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This prospective observational study included 345 (70%) of 489 patients discharged from an emergency psychiatric hospital during one year. Episodes of offending and victimization were recorded during first year after discharge. Forty-eight persons (14%) committed violent offenses only, 27 persons (8%) were violence victims only, and 42 persons (12%) were both offenders and victims. Significant differences in demographic and clinical variables were found between the three groups. The results pointed to two distinct groups of victims: one group with a robust offender–victim overlap and another group without offender–victim overlap. The latter group was difficult to distinguish from other discharged patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: First episode psychosis (FEP) patients have an increased risk for violence and criminal activity prior to initial treatment. However, little is known about the prevalence of criminality and acts of violence many years after implementation of treatment for a first episode psychosis. Aim: To assess the prevalence of criminal and violent behaviors during a 10-year follow-up period after the debut of a first psychosis episode, and to identify early predictors and concomitant risk factors of violent behavior. Method: A prospective design was used with comprehensive assessments of criminal behavior, drug abuse, clinical, social and treatment variables at baseline, five, and 10-year follow-up. Additionally, threatening and violent behavior was assessed at 10-year follow-up. A clinical epidemiological sample of first-episode psychosis patients (n=178) was studied. Results: During the 10-year follow-up period, 20% of subjects had been apprehended or incarcerated. At 10-year follow-up, 15% of subjects had exposed others to threats or violence during the year before assessment. Illegal drug use at baseline and five-year follow-up, and a longer duration of psychotic symptoms were found to be predictive of violent behavior during the year preceding the 10-year follow-up. Conclusion: After treatment initiation, the overall prevalence of violence in psychotic patients drops gradually to rates close to those of the general population. However, persistent illicit drug abuse is a serious risk factor for violent behavior, even long after the start of treatment. Achieving remission early and reducing substance abuse may contribute to a lower long-term risk for violent behavior in FEP patients. [Copyright &y& Elsevier]

Abstract: This retrospective study from three catchment-area-based acute psychiatric wards showed that of all the pharmacologically and mechanically restrained patients (n=373) 34 (9.1%) had been frequently restrained (6 or more times). These patients accounted for 39.2% of all restraint episodes during the two-year study period. Adjusted binary logistic regression analyses showed that the odds for being frequently restrained were 91% lower among patients above 50 years compared to those aged 18–29 years; a threefold increase (OR=3.1) for those admitted 3 times or more compared to patients with only one stay; and, finally, a threefold increase (OR=3.1) if the length of stay was 16 days or more compared to those admitted for 0–4 days. Among frequently restrained patients, males (n=15) had significantly longer stays than women (n=19), and 8 of the females had a diagnosis of personality disorder, compared to none among males. Our study showed that being frequently restrained was associated with long inpatient stay, many admissions and young age. Teasing out patient characteristics associated with the risk of being frequently restraint may contribute to reduce use of restraint by developing alternative interventions for these patients. [Copyright &y& Elsevier]

Individual differences in impulsive traits have been associated with a number of deviant behaviors, and impulsivity has been assumed to play a critical role in the manifestation of violent and other criminal behavior. Despite frequent citations of a positive association between impulsivity and violence in persons with psychosis, conflicting findings in the research literature elicited this systematic review. The main aims were to examine the empirical evidence of the association and to determine whether the research design and measurement used were sufficient for testing a possible causal relationship. Two types of empirical evidence were searched for in keeping with the traditional trait-state dichotomy: documentation of the direct impact of impulsivity on carrying out the violent act (state), and documentation of elevated levels of impulsivity in a person and increased occurrence of violent acts (trait). Searches that were conducted in six databases resulted in one study that supported the association and three that did not. Only 2 out of 22 estimates obtained from bivariate analysis indicated evidence of an impulsivity–violence link. No single study had a design that yielded data on a direct impact of impulsivity on carrying out the violent act (i.e., the state aspect of the association). [Copyright &y& Elsevier]

