Italian validation of MOAS and NOSIE: a useful package for psychiatric assessment and monitoring of aggressive behaviours

Reform of Forensic Mental Health Services in Italy: Stigma and Blaming the Messenger: Hermenoia

About 40 years after the reforms leading to the closure of psychiatric hospitals (Ospedale Psichiatrico [OP]) in Italy in favor of a widespread model with a strong rehabilitation emphasis, Italy has chosen to close High Security Hospitals as well (Ospedale Psichiatrico Giudiziario [OPG]). The new forensic treatment model is expected to be more respectful of the person, including the perpetrators of violent crimes, and aims to be less stigmatizing and more rehabilitative. Despite the favorable premises of the reform (Law n. 81/2014), Italian psychiatrists are now obliged to answer calls to give evidence on strictly legal issues such as the social dangerousness of the mentally ill offender drawing on evidence or paradigms that many believe do not belong to medical knowledge. Psychiatrists must now learn to communicate about the relationship between psychiatry and society as required by law. This public expression engages with the cultural climate of society. Otherwise, the risk is of increasing the level of complexity leading to real misunderstandings that paradoxically may feed the stigma. The Italian reform provides an opportunity for reflection on some issues concerning psychiatric action, on how the public perceives the mentally ill and their psychiatrists, on the relationship between psychiatry and the world of law, on clinical methodologies for structured professional judgment, on public communication regarding severe mental illness, and the risk that psychiatrists may inadvertently be blamed for conveying an unwelcome message about mental illness and social dangerousness-we have called this social sensitivity against psychiatrists "hermanoia," blaming the messenger. The authors do not provide certain solutions but propose good practices.

Italian Version of the Hospital Aggressive Behaviour Scale-Users: Initial Psychometric Evaluation among Hospital Healthcare Professionals

BACKGROUND

Healthcare professionals frequently encounter various forms of aggression, ranging from verbal abuse to physical assaults, which can compromise both their occupational well-being and patient-care quality. Despite its prevalence and serious consequences, workplace aggression is often underreported due to a lack of standardized assessment tools. This study aims to develop a valid Italian version of the Hospital Aggressive Behaviour Scale-Users.

METHODS

The scale's structure was evaluated using exploratory (EFA) and confirmatory (CFA) factor analyses on two samples of healthcare professionals during and after the pandemic. Reliability, measurement invariance, and nomological validity were examined.

RESULTS

EFA revealed a two-factor structure comprising eight items (χ2 = 59.651, df = 13, p = 0.00; CFI = 0.98; TLI = 0.95; RMSEA = 0.07; SRMR = 0.02), distinguishing non-physical and physical aggression, and meeting all recommended criteria. CFA confirmed this structure, demonstrating good reliability and outperforming alternative models. The same factor structure was confirmed in standard (χ2 = 35.01, df = 19, p = 0.00; CFI = 0.99; TLI = 0.99; RMSEA = 0.03; SRMR = 0.02) and emergency (χ2 = 30.65, df = 19, p = 0.04; CFI = 0.98; TLI = 0.97; RMSEA = 0.06; SRMR = 0.04) contexts. Full residual invariance was found across job tenure groups. Aggression was positively associated with emotional exhaustion, psychological distance, psychosomatic symptoms, post-traumatic stress symptoms, and turnover intentions while negatively related to job satisfaction. Nurses and healthcare assistants reported higher levels of aggression than doctors.

CONCLUSIONS

This study provides a reliable, context-specific instrument for documenting and analysing outsider aggression. The insights can inform targeted interventions, contributing to a healthier hospital environment.

Aggressive behaviour and diabetes: A clinical case of atypical metabolic improvement during clozapine treatment

Aggressive and violent behaviour is a challenging psychiatric emergency to manage, especially among vulnerable categories such as patients with Intellectual Developmental Disorder. Although there is some evidence that clozapine may be useful as an anti-violence compound, its use is limited by common metabolic complications. An adult patient presented with obesity, type II diabetes mellitus, compulsive food intake, severe Intellectual Developmental Disorder, and a treatment-resistant aggressive behaviour. Clozapine was administered resulting in reduced aggressive behaviour. Unexpectedly, a reduction in the food craving as well as a sustained improvement in both anthropometric parameters and glycemic control were observed during the clozapine treatment. Our case report, describes these findings for the first time, highlighting the need for more clinical research to investigate both the efficacy of clozapine in the Intellectual Developmental Disorder populations and its long-term effects with special regard to the metabolic outcomes in this type of patients.

A Scoping Review of the Intersectionality of Autism and Intellectual and Developmental Disability with Social Inequity on Diagnosis and Treatment of Youth

Objective: To describe how the intersectionality of race, ethnicity, and language with autism and intellectual and developmental disability (IDD) impacts mental health inequities in psychopharmacological management of youth. Method: This was a scoping review in which a series of searches were conducted in PubMed, Web of Science, Google Scholar, and manual review of the articles collected. Results: Although autism and/or IDD increases the risk for poor physical and mental health, social determinants of health such as race, ethnicity, and language account for approximately a third of poor outcomes. Minoritized children with autism/IDD experience significantly greater delays to diagnosis and misdiagnosis and are less likely to receive appropriate services. Access to psychological testing and psychosocial services is often limited by availability, skilled practitioners, a shortage of non-English-language providers or interpreters, and poor reimbursement. Conclusion: The intersectionality of autism and/or IDD with race, ethnicity, and language compounds the health inequities associated with either of these challenges independently.

Predictors of psychosocial functioning in people diagnosed with schizophrenia spectrum disorders that committed violent offences and in those that did not: Results of the Recoviwel study

Psychosocial functioning represents a core treatment target of Schizophrenia Spectrum Disorders (SSD), and several clinical and cognitive factors contribute to its impairment. However, determinants of psychosocial functioning in people living with SSD that committed violent offences remain to be more thoroughly explored. This study aims to separately assess and compare predictors of psychosocial functioning in people with SSD that did and that did not commit violent offences considering several clinical, cognitive and violence-related parameters. Fifty inmates convicted for violent crimes in a forensic psychiatry setting diagnosed with SSD (OP group) and fifty participants matched for age, gender, education, and diagnosis (Non-OP group) were included in the study. A higher risk of violent relapse as measured by HCR-20 clinical subscale scores (p < 0.002) and greater global clinical severity as measured by CGI-S scores (p = 0.023) emerged as individual predictors of worse psychosocial functioning, as measured by PSP scores, in the OP group. Greater global clinical severity (p < 0.001), worse performance in the processing speed domain as measured by the BACS Symbol Coding (p = 0.002) and TMT-A tests (p = 0.016) and higher levels of non-planning impulsivity as measured by BIS-11 scores (p < 0.001) emerged as individual predictors of worse psychosocial functioning in the Non-OP group. These results confirm that clinical severity impacts psychosocial functioning in all individuals diagnosed with SSD and suggest that while cognitive impairment clearly represents a determinant of worse functional outcomes in most patients, the risk of violent relapse is a specific predictor of worse psychosocial functioning in people with SSD that committed criminal offences.

