Feeling of worthlessness – a cause of attempted suicide in schizophrenia

The patient P.E., female,aged 54years old, divorced, from the rural area, medically retired, presented to the psychiatric service, brought by the ambulance from the emergency unit, for a suicide attempt by voluntary ingestion of medication (10 clonazepam tablets and 20 risperidone tablets). The patient is known to have a diagnosis of paranoid schizophrenia since 2008, with a history of multiple psychotic relapses (more than 10). The onset of schizophrenia occurred around the age of 35, due to marital tensions that eventually led to divorce.

In recent years, there have been no florid psychotic episodes in the patient’s history, only residual psychotic symptoms, behavioral disorders (impulsive-aggressive manifestations due to low frustration tolerance), as well as symptoms from the negative affectivity spectrum (depressive mood, feelings of worthlessness, guilt, self-stigma, social withdrawal). The evolution of the disease recorded three suicide attempts over time, occurring in the context of exacerbated symptoms. Despite numerous hospitalizations and disease complications, the patient has experienced long periods of partial remission, with generally good household functionality. The treatment has been correctly administered (Risperidone Consta® 37.5 mg every two weeks, clonazepam 0.5 mg/day in case of insomnia), and the patient has consistently attended outpatient services, undergoing regular medical check-ups.

From the patient’s life history, it emerged that she had been divorced for 12 years and she had two daughters. The marriage was marked by multiple conflicts with her husband, due to his aggressiveness, which contributed to the onset of schizophrenia. After the divorce, she had several romantic relationships, in which she experienced numerous disappointments. At the time of hospital presentation, the patient was living with her partner in his home, describing their relationship as marked by mutual support, understanding and protection. The patient’s relationships with her two daughters and her partner’s daughters could be characterized as harmonious. From an occupational point of view, the patient was a worker in the textile industry until the age of 35, coinciding with the onset of the illness.

Prior to the suicide attempt, the patient experienced a series of negative emotions; for instance, her partner was unavailable to communicate when the patient requested it (for objective reasons), at which point she directed her attention to household activities – cleaning the house. However, while inspecting the house, she realized how disorderly it was, and she felt incapable of receiving her stepdaughter’s visit, stating that she felt “so worthless…” and, consequently, impulsively ingested multiple medications. The patient’s explanation for this thought was that, when she was healthy, she was almost “obsessed” with cleanliness, enthusiastically performing all household activities. However, since becoming ill, despite her efforts, her work performance had been quite low, and the quality of her activities was not very good.

The physical examination revealed no changes. The psychiatric examination revealed hypomobile facial expressions, sad gaze, restrained attitude, low voice, uncertainty, coherent speech with some interruptions. Regarding cognition, there was global voluntary hypoprosexia, sectorial hyperprosexia (related to self-stigma), fixation hypomnesia; thinking was characterized by a coherent ideational flow, slightly slow, with depressive ideas of helplessness, worthlessness, self-devaluation, and low-intensity delusional ideas of reference. In terms of affectivity, the patient exhibited a depressive mood, emotional lability, anxious-depressive states/crying/irritability. Regarding functionality, the patient displayed relatively low activity (due to negative symptoms and decreased executive functions), increased impulsivity, tendency towards social isolation (ideas of reference, self-devaluation), and self-aggressive behavior (suicide attempt). The psychological examination tests revealed the presence of mild psychotic symptomatology (BPRS=48), and moderate depressive symptomatology (MADRS=20).

The diagnosis of paranoid schizophrenia was established 12 years age. Based on DSM IV-TR criteria, the current diagnosis is residual schizophrenia⁽¹⁾. Due to the current presence of depressive symptoms, previous medical records were examined to differentially diagnose with depressive schizoaffective disorder. The diagnosis of paranoid schizophrenia in the past was supported due to the fact that, for many years, the symptoms presented at emergency admission did not include depressive affective symptoms that meet the criteria for major depressive episode, a necessary condition for diagnosing depressive schizoaffective disorder.

