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Pilyagina, G. Y. (2004). Self-destructive (autoaggressive) behaviour: pathogenetic mechanisms, clinical-typological aspects of diagnostics and treatment. Abstract of the thesis for the doctor of medicine degree in specialty 14.01.16 — psychiatry. Kyiv: Ukrainian research institute of social and forensic psychiatry.
Relevance of the subject. According to WHO forecast, approximately 1.53 million people on the planet will commit suicide and even (10–20 times) more will attempt suicide in the year 2020 (WHO, 2002). It means one death per each 20 seconds and a suicidal attempt per 2 seconds on the average. These data shows the great scope of self-destructive behaviour (SDB) problem. Statistics and literature data point to the growth of SDB level for the last decades in all countries, including Ukraine (WHO, 1999, 2002; Bertolote, 2002). Only in Ukraine 14.5 thousand people commit suicide annually (Chupricov, Pilyagina, 2002 — in Russian).
One of the most dangerous aspects of the problem (SDB growth among the population of various range of countries) is an obvious tendency to the increase of suicidal attempts and other non-lethal equivalent forms of self-destructive activity. The permanent well-felt growth of the number of suicides has become the basis for creation of national programs of suicidal behaviour’s prevention. The existing tendencies reflect the vital necessity of resolving such problems on state level in our country and determine the main directions of suicidological research activity (Chupricov, Pilyagina, 1999, 2002 — in Russian, 2002; Complex Government Program «Health of the Nation», 2002 — in Ukrainian; WHO, 2002; A. Leenaars, 2003).
For the past half-century, during which SDB problem became one of the most actual problems of psychiatry, concrete forms of SDB, their development, social-psychologic predictors and clinic-psychopathologic disorders combined with SDB essentially changed.
Co-morbidity of SDB and different kinds of psychopathological disorders is one of the main directions of research, diagnostic-treatment and preventive activity in psychiatry and suicidology. The greatest level of suicides, suicidal attempts and other kinds of self-destructive acts can be registered at different kinds of depressions, schizophrenia and other psychotic disorders, at alcoholic and drug dependent syndrome (Hawton, Catalan, 1987; Fawcett et al., 1990; Lewinsohn et al., 1996; Blair-West et all, 1997; Inskip et al., 1998; Kjellander et al., 1998; Palmer, 2002; Reutfors et al., 2003). Now some facts alert, that the essential growth of the most able-bodied age men as frequent category of the self-murderers and «young-tendency» of self-destructive acts (Shaffer et al., 1996; Shah et al., 1998).
In the range of SDB’s causes the main positions are held by various psychological (numerous versions of interpersonal conflicts in family and with close people, lack of adequate self-realization, various psychological personal disorders) and social (lack of social activity and contacts, low material level, low level of social engagement) problems (Aldridge, 1999; Wasserman, 2002).
Nowadays the main research direction of suicidology (as considered) are: clinic-psychopathologic, neurobiological and epidemiological. The first two are the most important for diagnostic-treatment practice, whereas the epidemiological researches are to resolve more general social problems (Gunnell, 2002; Shaffer, 2002; Bertolote, 2003; De Leo, 2003; Rutz, 2003; Traskman-Bendz, 2003). Such great spectrum of researches is stipulated by the multifactorial basis of SDB phenomenology. Clinic-psychopathologic and neurobiological researches in suicidology are directed to concrete problems of SDB diagnostics and therapy (Rosanov et al., 1999; Lapitsky, Vaulin, 2000 — in Russian; Mann et al., 1999, 2003). Psychopharmacologic therapy and various kinds of psychotherapy belong to effective methods of therapy (Mokchovikov, 1998; Suicidology, 2001; Pilyagina, 2003 — in Russian; Montgomery et al., 1992; Rathus, Miller, 2002).
Nevertheless, the constant growth of suicide level mirrors the numerous unsolved problems in clinical suicidology. And perhaps the most important one is the deficiency of objective criteria for estimation of SDB’s formation or recurrence probability that enables to develop and to apply purposeful, stipulated by pathogenesis, effective methods of SDB therapy. The problem of verification of SDB formation (or its recurrence) probability is connected with the absence of specific clinic-pathogenetic SDB markers. This can be resolved both by determination of exact semantic definition of SDB’s separate phenomena and through thoroughful research of pathogenetic mechanisms of SDB’s development (Ambrumova, Tichonenko, 1980; Chuprikov et al., 1999 — in Russian; Wasserman, 2002).
For solution of the clinical suicidology problems SDB theoretical models have been being worked out (S. Freud, 1996; C. Meninger 2000; E. Shneidman, 2001 — in Russian; Mann et al., 1999; Wasserman, 2002). However these researches are mostly solitary and non-completed.
The aforesaid emphasizes the relevance and the expediency of the dissertation research. The dissertation investigates pathogenetic mechanisms of suicidogenesis and clinic-typology of various forms, types of SDB with allowance of clinic-phenomenological self-destructive signs, co-morbid psychopathologic disorders, psychological and social-demographic predictors of SDB, capability and effectiveness of its complex methods of diagnostic and therapy.
The aim and problems of the research. The aim of the research: analysis and systematization of the pathogenetic mechanisms of SDB formation, taking into account their co-morbidity with various kinds of psychopathologic disorders; definition and clinic-phenomenological description of internal and external SDB forms and also clinic-pathogenetic types of external SDB forms analyzed suicidogenesis process; creation and realization of complex diagnostic methods of self-destructive (autoaggressive) behaviour and complex methods of emergent treatment of external SDB forms.
For achievement of the set aim such problems were defined:
The object of the research — external and internal SDB forms; pathogenetic development mechanisms of various SDB forms and concrete clinic-pathogenetic types of external SDB forms; psychological SDB predictors.
The research’s methods. For the clinic-pathogenetic SDB development mechanisms’ study clinic-phenomenological approach (within the structured interview method’s framework) was used. The clinic-psychopathologic diagnostics method was used for estimating mental disorders of the patients.
With the view of formalized statistical estimation of patients’ psychopathological disorders, psychometric schedules method, according to PANSS (scale of estimation of positive and negative syndromes) and Ì. Hamilton’s anxiety scale, was used.
The experimental-psychological researches included a range of self-rating tests (in Russian adaptive translation). Were used: the modificative self-destructive (autoaggressive) predictors test (on basis of the presuicidal syndrome by E. Ringel); the reactive and personal anxiety test by C. Spilberger — Yu. Kchanin; the hopelessness scale by À. Beck; the test of social-psychologic adjustment diagnostic by C. Rogers — R. Diamond; the psychological protection scale by R. Plutchik; the mental condition’s test by H. Eyesenk, and the modificative negative life events test also.
For diagnostic verification of neurovegetative dysfunction (patients with SDB’s internal forms) the psychophysiological research method was applied (on research basis of cardiac rhythm variability).
For statistical data’s processing methods of variational statistics with definition of reliability of studied samplings’ differences were applied. The mathematical data processing of the research was conducted through a personal computer with the help of the applied (economical) package (packet) of Excel 5.0 for Windows.
Scientific significance of the outcomes. For the first time in Ukrainian psychiatry a complex research of SDB analysis, pathogenetical mechanisms of its development has been made and the theoretical model of various SDB forms’ and types’ development has been defined.
For the first time a complex analysis of SDB’s multifactorial genesis and integrated approach of pathogenetical mechanisms of SDB’s displays in clinically observable and unobservable periods of SDB (on the basis of the positions of pathological adaptation theory) has been made; the clinic phenomenology of concrete forms and types of SDB have been detected.
