Violence and mental disorders. A retrospective study of people in charge of a community mental health center

The violence profile of male mentally disordered offenders in a high secure unit in Turkiye

Our knowledge of the severity and reoffending is limited for mentally disordered offenders, and studies generally evaluate without separation between different diagnostic groups. It was aimed to determine the general profile of mentally disordered offenders who are inpatients in a high secure psychiatry unit from Turkiye and to evaluate the factors associated with violence profiles among different diagnostic groups. According to the results the schizophrenia patients committed the most severe crimes, and intellectual disability patients had some different features from schizophrenia and bipolar disorder patients. History of substance misuse in the intellectual disability group (p = 0,045) and comorbid antisocial personality disorder in the bipolar disorder group (p = 0,015) were associated with increased crime severity. Substance misuse history, history of substance use during the crime, and the existence of comorbid antisocial personality disorder were associated with increased offenses in each of the three diagnosis groups. Living alone (p = 0,004) and having a suicide history (p= 0,052) were associated with the high number of offenses in the schizophrenia group. This study is the first study that compares three diagnostic groups to involve a large patient group. We believe that clinicians must evaluate these parameters for the violence risk assessment of patients.

Workplace Violence Experienced by Community Mental Health Workers

A cross-sectional online survey was conducted to 1) investigate the prevalence of workplace violence and workers' emotional distress, 2) explore factors associated with workplace violence, and 3) assess workers' needs for preventive measures. A total of 763 community mental health workers participated in Korea. Among them, 85.85% of workers experienced workplace violence, including verbal (74.31%), emotional (66.45%), infectious (47.44%), informational (42.60%), sexual (32.50%), and physical (23.72%) abuse. Binary logistic regression analysis indicated that sex, occupation, certification, and working institution were significantly associated with workplace violence. Workplace violence affects workers' depression, anger, and anxiety negatively. The most-needed preventive measure is a two-person home visit.

Is co-occurrence of adult adhd with bipolar disorder a risk factor for violent behavior?

Research has shown that individuals with psychiatric disorders such as bipolar disorder (BD) and attention deficit and hyperactivity disorder (ADHD) have a higher likelihood of violent behavior. This study investigated the frequency of comorbid BD and ADHD in adultpatients and the relationship between this comorbidity and violent behavior. We assessed 105 remitted patients diagnosed with BD I (n = 91) or BD II (n = 14). The patients were administered the Sociodemographic Data Scale, the Wender-Utah Rating Scale (WURS), the Adult ADHD Self-Report Scale (ASRS), the Buss-Perry Aggression Questionnaire (BPAQ), and theViolence Tendency Scale (VTS) as self-reports. The same clinician administered the Diagnostic Interview for ADHD in adults (DIVA 2.0) to patients who scored≥36 on the WURS. Comorbid ADHD was diagnosed in 15.2% of patients according to the DIVA 2.0. In the multiple linear regression analysis, there was a statistically significant positive effect of the ASRS total score on the VTS and the BPAQ total score. Furthermore, it was found that male gender had a statistically significant positive effect on VTS total score and young age had a statistically significant positive effect on BPQA total score. These findings demonstrate an association between BD, comorbid ADHD, and violent behavior.

Nurses’, patients’, and informal caregivers’ attitudes toward aggression in psychiatric hospitals: A comparative survey study

Attitudes toward aggression is a controversial phenomenon in psychiatry. This study examined and compared attitudes toward patient aggression in psychiatric hospitals from the perspectives of nurses, patients and informal caregivers and identified factors associated to these attitudes. A total of 2,424 participants completed a self-reported instrument regarding attitudes toward aggression (12-items Perception of Aggression Scale; POAS-S). We analysed data from nurses (n = 782), patients (n = 886), and informal caregivers (n = 765). Pearson’s r correlations were used to examine associations between variables. Differences between group scores were analysed using ANOVA/MANOVA with post-hoc Sheffe tests. Multivariate logistic regression models and logistic regression analysis were used to examine the effects of respondents’ characteristics on their attitudes toward aggression. Nurses had significantly more negative and less tolerant perceptions toward aggression (mean [SD] 47.1 [7.5], p<0.001) than the patients (mean [SD] 44.4 [8.2]) and the informal caregivers (mean [SD] 45.0 [6.9), according to the POAS-S total scores. The same trend was found with the dysfunction and function sub-scores (mean [SD] 25.3 [4.1] and 15.0 [3.6], respectively); the differences between the groups were statistically significant (p <0.001) when nurses’ scores were compared to those of both the patients (mean [SD] 23.7 [5.3] and 14.0 [4.1], respectively) and the informal caregivers (mean [SD] 24.4 [4.2] and 13.9 [3.5], respectively). The study offers new understanding of aggressive behavior in different treatment settings where attitudes toward patient behavior raises ethical and practical dilemmas. These results indicate a need for more targeted on-the-job training for nursing staff, aggression management rehabilitation programs for patients, and peer-support programs for informal caregivers focused on patient aggression.

