Verschiedene Modelle zur Krankheitsentstehung
Die Schizophrenie gehört zur Hauptgruppe der sogenannten endogenen Psychosen. Sie ist auch heute noch, trotz der Vielzahl neuer und guter Behandlungsmöglichkeiten eine schwere psychische Krankheit ! Die Entstehung ist multikausal determiniert, es gibt also nicht die Ursache der Schizophrenie. Es gilt als etablierte Meinung, dass die Krankheit Schizophrenie durch ein Zusammenwirken verschiedener, biologischer wie psychosozialer Faktoren begünstigt, ausgelöst und unterhalten wird. Das Modell, nach welchem sich die moderne Schizophrenieforschung die Entstehung der Krankheit erklärt, nennt sich „Vulnerabilitäts-Stress-Modell„. Es versucht die verschiedenen Wirkfaktoren in einer einzigen Entstehungshypothese zu vereinen.
Eine weitere, relativ gesicherte und bekannte Hypothese im Zusammenhang mit dieser Erkrankung ist die sogenannte Dopamin-Hypothese der Schizophrenie, welche davon ausgeht, dass eine (relative) Überaktivität bestimmter Botensysteme in bestimmten Regionen im Gehirn, eben die dopaminergen Strukturen, v.a. im Bereich des limbischen Systems, wesentlich für die Entstehung psychotischer Symptome sind und welche Grundlage der modernen psychopharmakologischen Behandlung der Schizophrenie ist.
Eine weitere, gesicherte Erkenntnis ist die, dass Schizophrenien auch eine genetische Verursachung haben. Es gibt aber auch hier nicht das Gen für die Schizophrenie, sondern man geht aus von einer sogenannten polygenen Erbanlage mit unvollständiger Penetranz, die zu etwa 5% an der Manifestation einer späteren Schizophrenie beteiligt ist.
Schizophrenie-Typen nach ICD-10 (F2)
Das äussere Krankheitsbild bei der Schizophrenie ist sehr vielgestaltig, und deshalb unterscheidet man in der Systematik, abhängig vom Verlauf und von der Kernsymptomatik, verschiedene Schizophrenie-Typen.
In der ICD-10 (Internationale Klassifikation der Krankheiten) sind die Schizophrenien unter der Kategorie F2 kodiert. Folgende Störungstypen werden hier aufgezählt:
- Paranoide Schizophrenie (F20.0)
- vorherrschend sind Halluzinationen und Wahnvorstellungen
- Hebephrener Typ (F20.1)
- meist jugendliche Patienten mit vorwiegender Störung des Denkens und der Affekte (typischer „läppischer“ Affekt)
- Katatone Schizoprenie (F20.2)
- im Vordergrund stehen Störungen des Antriebs und der Psychomotorik
- Undifferenzierte Schizophrenie (F20.3)
- Schizophrenie ohne eindeutige Zugehörigkeit zu einer der anderen Formen der Kategorie F20
- Postschizophrene Depression (F20.4)
- im Anschluss an eine Schizophrenie auftretende, langanhaltende Depression mit noch andauernden, aber milderen Schizophrenie-Symptomen
- Schizophrenes Residuum (F20.5)
- Stadium der „chronischen“ Schizophrenie nach langjährigem Verlauf, in welchem sogenannte „Negativsymptome“ (Antriebsarmut, Affektverflachung und Verlust sozialer Kompetenz mit Rückzug etc.) vorherrschen
- Schizophrenia simplex (F20.6)
- schleichend und unspektakulär verlaufende Schizophrenie ohne Positivsymptomatik, daher oft schwer zu diagnostizieren>
Die aufgezählten Untertypen werden nicht als eigene Krankheitseinheiten, sondern lediglich als unterscheidbare „Ausprägungstypen“ ein und derselben schizophrenen Erkrankung verstanden. Dieser Auffassung gemäss
- können die verschiedenen Formen im Erkrankungsverlauf auch auseinander hervorgehen oder ineinander übergehen,
- kann sich die genaue Schizophrenie-Diagnose im Krankheitsverlauf ändern und sollte sich immer danach richten, was den Anlass zur letzten Untersuchung oder zur letzten Krankenhauseinweisung gegeben hat.