For the first time in a dissertation research a method of complex diagnostic of all forms and types of SDB in combination of various kinds of co-morbid psychopathological disorders has been created.
A complex analysis of psychological predictors of different forms and types of SDB formation in clinically observable periods, the specific character of family dysfunction and immediate causes of self-destructive acts have been applied for the first time.
It is also the first creation and application of effective schemes of complex emergent suicidological help.
Practical significance of the outcomes. The practical outcomes of the dissertation consist in the improvement of SDB’s diagnostics and treatment quality on purpose to upgrading of the qualified specialized medical care.
For the first time in a dissertation research a method of complex diagnostic investigation of various forms and types of SDB in combination of various kinds of co-morbid psychopathological disorders has been created and applied.
For the first time methods of system analysis of family dysfunction as one of the main suicidogenetical predictors used in SDB diagnostic and treatment process have been used, that has substantially improved diagnostic-treatment and psychological rehabilitation process of such patients.
For the first time methods of complex emergent suicidological help rendering as a specialized emergent treatment for suicidents in the first postsuicidal period have been created and applied (within the framework of somatic hospitals or specialized psychiatric hospitals).
The application of the dissertation’s outcomes to the clinical practice of psychiatry and suicidology contributes to the improvement of effective diagnostic and treatment SDB methods. The results and conclusions of the dissertation are meant for putting into practical activity of suicidologists, psychiatrists, medical psychologists, all experts, that working in suicidology, and postgraduate education.
For the first time the methods of complex emergent suicidological help (created in dissertation frameworks) have been applied in clinical practice in Kyiv emergent hospital, Vinnitsya regional specialized crisis centre and Lviv psychiatric hospitals. The dissertation’s outcomes have been used for preparation of materials for the section «Correction of self-destructive behaviour» of «The Psychology of Suicide» manual, for a methodical manual «Suicidology. The main terms and concepts» (both in Russian) and inserted in the educational process of children, social and forensic psychiatry sub-faculties of Kyiv postgraduate education medical academy, of medical psychology sub-faculty of Inter-regional academy of staff management (Kyiv).
Approbation of the dissertation’s outcomes. The main positions and conclusions of the dissertation research were reported and discussed at the meetings of Ukrainian research institute of social and forensic psychiatry and narcology, on international and Ukrainian conferences, workshops and seminars.
The publications. On the dissertation’s basis 37 scientific articles (16 of them are monoarticles without a co-authorship) and 2 methodical manuals were published.
The dissertation’s volume. The dissertation consists of 436 pages; the main text includes 282 pages and contains 61 tables, 12 figures. The main text consists of the introduction, the review of the medical information, seven sections, the conclusion, the reference list (523 titles and 3 appendices).
The analysis of the medical information sources demonstrates permanent attempts of SDB systematization on all stretch of suicidology development. The existing theoretical SDB concepts orient on modelling of etiologypathogenetical processes of suicidogenesis. They mirror the correlation of multi-etiological basis of suicidogenesis and various SDB characteristics as the following phenomenological effect (result) of it. But the analysis of the modern scientific suicidological researches doesn’t give the clear notion of suicidogenetical processes and doesn’t consider the pathogenetical development mechanisms of concrete forms and types of SDB.
That’s why the second section of the dissertation is devoted to the main concepts of SDB’s pathogenesis theoretical model. For this a research hypothesis of the dissertational research was formulated. This hypothesis is based on f SDB multifactorial etiology and adaptive character theses.
The main concepts of the SDB pathogenesis theoretical model were formulated on the basis of modern methodological approaches and fundamental natural sciences. The theoretical model of SDB’s pathogenesis includes the principles of evolutional-synergetic paradigm (Prigogin, Stingers, 1986; Nuller, 1992; Samokchvalov, 1994; Pilyagina, 2000; Ebeling et al., 2001; Haken, 2002 — in Russian). The principles of evolutional-synergetic paradigm gave the possibility to describe the exact mechanisms of pathological adaptation as the basis for SDB’s formation. The system clinic-phenomenological approach was used for estimation of the structural fundamentals of the theoretical model of SDB’s pathogenesis. It is based on multifactorial etiological SDB’s character including psychopathological, neurobiological (pathobiological) and psychological components of suicidogenesis. In this section the theory of pathological adaptation describes one of the substantive positions of the theoretical model of SDB’s pathogenesis. The description of pathological adaptation process shows the development process of self-destructive (autoaggressive) activity. The theory of SDB’s pathogenesis demonstrates the formation mechanisms of self-destructive coping behaviour during deviate personal ontogenetical development in predispositional (non-manifestative) and manifestative periods of pathological adaptation. The process of pathological adaptation as the pathogenetical basis of suicidogenesis explains the adaptative significance of SDB as the transformation of neuro-psychical activity disorders to displaced activity. The development of clinically observable SDB forms as displaced activity reduces the expressiveness of chronic personal frustration, that arises during ontogenetic development against the background of deviate child-parents relations. Deviate child-parents relations as one of the main psychological suicidogenetic predictors invokes early narcissistic trauma. The pathological character of personal formation against the background of a child narcissistic trauma exponentiates the cognitive-emotional dysbalance and disproportional, deviate psychological personal development. Thus the formed displaced activity, as a clinically observable SDB form, acquires features of internal activity (internal SDB forms — InSDBF) or external activity (external SDB forms — ExSDBF). Suicides or suicide attempts, as self-destructive (autoaggressive) acts, will be realized as external SDB forms in suicidogenical conflicts. The scheme of suicidogenesis, as an internal or an external SDB form of displaced activity, against the background of personal adaptive strategies’ deviation during the ontogenetic development, within the framework of the theoretical model of SDB pathogenesis, is based on the clinical experiment of the dissertation.
The theoretical concepts of the pathogenetic model of suicidogenesis were used as the basis of criteria of clinical-pathogenetical SDB typology as clinically observable ExSDBF. These criteria can be used for an adequate estimation of clinical-pathogenetical SDB types. They show the practical significance of the theoretical model of SDB’s pathogenesis. On the ground of clinic-pathogenetic SDB types’ definition the following types are offered: suicidal, parasuicidal, pseudosuicidal, asuicidal SDB types as types of ExSDBF. There are the main clinical and pathogenetic characteristics described in the table 1.
The criteria of clinical-pathogenetical typology of self-destructive behaviour
|The criteria of analysis||The clinical-pathogenetical types of ExSDBF|
|Suicidal type||Parasuicidal type||Pseudosuicidal type||Asuicidal type|
|The features of self-destructive behaviour||careful planning of self-destructive actions, selection of dangerous lethal ways of their implementation||impulsive self-destructive actions, selection of non-dangerous ways of their implementation mainly||demonstrative-intimidational self-destructive actions, certain selection of non-dangerous ways of their implementation; lethal outcome is possible as a casualty||impulsive implementation of self-destructive actions, severe refined dangerous lethal ways of their implementation; the possibility of lethal outcome is very high|
|The register of mental disorders||non-psychotic register more often||non-psychotic register||non-psychotic register||psychotic register|
|The mental answer-reaction||mechanism of “self-denying”; “tunnel” cognition, high affect of anxiety and fear of its full suppression||mechanism of displacement of frustrated aggression directed to oneself; affective anxiety reactions, distortion of locus of the awareness||manipulative, rental behaviour, “tunnel” cognition; affective anxiety reactions are possible||mechanism of psychotic displacement of frustrated aggression on oneself; psychotic mental disorders|
|The neurobiological basis||obligatory “actualization” of voluntary self-destruction program||decrease of stress-defense mechanisms; voluntary self-destruction program is not “actuated”||the program of a voluntary self-destruction is missing||“actualization” of voluntary self-destruction program is possible|
|Stages of the adaptational syndrome||transition from resistance-stage to exhaustion-stage||at the alarm-stage||can be without the adaptation syndrome or on its the alarm-stage||psychotic variant of the adaptational syndrome, on any of its stages|
|The personal psychological motivation||desire and attraction of voluntary death on the basis of “negative vital balance”||desire of immediate change of suicidal conflict, instead of achievement of voluntary death on the basis of high frustration of personal needs||desire to change manipulatively the actual situation against the background of the infantile psychological presetting||stipulated by the contents of morbid feelings, suicide motivation cannot be recognized mainly|
The characteristics of the experimental groups and the research methods are displayed in the third section. One experimental group included 350 suicidal attempters who were treated in Kyiv emergency hospital after a suicidal attempt. The second experimental group included 70 patients with internal SDB forms. These patients got the out-patient — consulting form of treatment in Kyiv mental hospital No. 1 and Kyiv emergency hospital. The respondent group consisted of 108 persons without self-destructive (autoaggressive) signs.
