The relationship between aggressive attributional style and violence by psychiatric patients.

The authors propose a new theoretical construct for understanding the risk of violent behavior by psychiatric patients: the aggressive attributional style. They propose that a cognitive style characterized by external hostile attributions increases the risk of violence by mentally ill persons. To evaluate this hypothesis, they administered several self-report measures relevant to the aggressive cognitive style, as well as measures of violent behavior in the community, to 110 psychiatric inpatients. Higher scores on several indicators of the aggressive attributional style were associated with violence. Multivariate logistic regression analyses showed that the relationship between attributional style and violence held up when demographic and diagnostic characteristics and impulsiveness were controlled. The authors discuss implications for development of cognitive interventions to reduce violence risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Violence and aggression in psychiatric units

OBJECTIVE: To help predict aggressive and violent behaviors, the frequency and types of these behaviors in acute psychiatric inpatient settings were examined, and potential interactions between staffing and patient mix and rates of the behaviors were explored. METHODS: Data on violent incidents were gathered prospectively in three adult acute psychiatric units in a general hospital and two units in a primary psychiatric hospital in Sydney, Australia. Staff recorded violent and aggressive incidents, which were ranked on an 8-level scale. They also completed weekly reports of staffing levels and patient mix. Poisson regression analysis was used to calculate relative rates, 95 percent confidence intervals, and p values. RESULTS: A total of 1,289 violent incidents were recorded over a seven-month period. Based on the scale, 58 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more nonnursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. In total these factors accounted for 62 percent of the variance in violence. CONCLUSIONS: Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be underreported, and the seriousness of an incident does not guarantee it will be reported.     

The treatment of mentally disordered offenders.

However narrowly defined, mentally disordered offenders (MDOs) are heterogeneous in demographics, diagnoses, offense characteristics, risk, and clinical needs. Treatment planning for MDOs should begin with an assessment of risk of future violent behavior in the community and risk of violence toward self or others inside an institution. Purposes of treatment among MDOs include treatments both to reduce risk of future violence and to alleviate the mental disorder. Relevant outcome measures include criminal and violent behavior, psychiatric symptomatology, admission to correctional or psychiatric facility, and quality of life. Clinical problems include aggression and problems of institutional management, criminal propensity, life skills deficits, substance abuse, active psychotic symptoms, social withdrawal, and depression. Because evidence relating them to risk of future violence is highest for the first 4 problems, it is argued that inpatient treatments should especially target them. Whenever risk levels and legal circumstances permit, community treatment is to be preferred. Sex offenders are discussed as a group for whom specialized services are indicated.… (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Comparing indicators of sexual sadism as predictors of recidivism among adult male sexual offenders.

Objective: In this longitudinal study, the predictive validity of a psychiatric diagnosis of sexual sadism was compared with three behavioral indicators of sadism: index sexual offense violence, sexual intrusiveness, and phallometrically assessed sexual arousal to depictions of sexual or nonsexual violence. Method: Five hundred and eighty six adult male sexual offenders were assessed between 1982 and 1992, and these offenders were followed for up to 20-years postrelease via official criminal records. Assessment information included the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis, offense characteristics, phallometric assessment results, and an actuarial risk measure (the Sex Offender Risk Appraisal Guide). Results: Predictive validity was demonstrated in univariate analyses for the behavioral indicators of sexual sadism (area under the curve [AUCs] from .58 to .62) but not psychiatric diagnosis (AUC = .54). Cox regression analyses revealed that phallometrically assessed sexual arousal to violence was still significantly associated with violent (including sexual) recidivism after actuarially estimated risk to reoffend was controlled. A psychiatric diagnosis of sexual sadism, in contrast, was unrelated to recidivism. Conclusions: The results support the use of more behaviorally operationalized indicators of sexual sadism, especially phallometric assessment of sexual arousal, and suggest the DSM criteria for sexual sadism require further work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Temporal architecture of violent incidents.

