Professional Documents
Culture Documents
Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s
Review article
a r t i c l e
i n f o
Article history:
Received 2 September 2009
Received in revised form 4 December 2010
Accepted 8 December 2010
Keywords:
Violence
In-patients
Risk factors
Epidemiology
a b s t r a c t
Although fairly frequent in psychiatric in-patient, episodes of aggression/violence are mainly limited to verbal
aggression, but the level of general health is signicantly lower in nurses who report frequent exposure to
violent incidents, and there is disagreement between patients and staff concerning predictors of these
episodes. We searched the Pubmed, Embase and PsychInfo databases for English, Italian, French or German
language papers published between 1 January 1990 and 31 March 2010 using the key words aggress*
(aggression or aggressive) violen* (violence or violent) and in-patient or psychiatric wards, and the
inclusion criterion of an adult population (excluding all studies of selected samples such as a specic
psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders
and mental retardation). The variables that were most frequently associated with aggression or violence in
the 66 identied studies of unselected psychiatric populations were the existence of previous episodes, the
presence of impulsiveness/hostility, a longer period of hospitalisation, non-voluntary admission, and
aggressor and victim of the same gender; weaker evidence indicated alcohol/drug misuse, a diagnosis of
psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute
psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff
(a good working climate) seems to be more useful in preventing aggression than some of the other strategies
used in psychiatric wards, such as the presence of male nurses.
2010 Elsevier Ireland Ltd. All rights reserved.
Contents
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.
Correlations between psychiatric disorders and aggressiveness . . . . . . .
2.
Rationale and aims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
Methods of the review . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Epidemiology of episodes of aggressiveness in psychiatric wards . . . . . .
4.2.
Demographic and clinical variables associated with aggression in psychiatric
5.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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10
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11
11
11
11
16
18
18
18
1. Introduction
1.1. Correlations between psychiatric disorders and aggressiveness
Corresponding author. Psychosocial Centre, Via Beatrice d'Este 28, 20017 Rho
Milan, Italy. Tel.: +39 02994303920; fax: +39 0293182492.
E-mail address: mbeghi@aogarbagnate.lombardia.it (M. Beghi).
0165-1781/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2010.12.024
11
12
Table 1
Aggressiveness in unselected psychiatric patient samples: associated variables.
Author
Study design
No. of patients
Study Variables
Results
Prospective cohort
(3-month follow-up)
2017
Prospective cohort
(1-month follow-up)
303
Prospective cohort
Retrospective cohort
32 potentially assaultive
at admission vs. 32
non-potentially assaultive
1269
Prospective cohort
(mean follow-up: 16 days)
328
Multicentre
retrospective cohort
Prospective cohort
(10-year follow-up)
Casecontrol
Casecontrol
Gender
Prospective cohort
(8 months follow-up)
Retrospective cohort
(mean follow-up: 2.5 years)
Cross-sectional
238 patients
Prospective cohort
(6-month follow-up)
Prospective cohort
(12- month follow-up)
Prospective cohort
(mean follow-up: 35 days)
72 pts.
3877 pts.
111 pts.
Prospective cohort
(7-month follow-up)
287 pts.
Casecontrol
Prospective cohort
(27-month follow-up)
Prospective cohort
(1 year follow-up)
Table 1 (continued)
Author
Study design
No. of patients
Study Variables
Results
Prospective cohort
(6-month follow-up)
Prospective cohort
(1 year follow-up)
Prospective cohort
(12-week follow-up)
Prospective cohort
(1-month follow-up)
Prospective cohort
(2-month follow-up)
Prospective cohort
(9 months follow-up)
Staff gender
232 pts.
MV: no correlation
UV: no correlation
78 pts.
535 pts.
Prospective cohort
(15 years' of recruitment)
Casecontrol
2103 pts.
51 Asians, 46 Europeans,
38 Hawaiians pts.
Prospective cohort
(3-month follow-up)
Prospective cohort
(2-week follow-up
44 pts.
Prospective cohort
(3 years follow-up)
Prospective cohort
(5-year follow-up)
650 incidents
Casecontrol
Prospective cohort
(3 months follow-up)
317 pts.
Retrospective cohort
(7 year follow-up)
111 injuries
Prospective cohort
(3-year follow-up)
307 pts.
Casecontrol
Prospective cohort
(15-year follow-up)
280 pts.
76 pts.
1534 pts.
