Suicide and violence in patients with major psychiatric disorders

The relationship between violence directed at the self and violence directed at others has intrigued psychiatrists for several decades. The goal of this study was to examine the relationship between suicide and violence against others in patients with major psychiatric disorders and to compare psychiatric symptoms associated with suicide in violent and non-violent patients. Subjects included physically assaultive psychiatric inpatients and a nonviolent comparison group. Physical and verbal assaults were recorded prospectively for 4 weeks. History of suicide attempts was obtained through chart review and patient interviews. The Brief Psychiatric Rating Scale was administered at the end of the 4 weeks by raters who were blind to both suicidal and violent behavior. The suicide attempters did not differ from the non-attempters on any measure of violent behavior or hostility. Suicide attempts were not accompanied by different symptoms in violent and non-violent patients; however, violence and suicide attempts were accompanied by dissimilar psychiatric symptoms. The physically assaultive patients presented with more severe positive psychotic symptoms than the non-assaultive patients. The suicide attempters, on the other hand, did not differ from non-attempters on psychotic symptoms, but presented with more severe depression and anxiety. The relationship between these symptoms and suicide attempts was noteworthy in its temporal stability, as most of the patients had attempted suicide many years prior to this study.     

Pathways to violent and non-violent criminality in an adolescent psychiatric population

In a Norwegian follow-up study of former adolescent psychiatric in-patients 222 patients who had committed violent crimes were compared to 287 patients who had committed non-violent crimes only. There were numerous significant differences between the criminal careers of violent and non-violent criminals. Individuals with a history of violent criminality only were uncommon and uncharacteristic of violent criminals in general. Regression analyses identified several strong and independent correlates of violent criminality. The study supported a division of antisocial behavior into violent and non-violent sub-groups, thus paralleling a concept of overt and covert pathways to delinquent behavior. The overt pathway seemed to be imbedded in the covert pathway.     

Low serum cholesterol in violent but not in non-violent suicide attempters

Many previous studies have suggested that low or lowered serum cholesterol levels may increase the risk of mortality not due to somatic disease: principally, suicide and violent death. Because violent death is rare, some studies have investigated afterwards the relation between cholesterol levels and either suicide attempts in psychiatric populations or violence in criminally violent populations. However, none of these studies have compared cholesterol levels in violent and non-violent suicide attempters. The blood of 25 consecutive drug-free patients following a violent suicide attempt and of 27 patients following a non-violent suicide attempt by drug overdose was drawn in the 24 h following admission. Patients with a diagnosis of alcohol abuse and with cholesterol-lowering therapy were excluded. Age, sex, body mass index, psychiatric diagnosis and the physical conditions of the suicide attempt were investigated. Thirty-two healthy subjects were used as a control group. There were no differences between the groups in age, frequency of psychiatric diagnoses or body mass index. There was more women in the group of non-violent suicide attempters than in that of violent suicide attempters (P<0.001). In analyses controlling for sex and age, the serum cholesterol concentration was 30% lower (F(2,82)=15.8; P<0.0001) in the group of violent suicide attempters (147+/-54 mg/dl) than in the group of non-violent suicide attempters (209+/-38 mg/dl) or control subjects (213+/-46 mg/dl). Our results showed that low serum cholesterol level is associated with the violence of the suicide attempt and not with the suicide attempt itself. Further investigations are necessary to determine the usefulness of this easily accessible parameter as a potential risk indicator for violent acts such as violent suicidal behavior in susceptible individuals.     

Can lipid analysis help identify repeatedly violent patients after discharge from acute psychiatry?

In this study of 196 patients discharged from an acute psychiatric ward, 11 patients (6%) were identified as exhibiting repeated violence and having frequent readmissions. Compared with non-violent patients and those with only one violent post-discharge episode, repeatedly violent patients were significantly characterised by male gender, higher rates of previous threats of violence, lack of empathy, more severe violence during follow-up, and lower high-density lipoprotein levels.     

