Self- and other-directed forms of violence and their relationship with lifetime DSM-5 psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol Related Conditions-III (NESARC-III)

Tobacco use, trauma exposure and PTSD: a systematic review

Tobacco use remains one of the most significant preventable public health problems globally and is increasingly concentrated among vulnerable groups, including those with trauma exposure or diagnosed with PTSD. The goal of this systematic review was to update and extend previous reviews. Of the 7224 publications that met the initial criteria, 267 were included in the review. Summary topic areas include conceptual frameworks for the relation between trauma or PTSD and tobacco use; associations between trauma exposure or PTSD and tobacco use; number and type of trauma exposures and tobacco use; PTSD symptoms and tobacco use; Treatment-related studies; and the examination of causal relations. Evidence continues to indicate that individuals exposed to trauma or diagnosed with PTSD are more likely to use tobacco products, more nicotine dependent and less likely to abstain from tobacco even when provided evidence-based treatments than individuals without trauma. The most commonly cited causal association proposed was use of tobacco for self-regulation of negative affect associated with trauma. A small proportion of the studies addressed causality and mechanisms of action. Future work should incorporate methodological approaches and measures from which we can draw causal conclusions and mechanisms to support the development of viable therapeutic targets.

Dual harm: Violent behaviour to others and self-harm behaviour in adults compulsorily admitted to a Dutch psychiatric hospital

BACKGROUND

Verbal and physical violence in psychiatric hospitals can have harmful consequences for staff members, such as physical injury, traumatisation, and sick leave, and they often accompany involuntary admission. Harm to others may co-occur with self-harm, i.e., dual harm. However, little is known about the association between dual-harm and violent behaviour towards staff members and its clinical outcomes, such as seclusion and rapid tranquilisation after involuntary admission to a psychiatric inpatient unit.

METHOD

A convenience sample of patients admitted involuntarily (N = 384; mean age = 48.03, SD = 19.92) between January 2016 and December 2019 in Western Brabant, the Netherlands, was used to design a retrospective file audit. Distinct harm groups, marked by the presence/absence of self- and/or other-harm, were investigated using multivariate linear regression modelling on the seriousness of violent acts and the total length of admission. Logistic regression analyses were used to study the association between harm groups and the administration of rapid tranquilisation, seclusion, and extended involuntary admissions.

RESULTS

Several harm groups were identified, including self-harm only, other-harm only, and dual-harm groups. Psychiatric patients admitted to the hospital because of (the risk of) violence towards others had a higher risk of violent incidents during admission and some restrictive measures. In a subgroup of patients with psychotic disorders, patients with dual harm committed the most serious violent incidents compared to those in the other harm groups.

CONCLUSION

Distinct harm groups were identified in a sample of involuntarily admitted patients. In a general adult psychiatric setting, patients at risk for violent behaviour, especially dual-harm patients, should be identified and monitored as part of the risk assessment. Future research is needed to explore more clinical correlates in the proposed distinction between harmful groups and to assess long-term prognosis.

Correlates of Past Childhood Homelessness in a Nationally Representative Sample of US Adults

ABSTRACT

Limited empirical data have been available on the adult sequelae of childhood homelessness. Using nationally representative data from the National Epidemiologic Survey of Alcohol and Related Conditions-III, we compared a hierarchy of adults who were never homeless, those who were only homeless as children, and those who were homeless both as children and adults, hypothesizing greater adversity as one moved up the three-level hierarchy on sociodemographic, behavioral, and lifetime mental health diagnostic characteristics. As a further evaluation of the status of adults who were homeless as both children and adults, we compared this highest risk group to those who had been homeless only as adults. Individuals who experienced childhood homelessness were 46.9 times more likely than others to also experience adult homelessness. Testing the hierarchical hypothesis, compared with those who were never homeless, individuals who experienced homelessness only as children reported numerous associated disadvantages, including childhood sexual abuse/neglect, parental adversities, adult incarceration, psychiatric disorders, and low academic achievement/employment. Those reporting both child and adult homelessness, in contrast to childhood homelessness alone, additionally met the criteria for multiple substance use disorders, confirming our hierarchical hypothesis. Those reporting both child and adult homelessness also showed more numerous social and psychiatric problems when compared with those experiencing homelessness for the first time as adults. This study demonstrates how homelessness in childhood is associated with extensive social and psychiatric adversities in both childhood and adulthood.

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

BACKGROUND

Patients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the 'triply troubled'. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB.

METHODS

A three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB.

RESULTS

A four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression.

CONCLUSIONS

The present study helps disentangle the heterogeneity of the 'triply troubled' patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care.

Childhood predictors of self-harm, externalised violence and transitioning to dual harm in a cohort of adolescents and young adults

BACKGROUND

The aetiology of dual harm (co-occurring self-harm and violence towards others) is poorly understood because most studies have investigated self-harm and violence separately. We aimed to examine childhood risk factors for self-harm, violence, and dual harm, including the transition from engaging in single harm to dual harm.

METHODS

Data from the Avon Longitudinal Study of Parents and Children, a UK-based birth cohort study, were used to estimate prevalence of self-reported engagement in self-harm, violence, and dual harm at ages 16 and 22 years. Risk ratios were calculated to indicate associations across various self-reported childhood risk factors and risks of single and dual harm, including the transition from single harm at age 16 years to dual harm at age 22.

RESULTS

At age 16 years, 18.1% of the 4176 cohort members had harmed themselves, 21.1% had engaged in violence towards others and 3.7% reported dual harm. At age 22 the equivalent prevalence estimates increased to 24.2, 25.8 and 6.8%, respectively. Depression and other mental health difficulties, drug and alcohol use, witnessing self-harm and being a victim of, or witnessing, violence were associated with higher risks of transitioning from self-harm or violence at age 16 to dual harm by age 22.

CONCLUSIONS

Prevalence of dual harm doubled from age 16 to 22 years, highlighting the importance of early identification and intervention during this high-risk period. Several childhood psychosocial risk factors associated specifically with dual harm at age 16 and with the transition to dual harm by age 22 have been identified.

Neurobiological metric of cortical delay discounting differentiates risk for self- and other-directed violence among trauma-exposed individuals

Self- and other-directed violence (SDV/ODV) contribute to elevated rates of mortality. Early trauma exposure shows robust positive associations with these forms of violence but alone does not distinguish those at heightened risk for later engagement in SDV/ODV. Novel assessment metrics could aid early identification efforts for individuals with vulnerabilities to violence perpetration. This study examined a novel neurobiological measure of impulsive choice for reward as a potential moderator of associations between childhood trauma exposure and lifetime SDV/ODV. A high-risk community sample of 177 adults (89 men; 50.3%) were assessed for childhood trauma exposure, engagement in SDV (e.g., suicide attempts), and ODV (e.g., assault). A cortical delay discounting (C-DD) measure was created using a multivariate additive model of gray matter thickness across both hemispheres, previously found to be positively associated with susceptibility to impulsivity and externalizing disorders. Childhood trauma exposure was positively associated with ODV and SDV; however, these relationships differed as a function of C-DD. Engagement in ODV increased as scores on C-DD increased, and SDV increased as scores on C-DD decreased. Furthermore, moderation revealed biological sex differences, as the association between childhood trauma and SDV depended on C-DD for women but not for men. Findings from the present work demonstrate that risk conferred by childhood trauma exposure to violence varied as a function of a C-DD. Together, these findings point to the utility of neurobiological markers of impulsive decision-making for differentiating risk for violence among individuals with a history of trauma exposure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association between overt aggression and anhedonia in patients with major depressive disorder during the acute phase

OBJECTIVE

To explore the factors influencing anhedonia at baseline and use them as confounding factors. To further investigate the correlation between overt aggression and anhedonia during the acute phase of major depressive disorder.

