Non-Suicidal Autoaggression in Patients with Paranoid Schizophrenia in Conditions of Long-Term Social Isolation

Patients with paranoid schizophrenia are one of the most common nosologies in forensic psychiatric practice [1-4]. The steady increase in their negative (deficient) personality changes is often accompanied by various behavioral disorders, including non-suicidal auto-aggressive actions or in short: “NSAA” [5-12]. The latter may reflect the process of restructuring the adaptivecompensatory mechanisms of the individual in the conditions of the disease process [13-16]. An important role in this process is played by the conditions of long-term social isolation [17,18,19]. The study of the forms of implementation of non-suicidal autoaggressive behavior by patients with paranoid schizophrenia can improve the effectiveness of ongoing therapeutic, diagnostic and preventive measures in relation to such patients.

Purpose of the study: to study the most common forms of NSAA in patients with paranoid schizophrenia who are in conditions of long-term social isolation.

Through a retrospective analysis of the available medical records, 257 patients with paranoid schizophrenia, who were in conditions of long-term social isolation (prison detention, compulsory treatment) were studied. All the subjects were men aged 20 to 55 years. The average age of the subjects was 34.1 ± 2.2 years. The average duration of a procedural disease was 16.5 ± 2.5 years. Type of flow of the schizophrenic process: continuously - progressive. The inclusion criteria were: 1) compliance of the diagnosis of paranoid schizophrenia with the criteria of the ICD-10 revision (F20.0); 2) the presence of NSAA in history, realized outside the psychotic period; 3) adherence to the criminal subculture declared by the subjects themselves (the so-called “criminal attitude behavior”, “criminal hierarchy of values”). The clinical picture of the subjects was determined by negative procedural personality changes with severe behavioral disorders. The premorbid personality structure was dominated by hysterical, paranoid traits. The definition of “NSAA” included a variety of actions directed against one’s health and accompanied by a violation of the integrity (functions) of organs or organ systems. However, there was no demonstration of intent to commit suicide. The concept of “criminal attitude behavior” was associated with “the steady anti-social orientation of the individual with the desire to use criminal slang, building relationships with others from the positions of the criminal hierarchy of values, flaunting the criminal past, applying specific tattoos.”The term “criminal hierarchy of values” was understood as a certain “set of rules of conduct, bearing an indisputable character (dogma), for persons identifying themselves with the criminal environment”.

