Aggression In Psychiatric Inpatients Research Articles

Effectiveness of an Aggression Management Training Program in Japan: A Quasi-Experimental Study

This study evaluated the effects of the Comprehensive Violence Prevention and Protection Program (CVPPP) training for managing patient aggression in 95 participants who attended the FY 2019 program using a single-group pretest–posttest design. The comparison of findings before and 1 month after the training showed a significant improvement in staff anger (p < 0.01) and their negative (p < 0.01) and positive attitudes (p < 0.01) toward psychiatric inpatient aggression and confidence (p < 0.01). Staff with controlling and self-affirming traits provided more effective care and demonstrated a positive attitude toward inpatient aggression (p < 0.05). Supplemental data for this article is available online at https://doi.org/10.1080/01612840.2021.1999542 .

At Risk of What? Understanding Forensic Psychiatric Inpatient Aggression through a Violence Risk Scenario Planning Lens

Violence risk assessment is an essential component of forensic mental health services designed to help mitigate and manage the re-occurrence of violence. Although there is large body of evidence supporting structured risk assessments, there is no empirical evidence regarding scenario planning—a specific component of the structured professional judgment approach to violence risk assessment. The purpose of this study was to investigate the base rates and concurrent validity of inpatient aggression scenarios to provide information about risk scenarios. Among a large representative sample of forensic psychiatric patients (N = 1240), the prevalence of risk scenarios (Repeat, Escalation, Twist, and Improvement scenarios) was investigated by retrospectively coding changes in inpatient aggression. The results suggested that Improvement scenarios, including a continued desistance of aggression, were common. Aggression scenarios shared significant pattern of associations with the Historical-Clinical-Risk Management-20 and the Psychopathy Checklist—Revised. Overall, this study presents initial empirical evidence related to violence risk scenario planning. Implications from these findings include how scenario planning may intersect with evaluator bias in forensic mental health assessments.

Criminal Thinking as a Risk Factor for Psychiatric Inpatient Aggression

Thinking styles that predispose offenders to antisocial behavior have been shown to predict violence and aggression among inmates. This study explored this relationship among civil psychiatric inpatients. Medical records of N = 74 discharged patients were reviewed for inpatient incidents using the Overt Aggression Scale (OAS), occurring subsequent to the administration of several measures including the Psychological Inventory of Criminal Thinking Styles (PICTS), and Brief Psychiatric Rating Scale (BPRS). Univariate negative binomial regression models demonstrated that a higher rate of aggressive incidents was predicted by higher PICTS Denial of Harm, higher BPRS Hostile Suspiciousness scores, and lower educational attainment. Violence (i.e., physical aggression towards others) was predicted by higher BPRS Hostile Suspiciousness, lower education, and younger age in univariate analyses. In multivariate negative binomial regression models using the above independent predictors, higher BPRS-Hostile Suspiciousness scores and lower educational attainment significantly predicted both outcomes. This study’s results reinforce the importance of symptom-driven hostility to predicting inpatient aggression and violence, while highlighting the relatively minor role of specific criminal thinking styles in aggressive behavior among institutionalized psychiatric patients.

Key components and strategies utilized by nurses for de-escalation of aggression in psychiatric in-patients: a systematic review protocol

This systematic review aims to identify the effective de-escalation strategies that nurses utilize to prevent aggressive behaviors.Specifically, this review has the following objectives.

Conflict and containment events in inpatient psychiatric units

To describe the types and frequency of conflict behaviours exhibited by patients during the first 2 weeks of admission to acute psychiatric units, the methods staff use to manage them and bring to the surface underlying common patterns. Many studies have investigated the prevalence and impact of psychiatric inpatient aggression. Much of the research to date has studied conflict and containment behaviours separately; however, some studies have reported relationships between certain behaviours suggesting that there are complex causal links between conflict and containment behaviours. A cross-sectional survey of conflict and containment events. Nursing notes were accessed for 522 patients during the first 2 weeks of admission, in 84 wards in 31 hospitals in the South East of England. Conflict and containment events occurring during this period were recorded retrospectively. Factor analysis revealed six patterns of conflict behaviour, which were related to containment methods and patient demographic factors. These factors confirm some previously reported patterns of conflict. This study brings to light underlying common patterns of disruptive behaviour by psychiatric inpatients. The reasons for these remain obscure, but may relate to (1) national variations in policy and practice shaping static structural differences of interest between patients and staff and (2) normal developmental age and gender-specific behaviours. Conflict behaviour patterns may be differently motivated and therefore require different management strategies by staff. There is a need for awareness by clinical staff to the fact that different types of conflict behaviours may be co-occurring or indicative of each other. Clinical staff should consider that implementation of and changes to hospital policies have the potential to change the nature and frequencies of certain conflict behaviours by patients.

