A bio-psycho-social model of violence related to mental health problems

The Association of Cortisol and Testosterone Interaction With Inpatient Violence: Examining the Dual-Hormone Hypothesis in a Psychiatric Setting

Psychiatric inpatient aggression is a concern as it poses a threat to safety of both patients and staff. While psychosocial and behavioral approaches are often put forward, the role of biological factors remains underexplored in a clinical context such as psychiatric hospitals. The dual-hormone hypothesis (DHH) posits that low levels of cortisol combined with high levels of testosterone promote status-seeking behaviors with some differences between sexes. This has yet to be studied among psychiatric inpatients. To explore the joint association of the DHH (cortisol and testosterone) and sex with psychiatric inpatient aggression. The sample included 375 psychiatric inpatients (206 women) from the Signature Biobank in Canada. Following their admission in a psychiatric hospital, participants provided hair and saliva for cortisol and testosterone analysis, respectively. Aggressive behaviors from the clinical files were reviewed from admission to discharge. Men with high salivary testosterone combined with low hair cortisol had higher odds of displaying aggression compared to men with high salivary testosterone and high hair cortisol. Men with low salivary testosterone and low hair cortisol had lower odds to perpetrate aggression compared to men with low salivary testosterone and high hair cortisol levels. The cortisol and testosterone interaction was not significant in women. Findings are consistent with the DHH for men. Given that the context hospitalization may trigger status-seeking behaviors, actions could be taken such as identifying specific hormonal profiles at the time of admission to identify patients at risk of aggression, allowing for tailored care protocols.

Prediction of Disruptive Behavior over Time from Changes in Patients' Global Functioning in Acute Psychiatric Care

Disruptive behavior of patients in acute psychiatric care is a problem for both patients and staff. Preventing a patient's impending disruption requires recognizing and understanding early signals. There are indications that a change in a patient's global functioning may be such a signal. The global functioning of patients is a multidimensional view on their functioning. It captures a patient's psychological symptoms, social skills, symptoms of violence, and activities in daily living. The aim of this study was to gain insight into the predictive value of global functioning on the risk of disruptive behavior of patients in acute psychiatric care. Also assessed was the time elapsed between the change in global functioning and a patient's disruptive behavior, which is necessary to know for purposes of early intervention. In a longitudinal retrospective study, we used daily measurements with the Brøset Violence Checklist (BVC) and the Kennedy Axis V (K-As) of each patient admitted to two acute psychiatric units over a period of six years. Data from 931 patients for the first 28 days after their admission were used for survival analysis and cox regression analysis. Disruptive behavior was mostly observed during the first days of hospitalization. Global functioning predicted disruptive behavior from the very first day of hospitalization. A cut-off score of 48 or lower on the K-As on the first admission day predicted a higher risk of disruptive behavior. If functioning remained poor or deteriorated substantially over three days, this was an additional signal of increased risk of disruptive behavior. Improvement in global functioning was associated with a decreased risk of disruptive behavior. More attention is needed for early interventions on global functioning to prevent disruptive behavior.

Relationships between dynamic risk factors for externalising problem behaviour and group climate in adults with mild intellectual disability in forensic treatment

BACKGROUND

Relationships between dynamic risk factors for externalising problem behaviour and group climate were investigated in 151 adult in-patients with mild intellectual disability or borderline intellectual functioning in a Dutch secure residential facility.

METHOD

Regression analysis was used to predict total group climate score and Support, Growth, Repression, and Atmosphere subscales of the 'Group Climate Inventory'. Predictor variables were Coping Skills, Attitude towards current treatment, Hostility, and Criminogenic attitudes subscales of the 'Dynamic Risk Outcome Scales'.

RESULTS

Less hostility predicted a better overall group climate, better support and atmosphere, and less repression. A positive attitude towards current treatment predicted better growth.

CONCLUSION

Results indicate relationships of hostility and attitude towards current treatment with group climate. A focus on both dynamic risk factors and group climate may provide a basis for improving treatment for this target group.

