Schizophrenia: Clinical Guidelines

List of Abbreviations

DSM-5 - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

PANSS - Positive and Negative Syndrome Scale

PSP - Personal and Social Performance Scale

SCI - Structured Clinical Interview

AT - autogenic training

ATC - Anatomical Therapeutic Chemical (Classification)

WHO — World Health Organization

GABA - gamma-aminobutyric acid

CBT - cognitive behavioral therapy

CG – clinical guidelines

CT — computed tomography

ICD-10 - International Classification of Diseases, 10th Revision

PET - Positron emission tomography

RCT - randomized controlled trial

RPS - Russian Society of Psychiatrists

SSRI - selective serotonin reuptake inhibitor

LoE – level of evidence

LER — level of evidence and recommendation

FSI - Federal State Budgetary Institution

fMRI - functional magnetic resonance imaging

SZ - schizophrenia

ECG - electrocardiography

EEG - electroencephalography

Terms and Definitions

Verschrobene-type defect - (from German *verschrobene* – "eccentric") – negative personality changes progressing over the course of schizophrenia, including oddness, eccentricity, emotional coldness, and a tendency to form overvalued ideas.

Progredience - the rate of accumulation of negative symptoms in the clinical picture of schizophrenia, determining the nature of personality and cognitive changes within the structure of the defect.

Mental dysontogenesis - a disorder of mental development as a whole or of its individual components, a disruption in the pace and timing of the development of specific mental spheres and their components.

Kandinsky-Clerambault syndrome - hallucinatory-paranoid syndrome or syndrome of psychic automatism, including delusions of persecution and influence, phenomena of psychic automatism, and pseudohallucinations.

Screening - the collection of information (typically via questionnaires) to identify a specific risk group from the general population, assess their need for further in-depth clinical diagnosis and necessary therapeutic/rehabilitative care (without precise qualification) based on key indicators of mental disorders. Screening is performed by primary care specialists (pediatricians, neurologists, medical psychologists).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Schizophrenia (hereinafter referred to as SZ) is a mental disorder characterized by a combination of productive (hallucinatory-delusional, catatonic-hebephrenic, affective, etc.) and negative (apathy, abulia, alogia, emotional and social withdrawal, etc.) symptoms, behavioral and cognitive impairments (memory, attention, thinking, etc.), leading to adverse social and economic consequences. SZ can develop at various ages, including in childhood.

Schizophrenic disorders in childhood are typically accompanied by significant and characteristic distortions of thinking and perception, as well as inappropriate affect. Clear consciousness and intellectual abilities are usually preserved, although a certain decline in cognitive functions may occur over time. Crucial psychopathological symptoms include the experience of thought echo, thought insertion or withdrawal, and thought broadcasting; delusional perception and delusions of external control; inertia; auditory hallucinations commenting on or discussing the patient in the third person; loosening of associations and negativism symptoms. The course of schizophrenic disorders can be continuous or episodic, with progression or stabilization of deficits; it may consist of one or several episodes of the illness with complete or incomplete remission [1].

Comment: the definitions of SZ have changed depending on the prevailing concept of SZ and the paradigm of its perception by physicians and researchers. In the definition given above (based on ICD-10), the primary features of schizophrenia are impairments of the thought process and perceptual disturbances. In the 20th century, the definition by A.V. Snezhnevsky was considered classic: "SZ is a progressive mental illness characterized by the dissociation of mental functions, i.e., the loss of unity of mental processes with rapidly or slowly developing personality changes of a specific type (decreased energy potential, progressive introversion, emotional impoverishment) and diverse productive psychopathological disorders" [2]. Thus, the core elements in understanding schizophrenia were its process-like course and personality deformation, with a predominance of negative symptoms. In ICD-11, schizophrenia is defined differently: "Schizophrenia is characterized by disturbances in multiple mental modalities, including thinking (e.g., delusions, derailment of thought processes), perception (e.g., hallucinations), self-experience (e.g., the experience that one's feelings, impulses, thoughts, or behavior are under the control of an external force), cognition (e.g., deficits in attention, verbal memory, and social cognition), volition (e.g., loss of motivation), affect (e.g., blunted emotional responsiveness), and behavior (e.g., behavior that appears odd or purposeless or is disrupted in connection with unpredictable or inappropriate emotional responses). Psychomotor disturbances, including catatonia, may be present. Persistent delusions, persistent hallucinations, thinking disturbances, and experiences of passivity, influence, or control are considered core symptoms" [3]. Thus, the spectrum of manifestations of SZ in this definition is significantly expanded, with a particular emphasis on phenomena of psychic automatism, thought disorders, and perceptual disturbances. These clinical guidelines have been prepared in accordance with ICD-10 in effect in the Russian Federation at the time of their writing.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Schizophrenia is presumed to be a polyetiological disease, the etiology and pathogenesis of which remain unknown to date. There are a large number of theories and hypotheses regarding its origin, which to varying degrees emphasize various hereditary factors and environmental influences.

Numerous studies postulate a high role of hereditary pathology in the origin of schizophrenia [4]. Inheritance is complex and polygenic in nature, and the manifestation of the disease likely depends on the accumulation of pathological factors across generations, which at a certain point collectively reach a critical threshold. Convincing evidence of the role of heredity in the origin of schizophrenia is provided by genealogical and twin studies [5, 6]. At the same time, it is generally accepted that in half of schizophrenia cases, de novo mutations play a leading role, which are absent in the genome of the patient's parents.

The so-called dopamine hypothesis of schizophrenia, which arose as a consequence of studying the antipsychotic action of neuroleptics, is dedicated to explaining the mechanism of realization of genetic pathology in schizophrenia [7]. Studies have shown that patients with schizophrenia have an increased concentration of dopamine in a number of brain regions [8]. Similar hypotheses have also been advanced regarding the role of glutamate and dysfunctions in GABAergic and cholinergic neurotransmitter systems [9].

Modern neuroimaging methods, primarily PET-CT and fMRI, have revealed numerous changes in the structure and functional characteristics of the brain in patients with schizophrenia. Findings include gray matter degradation, ventricular enlargement, and altered functional activity of the frontal and temporal lobes, as well as the hippocampus [10, 11, 12]. However, it has not been proven that these changes are not associated, for example, with the use of psychotropic medications, alcohol, or the consequences of a sedentary and cognitively impoverished lifestyle.

Numerous social factors, such as poverty, migration, urbanization, physical (including sexual) and emotional abuse in childhood, insufficient emotional support from parents, loneliness, as well as socially conditioned factors such as alcoholism and marijuana use, have been studied over the past half-century, but none of them has shown a convincing causal relationship with the onset of schizophrenia [13].

In recent years, the autoimmune theory has become an established theory of the origin of schizophrenia, combining hypotheses of a selective inflammatory process as the cause of damage to a number of brain cells (or, in a broader context, structures) and neurodysontogenesis [14, 15].

Most researchers attribute the difficulties in identifying the causes and pathogenetic mechanisms of schizophrenia to the well-known blurriness of the boundaries of the schizophrenia spectrum disorder continuum and the non-specificity of most recorded symptoms and syndromes. In particular, in cases of childhood-onset schizophrenia and schizoaffective disorder, diagnostic discrepancies between the first and second examinations could reach up to 50% of cases [16], which precludes the uniformity so essential for research. It is also impossible to rule out the hypothesis that schizophrenia represents several closely related states that are difficult to distinguish clinically, yet have different etiologies (e.g., mutations in various genes or groups of genes) and pathogenesis.

1.3 Epidemiology of the Disease or Condition

According to the World Health Organization (WHO), 0.3% to 0.7% of people worldwide suffer from schizophrenia. At the same time, data indicate that morbidity rates can vary significantly depending on the calculation methods used. Prevalence and incidence may fluctuate considerably depending on age, sex, ethnicity, and place of residence, including in the Russian Federation [17, 27]. It is known that men are affected on average 1.4 times more often than women, with this difference being driven primarily by the age group under 30 [18]. Schizophrenia is rare in childhood [19], with the proportion of individuals developing childhood-onset schizophrenia being less than 1% [20] (according to other authors, up to 4%) [21]. Among children recognized as disabled due to mental disorders in Russia, children with schizophrenia account for 4.4% [22]. According to epidemiological data for 2018 in Russia, the overall incidence rate of schizophrenia in children increased by 6.5%, from 13.53 per 100,000 population in 2000 to 14.41 per 100,000 population in 2018, while in the adolescent group, the incidence rate of schizophrenia increased by 44.7%, from 54.61 per 100,000 population in 2000 to 79.03 per 100,000 population in 2018 [23]. However, the reasons for such a significant increase in statistical indicators may not be directly related to an increase in the number of cases.

According to 2019 data, Russia has seen a steady increase in the incidence of psychoses and dementia states in children under 14 (by 50% since 1995), and a 70% increase in morbidity. Schizophrenia morbidity among the pediatric population also tended to increase from 1995 to 2010 (by 70%), with a slight decrease (by 20%) observed in recent years. However, the number of children registered with this diagnosis remains one-third higher than it was 20 years ago. The incidence of childhood schizophrenia grew until 2008 and subsequently declined. In 2017, the diagnosis of schizophrenia was established for the first time in life in 300,000 children. There is also a steady upward trend in the population of patients with schizophrenia aged 15–17 years. While in 1995 there were 53.3 per 100,000 adolescents, by 2016 their number had increased by 50% to 75.1 cases per 100,000 adolescents. Compared to 2000, overall morbidity rates for psychoses and dementia among adolescents have also increased (from 152 to 162 cases per 100,000 adolescents). It is possible that some of these cases are attributable to schizophrenia [24].

1.4 Features of Coding the Disease or Condition

Neither ICD-10 nor DSM-5 contains a specific category for schizophrenia developing in children or adolescents. The view is expressed that since the clinical presentation of adult and childhood-onset schizophrenia is identical, childhood schizophrenia should not be a separate disorder [25]. In the version of ICD-10 adapted for use in the Russian Federation, the childhood type of schizophrenia is included under code F20.8 (other schizophrenia), with the specific code F20.8xx3. This subcategory includes cases of schizophrenia that begin in childhood and are characterized by a specific and polymorphic clinical presentation. It also includes early-childhood cases of schizophrenia with a pronounced oligophrenia-like defect (due to severe mental retardation similar to oligophrenia) [26]. According to studies, up to 50% of early-onset schizophrenia cases (onset before age 13) are comorbid with autism spectrum disorder [202, 203].

Thus, Chapter V of ICD-10, adapted for use in the Russian Federation, includes the following categories:

F20.0 - Paranoid schizophrenia

F20.1 - Hebephrenic schizophrenia

F20.2 - Catatonic schizophrenia

F20.3 - Undifferentiated schizophrenia

F20.5 - Residual schizophrenia

F20.6 - Simple schizophrenia

F20.8 - Other schizophrenia, including F20.8xx3 - childhood schizophrenia

F20.9 - Schizophrenia, unspecified

Comment: ICD-11 does not provide for the subdivision of schizophrenia into subtypes.

It provides for the identification of a first episode of schizophrenia (current state, partial remission, full remission), multiple episodes of schizophrenia (current state, partial remission, full remission), and continuous course. Thus, the symptomatology of psychosis characterized as an episode of schizophrenia will not be relevant within the framework of ICD-11 [3].

1.5 Classification of the disease or condition

For the classification and diagnosis of schizophrenia in both adults and children, two main classifications with international status are currently used worldwide: ICD-10, issued under the auspices of the WHO, and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), developed by the American Psychiatric Association. Russia uses Chapter V of ICD-10 adapted for use in the Russian Federation [1]. The diagnostic and classification categories used in ICD-10 are provided in Section 1.4 of these clinical guidelines.

