Aggressive Behavior, Hostility, and Associated Care Needs in Patients With Psychotic Disorders: A 6-Year Follow-Up Study

Abstract

Background: Hostility and aggressive behavior in patients with psychotic disorders are associated with demographic and clinical risk factors, as well as with childhood adversity and neglect. Care needs are an essential concept in clinical practice; care needs in the domain of safety for others reflect the actual problem the patient has. Hostility, aggressive behavior, and associated care needs, however, are often studied in retrospect.Method: In a sample of 1,119 patients with non-affective psychotic disorders, who were interviewed three times over a period of 6 years, we calculated the incidence of hostility, self-reported maltreatment to others and care needs associated with safety for other people (safety-to-others). Regression analysis was used to analyze the association between these outcomes and risk factors. The population attributable fraction (PAF) was used to calculate the proportion of the outcome that could potentially be prevented if previous expressions of adverse behavior were eliminated.Results: The yearly incidence of hostility was 2.8%, for safety-to-others 0.8% and for maltreatment this was 1.8%. Safety-to-others was associated with previous hostility and vice versa, but, assuming causality, only 18% of the safety-to-others needs was attributable to previous hostility while 26% was attributable to impulsivity. Hostility, maltreatment and safety-to-others were all associated with number of unmet needs, suicidal ideation and male sex. Hostility and maltreatment, but not safety-to-others, were associated with childhood adversity. Neither safety-to-others, maltreatment nor hostility were associated with premorbid adjustment problems.Conclusion: The incidence of hostility, self-reported aggressive behaviors, and associated care needs is low and linked to childhood adversity. Known risk factors for prevalence also apply to incidence and for care needs associated with safety for other people. Clinical symptoms can index aggressive behaviors years later, providing clinicians with some opportunity for preventing future incidents.Next to these three outcome measures, demographic items and known clinical and early risk factors were incorporated in the analysis.

Risk and Prevention of Aggression in Patients With Psychotic Disorders

“…First, a 6-year follow-up study of patients with psychotic disorders confirmed earlier studies that childhood trauma is a risk factor for aggression (hazard ratio=1.74, 95% CI=1.03-2.93) (6). Another important and well-known childhood risk factor, conduct disorder, was confirmed in the article by Krakowski et al (1).…”

“…This relationship was not mediated by substance abuse (10). In more chronic psychotic disorders, 26% of the safety needs related to aggression were attributable to impulsivity 3 years earlier, assuming causality (6).…”

Aggression in Psychiatry: prevention, epidemiology & treatment

“…Meta-analytic data from psychotic disorders in general also found excitement associated with violence, but not uncooperativeness (Witt et al, 2013). More recent work found both excitement and uncooperativeness associated with different aggressiveness outcomes, although with differences between these measures (Faay et al, 2020). Compared with the different results considering the link between positive symptoms and violent behaviour in FEP (Brucato et al, 2019;Coid et al, 2013;Langeveld et al, 2014;Large and Nielssen, 2011) and psychotic disorders in general, where the positive symptom subscale is associated with violence (Volavka et al, 2016;Witt et al, 2013), we found hallucinations, delusions and unusual thought content low but significantly associated with hostility and disturbing and aggressive behaviour.…”

“…For the analysis of clinical factors associated with hostility, we selected seven PANSS items to see if these are related to PANSS P7 and PSP-D. We included the four PANSS items that are in the Excitement Component (PANSS-EC), along with hostility: P4 excitement, G14 poor impulse control, G4 tension and G8 uncooperativeness (Montoya et al, 2011). Impulsivity was associated with violence in FEP (Moulin, Golay, et al, 2018) and more chronic populations (Faay et al, 2020), but for excitement, tension and uncooperativeness, there is lacking evidence in a population of FEP. Next to these items, we wanted to examine whether delusions and hallucinations are associated with hostility or aggression because of the contrasting results from previous studies (Brucato et al, 2019;Coid et al, 2013;Langeveld et al, 2014;Large & Nielssen, 2011).…”

“…Impulsivity is associated with violent behaviour in early psychosis (Moulin, Baumann, et al, 2018;Moulin, Golay, et al, 2018). In patients with more chronic psychotic disorders, uncooperativeness and excitement were related to hostile and aggressive behaviour next to impulsiveness (Faay et al, 2020). However, as far as we are aware, there are no studies examining the association between symptoms such as uncooperativeness, excitement and tension with aggressive behaviour in FEP.…”