اقدام به هذیان های آزار و شکنجه: اهمیت جستجوی ایمنی

Objective Acting on delusions is a significant clinical issue. The concept of safety behaviours—actions carried out with the intention of reducing perceived threat—provides a new way of understanding acting on delusions. A study was conducted with the aim of examining the prevalence and correlates of safety behaviours related to persecutory delusions. Method One hundred patients with persecutory delusions were assessed for safety behaviours, acting on delusions, anxiety, depression, and psychotic symptoms. Case note data were collected on instances of serious violence or suicide attempts. Results Ninety-six patients had used safety behaviours in the last month. Greater use of safety behaviours was associated with higher levels of distress. A history of violence or suicide attempts was associated with greater use of safety behaviours. Safety behaviours were significantly associated with acting on delusions, but not with the negative symptoms of psychosis. Conclusion Safety behaviours are a common form of acting on persecutory delusions. These behaviours have the consequence that they are likely to prevent the processing of disconfirmatory evidence and will therefore contribute to delusion persistence.

In the 1990s an empirical literature emerged indicating that acting on delusions is common (Applebaum, Robbins, & Roth, 1999; Buchanan et al., 1993; Wessely et al., 1993). It was found that persecutory delusions are those most likely to be acted upon, that the actions are seldom violent, and that the responses are associated with negative emotions such as feeling sad or fearful. However, little is understood about why people act on delusions. One potential route to understanding acting on persecutory delusions is through the concept of safety behaviours. At the heart of persecutory delusions are threat beliefs (Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002; Freeman & Garety, 2004). Individuals believe that they are to suffer physical, social, or psychological harm. Many instances of acting on persecutory delusions may be anxious attempts to seek safety and prevent the perceived threat from occurring. Thus, safety behaviours are acting on delusions, but can be distinguished from the totality of such actions because of their intent. In this article, we investigate the prevalence and correlates of safety seeking in 100 individuals with persecutory delusions, the relationship with an established measure of acting on delusions, and whether the withdrawal often used as a safety behaviour is associated with negative psychotic symptoms. Safety behaviours Individuals who feel threatened often carry out actions designed to prevent their feared catastrophe from occurring; this has been termed ‘safety behaviour’ (Salkovskis, 1991). When the perceived threat is a misperception, such as in anxiety disorders and paranoia, there are important consequences. Individuals fail to attribute the absence of catastrophe to the incorrectness of their threat beliefs. Rather, they believe that the threat was averted only by their safety behaviours (e.g. ‘The reason I wasn’t attacked was because I left the street in time and made it back home’). What are actually instances of the incorrectness of threat beliefs are instead turned into ‘near misses’. Threat beliefs are likely to persist partly due to this failure to obtain and process disconfirmatory evidence. Manipulation studies have tested the idea that safety behaviours maintain anxiety disorders (e.g. Salkovskis, Clark, Hackmann, Wells, & Gelder, 1999; Sloan & Telch, 2002; Wells et al., 1995). It has been found that exposure plus decreased use of safety behaviours leads to greater reductions in threat beliefs and anxiety than exposure alone, consistent with the maintenance hypothesis. The concept of safety behaviours was developed in cognitive accounts of anxiety disorders (e.g. Clark, 1999; Salkovskis, Clark, & Gelder, 1996), but has since been applied to persecutory delusions (e.g. Morrison, 1998). Freeman, Garety, and Kuipers (2001) used a semi-structured interview—the Safety Behaviours Questionnaire—with 25 individuals with current persecutory delusions. It was found that all of the individuals had used safety behaviours in the past month. The most common type of safety behaviour was avoidance. For example, people would avoid going to the local shops or on buses where they feared attack. Apart from avoiding the situations perceived as most dangerous, the individuals also carried out actions to lessen the threat directly. When they felt they were in imminent danger they sought protection (e.g. would only leave the home with a trusted person), took steps to decrease their visibility (e.g. alternated routes and the time of return home), enhanced their vigilance (e.g. looking up and down the street), or acted as if they would resist attack (e.g. prepared to strike out). Further, a smaller proportion of people would try to comply with their persecutors (e.g. trying to do things that they thought the persecutors wanted them to do such as keeping the television volume low) or adopt the opposite behaviour of confronting them (e.g. shouting at neighbours). Greater use of safety behaviours was associated with higher levels of anxiety. The safety seeking appeared to be motivated by fear. The main aim of the current study was to examine the presence and correlates of safety behaviours in a larger sample of individuals with persecutory delusions using the Safety Behaviours Questionnaire. It was predicted that safety behaviours would be present in the majority of individuals with persecutory delusions and would be associated with higher levels of emotional distress. The second aim of the study was to assess the degree of overlap between acting on delusions, as assessed by the main instrument used in the 1990s, the Maudsley Assessment of Delusions Schedule (Wessely et al., 1993), and safety behaviours as assessed by the Safety Behaviours Questionnaire (Freeman et al., 2001). The MADs assesses a broad range of actions associated with delusions, including, for example, whether the person has written to anyone, whether they have lost their temper, and whether their belief has stopped them from watching television or listening to the radio. We predicted significant associations between the two measures. Further, we wished to look in closer detail at two particularly important clinical groups, those with a history of violence and those with a history of suicide or self-harm attempts (e.g. Verdoux et al., 2001), to examine whether they might be more likely to act on their delusions and use safety behaviours. We did not attempt to understand violence or suicide attempts as responses to delusions (see Appelbaum, Robbins, & Monahan, 2000; Walsh et al., 2004). Safety behaviours and the negative symptoms of psychosis A number of factors have been identified as causes (or confounders) of negative symptoms in psychosis. These include, for example, cognitive impairment (e.g. O’Leary et al., 2000), depression (e.g. Malla et al., 2002), side effects of medication (e.g. Kelley, van Kammen, & Allen, 1999), and understimulation (e.g. Wing & Brown, 1970). There has long been debate about the relationship between the positive and negative symptoms of psychosis (e.g. Wing, 1989). One argument is that, in some cases, negative symptoms are a secondary consequence of positive symptoms (e.g. Carpenter, Heinrichs, & Alphs, 1985). One plausible route that this might occur is via safety behaviours. Clearly, safety-seeking avoidance, often of inter-personal situations, may present as a loss of interest in activities (anhedonia-asociality) or as physical inactivity (avolition-apathy). Anxious vigilance may create inattention, and compliance with persecutors demands may result in poverty of speech (alogia). Further, the use of withdrawal as a safety mechanism may contribute to negative symptom development via understimulation, analogous to the effects of institutionalisation. The third aim of the current study was to assess the potential relationship between negative symptoms as assessed by the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1984b) and safety behaviours. It was predicted that greater use of safety behaviours would be associated with higher levels of negative symptoms.

Demographic and clinical data Basic demographic and clinical data are displayed in Table 1. The average age of the group was approximately 40, there were more males than females, the typical length of time since first onset of illness was 10 years, and the main diagnosis was schizophrenia. In this acute group there were high levels of delusions and hallucinations, but low levels of negative symptoms, especially affective flattening and inattentiveness. Table 1. Demographic and clinical data N Mean age (SD) 100 38.8 (11.0) Male/Female 100 69/31 Ethnicity: 100 White 80 Black—Caribbean 10 Black—African 4 Black—Other 1 Indian 2 Other 3 Employment: 98 Employed 6 Employed part-time 5 Student 2 Voluntary employment 5 Unemployed 79 Retired 1 Inpatient/Outpatient 100 55/45 Mean length of illness (SD) 99 10.4 (9.1) Mean number of admissions (SD) 97 4.4 (4.9) Diagnosis 100 Schizophrenia 86 Schizo-affective disorder 14 Medication: 93 None 3 Low (0–200 mg chlorpromazine equiv.) 31 Medium (200–400 mg chlorpromazine equiv.) 36 High (400+mg chlorpromazine equiv.) 23 Mean SAPS Global sum (SD) 100 8.4 (3.0) Mean Global Delusion (SD) 4.0 (.6) Mean Global Hallucination (SD) 3.0 (1.8) Mean SANS Global sum (SD) 100 7.4 (4.5) Mean Global Affective flattening (SD) .9 (1.3) Mean Global Alogia (SD) 2.6 (1.4) Mean Global Avolition (SD) 2.5 (1.4) Mean Global Anhedonia (SD) 2.5 (1.4) Mean Global Attention (SD) .8 (1.1) Mean BDI (SD) 95 26.1 (13.2) Mean BAI (SD) 93 24.5 (13.2) Table options The presence of safety behaviours All but four of the 100 individuals (96%) reported that they had carried out at least one safety behaviour in the last month (see Table 2). The most common safety behaviour was avoidance of threatening situations. In-situation safety behaviours were also present in over half of the group. Other types of safety behaviours were apparent in one-quarter to one-third of the participants. Delusional safety behaviours, actions that could not conceivably reduce the reported threat, were very rare. These findings are highly consistent with those of Freeman et al. (2001). Table 2. The presence of safety behaviours in individuals with persecutory delusions (N=100N=100) At least one safety behaviour in the last month (%) Mean score SD Avoidance 78 13.3 12.2 Positive actions: 87 6.9 5.4 In-situation 63 3.8 4.3 Escape 35 .9 1.5 Compliance 25 .8 1.4 Help-seeking 31 .8 1.4 Aggressive 24 .4 .9 Delusional 6 .2 .7 Total 96 20.5 14.1 Table options Safety behaviours and emotional distress Pearson correlations are reported. Higher total safety behaviours scores were associated with higher levels of anxiety, n=93n=93, r=.26r=.26, p=.012p=.012, and depression, n=95n=95, r=.25r=.25, p=.015p=.015. The association of emotional distress was with avoidance safety behaviours rather than other types; higher avoidance scores were significantly associated with anxiety, n=93n=93, r=.28r=.28, p=.008p=.008, but higher positive safety behaviour scores were not, n=93n=93, r=.08r=.08, p=.465p=.465. These associations were validated using the five-point PSYRATS item measuring the intensity of distress of the delusion. Intensity of distress of the delusion was associated with greater use of safety behaviours, n=99n=99, Spearman r=.21r=.21, p=.040p=.040, though in this case there was a significant association with positive safety behaviour scores, n=99n=99, Spearman r=.34r=.34, p=.001p=.001, but not avoidance safety behaviour scores, n=99n=99, Spearman r=.12r=.12, p=.241p=.241. Safety behaviours and demographic and clinical variables Males and females did not significantly differ in the use of safety behaviours (see Table 3), t=-1.24t=-1.24, df=98, p=.216p=.216, mean difference=−3.78, 95% CI=−9.90, 2.25. Level of medication was also unrelated to safety behaviour scores, F (2, 87)=2.01, p=.138p=.138. However, individuals with a history of violence reported more safety behaviours than those without, t=-2.84t=-2.84, df=95, p=.006p=.006, mean difference=−9.71, 95% CI=−16.5, −2.91. This was not accounted for by aggressive safety behaviours. Individuals with a history of violence were not more likely to use aggressive safety behaviours than individuals with no such history of violence, t=-.38t=-.38, df=95, p=.707p=.707, mean difference=−.1, 95% CI=−.5, .4. Individuals with a history of suicide attempts or self-harm reported more safety behaviours than individuals with no history of suicide, t=-2.09t=-2.09, df=96, p=.039p=.039, mean difference=−5.87, 95% CI=−11.45, −.29. In order to investigate whether the history of violence and history of suicide groups had higher safety behaviour scores because they were currently emotionally distressed, their scores were examined on the BDI and BAI (see Table 4). The history of violence group, compared with those with no history of violence, did not have significantly higher levels of anxiety, t=-.67t=-.67, df=88, p=.507p=.507, mean difference=−2.28, 95% CI=−9.08, 4.52, or depression, t=-.58t=-.58, df=90, p=.560p=.560, mean difference=−1.95, 95% CI=−8.58, 4.68. History of violence data and BAI scores were entered into a regression analysis with total safety behaviours scores as the dependent variable. History of violence, t=2.60t=2.60, p=.011p=.011, and anxiety, t=2.50t=2.50, p=.014p=.014, remained significant predictors. Similarly, the history of suicide group did not have significantly higher levels of anxiety compared with those with no such history, t=-1.04t=-1.04, df=89, p=.302p=.302, mean difference=−2.92, 95% CI=−8.51, 2.67, nor were there differences in depression, t=-1.69t=-1.69, df=91, p=.094p=.094, mean difference=−4.58, 95% CI=−9.95, .79. History of suicide and BAI scores were then entered into a regression analysis with total safety behaviours scores as the dependent variable. Again, anxiety was a significant predictor of safety behaviour scores, t=2.38t=2.38, p=.020p=.020, but history of suicide did not remain a significant predictor in this analysis, t=1.84t=1.84, p=.070p=.070. Table 3. Safety behaviours and demographic and clinical variables Variable N Safety behaviour questionnaire Mean score SD Gender Male 68 19.3 13.8 Female 31 23.1 14.5 Medication Low 31 20.2 13.1 Medium 35 17.5 13.9 High 23 25.0 15.6 Violence History of violence 20 28.0 14.1 No history of violence 77 18.3 13.5 Suicide attempts History of suicide 45 23.4 15.1 No history of suicide 53 17.5 12.7 Table options Table 4. Depression and anxiety scores by history of violence or suicide Anxiety Depression N Mean SD N Mean SD Violence History of violence 20 26.3 12.6 20 27.2 12.2 No history of violence 70 24.0 13.7 72 25.3 13.5 Suicide attempts History of suicide 42 26.0 14.4 43 28.4 13.7 No history of suicide 49 23.1 12.5 50 23.9 12.4