Prophylactic therapy for autoaggressive behavior in patients with paranoid schizophrenia with symptoms of depression

Abstract

Introduction. Patients with depressive symptoms in schizophrenia are prone to recurrent autoaggressive behavior, including suicidal, in the first few months after withdrawal from a psychotic episode. There was no effect on the recurrent autoaggressive behavior of typical and atypical neuroleptics, mood stabilizers and others, especially in the presence of symptoms of depression. Our study aims to develop psychotherapeutic interventions according to selected targets, which will help the patient to control impulsive aggressive or autoaggressive behavior now and prevent recurrence of such behavior in the future, given that drug therapy does not guarantee such an effect.

Materials and methods. The study involved 85 patients with paranoid schizophrenia by continuous sampling (out of 130 patients) and determining their possible inclusion in the study according to the inclusion / exclusion criteria. The following methods were used: clinical-anamnestic, clinical-psychopathological, pathopsychological, socio-demographic and mathematical statistics. All patients were examined on the scales PANSS, Calgary (CDSS), "Reasons for Life" (RFL), a questionnaire to determine normal behavior in stressful situations (Bass-Dark test) and methods for determining integrated forms of communicative aggression (Boyko V.V.).

Results. According to the study plan, we conducted individual and group psychotherapy for patients of the main and control groups in the department during hospitalization. Given the beginning of quarantine measures (Covid-19), the number of participants in the groups was reduced to 6 people, taking into account the possibilities of the branch. Individual therapy continued as planned. None of the patients dropped out of the study.

Group therapy included sessions of direct cognitive-behavioral therapy lasting 2 hours 2 times a week. Individual therapy was held 2 times a week depending on the patient's condition, the duration of the session was 50 minutes.

Pathopsychological examination on selected scales was performed before and after the course of psychotherapy and after 3 months. It was noted that the individual approach to psychotherapy with the definition of targets of psychotherapeutic interventions can increase the motivation of patients to therapy, improves emotional regulation, provides opportunities to find constructive means of self-regulation.

Conclusions. Psychotherapeutic work in case of autoaggressive manifestations should be aimed at the patient's values, individually focused on his needs, which are clarified with the help of appropriate questionnaires. Application of the proposed complex of preventive therapy (individual and group psychotherapy in the direction of CBT in combination with drug therapy) in patients with paranoid schizophrenia with symptoms of depression and autoaggressive manifestations allowed to achieve a significant sustainable and long-term improvement of the patient's condition both in the manifestations of autoaggression and in general indicators of aggression and emotional disorders.

Background

Patients with depressive symptoms in schizophrenia are prone to recurrent autoaggressive behavior, including suicidal, in the first few months after withdrawal from a psychotic episode [1]. There was no effect on the recurrent autoaggressive behavior of typical and atypical neuroleptics, mood stabilizers, and others, especially in the presence of symptoms of depression [1].

Studies show that predisposition to auto-aggression is comorbid disorders due to psychoactive substance use, treatment failure, reduced economic well-being, the experience of abuse, childhood behavioral disorders, and sexual violence [2]. In itself, the severity of a psychotic episode is not a predictor of auto-aggression, except in cases of depressive symptoms in patients [3]. The use of high doses of benzodiazepines and clozapine in the acute phase will lead to some reduction in aggression during this period [4], but will not cause a decrease in recurrent auto-aggressive behavior in patients with a history of such cases [5].

Our study aims to develop psychotherapeutic interventions according to selected targets. This will help the patient to control impulsive aggressive or auto-aggressive behavior for the present time and prevent recurrence of such behavior in the future, given that drug therapy does not guarantee such an effect.

Aim

To develop and test a set of measures for preventive therapy of auto-aggressive behavior in patients with paranoid schizophrenia with symptoms of depression based on the results of our own research.

Materials and methods

The study included 85 patients with paranoid schizophrenia by continuous sampling (out of 130 patients) and determining their possible inclusion in the study according to the inclusion/exclusion criteria. The following methods were used: clinical-anamnestic, clinical-psychopathological, pathopsychological, socio-demographic, and mathematical statistics. All patients were examined according to the scales PANSS, Calgary (CDSS), "Reasons for Life" (RFL), a questionnaire to determine normal behavior in stressful situations (Buss - Durkee), and a method for determining integrated forms of communicative aggression (V.V. Boyko).

