Skip to main content Skip to main navigation menu Skip to site footer
Research Articles
Published: 2020-09-13

Self-destructive behavior in patients with psychotic disorders of the schizophrenia spectrum

Shupyk National Medical Academy of Postgraduate Education
Shupyk National Medical Academy of Postgraduate Education
self-destructive behaviour self-injury psychotic disorders of the schizophrenia spectrum

Abstract

The present study assesses the difference in motivation of SDB and SI was found in different groups. In Gr1 PermSDB the main motivation was psychological problems associated with mental illness, social and interpersonal problems, while in Gr2 ImpSI the exclusive reason of SI was «command» to do it under influence of imperative pseudo-hallucinations. They were 95 patients with schizophrenia, schizoaffective disorder and acute polymorphic psychotic disorder examined in this issue and divided into 2 groups according to the pathways types of SDB: the first group – patients with permanent features of SDB as comorbid disturbance (Gr1 PermSDB), the second group – patients with impulsive SDB manifestations as secondary behavior disturbance on background acute psychotic episode with imperative pseudo-hallucinations (Gr2 ImpSI).

There was a weighty predominance of patients with schizophrenia and hallucinatory-paranoid syndrome in both groups. Patients with schizophrenia more frequently realized impulsive SI exactly with imperative pseudo-hallucinations as the cause of them.

Results confirmed that fundamentally diverse pathways for SDB manifestation and dynamic of it, also SI motivation exist in patients with SSPsD. It should be taken in the treatment tactic and rehabilitation course for such different patients.

Background

Self-destructive behavior (SDB) is a concept that refers to any behavioral acts or cognitive-affective phenomena that have an autoaggressive content or self-destructive behaviors. It can be manifested in the form of ideas or intentions of suicidal tendencies and/or suicidal or self-destructive acts (SDA), conscious and intentional or realized under the influence of painful experiences, regardless of the mental disorder in which such behavior occurs [1].

Suicidal behavior is only one variant of SDB. Suicide prevention is, first and foremost, the most important health issue, because according to the World Health Organization (WHO), about a million people die each year from suicide worldwide [2,3]. Suicide attempts, which are apparently associated with reduced life expectancy, are about 10 to 15 times more common than suicide. Overcoming their consequences requires even more attention and effort on the part of specialists.

Most cases of voluntary death are associated with the presence of severe mental or somatic pathology in a person who carries out suicidal acts [4]. More than 90% of suicide victims and most people who have attempted suicide have mental illness [3-9]. Mental illnesses that are most often associated with suicidal behavior are affective and psychotic disorders (PSD) [3-10]. Thus, according to the WHO, "the risk of suicide in schizophrenia is as great, if not greater, than the risk of suicide associated with affective disorders" [11]. That is why an important task for scientists is to study the relationship between the signs of SDB and PSD.

In PSD, the manifestations of SDB are also quite diverse, precisely because they develop in different pathogenetic ways. On the one hand, it may be an acute secondary occurrence of self-destructive intentions (in relation to PSD) with the impulsive implementation of SDA, including under the influence of psychotic symptoms (hallucinatory-paranoid, affective-paranoid, or delirium syndromes). Another pathogenetic pathway, when SDB develops as a long and comorbid, psychologically conditioned process of suicide genesis. In such cases, the implementation of the SDA is a reactive behavior, which is realized by patients against the background of acute traumatic circumstances or exacerbation (as a result) of psychotic and affective symptoms. That is, in the development of therapeutic tactics it is important to understand the process of suicide genesis SDB in patients with PSD, namely, that the implementation of SDA is realized not only on the basis of exacerbation of psychotic symptoms but also under the significant influence of psychological and personal factors.

Aim

The study of pathogenetic mechanisms and clinical features of SDB in patients with PSD determined the purpose of the research: to study the features of psychological mechanisms of pathogenesis of SDB and the implementation of SDA in patients with PSD of the schizophrenic spectrum (SPhS).