Abstract: Restraint use has been reported to be common in acute psychiatry, but empirical research is scarce concerning why and how restraints are used. This study analysed data from patients' first episodes of restraint in three acute psychiatric wards during a 2-year study period. Logistic regression analyses were used to identify predictors for type and duration of restraint. The distribution of restraint categories for the 371 restrained patients was as follows: mechanical restraint, 47.2%; mechanical and pharmacological restraint together, 35.3%; and pharmacological restraint, 17.5%. The most commonly reported reason for restraint was assault (occurred or imminent). It increased the likelihood of resulting in concomitant pharmacological restraint. Female patients had shorter duration of mechanical restraint than men. Age above 49 and female gender increased the likelihood of pharmacological versus mechanical restraint, whereas being restrained due to assault weakened this association. Episodes with mechanical restraint and coinciding pharmacological restraint lasted longer than mechanical restraint used separately, and were less common among patients with a personality disorder. Diagnoses, age and reason for restraint independently increased the likelihood for being subjected to specific types of restraint. Female gender predicted type of restraint and duration of episodes. [Copyright &y& Elsevier]

Objective: “Early warning signs of aggression” refers to recurring changes in behaviors, thoughts, perceptions, and feelings of the patient that are considered to be precursors of aggressive behavior. The early recognition of these signs offers possibilities for early intervention and prevention of aggressive behaviors in forensic patients. The Forensic Early warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying and monitoring these early warning signs of aggression. Methods: The FESAI was developed by means of qualitative and quantitative strategies. One hundred seventy six early detection plans were studied to construct a list of early warning signs of aggression. Inventory drafting was done by merging and categorizing early warning signs. Forensic nursing professionals assessed face validity, and interrater agreement was tested. Results: The investigation of early detection plans resulted in the FESAI, which contains 44 early warning signs of aggression subdivided into 15 main categories. The face validity of the form was very good, and the interrater agreement was satisfactory. Conclusions: Preliminary findings indicate that the FESAI provides a useful listing of early warning signs of aggression in forensic patients. It may facilitate the construction of early detection plans for the prevention of aggressive behaviors in forensic psychiatry. [Copyright &y& Elsevier]

Objective: Improvement of the interaction between forensic mental health nurses and patients may lead to a reduction of inpatient violence. The concept under study is detached concern, which refers to nurses'' skills to neutralize the emotional appeal of patients by a balanced attitude between objectivity and emotional involvement. The Patient Contact Questionnaire (PCQ) aims at measuring the degree of concern of nurses for their patients. Methods: The PCQ was applied in a pretest–posttest design, evaluating the effects of the Early Recognition Method (ERM). This method aims at the prevention of inpatient violence in forensic psychiatry. Subjects were 116 forensic mental heath nurses working on 16 wards of a large Dutch forensic hospital. First, the baseline scores were compared to scores reported in an earlier study conducted in general psychiatry. Second, pretest–posttest comparisons were carried out for all nurses, and for subgroups of nurses with regard to gender, educational level, years of working experience, and patient population. Third, pretest–posttest comparisons were made on the PCQ item level. Results: The baseline scores of male nurses indicated significantly higher levels of concern than those of female nurses. In addition, more experienced nurses scored significantly higher with regard to concern than less experienced nurses. When comparing the scores before and after applying ERM, no significant differences were found. However, the sores of female nurses showed a tendency toward more concern after implementation of ERM. Conclusions: Detached concern may be a meaningful concept in forensic mental health nursing in measuring nurses'' concern for their patients. Levels of detached concern did not change significantly after application of ERM. However, the application of the PCQ could contribute to a better understanding of the interaction between nurses and their patients. [Copyright &y& Elsevier]

Abstract: Recently patients'' responsibility for and ownership of their own treatment have been emphasised. A literature search on patients'''' structured self-reported assessment of future risk of violent, suicidal or self mutilating behaviour failed to disclose any published empirical research. The present prospective naturalistic study comprised all involuntary and voluntary acutely admitted patients (n =489) to a psychiatric hospital during one year. Patients'' self-reported risks of violence and self-harm at admission and at discharge were compared with episodes recorded during hospital stay and 3months post-discharge. Patients'' predictions were significant concerning violent, suicidal and self-injurious behaviour, with AUC values of 0.73 (95%CI=0.61–0.85), 0.92 (95%CI=0.88–0.96) and 0.82 (95%CI=0.67–0.98) for hospital stay, and 0.67 (95%CI=0.58–0.76), 0.63 (95%CI=0.55–0.72) and 0.66 (95%CI=0.57–0.76) after 3months, respectively. Moderate or higher risk predictions remained significant in multivariate analysis, and risk of violence even after gender stratification. Self-harm predictions were significant for women. Moderate or higher risk scores remained significant predictors of violence one year post-discharge. Controlling for readmissions the results remained the same. Low sensitivity limits the clinical value, but relatively high positive predictive values might be clinically important. Still future research is recommended to explore if self prediction is a valid adjuvant method to established risk assessment procedures. [Copyright &y& Elsevier]