During hospitalization, the patient’s condition improved; the outpatient medication regimen was supplemented with risperidone 4 mg/day, valproic acid 600 mg/day and duloxetine 60 mg/day. Additionally, the patient underwent supportive psychotherapy, including discussing the existential context of the suicide attempt, cognitive processing focusing on the suicidal ideas, and integrating emotions related to depressive feelings of worthlessness, helplessness, and self-stigma. At the follow-up outpatient consultation, six months after discharge, the patient was in remission, with residual depressive symptoms and mild behavioral disorders, following the treatment initiated during hospitalization.

The presence of depressive symptoms in schizophrenia raises several discussions. Firstly, it is necessary to differentially diagnose with schizoaffective disorder, a disorder in which a major affective episode (depressive or manic) can be identified concurrently with psychosis. In this case, the diagnosis is paranoid schizophrenia, because for many years, the illness manifested with florid psychotic symptoms, without the interference of affective episodes. In recent years, however, depressive symptoms have consistently been part of the clinical picture, as schizophrenia entered its residual phase.

The association of depression with schizophrenia is an important issue in psychiatry. Depressive symptoms in patients with schizophrenia have often been either ignored or rejected by clinicians, because they have often been assimilated to negative symptoms (anhedonia, apathy, hypobulia, social withdrawal, alogia). But it has been demonstrated over time that it is important to identify them, as they can lead to increased suicide risk, poor quality of life, significant deficits in functioning, a higher rate of relapse⁽²⁾, with depression being reported in all stages of schizophrenia’s evolution⁽³⁾.

Given the severity of these complications, numerous researchers have studied the relationship between depression and schizophrenia. It has been shown that there is a wide variety of depressive symptoms reported by patients with schizophrenia in the literature, with prevalence rates of up to 61%⁽⁴⁾. Moreover, patients with schizophrenia have an increased risk of developing depressive symptoms compared to the lifetime prevalence of depression in the general population⁽⁵⁾. The study of suicidal behavior in schizophrenia showed that 9-13% of patients commit suicide⁽⁶⁾, at least 20-40% of them make a suicide attempt and 1-2% of the latter will commit suicide in the next 12 months⁽⁷⁾. Depression is the most important risk factor for suicide, in the remission phases of the disease, in individuals with schizophrenia⁽⁸⁾.

There are several psychopathological instances where we encounter the association of depression with psychosis/schizophrenia. Thus, the diagnostic category of depressive episode with psychotic symptoms (psychotic symptoms within a depressive episode – a distinct clinical subtype of depression) is well known. Depression can occur at the onset of schizophrenia, before the onset of psychotic symptoms⁽⁹⁾, during acute psychotic episodes⁽¹⁰⁾. Additionally, there is a specific psychopathological condition defined as a diagnostic category, namely post-psychotic depression – a depressive episode that occurs following the first psychotic episode⁽¹⁰⁾. But most people with schizophrenia have subliminal depressive symptoms⁽¹¹⁾.

Birchwood and Upthegrove, in 2005⁽¹²⁾, considered depression to be an intrinsic part of schizophrenia, a fact that can be explained by several psychopathological mechanisms, namely: 1) depression that is intrinsic to psychosis; 2) depression as a psychological reaction to diagnosis and its implications for social status and position; 3) depression as a result of psychological traumas from childhood.

According to the diagnostic criteria of DSM IV-TR⁽¹⁾ and DSM-5⁽¹³⁾, schizophrenia is characterized by the presence of two types of symptoms: positive (delusional ideas, hallucinations, disorganized speech and behavior) and negative (apathy, anhedonia, flat affect, alogia). According to Stahl (2013), beyond the formal aspect of classification criteria manuals, numerous studies classify symptoms of schizophrenia into five dimensions: positive, negative, cognitive, aggressive, and affective. Regarding affective symptoms (depressive mood, anxiety, psychic tension, irritability, guilt feelings, etc.), these are often part of the symptomatology of schizophrenia⁽¹⁴⁾, even though they do not meet the DSM-5 criteria for an affective disorder.

