Int J Child Adolesc Health 2011;4(1):00-00.

Running title: Overdiagnosis of schizophrenia

Overdiagnosis of schizophrenia in adolescents in the former Soviet

Union: Mechanisms and complications
Sergei V Jargin, MD
Abstract: Previously we reported a case study, illustrating overdiagnosis of
schizophrenia in the former Soviet Union, when a patient with mild communication
abnormalities was diagnosed with schizophrenia at the age of 15 years. Presently the
patient is over fifty years; he has never had any psychiatric symptoms but remains
registered with the psycho-neurological dispensary. A complication of such
over-diagnosis is described here:: phenotiazines and an anticholinergic drug
trihexyphenidil (named cyclodol in Russia) was prescribed to the patient. He took the
medications himself and also supplied his schoolmates with cyclodol tablets, with a
comment that it is a narcotic drug, which resulted in severe intoxications and deliriums.
Apart from the known cases of political abuse of psychiatry, personality disorders,
neuroses, transitory derangements during adolescence etc have been misdiagnosed and
treated as schizophrenia. The patients with the diagnosis of schizophrenia remain
registered with the psycho-neurological dispensaries lifelong, which means a stigma for
them and their families. Besides, it can cause unemployment also in todays Russia
because some employers ask for a certificate from the psycho-neurological dispensary.
Over-institutionalisation has been common practice, while conditions in the psychiatric
hospitals, where the patients stay for long periods of time, have been primitive:
overcrowding, no privacy, insufficient hygiene, etc. Not much has changed until today,
but in view of the growing Russian economy we look forward to improvement of
conditions in psychiatry.
Keywords: Schizophrenia, adolescents, substance abuse, anticholinergics, delirium
Correspondence: Sergei V Jargin, MD, Peoples Friendship University of Russia,
Clementovski per 6-82, 115184 Moscow, Russia. Tel/fax: +7 495 9516788; E-mail:
sjargin@mail.ru
Submitted: May 23, 2010. Revised: July 15, 2010. Accepted: July 21, 2010.
INTRODUCTION
Previously we reported a case study (1) illustrating overdiagnosis of schizophrenia in
the former Soviet Union. The patient, whom the author observed since 1971, had mild
communication abnormalities and was diagnosed with schizophrenia at the age of 15
years. He was registered with a district psycho-neurological dispensary, which resulted
in exemption from military service and denial of the driving license. The dispensary
directed him to a special educational institution, where he acquired a profession as a
floriculturist. Later, following advices from his friends, among whom were physicians,
M completed technical education and successfully worked all his life as a motor
mechanic. Presently M is married and aged 54 years and he has never had any
psychiatric symptoms, but remains registered with the psycho-neurological dispensary.
It should be commented that overdiagnosis of mental disorders was a widespread
mechanism of exemption from compulsory army service (two years at that time) and
this procedure was accomplished in some cases more or less in agreement between a
patient and psychiatrist.

OVER-DIAGNOSIS
It is known that schizophrenia was often overdiagnosed in the former Soviet Union,
which was also used as a form of political reprisal. It is known by the international
community (2-6); less understood is the fact that overextended diagnostic criteria of the
sluggish schizophrenia affected also people having nothing to do with politics and
dissent: personality disorders, neuroses, transitory derangements during adolescence,
etc were misdiagnosed and treated as schizophrenia. It can be illustrated by the citations
(verbatim from Russian): A part of the patients with sluggish schizophrenia, after a
juvenile crisis, achieved a complete social and professional adaptation, continued
education and got married (7) or a majority of patients with juvenile sluggish
schizophrenia become compensated. (8) In the Soviet psychiatric literature,
schizophrenia has been considered to be a lifelong process: despite remissions and
periods of health, the disease is regarded to be still present, the diagnosis of
schizophrenia remaining thus appropriate (9). Accordingly, the patients remain
registered with the psycho-neurological dispensaries lifelong, which means a stigma
not only for the patients, but also for their relatives (10), contributing to breakdown of
families. Besides, it can cause unemployment also in todays Russia, because some
employers ask for a certificate from the psycho-neurological dispensary.
INTERNATIONAL ASPECTS
Access to foreign professional literature has always been limited, while in Russian
textbooks differential diagnosis between personality disorders, neuroses and
schizophrenia was explained vaguely, leaving much space for personal judgment. For
example, in a textbook (11), the differential diagnosis between the sluggish
schizophrenia, neuroses and psychopathies is not discussed at all, it is only stated that
observation of many months can be required for that purpose, thus justifying prolonged
institutionalization. Psychopathologic phenomena typical for neuroses (hysterical,
dissociative, phobias, obsessions), unusual interests, eccentricity etc. were presented as
diagnostic criteria for schizophrenia (11). Existence of nonsymptomatic (12) or
non-manifestative (13) schizophrenia was postulated as well. At the same time, the
sluggish schizophrenia was reported to be the most frequent form of the disease
(14-16). In recent textbooks (15,17), the sluggish schizophrenia is given as a synonym
of a schizotypal personality disorder according to the International Classification of
Diseases (ICD). Although ICD-10 has been formally accepted, the Soviet-time
classification of schizophrenia is still broadly used in Russia and other states of the
former Soviet Union (4). The term sluggish schizophrenia continues to appear in
publications (18,19), while ICD-10 is criticized (14). Interestingly, the same Russian
term vialotekushchaya is now translated into English not sluggish but slow
progressive (18,19).
The entity of schizophrenia was additionally expanded by the so-called
schizophrenic reactions (5), a concept that allows considering reactive conditions
within the scope of schizophrenia. Another contribution to the overextension of the
entity was the teaching by AV Snezhnevsky about Nosos and pathos (11), where the
active process is defined as nosos and hereditarily predisposing constitutional traits - as
the pathos of schizophrenia. According to this concept, the nosos can convert to the
pathos and vice versa. In this way, the disease is mixed up with constitution, permitting
the personality disorders and constitutional traits to be diagnosed as schizophrenia.
Moreover, childhood autism, which was introduced into Russian classifications as late
as in 1988 (20) was sometimes misdiagnosed as schizophrenia. With regard to the
treatment, antipsychotic drugs are recommended by Russian handbooks for all forms of
schizophrenia including the sluggish form (8,15) and increasing schizoidization (11).
Over-institutionalisation of patients with mental disorders has been common practice