METHODS

In this eight-week prospective study, 384 major depressive disorder patients were recruited from the outpatient section of Shanghai Mental Health Center from May 1, 2017, to October 30, 2018. Standard treatments were performed with escitalopram or venlafaxine for participants. Depressive symptoms, overt aggression, and anhedonia were assessed using the 17-item Hamilton Rating Scale for Depression, Modified Overt Aggression Scale, and Snaith-Hamilton Pleasure Scale at baseline, and in the 4th and 8th weeks.

RESULTS

Obsessive-compulsive symptoms and the duration of untreated psychosis were positively associated with aggression (P < 0.05). Patients with aggressive behaviour had worse cognitive impairment and severe anhedonia of pleasurable sensory experiences (P < 0.05). For anhedonia, being female (tau_b = -0.23, P = 0.012) was a protective factor, while number of recurrent, melancholic features, current obsessions, previous combination drug therapies, depressive symptoms, and aggressive behaviour were risk factors (P < 0.05). Social anhedonia related to interests/pastimes, and pleasurable sensory experiences were more severe in major depressive disorder patients with aggressive behaviour in the acute phase (P < 0.05).

CONCLUSIONS

Anhedonia persisted in major depressive disorder patients with aggressive behaviour after standardized treatment during the acute phase. Being female protected the pleasures from social interaction and sensory experience. However, the number of depressive episodes, melancholic features, current obsessive symptoms, previous combination drug therapies, depressive symptoms, and aggressive behaviour was positively associated with anhedonia.

Hurting the Grandiose Self: Examining Presence, Frequency, and Functions of Nonsuicidal Self-Injury in Pathological Narcissism

The present study examines whether dimensions of pathological narcissism are associated with the presence, frequency, and function of nonsuicidal self-injury (NSSI). Adults (N = 252) completed questionnaires assessing narcissistic grandiosity, narcissistic vulnerability, fluctuation between these narcissistic states, and borderline personality disorder (BPD) symptoms. Those with a history of NSSI (n = 105) also reported the method, frequency, and function of their NSSI engagement. When controlling for co-occurring BPD symptoms, there were very few associations between vulnerability, grandiosity, and narcissistic fluctuation and NSSI presence and frequency. However, a clear pattern emerged regarding NSSI functions. Although vulnerability and narcissistic fluctuation were not associated with any functions of NSSI when co-occurring BPD symptoms were controlled for, grandiosity was positively associated with all interpersonal functions of NSSI (e.g., peer bonding, revenge) and negatively associated with the intrapersonal function of affect regulation. These results suggest a unique relationship between narcissistic grandiosity and NSSI that may inform clinical intervention.

Multimorbidity and Correlates of Comorbid Depression and Generalized Anxiety Disorder in a Nationally Representative US Sample

ABSTRACT

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently occur together, but sociodemographic, behavioral, and diagnostic correlates of this comorbidity have not been comprehensively studied. Data from the nationally representative US sample surveyed in the National Epidemiologic Survey on Alcohol and Related Conditions-III ( N = 36,309) were used to define three groups, individuals with a) both past-year GAD and MDD ( n = 909, 16.9%), b) GAD only ( n = 999, 18.6%), and c) MDD only ( n = 3471, 64.5%). The comorbid group was compared with each single-diagnosis group on sociodemographic, behavioral, and diagnostic characteristics based on effect sizes (risk ratios and Cohen's d ) rather than p values because of the large sample sizes. Multivariable-adjusted logistic regression analyses were used to identify factors independently associated with the comorbid group. Bivariate analysis showed that the comorbid group had more parental and childhood adversities, additional psychiatric disorders, and poorer mental health quality of life than both single-disorder groups. Multivariable-adjusted logistic regression of the comorbid group showed that on two of five factors, additional psychiatric diagnoses were significantly more frequent than in the GAD-only group, and that on three of six factors, additional psychiatric diagnoses were significantly more frequent than in the MDD-only group. There is a significantly higher burden of social adjustment problems, comorbid psychiatric disorders, and poorer mental health-related quality of life among individuals with comorbid GAD-MDD than those with single disorders. The adversities associated with this non-SUD psychiatric comorbidity are comparable to those associated with the more extensively studied comorbidity of psychiatric and substance use disorders and deserve further research and treatment.

Clinical features of individuals with schizotypal personality disorder with and without suicidal ideation

This study compared demographic and clinical features in a sample of 384 participants: healthy controls (HC; n = 166) and individuals with schizotypal personality disorder (SPD) with (n = 50) and without (n = 168) suicidal ideation (SI) to examine specific risk factors for suicidality in SPD. Compared to the non-SI group, the SI group showed significantly greater severity of depression, aggression, impulsivity, affective lability, schizotypal features, poorer social adjustment, and had fewer social contacts. Individuals in the SI group were also more likely to have a history of a suicide attempt and comorbid borderline personality disorder in comparison to the non-SI group. Logistic regression analysis indicated that severity of depression and the number of social contacts drove the difference between the SI and non-SI groups. Compared with both SPD subgroups, the HC group was significantly less depressed, aggressive, impulsive, affectively labile, had fewer schizotypal features, was better socially adjusted, and had more social contacts. This study indicates that overall, the SI group is a more severely impaired group of individuals with SPD compared to the non-SI group. Better educating medical professionals about the diagnosis and management of SPD and its associations with suicidality is warranted.

Comparison of Black and white individuals who report diagnoses of schizophrenia in a national sample of US adults: Discrimination and service use

BACKGROUND

While there is increasing recognition of disparities in healthcare for Black Americans, there have been no comparisons in a nationally representative U.S. sample of Black and White adults with clinical diagnoses of schizophrenia.

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we compared Black (n = 240, 36.2%) and White (n = 423, 63.8%) adults who report having been told by a physician that they have schizophrenia. Due to the large sample size, effect sizes (risk ratios and Cohen's d), rather than p-values, were used to identify the magnitude of differences in sociodemographic and clinical characteristics, including experiences of discrimination and service use. Multivariate analyses were used to identify independent factors.

RESULTS

Black individuals with diagnoses of schizophrenia reported multiple sociodemographic disadvantages, including lower rates of employment, educational attainment, income, marriage, and social support, with little difference in incarceration, violent behavior, and quality of life. They reported much higher scores on a general lifetime discrimination scale (Cohen's d = 0.75) and subscales representing job discrimination (d = 0.85), health system discrimination (d = 0.70), and public race-based abuse (d = 0.55) along with higher rates of past year alcohol and drug use disorders, but lower rates of co-morbid psychiatric disorders. Multivariable-adjusted regression analyses highlighted the independent association of Black race with measures of discrimination and religious service attendance; less likelihood of receiving psychiatric treatment (p = 0.02) but no difference in substance use treatment.

CONCLUSION

Black adults with schizophrenia report numerous social disadvantages, especially discrimination, but religious service attendance may be an important social asset.

