The development of an observer-scale for measuring social dysfunction and aggression

Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions

BACKGROUND

There is a lack of evidence to underpin decisions on what constitutes the most effective and least restrictive form of coercive intervention when responding to violent behavior. Therefore we compared ratings of effectiveness and subjective distress by 125 inpatients across four types of coercive interventions.

METHODS

Effectiveness was assessed through ratings of patient behavior immediately after exposure to a coercive measure and 24 h later. Subjective distress was examined using the Coercion Experience Scale at debriefing. Regression analyses were performed to compare these outcome variables across the four types of coercive interventions.

RESULTS

Using univariate statistics, no significant differences in effectiveness and subjective distress were found between the groups, except that patients who were involuntarily medicated experienced significant less isolation during the measure than patients who underwent combined measures. However, when controlling for the effect of demographic and clinical characteristics, significant differences on subjective distress between the groups emerged: involuntary medication was experienced as the least distressing overall and least humiliating, caused less physical adverse effects and less sense of isolation. Combined coercive interventions, regardless of the type, caused significantly more physical adverse effects and feelings of isolation than individual interventions.

CONCLUSIONS

In the absence of information on individual patient preferences, involuntary medication may be more justified than seclusion and mechanical restraint as a coercive intervention. Use of multiple interventions requires significant justification given their association with significant distress.

Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment

BACKGROUND

Short-term structured risk assessment is presumed to reduce incidents of aggression and seclusion on acute psychiatric wards. Controlled studies of this approach are scarce.

AIMS

To evaluate the effect of risk assessment on the number of aggression incidents and time in seclusion for patients admitted to acute psychiatric wards.

METHOD

A cluster randomised controlled trial was conducted in four wards over a 40-week period (n = 597 patients). Structured risk assessment scales were used on two experimental wards, and the numbers of incidents of aggression and seclusion were compared with two control wards where assessment was based purely on clinical judgement.

RESULTS

The numbers of aggressive incidents (relative risk reduction -68%, P<0.001) and of patients engaging in aggression (relative risk reduction RRR = -50%, P<0.05) and the time spent in seclusion (RRR = -45%, P<0.05) were significantly lower in the experimental wards than in the control wards. Neither the number of seclusions nor the number of patients exposed to seclusion decreased.

CONCLUSIONS

Routine application of structured risk assessment measures might help reduce incidents of aggression and use of restraint and seclusion in psychiatric wards.

Neuropsychiatric evaluations of postictal behavioral changes

Postictal behavioral changes (PBCs), including psychosis, aggression, and mood change, are commonly observed in patients with epilepsy. Recognition and description of the clinical manifestations of PBCs would help in understanding and treating patients. Additionally, various quantified objective scales that are widely available in clinical psychiatry could be used to assess the clinical symptoms of PBCs. There are few reports in which objective rating scales have been used to assess neuropsychiatric symptoms in patients with epilepsy. However, there have been a small number of studies on interictal psychosis and depression in which either the Brief Psychiatric Rating Scale or the Hamilton Depression Scale was used. These inventories are likely to be useful for the assessment of PBCs. Other rating scales used for schizophrenia, depression, mania, and aggressive behavior are reviewed here. The author suggests that cross-sectional and longitudinal neuropsychiatric measurement combined with other modalities, including functional neuroimaging, could provide clues to the pathophysiology of PBCs.

Effects of nutritional supplements on aggression, rule-breaking, and psychopathology among young adult prisoners

In an earlier study, improvement of dietary status with food supplements led to a reduction in antisocial behavior among prisoners. Based on these earlier findings, a study of the effects of food supplements on aggression, rule-breaking, and psychopathology was conducted among young Dutch prisoners. Two hundred and twenty-one young adult prisoners (mean age=21.0, range 18-25 years) received nutritional supplements containing vitamins, minerals, and essential fatty acids or placebos, over a period of 1-3 months. As in the earlier (British) study, reported incidents were significantly reduced (P=.017, one-tailed) in the active condition (n=115), as compared with placebo (n=106). Other assessments, however, revealed no significant reductions in aggressiveness or psychiatric symptoms. As the incidents reported concerned aggressive and rule-breaking behavior as observed by the prison staff, the results are considered to be promising. However, as no significant improvements were found in a number of other (self-reported) outcome measures, the results should be interpreted with caution.

