Abstract
Keywords: Antipsychotic drugs, Schizophrenia, Personality disorders, Neurosis, Alcoholism, Russia
1.
Introduction
The
abuse of psychiatry in the former Soviet Union (SU) was broadly discussed
during the second half of the 20th century. In the 21st century, the interest
to this theme has subsided, which does not mean that the problem has remained
in the past. In addition to political pressures, the causes of abuse can include
low standards of training and practice, inadequate procedural quality assurance1, limited access to foreign professional
literature and poorly implemented legislation because professionals have not
been trained to use the new laws2 or
lacking motivation to use them.
2.
Case Report
A
case study illustrating overdiagnosis of schizophrenia in the former SU has
been reported previously3. A
16-year-old schoolboy (hereafter patient) with mild communication abnormalities
was brought to the psychiatrist by his mother. Later, the patient admitted that
the real goal was exemption from military service (conscription). The author
observed the patient for many years, also in stressful situations and did not
notice any mental abnormalities, apart from alcohol dependence that developed
later on. Aside from shyness during adolescence, the only notable complaint was
the statement that his “nerves were like ropes”. This was interpreted as cenesthopathy
and sluggish schizophrenia was diagnosed. The concept of cenesthopathy was
coined to describe unusual bodily sensations without objective findings; it is
no longer in the mainstream of contemporary psychiatry4,5. However, Russian literature has many
publications on cenesthopathy that culminated in the singling out of cenesthopathic
form of schizophrenia6-9. Besides, cenesthopathy
has been regarded as a symptom of “hypochondriacal” and sluggish schizophrenia.
The overdiagnosis of the latter entity in Russia has been discussed previously10. It is known that some forms of adolescent
turmoil may lead clinicians to diagnose a serious condition, to be confronted
one day with a completely recovered patient; although severe disorders in
adolescence usually do not disappear completely11.
The patient was prescribed a phenothiazine drug and trihexyphenidyl (known as
Cyclodol in Russia). There was no proper control of the drug intake. The
patient brought Cyclodol tablets to school and offered to others with the
comment that it was a narcotic drug. Curious teenagers took it during lessons, which
remained unnoticed by teachers. One boy suffered intoxication with a
delirium-like condition after an intake of trihexyphenidyl together with
alcohol12. The patient was registered
at the psycho-neurological dispensary, exempted from conscription, denied a
driver’s license and directed to a specialized educational institution, where
he acquired the profession of floriculturist. After that he worked in city
parks. Later on, following advice of his friends and some medics, the patient
switched to car repair work, completed an evening technical education, got
married and reduced his alcohol consumption. The patient suffered from stigma
all his life: registration at the psycho-neurological dispensary was known by
surrounding people, which impaired his relationships and employment
possibilities. Apparently, this contributed to the alcohol abuse.
3.
Discussion
Schizophrenia
has been often over diagnosed in the former SU, while the concept was broader
than that used in the United States and other countries1,13-15. Overextended diagnostic criteria of
sluggish schizophrenia affected many people, having nothing to do with politics
or dissent. Personality disorders, neuroses, reactive psychoses, transient
derangements in adolescence or bouffées délirantes, were misdiagnosed and
treated as schizophrenia. It can be illustrated by the following citations
(verbatim from Russian): “A part of the patients with sluggish schizophrenia,
after a juvenile crisis, achieved a complete social and professional
adaptation, continued education and got married16”
or “a majority of patients with juvenile sluggish schizophrenia become
compensated17”. Schizophrenia was
considered a lifelong process18,19.
