Schizophrenia in early childhood: signs and symptoms

Medically reviewed: 12, May 2024

Read Time:46 Minute
Based on the book of V. Bashina

Schizophrenia in early childhood: signs and symptoms

In children of early preschool age, the schizophrenic process is characterized by continuous and paroxysmal types of the course of the disease with malignancy, medium and low degrees of progression. It turned out that the main tendency for the formation of forms of the disease persists regardless of the age of the patients at the initial stage of the process. It is in this that one can see the unity of manifestations of schizophrenia in people of different age groups. At the same time, there was a clear relationship between different ontogenetic levels and the structure of symptoms and syndromes.

The symptomatology of early childhood schizophrenia, especially in the age aspect, still remains the least studied. When defining the objectives of our study, it was also emphasized that the section on symptomatology is usually preceded by descriptions of the course, dynamics, and outcomes of the disease. In our work, this section had to be arranged in a slightly different sequence, which reflected the search for ways to most fully resolve the issue. We will consider the main symptoms and syndromes of early-onset schizophrenia sequentially, and we will take into account the different age stages of development of sick children, as well as the identified forms of schizophrenia in them.

A. V. Snezhnevsky (1975) defines the syndrome as a pathogenetic formation that indicates not only the quality, but also the severity of a disorder of mental activity. The syndrome is a system consisting of the sum of various signs (symptoms).

Affective motor symptoms

The occurrence of affective and motor symptom complexes in the pre-manifest period in children suffering from schizophrenia under the age of 1 year. The symptom complex of affective disorders is represented by attacks of anxious crying, general anxiety with sleep disturbances at night and subsequent tearfulness during the day. These states of anxiety are intermittent, repeated several times a night for a week and are observed for 2-12 months. This type of disorder was identified in 22 patients; 8 had continuous malignant schizophrenia, 8 had paroxysmal near-malignant schizophrenia, and 6 had low-progressive schizophrenia.

The structure of these disorders is most likely associated with disturbances in the affective sphere and represents the first manifestations of causeless and unaccountable anxiety. It is typical that these attacks of anxious crying appear at night.

The next set of disorders consists of symptoms of motor agitation or lethargy. Motor agitation was detected throughout the day and was expressed in increased restlessness of the child, who made repeated monotonous movements of the head, arms, legs, and, at the age of six months, climbed out of diapers. The excitement was prolonged, at times giving way to states of adynamia. The child’s activity during the period of excitement only superficially resembled the physiologically determined mobility of a healthy child. It was monotonous and proceeded against a joyless emotional background. In the presence of these conditions, there was no “complication of the child’s motor development; there was a regression of the first skills. Sometimes there was an unreasonable refusal to feed, anxiety and crying appeared when picking up the child. This type of disorder was found in 12 children only with continuous malignant and paroxysmal, close to malignant, schizophrenia.

The other 14 children had akinesia. They became lethargic, moved little in the crib, did not express joy enough when seeing their mother, and became indifferent to toys, hunger, and discomfort. These conditions arose autochthonously and disappeared spontaneously. They are found in cases of continuous malignant, paroxysmal, close to malignant and low-progressive schizophrenia. Subsequently, all these children showed delays in the development of motor skills and speech.

Can states of motor agitation and adynamia with the listed features be classified as a catatonic-like type of disorder?

Similar conditions could be a consequence of adynamic depression or elevated mood with agitation. We, like others/authors who have paid attention to such disorders, do not have clinical symptoms sufficient to define them as catatonic-like disorders. At the same time, L. Bender (1968) classified similar conditions as substuporous. We have identified some facts confirming these assumptions. Firstly, states of motor excitement and adynamia occurred against an unchanged emotional background. Secondly, the majority of these patients developed attacks of a catatonic structure after 4 years, and by 9-11 years – attacks of catatonia with stupor.

There was, however, a single case when a child at the age of 6 months experienced states of motor agitation against a background of elevated mood, with causeless cheerfulness, laughter, readiness for contact with everyone around him and shortened sleep without symptoms of regression. Subsequently, this child experienced attacks of an affective nature in combination with neurosis-like disorders, but his intellectual development did not suffer. This case to some extent confirmed both the possibility of the development of motor restlessness – of an affective nature in children 6-12 months old, and its difference from motor restlessness of a catatonic nature on a non-affective background.

Thus, in children with schizophrenia, in addition to developmental disorders, in the pre-manifest period, positive disorders in the form of anxiety affect, motor agitation against a background of elevated mood, motor agitation and adynamia against an affectless background with symptoms of regression were possible. It is almost impossible to prove the specific nosological affiliation of the listed symptoms during the period of their appearance. Apparently, states of motor arousal against an indifferent emotional background, which are combined with regression in hand movements and can be considered as prognostically unfavorable, are of the greatest informative value.

Symptom complex of regressive disorders

Symptoms of regression in schizophrenia at the end of the 1st – beginning of the 2nd year of life consisted of deepening detachment from the environment, regression of walking and purposeful movements of the hands. Walking was replaced by crawling; instead of directed movements in the hands, chaotic movements of the hands and athetosis-like movements in the fingers appeared. The latter were normally characteristic of children 1–4 weeks of age. Along with the regression, a stereotypy of the movements available to the sick child in this state arose.

With the formation of symptoms of mental regression in children aged 1-5 years, first of all, the inherent cheerfulness of children faded away, emotional reactions became impoverished, and activity decreased. Children lost interest in the world around them, stopped dressing and washing themselves, ate sloppily, grabbed food with their hands, and crumbled it. They lost interest in their peers and lost the joy of communicating with their parents. The range of activities narrowed. Previously acquired ideas, concepts about the surrounding world, activities disappeared and were replaced in the child’s behavior and games using primitive tactile, taste, and olfactory sensations. The games lost their plot and objectivity. Later, as the manifestations of regression deepened, the game became even more simplified. The children shook, sniffed, and felt objects. The satisfaction from such a game came from the motor acts themselves and primitive sensations.

Motor skills changed: instead of subtle directed movements, previously acquired movements appeared in the form of waving the arms, shaking the hands, folding the fingers and twirling them near the eyes. Walking was used along with crawling; In addition, stereotypical spinning and swaying occurred.