The correspondence between the Staff Observation Aggression Scale-Revised and two other indicators for aggressive incidents

Previous research has shown good psychometric properties of the Staff Observation Aggression Scale-Revised (SOAS-R). However, it has never been investigated what proportion of aggressive incidents occurring in facilities is documented with the SOAS-R. Furthermore, if incidents are underreported, the consequences for the categorization of clients into aggressive and nonaggressive subgroups based on the SOAS-R are unknown. To examine this, in four inpatient psychiatric facilities for adults with mild intellectual disabilities, aggressive incidents were documented with the SOAS-R and two other indicators of aggressive incidents: the daily staff reports on clients' behavior and reports on of the use of restraints. Less than half of the incidents documented with the staff and restraint reports were also documented with the SOAS-R. On the other way around, however, it was also found that a substantial proportion of incidents reported on SOAS-R forms were not documented in the daily staff reports, which points to a more general problem of underreporting aggressive behavior. Apart from that, categorization of clients into an aggressive and a nonaggressive subgroup with SOAS-R data collected during 1 month or longer corresponded largely with the categorization based on both other indicators. This study showed that underreporting of aggressive incidents is likely to occur with the SOAS-R, making the instrument less suitable to assess absolute aggression incidence in facilities. Still, the SOAS-R seems a good instrument to categorize clients into aggressive and nonaggressive subgroups. Ways to improve the compliance of the ward team to document all aggressive incidents are addressed in the Discussion section of this article.

Valproate preparations for agitation in dementia

BACKGROUND

Agitation affects up to 70% of older people with dementia. Valproic acid derivatives have been used for the past 10 years to control agitation in dementia, but no systematic review of the effectiveness of this treatment has been published to date. A systematic review of 2004 examined three randomised, placebo-controlled trials of the effect of valproate therapy on older people with dementia who were agitated. The review was updated (October 2008) to include two additional studies.

OBJECTIVES

To determine whether evidence supports the use of valproate preparations in the treatment of agitation of people with dementia.

SEARCH STRATEGY

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 7 February 2008 using the terms: valproic OR valproate OR divalproex* . The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources.

SELECTION CRITERIA

Randomized, placebo-controlled trials with concealed allocation where agitation and dementia of participants were assessed

DATA COLLECTION AND ANALYSIS

1. Two reviewers extracted data from published trials 2. Odds ratios of average differences were calculated 3. Only "intention to treat" analyses were included 4. Analysis compared participants treated with valproic acid with controls

MAIN RESULTS

Meta-analysis in 2004 of the pooled results was limited because of the following problems.In Porsteinsson 2001, although the physicians having direct responsibility for patient care were blinded, a non-blinded physician, who had no direct contact with these physicians, adjusted divalproex sodium dosage on the basis of reports from blinded raters and from confidential laboratory reports. Therefore, because the physician who controlled therapy knew which patients were receiving divalproex, the trial did not satisfy the criterion of concealed allocation.In Tariot 2001, 54% of the treated patients dropped out compared with 29% of control patients. Of all treated patients, 22% dropped out because of adverse effects, and the study had to be discontinued prematurely.The third trial (Sival 2002) had a cross-over design. No results from the first phase of the study were available, and although the statistical section stated, "the t-test for independent samples is used to analyse the two-period cross-over trial", because the samples were not independent - they are the same patients in the treatment and placebo groups - a question must be raised about the correctness of the analyses.The valproate preparation used in the trials varied - one used short-acting sodium valproate, one long-acting divalproex sodium, and the third early-onset acting divalproex sodium. Average doses differed (480 mg/d - 1000 mg/d), as did duration of therapy (3 weeks - 6 weeks), and ways of evaluating patients and their response to therapy.A limited meta-analysis, pooling the results concerning adverse effects (Porsteinsson 2001, Tariot 2001) revealed the following: sedation occurred more frequently in patients treated with valproic acid than in controls. Urinary tract infection was more common among patients treated with valproic acid than controls.An updated systematic review (October 2008) of two new studies (Tariot 2005, Herrmann 2007) applied meta-analysis to the effect of valproate on agitation in demented patients and also combined these studies with the earlier reports to examine adverse effects among valproate treated patients. Because the study of Herrmann et al involved a cross-over design, only those results from the first part of this study were included in the updated review.The new meta-analysis of pooled results showed no improvement of agitation among valproate treated patients, compared with controls, and showed an increase in adverse events (falls, infection, gastrointestinal disorders) among valproate treated patients.

AUTHORS' CONCLUSIONS

The updated review corroborates the earlier findings that valproate preparations are ineffective in treating agitation among demented patients, and that valproate therapy is associated with an unacceptable rate of adverse effects. More research on the use of valproate preparations for agitation of people with dementia is needed. On the basis of current evidence, valproate therapy cannot be recommended for management of agitation in dementia.