Materials and method

We examined 95 patients with PSD SPhS, who underwent inpatient treatment at the Municipal Unprofitable Enterprise Clinical Hospital "Psychiatry" in Kyiv. Namely, 38 men (40%), 57 women (60%), the average age of patients was 34.9 ± 8 years.

Criteria for inclusion of patients in the study were: informed consent of the patient to participate in the study; age from 18 to 50 years; the presence of PSD SPhS (without pronounced deficient symptoms, intellectual-mnestic decrease and organic damage to the CNS); the presence of manifestations of SDB with the implementation of the SDA during the illness.

All the patients during the examination were diagnosed with PSD SPhS according to the criteria of the International Classification of Diseases X revision (ICD-10), as well as the fact of the SDA during the course of the disorder. Among the examined patients: 39 persons (41%) were diagnosed with schizophrenia (SPh, F20.0), 25 persons (26%) - schizoaffective disorder (SAD, F25), 20 people (21%) - acute polymorphic psychotic disorder with symptoms of schizophrenia (APPD, F 23.1), in 11 people (12%) - schizotypal disorder (STPD, F21).

According to the purpose of the study, all examined patients were divided into two groups. The first group (Gr1 ContSDB) included 40 patients (42% of the total number of examined patients) with PSD, who expressed a continuous availability of manifestations of SDB throughout the disease period or more than half of this period (both according to patients and medical records). The implementation of SDA by these patients took place under the influence of exacerbation of suicidal ideation or painful experiences with self-destructive content, which, to the fullest extent, did not depend on the severity of psychopathological symptoms. The second group (Gr2 ImpSDA) included 55 patients (58 % of the total number of examined patients), in whom the manifestations of SDB appeared only at the height of exacerbation of psychopathological symptoms, and this is what caused them to implement impulsive SDA. An essential feature of patients in this group was that after the reduction of acute psychotic symptoms, the manifestations of SDB in patients disappeared.

All subjects underwent a semi-structured clinical and diagnostic interview as a clinical and psychopathological method of research (according to diagnostic criteria ICD-10), which revealed the leading syndromic structure of the clinical picture of the disease and the nature of signs of SDB at the time of examination and history, and features implementation of the SDA by patients. All this made it possible to analyze the nature of the pathogenetic development of SDB and its differences in the groups of examined patients.

Results and Discussion

As a result of the study, as shown in Table 1, among the whole cohort of examined patients by nosological affiliation, a substantial significant advantage of the number of patients with SPh in relation to patients with SAD (p = 0.03), APPD (p = 0.003) and STPD (0.000) was found.

Nosological units Gr1 ContSDB, abs. (% by group / by nosology) Gr2 ImpSDA, abs. (% by group / by nosology) In total, abs. (%)
SPh (F20.0) 13 (32.5 / 33.3) 26 (47.3* / 66.7**) 39 (41.0)
SAD (F25) 9 (22.5 / 36.0) 16 (29.1 / 64.0*) 25 (26.4)
APPD (F23.1) 8 (20.0 / 40.0) 12 (21.8 / 60.0) 20 (21.0)
STPD (F21) 10 (25/90.9**) 1 (1.8 / 9.1) 11 (11.6)
In total, abs. (%) 40 (42.1) 55 (57.9) 95 (100)
Table 1. Distribution of the examined patients in groups by nosological affiliation. Note. Here and further: * p <0.05, ** p <0.01

With regard to the group of patients diagnosed with STPD, this group of patients currently has a small number of patients, so the statistical results can be regarded as preliminary. This group needs a further gaining of cases.

Significant and reliable dominance of the number of cases of SPh among all examined patients indicates that among PSD it is the presence of schizophrenic process that mostly influences the occurrence of SDB, although by different pathogenetic mechanisms, as well as manifestations in essence.