If the child spoke at the onset of the disease, then speech was subject to regression first of all. Phrases became simpler, shorter, then syllables and inarticulate sounds remained. In children with well-developed speech, at the onset of the disease, one could observe a stage when the construction of sentences was impaired. In such cases, the answer consisted of a stream of words that were not connected by semantic content. Personal verb forms and personal pronouns disappeared, and echolalia appeared. Such a speech disorder was replaced by an even more severe speech disorder: the pronunciation of words became tongue-tied, babbling, slurred, words were replaced by syllables and speech was completely lost.

Complete detachment from the environment was established. The children spent most of the day inactive, sometimes using primitive forms of play. In this state, they did not tolerate a change in their usual routine well. Everything that came from outside caused protest. The listed manifestations of regression were formed within 3-6 months.

Symptoms of regression, expressed to varying degrees, were found in all 42 children (100% of observations) with malignant continuous schizophrenia; in 77 attacks out of 127 (60.6% of observations) – paroxysmal, close to malignant schizophrenia; in 19 attacks out of 277 (6.9% of observations) – paroxysmal, low-progressive schizophrenia.

Mental regression in early childhood schizophrenia

Symptoms of pronounced mental regression, regression of motor skills, and speech exhausted the clinical picture in 16 children with continuous malignant schizophrenia. In 16 patients with paroxysmal, close to malignant, schizophrenia, symptoms of regression were found to a lesser extent; there was no complete regression of speech and motor skills. The clinical picture was also limited to partial regression of behavior in 18 children with paroxysmal, low-progressive schizophrenia.

At the same time, only a regression of complex behavioral skills was observed, subordination to relatives was lost, the feeling of embarrassment disappeared, the sense of what can and cannot be done in the presence of strangers, in public places, was lost.

In a number of cases, symptoms of mental regression were included in complex complexes of disorders. In 22 cases of paroxysmal, close to malignant, schizophrenia, catatonic-like disorders were found along with symptoms of regression. In 26 patients with continuous malignant schizophrenia, polymorphic symptom complexes were observed, consisting of affective, neurosis-like and catatonic-like disorders; later they were joined by symptoms of regression. In 13 attacks of low-progressive schizophrenia, in attacks of the affective type, symptoms of behavioral regression were also noted in the future.

Thus, by regression, we, like other authors, understand the temporary or final loss of some skills with their replacement by other, more primitive skills. In this case, a condition is formed that is not identical to the condition at an earlier stage of the child’s development. Analysis of observations convinced us that during this process a state arises, mosaically disfigured by the disease, which cannot be equated to certain, albeit earlier, physiological levels of a normally developing organism. In these states, certain forms of his activity were vaguely reminiscent of those at a lower, less mature level of development.

The considered regression phenomena are specific to schizophrenia, which occurs in children mainly under the age of 3, less often up to 5 years. This confirms that regression depends not only on the form of schizophrenia, but also mainly on the level of development of systems during the period of exposure to pathogenic factors, i.e., age factors play a large role in the formation of regressive manifestations.

Symptoms of regression of speech, motor skills, and behavioral skills in children aged 3-5 years were subsequently accompanied by features of delayed intellectual development, and an oligophrenia-like defect was formed. Therefore, the prognostic value of the symptom complexes under consideration is great. The less pronounced the symptoms of regression, the more favorable the prognosis. After attacks with erased manifestations of regression in children aged 3-5 years, during the period of remission, partial compensation of the condition was possible.

Catatonic-like, catatonic, catatonic-hebephrenic symptom complexes

The catatonic nature of adynamia and agitation in children under 1 year of age, as noted above, remains unproven.

In children with schizophrenia aged 1-3 years, states of aimless agitation and akinesia could be classified as catatonic-like. Excitement was expressed in a constant desire to walk in a circle or pendulum-like walking from obstacle to obstacle. The excitement was monotonous, not interrupted for hours, accompanied by ambition and ambivalence, impulsive actions: laughter, tears, aggression, sudden running in an uncertain direction.

The children did not pay attention to those around them, they did not respond to the call, as if they were deaf. Sometimes a reaction to speech addressed to them occurred in the form of eye movements, a turn of the head, the first steps towards the caller, which were immediately interrupted, replaced by an opposite movement or stomping in one place.

The gait became unusual: the movements were performed in an uneven rhythm, were sometimes sweeping, sometimes of limited volume and proceeded without coordination. Useless and involuntary movements were unexpectedly combined with purposeful ones.

Despite walking for hours, there was no visible fatigue. It was difficult to stop the children. If they were tried to be restrained, they silently sought to free themselves. Their resistance to the effects was depleted rather quickly, but after some time it was resumed. Left to their own devices, the children again took up the interrupted walking. Their facial expression was detached, grimaces appeared periodically: the children twisted their mouths, stretched their lips into a proboscis, squinted and immediately opened their eyes wide, wrinkled their foreheads. Although the children did not pay attention to those around them, they never bumped into objects and ran around the staff.

At this stage, speech became disordered. At first, the children repeated the same words several times without natural pleasure, the pace and volume of speech became unstable, the intonation and emphasis became unusual; then the children fell silent. But, left alone, sometimes waking up at night, they could correctly express their desire, they talked to themselves. In the subsequent course of the disease, the phenomena of mutism increased; Despite this, children could continue to unexpectedly respond to whispered speech or indirect address to them, or carry out instructions addressed to another child.

The state of excitement spontaneously alternated with lethargy. Then the children tried to lie down, lay inactive for a long time, huddled under the table, bed or in a quiet corner of the room, sometimes taking an imaginative position. Both during the period of excitement and lethargy, the children of this group did not experience muscle tension of “waxy flexibility,” which is especially important to pay attention to. Their muscle tone was variable, hypotension predominated; occasionally, transient hypertension was detected for a short time during the examination.

Sleep was disrupted, the children woke up at night and lay awake for a long time. They had to be forced to dress them, feed them, and take them out for walks. As soon as the active stimulation from the outside stopped, any primitive activity was immediately interrupted by jumping, walking, or a state of inaction.