Die einzelnen Schizophrenie-Typen noch einmal im Klartext:
- Der häufigste Untertyp ist die paranoide Schizophrenie. Hier bestimmen Wahnbildungen und/oder Halluzinationen die Symptomatik.
- Die Katatonie ist selten und wird v.a. durch psychomotorische Symptome bestimmt.
- Die hebephrene Schizophrenie kommt v.a. bei Jugendlichen vor. Im Vordergrund stehen affektive Störungen, formale Denkstörungen und läppisches Sozialverhalten. Die Prognose ist eher ungünstig.
- Der sogenannte Residualtyp der Schizophrenie entwickelt sich oft im Verlauf und ist gekennzeichnet durch Persönlichkeitsänderungen, Leistungsschwäche, Kontaktschwäche, affektive Nivellierung, Hypochondrie, in schweren Fällen auch durch hochgradigen Antriebs- und Interessenverlust, durch sozialen Rückzug bis hin zum Autismus, durch erhebliche Gefühlsverflachung und -verarmung und schwere Vernachlässigung der Körperpflege (Verwahrlosungstendenz). Man unterscheidet das „reine“ Residuum (Fehlen von sogenannter Positivsymptomatik) vom „gemischten“ Residuum (mit noch mässiger chronischer Positivsymptomatik).
- Die Schizophrenia simplex ist selten und schwer zu diagnostizieren, da sie sehr symptomarm ist und v.a. keine produktiven Symptome aufweist, an denen man sie erkennen könnte. Vorherrschend ist hier die sogenannte Negativsymptomatik mit Leistungsknick, sozialem Rückzug und Interessenverarmung, der Verlauf ist schleichend und chronifizierend.
Symptomatik der Schizophrenie
In der deutschsprachigen Psychiatrie sind die Konzepte von Bleuler (Grundsymptome und akzessorische Symptome) und Schneider (Symptome ersten und zweiten Ranges) von besonderer Bedeutung:
Für Bleuler gehörten
- zu den Grundsymptomen der Schizophrenie:
- Typische Störungen der Affektivität (v.a. Ambivalenz)
- Formale Denkstörungen (v.a. Zerfahrenheit)
- Ich-Störungen
- zu den akzessorischen Symptomen:
- Wahn
- Halluzinationen
- Katatone Symptome
Kurt Schneider unterschied Erstrangsymptome und Zweitrangsymptome
- Symptome ersten Ranges:
- Wahnwahrnehmung
- Dialogisierende akustische Halluzinationen
- Gedankenlautwerden, Gedankenentzug, Gedankeneingebung, Gedankenausbreitung
- Andere Beinflussungserlebnisse mit dem Charakter des Gemachten
- Symptome zweiten Ranges:
- Wahneinfall
- Sonstige Halluzinationen (optisch, olfaktorisch)
- Affektveränderungen
- Ratlosigkeit
- Und andere…
Die Unterscheidung von Positivsymptomatik und Negativsymptomatik spielt therapeutisch eine grosse Rolle, eine Unterteilung der Schizophrenien in Typ1 und 2 hat sich aber empirisch nicht bestätigt. Es gibt keine pathognomonischen Symptome der Schizophrenie!!!