Comments: traditional classifications of schizophrenia dating back to the times of E. Kraepelin and E. Bleuler, which in Russian psychiatry were most fully developed by A.V. Snezhnevsky and his pupils and colleagues [29], have not lost their relevance to this day. Thanks to the classical clinical approach, ICD-10 retains clinical forms of schizophrenia and takes into account the type of course, while research and clinical practice pay significant attention to such factors as the features of the course and therapy of the first episode, positive and negative symptoms, as well as affective and cognitive disorders within the clinical presentation of schizophrenia. In fact, it is precisely these features that determine such high variability of individual cases within the general continuum of schizophrenia spectrum disorders. The modern centrifugal trend present in the structure of ICD-10 and DSM-5, which led to the formation of independent diagnostic categories such as schizotypal disorder (latent schizophrenia, neurosis-like schizophrenia) or schizoaffective disorder, also has a flip side, manifested in the creation within DSM-5 of the category "schizophrenia spectrum and other psychotic disorders," indicating the etiopathogenetic and clinical affinity of these forms of mental pathology [30], even though certain forms of schizophrenia were removed from the classification

1.6 Clinical presentation of the disease or condition

The clinical presentation of schizophrenia is extremely polymorphic and may include various symptoms and syndromes of greater or lesser specificity. There are no absolute pathognomonic symptoms that allow for a definitive diagnosis of schizophrenia. In all cases, symptoms and syndromes are evaluated comprehensively. ICD-10 uses the following general criteria for diagnosing schizophrenia [1]:

1. Thought echo, thought insertion or withdrawal, and thought broadcasting;

2. Delusions of control, influence, or passivity, referred to body movements or specific limbs, thoughts, actions, or sensations; delusional perception;

3. Hallucinatory voices commenting on the patient's behavior or discussing them among themselves, or other types of hallucinatory voices coming from some part of the body;

4. Persistent delusions of other kinds that are culturally inappropriate and completely implausible in content;

5. Persistent hallucinations in any modality, when accompanied by fleeting or half-formed delusions without clear affective content, or persistent overvalued ideas that may occur daily for weeks or months;

6. Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

7. Catatonic symptoms, such as undifferentiated, sometimes stereotyped excitement, impulsive actions, posturing or waxy flexibility, negativism, mutism, and stupor; exaggerated mannerisms and grimacing are also possible;

8. "Negative" symptoms, such as marked apathy, speech poverty, blunted or inappropriate emotional responses, typically leading to social withdrawal and reduced social productivity; these signs are not due to depression or drug-induced neuroleptic side effects;

9. A significant and consistent qualitative change in behavior, manifested by loss of interests, aimlessness, inactivity, self-absorption, and social withdrawal.

To diagnose schizophrenia, at least one clear symptom (or two less distinct symptoms) belonging to items 1-4 listed above, or two symptoms belonging to items 5-9, must be present for a duration of at least one month.

ICD-10 proposes both general diagnostic criteria (see above) and specific criteria required for diagnosing individual forms of schizophrenia (see sections 1.4 and 1.5 of these clinical guidelines).

Comment: childhood-onset schizophrenia has a number of features that distinguish its clinical presentation from the typical adult pattern. Clinical manifestations of schizophrenia in children are divided into 2 groups: (1) symptoms and syndromes characteristic of schizophrenia (catatonic, hebephrenic, hallucinatory, delusional, psychopathy-like, affective, etc.), which in children are characterized by fragmentation, rudimentariness, incompleteness of individual components and the entire syndrome as a whole, transitoriness, and variability; (2) syndromes characteristic of childhood (fears, fantasies, speech disorders) and adolescence (dysmorphophobia, anorexia acquiring the features of delusional conviction), differing in comparison with similar symptoms observed in children with other mental illnesses by a specific shade caused by schizophrenia. They may be atypical, grotesque, bizarre, absurd. Symptoms of schizophrenic defect in patients develop in parallel with the psychophysical development continuing against the background of the disease. Thus, in childhood schizophrenia with a continuous course type, manifestations of mental underdevelopment resembling intellectual deficit in mental retardation—the so-called "oligophrenia-like" defect—may appear in the defect symptoms alongside traits of a specific emotional and volitional impairment.

The diagnosis of paranoid schizophrenia (F20.0) is made when the clinical picture is dominated by delusions (persecution, reference, significance, jealousy, special mission, etc.) and perceptual disturbances, typically true auditory and pseudohallucinations (threatening, commenting, or insulting hallucinatory "voices" or non-verbalized sounds such as noise, whistling, knocking; visual, gustatory, and tactile hallucinations are less common; cenesthopathies are possible). In paranoid schizophrenia, speech disorders, emotional disturbances, and catatonia may occur, but do not typically occupy a dominant position in the clinical picture.

Comment: paranoid schizophrenia, generally similar to that in adults, is extremely rare in preschool age; as a rule, it develops no earlier than 7-9 years of age. In children, paranoid schizophrenia is characterized by high polymorphism and rudimentariness of psychopathological syndromes, poverty and monotony of affective manifestations, and rapid shifts of states. Paranoid schizophrenia can progress continuously (continuous form) or episodically (episodic-progressive form). In the first variant, the clinical picture in children (9-10 years) is dominated by syndromes of delusion-like fantasizing, often transforming into delusions of imagination, sometimes with pseudohallucinations. Delusions of imagination, in the structure of which confabulations occupy a significant place—"retrograde mythomania"—are less common. Hallucinations are typically rudimentary and unstable, characterized by fragmentation and a peculiar separation of hallucinatory images. They are combined with a sense of hostility and alienation, approaching pseudohallucinations, which gives grounds to consider them a component of the mental automatism syndrome. At the age of 15-18, the clinical picture of manifest forms of paranoid schizophrenia becomes more similar to that described in adults.

The diagnosis of hebephrenic schizophrenia (F20.1) is made when the clinical picture is dominated by gross affective disturbances (inappropriate, absurd, mannered reactions), thought and speech disorganization, and volitional disturbances manifested in bizarre, aimless, senseless behavior. Hallucinations and delusions do not dominate the clinical picture; they are fragmented and rudimentary. Hebephrenic schizophrenia is characteristic of adolescence.

Comment: in the early-onset hebephrenic form, the primary manifestations are silliness with grimacing, absurd actions, increased readiness for communication against the background of mutism, pronounced exposure of drives, impulsive destructive actions, and hypomanic states with phenomena of attention hypermetamorphosis.

In catatonia-type schizophrenia (F20.2), the dominant manifestations in the clinical picture are catatonic psychomotor disorders, manifested in their extreme forms by stupor or raptus, negativism, or automatic obedience. For the diagnosis, along with the general criteria for schizophrenia, the following are required: (1) stupor or mutism, (2) motor excitement not controlled by the patient and unresponsive to external stimuli, (3) freezing in inadequate, bizarre postures, (4) negativism or rigidity, (5) waxy flexibility or other symptoms. It should be noted that catatonic manifestations per se are not specific to schizophrenia, and without other criteria for schizophrenia, the diagnosis of the catatonic form is not made.

Comment: the catatonic form of schizophrenia is frequently encountered in preschool age. Children are characterized by specific catatonic symptoms such as vocalisms (outcries), stereotyped movements, walking on tiptoe, running in circles, and spinning in place. Catatonic schizophrenia in children is accompanied by severe behavioral disturbances (eating disorders, sleep-wake cycle disruptions) and regression of higher mental functions, with the loss of acquired knowledge and skills.

The diagnostic category "Undifferentiated schizophrenia (F20.3)" is used when the observed clinical picture meets the general criteria for schizophrenia but does not fully correspond to any of the above categories, nor to residual schizophrenia. Residual schizophrenia (F20.5) is a chronic stage (the so-called "end-state") of schizophrenia, when several acute episodes or a continuous course dominated by positive psychotic symptoms are replaced by a period of persistent negative symptoms ("defect"). Simple schizophrenia (F20.6) is diagnosed when pronounced negative symptoms develop insidiously without preceding distinct psychotic episodes.

The diagnostic category "Residual schizophrenia (F20.5)" is used when the observed clinical picture is represented mainly by negative symptoms (speech poverty, emotional flattening, impoverished facial expressions, decreased activity, motor slowing, marked reduction in social productivity, and diminished self-care skills) occurring after previous psychotic episodes that met the criteria for schizophrenia.

Comment: the diagnosis of residual schizophrenia corresponds to the traditional concept of a "persistent schizophrenic defect"

The diagnostic category "Simple schizophrenia (F20.6)" is used in the presence of a progressive character of the mental disorder, eventually leading to the formation of a "persistent schizophrenic defect" without preceding distinct hallucinatory, delusional, or catatonic symptoms. The patient's behavior is characterized by pronounced social withdrawal, aimlessness, inactivity, and loss of interests.

Comment: when adapting ICD-10 (1999) in the Russian Federation, the category "Other type of schizophrenia (F20.8)" includes "Childhood-type schizophrenia (F20.8xx3)", which manifests in childhood and is characterized by specific age-related peculiarities, polymorphism of the clinical picture, malignant course, and an oligophrenia-like defect. The clinical picture of childhood schizophrenia is significantly influenced by the course type (coded by the fifth character in ICD-10). In malignant continuous schizophrenia (F20.x0) the initial period is marked by alienation from close relatives, decreased interest in the environment, and lethargy combined with irritability and stubbornness. The clinical picture of manifest states is dominated by catatonic excitation or stupor, and subcortical motor stereotypies. Manege-like running, jumping in place, jactitation, grimacing, wing-like arm flapping, clapping, and "vermiform movements" of the fingers displace purposeful movements. Catatonic manifestations are accompanied by symptoms of gross regression of higher mental functions. An oligophrenia-like defect in patients begins to form as early as the manifest period of the disease and persists throughout life [32]. With partial reduction of catatonia, psychopathy-like manifestations emerge in the form of impulsive aggression toward others, auto-aggression, and eating disorders.

Fecal retention in patients is accompanied by bizarre methods of defecation and manipulation of feces. Subsequently, negative symptoms increase—decreased energy potential, passivity, fatiguability, autization, emotional impoverishment, and thought disorders. In episodic type with a progressive defect (F20.x1) Traditionally, several clinical courses are distinguished. In the (1) catatonic variant, the premanifest stage is characterized by autistic dysontogenesis, decreased cognitive activity, irritability, and phobias. The manifest stage of the disease typically appears at the age of 5 years or older. The clinical picture of the psychosis is polymorphic and changeable. Along with catatonic disorders (typically agitation with motor stereotypies) and regressive disorders, more distinct affective disturbances appear, as well as rudimentary hallucinations (auditory, visual, olfactory). The course of the disease is episodic-progredient. Remissions are incomplete and therapeutic, accompanied by residual catatonic stereotypies, echolalia, atypical affective disorders with a monotonous, prolonged course, and cognitive deficit. 2–4 years after the manifestation of schizophrenia in children of this group, an oligophrenia-like defect develops with autism, emotional flattening, and passivity. In the majority of patients with episodic-progredient schizophrenia in children, as the disease progresses, positive symptoms are complemented or replaced by negative ones, and a cognitive defect is formed. Children with malignant continuous and episodic-progredient schizophrenia who have undergone catatonic-regressive episodes, following the relief of acute states, are characterized by pronounced impairments in all areas of social functioning. Particularly prominent are a gross cognitive deficit, the inability to learn, and difficulties in social adaptation. Patients exhibit indifference toward loved ones, lack of interest in peers, and frequent manifestations of unmotivated aggression. Such patients require constant care and supervision; the majority of children in this group live in specialized orphanages (children's residential care facilities), and later in psycho-neurological boarding houses. Throughout their lives, they retain residual productive disorders: aimless wandering behavior (fleet behaviour), motor stereotypies, aggression, and auto-aggression. In the (2) hebephrenic variant, the premanifest stage is characterized by autistic dysontogenesis and atypical affective disorders. Manifest polymorphic episodes develop in the 3rd–4th year of life. Patients experience sleep disturbances and a distorted circadian rhythm. Catatonic manifestations in the form of unusual, loud, piercing, or monotonous screaming, and impulsive destructive actions are combined with silliness, grimacing, and absurd acts, while mutism and hypermetamorphosis of attention persist. The course of the disease is episodic-progredient. Remissions are therapeutic, with residual positive and negative disorders. 4–5 years after the manifestation of the disease, a deep cognitive deficit develops, characterized by a lack of cognitive activity, asthenia, severe autism, and thought disorders. Recurrent episodes are observed predominantly during critical periods of ontogenesis. In the (3) paranoid variant, the premanifest stage is marked by an accentuation of schizoid personality traits and cognitive dysontogenesis. Hallucinatory-delusional episodes occur predominantly at puberty and adolescence (13–17 years) and tend to be protracted (ranging from 3 months to 2 years). This form of the disease is distinguished by great polymorphism and the rudimentary nature of psychopathological syndromes, their rapid shift, and the absence of spontaneous remissions. Remissions are therapeutic, with residual productive symptoms. Over the years, the distortion of mental development increases, leading to the formation of a specific personality structure—profound schizoidism, infantilism, and peculiarities and oddities in thinking, motor skills, and behavior. A personality defect of the Verschroben type is formed. In episodic type with a stable defect (F20.x2) The premanifest stage manifests as personality accentuation, cognitive dysontogenesis, neurotic, and affective disorders. As the manifest episode approaches, the level of premorbid functioning declines. Manifest episodes are dominated by affective, affective-neurotic-like, affective-depersonalizational disorders, or polymorphic states with anxiety affect, perceptual distortions, elements of a dream-like state, and catatonic inclusions. Subsequently, the course may change either toward worsening or toward compensation of the state with the achievement of stable remission, the basis of whose clinical picture consists of psychopathy-like personality changes.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition: general criteria for diagnosing schizophrenia are outlined in Section 1.6 of these clinical guidelines. Their identification and verification require and are sufficient with