The Quantification of Violence Scale: a simple method of recording significant violence

BACKGROUND

Although there are many rating scales recording the incidence and intensity of violence there are none that are specifically concerned with the measurement and assessment of severe violence.

AIMS

To develop a scale sensitive to variation centred on severe violence, establish its normative values, test its feasibility, and assess its reliability and validity in different populations.

METHOD

The Quantification of Violence Scale (QOVS) was developed in two stages. First, a list of 30 commonly experienced violent episodes in clinical psychiatric practice were evaluated and tested by weighting each episode by severity. Second, a numerical scale used to record the severity of the episode according to its degree of planning, intent and consequences. Violent episodes in two clinical populations were compared using the Modified Overt Aggression Scale (MOAS) and the preliminary version of the QOVS over periods up to 18 months, following which the numerical scale was developed.

RESULTS

Good (0.60-0.74) to Excellent (> 0.75) test-retest and inter-rater reliability agreement was obtained with both forms of the scale (intra-class correlations of 0.75 and 0.69 respectively), and similar agreement with MOAS scores was reached (0.67) in clinical populations. The scale was quick and easy to use in practice, and a score defining severe violence (9 on the numerical scale and 16 on the matched scale) was determined.

CONCLUSIONS

The QOVS, in its two forms, is a useful measure of recording significant violence in clinical and forensic practice.

Development of the Observation Scale for Aggressive Behavior (OSAB) for Dutch forensic psychiatric inpatients with an antisocial personality disorder

The Observation Scale for Aggressive Behavior (OSAB) has been developed to evaluate inpatient treatment programs designed to reduce aggressive behavior in Dutch forensic psychiatric patients with an antisocial personality disorder, who are "placed at the disposal of the government". The scale should have the sensitivity to measure changes in the possible determinants of aggressive behavior, such as limited control of displayed negative emotions (irritation, anger or rage) and a general deficiency of social skills. In developing the OSAB 40 items were selected from a pool of 82 and distributed among the following a priori scales: Irritation/anger, Anxiety/gloominess, Aggressive behavior, Antecedent (to aggressive behavior), Sanction (for aggressive behavior) and Social behavior. The internal consistency of these subscales was good, the inter-rater reliability was moderate to good, and the test-retest reliability over a two to three week period was moderate to good. The correlation between the subscales Irritation/anger, Anxiety/gloominess, Aggressive behavior, Antecedent, Sanction was substantial and significant, but the anticipated negative correlation between these subscales and the Social behavior subscale could not be shown. Relationships between the corresponding subscales of the OSAB and the FIOS, used to calculate concurrent validity, yielded relatively high correlations. The validity of the various OSAB subscales could be further supported by significant correlations with the PCL-R and by significant but weak correlations with corresponding subscales of the self-report questionnaires. The Observation Scale for Aggressive Behavior (OSAB) seems to measure aggressive behavior in Dutch forensic psychiatric inpatients with an antisocial personality disorder reliably and validly. Contrary to expectations, a negative relationship was not found between aggressive and social behavior in either the OSAB or FIOS, which were used for calculating concurrent validity.

Assessing risk for imminent violence in the elderly: the Brøset Violence Checklist

OBJECTIVE

The Brøset Violence Checklist (BVC) assesses confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects as either present or absent. It is hypothesised that an individual displaying two or more of these behaviours is more likely to be violent in the next twenty-four hour period. This study aims to test the validity of the instrument in geriatric settings and to report on the predictive value of an easy-to-use risk assessment instrument.

METHOD

Eight thousand eight hundred and thirty-five BVC observations were completed in two psychogeriatric wards (n = 42 patients) and two special care units for patients with dementia (n = 40 residents). To measure violent incidents the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R).

RESULTS

This study disclosed that patients in geriatric wards and residents in nursing homes who are aggressive have higher BVC scores than the non-violent subjects indicating that the BVC does predict violent episodes in these settings.

CONCLUSION

From a clinical perspective, it is most important that a prediction aid has good sensitivity, so that most cases are detected and have a high negative predictive value so that most non-cases on the measure are indeed non-cases. Our results indicate that the BVC was able to achieve this goal.

