How to deal with an aggressive schizophrenic?

How to deal with an aggressive schizophrenic?

Studying methods of prevention and ways of treatment of aggressive behavior in patients with schizophrenia is one of the actual problems of modern psychiatry. The aim is to study manifestations and methods of risk assessment of aggressive behavior, methods of their correction and actions of medical personnel. Materials and methods. Review of domestic and foreign literature, including methods of treatment and prevention of aggressive behavior. Results. The analysis has shown, that aggressive behavior in patients with schizophrenia occurs in 8.4% of cases, most frequently in the paranoid form, in the form of irritability (16-24%) and rampage (23-24%). The BVC (The Broset Violence Checklist) scale, allows the most accurate prediction of the risk of developing aggressive behavior. For treatment, a combination first-generation neuroleptic, haloperidol, with some kind of tranquilizer is usually used. Haloperidol is widely available and can be used in areas with limited financial resources. The combination of haloperidol with pipolphene (promethazine) is more effective. Monotherapy with haloperidol may cause excessive sedation and dystonia, which is not the case with the combination of these drugs. The “gold standard” of treatment is still clozapine. Conclusion. Timely identification of factors for aggressive behavior will allow health care providers to reduce the risk of aggression and develop a sequence of actions in case it develops.

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Aggressive behavior resulting in socially dangerous acts remains one of the most important problems in psychiatry, primarily in terms of the prevention of such behaviors. As defined by the World Health Organization, aggression is ubiquitous in both humans and animals, and its basis is considered to be multifactorial, including political, socioeconomic, cultural, neurobiological and psychological causes. As such, aggression is not a destructive force, but a natural and evolutionarily evolved mechanism that has contributed to the survival of the human race. Pathologically, however, aggression is defined as any behavior that is hostile, harmful, or destructive in nature and may cause harm or damage to people or objects [7].

As can be seen from the figure, aggression is divided into many forms and manifestations. This classification can be used in psychiatric clinical practice.

Figure. Classification of aggression presented by [3].

Aggression is most common in people with psychiatric disorders, particularly patients with schizophrenia [4-10].

Schizophrenia is a complex of mental and behavioral disorders manifested by hallucinations, slowed thought processes, cognitive disorders, speech disorders, emotional bluntness, decreased volitional and motivational activity and eventually leads to personality changes [5].

Approximately 1% of the world’s population suffers from schizophrenia, men and women alike [6]. Aggressive behavior occurs in schizophrenic patients in 8.4% of cases [1, 2]. It is necessary to remember that aggressive behavior is caused not only by psychopathological symptomatology, but also by such factors as personality weaknesses, changes in social status and concomitant substance use. Studies show that as the patient’s age increases, the risk of developing aggressive behavior decreases. It is most common in women, particularly the unmarried (divorced and widowed) (7, 8). Patients with paranoid schizophrenia are most prone to aggression, especially in the presence of delusions of exposure and delusions of persecution (4). The main forms of aggressive behavior in the paranoid form of schizophrenia, are negativism, that is, protest behavior, physical aggression, which is manifested in the use of physical force against another and indirect aggression. In the structure of aggressive behavior they are characterized by such aggressive emotional states as resentment, suspicion and irritation [8]. Factors provoking aggressive behavior in patients with schizophrenia in inpatient settings [1]:

  • Hallucinatory delusional symptomatology occurring in the first days of hospitalization. The risk of aggressive behavior decreased against the background of the treatment;
  • Patient’s reaction to admission to a psychiatric hospital;
  • Conflicts with medical staff regarding adherence to the ward regime;
  • Prohibition of smoking in the ward;
  • Prohibition of use of means of communication;
  • Lack of cultural and recreational activities.

Aggressive behavior of patients with schizophrenia is conditioned, on the one hand, by pathological structure of the personality, namely its properties such as egocentrism, difficulties in social adaptation, emotional instability. On the other hand, psychopathological phenomena, such as delusions, hallucinations, crepuscular disorders of consciousness, manic states can render considerable influence on formation of aggressive behavior in patients with schizophrenia.

