Staff Observation Aggression Scale Research Articles

Relationship between antipsychotic medication and aggressive events in patients with a psychotic disorder hospitalized for treatment

BackgroundDisruptive and aggressive behavior is frequent in patients with a psychotic disorder; furthermore, it is a recurrent reason for compulsory admission. Even during treatment, many patients continue to show aggressive behavior. Antipsychotic medication is posed to have anti-aggressive properties; its prescription is a common strategy for the treatment (and prevention) of violent behavior. The present study aims to investigate the relation between the antipsychotic class, according to the dopamine D2-Receptor binding affinity (i.e., “loose” – “tight binding”), and aggressive events perpetrated by hospitalized patients with a psychotic disorder.MethodsWe conducted a four-year retrospective analysis of legally liable aggressive incidents perpetrated by patients during hospitalization. We extracted patients’ basic demographic and clinical data from electronic health records. We used the Staff Observation Aggression Scale (SOAS-R) to grade the severity of an event. Differences between patients with a “loose” or “tight-binding” antipsychotic were analyzed.ResultsIn the observation period, there were 17,901 direct admissions; and 61 severe aggressive events (an incidence of 0.85 for every 1,000 admissions year). Patients with a psychotic disorder perpetrated 51 events (incidence of 2.90 for every 1,000 admission year), with an OR of 15.85 (CI: 8.04–31.25) compared to non-psychotic patients. We could identify 46 events conducted by patients with a psychotic disorder under medication. The mean SOAS-R total score was 17.02 (2.74). The majority of victims in the “loose-binding” group were staff members (73.1%, n = 19), while the majority of victims in the “tight-binding” group were fellow patients (65.0%, n = 13); (X2(3,46) = 19.687; p < 0.001). There were no demographic or clinical differences between the groups and no differences regarding dose equivalents or other prescribed medication.ConclusionsIn aggressive behaviors conducted by patients with a psychotic disorder under antipsychotic medication, the dopamine D2-Receptor affinity seems to have a high impact on the target of aggression. However, more studies are needed to investigate the anti-aggressive effects of individual antipsychotic agents.

Multivitamin, mineral, and n-3 PUFA supplementation to reduce aggression among long-stay psychiatric inpatients: a randomized clinical trial

IntroductionAggression and violent incidents are a major concern in psychiatric inpatient care. Nutritional supplementation was found to reduce aggressive incidents and rule violations in forensic populations and in children with behavioral problems.ObjectivesTo assess whether multivitamin, mineral, and n-3 PUFA supplementation would reduce the number of aggressive incidents among long-stay psychiatric inpatients.MethodsThe trial was a pragmatic, multicenter, randomized, double-blind, placebo-controlled study. Data were collected from 25 July 2016 through 29 October 2019 at 8 local sites for mental healthcare in the Netherlands and Belgium. Participants were randomized (1:1) to receive either three supplements containing multivitamins, minerals, and n-3 PUFA or placebo for 6 months. The primary outcome was the number of aggressive incidents using the Staff Observation Aggression Scale – Revised (SOAS-R). Secondary outcomes were the patients’ quality of life, affective symptoms, and adverse events.ResultsIn total, 176 participants were randomized (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (SD = 14.5), and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in those assigned to supplements (1.03 incidents per month; 95% confidence interval [CI]: 0.74-1.37) and placebo (0.90; 95% CI: 0.65-1.19), with a rate ratio of 1.08 (95% CI: 0.67-1.74; p = .75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes.ConclusionsSix months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric inpatients.DisclosureNo significant relationships.

Effects of multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation on aggression among long-stay psychiatric in-patients: randomised clinical trial

Aggression and violent incidents are a major concern in psychiatric in-patient care. Nutritional supplementation has been found to reduce aggressive incidents and rule violations in forensic populations and children with behavioural problems. To assess whether multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation would reduce the number of aggressive incidents among long-stay psychiatric in-patients. The trial was a pragmatic, multicentre, randomised, double-blind placebo-controlled study. Data were collected from 25 July 2016 to 29 October 2019, at eight local sites for mental healthcare in The Netherlands and Belgium. Participants were randomised (1:1) to receive 6-month treatment with either three supplements containing multivitamins, minerals and n-3 polyunsaturated fatty acid, or placebo. The primary outcome was the number of aggressive incidents, determined by the Staff Observation Aggression Scale - Revised (SOAS-R). Secondary outcomes were patient quality of life, affective symptoms and adverse events. In total, 176 participants were randomised (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (s.d. 14.5) and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in supplement (1.03 incidents per month, 95% CI 0.74-1.37) and placebo groups (0.90 incidents per month, 95% CI 0.65-1.19), with a rate ratio of 1.08 (95% CI 0.67-1.74, P = 0.75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes. Six months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric in-patients.

