Patient characteristics associated with aggression in mental health units
Introduction
Aggression in mental health units erodes the therapeutic environment, causes psychological and physical harms to patients and staff, and ultimately impairs care (Daffern and Howells, 2002). Research into aggression within mental health units typically neglects theoretical perspectives, distal, environmental and interactional causes in favor of proximal psychiatric symptoms, consistent with an internal model of inpatient aggression (Nijman et al., 1999). In this regard extant research reveals a small but significant association between some psychiatric symptoms and aggression; active positive symptoms of psychosis including delusions, conceptual disorganisation, hallucinations and paranoia appear to have the strongest association with aggression (Swanson et al., 2006, Douglas et al., 2009). Few models of inpatient aggression incorporating personal, interpersonal and environmental factors have been developed (for exception see Nijman et al. (1999), Duxbury and Whittington (2005).
Contemporary aggression theories such as the General Aggression Model (GAM; Anderson and Bushman, 2002) consider aggression to be the product of multiple interacting factors; accordingly, distal (i.e. personality characteristics) and situational factors (i.e. provocation) create an internal state which affects decision-making processes that determine aggressive action. According to the GAM, habitual aggression results from the acquisition of aggression-related cognitions including aggression-related behavioral scripts (i.e. scripts denoting how a person should interact with their environment), attitudes (i.e. a person's beliefs about the acceptability of aggression), and their related affective states (i.e. anger (Anderson and Bushman, 2002)). Interpersonal hostile-dominance (Dolan and Blackburn, 2006) and psychopathy (Hare, 2003) have also been associated with aggressive behavior in inpatient settings (Daffern et al., 2010). Where psychopathy is thought to comprise persistent behavioral deviancy accompanied by emotional-interpersonal detachment (Patrick et al., 2009), interpersonal hostile-dominance describes a pattern of relating to others in a manner that is antagonistic and domineering.
The current study examined the impact of interpersonal (e.g., hostile-dominance), personality (psychopathy), GAM-specified (aggressive script rehearsal, attitudes towards violence, and trait anger), and clinical (psychiatric symptoms) factors on aggression during psychiatric hospitalization. It was hypothesized that (1) the interpersonal and personality, GAM-specified, and clinical factors would all significantly predict inpatient aggressive behavior, and that (2) the addition of interpersonal variables would improve the prediction of aggression beyond clinical, personality and GAM-specified variables.
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Participants
Participants were 200 patients admitted to two acute units at the Alfred Hospital Inpatient Psychiatry Unit, Melbourne, Australia, between 12th of January 2012 and 10th of October 2012. The sample included 132 men (M=38.12 years, S.D.=11.14 years) and 68 women (M=38.69 years, S.D.=11.20 years) with an age range of 19–64 years (M=38.32 years, S.D.=11.13 years). The average length of hospital stay for participants was approximately two weeks (M=14.59 days, S.D.=15.96 days).
The most common primary
Results
All data was examined for accuracy, missing values, and outliers. A random check of 50 participants’ entered data showed data entry to be accurate. There were no missing values. Four participants were identified as having univariate outlier responses, as indicated by z-scores greater than 3.29. One participant was an outlier on the STAXI-2: TA and three participants were outliers on the PCL: SV. Given the large sample size, the decision was made to retain these participants in the analysis.
The
Discussion
At the univariate level, interpersonal hostile-dominance, psychopathy, aggressive script rehearsal, attitudes towards violence, trait anger, and PANSS Disorganized and Excited symptoms all predicted aggressive behavior. Positive symptoms did not independently predict aggression. Multivariable analysis showed that interpersonal hostile-dominance predicted aggressive behavior independent of clinical and GAM-specified factors. Furthermore, the addition of personality variables significantly
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of Conflicting Interests
The Authors declare that there is no conflict of interest.
Acknowledgements
None.
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