Gender differences in aggressive behavior at admission to a psychiatric hospital

As aggressive behavior has a negative impact in general psychiatry, its influence specifically from a gender-related point of view in an in-patient population of a psychiatric clinic was assessed at the time of admission. A group of 521 successively admitted psychiatric in-patients was investigated at admission with the help of the "Social Dysfunction and Aggression Scale". A slightly higher frequency and intensity of "verbal aggressive behavior" was observed in males. Within the other categories of aggressive behavior ("tension", "physical violence to things", and "assaults"), however, the percentages and intensities of gender-related aggressive behavior did not differ significantly. Furthermore, under the covarying impact of various psychiatric diagnoses, the gender-related differences concerning the intensity of "verbal aggressive behavior" disappeared. When comparing male and female subgroups, it was notable that male schizophrenic patients were younger than female patients when displaying comparable risks of showing at least one kind of aggressive behavior. In addition, in the female subgroup, "self-injurious behavior" was more strongly correlated to the category "tension" than in the male subgroup. Although there are some methodological shortcomings, the present results show that there are small qualitative differences in gender-related aggressive behavior in addition to minimal quantitative differences in the frequency and intensity of "verbal aggressive behavior" at admission.

Efficacy and tolerability of quetiapine in cluster B personality disorder: an open-label study

Objective. The aim of this open-label 8-week study was to assess the effectiveness of quetiapine on aggressive behaviour and social dysfunctions in patients suffering from a cluster B personality disorder (DSM-IV). Methods. The visits were performed at baseline and at days 14, 28 and 56. After a standard titration schedule, the patients received a dose augmented or reduced dose, within a range from 50 to 400 mg/day during the visits, depending on efficacy and tolerance. Assessment of efficacy was based on the French version of the Social Disability and Aggression Scale SDAS (SDAS-21). Response was defined as a decrease of ≥50% reduction of the total scores compared to baseline. Tolerability was assessed with the CGI, UKU, EPS-scales. Results and conclusion. Eight of the 12 patients included received 200 mg/day quetiapine after titration (all patients: 50-400 mg/day). At week 8, five out of 12 patients were responders based on the SDAS-21 scores for the average expression of the symptoms, and six out of 12 on the basis of SDAS-21 scores for the peak expression. There was a significant correlation between weight change and total SDAS variation (Kendall's τb= -0.644; p=0.02). These findings should be reexamined in further studies.

Adolescent-onset psychosis: prevalence, needs and service provision

BACKGROUND

Little is known of the epidemiology and care needs of people with adolescent-onset psychosis.

AIMS

To examine prevalence and the cross-sectional disability, needs and service provision for adolescent-onset psychosis in areas of central Scotland with a total population of 1.75 million.

METHOD

We identified and contacted 103 young people using an opt-out research design. Fifty-three participants and their carers and keyworkers were interviewed using a modified version of the Cardinal Needs Schedule.

RESULTS

The 3-year prevalence was 5.9 per 100,000 general population. Twenty-one (20%) adolescents were not in contact with mental health services; 80% of first admissions were to adult acute psychiatric wards. Those interviewed had high levels of morbidity: 29 (55%) had serious to pervasive impairment of functioning; there were relatively high levels of side-effects, negative symptoms, anxiety, occupational, friendship and family difficulties. Care provision was better for'clinical'than for'social'domains; 20% had five or more unmet needs; 17% had at least one intractable problem.

CONCLUSIONS

This low-prevalence disorder requires an assertive multi-agency approach in the context of a national planning framework.

A Prospective Study of Postictal Psychoses with Emphasis on the Periictal Type

PURPOSE

To assess prospectively episodes of postictal psychosis.

METHODS

We followed 108 consecutive patients with temporal lobe epilepsy, who were divided into three groups: those without psychotic episodes (n=87, N group), those with interictal psychosis (n=13, IIP group), and those with postictal psychosis (n=8, PIP group). The first episode of postictal psychosis, which was defined as a psychotic episode that occurred within 1 week after the end or within 3 days before the beginning of seizure clusters, was assessed with the Brief Psychiatric Rating Scale (BPRS) and Social Dysfunction and Aggression Scale (SDAS) during the observation period.

RESULTS

The duration of illness was significantly different between the N and PIP groups (p=0.004) and between the N and IIP groups (p=0.039). The average initial BPRS score (obtained 3.0 days after the end of the seizure cluster) was 19.7, and then decreased to 5.8 after 1 week, and finally normalized at 1.5 after 1 month. A statistically significant decrease in BPRS scores was found between the initial assessment and those obtained after 1 week (p=0.011). Those who had psychotic episodes without a lucid interval tended to have episodes more often than monthly, and experienced additional seizure recurrence even during the psychotic episodes. Two patients exhibited a frank manic phase, and three patients showed excessively aggressive behavior, as determined by the SDAS.