Facteurs individuels et contextuels participant à l’apparition de comportements violents en cours d’hospitalisations psychiatriques

BackgroundThe prevention of Physical Violent Behavior (VB) toward others during psychiatric hospitalization is a major concern of clinicians. These VBs can have a deleterious impact on the victims, inpatients or caregivers, as well as on the therapeutic milieu. Such violence can also have negative consequences for the assailant patients, such as repeatedly being hospitalized under restraint, stigmatization, and difficulties reintegrating into the community. ObjectivesThis study explored individual (age, gender, marital status, living status, diagnostic) and institutional (type of admission, length of stay, number of previous hospitalizations) risk factors, and how their interactions could increase the risk of VB during psychiatric hospitalizations. MethodThe study was carried out over a period of four years in the psychiatry department of the Lausanne University Hospital, on the 15 wards (219 beds) specialized in acute psychiatric care for adults. All the patients admitted to one of these wards during this period (n=4518), aged between 18 and 65 years, were included in the study. The sample was divided in two groups: non-violent patients (NVPs) and violent patients (VPs). VBs, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale – Revised (SOAS – R). Only physical assaults, associated or not with other types of violence, involving hospitalized patients were analyzed. Personal and institutional factors were extracted from the hospital database. Chi2 independence tests were used to assess differences between groups. Logistic regression models were used to identify the links between each factor and the VB. Classification and regression trees were used to study the hierarchical effect of factors, and combinations of factors, on VBs. ResultsDuring the study period, 414 VBs were reported involving 199 patients (4.40 % of all patients). VPs were significantly younger, male, more likely to be unmarried and living in sheltered housing before hospitalization. In this group, the proportion of patients with diagnoses of schizophrenia, and/or schizophrenia with comorbid substance abuse and cognitive impairment, were higher compared to NVPs. VPs were more frequently admitted involuntarily, had a longer average length of stay and a greater number of previous hospitalizations. The logistic regression model performed on individual factors have shown a significant link between age (OR=0.99; CI: 0.97–1.00; P-value=0.024), living in sheltered housing before admission (OR=2.46; CI: 1.61–3.75; P-value<0.000), schizophrenic disorders (OR=2.18; CI: 1.35–3.57; P-value=0.001), schizophrenic disorders with substance abuse comorbidity (OR=2.00; CI: 1.16–3.37; P-value=0.016), cognitive impairment (OR=3.41; CI: 1,21–8.25; P-value=0.010), and VBs. The logistic regression model on institutional factors have shown a significant link between involuntary hospitalization (OR=4.38; CI: 3.20–6.08; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00–1.01; P-value<0.000), number of previous hospitalizations (OR=1.06; CI: 1.00–1.12; P-value=0.031), and VBs. The logistic regression model on individual and institutional factors have shown a significant link between age (OR=0.99; CI: 0.97–1.00; P-value=0.008), living in sheltered housing before admission (OR=2.46: CI: 1.61–3.75; P-value=0.034), cognitive impairment (OR=3.41; CI: 1.21–8.25; P-value=0.074), involuntary hospitalization (OR=3.46; CI: 2.48–4.87; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00–1.01; P-value<0.000), and VBs. The classification and regression trees have shown that the relationship between long length of stay and repeated hospitalizations mainly potentiate the risk of violence. ConclusionThe results of this study have shown the existence of a small group of vulnerable patients who accumulate constrained hospital stays during which violence occurs. Exploring the clinical profiles and institutional pathways of patients could help to better identify these patients and promote a more appropriate mode of support, such as intensive clinical case management. This model could facilitate the development of a clinical network and the links between the structures and partners caring for a patient. This would create a continuous support, avoiding or limiting the lack of continuity of care and care disruption.