A prospective examination of the stability of hostile-dominance and its relationship to paranoia over a one-year follow-up

A hostile-dominant interpersonal style and paranoia increase the risk of aggression in psychiatric in-patients. Paranoia is also associated with hostile-dominance; however, the nature of this relationship is unclear. This study evaluated the relationship between hostile-dominance and paranoia over a one-year period. One hundred and twenty-two patients admitted to hospital for psychiatric treatment were recruited, 43 were available for follow-up. Forty-two participants provided usable data, including 20 men and 22 women, with an age range of 18–63 (M=41.02years, SD=13.00years). At recruitment and follow-up, the psychiatric symptomatology and interpersonal style of each patient was assessed using the Brief Psychiatric Rating Scale-18 and the Impact Message Inventory-Circumplex. Results showed that hostile-dominance was relatively stable over time even though symptoms of paranoia subsided. Higher levels of hostile-dominance were associated with higher levels of paranoia at both recruitment and follow-up. The implications of this research for understanding the relationship between interpersonal style, paranoia and aggression during psychiatric hospitalisation are discussed.

The Prediction of Imminent Aggression in Patients with Mental Illness and/or Intellectual Disability Using the Dynamic Appraisal of Situational Aggression Instrument

Objective: The aim of this paper was to determine whether imminent aggression in psychiatric inpatients can be accurately predicted using a structured risk assessment instrument, the Dynamic Appraisal of Situational Aggression (DASA). Methods: This prospective validation study involved 10 013 DASA risk assessments of patients residing in a psychiatric hospital. Twenty-four hours after the risk assessment, psychiatric nurses documented whether patients had behaved aggressively towards others or whether they had deliberately damaged property. They also noted the target of aggression, whether towards staff, patients or property. Results: The predictive validity of the DASA varied according to the type and target of aggression. The prediction of any aggressive behaviour, irrespective of type of aggression or target, was significantly greater than chance (AUC = 0.69). The strongest predictive accuracy (AUC = 0.80) was for physical aggression towards staff. Conclusions: These results suggest that imminent aggression in psychiatric hospitals may be able to be accurately predicted by psychiatric nurses using a structured risk assessment instrument.

Assessing the functions of aggression in psychiatric inpatients.

Conflict is inevitable in psychiatric wards where patients are admitted and treated involuntarily. Moreover, in these wards aggression is common and most probably also inevitable. How staff understand the determinants of a patient's aggression impacts on their willingness to help the patient. Causal attributions also influence the nature of prevention, management and treatment strategies that are activated. Traditionally, the most common way of describing and classifying aggression has been according to the anger-mediated/ instrumental dichotomy. This is however, a flawed dichotomy that may limit options for prevention, management and treatment. This paper describes a behaviorally oriented classification and recording system that may be used to structure assessments of aggression in psychiatric wards. It also describes an aggressive behavior recording form that can be used by nursing staff to monitor and record the functions of aggression. The advantage of these two instruments is that they emphasize the adaptive value of aggression for the patient and encourage the identification of function, from which effective treatments may be derived. An indirect benefit associated with the focus on function is that the number of incidents classified as motiveless (having no obvious function) may be reduced. For ward staff, this may lessen fear and increase confidence in their management of aggressive patients. Future research needs and opportunities for clinical application are described. Keywords: Aggressive behavior, behavioural classification system, function of aggressive behavior, motivation ********** The aggressive behavior of psychiatric patients admitted for hospital treatment has a profound impact on patients, staff, and ward functioning. Research relating to aggression in psychiatric hospitals has primarily adopted a structural assessment framework. The focus of this work has been to describe the frequency and type of aggressive behavior in different settings. The delineation of individual patient characteristics, specifically the psychopathological features of aggressive patients, has also been a focus of attention (for review see Daffern & Howells, 2002). Recently, the interactional nature of aggression (Whittington & Richter, 2005) and situational variables influencing aggression (Gadon, Johnstone & Cooke, 2006), including the physical structure of the ward, the remit and regime of the ward, and the behavior of staff and other patients, has been the focus of empirical and scholarly inquiry. Published studies of inpatient aggression have rarely adopted the function analytic approach despite a long tradition of behavioral principles being used to understand, treat and manage aggression and other disruptive behavior within psychiatric hospitals (see for example Paul & Lentz, 1987). Consequently, few methods are available to support practitioners examine the determinants and functions of inpatient aggression. In the absence of systematic and structured methods for organising information and formulating hypotheses about the determinants and functions of aggression, the selection of management strategies commonly used to contain aggressive patients (e.g., seclusion, one to one supervision, and provision of prn medication) may be inconsistent, and biased by characteristics of the patient that are unrelated to those factors that activated or maintain the aggressive behavior. For example, numerous patient characteristics, including diagnosis (Ionno, 1983), age (Tardiff, 1983), ethnicity and victim status (Gudjonsson, Rabe Hesketh & Szmukler, 2004) have been shown to bias the type of management strategy selected. Furthermore, it is often argued that these interventions are aversive, that their use should reduce the incidence of aggression and contribute to more adaptive behavior (Goren, Singh & Best, 1993). There is however little evidence to support this proposition and some evidence that coercive staff behaviors may paradoxically maintain and exacerbate undesirable behavior in hospitalized patients (Garrison et al. …

The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients

Considerable research has attempted to delineate the demographic and clinical characteristics of high-risk psychiatric patients and identify salient modifiable aspects of aggression prone environments. Recently, there has also been increased interest in the development and testing of structured schemes for the assessment of risk for aggression within inpatient psychiatric settings. Although some of these methods show acceptable predictive validity, their ability to inform day-to-day treatment and management decisions is limited. The current research was designed to identify existing and novel risk factors that would assist staff to identify and manage the risk for aggression in psychiatric inpatient populations. Results showed that assessments supported by structured risk measures were more accurate than unaided clinical judgements based only on nurses' clinical experience and knowledge of the patient alone. Seven test items emerged that were maximally effective at identifying acute psychiatric patients at risk for engaging in inpatient violence within 24 hours; these items have been combined in the development of the Dynamic Appraisal of Situational Aggression. Empirical analyses and clinical experience support the efficacy of the instrument in assisting clinical staff in the identification and management of inpatient aggression.