The research methods and the authorized procedure of the researching allowed to make the comparative clinic-phenomenological analysis of the clinical and the social-demographical characteristics that occurred with different SDB forms and types. The criteria of clinical-pathogenetical typology of self-destructive behaviour are demonstrating in table 1.
238 women and 112 men have been examined in the group of suicidal attempters. However the given ratio varied with, depending on the different clinical-pathogenetical SDB types. The number of women of pseudosuicidal type was 5.25 times more than the same of men. And the number of men of asuicidal type was 1.71 times more, than the same of women. In the group with InSDBF the number of women was in 3.24 times more, than of men.
The average age of the clinical groups was: 27.75±14.9 years in the group of suicidal attempters and 30.81±11.67 — in the group of internal forms of SDB. In cases of suicidal and asuicidal SDB types self-destructive acts (suicidal attempts) were committed by older people. In 54% of cases of pseudosuicidal SDB type — by young persons before 19 years.
The majority of suicidents had secondary-special and secondary education. The highest level of education was detected in the groups of suicidal and asuicidal SDB types (25 and 21.05% of cases). 41.43% of the patients with InSDBF had a high education level (graduated from college).
In both clinical groups the number of not married persons prevailed. 12.29% of suicidents and 17.14% of the patients with InSDBF were in divorce. 87.43% of suicidents and 90% of the patients with InSDBF lived in their own family or with the parents. According to these data the most significant cause of suicidogenesis is not mostly the actual social loneliness, but the specific form of psychological “loneliness among the close people”.
32.57% of suicidents had a full-time job, 25.71% were unemployed and 22.57% studied at school or in an institute. 47.14% of the patients with InSDBF had a full-time job, 18.57% were unemployed, the group of pupils and students included 24.29% of the person. There were no cases of disabling somatic pathology detected in the group of internal SDB forms, while 8.86% of such persons were fixed in the group of suicidents. The fact of an incurable disabling disease was the main cause for suicidal attempts of 8.29% of the suicidents (of suicidal and asuicidal types of SDB mainly).
Inheritable factors (parents of the patients suffered mental disorders or alcohol abuse) had 40% of the suicidents on the whole and 31.43% — in the group of internal SDB forms. The highest level of cases with mental disorders, as inheritable factors, was detected in pseudosuicidal type of SDB, and the least — in asuicidal SDB type. There was also a material predominance of the index’s ratio in the group of suicidents in comparison with the group of internal forms of SDB: mental disorders — 1.33 times more and alcoholic abuse — 1.25 times more.
A family suicidal history could be seen among 17.14% of the patients with internal forms of SDB, that is 1.62 times more often than in the group of suicidents on the whole (10.57% of cases). In suicident group this criterion could be detected mostly in the cases of asuicidal and pseudosuicidal SDB types.
In the fourth section suicident group’s experimental data is analyzed. It has shown clinic-phenomenological features and qualitative distinctions of SDB, verifying different kinds of pathogenetical mechanisms of SDB’s displays in concrete SDB types.
69.14% of the suicidents (in all the group) committed self-destructive (autoaggressive) acts for the first time. The “suicidomaniacal” tendency was detected almost for each the tenth of the suicidents of all SDB types but the parasuicidal.
For 33.71% of suicidents (of the group on the whole) a very acute presuicidal period (up to 1 hour) was detected, for 26% — acute (up to 1 day) and for 32% — protracted (up to 7 days). And only in 8.29% of cases a lingering presuicidal period (more than 7 days) happened. There was the apparent tendency to reduction of presuicidal period’s duration from lingering to the very acute one in the range: suicidal — parasuicidal — pseudosuicidal types of SDB. 52.17% of the suicidents of suicidal SDB type demonstrated the presuicidal period with realised planning and preparation of suicidal attempts. The “unsuicidal” pathogenetical mechanism of SDB’s formation has been recorded for asuicidal type of SDB, when implementation of self-destructive acts, including “momentary” variants, was explained by the impossibility to manage the arisen desire of self-mutilation, self-destruction under the effect of acute psychotic symptoms. This type of SDB is considered an “unsuicidal” because the motivation of self-destruction isn’t voluntary and is realized by these patients.
The most dangerous ways of self-destructive acts’ realization were those of suicidal and asuicidal SDB types. A tendency to self-destruction in suicidal type of SDB was absolutely voluntary and realized against the background of continuous and severe psychogenical or affective disorders, whereas in case of asuicidal SDB type suicidents acted self-destructively by the direct influence of psychotic symptoms (of cognition, emotions or consciousness psychotic disorders). SDB of asuicidal type formed mainly on the ground of chronic psychotic disorders or acute severe exogenic (alcoholic, drug) intoxications. In parasuicidal and pseudosuicidal SDB types the threat of life (along of self-destructive acts) was much less. In parasuicidal SDB type the impulsive suicidogenesis was mostly supported by different forms of adjustment disorders based on personal psychological deviations. Such suicidents declared the tendency to self-destruction as to “self-exception” themselves from of a psychotraumatic situation, whereas their true motivation was based on the need for change of the situation instead of the intention to die. The actual motivation of pseudosuicidal SDB type is also based on the need for a desirable change of conflict situations, however self-destructive acts are used as a way of manipulation. Hysterical symptomatology (infantile presetting) as the decompensation of hysterical personal disorder or the leading form of psychological personal deviation, is one of the main clinic-phenomenological feature of pseudosuicidal SDB type.
Each third self-destructive act (31.71% in the group) was committed under alcoholic influence. This attests the significance of alcohol as a suicidogenetical factor. The majority of suicidents of suicidal SDB type used alcohol for more burdening effect of suicidal attempt (mainly by overdoses), while parasuicidal SDB type of suicidents used alcohol in order to reduce the consciousness’ control, actuate the impulsiveness and facilitate the taking of suicidal decision.