Multivitamin, mineral and n-3 pufa supplementation to reduce aggression among chronically admitted psychiatric patients: A randomized clinical trial

IntroductionAggression and violent incidents are a major concern in psychiatric inpatient care, potentially leading to physical and psychological consequences for both patients and staff. Nutritional supplementation was found to reduce aggressive incidents and rule violations in forensic populations and children with behavioural problems.ObjectivesTo assess whether multivitamin, mineral and n-3 PUFA supplementation is effective in reducing the number of aggressive incidents among psychiatric patients who are chronically admitted.MethodsIn a pragmatic, multicentre, randomized, double-blind, placebo-controlled study, psychiatric inpatients were randomized to receive either three supplements containing multivitamins, minerals, and n-3 PUFA or placebo. During the intervention period of six months, aggressive incidents were assessed using the Staff Observation Aggression Scale – Revised (SOAS-R). Secondary outcome parameters were the patients’ quality of life and affective symptoms. The trial was registered in the Clinical Trials Register (NCT02498106).ResultsA total of 176 patients were enrolled and randomly assigned to receive supplements (n=87) or placebo (n=89). They were on average 49.3 years old (SD=14.5), and 64.2% were male. Most patients had a psychotic disorder (60.8%). Supplementation versus placebo significantly increased circulating micronutrient levels. The primary outcome of SOAS-R incidents was similar in those assigned to supplements (1.03 incidents per month; 95% confidence interval [CI]: 0.74-1.37) and placebo (0.90; 95%CI: 0.65-1.19), with a rate ratio of 1.08 (95%CI: 0.67-1.74; p=0.75). Differential effects were neither found in sensitivity analyses on the SOAS-R, nor on secondary outcomes.ConclusionsSix months of nutritional supplementation did not reduce aggressive incidents among chronically admitted psychiatric inpatients.DisclosureNo significant relationships.

Incidents of aggression in German psychiatric hospitals: Is there an increase?

In a meta-analysis of international studies, 17% of admitted patients in psychiatric hospitals had exhibited violent behavior toward others. Reported data from studies in Germany were considerably lower until recent years. However, studies examining only single hospitals, as well as the quality of the data itself, have raised questions as to the validity of these findings. Indeed, a debate currently exists as to whether there has, in fact, been an increase of violent incidents in German mental institutions. In a group of 10 hospitals serving about half the population of the Federal State of Baden-Wuerttemberg with 11 million inhabitants, the Staff Observation Aggression Scale-Revised (SOAS-R) was introduced into patients' electronic charts as part of routine documentation. Data recording was strongly supported by staff councils and unions. A completed data set is now available for the year 2019. For one hospital, data are available since 2006. Due to some doubts with respect to fully covering self-directed aggression, we restricted the analysis to aggression toward others and toward objects. In 2019, 17,599 aggressive incidents were recorded in 64,367 admissions (1,660 staying forensic psychiatric inpatients included). 5,084 (7.90%) of the admitted cases showed aggressive behavior toward others. Variation between hospitals was low to modest (SD = 1.50). The mean SOAS-R score was 11.8 (SD between hospitals 1.20%). 23% of the incidents resulted in bodily harm. The percentage of patients showing violent behavior was highest among patients with organic disorders (ICD-10 F0) and lowest among patients with addictive or affective disorders (F1, F3, F4). Forensic psychiatry had the highest proportion of cases with aggressive behavior (20.54%), but the number of incidents per bed was lower than in general adult psychiatry and child and adolescent psychiatry (indicating a lower risk for staff). In the hospital with longer-term recordings available, an increase could be observed since 2010, with considerable variation between years. This is the most robust estimate of the frequency of violent incidents in German psychiatric hospitals thus far. The incidence is about half of what has been reported internationally, probably due to sample selection bias in previous studies and a relatively high number of hospital beds in Germany. Available data suggest an increase of violent incidents over the last ten years; however, it is unclear to which extent this is due to increased reporting.

Characteristics of aggressive incidents in emergency primary health care described by the Staff\xa0Observation Aggression Scale \u2013 Revised Emergency (SOAS-RE)