Effectiveness of deep brain stimulation on refractory aggression in pediatric patients with autism and severe intellectual disability: meta-analytic review

Some patients with autism and severe intellectual disability may experience uncontrolled aggression, causing serious injury or harm to others, and the therapeutic ineffectiveness of traditional pharmacological and behavioral treatment may aggravate symptoms. Deep brain stimulation (DBS) has been tested in patients with little evidence in children and adolescents. Therefore, we analyzed the efficacy and safety of DBS in refractory aggression in pediatric subjects with autism (ASD) and severe intelligence deficit (ID).Methods A meta-analytic review of Web of Science (WOS) and Scopus articles, following Prisma criteria. A total of 555 articles were identified, but after applying the inclusion criteria, only 18 were analyzed. The review of the registries and the extraction of information was performed by 2 independent groups, to reduce the evaluator's bias. For the description of the results, pediatric patients with ASD or ID present in each registry, with an application of specialized scales (Overt aggression scale, OAS, and THE modified version of the OAS, MOAS) pre and post-DBS, with a clinical follow-up of at least 12 months, were considered valid. Clinical improvement was calculated using tests of aggressiveness. In each registry with available data and then pooling the means of all patients in the OAS and MOAS, the effect size of DBS (overall and per study) was estimated. Finally, the adapted NOS scale was applied to rate the studies' quality and level of bias.Results In the studies analyzed, 65/100 were pediatric patients, with a mean age of 16.8 years. Most of the studies were conducted in South America and Europe. In all teams, aggressive behavior was intractable, but only 9 groups (53/65) applied specialized scales to measure aggressiveness, and of these, only 51 subjects had a follow-up of at least 12 months. Thus, in 48/51 a clinical improvement of patients was estimated (94.2%), with a considerable overall effect size (OAS: d = 4.32; MOAS: d = 1.46). However, adverse effects and complications were found in 13/65 subjects undergoing DBS. The brain target with the most evidence and the fewest side effects was the posteromedial hypothalamic nuclei (pHypN). Finally, applying the adapted NOS scale, quality, and bias, only 9 studies show the best indicators.Conclusion An optimal level of efficacy was found in only half of the publications. This is mainly due to design errors and irrelevant information in the reports. We believe that DBS in intractable aggressiveness in children and adolescents with ASD and severe ID can be safe and effective if working groups apply rigorous criteria for patient selection, interdisciplinary assessments, objective scales for aggressiveness, and known surgical targets.

Systematic Aggression Registration in Forensic Psychiatric Care: A Qualitative Study on Preconditions for Successful Implementation

Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.

Investigating the Effectiveness of Brexpiprazole in Subjects with Schizophrenia Spectrum Illness and Co-Occurring Substance Use Disorder: A Prospective, Multicentric, Real-World Study

BACKGROUND

Dual disorders (DDs) involve the coexistence of a substance use disorder (SUD) with another mental illness, often from the psychotic and affective categories. They are quite common in clinical practice and present significant challenges for both diagnosis and treatment. This study explores the effectiveness of brexpiprazole, a third-generation antipsychotic, in an Italian sample of individuals diagnosed with schizophrenia spectrum disorder and a comorbid SUD.

METHODS

Twenty-four patients, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and enrolled in several Italian hospitals, underwent a psychometric assessment at baseline (T0) and one month (T1) after starting brexpiprazole treatment administered at a mean dosage of 2 mg/day.

RESULTS

Brexpiprazole demonstrated significant reductions in psychopathological burden (Positive and Negative Syndrome Scale/PANSS total score: p < 0.001). Positive (p = 0.003) and negative (p = 0.028) symptoms, substance cravings (VAS craving: p = 0.039), and aggression (MOAS scale: p = 0.003) were notably reduced. Quality of life improved according to the 36-item Short Form Health Survey (SF-36) subscales (p < 0.005).

CONCLUSIONS

This study provides initial evidence supporting brexpiprazole's efficacy and safety in this complex patient population, with positive effects not only on psychopathology and quality of life, but also on cravings. Further studies involving larger cohorts of subjects and extended follow-up periods are needed.

Examining Lurasidone Efficacy in Patients with Schizophrenia Spectrum Illness and Concurrent Alcohol and Substance Use Disorder: A Prospective, Multicentric, Real-World Investigation

Background: Dual disorders (DD) entail the coexistence of a substance use disorder (SUD) and another mental health condition, often within psychotic and affective disorders. This study aims to evaluate lurasidone, an innovative atypical antipsychotic, in individuals diagnosed with schizophrenia spectrum disorder and concurrent comorbidities of alcohol use disorder/substance use disorder (AUD/SUD). Methods: A cohort of 23 subjects diagnosed with schizophrenia spectrum disorder and comorbid AUD/SUD underwent psychometric assessments at baseline (T0) and one-month (T1) post-lurasidone initiation. Results: Lurasidone exhibited significant reductions in psychopathological burden, evidenced by decreased total PANSS scores (Z = 2.574, p = 0.011). Positive symptoms, substance craving (VAS Craving; Z = 3.202, p = 0.001), and aggressivity (MOAS scale; Z = 2.000, p = 0.050) were notably reduced. Clinical Global Impression (CGI) scores significantly improved (Z = 2.934, p = 0.003). Quality of life enhancements were observed in SF-36 subscales (energy, emotional well-being, and social functioning) (p < 0.05) and Q-LES-Q-SF scale (Z = -2.341, p = 0.021). A safety analysis indicated lurasidone's good tolerability, with only 8.7% reporting discontinuation due to side effects. Conclusions: This study offers initial evidence supporting lurasidone's efficacy and safety in dual diagnoses, highlighting positive effects on psychopathology, substance craving, and quality of life. These findings emphasize the need for tailored, comprehensive treatment strategies in managing the complexities of this patient population.

Group interpersonal psychotherapy (IPT-G) for borderline personality disorder: A randomized controlled study

Recent evidence supported the notion that add-on group therapy should be provided to individuals with borderline personality disorder (BPD) who already undergo individual psychotherapy. The present 20 week-study was aimed to evaluate the efficacy of the adjunction of group interpersonal psychotherapy (IPT-G) to individual interpersonal psychotherapy adapted for BPD - revised (IPT-BPD-R) in comparison with individual IPT-BPD-R alone in a group of BPD patients. In addition, demographical and clinical characteristics that can be considered predictors of response to add-on group therapy were investigated. Forty-six patients were randomly assigned to 1) IPT-BPD-R plus IPT-G or to 2) IPT-BPD-R in the waiting list for IPT-G. Patients were assessed at baseline and after 20 weeks with: the Clinical Global Impression Scale, Severity item (CGI-S); the Social Occupational Functioning Assessment Scale (SOFAS); the Satisfaction Profile (SAT-P); the Borderline Personality Disorder Severity Index (BPDSI); the Modified Overt Aggression Scale (MOAS); the Childhood Trauma Questionnaire - Short Form (CTQ-SF); the Inventory of Interpersonal Problems (IIP-32); and the Reading the Mind in the Eyes Test (RMET). Statistical analyses included: ANOVA for repeated measures to compare score changes of the rating scales within groups (trial duration) and between groups (treatment modalities), and multiple regression analysis to identify which clinical factors are significantly and independently related to the difference of BPDSI score between baseline and week 20 (Δ BPDSI). The significance level was P ≤ 0.05. Both significant within-subjects effects (duration) and between-subjects effects (treatment modalities) were found for the following rating scales: MOAS; BPDSI items "feelings of emptiness", "outbursts of anger," and "affective instability"; RMET; SAT-P items "work" and "sleep, food, free time"; and IIP-32 scale "domineering/controlling". At the multiple regression analysis BPDSI item "impulsivity", RMET, and the subscale "socially inhibited" of the IIP-32 were significantly and independently related to Δ BPDSI score. In conclusion, the add-on of IPT-G produced higher improvement in core BPD symptoms, social cognition, a dysfunctional interpersonal style, and subjective quality of life. Subjects who were less impulsive, less socially inhibited, and with higher abilities in social cognition obtained greater benefits from the adjunction of group therapy. CLINICAL TRIALS REGISTRATION NUMBER: ACTRN12623000002684, Australian New Zealand Clinical Trials Registry (ANZCTR).

Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study

BACKGROUND

Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting.

