Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys

Data from the Epidemiologic Catchment Area survey were used to examine the relationship between violence and psychiatric disorders among adults living in the community. Psychiatric assessment of survey respondents was based on the Diagnostic Interview Schedule, which also provided self-report information about violent behavior. Those who reported violent behavior within the preceding year tended to be young, male, and of low socioeconomic status, and more than half met DSM-III criteria for one or more psychiatric disorders. Subjects with alcohol or drug use disorders were more than twice as likely as those with schizophrenia to report violent behavior. In a multivariate model of the predictors of violence, a significant interaction effect was found between major mental illness and substance abuse. The risk of violent behavior increased with the number of psychiatric diagnoses for which respondents met DSM-III criteria.     

Violence and Psychiatric Disorders: Results from an Epidemiological Study of Young Adults in Israel

This paper investigates the association between various psychiatric disorders and violent behavior using data from a community-based epidemiological study of young adults in Israel (N = 2678). Self-reports of recent fighting and weapon use were elevated among respondents diagnosed with psychotic or bipolar disorders but not among those diagnosed with non-psychotic depression, generalized anxiety disorder or phobias compared to respondents without these disorders. Violence was measured using the Psychiatric Epidemiology Research Interview; psychiatric disorders were diagnosed using a modified version of the Schedule for Affective Disorders and Schizophrenia. The analyses controlled for lifetime substance abuse, antisocial personality disorder and demographic characteristics, thereby extending support for a causal connection between some types of psychiatric disorders and violence. The association between disorder and violence was stronger among respondents with less education, indicating the potentially important role of social and cultural contexts in moderating the association between mental illness and violence.     

Predicting violence using structured professional judgment in patients with different mental and behavioral disorders

We examined whether a leading instrument for the prediction of future violence in those with a mental disorder. The Historical, Clinical, Risk Management-20 (HCR-20) was equally effective across a wide range of mental health diagnoses. Records at the time of discharge from secure psychiatric services were used to score the HCR-20 risk assessment scheme. Patients were stratified according to whether they had received a particular mental health diagnosis. Reconvictions within 2 years of discharge were obtained from official sources and classified as to whether the offence was violent or not. Those with a diagnosis of either personality disorder or substance abuse were most likely to be reconvicted, whilst those with either a diagnosis of schizophrenia or mental retardation were the least likely. The HCR-20 was a statistically significant predictor of future violence in all groups; however, it returned only weak effects for the personality disordered group, but strong effects for those in the schizophrenia or mental retardation group. The HCR-20 risk assessment scheme is effective across a wide range of diagnoses. Nevertheless, the prediction of future events appears more difficult in those disorders characterized by impulsive behaviors and further research efforts are needed to understand how such prediction can be improved.     

Family violence and psychiatric disorder

The relationship between family violence and psychiatric disorders was examined using standardized diagnostic interviews of 1200 randomly selected residents of a large Canadian city. The results showed that higher than expected proportions of those exhibiting violent behavior had a psychiatric diagnosis and the rate of violent behaviors in those with diagnoses (54.4%) significantly (p less than .0001) exceeds the rate in the remainder of the sample (15.5%). Particularly high rates of violence are found in those where alcoholism is combined with antisocial personality disorder and/or recurrent depression (80-93%). Also at high risk for violence are those who have made suicide attempts (over 50%) and those who have been arrested for non-traffic offences (two-thirds). These data suggest that psychiatric disorders have a strong relationship to violent behavior, and are not in agreement with the predominantly sociological explanations of family violence.     

The psychiatric epidemiology of violent behaviour

This paper reviews the current state of the debate on the relationship between mental disorder and violent behaviour. Starting from the discussion of methodological approaches to assessing a possible association, the most important studies carried out on the issue in recent years are discussed. Their results concur in supporting the assumption that there is a moderate but reliable association between mental disorder and violence. However, this does not imply that people with mental illness are generally more likely to commit violent acts than members of the general population. An elevated risk of violent behaviour is only evident for specific psychiatric diagnoses and symptom constellations. For schizophrenia and other psychotic disorders, a significant increase in the likelihood to commit violent acts is reported. Substance use disorders and antisocial personality disorder, however, represent a markedly higher risk for violent behaviour. The article further discusses possible determinants of violent behaviour such as psychotic symptoms and comorbidity with substance abuse and considers who is at particular risk of becoming a target of violent acts.     