BackgroundWorkplace violence in emergency primary health care is prevalent, but longitudinal studies using validated assessment scales to describe the characteristics of workplace violence in these settings are lacking. The aim of the present study was to determine the characteristics of aggressive incidents in emergency primary health care clinics in Norway.MethodsIncidents of workplace violence were reported with the Staff Observation Aggression Scale – Revised Emergency (SOAS-RE). The study was conducted in ten emergency primary health care clinics over a period of one year.ResultsA total of 320 aggressive incidents were registered. The mean overall SOAS-RE score for reported aggressive incidents was 9.7 on a scale from 0 to 22, and 60% of the incidents were considered severe. Incidents of verbal aggression accounted for 31.6% of all reported incidents, threats accounted for 24.7%, and physical aggression accounted for 43.7%. Verbal aggression was most often provoked by long waiting time. Physical aggression was most often provoked when the patient had to go through an involuntary assessment of health condition. Almost one third of the aggressors were females, and nurses were the most frequent targets of all aggression types. No differences in psychological stress were found between types of aggression.ConclusionsThis study shows that workplace violence in emergency primary health care clinics is a severe problem. Patterns in provocation and consequences of aggressive incidents can be used to improve our understanding of and prevention and follow-up procedures of such incidents.

Machine Learning Approach to Inpatient Violence Risk Assessment Using Routinely Collected Clinical Notes in Electronic Health Records

Inpatient violence remains a significant problem despite existing risk assessment methods. The lack of robustness and the high degree of effort needed to use current methods might be mitigated by using routinely registered clinical notes. To develop and validate a multivariable prediction model for assessing inpatient violence risk based on machine learning techniques applied to clinical notes written in patients' electronic health records. This prognostic study used retrospective clinical notes registered in electronic health records during admission at 2 independent psychiatric health care institutions in the Netherlands. No exclusion criteria for individual patients were defined. At site 1, all adults admitted between January 2013 and August 2018 were included, and at site 2 all adults admitted to general psychiatric wards between June 2016 and August 2018 were included. Data were analyzed between September 2018 and February 2019. Predictive validity and generalizability of prognostic models measured using area under the curve (AUC). Clinical notes recorded during a total of 3189 admissions of 2209 unique individuals at site 1 (mean [SD] age, 34.0 [16.6] years; 1536 [48.2%] male) and 3253 admissions of 1919 unique individuals at site 2 (mean [SD] age, 45.9 [16.6] years; 2097 [64.5%] male) were analyzed. Violent outcome was determined using the Staff Observation Aggression Scale-Revised. Nested cross-validation was used to train and evaluate models that assess violence risk during the first 4 weeks of admission based on clinical notes available after 24 hours. The predictive validity of models was measured at site 1 (AUC = 0.797; 95% CI, 0.771-0.822) and site 2 (AUC = 0.764; 95% CI, 0.732-0.797). The validation of pretrained models in the other site resulted in AUCs of 0.722 (95% CI, 0.690-0.753) at site 1 and 0.643 (95% CI, 0.610-0.675) at site 2; the difference in AUCs between the internally trained model and the model trained on other-site data was significant at site 1 (AUC difference = 0.075; 95% CI, 0.045-0.105; P < .001) and site 2 (AUC difference = 0.121; 95% CI, 0.085-0.156; P < .001). Internally validated predictions resulted in AUC values with good predictive validity, suggesting that automatic violence risk assessment using routinely registered clinical notes is possible. The validation of trained models using data from other sites corroborates previous findings that violence risk assessment generalizes modestly to different populations.

Trois profils cliniques à risque de comportements violents dans une cohorte de patients présentant un premier épisode de psychose

ObjectiveThis study aims to determine whether it is possible to identify clinical profiles at risk of violent behaviors (VB) in the early phase of psychotic disorders, on the basis of the main dynamic psychopathological risk factors and describe characteristics of the groups with highest levels of violent behaviors. MethodA total of 265 patients, aged 18 to 35, treated at the Treatment and early Intervention in Psychosis Program (TIPP–Lausanne), a specialized early psychosis program, were included in this study. We conducted a latent-class analysis and a discriminative analysis on the basis of the main dynamic VB risk factors: substance use disorder, impulsivity, positive symptoms, insight, aggression, hostility, anger, emotional instability and adherence to treatment. These factors were evaluated by specialized scales and on the basis of the Positive and Negative Syndrome Scale (PANSS). VB were restricted to physical aggression against people, defined as “serious violence”. They were assessed on the basis of a questionnaire listing violent offenses (Swiss Criminal Code) and VB such as assault and battery, information through the forensic psychiatric services and on the basis of the Staff Observation Aggression Scale (SOAS-R scale) during inpatient treatment phase. ResultsFour heterogeneous subgroups were identified with respect to the studied clinical characteristics, including two groups with high rates of VB. The first group, comprising 46% of patients with VB, is distinguished by the prevalence of a range of dimensions related to hostility, impulsivity and emotional instability, associated with high levels of substance abuse and positive symptoms. These clinical dimensions are very significant at the statistical level, since they explain 70% of the construction of subgroups (discriminant analysis). The second group with 37% of patients with VB, is characterized by a lack of insight, lack of adherence to treatment and substance use. These two clinical profiles could increase the impairment of cognitive, functional and relational abilities and contribute to the development of VB in this early phase of psychosis. The third subgroup, with a violent behaviors rate of 28.6%, is distinguished by its high proportion of diagnoses of substance abuse (100%) and women (54%). A last subgroup of patients, the largest quantitatively, has a low proportion of VB (15%) and the lowest levels on the studied factors, suggesting that the majority of patients with this profile commit few VB. ConclusionOur results show that it is possible to identify groups at risk of violent behaviors during the early phase of psychosis on the basis of clinical characteristics that may evolve and therefore be the focus of preventive care. These results highlight the need to target substance use, impulsivity and lack of insight at follow-up in order to prevent VB.