The vast majority of those surveyed (242 people) inflicted the first NSAA on themselves at the age of 14 years. Such actions were defiantly blackmailing in nature, and also served as a tool for relieving psycho-emotional stress. Such self-harm was limited to superficial cuts in the area of the shoulder, forearm, inner thigh. A retrospective analysis made it possible to attribute such actions to the prodromal period of the schizophrenic process, when the manifestation of the disease was determined by nonspecific behavioral disorders. The next stage in the implementation of selfdamaging behavior was the placement of the subjects in a judicial situation, after they had committed offenses. Being at the stage of conducting a forensic psychiatric examination, the subjects closely communicated with persons who had previously been repeatedly in places of deprivation of liberty, adopting their practical experience in the field of causing non-suicidal self-harm. At the same time, the clinical picture of the subjects was determined by negative procedural changes in the personality in the form of an increase in aggressive tendencies, emotional coarsening, structural disorders of thinking, loss of criticism of one’s behavior. Most often, their implementation was in the nature of a protest against existing regime restrictions, and also reflected the desire to avoid criminal liability. At the same time, we conventionally divided all NSAAs committed by the subjects into two groups. The first group concerned the modification of the dermal and subcutaneous layers. The second group was represented by systemic NSAA, initially aimed at persistent changes in the functioning of the internal organ systems of the individual. In the first group, incised and stab-cut wounds were most often applied, corresponding to the principle of “the greatest accessibility and least traumaticity”. An example is the application of superficial incised wounds, for example, scratches, localized mainly in the region of the upper shoulder girdle. Much less often, incised wounds were accompanied by an additional semantic load. Thus, one of the patients we observed, as a sign of rejection of regime requirements, had a tendency to carve obscene words in the form of superficial wounds on various parts of the body. In the summer, a common method of implementing NSAA was rubbing the skin with plants with a local irritant effect, for example, the juice of the ranunculus family. At the same time, the subjects actively prevented the healing of the resulting contact dermatitis by combing the injury sites, artificially infecting the wounds. There have been cases of causing burns to the surface of the skin by applying hot objects, melted sugar. Among other ways of introducing foreign agents, one can single out the introduction of intramuscular and even intravenous various chemicals: formalin, gasoline, infusion of strong tea, tobacco, which leads to the development of purulent inflammation of varying degrees of intensity; Meet subcutaneous infection by the introduction of saliva, plaque. Cases of the development of artificial tumors obtained by introducing Vaseline, machine oil or paraffin under the skin are described. In this case, molten paraffin is most often injected into the joint area, which is accompanied by its extremely slow reverse development. There are also described cases of the development of artificial subcutaneous emphysema by puncturing the mucous membrane of the gums above the gums, followed by the introduction of air through a syringe; As a rather exotic example of auto-aggressive behavior, one can cite the case of inserting a peeled garlic clove into the rectum, or rubbing the armpits with salt to induce a fever. In a number of cases, the subjects achieved the development of contractures of the limbs by bandaging them, and putting on leather or rubber bandages; Speaking about the features of non-suicidal auto-aggressive behavior in places of deprivation of liberty, one cannot fail to mention such an important element of the criminal subculture as tattooing. Without considering in the context of this study all the informative significance inherent in such symbols, let us dwell in more detail on the methods of their implementation. More than a dozen ways of applying tattooed images are described, which are, in fact, elements of non-suicidal auto-aggressive behavior. One of them is the melting of rubber products, and the resulting ash is mixed with urine and the dot method is used when applying a certain pattern. Another way is to apply the outlines of the future image with a razor blade, followed by filling the wound surface with ink or ink. Finally, there are also ready-made devices, which are sets of needles formed for specific patterns. The basis of the second group of NSAA were cases of swallowing fastened metal objects of small volume (needles, pieces of wire, razor blades) fastened together. There have been cases of swallowing bleach wrapped in bread crumb, and even a cactus. Close to the presented forms of realization of non-suicidal autoaggression is the swallowing of a piece of fat, previously fixed to the teeth with a thread, in order to cause jaundice. Moreover, in their aspirations to obtain relaxation of the regime, the subjects did not stop at more aesthetically unsightly variants of auto-aggressive actions, for example, eating cockroaches, rats, etc. Very common are cases of simulation of respiratory diseases, in particular, tuberculosis. To do this, they inhale sugar, salt, rub the chest area with lead objects before an x-ray. For the same purpose, pre-cut and crushed fingernails and toenails were inhaled. Finally, the independent NSAA group can mention cases with modification of the genital organs. If in the cases mentioned earlier, NSAAs were applied to change adverse environmental conditions according to the “here and now” principle, then self-harm of the genital organs was often distinguished by their hedonistic orientation. Such manipulations were carried out in order to increase the satisfaction from sexual intercourse with a heterosexual partner after release from conditions of social isolation. Either it served as an excuse to assert its superiority over the weaker patients or prisoners through the use of sexual violence, which was also actively supported by the traditions existing in the criminal subculture. An example is the introduction of round or oblong objects under the skin in the urethral region, as well as the introduction of paraffin into the area of the outer flesh.Various abrasives have been used in the manufacturing process of the foreskin insertion item. This made it possible to give a smooth surface to the future tool for inflicting selfdamage. For this purpose, some subjects carried such a blank in their mouths in the oral cavity for several days. Next, the workpiece was injected under the skin, pre-treated with antiseptics, and then the injection site was bandaged for several days. Conclusion. Thus, the NSAA described by us in patients with paranoid schizophrenia did not differ significantly from those that are common in conditions of prolonged social isolation. In the article, we presented a small part of the ways to implement non-suicidal auto-aggressive behavior in such patients in the penitentiary system. Of course, the phenomenon of non-suicidal auto-aggression in such individuals requires a deeper study, including from the standpoint of understanding the psychopathological motives for its implementation.

None.

No Conflict of interest.