Premorbid risk factors for violence in adult mental illness

The role of premorbid factors in the violence associated with adult mental illness has received little attention. We previously found that the premorbid onset of substance abuse in early adolescence or childhood was a more powerful predictor of violence in adult patients with chronic mental illness than comorbid substance abuse. In the present study, we retrospectively assessed patients with chronic mental illness for a history of childhood conduct disorder. Consecutive referrals to a community treatment team were evaluated with a standardized protocol that included questions about violent behavior. Patients who met DSM-IV criteria for a primary diagnosis of major axis I disorder (N = 64) were assessed for behavior prior to age 15 with a checklist for DSM-IV criteria of conduct disorder using self-report data, supplemented by collateral information from charts and relatives when possible. About half of the sample had a history of committing violent acts in the community, and 26% met criteria for childhood conduct disorder. The odds of violence in adulthood was 10-fold higher for subjects with a history of childhood conduct disorder. Not surprisingly, there was considerable overlap between conduct disorder and early-onset substance abuse. About half of the patients with a history of substance abuse prior to age 15 also had a history of conduct disorder. However, these two premorbid conditions appear to be at least partially independent in predicting adult violence in this population.     

Mental disorder, intellectual deficiency, and crime. Evidence from a birth cohort.

Studies of criminality among patients in psychiatric hospitals and of mental disorder among incarcerated offenders have suggested an association between the major mental disorders (schizophrenia and major affective disorders) and crime. However, these investigations are characterized by notable methodological weaknesses, and, consequently, this conclusion has remained tentative. Little is known about the criminality of intellectually handicapped people. The present study examined the relationship between crime and mental disorder and crime and intellectual deficiency in an unselected Swedish birth cohort followed up to age 30 years. It was found that men with major mental disorders were 2 1/2 times more likely than men with no disorder or handicap to be registered for a criminal offense and four times more likely to be registered for a violent offense. Women with major disorders were five times more likely than women with no disorder or handicap to be registered for an offense and 27 times more likely to be registered for a violent offense. These subjects committed many serious offenses throughout their lives. The criminal behavior in over half these cases appeared before the age of 18 years. Intellectually handicapped men were three times more likely to offend than men with no disorder or handicap and five times more likely to commit a violent offense. Intellectually handicapped women were almost four times more likely to offend than women with no disorder or handicap and 25 times more likely to commit a violent offense.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics

Between 1981 and 1995, approximately 5 million people from either Mexico, Cuba, Central America, or South America immigrated to the United States. Some regional studies have suggested that as Hispanic immigrants become acculturated to American society, their risk of mental illness increases sharply. This study examined the lifetime risk of psychiatric and substance use disorders among U.S. Hispanic subgroups and the specific role of nativity, parental nativity, language preferences, and other sociodemographic characteristics as risk factors for these disorders. The study used the National Comorbidity Survey (NCS), a national probability sample of 8098 U.S. adults aged 15 to 54. Selected DSM-III-R psychiatric diagnoses were collapsed into eight categories. When compared with non-Hispanic whites, Mexican-Americans were less likely to have any psychiatric disorder. After multivariate adjustment, acculturation items predicted greater risk of having any DSM-III-R disorders for Mexican-Americans and "other" Hispanics and greater risk of having a substance abuse disorder for Puerto Ricans, among other significant relationships. The results suggest that there is likely to be an increasing prevalence of psychiatric and substance use disorders among Hispanics that may be attributable to increasing levels of acculturation among the more than 5 million recent immigrants from Latin America.     

Behavioral interventions for dual-diagnosis patients.