Accordingly, patients remain registered with psycho-neurological dispensaries
lifelong, which contributes to stigma for them and their families. The
procedure of cancellation of the registration has been rare and usually
unsuccessful13. The registration can
contribute to unemployment because some employers ask for a certificate from a
psycho-neurological dispensary. Access to foreign professional literature has
been limited, while in Russian textbooks, differential diagnosis between
personality disorders, neuroses and schizophrenia has been explained vaguely,
leaving space for individual judgment. For example, in the well-known textbook
by Lichko8, the differential
diagnosis between sluggish schizophrenia, neuroses and personality disorders is
not discussed at all, while it is only stated that many months of observation
can be needed, thus justifying prolonged institutionalization. This is not
surprising: Soviet psychiatrists sometimes constructed diagnoses through words,
not necessarily using objective criteria: “narrative orientation of diagnosis19”. The vague and subjective concept of
Praecoxgefühl, potentially conductive to the overdiagnosis of schizophrenia, is
reappearing in the current literature, being suggested as a basis for the
‘diagnostic hypotheses.’ Lack of confidential ‘transparent’ contact with a
patient has been posited as a foundation of the Praecoxgefühl (Gornushenkov and
Pluzhnikov 2020). Obviously, this approach may facilitate political misuse of
psychiatry.
Psychopathologic
phenomena typical for histrionic, dissociative, obsessive-compulsive disorders,
prolonged asthenization, unusual interests and dissent have been presented as
diagnostic criteria for schizophrenia8,20-23.
The existence of latent, asymptomatic and non-manifestative forms of the
disease was postulated20. Similarity
between oligosymptomatic “latent” and “residual” schizophrenia was pointed out24. Chapters about neuroses and personality
disorders have been added to recent textbooks but descriptions are somewhat
vague25. Admittedly, the most recent
textbook by is better than preceding ones.
In
some textbooks26,27, sluggish
schizophrenia has been presented as a synonym of a schizotypal personality
disorder according to the International Classification of Diseases (ICD).
Although the 10th Revision of ICD was accepted, the Soviet-era classification
has been further in use, while ICD was criticized28,29.
The term sluggish schizophrenia continues to be used, whereas the same Russian
term vyalotekushchaya is now translated in English summaries of some articles
not as sluggish but as “slow progressive”. It was pointed out by leading
psychiatrists that the Soviet classification of mental disease is based on
etiology and pathogenesis, supposed to be an advantage over foreign
classifications based predominantly on syndromes30.
Note that the etio-pathogenetic approach, in conditions of insufficient
knowledge on etiology and pathogenesis and lack of diagnostic tools,
contributes to overdiagnosis. “Asymptomatic” or “non-manifestative” forms of
schizophrenia20 cannot be diagnosed
by a blood test like e.g. those of syphilis.
The
sluggish variety was reportedly the most common form of the disease: ~50% of
all schizophrenia cases19,26,28. The
entity was additionally expanded by so-called schizophrenic reactions, a
concept that allows diagnosing reactive conditions as “psychogenic
exacerbations” of the disease that had been non-manifest prior to environmental
stress21. Another contribution to the
overextension of the entity was the doctrine about the “Nosos and Pathos” by
the leading Soviet psychiatrist Andrei Snezhnevsky8,
where the manifestative disease is called Nosos and hereditarily predisposing
constitutional traits - the Pathos of schizophrenia. According to this
doctrine, the Nosos can transmute to the Pathos and vice versa. In this way,
the disease is mixed up with constitution, permitting to diagnose personality
disorders and constitutional traits as schizophrenia. Furthermore, anorexia and
bulimia have been discussed within the scope of schizophrenia31. Childhood autism, introduced into Russian
classifications in the late 1980s but not uniformly accepted, was sometimes
classified and treated as childhood schizophrenia32,33.
Substantial overlap of childhood autism and schizophrenia is discussed now as
before34,35. Some experts should
consider potential consequences of a false-positive diagnosis of schizophrenia
in this country, exemplified by the Case report above.
With
regard to the treatment, antipsychotic drugs have been recommended by Russian
handbooks for all forms of schizophrenia, including the sluggish form,
shizotypal disorder, remissions17,26,36
and “increasing shizoidization8”.
Moreover, antipsychotics have been recommended for neuroses and personality
disorders27. This is partly at
variance with the international literature, where neuroleptics are discussed
for resistant cases37. Clinical
recommendations are avoided here. Tendentious citation is sometimes used, for
example: The possibility of [antipsychotics] use in patients with antisocial
personality and borderline personality disorders is pointed out in the MSD
Manual. The following is said in the cited source: “Typically, personality
disorders are not very responsive to medications… There is no evidence that any
particular treatment leads to long-term improvement [of antisocial personality
disorder] … Medications are not consistently effective for core symptoms of
borderline personality disorder.” Side effects of antipsychotics are well
known, including those contributing to stigmatization29.