1) objective and subjective medical history data

2) clinical psychopathological examination data

3) clinical pathopsychological assessment data

2.1 Complaints and Anamnesis

Level of Evidence — 2

Comment: The collection of complaints and medical history is performed by a psychiatrist. Information necessary for a comprehensive objective history may be contained in medical records or provided by the parents (or other legal representatives) of the minor. Objective history data are gathered from the parents of a child with suspected schizophrenia through a structured interview, generally conducted in chronological order. The interview may establish circumstances relevant to the diagnosis of schizophrenia, including: (1) a history of mental disorders in the family or close relatives; (2) characteristics of pregnancy and childbirth, including pathology or exposure to adverse factors; (3) early development characteristics, including physical and mental development, specifically speech, communication skills, self-care skills, knowledge of the surrounding world, and play behavior; (4) course of age-related crisis periods; (5) adaptation to kindergarten and school, interaction with peers and teachers, and academic performance; (6) mental status during various age periods, behavioral characteristics, presence of psychopathological symptoms and their dynamics; (7) previously diagnosed mental disorders, treatment characteristics and efficacy, and individual drug tolerability; (8) course of the current illness period immediately preceding the seek for psychiatric care. Complaints and subjective history data in children with suspected schizophrenia cannot always be successfully gathered. Children may report information inconsistently, conceal certain facts, or conversely, provide unreliable information or interpret details through the lens of illness. However, with clinical analysis, this information can be exceptionally important for diagnosis [42-43]. At the same time, children often report important anamnestic details unknown to their parents [44].

Level of Evidence — 2

Comment: the diagnosis of schizophrenia is established based on obtained objective and subjective history data and symptoms identified during the current psychiatric examination that form a clinical picture meeting ICD-10 diagnostic criteria (see Section 1.6. Clinical picture of the disease or condition (group of diseases or conditions) of these clinical guidelines).

Level of Evidence — 5

2.2 Physical Examination

Level of Evidence — 5

Level of Evidence — 5

Comment. Physical examination methods are not of decisive importance directly for diagnosing schizophrenia in children. Despite reports in scientific literature regarding somatic disorders and physical development features associated with childhood schizophrenia [58-61], there is no conclusive evidence of such a link. At the same time, physical examination data are important for detecting disorders comorbid with schizophrenia (e.g., organic brain damage, general somatic or endocrine pathology), the identification of which can significantly affect therapeutic tactics, including the list of medications and other therapeutic interventions used. The ordering of laboratory diagnostic tests (see Section 2.3 of these clinical guidelines) and instrumental diagnostic tests (see Section 2.4 of these clinical guidelines), as well as specialist consultations, is primarily within the purview of the pediatrician and neurologist. These examinations should not be overutilized, as they most frequently prove to have low diagnostic informativeness.

2.3 Laboratory Diagnostics

Level of Evidence — 5

Level of Evidence — 5

Level of Evidence — 5

Level of Evidence — 5

Level of Evidence — 1

Comment. Laboratory diagnostic tests are not of decisive importance directly for diagnosing schizophrenia in children. At the same time, laboratory diagnostic tests are important for identifying conditions comorbid with schizophrenia (e.g., general somatic or endocrine pathology), the detection of which can significantly affect treatment tactics, including the list of medications used and other therapeutic interventions. The ordering of laboratory diagnostic tests, instrumental diagnostic tests (see section 2.4 of these clinical guidelines), and medical specialist consultations is primarily the competence of a pediatrician and neurologist.

2.4 Instrumental Diagnostics

There are no instrumental diagnostic methods for schizophrenia, including in childhood.

• Before prescribing therapy, to perform differential diagnosis with other diseases, primarily of organic etiology, and to assess various somatic health risks, some patients are recommended to undergo additional examination methods [32, 37, et al.], which include:

- electroencephalography (EEG), electroencephalography with provocative tests, video-electroencephalography monitoring (service codes - A05.23.001, A05.23.001.001, A05.23.001.002) [65–66, 210],

GOR CGrade of Recommendation – C

Level of Evidence — 5

- magnetic resonance imaging (MRI) of the brain and other types of brain neuroimaging (computed tomography of the brain (service code - A05.23.009) [67–68].

Level of Evidence - 3

Grade of Recommendation BStrength of Recommendation - B.

Comments: MRI and EEG are recommended for initial patients who have never undergone these studies before, or if there are clinical or anamnestic indications. In case of suspected epilepsy, a space-occupying brain lesion, or other pathology, electroencephalography, computed tomography, or brain MRI may be ordered by a neurologist. Modern studies have yielded much data indicating a statistically traceable relationship between the anatomy of the brain and its individual structures and the presence, onset character, and course of schizophrenia in children and adolescents [73–75]; however, EEG and MRI data are not of decisive importance directly for diagnosing schizophrenia in children.

• Electrocardiography (ECG) with exercise (service code - A12.10.001) is recommended for all children with diagnosed schizophrenia to assess the safety of psychopharmacological therapy, especially antipsychotics that prolong the QT interval [69–72].

GCR CGrade of Recommendation — C

Level of Evidence - 4

2.5 Other Procedures

Level of Evidence — 5

Comment: Abroad, psychometric scales designed to assess the overall severity of the mental state, symptom severity, preservation of social skills, and adaptation to the educational process have recently become widespread. Before being approved for use, these techniques undergo a complex procedure of standardization and validation. Unfortunately, in Russia today there are no domestic methods with sufficiently high validity parameters that are easy to use and tested on representative samples. Many foreign methods, having been translated into Russian, require re-validation, which has not been performed to date. Therefore, it is not feasible to use the PANSS scale (child version), service type: Clinical and psychological counseling (service code - A13.29.006) for all children with suspected and diagnosed schizophrenia to assess symptom severity over time and evaluate treatment efficacy [80–84], although in some cases, when the general clinical impression is insufficient to assess the child's state, it is desirable to do so (see Appendix G1 to these clinical guidelines).

GCR BGrade of Recommendation — B

Level of Evidence — 2

Comment: despite the fact that foreign methods are not validated for use in Russia, the method can be used as a convenient guideline during a clinical interview with the patient, using data obtained from observation, which will objectify the dynamics of the state by comparing data from the same patient. An important additional option for using the scale is the Structured Clinical Interview for Positive and Negative Syndrome Scale (SCI-PANSS) [85]

The Personal and Social Performance Scale can also be used as a guideline, service type: Clinical and psychological counseling (service code - A13.29.006) for children with suspected and diagnosed schizophrenia to assess the ability to learn and acquire speech skills, relationships with relatives and others, self-care skills, and arousal and aggressive behavior, including during ongoing treatment, as well as to evaluate treatment efficacy and during the creation and implementation of an individual plan for psychocorrection and medical rehabilitation [86–90] (see Appendix G2 to these clinical guidelines).

GCR CGrade of Recommendation — C

Level of Evidence — 5

Comment: the same scale is used in children and adults; separate studies in children with schizophrenia have not been conducted. The method can be used as a convenient guideline during a clinical interview with the patient, using data obtained from observation, which will objectify the dynamics of the state by comparing data from the same patient.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Pharmacotherapy is an essential condition for the treatment of schizophrenia [91]. The main pharmacological class of drugs prescribed both to relieve psychotic symptoms and to prevent relapses is antipsychotics (neuroleptics) [92, 93]. Along with antipsychotics, drugs of other classes are used [94]. Psychotherapy is used as an adjunct to pharmacological therapy [95].

Level of Evidence — 2

Comment: Although most guidelines do not recommend the use of ECT in childhood, there are no absolute contraindications to this method [204]. There are isolated indications of the efficacy of ECT in adolescents over 12 years of age with diagnosed schizophrenia in the presence of catatonic symptoms [204, 205]. Foreign literature contains data on the efficacy of ECT in adolescent and youth schizophrenia in 42% of cases, but these conclusions are based on a very limited number of observations [211]

3.1. Treatment with antipsychotics

Antipsychotics are used in the treatment of schizophrenia in children to relieve positive symptoms (perceptual distortions, delusions or their equivalents, aggression, catatonic symptoms). There is evidence of the efficacy of a number of antipsychotics against negative symptoms [78]. Due to limited safety data on the use of many antipsychotics in childhood, the range of drugs recommended for children is significantly narrower compared to adults [79]. The prescription of antipsychotics to children is based on several principles: (1) due to the risk of side effects (extrapyramidal symptoms), second-generation antipsychotics should be preferred; (2) monotherapy with a single drug at the minimum effective dose is preferred; in case of combination therapy, the increased risk of side effects and drug interactions of antipsychotics must be taken into account [28, 144]; (3) if therapy fails within 4–6 weeks (provided good tolerability and administration at the optimal therapeutic dose), the drug should be replaced; (4) using doses higher than recommended generally does not improve the therapeutic effect, but sharply increases the risk of side effects [100]; (5) prior to prescribing certain drugs, comorbid somatic (neuroendocrine, neurological, cardiological, etc.) pathology should be excluded; (6) the duration of antipsychotic therapy after relief of the acute state in maintenance doses must be at least 1 year.

Level of Evidence — 1

Level of Evidence — 5

Comment: the choice of a specific drug depends on a number of additional factors, in particular, the features of the clinical picture, the child's age, the presence of comorbid pathology, and the physician's experience.

Level of Evidence — 2

Level of Evidence — 1

Level of Evidence — 1

Level of Evidence - 4

Level of Evidence - 4

Level of Evidence - 3

Level of Evidence - 3

Level of Evidence — 1

Level of Evidence — 1

Level of Evidence — 1

Level of Evidence — 1

Level of Evidence - 4

Level of Evidence — 1

Level of Evidence — 2

Level of Evidence — 1

Level of Evidence - 4

3.2. Treatment with antidepressants

In schizophrenia, depression can occur both within the structure of psychosis and in the prodromal period, during remissions, and as residual symptoms of schizophrenia. According to established opinion, depressive symptoms during acute psychoses often resolve in parallel with hallucinatory-delusional symptoms and do not require a separate prescription of antidepressants. The prescription of antidepressants is mainly restricted to so-called post-psychotic depressions when other therapeutic measures are ineffective [132,145-146,196]. If antidepressants are necessary, SSRIs are preferred [147,196], although the increased probability and risk factors for suicide should be taken into account [106,111,196].

Level of Evidence - 4

Level of evidence validity - 4

3.3. Treatment with other drug classes

Level of Evidence - 4

Level of Evidence - 4

3.4. Other Treatment

Psychotherapy

Psychotherapy in Russia lacks a clear definition and strict legislative regulation. Numerous works aimed at finding psychotherapy approaches and methods that meet efficacy criteria have revealed proven efficacy for a very small spectrum of psychotherapeutic interventions in schizophrenia, especially in childhood [161-166]. No convincing data have been obtained regarding the efficacy of treating schizophrenia with diet therapy, physiotherapeutic methods, and other treatment modalities practiced in medicine.

Level of Evidence – 1

Comment: within the framework of cognitive behavioral therapy, new techniques and methods frequently emerge, which typically receive new proprietary names. In particular, cognitive and behavioral approaches form the basis of ACT (acceptance and commitment therapy), DBT (dialectical behavior therapy), and schema therapy. Thus, these types of psychotherapy can also be used to provide care for children with schizophrenia.