The Staff Observation Aggression Scale \u2013 Revised (SOAS-R) \u2013 adjustment and validation for emergency primary health care

BackgroundMany emergency primary health care workers experience aggressive behaviour from patients or visitors. Simple incident-reporting procedures exist for inpatient, psychiatric care, but a similar and simple incident-report for other health care settings is lacking. The aim was to adjust a pre-existing form for reporting aggressive incidents in a psychiatric inpatient setting to the emergency primary health care settings. We also wanted to assess the validity of the severity scores in emergency primary health care.MethodsThe Staff Observation Scale - Revised (SOAS-R) was adjusted to create a pilot version of the Staff Observation Scale – Revised Emergency (SOAS-RE). A Visual Analogue Scale (VAS) was added to the form to judge the severity of the incident. Data for validation of the pilot version of SOAS-RE were collected from ten casualty clinics in Norway during 12 months. Variance analysis was used to test gender and age differences. Linear regression analysis was performed to evaluate the relative impact that each of the five SOAS-RE columns had on the VAS score. The association between SOAS-RE severity score and VAS severity score was calculated by the Pearson correlation coefficient.ResultsThe SOAS-R was adjusted to emergency primary health care, refined and called The Staff Observation Aggression Scale - Revised Emergency (SOAS-RE). A total of 350 SOAS-RE forms were collected from the casualty clinics, but due to missing data, 291 forms were included in the analysis. SOAS-RE scores ranged from 1 to 22. The mean total severity score of SOAS-RE was 10.0 (standard deviation (SD) =4.1) and the mean VAS score was 45.4 (SD = 26.7). We found a significant correlation of 0.45 between the SOAS-RE total severity scores and the VAS severity ratings. The linear regression analysis showed that individually each of the categories, which described the incident, had a low impact on the VAS score.ConclusionsThe SOAS-RE seems to be a useful instrument for research, incident-recording and management of incidents in emergency primary care. The moderate correlation between SOAS-RE severity score and the VAS severity score shows that application of both the severity ratings is valuable to follow-up of workers affected by workplace violence.

T246. DECREASING AGGRESSIVE BEHAVIOR IN PATIENTS WITH COGNITIVE IMPAIRMENTS BY TRAINING PSYCHIATRIC STAFF IN INTERACTIVE SKILLS