Executive function and in-patient violence in forensic patients with schizophrenia

BACKGROUND: The literature on the association between neuropsychological deficits and in-patient violence in schizophrenia is limited and the findings inconsistent. AIMS: To examine the role of executive function deficits in inpatient violence using measures of dorsolateral (DLPFC) and ventrolateral prefrontal cortical (VLPFC) function. METHODS: Thirty-three violent and forty-nine non-violent male forensic in-patients with schizophrenia were assessed using neuropsychological tasks probing DLPFC and VLPFC function and on measures of symptoms and psychopathy. RESULTS: There were no significant group differences in neuropsychological task performance. Higher rates of violence were significantly associated with lower current IQ scores and higher excitement symptom scores. The 'violent' group had significantly higher interpersonal and antisocial domain psychopathy scores. In a logistic regression analysis, IQ and the interpersonal domain of psychopathy were significant discriminators of violent v. non-violent status. CONCLUSIONS: Personality factors rather than symptoms and neuropsychological function may be important in understanding in-patient violence in forensic patients with schizophrenia.     

The P50 auditory evoked potential in violent and non-violent patients with schizophrenia

BACKGROUND: Emotionally driven violence is facilitated by increased arousal. It may be a consequence of an information-processing deficit and the cognitive attributions for the stimuli given by the subject. The aim of this study was to compare the P50 evoked potential responses of violent patients with schizophrenia with non-violent patients with schizophrenia and healthy controls. METHOD: Patients were classified into violent and non-violent in accordance to the Overt Aggression Scale. P50 auditory evoked potentials of 32 unmedicated patients with schizophrenia (violent=14, non-violent=18) and 17 healthy controls were recorded during five runs of 30 click pairs. RESULTS: Healthy controls exhibited a lower S2/S1 ratio when compared to violent (p<0.001) and non-violent (p=0.04) patients. Using a cutoff point of 0.50 for S2/S1 ratio to define abnormal gating a significant proportion of violent patients did not show P50 suppression (71.4%) in comparison to non-violent patients (38.9%) and healthy controls (23.5%) (p=0.02). CONCLUSIONS: Violent behavior in patients with schizophrenia could be associated with a disturbed information sensory gating. Violence in patients with schizophrenia may be facilitated by an increased arousal which may in turn be the result of an information-processing deficit.     

Exposure to Family Violence of Israeli Inmates: Does Sex Make a Difference?

The purpose of the current study was to examine differences by sex (a) in history of child abuse and neglect (CAN) and exposure to parental partner violence (PPV); and (b) in the association of CAN and PPV with violent offenses, substance use, suicidal behavior, and psychiatric problems. This cross-sectional study investigated sex differences in CAN and exposure to PPV in a sample of 290 Israeli inmates (65 women and 225 men). Participants completed a self-report measures of the Childhood Trauma Questionnaire, and the revised Conflict Tactics Scale to measure PPV. The findings indicated that the female inmates had experienced significantly more sexual abuse (p?<?.001), and more exposure to PPV (p?=?.030), compared with male inmates. Female inmates who had experienced CAN were at higher risk of committing violent offenses than male inmates and female inmates were also more likely than male inmates to have been engaged in suicidal behaviors (39.3% and 18.5%, respectively), and to have had psychiatric problems (40% and 14.2%, respectively). The findings also revealed that psychiatric problems and suicidal behavior can be predicted by CAN and family substance use. The findings highlight the effects of the adverse childhood experience of exposure to CAN and PPV on behavioral problems. Appropriate treatment requires simultaneous intervention that targets all three issues of childhood trauma, substance use disorders, and psychiatric problems for both sexes.

     

Violence in psychiatric in-patients: review and clinical implications

The literature on violence by psychiatric patients is reviewed. Emphasis is given to recent papers relevant to clinical management. Most studies are cross-sectional. The Maudsley/Bethlem Violent Incidents Register is used to provide longitudinal data over a period in excess of 20 years. In acute units most violent actions are carried out by patients suffering from schizophrenia, personality disorder and alcohol or substance abuse. In longer stay units violence tends to be associated with either intractable schizophrenia or with organic syndromes-particularly mental impairment. Most in-patient violence is minor and repetitive. Patients at risk are usually easily identifiable by a past history of violence or aggression. Most psychiatric patients are non-violent, but a small proportion of patients account for a large number of incidents. Violence by psychotic patients is particularly likely to occur in the period leading up to and immediately following admission, when the patient is acutely disturbed. The prevention of violence is largely a matter of good psychiatric and nursing care for patients at risk. Much of the violence committed by recently admitted psychotic patients could be prevented if after care facilities were more effective in preventing non-compliance and relapse.     

