Skip to main content Accessibility help
×
Home

Aggressiveness and violence in psychiatric patients: a clinical or social paradigm?

  • Massimo C. Mauri (a1), Giovanna Cirnigliaro (a2), Chiara Di Pace (a1), Silvia Paletta (a1), Alessandra Reggiori (a1), Carlo A. Altamura (a1) and Bernardo Dell’Osso (a2) (a3) (a4)...

Abstract

Objective

Psychiatric disorders are often considered the leading cause of violence. This may be due to a stereotype created by media and general opinion.

Method

The Modified Overt Aggression Scale (MOAS) was used to evaluate the severity of aggressive and violent behaviors in 400 patients who attended a post-acute psychiatric service in Milan from 2014 to 2016 and suffered from different psychiatric disorders. The psychopathological clinical picture was evaluated by Clinical Global Impression (CGI). The study also assessed the possible correlation between epidemiologic and sociodemographic factors, clinical variables, and aggression and violence.

Results

Of the total number of subjects, 21.50% showed a MOAS score >0, 11.50% presented mild aggression (0–10 MOAS weighted score), 9% moderate aggression (11–20), and 1% severe aggression (MOAS >20). With respect to violent behaviors, 16% of patients showed a score >0 in one MOAS subscale other than verbal aggression according to violence definition. The severity of clinical picture seemed to be related to higher weighted MOAS score. Multivariate testing of different sociodemographic and clinical variables showed that violence was related to unemployment status, and significantly correlated to compulsory admission (TSO), suicide attempts (TS), and personality disorders, while the severity of clinical psychiatric picture seemed to play a secondary role.

Conclusion

Results have shown that personality disorders and sociodemographic factors, including economic factors, seem to be major determinants of violence among patients diagnosed with mental disorders.

Copyright

Corresponding author

*Address for correspondence: Massimo Carlo Mauri, MD, Department of Neuroscience and Mental Health, Clinical Psychopharmacology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy. (Email: massimo.mauri@policlinico.mi.it)