Five hundred five reports of violent incidents in British pubs and bars were studied by using logical pathway modeling to provide information on the processes underlying work-related violence. Logical pathway modeling is innovative in examining and mapping sequences in real incidents at a population level. The data reveal the most common pathway to be misbehavior by customers, intervention by staff (before any physically violent act), physical attack on staff, and injury to staff. The data also highlight the likelihood of further action after assailants have exited and identify stages in incidents at which most staff and customer injuries and damage to property occur. Results assist in the design of strategies to reduce the risk from future violence, particularly by training staff to recognize and to handle potentially violent situations and to maintain vigilance and security following problem incidents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Occupational allergic disease in cereal workers by stored grain pests

This review paper explored the concepts of risk assessment and management in relation to 'serious' violence by individuals with mental disorder. The paper highlighted the political context in which concern over serious violence by those with mental disorder is increasing. Government guidance on risk assessment was considered and identified as having an actuarial bias. Correlational studies, which provide actuarial indicators of risk, were explored and a picture was developed that demonstrated the difficulty of determining risk of violence to others simply on the basis of psychiatric symptomatology. The literature led to a conclusion that risk assessment for violence is an inexact science, and that actuarial indicators need to be supported by structured thorough clinical investigation. Legal concerns around the assessment and management of risk were also explored. The Health and Safety Executive model for risk management was explored in relation to the findings of the risk-assessment literature and the recommendations of reports into serious violent incidents. The model was shown to have potential utility in providing a legally sound framework for the assessment and management of risk of violence in mental disorder.     

Cholesterol and violence: is there a connection?

PURPOSE: To determine whether the seeming relation between low or lowered cholesterol levels and violence is consistent with causality according to Hill's criteria and whether construct validity is supported by convergence of findings across different types of studies. DATA SOURCES: Search of the MEDLINE database for English-language articles published between 1965 and 1995 was supplemented by searches of the PsycINFO and Current Contents databases and bibliographies of relevant articles. STUDY SELECTION: Peer-reviewed observational and experimental articles and meta-analyses that presented original research; related cholesterol levels to behaviorally defined violence; and, if experimental, had single-factor (lipid-only) intervention. DATA EXTRACTION: Studies were grouped according to type. Data on the relation of violence to cholesterol levels from each study were recorded. DATA SYNTHESIS: Observational studies (including cohort, case-control, and cross-sectional studies) consistently showed increased violent death and violent behaviors in persons with low cholesterol levels. Some meta-analyses of randomized trials found excess violent deaths in men without heart disease who were randomly assigned to receive cholesterol-lowering therapy. Experimental studies showed increased violent behaviors in monkeys assigned to low-cholesterol diets. Human and animal research indicates that low or lowered cholesterol levels may reduce central serotonin activity, which in turn is causally linked to violent behaviors. Many trials support a significant relation between low or lowered cholesterol levels and violence (P < 0.001). CONCLUSIONS: A significant association between low or lowered cholesterol levels and violence is found across many types of studies. Data on this association conform to Hill's criteria for a causal association. Concerns about increased risk for violent outcomes should figure in risk-benefit analyses for cholesterol screening and treatment.     

Psychopathic traits in a large community sample: Links to violence, alcohol use, and intelligence.

Numerous studies conducted with offender or forensic psychiatric samples have revealed that individuals with psychopathic traits are at risk for violence and other externalizing psychopathology. These traits appear to be continuously distributed in these samples, leading investigators to speculate on the presence of such traits in the general population. Nonetheless, few studies of psychopathy have been conducted with large random samples of individuals from the community. The community sample from the MacArthur Violence Risk Assessment Study provides an opportunity to examine the prevalence and structural nature of psychopathic traits, as well as their association with external correlates in an urban community. The community data (N = 514) represent a stratified random sample of persons between the ages of 18 and 40 who were assessed on the Psychopathy Checklist: Screening Version (PCL: SV) and also for violent behavior, alcohol use, and intellectual functioning. Structural equation model analyses revealed that a 4-factor model found in offender and forensic psychiatric samples fit the community data well and was invariant across sex and ethnicity. Also, a superordinate factor comprehensively accounted for the 4 psychopathy first-order factors and significantly predicted the external correlates. The findings offer insight into the dimensional nature of the psychopathy construct. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The validity and reliability of the Violence Risk Scale: A treatment-friendly violence risk assessment tool.