The study consisted of three stages.

1. Clinical and psychopathological examination of 85 patients with paranoid schizophrenia (using the scales PANSS, Calgary (CDSS), "Reasons for Life" (RFL), a questionnaire to determine normal behavior in stressful situations (Buss - Durkee) and methods for determining integrated forms of communicative aggression (V.V. Boyko).

2. The stage of carrying out a set of preventive measures of auto-aggressive behavior (measures for prevention and treatment of auto-aggressive behavior - MPTAB).

3. The stage of evaluating the effectiveness of the proposed complex MPTAB 3 months after its completion.

Results

At the beginning of the study, we found that the presence of depressive symptoms can negatively affect the belief of patients with schizophrenia in the ability to survive. The progression of the underlying disease causes a decrease in social responsibility and moral qualities of the main contingent of patients. We used this data to develop long-term psychotherapeutic interventions.

The targets of psychotherapeutic interventions were selected directions, according to the RFL scale (48 points). The most significant for the patients of the main group were the subscales “responsibility to the family” (4.2 ± 1.1 points), “feelings for children” (5.1 ± 0.7 points), and “fear of suicide” (3.6 ± 0,9 points). At the same time, in both groups, there was a low level on the subscale "belief in the possibility of survival" (2.9 ± 0.9 and 3.2 ± 1.0, respectively) (p> 0.05).

The MPTAB complex included standard drug treatment and individual psychotherapy (2 times a week for 50 minutes) and a session of the group (cognitive-behavioral therapy) lasting 2 hours 2 times a week.

According to the PANSS scale, patients in the main group at the time of inclusion in the study, at the beginning of hospitalization, had a mean score of 121.3 ± 8.06, at the end of the study 101.2 ± 5.8, p <0.05. The difference in factors on the PANSS scale in the main group at hospitalization and at the time of discharge is reported in Table 1, between discharge and after 3 months in Table 2.

Table 1. Dynamics of psychopathological symptoms in the main group according to the PANSS scale (five-factor model) both at hospitalization and at the time of discharge. Note: SD - standard deviation; p is the error probability index calculated by the Mann-Whitney test.

Index on the PANSS scale	At the beginning of hospitalization (n = 41)		At discharge (n = 41)		p
	Mean score, X	SD	Mean score, X	SD
Positive factor	31.9	3.21	15.2	2.11	0.0001
Negative factor	29.4	3.15	24.1	2.4	0.081
Disorganization factor	24.0	2.62	18.7	3.35	0.05
The factor of aggression and agitation	18.3	2.14	8.2	1.18	0.0001
Anxiety and depression factor	17.9	2.54	5.3	1.34	0.05
Total score	121.3	8.06		5.8	0.05
Composite index	-3.1	4.30	8.9	3.05	0.0001

We see a statistically significant improvement both in the positive factor and the disorganization factor. Also, on the factor of aggression and agitation, anxiety, and depression. There was no statistically significant difference in the negative factor.

Table 2. Dynamics of psychopathological symptoms in the main group on the PANSS scale (five-factor model) at the time of discharge and after 3 months. Note: SD - standard deviation; p is the probability of error calculated by the Mann-Whitney test.

Index on the PANSS scale	At discharge (n=41)		In 3 months (n=41)		p
	Mean score, X	SD	Mean score, X	SD
Positive factor	15.2	2.11	13.1	1.8	0.091
Negative factor	24.1	2.41	24.7	2.41	0.135
Disorganization factor	18.7	3.35	16.5	3.12	0.05
The factor of aggression and agitation	8.2	1.18	8.3	1.18	0.261
Anxiety and depression factor	5.3	1.34	4.4	1.12	0.05
Total score		5.8	97.8	4.81	0.352
Composite index	8.9	3.05	11.6	3.92	0.142

From the received data it is possible to draw a conclusion that 3 months after discharge from a hospital a positive dynamic of a condition of patients remained. The level of aggression and agitation remained at the same level, which indicates a fairly stable result.

In comparison with the control group, we can conclude that at discharge the level of anxiety and depression in the main group was statistically lower than in the control group, also after 3 months. The level of aggression and agitation in the control group at discharge was statistically significantly higher than in the main (see Table 3).

Table 3. Comparison of psychopathological symptoms in the main and control groups on the PANSS scale (five-factor model) at the time of discharge. Note: SD - standard deviation; p is the probability of error calculated by the Mann-Whitney test.