Level of Evidence — 2

Level of Evidence — 1

Level of Evidence — 5

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Medical rehabilitation for schizophrenia should be carried out at all stages of psychiatric care. It is aimed at forming or restoring cognitive, motivational, and emotional resources of the personality, skills, knowledge, and abilities that are deficient or lost as a result of the illness, enabling the individual to interact with others, solve everyday tasks, and cope with more complex problems [177], as well as building adherence to ongoing therapy [137].

Level of Evidence — 1

Level of Evidence - 3

Level of Evidence — 2

Comment: methods of cognitive remediation and social skills training are used, carried out, as a rule, by specialists in the field of psychology. There is no convincing data supporting the efficacy of rehabilitation methods based on natural therapeutic factors (balneotherapy, spa therapy, terrain cure, and other health resort treatment methods). No convincing data have been obtained regarding the benefits of animal-assisted therapy (AAT) using dogs, horses, dolphins, or petting zoos. Data obtained by some researchers on the efficacy of rehabilitating schizophrenia patients using video games [190] have an extremely low level of evidence due to exceptionally small patient samples.

5. Prevention and Dispensary Observation

Schizophrenia is a mental disorder for which there are no primary prevention measures. At the same time, early detection and timely initiated treatment can significantly influence the prognosis in schizophrenia [154]. By Order of the Russian Ministry of Health No. 396n dated June 13, 2019, "On Amending the Procedure for Preventive Medical Examinations of Minors, Approved by Order of the Ministry of Health of the Russian Federation No. 514n dated August 10, 2017," additions were made concerning screening within the framework of preventive medical examinations of two-year-old children to identify a risk group for the emergence or presence of mental development disorders through parental questionnaires. The psychiatrist examines only those children who are included in the specified risk group.

Level of Evidence — 5

Comment: Dispanserizatsiya (clinical dispansery observation) may be established regardless of the consent of the person suffering from a mental disorder or their legal representative in cases provided for by Part 1 of Art. 27 of the Law of the Russian Federation No. 3185-1 dated July 2, 1992, "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision" (hereinafter referred to as Law No. 3185-1).

"Decisions on the necessity of establishing clinical dispansery observation and its termination are made by a commission of psychiatrists appointed by the head of the medical organization providing outpatient psychiatric care, or by a commission of psychiatrists appointed by the executive authority of a constituent entity of the Russian Federation in the field of healthcare" (Part 2, Art. 27 of Law No. 3185-1). Such an examination is possible both upon a person's voluntary application for psychiatric care and involuntarily, if there are indications for involuntary examination.

The basis for establishing clinical dispansery observation is the presence of a chronic and protracted mental disorder with severe, persistent, or frequently exacerbating pathological manifestations (Part 1, Art. 27 of Law No. 3185-1).

The procedure for dispensary observation of a person suffering from a chronic and prolonged mental disorder with severe, persistent, or frequently exacerbating morbid manifestations is defined by Order of the Russian Ministry of Health No. 453n dated June 30, 2022, “On approval of the Procedure for dispensary observation of a person suffering from a chronic and prolonged mental disorder with severe, persistent, or frequently exacerbating morbid manifestations,” which entered into force on March 1, 2023. In accordance with the appendix to the Procedure, 5 dispensary observation groups are defined: D-1, D-2, D-3, D-4, D-5 (active dispensary observation), within which subgroups may be distinguished if necessary.

Upon recovery or significant and persistent improvement in a person's mental state, dispensary observation is terminated (Part 4, Article 27 of Law No. 3185-1).

Comment: secondary prevention of schizophrenia aims to prevent recurrent exacerbations, while tertiary prevention aims to restore patients' social functioning to the maximum possible extent (see the section “Medical rehabilitation and sanatorium-resort treatment, medical indications and contraindications for the use of medical rehabilitation methods, including those based on natural healing factors” of these guidelines).

6. Organization of Medical Care

Diagnosis, treatment, monitoring, and rehabilitation of children with schizophrenia can, in the vast majority of cases, be carried out on an outpatient basis or in a day hospital setting. In accordance with Federal Law No. 323-FZ dated November 21, 2011, “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation,” parents or legal representatives of a child with schizophrenia have the right to seek medical care at their place of permanent registration. If this is not possible, they have the right to receive care in other medical institutions located outside their place of permanent residence.

Indications for hospitalization in a hospital for children with schizophrenia are: (1) pronounced manifestations of agitation and aggression, including the risk of harming others and oneself, (2) high suicide risk, (3) newly diagnosed schizophrenia, the need for additional comprehensive examination and selection of therapy, (4) prominent psychotic symptoms and grossly disorganized behavior, (5) severe concomitant somatic pathology complicating the selection of treatment, (6) manifestations of resistance and poor tolerability of therapy, (7) unavailability of adequate outpatient care at the place of residence, (8) pronounced social maladaptation of the child and family members with the inability to meet basic living needs (social indications).

Indications for discharge from the hospital for children with schizophrenia are: elimination of suicide risks, relief of pronounced manifestations of agitation and aggression, stabilization of the mental and somatic state with the reduction of pathological symptoms.

Comment: preschool-aged children with schizophrenia rarely have a high suicide risk and such grossly disorganized behavior that it cannot be controlled within the family; at the same time, placing them in a hospital, especially without parents, is often accompanied by the formation of psychogenically conditioned comorbid disorders and the risk of hospitalism [192-194]. Traditional concepts of the three stages of schizophrenia therapy (acute treatment stage — treatment of acute psychosis/exacerbation of psychotic symptoms, continuation stage — stabilization of the condition, and maintenance stage — relapse prevention) are fully applicable to adolescent patients with schizophrenia [195-198]. A differentiated, comprehensive approach to the management of children with schizophrenia has proven itself well in practice in Russia [197].

7. Additional Information

Given the specifics of the disease, in particular its chronic course and progressive nature of impairments, the "outcome" of the disease in the case of schizophrenia should be understood not as a final outcome, but as intermediate results achieved during treatment. Factors that worsen the course of schizophrenia and its prognosis are traditionally considered to be refusal of timely and effective treatment, abuse of alcohol and other psychoactive substances, lack of social rehabilitation and family support, and stress [200-201].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Balakireva Elena Evgenyevna, Candidate of Medical Sciences, Leading Researcher, Department of Child Psychiatry, Mental Health Research Center. Member of the Russian Society of Psychiatrists (RSP).

2. Ivanov Mikhail Vladimirovich, Candidate of Psychological Sciences, Leading Researcher, Department of Child Psychiatry, Mental Health Research Center. Member of the Russian Society of Psychiatrists (RSP).

3. Ivashchenko Dmitry Vladimirovich, Doctor of Medical Sciences, Associate Professor, Head of the Department of Child Psychiatry and Psychotherapy, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health. Member of the Russian Society of Psychiatrists (RSP).

4. Koval-Zaitsev Alexey Anatolyevich, Candidate of Psychological Sciences, Leading Researcher, Department of Child Psychiatry, Mental Health Research Center. Member of the Russian Society of Psychiatrists (RSP).

5. Kulikov Anton Vladislavovich, Candidate of Medical Sciences, Senior Researcher, Department of Child Psychiatry, Mental Health Research Center. Member of the Russian Society of Psychiatrists (RSP).

6. Makushkin Evgeny Vadimovich, Doctor of Medical Sciences, Professor, Head of the Scientific and Medical Center for Child Psychiatry, National Medical Research Center for Children's Health of the Russian Ministry of Health. Member of the Russian Society of Psychiatrists (RSP).

7. Nikitina Svetlana Gennadyevna, Candidate of Medical Sciences, Senior Researcher, Department of Child Psychiatry, Mental Health Research Center. Member of the Russian Society of Psychiatrists (RSP).

8. Perezhogin Lev Olegovich, Doctor of Medical Sciences, Head of the Department of Social Psychiatry of Children and Adolescents, V.P. Serbsky National Medical Research Center for Psychiatry and Narcology of the Russian Ministry of Health. Member of the Russian Society of Psychiatrists (RSP).

   The members of the working group for the development and revision of clinical guidelines declare no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines:

1. Psychiatrist

2. Psychotherapist

3. Medical psychologist

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnosis, treatment and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Legislative and regulatory acts governing the provision of care for schizophrenia

1. Federal Law No. 323-FZ of November 21, 2011, "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation";

2. Law of the Russian Federation No. 3185-1 of July 2, 1992, "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision";

3. Procedure for Providing Medical Care for Mental Disorders and Behavioral Disorders (Approved by Order of the Ministry of Health of the Russian Federation No. 566n of May 17, 2012);

4. Order of the Ministry of Health of the Russian Federation No. 1233n of December 20, 2012, "On the Approval of the Standard of Specialized Medical Care for Schizophrenia, Acute (Subacute) Phase, with Treatment Resistance and Therapy Intolerance";

5. Order of the Ministry of Health of the Russian Federation No. 1400n of December 24, 2012, "On the Approval of the Standard of Specialized Medical Care for Schizophrenia, Acute (Subacute) Phase with Protracted Course and Preponderance of Social Rehabilitation Problems";

6. Order of the Ministry of Health of the Russian Federation No. 1421n of December 24, 2012, "On the Approval of the Standard of Specialized Medical Care for Schizophrenia, Subacute Phase in a Day Hospital Setting";

7. Order of the Ministry of Health of the Russian Federation No. 420 of December 31, 2002, "On the Approval of Primary Medical Documentation Forms for Psychiatric and Narcological Facilities".

Information on indications for use, contraindications, methods of administration, and dosages of medicinal products is publicly available on the website of the State Register of Medicines grls.rosminzdrav.ru

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Information for Parents

Schizophrenia is a chronic mental disorder occurring in both adults and children. Schizophrenia has been known since antiquity; patient descriptions corresponding to the modern concept of schizophrenia, which took shape in the early 20th century, are present even in ancient and medieval literature. Cases of schizophrenia have been described in people of all ages, from infants to the elderly, in men and women, and among all races. According to the World Health Organization, 0.3% to 0.7% of people worldwide suffer from schizophrenia, which amounts to approximately 20-30 million individuals. Schizophrenia is rare in childhood; the proportion of individuals who develop schizophrenia in childhood is less than 1% (according to other authors, up to 4%) of all affected individuals. Among children recognized as disabled due to mental disorders in Russia, children with schizophrenia account for 4.4%. According to recent epidemiological data in Russia, the overall incidence rates of schizophrenia in children have increased by 6.5% since 2000.

Schizophrenia is presumed to be a polyetiological disease, the etiology and pathogenesis of which remain unknown to date. There are numerous theories and hypotheses regarding its origin, which emphasize various hereditary factors and environmental influences to varying degrees, but none can claim absolute validity. In recent years, it is generally accepted that most cases of schizophrenia develop due to a random combination of several (possibly several dozen) common genes among people and spontaneous mutations leading to impaired metabolism of the brain's crucial neurotransmitters — dopamine, serotonin, and others. People with such abnormalities do not fall ill immediately, but constitute a risk group for the development of schizophrenia. Additional negative environmental factors are required for the disease to develop. Currently, the leading damaging factor hypothesized by scientists is an autoimmune process leading to alterations in brain structure at the cellular and functional levels. Numerous social factors, such as poverty, migration, urbanization, physical (including sexual) and emotional abuse in childhood, insufficient emotional support from parents, loneliness, as well as socially conditioned factors such as alcoholism and marijuana use, have been studied over the past half-century, but none have shown a convincing causal relationship with the onset of schizophrenia.

The clinical picture of schizophrenia is very diverse; individual forms of schizophrenia combined with different types of its course create a bizarre continuum of individual clinical cases. All symptoms of schizophrenia are nonspecific to varying degrees. Attempts to isolate symptoms that are pathognomonic and unique to schizophrenia, such as the famous "first-rank symptoms" proposed by K. Schneider, have been unsuccessful. Modern diagnostic approaches outlined in international classifications (diagnostic systems), such as the International Classification of Diseases, 10th Revision (ICD-10, used in Russia since 1999), rely on a categorical approach requiring the identification of a specific number of symptoms present in the clinical picture for a certain duration during diagnosis.