OBJECTIVE

This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022).

METHODS

During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events.

RESULTS

In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators.

CONCLUSIONS

A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

Improvements in Treatment Adherence after Family Psychoeducation in Patients Affected by Psychosis: Preliminary Findings

(1) Background: Family psychoeducation is a well-recognized intervention which aims to improve the outcomes of illness in patients affected by psychosis. It has benefits in treatment adherence and leads to a reduction in relapses, higher levels of patient insight, and lower levels of stress within the family and among caregivers. (2) Methods: Eight patients and their families were recruited and randomly assigned to a Falloon-based family psychoeducation (FPP) intervention, and nine patients and their families were randomized to a Gestalt-based family intervention (GT). We compared the outcomes of these two treatment groups at a baseline assessment (T0), at the end of the programs (T1), and 6 and 12 months after the end of the programs (T2 and T3). The assessments included examinations of cognition (The Mini-Mental State Examination (MMSE) and The Five Point Test (5 Point)), the psychopathology and severity of illness (The Brief Psychiatric Rating Scale (BPRS), The Positive and Negative Syndrome Scale (PANSS), and The Clinical Global Impression Scale (CGI)), expressed emotion in families (Expressed Emotionality (Family Questionnaire-EE)), patient quality of life (The World Health Organization Quality of Life-BREF (WHOQOL-B)), social functioning (The Personal Social Performance (SPS)), aggression (Modified Overt Aggression Scale (MOAS)), and treatment adherence (The Brief Medication Adherence Report Scale (BMARS)). The primary aim was to test whether the FFP vs. GT program was more effective in improving treatment adherence over time. (3) Results: treatment adherence improved much more in the FFP group over time at any follow-up: +43.1% at T1, +24.0% at T2, and +41.6% at T3. Other characteristics, including psychopathology and the clinical stability of the subject, did not change over time. (4) Discussion: Family psychoeducation based on the Falloon program was effective at improving treatment adherence and contributed to avoiding relapses in the long term. Further studies on larger samples should be conducted to confirm this evidence, and similar psychoeducational programs should be routinely promoted in the clinical setting.

Abnormalities in electroencephalographic microstates among violent patients with schizophrenia

Schizophrenia is often associated with a remarkably increased risk of violence, which has become a public health concern and brought a great economic burden. Recent studies have reported changes in the electroencephalograms (EEG) of patients with schizophrenia. The evidence for an association between EEG and violence in patients with schizophrenia is not conclusive. This study aimed to investigate EEG microstates in violent patients with schizophrenia. Forty-three violent patients with schizophrenia (the VS group) and 51 non-violent patients with schizophrenia (the NVS group) were included, and their EEG microstates were recorded using 21-Channel EEG recordings. The two groups were compared for differences of four microstate classes (A-D) with regards to three microstate parameters (duration, occurrence, and coverage). Compared with the NVS group, the VS group exhibited increased duration, occurrence, and coverage of microstate class A and decreased occurrence of microstate class B. The VS group also had lower probabilities of transitions from "B to C" and from "C to B", as compared with the NVS group. In addition, the MOAS score was positively correlated with the duration, occurrence, and coverage of microstate A. The present study found an abnormal pattern of EEG microstates in violent patients with schizophrenia, which might help clinicians identify patients with schizophrenia who might engaged in violence as well as develop intervention strategies at an early stage.

The Management of Workplace Violence against Healthcare Workers: A Multidisciplinary Team for Total Worker Health® Approach in a Hospital

The risk of aggression against healthcare workers (HCWs) is a globally well-known topic. However, workplace violence (WV) is often considered as part of HCW’s job, leading to a general underreporting. This cross-sectional study aims at providing a descriptive analysis of aggressive acts against HCWs registered in a 34-month period in a pediatric hospital. According to a specific protocol, each aggressive act was analyzed by a multidisciplinary team using the “Modified Overt Aggression Scale” (MOAS), the “General Health Questionnaire-12” (GHQ-12), and the “Short Form-36 Health Survey” (SF-36) to build a report addressing improvement measures. A three-domain model of WV was also developed considering: (1) assaulted HCWs, (2) attacker-related issues, and (3) environmental context. Contributing factors to overt aggression were outlined and tested using univariate analyses. Statistically significant factors were then included in a multiple linear regression model. A total of 82 aggressive acts were registered in the period. MOAS scores registered a mean value of 3.71 (SD: 4.09). Verbal abuse was the most common form of WV. HCWs professional category, minor psychiatric disorder, emotional role limitation, type of containment used, and emotion intensity were significantly associated with overt aggression (p < 0.05), as well as the attacker’s role in the hospital (p < 0.05). The multiple regression analysis confirmed these findings (p < 0.001). Raising awareness on the aggression risk and contributing factors may lead to a relevant improvement of workplace environment, individual workers’ health, and organizational well-being.

Reporting Incidents in the Psychiatric Intensive Care Unit: A Retrospective Study in an Italian University Hospital

ABSTRACT

To evaluate the characteristics of the reported workplace violence in a psychiatric intensive care unit (PICU) by analyzing an electronic hospital incident reporting system (IRS). One hundred thirty reports were retrieved from January 2017 to June 2020, referring to assaults committed by patients (71% males) with an average age of 29.8 years (SD, 14.9). The most frequent psychiatric diagnosis was a neurodevelopmental disorder (33%). Physical aggression (84%) was more frequent than the other types of aggression. Nurses and unlicensed assistive personnel were the most frequent victims (65%). Aggressions were more frequent on Friday (18%) and between 4 p.m. and 8 p.m. (35%). A total of 64.9% of the incidents happened in the first 5 days of hospitalization. A significant association between physical aggression and diagnosis of neurodevelopmental disorder emerged. IRS could be helpful to identify high-risk patient groups and develop clinical strategies to reduce adverse events in clinical practice.

Substance Abuse Associated with Aggressive/Violent Behaviors in Psychiatric Outpatients and Related Psychotropic Prescription

Psychiatric disorders with substance abuse are considered the leading causes of most violent and aggressive behaviors in the general population. This study was aimed to assess the impact of substance abuse and the therapeutic approaches adopted by psychiatrists in aggressive vs non-aggressive outpatients (n = 400) attending community-based psychiatric services and recruited over a 3-year period. Clinical and therapeutic variables were collected from medical records and the Modified Overt Aggression Scale (MOAS) was used to assess any aggressive/violent behavior. Violent behaviors were significantly higher in alcohol and substance abusers compared to non-abusers (p < 0.01), except for heroin abusers. Mean weighted MOAS score was significantly higher in patients taking antipsychotics (p < 0.005). The administration of Haloperidol, Zuclopenthixol, and Clozapine was more frequent in aggressive than in non-aggressive patients. The most frequently administered drug in these patients was Haloperidol (23.91%), with a higher mean daily dosage in violent vs non-violent patients. Our results confirm the well-established relationship between substance abuse and violent behaviors in psychiatric inpatients also within outpatient community services. Observed rates of most frequently prescribed antipsychotics to aggressive patients did not show any preference for newer generation compounds, with clinicians operating in the community setting likely being in need for further evidence and specific training to support their treatment choice.