The Model for Understanding Inpatient Aggression: A Version for Mental Health Nurses Working in Prisons

Preventing and managing aggression remains an important and challenging task for mental health nurses. Despite the concern, there is a dearth of frameworks to assist practice and inform assessment and intervention related to aggression, for forensic mental health nurses working in prisons. This paper presents a model for understanding aggression within prison mental health units. The model elucidates various personal and situational determinants of aggression. It offers a systematic framework for mental health nurses to investigate and understand aggression, to ultimately assist nurses to provide care in an informed and effective manner, and for services to consider structural factors that contribute to the risk of aggression.

How clinicians make decisions about CTOs in ACT: a qualitative study

BACKGROUND

The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.

METHODS

Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.

RESULTS

The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.

CONCLUSIONS

According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.

Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit

Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL) were examined in an inpatient (N = 348) and a 3-months follow-up (N = 101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist.

A feasibility study on violence prevention in outpatients with schizophrenia

Patients with schizophrenia have an increased risk of violent behavior, and occupy a large percentage of forensic beds. Most patients in forensic psychiatry have already undergone general psychiatric therapy. This predestinates general psychiatrists to identify those patients presenting such a risk, and to try to intervene so that violence can be prevented. Feasibility study of violence prevention using cognitive-behavioral therapy interventions in male patients with schizophrenia on a general psychiatric ward. Of our patients admitted with schizophrenia, 39.1% had committed violent acts against others; the severity of the act was usually low. The percentage of non-participants was high (83.1%). Study subjects were younger, had not been ill for as long, and were less apt to drop out of the ongoing general psychiatric treatment than the non-participants. Study subjects and non-participants did not differ in the violent act's severity. Our therapy manual proved to be sensible and practical. Those of us attempting to prevent schizophrenic patients from committing violence must deal with individuals who are generally hard to reach. We succeeded in achieving a low drop-out rate after having recruited patients who had displayed a substantial propensity to violence against others.

Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning

Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.

Causality in criminal forensic and in civil disability cases: Legal and psychological comparison

Causality (or causation) is central to every legal case, yet its underlying philosophical, legal, and psychological definitions and conceptions vary. In the criminal context, it refers to establishing the responsibility of the perpetrator of the criminal act at issue in terms of the person's mental state (mens rea), and whether the insanity defense applies. In the forensic disability and related context, it refers to whether the index event is a material or contributing cause in the multifactorial array that led to the psychological condition at issue. In both the criminal and tort contexts, the legal test is a counterfactual one. For the former, it refers to whether the outcome involved would have resulted absent the act (e.g., in cases of simultaneous criminal lethal action, which one is the but-for responsible one). For the latter, it concerns whether the claimed psychological condition would be present only because of the incident at issue. The latter event at issue is distinguished from the criminal one by its negligence compared to the voluntary intent in the criminal case. The psychological state of the perpetrator of criminal conduct can be analyzed from a biopsychosocial perspective as much as the civil one. In this regard, in the civil case, such as in forensic disability and related assessments, pre-existing, precipitating, and perpetuating factors need to be considered causally, with personal and social resilience and protective factors added, as well. In the criminal context, the same biopsychosocial model applies, but with mental competence and voluntariness added as a critical factor. The advent of neurolaw has led to use of neuroscience in court, but it risks reducing the complexity of criminal cases to unifactorial, biological models.

Comparing theories' performance in predicting violence

The stakes of choosing the best theory as a basis for violence prevention and offender rehabilitation are high. However, no single theory of violence has ever been universally accepted by a majority of established researchers. Psychiatry, psychology and sociology are each subdivided into different schools relying upon different premises. All theories can produce empirical evidence for their validity, some of them stating the opposite of each other. Calculating different models with multivariate logistic regression on a dataset of N = 21,312 observations and ninety-two influences allowed a direct comparison of the performance of operationalizations of some of the most important schools. The psychopathology model ranked as the best model in terms of predicting violence right after the comprehensive interdisciplinary model. Next came the rational choice and lifestyle model and third the differential association and learning theory model. Other models namely the control theory model, the childhood-trauma model and the social conflict and reaction model turned out to have low sensitivities for predicting violence. Nevertheless, all models produced acceptable results in predictions of a non-violent outcome.