All symptoms of schizophrenia can be divided into five groups (this division is not used in ICD-10). Positive symptoms (i.e., those that a healthy person does not have and that stand out upon their appearance) include (1) delusions, i.e., "a set of morbid ideas, reasoning, and conclusions that take possession of the patient's consciousness, distort reality, and are not amenable to external correction" (Bleikher V. M., 1983)—typically, delusions are built around ideas of influence, persecution, and a special mission; (2) hallucinations, i.e., perceptual distortions, typically voices commenting on the patient's behavior, discussing them, and localized either outside or inside the body, especially in the head; (3) catatonic symptoms (freezing, bizarre postures, walking in circles, agitation or stupor, vocalizations); (4) agitation (fussing excitement and inner tension); (5) behavioral and speech disturbances. Positive symptoms are hypothesized to be associated with abnormalities in mesolimbic neural networks. Negative symptoms (i.e., the result of a deficit in normally intact functions) are represented by (1) poverty of speech, (2) blunting and a limited range of emotions, (3) decreased social contacts, passivity, (4) stereotypy in thinking and difficulties in abstracting, (5) attention impairments, decreased motivation, and anhedonia. They are much harder to notice in children than positive psychotic symptoms, but careful observation reveals content and lexical impoverishment of speech, limited non-verbal communicative responses, restricted eye contact with the interlocutor, neglect of one's own appearance and grooming, sometimes including personal hygiene. Parents and close relatives usually notice changes in interests, loss of motivation for studies, sports, and hobbies, and avoidance of social contacts. Negative symptoms may appear earlier than positive ones, serving as peculiar harbingers of psychosis. Their emergence is hypothesized to be linked to dysfunctions in the prefrontal cortex. Cognitive symptoms are associated with executive dysfunction (memory and intelligence in schizophrenia patients, except for those with very early onset, are usually preserved), i.e., with goal-setting, planning, attention allocation, evaluation and monitoring of completed actions, and modulation of one's behavior based on indirect social cues. Cognitive symptoms are likely mediated by the dorsolateral prefrontal cortex. Affective symptoms include anxiety, tension, feelings of guilt, unease, and irritability. They result from dysfunction in the ventromedial prefrontal cortex. Aggression manifests as verbal, non-verbal, physical impact directed at inanimate objects, animals, people, including oneself, and is typically associated with the content of hallucinatory and delusional symptoms. In younger schizophrenia patients, aggression and auto-aggression may be unpredictable and spontaneous, posing a high degree of danger to themselves and others. Aggression manifestations are associated with neurotransmitter metabolism disturbances in the amygdala and orbitofrontal cortex.

Treatment for schizophrenia is typically prolonged and comprehensive. The scientific literature describes a few cases of practical recovery confirmed by long-term follow-up. However, as a rule, such an outcome is difficult to achieve. Many patients with schizophrenia, despite ongoing treatment, become disabled due to their mental disorder. Therefore, the goal of treatment becomes achieving stable remission and preventing the desocialization of patients.

In the treatment of schizophrenia in children, pharmacotherapy occupies a leading place. Productive symptoms are managed with neuroleptics (antipsychotics), some of which are likely capable of alleviating negative symptoms as well; however, negative symptoms in schizophrenia are characterized by persistence and worsen as the disease progresses, whereas positive symptoms can usually be controlled. Along with antipsychotics, antidepressants (for depressive affective symptoms), anxiolytics (for anxiety states), and mood stabilizers are used. Antiparkinsonian medications are used to prevent side effects of neuroleptic drugs. Shock therapy methods (electroconvulsive therapy, insulin coma therapy) are not used in the treatment of children. Prescribing treatment for schizophrenia is strictly the prerogative of a psychiatrist.

The most crucial component of successful schizophrenia therapy is the socialization of patients. If a patient's mental state allows them to study or work, such an opportunity should not be neglected. After acute conditions are resolved, psychotherapeutic support, including cognitive behavioral therapy and family therapy, is indicated for all patients. Family and friends' support and the engagement of patients in social relationships are of great importance for achieving therapeutic success in schizophrenia.

Information for patients (older children)

Schizophrenia is a mental disorder that disrupts a person's perception of reality. It can cause hallucinations, delusions, thought disorders, learning difficulties, and an unwillingness to socialize with others.

In its early stages, schizophrenia may resemble typical adolescent behavior: withdrawal, abandonment of hobbies, and loss of contact with friends. However, there are important differences: no new interests replace the old ones, processing information (especially academic) becomes difficult, and profound apathy toward one's life takes over the personality. Concurrently, positive symptoms develop: hallucinations and delusions. Hallucinations in schizophrenia can be auditory or visual. Auditory hallucinations resemble a "voice" sounding inside the patient's head. In schizophrenia, the patient understands that the "voice" is heard only by them. Delusions typically involve the conviction that one is being persecuted or that others want to harm them, and these individuals can be complete strangers or even mystical entities (e.g., demons).

To the patient, the "voices" are beyond their control, "arise on their own," and can interfere with the thought process and voluntary actions. "Voices" in schizophrenia are not a mystery to science. In fact, they are the person's own thoughts that, due to the mental disorder, are perceived as external influence. Today, the most likely cause is considered to be dysfunction of subcortical brain nuclei responsible for recognizing whether external stimuli are one's own or external.

The difficulty in recognizing hallucinations and delusions for the patient themselves lies in a reduced insight into their condition. This means the patient does not view what is happening as unusual: they take the emerging hallucinations for granted and do not rationally evaluate their delusions.

Schizophrenia is also characterized by volitional disorders. Externally, this manifests as an unwillingness to do anything, neglect of personal hygiene, and lack of initiative. Volitional disorders are dangerous because the patient may commit dangerous acts under the influence of hallucinations—up to and including suicide, because "the voice commanded it."

If schizophrenia is suspected, one should definitely consult a psychiatrist. The goal of treatment is to reintegrate the patient into society so they can lead a full life. Antipsychotics (also known as neuroleptics) are used to treat schizophrenia. Their efficacy has been proven in numerous scientific studies. Antipsychotics are prescribed for a long period—at least 1 year—and treatment may be continued at the discretion of the attending physician. Antipsychotics are the most effective therapy for schizophrenia, suppressing delusions and hallucinations and normalizing the patient's thought processes. People with schizophrenia who receive treatment can study and work. To achieve this, it is important to купировать acute symptoms.

The state in which a patient's hallucinations have ceased, delusions have resolved, and thinking has normalized is called remission. Once achieved, psychotherapeutic methods can be introduced, primarily cognitive behavioral therapy.

Cases where schizophrenia symptoms resolve without treatment are extremely rare. It is strongly discouraged to neglect medical care or refuse medication. Untreated schizophrenia leads to disability in the vast성이 of cases.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Positive and Negative Syndrome Scale.

Russian title - Positive and Negative Syndrome Scale (PANSS).

Original title - Positive and Negative Syndrome Scale — PANSS

Source - Kay S.R, Fiszbein A, Opler L.A. The positive and negative syndrome scale (PANSS) for schizophrenia. 1987. Schizophr Bull. 13 (2): 261-76. doi:10.1093/schbul/13.2.261

Type (underline):

- rating scale

- index

- questionnaire

- other (specify)

Purpose: The Positive and Negative Syndrome Scale is used to assess the mental state of patients with schizophrenia and to evaluate changes in their condition over time, particularly during treatment.

Content (template):

Assessment is based on the severity of positive and negative symptoms. The positive symptoms assessed are: (1) delusions, (2) conceptual disorganization, (3) hallucinatory behavior, (4) excitement, (5) grandiosity, (6) suspiciousness/persecution, (7) hostility. The negative symptoms assessed are: (1) blunted affect, (2) emotional withdrawal, (3) poor rapport, (4) passive/apathetic social withdrawal, (5) difficulty in abstract thinking, (6) lack of spontaneity and flow of conversation, (7) stereotyped thinking. Along with positive and negative symptoms, the scale assesses general psychopathological syndromes: (1) somatic concern, (2) anxiety, (3) guilt feelings, (4) tension, (5) mannerisms and posturing, (6) depression, (7) motor retardation, (8) uncooperativeness, (9) unusual thought content, (10) disorientation, (11) attention deficit, (12) lack of judgment and insight, (13) disturbance of volition, (14) poor impulse control, (15) preoccupation, (16) active social avoidance.

Assessment domains and criteria:

Positive Syndrome Scale (P)

P1. Delusions

Unfounded, unrealistic, and idiosyncratic beliefs. Severity is rated based on the thought content expressed in the interview and its impact on social relations and patient behavior.

1. Absent: the patient's condition does not meet the definition of the traits.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: presence of one or two vague, poorly structured, and unstable delusions that do not impair the patient's thinking, behavior, or relationships with others.

4. Moderate: kaleidoscopic alternation of multiple poorly structured and unstable delusions, or the presence of several well-structured ideas that occasionally affect the patient's thinking, relationships with others, and behavior.

5. Marked: presence of numerous, well-structured, and persistent delusions that periodically affect the patient's thinking, social relationships, and behavior.

6. Severe: presence of a complex of structured, often

systematized, persistent delusions that noticeably impair the thought process, the patient's relationships with others, and their behavior.

7. Extreme: presence of a persistent complex of numerous or detailed systematized delusions that significantly impact the main aspects of the patient's life, leading to inappropriate actions that in some cases pose a danger to the patient and others.

P 2. Thought disorders

Disorganization of the thought process characterized by a breakdown in the goal-directed flow of thoughts, i.e., overinclusiveness (circumstantiality), rambling (rezonerstvo), derailment, amorphousness of associations, inconsistency, paralogical thinking, or "thought blocking" (sperrung). Severity is assessed based on the state of the cognitive-speech process during the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: thinking is circumstantial, overelaborate, paralogical, or characterized by derailment. The patient experiences some difficulty when attempting to concentrate on a single thought; random associations may appear if the physician persists.

4. Moderate: during brief, simple communication, the ability to concentrate on specific thoughts is preserved; however, with the slightest pressure or in more complex situations, thinking becomes more amorphous (vague) and lacking in goal-directedness.

5. Marked: the patient almost always experiences difficulty in organizing a goal-directed flow of thoughts, manifested as derailment, inconsistency, and vagueness of thinking even in the absence of external pressure.

6. Severe: cognitive activity is severely disrupted; inconsistency and incoherence of thinking are observed almost constantly.

7. Extreme: incoherence of thinking reaches the level of word salad (incoherence). There is pronounced loosening of associative ties, leading to a complete loss of the ability to communicate, up to "schizophasia" or mutism.

P 3. Hallucinations

Statements or behavior indicating perception without a corresponding external stimulus. Pathological perception may occur in the auditory, visual, olfactory, or somatic modalities. Severity is assessed based on verbal reports or external manifestations during the interview, as well as information obtained from medical staff or relatives.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: one or two rare but distinct hallucinations, or several vague pathological perceptions that do not affect the patient's thinking or behavior.

4. Moderate: frequent but non-continuous hallucinations; the patient's thinking and behavior are mildly impaired.

5. Marked: frequent hallucinations involving sometimes more than one sensory modality and markedly disrupting thinking and/or behavior. Delusional interpretation of hallucinatory experiences with corresponding emotional and verbal accompaniment is possible.

6. Severe: practically continuous hallucinations that substantially impair the patient's thinking and behavior; perceptual disturbances are experienced as real-life events with corresponding emotional and verbal reactions that severely impede the patient's adaptive capacities.

7. Extreme: the patient's personality is almost entirely engulfed by hallucinations, which essentially dictate the direction of their thinking and behavior. Hallucinations are accompanied by persistent delusional interpretation, verbal and behavioral reactions, which implies, among other things, complete subordination to imperative hallucinations.

P4. Excitement

Hyperactivity manifested by increased motor function, heightened sensitivity to external stimuli, elevated level of arousal (hypervigilance), and excessively labile mood. Severity is assessed by behavior during the interview, as well as information obtained from medical staff and relatives.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: the patient is somewhat agitated and the level of arousal is elevated, but clearly defined episodes of excitement or excessive mood lability are absent. Speech may be accelerated.

4. Moderate: evident agitation, increased irritability, acceleration of speech and motor activity are noted during the interview. Episodes of intense excitement may occasionally be observed.

5. Marked: substantial hyperactivity or frequent episodes of motor excitation. The patient finds it difficult to sit quietly in one place for more than a few minutes.

6. Severe: the patient is extremely agitated throughout the entire interview, attention is scattered; sleep and eating may be impaired.

7. Extreme: extreme agitation of the patient prevents normal eating, disrupts sleep, and impairs interpersonal relationships.