The development of risk assessment tools that use dynamic variables to predict recidivism and to inform and facilitate violence reduction interventions is the next major challenge in the field of risk assessment and management. This study is the first in a 2-step process to validate the Violence Risk Scale (VRS), a risk assessment tool that integrates violence assessment, prediction, and treatment. Ratings of the 6 static and 20 dynamic VRS variables assess the client's level of risk. Ratings of the dynamic variables identify treatment targets linked to violence, and ratings of the stages of change of the treatment targets assess the client's treatment readiness and change. The VRS scores of 918 male offenders showed good interrater reliability and internal consistency and could predict violent and nonviolent recidivism over both short- and longer term (4.4-year) follow-up. The probability of violent and nonviolent recidivism varied linearly with VRS scores. Dynamic and static variables performed equally well. The results support the contention that the VRS can be used to assess violent risk and to guide violence reduction treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental illness and violence: an epidemiological appraisal of the evidence

OBJECTIVE: To conduct a critical review of the literature on the matter of mental illness and violence, to examine whether there is enough evidence to establish a causal link, and to provide epidemiological background to measure the risk to the population. METHOD: Based on a computerized search of the literature on mental illness and violence previously conducted for Health Canada, studies in the area were critically reviewed and divided into 3 main categories: 1) studies of criminal and violent behaviour among psychiatric patients, 2) studies of psychiatric illness among offenders (prevalence studies in institutions, analytical studies, and community follow-up of offenders), and 3) epidemiological community-based studies on the issue of mental illness and violence (police-citizen encounters, representative samples, and other epidemiological studies). Causality rules and measures of risk were then applied to the evidence elicited. RESULTS: The review of the literature suggests that only a small minority of hospitalized patients, typically those suffering from acute psychotic symptoms, are involved in violent incidents. Formerly hospitalized patients are at a higher risk of committing violence if they are not properly treated and are experiencing threat/control-override psychotic symptoms. Substance abuse disorders significantly raise the risk for violence. Family members are the most at risk of being victimized. CONCLUSION: An association exists between mental illness and violence, but the many covariations that naturally affect the equation between them introduce uncertainties in establishing causality.     

Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the Psychopathy Checklist: Screening Version.

This study examined the predictive validity of the HCR–20 (Historical, Clinical, and Risk Management) violence risk assessment scheme and the Psychopathy Checklist: Screening Version (PCL:SV). Files of 193 civilly committed patients were coded. Patients were followed up in the community for an average of 626 days. Receiver operating characteristic analyses with the HCR–20 yielded strong associations with violence (areas under curve [AUCs?=?.76–.80). Persons scoring above the HCR–20 median were 6 to 13 times more likely to be violent than those scoring below the median. PCL:SV AUCs were more variable (.68–.79). Regression analyses revealed that the HCR–20 added incremental validity to the PCL:SV and that only HCR–20 subscales predicted violence. Implications for risk assessment research, and the clinical assessment and management of violence, are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The prevalence of allergic rhinitis and nasal symptoms in Nottingham

An overview of the most important older and newer results regarding the relationship between violent and criminal behavior on the one hand and schizophrenic illness on the other hand is presented. Four different methods are available to study this relationship: (i) study of the prevalence of mental illness in criminal/violent populations; (ii) study of criminality/violence rate in samples of psychiatric patients; (iii) study of criminality/violence in community samples comparing mental patients with non-patient community residents; and (iv) study of criminality/violence in birth cohorts prospectively. All these methods have been used; but samples composed of schizophrenic patients exclusively were only exceptionally studied. The results indicate that there is a modest but significant relationship between schizophrenia and violence and crime which persists even after controlling for demographic and socio-economic variables. The probability of schizophrenic patients to be criminal or violent depends on the acuity of their illness and is increased by their use of psychoactive substances. Generally, however, violent and criminal acts directly attributable to mental illness account only for a very small proportion of such acts in the society.     