The most frequent motives of self-destructive acts (for the suicidents) were based on escape behaviour (from psychotraumatic experiences), protest behaviour and desire of revenge. A half of the suicidents (48.91%) of suicidal SDB type claimed that the main motivation of the self-destructive acts (suicidal attempt) was a wish to shrink from severe mental conditions and get rid of unbearable feelings. Almost every tenth suicident of this type by commitment of a suicidal attempt refused his/her life (so-called “negative life balance”) or sacrificed oneself. The main motivation of self-destructive acts for parasuicidal SDB type were: the tendency to escape from a psychotraumatic situation, punishment (35.61%) and the desire of deliverance from feelings of hopelessness, protest and craving for revenge (34.09%). Demonstrative-intimidation motives of self-destructive acts could be called distinctive only for pseudosuicidal type of SDB. The prevailing motivation for self-destructive acts in this subgroup (62% of cases) included the sense of protest and desire of revenge. For all the suicidents of asuicidal SDB type the motivation of self-destructive acts was based on psychotic symptomatology: in 82.9% of cases — under effect of persecutory delusional ideas, depressive-paranoid and hallucinatory-paranoid symptomatology, including imperative pseudohallucinations. Some of the suicidents (10.53% of asuicidal SDB type) were not able to act consciously at the moment of self-destructive actions because of acute alcohol intoxication. 6.58% of the suicidents of this subgroup made self-destructive acts under keen drug intoxication and acute delirious syndrome.
A suicidal-fixed variant of postsuicidal period (firmly saved suicidal tendencies after suicidal attempt) was detected for 50% of the suicidents of suicidal SDB type (against the background of a true and intense tendency to die) and for 35.53% of the suicidents of asuicidal (in connection with hard state of psychotic disorders) type of SDB. The rental tendencies as a manipulative variant of the postsuicidal period was apparent for 30% of the suicidents of pseudosuicidal SDB type. The critical estimation of self-destructive acts was detected in 76.52% of the cases of parasuicidal type of SDB. The critical postsuicidal period was recorded in 53.14% of all the cases (for all the suicidents). For 48.86% of all suicidents a spontaneous effect of “breaking off” of self-destructive (autoaggressive) signs immediately after self-destructive acts against the background of affective suicident’s reaction on the mental disorders (tension, anxiety) and the psychological problems (frustration). The “breaking off” effect of self-destructive acts was fixed mainly in parasuicidal and pseudosuicidal types of SDB in 78.03 and 64% of the cases (respectively), and only in some cases. Whereas for suicidents of suicidal and asuicidal SDB types the “breaking off” effect was present in 3.35 times less frequent against the background of severe psychopathological disorders and strong preservation of self-destructive tendencies in the postsuicidal period.
The analysis of SDB and co-morbid psychopathological disorders (in table 2) among the suicidents has revealed that most often in the group taken as a whole (suicidal, parasuicidal and pseudosuicidal types of SDB) transient reactive disorders were detected (61.71% of the cases). This psychogenic reactions regarded different kinds of adaptational disorders and lasted for no more than one year. In the group of asuicidal SDB type no cases of adaptational disorders detected.
The most widespread types of psychopathologic disorders in patients with the internal forms of of SDB (InSDBF) and suicidal patients with different clinical-pathogenetic types of SDB (in %)
|The kinds of psychopathologic personal disorder||Patients with InSDBF||Subgroups of suicidal patients by types of ExSDBF|
|Depressive disorder of organic genesis (F06.32)||1.43||7.61||1.52||—||—|
|Mixed disorder of adaptation (emotions and behavior) on background of disorder of organic genesis (F43.25 + F06.6)||—||4.35||3.79||—||—|
|Acute severe alcohol intoxication with transient conscious disturbances (F10.01)||—||—||—||—||11.89|
|Paranoid schizophrenia, episodic course with stable defect (F20.02)||—||—||—||—||22.38|
|Paranoid schizophrenia, observable term less than year (F20.09)||—||—||—||—||15.79|
|Schizotypical personal disorder (F21)||11.43||2.17||0.76||—||—|
|Acute schizophrenia-like disorder (F23.2)||—||—||—||—||6.58|
|Acute transient psychogenic psychosis (F23.9)||1.43||—||—||—||5.28|
|Delusional hypochondriac disorder (F22.8)||—||—||—||—||3.95|
|Severe depressive episode with depressive-delusional symptoms (F32.3)||—||—||—||—||7.89|
|Severe depressive episode without psychotic symptoms (F32.2)||2.86||11.34||—||—||—|
|Recurrence depressive disorder, severe depressive episode without psychotic symptoms (F33.2)||4.29||3.26||—||—||—|
|Moderate depressive episode (F32.10)||1.43||2.17||—||—||—|
|Agoraphobia with panic disorder (F40.01)||5.71||—||1.52||—||—|
|Obsessive-compulsive disorder (F42.2)||7.14||—||—||—||—|
|Acute reaction on stress (F43.0)||—||6.52||38.64||32.0||—|
|Acute reaction on stress in patient with harmful alcohol using (F43.0 + F10.0)||—||2.17||8.34||2.0||—|
|Acute reaction on stress at hysteric personal disorder (F43.0 + F60.4)||2.63||1.09||4.55||30.0||—|
|Posttraumatic stress disorder (F43.1)||8.57||2.17||3.03||—||—|
|Mixed anxious-depressive reaction (F43.22)||8.57||—||—||—||—|
|Mixed disorder of adaptation (emotions and behavior) (F43.25)||14.29||36.96||31.06||8.0||—|
|Mixed disorder of adaptation (emotions and behavior) on background of neurasthenia (F43.25 + F48.0)||5.71||3.26||—||—||—|
|Emotionally unstable personal disorder, impulsive type (F60.30)||2.86||3.26||2.28||2.0||—|
|Infantile personal disorder (F60.8)||5.72||0.76||—||10.0||—|
|Hysteric personal disorder (F60.4)||4.29||—||—||16.0||—|
|Quantity investigated patients in groups (persons)||70||92||132||50||76|
For 18.57% of all the suicidents (34.85% of suicidents of parasuicidal and 36% of pseudosuicidal SDB types) in the nearest postsuicidal period, after self-destructive acts, no mental disorders emerged. For suicidal and asuicidal types of SDB various kinds of psychopathological disorders were detected for all the suicidents, as well as in the group of internal SDB forms.
The mixed emotional-behavioural adjustment disorder was diagnosed for 46.74% of the suicidents of suicidal SDB type. Different variants of affective depressive disorders of endogenic spectrum (mainly moderate or severe depressive episode without psychotic symptoms) — took place in 32.61% of the cases. The prevailing clinical symptom-complex in this subgroup was depressive syndrome which, with allowance of its mixed versions, was true for 79.35% of the suicidents (in table 3).
The most widespread psychopathologic syndromes in patients with the internal forms of SDB (InSDBF) and suicidal patients with different clinical-pathogenetic types of SDB (in %)
|Psychopathologic syndromes||Patients with InSDBF||Subgroups suicidal patients by types of ExSDBF|
|Depressive-phobic (self-destructive acts in acute severe alcohol intoxication at the asuicidal SDB type)||7.14||14.13||2.27||—||2.63|
|Hallucinatory-paranoid with imperative pseudohallucinations||—||—||—||—||26.32|
|Quantity investigated patients in groups (persons)||70||92||132||50||76|
Various kinds of adjustment disorders were detected in 88.64% of cases of parasuicidal SDB type. The fact that acute stress reaction in this subgroup is 1.29 times more than the other much long-lasting variants of adaptational disorders proves the thesis about the predominance of impulsive pathogenetical mechanism of SDB’s formation in reply to unexpectedly arise of psychotraumatical event of parasuicidal SDB type. The “anxiety-impulsive” SDB’s genesis of parasuicidal SDB type is confirmed by the predominance of anxiety-phobic and anxiety-asthenic symptomatology (74.24%) in this subgroup, whereas the depressive syndrome dominated in suicidal type of SDB against the background of adaptive personal reserves’ exhaustion. The impulsive character of self-destructive acts of parasuicidal SDB type is also confirmed by the higher level of specific weight of dysphoric and hysterical symptomatology comparing to the subgroup with suicidal type of SDB (3.72 and 3.31 times respectively).
