Violence by Psychiatric Inpatients: A Review tural considerations,
Simon Davis, M.S.W.
amined.
The literature on violence by psy chiatric inpatients provides some evidence that rates ofviolence may be increasing over time and that they are higher in the United States than in other nations. This review examines the extent of in patient vioknce and describes the individual, situational, and struc turalfactors with which it is asso ciated. Individual factors include acute illness, psychosis, drug abuse, age, and history ofvioknce. Situa tionalvariables include ovenrowd ing, provocation, staff inexper ience, and management tolerance of violence. Structural factors in dude changes in mental health pol icy that have made dangerousness a frequent criterion for commit ment and a shortage of treatment resources. The author concludes that violence is the result ofan in teraction between the various types offactors and is not simply an ex pression of individual pathology. Interest in violence committed by psychiatric inpatients has been heightened by the perception that such violence has increased in the era of deinstitutionalization. The litera ture on inpatient violence is re viewed
briefly here, beginning
with
an analysis of the incidence, preva lence, and changing rates of in patient violence. The underlying fac tors affecting these rates, grouped by individuaI@ situational,
and struc
Mr. Davis is a doctoral candidate in criminology at Simon Fraser University in Vancouver, British Columbia. His address is C2-1 100 West 6th Avenue, Vancouver, Brit ish Columbia,
Canada
V6H
1A4.
Hospital and Community Psychiatry
are also ex
These categories
are some
what arbitrary; in fact, as will be em phasized later, violence is an interac tive process. The violent patient must be considered in the context not only ofthe illness but also in the context of broader situational and structural factors.
haps less visible than their physical effects, can be just as serious [6]). A number of researchers have found that a minority
ofpatients
are
responsible ftr a majority ofthe mci dents. For example, a study by Bar ber and colleagues (7) at a U.S. state mental hospital found that 15 pa tients (3.3 percent of the census) ac counted for 48.6 percent of the as
Incidence and prevalence
saultive incidents
Variations in methodology have made it difficult to pin down the ex tent of violence in psychiatric facili ties. Studies ofinpatient violence are hard to compare because of differing definitions of violence and the van ety of settings in which the studies took place, ranging from general to
od. Similarly, Quinsey (8) found that 13 percent of the patients at a Cana dian secure forensic unit committed 61 percent of the assaults in a one year period. Another trend supported by the literature is that rates of violence seem to be higher in the United States than in other countries. Ac cording to Edwards and Reid (3), the total number of violent incidents during one year in the 28 New York State psychiatric facilities totaled 12,000, compared with only 311 violent assaults in all similar British
psychiatric
to forensic hospitals.
Reid and associates (1), in a survey ofa number ofUnited States psychi atnic hospitals, concluded that there was a “¿small but noticeable
rate of as
sault in [the] hospitals.― They re ported an average of2.54
assaults per
in a one-year pen
bed per year; very few of the assaults led to serious injury. The rate of as saults varied greatly from one hospi tal to another and even among units that appeared to be quite similar. The rates were higher on special
flicilities over three and a half years.
secure units than on other units and
U.S. psychiatric hospital. The num ben ofstaffinjured also rose, from 56 in 1975 to 289 in 1980. Similarly, a study ofa British psychiatric hospi
were also higher in state hospitals than in private hospitals. Based on a review
of several
sun
veys ofpsychiatnic hospitals in the New York City area, Kay and as sociates (2) reported that, on average, between 7 and 10 percent of patients were involved in assaults during a one- to three-month period of obser vation. Nevertheless, others (3—5) have supported the conclusion of Reid and colleagues that serious mci dents are rare. (This conclusion might be qualified, however, by the knowledge that the psychological ef fects of such incidents, though per June 1991
Vol. 42
No. 6
Finally, there is some evidence that rates ofviolence may be increas ing over time (9,10). For instance, Adler and colleagues (1 1) found a steady increase in assaults at a private
tal by Noble and Rodger(1
2) found a
“¿progressive increase―in violent in cidents, from 260 in 1976 to 1,100 in 1984 (although subsequently the number declined slightly). Individual factors As noted earlier, studies focusing on individual factors as predictors of violence may not take into account situational
and structural
effects. In
addition, independent variables used in studies of individual factors may
585
be chosen for convenience or ease of measurement; their inclusion may lack any theoretical rationale (8). These methodological shortcomings should be borne in mind in the fol lowing discussion ofstudies examin ing the relationship between mdi vidual factors and rates of assault. Using diagnosis as a predictor of violence presents some problems. Patients may have multiple diag noses, making it difficult to tease out separate effects; for instance, a schizophrenic patient may also have a personality disorder, an underlying organic brain disorder, or intellectual impairment. Studies using diagnosis as a predictor must also take into ac count the base rates of that diagnosis in the study population; for example, the finding that patients with a diag nosis ofschizophrenia are involved in violent incidents must be considered in the context ofwhether they are overrepresented in psychiatric hospi tals relative to other diagnostic groups. In addition, patients with a par ticular diagnosis do not follow a uniform course over time. Lee and colleagues (1 3) noted that “¿patients with the same diagnosis may mani fest different behavior at different times, making diagnosis an unreli able predictor of incidents.―In that sense, diagnosis may be useful only if one specifies the stage of illness; for instance, newly admitted patients in an acute
stage
could
be distinguished
from longer-term patients. Finally, studies may identify de mographic predictors of violence, such as age and history ofsimilar be havior, that in fact are the same for outpatients or the public in general (14). As a result, these studies do not contribute any new information to the understanding of violence. Diagnosis. Several researchers have attempted to establish a rela tionship between inpatient violence and diagnosis. Although they have reached no definitive conclusions, a
22), personality disorders (23—25), and mental retardation (25,26) as predictors of violence. These find ings are perhaps not surprising, for several reasons. First, patients in an acute manic state are often physically agitated. Second,
neurological
lesions,
patti
cularly in the temporal lobe, may disinhibit bebavior(27). Third, mdi viduals with personality disorders are almost by definition capable of antisocial behavior (28); in the nar cissistic personality, for example, “¿rage, hate, and envy exist to a pronounced degree―(29). Finally, those with intellectual handicaps may have a greater propensity pulsivity (30).
