Violent Behavior In Patients Research Articles

Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence

The authors evaluated characteristics of patients whom clinicians accurately assessed as being at high or low risk for violence and patients for whom clinicians overestimated or underestimated the risk. At admission, physicians estimated the probability that each of 226 psychiatric inpatients would physically attack someone during the first week of hospitalization. Nurses rated assaultive behavior in the hospital with the Overt Aggression Scale. Acute symptoms were rated with the Brief Psychiatric Rating Scale. For the group as a whole, assessed levels of risk were substantially related to later physical aggression (sensitivity = 67%, specificity = 69%). Multinomial logit analysis showed that patients with psychotic disorders such as schizophrenia, organic psychotic conditions, and mania were more likely to be accurately assessed by clinicians as being at high risk (true positives) than to be true negatives or false positives. A recent history of violence was associated with higher estimated risk but did not distinguish true positives from false positives. An admission mental status characterized by low levels of hostility, uncooperativeness, and suspiciousness and high levels of depression, guilt, and anxiety differentiated true negative patients from others, but symptom profiles did not differ among true positives, false positives, and false negatives. Clinical judgments emphasizing gender and race/ethnicity were associated with predictive errors: nonwhite and male patients tended to be false positives. While clinicians can accurately classify the potential for violence in the majority of patients at admission, systematic errors characterize inaccurate assessments of the risk. Awareness of these patterns may help improve assessment of the risk of violence in clinical practice.

Patient overcrowding in psychiatric hospital units: Effects on seclusion and restraint

The effects of environmental crowding on the behavior of persons in institutional and noninstitutional setting have been studied extensively, but much less frequently with psychiatric patients. The relationship of violent patient behavior, as measured by incidents of seclusion and/or restraint, and population density, as measured by the average census of patients in psychiatric units, was determined in this retrospective study. The results demonstrate a significant and strong positive relationship between number of seclusion and/or restrain incidents and overcapacity.

Anger attacks in unipolar depression, Part 1: Clinical correlates and response to fluoxetine treatment

Anger attacks are sudden, intense spells of anger associated with a surge of autonomic arousal including such symptoms as tachycardia, sweating, flushing, and a feeling of being out of control. The purpose of this study was to determine whether depressed patients with and without anger attacks exhibit distinct psychological characteristics and whether these attacks respond to treatment with fluoxetine. The Anger Attacks Questionnaire, the Hamilton Rating Scale for Depression, the Symptom Questionnaire, and the Cook-Medley Hostility Scale were among the scales administered at the Depression Research Program of the Clinical Psychopharmacology Unit at the Massachusetts General Hospital to 127 medication-free outpatients with major depression and to 85 of these patients after 8 weeks of open treatment with a fixed dose (20 mg/day) of fluoxetine. At baseline, 44% of the depressed outpatients reported having anger attacks; these patients had significantly higher scores on measures of anxiety, somatization, and state and trait hostility than did the subjects who did not exhibit such attacks. After treatment, there were significant reductions in these measures, and the anger attacks disappeared in the majority (71%) of the patients who had previously reported them. There was a trend toward greater overall clinical improvement for patients with anger attacks than for patients without them. This study identified a subgroup of highly irritable and hostile depressed patients who report the presence of anger attacks and have a psychological profile distinct from that of depressed patients without anger attacks. Furthermore, fluoxetine treatment appears to be beneficial in reducing anger and hostility in these patients.

The effect environmental change has on the frequency of violent incidents

Violence is an important consideration in the management of psychiatric patients. Probably one in ten psychiatric patients assault staff (DHSS, 1988), although this may be an underestimate (Lion et al, 1981). Fellow patients are assaulted less frequently (Nobel & Rodger, 1989). Several factors have been associated with violent behaviour in patients: suffering from schizophrenia, delusions, hallucinations (Noble & Rodger, 1989); being young, compulsorily detained and an increased use of temporary nursing staff (James et al, 1990).

Naloxone-Associated Patient Violence: An Overlooked Toxicity?