Acceleration of speech and increased motor excitation can lead to speech incoherence, confusion, and exhaustion.

P5. Grandiosity

Inflated self-esteem and an unjustified conviction of superiority, including ideas of possessing special abilities, wealth, knowledge, fame, power, or moral righteousness. Severity is assessed by the content of thoughts revealed in the interview with the physician and their reflection in the patient's behavior.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: some expansiveness and boastfulness are noted. Clearly elaborated grandiose ideas are not detected.

4. Moderate: the patient asserts superiority over others and maintains an inflated self-image; poorly elaborated delusions of special status or abilities may be present, which, however, do not dictate the patient's behavior.

5. Marked: clearly elaborated ideas of outstanding abilities, power, or exceptional status, which influence the patient's attitude toward others but do not manifest in their behavior.

6. Severe: clearly elaborated delusions of superiority in multiple domains simultaneously (wealth, knowledge, fame, etc.) manifest not only in statements but also in relationships with others, as well as in certain actions.

7. Extreme: thinking, interpersonal relationships, and behavior are almost entirely determined by multiple delusions of extraordinary abilities, wealth, knowledge, fame, power, and/or moral virtues, which may acquire an absurd content.

P6. Suspiciousness / Persecution

Unfounded or exaggerated ideas of persecution, manifested by wariness, distrust, suspicious vigilance, or a more overt conviction of hostility from others. Severity is assessed by the content of thoughts expressed during the interview and their impact on the patient's behavior.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: the patient displays wariness or even overt distrust, but impairments in thought processes, behavior, and interpersonal relationships are practically absent.

4. Moderate: distrust is pronounced enough to hinder the interview with the physician and affect the patient's behavior; nevertheless, persecutory delusions are absent. On the other hand, some patients may exhibit poorly elaborated persecutory delusions that do not affect social relationships.

5. Marked: distrust is so intense that it leads to the disruption of relationships with others. Elaborated persecutory delusions may be present that little alter the nature of interpersonal relationships or the patient's behavior.

6. Severe: elaborated persecutory delusions that tend to expand and systematize, having a substantial impact on the patient's relationships with others.

7. Extreme: a complex of systematized persecutory delusions that almost entirely determines the patient's train of thought, social relationships, and behavior.

P7. Hostility

Verbal or other manifestations of anger and antagonism, including sarcasm, passive-aggressive behavior, threats, and overt assault. Severity is assessed by behavior during the interview and information obtained from medical staff and relatives.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: indirect or covert manifestations of anger, e.g., sarcasm, disrespect, hostile remarks, episodes of irritability.

4. Moderate: overt hostility, rapid

irritability, and direct manifestations of anger and resentment.

5. Marked: the patient is extremely irritable, occasionally resorting to verbal insults and threats.

6. Severe: contact with the patient is difficult due to verbal insults and threats, which also significantly disrupts relationships with others. The patient may be bellicose and prone to destruction, but does not commit physical assaults on people.

7. Extreme: marked anger with virtually complete lack of contact with the physician and others, or episodes of physical assault on people.

Negative Syndromes (N)

N1. Blunted Affect

Reduced emotionality, expressed as a decrease in facial expressiveness, inability to display feelings, and communicative gesturing. Severity is assessed by observing the physical manifestations of the patient's vital tone and emotionality during the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: facial expressions and communicative gestures appear strained, forced, artificial, or impoverished.

4. Moderate: a reduction in the range of facial expressiveness and gesturing determines a characteristic "bored" (expressionless) appearance.

5. Marked: affect is usually "blunted" (flattened), facial expressions are scanty, gesturing is impoverished.

6. Severe: pronounced affect blunting and deficiency of emotional reactions are observed most of the time. Extremely strong uncontrolled affective outbursts in the form of excitement, fits of rage, or motiveless laughter are occasionally possible.

7. Extreme: facial modulations and communicative gestures are practically absent. Facial expression is persistently indifferent or frozen.

N2. Emotional Withdrawal

Lack of interest in life events, participation in them, and a sense of emotional involvement in them. Severity is assessed by information obtained from medical staff and relatives, as well as by observing the patient's behavior during the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: the patient is usually low in initiative and may occasionally show weak interest in surrounding events.

4. Moderate: the patient generally emotionally disengages from the influence of the environment and its demands, but with active encouragement can be engaged in more active activities.

5. Marked: the patient exhibits distinct emotional detachment from surrounding people and ongoing events and does not respond to any attempts at activation from the outside. They appear reserved, compliant, aimless, and at times can be engaged in at least brief communication and arouse interest in their own needs.

6. Severe: marked indifference to the surroundings and lack of emotional reactions manifest in a sharp reduction of verbal communication with people and neglect of personal needs, thus requiring the organization of special supervision and care for the patient.

7. Extreme severity: due to profound indifference to the environment and lack of emotional experiences, the patient appears almost completely detached, uncommunicative, and indifferent to their own needs.

N3. Difficulties in communication (poor contact, uncommunicativeness)

Lack of openness and frankness in conversations with people, empathy, interest, or involvement with the interlocutor, manifested by difficulty in establishing interpersonal contacts and a reduction in the volume of verbal and non-verbal communication. The severity is assessed by the patient's behavior and attitude toward the physician during the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: some artificiality, stiffness, and grandiloquence are felt when communicating with the patient. The patient's speech lacks emotional depth and is often impersonal and pedantic in nature.

4. Moderate severity: the patient generally appears alienated, keeps a distance from the interlocutor, answers questions mechanically, and their actions express boredom or a lack of interest in the conversation.

5. Marked severity: obvious alienation and lack of interest on the part of the patient in the conversation significantly impede productive contact with them. The patient tries to avoid eye contact with the interlocutor.

6. Severe severity: the patient is extremely indifferent to the environment, keeps a distance from the interlocutor, avoids eye contact, and cannot sustain a return gaze. Answers are monosyllabic and superficial. Attempts at non-verbal contact remain practically unanswered.

7. Extreme severity: the patient cannot be engaged in conversation, appears completely indifferent, and persistently avoids verbal and non-verbal contact with the physician.

N4. Passively apathetic social withdrawal

Decreased interest and initiative in social relationships due to passivity, apathy, loss of energy, and volitional drives, leading to reduced sociability and neglect of daily activities. Severity is assessed based on information about the patient's social behavior obtained from medical staff and relatives.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: occasionally shows interest in social communication, but has little initiative. Enters into contact with other people only upon the latter's initiative.

4. Moderate severity: participates passively, mechanically, and without interest in most social relationships, trying to stay in the background.

5. Marked severity: takes passive participation in a very narrow circle of social contacts, showing practically no interest in them or initiative. Spends little time communicating with other people.

6. Severe severity: the patient is apathetic most of the time, tends toward self-isolation, very rarely shows any social activity, and at times neglects their own needs. Enters into social contacts only occasionally.

7. Extreme severity: the patient is profoundly apathetic, socially isolated, neglects their own needs, and ceases to care for themselves.

N5. Impairment of abstract thinking

Disorder of abstract-symbolic thinking, manifested by difficulty in classification and generalization, as well as the inability to move away from concrete or egocentric ways of solving problems. Severity is assessed by responses to questions about the semantic commonality of objects or concepts, interpretation of proverbs, and the predominance of concrete thinking over abstract thinking during the conversation.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: a tendency to give a literal or personal interpretation of complex proverbs is noted. Difficulties are possible when interpreting abstract or distantly related conceptual interpretations.

4. Moderate severity: the patient frequently resorts to concrete thinking, experiences difficulties in interpreting most proverbs and some abstract concepts, as well as in identifying the most characteristic feature and functional phenomenon of an object or item.

5. Marked severity: thinking is predominantly concrete; the patient experiences difficulties in interpreting most proverbs and concepts.

6. Severe severity: the patient is unable to understand the abstract meaning of any of the proposed proverbs or figurative expressions, and classifies only the most elementary concepts by functional similarity. Thinking is completely unproductive or limited to the ability to identify characteristic features, determine functional purpose, or idiosyncratic interpretations.

7. Extreme severity: only concrete thinking remains in the patient, with a complete lack of understanding of proverbs, common metaphors and comparisons, or simple concepts; the ability to classify objects and phenomena even on the basis of the most characteristic features and functional properties disappears. This score can also be used to assess patients with whom conversation is practically impossible due to severely impaired cognitive activity.

N6. Impairment of spontaneity and flow of speech

Difficulty in normal verbal communication due to apathy, a sense of defenselessness, decreased volitional drives, or thought disorders, manifested by a disturbance in the fluency of speech and the productivity of verbal contact. A score is given based on the severity of these signs during the interview with the physician.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: the patient is uninitiative during the conversation, their answers are usually brief and devoid of details, and direct and leading questions must be asked to obtain information.

4. Moderate severity: the patient's speech lacks fluency, is uneven or intermittent. Leading questions often have to be asked to obtain the required information.

5. Marked severity: the conversation clearly suffers from a lack of spontaneity and frankness on the part of the patient; answers to questions consist of one or two short sentences.

6. Severe severity: the patient's answers are reduced to a few words or short phrases aimed at terminating the conversation or sharply reducing the volume of communication with the physician (e.g., "I don't know", "I can't talk about this"). As a result, the conversation is severely hampered and unproductive.

7. Extreme severity: the patient's speech is generally reduced to occasional utterances; conversation with them is impossible.

N7. Stereotyped thinking

Impairment of fluency, spontaneity, and flexibility of thinking, manifested by rigidity, repetitiveness, or banality of thoughts. Severity is assessed by the nature of the cognitive process during the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: some rigidity of attitudes and ideas is revealed. The patient may refuse to consider alternative viewpoints or experience difficulty in switching from one thought to another.

4. Moderate severity: the conversation constantly returns to the same topic, and the patient has difficulty switching to another topic.

5. Marked severity: the rigidity and stereotypy of thinking are so pronounced that the conversation, despite the physician's opposition, is limited to two or three prevailing topics.

6. Severe severity: uncontrolled repetition of demands, statements, individual thoughts, or questions, which significantly complicates the conversation.

7. Extreme severity: constantly repeated ideas or individual phrases dominate the patient's thinking, behavior, and speech, leading to inadequacy and a sharp limitation of contact with the physician.

Scale of General Psychopathological Syndromes (G)

G1. Somatic concern

Complaints about physical health or the conviction of having a somatic disease or disorder, which can range from a vague feeling of illness to distinct delusions of a fatal somatic disease. Severity is assessed based on the patient's statements during the interview with the physician.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: noticeable concern about one's health or physical condition, manifested in occasional questions and the desire to receive support from the physician.

4. Moderate severity: complaints of poor health or disorders of individual body functions. However, there is no delusional conviction. The condition is amenable to psychotherapeutic intervention.

5. Marked severity: the patient frequently or constantly complains of a physical illness or bodily dysfunction. One or two delusional ideas on this topic may be noted, which do not entirely determine the patient's thoughts and behavior.

6. Severe severity: the patient is sufficiently preoccupied with one or more delusional ideas of physical illness or organic lesion of various bodily functions. However, there is no complete envelopment of the personality, including its affective sphere, by delusional ideas. The physician has difficulty distracting the patient from these thoughts.

7. Extreme severity: numerous and frequently manifested delusional ideas of somatic illness or several delusional ideas of a catastrophic outcome of the disease, completely absorbing the patient's thoughts and feelings.

G2. Anxiety

Subjective experience of nervousness, anxiety, apprehension, or tension, ranging from excessive concern about the present or future to panic reactions. Severity is assessed based on information obtained from the patient during the interview and corresponding physical manifestations.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: The patient expresses some concern, excessive worry, or apprehension, which is not accompanied by any somatic or behavioral reactions.

4. Moderate: The patient reports increased nervousness and anxiety accompanied by mild physical signs, such as fine hand tremor or sweating.

5. Severe: The patient reports anxiety accompanied by somatic and behavioral reactions, such as noticeable tension, impaired concentration, palpitations, and sleep disturbances.

6. Very severe: A nearly constant subjective experience of fear accompanied by phobias, marked anxiety, and various somatic manifestations.

7. Extreme: The patient's life is significantly disrupted by a nearly constant feeling of anxiety, which may occasionally escalate into panic attacks.