for im
Stage ofillness. Although it is re lated to diagnosis,
stage of illness is
arguably a more useful predictor of violence because it takes into account whether the disorder is in an acute phase
or in remission,
usually
by
symptom assessment. However, some studies have grouped patients by length ofstay, although one can not assume that patients with longer stays are less acutely ill than those with short stays. Psychotic disorders do not always settle down with time, and patients may suffer ongoing de lusions and hallucinations.
Many studies suggest that pa tients with psychotic disorders, such as schizophrenia, are violent mainly in the acute phase of the illness, or when they are actively experiencing thought disorder, delusions, and ha! !ucinations (7,19,3 1,32). Studies in dicating that low serum neuroleptic levels may correlate strongly with as saultiveness provide further support for this view (33). Other studies suggest that the level of assaultiveness changes over time; typically, the level of violence
disorders, and organic brain disor ders. It has been suggested that chronic patients (those who have long hospi tal stays) have less potential for vio lence than recently admitted pa tients (2). On the other hand, some investigators have found that the chronic subgroup poses a substantial risk for violence (38), a finding that is consistent with the fact that the patients remain hospitalized. Barber and colleagues (7), for instance, found that balfofthe
assaultive
mci
dents they reported were committed by 15 patients who had had long stays (an average stay offour and one halfyears) and who were unrespon sive to treatment. Cooper and Mendonca (39) noted that assaults by patients had a bimodal nature that was a function of length of stay; the rates of assault peaked early in the patients' stay and then later reached a second peak. They suggested that ward staff may contribute to the pattern by expect ing difficult behavior from newly ad mitted patients and being less prepared for it from patients whose stays are longer. Behavior. Several authors have concluded that inpatient violence can be predicted by behavioral cues (12,40,41). Kay and colleagues (2) found a high association between verbal and physical aggression, sug gesting one predicts the other. Lee and colleagues (1 3) concluded that “¿behavior patterns ofpatients
imme
diately before incidents might have better predictive value than diag nosis―;they recommended the use of physical or pharmacological re straints for patients who are “¿hyper active, loud, and hostile. “¿ (These findings may seem, at least to the casual reader,
self-evident
or tauto
of paranoid schizophrenia (17). Other studies have implicated mania (1 8, 19), neurological disorders (20—
zation. However, the risk may be come relatively more prominent at later stages among those with other disorders, such nonparanoid schizo phrenia, nonpsychotic disorders, mental retardation (37), personality
logical, although they may have some utility in the short-term pre diction of violence.) Cognition. Apter and colleagues (42) found that violent patients were more likely to use displacement as a defense mechanism; they concluded that “¿many acts ofviolence represent displacement ofaggression from pni mary objects onto symbolic repre sentations ofor substitutes for those objects. “¿ Bigelow and colleagues
586
June 1991
Hospital and Community Psychiatry
considerable
number ofstudies
have
found higher rates ofinvolvement by schizophrenics patients (4,1 5,16), particularly
those in the subcategory
among
acutely psychotic
individuals
drops one to two months after ad mission (34—36).Consequently, pa tients with paranoid schizophrenia may be at higher risk for committing assault in an early stage of hospitali
Vol. 42
No. 6
(1 5) found that “¿denial ofillness―was a substantial block to rehabilitation. Problems with low self-esteem, which are exacerbated
in the institu
tional setting, may lead one to use force to achieve one's needs (43). Davis and Boster (44) found that the violent group of patients they stud ied tended to regard themselves as persons to be feared and to have lim ited patterns ofimagination and fan tasy that inhibited alternative re sponses.The fantasies they did report were violent in nature. History. A history of violent be havior has often been found to predict future violent behavior (45, 46). Some authors have found it to be the best single predictor of sub sequent
violent
behavior
(44,47).
Drugs and alcohol. There is probably little doubt that drugs and alcohol, particularly central nervous system stimulants such as ampheta mines and cocaine, exacerbate inpa tient violence in the short term (27). Socioeconomic status. There has been some suggestion that assaultive patients are more likely to come from lower socioeconomic classes (16,27); however, the relationship between socioeconomic class and inpatient violence is not conclusive. Race. Few conclusions can be drawn about race as a predictor of in patient violence. For instance, Noble and Rodger
(1 2) found that the black
members of their sample were rela tively more likely to be involved in violent incidents, whereas Lawson and colleagues (48) found whites were more likely to be involved. Age. A number of researchers have found that assaults are more often
committed
by younger
in
patients (4,45,49), but the findings remain inconclusive.
Adolescent
pa
tients in particular may be impli cated (50,5 1). Sex. Study results bearing on the effect of gender on assaultiveness have been interesting, since common sense suggests male inpatients would be more assaultive than female in patients. Some researchers (45) have found males to be more assaultive, but a number ofothers have reported no relationship between sex and vio
tiveness by female patients
(26,52).