In psychiatry, various scales, questionnaires and questionnaires are used to assess the occurrence of aggression. The BVC scale (The Broset Violence Checklist), which allows to predict the risk of development of aggressive behavior, is well established in the domestic literature. The most frequent manifestations in schizophrenic patients are irritability (16-24%), which is expressed by easily arising anger, temper in response to common stimuli, and rage (23-24%), which is manifested by explicit behavior accompanied by yelling and noise, such as slamming the door, shouting, shouting in a conversation. Such manifestations as confusion, verbal threats, physical threats, destructive actions are very rare (1-2%) [1, 2].

Medication treatment of aggression

Typical antipsychotics are the mainstay of long-term treatment of aggressive behavior in schizophrenia. Clozapine is the gold standard for treating patients with schizophrenia who exhibit aggressive behavior. Studies have compared clozapine, olanzapine, and risperidone in patients with schizophrenia or schizoaffective disorder. The efficacy of clozapine was superior to olanzapine, which in turn was superior to haloperidol. Although its anti-aggressive efficacy is firmly established, clozapine is not a panacea. Many patients do not respond to this medication. Olanzapine is effective against overt physical aggression and against hostility in long-term exacerbation patients with schizophrenia. Prompt use of sedatives or sedative agents is important. Lorazepam is a benzodiazepine that is reliably absorbed intramuscularly and has no active metabolites with a half-life of 10 to 20 hours; the usual dose is 0.5-2.0 mg every 1-6 hours. Lorazepam is not recommended for long-term daily use because of the potential for tolerance and dependence. A first-generation combination treatment, haloperidol with lorazepam (its counterpart is phenazepam or another benzodiazepine-type tranquilizer), is commonly used. Haloperidol is widely available and can be used in areas with limited resources. The combination of haloperidol with promethazine (pipolphene) is more effective. Haloperidol used alone may cause excessive sedation and dystonia, which is not the case with the combination of these drugs. If compared with the combination of haloperidol with midazolam (dermicum), this combination is more sedating. The risk of over-sedation is much lower when haloperidol is used with promethazine. This combination is more effective in inducing sedation or tranquilization for 30 minutes. Haloperidol with promethazine is safer and more effective; in addition, the side effects of haloperidol can be mitigated by simultaneous administration of promethazine. Midazolam and lorazepam can cause respiratory depression [6]. Second-generation antipsychotics are also used for treatment. The three most used short-acting drugs are intramuscular drugs (ziprazidone, olanzapine, and aripiprazole). Their main advantage over first-generation antipsychotics is their lower propensity to develop extrapyramidal side effects. Their action is rapid, but recurrence of aggression may occur with the need for reintroduction. Inhaled loxapine is in clinical development, where the drug is delivered using a handheld device that produces a thermally formed condensing aerosol without fillers or propellants, resulting in rapid delivery to the lungs and then to the systemic circulation. Inhaled loxapine provides rapid, well tolerated treatment for patients with schizophrenia [6].

Actions in aggressive patient behavior

Aggression most often accompanies exacerbations of schizophrenia when such patients are in a psychiatric hospital. Therefore, medical personnel – doctors, nurses, orderlies – should be familiarized with the manifestations of aggression. The patient can be physically restrained only if he or she is a danger to himself or herself and others. It is necessary to remember that inappropriate use of restraint can increase agitation, aggressive behavior and destructive actions. Restraint should be discontinued as soon as the patient calms down and demonstrates evidence of regaining self-control. During physical restraint, there is a risk of trauma to both patient and staff, so there is a need for verbal intervention, to support patients, to negotiate the timing of isolation, to renew good relationships that could help reduce aggression and return the patient to a calm state.

  • Show your interest in the patient’s condition and empathy;
  • speak softly, but clearly and calmly;
  • help the patient to remain in control and listen to their thoughts;
  • Do not threaten, blame or judge the patient;
  • Encourage the patient, communicate with the patient, and show listening skills;
  • Allow the patient to find a solution to the problem;
  • Offer medication: begin oral therapy.

Lorazepam (2-4 mg) may be used to start. If the patient refuses oral administration, the drug should be administered intramuscularly. Observation of the patient should last at least 20 minutes. If there is no effect from lorazepam, haloperidol (5mg) should be used, which may be repeated every hour up to a maximum of 20mg.

After the interventions, the patient should be monitored until the signs of aggression disappear [9].

Thus, the literature review revealed that aggressive behavior is quite common among patients with schizophrenia. Early detection of patients’ propensity for aggressive behavior in schizophrenia using the BVC (The Broset Violence Checklist) scale can prevent the risk of aggression. The “gold standard” of drug treatment is clozapine.

