Assessment of aggression in inpatient settings

Abstract

The threat of violence is a major concern for all individuals working or receiving treatment in an inpatient psychiatric setting. One major focus in forensic psychology and psychiatry over the past several decades has been the development of risk assessments to aid in the identification of those individuals most at risk of exhibiting violent behavior. So-called second- and third-generation risk assessments were developed to improve the accuracy of decision making. While these instruments were developed for use in the community, many have proven to be effective in identifying patients more likely to exhibit institutional aggression. Because the purpose of risk assessment is the reduction of violence, dynamic factors were included in third-generation risk instruments to provide opportunities for intervention and methods for measuring change. Research with these instruments indicates that both static factors (second-generation) and dynamic factors (third-generation) are important in identifying those patients most likely to engage in institutional aggression, especially when the aggression is categorized by type (impulsive/reactive, organized/predatory/instrumental, psychotic). Recent research has indicated that developing a typology of aggressive incidents may provide insight both into precipitants to assaults as well as appropriate interventions to reduce such aggression. The extant literature suggests that both static and dynamic risk factors are important, but may be differentially related to the type of aggression exhibited and the characteristics of the individuals exhibiting the aggression.

Objective predictors of outcome in forensic mental health services—a systematic review

“…This literature is large and robust and has been reviewed elsewhere. [20][21][22] Further, these tools require the assessment of a combination of demographic and clinical factors that may relate to risk collectively, but often individual item predictive validity is not given. 6.…”

Psychosocial approaches to violence and aggression: contextually anchored and trauma-informed interventions

“…A comprehensive violence prevention assessment is ongoing and utilizes standardized measures; clinical observation; and collaboration, engagement, and empowerment with the person served. 19,20 Staff monitor both the universal indicators for potential escalation, as well as an individual's specific contextual triggers and indicators of escalating risk. When done in collaboration with the person served, this model proves to be more effective as individuals learn to accurately assess their own ongoing fluctuations in stress, triggers, and coping resources.…”

Deconstructing violence as a medical syndrome: mapping psychotic, impulsive, and predatory subtypes to malfunctioning brain circuits

“…This idea models the dimensional approach taken to psychopathology by the Research Domain Criteria (RDoC) strategy, which complements the categorical diagnostic strategy of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. 36 Specifically, violence in forensic settings can be approached as a medical syndrome, 1,2 and can be deconstructed into 3 major symptom domains: psychotic, impulsive, and predatory, 2,[37][38][39][40][41][42][43][44][45][46] each with a hypothetically distinct neurobiological basis and different theoretically malfunctioning brain circuits. (eg, Stahl and Morrissette 43 ).…”

“…Although many if not most patients in forensic settings have a psychotic illness, this is actually the least common type of violence ( Figure 1). [37][38][39][40][41][42][43][44][45][46] Predatory violence may actually be more common than psychotic violence in forensic settings. Although predatory violence is not the most common form of violence in forensic settings, it is often the most severe, but perhaps the least treatable, and therefore requires therapeutic security measures.…”

“…It is actually impulsive violence that is the most common in forensic settings, and thus the subtype of violence that is in most desperate need of treatment in terms of frequency of occurrence, as well as relative lack of evidence from large, multicenter, randomized trials. [37][38][39][40][41][42][43][44][45][46] Empiric findings from recent treatment guidelines 2,3 and from clinical experience, as well as the existing literature, suggest that novel and aggressive psychopharmacologic management may reduce impulsive violence in this population.…”