A systematic review of the co-occurrence of self-harm and aggression: Is dual harm a unique behavioural construct?

Introduction

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. It is unclear whether sufficient evidence exists for dual harm as a unique clinical entity. This systematic review aimed to examine whether there are psychological factors that are uniquely associated with dual harm when compared to those who have engaged in sole harm (self-harm alone, aggression alone) and no harmful behaviours. Our secondary aim was to conduct a critical appraisal of the literature.

Methods

The review searched PsycINFO, PubMed, CINAHL, and EThOS on September 27, 2022, resulting in 31 eligible papers that represented 15,094 individuals. An adapted version of the Agency for Healthcare Research and Quality was used to assess risk of bias and a narrative synthesis was conducted.

Results

The included studies assessed differences in mental health problems, personality, and emotion related factors between the different behavioural groups. We found weak evidence that dual harm is an independent construct with unique psychological characteristics. Rather, our review suggests that dual harm results from the interaction of psychological risk factors that are associated with self-harm and aggression.

Discussion

The critical appraisal identified numerous limitations within the dual harm literature. Clinical implications and recommendations for future research are provided.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197323, identifier CRD42020197323.

The association between recreational cannabis use and posttraumatic stress disorder: A systematic review and methodological critique of the literature

BACKGROUND

Given recent changes in the legal status of cannabis, the risks and benefits associated with its use have become an important public health topic. A growing body of research has demonstrated that posttraumatic stress disorder (PTSD) and recreational cannabis use (RCU) frequently co-occur, yet findings are inconsistent (e.g., direction of effect) and methodological variability makes comparison across studies difficult.

METHODS

We conducted a comprehensive systematic review of all studies (N = 45) published before May 2020 regarding etiologic models of co-occurring RCU and PTSD, as well as provided a methodological critique to inform suggestions for future research initiatives.

RESULTS

Findings indicate that a majority of studies (n = 37) demonstrated a significant association between RCU and PTSD. Findings provide evidence for the self-medication and high-risk models posited to explain co-occurring RCU and PTSD despite variability in assessment of RCU, which includes commonly used non-standardized self-report questions.

CONCLUSION

The association between RCU and PTSD is likely bidirectional. Results inform clinicians and researchers working in the mental health and cannabis use fields how the variability in findings on the association between RCU and PTSD may be attributable, in part, to methodological issues that permeate the extant literature pertaining to RCU and PTSD.

Reseach progress in dual harm

Growing evidence supports an association between self-harm and aggression, and the two behaviors frequently co-occur. The co-occurrence of self-harm and aggression is termed as dual harm. Existing evidence reveals that rather than a simple co-occurrence of self-harm and aggression, dual-harm may be an independent behavior different from a sole harm behavior. Identification of characteristics and influencing factors for dual harm may help develop effective prevention strategies for the affected population. A review of the literature yields a high incidence of dual harm among the clinical and forensic populations. Individuals with dual harm engage in an earlier, more frequent, and a wider range of harmful behaviors, with the increased use of lethal methods. Common factors that affect dual harm include childhood adversities, emotional dysregulation, personality traits, mental disorders, and biological factors. A comprehensive theory to explain dual harm is still not available. Currently, two main theories for explaining mechanism of dual harm are the two-stage model of countervailing forces and the cognitive-emotional model. An in-depth exploration of characteristics, influencing factors, and theories for dual harm is of great importance for the prevention of dual harm.

Lifetime risk and correlates of incarceration in a nationally representative sample of U.S. adults with non-substance-related mental illness

PURPOSE

High rates of psychiatric disorders in correctional facilities have fueled widespread concern about the "criminalization of mental illness." While the link between incarceration, substance abuse, and antisocial-personality disorder is well established, the relationship between non-substance-related psychiatric disorders and incarceration has not been thoroughly investigated. This study examines the association of mental illness, excluding substance use disorders, with risk for incarceration in US adults.

METHODS

Nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) were used to compare the proportions of respondents with lifetime incarceration among those with no lifetime history of DSM-5 disorders, or with lifetime history of mental illness, substance use disorders, dual diagnosis, and antisocial personality/conduct disorder. Logistic regression analysis was used to examine the independent association of incarceration with mental illness alone, both in comparison to and net of associations with sociodemographic and behavioral characteristics.

RESULTS

Among adults with mental illness alone, 6.7% reported past incarceration, compared to 4.8% with no history of DSM-5 disorders, and 20-40% in other DSM-5 diagnostic groups. Sociodemographic and behavioral risk factors were more strongly associated with incarceration (c-statistics = 0.74 and 0.77, respectively), than mental illness (c-statistic = 0.56). Schizophrenia or other psychoses and borderline personality disorder were independently associated with incarceration, but with effect sizes no greater than eight other sociodemographic or behavioral risk factors.

CONCLUSION

A weak association of mental illness alone with incarceration was found, despite high level of public attention to "criminalization of mental illness."

Rates and correlates of dual diagnosis among adults with psychiatric and substance use disorders in a nationally representative U.S sample

Treatment needs of adults diagnosed with both psychiatric and substance use disorders (i.e., dual diagnosis) have not received detailed characterization in a nationally representative US sample. Data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III were used to compare socio-behavioral, diagnostic, and service use characteristics of dually diagnosed adults to those with psychiatric disorders or SUDs alone. Adults with dual diagnosis were estimated to constitute 25.8% of those with any psychiatric disorder; 36.5% of those with any SUD and 17.8% of the 75.8 million adults with either disorder. Among those with psychiatric disorders, the independent correlates of dual diagnosis reflected substantial social or psychopathological disadvantages (e.g., violent behavior, poor mental health-related quality of life [HRQOL], police trouble, homelessness, and incarceration). Similarly, among those with SUD all independent correlates of dual diagnosis also reflected social or psychopathological disadvantages including poor mental HRQOL, witnessing trauma in childhood, childhood sex abuse, drug use diagnoses, suicide attempt, medical problems, having more than one SUD diagnosis, child neglect, repeated adult traumas, and less social support. Provision of medical, psychiatric, addiction and especially diverse social services in an integrated and accessible setting appear necessary and deserve further study.

The association of childhood adversities and mental health problems with dual-harm in individuals with serious aggressive behaviors

BACKGROUND

The coexistence of self-harm and aggression, which is referred to as dual-harm, is commonly seen in forensic population. Self-harm and aggression have often been studied separately, previous studies on risk factors of aggression or self-harm mainly focused on childhood adversities, emotional regulation, impulsivity and psychopathology, given their importance in the two behaviors. However, the factors associated with dual-harm remain unclear. This study aimed to explore potential risk factors associated with co-occurring self-harm among individuals with serious aggressive behaviors.

METHODS

This multi-center, cross-sectional case-control study was conducted from May 2013 to January 2016 and involved seven qualified forensic institutes located in seven provinces in China. Participants were individuals with serious aggressive behaviors and were suspected to have mental disorders. Lifetime history of self-harm was obtained by a self-report questionnaire, and serious aggressive behaviors were assessed with the use of participants' forensic archive. Sociodemographic and clinical information were collected using a self-designed standardized data collection form, and childhood adversities was assessed using a clinician-rated scale designed by our research team. The Psychopathy Checklist-Revised (PCL-R) was used to assess psychopathic traits and the Brief Psychiatric Rating Scale (BPRS) was used to assess psychiatric symptoms of the participants. Univariate and multivariate logistic regression analyses were performed to analyze the relevant factors for dual-harm.