Antipsychotic Polypharmacy and High-Dose Antipsychotic Regimens in the Residential Italian Forensic Psychiatric Population (REMS)

Few data exist regarding treatment with antipsychotics in forensic psychiatric patient populations with high social dangerousness. We performed a secondary analysis of 681 patients treated with at least one antipsychotic, extracted from a 1-year observational retrospective study, conducted on 730 patients treated in the Italian Residencies for Execution of Security Measures (REMS) (96.4% of the REMS population). We aimed at investigating antipsychotic polypharmacy (prescription of two or more concomitant antipsychotics) and high dose/very high-dose antipsychotics, as well as the possible factors associated with such therapeutic regimens. High dose/very high-dose antipsychotics were defined as a prescribed daily dose to WHO-defined daily dose ratio greater than 1.5 or 3.0, respectively. Binary logistic regression analysis was used in three models to test possible predictors of antipsychotic polypharmacy, high-dose antipsychotics, and very high-dose antipsychotic prescription. Antipsychotic polypharmacy resulted in n = 308 (45.2%) of the patients, n = 346 (50.8%) received high-dose antipsychotics, and n = 96 (14.1%) very high-dose antipsychotics. The multivariate analysis disclosed an association between antipsychotic polypharmacy and male gender (odds ratio (OR): 2.75 and 95% CI: 1.34–5.65), long-acting injectable (LAI) antipsychotic prescription (OR: 2.62 and 95% CI: 1.84–3.74), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.13–2.36). High-dose antipsychotics were also associated with male gender (OR: 2.01 and 95% CI: 1.02–3.95), LAI antipsychotic prescription (OR: 2.78 and 95% CI: 1.95–3.97), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.12–2.36). The use of antipsychotic polypharmacy and high-dose antipsychotics is frequent in the REMS population. These results might depend on regulatory and organizational aspects of the REMS system, including variability in structures, lack of a common model of care, and lack of stratified therapeutic security.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Identification of violent patients with schizophrenia using a hybrid machine learning approach at the individual level

Despite numerous risk factors associated with violence in patients with schizophrenia, predicting and preventing violent behavior is still a challenge. At present, machine learning (ML) has become a promising strategy for guiding individualized assessment. To build an effective model to predict the risk of violence in patients with schizophrenia, we proposed a hybrid ML method to improve the prediction capability in 42 violent offenders with schizophrenia and 33 non-violent patients with schizophrenia. The results revealed that the final model, which combined multimodal data, achieved the highest prediction performance with an accuracy of 90.67%. Specifically, the model, which fused three modalities of neuroimaging data, achieved a better accuracy than other fused models. In addition, the msot discriminative neuroimaging features involved in the prefrontal-temporal cognitive circuit and striatum reward system, indicating that dysfunction in cortical-subcortical circuits might be associated with high risk of violence in patients with schizophrenia. This study provides the first evidence supporting that the combination of specific multimodal neuroimaging and clinical data in ML analysis can effectively identify violent patients with schizophrenia. Furthermore, this work is crucial for the development of neuro-prediction models that could facilitate individualized treatment and interventions for violent behaviors in patients with schizophrenia.

Young age and the risk of violent behaviour in people with severe mental disorders: prospective, multicentre study

Background

During adolescence and young adulthood people appear to be more prone to violent behaviour. A greater tendency to violent behaviour appears to be associated with hyperactivity, impulsivity and low tolerance for frustration and provocation in social settings.

Aims

This prospective cohort study aimed to evaluate rates of violent behaviour among young people with mental disorders, compared with older age groups.

Method

A total of 340 individuals with severe mental disorders (125 living in residential facilities and 215 out-patients) were evaluated at baseline with the SCID-I and II, Brief Psychiatric Rating Scale, Specific Level of Functioning scale, Brown–Goodwin Lifetime History of Aggression scale, Buss–Durkee Hostility Inventory, Barratt Impulsiveness Scale and State–Trait Anger Expression Inventory-2. Aggressive behaviour was rated every 15 days with the Modified Overt Aggression Scale (MOAS).

Results

The sample comprised 28 individuals aged 18–29 years, 202 aged 30–49 and 110 aged 50 and over. Younger age was associated with a personality disorder diagnosis, substance use disorder, being single and employed. These results were confirmed even controlling for the gender effect. The patterns of the cumulative MOAS mean scores showed that younger (18–29 years old) individuals were significantly more aggressive than older (≥50) ones (P < 0.001).

Conclusions

This study highlights how young age in people with severe mental disorders is correlated with higher levels of impulsivity, anger and hostility, confirming previous analyses. Our results may assist clinicians in implementing early interventions to improve anger and impulsivity control to reduce the risk of future aggressive behaviours.

A Study Into the Severity of Forensic and Civil Inpatient Aggression

Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

Substance use disorders and violent behaviour in patients with severe mental disorders: A prospective, multicentre study

OBJECTIVE

The relationship between alcohol and substance use and the risk of violence exhibited by patients with mental disorders is under-researched. This prospective cohort study aims to compare patients with severe mental disorders and with different substance use behaviors in terms of sociodemographic and clinical characteristics, hostility, impulsivity and aggressive behaviors. Furthermore, this study aims to assess differences in violent behaviors during a 1-year monitoring follow-up.

METHODS

A total of 378 participants with severe mental disorders from Italian residential facilities and from four Departments of Mental Health (244 outpatients and 134 residential patients) were enrolled. Participants were categorized as Persons with Current Substance Use, Persons with Former Substance Use and Persons with Non-Substance Use. All these patients underwent a complex multidimensional assessment, including the lifetime and current substance use; a subsample of outpatients was also assessed with a laboratory substance assay including the testing for specific substances. We assessed the differences among these three groups in hostility, impulsivity and aggressive behaviors.

RESULTS

The results of the close 1-year monitoring show a significantly higher risk of violence for patients with severe mental disorders Persons with Current Substance Use compared to Persons with Former Substance Use and Persons with Non-Substance Use. Persons with Current Substance Use showed significantly higher scores for irritability, negativism and verbal assault compared to Persons with Non-Substance Use. Persons with Former Substance Use showed significantly higher scores for lifetime history of aggressive behaviors compared with patients with Persons with Non-Substance Use.

CONCLUSION

These findings suggest that patients with comorbid mental illness and substance use disorders should be referred for specific interventions to reduce aggressive behavior and ensure patient well-being and community safety.

Validation of the 30-item nurses' observation scale for inpatient evaluation and mental health-care promotion

CONTEXT

The 30-item nurses' observation scale for inpatient evaluation (NOSIE-30) developed for the behavioral and observational rating of psychiatric inpatients.

AIMS

The purpose of this study was to evaluate the validation of the NOSIE-30 and mental health-care promotion.

MATERIALS AND METHODS

The participants with psychiatric disorders were selected from 310 inpatients referred to the military educational hospital in Iran. This study was carried out in two phases: First, translation of the NOSIE-30 into Persian followed the stepwise, iterative procedures developed by the International Quality of Life Assessment project approach. Second, face validity, criterion-related validity and construct validity, and reliability of the Persian version were determined. The concurrent validity was assessed by using the global assessment of functioning (GAF) instrument. Data were analyzed with the SPSS software of version 22. Exploratory factor analysis, the Cronbach's alpha coefficient, and interrater agreement with intraclass correlation coefficient and Pearson's correlation coefficient were used to data analysis.

RESULTS

Pearson's correlation coefficient between the NOSIE and GAF was 0.75. The interrater reliability for subscale scores and structure of the NOSIE were ranging from 0.70 to 0.94 and Cohen's kappa = 0.74. Furthermore, the internal consistency of the scale's total scores was estimated by Cronbach's alpha = 0.85.

CONCLUSIONS

The finding indicated that NOSIE-30 Persian version scale has the desirable validity and reliability for evaluating the nursing care of inpatients. Thus, nurses can promote mental health care by applying this scale in the psychiatric setting.