Various variants of adjustment disorders were the most widespread kind of mental disorders for pseudosuicidal type of SDB (72% of the cases), as well as for the other types of SDB. The acute stress reaction in this subgroup happened 1.44 times more frequent, than in the group of parasuicidal SDB type. These disorders represented demonstrative-manipulative affective-impulsive personal reaction in a conflict situation. Hysterical or infantile personal disorders were diagnosed for 56% of the suicidents of the group. That is not typical for any other subgroup. Hysterical syndrome in its full sense was diagnosed only once, whereas in all the cases (excluding one case with anxiety symptomatology) combined version of hysterical syndrome were fixed: hysterical-anxiety (52% of the cases), hysterical-dysphoric (42% of the cases), and, much less often, hysterical-depressive syndrome (2% of the cases).
Pathogenetical mechanisms of suicidogenesis of asuicidal SDB type qualitatively differed from the other types of SDB. Paranoid schizophrenia with different development types (43.42% of the cases) was the most often kind of mental disorders of asuicidal SDB type. More than a third part of suicidents with schizophrenia had the observation period less than a year. The main psychogenic trigger for these suicidents was the awareness of the illness against the background of positive psychotic symptomatology. The ratio of schizophrenia, other psychotic disorders (chronic delusional, transient schizophrenia-like and psychogenic reactive psychosises), psychotic disorders due to drug dependent syndrome, affective psychosises and organic (posttraumatical) psychosises of asuicidal SDB type was 8.25:4:2.75:1.5:1. Depressive-paranoid syndrome, hallucinatory-paranoid syndrome (Kandinsky–Clerambault syndrome) and paranoid syndrome were the dominant symptomocomplexes of this subgroup.
Psychometric scale testing in the group of suicidents confirmed the significant differences between mental disorders of different SDB types. According to data of Positive and Negative Syndromes Scale (PANSS), the minimal level of psychic disorders was apparent for parasuicidal type of SDB, while the higher — for asuicidal and suicidal SDB types. The most pathognomonical SDB factors were those that were fixed by risk of aggression scale, that included such criteria as anger and rage, difficulty of gratification’s respite — delay of reward and an affective liability. There were no significant statistical distinctions for all the types of SDB.
The outcomes of the research, presented in the fifth section, have confirmed the qualitative distinctions in the processes of suicidogenesis for patients with InSDBF if compared with pathogenetical mechanisms of SDB’s formation for the group of suicidents.
Suicidal fantasies and thoughts, as passive kinds of InSDBF, dominated in this group: 25.71% of the cases for each parameter. Suicidal intentions and tendencies, as active kinds of internal SDB forms, was apparent for the patients in 17.14% of the cases for each parameter. The tendency to making self-destructive displays “more heavy” was directly proportional to the acuteness and expressiveness of psychopathological symptomatology of InSDBF.
Duration of self-destructive (autoaggressive) displays of InSDBF was much more than in the group of suicidents. Less than one month duration of self-destructive displays wasn’t detected in any case of internal SDB forms. Period exceeding three months were apparent in 28.57% of the cases. Long-lasting self-destructive tendencies of InSDBF without external realization (suicidal attempt) exasperated the internal frustrate tension and the rising of psychopathological symptomatology (its acuteness and expressiveness). This process mirrored the formation mechanism of internal direction of displaced activity. Thus a principle impossibility of constructive overcoming behaviour’s formation could be observed. This mechanism determined pathological forms of coping behaviour (quite self-destructive behaviour) and created a material self-destructive danger of InSDBF in the process of chronification and aggravation of mental disorders of the patients.
While protest, revenge or life refusal were the most frequent motives for suicidents, for the patients with the InSDBF the most typical motivation was some external help which meant obscuration of the responsibility for constructive personal changes. A negative attitude to self-destructive tendencies was fixed in 67.14% of the cases of the internal SDB forms. The fear of own self-destructive displays and impossibility to control the mental condition of themselves were the main proximate and cause for visiting a psychiatrist. The comparative data analysis has shown that the negative attitude to SDB and rental tendencies happened more often with the internal forms of SDB, than in the group of suicidents. Whereas positive attitude to self-destructive acts’ realization could be met more often than with the suicidents.
Autoaggressive motions of the patients with InSDBF formed co-morbidly to the increase of psychopathological disorders. In the group with InSDBF psychopathological symptomatology was apparent at all registers of mental alienations: from disorders of exogenous (organic depressions) and endogenous (schizophrenia, schizotypical disorder) genesis to different kinds of psychogenic neurotic adaptational disorders and personal disorders. Whereas in the group of suicidents a material distinction in the registers disorders, depending on concrete type of SDB, was detected. The most severe psychopathological disorders, their diversification were detected for InSDBF and suicidal and asuicidal SDB types in the group of suicidents. That corresponded to the severe psychopathological disorders and attested the great importance of pathological effect for self-destructive influence of mental activity for this forms and types of SDB.
The average duration of mental disorders in the group of InSDBF was more than three years. There were no acute transient mental disorders among the patients with internal forms of SDB. Self-destructive expressiveness of the patients with InSDBF, as an internal form of displaced activity, was rising in the process of chronification of psychopathological disorders. Therefore lingering and chronic forms of neurotic disorders, of asthenic circle mainly, prevailed among the patients with InSDBF (in table 2). And it was different from the group of suicidents, where these were adjustment and affective disorders. The anxiety-phobic syndrome was fixed as the most typical symptomatology for InSDBF, which determined by subjective heaviness of morbid experiences (in table 3).
The data of psychometric scale testing in this group according to both PANSS and M. Hamilton’s anxiety scales (in terms of the level of parameters) were close to the values detected for pseudosuicidal and suicidal types of SDB. The data of aggressions risk scale by PANSS (the most pathognomonical criteria, in terms of suicidogenesis, for ExSDBF) in group with the InSDBF was least expressed (in table 4). The data of Hamilton’s anxiety scale in the group with InSDBF fixed a material large expressiveness of psychosomatic and somatic disorders towards the parameters in the group of suicidents. The prevalence of psychosomatic pathology for InSDBF mirrored the processes of internalisation of displaced activity in this group of the patients, in comparison with suicidents that bear an external form of displaced activity.
The comparison of average indexes by Positive and Negative Syndromes Scale (PANSS) and M. Hamilton’s anxiety scale in experimental groups (points, M±m)
|Scales||Total data for InSDBF||Total data for ExSDBF||The clinical-pathogenetical types of ExSDBF|
|N = 70||N = 350||N = 92||N = 132||N = 50||N = 76|
|estimate of aggression risk||8.3±10.1||10.3±2.4||9.1±2.6||9.7±1.9||10.4±1.8||12.5±2.0|
|total sum point||64.3±17.8*||74.4±27.6*||71.1±19.9*||58.6±11.3*||61.1±11.4*||114.5±23.5|
|M. Hamilton’s||point of sum||19.0±6.8||16.4±5.4*||20.8±4.6||11.1±5.0**||8.6±5.2**||25.2±6.0|
* — p < 0.05;
** — p < 0.01 (reliable statistic distinguish between asuicidal type of ExSDBF (the greatest indexes level) and other types and forms of SDB).