In a number of children aged 3-5 years, motor excitation was combined with ideational excitation. The structure of motor excitation remained unchanged; speech excitation occurred periodically throughout the day and was expressed in speech pressure. The speech consisted of a stream of words and syllables not connected with meaning, incomprehensible phrases, fragments of memories, fragmentary facts, echolalia of phrases only spoken by someone. The children talked non-stop, sometimes to the point of exhaustion. Words were either pronounced clearly, or distorted, inserting unnecessary letters and syllables, omitting necessary sounds. They chanted without finishing the last syllables or combining the last and first syllables, and rhymed incomprehensible phrases. The children did not use speech for the purpose of contact: they did not make requests or answer questions.

The regressive-catatonic-like symptom complex of disorders was defined by a drop in activity, the appearance of affective indifference, regression of behavior, motor skills and speech, which was later joined by states of catatonic-like excitement or passivity (adynamia with pretentious poses). Ambivalence in actions and impulsive actions appeared. With incomplete regression of speech, echolalia, speech when addressed in a whisper, and delayed responses were found.

Regressive movements included athetosis-like movements in the fingers, jumping on the toes, crawling instead of walking, and other previously overcome movements. Regressive movements were repeated many times, for hours every day. When performing them, satiety did not occur; they arose against a “cold”, indifferent affective background, and were aimless. Naturally, in children 2-5 years old they were more complex than similar movements in children of a younger age, and always bore both the imprint of previous forms of movement and a touch of motor dexterity, which was achieved by the onset of the disease. Therefore, such movements have always been characterized by individuality.

In all children, along with the listed states of catatonic arousal, with a sharp worsening of the condition, chaotic arousal with negativism and aggression, auto-aggression and impulsivity arose. At the same time, the patients actively resisted the effects, were tense and angry.

A catatonic symptom complex with symptoms of numbness and muscle tension was found in children 3-5 years of age and older. They became increasingly immobile and lethargic. Some in this state preferred to sit bent over with their heads down; others – unnaturally straightened, throwing their heads back, turning their unblinking gaze into the distance. Sometimes children did not get out of bed, in which they had been for a long time, in the “fetal” position: the head was brought to the chest, the legs were bent at the knees, the hands were in the elbow joints, pressed to the chest and stomach.

When trying to straighten the child and lay him down more comfortably, he developed muscle tension and an “air cushion”-type posture was observed. With some relief of the condition, when the child was able to be raised, he resisted any influence in this state. In all muscle groups, during active examination, hypertension and even distinct catalepsy appeared; the arms and head remained in the given position for some time. When such a child was led, the resistance was not exhausted, the gait was shuffling, he had difficulty lifting his legs off the floor. The pose remained “frozen” even while walking; the arms, bent at the elbow joints, were pressed to the body, the neck and torso were unnaturally straightened. As soon as they stopped leading the child, he stopped and marked time. The facial expression was mask-like, at times distorted by grimaces.

These children had echopraxia and sometimes perseveration, when they repeated the same action many times. At times, the children became extremely submissive, maintaining the poses assigned to them, so that even the children around them, noticing this phenomenon, tried to play with them, like with “dolls,” giving a certain position to their hands and head. Occasionally this state was interrupted by impulsive running and aggression directed at the first person he met.

The stuporous states were still not so deep; at times the children became more pliable and did not resist if they were taken to another room, to the table, or for a walk.

The catatonic-hebephrenic symptom complex was determined by intermittent motor agitation, elevated mood with features of causeless gaiety, foolishness, and disinhibition of primitive drives. The behavior contained elements of a game that was monotonously repeated during this period. At the same time, shallow manifestations of mental regression were sometimes discovered, in the form of loss of complex behavioral skills.

A similar set of symptoms was noted in children 5-6 years old.

The complex of disorders that defined catatonic-like states with dreaminess was characterized by sleep disturbances, confusion, dreams of a frightening nature, fragmentary visual hallucinations, short-term periods of fascination, when children in detachment did not recognize those around them, smiled at something, caught something in the air, sometimes experienced a feeling of “flight”. These disorders were quickly replaced by catatonic arousal or states of aspontaneity. These conditions occurred in children at least 5 years of age.

The depressive-substuporous symptom complex will be clinically characterized in the course of describing affective disorders, since they were the main ones with it.

So, catatonic-like and catatonic-like in combination with pronounced manifestations of regression or polymorphic states with catatonic-like excitation are not characterized by a complete symptom complex of disorders characteristic of the catatonic syndrome in mature patients suffering from schizophrenia. Motor excitations, as well as states of adynamia, occurred against the background of hypotension or changing muscle tone. In this case, the phenomena of numbness and waxy flexibility were absent, there were no clear perseverations, and in addition, in a number of cases, a pronounced regression of motor skills and speech was observed.

Meanwhile, the catatonic type of excitation, like the catatonic one, was characterized by the involuntary nature of its appearance, the unpurposeful nature of the movements, and their stereotypical repetition. Excitation arose autochthonously and could not be interrupted at the will of the child and with speech influence from the outside; usually it was intermittent, died out and resumed without an external reason. Cataton-like arousal was characterized by symptoms of ambivalence, impulsiveness, the presence of stereotypy, mannerisms of postures and movements. It was accompanied by partial or complete mutism.

At the same time, inconsistency in the pronunciation of the same sounds, neologisms, contamination, echolalia, speech in response to a whisper, Tramer phonographism, negativistic opposite responses, lack of responses and speech excitation in the form of speech pressure were revealed.

In catatonic-like states, there was no stiffness, mannerism of posture, movements, intermittent changing muscle tone, angularity of movements along with plasticity and, at times, even gracefulness were noted. Negativism was easily replaced by passive submission. Despite the many movements that patients in a catatonic state performed without any need, it was impossible to get them to perform the simplest and most necessary movements when prompted from the outside. Ambitiousness in these states was reduced to a quick change of two opposite movements or to the incompleteness of an action, breaking it off halfway.