03. Guilt feelings

Feelings of remorse or self-blame regarding past real or imaginary misdeeds. Severity is assessed based on the patient's reports of guilt and the degree to which it affects their thinking and behavior.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: Targeted questioning reveals a vague sense of guilt and self-blame regarding a minor misdeed, which, however, does not heavily preoccupy the patient.

4. Moderate: The patient expresses clear concern about a real misdeed, which does not, however, affect their behavior; full cognitive preoccupation with these thoughts is not observed.

5. Severe: The patient experiences intense guilt with ideas of self-deprecation or punishment. The feeling of guilt may be related to the development of delusional psychosis, may occur spontaneously, may serve as a source of preoccupation and/or depressed mood, and does not lessen after talking with the physician.

6. Very severe: Ideas of guilt reach delusional proportions and are accompanied by feelings of hopelessness and worthlessness. The patient is convinced that they will be severely punished for their misdeeds and may view ongoing events as such a punishment.

7. Extreme: The patient's entire lifestyle is subjugated by the unshakable idea of their own guilt. They believe they deserve the harshest punishment, up to and including life imprisonment, torture, and/or death. Suicidal thoughts or a tendency to attribute problems faced by others to their own past actions may also occur simultaneously.

04. Tension

External manifestations of fear, anxiety, and agitation, such as stiffness in conversation, tremor, sweating, and motor restlessness (akathisia). Severity is assessed during the interview based on the patient's statements and corresponding physical signs of mental tension.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: Questionable pathology; assessed indicators may be at the upper limit of normal.

3. Mild: The patient's posture and movements indicate a mild degree of agitation (e.g., some stiffness of movement, transient akathisia, tendency to change posture, fine and rapid hand tremor).

4. Moderate: Distinct manifestations of increased nervousness in the form of fidgetiness, hand tremor, sweating, and nervous mannerisms.

5. Severe: Marked tension with a wide variety of manifestations (e.g., nervous shivering, profuse sweating, and motor restlessness) while maintaining generally normal behavior during the interview.

6. Very severe: The degree of tension is such that it interferes with normal communication. For example, the patient may exhibit constant fidgetiness, inability to sit in one place for long, or accelerated breathing.

7. Extreme: The patient's condition is close to panic. Marked acceleration of motor activity, continuous pacing, or running around the room is observed. The patient cannot remain in one place for more than a minute, making conversation impossible.

05. Mannerisms and posturing

Unnatural movements and/or postures that give the patient's behavior an awkward, dysplastic, or eccentric character. Severity is assessed by observing the physical manifestations of the disorder during the interview, as well as from information obtained from relatives and medical staff.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: Questionable pathology. Assessed signs may be at the upper limit of normal.

3. Mild: Some awkwardness of movement or slight rigidity in postures.

4. Moderate: Noticeable awkwardness or dysplastic (fragmented) movements; the patient may assume unnatural postures for a short time.

5. Severe: The patient occasionally makes strange, ritual-like movements or freezes in unnatural, distorted postures for fairly long periods of time.

6. Very severe: Frequent repetitions of eccentric, "ritualistic" movements, mannerisms, or stereotyped movements; freezing in unnatural postures may be observed for prolonged periods.

7. Extreme: Normal functioning is severely impaired due to the patient's nearly constant performance of ritualistic or stereotyped movements, pronounced mannerisms, or prolonged freezing in unnatural postures.

06. Depression

Experience of sadness, despondency, helplessness, and pessimism. Severity is assessed based on the patient's reports of their mood during the interview and corresponding changes in interpersonal relationships and behavior.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: Subjective feelings of sadness and depressed mood are elicited only upon targeted questioning; appearance and behavior remain unchanged.

4. Moderate: Distinct experiences of sadness and hopelessness, which the patient may mention on their own initiative, but which do not significantly affect the patient's behavior and social relationships. Psychotherapeutic correction of the condition is possible.

5. Severe: Clearly depressed mood with experiences of sadness, pessimism, loss of life interests, psychomotor retardation, and some sleep and appetite disturbances. Not amenable to psychotherapeutic correction.

6. Very severe: Deeply depressed mood with persistent experiences of hopelessness and personal worthlessness; the patient occasionally weeps, accompanied by significant deterioration in sleep and appetite, decreased motor activity, loss of life interests, and possible lapses in self-care.

7. Extreme: Depressive experiences significantly impair the patient's functioning. Marked somatovegetative disorders, psychomotor retardation, loss of all social interests, lapses in self-care, and impaired concentration are observed. The patient weeps frequently; depressive or nihilistic delusions, as well as suicidal thoughts and tendencies, may develop.

07. Motor retardation

Decreased motor activity manifested by slowed movements and speech, sluggish reactions to stimuli, and reduced physical tone. Severity is assessed both by behavior during illness and from reports by medical staff and relatives.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: Mild, but noticeable slowing of movements and speech. Some reduction in productivity during conversation and gesturing may occur.

4. Moderate: The patient's movements are clearly slowed, speech may be unproductive, the patient takes a long time to answer questions, long pauses appear in conversation, and speech rate is reduced.

5. Severe: Motor activity is markedly reduced, making communication with the patient unproductive and interfering with the performance of social and professional duties. The patient sits or lies down for long periods.

6. Very severe: Movements are extremely slowed; motor and speech activity are minimal. The patient spends entire days sitting or lying around aimlessly.

7. Extreme: The patient is almost completely immobile and responds poorly to external stimuli.

08. Uncooperativeness (refusal to cooperate, poor sociability)

Active refusal to cooperate and follow instructions from the physician, medical staff, or relatives, which may be associated with mistrust, defense mechanisms, stubborness, negativism, defiance of authority, hostility, or belligerence. Severity is assessed based on behavior during the interview, as well as information obtained from medical staff and relatives.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: The patient complies with requirements while expressing displeasure, impatience, or a sarcastic attitude. Tries to avoid discussing undesirable topics.

4. Moderate: At times, the patient openly refuses to follow basic rules of communal living, such as making the bed, following the daily schedule, etc.; may exhibit hostile, negativistic defense reactions, which, however, in most cases do not preclude the possibility of reaching an agreement.

5. Severe: The patient frequently violates communal living rules; those around characterize them as an "outcast" or as someone with a severely impaired ability to communicate. During the interview, they are irritable or withdrawn and try to avoid answering many questions.

6. Very severe: The patient strongly resists cooperation and rapport-building, exhibits active negativism, and is sometimes belligerent. They refuse to follow most communal living rules and often do not wish to converse with the physician.

7. Extreme: Active resistance significantly hinders the performance of almost all major social functions. A complete refusal to participate in any social activity is possible, including personal hygiene rules, conversations with relatives or medical staff. Even a brief dialogue with the physician is difficult.

09. Unusual thought content

Thinking characterized by the presence of strange, fantastic, or eccentric thoughts, varying in content from atypical or detached from life to distorted, unnatural, or clearly absurd. Severity is assessed based on the content of thoughts expressed by the patient during the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: Somewhat strange or idiosyncratic (non-conventional) thought content, or the use of familiar ideas in an unusual context.

4. Moderate: Frequent distortion of thoughts, sometimes reaching the level of eccentric ones.

5. Severe: The patient expresses many strange and fantastic thoughts (e.g., believes they are the adopted son of a king or that they just escaped death), and sometimes clearly absurd ones (e.g., that they have hundreds of children, receive radio signals from space through a dental filling).

6. Very severe: The patient expresses numerous illogical and absurd thoughts (e.g., that they have three heads, that they are an alien from another planet).

7. Extreme: Thinking is overloaded with absurd, eccentric, and fantastic ideas.

010. Disorientation

Loss of awareness of one's relationship to reality, including place, time, and people around, due to confusion or detachment from reality. Severity is assessed based on a targeted interview with the patient.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: General orientation is largely preserved; the patient experiences difficulties with certain specific questions. For example, they may know where they live but get the exact address wrong; recognize medical staff by face but not know what they do; know the month but confuse the days of the week or err by at least two days in dates. Sometimes a narrowing of the patient's knowledge base may be noted: they may be oriented in their immediate environment, but not beyond it. For example, the patient knows the staff they have to deal with, but does not know the names of political figures.

4. Moderate: The patient does not always recognize people and correctly name the place or time of stay. For example, they may know they are in a hospital, but not know its name; know the name of the city, but not the names of the region, district, or street; know the name of the attending physician, but not the names of many other staff members; can name the year and season, but are confused about the month.

5. Severe: The patient recognizes people with great difficulty, has a very vague idea of their whereabouts, and most people around them seem unfamiliar. They can more or less correctly name the year, but do not know the current month, day of the week, or even the season.

6. Very severe: The patient practically fails to recognize people and does not know the time and place of their location. For example, they have no idea where they are, are off by more than a year in determining the time, and can barely name one or two people who have been around them recently.

7. Extreme: The patient has completely lost orientation regarding people, place, and time; is completely oblivious to or incorrectly pictures their location and the current year, and fails to recognize the closest people: parents, spouse, friends, or the attending physician.

011. Attention impairment

Disorder of goal-directed attention, manifested by a lack of concentration, increased distractibility, difficulties in focusing, maintaining, or switching attention to new objects. Severity is assessed based on observation of the patient throughout the interview.

1. Absent: the patient's condition does not meet the definition of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: Limited ability to concentrate, manifested by some distractibility or waning attention toward the end of the interview.

4. Moderate: The interview with the patient is difficult due to increased distractibility, difficulty focusing on a given topic for long periods, or conversely, quickly switching to new topics.

5. Severe: Communication with the patient is seriously impaired due to poor concentration, frequent distractibility, and/or poor ability to switch to other topics.

6. Very severe: The patient's attention can be engaged only briefly or with great difficulty due to frequent distraction by internal experiences or extraneous external stimuli.

7. Extreme: Attention is so impaired that even a brief conversation becomes impossible.

012. Impaired insight

Inadequate understanding of one's mental state and current life situation, manifested by the inability to recognize the presence of a disease or its symptoms in the past and present, denial of the need for hospitalization or psychiatric treatment, making decisions without sufficient consideration of their consequences, and building unrealistic plans for the future. Severity is assessed by the content of thoughts expressed by the patient during the interview.

1. Absent: The patient's condition does not fit the description of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: The patient acknowledges the presence of a mental disorder, but underestimates its severity, the need for treatment, or prevention. The ability to adequately plan future actions may be impaired.

4. Moderate: The patient has only a vague or distant idea of their illness. At times they may deny its presence or fail to understand what the main symptoms of the illness are, such as delusions, thought disorders, suspiciousness, or social alienation. The patient may acknowledge the need for treatment only for clinical manifestations such as anxiety, tension, or sleep disturbances.

5. Severe: The patient acknowledges the presence of a mental disorder in the past, but not in the present. When questioned, they may point to the presence of certain non-existent or irrelevant symptoms, showing a tendency to misinterpret them or even elaborate them delusionally. The need for psychiatric treatment is usually denied.

6. Very severe: Does not consider themselves mentally ill; denies the presence of any psychiatric symptoms in both the past and the present, while formally agreeing to hospitalization and treatment, yet failing to understand their meaning and necessity.

7. Extreme: The patient completely denies the presence of a mental illness in both the past and the present; interprets hospitalization and treatment through delusional mechanisms (e.g., as punishment for misdeeds, as actions of persecutors, etc.). Consequently, the patient usually refuses to cooperate with medical staff, tries to avoid taking medications, and fails to comply with the treatment regimen.

013. Volitional disorder

Impairment of volitional initiative, the ability to achieve set goals and control one's thoughts, behavior, movements, and speech. Severity is assessed based on the patient's statements and behavior during the interview.

1. Absent: The patient's condition does not fit the description of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild: Some indecisiveness appears in the patient's speech and thoughts, which practically does not affect communication and behavior.

4. Moderate: The patient is frequently ambivalent; experiences difficulties in decision-making. The interview with the patient is somewhat difficult due to the scattered nature of their thoughts.

5. Marked severity: volitional impairments affect both the patient's thinking and behavior; pronounced indecisiveness is observed, which hampers spontaneous motor and speech activity, as well as impedes the establishment of social relationships.

6. Severe impairment: volitional disorders hinder the performance of even the simplest automatic actions, such as dressing and self-care; distinct speech disorders are noted.

7. Extreme severity: virtually complete absence of volitional acts, manifested as psychomotor retardation up to complete immobility and/or mutism.