(21), while conditions in the psychiatric hospitals, where the patients stayed for long
periods of time, have been primitive: overcrowding, no privacy, poor hygiene, dirty
toilet in the corridor, etc. Not much has been changed until today, but in view of the
growing Russian economy, we look forward to an improvement of conditions in
psychiatry.
DRUG TREATMENT
A possible complication of the overdiagnosis can be illustrated by the case described
previously (1). A treatment with phenotiazines and an anticholinergic trihexyphenidil
(Artane; named Cyclodol in Russia) was prescribed to the patient M. The psychoactive
drugs, obviously, did not contribute to his progress in the school studies and
development of adequate social skills; neither did a 4-week stationary examination at a
psychiatric hospital as a part of the procedure of exemption from military service.
Furthermore, M not only took the medications himself, he also supplied his classmates
(including the author of this letter) with Cyclodol tablets, with a comment that it is a
narcotic drug and one gets high of it. Narcotics were hardly known by Soviet
adolescents at that time, and they were curious. 7-8 tablets (apparently, it were 0,002 g
tablets), taken at once, provoked disturbances of perception and some degree of
disorientation; children took them also during lessons, which remained unnoticed by
teachers. The intoxication was found by the author to be unpleasant, and he took the
tablets only twice; but other schoolchildren took the drug many times.
The culmination took place in May 1973, during the last ring party, a
traditional celebration before the last examinations in Soviet schools. The participants
consumed large amounts of beer with vodka, while M brought a handful of the
Cyclodol pills. The author of this letter took about 18 tablets, and some other
schoolboys took similar or lesser amounts. After that, he developed a full-blown
delirium with severe derangements of perception and orientation, accompanied by
agitation, delusions and visual hallucinations. He saw his deceased grandmother in the
branches of a tree, moving in the wind, and talked with her. He perceived dirty spots on
the asphalt as his spaniel dog, and tried to separate her from the asphalt. He loitered in
the center of Moscow, asking passers-by where is the office of the criminal police and
explained to a neighbor passenger in a bus that he wish to report a crime, because, as it
is known to him, a dead body had been found in a public garden. In spite of a partial
amnesia, it was clear that he had spent the night in a public garden, sleeping under the
impact of alcohol, but the anticholinergic-induced delirium continued next day.
Surprisingly, he came home the next days afternoon without being arrested. Overall,
the delirium lasted about 28 hours, until the early evening. The insight regarding his
condition returned quite abruptly under the hot shower. Other participants of the party
reported similar symptoms including visual hallucinations.
The anticholinergics abuse, its clinical picture, pharmacological and
psychological mechanisms are known (22-27). An overdose of trihexyphenidil
(Artane), a centrally and peripherally acting anticholinergic, produces the states of
mental alteration, mainly hallucinations and deliriums (22). Trihexyphenidyl is
consumed by polydrug users in association with alcohol, other licit or illicit drugs,
impairing cognitive functions such as memory, attention, and learning (22). The abuse
and dependence potential of trihexyphenidil is associated with its hallucinogenic and
euphoric effects (23).
CONCLUSIONS
A concluding point is that overdiagnosis of schizophrenia, together with an inadequate
supervision of the therapy and administrative control (prescription limitation,
controlling of a number of pills taken between prescriptions, needs of prescribing etc.,

etc) can contribute to dissemination of psychoactive substances among seeking

different drugs adolescents, which is associated with the risk of severe intoxications.
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