One might account for this incon sistency by viewing inpatients as a select group ofdisturbed, agitated individuals; hence, the process of selection obscures sex role differences normally found in the community. Tardiff(53) suggested that there is a “¿blurring of sex role differences once a person becomes a chronic patient in a state hospital,―and female patients adopt more aggressive, traditionally masculine characteristics.
inpatient violence has been of con siderable interest. Quinsey (8) iden rifled two distinct points of view on this matter: patients usually claimed that teasing by other patients or pro vocation by staff caused the assault, whereas the staff typically claimed that there was no reason for the ac tion; in short, staff may be unaware
of triggering events. The idea that staff in some way provoke assaults is supported by two pieces of evidence. First, staff members may be as saulted at a higher rate than other pa Situational factors tients; studies by Quinsey (8) and Researchers who have examined the Fottrell (56) reported a 2-to-i ratio. role ofsituational factors in inpatient Second, staffare not always assaulted violence have recognized that vio at a uniform rate; that is, some seem lence is an interactive phenomenon to be attacked repeatedly (57). and that aspects ofthe immediate en Ultimately, a certain amount of vironment—the physical plant and physical “¿provocation― by staff may the presence of staff and other pa be unavoidable because the attacks tients—affect an individual's behav often occur when they are adminis ior. A common theme in studies cx tering medication or leading or re ploring situational factors is that as straining agitated patients (57—59). saults are in some way provoked However, inexperience and lack of (32,50) and are not simply the spon training among staff may contribute taneous manifestation of underlying to assaults (60,61). For instance, pathology. A study by Barnard and Convey (52) found that nursing as colleagues (34) concluded that “¿en sistants were assaulted more often, vironmental factors were more sig on a relative basis, than were re nificant than were race and diagnosis gistered nurses; the assistants had of the patient― in understanding in considerable contact with patients stitutional violence. despite “¿their comparative lack of Several studies have found that rai― the number of violent incidents Further, Carmel and Hunter (62) varies as a function ofthe time of day found that more recently hired, inex or the setting within the hospital penienced staffwere more likely to be (34,54,55). Typically, these studies injured from assault; they also found have indicated that the potential for that nurses were by far the most fre assaultive incidents is greater in quent victims among professional periods when patients move or staffand that male nurses were in gather in groups; for example, when jured more often than females. (Of they walk together from the ward to course, male nurses may be expected the dining room, where a large num to be more involved in physical mci ben are clustered together. Dunivage dents.) The finding that lesser (3 2) suggested that overcrowding, trained staff are more at risk for lack ofpnivacy, and inactivity may being assaulted may be significant, contribute to violence.
Depp(54)founda slightlyhigher assault rate for mixed-sex wards than for same-sex wards and speculated that a mixed ward may produce “¿stimuli overload among very dis turbed patients. “¿ The same author detected
a “¿patienthierarchy― effect,
in which patients assaulted those they perceived as having lower status
but it is not easily reconciled
with
the fact that they may have the most contact with patients. There is some suggestion that staff attitudes provoke violence. (Engel and Marsh [63] call this a case of “¿blaming the victim. “¿) Moldin (61) suggested that in some cases “¿staff attitudes and behavior may
in order to maintain status and in
[be] the most important factors
have reported higher rates of assaul
fluence. The issue of staff provocation of
modulating . . . aggressive behavior― and that staffexpectations about pa
Hospital and Community Psychiatry
June 1991
lence (2,31,32),and some in fact
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587
tients they regard as potentially violent may result in a self-fulfilling prophecy. Moldin and others also (32,57,64) discussed the possibility that some staff, consciously or un consciously, may subtly encourage patient violence by identifying with the aggressor or because of a desire that harm will come to the victim; for instance, a staff member with lower status may wish to get back at a doctor. Other writers have discussed the possibility that staff members may displace personal feelings of anger and aggression onto the patient (32,59,60,64). Staff members de scnibed as rigid, intolerant, authoni
process ofbecoming a ‘¿last resort' for the violent mentally ill.― Mental health professionals in the community
may have a different
per
ception: with the relative unavail ability of mental hospital beds, seriously disturbed patients are backed up into the acute care hospi so that, according to Bigelow and colleagues (1 5), it is becoming the “¿residence of last resort. “¿ These au thors make the point that discharge to community facilities, such as boarding
homes and group homes, is
community may be carried over into the wards of inner-city hospitals. Anderson and colleagues (67) at tnibuted the high rate ofweapon car lying by psychiatric emergency pa tients to the rougher surroundings of the inner-city hospital they studied. Conclusions Studies have revealed several factors that may be predictive ofviolence in inpatient settings. Among them are the presence of psychosis and phase of illness. Psychotic inpatients are probably
at greatest
risk for commit
blocked because they are too few in number and their staffing and pro grams are unable to handle the “¿difficult― client. Some authors (11) tanian (32,39,57), adversarial (52), or have argued that the right to refuse “¿macho― (64) may also provoke vio treatment (in some jurisdictions) has lence. Others have suggested that in contributed to inpatient violence; consistent limit setting (61,65) they note that paranoid, hostile pa negatively affects the ward atmos tients remain paranoid and hostile if phere. Soloff(57) discussed the “¿bat they are not medicated. tered nurse syndrome,―in which pa For all ofthese reasons—agreater tients resort to violence in the face of recognition ofpatients' civil rights, intimidation to defend their self-es fewer beds, and more restrictive teem. He said this syndrome, “¿repre policies regarding detention of pa sents the staff member's pathology tients past specified time periods more than the patient's― and that the average length of stay for in such nurses “¿should be counseled out patients has dropped considerably ofthe mental health setting for their over the years (1 1); although in one own good. “¿ (Research in correctional sense this development has had its settings has uncovered the parallel