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.

How patients with schizophrenia “as a Victim” cope with violence in Indonesia: a qualitative study

Background

There is increasing concern about the level of violence and people with schizophrenia. However, research about violence in correlation with schizophrenia mostly focuses on patients as offenders rather than victims. Phenomenology was chosen to explore experience of patients with schizophrenia as a victim coping with violence in Indonesia.

Results

Of the 40 interviewees, average age was 35.8 years old (range 21–43). The 40 patients with schizophrenia comprised 26 males and 14 females. Violence typically included pushing, punching, or kicking, and restrained. The patient’s coping experiences as victims of violence were categorized into three themes: submission (n = 28), expression of anger to object (n = 33), and positive coping strategy (n = 23).

Conclusion

To shorten the evaluation required to choose coping strategies, domestic violence education/psychoeducation would be relevant.

[Assessment of psycho-trauma caused by the aggressions committed by patients with psychosis against their family caregivers: across-sectional survey]

Introduction

prendre en charge un patient psychotique est associé à un risque d´exposition à la violence qui peut toucher tous les intervenants, en particulier l´entourage familial. La violence que la fonction d´aide engendre peut avoir un impact psychologique sur l´aidant. Nos objectifs étaient de relever la prévalence des agressions perpétrées par les patients psychotiques envers leurs aidants familiaux, évaluer l´impact psycho-traumatique chez eux et identifier les facteurs qui lui sont associés.

Méthodes

des aidants familiaux de patients psychotiques ont été interviewés. Nous avons utilisé deux échelles psychométriques: l´échelle de perception de la prévalence de l´agression et l´échelle révisée d´impact de l´événement.

Résultats

le nombre total des participants était de 95. Trois aidants sur quatre (75,8%) ont rapporté avoir été victimes d´agression modérée à sévère de la part de leurs proches malades durant l´année écoulée. Une agression modérée à sévère était significativement plus fréquente chez les aidants de sexe masculin, d´un âge plus avancé, parents de patient psychotique et vivant dans un autre foyer que lui. Un taux de 54,7% des aidants présentait un état de stress post-traumatique (ESPT) probable et le risque d´apparition de ce trouble augmentait significativement avec l´intensité perçue des agressions. Le même profil sociodémographique de l´aidant lié à la gravité des agressions était à risque de développement d´un ESPT chez l´aidant.

Conclusion

les agressions commises par les patients psychotiques sur leurs aidants familiaux paraissent avoir un impact psycho-traumatique important. Aussi, des interventions ciblant la violence des malades psychotiques dans leur milieu familial devraient être intégrées dans la prise en charge.

Experimental Social Stress: Dopaminergic Receptors, Oxidative Stress, and c-Fos Protein Are Involved in Highly Aggressive Behavior

Aggression is defined as hostile behavior that results in psychological damage, injury and even death among individuals. When aggression presents itself in an exacerbated and constant way, it can be considered escalating or pathological. The association between social stress and the emergence of exacerbated aggressiveness is common and is suggested to be interconnected through very complex neurobiological factors. For example, alterations in the expression of the dopaminergic receptors D1 and D2, reactive oxygen species (ROS) and the c-Fos protein in the cortex have been observed. Our objective was to analyze which factors are involved at the neurobiological level in the highly aggressive response of Swiss Webster adult male mice in a vivarium. In this work, we investigated the relationship among dopaminergic receptors, the production of ROS and the expression of c-Fos. Mice with exacerbated aggression were identified by the model of spontaneous aggression (MSA) based on the grouping of young mice and the regrouping of the same animals in adulthood. During the regrouping, we observed different categories of behavior resulting from social stress, such as (i) highly aggressive animals, (ii) defeated animals, and (iii) harmonic groups. To evaluate the dopaminergic system and the c-Fos protein, we quantified the expression of D1 and D2 dopaminergic receptors by Western blotting and fluorescence immunohistochemistry and that of the c-Fos protein by fluorescence immunohistochemistry. The possible production of ROS was also evaluated through the dihydroethidium (DHE) assay. The results showed that aggressive and subordinate mice showed a reduction in the expression of the D1 receptor, and no significant difference in the expression of the D2 receptor was observed between the groups. In addition, aggressive mice exhibited increased production of ROS and c-Fos protein. Based on our results, we suggest that exacerbated aggression is associated with social stress, dysregulation of the dopaminergic system and exacerbated ROS production, which leads to a state of cellular oxidative stress. The overexpression of c-Fos due to social stress suggests an attempt by the cell to produce antioxidant agents to reduce the toxic cellular concentration of ROS.