Although most of the movements were repeated monotonously, there was no similarity in the movements and true perseveration appeared only in children older than 5-6 years. Echopraxia also occurred at the same age as perseveration. These features of catatonic-like motor excitation and adynamia, speech disorders in children with schizophrenia, served as the basis for classifying them as a symptom complex of disorders close to catatonic, and because of some differences, we considered it possible to call them catatonic-like disorders.

The correctness of our assumption was confirmed by data on the complication of motor and speech excitation in the same patients with age in repeated attacks of the disease.

This was shown in cases in which catatonic disorders were observed during the first attacks, and later, especially after 5 years of age, attacks with catatonic disorders, phenomena of muscle numbness, waxy flexibility, perseverations, and an “air cushion” position. , embryonic position. An age-related feature of the catatonic symptom complex was the short duration of states of torpor (hours, rarely individual days), their lesser depth, and greater severity of passive submission.

Catatonic-like, catatonic and catatonic-hebephrenic symptom complexes were found in 26 children with continuous malignant schizophrenia (61.9% of the entire group of patients with continuous malignant schizophrenia) and in 54 with paroxysmal, close to malignant schizophrenia, i.e. 42.5% of all cases of paroxysmal, close to malignant schizophrenia. Affective-catatonic-like symptom complexes and catatonic-like disorders with dreaminess were noted only in 19 (6.9%) children with paroxysmal low-progressive schizophrenia. Thus, a clear relationship was revealed between the types of schizophrenia and the complex symptom complexes of disorders that determined them at different stages of the disease.

The relationship between the structural features of the listed symptom complexes and the patient’s ontogenesis is clearly expressed. In children under 3 years of age, catatonic-like symptom complexes in combination with symptoms of regression were noted; The catatonic symptom complex was found in children over 3 years old, the catatonic-hebephrenic complex – in children over 5 years old, the affective-substuporous symptom complex separately and in combination with symptoms of sleepiness – in children over 3 years old. Thus, the most universal complex of disorders in children under 3 years of age is catatonic-like with features of regression.

Symptoms of perceptual deceptions

Hallucinations, as in adulthood, included imaginary perceptions that arose without the presence of an external object. In 11 children aged 1!/2-3 years, in all cases, in the presence of speech, visual and tactile hallucinations were detected. They occurred in a drowsy state at night or when falling asleep, which was interrupted by unaccountable expressed anxiety.

Depending on the type of hallucination, some children said that they were being bitten by insects, shook something off themselves, others claimed that they saw something or something in front of them that was not really there. “There is a fly”, “butterfly”, “bus”, etc. And during the day these children became anxious, they developed a fear of ordinary objects, strangers, new surroundings. They would not let go of their mother, became irritable, refused to play, and ate poorly.

Such conditions are characterized by recurrence, from day to day or after several days, absolute identity of complaints, and the inability to convince patients of anything. The deceptions of perception were reminiscent of its changes in states of infectious delirium at high temperatures, noted in children by many authors (T. P. Simeon, M. M. Model, L. I. Galperin, 1935; G. E. Sukhareva, 1947; N. Maudsley , 1871, etc.). Apparently, we can attribute these perception disorders to illusory, dreaming, hypnogagic visual and tactile hallucinations.

In the remaining 52 children, perceptual deceptions were detected at the age of 3-6 years. In this older age group, these disorders mainly occurred in a state of sleep, less often in the daytime, in a state of pronounced fear, unaccountable horror, and anxiety. Hallucinations were simple in content, episodic, short-term, disappeared with a decrease in anxiety, i.e., they were mainly associated with the affect of fear.

Children in this group exhibited not only visual and tactile hallucinations, as in younger patients, but also auditory and oral hallucinations (a special form of visceral hallucinations). With this type of disorder, during the period of falling asleep, in the evening, during the day, or when waking up from sleep at night and during the day, children (in 32 cases) experienced fear, looked around in alarm, peered into the space in front of them, within the bed, less often in other places premises and “saw” simple images. At the same time, the children assured: “There is a wolf there. He is yellow”. “There are fleas on the ceiling”, “There is a spider”, “Mugs, I’m afraid of them, I see them”, etc. Or they said: “There are snakes on the bed”, “Bedbugs bite”, etc., in the latter cases sensed, “felt,” an extraneous presence.

In 4 children, visual hallucinations occurred during the daytime and were accompanied by fear and severe anxiety. They saw a “scary guy,” “he’s gray.” They froze in horror before the visions, sometimes they tried to bypass these places or asked their relatives to “transport them through them.” They were afraid of places in the room where they first experienced deceptions. And then fears appeared regarding their own health, hyperkinesis, a state of agitated anxiety with tossing and crying.

We discovered auditory deceptions for the first time in children 3-4 years old. They heard “knock”, “clock striking”, “cock crow”. In children aged 5-6 years, auditory deceptions had a more complex content: “someone is crying”, “they are saying something incomprehensible”. Only 2 children – 5 years 2 months and 5 years 6 months – were able to say that they heard “conversation in their ears.” “The voice said: you will die.”

Only in a few observations at the same age in sick children did we identify auditory deceptions during the daytime. The children were isolated from their peers and the outside world, they were busy, they hardly spoke to the staff, their relatives, being on the sidelines, they listened to something for a long time, sometimes answered in monosyllables, gesticulated, and grimaced. In these cases, it was possible to establish that they heard a voice from the wall. Children generally did not convey the content of auditory deceptions (someone says, he says… he swears…).

In 3 children, tactile hallucinations were found along with visual ones, in 4 – only tactile ones. They were more complex than similar tactile hallucinations in children of the previous group. They had a special children’s content. The children stated: “There are pieces of glass on their hands”, “boys in their hands”, “there is a thread in their fingers”.

In 7 children, modified visceral hallucinations were identified, which we called oral. Children experienced painful sensations from the oral cavity: “There is paper and glands in the mouth,” “burnt paper in the mouth,” “hair in the mouth.” There were also actual visceral hallucinations: “There is a man sitting in the stomach, he is squeaking.” Finally, 3 children, along with visual hallucinations, had olfactory hallucinations; they felt an unpleasant odor from food.

