensure that the patient completely abstains from drinking alcohol, which is often impossible to do outside a hospital. In addition, the patient’s psychomotor agitation, severe memory impairment, and inability to adequately orientate deprive the person of the ability to self-care. To maintain the normal functioning of the patient’s body, timely nutrition, hygiene procedures, and medical procedures, the assistance of qualified medical personnel is required.

Treatment of amnestic syndrome caused by alcoholism involves detoxification procedures at the beginning of therapy.

As a rule, a solution of glucose and magnesium sulfate is administered intravenously. To restore mnestic function, improve attention and learning ability, it is advisable to conduct a course of therapy with nootropic drugs. To eliminate irrational anxiety and psychomotor agitation, the patient is prescribed benzodiazepine tranquilizers. For severe psychotic symptoms of Korsakoff psychosis, low doses of antipsychotics are used. The success of treatment for Korsakoff's syndrome depends on numerous factors: the age of the patient, general condition

health, the presence of chronic somatic diseases, the severity of cognitive disorders, alcoholism experience.

In most patients, memory defects lose their expressiveness during therapy. However, in those patients who, due to lack of motivation, stubbornly resist treatment, Korsakov's syndrome rapidly progresses. Despite the rapid development of medicine, the treatment of Korsakoff's syndrome is an urgent and difficult medical task for psychiatrists around the world.

read also Kleine-Levin syndrome Kleine–Lewin syndrome is a reversible disease nervous system, which is quite rare in clinical practice.

Pathological condition It is described in the medical literature under different names: periodic hibernation syndrome, periodic hypersomnia syndrome, sleeping beauty syndrome. In domestic medicine, the disease is considered within the framework of hypersomnia - sleep disorders. According to the criteria of the International Classification of Diseases, 10th revision (ICD-10), sleeping beauty syndrome does not correspond to the clinical picture of behavioral syndromes described in categories F50–59. According to […]... Korsakov's syndrome(amnesic syndrome; eng. Korsakoff's syndrome) - a combination of memory disorders for current events (the so-called fixation amnesia; if it is preserved for more distant events) and orientation in place, time, environment with the presence of confabulations (false memories). First described by a Russian psychiatrist in 1887. May occur with severe intoxication, especially chronic alcohol intoxication, vitamin B deficiency,

The pathopsychological basis of memory disorders for current events in Korsakov's syndrome They consider violations of their retention (retention) and especially reproduction (reproduction), while direct memorization is little impaired. A significant role in the pathogenesis is assigned to bilateral damage to certain structures of the limbic system of the brain (papillary bodies, fornix, and partly the hippocampus). The pathogenetic mechanisms of Korsakov's syndrome are determined by the pathogenesis of the underlying disease. Thus, one of the leading links in the pathogenesis is Korsakov's syndrome of alcohol etiology (Korsakov's psychosis), as well as Korsakov's syndrome in certain types of nutritional deficiency (beriberi, secondary vitamin deficiency in diabetes mellitus, uncontrollable vomiting of pregnant women) is a deficiency in the body of vitamin B, which, due to secondary, insufficiently understood metabolic disorders, leads to various morphological changes (necrosis, demyelination, gliosis, proliferation of capillaries, microhemorrhages, etc.) of the deep structures of the brain, especially the papillary bodies and vaults

Among the manifestations of Korsakov's syndrome, memory disorders for current events are especially pronounced. Patients almost instantly forget the content of what they just said, after a few minutes they do not remember who approached them, which is why they can say hello to the same people many times, ask the same questions, and cannot say what they are doing. they just studied, they ate, they read the same page in a book for weeks, immediately forgetting what they read. Verbal memory is most severely impaired, figurative memory is to a lesser extent, so-called emotional memory is even less impaired, and therefore, completely not remembering the content of an unpleasant event, the patient may get into a bad mood in the environment where it happened, or at the sight of a face, related to him.

Despite a pronounced memory disorder for current events, memory for past life events, often distant, remains relatively intact, and some memories of long-standing events are particularly vivid. However, the events immediately preceding the disease, often spanning weeks, months and even years, may completely disappear from the patient’s memory, which suggests the presence of retrograde amnesia of varying duration.