Abstract: The main purpose of this article is to delineate findings from a review of the literature on the empirical basis for the existence of a relationship between Asperger''s syndrome (AS) and violence risk. A second aim is to examine whether certain characteristics of the disorder may have a higher violence-triggering potential. Results of this review show that there are very few empirical studies that confirm a stable link between AS and violence. Only 11 studies involving 22 patients and 29 violent incidents met the criteria for inclusion in the review after the search of the literature. However, a qualitative analysis of the studies yielded some indications of possible patterns of dynamics of violence that may prove to be typical of persons with AS. A tentative comparison of AS and psychopathy indicated that there may be qualitative differences in the characteristics of violent behavior between the disorders. Suggestions for further research are presented. [Copyright &y& Elsevier]

Abstract: This paper presents data from a systematic review and meta-analysis of published quality of life (QOL) studies on the subjective general well-being (GWB) of persons with major mental disorder (MMD) who live in the community. Four research questions were addressed: (1) What is the subjective QOL in persons with MMD who live in the community? (2) Are any specific subjective subdomains of QOL superior predictors of subjective GWB? (3) Is there an association between measures of psychopathology and subjective GWB? (4) Is there an association between sociodemographic variables and subjective GWB? We initially considered 134 potentially relevant articles, but only 42 studies reporting on 49 study units (N =6774 persons with MMD) met criteria of acceptable quality or relevance to be included in the meta-analysis. First, we found that measures of subjective GWB were relatively high. Second, certain subdomains such as Leisure and Social relations were strong predictors of subjective GWB, while the links between both Personal safety and Work, and GWB were weak. Third, we found that the empirical basis for using subjective QOL as an outcome variable in clinical research is scant. In particular, the relationship between changes in measures of psychopathology and subjective QOL appears to be obscure. Finally, the present study failed to confirm any stable relationship between sociodemographic factors and subjective GWB in persons with MMD who live in the community. Consequences of the findings for clinical practice and research are discussed. Limitations inherent in the meta-analytic approach in general, and the lack of homogeneity in the reviewed studies, need to be considered when interpreting the results of this meta-analysis. [Copyright &y& Elsevier]

Abstract: Lack of insight has established itself both as an important element of models of risk of violence and as a clinical item in structured approaches to measuring risk of violence. The main purpose of this paper is to delineate findings from a review of the literature concerning the empirical basis for the existence of a relationship between insight and violence risk. A second aim is to examine whether certain dimensions of insight may have a higher violence-triggering potential, and, if so, to learn more about valid and reliable approaches for measuring these dimensions. Results of this review show that there are very few empirical studies that demonstrate a possible association between insight and violence risk. Five out of a total of nine investigations found a positive relationship between poor insight and violent behavior. Nonetheless, the strength and specific nature of the relationship remain unclear due to considerable methodological and conceptual shortcomings in the reviewed studies. Seven recommendations for future research are presented to address these shortcomings. [Copyright &y& Elsevier]

The main scope of this paper is to delineate some findings from a review of the literature concerning the possible impact of delusions on violence toward others by psychiatric patients. According to this review, studies on a possible association between delusions and increased risk of violence are scarce, but steadily growing, and have shown some interesting results. However, since delusions are also common in nonviolent psychiatric patients, there is emerging evidence that our attention should be directed to specific hallmarks of delusions that indicate an increased risk of violence. Among the main findings of the present review are: the number of empirical studies were surprisingly low; about 80% of the studies were conducted during the last 8 years; and less than one third of the studies used a prospective design. Further findings were that persecutory delusions appear to increase risk of violence in some patients; co-occurence of persecutory delusions and emotional distress may increase risk of violence; and there is limited but tentative support to the existence of an association between symptoms of perceived threat and internal control override (TCO) and violence. [Copyright &y& Elsevier]

