Academic journal article Hong Kong Journal of Psychiatry

Violent Behaviour and Its Predictors in Psychiatric Patients-A Study in Hong Kong

Academic journal article Hong Kong Journal of Psychiatry

Violent Behaviour and Its Predictors in Psychiatric Patients-A Study in Hong Kong

Article excerpt

Introduction

Violence in patients with mental disorder has always been an important area of concern. An influential German study published in 1982 concluded that persons with psychiatric disorder were no more likely to be violent than the general population. (1) In the last 2 decades however, other studies suggested that there was a moderate and reliable association between mental disorder and violence. (2,3) According to the Cambridge Advanced Learner's Dictionary, violence is defined as "actions or words which are intended to hurt people". In relation to psychiatric practice, there was no single, universal definition. Swanson et al (4) defined violence as "any physical fighting or assaultive actions causing bodily injury to another person, or as any use of a lethal weapon to harm or threaten someone". Despite the differences between such definitions, their common ingredients include: acts or threats of force, with or without weapons that could lead to injury or damage. The Royal College Research Unit in 1998 defined a violent incident as "a situation where a mental health service user is either actively violent or on the brink of being so". In the general population, a number of factors were identified as predictors of a propensity to violence. (5,6) Further exploration was required to find out whether similar factors contributed to violent behaviour in psychiatric patients. Research strategies for investigating the relationship between mental illness and violent behaviour can be classified into 3 broad categories.

The first approach involved community studies, which examined the presence of mental illness and the level of engagement in violent behaviour. In one of the most important studies of this type, (7) data pertaining to 10,059 subjects from the Epidemiological Catchment Area Study in the United States were analysed. Psychiatric assessment of the participants was based on the Diagnostic Interview Schedule (DSM-III) and their levels of violent behaviour were studied. Those reporting violent behaviour within the preceding year tended to be young, male, and of low socio-economic status; more than half of them met DSM-III criteria for one or more psychiatric disorders. The risk of violent behaviour increased with the number of psychiatric diagnoses that the respondents met. In another major community-based study, Link et al (8) compared the official and self-reported violence of psychiatric patients with community residents who never received psychiatric treatment. They found that psychiatric patients had higher rates of violence than community residents. Stueve and Link (9) found that there was a higher rate of violence among psychiatric patients than the general population. These community studies were subject to sampling bias, because seriously ill as well as seriously violent subjects were excluded.

The second approach was to examine the frequency of mental illness in people who behaved violently. One pre-eminent study examined the psychiatric status of 1,241 men remanded to Brixton Prison in London, England. (10) Nine percent of those subsequently convicted of non-fatal violent crimes and 11% convicted of fatal violence were diagnosed as having schizophrenia. Monahan (11) using data from a California prison study concluded that the incidence of schizophrenia among prisoners was 6%, which was more than 3 times the estimated rate in the general American population of 1.7%. Teplin (12) investigated 728 remanders in the United States that the prevalence of schizophrenia in the jail population was 2.7%, also 3 times higher than that of the general population (0.91%). In Australia, Wallace et al (13) found that those with schizophrenia were 4 times more likely to be convicted of interpersonal violence and 10 times more likely to be convicted of homicide than members of the general population. Studies based on offender populations were complicated both by the selection process, and by the high rates of substance abuse and severe personality disorder which tended to obscure mental illness, if it was present. …

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