The development of questions of methodology and organization of treatment and rehabilitation measures for patients with schizophrenia with aggressive behavior, aimed at the prevention of repeated socially dangerous acts, should be carried out with the involvement of doctors, nursing staff, and health care organizers.

Rehabilitation in schizophrenia

Rehabilitation in schizophrenia, this is one of the most important stages of recovery and socialization of the patient with schizophrenia.

Call +7(495) 135-01-09 and we will be able to help you even in the most complicated cases!

For the duration of treatment, we issue a medical certificate which does not state the reason for inability to work during hospitalization or outpatient treatment in a specialized department of the clinic. Confidentiality of the reason for referral to the clinic is guaranteed.

Special psychotherapeutic group sessions are held!

The relatives of a person suffering from schizophrenia have a great responsibility to organize a family member’s meeting with a psychiatrist, maintain contact with the treating physician, and follow all necessary recommendations. Often the patient’s relatives lack the most basic information about the behavior of a schizophrenic patient, communication skills and knowledge of the rights of a schizophrenic patient. Transfiguration clinic pays special attention to work with relatives, their awareness and psychological help to family members of a patient with schizophrenia.

What is the reason why most patients, despite treatment, end up back in psychiatric clinics?

The importance of rehabilitation for schizophrenia

This is mainly due to the refusal to undergo rehabilitation for schizophrenia, taking supportive therapy. Violation of the regime during rehabilitation for schizophrenia, independent, uncontrolled reduction of the doses of drugs taken. Of course, the easiest way to blame patients for unconsciousness, laying all the blame for another relapse of the disease on them. However, much of the blame for this situation still lies with doctors and the health care system as a whole.

Often, after discharge from a psychiatric hospital, a patient in rehabilitation for schizophrenia is actually left to himself and unable to continue to cope with his illness. He faces wary looks from family and co-workers or tries to hide the fact of his hospitalization altogether.

He is left alone with fears about his future, which often seems uncertain. In this case, there is a risk of severe mental illness, such as psychosis, which must be treated and rehabilitated in a specialized hospital.

In addition to such “bright” symptoms as delirium and hallucinations during an attack, schizophrenia can manifest as mood swings, unreasonable anxiety, and peculiar personality changes. It becomes difficult for patients to communicate with people and properly understand the world at large.

Thus, the patient needs support and rehabilitation for a long period after the acute episode. Assistance in rehabilitation of patients with schizophrenia consists, first of all, in informing the patient and his relatives about the course of the disease, debunking “myths” about the disease.

What kind of rehabilitation is needed for schizophrenia

A person suffering from schizophrenia often does not fully understand the depth of his mental affection, therefore the closest relatives have to monitor his health, nutrition, appearance and adaptation in society.

Often, if a person does not undergo rehabilitation for schizophrenia, there is so much destruction of the patient’s personality that he is unable to live an independent life, work or create a family. In this case, disability for mental illness is formalized: the patient is assigned a pension depending on the group and other social benefits are added. Within 5 years, the patient needs to undergo a medical and labor expert commission annually, undergo rehabilitation for schizophrenia, take prescribed medications, and regularly visit his or her doctor. If the condition does not recover after 5 years, disability is assigned for life. In the absence of visits to the psychiatrist and refusal of the recommended treatment, the patient’s behavior may be interpreted by the medical commission as recovery. In this case, disability is not extended.

The main rehabilitation for schizophrenia is to ensure regular check-ups by a psychiatrist, monitoring the intake of antipsychotic medications, maintaining physical health, and undergoing social and psychological rehabilitation. This kind of comprehensive therapy is available at the Transfiguration Clinic.

Rational employment is necessary for patients, allowing them not to fall out of society, to feel needed and useful to society. Finally, psychotherapy has an important impact on rehabilitation of patients with schizophrenia, allowing the patient to understand their illness and timely address the doctor to prevent relapses and adapt to the world around them.