RESULTS

A total of 423 individuals with serious aggressive behaviors were enrolled in the current study. Of them, 74 (17.5%) with self-harm history assigned into the dual-harm group (D-H) and 349 (82.5%) without self-harm history assigned into the aggression-only group (A-O). According to the binary logistic regression analysis, current diagnosis of mood disorder (OR = 3.2, 95%CI: 1.2-8.5), child abuse (OR = 2.8, 95%CI: 1.3-6.2), parental death (OR = 3.0, 95%CI: 1.2-7.5), and the score of the affective subscale in BPRS (OR = 1.7, 95%CI: 1.3-2.4) were significantly associated with dual-harm.

CONCLUSIONS

Our study suggested the necessity of integrated evaluation of self-harm among individuals with serious aggressive behaviors. Childhood adversities and psychiatric symptoms in this population require special attention.

Gender Differences in Diagnostic Remission of Posttraumatic Stress Disorder (PTSD): Proportions and Correlates of Remission in a Nationally Representative U.S. Sample

This study examines differences in a nationally representative sample, in proportions of men and women with lifetime diagnoses of Posttraumatic Stress Disorder (PTSD) who achieved diagnostic remission and gender-specific correlates. Data from the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions-III included 1,997 adults with a lifetime PTSD diagnosis (70.8% female and 29.2% male). Of these 25.3% of women and 24.3% of men experienced remission (ns). Women who remitted were older than other women, more likely to be retired, and less likely to report disability, past homelessness, suicide attempts, criminal history, violent behavior, or parental histories of drug problems or suicide. Men who remitted were less likely than other men to be separated/divorced, disabled, incarcerated after age 15, and reported fewer violent behaviors. Remission was significantly more strongly associated among women than men with greater age, emergency room visits, trauma and less with schizotypal personality. Although women were twice as likely to be diagnosed with PTSD, there were no significant gender differences in the proportions who experienced remission. Remission was associated with diverse sociodemographic and clinical disadvantages among both men and women but only four were statistically significantly different between genders.

"Lives of despair" at risk for "deaths of despair": tracking an under-recognized, vulnerable population

PURPOSE

The substantial and unexpected increase in "deaths of despair" in the US (e.g., deaths from drug overdose, suicide, and alcohol-related liver diseases) reported by economists Case and Deaton in 2015 raises questions about the number and characteristics of US adults potentially living "lives of despair" with these problems.

METHODS

We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III) to examine population estimates and characteristics of adults with lifetime history of substance use disorder (SUD) and suicide attempt, or either condition alone, as compared to those with neither.

RESULTS

An estimated 7.2 million adults had both lifetime SUD and suicide attempt and 78.8 million had either. Those with both faced far more psychosocial adversities, familial adverse experiences and psychiatric disorders compared to those with the other two groups, and reported greater mental health service utilization. Multivariable analysis showed that psychiatric multimorbidity and violence were the strongest correlates of having both conditions as compared to neither while those with either condition fell in between.

CONCLUSION

A substantial number of US adults live with a lifetime SUD and suicide attempt with a multiplicity of additional socioeconomic, psychiatric and familial problems. While their utilization of mental health care service exceeds those with either or neither conditions, quality of life remained much poorer, suggesting that mental health treatment alone may not be enough to mitigate their sufferings, and a combination of both social policy support and quality mental health care may be needed.

Driving After Cannabis Use Among Young Adults in Michigan

Introduction: Driving after cannabis use is associated with a number of risks. Examination of driving after cannabis use among young adults is particularly important, as young adults have the highest rates of cannabis use and among the highest rates of traffic crashes. The current study examines rates and correlates of driving after cannabis use among young adults (aged 18-25) who reported past month cannabis use. Methods: Participants were from Michigan and recruited through paid Facebook and Instagram advertisements between February and March 2018 (n=461). Results: Nearly a third (31.9%) of the sample reported driving after cannabis use in the past month. Young adults who were employed (aOR=1.872, p=0.045), had medical cannabis cards (aOR=2.877, p<0.001), endorsed coping reasons for use (aOR=2.992, p=0.007), and endorsed social/recreational reasons for use (aOR=1.861, p=0.034) had greater odds of driving after cannabis use. Students had lower odds of driving after use (aOR=0.573, p=0.011). Conclusions: Employment and having a medical cannabis card may be important risk markers for identifying individuals more likely to drive after use of cannabis. Prevention efforts could provide psychoeducation at dispensaries to individuals with medical cannabis cards about the risks of driving after use. Coping motives for cannabis use may also be useful in identifying young adults at the greatest risk of driving after use of cannabis.

Nonsuicidal Self-Injury and Intimate Partner Violence: Directionality of Violence and Motives for Self-Injury

Nonsuicidal self-injury (NSSI) is associated with intimate partner violence (IPV) perpetration and victimization. However, extant research has not distinguished between unidirectional and bidirectional IPV and has not examined relationships between IPV and functions of self-injury. This study of 1,018 university students revealed a significantly higher prevalence of NSSI among those who reported bidirectional IPV compared with nonviolent individuals. However, rates of NSSI in the unidirectional IPV groups are more similar to rates of NSSI in the bidirectional group than in nonviolent individuals. Individuals who engaged in bidirectional IPV were more likely to endorse interpersonal functions of self-injury than those who engaged in unidirectional IPV or no IPV. In contrast, intrapersonal functions of NSSI were not associated with IPV. Findings suggest that the association between IPV and NSSI may be best understood in the context of relationship conflict, rather than as a distinct correlate of either IPV victimization or IPV perpetration.

Risk factors for violent behaviors in patients with schizophrenia: 2-year follow-up study in primary mental health care in China

OBJECTIVE

The consequences and impact of violent behavior in schizophrenia are often serious, and identification of risk factors is of great importance to achieve early identification and effective management.

METHODS

This follow-up study sampled adult patients with schizophrenia in primary mental health care in a rural area of southern China, in which 491 participants completed a comprehensive questionnaire at baseline and the 2-year follow-up. Sociodemographic, clinical and psychological assessment data were collected from all participants. Paired sample T-Tests and the McNemar Test were performed to examine changes over the follow-up period. Generalized Estimating Equations (GEE) were used to analyze the risk factors for violent behavior.

RESULTS

The results showed that about two in five community-dwelling patients with schizophrenia reported violent behavior in the past year. At follow-up, participants were significantly less employed, had more times of hospitalization, more psychotropic medication, and severer depressive symptoms, but had better health-related quality of life than at baseline. Use of clozapine and better insight into medication decreased the possibility of violent behavior, while more severe positive symptoms, insomnia, as well as use of second-generation antipsychotics other than clozapine, antidepressants and mood stabilizers increased the possibility of violent behavior.

CONCLUSIONS

Risk evaluation, prevention and management of violence in patients with schizophrenia are demanded in primary mental health care.

The inter-connections between self-harm and aggressive behaviours: A general network analysis study of dual harm

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. This behaviour is especially prevalent within criminal justice and forensic settings. The forms of aggression that should be included in the definition of dual harm have not yet been established. This study aimed to use network analysis to inform an evidence-based definition of dual harm by assessing the relationship between self-harm and different forms of aggressive behaviour in young people (N = 3,579). We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results revealed low correlations between the variables, leading to sparse network models with weak connections. We found that when separated into their distinct forms, aggressive acts and self-harm are only weakly correlated. Our work provides preliminary evidence to assist in understanding and managing dual harm within clinical and forensic settings and informs recommendations for future research.