As it was fixed by the results of research, impulsive SDA is the most characteristic of patients with SPh. Therefore, the number of patients with SPh in Gr2 ImpSDA was significantly higher in relation to Gr1 ContSDB - namely, 1.92 times (p = 0.003). The study also showed that in Gr2 ImpSDA the number of patients with SPh significantly exceeded the number of patients with other PSD SphS: in relation to patients with SAD in 1.62 times (p = 0.049), and with patients with APPD - 2.16 times (p = 0.005).

The obtained results testified to significantly considerable differences in the ways of SDB development in different PSD SPhS. Thus, in all types of PSD SPhS, the realization of impulsive SDA prevailed, which patients performed under the influence of acute hallucinatory-paranoid symptoms, first of all, imperative pseudo-hallucinations. However, in almost 40% of patients (34.3% of cases with SPh, 40.0% - with APPD, and in 40.9% - with SAD) manifestations of SDB were psychologically "embedded" in painful experiences, existing as a comorbid process, which had a significant pathoplastic influence on the development of the underlying disease and the current mental state of patients and their behavior. That is why it is important to consider the process of treatment and psychological rehabilitation of such patients.

In addition to nosological affiliation, we studied the leading clinical syndromes in this sample of patients - the presence of hallucinatory-paranoid, affective-paranoid, anxiety-depressive, psychopath-like, and obsessive-compulsive syndromes was recorded (see Table 2). Hallucinatory-delusional and affective-delusional syndromes were detected in the majority of patients (89.4%), while the remaining syndromes - anxiety-depressive, psychopath-like, and obsessive-compulsive - were present in only 11 patients (11.6%) diagnosed STPD. This indicates qualitative clinical differences in patients with different types of PSD SPhS.

Hallucinatory-paranoid symptom complex was 2.5 times more common in Gr2 ImpSDA (p = 0.000), while affective-paranoid syndrome was 2.9 times more common among patients in Gr1 ContSDB, although without a statistically considerable difference. However, if the statistical analysis excludes cases of syndromes that were characteristic only of patients with STPD, the difference between the number of patients with affective-delusional and hallucinatory-delusional syndromes in Gr1 ContSDB was significant (p = 0.000). This proves that there are qualitative differences in the clinical and pathogenetic basis of the development of SDB and the implementation of SDA in different variants of PSD SPhS. Namely, patients with Gr1 ContSDB performed SDA, mostly under the influence of affective disorders, while SDA in patients with Gr2 ImpSDA was provoked by the influence of hallucinatory symptoms.

Table 2

Syndromes Gr1 ContSDB, n = 40 abs. (%) Gr2 ImpSDA, n = 55 abs. (%) SPh, n = 39 abs. (%) SAD, n = 25 abs. (%) APPD, n = 20 abs. (%) STPD, n = 11 abs. (%)
Hallucinatory-paranoid 8 (20.1) 42** (76.4) 33** (84.6) 7 (28.0) 9 (45.0) 1 (9.1)
Affective-paranoid 23** (57.5) 17 (23.6) 6 (15.4) 18* (72.0) 11 (55.0) 1 (9.1)
Anxiety-depressive 5 (12.5) - - - - 5 (45.5)
Psychopath-like 3 (7.5) - - - - 3 (27.3)
Obsessive-compulsive 1 (2.5) - - - - 1 (9.1)
Table 2. Distribution of the examined patients according to the leading clinical syndrome by groups and at separate nosologies

Analyzing the distribution of patients by clinical syndromes in some nosologies, it was found that hallucinatory-paranoid syndrome significantly dominated in patients diagnosed with SPh (p = 0.000), while in SAD more often than twice, there was an affective-paranoid symptom complex - depressive-delusional (p = 0.001). Whereas among patients with APPD the predominance of affective-paranoid symptoms did not have a statistically significant difference (by 10.0%, p = 0.5).

The conducted clinical and diagnostic interview also confirmed the qualitative differences of motivational attitudes in the clinical and pathogenetic development of SDB in the patients' examined groups.