BackgroundPreventive measures to decrease aggressive incidents in psychiatric care range from friendly responses to advanced de-escalation techniques.But interventions have not often been systematically evaluated and often have different emphasis. There is also large variation in the outcome measurements used.A method that has been used in Sweden is an interactive training approach, which aims to establish and maintain calmness and security for patients with cognitive impairments. Experiences from Gothenburg indicate decreased levels of coercive measures after training staff and providing supervision. The in-patient-unit where such training and application has been carried out most consistently, won a national award in 2016 for having no coercive measures taken in six months, despite 90 percent of the patients receiving compulsory care.The intervention is a well defined 3-day-course, with two trainers and twelve participants. The main part of the course is devoted to the role playing of conflict situations with patients, based on the participants’ own experiences and examples. Visual analysis tools are used to make the role plays into learning situations.AimWe describe here the study protocol for a planned project that will test the Interactive Training approach in four regional hospitals. In addition, group interviews will be applied to increase understanding of staff experiences, as well as the evaluation of the implementation process.MethodsPlanned sub-studies:1. Staff’s experience of using interactive methods will be analyzed through focus-groups; four group interviews with 5 people in each group. (Assisting nurses and nurses working full-time, who have been educated in interactive conflict-handling and worked according to the method for at least one year).2. Intervention study. The staff at the psychiatric departments of four different hospitals will receive training in interactive conflict handling, and after the course, supervision. The purpose is to compare the number of aggressive events before and after the intervention.The instruments that will be used for measurement of the effect are the Staff Observation Aggression Scale - revised (primary outcome), the Social Dysfunction Aggression Scale and the Clinical Global Impression - Severity Scale.We will also document the type of care (voluntary or compulsory), the number of psychiatric hospital beds, the number of inpatient patients, the number of staff employed, if the patient was affected by alcohol or illegal drugs and several other variables. Diagnoses will be retrieved from patient records.3. Evaluation of implementation. The purpose is to analyze the implementation of the intervention at four hospitals. Group interviews will be conducted and the data will be analyzed qualitatively by using Normal Process Theory (NPT) as a framework. NPT is an action research perspective that focuses on what actors actually do and discerns between, implementation, embedding integration as different levels of change.ResultsData collection for the first sub-study will be completed in June 2018 and results from the second and third are anticipated to be available by March 2019 and December 2019, respectively.DiscussionPossible methodological problems are that data from focus-groups may not be possible to generalize. However, qualitative data may capture experiences that shed light on the psychological working-mechanisms of the intervention.The intervention study is expected to generate rich data, where essential variables are controlled for, for example organizational features, distribution of diagnoses and severity of symptoms. However, in a complex organization, it may not be possible to control for all variables that might explain variations in outcome.

The Prison Adjusted Measure of Aggression (PAMA): Psychometric characteristics of a new tool measuring change in aggressive behaviors in correctional settings

There is a need for instruments that can be used in correctional settings to measure changes in aggressive behaviors over a limited time period. This study aimed to validate an instrument (the Prison Adjusted Measure of Aggression, PAMA) that assesses specifically the past month's aggressive behaviors and is adapted for use in correctional facilities. The psychometric properties of the self-rated and interview versions of the PAMA were explored and compared to those of two well-established measures of aggression: The Staff Observation Aggression Scale (SOAS); and the self-rate Aggression Questionnaire-Revised Swedish Version (AQ-RSV). The study group comprised 93 male and 59 female inmates, who were followed for two months. During the study, the prevalence of aggressive acts was observed and reported by SOAS. On two occasions, at monthly intervals, subjects reported their own aggressive behaviors using AQ-RSV and the self-report version of the PAMA; also, a psychologist conducted interviews according to PAMA. This study's main finding was that the self-rated version of PAMA is a valid measure of different types and dimensions of aggression (physical and verbal aggression, hostility) and has acceptable psychometric properties. Therefore, PAMA could potentially be of value for use in correctional services evaluating aggression managing treatment interventions.

Characteristics of Aggressive Behavior in People With Mild to Borderline Intellectual Disability and Co-Occurring Psychopathology

ABSTRACTIntroduction: People with intellectual disabilities and co-occurring psychopathology have a relatively high likelihood to engage in aggressive behavior. Nevertheless, structured clinical assessment of aggressive behavior, including when and where it occurs, is scarce in this population. Methods: On three wards specializing in the care for people with mild to borderline intellectual disability and co-occurring psychopathology, staff members completed the Staff Observation Aggression Scale–Revised adapted for people with intellectual disabilities (SOAS-R-ID) during a nine-month period, every time they witnessed aggressive behavior. Results: Based on 236 SOAS-R-ID forms, it was found that aggressive incidents were most common on Thursdays, and on two specific moments of the day (between 9–11 a.m. and 7–9 p.m.). The aggressive behavior was often exclusively of a verbal nature and was usually targeted against staff members (77.1% of the incidents). The Interclass (Pearson) Correlation Coefficient agreement between observers on the total score of the SOAS-R-ID was 0.72. Correlation between the judgment of the severity of aggressive behavior made by the staff members and the SOAS-R-ID severity scores was moderate (r = .40), but significant. Conclusions: Because aggressive behavior appeared to result often from interactions between the client and staff member or other clients, these interactions might be an important starting point for interventions. Structured clinical assessment of aggressive behavior can help to devise and test the effects of interventions. The SOAS-R-ID seems to be a clinically useful instrument and could therefore help to reduce the frequency of these incidents in the future.

