Liselotte Pedersen

Subtypes of aggression in patients with schizophrenia: The role of personality disorders

BACKGROUND Research has repeatedly demonstrated that schizophrenia has a small but significant association with violence. It is further recognised that a subgroup of people with such links also have personality disorders, but the extent to which type of violence or aggression varies according to subgroup is less clear. AIM This study aimed to investigate, among co-morbid cases, if the number or type of personality disorders predicts type of aggression. METHODS In a cross-sectional study, 108 patients with schizophrenia were assessed for personality disorder, Axis-I diagnosis, verbal IQ, social functioning and type of aggression. RESULTS Logistic regression revealed that the more personality disorders identified (Cluster B personality disorders compared with Clusters A and C) and anti-social personality disorder compared with other Cluster B disorders significantly predicted premeditated aggression. CONCLUSIONS These findings suggest that detailed personality assessment should be a routine part of comprehensive assessment of patients with schizophrenia. Improved knowledge of the presence and type of personality disorders may help detect and manage the risk of some types of aggression.

HCR-20 violence risk assessments as a guide for treating and managing violence risk in a forensic psychiatric setting

Abstract Over the past decades there has been a vast development in the research into risk factors for violence and the development of risk assessment instruments. One instrument that has been given special attention is the HCR-20 violence risk assessment scheme. However, little attention has been paid to the clinical applicability of this tool, i.e. how does this assessment scheme perform when utilized in clinical practice as a tool to guide intervention and management in order to alleviate risk of violent behaviour? The present study was a true prospective study into the utilization of the HCR-20 as a clinical routine. Data on forensic psychiatric patients (n = 81) from a forensic unit in Denmark are presented. As part of a clinical routine all patients were assessed for risk of future violence utilizing the structured professional judgement model, the HCR-20. Outcome measures were aggressive episodes during hospitalization and new convictions post discharge. The predictive validity of the HCR-20 was lower compared with previous findings. It is argued that this does not necessarily indicate poor predictive accuracy of the HCR-20. Rather, it may indicate that the HCR-20 is suitable for guiding risk management in order to prevent violent behaviour.

Subtypes of aggression in patients with schizophrenia: the role of psychopathy

Psychopathy is strongly related to aggression in community, forensic psychiatric and offender samples, including in patients with schizophrenia. However, most studies have failed to distinguish between impulsive or premeditated aggression. In a cross-sectional study of 108 patients with schizophrenia and comorbid psychopathy, we investigated if psychopathy measured with the total Psychopathy Checklist-Revised (PCL-R) score and the factors described in the two-factor model and the facets described in the four-factor model are associated with type of aggression in schizophrenia and to explore if the three- and four-factor models are associated with premeditated aggression. Results revealed that PCL-R total score, Factor 1 and 2 of the two-factor model and Facets 1–4 of the four-factor model were related to premeditated aggression and that the four-factor model was better related to premeditated aggression than the three-factor model. These findings delineate the role of psychopathy including antisocial features in the understanding of premeditated aggression in schizophrenia.

Discourses of aggression in forensic mental health: a critical discourse analysis of mental health nursing staff records

Managing aggression in mental health hospitals is an important and challenging task for clinical nursing staff. A majority of studies focus on the perspective of clinicians, and research mainly depicts aggression by referring to patient-related factors. This qualitative study investigates how aggression is communicated in forensic mental health nursing records. The aim of the study was to gain insight into the discursive practices used by forensic mental health nursing staff when they record observed aggressive incidents. Textual accounts were extracted from the Staff Observation Aggression Scale-Revised (SOAS-R), and Faircloughs critical discourse analysis was used to identify short narrative entries depicting patients and staffs in typical ways. The narratives contained descriptions of complex interactions between patient and staff that were linked to specific circumstances surrounding the patient. These antecedents, combined with the aggression incident itself, created stereotyping representations of forensic psychiatric patients as deviant, unpredictable and dangerous. Patient and staff identities were continually (re)produced by an automatic response from the staff that was solely focused on the patients behavior. Such response might impede implementation of new strategies for managing aggression.

Incidence and prevalence rates of personality disorders in Denmark—A register study

Abstract Background: Personality disorders (PDs) are prevalent in about one in every 10 adults. Prior to the introduction of the ICD-10 in Denmark, the incidence rate for PD (including schizotypal) among psychiatric patients was approximately 12% and the prevalence rate 14%. Aims: The aim of the present clinical epidemiology study is to investigate the use of ICD-10 PD as primary and secondary diagnoses in years 1995, 2000 and 2006, comorbid disorders and their relation to age and gender. Methods: The study includes all adult patients admitted to any psychiatric hospital (inpatients and outpatients) in Denmark. Results: Both incidence and prevalence rates of PD diagnoses decrease over the study period. It is evident that all specific diagnoses significantly decrease or remain stable whereas the unspecified and mixed type significantly increases constituting up to 50% of diagnoses. Emotionally unstable PD stands out as the single most prevalent covering around one third of PD diagnoses. A decrease is found in the prevalence of patients receiving a PD diagnosis as a primary diagnosis, but an increase as a secondary diagnosis (most often as comorbid to depression or anxiety disorder). Differences are found in relation to gender and age. Conclusion: PDs are among the most prevalent disorders; however, rates are decreasing in psychiatric settings. There seem to be a rather huge gap between clinical evaluation and research data on prevalence of PDs. Clinicians need more education and sufficient time for in-depth personality assessment of PDs in all patient groups.

Coping with Violence in Mental Health Care Settings: Patient and Staff Member Perspectives on De-escalation Practices

This multiple case study explored de-escalation processes in threatening and violent situations based on patients and staff members perspectives. Our post hoc analysis indicated that de-escalation included responsive interactions influenced by the perspectives of both patients and staff members. We assembled their perspectives in a mental model consisting of three interdependent stages: (1) memories and hope, (2) safety and creativity and (3) reflective moments. The data indicated that both patients and staff strived for peaceful solutions and that a dynamic and sociological understanding of de-escalation can foster shared problem solving in violent and threatening situations.

A Co-operative Inquiry Into Generating, Describing, and Transforming Knowledge About De-escalation Practices in Mental Health Settings

De-escalation is concerned with managing violent behaviour without resorting to coercive measures. Co-operative Inquiry provided the conceptual basis for generating knowledge regarding de-escalation practices in acute mental health care settings. The research included service users and staff members as co-researchers and knowledge was generated in dynamic research cycles around an extended epistemology of knowing: experiential, presentational, propositional, and practical. Through this process, co-researchers became de-escalation learners, implementing de-escalation practices while transforming violence management. Neighbouring mental health communities’ involvement strengthened the transformation process and assisted in validating the research results.