1. Kutscher S, Schiffer B, Seifert D (2009) Schizophrene Patienten im psychiatrischen Massregelvollzug (S63 StGB) Nordrhein-Westfalens [Patients with schizophrenia in forensic-psychiatric hospitals (section 63 German Penal Code) in North Rhine-Westphalia]. Fortschr Neurol Psychiatr 77(2): 91-96.
2. Fazel S, Wolf A, Palm C, Lichtenstein P (2014) Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: A 38-year total population study in Sweden. Lancet Psychiatry 1(1): 44-54.
3. Lau Steffen (2019) “Latent class analysis identified phenotypes in individuals with schizophrenia spectrum disorder who engage in aggressive behaviour towards others.” European Psychiatry 60: 86-96.
4. Kirchebner, Johannes (2020) Stress, Schizophrenia, and Violence: A Machine Learning Approach.” Journal of Interpersonal Violence 37: 602 - 622.
5. Haw C, Hawton K, Sutton L, Sinclair J, Deeks J (2005) Schizophrenia and deliberate self-harm: a systematic review of risk factors. Suicide Life Threat Behav 35: 50-62.
6. Andriopoulos I, Ellul J, Skokou M, Beratis S (2011) Suicidality in the "prodromal" phase of schizophrenia. Compr Psychiatry 52(5): 479-85.
7. Mork, Erlend (2012) Self-Harm in Patients with Schizophrenia Spectrum Disorders. Archives of Suicide Research 16: 111-123.
8. Pluck G, Lekka NP, Sarkar S, Lee KH, Bath PA, et al. (2013) Clinical and neuropsychological aspects of non-fatal self-harm in schizophrenia. Eur Psychiatry 28: 344-348.
9. Domínguez-Baleón C, Gutiérrez-Mondragón LF, Campos-González AI, Rentería ME (2018) Neuroimaging Studies of Suicidal Behavior and Non-suicidal Self-Injury in Psychiatric Patients: A Systematic Review. Front Psychiatry 9: 500.
10. Güney E, Alnıak İ, Erkıran M (2020) Predicting factors for non-suicidal self-injury in patients with schizophrenia spectrum disorders and the role of substance use. Asian J Psychiatr 52: 102068.
11. Yin Y, Tong J, Huang J, et al. (2020) Suicidal ideation, suicide attempts, and neurocognitive dysfunctions among patients with first-episode schizophrenia. Suicide Life Threat Behav 50(6): 1181–1188.
12. Wright M (2020) Schizophrenia and schizophrenia spectrum disorders. JAAPA 33(6): 46-47.
13. Edmondson AJ, Brennan CA, House AO (2016) Non-suicidal reasons for self-harm: A systematic review of self-reported accounts. J Affect Disord 191: 109-117.
14. Taylor PJ, Jomar K, Dhingra K, Forrester R, Shahmalak U, et al. (2018) A meta-analysis of the prevalence of different functions of non-suicidal self-injury. J Affect Disord 227: 759-769.
15. Álvarez MJ, Masramom H, Foguet-Boreu Q, Tasa-Vinyals E, García-Eslava JS, et al. (2021) Childhood trauma in schizophrenia spectrum disorders: Dissociative, psychotic symptoms, and suicide behavior. J Nerv Ment Dis 209: 40- 48.
16. Burgin S, Reniers R, Humpston C (2022) Prevalence and assessment of self-disorders in the schizophrenia spectrum: a systematic review and meta-analysis. Sci Rep 12(1): 1165.
17. Penney Stephanie R (2018) Age onset of offending and serious mental illness among forensic psychiatric patients: A latent profile analysis. Criminal Behaviour and Mental Health 28: 335-349.
18. Smith, Hayden P (2019) “Working with prisoners who self‐harm: A qualitative study on stress, denial of weakness, and encouraging resilience in a sample of correctional staff.” Criminal Behaviour and Mental Health 29: 7-17.
19. Kappes, Johannes René (2021) “Self-Harm Among Forensic Psychiatric Inpatients with Schizophrenia Spectrum Disorders: An Explorative Analysis.” International Journal of Offender Therapy and Comparative Criminology 67: 352 - 372.