CONCLUSIONS

Postictal psychosis should be subdivided into the nuclear type, with an established clinical picture as an indirect aftereffect of seizure activity, and the atypical periictal type, which is a direct manifestation of limbic discharge.

Is the reducing effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative study

Is the reducing effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative study Abstract This study explores the decline in the amount of reported aggression incidents when using the Staff Observation Aggression Scale (SOAS). Because this decline could hold significant implications for practice or research, the objective of this study was to explore the plausible explanations for this phenomenon. The influence of systematic feedback of the gained data was also studied. The SOAS was introduced on a closed ward in a psychiatric institution in the Netherlands as a measuring instrument to assess the amount of aggression incidents during a 16-week period. The standard procedure for reporting general incidents was continued. After 10 weeks of registration, systematic feedback of the gathered data took place. Statistic analysis was used to determine significant changes in the total amount as well as on the various forms of aggression. During this observation period, qualitative data were collected to support the analysis of the quantitative data. A significant decrease in the total amount of reported aggression incidents as well as in the categories of 'verbal aggression' and 'remaining aggression' was found. However, the category 'physical aggression' was stable during the entire observation period. The number of standard procedure reports did not decrease when compared with the pre-test period. Nursing staff did not recognize a reduction in the amount of aggression incidents. The role of a learning effect in the reduction of reports on aggression incidents is not excluded but there are indications that the reduction is also the result of 'reporting fatigue' and 'shifting attention'.

NETER alcoholic typology (NAT)

AIMS

To establish an alcohol-dependent drinker's clinical typology, based on patients attending the Alcoholism Unit of Santa Maria's General Hospital in Lisbon, Portugal.

METHODS

A multivariate statistical analysis was used to extract the typology solution.

RESULTS

We obtained five factors: Anxiopathic, typifies anxious functioning; Heredopathic, congregates familiar and genetic influences on alcoholism; Thimopathic, typified by affective symptomatology; Sociopathic, characterized by disruptive behaviours under alcohol influence; and Adictopathic, isolates younger individuals who consume alcohol and other types of psychoactive substances.

CONCLUSIONS

There are increasingly alcoholic polymorphic subtypes derived from the interactive complexity between genetic/family and psychosocial factors.

Fifteen years of research with the Staff Observation Aggression Scale: a review

OBJECTIVE

Research on the prevalence and causes of in-patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.

METHOD

Studies with SOAS aggression data were compiled using MEDLINE, the Internet, and references from SOAS papers.

RESULTS

Reviews of studies on psychometric properties suggest fair to good inter-rater reliability and validity for SOAS assessments. The number of aggressive incidents per patient per year found on acute admissions wards (n = 38) considerably varied, with a range of 0.4-33.2 incidents (mean = 9.3).

CONCLUSION

Although the aggression data included in the present review were obtained in highly comparable ways, substantial differences in aggression rates between wards were still found. Some countries (e.g. the Netherlands) appear to have a relatively high incidence of aggression on acute wards.

Valproic acid for agitation in dementia

BACKGROUND

Agitation affects up to 70% of older people with dementia. Valproic acid has been used for the past 10 years to control agitation in dementia, but no systematic review of the effectiveness of this drug has been published to date. The current study examines three randomized, placebo-controlled trials of the effect of valproic acid on older people with dementia who were agitated.

OBJECTIVES

To determine whether evidence supports the use of valproic acid in the treatment of agitation of people with dementia.

SEARCH STRATEGY

Trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 10 July 2003 using the terms ("agitat*" or "distur*" or "behavi*" or "aggress*") and "valproic" or "valproate" or "divalpro*." This Register contains articles from all major health care databases and many ongoing trials databases and is regularly updated. The reviewers contacted the authors of publications and drug companies manufacturing valproic acid for additional information.

SELECTION CRITERIA

Randomized, placebo-controlled trials with concealed allocation where agitation and dementia of participants were assessed

DATA COLLECTION AND ANALYSIS

1. Two reviewers extracted data from published trials. 2. Odds ratios of average differences were calculated. 3. Only "intention to treat" analyses were included. 4. Analysis compared participants treated with valproic acid with controls.