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.

Aggressiveness and violence in psychiatric patients: a clinical or social paradigm?

OBJECTIVE

Psychiatric disorders are often considered the leading cause of violence. This may be due to a stereotype created by media and general opinion.

METHOD

The Modified Overt Aggression Scale (MOAS) was used to evaluate the severity of aggressive and violent behaviors in 400 patients who attended a post-acute psychiatric service in Milan from 2014 to 2016 and suffered from different psychiatric disorders. The psychopathological clinical picture was evaluated by Clinical Global Impression (CGI). The study also assessed the possible correlation between epidemiologic and sociodemographic factors, clinical variables, and aggression and violence.

RESULTS

Of the total number of subjects, 21.50% showed a MOAS score >0, 11.50% presented mild aggression (0-10 MOAS weighted score), 9% moderate aggression (11-20), and 1% severe aggression (MOAS >20). With respect to violent behaviors, 16% of patients showed a score >0 in one MOAS subscale other than verbal aggression according to violence definition. The severity of clinical picture seemed to be related to higher weighted MOAS score. Multivariate testing of different sociodemographic and clinical variables showed that violence was related to unemployment status, and significantly correlated to compulsory admission (TSO), suicide attempts (TS), and personality disorders, while the severity of clinical psychiatric picture seemed to play a secondary role.

CONCLUSION

Results have shown that personality disorders and sociodemographic factors, including economic factors, seem to be major determinants of violence among patients diagnosed with mental disorders.

Inferior frontal gyrus gray matter volume is associated with aggressive behavior in schizophrenia spectrum disorders

We aimed to assess potential gray matter (GM) alterations for aggressive patterns of behavior in a sample of in- and outpatients with schizophrenia spectrum disorders. Eighty-four patients previously participating in brain volumetric studies were included. Aggression was assessed using the Modified Overt Aggression Scales (MOAS) based upon review of clinical records of the hospital register. Multiple regression analyses for total MOAS and each MOAS subscale separately were conducted correcting for age, sex, history of addiction, chlorpromazine equivalents, illness duration, and total intracranial volume. Significant effects were reported in two cases; the total MOAS scores and MOAS verbal aggression scores were associated with GM volume in left inferior frontal gyrus. From the demographic/clinical characteristics, only the number of episodes correlated with the subscales and the total MOAS scores. Our results highlight the role of GM volume in left inferior frontal gyri in patients with history of aggression. This evidence ties in well with previous data reporting involvement of these regions in response control and semantic networks.

Who Are the Victims of NGRI Acquittees? A Study of Belgian Internees

BACKGROUND

The limited literature on victim characteristics of offenders found not guilty by reason of insanity (NGRI) shows that most victims are adults who are known to the offender. It is currently unclear whether victims are mainly male or female or whether there are differences in the type of victims according to the offenders' psychiatric disorder.

METHOD

Victim characteristics were retrospectively collected from 362 NGRI acquittees, and the influence of psychiatric diagnoses on victim profiles was examined.

RESULTS

Victims were mainly adult acquaintances and were equally likely to be male or female. Family members and caregivers were the most frequent type of acquaintance victims. Further analyses suggest that these victim characteristics are similar for perpetrators with different psychiatric diagnoses.

CONCLUSION

Victimization of strangers and minors was unlikely in NGRI offenders.

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.