What to do if you fall ill with schizophrenia

  • Find an opportunity to visit a psychiatrist.
  • Applying to our private psychiatric clinic will fully preserve the anonymity and social rights of any person.
  • In the diagnosis and the selection of appropriate drug therapy, as well as the exacerbation of schizophrenia, hospitalization is necessary.
  • Keep in constant contact with the attending physician. As soon as you notice signs of changes in behavior or thinking, inform the doctor immediately.
  • Make sure you take your prescribed medications at all times.
  • A patient with schizophrenia should be treated in full, including social and psychological rehabilitation and family psychotherapy.

How to communicate with patients with schizophrenia

Schizophrenia patients usually have a well-developed intellect, but their system of logical constructions, in view of mental lesion, has a unique character. Such a person understands what you say to him, but in the analysis and in the answer to your question he relies on his own installations, values, or even just a momentary mood.

It is better not to argue with a person in a state of psychosis, or demonstrating delusional symptoms. It is not only useless – you will not be able to convince him of the fallacy of his judgments, but also unsafe – you will become his enemy. And then it will be very difficult to re-establish contact.

Behavior of a patient with schizophrenia during a flare-up

Schizophrenia patients during a relapse often experience hallucinations, are aggressive, tense and anxious, and they have sleep disorders. Behaviorally, such patients are suspicious, listen to things, may run away from imaginary enemies, hide, or show unkindness and aggression to those whom they consider to be ill-wishers. Suicide attempts and suicidal thoughts are also possible.

During exacerbations, patients suffering from schizophrenia may leave home, eat almost nothing, express delusional thoughts, and make attempts to protect themselves from “persecution”. Try to arrange for the patient to see a psychiatrist as soon as possible.

Rehabilitation for schizophrenia largely prevents the possibility of periods of exacerbation of the disease. It preserves the patient’s intelligence and cognitive function.

Speech of the schizophrenic patient

The expressions and speech of patients with schizophrenia are directly affected by changes in thinking and the emotional-volitional sphere. Speech becomes grammatically irregular: neologisms appear – words invented by the patient and devoid of any sense. Thinking discontinuity leads to discontinuity in speech: despite the apparent ordering of the words in a phrase, its general sense is lost – there are many words, but all about nothing, the so-called “verbal octopus”.

Phonetic speech disorder is expressed in the setting of incorrect accents in words, unusual intonations in phrases and substitution of sounds for unusual ones. As the delirium simplifies, speech becomes poorer and the sense of communication with the schizophrenic patient becomes formal and superficial.

At first, the written expression of the speech function manifests itself by its floridness and fantastic plot, which is then replaced by stereotypical writing of phrases and figures with complete deprivation of meaning. The handwriting at the beginning of the disease is characterized by embellishments and curlicues, and when the personality collapses, it is replaced by simple signs which are not connected to each other.

Over time, the speech of patients becomes emotionally colorless, there is no interest in the interlocutor, indifference to the reaction of the bystander.

Rehabilitation for schizophrenia involves keeping the patient in the doctor’s field of vision, which allows for timely adjustment of dosages of medications and the treatment regimen.

Schizophrenia rehabilitation – how to talk

The patient is withdrawn to himself and it is practically impossible to get through to his mind. He is distrustful even of those closest to him and sometimes aggressive. The person relies on his internal logic and it is not possible to convince him in the usual ways.

If you want to get a result of the resumption of treatment – try to make contact with the sick person. Stop proving them wrong, press and convince. Agree with what you can agree, and ignore everything else. As long as the patient’s thoughts are fixed on his painful experiences, it is impossible to turn him over to other ideas. Use the symptoms he is complaining about as a guide. Ask him if he wants to get better sleep, get rid of bothering neighbors or anxiety, and pursue the line. Call a psychiatrist at home in the guise of a psychologist, policeman or neurologist. Everything else is up to the specialist.

If you want to learn to understand your sick family member, come in for a consultation with a psychiatrist-psychotherapist. After preliminary training – to persuade the patient to be treated will be much easier. Our clinic conducts special sessions for relatives of patients with endogenous processes.

When a person in a psychotic condition refuses to go for consultation, invite the doctor to the house, or call the psychiatric care team. If the patient consults a psychiatrist for the first time, along with a call to the ambulance, securely call the police, who have a psychiatrist in their structure, or simply confirm the patient’s asocial and violent behavior. In this case, the hospitalization will be involuntary and the person will be registered at PND for control, as he will need rehabilitation due to schizophrenia.

Are schizophrenic patients aware of their illness?

