Elizabeth Walsh

Bullying victimization uniquely contributes to adjustment problems in young children: a nationally representative cohort study

OBJECTIVE. It has been shown that bullying victimization is associated with behavior and school adjustment problems, but it remains unclear whether the experience of bullying uniquely contributes to those problems after taking into account preexisting adjustment problems. METHODS. We examined bullying in the Environmental Risk Study, a nationally representative 1994–1995 birth cohort of 2232 children. We identified children who experienced bullying between the ages of 5 and 7 years either as pure victims or bully/victims. We collected reports from mothers and teachers about children’s behavior problems and school adjustment when they were 5 years old and again when they were age 7. RESULTS. Compared with control children, pure victims showed more internalizing problems and unhappiness at school when they were 5 and 7 years. Girls who were pure victims also showed more externalizing problems than controls. Compared with controls and pure victims, bully/victims showed more internalizing problems, more externalizing problems, and fewer prosocial behaviors when they were 5 and 7 years. They also were less happy at school compared with control children at 7 years of age. Pure victims and bully/victims showed more behavior and school adjustment problems at 7 years of age, even after controlling for preexisting adjustment problems at 5 years of age. CONCLUSIONS. Being the victim of a bully during the first years of schooling contributes to maladjustment in young children. Prevention and intervention programs aimed at reducing mental health problems during childhood should target bullying as an important risk factor.

Predicting violence in schizophrenia: a prospective study

BACKGROUND People with schizophrenia are more violent than the general population, but this increased risk is attributable to the actions of a small subgroup. Identifying those at risk has become an essential part of clinical practice. AIMS To estimate the risk factors for assault in patients with schizophrenia. METHODS Two hundred seventy-one patients with schizophrenia were interviewed using an extensive battery of instruments. Assault was measured from multiple data sources over the next 2 years and criminal records were obtained. Multiple sociodemographic and clinical variables measured at baseline were examined as possible predictors of assault during follow-up. RESULTS Sixty-nine (25%) patients committed assault during the 2-year follow-up. The model that best predicted assault included a history of recent assault (OR 2.33, 95% CI 1.17-4.61), a previous violent conviction (OR 2.02, 95% CI 1.04-3.87), having received special education (OR 2.76, 95% CI 1.22-6.26) and alcohol abuse (OR 3.55, 95% CI 1.24-10.2). CONCLUSIONS Previously established risk factors including a history of violence and alcohol abuse are replicated in this study. Although low premorbid IQ did not predict violence, a need for special education did.

Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care

Abstract Objectives: To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case management. Design: Randomised controlled trial with two year follow up. Setting: Four inner city community mental health services. Participants: 708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group. Intervention: Intensive case management (caseload 10–15 per case manager) for two years compared with standard case management (30-35 per case manager). Main outcome measure: Physical assault over two years measured by interviews with patients and case managers and examination of case notes. Results: No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86). Conclusions: Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care. What is already known on this topic Psychosis and violence are known to be associated Community psychiatric interventions aimed at reducing the risk of violence have not been evaluated What this study adds Increasing the intensity of contact between patients and case managers does not reduce the prevalence of violent behaviour in patients with psychosis Younger age, learning difficulties, and a history of violence, drug misuse, and victimisation predict violent behaviour in psychotic patients

Aggressive behaviour at first contact with services: findings from the AESOP First Episode Psychosis Study

BACKGROUND Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness. METHOD The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others. RESULTS Almost 40% (n=194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n=103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending. CONCLUSIONS Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression.

Self-harm in first-episode psychosis

BACKGROUND Little is known about self-harm occurring during the period of untreated first-episode psychosis. AIMS To establish the prevalence, nature, motivation and risk factors for self-harm occurring during the untreated phase of first-episode psychosis. METHOD As part of the AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) study, episodes of self-harm were identified among all incident cases of psychosis presenting to services in south-east London and Nottingham over a 2-year period. RESULTS Of the 496 participants, 56 (11.3%) had engaged in self-harm between the onset of psychotic symptoms and first presentation to services. The independent correlates of self-harm were: male gender, belonging to social class I/II, depression and a prolonged period of untreated psychosis. Increased insight was also associated with risk of self-harm. CONCLUSIONS Self-harm is common during the pre-treatment phase of first-episode psychosis. A unique set of fixed and malleable risk factors appear to operate in those with first-episode psychosis. Reducing treatment delay and modifying disease attitudes may be key targets for suicide prevention.

Violence in society

As increasing numbers of mentally ill patients have been treated and reside in the community, public concern about their potential for violence has increased. Fear and stigma of mentally ill people have been exaggerated by high profile and occasionally sensationalist reporting of rare, albeit tragic, violent acts1 Are people with mental illness more violent than other people? An influential German study published in 1973 led to the belief that people with mental disorder were no more likely to be violent than the general population.2 This view remained unchallenged until the late 1980s. The best epidemiological data on violence and mental disorder come from the American ECA (epidemiologic catchment area) study.3 Self reported violence in the past year was measured among a representative community sample of 10 059 individuals. The prevalence of violence in people with no psychiatric disorder was 2%, and it was much higher in young men. Violence was reported in 8% of people with schizophrenia. People with alcohol (24%) or drug misuse or dependence disorders (34%) presented the highest risk. This study clearly shows that the increased risk of …

Violence in psychosis: estimating the predictive validity of readily accessible clinical information in a community sample.

OBJECTIVE This study sought to assess the validity of different combinations of readily available clinical information in predicting assaults by patients with psychosis, predominantly in the community. The combinations of information were: a) age and sex, b) age, sex and history of criminality/violence c) age, sex, history of violence and drug use and d) age, sex, history of violence, drug use and personality disorder. METHOD 708 subjects were followed for 2 years. Assaults were measured using multiple sources of information. Prediction validity was measured using the area under the receiver operating curves (AUC) and the number needed to detain (NND). A simple prediction tool was developed. RESULTS The AUC values using the four combinations of information were a) 0.65, b) 0.70, c) 0.71, and d) 0.73. Prediction based on combination b), c), and d) implied a NND of 3. A rule based on c), the most accessible information, is suggested as a simple screening tool. CONCLUSIONS Readily available clinical information allowed the prediction of assault over 2 years, in a sample of general psychiatric patients with psychosis, with a level of predictive accuracy comparable to that described using more detailed risk assessment tools. The information used in the predictive model was: age, sex, having committed an assault in the last 2 years (self-report) and having used any drug in the last year (self-report).

Prevalence and predictors of parasuicide in chronic psychosis

This study estimates the prevalence of and risk factors for parasuicide in a large community‐based sample of patients with chronic psychosis.

Does co-morbid personality disorder increase the risk of suicidal behaviour in psychosis?

Objective: To examine the association between co‐morbid personality disorder (PD) and suicidal behaviour over a 2‐year period in a sample of patients with psychosis.

Do forensic psychiatric inpatient units pose a risk to local communities

Abstract There has been rapid expansion of forensic psychiatric services in the United Kingdom over the last decade. This has been associated with concern from communities about the risk to which they are subjected by the presence of secure units in their local area. However, this assumption of risk is based on anecdotal or unrelated evidence. Our study aimed to determine the nature and level of risk posed by inpatients of medium secure units to their local communities in the south-east of England. Results showed that the contribution of these units to local crime figures included just one conviction for burglary over a five-year period. Other serious untoward incidents and their implications are discussed.