Staff members’ evaluation of inpatients’ motivation for aggression – the roles of staff restrictions and aggression severity

Improved understanding of inpatient aggression can come from systematic assessment of motivation for aggressive incidents. This study investigates staff members’ evaluation of motivation for aggressive incidents, and how such evaluations are influenced by staff restrictions and aggression severity. Staff reports of aggressive incidents in a secure psychiatric unit were collected in clinical practice over a ten-year period (2006–2015). Motivation for aggression was assessed with the Aggressive Incident Motivation Evaluation Scale, measuring irritable, instrumental, and defensive dimensions. Information about staff restrictions was collected with the Staff Observation Aggression Scale – Revised, and severity was rated with the Visual Analog Scale. Multilevel analyses of 2649 aggressive incidents, committed by 67 inpatients, revealed greater variation in aggression motivation across incidents than between individual patients. Staff restrictions preceding the aggressive incident and rating of severity were positively related to staffs’ evaluation of motivation for aggression, but their impacts differed across motivational dimensions. Staff reports of motivation provide important additional information beyond current standard report forms. Systematically evaluating motivation is essential to risk management, and may contribute to develop more fine-tuned interventions for preventing and managing aggression in inpatient settings.

Violent images, anger and physical aggression among male forensic inpatients

PurposeThe present study of forensic hospital patients examined whether their imagination of violence is related to self-reported anger, psychological distress, and to staff observations of aggressive behaviour in hospital. In view of the relevance of psychological trauma for anger and aggression, we further investigate whether the associations of imagined violence to anger and aggression are stronger when the patient has trauma-related intrusion symptoms. MethodsParticipating male forensic inpatients (N=54) were individually tested and followed-up for five months. Aggressive episodes were measured using the Staff Observation Aggression Scale–Revised. ResultsPatients who imagine violence, compared to those who do not, were higher in psychological distress (anger, symptoms of PTSD, psychosis, depression, and anxiety), and displayed more aggressive acts both retrospectively and during the follow-up period. Imagined violence and trauma-related intrusions separately contributed to anger and aggressive behaviour. ConclusionsThe study calls attention to violent images as an important variable involved in aggressive responding. The role of violent images as a mediator of the well-established association between anger and aggression, including symptom severity as a potential moderator, needs further investigation. Therapeutic strategies focusing on forensic patients' violent images may improve treatment response in the prevention of aggression.

Characteristics of aggression among psychiatric inpatients by ward type in Japan: Using the Staff Observation Aggression Scale - Revised (SOAS-R).

Aggressive behaviour by psychiatric patients is a serious issue in clinical practice, and adequate management of such behaviour is required, with careful evaluation of the factors causing the aggression. To examine the characteristics of aggressive incidents by ward type, a cross-sectional descriptive study was conducted for 6 months between April 2012 and June 2013 using the Staff Observation Aggression Scale - Revised, Japanese version (SOAS-R) in 30 wards across 20 Japanese psychiatric hospitals. Participating wards were categorized into three types based on the Japanese medical reimbursement system: emergency psychiatric, acute psychiatric, and standard wards (common in Japan, mostly treating non-acute patients). On analyzing the 443 incidents reported, results showed significant differences in SOAS-R responses by ward type. In acute and emergency psychiatric wards, staff members were the most common target of aggression. In acute psychiatric wards, staff requiring patients to take medication was the most common provocation, and verbal aggression was the most commonly used means. In emergency psychiatric wards, victims felt threatened. In contrast, in standard wards, both the target and provocation of aggression were most commonly other patients, hands were used, victims reported experiencing physical pain, and seclusion was applied to stop their behaviour. These findings suggest that ward environment was an important factor influencing aggressive behaviour. Ensuring the quality and safety of psychiatric care requires understanding the characteristics of incidents that staff are likely to encounter in each ward type, as well as implementing efforts to deal with the incidents adequately and improve the treatment environment.

Observational study of aggressive behaviour and coercion on an Indian acute ward.