Dual-harm in adolescence and associated clinical and parenting factors

PURPOSE

Both aggression toward others and self peak in adolescence and interpersonal violence and suicide are among the leading causes of death in young people worldwide. Individuals who show both aggression toward others and self, i.e. dual-harm, may experience the worst outcomes. The current study investigates clinical and parenting factors associated with dual-harming in adolescence, to provide new insights for prevention and treatment.

METHODS

In a prospective cohort of adolescents, oversampled on emotional and behavioral problems (n = 1022; aged 12-17 years), we investigated co-occurrence in harm toward others and self and presented findings in an area-proportional Euler diagram. Four harm groups (no harm, other-harm, self-harm, and dual-harm) were compared on intelligence scores, general functioning, emotional and behavioral problems, substance use, parental hostility, and harsh parenting with ANCOVAs and logistic regressions.

RESULTS

In adolescents that other-harmed, the risk of self-harm was 1.9 times higher than for those who did not harm others. Dual-harm adolescents reported worse overall functioning, more emotional and behavioral problems, more parental hostility and harshness, and were more likely to use substances than those who did not engage in aggressive behaviors. No evidence of differences in intelligence scores between groups were found.

CONCLUSION

These findings highlight a vulnerable group of adolescents, at risk of future suicide, violent offending, and the development of severe psychopathology. Dual-harm is a promising marker for early intervention and referral to specialized mental health professionals. Further research is needed to examine underlying pathways and risk factors associated with persistent dual-harm trajectories into adulthood.

A population-wide perspective on the reach of substance use disorders: Parental exposure, diagnostic remission, and current disorders

BACKGROUND AND OBJECTIVES

Parental substance use disorder (SUD) increases the risk for childhood adversities. Lifetime and current SUDs are associated with functional impairment and psychiatric comorbidity. Research shows that these abate with diagnostic remission. However, a hierarchically ordered heuristic profile of adult subpopulations affected by SUDs has not been explored.

METHODS

We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; N = 36,309) to compare four subpopulations defined by the following hierarchy: (1) neither parental nor lifetime SUD (un-affected group); (2) parental SUD but no personal SUD; (3) past but not current SUD (diagnostic remission); and (4) current SUD. We conducted bivariate comparisons and multivariable-adjusted logistic regression to identify characteristics independently differentiating each group.

RESULTS

Almost half of the US adult population (108.9 million) were at risk from SUDs. Relative to the unaffected group (56.1%), the parental-exposure-only group (13.9%) experienced diverse parental and childhood adversities and increased risk for psychiatric disorders. Compared to the parental-exposure-only group those in the remitted group (14.1%) were more likely to report behavioral problems and lifetime psychiatric multimorbidities. Those with current SUD (15.9%) had a poorer mental health-related quality of life.

DISCUSSION AND CONCLUSIONS

This heuristic SUD hierarchy is associated with increasing adversities affecting almost half the US population, although only 15.9% meet the criteria for a current disorder.

SCIENTIFIC SIGNIFICANCE

Our findings provide a rigorous population-based estimate of the staggering public health impact of SUDs in the United States and suggest that almost half of the US population is either directly or indirectly affected by SUDs.

Psychosocial function, legal involvement and violence in mental disorder

BACKGROUND

The correlates of legally significant outcomes that have been identified in people with mental disorders are of limited value in understanding the mechanisms by which these outcomes occur.

AIMS

To describe the relationships between mental disorder, impaired psychosocial function, and three legally significant outcomes in a representative sample of the US population.

METHODS

We used a population survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III, sample size 36,309), to identify people who self-reported serious trouble with the police or the law over the past 12 months and two lifetime outcomes, being incarcerated and engaging in violence to others. DSM-5 categories were generated using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Psychosocial function was assessed using social and role-emotional function scores of the 12-Item Short-Form Health Survey Version 2.

RESULTS

Participants with mental disorder, but not people with no diagnosis, who reported serious trouble with the police or with the law during the previous 12 months reported significantly worse psychosocial function than those who did not report such trouble. The size of the statistical effect varied by diagnosis, moderate for some forms of mental illness and for alcohol abuse and nonsignificant for drug abuse and the personality disorders. Effect sizes were largest for diagnoses where legally significant outcomes were least common.

CONCLUSIONS

The effect of impaired psychosocial function, for instance in disrupting family and social networks that would otherwise protect against these legally significant outcomes, warrants further investigation in studies with longitudinal designs.

Diagnostic remission of substance use disorders: Racial differences and correlates of remission in a nationally representative sample

INTRODUCTION

Research has shown racial/ethnic minorities to have similar risk of developing substance use disorders (SUDs) as Whites. However, few studies have compared the likelihood of diagnostic remission (i.e., no longer meeting criteria for current SUDs).

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), we examined all adults with lifetime SUDs; compared the proportions experiencing diagnostic remission; and used logistic regression analyses to compare Black, Hispanic, and other racial/ethnic minorities to Whites. The research team initially used bivariate comparisons to identify potentially confounding factors also associated with remission. The study used multivariable-adjusted logistic regression analyses to adjust for these potentially confounding covariates. The team conducted separate analyses for alcohol use disorder (AUD) and drug use disorders (DUDs).

RESULTS

Of 10,916 individuals with lifetime SUDs, 5120 no longer met criteria for an SUD in the past year (55.2% of White, 34.0% of Black, 38.5% Hispanic, and 40.1% of other individuals). In unadjusted analyses, Black, Hispanic, and others were significantly and about half as likely as Whites to have remitted with odds ratios (ORs) of 0.42 (95% CI 0.36-0.48), 0.51 (0.45-0.58), and 0.55 (0.45-0.65), respectively. The study found similar results for both AUD and DUDs. Adjusting for potentially confounding factors only modestly improved the likelihood of remission among racial/ethnic minorities compared to White individuals.

CONCLUSION

Minority race/ethnicity is robustly associated with reduced likelihood of diagnostic remission from SUDs even after adjusting for other factors. This study could identify only partial moderators of these disparities; these moderators deserve further study.

Treatment of substance use disorders among black and white adults: rates, correlates, and racial discrimination

BACKGROUND

Racial disparities in access to psychiatric treatment are well documented, but less is known about disparities in use of substance use disorder (SUD) treatment.

OBJECTIVES

To compare Black and White individuals with SUDs on overall differences and correlates of SUD treatment receipt.

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), we compared Black (n = 1,312 unweighted) and White (n = 3,076 unweighted) adults with past-year SUDs on proportions who received SUD treatment and on sociodemographic and clinical correlates of receiving treatment. Due to large samples, effect sizes, rather than p-values, were used to identify substantial differences between racial groups. Multivariate analyses were used to identify independent differentiating factors.

RESULTS

Black individuals with past-year SUDs were no less likely to receive treatment than White individuals (10.1% versus 11.3%; p = 0.24). Bivariate analyses demonstrated similar correlates of treatment receipt between racial groups, including sociodemographic disadvantage, racial discrimination, criminal justice involvement, low social support, multimorbidity of SUDs and psychiatric disorders, and prior SUD treatment. Multivariate analyses demonstrated that low income, unemployment, and criminal justice involvement had a significantly stronger association with receiving treatment for Whites, while parental problems with alcohol was more strongly associated with treatment among Black individuals (p < 0.05).

