Categorization of Aggressive Acts Committed by Chronically Assaultive State Hospital Patients

Department of Psychiatry, Division of Psychiatry and the Law, University of California-Davis, 2230 Stockton Blvd., Sacramento, CA 95817, USA.
Psychiatric Services (Impact Factor: 2.41). 05/2007; 58(4):521-8. DOI: 10.1176/
Source: PubMed


This study examined factors motivating inpatient aggression in a sample of chronically assaultive state hospital patients.
Inpatients who had committed three or more assaults over a one-year period were identified by using an incident report database. Aggressive episodes were categorized as impulsive, organized, or psychotic by using a procedure for classifying assaultive acts based on record review. Each assault type was further subcategorized. The relationship between assault type, victim (staff or patient), and legal status of the assaulter was also assessed.
A total of 839 assaults committed by 88 chronically aggressive patients were reviewed. Although most patients had a primary psychotic disorder, the most common type of assault was impulsive (54%), rather than psychotic or organized. Staff were most often victimized by impulsive assaults in situations involving attempts to change a patient's unwanted behavior and refusal of a patient request. Organized and psychotic assaults occurred less frequently (29% and 17%, respectively) and were more likely to target other patients. Organized assaults were most often motivated by a desire to seek revenge. Psychotic assaults were most often committed by an assailant acting under the influence of paranoid ideations. Civilly committed patients were overrepresented in the sample. Criminally committed patients committed more acts of organized aggression, although this finding did not reach significance.
These findings indicate that assaultive behavior among state hospital inpatients is complex and heterogeneous. Because each type of assault requires a different management approach, characterizing aggressive behavior may be important in determining which institutional programs and treatment-plan interventions to implement when addressing inpatient aggression.

    • "Various forms of impulsivity have been found to be elevated in disorders across the psychosis spectrum , including bipolar disorder (Peluso et al., 2007; Strakowski et al., 2010; Swann et al., 2001), schizoaffective disorder, and schizophrenia (Enticott et al., 2008; Nolan et al., 2011; Premkumar et al., 2008). It appears to exacerbate morbidity in these disorders, as impulsivity has been associated with increases in the risks for violence (Quanbeck et al., 2007; Volavka and Citrome, 2008), substance abuse (Dervaux et al., 2001; Schiffer et al., 2010), more intensive hospital course (Bigelow et al., 1988; Bowers et al., 2008; Greenfield et al., 1989), and suicide attempts (Gut-Fayand et al., 2001; Swann et al., 2005, 2009). Impulsivity has also been used to guide treatment and it is an important factor to consider when selecting appropriate medication regimens (Chengappa et al., 2002; Dursun et al., 2000; Krakowski et al., 2006; Spivak et al., 2003; Volavka and Citrome, 2008). "
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    ABSTRACT: Patients with psychotic disorders appear to exhibit greater impulsivity-related behaviors relative to healthy controls. However, the neural underpinning of this impulsivity remains uncertain. Furthermore, it remains unclear how impulsivity might differ or be conserved between psychotic disorder diagnoses in mechanism and manifestation. In this study, self-reported impulsivity, measured by Barratt Impulsiveness Scale (BIS), was compared between 305 controls (HC), 139 patients with schizophrenia (SZ), 100 with schizoaffective disorder (SZA), and 125 with psychotic bipolar disorder (PBP). In each proband group, impulsivity was associated with regional cortical volumes (using FreeSurfer analysis of T1 MRI scans), suicide attempt history, Global Assessment of Functioning (GAF), and Social Functioning Scale (SFS). BIS scores were found to differ significantly between participant groups, with SZA and PBP exhibiting significantly higher impulsivity than SZ, which exhibited significantly higher impulsivity than HC. BIS scores were significantly related to suicide attempt history, and they were inversely associated with GAF, SFS, and bilateral orbitofrontal cortex (OFC) volume in both SZA and PBP, but not SZ. These findings indicate that psychotic disorders, particularly those with prominent affective symptoms, are characterized by elevated self-reported impulsivity measures. Impulsivity's correlations with suicide attempt history, GAF, and SFS suggest that impulsivity may be a mediator of clinical outcome. The observed impulsivity-OFC correlations corroborate the importance of OFC deficits in impulsivity. These correlations' presence in SZA and PBP but not in SZ suggests that impulsivity may have different underlying mechanisms in affective and non-affective psychotic disorders.
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    • "s known to have a variable clinical course . Between psychotic episodes , the patient often has stable episodes in which the patient has control over his behavior and can be held responsible for his actions . There - fore investigation is needed to examine whether the incident fully de - rived from the psychiatric disorder ( Kumar et al . , 2006 ; Quanbeck et al . , 2007 ) . It is important that this investigation will be assessed by in - dependent ( forensic ) psychiatrists and psychologists ( Coyne , 2002 ; Hoge & Gutheil , 1987 ) . Coyne ( 2002 ) argues that investigating the in - cident will provide in an objective trial of the facts by judicial profes - sionals , rather than a self - proclaimed jud"
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    • "Finally, more junior staff, when faced with an agitated, demanding and threatening patient, perhaps more likely to refer the dispute up to a qualified member of staff, rather than confront the patient or set limits themselves. All these are well known to be amongst the immediate antecedents of violent incidents on psychiatric wards (Quanbeck et al., 2007; Daffern and Howells, 2007). "
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