Hallucinations were always accompanied by an anxious affect, were episodic and short-lived, usually occurring over 2-4 weeks, rarely longer. As soon as the anxiety was relieved, the condition improved, and the hallucinations almost always disappeared. Only in 4 children out of 52 deceptions were observed for 2-6 months. When anxiety, fear disappeared, hallucinations stopped; asking about the experience always provoked a protest from the child. At the same time, the children became worried, became tense, and developed vegetative reactions.

Psychotherapeutic conversations did not relieve anxiety, the children were not dissuaded from their experience, and no critical attitude appeared towards it. Apparently, the lack of “interpretation” of the experience deprived the child of the opportunity to “somehow understand” the painful state, therefore, repeated deceptions of perception, as the first time, were accompanied by fear, were, as it were, welded to the affect of anxiety, the child did not get used to them, and at the same time I experienced fear in an autistic way. The latter is characteristic of hallucinations in schizophrenia.

Wake-up visual hallucinations are difficult to distinguish from frightening dreams with visualization of frightening images. At the same time, the children’s conviction in the presence of the experience, the projection outside of the hallucinatory image, its precise definition by the same name, the cliché-like repetition and similarity of images and sensations in repeated cases gave reason to assume that the children had true hallucinations.

In those cases when they “saw” something different each time, and with repeated questions they supplemented their story with new details about what they “saw”; this type of disorder could not be attributed to perception disorders, hypnogagic, drowsy, illusory hallucinations, but one had to assume hallucinations of Dupre’s imagination with visualization of the represented image, or the phenomenon of eidetism.

In 12 children suffering from paroxysmal, low-progressive schizophrenia, special “visions” were discovered – deceptions of perception, similar to the hallucinations of Dupre’s imagination.

This type of disorder was identified only in children over 5 years old with schizophrenia during the period of anxiety. “Visions” were characterized by the involuntary appearance of ideas of previously seen images, with a certain localization of these seen images in the “eyes”, “before the eyes”. “Visions” were also always small in size and sometimes resembled “pictures in a book” or “cartoons”. The images in the “visions” replaced each other and were repeated with new additions in the following days.

The children could not free themselves from them at will. At times, “deceptions” arose after thinking about these phenomena. Often, voluntary and involuntary in the appearance of figurative ideas were not always clearly distinguished by children. Questioning about these phenomena was usually unpleasant for the child. Children were always aware of the unreal nature of such “visions.”

It can be assumed that in these cases special deceptions of perception arose, on the one hand, close to hallucinations of the imagination of the Dupre type, on the other, to pseudo-hallucinations. In the latter case, there should be a feeling of “doneness”, “influence”. In sick children of preschool age, we were not able to observe the perception of these qualities in the structure of deceptions. Due to the fact that the story of little patients about the experienced states is scanty and, moreover, due to the autistic nature of the experience, the experience is incomplete, the nature of the disorders described remains insufficiently clear. It can be assumed that this state may also relate to the range of violent ideas with their visualization. However, this assumption is somewhat contradicted by the localization of vision in external space.

The frequency of the considered hallucinations in different symptom complexes in various forms of schizophrenia in early preschool children is as follows. Hallucinations were found in 47.6% of cases of continuous malignant schizophrenia, in 23.8% of paroxysmal, close to malignant schizophrenia, and in 9.7% of paroxysmal, low-progressive schizophrenia. The deceptions of perception were drowsy or arose at the height of anxiety, expressed fear in the daytime. Hallucinations in the picture. Diseases in themselves are not signs of a poor prognosis. However, their combination with catatonic disorders, especially regression, is prognostically unfavorable. The latter type of disorder was found only in patients with continuous malignant and paroxysmal, close to malignant schizophrenia. Anxiety with hallucinations without regression reflected the severity of the condition. Attacks with this symptom complex of disorders are characteristic of low-progressive schizophrenia. After them, a stable remission was formed, in which shallow changes in the personality of the pseudopsychopathic circle were detected.

In 5.8% of cases of paroxysmal low-progressive schizophrenia, deceptions of perception similar to the hallucinations of Dupre’s imagination were found. Perceptual deceptions were encountered only in low-progressive paroxysmal schizophrenia, along with neurosis-like and affective disorders. This symptom complex of disorders is prognostically more favorable than previous symptom complexes with perceptual deceptions.

Symptoms of the prototypes of delirium

The symptom complex of disorders with pathological judgments such as delusional ones was not found in children with schizophrenia under the age of 5 years. Meanwhile, in 5-7-year-old patients, conditions were identified that were characterized by an affect of anxiety, restlessness, unaccountable fear, and negativism. At the height of this state, hostility towards relatives suddenly appeared. The feeling of antipathy was often so strong that the children were not left alone with the person to whom it was manifested. In the presence of these persons, the children became anxious, fussy, and sought to cause harm: they pushed, pinched, and hit them.

The hostile attitude sometimes spread to another family member, whom the children also began to alienate. This attitude of hostility was not explained at all or was explained differently each time: “She is a stranger,” “He is black,” “He has dirty eyes,” etc. In these cases, apparently, a feeling was rather formed that did not reach in its development of the level of persistent pathological judgment. At the same time, remaining at the level of sensation, it acquired the same qualities as pathological judgment. It was causeless and could not be corrected from the outside; it determined the child’s behavior. In this way, a “delirium” of sensation was formed; this was its age-specific originality.

A number of patients had a similar attitude towards food. Children experienced fear and anxiety during feeding. They wanted to eat and immediately refused food. At the same time, they were worried, crying, screaming, and did not give in to persuasion. They explained the reason for their anxiety and refusal to eat differently: “the food is bad”, “dirty”, “they touched it with their hands”, etc. This state differed from obsessive fears of becoming infected, since in the latter case children of this age realized the wrongness of their relationship, struggled with it. This was not a refusal out of conviction due to an overvalued attitude towards one’s appearance with the desire to lose weight, as in anorexia syndrome.