In terms of neurobiology, numerous studies have shown that there is, in fact, a transdiagnostic psychopathological model, a continuum between affective disorders and disorders in the psychotic spectrum, based on disturbed neuroplasticity, expressed through: decreased hippocampal volume, significant decrease in brain-derived neurotrophic factor (BDNF), resulting in decreased neurogenesis, decreased hypofrontal cerebral blood flow, reduced dendritic spines (in number and size), and decreased neuroplasticity. In addition, neuroinflammation theories support the idea that both depression and schizophrenia are systemic inflammatory diseases, studies showing changes in inflammatory markers, such as: increased levels of serum cortisol, cytokines, tumor necrosis factor-alpha, increased C-reactive protein during acute episodes, increased biomarkers of oxidative stress, indicating increased free radicals, immune dysregulation, and comorbid autoimmune disorders^(15,16).

Miller’s theory (2019) integrates the results of studies focusing on the associations between inflammation and schizophrenia. Increased psychosocial stress interacts with genetic and/or epigenetic factors, resulting in peripheral inflammation, characterized by cellular activation, cytokine production, and acute-phase response. In the context of increased blood-brain barrier permeability, there is also central inflammation⁽¹⁷⁾.

As a result, cytokine production, microglial activation and the activation of the tryptophan catabolic pathway can lead to brain disconnectivity, decreased neurogenesis, neurotransmitter disturbances (dopamine, glutamate, acetylcholine), and white matter pathology, thus contributing to the psychopathology of schizophrenia. Induction of the enzyme indoleamine 2,3-dioxygenase (IDO) results in increased production of kynurenine, which is converted into kynurenic acid, an antagonist of the NMDA receptor, and this pathway has been implicated in schizophrenia. Inflammation may also play a role in specific symptom domains, such as positive, negative, affective and cognitive symptoms⁽¹⁸⁾.

Regarding treatment, in the presence of depression in schizophrenia, if the patient is undergoing treatment with a typical antipsychotic, switching to an atypical antipsychotic is recommended⁽⁵⁾. An important component of treatment is cognitive behavioral therapy, which aims to process self-stigmatization, shame, difficulty in regaining trust in one’s own thoughts after recovering from delusional beliefs, and weak motivation. Some treatment guidelines consider the use of antidepressants, which are recommended in the treatment of unipolar depression⁽¹⁹⁾, although a recent meta-analysis provides limited evidence of their effectiveness⁽²⁰⁾.

The coexistence of depressive symptoms with schi­zo­phrenia must clarify the psychopathological condition, so that, nosologically, a distinction can be made between depression-syndrome or depression-independent mental disorder (major depressive episode fulfills the complete set of criteria), in comorbidity with schizophrenia. In this case, depression is considered a symptom, a psychological reaction to diagnosis, and its implications for social status and position.

In the presented case, we are witnessing a convergence of depressive symptomatology that can be explained psychopathologically by the “cognitive triad” expressed in three instances – life is worthless, the future is hopeless, the self has no value – and in residual subclinical positive symptoms (impulsivity and low frustration tolerance). Impulsivity together with aggression are risk factors associated with suicidal behavior. Impulsivity is a mental construct that is composed of a wide range of behaviors that reflect an inability to self-regulate emotionally, and includes: poor planning, premature responses without foreseeing consequences, sensation seeking, inability to inhibit responses, predilection for immediate rewards⁽²¹⁾. Thus, a suicide attempt has occurred in a stressful context on a background of low frustration tolerance, impulsivity, and depression within the schizophrenic disorder.

Depression in schizophrenia represents a challenge for a categorical and hierarchical diagnostic system. In this sense, even the diagnostic category represented by schizoaffective disorder has been questioned regarding its inclusion in the diagnostic criteria of DSM-5. In current studies, depression is now recognized to frequently occur in schizophrenia, especially when it develops in adolescence. However, all these have not translated into a proportional clinical recognition and resolution of uncertainties in therapeutic approaches. 

Corresponding author: Lavinia Duică E-mail: laviniaduica@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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