Dual diagnosis patients come to treatment with a variety of deficits,talents, and motivations. A biopsychosocial treatment plan involves multiple interventions, including medications, medical treatment, psychotherapy, family therapy, housing, and vocational rehabilitation. Treatment must be individualized and integrated, and this requires collaboration among a variety of health caregivers. There is empirical evidence that dual-diagnosis patients can be helped to stabilize, to remain in the community,and even to enter the workforce. Behavioral interventions are key ingredients to integrated and comprehensive treatment planning. There is no single model for dual disorders that explains why substance use and psychiatric illness co-occur so frequently. Mueser et al described four theoretical models accounting for the increased rates of comorbidity between psychiatric disorders and substance use disorders. They suggested that there could be a common factor that accounts for both, primary psychiatric disorder causing secondary substance abuse, primary substance abuse causing secondary psychiatric disorder, or a bidirectional problem, where each contributes to the other. There is evidence for each, although some are more compelling than others, and none is so compelling that it stands alone. Although family studies and genetic research could explain the common factor, no common gene has appeared. Antisocial personality disorder has been associated with very high rates of substance use disorders and mental illness; however, its prevalence is too low to explain most of the co-occurring phenomena. Common neurobiology, specifically the dopamine-releasing neurons in the mesolimbic system, also may be involved in mental illness, but this is not compelling at the moment. The Self-medication model is very appealing to mental health professionals, as an explanation for the secondary substance abuse model. Mueser et al suggest that three lines of evidence would be present to support this explanation: (1) patients would report beneficial effects of substance use on their symptoms; (2) epidemiology would report that a specific substance would be used by specific psychiatric disorders, and (3) psychiatric patients with severe symptoms would be more likely to abuse substances than those with mild symptoms. Unfortunately the research data do not support these. The primary substance abuse causing secondary psychiatric disorder model could be explained by neuronal kindling from substance-induced disorders. Patients who develop the psychiatric disorder after the substance use disorder do have a course of illness similar to those with a psychiatric disorder, but without substance use disorder. The bidirectional model is consistent with the tendency of disturbed teenagers to socialize with youth using alcohol and drugs; however, this model has not been tested rigorously in research studies. With such a disparate set of models, behavior interventions are conceptualized best as a multi-component program, a treatment plan that generates a problem list and devises an intervention to respond to each member of the list. This requires a talented, multi-disciplinary team or network that can assess carefully and package the interventions creatively, and dose the treatment components empathically to fit the patient's tolerance, motivation, and abilities.     

Risk factors and correlates of violence among acutely ill adult psychiatric inpatients

OBJECTIVE: The purpose of the study was to identify risk factors and correlates of violence committed by patients in an acute adult psychiatric inpatient unit in a district general hospital of the United Kingdom's National Health Service. METHODS: Incidents of violence committed by inpatients over a one-year period in 1997-1998 were retrospectively analyzed. The clinical characteristics of 49 violent patients were compared with those of all patients admitted to the unit during the study period (N=474) and with a random sample of nonviolent patients (N=140). Logistic regression analysis was used to identify clinical variables that predicted violent behavior. RESULTS: Violence was not positively associated with schizophrenia or negatively associated with depression. Frequent medication change, high use of sedative drugs, past violent behavior, an ICD-10 diagnosis of dissocial personality disorder or emotionally unstable personality disorder (DSM-IV antisocial personality disorder or borderline personality disorder), and long hospitalization were the most powerful predictors of violence. Together these variables had a sensitivity of 76 percent, a specificity of 97 percent, and a positive predictive value of 90 percent in predicting which patients became violent. Compulsory (involuntary) admission, comorbid diagnoses, past self-harm, and nonalcohol drug abuse were also associated with violent behavior. CONCLUSIONS: Clinicians' judgment about an inpatient's potential for violence may be augmented by knowledge of the risk factors identified in this study. Medication variables could be especially useful predictors, particularly when information about other risk factors is not available. Factors other than mental illness per se may be crucial determinants of violence in acute inpatient settings.     

Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

Dispelling the stigma of schizophrenia: II. The impact of information on dangerousness.

This study addressed a relatively neglected topic in schizophrenia: identifying methods to reduce stigma directed toward individuals with this disorder. The study investigated whether presentation of information describing the association between violent behavior and schizophrenia could affect subjects' impressions of the dangerousness of both a target person with schizophrenia and individuals with mental illness in general. Subjects with and without previous contact with individuals with a mental illness were administered one of four "information sheets" with varying information about schizophrenia and its association with violent behavior. Subjects then read a brief vignette of a male or female target individual with schizophrenia. Results showed that subjects who reported previous contact with individuals with a mental illness rated the male target individual and individuals with mental illness in general as less dangerous than did subjects without previous contact. Subjects who received information summarizing the prevalence rates of violent behavior among individuals with schizophrenia and other psychiatric disorders (e.g., substance abuse) rated individuals with a mental illness as less dangerous than did subjects who did not receive this information. Implications of the findings for public education are discussed.     