Finally, it was not associated with loss of appetite; on the contrary, the child experienced a feeling of hunger and the desire to eat persisted. In these cases, a persistent, uncorrectable negative attitude towards food was formed, which was accompanied by anxiety and an inexplicable fear of eating something bad. With such an attitude towards food, the delusion of “poisoning” characteristic of adult patients did not develop. In these cases, as with a feeling of antipathy towards certain people, a pathological sensation arose from the possibility of eating food, vaguely reminiscent of delirium of poisoning. This feeling was incomprehensible to the child. The children could not explain it and did not give it an “interpretation.” Thus, the attitude towards food was formed not at the level of judgments, but at the level of sensations, it was vague and at the same time could not be corrected from the outside; it determined the child’s behavior. It should be noted that since the formation of a feeling of antipathy towards relatives or a special attitude towards food, the condition of children has somewhat stabilized. The anxiety became less pronounced.

With continuous malignant schizophrenia (in 16% of children), the listed disorders were soon joined by catatonic symptoms, and then the final state was formed.

In paroxysmal, low-progressive schizophrenia (in 10% of children), the state was exhausted by an affect of anxiety and a feeling of antipathy. After recovering from an attack in low-progressive schizophrenia (in 5.7% of children), at late stages of the disease, in the clinical picture, along with behavioral disturbances and neurosis-like affective disorders, a feeling of antipathy towards one of the parents appeared.

And in these cases, it was possible to observe how a similar inexplicable and undissuadable feeling of ill will towards a father, mother or close relative was formed. This feeling was characterized by the above-listed qualities of pathological sensation. In six children with indolent schizophrenia (17.1%), delusional fantasies were identified at late stages of the disease. In this disorder, pathological judgments arose in the circle of fantasies. The children were convinced of their special purpose, called themselves the leaders of “hooligan gangs,” etc.; all their activities boiled down to pathological fantasy.

They became convinced of the reality of fictitious facts. Behavior was subject to fiction. At times the fantasizing proceeded with features of violence. The listed features of such fantasies gave reason to assume that it was close to delusion, which is why they received the name “delusion-like.” These conditions occurred in children older than 5 years.

In 20 children with low-progressing paroxysmal schizophrenia (13.3%), false judgments were formed that were closely related to the affect of increased or decreased mood. These statements were also usually combined with fantasies: “I am the ruler of the Khanate,” “I am the strongest.” Ideas of self-denial were usually expressed in the form of a desired negation; There was no complete conviction of the presence of denial in children aged 4–6 years. After attacks with this symptom complex of disorders, remission was established.

A symptom complex of disorders close to obsessive

36 children aged 1-2 years and 56 children aged 2-3 years experienced unaccountable fear, apprehension, apprehension and motor disorders.

Motor disorders at the age of 1-3 years were aimless movements that first appeared in a directional manner and then lost their purpose. Aimless movements occurred during the daytime, were repeated monotonously, intensified with excitement, and did not depend on changes in muscle tone, which made them different from choreiform movements. The same child could have several types of aimless movements, and some were periodically replaced by others. Aimless, monotonous movements in children under 3 years of age easily became stereotypical.

In addition, hyperkinesis, tics and unnecessary movements were noted, which were always variable in form and were observed along with purposeful actions. The children could not stand or sit quietly, they fiddled with their clothes, touched their faces with their hands, etc.

Hyperkinesis and tics were usually not noticed by children. Monotonous aimless and unnecessary movements were noticed if attention was paid to them from the outside, and then for a short time the children could restrain themselves from performing them. It can be assumed that in children under 3 years of age, aimless repetitive movements were close to obsessive movements, occupying an intermediate position between obsessions and hyperkinesis, since initially they had a purposeful (cortical) origin, and then often became automated.

Children aged 1-2 years mainly showed unaccountable fear. It was groundless and repetitive. At times, fear was accompanied by states of agitation. At 2-3 years of age, an objective fear of cars, streets, strangers, etc. arose. It appeared when the child encountered a frightening situation, a frightening object, or when reminded of it. As soon as the source of the pathological experience disappeared from the child’s field of vision, his well-being improved. Due to a specific perception of reality, a child, if he was in a calm state when asked about the cause of fear, usually completely denied the presence of fear. The alienation and obsessive nature of fear were not identified by children of this age; this is the age-specific peculiarity of this type of disorder.

184 children aged 3-5 years had monotonous aimless movements similar to those described earlier, which were not always noticed by the child and were easily automated, and also unaccountable fear, repeated fear and more complex motor and ideation disorders were observed, which were obsessive in nature. Children of this age were already beginning to feel the aimless nature of movements and were burdened by them. When questioned, they said that they “couldn’t restrain themselves” from doing them.

Along with periodically arising unaccountable fear, these children began to develop true phobias. Their themes were often unusual: phobias of fire, clouds, shadows, language, etc. Fears that concerned primarily their own well-being also became clear. Children were afraid that something bad would happen to them: “Mother will not come to the garden for them,” “They will be forgotten,” “They will get sick,” etc. Children over 3 years old also had fears for the lives of their loved ones outside of direct connection with danger, characterized by a feeling of alienation and a desire to get rid of them. The children already formulated them differently: “I know that I shouldn’t think about it, but I can’t help it.”

Children aged 3-6 years experienced a special kind of ideational obsessions in the form of obsessive questions. The basis of such questions is the physiological state in the first age crisis, in which the child, normally, when learning about the world around him, used the experience of his elders, and therefore constantly asked questions. Sick children repeated the same questions many times, did not need answers to them, or only required a specific answer. The significance of such questions in understanding the surroundings was lost, they became aimless. The children realized their uselessness, but could not cope with the temptation, asking the same question over and over again, which had become useless.

The rhyming of the same neologisms also acquired an obsessive character: “model – vodel …”, “roar, okyn, kameleta”, etc., which were also based on age-related word creation, but it, like questions, became aimless, intrusive character.

Children over 3 years of age also developed obsessive urges to utter swear words and perform dangerous actions: “I want to get hit by a car, fall into a well, stand on a ledge,” etc. Some children immediately developed contrasting urges: fear death and the desire to look into a sewer hatch where one could fall, etc. Obsessive aggressive urges also appeared: “biting, hitting, pinching” relatives. If the children carried them out, they then experienced a dual feeling – remorse and pleasure.

