Gestion de la colère dans la schizophrénie

Abstract

Listen

Translate article

La gestion de la colère est devenue une indication classique des thérapies comportementales et cognitives, mais son application chez les patients souffrant de schizophrénie a été jusqu’ici très peu étudiée. En plus des indications de la TCC déjà connues pour les troubles psychotiques, il est souvent utile, pour faire l’analyse fonctionnelle et proposer des techniques adaptées, de viser directement la colère en tant qu’émotion, comme les comportements coléreux. Les premières données de la recherche clinique, ainsi que notre expérience, laissent à penser que cet abord est prometteur, susceptible de réduire les comportements agressifs et d’améliorer la qualité de vie du patient. Although the cognitive-behavioral model of anger management has been successful with several types of populations, therapy with psychotic patients rarely evaluates the need or puts into practice its usage. In this article a review of studies on the occurrence, prevention and management of anger in psychotic disorders is presented. Following that, some suggestions to adapt the functional analysis and therapeutic techniques of anger management for psychotic patients are suggested. In schizophrenia, anger is not a simple derivative of psychosis. It is often an independent factor, correlated amongst other things, particularly to self-injurious behaviors and to poor-quality social relationships. In psychiatric units, aggressive behaviors are most often caused by interpersonal incidents related to limit-setting by staff. Some studies have confirmed that the attitude of nursing staff has a great influence on the behavioral outcome of anger. They underline the importance of training staff to intervene as soon as possible in the stimulus chain and to adopt an empathetic attitude providing the patient with choices. Cognitive deficits and emotional difficulties inherent to schizophrenia are often severe enough to impair the quality of social interactions. They often prevent patients from adjusting their emotional reactions to real-life situations, causing anger and violence. These same deficits make the practice of cognitive behavioral therapy difficult and require the adaptation of both case formulation and suggested techniques. If they do not want to work on their delusions and hallucinations, making anger the main target of therapy can, in some cases, better motivate the patient. Case formulation must take into account the chronic nature of schizophrenia. The therapist can add elements to the functional analysis likely to promote the success of the therapy, including patient motivation, strengths and values. This helps the person accept their illness, improve self-esteem and see beyond their diagnosis. In this article we present a functional analysis system which allows for the collection of the most relevant data, to identify relationships between elements of the behavioral sequence, to make assumptions about triggers and maintenance factors, and to retain the most promising therapeutic approaches. The usual CBT techniques can be modified to take into account any individual memory, attentional and/or executive function problems. The aim is to set clear, accessible goals, repeat the exercises, use simple language, and, from time to time, abandon written materials (such as Beck's columns) in favor of short, frequent oral discussions. The patient can often manifest difficulty focusing attention on these materials. Such tools can sometimes encourage patients to write up long texts that cannot be used in therapy. Two principles must be respected in therapy. First, it is important to avoid exposure to anger-provoking situations. This technique is contraindicated in the case of schizophrenic spectrum disorders. Second, as with the general population, we must advise against catharsis. Indeed, repetition of violent behavior, associated with intense activation of the sympathetic nervous system, reinforces angry responses and increases assimilation of this behavior. Therefore, both in the patient's personal life and in health care settings, we would advise against tools such as punch bags and balls, which allow patients to reproduce their angry behavior. If the patient needs to vent their frustration, they should choose a sport that does not reproduce angry behavior and violent acts. For example, running, cycling or swimming could be recommended. Anger management based on cognitive behavioral therapy seems a promising therapy. It deserves to be practiced more widely and to be scientifically assessed in the psychotic population.