References

Hide All
1. Wolf, A, Gray, R, Fazel, S. Violence as a public health problem: an ecological study of 169 countries. Soc Sci Med. 2014; 104: 220227. doi:10.1016/j.socscimed.2013.12.006.
2. Mathers, C, Fat, D, Boema, J. The Global Burden of Disease: 2004 Update. Geneva: World Health Organization; 2008.
3. Vassos, E, Collier, DA, Fazel, S. Systematic meta-analyses and field synopsis of genetic association studies of violence and aggression. Mol Psychiatry. 2014; 19(4): 471477. doi:10.1038/mp.2013.31.
4. ISTAT. Reati, vittime e percezione della sicurezza. Anni 2008-2009. Istat Roma; 2010: 1–32.
5. ISTAT. La Violenza Contro le Donne Dentro e Fuori la Famiglia. 2015. http://www.istat.it/it/archivio/161716.
6. Brennan, J. Mentally ill aggressiveness—popular delusion or reality. Am J Psychiatry. 1964; 120(12): 11811184.
7. Warburton, KD, Stahl, SM. Violence in Psychiatry. Cambridge, UK: Cambridge University Press; 2016.
8. Hodgins, S. Mental disorder, intellectual deficiency, and crime: evidence from a birth cohort. Arch Gen Psychiatry. 1992; 49(6):476483.
9. Barbui, C, Saraceno, B. Closing forensic psychiatric hospitals in Italy: a new revolution begins? Br J Psychiatry. 2015; 206(6): 445446. doi:10.1192/bjp.bp.114.153817.
10. Bo, S, Abu-Akel, A, Kongerslev, M, Haahr, UH, Simonsen, E. Risk factors for violence among patients with schizophrenia. Clin Psychol Rev. 2011; 31(5): 711726. doi:10.1016/j.cpr.2011.03.002.
11. Amoo, G, Fatoye, FO. Aggressive behavior and mental illness: a study of in-patients at Aro Neuropsychiatric Hospital, Abeokuta. Niger J Clin Pract. 2010; 13(3): 351355.
12. Fazel, S, Gulati, G, Linsell, L, Geddes, JR, Grann, M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009; 6(8): e1000120. doi: 10.1371/journal.pmed.1000120
13. Fazel, S, Lichtenstein, P, Grann, M, Goodwin, GM, Långström, N. Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review. Arch Gen Psychiatry. 2010; 67(9): 931938.
14 Fazel, S, Wolf, A, Chang, Z, Larsson, H, Goodwin, GM, Lichtenstein, P. Depression and violence: a Swedish population study. Lancet Psychiatry. 2015; 2(3): 224232.
15. Swanson, JW, Holzer, CE, Ganju, VK, Jono, RT. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Community Psychiatry. 1990; 41(7): 761770.
16. Mitrev, I, Massaldjieva, R. Suicidal behaviour and aggression in psychiatric inpatients. Folia Med (Plovdiv). 2004; 46(4): 2226.
17. Walsh, E, Buchanan, A, Fahy, T. Violence and schizophrenia: examining the evidence. Br J Psychiatry. 2002; 180(6): 490495. doi:10.1192/bjp.180.6.490.
18. Wehring, HJ, Carpenter, WT. Violence and schizophrenia. Schizophr Bull. 2011; 37(5): 877878. doi:10.1093/schbul/sbr094.
19. Ferns, T, Cork, A. Managing alcohol related aggression in the emergency department (Part I). Int Emerg Nurs. 2008; 16(1): 4347. doi:10.1016/j.ienj.2007.12.001.
20. Zinkiewicz, L, Curtis, A, Meurer, H, Miller, P. Demographic risk factors for alcohol-related aggression in and around licensed venues. Alcohol Alcohol. 2016; 51(2): 196200.
21. Colasanti, A, Natoli, A, Moliterno, D, Rossattini, M, De Gaspari, IF, Mauri, MC. Psychiatric diagnosis and aggression before acute hospitalisation. Eur Psychiatry. 2008; 23(6): 441448. doi:10.1016/j.eurpsy.2007.09.005.
22. Roberton, T, Daffern, M, Bucks, RS. Emotion regulation and aggression. Aggression and Violent Behavior. 2012; 17(1): 7282. doi:10.1016/j.avb.2011.09.006.
23. Elbogen, EB, Johnson, SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009; 66(2): 152161. doi:10.1001/archgenpsychiatry.2008.537.
24. Chang, JC, Lee, CS. Risk factors for aggressive behavior among psychiatric inpatients. Psychiatr Serv. 2004; 55(11): 13051307.
25. Kim, HK, Laurent, HK, Capaldi, DM, Feingold, A. Men’s aggression toward women: a 10-year panel study. J Marriage Fam. 2008; 70(5): 11691187.
26 Rodriguez, E, Lasch, KE, Chandra, P, Lee, J. Family violence, employment status, welfare benefits, and alcohol drinking in the United States: what is the relation? J Epidemiol Community Health. 2001; 55(3): 172178.