014. Impairment of impulse control (aggressiveness)

Impairment in the regulation and control of internal drives, leading to unexpected, unmodulated, voluntary, and non-target-directed discharges of tension and emotions without regard for potential consequences. Severity is assessed based on behavior during the interview and information from medical staff and relatives.

1. Absent: The patient's condition does not fit the description of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: under stress or when desires are unfulfilled, the patient is easily irritated or upset, but rarely acts impulsively in accordance with their experiences.

4. Moderate severity: the patient becomes wrathful and prone to verbal attacks at the slightest provocation, occasionally resorting to threats. One or two episodes of physical resistance or a tendency toward destructive actions may be noted.

5. Marked severity: periodic impulsive outbursts are observed, accompanied by insults, property damage, or threats of physical violence. One or two episodes of attacking people may occur, necessitating patient isolation, physical restraints, or other calming measures.

6. Severe impairment: frequent impulsive (uncontrolled) outbursts of aggressiveness are observed; the patient constantly threatens, makes demands, or destroys surrounding objects without a clear understanding of the consequences of these actions. The patient exhibits a distinct tendency toward violent acts, including assaults motivated by sexual drive. Behavior may be driven by compliance with imperative hallucinations.

7. Extreme severity: the patient makes continuous attempts to attack people with the intent to kill or rape, and is prone to self-harm. At the same time, they exhibit extreme cruelty. Due to the inability to control dangerous impulses, the patient requires constant monitoring, isolation, or physical restraint.

015. Preoccupation with internal experiences

Preoccupation with internal experiences, thoughts, feelings, or autistic fantasies, leading to impaired adaptation and orientation in the surrounding environment. Severity is assessed based on the patient's responses and behavior during the interview.

1. Absent: The patient's condition does not fit the description of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: excessive preoccupation with one's needs and problems, manifested in persistent attempts to steer the conversation toward topics of concern to the patient, with a lack of interest in other issues.

4. Moderate severity: at times, the patient appears self-absorbed, engrossed in daydreams or experiences, which somewhat hinders the conversation with them.

5. Marked severity: the patient is engrossed in autistic fantasies or internal experiences, which affects their behavior and significantly impairs social and communicative activity. Sometimes the patient sits with a blank stare, whispers and/or talks to themselves, and performs stereotyped movements.

6. Severe impairment: the patient is almost completely absorbed by their internal experiences, which significantly impairs concentration, participation in conversation, and orientation in the environment. The patient often smiles or laughs at something, whispers, and talks to themselves.

7. Extreme severity: complete preoccupation with internal experiences, accompanied by a sharp decline in adaptation. The patient's behavior is entirely subordinated to hallucinations, and they pay little attention to surrounding people and the environment.

016. Active social withdrawal

Reduction in social activity stemming from groundless fear, hostile or suspicious attitudes. Severity is assessed based on information regarding the patient's social activity obtained from medical staff or relatives.

1. Absent: The patient's condition does not fit the description of the disorder.

2. Very mild: questionable pathology; evaluated signs may be at the upper limit of normal.

3. Mild severity: the patient feels awkward in the presence of other people and prefers to spend time alone, although they exhibit social activity when necessary.

4. Moderate severity: the patient is reluctant to enter into social contacts, requires constant encouragement, and may abruptly terminate them upon the emergence of anxiety, suspicion, or hostile attitudes.

5. Marked severity: the patient refuses most social contacts with fear or anger, despite attempts by others to engage them. They spend most of their time alone to no purpose.

6. Severe impairment: due to intense fear, hostile or suspicious attitudes, the patient exhibits only the most necessary social activity. When initiative is shown by others, the patient displays a clear desire to avoid contacts and generally tries to stay away from people.

7. Extreme severity: the patient cannot be engaged in social relationships due to severe fear, hostility, or persecutory delusions. They strive by all means to avoid contacts and remain in complete isolation.

Key (interpretation): using this scale measures the degree of impairment in the aforementioned categories across three subscales, taking into account the child's age. The nature of expected impairments is described within the diagnostic material itself. Assessments include: (1) severity of positive symptoms on the Positive Syndrome Scale (7 items); (2) severity of negative symptoms on the Negative Syndrome Scale (7 items); (3) composite index (positive symptom scores minus negative symptom scores); (4) severity of other mental disorders on the General Psychopathology Scale (16 items); (5) risk of potential aggression (3 additional items along with anamnestic data).

Comment: abroad, completion of the scale is typically performed by psychologists, which is why the Structured Clinical Interview for Positive and Negative Syndrome Scale (PANSS) has been developed (Opler L.A., Kay S.R., Lindenmayer J.P., Fiszbein A., 1999). In routine clinical practice, an experienced specialist performs the rating automatically during the clinical interview with the patient.

Explanations: the scale should be used dynamically; the recommended interval for re-administering the scale is 7–10 days.

Appendix G2. Personal and Social Performance Scale.

Russian title - Personal and Social Performance Scale.

Original title - Personal and Social Performance scale (PSP)

Source - Morosini P.L., Magliano L., Brambilla L., Ugolini S., Pioli R. Development, reliability and acceptability of a new version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social functioning. Acta Psychiatrica Scandinavica 2000. 101: 323-329

Type (underline):

- rating scale

- index

- questionnaire

- other (specify)

Purpose: The Personal and Social Performance Scale is used to assess the ability to learn and acquire speech skills, evaluate relationships with loved ones and others, assess self-care skills development, evaluate agitation and aggressive behavior—including during ongoing treatment—and assess treatment efficacy as well as during the creation and implementation of an individual psychological correction and medical rehabilitation plan.

Content (template):

An assessment in 4 main domains of functioning is used, taking into account the child's age:

Domains of functioning:

(a) ability to learn and acquire speech skills;

(b) relationships with loved ones and others;

(c) self-care;

(d) agitation and aggressive behavior.

Criteria for domains a–d:

Domain (a): categories (assessment is carried out by a psychiatrist or medical psychologist)

- The absence of problems in the learning ability domain in children was characterized by the successful acquisition of key subject-practical activity skills appropriate for the given age. As a rule, such children attended a regular kindergarten group, studied under a general school education curriculum, or could be placed in such institutions.

- Mild severity of impairments in this domain was characterized by fluctuations in work capacity, deterioration of concentration under load, and certain difficulties when engaging in goal-directed activities. Children in this group needed to exert more effort to master the material, but they were able to cope with it without outside help.

- Marked difficulties manifested as an uneven pace of intellectual activity, decreased academic performance, rapid fatiguability, distractibility, and a restricted range of interests. Some patients exhibited age-inappropriate speech sound production disorders. Children continued to study under general educational standards, but often required additional specialist support: tutors, psychologists, speech therapists.

- Significant impairments in this area were characterized by a progressive delay in intellectual development, a marked lag behind peers, immaturity or overvalued interests, and difficulty switching attention. Phrasal speech disorders, and difficulties in acquiring reading and writing skills were observed. These children were recommended additional specialist support, as well as age-appropriate specialized educational conditions: attendance in a developmental delay group, individual education, or transfer to a curriculum for children with mental retardation.

- Severe learning impairments implied the presence of cognitive deficit accompanied by pronounced thought disorders specific to this disease. Marked speech underdevelopment was noted. Preschool children attended developmental delay groups or remained unorganized. School-age children were educated according to correctional programs for individuals with mild mental retardation.

- Very severe maladaptation in this area was characterized by a profound cognitive defect; often, speech skills were absent, or speech did not serve a communicative function. School-age children from this group studied under an auxiliary program for individuals with severe mental retardation or remained unorganized; in isolated cases, they were placed in psychoneurological residential facilities.

Domain (b): categories (evaluated by a psychiatrist or medical psychologist)

- Evaluation based on the criterion of relationships with loved ones and others was performed as follows: the absence of problems in this area was characterized by emotional attachment to loved ones, active communicative interaction, a desire to expand one's social circle, the ability to understand emotions and non-verbal cues of others (taking age into account), and the establishment of friendships. Children eagerly communicated within a peer group and adapted well to the collective.

- Mild impairments were distinguished by emotional flatness, a certain formality in communication with others, and selectivity and superficiality of contacts.

- Marked impairments were characterized by a restricted range of contacts, difficulty or inability in establishing friendships, a desire for solitude, a preference for activities involving mechanisms rather than people, difficulty adapting to a new collective, and avoidance of group or class attendance.

- Significantly pronounced difficulties were observed in children distinguished by emotional flattening, egocentrism, difficulty in recognizing and using non-verbal cues in communication while preserving expressive speech, an active desire for solitude, restriction of contacts to family members, fears, hostility, or lack of interest in other children. Significant difficulties in functioning within a collective were noted.

- Severe impairments in this area implied underdevelopment of emotional responsivity ranging up to indifference toward loved ones, or pronounced symbiotic attachment to the mother, difficulty in differentiating between "friend or foe", and selective responsivity to directed speech.

- Very severe impairments were characterized by a lack of response to directed speech, active withdrawal from contact with any people, monotony of emotional responses, and detachment from surroundings.

Domain (c): categories (evaluated by a psychiatrist or medical psychologist)

- The norm for the acquisition of self-care skills for children aged 3-4 years is the ability to use cutlery and the potty, and independently put on and take off clothes; for 6-7 years, the ability to tie shoelaces, button clothes, and independently perform hygiene procedures; for 8-10 years, the ability to look after one's belongings, prepare simple dishes, and count change; from 10-11 years, the ability to make purchases in a store, clean the house, and use basic household appliances.

- Mild impairments in this area were characterized by minor difficulties in performing basic skills (skills were acquired according to age).

- Marked impairments were characterized by clumsiness and difficulty in executing skills (despite timely skill development). Significant impairments were observed in children who required adult guidance for self-care; skills were acquired according to age but were performed partially or in a distorted manner.

- Severe impairments implied the acquisition of skills at a younger age level; in daily life and self-care, adult assistance was required in most situations.

- Very severe impairments were observed in children who were completely incapable of self-care and required the constant presence of an adult.

Domain (d): categories (evaluated by a psychiatrist or medical psychologist)

- The absence of agitation and aggressive behavior was considered the norm.

- Mild criteria included withdrawal, coarseness, demonstrative behavior, and active complaints about others.

- Marked criteria included boundary issues in behavior, insolence, and manifestations of negativism.

- Significantly pronounced manifestations included: profanity directed at others, property damage, and socially unacceptable behavior (taking age into account).

- Severe manifestations included: verbal threats directed at others, aggression toward others and/or autoaggression, without the intention to inflict serious physical harm.

- Very severe criteria included targeted aggressive acts aimed at inflicting serious physical harm, or chaotic non-targeted aggression and autoaggression.

Key (interpretation): this scale measures the degree of difficulty in 4 main functional domains, taking into account the child's age. The level of functional impairment is assessed by the severity of difficulties experienced by the patient over the past 7 days. Based on the clinical assessment, the interval corresponding to the level of social functioning is selected: (in points)

- 100-91 points: Full functioning in all four main domains. The patient's positive qualities are highly appreciated by others, they successfully cope with everyday problems, and their interests and activities are diverse.

- 90-81 points: Good level of functioning in all four main domains, with only those problems or difficulties encountered by all people.

- 80-71 points: Minor difficulties in one or more domains a-c.

- 70-61 points: Marked, but not reaching a significant level, difficulties in one or more domains a-c, or minor problems in domain d.

- 60-51 points: Significant difficulties in one of the domains a-c, or marked problems in domain d.

- 50-41 points: Significant difficulties in two or more domains a-c, or severe difficulties in one of the domains a-c, with or without marked problems in domain d.

- 40-31 points: Severe difficulties in one domain and significant difficulties in at least one of the domains a-c, or significant problems in domain d.

- 30-21 points: Severe difficulties in two domains a-c, or severe problems in domain d, with or without impairments in domains a-c.

- 20-11 points: Severe impairments in all domains a-d, or very severe problems in domain d, with or without impairments in the main domains a-c. If the patient responds to external stimuli, they fall into the 20-16 points interval; if not, into the 15-11 points interval.

- 10-1 points: A-spontaneity combined with gross behavioral disturbances without danger to the patient's life (scores 6-10) or with danger to the patient's life, e.g., threat of death due to starvation, dehydration, infections, inability to assess a dangerous situation (scores 5-1).

Explanations: the scale should be used dynamically; the recommended interval for re-administering the scale is 7–10 days.