Finally,
antipsychotic drugs (phenothiazines, haloperidol and others) have been recommended
and applied in adults and adolescents diagnosed with alcohol dependence in the
absence of psychosis38-43. The
alcohol craving has been baselessly interpreted as an “altered state of
consciousness”, as a paranoid or delusional phenomenon44,45 within the scope of “productive
psychopathology40”. Accordingly, the antipsychotic
medication has been recommended by authoritative handbooks49,40. Apart from other potential side effects,
the synergism between some antipsychotics and alcohol, aggravating liver
injury, should be taken into account46.
With regard to alcohol-related dementia (and other dementia in alcohol
consumers) it should be stressed that antipsychotic use compared with non-use
was associated with increased risks of stroke, venous thromboembolism,
myocardial infarction, heart failure, fracture, pneumonia and acute kidney
injury47. Unfounded
psychopathological interpretations of alcohol consumption and overextended
diagnostic criteria of alcoholism, used in Russia, have been pointed out45.
The
over-institutionalization of patients with mental disorders has been common
practice2. Accordingly, the Russian
Federation (RF) had one of the highest levels of psychiatric beds per capita in
Europe7. Conditions in psychiatric
hospitals, where the patients stay for a long time, have been primitive:
overcrowding, no privacy, insufficient hygiene. Some institutions are investing
in major repairs of buildings but overcrowding persists both in wards and
restrooms. The overcrowding of toilets is increased because patients use them
for smoking. Usually there are no cubicles: lavatory pans and urinals are in
the same crowded room48. Furthermore,
a shortage of nurses and auxiliary personnel is a problem, while unprepared
persons were sometimes employed without training or adequate instruction. In
some cases, it resulted in the maltreatment of patients, supplying them with
alcohol and so forth. In spite of a formal condemnation of the Soviet-era abuse
of psychiatry, a tendency of its belittling can be noticed28. It was stated, for example, that conceptual
differences between the Soviet and Western psychiatry have been minimal, while
the abuse was caused mainly by political factors49.
In fact, as discussed above, the Soviet concept of schizophrenia has been
considerably broader than that used in the West. Along with the extended
diagnostic criteria of the disease, a broader concept of social dangerousness
has been applied14,15 a criterion
being a risk of “damage to the interests of society50”, which leaves space for individual judgment and may
include political considerations. At the same time, the social dangerousness is
an indication for hospitalization51.
The motivation to preserve the over-extended and vague diagnostic criteria is
understandable: it is easier in everyday practice and also from the legal
viewpoint to commit to inpatient care. Now, as before, the emphasis remains on
medical aspects of treatment, without adequate consideration of psychosocial
and occupational rehabilitation52.
4.
Conclusion
As
far as we know, the Soviet and present rulers, the party and military
nomenklatura53, did not allow the use
of invasive procedures without indications on themselves and their relatives54. Alcoholics from their milieu have not been
compulsorily treated by drip infusions days on end being infected with viral
hepatitis, neither have they drunk technical ethanol sold in vodka bottles
through legally operating shops55. The
question has been discussed why psychiatry but not physical medicine is open to
abuse49,56. In fact, as discussed in
this article, physical medicine can be abused as well, while psychiatry is open
to abuse, especially in certain locations of the world, including the former
SU. The first step away from it must include the broader use of the
international literature and the exchange of experience by means of the
temporary practice of Russian psychiatrists abroad and of authorized foreign
advisors in Russia. Of note, some Soviet-era approaches to diagnostics and
treatment of mental diseases were, as in medicine in general, caused by
preference given by the healthcare authorities to less individualized methods
applicable en masse to large contingents of patients. Today, in view of the
upturn in the Russian economy, individualized evidence-based methods should be
applied in accordance with international practice57-60.
5.
Conflict of Interest Statement
The
authors declare no conflict of interest.
6.
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