Psychophysiological research (analysis of tension index by R. Bayevsky — the definition of sympathicotonia-parasympathicotonia correlation) has confirmed the pathological function of vegetative regulation mechanisms of the patients with internal forms of SDB. The dysfunction of vegetative regulation of the InSDBF points to the material exhaustion of adaptive reserves of the patients against the background of chronic self-destructive displays. Dynamics of the tension index corresponded to the clinical syndromal characteristics of a neurotic symptomatology — the predominance of anxiety-phobic (a high rising of sympathicotonia) or asthenic-depressive (a high rising of parasympathicotonia) syndromes.
Analysis of suicidogenesis’ psychological predictors is described in sixth section. The research has revealed their importance for suicidogenesis from the position of theoretical model of SDB’s pathogenesis.
The comparative analysis of premorbidal personal type has revealed the prevailation of psychasthenic type in the both clinical groups. The prevalence of psychasthenic personal type (for 40.88% of the suicidents and 60% of the patients with internal forms of SDB) is determined by a specific mechanism of «behavioural compensation». This mechanism, due to formation of self-destructive forms of coping behaviour as a variant of displaced activity, indemnified a low self-rating of these patients against the background of the reduced or exhausted adaptive resources. The sufficient specific in the group of suicidents belonged to the labile variant of affective-unstable personal type and hysterical personal type.
The research has demonstrated the prevalence and the expressiveness of various variants of family dysfunction and their combinations as one of main suicidogenetic psychological predictors. Disorders of family communications and absence of partner interaction was apparent almost in 90% of the cases for all the forms and types of SDB. Various forms of emotional dependency as pathological immature interpersonal relationships were the second-place parameter of in-family dysfunction frequency for the both clinical groups. The development of emotionally dependent relations is determined by symbiotic deviant parents-children relations with hyperprotective, victim and perfectional parent presetting. The symbiotic deviant parents-children interactions promoted disorders of pathological personal development and consolidated individual infantile forms of coping behaviour. In consequence of it the tendency to gradual transformation of infantile forms of coping behaviour in self-destructive versions of displaced activity formed. Emotionally dependent in-family relations were apparent mostly in pseudosuicidal type of SDB and InSDBF(in 68.89 and 61.4% of the cases respectively). Rigid perfectional parent presetting, as a specific form of psychological violence (based on the concept of dependent conditional love) were 2.23 times more frequent for InSDBF (60% of the cases) than for the group of suicidents (26.29% of cases). Mother’s symbiotic hyperprotective behaviour with the combination of father’s distant submissive behaviour was detected in 30 and 32% of the cases of InSDBFand in the group of suicidents respectively. The majority of such variant of deviant parents-children relations was fixed for pseudosuicidal type of SDB (52% of cases). Victim-manipulative parent presetting were met 2.25 times more often for InSDBF than in the group of suicidents: 44.29 and 19.71% of the cases respectively. The minority of such variants of family dysfunction was fixed for the parasuicidal SDB type. Exhausting manipulative tendencies (position of constant hyperresponsibility and “ought to” towards parents, without age consideration) for InSDBF happened 2.84 times more often than in the group of suicidents (47.14 and 16.57% of the cases respectively). Denying and emotionally indifferent parents’ relation towards children was also more typical for the patients with InSDBF than for the group of suicidents (35.71 and 21.71% of cases respectively). A surprising outcome of the research was the lowest value of direct physical violence, which wasn’t a significant suicidogenetic psychological predictor in the both clinic groups. The cases of physical aggression towards probands emerged much more often for the patients with asuicidal and parasuicidal types of SDB, less often — with internal forms of SDB. Therefore, the specific forms of psychological violence as a kind of deviant parents-children interactions and the factor of children psychological traumatization had a greater self-destructive effect and suicidogenetic potential than the cases of repeated direct physical violence. The greatest suicidogenetic effect of deviant parents-children interactions’ influence emerged for the people with InSDBF and pseudosuicidal SDB type, the lowest — for those with parasuicidal and asuicidal types of SDB.
The criterion of availability / absence of existential crisis mirrored the suicidal readiness of person and the completed transformation of clinically unobservable SDB forms to observable. The existential crisis was apparent almost in all the cases of internal SDB forms, whereas in the group of suicidents it emerged in 73.71% of the cases, mainly for suicidal type of SDB.
Infantile presetting in interpersonal relations were true 87.14% of the suicidents with all types of SDB but asuicidal one. Infantile presetting was fixed in all the cases of pseudosuicidal type of SDB, and communicative misunderstanding and feel of ambient outcast — in 98%. The patients with InSDBF had the highest level of existential crisis and the lowest — of infantile interpersonal presetting.
The definition of the control’s locus and concrete variant of coping behaviour demonstrated the character of psychological deviations in the process of suicidogenesis. Internal control’s locus was not detected in any case of pseudosuicidal SDB type. The greatest level of it belonged to suicidal type of SDB (59.78% of the cases). External control’s locus with violent and impulsive self-destructive displays was the last (lowest) parameter (17.14% of the cases) for internal forms of SDB. For the group of suicidents, taken as a whole, external control’s locus was 2.13 times more frequent than for the patients with InSDBF.
Regression-affective variant of coping behaviour was the main pattern of displaced activity for the both clinical groups. The deviant variant of coping behaviour forced the transformation of pathological adaptation to clinically observable forms of SDB.
The research has revealed a great spectrum of the reasons defined by the patients as direct causes for self-destructive acts’ realisation or development of internal SDB forms. Mostly, not one concrete reason but their combination, that included the contents of suicide conflict, the characteristic of psychological problem and the typical pattern of coping behaviour, were pointed. The pointed reasons were divided into following spheres: problems with mental and somatic health, including psychopathological disorders; psychological personal deviations (experience of one’s own inconsistency, hopelessness); interpersonal family conflicts, conflicts with friends or close ambient, break of partner relations; cases of physical and psychological violence on part of ambient; social problems. Exact psychopathological disorders and the desire to be saved from unbearable morbid feelings emerged as the suicidogenical trigger only in asuicidal type of SDB. The presence of psychopathological and somatic problems, their subjective heaviness, all the spectrum of psychological problems were the main causes of suicidogenesis for InSDBF and for suicidal SDB type. Clinically observable process of SDB development for InSDBF was based on the specific group of psychological problems, such as displays of existential crisis. Different kinds of interpersonal conflicts were the most typical causes of impulsive self-destructive acts for pseudosuicidal and parasuicidal types of SDB.
The data of psychological tests (in tables 5–8) has confirmed the statistical difference between experimental groups and the respondent group. The reliability of the distinctions estimated on t-Student criterion for all the tests, the statistical difference was considered authentic at ð < 0.05. The results’ estimation on the whole has shown the greatest expressiveness of psychological personal deviations of people with suicidal types of SDB and internal SDB forms.