To report two cases of a previously unreported adverse effect, violent patient behavior, after the reversal of sedation by intravenous naloxone. Case report. Responses of two individuals who had reversal of sedation by intravenous naloxone are compared. Placement of patient restraints before the administration of intravenous naloxone to obtunded or unconscious patients can make an important contribution to the safety of patients, healthcare personnel, and public safety personnel, as illustrated by the violent reaction of one unrestrained patient after naloxone administration. Patient restraint should be considered before naloxone administration to protect the patient and healthcare workers. In the prehospital setting, limiting the use of naloxone to patients with decreased mental status and respiratory depression would decrease the likelihood of naloxone-induced violent behavior.

Staff attitudes toward violence in the general hospital: A comparison between Amsterdam and Tel Aviv

This study reports the results of a cross-cultural comparative investigation of violent behavior of patients, relatives, and visitors toward the medical staff in two general hospitals. The situation in an Israeli community general hospital in Tel Aviv was compared to that of a Dutch university hospital. General impressions existed that violence appeared to be a serious problem in the hospital in Tel Aviv, whereas there are scarcely any reports of violence in general hospitals in the Netherlands. Semistructured interviews with members of the medical and nursing staff confirmed these impressions. In Israel, the “aggressor” would be described as a young male without any specific traits, whereas in the Netherlands, he would be associated with alcohol abuse, drug addiction, and would possibly belong to street gangs or be a member of a minority group. Circumstances that may lead to violence are mentioned and situational, and social and cultural influences are discussed.

The Tradition of Toughness: A Study of Nonprofessional Nursing Care in Psychiatric Settings

Violence is a significant problem in psychiatric settings; however, nursing research that identifies organizational influences related to violent patient behavior is rare. This paper reports on an exploratory study conducted on the psychiatric units of a metropolitan public hospital. The key concept generated by the data was the "tradition of toughness." Within this psychiatric setting, "control" of patient behavior was emphasized resulting in norms and roles that operationalized the theory. The norms were (a) "The need for physical restraint" and (b) "It's not you we don't trust." The nursing role was labelled "enforcing" and included the strategies of (a) "Policing," (b) "Supermanning," and (c) "Putting on a show."

Protecting third parties: a decade after Tarasoff.

The authors discuss current public policy concerning the treatment of potentially violent psychiatric patients and outline some legal and ethical precedents of the current policy. Therapeutic interventions before and after the Tarasoff decision are compared. The authors make specific recommendations for clinicians, who they believe tend to interpret laws too restrictively. They suggest that courts need to rethink current liability standards so that legal decisions can be more clinically informed. Finally, they believe that legislative interventions which specify that warning the potential victim and notifying the police absolve psychotherapists from liability may lead to reflexive rather than reflective management of violent patients.

Helping the employee victim of violence in hospitals.

Violent behavior of patients is an occupational health hazard of health care professionals that the authors believe has not been fully recognized. Hospitals have developed a wide variety of techniques to manage patients who assault staff but have consistently ignored the plight of the victimized employee. Although professional staff who have been assaulted resist seeing themselves as victims, the authors believe they experience the feelings and reactions typical of other victims and therefore may need help in dealing with emotional trauma. The authors describe a victims' assistance program adopted by Royal Victoria Hospital in Montreal and discuss problems associated with implementing programs like it.

Training for prevention of assaultive behavior in a psychiatric setting.

A two-day training workshop for mental health center staff on preventing or dealing with patients' assaultive behavior included a values clarification exercise, a discussion of guidelines for preventing assaultive behavior, and practice of defense and restraining techniques. Fifteen staff members who were judged by peers to be most effective in defusing violent patient behavior participated in a follow-up seminar to identify components of their successful interventions. Those components included keeping calm, being honest, suggesting alternatives to violent behavior, and using positive reinforcement. The author recommends that a center's administrative staff keep policies and procedures related to violent behavior up to date in order to ensure consistency of interventions, and that they participate in a training program as well.