CONCLUSION

Recognizing methodological limitations, our findings are encouraging suggesting that Black individuals with SUDs are not less likely than White individuals to receive treatment and have few differences in correlates of receiving treatment. However, treatment receipt was low for both groups and remains a major unmet challenge.

Clinical features and psychiatric comorbidities in military veterans with schizophrenia with or without suicidality

Suicide is currently among the leading causes of death among individuals with schizophrenia. Reducing mortality from suicide remains a major clinical challenge in the care of veterans with schizophrenia. There is a need to increase our understanding of what elevates suicide risk in veterans with schizophrenia as a first step towards the future development of suicide prevention interventions. This study compared demographic and clinical features of military veterans with schizophrenia with vs. without suicidality to determine specific risk factors for suicidality. The sample consisted of two groups of veterans with schizophrenia: suicide ideators and/or attempters (SIA) and individuals without a history of suicidal ideation or attempts (no-SIA). Participants were interviewed using the Structured Clinical Interview for DSM-5 Axis I disorders (SCID-I), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale (HDRS), and Schizotypal Personality Questionnaire (SPQ). In bivariate analyses, the PANSS-Positive Symptom scores, PANSS-General Psychopathology scores, HDRS total score, HDRS-Paranoid symptoms item score, and SPQ total scores were higher among SIA compared with no-SIA patients. In this unique clinical sample of veterans with schizophrenia, SIA patients were more likely to have mood disorders, post-traumatic stress disorder (PTSD), and/or alcohol use disorder in comparison to the no-SIA group. Logistic regression analysis indicated that the HDRS total score and presence/absence of comorbid mood disorder drive the difference between the groups. These results indicate that suicide risk assessment in veterans with schizophrenia should include identifying individuals with comorbid mood disorders/symptoms, PTSD, alcohol use disorder, marked positive symptoms, and schizotypal features.

Development and Psychometric Properties of the Test of Passive Aggression

Background: To date, most research on aggression in mental disorders focused on active-aggressive behavior and found self-directed and other-directed active aggression to be a symptom and risk-factor of psychopathology. On the other hand, passive-aggressive behavior has been investigated less frequently and only in research on psychodynamic defense mechanisms, personality disorders, and dysfunctional self-control processes. This small number of studies primarily reflects a lack of a reliable and valid clinical assessment of passive-aggressive behavior. To address this gap, we developed the Test of Passive Aggression (TPA), a 24-item self-rating scale for the assessment of self-directed and other-directed passive-aggressive behavior. Method: Study 1 examined the internal consistency and factorial validity of the TPA in an inpatient sample (N = 307). Study 2 investigated the retest-reliability, internal consistency, and construct validity (active aggression, personality traits, impulsivity) of the TPA in a student sample (N = 180). Results: In line with our hypothesis, Exploratory Structural Equation Modeling revealed an acceptable to good fit of a bi-factorial structure of the TPA (Chi-square-df-ratio = 1.98; RMSR = 0.05, fit.off = 0.96). Both TPA scales showed good to excellent internal consistency (α = 0.83-0.90) and 4-week retest-reliability (r tt = 0.86). Correlations with well-established aggression scales, measures of personality, and impulsivity support discriminant and convergent validity of the TPA. Conclusions: The TPA is a reliable and valid instrument for the assessment of self-directed and other-directed passive-aggressive behavior.

The Co-occurrence of Self-Harm and Aggression: A Cognitive-Emotional Model of Dual-Harm

There is growing evidence that some individuals engage in both self-harm and aggression during the course of their lifetime. The co-occurrence of self-harm and aggression is termed dual-harm. Individuals who engage in dual-harm may represent a high-risk group with unique characteristics and pattern of harmful behaviours. Nevertheless, there is an absence of clinical guidelines for the treatment and prevention of dual-harm and a lack of agreed theoretical framework that accounts for why people may engage in this behaviour. The present work aimed to address this gap in the literature by providing a narrative review of previous research of self-harm, aggression and dual-harm, and through doing so, presenting an evidence-based theory of dual-harm – the cognitive-emotional model of dual-harm. This model draws from previous studies and theories, including the General Aggression Model, diathesis-stress models and emotional dysregulation theories. The cognitive-emotional model highlights the potential distal, proximal and feedback processes of dual-harm, the role of personality style and the possible emotional regulation and interpersonal functions of this behaviour. In line with our theory, various clinical and research implications for dual-harm are suggested, including hypotheses to be tested by future studies.

Mental illness and the risk of self- and other-directed aggression: Results from the National Survey on Drug Use and Health

Aggression and mental illness have been classically interlinked, often causing controversy and debate. Previous studies have shown that mental illness can be a risk factor to self- and other-directed aggression. However, these associations have rarely been simultaneously studied within the same population. Therefore, we aimed to study whether psychiatric disorders differentially increase the likelihood of one subtype of aggression over the other. We used the publicly available data of the National Survey on Drug Use and Health (NSDUH) from 2008 through 2014, for a total sample of 270,227 adult respondents. We designed our independent variable according to three categories: no mental illness (NMI), low or moderate (LMMI) and serious (SMI). We constructed regression models to estimate the odds ratios for those having a mental illness committing (a) a subtype of aggression over the past year compared with no aggression and (b) other-directed compared to self-directed aggression. We found that most respondents with mental illness reported no past-year aggression of any type. However, respondents with mental illness had higher odds of perpetrating all subtypes of aggression. Additionally, respondents with LMMI and SMI were respectively 1.7 and 3 times more likely to engage in self- rather than other-directed aggression. Future research should focus on identifying accurate and reliable predictors of self- and other-directed aggression among individuals with mental illness.

Adverse Childhood Experiences and Risk of Subsequently Engaging in Self-Harm and Violence towards Other People-"Dual Harm"

The etiology of “dual harm” (the co-occurrence of self-harm and externalized violence in the same individual) is under-researched. Risk factors have mostly been investigated for each behavior separately. We aimed to examine adversities experienced between birth and age 15 years among adolescents and young adults with histories of self-harm and violent criminality, with a specific focus on dual harm. Three nested case-control studies were delineated using national interlinked Danish registers; 58,409 cases in total aged 15–35 were identified: 28,956 with a history of violent criminality (but not self-harm), 25,826 with a history of self-harm (but not violent criminality), and 3987 with dual-harm history. Each case was matched by date of birth and gender to 20 controls who had not engaged in either behavior. We estimated exposure prevalence for cases versus controls for each of the three behavior groups, and incidence rate ratios (IRRs). Experiencing five or more childhood adversities was more prevalent among individuals with dual-harm history (19.3%; 95% CI 18.0, 20.8%) versus self-harm (10.9%; 10.5, 11.3%) and violence (11.4%; 11.0%, 11.8%) histories. The highest IRRs for dual harm were linked with parental unemployment (5.15; 95% CI 4.71, 5.64), parental hospitalization following self-harm (4.91; 4.40, 5.48) or assault (5.90; 5.07, 6.86), and parental violent criminality (6.11; 5.57, 6.70). Growing up in environments that are characterized by poverty, violence, and substance misuse, and experiencing multiple adversities in childhood, appear to be especially strongly linked with elevated dual-harm risk. These novel findings indicate potential etiologic pathways to dual harm.