Biosocial aspects of domestic violence

Domestic violence, defined as acts of verbal abuse and physical violence performed against women by current intimate main partners, was surveyed by means of the Conflict Tactics Scale. We examined the relationships between a biological variable (testosterone level), social variables (demographics, social integration), and behaviour (substance use) and self-reported domestic violence. Forced-entry OLS regression models allowed us to study how social and behavioural variables modified the effects of testosterone on this specific violent behaviour.The sample consisted of 54 men who had a main sexual partner and who identified themselves as Black, White, or Hispanic. The men were recruited from various social-service-agency sites in the area of Miami, Florida, on the basis of their risk factors for HIV/AIDS. The sample can best be described as culturally diverse men of low socioeconomic status who had a main sexual partner. A high percentage of participants reported some level of both verbal and physical aggression towards their partners. Testosterone levels were significantly associated with levels of both verbal aggression and physical violence self-reported by the men. Testosterone level, demographic characteristics, and alcohol consumption contributed to explaining the variance in self-reported verbal and physical abuse. The high heritability of testosterone level and its association with violent behaviour warrant the inclusion of this variable in studies of antisocial and criminal behaviour including domestic violence.     

The Extended Staff Observation Aggression Scale (SOAS-E): development,presentation and evaluation

The Staff Observation Aggression Scale (SOAS) was developed as a scale for reporting aggressive incidents involving psychiatric in-patients. The SOAS — Extended Version (SOAS-E) has the same aim, but has additional categories and subcategories. The SOAS-E clearly distinguishes between violent and non-violent aggressive behaviour and characterizes in more detail the associated situation. However, the main contribution of the SOAS-E is the introduction of a category of‘warning signals’ that precede the releasing‘provocation factor’ as a separate and primary aspect of the cyclus of aggressive incidents. The development of the SOAS-E is described, and the testing and inter-rater reliability of the warning signals category are examined. Compared to the SOAS, the additional categories of the SOAS-E are found to increase the scope for a detailed characterization of aggressive behaviour in psychiatric wards.     

Risk factors for violence among long-stay psychiatric patients: national study.

This study identified risk factors for violence among long-stay (1 year or more) psychiatric patients in Israel (n = 2946) using data from a national reevaluation of such patients. Patients were rated as being violent if hospital staff or patient charts indicated an incident of physical violence at least every few months. The relationship between violence and patients' functioning, living conditions, treatment, background and hospitalization history was studied. In total, 22.8% of patients were violent. Based on logistic regression analysis, the risk factors for being violent were younger age, younger age at first hospitalization, poorer self-care, having more frequent visitors, and the patient not having his or her own clothing. The data for age and lack of gender differences confirm previous findings. However, the results regarding clothing, visitors, poor self-care and age of onset are unique. The results of this study suggest that the violent behaviour of in-patients is related to both individual and environmental variables.     

Cerebrospinal fluid monoamine metabolites and suicide

Prospective studies of the serotonergic system and suicide report that low 5-hydroxyindolacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and a history of attempted suicide predict suicide risk. Low CSF homovanillic acid (HVA) is reported to be associated with past and future lethality of suicide attempts but not with suicide. The interrelationships between monoamine metabolites, violent method, suicide intent and lethality of suicidal behaviour are complex. We hypothesized that CSF 5-HIAA and HVA levels are related to suicide intent, violence and lethality of suicidal behaviour. Fifteen male suicide attempters admitted to a psychiatric ward at the Karolinska University Hospital and eight healthy male volunteers were submitted to lumbar puncture and CSF 5-HIAA and HVA were assayed. Suicide intent with the Beck Suicide Intent Scale (SIS), lethality and violence of suicidal behaviour were assessed. All patients were followed up for causes of death. Six suicides and one fatal accident were identified with death certificates. Mean CSF 5-HIAA but not CSF HVA differed between suicides and survivors. Violent suicides had higher suicide intent and CSF 5-HIAA than non-violent suicides. In violent suicides, CSF 5-HIAA levels were negatively correlated with SIS. Greater suicide intent may be associated with greater aggressive intent and predicts a violent suicide method.     