According to the clinical impressions of a number of authors and mental health professionals, an increased risk of violence is associated with the presence of hallucinations and — in particular — command hallucinations. In contrast to this, some empirical studies have reported that there is no evidence of such a relationship. The present review examines the role of hallucinations in violence toward others. Possible empirical evidence for a violence-escalating interaction between delusions and hallucinations is also analyzed. Among the main findings were: There appears to be no evidence that auditory command hallucinations are dangerous per se. However, there is some evidence that voices ordering acts of violence toward others may increase compliance and thereby be conducive to violent behavior. Finally, the evidence for or against the existence of a possible violence-escalating interaction between delusions and hallucinations is inconclusive. The findings are discussed particularly in relation to problems of measurement and other research design factors. Discrepancies between some of the findings of the present review and current clinical lore are also briefly considered. [Copyright &y& Elsevier]

The Violence Risk Screening - Police Version (V-RISK-POL) is a seven-item screening tool for use at police stations by police officers and law enforcement officials to assist in the process of decision making regarding release, restrictive measures or arrest for apprehended individuals where the risk of future violence must be considered. The screen is based on the V-RISK-10, originally developed for emergency psychiatry. We examined psychometric properties and the prospective predictive validity of future violent convictions for the V-RISK-POL in a sample of 111 persons arrested for suspicion of violent crimes. Seventeen persons were convicted for a new violent crime committed during the 24-40months follow-up. The V-RISK-POL demonstrated good internal consistency; Cronbach's alpha=0.81 (95% CI=0.75-0.86) and moderate predictive validity; the area under the curve of the receiving operator characteristics (AUC)=0.753 (95% CI=0.644-0.843). Further research on larger and more heterogeneous samples is necessary to examine whether the screen may be useful in the police context. [ABSTRACT FROM AUTHOR]

Abstract: Cross-sectional studies have reported an association between lipids and serotonin levels and aggression, but a literature search revealed a paucity of prospective studies. Subjects of the present naturalistic study were 254 of all (489) involuntary and voluntary acutely admitted patients to a psychiatric hospital during 1year. Serum lipids and platelet serotonin at admission were prospectively compared with recorded intra-institutional and 1-year post-discharge violence and self-harm. Total cholesterol had a significant negative relationship to inpatient suicidal behaviour and inpatient violent behaviour and to 3-month post-discharge violent behaviour. Triglycerides were a significant marker of inpatient self-mutilation and of self-mutilation in combination with suicidal behaviour at 3 and 12 months of follow-up. High-density lipoprotein (HDL) had a significant negative relationship to violence at 12-months, and to repeated violence in seven patients with two or more admissions. The post-discharge relationships between total cholesterol and violence and between triglycerides and self-harm remained significant even when controlling for other possible explanatory variables in a multivariate model. Results did not change after controlling for current medication at admission. There was no association between platelet serotonin and violence or self-harm. Future research may examine if lipid measurements add incremental validity to established clinical risk assessment procedures of violent and self-harm behaviour. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: Violence risk assessment instruments are mainly based on historical and clinical risk factors. Biological factors have been related to violent behaviour but hardly used in risk assessment. A recent study indicated that both low total cholesterol (TC) and the patients’ own estimates about their risk of future violent behaviour, the Self-report Risk Scale (SRS), significantly predicted violent behaviour during hospital stay and the first 3 months after discharge from an acute psychiatric department. Our aim was to investigate whether combining three methods, a screening instrument for risk of violence (V-RISK-10), low TC and the SRS, into one multifaceted risk assessment model may enhance predictive validity. This prospective naturalistic study involved 134 of all (489) acutely admitted patients to a general psychiatric hospital during 1 year. Low TC, SRS and V-RISK-10 at admission were prospectively compared with recorded violence during hospital stay and the first 3 months after discharge. The multifaceted risk assessment model yielded a significant increase in explained variance beyond that of the V-RISK-10. AUC values were higher, but differences were not significant. The biopsychosocial approach to violence risk assessment seems promising, but further studies are needed to test the feasibility and predictive validity of multifaceted models. [Copyright &y& Elsevier]