27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., International Version with ICD 10 codes. Washington, DC: American Psychiatric Association; 1995.
28. Busner, J, Targum, SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007; 4(7): 2837.
29. Yudofsky, SC, Silver, JM, Jackson, W, Endicott, J, Williams, D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986; 143(1): 3539. doi:10.1176/ajp.143.1.35.
30. Foley, SR, Kelly, BD, Clarke, M, et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophr Res. 2005; 72(2–3): 161168. doi:10.1016/j.schres.2004.03.010.
31. He, J, Hong, W, Shao, Y, Han, H, Xie, B. [Application of MOAS for evaluating of violence risk in the inpatients with mental disorders]. Fa Yi Xue Za Zhi. 2017; 33(1): 2831. doi:10.3969/j.issn.1004-5619.2017.01.007.
32. Kay, SR, Wolkenfeld, F, Murrill, LM. Profiles of aggression among psychiatric patients. I. Nature and prevalence. J Nerv Ment Dis. 1988; 176(9): 539546.
33. Cornaggia, CM, Beghi, M, Pavone, F, Barale, F. Aggression in psychiatry wards: a systematic review. Psychiatry Res. 2011; 189(1): 1020. doi:10.1016/j.psychres.2010.12.024.
34. Biancosino, B, Delmonte, S, Grassi, L, et al. Violent behavior in acute psychiatric inpatient facilities. J Nerv Ment Dis. 2009; 197(10): 772782. doi:10.1097/NMD.0b013e3181bb0d6b.
35. Ballerini, A, Boccalon, R, Boncompagni, G, et al. An observational study in psychiatric acute patients admitted to General Hospital Psychiatric Wards in Italy. Ann Gen Psychiatry. 2007; 6: 2. doi:10.1186/1744-859X-6-2.
36. Dack, C, Ross, J, Papadopoulos, C, Stewart, D, Bowers, L. A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatr Scand. 2013; 127(4): 255268. doi:10.1111/acps.12053.
37. Szabo, K, White, C, Cummings, S, Wang, R. Inpatient aggression in community hospitals. CNS Spectr. 2015; 20(3): 223230. doi:10.1017/S1092852914000820.
38. Amore, M, Menchetti, M, Tonti, C, et al. Predictors of violent behavior among acute psychiatric patients: clinical study. Psychiatry Clin Neurosci. 2008; 62(3): 247255. doi:10.1111/j.1440-1819.2008.01790.x.
39. Pinna, F, Tusconi, M, Dessi, C, Pittaluga, G, Fiorillo, A, Carpiniello, B. Violence and mental disorders. A retrospective study of people in charge of a community mental health center. Int J Law Psychiatry. 2016; 47: 122128. doi:10.1016/j.ijlp.2016.02.015.
40. Amore, M, Tonti, C, Esposito, W, Baratta, S, Berardi, D, Menchetti, M. Course and predictors of physical aggressive behaviour after discharge from a psychiatric inpatient unit: 1 year follow-up. Community Ment Health J. 2013; 49(4): 451456. doi:10.1007/s10597-012-9530-1.
41. Choe, JY, Teplin, L a., Abram, KM. Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatr Serv. 2008; 59(2): 153164. doi:10.1176/appi.ps.59.2.153.
42. Bowers, L. Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing. J Psychiatr Ment Health Nurs. 2005; 12(2): 231236. doi:10.1111/j.1365-2850.2004.00825.x.
43. Callaghan, P, Oud, N, Nijman, H, Palmstierna, T, Duxbury, J. Violence in Clinical Psychiatry. Oud Consultancy Amsterdam; 2017.
44. Stuart, H. Violence and mental illness: an overview. World Psychiatry. 2003; 2(2): 121124.
45. Nawal, R, Magda, F, El-Leithy, W, Haydy, H, Khaled Abd, E. Correlation between aggressive behavior and sociodemographic characteristics in patients with schizophrenia at a psychiatry outpatient clinic. Middle East Current Psychiatry, Ain Shams University. 2017; 24(1): 3035.
46. Mauri, MC, Rovera, C, Paletta, S, De Gaspari, IF, Maffini, M, Altamura, AC. Aggression and psychopharmacological treatments in major psychosis and personality disorders during hospitalisation. Prog Neuro-Psychopharmacology Biol Psychiatry. 2011; 35(7): 16311635. doi:10.1016/j.pnpbp.2011.05.008.
47. Di Giacomo, E, Clerici, M. [Violence in psychiatric inpatients]. Riv Psichiatr. 2010; 45(6): 361364.