We evaluated prevalence of aggressive behaviour and coercive measures on an acute Indian psychiatric ward where relatives are always present at the ward. Non-interacting, independent observers (specifically trained mental health clinicians) on an Indian acute, 20-bedded psychiatric ward gave structured reports on all violent episodes and coercive measures during a 30-day period. They used the Staff Observation Aggression Scale -Revised, Indian (SOAS-RI). The severity of the SOAS-RI reports were independently analysed by one of the authors. 229 violent incidents were recorded, involving 63% of admitted patients. 27% of all admitted patients were subjected to intravenous injections. Relatives provoked 35% of the incidents and were the target in 56% of the incidents. Patientś own relatives were involved in managing the aggression in 35% of the incidents. Relatives of other patients were involved in 14% of the incidents. The likelihood of a patient to be physically restrained and that a relative would be participating in the coercive measures was increased when medical staff was targeted. Relatives are commonly triggers and victims of aggressions on the inverstigated acute Indian psychiatric wards. Doctors and nurses are less likely to be victims but aggression towards them leads more commonly to coercive measures.

Assessment and determinants of aggression in a forensic psychiatric institution in Hong Kong, China

Institutional aggression in forensic psychiatric setting is an under-researched subject, despite the magnitude of the problem. No studies have been conducted on the assessment of risk and the examination of predictors of aggression among the Chinese forensic psychiatric population. Our study aimed to examine the determinants of aggression in the only forensic psychiatric institution in Hong Kong, and to test the psychometric properties of a risk-assessment instrument, the Dynamic Appraisal of Situational Aggression (DASA). We recruited a representative sample of 530 consecutively admitted detainees. Qualified nurses completed two risk-assessment instruments, the DASA and the Brøset Violence Checklist (BVC), once daily during the participants׳ first 14 days of admission. Aggressive incidents were recorded using the revised Staff Observation Aggression Scale (SOAS-R), and participants׳ data were collected for multivariate analyses. We showed that female gender, diagnoses of personality disorder and substance-related disorder, and admission at other correctional institutions were associated with institutional aggression. Aggression was perpetrated by 17.7% of the participants, and the DASA was demonstrated to have good psychometric properties in assessing and predicting aggressive incidents. Our findings preliminarily support the use of daily in-patient risk-assessment and affirm the role of dynamic factors in institutional aggression.

Aggression on haemodialysis units: a mixed method study.

Aggression on haemodialysis units is a growing problem internationally that has received little research attention to date. Aggressive behaviour by patients or their relatives can compromise the safety and well-being of staff and other patients sharing a haemodialysis session. The objectives of the study were twofold: First, to identify the prevalance and nature of aggression on haemodialysis units; and second, to investigate factors that contribute to aggressive behaviour on haemodialysis units. A cross-sectional, sequential mixed method research design was adopted, with two research methods utilised. Incidents of aggressive behaviour were recorded over a 12-month period, using a renal version of the Staff Observation Aggression Scale. Six months after the incident data collection had commenced, semi-structured qualitative interviews were conducted with 29 multidisciplinary members of staff. Over 12 months, 74 aggressive incidents were recorded. The majority of incidents involved verbal aggression, and the perpetrators were a minority of patients, relatives and staff. Two patients were responsible for 38% of all incidents; both patients had mental health problems. Distinct temporal patterns to the aggressive behaviour were observed according to the day of the week and time of day. This study demonstrates that aggression is a significant problem on haemodialysis units, with verbal aggression most prevalent. The temporal patterns to aggression observed are related to the uniqueness of the haemodialysis setting, with a distinctly different treatment environment compared with other healthcare settings.

Pathologische Kreatinkinasewerte (CK) und Zwangsmaßnahmen in der Akutpsychiatrie

The aim of this study was to investigate the association of compulsory measures (CM) with pathological Creatine Kinase (CK) levels in 317 patients admitted to a secure psychiatric ward. The assumptions is that CK-activity is increased prior to administration of CM because increases in CK-levels may represent aggressive behaviour as precursors of a higher chance of administrating CM. The CK-levels were assessed immediately following admission. During the course of the patients' stay the frequency of different CM was assessed by the use of the Staff Observation Aggression Scale. In a CHAID analysis pathological CK-levels were associated with subsequent administration of CM. Lifetime aggression and main diagnosis were associated with administration of CM as well. In a ROC analysis concerning pathological CK-activity the AUC for subsequent administration of CM was 70.5 % with a sensitivity of 73.5 % and a specifity of 67.5 %. Despite some methodological shortcomings the study indicates that it could be useful to measure CK-activity at the time of admission because pathological levels may indicate an increased probability of administration of CM subsequent to aggressive behaviour.