Violence in inpatients with schizophrenia: a prospective study.

Accurate evaluations of the dangers posed by psychiatric inpatients are necessary, although a number of studies have questioned the accuracy of violence prediction. In this prospective study, we evaluated several variables in the prediction of violence in 63 inpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Nurses rated violent incidents with the Overt Aggression Scale. During hospitalization, sociodemographic variables, clinical history, neurological soft signs, community alcohol or drug abuse, and electroencephalographic abnormalities did not differ between violent and nonviolent groups. Violent patients had significantly more positive symptoms as measured by the Positive and Negative Syndrome Scale (PANSS), higher scores on the PANSS general psychopathology scale, and less insight in the different constructs assessed. A logistic regression was performed to discriminate between violent and nonviolent patients. Three variables entered the model: insight into symptoms, PANSS general psychopathology score, and violence in the previous week. The actuarial model correctly classified 84.13 percent of the sample; this result is significantly better than chance for the base rate of violence in this study. At hospital admission, clinical rather than sociodemographic variables were more predictive of violence. This finding has practical importance because clinical symptoms are amenable to therapeutic approaches. This study is the first to demonstrate that insight into psychotic symptoms is a predictor of violence in inpatients with schizophrenia.     

Characteristics of violent behaviour in acute psychiatric in-patients: a 5-year Italian study.

OBJECTIVE: In order to examine prospectively the characteristics of violence among psychiatric patients, a 5-year study was carried out in an acute psychiatric unit. METHOD: All assaultive behaviour occurred in the ward during the study period were assessed routinely using the Staff Observation Aggression scale (SOAS). RESULTS: Of 1534 patients admitted to the unit during the study period, 116 were responsible for 329 aggressive episodes (prevalence of violence=7.5%, 2.8 incidents/patient). Most violent patients had an ICD-9 diagnosis of schizophrenia and/or delusional syndromes (55.1%), a history of violence (80.7%) and previous psychiatric admissions (92%). Approximately half of the incidents had no specific cause, occurred during daytime and the first week of admission and, in most cases, were directed towards individuals (77.8%). CONCLUSION: Although confirming the low rate of violence among Italian psychiatric in-patients, the study indicates the need for more attention to the problem of aggression in general hospital psychiatric units.     

Serum leptin and cholesterol values in violent and non-violent suicide attempters

Earlier studies have linked lipid metabolism to suicide and impulsive-aggressive behaviors. We previously reported that suicide attempters had significantly lower leptin and cholesterol levels than controls. Since lower cholesterol levels have been related to violence alone, we decided to evaluate serum total cholesterol and leptin levels in violent and non-violent suicide attempters. In the present study, 19 violent, 16 non-violent suicide attempters, and 20 age- and sex-matched healthy controls were compared for serum total cholesterol and leptin levels. Violent suicide attempters had significantly lower total cholesterol and leptin levels compared with those with non-violent suicide attempts. Our results suggest that low serum cholesterol and leptin levels are related to the following two dimensions of suicide attempts: suicidality and violence.     

Serotonin, testosterone and alcohol in the etiology of domestic violence

In a previous study we administered the panicogenic agent sodium lactate to a select group of perpetrators of domestic violence and comparison groups. Results of that study showed that perpetrators exhibited exaggerated lactate-induced fear, panic and rage. In this current study, we compared the cerebral spinal fluid (CSF) concentrations of 5-hydroxyindoleacetic acid (5-HIAA) and testosterone obtained from perpetrators of domestic violence and a group of healthy comparison subjects. All subjects were assessed for DSM-III-R diagnoses. Perpetrators with alcohol dependence (DV-ALC) (n=13), perpetrators without alcohol dependence (DV-NALC) (n=10) and healthy comparison subjects (HCS) (n=20) were clinically assessed using the Spielberger Trait Anxiety, Brown-Goodwin Aggression Scale, Buss Durkee Hostility Inventory and Straus Conflict Tactics. Following an overnight fast and bed rest, subjects received a lumbar puncture to obtain CSF concentrations of 5-HIAA and testosterone. Perpetrators scored significantly higher on measures of aggression than HCS. DV-NALC had significantly lower concentrations of CSF 5-HIAA and higher Straus Conflict Tactics (CT) physical violence scores than DV-ALC and HCS. DV-ALC had significantly higher concentrations of CSF testosterone than DV-NALC. DV-ALC also had significantly higher Straus CT physical violence scores than HCS. DV-NALC and DV-ALC differed on 5-HIAA concentrations, testosterone concentrations, Straus CT physical violence scores and alcohol dependence. These results suggest that DV-NALC and DV-ALC groups could have different biological mechanisms mediating domestic violence.     