Index on the PANSS scale	Main group (n=41)		Control group (n=44)		p
	Mean score, X	SD	Mean score, X	SD
Positive factor	13.1	2.11	13.6	1.43	0.189
Negative factor	24.7	2.41	27.8	3.02	0.035
Disorganization factor	16.5	3.35	20.2	4.02	0.127
The factor of aggression and agitation	8.3	1.18	11.2	1.76	0.05
Anxiety and depression factor	4.4	1.34	8.9	1.54	0.05
Total score	97.8	5.8	105.8	6.01	0.162
Composite index	11.6	3.05	14.2	8.3	0.05

When comparing the results with the control group after 3 months, both groups retained the benefits of inpatient treatment. In the control group, gains in the regulation of aggression were not preserved, compared with the main group (see Table 4).

Table 4. Comparison of psychopathological symptoms in the main and control groups on the PANSS scale (five-factor model) 3 months after discharge. Note: SD - standard deviation; p is the probability of error calculated by the Mann-Whitney test.

Index on the PANSS scale	Main group (n=41)		Control group (n=44)		p
	Mean score, X	SD	Mean score, X	SD
Positive factor	13.1	1.8	12.4	1.51	0.189
Negative factor	24.7	2.41	25.8	3.21	0.129
Disorganization factor	16.5	3.12	19.3	4.12	0.127
Factor of aggression and agitation	8.3	1.18	15.9	2.76	0.05
Anxiety and depression factor	4.4	1.12	6.8	1.54	0.125
Total score	97.8	4.81	100.4	5.01	0.162
Composite index	11.6	3.92	13.4	3.25	0.09

According to the Buss - Durkee questionnaire, we have a statistically significant decrease in verbal aggression and auto-aggression. At the time of discharge, it was 2.9 ± 0.9 in the main group, and 3.8 ± 1.9, p <0,05 in the control group. In 3 months, the level of verbal aggression in the main group was 3.1 ± 1.2, in the control - 4.9 ± 2.2 p <0.05. We see that the acquisition of treatment in the control group for verbal aggression is almost not preserved, and after 3 months returned to baseline.

The rate of auto-aggression, which at the time of hospitalization in the main group was statistically higher than in the control (4.5 ± 1.1 and 2.7 ± 0.4 at p <0.001). After discharge in the main group, the rate of auto-aggression was 2.8 ± 1.1, in the control group - 1.8 ± 0.5, p = 0.105. 3 months after discharge it was 3.1 ± 2.1 in the main group, 2.6 ± 0.8 in the control group, p = 0.235. That is, the achievement of treatment 3 months after discharge did not persist in the control group, the rate of auto-aggression returned to the rates of treatment at the beginning.

According to the method of determining integral forms of communicative aggression (V.V. Boyko), we found a significant decrease in the level of auto-aggression in the main group, compared with the control. At the time of hospitalization, the rates were (3.4 ± 1.2 and 1.8 ± 0.5, p <0.05, respectively). After discharge - 1.9 ± 0.4 and 1.4 ± 0.3, p = 0.115, respectively. In 3 months after discharge in the main group of treatment gains remained 2.1 ± 0.8, in the control slightly increased - 1.9 ± 0.6 (p = 0.245).

Thus, as a result of the study, we see that the use of individual and group psychotherapy in the direction of CBT in combination with drug therapy can achieve a significant improvement in the patient's condition. Both in the manifestations of auto-aggression and in general indicators of aggression. Thus, psychotherapeutic work should be directed on the values ​​of the patient, individually to be guided by their needs, using the corresponding questionnaires. Thus, we see that the applied directions allow keeping the acquired results for a long time after the applied interventions.

Conclusion

Psychotherapeutic work in case of autoaggressive manifestations should be aimed at the patient's values, individually focused on their needs, which are clarified with the help of appropriate questionnaires.

The application of the proposed complex of preventive therapy (individual and group psychotherapy in the direction of CBT in combination with drug therapy) in patients with paranoid schizophrenia with symptoms of depression and auto-aggressive manifestations allowed to achieve significant sustained and long-term improvement of the patient's condition. Both in auto-aggressive manifestations and in general indicators of aggression and emotional disorders.

Additional information

Conflict of interests

The authors declare no competing interests exist.