Peculiarities of mental changes when suffering from this disease are such that patients are not capable of fully realizing their illness. Moreover, this diagnosis still has negative connotations in our society. Even in remission, when criticism partially returns to him, the patient may simply be ashamed of his illness and hide it even from his loved ones.

Understand what changes occur when the disease, to realize his illness and learn to cope with it, a person can be on courses of social and psychological help. Preobrazheniye Psychiatric Clinic in Moscow has developed a special program of psychotherapeutic assistance for patients with schizophrenia.

Rehabilitation of patients with schizophrenia

  • Individual selection of a neuroleptic and the form of its administration (tablets, prolongation);
  • restoration of the patient’s physical health;
  • social assistance;
  • individual and group psychotherapeutic work;
  • receiving recommendations for observation, treatment and regimen.

Social and psychological rehabilitation of patients with schizophrenia begins with art therapy – a method which allows to understand oneself through artistic expression and to reconnect with the world.

Rights of a schizophrenia patient

dignity and rights of a schizophrenia patient are protected by law “about psychiatric aid and guarantees of rights of citizens during its rendering” from July, 2nd, 1992, #3185-I. Additions to this document are contained in Federal Laws of 21.07.1998 N 117-FZ, of 25.07.2002 N 116-FZ, of 10.01.2003 N 15-FZ, of 29.06.2004 N 58-FZ, of 22.08.2004 N 122-FZ, of 27.07.2010 N 203-FZ, of 07.02.2011 N 4-FZ, of 06.04.2011 N 67-FZ as amended by the Decree of the Constitutional Court of the Russian Federation of 27.02.2009 N 4-P.

This legislative act describes how the examination of mental condition should take place, the rights of people with mental pathology, when and for how long a disability is granted, a list of contraindications for professional activity for people with mental illness is given. It also says about the confidentiality of the fact of seeking psychiatry, consent and refusal of treatment, and the conditions for compulsory medical care.

Counseling is possible only with the person’s consent upon reaching 15 years of age. Prior to this age – at the request and consent of the parents or guardian. In the same way, parents or an adult citizen sign a statement about taking or refusing counseling observation. Dispensary observation is established without the consent of the patient, but can be appealed.

On the basis of a court order, patients are placed in a psychiatric hospital on an involuntary basis, if they may harm themselves or others, and also in cases where their health may deteriorate considerably without treatment, or if they are unable to satisfy their basic vital necessities (Article 29, points a, b and c). If a mentally ill person’s condition is still dangerous, re-examination takes place every month for six months, and then once every six months thereafter. For the duration of the acute state of illness, the person is exempted from responsibility for the misdemeanors he has committed.

The society provides: all kinds of psychiatric and psychological assistance, assistance at home and care for the disabled by social workers, support in training and employment, . Every PDP employs a free lawyer, who advises sick people and their relatives on all legal aspects.

The patient is explained the purposes of hospitalization in language he understands. He has the right to appeal to the head of the department and the head physician regarding diagnosis, treatment, discharge from the clinic and regarding violations of his rights under this law. The patient may submit any petitions and complaints to all authorities without censorship, as well as meet one-on-one with a lawyer and a priest. On an equal basis with other citizens, the mentally ill person has the right to shop, to be educated, and to receive remuneration for his labor. While in the hospital he may subscribe to periodicals, read any books, send and receive parcels and packages, use the telephone and receive visitors, and wear his own clothes. There is a special commission made up of people outside the health authorities to protect the rights of patients in psychiatric institutions.

Celebrities with schizophrenia

Contrary to the expression: “genius and insanity,” the percentage of schizophrenic patients among celebrities is not more common than in other environments.

Famous schizophrenics
  • Vincent Van Gogh was a Dutch impressionist painter;
  • Sid Barrett – musician, founder of the band Pink Floyd;
  • Nikolai Vasilievich Gogol – Russian writer;
  • John Nash, American mathematician and economist;
  • Friedrich Wilhelm Nietzsche, German philosopher;
  • Amanda Bynes – Los Angeles actress;
  • Salvador Dali, the Spanish surrealist painter suffered from schizotypal disorder.

These people were under the care of good doctors. And even at that time, a good doctor could get the disease under control! Today it is much easier, but it takes the experience and knowledge of a specialist. There is no need to be afraid of the disease! Any disease can be cured. And if you take the disease under control, it can give you genius!

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