Identity pathology and borderline personality disorder: an empirical overview

Pathological identity-related functioning is a core feature of borderline personality disorder (BPD) that is grievously underrepresented in the empirical literature. Burgeoning evidence indicates that identity pathology is multifaceted, influenced by transactions between social and endogenous processes, and associated with a wide variety of maladaptive outcomes. Although historically defined by patterns of instability (e.g. frequent and rapid changes to career goals, religious beliefs, core values, friend groups, etc.), accumulating research indicates that identity pathology also manifests as distress and functional impairment related to excessive rigidity (i.e. unrelenting negative self-evaluations; overidentification with a restricted role or group membership) and/or incongruous behavior (i.e. simultaneously holding discordant beliefs/values/attitudes, actions that are grossly contradictory with values, incoherent sense of self, etc.). Despite the complex nature of this construct, and its centrality to BPD, researchers often assess identity pathology indirectly, inadequately, or fail to measure it entirely. In this article, we briefly describe how identity pathology may fit into etiological models of BPD, highlight emerging themes from recent research, and identify important gaps in our knowledge. We also discuss limitations associated with current assessment practices, recommend alternatives, and articulate a research agenda for the future.

Immigration, Criminal Involvement, and Violence in the U.S.: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III

Topics of immigration and crime often receive national attention, despite evidence of the "immigrant paradox," in which immigrants have lower than expected crime and violence given their extreme social disadvantage. Research examining the immigrant paradox using an expanded set of crime outcomes and the latest available population data is needed. Using the National Epidemiologic Survey on Alcohol and Related Conditions Wave III data (2012-2013; n = 36,309), we analyzed the association between first-generation immigrant status alongside violence (i.e., other-directed, self-directed, victimization) and criminal involvement (i.e., crime, legal problems, incarceration) outcomes. Immigrants self-reported lower rates of all outcomes compared to U.S.-born adults, providing continued support for the immigrant paradox. Future research considering later generations of immigrants, as well as differential mechanisms through which immigrants and U.S.-born adults engage in violence and crime, is needed.

Cues for different diagnostic patterns of interpersonal violence in a psychiatric sample: an observational study

BACKGROUND

Interpersonal violence has increased as a health concern, especially in psychiatry practice, over the last decades. Nevertheless, most patients with stable mental disorders do not present an increased risk of violence, and mental disorder is not a necessary or sufficient cause of violent behaviours. People with mental disorders endorse more often a number of risk factors for violence that could confound this association, such as young age and male gender. The aim of this study was to investigate the effect of age, gender, and diagnosis on reported levels of interpersonal violence in a sample of people with severe mental illness.

METHODS

The sample was composed of 160 inpatients: 73 with a psychosis within the schizophrenia spectrum, 53 with a mood disorder and 34 with a personality disorder. All patients enrolled in the study were assessed for experiences of victimization and perpetration of interpersonal violence using the Karolinska Interpersonal Violence Scale interview. Demographic variables were also collected.

RESULTS

Both violence perpetration and victimization negatively correlated with age. Compared to males, females were exposed to higher degree of victimization in childhood and adulthood, whereas males were more involved in the perpetration of violence in childhood. Personality disorders were associated with higher levels of interpersonal violence, both perpetration and victimization; an interaction effect of gender and diagnosis was also observed for violence perpetration in adulthood. Distinct patterns of interpersonal violence did emerge for the diagnostic groups with mood disorder showing a victimization pattern, personality disorders a perpetration pattern and psychoses less defined patterns.

CONCLUSIONS

The main finding is that psychotic disorders, mood disorders and personality disorders have different patterns of violent experiences interacting with age and gender. This study offers a better understanding of how gender and age could affect violent behaviours. Moreover, study findings may increase the comprehension of the reason why some mental disorders, compared to others, are more associated with the risk of victimization or perpetration of violence. These patterns could have pathophysiological or pathoplastic meaning addressing clinical and diagnostic trajectories and they could interact with other intervening risk factors.

Drug Use Disorders and Violence: Associations With Individual Drug Categories

We conducted a systematic review that examined the link between individual drug categories and violent outcomes. We searched for primary case-control and cohort investigations that reported risk of violence against others among individuals diagnosed with drug use disorders using validated clinical criteria, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We identified 18 studies published during 1990–2019, reporting data from 591,411 individuals with drug use disorders. We reported odds ratios of the violence risk in different categories of drug use disorders compared with those without. We found odds ratios ranging from 0.8 to 25.0 for most individual drug categories, with generally higher odds ratios among individuals with polydrug use disorders. In addition, we explored sources of between-study heterogeneity by subgroup and meta-regression analyses. Cohort investigations reported a lower risk of violence than case-control reports (odds ratio =  2.7 (95% confidence interval (CI): 2.1, 3.5) vs. 6.6 (95% CI: 5.1, 8.6)), and associations were stronger when the outcome was any violence rather than intimate partner violence (odds ratio = 5.7 (95% CI: 3.8, 8.6) vs. 1.7 (95% CI: 1.4, 2.1)), which was consistent with results from the meta-regression. Overall, these findings highlight the potential impact of preventing and treating drug use disorders on reducing violence risk and associated morbidities.

Risky driving behaviours among stimulant drug users and the role of aggression: findings from a national survey

BACKGROUND AND AIMS

Stimulant drug users have a greater prevalence of risky driving behaviour. This study aimed to assess how far this association remains after adjusting for aggressiveness.

DESIGN

Cross-sectional interview study assessing associations between measures of risky driving behaviours as outcomes, measures of stimulant drug use as predictors and a measure of aggressiveness as a covariate.

SETTING

United States.

PARTICIPANTS

Data were drawn from wave 3 (2012-13) of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III) (n = 36 309 aged ≥ 18 years).

MEASUREMENTS

Stimulant drug use, past-year DSM-5 stimulant use disorder, aggression and measures of risky driving were assessed using face-to-face interviews conducted using the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-5) and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

FINDINGS

Overall, 2714 (8.3%) respondents indicated life-time stimulant use, and 112 (0.3%) met criteria for past-year DSM-5 stimulant use disorder. More than 10% of ongoing stimulant users and one-third of respondents with DSM-5 stimulant use disorder reported stimulant-specific driving under the influence of drugs (DUID) in the past-year (both P < 0.0001). Adjusted for demographics and independent of aggression, life-time stimulant users reported increased likelihood of driving [adjusted odds ratio (aOR) = 3.00, 95% confidence interval (CI) = 2.63-3.42] or speeding under the influence of drugs (aOR = 3.39, 95% CI = 3.01-3.82) and licence revocation (aOR = 2.16, 95% CI = 1.87-2.50) (all P < 0.0001). Past-year DSM-5 stimulant use disorder was associated with all outcomes (aOR = 5.48, 95% CI = 2.95-10.18 and aOR = 3.87, 95% CI = 2.23-6.70, respectively, all P < 0.0001), except licence revocation (aOR = 1.72).

CONCLUSIONS

Stimulant use appears to be positively associated with risky driving behaviours after adjusting for aggressiveness.