benefits, it has also meant that pa notion of the “¿violence-generating tients may remain disturbed for the guard―[66].) duration oftheir hospital stay. Using a broaderperspective, some Soloff and colleagues (37) have writers have speculated that a “¿norm suggested that inpatient violence is of violence―contributes to ward as related to the flict that more patients saults; that is, there is an expectation with personality disorders are now that violence is acceptable and will treated on an inpatient basis. Alter be tolerated (32,60). It has been sug natively, some writers, such as gested that such a norm begins at the Armstrong (58), have offered a de top with bad management practices mographic explanation for the in and the underinvolvement of medi crease in violence. Because of the calstaff(3,1 1). preponderance of “¿baby boomers,― more patients are in the age range at Structural factors higher risk for mental illness and A perception exists that inpatient violent behavior. violence has been increasing oven the Cooper and Mendonca (39) sug years. Most people regard the in gested that there are greater cultural crease as a by-product of deinstitu and social sanctions for violence in tionalization and more restrictive in the United States, which may in part voluntary commitment policies. In explain why rates ofinpatient vio many jurisdictions dangerousness to lence are higher in this country than selfor others is the main criterion for they are in Britain and Sweden, for commitment; hence, by definition patients are potentially violent when instance. Finally, the location of the hospi they enter the hospital (44). Barber and colleagues (7) have suggested tal must be taken into account. Soloff that “¿the state hospital may be in the (57) noted that racial tensions in the
from staffand other patients, staff ex pectations, staff inexperience, poor management practices, and a “¿norm of violence― that tolerates a bad situation. At the structural level, a shortage of beds and community resources as well as more restrictive commitment and detention policies may result in a psychiatric population that has gone without treatment and is more agitated and disturbed than in the past. This situation calls for political decisions that balance individual freedoms against the parens patriae powers of the state. Cultural sanc tions for violence, both at the nation al and local level, must also be taken into consideration. Inpatient violence is an ongoing concern, particularly in view of the evidence that rates of violence may be increasing. This brief overview has emphasized that violence results from an interaction of multiple ftc tons: although clinical symptoms may be the most visible, clinicians
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ting violence during the acute phase of the illness, which, for the major ity, occurs relatively early in the hos pital stay. Temporary states of vio lence are exacerbated by drug abuse. Age and a history ofviolent behavior may be significant, as they are for the general population. The role of cog nitive factors, particularly the pa tient's self-concept, in the propensity for violence must also be inves tigated. Sex may not be a very useful discriminating factor. At the institutional level, a cer tam amount ofviolence may be in evitable in the process of dealing with involuntary, treatment-resis tant patients. Violence will be af fected by overcrowding,
provocation
should not perceive them as the sole cause (27). Owens and Ashcroft (68) have suggested that an overall model ofviolence must incorporate the dif ferent influences— individual, situa tional, and structural—but that given the present state ofoun knowl edge of these factors, the model will necessarily be tentative. Identifying a wide range ofvaniables, they noted, provides a greater scope for dealing with the problem. At the very least, situational factors may be addressed and manipulated to reduce levels of violence.
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65. Morrison E: Theoretical modeling to predict violencein hospitalizedpsychi atric patients. Researchin Nursing and Health 12:31—40,1989 66. Toch H: Police, Prisons, and the Problem
of Violence. Rockville, Md, Center for Studies of Crime and Delinquency, Na tional Institute ofMental Health, 1977
67. AndersonA, Ghali A, Bansil R: Weapon carrying among patients in a psychiatric emergencyroom. Hospital and Commu nity Psychiatry 40:845—847, 1989 68. Owens R, AshcroftJ: Violence: A Guide
for the Caring Professions. London, Croom Helm, 1985
Prevalence of Tardive Dyskinesia Among Three Ethnic Groups of Chronic Psychiatric Patients John Sramek, Pharm.D. Swati Roy, Ph.D. Tom Ahrens, Pharm.D. Pramual Pinanong, M.D. Neal R. Cutler, M.D. Edmond Pi, M.D. The relationship between preva knce oftardive dyskinesia and eth nicity (black, white, or Hispanic) was examined in a group of 491 chronic psychiatric patients at a large state psychiatric hospital in California. Overall, the prevalence oftardive dyskinesia was 1 7.7 per
cent. No significant differences in the prevalence of tardive dys kinesia or in neuroleptic dosage levels were found among the three groups. A relationship was found between lower prevalence of tar dive dyskinesia and higher current neuroleptic dosage, suggesting that higher dosage masks symptoms of tardive dyskinesia. The reported prevalence of tardive dyskinesia among chronic psychiat nc patients taking neuroleptic drugs ranges from .5 percent
to 65 percent,
although recent studies using stan
Dr. Sramek is director of research for California Clinical TriaLs,8500
are staffmembers at Metropolitan State Hospital. Dr. Cutler is direc
Wilshire
tor of California Clinical Trials.
Boulevard,
Beverly
Hills, California 9021 1. When this work was done he was director of research at Metropolitan State
California
Hospital
medical director of adult psychi
in Norwalk,
California.
Dr. Pi is professorofdinical
psychi
atry at the University of Southern School
ofMedicine
and
dardized rating measures have nar rowed the range to between 20 and 30 percent
(1—5).As Kane and col
leagues (6) indicated, studies
have important
prevalence limitations,
but they can identify populations that may be at increased risk for de veloping tardive dyskinesia and fac
tors that may be associated with higher risk. Few studies have compared the prevalence of tardive dyskinesia among ethnic groups, and all have been transcultural studies. In 1975 Ogita and colleagues (7) found a similar prevalence of tardive dys kinesia at a French and a Japanese psychiatric hospital. More recently,
Binder and coworkers (8) found that the prevalence of tardive dyskinesia among Japanese inpatients (2 1 pen cent) was comparable to the mean prevalence (20 percent) reported in
Dr. Roy is research coordinator
atric inpatient services at Los An
European and North American stud ies. Gardos and colleagues (9) report
and Drs.
geles County Hospital.
ed that the prevalence oftardive dys
590
Ahrens
and Pinanong
June 1991
Vol. 42
No. 6
Hospital and Community Psychiatry
Simon Davis, M.S.W.
amined.