Suicidal and violent behaviour in mood disorders: A major public health problem. A review for the clinician

Abstract

Suicide attempt, and particularly completed suicide are relatively rare events in the community, but they are very common among psychiatric patients. Since over 90% of suicide victims suffer from (mostly untreated) current major mental disorders (particularly from major depressive episode), psychiatric risk factors are the clinically most useful predictors, especially if psychosocial and demographic risk factors are also pesent. Violent behaviours associated with mood disorders constitute a related yet independently also important aspect of this illness, and assessment and management of violence is a key component of everyday psychiatric practice. While most people with current mental disorder are not violent, violence is more common among seriously mentally ill individuals than in healthy persons. This is particularly true for untreated schizophrenics and untreated patients with major mood disorders, first of all in the cases of comorbid substance use disorders, mainly among those with current mania or postpartum depression. Although specific clinical studies are lacking, it is very lilely that successful acute and long-tem treatment of mood disorders can reduce the risk of violent behaviour in this patient population.     

Psychotic symptoms and disorders and the risk of violent behaviour in the community

This study uses data from the Epidemiologic Catchment Area (ECA) surveys to examine the strength of the association between psychotic symptoms and violent behaviour, controlling for underlying mental disorder, substance abuse, sociodemographic characteristics and use of mental health services, in a representative sample of community residents. A replication is conducted of a study that found an increased risk of violence associated with a particular cluster of psychotic symptoms involving perceived threat and internal control-override (TCO). Respondents who reported TCO symptoms were about twice as likely to engage in assaultive behaviour as those with hallucinations or other psychotic symptoms, and about five times as likely as those with no mental disorder. The combination of substance use disorders with TCO symptoms added significantly to the risk of violent behaviour. Those with a history of using mental health services also posed a higher risk of violence, probably due to the differential selection of more severely ill and ‘dangerous’ individuals into treatment settings. Copyright © 1996 Whurr Publishers Ltd.     

The role of violence in decisions about hospitalization from the psychiatric emergency room.

OBJECTIVE: The authors evaluated the relationship between violent behavior and decision making about hospitalization from the psychiatric emergency room. METHOD: The medical charts of 321 patients evaluated in an urban psychiatric emergency room during a 4-week period were reviewed retrospectively. Violent behavior was defined as physical attacks on persons or fear-inducing behavior before or during the evaluation in the emergency room; and its value in predicting hospitalization decisions was assessed with logistic regression analyses that also included 12 demographic, clinical, and contextual variables. RESULTS: A model predicting hospitalization decisions was developed and cross-validated. Although violent patients were more likely to be hospitalized than nonviolent patients, clinical variables such as diagnosis and overall severity of psychiatric impairment were more important than violent behavior in predicting hospitalization decisions. CONCLUSIONS: Despite legal pressures to focus on overt behaviors such as violence as a basis for liability prevention and civil commitment, clinicians in this study did not allocate inpatient resources to preventively detain persons unlikely to benefit from treatment. Rather, they hospitalized the most severely disturbed patients, with diagnoses such as schizophrenic and manic disorders for which a widely accepted therapeutic armamentarium exists. The results are consistent with clinical recommendations that in the evaluation of the violent patient, attention needs to be given to the underlying disorder, since violent behavior itself can result from diverse causes only some of which require inpatient psychiatric treatment.     

精神疾病患者家庭暴力行为的预测因素分析

目的:研究精神疾病患者家庭暴力行为相关因素。方法:应用人口学资料、既往史、简明精神病评定量表(BPRS)、明尼苏达多相人格调查表(MMPI),人格诊断问卷(PDQ4 )早年不良家庭环境问卷等对38例具有家庭暴力行为和40例无家庭暴力行为的精神疾病患者进行对照研究。结果:两组以下各项差异显著:有既往攻击行为史及酒滥用史,早年不良家庭环境,精神分裂症、抑郁症病史,BPRS总分、敌对猜疑、焦虑抑郁,PDQ4 中人格障碍等因素。结论:精神病理症状、心理社会因素和病理性人格障碍与家庭暴力行为明显关联,可作为其主要预测因子。     

Mental disorders and violence in a total birth cohort: results from the Dunedin Study

BACKGROUND: We report on mental disorders and violence for a birth cohort of young adults, regardless of their contact with the health or justice systems. METHODS: We studied 961 young adults who constituted 94% of a total-city birth cohort in New Zealand, April 1, 1972, through March 31, 1973. Past-year prevalence of mental disorders was measured using standardized DSM-III-R interviews. Past-year violence was measured using self-reports of criminal offending and a search of official conviction records. We also tested whether substance use before the violent offense, adolescent excessive perceptions of threat, and a juvenile history of conduct disorder accounted for the link between mental disorders and violence. RESULTS: Individuals meeting diagnostic criteria for alcohol dependence, marijuana dependence, and schizophrenia-spectrum disorder were 1.9 (95% confidence interval [CI], 1.0-3.5), 3.8 (95% CI, 2.2-6.8), and 2.5 (95% CI, 1.1-5.7) times, respectively, more likely than control subjects to be violent. Persons with at least 1 of these 3 disorders constituted one fifth of the sample, but they accounted for half of the sample's violent crimes (10% of violence risk was uniquely attributable to schizophrenia-spectrum disorder). Among alcohol-dependent individuals, violence was best explained by substance use before the offense; among marijuana-dependent individuals, by a juvenile history of conduct disorder; and among individuals with schizophrenia-spectrum disorder, by excessive perceptions of threat and a history of conduct disorder. CONCLUSIONS: In the age group committing most violent incidents, individuals with mental disorders account for a considerable amount of violence in the community. Different mental disorders are linked to violence via different core explanations, suggesting multiple-targeted prevention strategies.     

Psychiatric impairment,social contact,and violent behavior: evidence from a study of outpatient-committed persons with severe mental disorder

The need to better understand and manage risk of violent behavior among people with severe mental illness in community care settings is increasingly being recognized, as public-sector mental health systems face mandates to provide more cost-effective services in less restrictive environments. The potential for serious violence in a small proportion of severely mentally ill (SMI) individuals has emerged as a key factor that increases cost and limits continuity and normalization of community-based services for populations with psychiatric disabilities. A major challenge to developing better strategies for risk assessment and management in community care settings involves specifying complex interactions between psychiatric impairment and the conditions of social life – including the quality and frequency of contact with others at close quarters. This is a study of the determinants of violent behavior in a sample of 331 adults with severe mental disorders in community-based treatment. An interaction between severity of functional impairment and frequency of social contact was found to be significantly associated with risk of violence. Among respondents with Global Assessment of Functioning (GAF) scores in the lowest 20%, more frequent contact with family and friends was linked to a higher probability of violent events. However, among better functioning respondents, frequent social contact was associated with lower risk of violence and greater satisfaction with relationships. These findings suggest that, where violence risk is concerned, the most salient feature of psychiatric impairment is the impairment of social relationships –the ways in which disorders of thought and mood not only distort one's subjective appraisal of experience and threat, but impair the ability to relate meaningfully to others, to resolve conflict and derive necessary support from family and friends. Thus, social contact may be a mixed blessing for SMI individuals. For some, it signals a positive quality of life, but for others – particularly those with extreme psychiatric impairment – frequent contact may add to conflict, stress, and increased potential and opportunity for physical violence. The impact of psychiatric impairment on violent behavior cannot be known in isolation, but must be considered in a social context. Effective community-based strategies to anticipate and prevent violence in the lives of persons with severe mental illness must take into account such interactions between social and clinical variables.     

Gender differences in violent behaviors: relationship to clinical symptoms and psychosocial factors

OBJECTIVE: Men are more violent than women in the general population, but this has not been found to be the case among psychiatric inpatients. The reason for this exception is poorly understood. The present study investigated gender differences in violent behaviors among patients with major psychiatric disorders. It examined various clinical symptoms and psychosocial factors to determine their differential impact on violence in men and women. METHOD: Physical assaults and verbal assaults committed by psychiatric inpatients were recorded prospectively. Patients whose violent incident occurred during their first 2 months of hospitalization were eligible for the study. Patient history of community violence was also obtained. Psychiatric symptoms and ward behaviors were assessed upon entry into the study and after 4 weeks. RESULTS: A similar percentage of women and men had an incident of physical assault in the hospital. Among the patients entered into the study, the women had a much higher level of verbal assaults throughout the evaluation period and a higher level of early physical assaults (i.e., within the first 10 days of the 4-week study period). Positive psychotic symptoms were more likely to result in assaults in women than in men. Physical assaults in the community, on the other hand, were more common in men and were associated with substance abuse, property crime, and a history of school truancy. CONCLUSIONS: There are gender differences in the patterns of violent behavior among patients with major psychiatric disorders. Furthermore, psychiatric symptoms and psychosocial risk factors have a different impact on this behavior in men and women. This has important implications for the prediction and differential treatment of violent behavior.