At this age, obsessive philosophizing arose: “abstruse” questions from the field of “astronomy,” “about life and death,” and “philosophy.” Repeated ideas were alien and painful for children. Some in this state also experienced recurring dreams with the same content that burdened them.

With the emergence of awareness of the uselessness of obsessive thoughts, movements, and fears, protective rituals arose, with the help of which children tried to get rid of movements and thoughts that were unpleasant to them. Then one unnecessary movement was replaced by another unnecessary movement or repetition of words, muttering or actions. When obsessions took hold of the patients, states of severe anxiety and restlessness set in, and vegetative symptoms were added. Children’s hands and feet were cold, redness and paleness of the skin were noted, sweating, “unpleasant sensations” in the heart, and nausea appeared. All this was accompanied by a feeling of unaccountable fear and agitation.

In the evening hours, a number of children’s obsessions intensified, so they had difficulty falling asleep. Some of them developed phobophobia, the fear that “fears” would interfere with sleep, so the children refused to go to bed.

Thus, with age, in children there was a clear transformation of disorders close to obsessional in the motor and ideational spheres, which acquired an obsessive character. The obsessive disorders themselves gradually became more complex with the age of the children; various phobias, ritual manifestations, polar obsessions, and obsessive philosophizing arose.

The described type of disorders in combination with affective ones was observed for a short time, at the initial stage of disease development in 52.3% of patients with continuous malignant schizophrenia and in 39% with paroxysmal, close to malignant schizophrenia.

Actually obsessive disorders in combination with affective manifestations and psychopathic behavior were found in 63% of children with low-progressive paroxysmal schizophrenia and in 100% with continuous sluggish schizophrenia.

In children suffering from continuous malignant and paroxysmal, close to malignant, schizophrenia, such disorders were only at the beginning of the disease, mainly limited to hyperkinesis, tics, unnecessary movements, states of unaccountable fear and apprehension; they did not become more complicated, but were replaced by affective, hallucinatory, catatonic-like and catatonic-hebephrenic disorders. In cases of continuous sluggish schizophrenia or paroxysmal low-progressive schizophrenia, neurosis-like disorders were observed over a long period in combination with affective disorders and pseudopsychopathic behavior.

Other affective syndroms in childhood schizophrenia

There are affective syndromes, defined by mood disorders of the depressive and manic type in isolation or in combination with other disorder.

The likelihood of the affective nature of states of night crying and anxiety, states of motor agitation against the background of elevated mood in children under 1 year of age has already been discussed above.

In children aged 1–3 years, affective symptom complexes were identified in the following forms.

Adynamic depression is characterized by a monotonously joyless mood, lethargy, slowness, decreased interest in the environment, monotony of behavior, and play that is poor in content and away from everyone. The depressive triad is expressed quite clearly. A joyless mood is reflected in the picture of behavior, decreased interests, and the absence of mood lability characteristic of children. Children do not express any complaints during this period. People around them sometimes assume that these patients have a decrease in intelligence, since they seem to lose only recently acquired knowledge and skills, do not use them in games, do not accumulate new knowledge, do not remember fairy tales, poems, do not master new games, and need encouragement to activity. Motor sluggishness is clearly expressed, as are somatic changes. Adynamia in children is sometimes accompanied by impotence, then they are in a monotonous position for a long time, rarely changing positions.

Anxious depression with agitation is possible even at this early age; it is characterized by an anxious mood and general anxiety. Unreasonable reactions of protest intensify in behavior, and at times hysteroform reactions with sharp negativism, capriciousness, and crying appear. Periodically during the day, states of acute anxious agitation occur, which are accompanied by vasovegetative disorders, sweating, redness and blanching of the skin, changes in appetite, and increased thirst. The ideational component of the depressive triad in these states is reflected in inactivity and unproductivity. Basically, aimless motor restlessness is expressed, inhibition appears only at times. The game is completely disrupted, children cannot do anything.

Hypomanic states are also possible in children of this age group. An elevated mood with a hint of gaiety is combined with motor fussiness. Purposeful activity is not only not made easier, but also frustrated. Children cannot concentrate on anything, attention becomes superficial, they easily lose balance, get irritated, and quarrel. The child’s appearance also changes: a sparkle in the eyes appears, a blush appears on the cheeks, facial reactions and gestures intensify, and often the eyes are open wider than usual. The voice becomes loud. The speech noticeably jumps from topic to topic and accelerates its tempo. Communication with others is often completely disrupted. Children stop answering questions, talk only about their own things, shout out individual phrases, excerpts from songs, poems, sometimes incomprehensible syllables, individual words not connected by meaning. Falling asleep is disrupted, sleep becomes shorter, children stop sleeping during the day and at the same time do not experience fatigue. Appetite increases, sometimes only selectively.

In children 3-6 years old, states of adynamic, anxious depression and hypomania are also observed. In patients of this age, the states of adynamic depression are similar to those already described in children of the younger age group (1-3 years).

Anxious depression is characterized by greater severity of anxiety, although, as in younger children, it is also possible for the anxious state to alternate with periods of lethargy and adynamia. In a state of anxiety, thrashing, crying, moodiness, and incomprehensible alternating desires arise. Vasovegetative disorders are especially pronounced: sweating, hyperemia and pallor of the skin, changing appetite, vomiting, tremor, general “trembling”, as in chills. All of the listed phenomena of the anxiety state made it similar to diencephalic attacks. In a number of cases of anxious depression, states of protest and negativism were especially intensified, which arose autochthonously and were repeated many times during the day. Ordinary persuasion did not calm the child, which immediately distinguished these states from childhood capriciousness.

Patients in this older age group were already experiencing depression with ideas of guilt. These conditions most closely resembled depression of the endogenous type with the classic depressive triad. The children’s mood was clearly reduced. They either whined monotonously without tears, or cried irrepressibly. The child’s appearance changed, his face acquired a pained expression. Restlessness with aimless fussiness was replaced by low mobility.

At times, as adynamia deepened, the posture changed, the children became like old people, they walked with their heads down, bent over, dragging their feet, and did not move their arms. They spoke in a low voice and refused to play games. Sleep was disturbed and appetite decreased.

