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VIOLENCE, AGGRESSION & MENTAL ILLNESSDr Tuti Iryani Mohd Daud Senior Lecturer & Consultant Psychiatrist, National University of Malaysia Medical Centre.
Part 1: Violence, aggression and mental illness
Part 2: De-escalation technique
Part 3: Seclusion and restraints
MANAGING AGGRESSION (Video series)
BY THE END OF THIS LECTURE, YOU WILL BE ABLE TO:
Discuss the relationship between aggression, violence & mental illness
(problems with media reporting)
Identify risk factors contributing to aggression
Describe the neurobiology of aggression & violence
Describe cycle of assault
Aggression vs Violence
Aggression:
“as behavior directed toward another individual carried out with the proximate (immediate) intent to cause harm. Furthermore, the perpetrator must believe that the behavior will harm the target, and that the target is motivated to avoid the behavior. Actual harm is not required. “ (Anderson and Huesmann, 2007)
Violence:
“The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.“ (WHO, 2002)
“extreme form of aggression, such as assault, rape or murder.” (American Psychological Association)
Violence
Aggression
References:Anderson, C. A. and L. R. Huesmann (2007). Human aggression: A social-cognitive view. The Sage Handbook of Social Psychology, Revised Edition. M. A. Hogg and J. Cooper. London, Sage Publications: 296-323.World Health Organization (2002). World report on violence and health: summary. Geneva, World Health Organization.
Are the mentally ill violent?
Violence
General population
Violence and aggression in the community (Rueve & Welton, 2008)
Reference:Asnis GM, Kaplan ML, Hundorfean G, Saeed W. Violence and homicidal behaviors in psychiatric disorders. Psych Clin N Am. 1997;20: 405–425. Rueve, M. E. and R. S. Welton (2008). "Violence and Mental Illness." Psychiatry (Edgmont) 5(5): 34-48.
Mentally ill
3.7% among general US population
4% among outpatient
(in an urban setting) (Asnis et al, 1997)
Mentally ill
Violence and aggression in the community
individuals with major mental disorder
who did not abuse substances
individuals without mental disorder
who did not abuse substances
=
}
Substance abuse (risk of violence increases by 2 fold)
References: Monahan J, Steadman HJ, Silver E et al. Risk
assessment: the MacArthur Study of Mental Disorder and Violence. Oxford: Oxford University Press, 2001.
Steadman HJ, Mulvy EP, Monahan J et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighbourhoods. Arch Gen Psychiatry 1998;55:393-404.
Prospective study (Steadman et al, 1998) 18% - major mental illness 31% - major mental illness + comorbid substance use 43% - major mental illness + comorbid substance use + personality disorder
RISK FACTORS FOR VIOLENCE
Static (patient characteristics that cannot be changed with clinical intervention)
• Prior history of violence • male sex • younger adult age • lower intelligence • history of head trauma or
neurological impairment • dissociative states • history of military service • weapons training • diagnoses of major mental illnesses • dysfunctional family of origin and a
history of abuse as a child.
Dynamic (variables in a patient’s presentation that can potentially be improved with clinical intervention)
• substance abuse • persecutory delusions • command hallucinations,
nonadherence with treatment, impulsivity
• low Global Assessment of Functioning (GAF) score
• homicidality, • depression, • hopelessness, • suicidality, • feasibility of homicidal plan, • access to weapons, • recent move of a weapon out of
storage.
Rueve, M. E. and R. S. Welton (2008). "Violence and Mental Illness." Psychiatry (Edgmont) 5(5): 34-48.
1. Majority of people with mental illness are not violent. • The major determinants: young, male, and of lower socio-economic status.
2. General public magnify the relationship between major mental disorders and violence • It is far more likely that people with a serious mental illness will be the victim of violence.
3. Substance abuse appears to be a major determinant of violence. • a third of self-reported violent acts
• 7 out of every 10 crimes of violence among mentally disordered offenders.
4. Research in the past had focussed on the person with the mental illness. • need emphasis on the triggers
Stuart, H. (2003). "Violence and mental illness: an overview." World Psychiatry 2(2): 121-124.
VIOLENCE & MENTAL ILLNESS
Source: https://www.time-to-change.org.uk/sites/default/files/film-report-screening-madness-time-to-change.pdf
DEPICTION OF MENTAL ILLNESS IN THE MEDIA
Source: https://www.time-to-change.org.uk/sites/default/files/film-report-screening-madness-time-to-change.pdf
Negative media coverage
Negative attitude towards mental illness
Reference:McKeown, M. and B. Clancy (1995). "Media influence on societal perceptions of mental illness." MENTAL HEALTH NURSING-LONDON-COMMUNITY PSYCHIATRIC NURSES ASSOCIATION 15: 10-10.
Fules
Response to
Neurobiology of aggression and
violence
From: Neurobiology of Aggression and Violence American Journal of Psychiatry
Figure 1. Susceptibility to Aggression and Psychiatric Diagnosis
Copyright © American Psychiatric Association. All rights reserved.
Date of download: 09/19/2015
Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.
From: Neurobiology of Aggression and Violence American Journal of Psychiatry
Figure 2. Initiation and Modulation of Aggression
a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure appeared in Davidson et al., Science 2000; 289:591.
Copyright © American Psychiatric Association. All rights reserved.
Date of download: 09/19/2015
Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.
From: Neurobiology of Aggression and Violence American Journal of Psychiatry
Figure 4. Pretreatment Abnormalities in the Pathophysiology of Aggression
a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure appeared in Davidson et al., Science 2000; 289:591.
Copyright © American Psychiatric Association. All rights reserved.
Date of download: 09/19/2015
Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.
Cycle of assault
Trigger
Escalation phase
Crisis phase
Recovery phase
Post-crisis depression
phase
CYCLE OF ASSAULT (Kaplan & Wheeler,1983)
Perceived as serious threat
body and mind prepare for a fight.
Violent act
body and mind relaxes
fatigue, depression, and
guilt.
Source: http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf
Trigger
Escalation phase
Crisis phase
Recovery phase
Post-crisis depression
phase
CYCLE OF ASSAULT (Kaplan & Wheeler,1983)
Perceived as serious threat
body and mind prepare for a fight.
Violent act
body and mind relaxes
fatigue, depression, and
guilt.
Source: http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf
De-escalation technique
Seclusion & restraints Breakaway technique
Observation
Communication Counselling
Negotiation and observation
SUMMARY• Majority of people with mental illness are not
violent • Among those with mental illness, only a small
proportion are at higher risk of violence: • i.e. comorbid substance use, comorbid personality disorder, poor
illness control
• To understand the principles of managing aggression, it is useful to understand the: • Neurobiology
• cycle of assault
This work by Dr. Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial-
NoDerivatives 4.0 International License.
This work by Dr. Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License.