Proximity alert! Distance related cuneus activation in military veterans with anger and aggression problems

Problems involving anger and aggression are common after military deployment, and may involve abnormal responses to threat. This study therefore investigated effects on neural activation related to threat and escapability among veterans with deployment experience. Twenty-seven male veterans with anger and aggression problems (Anger group) and 30 Control veterans performed a virtual predator-task during fMRI measurement. In this task, threat and proximity were manipulated. The distance of cues determined their possibility for escape. Cues signaled impending attack by zooming in towards the participant. If Threat cues, but not Safe cues, reached the participants without being halted by a button press, an aversive noise (105dB scream) was presented. In both the Threat and the Safe condition, closer proximity of the virtual predator resulted in stronger activation in the cuneus in the Anger versus Control group. The results suggest that anger and aggression problems are related to a generalized sensitivity to proximity rather than preparatory processes related to task-contingent aversive stimuli. Anger and aggression problems in natural, dynamically changing environments may be related to an overall heightened vigilance, which is non-adaptively driven by proximity.

Sexual assault and general body injuries: A detailed cross-sectional Australian study of 1163 women

OBJECTIVES

To describe the frequency and severity of general body injury in women alleging recent sexual assault and then identify demographic and assault characteristics associated with injury severity.

DESIGN

Cross-sectional study.

SETTING

Sexual Assault Resource Centre (SARC), Western Australia.

PARTICIPANTS

Total of 1163 women attending SARC from Jan-2009 to Mar-2015.

METHODS

Women underwent a standardised medical examination and data collection by forensically trained doctors. Multivariate ordinal logistic regression analyses were performed. An algorithm was used to classify general body injuries as mild, moderate or severe.

RESULTS

General body injury was observed in 71% of women; 52%, 17% and 2% were classified as having respectively, mild, moderate and severe injuries. Moderate or severe injury was observed in 30.4% of women assaulted by intimate partners, 16.4% of women assaulted by strangers and 14.9% of women assaulted by friends/acquaintances. In regression analysis, an interaction between mental illness and assailant type existed after adjusting for age, intellectual disability, time-to-examination, number of assailants and location. Mental illness was an independent predictor for lower injury severity (adjusted odds ratio=0.5, 95% CI 0.3, 0.9) in women assaulted by strangers and higher injury severity in women assaulted by a friend/acquaintance (adjusted odds ratio=2.4, 95% CI 1.6, 3.6). While women assaulted by intimate partners had more frequent moderate-to-severe injuries than other women their current mental illness status was not associated with risk of injury severity.

CONCLUSION

This study highlights the increased injury severity in women assaulted by intimate partners. The risk of moderate/severe injury for women with mental illness assaulted by their acquaintances was unexpected and requires further investigation.

Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services

BACKGROUND

People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.

METHODS

This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).

DISCUSSION

The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724748 . Registered on 25th of April 2016.

Plasma levels of Th17-related cytokines and complement C3 correlated with aggressive behavior in patients with schizophrenia

Increasing evidence indicates that immune inflammatory processes, especially autoimmune reaction, should be considered in the pathophysiology of schizophrenia and aggressive behavior. The present study aimed to explore the correlation between immune factors (C3 and Th17-related cytokines) and aggressive behavior in schizophrenia patients. Forty schizophrenia patients and forty age- and gender-matched healthy controls participated in the study. Blood samples were assessed by ELISA upon enrollment. Positive and negative syndrome scale (PANSS) and modified overt aggression scale (MOAS) were used to estimate the severity and aggressive symptoms of schizophrenia patients. Plasma levels of IL-17, IL-23, and TGF-β1 in schizophrenia patients were significantly higher than those in healthy controls [(37.63±17.82) vs. (29.34±10.38)pg/ml, p=0.02; (101.40±135.26) vs. (13.09±5.94) pg/ml, p=0.01; (2864.57±2163.61) vs. (1839.69±1797.73)pg/ml, p=0.04], whereas C3 levels were significantly lower in schizophrenia patients [( 120,479.67± 65,612.50) vs. ( 208,060.21± 217,008.21)ng/ml, p=0.02]. IL-17, IL-23, and TGF-β1 levels were positively related to total scores of MOAS (p=0.02, p=0.02 and p=0.03, respectively) and PANSS (p=0.04, p=0.04 and p=0.02, respectively), whereas C3 levels were negatively related to total PANSS scores (p=0.03). IL-17 and IL-23 levels were positively correlated with PANSS excited component scores (p=0.04 and p=0.01, respectively). Our findings suggested that the Th17-related cytokine levels were positively related to the severity of schizophrenia and aggressive behavior, whereas C3 levels were negatively related to the severity of schizophrenia. This study demonstrated that elevated levels of Th17-related cytokines and decreased levels of C3 could be potential biomarkers for schizophrenia and aggressive behavior.