Diurnal fluctuations in mood were typical for this type of depression. In the evening, and sometimes in the middle of the day, before naps, motor restlessness and aimless walking arose. Children made a fuss, interfered in the affairs of adults, damaged toys, and laughed for no reason. Productivity during these hours remained reduced; children could not listen to reading and did not concentrate on the games offered.

Depressive states of this type were also characterized by the possibility of deepening the depressive state itself. Children aged 4-6 years had fleeting complaints of unpleasant or painful sensations in different parts of the body, mainly in the limbs. Sometimes there were fleeting statements that reflected the patients’ experiences of “boredom” and “melancholy.” At the same time, some children experienced symptoms of depressive derealization: “everything is like a fog,” “like in a dream,” “all things are old.” In the latter case, not only the perception of reality and the clarity of objects in the surrounding world changed, but also the sense of the time of their use, i.e. elements similar to the manifestations of “already seen” appeared.

Sometimes children in these states experienced a feeling of stopping time and the phenomenon of sleep alienation. Some children began to worry about their “age”, they experienced fear of approaching old age, they were worried that they had lived for many years. Sometimes their perception of their own personality was upset with a feeling of its decrease: “I am becoming smaller and smaller,” and with further deepening of depression, statements appeared close to the ideas of denial: “He is dead, we need him in the police,” “Let me not exist, let them cut it in half with a knife.” In nihilistic or similar statements, there was usually no complete conviction of one’s own denial; nihilism manifested itself more in the form of a desired rather than a true feeling of self-denial.

Conditions close to melancholic raptus with vegetative disorders

Even older children, 6–8 years old, showed depressive states with manifestations of sensual delusions of fantastic content. At the same time, children perceived themselves and their surroundings on two levels. The illusion of a negative double arose (the father and at the same time a figurehead), etc. More often, the negative double was perceived in the guise of an evil beast. Often there was a change from a positive double to a negative one. Even with a slight change in state, pathological ideas immediately receded. These disorders were usually noted fragmentarily and unevenly in different patients, which was associated not only with the depth of the depressive state, but also with different degrees of mental maturity of the children. A noticeable complication of ideation disorders occurred in sick children older than 5-6 years.

Depressive states were always accompanied by somatic changes:

  • children lost weight,
  • the skin became dry and pale gray in color,
  • bruises appeared under the eyes,
  • appetite decreased.

The tongue is usually coated and the lips become parched. The children refused food and were constipated.

The adynamic type of depression was found in 11.4% of children with continuous flaccid schizophrenia, and in 23% with paroxysmal recurrent schizophrenia. Adynamic depression in some patients with features of selective mutism, with the possibility of alternating adynamic depression, mixed states was identified in 20% of children with schizophrenia with a sluggish continuous course and in 22% with paroxysmal, low-progressive schizophrenia.

Anxious depression with agitation was found in 29.3% of patients with recurrent schizophrenia.

Anxious depression with features of negativism, dysphoric manifestations in combination with neurosis-like disorders, cravings, behavioral disorders was observed in 42.8% of patients with indolent schizophrenia and in 15% with paroxysmal, low-progressive schizophrenia. With this type of depression in children with paroxysmal low-progressive schizophrenia and sluggish continuous schizophrenia, the severity of the melancholy affect is low – mainly a feeling of anxiety and dissatisfaction was detected. Unlike patients with recurrent schizophrenia, dissatisfaction in these cases is directed at others, and not at oneself. The actions showed manifestations of aggression with sadistic impulses.

The depressive mood background was reflected in play activities, fantasies, and desires. Sick children played funerals, drew crosses and graves. Sometimes they had dreams in which they experienced death. Along with these disorders, children feared for their health. The combination of aggressive tendencies in behavior with affective instability, explosiveness, and gloominess gave depression a dysphoric connotation. Usually, the worsening of the condition led to an increase in obsessive fears, pathological fantasies and drives, rather than a deepening of the corresponding depressive affect.

Anxious depression with depersonalization disorders was detected in 6.1% of patients with low-progressive paroxysmal schizophrenia, depression with ideas of guilt – in 25.6% of patients with recurrent schizophrenia. — Delineated hypomanic states were found in 15.3% of children suffering from recurrent schizophrenia, mixed states and states of hypomania in combination with behavioral disorders, neurosis-like disorders were found in 37.2% of children suffering from paroxysmal low-progressive schizophrenia.

Conditions close to depressive-substuporous were identified in 4.7% of children with low-progressive paroxysmal schizophrenia and in 5.9% of children with paroxysmal, close to malignant, schizophrenia.

Affective symptom complexes as the initial ones, followed by the development of regressive-catatonic-like disorders, were identified in 26.2% of children with paroxysmal, close to malignant, schizophrenia. Depression in these cases is atypical.

Depression usually gave way to hypomania with goofy behavior. Hypomania was characterized by instability of mood, which at times resembled states with labile affect. Depression, especially states of hypomania, is characterized by disturbances in the communicative function of speech, severe behavioral disorder with revival of pathological drives. This stage of the disease in the clinical picture of the attack was followed by catatonic, catatonic disorders, regression of behavioral, motor skills and speech.

This article is written by

Anders Svensson - psychiatrist
Anders Svensson - psychiatrist
Dr. Anders Svensson is a distinguished psychiatrist with a multifaceted career marked by excellence in research, education, and patient care. Born and raised in Stockholm, Sweden, Dr. Svensson's journey in the field of psychiatry began at the esteemed Karolinska Institute, where he earned his medical degree. Dr. Svensson has Ph.D. in Psychiatry, during which he conducted groundbreaking research at the intersection of neurobiology and mood disorders.

In his clinical practice, Dr. Svensson has worked at prominent psychiatric institutions, including the Karolinska University Hospital.

His commitment to improving mental health literacy led him to a role as a lecturer at the Stockholm School of Medicine, where he has shared his knowledge with the next generation of healthcare professionals.

Currently, Dr. Svensson has taken on a new and exciting endeavor as a contributor to NetdoctorWeb, a reputable platform dedicated to providing reliable and accessible health information.

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