Disorders of orientation in time, place and environment characteristic of Korsakov's syndrome are expressed to varying degrees. Time orientation is most severely impaired, and patients often cannot name not only the date, day of the week, month and year, but also the time of year. Orientation in a place is also inaccurate in most cases. Patients with more severe disorders cannot even navigate their surroundings; for example, they cannot find their bed or find their way to the dining room or toilet.

False memories in Korsakoff's syndrome are of two types. More typical are the replacement of memory gaps for current events with memories of real events that occurred in the past. Thus, patients who have been in the hospital for a long time say that they recently “came from work”, “were visiting relatives”, etc. This type of false memories is called pseudo-reminiscence. Less often, when asked about their current lives, patients report fictitious stories, often of fantastic content (“traveled to the countries of Africa and Asia, met the Abyssinian Negus,” “flyed on a spaceship,” etc.). Such memory deceptions are called confabulations. Patients with Korsakoff's syndrome are suggestible. Asking questions can trigger one type of false memory or another.

An influx of abundant confabulations with deep disorientation and incoherent thinking in the absence of clouding of consciousness is called confabulatory confusion. It is mainly observed in Korsakoff's syndrome in patients with a variant of senile dementia, referred to as Wernicke's chronic presbyophrenia.

Some patients with Korsakoff's syndrome experience false recognition phenomena, when they mistake others for people they have met before.

In most cases, patients with Korsakov's syndrome are characterized by one or another degree of intellectual deficiency, which is expressed in weakened productivity, stereotypicality and monotony of judgments, their pronounced dependence on external impressions, the inability to notice contradictions in their own statements, and to detect the incompatibility of false memories with reality. At the same time, some patients are distinguished by a certain intelligence and, within a specific situation, skillfully mask memory defects.

Most patients with Korsakov's syndrome experience a more or less pronounced decrease in the level of impulses and volitional activity, and therefore, left to their own devices, they can remain inactive for hours. More often these are elderly people. They have a predominant apathetic or apathetic-euphoric mood background. Young people are usually more active.
Consciousness in patients, as a rule, is not clouded. At the same time, it is possible to combine Korsakov's syndrome with states of clouded consciousness, more often with symptoms of delirium (delirious syndrome), accompanied by motor restlessness and occurring mainly at night.

Korsakoff syndrome can have a number of age characteristics. Thus, in children, false memories are usually absent or weakly expressed. In old age, orientation disorders are especially intense (amnestic disorientation), and orientation in the immediate environment is often disturbed, false memories manifest themselves in the form of replacement of memory gaps with events of the distant past (ecmnestic confabulations), and false recognitions are frequent.

Typically, Korsakoff's syndrome is a relatively persistent chronic condition. However, cases of transient Korsakoff syndrome are possible, for example, with delirium tremens, carbon monoxide poisoning, and after traumatic brain injury. The course depends mainly on the nature of the underlying disease. Thus, alcoholic Korsakoff syndrome occurs acutely, immediately after the patient emerges from a state of darkened consciousness, then a long (from 2 to 15 years) course is possible, followed by a slow reverse development, which leads to intellectual failure (memory weakness, decreased activity and apathetic or apathetic behavior). euphoric mood). Korsakov's syndrome with severe cerebral hypoxia develops acutely, following a state of darkened consciousness; the period of reverse development of Korsakoff syndrome is relatively shorter (from several weeks to 2-3 years). More often there is an intellectual-mnestic decline; sometimes the illness ends in complete recovery. Korsakov syndrome in traumatic brain injuries also begins acutely, after a state of darkened consciousness. The outcome of complete recovery is rare; a persistent psychoorganic syndrome often develops.

Treatment depends on the underlying disease and is often symptomatic. Drugs that stimulate metabolic processes in the brain (nootropics, vitamins) are recommended. For Korsakoff syndrome, which developed as a result of vitamin B1 deficiency, intramuscular injections of vitamin B1 are used; prescribe a diet rich in proteins and low in carbohydrates (in order to reduce the need for vitamin B1).

The prognosis in most cases is serious; a persistent disturbance of mental activity occurs, including intellectual-mnestic disorders, which sharply reduces the possibility of social readaptation. In some cases, especially with post-traumatic, less often post-hypoxic Korsakoff syndrome, recovery is possible without pronounced intellectual-mnestic disorders.

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