Es ist natürlich nicht möglich, in diesem Rahmen eine Unterrichtung in der Erhebung eines psychopathologischen Befundes zu geben. Die vielfältigen Äusserungsformen (Symptomatik) der Schizophrenie werden mit folgenden Fachbegriffen wiedergegeben und systematisiert:
- Alogie:
- Verarmung der Sprache
- Verlängerung der Antwortlatenz (Ursache sind Denk- und Ausdrucksstörungen, aber auch die gestörte Kommunikationsfähigkeit)
- Affektverflachung:
- Verarmung des Fühlens und der emotionalen Ausdrucks- und Reaktionsfähigkeit
- Anhedonie:
- Unfähigkeit, Vergnügen oder Freude zu empfinden
- Asozialität:
- Eingeschränkte oder fehlende Konfliktfähigkeit und dadurch Mangel an sozialen Interaktionen
- Ich-Störungen:
- Depersonalisation
- Derealisation
- Autismus
- Gefühl des Gemachten
- Gedankeneingebung-, -entzug, -ausbreitung
- Wahn (sogenannte inhaltliche Denkstörungen):
- Wahneinfall
- Wahnstimmung
- Wahnwahrnehmung
- Systematisierter Wahn
- „doppelte Buchführung“
- schizophrener Wahn ist im Ggs. zu Wahn bei anderen Erkrankungen oft bizarr, magisch-mystisch und meist uneinfühlbar
- Halluzinationen:
- Akustisch
- Imperative Stimmen
- Dialogisierende Stimmen (unterhalten sich untereinander über den Patienten)
- Kommentierende Stimmen
- Gedankenlautwerden!!!
- Elementare akustische Halluzinationen (Akoasmen)
- Optisch (nicht typisch!!!)
- Olfaktorisch
- Gustatorisch
- Taktil
- Leibeshalluzinationen (Zönästhesien)
- Akustisch
- Formale Denkstörungen:
- Paralogik (Logik der Argumentation wird verzerrt, unstimmig, unrichtig)
- Konkretismus (abstrakte Begriffe werden konkret interpretiert)
- Kontamination (heterogene Sachverhalte verschmelzen )
- Neologismen Wortneuschöpfungen)
- Zerfahrenheit (Gedanken verlieren ihren Zusammenhang)
- Schizophasie (äusserste Zerfahrenheit mit „Wortsalat“)
- Vorbeireden (falsche Antworten auf gestellte Fragen)
- Sperrung (plötzliches Unterbrechen des Gedankens beim Sprechen, subjektiv als Gedankenabreissen oder Gedankenentzug erlebt!!)
- Affektive Störungen:
- Mangelnder affektiver Rapport
- Parathymie (Affekt passt nicht zur Situation oder zum Gesagten)
- Paramimie
- Läppischer Affekt
- Psychotische Ambivalenz (Der Psychotische kann hassen, lieben, etwas haben wollen und nicht haben wollen zugleich im selben Augenblick)
- Affektive Verarmung
- Katatonie (= die Psychomotorik betreffend):
- Katatoner Stupor (bewegungslos bei erhaltenem Bewusstsein!!!)
- Mutismus (spricht nicht, meist infolge psychotischer Erlebnisse, die später erzählt werden können)
- Katalepsie (bei Substupor (kommt öfter vor, als vollständiger Stupor!!!) passive Formbarkeit der Gliedmassen durch flexibilitas cerea)
- Negativismus (Patient macht automatisch das Gegenteil des Verlangten)
- Befehlsautomatismus (Patient führt automatisch alles Verlangte aus)
- Echolalie (Patient spricht alles Gehörte und/oder Gesehene nach)
- Echopraxie (automatisches Nachvollziehen jeder gesehenen Handlung)
- Bewegungsstereotypien (sinnlose, rhythmische leer laufende Bewegungen wie Rumpfschaukeln, Klopfen, Grimassieren etc.)
- Haltungsstereotypien (bestimmte Haltungen werden in stereotyper Weise beibehalten)
- Verbigeration (Wörter oder Satzteile werden stereotyp wiederholt)
- Sperrungen (Unterbrechungen des Bewegungsablaufes)
- Raptus (katatoner Erregungszustand mit starker motorischer Unruhe und z.T. stereotypen Bewegungsabläufen, Schreien, Herunterreissen der Kleider, Grimassieren bis zum ungeordneten Bewegungssturm mit Sich-Herumwälzen, Um-sich-Schlagen, zielloser Aggressivität)
- Störungen des Antriebs und des Sozialverhaltens:
- Abulie (Mangel an Willen, Interesse, Initiative oder Energie)
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