Further Exploration of Personal and Social Functioning: The Role of Interpersonal Violence, Service Engagement, and Social Network

Social functioning (SF) has mainly been studied in major psychoses in relation to symptom severity, but other factors may interfere with the achievement of a functional remission. The aim of this study is to explore interpersonal violence (IV), service engagement (SE), and social network (SN), together with demographics, as predictors of SF in a sample of subjects with severe mental illness (SMI). Consecutive adult inpatients were evaluated using self-report and clinician-rated questionnaires. Findings suggest that IV, SE, SN, male sex, and illness duration explained 39.1% of SF variance in people affected by SMI. IV was the strongest predictor, followed by sex and duration of illness. Lifetime expression of violence is a stronger predictor than lifetime exposure to violence. Positive SE and SN were found to predict SF, whereas age was not associated. This study underlines the need of other non-symptom-related variables for the comprehension of SF in mental disorders.

Adolescents Who Self-Harm and Commit Violent Crime: Testing Early-Life Predictors of Dual Harm in a Longitudinal Cohort Study

OBJECTIVE

Self-harm is associated with violent offending. However, little is known about young people who engage in "dual-harm" behavior. The authors investigated antecedents, clinical features, and life characteristics distinguishing dual-harming adolescents from those who self-harm only.

METHODS

Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative U.K. cohort of 2,232 twins born in 1994 and 1995. Self-harm in adolescence was assessed through interviews at age 18. Violent offending was assessed using a computer questionnaire at age 18 and police records through age 22. Risk factors were assessed between ages 5 and 12. Adolescent mental health, victimization, personality functioning, and use of support services were measured at age 18.

RESULTS

Self-harm was associated with violent crime (odds ratio=3.50, 95% CI=2.61-4.70), even after accounting for familial risk factors. Dual harmers had been victims of violence from childhood and exhibited lower childhood self-control and lower childhood IQ than self-only harmers. Dual harmers experienced higher rates of concurrent psychotic symptoms and substance dependence. They also exhibited distinct personality styles characterized by resistance to change and by emotional and interpersonal lability. However, dual harmers were not more likely than self-only harmers to have contact with mental health services.

CONCLUSIONS

Dual harmers have self-control difficulties and are immersed in violence from a young age. A treatment- rather than punishment-oriented approach is indicated to meet these individuals' needs. Connecting self-harming adolescents with delinquency-reduction programs and transdiagnostic approaches that target self-regulation may reduce harmful behaviors. Preventing childhood maltreatment and implementing strategies to reduce victimization exposure could mitigate risk for both internalized and externalized violence.

Psychiatric Disorders and Crime in the US Population: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Wave III

OBJECTIVE

Current knowledge regarding the intersection of psychiatric disorders and crime in the United States is limited to psychiatric, forensic, and youth samples. This study presents nationally representative data on the relationship of DSM-5 psychiatric disorders, comorbid substance and mental health disorders, and multimorbidity (number of disorders) with criminal behavior and justice involvement among non-institutionalized US adults.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; 2012-2013; N = 36,309). Logistic regressions were used to examine the association of specific disorders (eg, mood, anxiety, eating, posttraumatic stress, substance use), comorbid substance use and mental health disorders, and multimorbidity with lifetime criminal behavior, incarceration experience, and past-12-month general, alcohol-related, and drug-related legal problems.

RESULTS

Overall, 28.5% of participants reported a history of criminal behavior, 11.4% reported a history of incarceration, 1.8% reported current general legal problems, 0.8% reported current alcohol-related legal problems, and 2.7% reported current drug-related legal problems. The presence of any disorder was associated with a 4 to 5 times increased risk of crime outcomes. Drug use disorders were associated with the highest risk of lifetime crime (adjusted odds ratio [AOR] = 6.8; 95% CI, 6.1-7.6) and incarceration (AOR = 4.7; 95% CI, 4.1-5.3) and current legal problems (AOR = 3.3; 95% CI, 2.6-4.2). Multimorbidity and comorbid substance use and mental health disorders were associated with additional risk. Controlling for antisocial personality disorder did not change the findings.

CONCLUSIONS

Community adults with substance use disorders, comorbid substance use and mental health disorders, and increasing multimorbidity are most at risk of crime and justice involvement, highlighting the importance of community-based addiction treatment.

Interpersonal violence: identification of associated features in a clinical sample

Violence is a burdensome problem in daily psychiatric practice, even though the diagnosisof a mental disorder is not sufficient to determine a violent behavior; therefore, other factors are involved. We predicted that the participants could be distributed in two groups (e.g. high versus low violence-maltreatment groups) because this grouping would better describe specific patterns of associations in a clinical sample. We aimed to investigate the relation between interpersonal violence and maltreating experiences in childhood. Affective states and personal functioning were also explored as meaningful outcomes. Consecutive patients (N = 101) admitted to a psychiatric unit were evaluated with the Risky Families Questionnaire, the Psychological Maltreatment Review, the Karolinska Interpersonal Violence Scale (KIVS), the Positive and Negative Affect Schedule and the Personal and Social Performance Scale. Single, with average education and unemployed individuals showed significantly higher KIVS scores. High levels of interpersonal violence (IV) in childhood correlated with a harsh family climate in early life. Moreover, IV correlated with perceived parental maltreatment and did not with parental support. The cluster analysis identified two clusters of patients. The first (n = 41) showed negative dysfunctional experiences; the second (n = 60) showed a more positive perception of parental support.The impairment of social functioning and emotions regulation are both involved in this complex relation. The study supports the hypothesis of a clustering of patients that needs tailored management of violence causes and consequences.

Associations between personality disorders and cannabis use and cannabis use disorder: a population-based twin study

BACKGROUND AND AIMS

Individual differences in DSM-IV personality disorders (PDs) are associated with increased prevalence of substance use disorders. Our aims were to determine which combination of PDs trait scores best predict cannabis use (CU) and cannabis use disorder (CUD), and to estimate the size and significance of genetic and environmental risks in PD traits shared with CU and CUD.

DESIGN

Linear mixed-effects models were used to identify PD traits for inclusion in twin analyses to explore the genetic and environmental associations between the traits and cannabis use.

SETTING

Cross-sectional data were obtained from Norwegian adult twins in a face-to-face interview in 1999-2004 as part of a population-based study of mental health.

PARTICIPANTS

Subjects were 1419 twins (μage  = 28.2 years, range = 19-36) from the Norwegian Institute of Public Health Twin Panel with complete PD and cannabis data.

MEASUREMENTS

PD traits were assessed using DSM-IV criteria. Life-time CU and CUD were based on DSM-IV abuse and dependence criteria, including withdrawal and craving.

FINDINGS

After adjusting for age and sex, antisocial [β = 0.23, 95% confidence interval (CI) = 0.19-0.28] and borderline PDs (β = 0.20, 95% CI = 0.14-0.26) were associated strongly with CU. Antisocial (β = 0.26, 95% CI = 0.21-0.31) and borderline PDs (β = 0.12, 95% CI = 0.06-0.18) were also linked strongly to CUD. Genetic risks in antisocial and borderline PD traits explained 32-60% of the total variance in CU and CUD. Dependent and avoidant PDs explained 11 and 16% of the total variance in CU and CUD, respectively.

CONCLUSIONS

Individual differences in the liability to cannabis use and cannabis use disorder appear to be linked to genetic risks correlated with antisocial and borderline personality disorder traits.