The literature on violence by psy chiatric inpatients provides some evidence that rates ofviolence may be increasing over time and that they are higher in the United States than in other nations. This review examines the extent of in patient vioknce and describes the individual, situational, and struc turalfactors with which it is asso ciated. Individual factors include acute illness, psychosis, drug abuse, age, and history ofvioknce. Situa tionalvariables include ovenrowd ing, provocation, staff inexper ience, and management tolerance of violence. Structural factors in dude changes in mental health pol icy that have made dangerousness a frequent criterion for commit ment and a shortage of treatment resources. The author concludes that violence is the result ofan in teraction between the various types offactors and is not simply an ex pression of individual pathology. Interest in violence committed by psychiatric inpatients has been heightened by the perception that such violence has increased in the era of deinstitutionalization. The litera ture on inpatient violence is re viewed
briefly here, beginning
with
an analysis of the incidence, preva lence, and changing rates of in patient violence. The underlying fac tors affecting these rates, grouped by individuaI@ situational,
and struc
Mr. Davis is a doctoral candidate in criminology at Simon Fraser University in Vancouver, British Columbia. His address is C2-1 100 West 6th Avenue, Vancouver, Brit ish Columbia,
Canada
V6H
1A4.
Hospital and Community Psychiatry
are also ex
These categories
are some
what arbitrary; in fact, as will be em phasized later, violence is an interac tive process. The violent patient must be considered in the context not only ofthe illness but also in the context of broader situational and structural factors.
haps less visible than their physical effects, can be just as serious [6]). A number of researchers have found that a minority
ofpatients
are
responsible ftr a majority ofthe mci dents. For example, a study by Bar ber and colleagues (7) at a U.S. state mental hospital found that 15 pa tients (3.3 percent of the census) ac counted for 48.6 percent of the as
Incidence and prevalence
saultive incidents
Variations in methodology have made it difficult to pin down the ex tent of violence in psychiatric facili ties. Studies ofinpatient violence are hard to compare because of differing definitions of violence and the van ety of settings in which the studies took place, ranging from general to
od. Similarly, Quinsey (8) found that 13 percent of the patients at a Cana dian secure forensic unit committed 61 percent of the assaults in a one year period. Another trend supported by the literature is that rates of violence seem to be higher in the United States than in other countries. Ac cording to Edwards and Reid (3), the total number of violent incidents during one year in the 28 New York State psychiatric facilities totaled 12,000, compared with only 311 violent assaults in all similar British
psychiatric
to forensic hospitals.
Reid and associates (1), in a survey ofa number ofUnited States psychi atnic hospitals, concluded that there was a “¿small but noticeable
rate of as
sault in [the] hospitals.― They re ported an average of2.54
assaults per
in a one-year pen
bed per year; very few of the assaults led to serious injury. The rate of as saults varied greatly from one hospi tal to another and even among units that appeared to be quite similar. The rates were higher on special
flicilities over three and a half years.
secure units than on other units and
U.S. psychiatric hospital. The num ben ofstaffinjured also rose, from 56 in 1975 to 289 in 1980. Similarly, a study ofa British psychiatric hospi
were also higher in state hospitals than in private hospitals. Based on a review
of several
sun
veys ofpsychiatnic hospitals in the New York City area, Kay and as sociates (2) reported that, on average, between 7 and 10 percent of patients were involved in assaults during a one- to three-month period of obser vation. Nevertheless, others (3—5) have supported the conclusion of Reid and colleagues that serious mci dents are rare. (This conclusion might be qualified, however, by the knowledge that the psychological ef fects of such incidents, though per June 1991
Vol. 42
No. 6
Finally, there is some evidence that rates ofviolence may be increas ing over time (9,10). For instance, Adler and colleagues (1 1) found a steady increase in assaults at a private
tal by Noble and Rodger(1
2) found a
“¿progressive increase―in violent in cidents, from 260 in 1976 to 1,100 in 1984 (although subsequently the number declined slightly). Individual factors As noted earlier, studies focusing on individual factors as predictors of violence may not take into account situational
and structural
effects. In
addition, independent variables used in studies of individual factors may
585
be chosen for convenience or ease of measurement; their inclusion may lack any theoretical rationale (8). These methodological shortcomings should be borne in mind in the fol lowing discussion ofstudies examin ing the relationship between mdi vidual factors and rates of assault. Using diagnosis as a predictor of violence presents some problems. Patients may have multiple diag noses, making it difficult to tease out separate effects; for instance, a schizophrenic patient may also have a personality disorder, an underlying organic brain disorder, or intellectual impairment. Studies using diagnosis as a predictor must also take into ac count the base rates of that diagnosis in the study population; for example, the finding that patients with a diag nosis ofschizophrenia are involved in violent incidents must be considered in the context ofwhether they are overrepresented in psychiatric hospi tals relative to other diagnostic groups. In addition, patients with a par ticular diagnosis do not follow a uniform course over time. Lee and colleagues (1 3) noted that “¿patients with the same diagnosis may mani fest different behavior at different times, making diagnosis an unreli able predictor of incidents.―In that sense, diagnosis may be useful only if one specifies the stage of illness; for instance, newly admitted patients in an acute
stage
could
be distinguished
from longer-term patients. Finally, studies may identify de mographic predictors of violence, such as age and history ofsimilar be havior, that in fact are the same for outpatients or the public in general (14). As a result, these studies do not contribute any new information to the understanding of violence. Diagnosis. Several researchers have attempted to establish a rela tionship between inpatient violence and diagnosis. Although they have reached no definitive conclusions, a
22), personality disorders (23—25), and mental retardation (25,26) as predictors of violence. These find ings are perhaps not surprising, for several reasons. First, patients in an acute manic state are often physically agitated. Second,
neurological
lesions,
patti
cularly in the temporal lobe, may disinhibit bebavior(27). Third, mdi viduals with personality disorders are almost by definition capable of antisocial behavior (28); in the nar cissistic personality, for example, “¿rage, hate, and envy exist to a pronounced degree―(29). Finally, those with intellectual handicaps may have a greater propensity pulsivity (30).
for im
Stage ofillness. Although it is re lated to diagnosis,
stage of illness is
arguably a more useful predictor of violence because it takes into account whether the disorder is in an acute phase
or in remission,
usually
by
symptom assessment. However, some studies have grouped patients by length ofstay, although one can not assume that patients with longer stays are less acutely ill than those with short stays. Psychotic disorders do not always settle down with time, and patients may suffer ongoing de lusions and hallucinations.