The analysis of motivational attitudes in the statements of patients with PSD SPhS on their implementation of SDA (patients' answers to the question "Why did you perform these actions (SDA)?". The clinical diagnostic interview also confirmed significant differences in each group of examined patients (data are given in Table 3).

Motivational attitudes of patients Gr1 ContSDB, abs. (%) Gr2 ImpSDA, abs. (%)
Attempts to reduce the high level of subjective anxiety ("… wanted to reduce anxiety… stress ...", "… then it became easier….") 21 (52.0%)**
Efforts and a way to draw attention to yourself ("… so she didn't notice me, only then she understood…", "… when I did so they paid attention to me…") 9 (22.0%)**
Impossibility to accept the presence of a mental illness or psychiatric diagnosis ("I don't want to live like that", "Who needs me like this?", "What is the point of living like this?") 2 (5.0%)**
Attempts to overcome feelings of conflict in the family ("…got conflicts…", "… I can no longer tolerate these quarrels…") 3 (7.5%)**
Influence of imperative pseudo-hallucinations "… I was ordered (told) by voices". 41 (74.0%)**
Influence of hallucinatory symptoms and delusions (mainly persecution and influence) ("… I was watched. ...I didn't want to be caught…" and "… I was watched… got…. I wanted to stop…") 8 (15.0%)
Delusional ideas of self-blame ("… I don't want to live after what I did" and "… I have a lot of suicides, it's my fault…") 5 (12.5%) 6 (10.9%)
Table 3. Distribution of the examined patients by groups (Gr1 ContSDB and Gr2 ImpSDA), according to the motivational attitudes that preceded the implementation of the SDA.

According to this analysis, in more than half of the cases (43.2% of cases among the entire sample), imperative pseudo-hallucinations prevailed as the leading motivational setting for the implementation of the SDA, and all these cases were referred to the Gr2 ImpSDA. These patients implemented self-destructive actions only under the influence of imperative pseudo-hallucinations during a significant exacerbation of psychotic symptoms (p = 0.000). In three-quarters of cases (74.5%) this was the main reason for patients' self-destructive decision (the moment of transition from the emergence of the idea to the direct implementation of the SDA) in Gr2 ImpSDA. The remaining patients (14 people, 25%) were divided into two subgroups: the first (8 patients, 15%) also showed hallucinatory-delusional symptoms when the main plot of delusional experiences were delusional ideas of persecution and influence. Whereas in the second subgroup (6 patients, 10%) delusional ideas of self-blame came to the fore, and hallucinatory symptoms were weak or absent.

Among the patients of Gr1 ContSDB, no case of implementing SDA under the influence of imperative pseudo-hallucinations as a certain motivation for the implementation of self-destructive acts was identified. Motivational statements in this group were quite diverse, but they could be combined into groups of motives, as shown in the Table. 3. That is, the exacerbation of SDB with subsequent implementation of the SDA among patients in Gr1 ContSDB occurred primarily due to personal experiences related to psychological problems - they are, to a greater extent, caused exacerbation of psychopathological symptoms and became the basis for a suicidal decision. The most common motive for implementing SDA was the experience of unbearably high levels of internal anxiety (more than half of the cases), and almost one in four patients in this group wanted to attract the attention of those closest to them (relatives). These motivational attitudes should focus on the psychological correction and/or psychological support of such patients. There were fewer numerous subgroups of cases where patients stated that the basis for the decision to carry out the trial was family conflicts (7.5%) or unwillingness to accept the presence of mental illness (5.0%). The only group of patients (11.6% of the entire cohort of subjects), in which the main motivating factor for the manifestations of SDB were delusional ideas of self-blame, included representatives of both groups: 5 patients with Gr1 ContSDB (12.5%), in which manifestations of SDB are present constantly and even in periods of remission, as well as 6 patients (10.9%) with Gr2 ImpSDA, in whom the manifestations of SDB occur only at the height of exacerbation of psychotic symptoms. Although the symptoms of all these patients were similar in motivation (the plot of delusional experiences), it had an important difference. Thus, in patients with Gr1 ContSDB, the manifestations of SDB were recorded in the form of suicidal thoughts and statements that remained after the removal of the acute psychotic state, although they reduced their intensity. Whereas in patients with Gr2 ImpSDA any manifestations of SDB were almost completely reduced after the acquisition of acute psychopathological symptoms.