Facial emotion recognition in people with schizophrenia and a history of violence: a mediation analysis

Evidence for an association between impaired facial emotion recognition and violence in people with schizophrenia is inconclusive. In particular, the role of misidentification patterns involving specific emotions such as anger and the influence of clinical characteristics on this association remain unclear. In this study, we compared facial emotion recognition performance in age- and gender-matched schizophrenia spectrum disorders subjects with (N = 52) and without (N = 52) a history of violence. Data on current symptom severity, Cluster B personality status, past victimization, and alcohol and substance misuse were also collected. Compared to those without, subjects with a history of violence showed worse facial emotion recognition performances, involving anger, fear, disgust, sadness, and happiness. When formally testing the reporting of angry faces, evidence of enhanced sensitivity to anger was not supported. Finally, when the impact of current symptoms was assessed, higher severity of activation symptoms, including motor hyperactivity, elevated mood, excitement and distractibility, mediated the relationship between history of violence and poor facial emotion recognition performance. As a whole, our findings seem to support the role of perceptual deficits involving different emotions as well as of a mediation played by activation symptoms. Facial emotion recognition deficits associated with the propensity to violence, as well certain symptoms mediating their relationship, should be targeted by specific treatment approaches.

Neuropsychological features in patients with severe mental disorders and risk of violence: A prospective multicenter study in Italy

In Severe Mental Disorders (SMDs) the most important cognitive deficits involve the Executive Functions (EFs). In this study we examined the association between EFs and aggressive behaviour in outpatients with SMDs. We included a total of 247 outpatients divided into two groups: 'cases', patients with a history of violence (N=126) and 'non-violent' (N=121). We compared their EFs score and then categorized the participants into four groups (Pathological Non-Violent comparison group; Non-Pathological Non-Violent comparison group; Pathological Violent cases and Non-Pathological Violent cases), based on the scores of a subtest assessing processing speed (i.e., Symbol-coding task) of the Brief Assessment of Cognition in Schizophrenia (BACS). We followed the 4 groups during a 1-year follow-up (FU) monitoring violent behaviour with the Modified Overt Aggression Scale (MOAS). According to the classification based on the BACS-Symbol Coding Task we found no statistically significant differences between subgroups in MOAS scores. We only found that the trend curve for PV was almost consistently over the other group curves in the MOAS 'aggression against people'. Our results suggested a worse performance in the violent compared to non-violent group in EFs. Despite this evidence, the score on the processing speed task was not associated with aggressive behaviour during FU.

The Overt Aggression Scale Modified (OAS-M) for clinical trials targeting impulsive aggression and intermittent explosive disorder: Validity, reliability, and correlates

While aggressive behavior is common, and a disorder of impulsive aggression has been defined in the DSM-5 (Intermittent Explosive Disorder: IED), there are no currently FDA approved interventions to reduce these behaviors. One obstacle to the development of interventions to treat aggression is the paucity of psychometrically valid measures to assess aggressive behavior in the context of clinical trials, especially those in the outpatients setting. While there are many assessment of trait aggression, very few attempt to assess current aggressive behavior over time and/or in individuals not in a closed setting. The Overt Aggression Scale Modified (OAS-M) was developed to fill this void and this paper reviews its development along with presenting new data on its validity, reliability, and correlates with related constructs. Overall, the OAS-M is a valid and reliable measure of state (e.g., week to week) aggression, has good psychometric properties, and shows evidence of change in clinical trials of agents with putative anti-aggressive efficacy.

Prescribing Patterns of Psychotropic Drugs and Risk of Violent Behavior: A Prospective, Multicenter Study in Italy

BACKGROUND

This prospective cohort study aimed at evaluating patterns of polypharmacy and aggressive and violent behavior during a 1-year follow-up in patients with severe mental disorders.

METHODS

A total of 340 patients (125 inpatients from residential facilities and 215 outpatients) were evaluated at baseline with the Structured Clinical Interview for DSM-IV Axis I and II, Brief Psychiatric Rating Scale, Specific Levels of Functioning scale, Brown-Goodwin Lifetime History of Aggression, Buss-Durkee Hostility Inventory, Barratt Impulsiveness Scale, and State-Trait Anger Expression Inventory-2. Aggressive behavior was rated every 15 days with the Modified Overt Aggression Scale and treatment compliance with the Medication Adherence Rating Scale.

RESULTS

The whole sample was prescribed mainly antipsychotics with high levels of polypharmacy. Clozapine prescription and higher compliance were associated with lower levels of aggressive and violent behavior. Patients with a history of violence who took clozapine were prescribed the highest number of drugs. The patterns of cumulative Modified Overt Aggression Scale mean scores of patients taking clozapine (n = 46), other antipsychotics (n = 257), and no antipsychotics (n = 37) were significantly different (P = .001). Patients taking clozapine showed a time trend at 1-year follow-up (24 evaluations) indicating a significantly lower level of aggressive behavior. Patient higher compliance was also associated with lower Modified Overt Aggression Scale ratings during the 1-year follow-up.

CONCLUSION

Both inpatients and outpatients showed high levels of polypharmacy. Clozapine prescription was associated with lower Modified Overt Aggression Scale ratings compared with any other antipsychotics or other psychotropic drugs. Higher compliance was associated with lower levels of aggressive and violent behavior.

Prevalence of aggression in patients with schizophrenia: A systematic review and meta-analysis of observational studies

OBJECTIVE

Aggression is common in patients with schizophrenia and is clinically significant, but its prevalence is inconsistent across studies. This is a meta-analysis of the prevalence of aggression and its associated factors in patients with schizophrenia.

METHODS

PubMed, EMBASE, PsycINFO, the Cochrane Library, Medline and Web of Science databases were systematically searched. Studies that reported the prevalence of aggression in patients with schizophrenia using the Modified Overt Aggression Scale (MOAS) were included and analyzed using the random-effects model.

RESULTS

Fifteen studies with 4855 patients were initially included; of these, 13 studies with 3929 patients were pooled in the final meta-analysis. The pooled prevalence of aggression was 33.3% (95%CI: 21.5%-47.7%); specifically, the estimated prevalence of verbal, property-oriented, auto and physical aggression were 42.6% (95%CI: 17.0%-72.9%), 23.8% (95%CI: 10.1%-46.4%), 23.5% (95%CI: 6.5%-57.7%), and 23.7% (95%CI: 10.4%-45.3%), respectively. Subgroup analyses revealed that different MOAS cut-off values (P < 0.001) and source of patients (inpatients vs. community-dwelling patients) significantly moderated the results (P < 0.001). Meta-regression analyses found that studies published recently reported higher aggression rate, while higher quality assessment score was associated with lower aggression rate (both P < 0.01).

CONCLUSIONS

This meta-analysis confirmed that aggression is common in schizophrenia patients. Considering the significant clinical risk issues, appropriate treatments and effective management of aggression in this population need to be developed.

Interpersonal Psychotherapy as a Single Treatment for Borderline Personality Disorder: A Pilot Randomized-Controlled Study

Recent guidelines share the recommendations that psychotherapy plays a central role in the treatment of borderline personality disorder (BPD). In recent years, interpersonal psychotherapy adapted for treating BPD (IPT-BPD) was added to specific psychotherapies and was tested in combination with pharmacotherapy. The present study is aimed to assess the efficacy of IPT-BPD revised (IPT-BPD-R) as single treatment in a sample of BPD patients. Results obtained in a group of patients receiving IPT-BPD-R were compared with those observed in a control group in waiting list plus clinical management (WL/CM). Forty-three BPD subjects were randomly allocated to one of the two arms. Patients were assessed at baseline and after 10 months with the following assessment instruments: Clinical Global Impression Scale, Severity item (CGI-S), Social Occupational Functioning Assessment Scale (SOFAS), Borderline Personality Disorder Severity Index (BPDSI), Barratt Impulsiveness Scale, version 11 (BIS-11), Modified Overt Aggression Scale (MOAS), and Self Harm Inventory (SHI). Statistical analysis was performed with one-way analysis of variance (ANOVA) or chi-square test to compare baseline characteristics of the two treatment groups. Comparison of score changes at the end of the trial between the two groups was calculated for each rating scale with the analysis of variance for repeated measures. Seven patients (16.3%) discontinued the treatment in the first month of the trial for non-adherence. We found a significant effect within subjects (trial duration) for all rating scales, except for the MOAS. A significant effect between subjects (treatment modality) was found for CGI-S; SOFAS; BIS-11 total score and subscale "non-planning impulsivity"; BPDSI total score and items "interpersonal relationships," "impulsivity," and "identity." So, results showed differences between groups in favor of psychotherapy in terms of reduction of severity of general psychopathology, improvement of social and occupational functioning, and decrease of global BPD symptoms and three specific domains. On the other hand, we did not find any differences between groups for self-harm behaviors and aggressive behaviors.