Interaction between birth complications and early maternal rejection in predisposing individuals to adult violence: specificity to serious, early-onset violence

OBJECTIVE: The authors previously reported that birth complications interact with early maternal rejection in predisposing individuals to violence at age 18 years. This study extended the follow-up period for violent offending from 18 years to 34 years, thus increasing the sample of violent offenders threefold and allowing more detailed analyses on onset and type of violence, the form of maternal rejection, and the effect of maternal mental illness. METHOD: Complications in the births of 4,269 males in Denmark, maternal rejection of these individuals before the age of 1 year, and their histories of criminal offenses at age 34 years were assessed. RESULTS: The biosocial interaction previously observed held for violent but not nonviolent crime, was specific to more serious forms of violence and not threats of violence, held for early-onset but not late-onset violence, and was not accounted for by psychiatric illness in the mothers. Being reared in a public care institution in the first year of life and the mother's attempt to abort the fetus were the key aspects of maternal rejection that interacted with birth complications in predisposing a subject to violence. CONCLUSIONS: These findings 1) indicate that the mechanisms underlying early-onset, serious violence differ from those for less serious, late-onset violence, 2) implicate very early factors in the development of violence, 3) highlight the potential importance of integrating psychosocial with biological factors in understanding and preventing violence, and 4) suggest that interventions to reduce birth complications and maternal rejection may help reduce violence.     

Subtypes of partner violence perpetrators among male and female psychiatric patients.

The goal of this naturalistic study was to examine heterogeneity among female and male civil psychiatric patients with a history of intimate partner violence (IPV) perpetration. Participants were 567 patients drawn from the MacArthur Violence Risk Assessment Study (J. Monahan et al., 2001). The authors examined subtype composition among 138 women and 93 men with positive histories of IPV and compared these groups with 111 women and 225 men with no histories of IPV. Findings for men and women were consistent with reports from studies of male perpetrators in forensic and community settings in that generally violent/antisocial, borderline/dysphoric, and family only/low-psychopathology subtypes of perpetrators were identified in both men and women. This study provides preliminary evidence for the generalizability of typologies derived from nonpsychiatric partner violence perpetrators to psychiatric populations and suggests that typologies derived from studies of male IPV perpetrators may provide useful guidance for the investigation of female IPV perpetration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between confidence and accuracy in clinical assessment of psychiatric patients' potential for violence

The authors studied the relationship between confidence and accuracy in clinical assessments of psychiatric patients' short-term risk of violence. At the time of entry to the hospital, physicians (N = 78) estimated the probability that each of 317 patients would physically attack other people during the first week of psychiatric hospitalization. The clinicians also indicated the degree of confidence they had in their estimates of violence potential. Nurses rated the occurrence of inpatient physical assaults with the Overt Aggression Scale. The results showed that when clinicians had a high degree of confidence, their evaluations of risk of violence were strongly associated with whether or not patients became violent. At moderate levels of confidence, clinicians' risk estimates had a lower, but still substantial relationship with the later occurrence of violence. However, when clinicians had low confidence, their assessments of potential for violence had little relationship to whether or not the patients became violent. The findings suggest that the level of confidence that clinicians have in their evaluations is an important moderator of the predictive validity of their assessments of patients' potential for violence.     

