Violence In Psychiatry Research in Norway by Roger Almvik and Jim Aage Nöttestad

There are only a few studies on violence and mental health in Norway. The main studies have been the doctoral dissertations of K. Rasmussen (1995), and Stål Bjørkly (1995); and an article on prediction by Linaker and Busch-Iversen (1995). R.Almvik (1997) follows up the work by Linaker-Busch in a study.

Rasmussen (Rasmussen, Levander & Sletvold 1995) compared thirteen aggressive schizophrenic patients from a maximum security psychiatric unit to thirteen non-aggressive schizophrenic patients, and thirteen healthy controls, using case history data, ratings of psychopathology, schizophrenic symptoms and neuropsychological tests. The aggressive schizophrenics had spent more time in prison than the non-aggressive, had more crime and substance abuse among close relatives, had earlier problem onset, and scored significantly higher on psychopathy. They displayed a specific pattern of neuropsychological dysfunction, that was consistent with frontal lobe dysfunction.

She (Rasmussen & Levander 1996a) also found, by factor analysis, in a study of 94 consecutively admitted patients, five types of crime/aggression patterns: a non-violent type; a type with aggression/violence in an institutional setting; a sexual violence type; a homicidal type; and a type with arson as the major feature. Aggression within an institutional setting was the only type related to psychopathology. Psychopathy correlated strongly with both non-violent and violent crime, as well as with early adjustment problems. Arson was not explained by any of the background or symptom variables. Prevention detention was poorly predicted.

Rasmussen (Rasmussen and Levander 1996b) also studied assaults on staff in a maximum-security psychiatric hospital. Assaults on staff were analysed over a 5-year period. During this, time 94 patients were admitted to the unit. Fifty-two (55%) of the patients engaged in assaultive behaviour, generating 1945 incident reports. A small number of patients were responsible for a large number of the incidents. Serious incidents were rare. Incidents were evenly distributed throughout the day, week and year. Patients who attacked less often caused more serious harm, showed a decrease in assaults over time, and the preceding events suggested that the violence was functional. For assaultive patients it was difficult to identify a preceding event. The preceding events that were that were identified seemed more unreasonable, and the frequency of assault was constant over time. Assaultive patients were more often women, had more positive and borderline symptoms, were younger, and scored lower on psychopathy and depressive symptoms.

Bjørklys work is mainly on prediction of violence. He (Bjørkly 1993) designed a Scale for the Prediction of Aggression and Dangerousness in Psychotic Patients (PAD). The scale is based on an interactional understanding of aggressive behaviour in psychotic patients. The model emphasises detailed analysis of each patient's situational and interactional vulnerability, in addition to personal variables, for improved prediction of aggressive behaviour. Situational vulnerability is, thus, defined as increased likelihood to act aggressively towards others in a given interaction. Based on 29 items grouped in 7 main categories, the PAD scores describe a patients profile of interactional vulnerability.

Linaker and Busch-Iversen (1995) topic in their study is predictors of imminent violence in psychiatric inpatients. As a part of the study, they studied the behaviour and symptoms seen in 24-hr periods preceding violent episodes. Six behaviours were more common before violence: confusion, irritability, boisterousness, physical threats, verbal threats and attacks on objects. Roger Almvik has followed up this work (Almvik 1996, Almvik & Woods, 1997 [in press]). A logistic regression equation based on these behaviours in a randomised half of the observations predicted the occurrence of subsequent violence in 92.1 % of the other half of the sample without any false positives, giving a sensitivity of 81.3 and a specificity of 100 %. They concluded that the short-term prediction of violence in this way seems good. A not yet published paper from Morken, Linaker and Langsrud have asked what we can learn from variations in patient-staff incidents in psychiatric acute wards. From 1990, they registered the time and day of the staff-patient incidents in order to look for patterns in the time were there were most incidents. Of totally 653 reports, they selected those 347, which had at least resulted in pain. Of those 347 reports, 228 came from one ward that has a seclusion area. They found differences in frequency of injuries during the year with a maximum in June and in October and November. Further, they found differences during the week with more injuries in weekdays than in weekends. On weekdays, but not in weekends, they found more injuries from 11 am to 2 p.m. than in the afternoons and evenings. The nurses were more often interrupted in their work with the patients early in the day in weekdays, at the same time, as there were most injuries. There was a positive correlation between disturbances in the contact between staff and patients and the frequency of injuries. They conclude that the variation during the week and during the day is social rhythms. The researchers think that it is possible to use SOAS registrations to analyse variations in aggressive behaviour among psychiatric patients. By analysing variations in the frequency of patient-staff incidents, the staff in a ward can find out when the ward is functioning at its best. They also conclude that the variation during the year could be social or biological rhythms.

References:

Almvik, R. (1996). Prevention of psychiatric inpatient violence. Norwegian Journal of Nursing, 16, 51-53.

Almvik, R., Woods, P. (1997). Predicting inpatient violence using the Brøset Violence Checklist (BVC) International Journal of Psychiatric Nursing Research (in press).

Bjørkly, S. (1995). Diagnosis and prediction of intrainstitutional aggressive behaviour in psychotic patients. Department of Clinical Psychology, faculty of Psychology, University of Bergen. Norway

Bjørkly, S. (1993). Scale for the prediction of aggression and dangerousness in psychotic patients, an introduction. Psychological reports, 73, 1363-1377.

Morken, G., Linaker, O.M., Langsrud, K. (1997). What can we learn from variations in patient-staff incidents in psychiatric acute wards? Unpublished paper.

Rasmussen, K. (1995). Violence in the mentally disordered, A differential clinical perspective. Faculty of Medicine. Department of Psychiatry and Behavioural sciences. Section for Forensic Psychiatry, regional Security Unit, Brøset. Trondheim. Norway.

Rasmussen, K., Levander, S. & Sletvold, H. (1995). Aggressive and non-aggressive schizophrenics: symptom profile and neuropsychological differences. Psychology, Crime & Law, 2, 119-129.

Rasmussen, K. & Levander, S. (1996a). Crime and Violence among psychiatric patients in a maximum-security psychiatric hospital. Criminal Justice and behaviour, 23, 455-471.

Rasmussen, K. & Levander, S.(1996b). Individual rather than situational characteristics predict violence in a maximum-security hospital. Journal of interpersonal violence, 11, 376-399.

Linaker, O.M. & Busch-Iversen, H. (1995). Predictors of imminent violence in psychiatric inpatients. Acta Psychiatrica Scandinavia, 92, 250-254.

For further information on this paper please contact the author E-mail Roger Almvik

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