48. Ellis, L. Sex, status, and criminality: a theoretical nexus. Soc Biol. 2004; 51(3–4): 144160.
49. Markowitz, FE. Socioeconomic disadvantage and violence: recent research on culture and neighborhood control as explanatory mechanisms. Aggression and Violent Behavior. 2003; 8(2): 145154. doi:10.1016/S1359-1789(01)00059-3.
50. Orzechowska, A, Florkowski, A, Gruszczynski, W, Zboralski, K. [Socio-economic status, aggressive behaviours and coping with stress]. Psychiatra Pol. 2009; 43(1): 5363.
51. Conger, R, Conger, K, Martin, M. Socioeconomic status, family processes and individual development. J Marriage Fam. 2010; 72(3): 685704. doi:10.1111/j.l741-3737.2010.00725.x.
52. Cramer, C. Unemployment and participation in violence. Conflict, Security and Development. World Development Report 2011. http://web.worldbank.org/archive/website01306/web/unemployment.html.
53. Raja, M, Azzoni, A. Hostility and violence of acute psychiatric inpatients. Clin Pract Epidemiol Ment Health. 2005; 1: 11. doi:10.1186/Received.
54. Bowers, L, Douzenis, A, Galeazzi, GM, et al. Disruptive and dangerous behaviour by patients on acute psychiatric wards in three European centres. Soc Psychiatry Psychiatr Epidemiol. 2005; 40(10): 822828. doi:10.1007/s00127-005-0967-1.
55. Ketelsen, R, Zechert, C, Driessen, M, Schulz, M. Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk. J Psychiatr Ment Health Nurs. 2007; 14(1): 9299. doi:10.1111/j.1365-2850.2007.01049.x.
56. Lam, JN, McNiel, DE, Binder, RL. The relationship between patients’ gender and violence leading to staff injuries. Psychiatr Serv. 2000; 51(9): 11671170. doi:10.1176/appi.ps.51.9.1167.
57. Grassi, L, Peron, L, Marangoni, C, Zanchi, P, Vanni, A. Characteristics of violent behaviour in acute psychiatric in-patients: a 5-year Italian study. Acta Psychiatr Scand. 2001; 104(4): 273279.
58. McNiel, DE, Binder, RL, Greenfield, TK. Predictors of violence in civilly committed acute psychiatric patients. Am J Psychiatry. 1988; 145(8): 965970.
59. Rhoades, G, Stanley, S, Kelmer, G, Markman, H. Physical aggression in unmarried relationships: the roles of commitment and constraints. J Fam Psychol. 2010; 24(6): 678687.
60. Tardiff, K. A prospective study of violence by psychiatric patients after hospital discharge. Psychiatr Serv. 1997; 48(5): 678681.
61. Catanesi, R, Carabellese, F, Guarino, D. Analysis of violent behavior in a population of psychiatric patients in Puglia and Basilicata. Italian Journal of Criminology. 2007; 1(1): 63–79.
62. Papadopoulos, C, Ross, J, Stewart, D, Dack, C, James, K. The antecedents of violence and aggression within psychiatric in-patient settings. Acta Psychiatr Scand. 2012; 125(6): 425439. doi:10.1111/j.1600-0447.2012.01827.x.
63. Renwick, L, Stewart, D, Richardson, M, et al. Aggression on inpatient units: clinical characteristics and consequences. Int J Ment Health Nurs. 2016; 25(4): 308318. doi:10.1111/inm.12191.
64. McFarlane, WR, Dixon, L, Lukens, E, Lucksted, A. Family psychoeducation and schizophrenia: a review of the literature. J Marital Fam Ther. 2003; 29(2): 223245. doi:10.1111/j.1752-0606.2003.tb01202.x.
65. Patterson, GR, DeBaryshe, BD, Ramsey, E. A developmental perspective on antisocial behaviour. In: Mazerolle P, ed. Developmental and Life-Course Criminological Theories. London: Taylor & Francis Group; 2017: 2632.
66. Rüsch, N, Müller, M, Lay, B, et al. Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness. Eur Arch Psychiatry Clin Neurosci. 2014; 264(1): 3543.
67. Gvion, Y, Apter, A. Aggression, impulsivity, and suicide behavior: a review of the literature. Arch Suicide Res. 2011; 15(2): 93112.
68. Gvion, Y, Apter, A. Aggression, impulsivity, and suicide behavior: a review of the literature. Arch Suicide Res. 2011; 15(2): 93112.
69. Swanson, W, Swartz, S, Essock, M, Osher, C. The social-environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health. 2002; 92(9): 15231531.

Keywords

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed