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A retrospective analysis of the violent incident forms returned over a one year period in a psychiatric hospital recorded 283 incidents involving 144 patients. Almost all were of a petty nature, none leading to lasting injuries. Compared with the average daily in-patient population, offending patients were more likely to be male, to be less than 45 years old, and to have a diagnosis of schizophrenia.
A case of Capgras syndrome associated with extreme violent behaviour is described. The patient's psychodynamics support the belief that the Capgras delusion initially arises from an altered affective response towards one or more others and proceeds to intolerable ambivalent feelings. This ambivalence is neutralised through the imagined existence of doubles.
Recent surveys indicate that the frequency of assaults on psychiatric staff by in-patients has increased substantially over the past decade. With patient assaultiveness becoming of greater concern, the need to predict, anticipate, and avoid confrontations with potentially assaultive patients has grown. Regrettably, the vast majority of studies examining the nature, correlates, and predictors of in-patient assaultiveness suffer from methodological problems that limit the validity of their findings.
Three groups of neuropsychiatric out-patients, homogeneous according to parameters of violent behaviour, were identified in a previous study using a cluster analysis procedure and compared in this study on psychometric variables. These groups were (a) a group manifesting frequent, impulsive violence (n = 35), (b) a non-violent group (n = 57), and (c) a group whose violent behaviour was much less frequent and severe than in the first group, and more provoked (n = 31). Impulsively violent patients showed language and visual-perceptual deficits, but no other neuropsychological or intellectual deficits. The MMPI F, K and Ma and MacAndrews Alcoholism scales and a perceptual organisation factor derived from the Holtzman Inkblot Test significantly discriminated groups. Results of this and the initial study have implications regarding psychological aspects of aggression and underlying biological mechanisms.
Absence of patients without leave is common in psychiatric hospitals, and causes anxiety to staff, relatives, and the lay public. Such incidents are difficult to predict. This study attempted to identify the characteristics of patients absconding from a UK hospital over one year. Numbers were small, as those patients discharged against advice and failing to return from leave were excluded. Absconders were predominantly male, young, compulsorily admitted, and discharged with a diagnosis of schizophrenia. They tended to be single, had many previous admissions, and a longer total length of stay, and the police were more often involved in their admission. Reasons for absconding and the implications for management of newly admitted psychiatric patients are discussed.
The paper describes the two-year follow-up results from 323 out of 386 patients fulfilling a modified version of Feighner's criteria for diagnosis of schizophrenia, in Lucknow, Vellore, and Madras. There was remission in 66% of cases. Short duration of illness, consistent compliance with medication, positive attitudes of relatives and neighbours, absence of economic difficulties, increase in religious activities on the part of patients, a rural background, and a non-schizoid pre-morbid personality were associated with good outcome. Features of depression, dangerous behaviour, and absence of agitation were associated with poor outcome.
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To compare the crime rate of schizophrenics with that of the general population, data from the Central Swedish Police Register on 790 schizophrenic patients discharged from hospitals in Stockholm in 1971 was analysed for the period of 1972-86. Relative risk of criminal offence was assessed by comparing the observed number of offences committed with the expected number (estimated from official statistics). The crime rate among male schizophrenics was almost the same as that in the general male population, whereas among females it was twice that of the general female population. The rate of violent offences was, however, four times higher among the schizophrenics. The violence recorded was almost exclusively of minor severity.
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The shortening of the periods of detention for treatment, deterrence or retribution have made a live issue of whether (or when) it is justifiable to detain violent and sexual offenders solely for the protection of others. Anti-protectionist arguments have made 'dangerousness' a dirty word, but are based either on actuarial statistics of doubtful relevance or on confused moral reasoning. A typology of 'dangerousness' is tentatively offered, and the impossibility of adequately supervising some dangerous offenders in the community is emphasised. That said, offenders detained solely for the sake of others are entitled to more than merely 'humane containment'.
Following in-patient psychiatric treatment under Section 3 of the Mental Health Act, some patients have in the past remained on Section after discharge, and subsequently the Section has been renewed while the patient remained 'on leave'. People treated thus with 'extended leave' probably resemble closely those who would be placed on a community treatment order if this were available. A group of these extended-leave patients was compared with a control group, matched for age, sex and diagnosis, selected by consultant psychiatrists as not requiring treatment using a community treatment order. The two groups showed very few differences, but the extended-leave patients more commonly had a history of recent dangerousness and non-compliance with psychiatric treatment. Use of extended leave improved treatment compliance, reduced time spent in hospital, and reduced levels of dangerousness.
Several English consultant psychiatrists were asked to identify which patients currently under their care they would recommend for treatment with a community treatment order, if such a provision existed. The psychiatrists were asked to match each such 'nominated' patient for age, sex and diagnosis with one or two control patients, not considered to require compulsory treatment in the community. From specific data collected, it was found that: the two groups did not differ in their 'lifetime' histories of psychiatric admissions, substance misuse, criminal charges or dangerousness; 65-72% of the total sample had a history of serious dangerousness; but in the 12 months before nomination, the 'nominated' patients were significantly less likely than the controls to have complied with psychiatric treatment, and more likely to have defaulted from follow-up. The results indicate that a psychiatrist's decision to recommend a patient for treatment with a community treatment order will depend predominantly on specific criteria related to the patient's recent past.
Special hospitals are principally concerned with the treatment of patients of dangerous, violent or criminal propensities referred from the courts and prisons. However, patients can be transferred from local NHS hospitals. The case of one such patient illustrates the potential benefits of such a transfer, even for patients who are not of immediate danger to others.
During a six-month period, 306 psychiatric assessments were recorded prospectively on specifically designed schedules. There was a skewed distribution towards younger patients, and 78% were male. Just over half were seen for a court report, one-third of cases came from solicitors, and in two-thirds the request was merely for advice. Secure care was only sought in 15%. In nearly two-thirds an offence had precipitated the referral. Half were seen in prison. The majority had a history of dangerous behaviour and one-fifth were regarded as a sexual risk to others. Only one-third had not previously seen a psychiatrist. A personality disorder was diagnosed in 41%, but only 6% were considered to be psychopaths. These and other findings are discussed to help give an insight into the service.
Rapid tranquillisation--giving a psychotropic to control behavioural disturbances--is common in medical practice, yet few surveys describe its use in psychiatric populations. Over five months, 102 incidents, involving 60 patients, were retrospectively surveyed. Patients most often involved were young white men. The commonest diagnosis was affective disorder (manic phase) (39%) followed by schizophrenia (33%). Fifteen patients were involved in 57% of the incidents. The majority of incidents involved injury to people or damage to property. The most frequently used drugs were diazepam and haloperidol, alone or in combination. Droperidol, chlorpromazine, sodium amytal and paraldehyde were rarely used. Diazepam alone or in combination with haloperidol delivered intravenously was most rapidly effective and was associated with greatest staff satisfaction. Serious side-effects were rare.
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Of 253 patients in their first schizophrenic episode, 52 behaved in a way threatening to the lives of others before their admission to hospital. These 52 patients were studied from data collected at the time of their initial presentation. Despite a history of illness in excess of 1 year in 24 cases, and evidence that violence was motivated by psychotic symptoms in 23 cases, fewer than half of the patients were admitted to hospital as a direct result of their dangerous behaviour. Life-threatening behaviour was more common where the patient had been ill for longer, and where there were delusions of being poisoned.