UV: afternoon
UV: correlation with impulsiveness; inverse
correlation with depression
UV: correlation with same gender of aggressor and
victim (males vs. males, females vs. females)
UV: correlation with younger age for Europeans and
Hawaiians, impulsiveness for Asians, relational instability
for Hawaiians
UV: correlation with dementia
MV: narcissism, psychosis, fewer depressive symptoms,
and signicantly fewer years of formal education
UV: student nurses more assaulted
UV: correlation with schizophrenia, history of
violence, previous admission
Retrospective cohort
(6 months follow-up)
Prospective cohort
(3-year follow-up)
13
14
Table 1 (continued)
Study design
No. of patients
Study Variables
Results
Prospective cohort
(1-year follow-up)
2210 pts.
360 pts.
Prospective cohort
(6 months follow-up)
Prospective cohort
Casecontrol
76 aggressive vs.
314 non-aggressive pts.
Casecontrol
Casecontrol
Casecontrol
Not specied
48 violent the previous 24 h vs.
93 non-violent pts.
50 pts. from forensic hospital and
29 from general psychiatric hospital
853 pts.
Prospective cohort
(5 year follow-up)
Prospective cohort
(3-year follow-up)
119 pts.
Prospective cohort
(6-month follow-up)
Casecontrol
103 pts.
Prospective cohort
(12-month follow-up)
268 pts.
Casecontrol
Prospective cohort
(10.5 month follow-up)
Prospective cohort
(3-year follow-up)
Prospective cohort
(7-month follow-up)
527 pts.
352 pts.
Prospective cohort
Prospective cohort
(828 days' follow-up)
212 pts.
No mental retardation,
age 1855
154 pts.
855 pts.
105 pts.
UV: no correlation
UV: aggression correlated to overcrowding
UV: correlation with schizophrenia, same gender of aggressor
and victim (male vs. male, female vs. female)
UV: correlation with increasing number of staff members,
non-voluntary admission, use of restraint
Author
Table 1 (continued)
Author
Study design
No. of patients
Study Variables
Results
Retrospective cohort
(7.5-year follow-up)
Retrospective cohort
(1-year follow-up)
806 pts.
Race
UV: no correlation
Casecontrol
313 pts.
Retrospective cohort
(6-year follow-up)
2395 pts.
Prospective
388 aggressiveepisodes in
5251 admissions
Prospective cohort
(2 years follow-up)
1655 pts.
Prospective cohort
(15-month follow-up)
Prospective cohort
170 pts.
Prospective cohort
(2 years' recruitment)
118 pts.
Retrospective cohort
Casecontrol
73 restraint events
49 violent vs.
474 non-violent pts.
Casecontrol
Casecontrol
Prospective cohort
(1-year follow-up)
Casecontrol
533 pts.
47 aggressive vs.
288 non-aggressive pts.
397 pts.
Prospective cohort
85 pts.
48 staff members
15
16
Table 2
Summary of investigated variables.
Factor
Multivariate analysis
(no. of studies)
Univariate analysis
(no. of studies)
Age
Gender
Race/nationality
marital status
Occupation
Housing status
Education
Social class
Psychiatric disorder
Disease severity
Familial history of psych. disorders
Alcohol/drug misuse
Depression
Bipolar disorder
Any mood disorder
Schizophrenia
Schizoaffective disorder
Other psychosis
Any psychosis
Organic psychosis
Adjustment disorder
Personality disorder
Anxiety disorder
Cognitive disorder
Non-psychiatric disorder
Age at onset
Length of hospitalisation
Type of admission
Total number of admissions
Length of illness
History of violence
Hostility/impulsiveness
Narcissism
Suicidal risk
Sexual/physical abuse
Staff experience
Staff gender
Number of staff
Use of coercive measures
Therapeutic alliance
Criminal record
Patient attitude towards admission
Period of the day
Size of wards (crowding)
Executive functioning
CPK level
Response to treatment
6
6
4
5
2
3
3
1
1
5
3
3
2
6
1
2
2
2
2
2
2
1
1
2
4
2
1
4
1
1
1
1
1
1
1
1
1 young
1 male
1 single
1 unemployed
2 poor
1 secondary, 1 low
3
1 inverse
1 long
2 non-voluntary
1
1
1
1 high
1
1 inverse
1 negative
11 young, 2 old
5 male, 3 females
1 strangers, 1 maori, 1 minority
1 single
1 unemployed
5
4 inverse
3
1
10, 2 reverse
2
1
4
1 inverse
6
34
36
12
7
5
4
6
1
3
1
1
19
17
16
5
22
7
2
7
2
16
3
9
8
2
11
6
9
1
6
6
5
3
5
5
1
1
2
3
4
1
1
1
Early
7 long
4 non-voluntary
4
1 long
6
4
2, 1 reverse
1
3 poor
1 female, 4 same gender
1
1 inverse
1 evening, 2 afternoon
2
1
1 high
1 poor
17
Table 3
Aggressiveness in in-patients with psychosis: associated variables.