Outbreak of adenovirus 35 pneumonia among adult residents and staff of a chronic care psychiatric facility

Outbreaks of acute respiratory disease caused by adenovirus are rarely documented in civilian populations, and adenovirus 35 is an uncommon serotype best recognized as a cause of serious disease in immunocompromised patients. An outbreak of adenovirus 35 pneumonia among residents and staff of a chronic care psychiatric facility was investigated. Fourteen (26%) of 53 residents and 4 (2%) of approximately 200 staff had radiographically confirmed pneumonia. Thirteen (93%) of 14 residents with pneumonia were hospitalized, 5 (36%) required mechanical ventilation, and 1 (7%) died. One staff member was hospitalized. Adenovirus infection was diagnosed in 17 (94%) persons with pneumonia by culture or serology and was confirmed as adenovirus 35 infection in 8 persons. Residents with pneumonia had resided at the facility longer than other residents. Chronic illness was not a risk factor for severe disease. Crowding and poor hygienic behaviors probably facilitated transmission among residents.     

Initial assessment and intervention strategies to reduce workplace violence

Homicide is now the cause of 12 percent of deaths in the workplace, and workplace violence by disgruntled employees or former employees continues to increase. The family physician may be the first or only professional to examine such persons before an act of violence occurs. The assessment of a potentially violent employee includes evaluating for threats, a history of violence, paramilitary interests, access to weapons, paranoia, substance abuse and a sense of having no future or no alternative to violence. A shame-rage cycle that may include a sense of evernarrowing options often precedes the violent act and may reveal warning signs that represent potential opportunities for intervention before the act is committed. Initial interventions include ensuring the immediate safety of potential victims, initiating measures to reduce acute shame and rage in the person at risk and facilitating an effective referral. Preventive strategies at the organizational level include preemployment screening, explicit nonharassment policies, employee counseling, physical security measures and the establishment of an organizational clearinghouse for reporting and assessing threatening behaviors.     

Combat experience and youth: Influences on reported violence against women.

A study of 101 VA psychiatric and chemically dependent inpatients (mean age 44.8 yrs) was conducted to investigate the hypothesis that combat veterans (n?=?54) would report a higher frequency of physical violence against female partners than noncombat veterans (n?=?47). Veterans were interviewed by staff psychologists seeking information about the frequency and severity of violence toward their female partners and about whether or not they had been in combat. Results show no significant differences in reported violence toward female partners between the combat and noncombat veterans even when age was controlled. Younger men were, however, more violent toward women than older men. Data cast doubt on the view that combat experience leads to violence within marital relationships. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Life cycle of Ixodes minor (Acari: Ixodidae) in the laboratory

OBJECTIVE: It is commonly believed that the full moon exerts an influence on violence and aggression in psychiatric settings. The literature to date is contentious. This study used a robust methodology to examine the hypothesis that there was an increased frequency of violent and aggressive behaviour among hospitalised psychiatric clients at the time of the full moon. METHOD: Prospective data were collected in five inpatient psychiatric settings across the Northern Sydney Area Health Service. Morrison's hierarchy of violence and aggression was used to rate behaviour. Lunar phases were clearly defined and Poisson regression used to examine relationships between lunar phase and violence. Extraneous temporal variation was considered. RESULTS: No significant relationship was found between total violence and aggression or level of violence and aggression and any phase of the moon. CONCLUSION: Future research could profitably examine the implications of a belief in the lunar effect among health workers in the face of evidence that no relationship exists between violence, aggression and the lunar cycle.     

The 4-3 MMPI profile type: A failure to replicate.

Using a sample of male prison inmates as Ss, the incidence of violent crimes for 65 persons with the 4-3 MMPI profile type and 64 with other 2-point code types was compared. Results fail to replicate the findings of some earlier investigators, who reported that violent behaviors are more common for persons with the 4-3 profile type. The failure to identify a significant relationship between the 4-3 profile type and violent behavior suggests that caution should be exercised in generalizing to populations that differ from those in which the relationship between violence and the 4-3 profile type is established. (PsycINFO Database Record (c) 2010 APA, all rights reserved)