Many studies suggest that pa tients with psychotic disorders, such as schizophrenia, are violent mainly in the acute phase of the illness, or when they are actively experiencing thought disorder, delusions, and ha! !ucinations (7,19,3 1,32). Studies in dicating that low serum neuroleptic levels may correlate strongly with as saultiveness provide further support for this view (33). Other studies suggest that the level of assaultiveness changes over time; typically, the level of violence
disorders, and organic brain disor ders. It has been suggested that chronic patients (those who have long hospi tal stays) have less potential for vio lence than recently admitted pa tients (2). On the other hand, some investigators have found that the chronic subgroup poses a substantial risk for violence (38), a finding that is consistent with the fact that the patients remain hospitalized. Barber and colleagues (7), for instance, found that balfofthe
assaultive
mci
dents they reported were committed by 15 patients who had had long stays (an average stay offour and one halfyears) and who were unrespon sive to treatment. Cooper and Mendonca (39) noted that assaults by patients had a bimodal nature that was a function of length of stay; the rates of assault peaked early in the patients' stay and then later reached a second peak. They suggested that ward staff may contribute to the pattern by expect ing difficult behavior from newly ad mitted patients and being less prepared for it from patients whose stays are longer. Behavior. Several authors have concluded that inpatient violence can be predicted by behavioral cues (12,40,41). Kay and colleagues (2) found a high association between verbal and physical aggression, sug gesting one predicts the other. Lee and colleagues (1 3) concluded that “¿behavior patterns ofpatients
imme
diately before incidents might have better predictive value than diag nosis―;they recommended the use of physical or pharmacological re straints for patients who are “¿hyper active, loud, and hostile. “¿ (These findings may seem, at least to the casual reader,
self-evident
or tauto
of paranoid schizophrenia (17). Other studies have implicated mania (1 8, 19), neurological disorders (20—
zation. However, the risk may be come relatively more prominent at later stages among those with other disorders, such nonparanoid schizo phrenia, nonpsychotic disorders, mental retardation (37), personality
logical, although they may have some utility in the short-term pre diction of violence.) Cognition. Apter and colleagues (42) found that violent patients were more likely to use displacement as a defense mechanism; they concluded that “¿many acts ofviolence represent displacement ofaggression from pni mary objects onto symbolic repre sentations ofor substitutes for those objects. “¿ Bigelow and colleagues
586
June 1991
Hospital and Community Psychiatry
considerable
number ofstudies
have
found higher rates ofinvolvement by schizophrenics patients (4,1 5,16), particularly
those in the subcategory
among
acutely psychotic
individuals
drops one to two months after ad mission (34—36).Consequently, pa tients with paranoid schizophrenia may be at higher risk for committing assault in an early stage of hospitali
Vol. 42
No. 6
(1 5) found that “¿denial ofillness―was a substantial block to rehabilitation. Problems with low self-esteem, which are exacerbated
in the institu
tional setting, may lead one to use force to achieve one's needs (43). Davis and Boster (44) found that the violent group of patients they stud ied tended to regard themselves as persons to be feared and to have lim ited patterns ofimagination and fan tasy that inhibited alternative re sponses.The fantasies they did report were violent in nature. History. A history of violent be havior has often been found to predict future violent behavior (45, 46). Some authors have found it to be the best single predictor of sub sequent
violent
behavior
(44,47).
Drugs and alcohol. There is probably little doubt that drugs and alcohol, particularly central nervous system stimulants such as ampheta mines and cocaine, exacerbate inpa tient violence in the short term (27). Socioeconomic status. There has been some suggestion that assaultive patients are more likely to come from lower socioeconomic classes (16,27); however, the relationship between socioeconomic class and inpatient violence is not conclusive. Race. Few conclusions can be drawn about race as a predictor of in patient violence. For instance, Noble and Rodger
(1 2) found that the black
members of their sample were rela tively more likely to be involved in violent incidents, whereas Lawson and colleagues (48) found whites were more likely to be involved. Age. A number of researchers have found that assaults are more often
committed
by younger
in
patients (4,45,49), but the findings remain inconclusive.
Adolescent
pa
tients in particular may be impli cated (50,5 1). Sex. Study results bearing on the effect of gender on assaultiveness have been interesting, since common sense suggests male inpatients would be more assaultive than female in patients. Some researchers (45) have found males to be more assaultive, but a number ofothers have reported no relationship between sex and vio
tiveness by female patients
(26,52).
