Emergency psychiatric assessment of violence

OBJECTIVE: The purpose of the study was to 1) ascertain whether there are clinical and demographic characteristics that distinguish dangerous from nondangerous patients evaluated in a psychiatric emergency service and 2) identify variables that distinguish dangerous patients who are hospitalized form those who are not. METHOD: The authors conducted a case comparison study of 99 psychiatric emergency patients whom staff identified as dangerous to others, that is, violent or potentially violent. Clinical staff were interviewed and records reviewed. These data were contrasted with record review data for 95 nondangerous patients. RESULTS: Log linear analysis showed that 1) variables relating to violence in community samples--age, sex, and past history of violence--related minimally or not at all to violence in this sample and 2) disposition to hospital versus community was associated with psychotic mental status and restraint in the psychiatric emergency service. Patients requiring restraint were more likely to have recently committed assault or battery and to have been brought in by the police. CONCLUSIONS: Enduring personal characteristics of patients relate neither to psychiatric emergency service assessments of current dangerousness nor to the decision to hospitalize. These determinations appear to be related to assessments of current patient state and immediate past behavior.     

Clinical prediction of violence as a conditional judgment

Previous research on the prediction of violence in mentally ill individuals has focused primarily on determinations about the appropriateness of institutional confinement. The assessment and management of violent, mentally ill individuals in the community, however, requires clinicians to take a more detailed look at the factors that might precipitate or inhibit violence in the community. This paper examines a model of conditional prediction, in which clinicians provide assessments of the factors that they expect to be associated with violence in particular patients. These types of predictions were elicited from clinicians for a sample of 712 patients seen in an urban psychiatric emergency room. These patients were then followed in the community for 6 months, using both interviews and official records. Results showed that clinicians were generally accurate about the seriousness and location of the violence, but overestimated the role of medication compliance and drug use in the violent incidents.     

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.     

A psychopathological study of aggression in schizophrenic patients]

For some schizophrenic patients violent behavior occurs during acute phases of their illness. Some of these patients who exhibit violent behavior recover quickly from this phase. Further, there is a marked improvement in the quality life during remission. In this study the psychopathological features of aggression in 24 schizophrenic patients were considered. All of these patients were involuntary emergency admissions due to an uncontrollable violent episode. The interaction between aggression and delusion was categorized as follows: convergent type, aggression due to delusion; reactive type, aggression instigated by hallucination or delusional perception; and divergent type, random outbursts of violence and aggression. The intensity of catatonic features and fixed targets of violence distinguishes convergent type violent schizophrenic patients from reactive and divergent type patients. Convergent aggressive behavior can be more easily treated then the other two types and should have significant bearing over the course of treatment.     

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.     

The current state of psychiatry in the treatment of violent patients.

During the past 2 decades psychiatry has made great progress in describing patterns of violence by psychiatric patients and developing standards for the evaluation and treatment of these patients. Studies have found that roughly 10% of patients were violent toward other persons just prior to psychiatric hospitalization. Young male patients and patients in certain diagnostic groups had higher rates of violence. This report describes the proper evaluation of violent patients and proposes a model for the short-term potential of violent behavior. Psychiatry has developed guidelines for the acute treatment of violent patients using verbal intervention, physical restraint, and emergency medication. Long-term treatment relies on medication for the underlying disorder. Beyond their traditional indications, carbamazepine, propranolol hydrochloride, and lithium carbonate may be effective in diminishing violence. Some violent patients respond to long-term psychotherapy.     

Can prediction of violence among psychiatric inpatients be improved?

In an effort to improve the prediction of violence among psychiatric inpatients, the authors retrospectively studied 25 patients who were violent and 34 who were not violent after admission to a psychiatric emergency ward in Norway. The only demographic variable that discriminated between the two groups was violence in the family of origin; the violent group had experienced significantly more. The best single predictor of violence was a history of previous violence by the patient, which correctly classified 80 percent of the patients. The combined information about patients' level of aggression rated at referral and level of anxiety rated at admission correctly classified 78 percent. In a subgrouping of violent patients who inflicted injuries and did not inflict injuries, a higher percentage of the injury-inflicting patients were found to have a diagnosis of schizophrenia. These patients also had a higher level of aggression at referral.     

Predictive validity of judgments of dangerousness in emergency civil commitment

The authors investigated the predictive validity of judgments of dangerousness made in the context of emergency civil commitment. The medical charts of 101 consecutive patients involuntarily admitted to a university-based acute inpatient unit were reviewed for evidence of violence within the first 72 hours of hospitalization. More than two-thirds of the patients committed as a danger to others engaged in some type of violence, compared with fewer than one-third of other involuntary patients. The findings suggest that the emergency commitment situation permits judgments of dangerousness with a relatively high degree of short-term predictive validity.     

Characteristics of Violent Versus Nonviolent Patients with Schizophrenia

Recent research has demonstrated an associative link between some forms of mental illness and violence. While much of this violence is committed by persons with schizophrenia, the characteristics of violent versus nonviolent schizophrenic patients has received limited attention. Two studies with small sample sizes compared these groups on psychological dimensions in acute care settings, but there appears to be no study of continuing care inpatients. This study compared a statewide sample of violent and nonviolent inpatients with schizophrenia on several domains of social interpersonal behavior. In a between-group analysis, violent patients showed evidence of serious dysfunction in community self-care and community adjustment, whereas the nonviolent were more impaired in the areas of depression, restlessness, and internal confusion. A within-group analysis of patients with interpersonal violence and those with noninterpersonal violence yielded similar findings of serious community dysfunction versus internal confusion. The implications are discussed.     

Violence in inpatients with schizophrenia: a prospective study.

Accurate evaluations of the dangers posed by psychiatric inpatients are necessary, although a number of studies have questioned the accuracy of violence prediction. In this prospective study, we evaluated several variables in the prediction of violence in 63 inpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Nurses rated violent incidents with the Overt Aggression Scale. During hospitalization, sociodemographic variables, clinical history, neurological soft signs, community alcohol or drug abuse, and electroencephalographic abnormalities did not differ between violent and nonviolent groups. Violent patients had significantly more positive symptoms as measured by the Positive and Negative Syndrome Scale (PANSS), higher scores on the PANSS general psychopathology scale, and less insight in the different constructs assessed. A logistic regression was performed to discriminate between violent and nonviolent patients. Three variables entered the model: insight into symptoms, PANSS general psychopathology score, and violence in the previous week. The actuarial model correctly classified 84.13 percent of the sample; this result is significantly better than chance for the base rate of violence in this study. At hospital admission, clinical rather than sociodemographic variables were more predictive of violence. This finding has practical importance because clinical symptoms are amenable to therapeutic approaches. This study is the first to demonstrate that insight into psychotic symptoms is a predictor of violence in inpatients with schizophrenia.     

Clinical decision-making about inpatient violence risk at admission to a public-sector acute psychiatric hospital

This is an examination of the extent to which patients who are violent in the hospital can be distinguished from nonviolent patients, based on information that is readily available at the time of admission to a state acute psychiatric hospital. The charts of 235 inpatients were examined retrospectively, by selecting 103 patients who had engaged in inpatient violence and comparing them with 132 randomly selected patients who had not during the same period. Data were gathered from initial psychiatric assessment and admissions face sheets in patients' charts, reflecting information available to a mental health professional within the first 24 hours of a patient's admission. Multivariate analysis showed that violent and nonviolent patients were distinguished by diagnosis, age, gender, estimated intelligence, psychiatric history, employment history, living situation, and agitated behavior. These factors led to an 80 percent correct classification of violent patients and thus may assist clinicians to structure decision-making about the risk of inpatient violence.     

Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness

This study examines potential improvement in treatment adherence during a study of involuntary outpatient commitment among individuals with severe mental illnesses. Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment after hospital discharge. A nonrandomized group with a recent history of serious violence was also studied under outpatient commitment. Randomized control and outpatient commitment groups did not differ significantly in group comparisons of treatment adherence. However, analyses of all subjects, including nonrandomized violent subjects, showed that those who underwent sustained periods of outpatient commitment (6 months or more) were significantly more likely to remain adherent with medication and other treatment, compared with those who underwent only brief outpatient commitment or none. Administration of depot antipsychotics also significantly improved treatment adherence independently of the effect of sustained outpatient commitment. Sustained periods of outpatient commitment may significantly improve adherence with community-based mental health treatment for persons with severe mental illness and thus may help improve other clinical outcomes affected by adherence.     

A randomized controlled trial of outpatient commitment in North Carolina

OBJECTIVE: A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses. METHODS: A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records. RESULTS: In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders. CONCLUSIONS: Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes.     

Criminal and violent behavior in schizophrenic patients: An overview

Abstract  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.     

Violent behaviour by general psychiatric patients in Sweden - validation of Classification of Violence Risk (COVR) software

The objectives of the study are to report the 20-week base rate of violent behaviour in the community among a general psychiatric patient population from Stockholm and to establish the validity of a violence risk assessment software program, Classification of Violence Risk (COVR), in a European setting. Three hundred and thirty one patients at two psychiatric hospitals in Stockholm were interviewed upon discharge. Telephone interviews with the patients and collaterals were conducted 10 and 20 weeks later. The violent behaviour was also measured through a national criminal register. The allocation of patients into different risk groups according to COVR software was compared with the occurrence of actual acts of violence during the follow-up. The base rate of violent behaviour was 5.7% and a ROC-analysis showed that the AUC for COVR was 0.77. Since there were few patients in the high risk groups, the 95% confidence interval for the proportion of violent patients was wide. The base rate of violent behaviour is relatively low in Sweden and prediction is therefore difficult. The predictive validity of COVR software is comparable to other risk assessment tools.     

Aggressive and violent behavior in a population of psychiatric inpatients

The aim of this observational study was to assess the rates of aggressive and violent behavior in patients admitted to an Italian emergency psychiatric unit and to explore possible risk factors for patient violence. In a population of 313 consecutive patients, we considered aggressive or violent behavior, rated according to a hierarchy from no aggressive behavior to serious physical violence. The results confirm that young age, psychotic symptoms, excitement, akathisia, and diagnosis of personality disorder are risk factors for violent behavior. The unique and major finding of the study is the low prevalence of aggressive and violent acts in this sample of patients, possibly related to their cultural background and to the system of psychiatric care. These data provide supportive evidence for the importance of sociocultural factors in the behavior of psychiatric patients and suggest the need to explore new strategies of prevention and treatment of patient aggression and violence. A non-restraint policy could be a critical factor in reducing violence among psychiatric inpatients.     

Violent and destructive behavior among the severely mentally Ill in rural areas: Evidence from Arkansas' community mental health system

A comparison of rates of violence among admissions to the Arkansas State Hospital system between urban and rural areas tested the hypothesis that thresholds for admission to the hospital were greater in rural than in urban areas. Data on violent and destructive behavior were recorded from the medical records of 609 patients. Logistic regression was used to model the presence or absence of vilent behavior in urban and rural admissions controlling for selected demographic and clinical characteristics. Results indicated that rural patients showed incrreased likelihood of violent and destructive behavior prior to admission supporting the hypothesis that barriers to mental health services in rural areas may be creating differential thresholds of service access and utilization. The increased rate of violence was particularly evident in those using substances prior to admission in rural areas suggesting that community management of the violent, substance abusing patient may be particularly difficult for rural areas.This research was supported by the NIMH Center for Rural Mental Health Services Research NIMH P50-MH48197 and the VA Health Services Research and Development Field Program HFP 48-019. The author was an Assistant Professor at the University of Arkansas for Medical Sciences when this research was conducted.     

Managing the aggressive and violent patient in the psychiatric emergency

Throughout history most societies have assumed a link between mental disorders and violence. Although the majority of users of mental health services are not violent, it is clear that a small yet significant minority are violent in inpatient settings and in the community. The assessment of a violent patient may be very difficult due to the lack of a full medical and psychiatric history and the non-cooperativeness of the patient. Thus a full assessment is important for the early decisions that the clinician has to take in a very quick and effective way. The primary task and the short term outcome in a behavioral emergency is to act as soon as possible to stop the violence from escalating and to find the quickest way to keep the patient's agitation and violence under control with the maximum of safety for everybody and using the less severe effective intervention. The pharmacological treatment of acute, persisting and repetitive aggression is a serious problem for other patients and staff members. Currently, there is no medication approved by the Food and Drug Administration (FDA) for the treatment of aggression. Based on rather limited evidence, a wide variety of medications for the pharmacological treatment of acute aggression has been recommended: typical and atypical antipsychotics and benzodiazepines.