Self-harm behaviour and externally-directed aggression In psychiatric outpatients: a multicentre, prospective study (viormed-2 study)

The aim of the project was to investigate differences between outpatients with Severe Mental Disorders (SMDs) with and without a history of Self-Harm behaviour (SHb) and/or Violent behaviour against other people (Vb) in relation to: (a) socio-demographic and clinical characteristics, (b) violent behaviour during a 1-year FU, (c) predictors of SHb and Vb during the FU. Outpatients with SMDs, with and without a history of Vb were enrolled. They were divided in four groups: patients with lifetime Vb (V), patients with both Vb and SHb (V-SH), patients with only SHb (SH) and patients with no history of SHb and Vb (control group, CONT). The frequency and severity of SHb and Vb during the FU were assessed every two weeks by the MOAS. Overall 246 patients were enrolled. BPRS-E Depression item, the SLOF Social acceptability, the BDHI Indirect Aggression, the BIS Motor Impulsiveness and the STAXI-2 Control-Out showed significant correlations with all the four groups (p < 0.030). V and V-SH patient groups reached higher scores in all MOAS sub-scales. Age among the SH group and BPRS-E affect-anxiety subscale among the V group significantly predicted aggression against people. In people with SMDs a history of SHb or Vb is associated with different medium-term outcomes.

Violence risk and mental disorders (VIORMED-2): A prospective multicenter study in Italy

Background

The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry.

Aim

The aim of this study was to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of outpatients with severe mental disorders.

Method

This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with or without a history of violence, were enrolled in four Italian Departments of Mental Health and underwent a comprehensive multidimensional assessment.

Results

The sample included 247 outpatients, for a total of 126 cases and 121 controls. Compared to controls, patients with a history of violence had a greater frequency of lifetime domestic violence, a greater lifetime propensity to misuse substances, and a higher number of compulsory admissions. The forthnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between the two groups. Verbal aggression was significantly associated with aggression against objects and physical aggression. Moreover, outpatients with an history of violence showed statistically significant higher MOAS scores compared to both residential patients with an history of violence, assessed in the first wave of this project, and all controls.

Conclusions

Patients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.

Testing the association of serum uric acid levels with behavioral and clinical characteristics in subjects with major affective disorders: A cross-sectional study

Previous research has hypothesized a role for serum uric acid as a marker of mental disorders and related behaviors, possibly due to its link with purinergic transmission and antioxidant activity. We tested the association of serum uric acid levels with specific behavioral and clinical characteristics in 99 individuals suffering from major affective disorders. Subjects were assessed and interviewed using the Kessler Psychological Distress Scale, the Columbia-Suicide Severity Rating Scale, the Modified Overt Aggression Scale, and the Barratt Impulsiveness Scale. We found that psychological distress and suicidal ideation severity were associated with lower uric acid serum levels. On the other hand, verbal aggression and history of violence were associated with higher levels of serum uric acid. However, according to linear regression analyses, there were no behavioral and clinical characteristics independently associated with serum uric acid. Serum uric acid levels were influenced by creatinine and BMI, as well as, possibly, by white blood cells count and gender. Despite some limitations, these results suggest that no behavioral / clinical features are associated with variations of serum uric acid, which rather seem attributable to specific biochemical and metabolic parameters. Nevertheless, the role of purinergic system in different mental disorders and behavioral abnormalities, deserves further research.

Personality, Schizophrenia, and Violence: A Longitudinal Study

The aims of this study were (a) to investigate the presence of clinically significant personality traits and personality disorders (PD) in patients living in residential facilities, with or without a history of violence (69 and 46, respectively); and (b) to investigate any associations between clinically significant personality traits and PDs, aggression, impulsivity, hostility, and violent behavior during a 1-year follow-up. The most frequent primary diagnoses were schizophrenia (58.3%) and PD (20.9%). Those with a history of violence demonstrated more antisocial and alcohol dependence features and lower depressive PD symptoms than the control group. Hostility levels, antisocial symptoms, and drug dependence, as well as a Structured Clinical Interview for DSM-IV Axis II diagnosis of PD, predicted aggressive and violent behavior during follow-up. The study confirms the relevance of assessing PDs both to evaluate the risk of violent behavior and to plan appropriate preventive and treatment intervention.

Clinical and neuropsychological features of violence in schizophrenia: A prospective cohort study

The increased risk of violence in schizophrenia has been linked to several environmental, clinical and neuropsychological factors, including executive dysfunction. However, data about the nature of these effects are mixed and controversial. The main aim of this study was to investigate the relationship between clinical and neuropsychological factors with violence risk in patients with schizophrenia, taking into account current psychopathology and lifetime alcohol use. We compared a sample of patients living in Residential Facilities (RFs) with schizophrenia and a past history of interpersonal violence (vSZ, N=50) to patients with schizophrenia matched on age, gender and alcohol abuse/dependence but with no violence history (nvSZ, N=37). We then established the association between the clinical and neuropsychological factors that predicted violence over a 1year follow-up period. The results revealed that vSZ patients living in RFs were characterized by greater compulsory hospital admissions, higher anger and less negative symptoms as compared to nvSZ patients. vSZ patients performed better on executive and motor tasks than nvSZ; however, these differences appeared to be explained by the lower negative psychotic symptom in the vSZ group. Both groups were involved in episodes of violence during the follow-up period; among the two, the vSZ patients were more likely to be violent. Negative symptoms predicted less verbal aggression at 1year follow-up. Overall, these findings support a key role of negative rather than positive symptoms in driving violence risk among SZ patients living in RFs, in a manner that negative symptoms are linked to a lower risk of violence.

Monitoring and predicting the risk of violence in residential facilities. No difference between patients with history or with no history of violence

BACKGROUND

Most people with mental disorders are not violent. However, the lack of specific studies in this area and recent radical changes in Italy, including the closure of six Forensic Mental Hospitals, has prompted a more detailed investigation of patients with aggressive behaviour.

AIMS

To compare socio-demographic, clinical and treatment-related characteristics of long-term inpatients with a lifetime history of serious violence with controls; to identify predictors of verbal and physical aggressive behaviour during 1-year follow-up.

METHODS

In a prospective cohort study, patients living in Residential Facilities (RFs) with a lifetime history of serious violence were assessed with a large set of standardized instruments and compared to patients with no violent history. Patients were evaluated bi-monthly with MOAS in order to monitor any aggressive behaviour.

RESULTS

The sample included 139 inpatients, 82 violent and 57 control subjects; most patients were male. The bi-monthly monitoring during the 1-year follow-up did not show any statistically significant differences in aggressive behaviour rates between the two groups. The subscale explaining most of the MOAS total score was aggression against objects, although verbal aggression was the most common pattern. Furthermore, verbal aggression was significantly associated with aggression against objects and physical aggression.