One might account for this incon sistency by viewing inpatients as a select group ofdisturbed, agitated individuals; hence, the process of selection obscures sex role differences normally found in the community. Tardiff(53) suggested that there is a “¿blurring of sex role differences once a person becomes a chronic patient in a state hospital,―and female patients adopt more aggressive, traditionally masculine characteristics.
inpatient violence has been of con siderable interest. Quinsey (8) iden rifled two distinct points of view on this matter: patients usually claimed that teasing by other patients or pro vocation by staff caused the assault, whereas the staff typically claimed that there was no reason for the ac tion; in short, staff may be unaware
of triggering events. The idea that staff in some way provoke assaults is supported by two pieces of evidence. First, staff members may be as saulted at a higher rate than other pa Situational factors tients; studies by Quinsey (8) and Researchers who have examined the Fottrell (56) reported a 2-to-i ratio. role ofsituational factors in inpatient Second, staffare not always assaulted violence have recognized that vio at a uniform rate; that is, some seem lence is an interactive phenomenon to be attacked repeatedly (57). and that aspects ofthe immediate en Ultimately, a certain amount of vironment—the physical plant and physical “¿provocation― by staff may the presence of staff and other pa be unavoidable because the attacks tients—affect an individual's behav often occur when they are adminis ior. A common theme in studies cx tering medication or leading or re ploring situational factors is that as straining agitated patients (57—59). saults are in some way provoked However, inexperience and lack of (32,50) and are not simply the spon training among staff may contribute taneous manifestation of underlying to assaults (60,61). For instance, pathology. A study by Barnard and Convey (52) found that nursing as colleagues (34) concluded that “¿en sistants were assaulted more often, vironmental factors were more sig on a relative basis, than were re nificant than were race and diagnosis gistered nurses; the assistants had of the patient― in understanding in considerable contact with patients stitutional violence. despite “¿their comparative lack of Several studies have found that rai― the number of violent incidents Further, Carmel and Hunter (62) varies as a function ofthe time of day found that more recently hired, inex or the setting within the hospital penienced staffwere more likely to be (34,54,55). Typically, these studies injured from assault; they also found have indicated that the potential for that nurses were by far the most fre assaultive incidents is greater in quent victims among professional periods when patients move or staffand that male nurses were in gather in groups; for example, when jured more often than females. (Of they walk together from the ward to course, male nurses may be expected the dining room, where a large num to be more involved in physical mci ben are clustered together. Dunivage dents.) The finding that lesser (3 2) suggested that overcrowding, trained staff are more at risk for lack ofpnivacy, and inactivity may being assaulted may be significant, contribute to violence.
Depp(54)founda slightlyhigher assault rate for mixed-sex wards than for same-sex wards and speculated that a mixed ward may produce “¿stimuli overload among very dis turbed patients. “¿ The same author detected
a “¿patienthierarchy― effect,
in which patients assaulted those they perceived as having lower status
but it is not easily reconciled
with
the fact that they may have the most contact with patients. There is some suggestion that staff attitudes provoke violence. (Engel and Marsh [63] call this a case of “¿blaming the victim. “¿) Moldin (61) suggested that in some cases “¿staff attitudes and behavior may
in order to maintain status and in
[be] the most important factors
have reported higher rates of assaul
fluence. The issue of staff provocation of
modulating . . . aggressive behavior― and that staffexpectations about pa
Hospital and Community Psychiatry
June 1991
lence (2,31,32),and some in fact
Vol. 42
No. 6
587
tients they regard as potentially violent may result in a self-fulfilling prophecy. Moldin and others also (32,57,64) discussed the possibility that some staff, consciously or un consciously, may subtly encourage patient violence by identifying with the aggressor or because of a desire that harm will come to the victim; for instance, a staff member with lower status may wish to get back at a doctor. Other writers have discussed the possibility that staff members may displace personal feelings of anger and aggression onto the patient (32,59,60,64). Staff members de scnibed as rigid, intolerant, authoni
process ofbecoming a ‘¿last resort' for the violent mentally ill.― Mental health professionals in the community
may have a different
per
ception: with the relative unavail ability of mental hospital beds, seriously disturbed patients are backed up into the acute care hospi so that, according to Bigelow and colleagues (1 5), it is becoming the “¿residence of last resort. “¿ These au thors make the point that discharge to community facilities, such as boarding
homes and group homes, is
community may be carried over into the wards of inner-city hospitals. Anderson and colleagues (67) at tnibuted the high rate ofweapon car lying by psychiatric emergency pa tients to the rougher surroundings of the inner-city hospital they studied. Conclusions Studies have revealed several factors that may be predictive ofviolence in inpatient settings. Among them are the presence of psychosis and phase of illness. Psychotic inpatients are probably
at greatest
risk for commit
blocked because they are too few in number and their staffing and pro grams are unable to handle the “¿difficult― client. Some authors (11) tanian (32,39,57), adversarial (52), or have argued that the right to refuse “¿macho― (64) may also provoke vio treatment (in some jurisdictions) has lence. Others have suggested that in contributed to inpatient violence; consistent limit setting (61,65) they note that paranoid, hostile pa negatively affects the ward atmos tients remain paranoid and hostile if phere. Soloff(57) discussed the “¿bat they are not medicated. tered nurse syndrome,―in which pa For all ofthese reasons—agreater tients resort to violence in the face of recognition ofpatients' civil rights, intimidation to defend their self-es fewer beds, and more restrictive teem. He said this syndrome, “¿repre policies regarding detention of pa sents the staff member's pathology tients past specified time periods more than the patient's― and that the average length of stay for in such nurses “¿should be counseled out patients has dropped considerably ofthe mental health setting for their over the years (1 1); although in one own good. “¿ (Research in correctional sense this development has had its settings has uncovered the parallel benefits, it