Aggression, violence and mental illness
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The document discusses the relationship between mental illness and violence. It finds that the majority of mentally ill individuals are not violent and that substance abuse is a major determinant of violence. It describes the neurobiology of aggression and the cycle of assault. Understanding these principles can help with managing aggression.
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Aggression, violence and mental illness
- 1. VIOLENCE, AGGRESSION & MENTAL ILLNESS Dr Tuti Iryani Mohd Daud Senior Lecturer & Consultant Psychiatrist, National University of Malaysia Medical Centre.
- 2. Part 1: Violence, aggression and mental illness Part 2: De-escalation technique Part 3: Seclusion and restraints MANAGING AGGRESSION (Video series)
- 3. BY THE END OF THIS LECTURE, YOU WILL BE ABLE TO: Discuss the relationship between aggression, violence & mental illness (problems with media reporting) Identify risk factors contributing to aggression Describe the neurobiology of aggression & violence Describe cycle of assault
- 5. Aggression: “as behavior directed toward another individual carried out with the proximate (immediate) intent to cause harm. Furthermore, the perpetrator must believe that the behavior will harm the target, and that the target is motivated to avoid the behavior. Actual harm is not required. “ (Anderson and Huesmann, 2007) Violence: “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.“ (WHO, 2002) “extreme form of aggression, such as assault, rape or murder.” (American Psychological Association) Violence Aggression References: Anderson, C. A. and L. R. Huesmann (2007). Human aggression: A social-cognitive view. The Sage Handbook of Social Psychology, Revised Edition. M. A. Hogg and J. Cooper. London, Sage Publications: 296-323. World Health Organization (2002). World report on violence and health: summary. Geneva, World Health Organization.
- 6. Are the mentally ill violent?
- 7. Violence General population Violence and aggression in the community (Rueve & Welton, 2008) Reference: Asnis GM, Kaplan ML, Hundorfean G, Saeed W. Violence and homicidal behaviors in psychiatric disorders. Psych Clin N Am. 1997;20: 405–425. Rueve, M. E. and R. S. Welton (2008). "Violence and Mental Illness." Psychiatry (Edgmont) 5(5): 34-48. Mentally ill 3.7% among general US population 4% among outpatient (in an urban setting) (Asnis et al, 1997)
- 8. Mentally ill Violence and aggression in the community individuals with major mental disorder who did not abuse substances individuals without mental disorder who did not abuse substances = } Substance abuse (risk of violence increases by 2 fold) References: Monahan J, Steadman HJ, Silver E et al. Risk assessment: the MacArthur Study of Mental Disorder and Violence. Oxford: Oxford University Press, 2001. Steadman HJ, Mulvy EP, Monahan J et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighbourhoods. Arch Gen Psychiatry 1998;55:393-404. Prospective study (Steadman et al, 1998) 18% - major mental illness 31% - major mental illness + comorbid substance use 43% - major mental illness + comorbid substance use + personality disorder
- 9. RISK FACTORS FOR VIOLENCE Static (patient characteristics that cannot be changed with clinical intervention) • Prior history of violence • male sex • younger adult age • lower intelligence • history of head trauma or neurological impairment • dissociative states • history of military service • weapons training • diagnoses of major mental illnesses • dysfunctional family of origin and a history of abuse as a child. Dynamic (variables in a patient’s presentation that can potentially be improved with clinical intervention) • substance abuse • persecutory delusions • command hallucinations, nonadherence with treatment, impulsivity • low Global Assessment of Functioning (GAF) score • homicidality, • depression, • hopelessness, • suicidality, • feasibility of homicidal plan, • access to weapons, • recent move of a weapon out of storage. Rueve, M. E. and R. S. Welton (2008). "Violence and Mental Illness." Psychiatry (Edgmont) 5(5): 34-48.
- 10. 1. Majority of people with mental illness are not violent. • The major determinants: young, male, and of lower socio-economic status. 2. General public magnify the relationship between major mental disorders and violence • It is far more likely that people with a serious mental illness will be the victim of violence. 3. Substance abuse appears to be a major determinant of violence. • a third of self-reported violent acts • 7 out of every 10 crimes of violence among mentally disordered offenders. 4. Research in the past had focussed on the person with the mental illness. • need emphasis on the triggers Stuart, H. (2003). "Violence and mental illness: an overview." World Psychiatry 2(2): 121-124. VIOLENCE & MENTAL ILLNESS
- 13. Negative media coverage Negative attitude towards mental illness Reference: McKeown, M. and B. Clancy (1995). "Media influence on societal perceptions of mental illness." MENTAL HEALTH NURSING-LONDON-COMMUNITY PSYCHIATRIC NURSES ASSOCIATION 15: 10-10. Fules Response to
- 16. From: Neurobiology of Aggression and Violence American Journal of Psychiatry Figure 1. Susceptibility to Aggression and Psychiatric Diagnosis Copyright © American Psychiatric Association. All rights reserved. Date of download: 09/19/2015 Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.
- 17. From: Neurobiology of Aggression and Violence American Journal of Psychiatry Figure 2. Initiation and Modulation of Aggression a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure appeared in Davidson et al., Science 2000; 289:591. Copyright © American Psychiatric Association. All rights reserved. Date of download: 09/19/2015 Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.
- 18. From: Neurobiology of Aggression and Violence American Journal of Psychiatry Figure 4. Pretreatment Abnormalities in the Pathophysiology of Aggression a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure appeared in Davidson et al., Science 2000; 289:591. Copyright © American Psychiatric Association. All rights reserved. Date of download: 09/19/2015 Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.
- 19. Cycle of assault
- 20. Trigger Escalation phase Crisis phase Recovery phase Post-crisis depression phase CYCLE OF ASSAULT (Kaplan & Wheeler,1983) Perceived as serious threat body and mind prepare for a fight. Violent act body and mind relaxes fatigue, depression, and guilt. Source: http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf
- 21. Trigger Escalation phase Crisis phase Recovery phase Post-crisis depression phase CYCLE OF ASSAULT (Kaplan & Wheeler,1983) Perceived as serious threat body and mind prepare for a fight. Violent act body and mind relaxes fatigue, depression, and guilt. Source: http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf De-escalation technique Seclusion & restraints Breakaway technique Observation Communication Counselling Negotiation and observation
- 22. SUMMARY • Majority of people with mental illness are not violent • Among those with mental illness, only a small proportion are at higher risk of violence: • i.e. comorbid substance use, comorbid personality disorder, poor illness control • To understand the principles of managing aggression, it is useful to understand the: • Neurobiology • cycle of assault
- 23. This work by Dr. Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License.
- 24. This work by Dr. Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.