MAIN RESULTS

Meta-analysis of the pooled results of the included trials could not be performed because of the following problems. In Porsteinsson 2001, although the physicians having direct responsibility for patient care were blinded, a non-blinded physician, who had no direct contact with these physicians, adjusted divalproex sodium dosage on the basis of reports from blinded raters. Therefore, because the physician who controlled therapy knew which patients were receiving divalproex, the trial did not satisfy the criterion of concealed allocation. In Tariot 2001, 54% of the treated patients dropped out compared with 29% of control patients. Of all treated patients, 22% dropped out because of adverse effects, and the study had to be discontinued prematurely. The third trial (Sival 2002) had a cross-over design. No results from the first phase of the study were available, and although the statistical section stated, "the t-test for independent samples is used to analyze the two-period cross-over trial", because the samples were not independent - they are the same patients in the treatment and placebo groups - a question must be raised about the correctness of the analyses. The type of valproate used in the trials varied - one used short-acting sodium valproate, one long-acting divalproex sodium, and the third early-onset acting divalproex sodium. Average doses differed (480mg/d - 1000mg/d), as did duration of therapy (3 wks - 6 wks), and ways of evaluating patients and their response to therapy. A limited meta-analysis, pooling the results concerning adverse effects (Porsteinsson 2001, Tariot 2001) revealed the following: Sedation occurred more frequently in patients treated with valproic acid than in controls Urinary tract infection was more common among patients treated with valproic acid than controls Because of differences in identifying adverse effects it was not possible to pool other observations concerning adverse effects between the two studies that were examined.

REVIEWERS' CONCLUSIONS

The trials reviewed should be regarded as preliminary. Individual reports suggest that low dose sodium valproate is ineffective in treating agitation among demented patients, and that high dose divalproex sodium is associated with an unacceptable rate of adverse effects. More research on the use of valproate preparations for agitation of people with dementia is needed. On the basis of current evidence, valproate preparations cannot be recommended for the treatment of agitation in dementia.

Olanzapine improves social dysfunction in cluster B personality disorder

Treatment with antipsychotics is a common approach for personality disorder. Conventional antipsychotics may be efficacious particularly against psychoticism, but less against other symptoms in these patients. They are, furthermore, associated with adverse drug reactions poorly tolerated by patients with personality disorder. Atypical antipsychotics have a more convenient pharmacological profile with a lower risk for extrapyramidal symptoms and a broader therapeutic profile, showing some efficacy against impulsivity, aggressivity and affective symptoms. The medical records of ten patients with a DSM-IV diagnosis of a cluster B personality disorder who had received olanzapine treatment were reviewed. A mirror-image design anchored to the start date of olanzapine treatment and extending 8 weeks in either direction was used. The assessment consisted of a qualitative chart review and a retrospective completion of the GCI-C and an adapted French version of the SDAS, using the observer-rated items. The olanzapine dose range was 2.5-20 mg during the 8 weeks of observation. The mean SDAS score (items 1-15) was 28.8+/-8.4 for the 8 weeks preceding olanzapine prescription and was improved to 13.6+/-5.8 after 8 weeks of treatment.

Sodium valproate in the treatment of aggressive behavior in patients with dementia--a randomized placebo controlled clinical trial

OBJECTIVES

The efficacy and tolerability of sodium valproate 2 x 240 mg compared to placebo were investigated in aggressive behavior in dementia.

DESIGN

A randomized, placebo controlled, double-blind cross-over design. The trial included a baseline period (one week); a placebo period (three weeks); a wash-out period with placebo (one week); and a treatment period with sodium valproate (three weeks).

SETTING

A psychogeriatric short-stay ward at a psychiatric teaching hospital.

PARTICIPANTS

Demented patients who met Patel's criteria for aggressive behavior and had a score of > or =3 on at least one of the items of the Social Dysfunction and Aggression scale-9 (SDAS-9).

INTERVENTION

A fixed dose of sodium valproate 2 x 6 ml of a 40 mg/ml suspension (daily defined dose of 480 mg) was compared to placebo.

MEASUREMENTS

Primary outcome variables were changes of the score of SDAS-9 and Clinical Global Impression scale (CGI) performed at the last week of each treatment period.

RESULTS

Data of 42 patients (F=25 and M=17; age 80.4+/-6.8 years) were analyzed. Treatment with sodium valproate showed no differences compared to placebo on aggressive behavior. The mean plasma level of sodium valproate was 40.9+/-10.8 microg/ml. Regression analysis showed a trend for improvement between the plasma levels of sodium valproate and the SDAS-9 and the CGI scores. Adverse events were not related to the plasma levels of sodium valproate. Secondary outcome measurements showed significant improvement on restless, melancholic and anxious behavior; a trend for improvement was found on suspicious and dependent behavior. Possible limitations of this study are the low dose of sodium valproate, the relatively short treatment period (three weeks), and the absence of statistical corrections for multiple comparisons.