has also meant that pa notion of the “¿violence-generating tients may remain disturbed for the guard―[66].) duration oftheir hospital stay. Using a broaderperspective, some Soloff and colleagues (37) have writers have speculated that a “¿norm suggested that inpatient violence is of violence―contributes to ward as related to the flict that more patients saults; that is, there is an expectation with personality disorders are now that violence is acceptable and will treated on an inpatient basis. Alter be tolerated (32,60). It has been sug natively, some writers, such as gested that such a norm begins at the Armstrong (58), have offered a de top with bad management practices mographic explanation for the in and the underinvolvement of medi crease in violence. Because of the calstaff(3,1 1). preponderance of “¿baby boomers,― more patients are in the age range at Structural factors higher risk for mental illness and A perception exists that inpatient violent behavior. violence has been increasing oven the Cooper and Mendonca (39) sug years. Most people regard the in gested that there are greater cultural crease as a by-product of deinstitu and social sanctions for violence in tionalization and more restrictive in the United States, which may in part voluntary commitment policies. In explain why rates ofinpatient vio many jurisdictions dangerousness to lence are higher in this country than selfor others is the main criterion for they are in Britain and Sweden, for commitment; hence, by definition patients are potentially violent when instance. Finally, the location of the hospi they enter the hospital (44). Barber and colleagues (7) have suggested tal must be taken into account. Soloff that “¿the state hospital may be in the (57) noted that racial tensions in the
from staffand other patients, staff ex pectations, staff inexperience, poor management practices, and a “¿norm of violence― that tolerates a bad situation. At the structural level, a shortage of beds and community resources as well as more restrictive commitment and detention policies may result in a psychiatric population that has gone without treatment and is more agitated and disturbed than in the past. This situation calls for political decisions that balance individual freedoms against the parens patriae powers of the state. Cultural sanc tions for violence, both at the nation al and local level, must also be taken into consideration. Inpatient violence is an ongoing concern, particularly in view of the evidence that rates of violence may be increasing. This brief overview has emphasized that violence results from an interaction of multiple ftc tons: although clinical symptoms may be the most visible, clinicians
588
Hospital and Community Psychiatry
June 1991
Vol. 42
No. 6
ting violence during the acute phase of the illness, which, for the major ity, occurs relatively early in the hos pital stay. Temporary states of vio lence are exacerbated by drug abuse. Age and a history ofviolent behavior may be significant, as they are for the general population. The role of cog nitive factors, particularly the pa tient's self-concept, in the propensity for violence must also be inves tigated. Sex may not be a very useful discriminating factor. At the institutional level, a cer tam amount ofviolence may be in evitable in the process of dealing with involuntary, treatment-resis tant patients. Violence will be af fected by overcrowding,
provocation
should not perceive them as the sole cause (27). Owens and Ashcroft (68) have suggested that an overall model ofviolence must incorporate the dif ferent influences— individual, situa tional, and structural—but that given the present state ofoun knowl edge of these factors, the model will necessarily be tentative. Identifying a wide range ofvaniables, they noted, provides a greater scope for dealing with the problem. At the very least, situational factors may be addressed and manipulated to reduce levels of violence.
chiatry 155:384—390,1989
30. Wilson JQ, Hermstein
13. Lee H, Villar 0, Juthani N, et al: Char
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Psychiatry141:10—15, 1984 15. Bigelow
Characteristics of state hospital patients who arehardtoplace. Hospitaland Com muniry Psychiatry 39:181—185, 1988 16. Edwards J, Jones D, Reid W: Physical assaults in a psychiatric unit ofa general
hospital. Americanjournalof Psychiatry 145:1568—1571, 1988 17. Bradford J: The forensic psychiatric aspects of schizophrenia. Psychiatric 96—103,1983
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Prevalence of Tardive Dyskinesia Among Three Ethnic Groups of Chronic Psychiatric Patients John Sramek, Pharm.D. Swati Roy, Ph.D. Tom Ahrens, Pharm.D. Pramual Pinanong, M.D. Neal R. Cutler, M.D. Edmond Pi, M.D. The relationship between preva knce oftardive dyskinesia and eth nicity (black, white, or Hispanic) was examined in a group of 491 chronic psychiatric patients at a large state psychiatric hospital in California. Overall, the prevalence oftardive dyskinesia was 1 7.7 per
cent. No significant differences in the prevalence of tardive dys kinesia or in neuroleptic dosage levels were found among the three groups. A relationship was found between lower prevalence of tar dive dyskinesia and higher current neuroleptic dosage, suggesting that higher dosage masks symptoms of tardive dyskinesia. The reported prevalence of tardive dyskinesia among chronic psychiat nc patients taking neuroleptic drugs ranges from .5 percent
to 65 percent,
although recent studies using stan
Dr. Sramek is director of research for California Clinical TriaLs,8500
are staffmembers at Metropolitan State Hospital. Dr. Cutler is direc
Wilshire
tor of California Clinical Trials.
Boulevard,
Beverly
Hills, California 9021 1. When this work was done he was director of research at Metropolitan State
California
Hospital
medical director of adult psychi
in Norwalk,
California.
Dr. Pi is professorofdinical
psychi
atry at the University of Southern School
ofMedicine
and
dardized rating measures have nar rowed the range to between 20 and 30 percent
(1—5).As Kane and col
leagues (6) indicated, studies
have important
prevalence limitations,
but they can identify populations that may be at increased risk for de veloping tardive dyskinesia and fac
tors that may be associated with higher risk. Few studies have compared the prevalence of tardive dyskinesia among ethnic groups, and all have been transcultural studies. In 1975 Ogita and colleagues (7) found a similar prevalence of tardive dys kinesia at a French and a Japanese psychiatric hospital. More recently,
Binder and coworkers (8) found that the prevalence of tardive dyskinesia among Japanese inpatients (2 1 pen cent) was comparable to the mean prevalence (20 percent) reported in
Dr. Roy is research coordinator
atric inpatient services at Los An
European and North American stud ies. Gardos and colleagues (9) report
and Drs.
geles County Hospital.
ed that the prevalence oftardive dys
590
Ahrens
and Pinanong
June 1991
Vol. 42
No. 6
Hospital and Community Psychiatry