CONCLUSIONS

Patients with a history of violence in RFs, where treatment and clinical supervision are available, do not show higher rates of aggressiveness compared to patients with no lifetime history of violence. Since verbal aggression is associated with more severe forms of aggression, prompt intervention is warranted to reduce the risk of escalation.

The Italian version of the Brain Injury Rehabilitation Trust (BIRT) personality questionnaires: five new measures of personality change after acquired brain injury

The aim of this study was to describe the translation and adaptation of the BIRT personality questionnaires for the Italian population. This included the replication of validity testing and the collection of normative data. Following translation and adaptation according to cross-cultural guidelines, the questionnaires were administered as a pre-test to a sample of 20 healthy subjects and then to 10 patients. The questionnaires were then administered to 120 healthy subjects equally distributed by sex, education, and age, to collect normative data from an Italian population. The questionnaires were easily administered to both healthy subjects and patients. Statistical analysis on normative data was conducted to find the mean value for each questionnaire. This study lays the foundations for using a new instrument to assess behavioral changes after acquired brain injury on the Italian population.

Aggression, impulsivity, and suicide risk in benign chronic pain patients - a cross-sectional study

OBJECTIVES

The objective of this study was to investigate the role that psychopathological dimensions as overt aggression and impulsivity play in determining suicide risk in benign chronic pain patients (CPPs). Furthermore we investigated the possible protective/risk factors which promote these negative feelings, analyzing the relationship between CPPs and their caregivers.

METHODS

We enrolled a total of 208 patients, divided into CPPs and controls affected by internistic diseases. Assessment included collection of sociodemographic and health care data, pain characteristics, administration of visual analog scale (VAS), Modified Overt Aggression Scale (MOAS), Barratt Impulsiveness Scale Version 11 (BIS), Hamilton Depression Rating Scale (HDRS), and a caregiver self-administered questionnaire. All variables were statistically analyzed.

RESULTS

A significant difference of VAS, MOAS-total/verbal/auto-aggression, HDRS-total/suicide mean scores between the groups were found. BIS mean score was higher in CPPs misusing analgesics. In CPPs a correlation between MOAS-total/verbal/auto-aggression with BIS mean score, MOAS with HDRS-suicide mean score and BIS with HDRS-suicide mean scores were found. The MOAS and BIS mean scores were significantly higher when caregivers were not supportive.

CONCLUSION

In CPPs, aggression and impulsivity could increase the risk of suicide. Moreover, impulsivity, overt aggression and pain could be interrelated by a common biological core. Our study supports the importance of a multidisciplinary approach in the CPPs management and the necessity to supervise caregivers, which may become risk/protective factors for the development of feelings interfering with the treatment and rehabilitation of CPPs.

Criterion-related validity of challenging behaviour scales: a review of evidence in the literature

BACKGROUND

Behaviour that challenges has negative impacts on physical and emotional well-being and quality of life. Challenging behaviour scales are used to identify needs and evaluate interventions and must be valid measures. Criterion-related validity is important, and the best quality assessment uses direct measures of behaviour as criteria. Previous reviews of scales affirm their validity but present little supporting evidence. The current review examines the evidence presented in studies of validity.

METHODS

Searches of MEDLINE and PsycINFO to identify scales that focus on challenging behaviour and find publications that assess their criterion-related validity.

RESULTS

Searches identified twelve scales and 21 publications that assess validity. One assessment used direct measures of behaviour, and the remainder used indirect measures that themselves have limited evidence of validity, including membership of diagnostic or service groups and other scales.

CONCLUSIONS

Little firm evidence of validity was found, but what was found is encouraging.

Aggressive behaviour and its prevalence within five typologies

Crucial to understanding an individual, presenting with intellectual disability and the management of their challenging behaviours, is the knowledge of the types of those specific behaviours. The term aggressive behaviour is a universal term that embraces many aspects of behaviour that vary in terms of severity, frequency and seriousness for the individual and those around them. Hence, greater consideration regarding intervention, management, person-centred strategies and prevalence and frequency rates are required in service provision for individuals with intellectual disability and aggressive behaviour. This review presents the context of aggressive behaviour and its prevalence within the five typologies of aggressive behaviour: verbal aggression, aggression against others, sexually inappropriate behaviour, self-injurious behaviour and aggression against property, as identified by Crocker et al. (2007). The focus of this review is to report on the prevalence of aggressive behaviour reported for individuals with intellectual disability and consider the ambiguity in defining aggressive behaviour.

Nursing care complexity in a psychiatric setting: results of an observational study

For nurses working in mental health service settings, it is a priority to perform patient assessments to identify patients' general and behavioural risks and nursing care complexity using objective criteria, to meet the demand for care and to improve the quality of service by reducing health threat conditions to the patients' selves or to others (adverse events). This study highlights that there is a relationship between the complexity of psychiatric patient care, which was assigned a numerical value after the nursing assessment, and the occurrence of psychiatric adverse events in the recent histories of the patients. The results suggest that nursing supervision should be enhanced for patients with high care complexity scores.

Efficacy of omega-3 fatty acids in the treatment of borderline personality disorder: a study of the association with valproic acid

Omega-3 fatty acids have received increasing interest due to their effects in stabilizing plasmatic membranes and regulating cell signaling. The efficacy of omega-3 fatty acids in psychiatric disorders, in particular mood disorders, has been studied. There have been two trials on eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) in the treatment of borderline personality disorder (BPD). The present 12-week controlled trial aimed to assess the efficacy of the association of EPA and DHA with valproic acid, compared to single valproic acid, in 43 consecutive BPD outpatients. Participants were evaluated at baseline and after 12 weeks with: Clinical Global Impression - Severity (CGI-S), Hamilton Scales for depression and anxiety (HAM-D, HAM-A), Social and Occupational Functioning Assessment Scale (SOFAS), borderline personality disorder severity index (BPDSI), Barratt Impulsiveness Scale - version 11 (BIS-11), Modified Overt Aggression Scale (MOAS), Self-Harm Inventory (SHI) and Dosage Record Treatment Emergent Symptom Scale (DOTES).

Study on psychoeducation enhancing results of adherence in patients with schizophrenia (SPERA-S): study protocol for a randomized controlled trial

Background

Poor adherence to pharmacotherapy negatively affects the course and the outcome of schizophreniaspectrum psychoses, enhancing the risk of relapse. Falloon and coworkers developed a Psychoeducation Program aimed at improving communication and problem-solving abilities in patients and their families. This study set out to evaluate changes in adherence to pharmacotherapy in patients diagnosed with schizophrenia-spectrum psychoses, by comparing one group exposed to the Falloon Psychoeducation Program (FPP) with another group exposed to family supportive therapy with generic information on the disorders.

Methods

340 patients diagnosed with schizophrenia and related disorders according to standardized criteria from 10 participating units distributed throughout the Italian National Health System (NHS), will be enrolled with 1:1 allocation by the method of blocks of randomized permutations. Patients will be reassessed at 6, 12 and 18 months after start of treatment (duration: 6 months).

The primary objective is to evaluate changes in adherence to pharmacotherapy after psychoeducation. Adherence will be assessed at three-month intervals by measuring blood levels of the primary prescribed drug using high pressure liquid chromatography, and via the Medication Adherence Questionnaire and a modified version of the Adherence Interview. Secondary objectives are changes in the frequency of relapse and readmission, as the main indicator of the course of the disorder.

Enrolled patients will be allocated to the FPP (yes/no) randomly, 1:1, in a procedure controlled by the coordinating unit; codes will be masked until the conclusion of the protocol (or the occurrence of a severe negative event). The raters will be blind to treatment allocation and will be tested for blinding after treatment completion. Intention-to-treat will be applied in considering the primary and secondary outcomes. Multiple imputations will be applied to integrate the missing data. The study started recruitment in February 2013; the total duration of the study is 27 months.