The data of self-rating test on expressiveness of autoaggressive predictors in suicidal patient with different clinical-pathogenetic types of SDB, patients with the internal forms of SDB (InSDBF) and in reference group (points, M±m)
|Groups of research persons||The self-rating test on expressiveness of autoaggressive predictors|
|autoaggressive features||aggressiveness||impulsiveness||affective distress||disturbances of cognitive acting||limitation of interpersonal contacts||vegetative distress|
|Suicidal type, N = 92||34,27±11,32**||17,67±3,9**||11,87±4,1**||37,4±8,03**||24,8±5,95**||18,73±4,5**||29,93±6,56**|
|Parasuicidal type, N = 132||16,52±9,72**||14,69±4,05*||9,93±3,34*||26,21±7,15*||20,52±4,19*||13,76±4,04*||24,1±9,53**|
|Pseudosuicidal type, N = 50||15±10,09**||15,42±6,1*||10,08±4,38**||23,25±10,76*||20,08±7,29*||14±6,01*||20,33±9,37*|
|Asuicidal type, N = 76||20,15±10,82**||12,46±4,81||9,08±4,7*||26,54±9,76*||20,92±5,31*||16,31±1,56**||25,46±8,38**|
|Average index in group of suicidal patients, N = 350||20,8±12,5**||15,04±4,78*||10,22±4,0**||28,19±9,75*||21,45±5,6*||15,36±6,76**||24,97±9,08**|
|Average index in group of InSDBF, N = 70||23,67±9,1**||16,37±4,5**||10,33±3,6**||32,33±8,6**||23,15±4,1**||16,67±6,0**||28,37±6,1**|
|Average index in reference group, N = 108||6,82±6,23||9,03±4,03||5,82±3,31||13,86±8,36||14,63±5,58||8,49±4,62||11,46±7,87|
|Policemen, N = 58||5±3,94||7,81±3,17||4,79±2,76||11,14±6,68||13,42±5,67||7,26±3,83||8,75±6,56|
|Unemployed persons, N = 25||8,73±7,86||9,69±4,6||6,81±3,61||17,38±9,58||16,38±5,46||10,23±5,26||14,42±8,6|
|Students of colleges, N = 25||9,84±7,81||11,72±4,36||7,6±3,42||17,68±8,64||16,12±4,75||10,04±5,04||15,84±7,62|
* — p < 0.05;
** — p < 0.01 (reliable statistic distinguish between experimental groups and reference group).
The data of testing suicidal patient with different clinical-pathogenetic types of SDB, patients with the internal forms of SDB (InSDBF) and reference group by self-rating tests on expression of reactive and personal anxiety by C. Spilberger — Yu. Khanin; of mental conditions by H. Eyesenk; of hopelessness level by A. Beck (pointes, M±m)
|Groups of research persons||Test for anxiety estimation||Test for mental conditions’ estimation||Test for estimation of hopeless-ness level|
|personal anxiousness||reactive anxiety||anxiousness||frustration||aggressiveness||rigidity|
|Suicidal type, N = 92||53.47±6.7**||43.6±10.7**||11.93±4.7**||12.47±3.3**||10.4±3.7||11.2±3.5*||10.38±5.8**|
|Parasuicidal type, N = 132||47.66±10.6*||38.24±12.4**||10.45±4.1*||10.03±3.9*||10.21±4.2||10.48±3.6*||5.28±4.1*|
|Pseudosuicidal type, N = 50||46.17±8.1*||34.58±8.5*||8.67±4.3||9.67±3.5*||11.58±4.8*||9.58±2.8||4.08±3.3*|
|Asuicidal type, N = 76||46.8±10.5*||39.08±13.0**||11±4.9*||10.15±4.7*||10.69±4.3||11.15±4.1*||5.67±4.9*|
|Average index in group of suicidal patients, N = 350||48.49±9.7**||38.93±11.7*||10.52±4.4*||10.52±3.9*||10.38±4.2||10.61±3.5*||6.24±4.9*|
|Average index in group of InSDBF, N = 70||55.3±9.2**||41.86±9.2**||13.7±3.6**||12.74±4.3**||11.74±3.9*||12.35±4.0**||9.07±3.8**|
|Average index in reference group, N = 108||39.03±7.9||25.53±8.3||6.39±3.7||6.43±3.4||9.05±3.2||8.31±3.3||2.83±2.8|
|Policemen, N = 58||36.96±5.6||24.19±7.2||5.57±3.1||5.71±2.7||9.2±2.7||8.28±2.9||2.46±2.3|
|Unemployed persons, N = 25||41.77±10.3||25.69±8.6||7.62±4.1||7.46±4.4||9.15±3.5||8.35±3.7||3.27±3.7|
|Students of colleges, N = 25||41.92±9.1||29.04±9.9||7.4±4.1||7.36±3.5||8.52±3.4||8.36±4.0||3.4±2.8|
* — p < 0.05;
** — p < 0.01 (reliable statistic distinguish between experimental groups and reference group).
The data of main scales of the self-rating test of expression of social-psychologic adaptation C. Rogers — R. Diamond in suicidal patients with different clinical-pathogenetic types of SDB, patients with the internal forms of SDB (InSDBF) and reference group (points, M±m)
|Groups of research persons||The main scales of the self-rating test of expression of social-psychologic adaptation|
|external locus of the awareness control||internal locus of the awareness control||acceptance by self||unacceptance by self||acceptance ambient||unacceptance ambient||emotional discomfort||emotional comfort||escape-ness (flight)|
|Suicidal type, N = 92||30.87±7.4**||35±5.9*||28.33±8.6*||18.33±7.8**||18.33±5.6||16.87±4.7**||24.47±5.2**||16.13±4.1||15.2±3.4*|
|Parasuicidal type, N = 132||24.34±7.4**||40.07±9.2||34.31±6.8||13.62±5.4*||19.7±4.6||11.59±4.6*||16.52±7.1**||18.55±4.9||13.62±3.2*|
|Pseudosuicidal type, N = 50||17.67±8.9*||37.5±8.9||39±6.1||7.83±4.1||20.58±2.9||9.67±3.8||12.17±6.3*||17.75±5.6||13.17±4*|
|Asuicidal type, N = 76||23.2±10.7**||34.4±12.9*||32.2±14.3*||14.2±9.7*||19±3.8||11.4±4.9||20±9.8**||10.4±6.4*||13.6±5.8*|
|Average index in group of suicidal patients, N = 350||24.14±8.8**||37.95±8.7||32.86±8.4||13.75±6.9*||19.07±4.6||12.97±5.5**||18.03±7.5**||17.09±5.1||13.97±3.7*|
|Average index in group of InSDBF, N = 70||25.33±7.1**||41.85±7.6||30.48±8.0*||13.5±6.2*||15.83±4.6*||16.09±4.9**||21.8±6.4**||15.89±3.9||14.09±3.9*|
|Average index in reference group, N = 108||10.08±8.4||40.86±8.4||37.16±8.4||6.88±5.0||21.4±4.0||8.68±4.6||7.97±6.1||18.65±4.4||8.69±4.1|
|Policemen, N = 58||7.59±6.2||41.97±7.7||37.73±7.9||5.65±4.2||21.63±4.2||8.18±3.9||5.43±4.5||18.95±2.2||8.36±3.8|
|Unemployed persons, N = 25||12.12±8.2||41.38±8.5||38.15±8.1||7.37±4.6||21±4.2||8.65±5.0||10.12±6.7||19.54±2.1||9±4.7|
|Students of colleges, N = 25||14.8±11.1||37.24±9.6||34.52±9.8||9.76±6.2||20.47±3.2||10.04±5.4||12.72±6.0||16.88±3.3||9.28±4.4|
* — p < 0.05;