What's the point? Towards a methodology for assessing the function of psychiatric inpatient aggression

There are few examples in the literature of the application of functional analysis to psychiatric inpatient aggression. Structural assessment approaches have dominated. This paper introduces a system for classifying the functions of aggression in psychiatric inpatients that was applied to 502 aggressive behaviours exhibited by patients in a secure forensic psychiatric hospital. At least one function was identified for the majority of aggressive incidents; the most common functions pertaining to patients’ responses to the restrictions and demands of the inpatient setting, to express anger or to punish others perceived as provocative, and to maintain status. There was little evidence suggesting that aggression was used to obtain tangible rewards, to reduce social isolation, or to simply observe the suffering of others. Differences in the function of aggressive behaviour were found across victim types. Results of this study have implications for the prediction and prevention of inpatient aggression and for the treatment of aggressive inpatients.

Video Recording in the Assessment of Violent Incidents in Psychiatric Hospitals

Research into causes and management of aggressive behavior in mental illness has been hampered by difficulties related to the accurate detection, description, and classification of aggression. Much aggressive behavior, particularly verbal aggression, is unreported or reported inaccurately. We describe the use of video surveillance to study aggression in psychiatric inpatients. The videos supplement or correct eyewitness accounts, accurately identifying aggressors and victims, as well as specific aggressive behaviors. Video has provided a tool for studying behavioral precursors and environmental catalysts of assaults. These observations have contributed to our efforts to create a typology of aggression based on underlying causes. Furthermore, video has played a direct role in clinical care, documenting or revealing medication side effects, as well as feigned or self-induced injuries. The ethical and responsible use of video surveillance of psychiatric inpatients has the potential to enhance our understanding and treatment of aggression.

Hostility during admission interview as a short-term predictor of aggression in acute psychiatric male inpatients.

A critical step for improving the prediction of on-ward violence is the identification of variables that are not only consistently associated with an increased risk of aggression but also easily evaluated during the admission interview. The goal of this prospective study was to assess the predictive utility of hostility during admission interview. The sample consisted of 80 newly admitted male patients with heterogeneous DSM-IV psychiatric diagnoses recruited from the psychiatric ward of an urban public hospital. Psychiatric symptoms at admission were assessed with the Brief Psychiatric Rating Scale (BPRS). Aggressive behavior during the first week of hospitalization was measured with the Modified Overt Aggression Scale. Data were collected between January and June 1998. In a multiple regression model, BPRS items hostility and tension-excitement emerged as significant predictors of verbal aggression, whereas thinking disturbance (high) and suspiciousness-uncooperativeness (low) emerged as significant predictors of aggression against objects. In contrast, when aggression was treated as a binary dependent variable in a logistic model, hostility during the admission interview had no utility in predicting on-ward aggressive behavior. This study confirms the importance of distinguishing between different types of aggression to improve the accuracy of predictions of violence. The findings suggest that the question whether hostility is a useful short-term predictor of aggression in psychiatric inpatients cannot be answered conclusively. The predictive utility of hostility was relatively high for predicting verbal aggression but was negligible for predicting other types of aggressive behavior.

Psychiatric inpatient aggression: A review of structural and functional assessment approaches

Despite the high rate of aggression on psychiatric wards, uncertainty exists about the nature of the relationship between mental illness, unpatient treatment and aggression. As a consequence, the frequently employed strategies used to manage aggressive inpatients, such as seclusion, isolation, sedation, and restraint, are implemented inconsistently and possibly selected on the basis of characteristics unrelated to the cause of aggression. Further, the implementation of these management strategies may precipitate aggression, model aggressive ways of interacting with others, or reinforce aggression. Aggression may, therefore, be maintained rather than eliminated through normal ward practices. The purpose of the present paper is to review the literature on psychiatric inpatient aggression. Assessment approaches in this area may be categorized as structural (which emphasise form) or functional (which emphasise purpose). Most research in this field has utilized a structural approach. While these studies have identified a number of demographic, clinical, and situational characteristics of high-risk individuals and environments, which assist resource allocation and actuarial assessments of risk, they fail to clarify the purpose of aggression or assist the development of psychological interventions aimed at reducing aggression. This review concludes that a functional analysis of inpatient aggression may guide the selection of management strategies used to contain aggressive incidents and ensure such strategies are consistent with the psychological interventions developed to reduce the likelihood of future aggression. The implications of this conclusion for future research are discussed.