Discussion

If the psychoeducation program proves effective in improving adherence to pharmacotherapy and in reducing relapse and readmissions, its application could be proposed as a standard adjunctive psychosocial treatment within the Italian NHS.

Trial registration

Protocol Registration System of ClinicalTrials.gov NCT01433094; registered on 20 August 2011; first patient was randomized on 12 February 2013.

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression

OBJECTIVE

To combine the results of earlier comparison studies of in-patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

METHOD

A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings.

RESULTS

Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse.

CONCLUSION

By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression.

Trans fat consumption and aggression

Background

Dietary trans fatty acids (dTFA) are primarily synthetic compounds that have been introduced only recently; little is known about their behavioral effects. dTFA inhibit production of omega-3 fatty acids, which experimentally have been shown to reduce aggression. Potential behavioral effects of dTFA merit investigation. We sought to determine whether dTFA are associated with aggression/irritability.

Methodolgy/Prinicpal Findings

We capitalized on baseline dietary and behavioral assessments in an existing clinical trial to analyze the relationship of dTFA to aggression. Of 1,018 broadly sampled baseline subjects, the 945 adult men and women who brought a completed dietary survey to their baseline visit are the target of this analysis. Subjects (seen 1999–2004) were not on lipid medications, and were without LDL-cholesterol extremes, diabetes, HIV, cancer or heart disease. Outcomes assessed adverse behaviors with impact on others: Overt Aggression Scale Modified-aggression subscale (primary behavioral endpoint); Life History of Aggression; Conflict Tactics Scale; and self-rated impatience and irritability. The association of dTFA to aggression was analyzed via regression and ordinal logit, unadjusted and adjusted for potential confounders (sex, age, education, alcohol, and smoking). Additional analyses stratified on sex, age, and ethnicity, and examined the prospective association. Greater dTFA were strongly significantly associated with greater aggression, with dTFA more consistently predictive than other assessed aggression predictors. The relationship was upheld with adjustment for confounders, was preserved across sex, age, and ethnicity strata, and held cross-sectionally and prospectively.

Conclusions/Significance

This study provides the first evidence linking dTFA with behavioral irritability and aggression. While confounding is always a concern in observational studies, factors including strength and consistency of association, biological gradient, temporality, and biological plausibility add weight to the prospect of a causal connection. Our results may have relevance to public policy determinations regarding dietary trans fats.

Clinicaltrials.gov # NCT00330980

Aggressive behavior, cognitive impairment, and depressive symptoms in elderly subjects

Patients with dementia often have neuropsychiatric symptoms. The objective of this study was to evaluate the relationship between neuropsychiatric symptoms and progressive cognitive decline by assessing cognitive impairment, depressive symptoms, and aggressive behavior in a sample of elderly subjects. The study sample consisted of 201 subjects admitted to nursing homes. For the purpose of the present study each subject was evaluated using the Mini-Mental State Examination, the Geriatric Depression Scale, and the Modified Overt Aggression Scale. The results show that aggressive behavior and depressive symptoms are associated with progressive cognitive decline in elderly subjects. Early assessment of these conditions can promote rational therapeutic strategies that may improve the quality of life and delay institutionalization for elderly patients.

Self-perceived needs are related to violent behavior among schizophrenia outpatients

This study assessed the relationship between self-perceived clinical and social needs and aggressive behavior in outpatients with schizophrenia. A total of 895 outpatients with schizophrenia were enrolled. The presence of aggressive episodes was assessed using the Modified Overt Aggression Scale. Self-perceived needs were assessed using the Camberwell Assessment of Need in six areas of needs (food, household skills, self-care, daytime activities, psychotic symptoms, satisfaction with treatment, and company). The most common areas of needs were "psychotic symptoms" (81.6%), "daytime activities" (60.6%), and "household skills" (57.5%). More needs were expressed by patients who had more severe illnesses (p < 0.001) and more aggressive behavior (p < 0.001). Multivariate analysis showed that, in schizophrenia outpatients, self-perceived needs were associated with aggressive behavior (adjusted odds ratio, 11.43; 95% confidence interval, 5.11 to 25.56). Appropriate compliance with antipsychotic treatment was related with lower aggressive behavior (p < 0.001).

The reliability and validity of the Chinese version of the Modified Overt Aggression Scale

Objective. Instruments to assess aggressive behaviors in the psychiatric ward are crucial for monitoring risky behaviors. The purpose of this study was to assess the validity and reliability of the Chinese version of the Modified Overt Aggression Scale (MOAS). Methods. We translated the English version of MOAS into Chinese. We interviewed and trained two volunteers to act as agitated patients in the seclusion room. One senior psychiatrist, experienced in using the MOAS, directed scenarios of different aggressive intensity and established the standard scores. The validity was assessed by comparing the other raters' scores with those of the director's. Inter-rater reliability was also assessed. Results. Inter-rater reliability, based on Intra-class correlation coefficient (ICC=0.94, P<0.001) and Kendall's W coefficient of concordance (W=0.83, P= 0.001), was high. The validity was assessed by the Mann-Whitney test. The results showed that the raters adequately differentiated (z=- 2.89, P= 0.002) between the above-average and below-average scores of the MOAS. Conclusion. The Chinese version of the MOAS has modest psychometric properties. The model, which used trained volunteers acting as patients and compared their scores with those of the director, may be used in further studies for developing psychometric instruments to assess abrupt behaviors.

Clinical features and therapeutic management of patients admitted to Italian acute hospital psychiatric units: the PERSEO (psychiatric emergency study and epidemiology) survey

BACKGROUND

The PERSEO study (psychiatric emergency study and epidemiology) is a naturalistic, observational clinical survey in Italian acute hospital psychiatric units, called SPDCs (Servizio Psichiatrico Diagnosi e Cura; in English, the psychiatric service for diagnosis and management). The aims of this paper are: (i) to describe the epidemiological and clinical characteristics of patients, including sociodemographic features, risk factors, life habits and psychiatric diagnoses; and (ii) to assess the clinical management, subjective wellbeing and attitudes toward medications.

METHODS

A total of 62 SPDCs distributed throughout Italy participated in the study and 2521 patients were enrolled over the 5-month study period.

RESULTS

Almost half of patients (46%) showed an aggressive behaviour at admission to ward, but they engaged more commonly in verbal aggression (38%), than in aggression toward other people (20%). A total of 78% of patients had a psychiatric diagnosis at admission, most frequently schizophrenia (36%), followed by depression (16%) and personality disorders (14%), and no relevant changes in the diagnoses pattern were observed during hospital stay. Benzodiazepines were the most commonly prescribed drugs, regardless of diagnosis, at all time points. Overall, up to 83% of patients were treated with neuroleptic drugs and up to 27% received more than one neuroleptic either during hospital stay or at discharge. Atypical and conventional antipsychotics were equally prescribed for schizophrenia (59 vs 65% during stay and 59 vs 60% at discharge), while atypical drugs were preferred in schizoaffective psychoses (72 vs 49% during stay and 70 vs 46% at discharge) and depression (41 vs 32% during stay and 44 vs 25% at discharge). Atypical neuroleptics were slightly preferred to conventional ones at hospital discharge (52 vs 44%). Polypharmacy was in general widely used. Patient attitudes toward medications were on average positive and self-reported compliance increased during hospital stay.

CONCLUSION

Results confirm the widespread use of antipsychotics and the increasing trend in atypical drugs prescription, in both psychiatric in- and outpatients.