Conclusion

  1. The study showed a significant difference in patients' motivational attitudes with the implementation of the SDA, according to the analysis of patients' statements.
  2. In Gr2 ImpSDA patients committed self-harm under the influence of imperative pseudo-hallucinations. The implementation of the SDA by patients with Gr1 ContSDB occurred primarily due to personal experiences related to psychological problems, and not only against the background of exacerbation of psychotic symptoms.
  3. The diversity of motives among patients with Gr1 ContSDB was primarily aimed at reducing the high level of subjective anxiety and attempts to attract the attention of the immediate environment, and to a lesser extent - to overcome the experiences of family conflicts and the inability to accept mental illness or psychiatric diagnosis.
  4. At the same time, we found a cohort of patients that was common to both groups. These are patients who had the leading psychopathological symptoms - delusional ideas of self-blame.

Additional information

Conflict of interests

The authors declare no competing interests exist.

References

  1. Wasserman D, Wasserman C, et al. Oxford Textbook of Suicidology and Suicide Prevention. Oxford University Press; 2009. doi:https://doi.org/10.1093/med/9780198570059.001.0001
  2. Saxena S, Krug E, Chestnov O. Preventing Suicide: A Global Imperative. World Health Organization; 2014.
  3. Hawton K, van HK. Suicide. Lancet. 2009;373:1372-81. doi:https://doi.org/10.1016/s0140-6736
  4. Jokinen J, Talbäck M, Feychting M, Ahlbom A, Ljung R. Life expectancy after the first suicide attempt. Acta Psychiatr Scand. 2018;137(4):287-95. doi:https://doi.org/10.1111/acps.12842
  5. Hedegaard H, Curtin S, Warner M. Suicide Mortality in the United States, 1999-2017. NCHS Data Brief. 2018;(330):1-8.
  6. Rutz W, Rihmer Z. Suicidality in men—Practical issues, challenges, solutions. J Men’s Health Gender. 2007;393. doi:https://doi.org/10.1016/j.jmhg.2007.07.046
  7. Mann J. A current perspective of suicide and attempted suicide. Ann Intern Med. 2002;136(4):302-11. doi:https://doi.org/10.7326/0003-4819-136-4-200202190-00010
  8. Sher L, Oquendo M, Mann J. Risk of suicide in mood disorders. Clin Neurosci Res. 2001;1:337-44.
  9. Brådvik L. Suicide risk and mental disorders. Int J Environ Res Public Health. 2018;15:20-8. doi:https://doi.org/10.3390/ijerph15092028
  10. Caldwell C, Gottesman I. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull. 1990;16(4):571-89. doi:https://doi.org/10.1093/schbul/16.4.571
  11. Sartorius N, Jablensky A, Korten A, et al. Early manifestations and first-contact incidence of schizophrenia in different cultures: A preliminary report on the initial evaluation phase of the WHO Collaborative Study on Determinants of Outcome of Severe Mental Disorders. Psychological Medicine. 1986;16(4):909-28. doi:https://doi.org/10.1017/s0033291700011910

How to Cite

1.
Pyliagina Г, Bashinskiy О. Self-destructive behavior in patients with psychotic disorders of the schizophrenia spectrum . PMGP [Internet]. 2020 Sep. 13 [cited 2024 Mar. 29];5(3):e0503263. Available from: https://e-medjournal.com/index.php/psp/article/view/263