Author
Design
No. of patients
Prospective cohort
(about 1-month
follow-up)
Prospective cohort
(6 months follow-up)
Studied variables
Prospective cohort
(8-week follow-up)
Casecontrol
Results
Correlation with clinical variables (age at
onset, number of admissions, history of
suicide attempts)
Prospective cohort
Prospective cohort
(6-month follow-up)
Prospective cohort
(6-week follow-up)
Brief-term
prospective cohort
Casecontrol
Prospective cohort
(5-day follow-up)
Retrospective cohort
99 psychotic pts.
Retrospective cohort
(4 years' enrolment)
Casecontrol
Prospective cohort
(2 years' enrolment)
18
5. Discussion
Despite the abundance of published reports, the papers are often
difcult to compare because of differences in study samples, aims and
methodologies.
As far as aggressiveness is concerned, the published data agree on
some risk factors. A previous episode of aggression and a longer length
of stay in an in-patient clinic are the most consistent predictors: the
rst suggests that keeping careful records increases awareness of risk
and improves risk assessments which may then in turn prevent
further violence; in the case of the second, it needs to be understood
whether the episode of aggression is a consequence of the admission
or vice versa. In addition, length of stay is aspecic as it could reect
the severity of the clinical picture or simply mean that the patient has
had more time to show aggression. In terms of gender, there is not a
large difference but aggression seems to be directed towards others of
the same sex.
According to Duxbury and Whittington (2005), patients and
nurses disagree about the reason for aggressive/violent behaviour.
They investigated the causes of violence using the Management of
Aggression and Violence Attitude Scale, and found that patients saw
environmental conditions and poor communication as signicant
precursors, whereas nurses considered the patients' mental illnesses
to be the main reason, although they also recognised the negative
impact of an in-patient environment. It was clear that both sets of
respondents were dissatised with the restrictive and underresourced provisions that lead to interpersonal tensions, which
suggests that harmony among staff may be more useful in preventing
aggression than some of the other strategies used in psychiatric wards
such as the presence of male nurses. In psychotic patients, positive
psychotic symptoms (especially delusions and threatening hallucinations) can directly inuence an aggressive behaviour. Although they
are not very frequent, they deserve attention because of the potential
for successful pharmacologic treatment (Nolan et al., 2003).
A recent review by Hamrin et al. (2009) has shown that violence
arises from the complex interactions of the patients, staff and culture
of a specic unit. In-patient psychiatric staff can decrease the potential
for violence by using therapeutic relationship strategies such as
practising good communication, advocating for clients, being available, having strong clinical assessment skills, providing patient
education, and collaborating with patients in treatment planning.
Melle et al. (1996) found that increased individualised support from
staff leads patients with schizophrenia to perceive a low level of
aggression, and a structured assessments of the short-term risk of
violence in acute psychiatric wards by Aberhalden et al. (2008) and
Bowers et al. (2006) found that nurses' training reduces severe events
of patient aggression (adjusted risk reductions of respectively 41% and
53%). By contrast, Sjstrm et al. (2001) found no statistically
signicant reduction in the number of aggressive patients or in the
number of staff members on sick leave after a training course but they
found a reduction on the perceived aggressive incidents.
Cultural improvements include providing meaningful patient
activities and appropriate levels of stimulation, as has also been
conrmed by Cowin et al. (2003). Bowers et al. (2002) found that is
possible to distinguish two independently varying emphases of ward
security policies: the rst aims at preventing harm to patients by
means of door security, the banning of items, and restrictions on inpatients; the second aims at reducing risks to staff by using patient
searches, security guards and sophisticated alarm systems. There is
some preliminary evidence that these security policies are differentially associated with levels of absconding and violent incidents, and
so further research to guide practice is urgently required.
These data were conrmed by a comparative survey of German,
British and Swiss psychiatric wards carried out by Lepping et al.
(2009). This found that British ward managers were the most satised
with risk management and the current practices used to deal with
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