CONCLUSION

This study showed no effect of sodium valproate 2 x 240 mg over placebo on aggressive behavior in dementia.

Violence and its prediction at a psychiatric hospital

Aggressive behaviour in psychiatric inpatients was assessed before and after a training course for staff members. The Social Dysfunction Aggression Scale (SDAS) was used to report and assess aggressive behaviour over time, and the Staff Observation Aggression Scale (SOAS) to report and assess single aggressive incidents. In addition, the numbers of nursing staff members who were on sick leave because of injuries in the periods before and after the course were recorded and compared. No statistically significant reduction was found in the number of aggressive patients or in the number of staff members on sick leave. One interesting finding was a lower reporting on the SOAS of perceived aggressive incidents after the training course in comparison with the SDAS reports. Directed verbal aggressiveness and violence towards things were found to be predictors of violence.

No correlation of serum cholesterol levels with measures of violence in patients with schizophrenia and non-psychotic disorders

Epidemiological studies, animal studies, and clinical studies yielded conflicting results concerning a supposed association between increased risk for suicide and violence, and low serum cholesterol levels. Until now, no data has been available for patients with schizophrenia, a disorder with a well-known increased risk of violence. Correlations of serum cholesterol levels at admission and measures of violence were investigated in 103 consecutively admitted patients (44 males, 59 females) of a general psychiatric admission unit. Seventy subjects were diagnosed as suffering from schizophrenia or schizoaffective disorder (ICD-10 F 20, F25), and 33 were diagnosed as suffering from non-psychotic disorders (mainly personality disorders). The level of total exhibited violence during the inpatient treatment period was measured in each patient by the Modified Overt Aggression Scale (MOAS), the Social Dysfunction and Aggression Scale (SDAS), the Staff Observation Aggression Scale (SOAS), and the Violence Scale (VS). Correlations of all violence measures were high (0.75-0.90), but no correlation was found with cholesterol levels, neither for psychotic nor for non-psychotic subjects, neither for men nor for women. The hypothesis of associations of violence and cholesterol levels is not supported by the data.

Natural history of aggressive behaviour in dementia

OBJECTIVE

This article analyses changes in aggressive behaviour throughout the course of dementia.

DESIGN

Prospective, 10 year, longitudinal study of aggressive behaviour in dementia, with autopsy follow-up.

SETTING

Subjects with dementia, living at home with a carer, Oxfordshire, UK.

PARTICIPANTS

Ninety-nine people with dementia (Alzheimer's disease and/or vascular dementia) who were living at home with a carer.

MEASURES

At 4-monthly intervals, the carers were interviewed about the subjects and the subjects were assessed cognitively. Subjects' behaviour was assessed using the Present Behavioural Examination. This is an investigator-based, semi-structured interview consisting of eight main sections monitoring behavioural and psychological change. Eight different aspects of aggressive behaviour were assessed in detail and comparison made with other relevant factors.

RESULTS

Verbal aggression is the most common and longest lasting form of aggressive behaviour. Aggressive resistance and physical aggression are most likely to persist until death. Intimate care is the main factor precipitating aggressive behaviour. There are no correlations between any type of aggressive behaviour and age, gender or time since onset of dementia.

CONCLUSIONS

Aggressive behaviour creates problems for carers. In general, the physical types of aggressive behaviour are most prevalent in people with more severe dementia.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

The effect of clozapine on aggressive behaviour in patients with chronic schizophrenia

We studied the effect of 12 months' treatment with clozapine (150-400 mg/day) in 16 chronic schizophrenic patients with aggressive behaviour. The number of aggressive episodes, the time spent in seclusion and physical restraint, and the number of pharmacological interventions used as chemical restraint during the 12 months of clozapine treatment were calculated and compared to those for the previous 12-month period (during which treatment was with conventional antipsychotics). During clozapine therapy there was a statistically significant decrease (P<0.001) in all the parameters of aggressive behaviour which we investigated, as compared with the pre-clozapine period. The reduction in aggressive behaviour was more prominent within the first 6 months of clozapine administration. Clozapine treatment was also associated with a global improvement in psychosis, as measured by the Brief Psychiatric Rating Scale. Despite the limitations in sample size and study design, our results confirm that clozapine appears more effective than classical antipsychotics in reducing aggressive behaviour in chronic schizophrenic patients.