** — p < 0.01 (reliable statistic distinguish between experimental groups and reference group).
The data of self-rating test of psychological protection actualization by R. Plutcheck in suicidal patients with different clinical-pathogenetic types of SDB, patients with the internal forms of SDB (InSDBF) and in reference group (points, M±m)
|Groups of research persons||Test of psychological protection actualization by R. Plutcheck|
|Suicidal type, N = 92||6.33±2.12||5.80±2.11||9.87±2.1*||5.80±1.6*||8.47±2.29*||7.07±2.76**||6.00±2.33*||4.70±2.71|
|Parasuicidal type, N = 132||7. 97±2.87||5.62±2.56||8.34±3.44*||5.66±2.45*||7.93±3.18*||6.79±3.55**||7.00±2.87||5.07±2.4|
|Pseudosuicidal type, N = 50||8.50±2.75||4.42±2.02||7.83±3.38*||5.58±1.51||7.75±3.01*||6.67±3.14**||8.33±2.39||6.33±2.46*|
|Average index in group of suicidal patients, N = 350||7.30±2.78||5.49±2.39||8.65±3.02*||5.61±1.97*||7.96±2.87*||6.83±3.1**||7.06±2.63||5.28±2.48|
|Average index in group of InSDBF, N = 70||7.52±2.8||7.11±2.8**||10.3±2.5**||6.50±2.4*||8.54±3.3*||7.96±3.2**||8.15±3.2||5.72±2.8|
|Average index in reference group, N = 108||8.17±2.39||5.23±2.14||5.16±3.27||4.26±2.11||5.59±3.24||3.64±2.5||7.93±2.49||3.91±2.35|
|Policemen, N = 58||8.56±1.87||5.55±1.94||4.28±2.97||4.43±1.96||6.33±2.88||3.68±2.39||8.81±1.66||3.83±1.97|
|Unemployed persons, N = 25||8.5±2.88||4.04±1.64||6.19±3.24||4±2.28||5.12±3.65||2.96±2.09||7.88±2.49||4.5±2.76|
|Students of colleges, N = 25||6.72±2.72||5.6±2.71||6.52±3.4||4.04±2.37||4.04±3.21||4.24±3.04||5.52±2.89||3.52±2.8|
** — p < 0.01 (reliable statistic distinguish between experimental groups and reference group).
The data of modificated self-destructive (autoaggressive) predictors test has demonstrated that, on the average, the criterion of self-destructive motions of the group of suicidents exceeded the average value of respondent group in 3.05 times, of suicidal SDB types — in 5.02 times, and of InSDBF — in 3.47 times. Much higher data in the clinical groups was by the criterion of aggressiveness (internal forms of SDB, suicidal and pseudosuicidal types of SDB). The level of impulsiveness for all the forms and SDB types exceeded the values, detected in the respondent group, more than twice.
The level of hopelessness, according to the hopelessness scale by À. Beck, for suicidal type of SDB and InSDBF exceeded the average value of the respondent group in 3.67 and 3.2 times.
The diagnostics test of social-psychological adaptation by C. Rogers — R. Diamond has confirmed the significance of control’s locus in suicidogenesis. In the both clinical groups the data by this criterion materially exceeded the monitoring values. The values of “acceptance–non-acceptance of themselves and the ambient” criterion have revealed the fact that the patients of clinical groups tend towards self-acceptance more. The exception here were the suicidents with pseudosuicidal type of SDB. The index of “self-acceptance” for this subgroup of suicidents exceeded the values of the respondent group. The level of escapism (tendency to escape from problems’ solutions as a specific form of coping behaviour in psychotraumatic situations) was authentically above the monitoring values in both the clinical groups.
The psychological protection scale by R. Plutchik has demonstrated the authentically higher level of the indexes of regression, displacement, projection and compensation scales in the both clinical groups. This data has confirmed position of theoretical model of SDB pathogenesis that claims that SDB’s development mirrored the transformation of pathological adaptational process against the background of ontogenetic evolutional disorders to external or internal variants of displaced activity.
Much lower level of suicidal SDB type’s intellectualization (comparing to the monitoring values) confirmed the disability of the patients to estimate themselves and the ambient reality adequately. The authentically higher level of suppression detected for internal forms of SDB.
In the both clinical groups the authentically higher level of alarm (comparing to the respondent group), frustration and rigidity indexes, according to mental condition’s test by H. Eyesenk, was fixed. It confirmed the significance of existential anxiety and frustrate dissatisfaction as psychological predictors of suicidogenesis. Authentically higher level of rigidity in the both clinical groups testified to the disability for non-rigid formation of new behaviour styles (of all forms and types of SDB) against the background of the exhausted adaptive personal reserves.
The modificated negative life events test has revealed an authentically higher level of psychotraumatic events in biography of InSDBF and suicidal and asuicidal types of SDB, comparing to the results of the respondent group.
In the seventh section of the dissertation the data of complex emergent suicidological help effectiveness for suicidents in the nearest the postsuicidal period is shown. The findings of investigation testified that the rendering complex emergent suicidological help is the most adequate and effective variant of SDB therapy in the real conditions of suicidents’ treatment in the nearest postsuicidal period. The complex emergent suicidological help included an adequate psychopharmacotherapy (directed to letup of anxiety, phobic and asthenic symptomatology) and psychotherapeutic intervention (forced the activation of antisuicidal barrier, transformation of desadaptive coping behaviour and the self-destructive personal motive presetting).
The character and the volume of pharmacotherapy was determined by the clinic-pathogenetical type of SDB and the kind of co-morbid psychopathological disorders. Its main aim, not taking into consideration the clinic-pathogenetical types of SDB, was decreasing of the expressiveness of affective disorders (“strength” of the affect, anxiety, phobic, depressive symptoms), cognitive disorders (rigidity, frustration) and vegetative dysfunction. The patients with suicidal and asuicidal types of SDB required a strong psychopharmacotherapy. The volume of the pharmacotherapy for parasuicidal and pseudosuicidal types of SDB was much smaller, because of the higher frequency of subclinical level of psychopathological disorders’ expressiveness and “breaking off” effect after self-destructive acts in these suicidents subgroups. Pharmacotherapy for suicidents with non-psychotic disorders included mainly benzodiazepine tranquilizators (usage of antidepressants for such patients is quite limited because of the duration of emergent treatment and the main character of the disorders — with anxiety-phobic symptomatology). Injection forms of sedative neuroleptics were used for suicidents with psychotic disorders (with depressive-paranoid syndrome — in combination with antidepressants).
As the method of emergent psychotherapy of SDB we used crisis psychotherapy (on the basis of the existential-humanist approach). Crisis psychotherapy is used more often in cases of personal and family forms of work. Abreaction of negative emotions, reduction of affective-cognitive dysbalance and fast cognitive re-shaping of crisis situation are the main aims of the psychotherapeutic intervention. The main psychotherapeutic effect included crisis support and motivation for the further psychotherapy in consequence of real treatment management.
The dynamics of psychometric scaling (by Ì. Hamilton’s anxiety scale) after the complex emergent suicidological help has demonstrated the most material decrease of the indexes of the group of suicidents on the whole by criteria of tension (20.25%), depressive mood (19.75%), behavior pattern in the process of inspection (19.65%), dyssomnia (16.5%), phobic feelings (15%), anxiety (12%). The higher indexes on Ì. Hamilton scale after the realization of the complex emergent suicidological help were detected for suicidal and asuicidal types of SDB, therefore these patients required more long-lasting and stronger pharmacological therapy in consequence of the expressiveness of self-destructive displays and psychopathological symptomatology.
The main outcome of the complex emergent suicidological help rendering was a jump of antisuicidal presetting in the most adaptive group of patients — with parasuicidal type of SDB. That has determined a favourable prognostic effect for SDB’s recurrence. The expressiveness of self-destructive displays and psychopathological symptomatology lowered in the suicidal and asuicidal types of SDB, and these suicidents aimed to the necessity of the further treatment. The primary aim of the emergent treatment of pseudosuicidal type of SDB was the actualisation of antisuicidal presetting and clarification of personal disorders’ influence on self-destructive behaviour styles’ formation. These suicidents were oriented to the necessity of the further family psychotherapy.
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