Relationship between solvent inhalation and antisocial behavior: Special emphasis on two types of violence seen in solvent abusers

Abstract Organic solvent inhalation is a serious problem among youths in Japan. It induces physical and mental disorders, and is related closely to crime and delinquency. The relationship between solvent inhalation and antisocial behavior was investigated in 75 youths. The subjects were divided into three groups according to the level of violent behavior and the time of appearance: a non-violent group, a late-onset group (violence occurred after the start of inhalation) and an early-onset group (violence had occurred before the start of inhalation). Various parameters were compared among the groups. The late-onset group showed the following characteristics: (i) the frequency of inhalation was high, and many subjects experienced hallucinations and mood changes caused by inhalation; (ii) the family environment was characterized by conflict; and (iii) the subjects had strong psychological conflicts and showed dissociative coping with frustration. The violence, psychological conflict and dissociation in this group were found to be related to the inhalation, with familial conflict as a background. The violence in the early-onset group was considered to be the manifestation of a violent personality as the frequency of inhalation and the incidence of mental symptoms were both low. The subjects in this group showed weak psychological conflict and tended to be demanding of others when attempting to cope with frustration. Two types of violent behaviors in the teenagers who inhaled solvents were identified. The violence of solvent inhalers should be managed according to the type.     

Anxiety,depression, impulsivity and substance misuse in violent and non-violent adolescent boys in detention in China

The present investigation aims to identify the factors which differentiate violent from non-violent juvenile offenders, with a particular emphasis on the association between internalizing psychiatric morbidity (i.e. anxiety and depression), impulsivity, substance misuse, and violence. A total of 323 incarcerated male juvenile offenders from one of three Youth Detention Centers (YDCs) in China were recruited between August 2007 and November 2008. Interviews were conducted by trained psychiatrists using the Barratt Impulsivity Scale (BIS-11), the Screen for Child Anxiety Related Emotional Disorders (SCARED), and the Birleson Depression Self-Rating Scale (DSRS) to assess impulsivity, anxiety and depression, respectively. The Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) was also used to assess psychiatric diagnoses. Violent offenders had significantly higher BIS-11 total scores, and attention and nonplanning subscale scores (p<0.05). In the multiple logistic regression model, substance use disorders (SUD) and BIS-11 total scores independently predicted violence. Prison-based treatment services designed to reduce impulsivity and substance misuse in juvenile detention facilities should be prioritized.     

Short-term effects of psychiatric symptoms and interpersonal stressors on criminal violence

BACKGROUND: The aim of the study was to analyse the triggering or acute risk effect of psychiatric symptoms and interpersonal stressors on criminal violence. METHOD: One hundred and thirty three violent offenders were recruited from a forensic psychiatric evaluation (FPE) unit and a national prison evaluation unit in Sweden during 2002-2003, and were interviewed about trigger exposures. A case-crossover design was used eliminating long-term within individual confounding. RESULTS: Suicidal ideation or parasuicide within 24 h before the violent event conferred a ninefold risk increase. In contrast, violent ideation did not trigger criminal violence. Hallucinations yielded a fourfold risk increase, whereas paranoid thoughts were associated with a small and statistically non-significant risk increase. Acute conflicts with others and being denied psychiatric care within 24 h before violence also increased the risk of acting violently. CONCLUSIONS: Some tested psychiatric symptoms and stressors triggered criminal violence, whereas others did not. The case-crossover design may be particularly useful for the study of triggers of violence.