Psychopharmacologic treatment of pathologic aggression

Several drugs are apparently effective in treating pathologic anger and aggression. Because many of the studies on aggressive populations allowed the use of concomitant medications, it is unclear whether the efficacy of each drug in a particular population is dependent on the presence of other medications, such as antipsychotic agents. Finally, one needs to be circumspect in inferring efficacy of a particular drug in aggressive patients with neuropsychiatric conditions other than the ones in which some efficacy has been established. Lithium appears to be an effective treatment of aggression among nonepileptic prison inmates, mentally retarded and handicapped patients, and among conduct-disordered children with explosive behavior. Certainly, lithium would be the treatment of choice in bipolar patients with excessive irritability and anger outbursts, and it has been shown to be effective in this population. Anticonvulsant medications are the treatment of choice for patients with outbursts of rage and abnormal EEG findings. The efficacy of these drugs in patients without a seizure disorder, however, remains to be established, with the exception perhaps of valproate and carbamazepine. In fact, dyphenylhydantoin did not appear to be effective in treating aggressive behavior in children with temper tantrums and was found to be effective in only a prison population. There is some evidence for the efficacy of carbamazepine and valproate in treating pathologic aggression in patients with dementia, organic brain syndrome, psychosis, and personality disorders. As Yudofsky et al point out in their review of the literature, although traditional antipsychotic drugs have been used widely to treat aggression, there is little evidence for their effectiveness in treating aggression beyond their sedative effect in agitated patients or their antiaggressive effect among patients whose aggression is related to active psychosis. Antipsychotic agents appear to be effective in treating psychotic aggressive patients, conduct-disordered children, and mentally retarded patients, with only modest effects in the management of pathologic aggression in patients with dementia. Furthermore, at least in one study, these drugs were found to be associated with increased aggressiveness in mentally retarded subjects. On the other hand, atypical antipsychotic agents (i.e., clozapine, risperidone, and olanzapine) may be more effective than traditional antipsychotic drugs in aggressive and violent populations, as they have shown efficacy in patients with dementia, brain injury, mental retardation, and personality disorders. Similarly, benzodiazepines can reduce agitation and irritability in elderly and demented populations, but they also can induce behavioral disinhibition. Therefore, one should be careful in using this class of drugs in patients with pathologic aggression. Beta-blockers appear to be effective in many different neuropsychiatric conditions. These drugs seem effective in reducing violent and assaultive behavior in patients with dementia, brain injury, schizophrenia, mental retardation, and organic brain syndrome. As pointed out by Campbell et al in their review of the literature, however, systematic research is lacking, and little is known about the efficacy and safety of beta-blockers in children and adolescents with pathologic aggression. Although widely used in the management of pathologic aggression, the use of this class of drugs has been limited partially by marked hypotension and bradycardia, which are side effects common at the higher doses. The usefulness of the antihypertensive drug clonidine in the treatment of pathologic aggression has not been assessed adequately, and only marginal benefits were observed with this drug in irritable autistic and conduct disorder children. Psychostimulants seem to be effective in reducing aggressiveness in brain-injured patients as well as in violent adolescents with oppositional or conduct disorders, particu

Clinical research in aggressive patients, pitfalls in study design and measurement of aggression

1. Experience from scale validation studies and from controlled drug trials provided clues for optimalisation of studies in aggressive patients. 2. Definitions of target behaviour, selection of patients and measurement of aggression are reviewed and recommendations are presented.

Citalopram, a selective serotonin reuptake inhibitor, in the treatment of aggression in schizophrenia

The aim of this double-blind cross-over study was to investigate whether treatment with the selective serotonin reuptake inhibitor, citalopram reduces aggressiveness in chronically violent schizophrenic inpatients. Initially 19 patients were enrolled into this double-blind cross-over study in which the patients were treated for 24 weeks with placebo and 24 weeks with citalopram (20-60 mg/day) as a supplement to their previous neuroleptic medication. Fourteen patients completed the entire study, but sufficient data on 15 patients could be used in the end-point analysis of efficacy. Psychiatric assessments (Brief Psychiatric Rating Scale, Clinical Global Impression Scale for Severity of Illness, Social Dysfunction and Aggression Scale and the Global Aggression Scale) and side effects (UKU Side Effect Scale) were recorded at baseline and 4 times during both periods. Aggressive incidents (Staff Observation Aggression Scale) were recorded throughout the study. During citalopram treatment, the frequency of aggressive incidents was significantly lower and the mental state did not deteriorate. Patients either experienced no side effects or else side effects were equally mild during both periods.