The first step in the validation of a new screen for violence risk in acute psychiatry: The inpatient context.

BACKGROUND: Instruments for evaluating the risk of violence towards others have mostly been developed for assessment of risk for recidivism into violent crime in forensic psychiatry. In general psychiatry there is a considerable need for specialised, brief and structured assessment tools to inform risk decisions. METHOD: The study aimed to validate a brief structured clinical risk assessment screen of inpatient violence (V-RISK-10), a 10-item structured clinical checklist with a good vignette-based interrater reliability (ICC=0.87). In this study it was used for risk assessment of a one-year sample of patients (N=1.017) admitted to two acute psychiatric units. Risk assessments at admission were compared to prospective records of aggressive and violent acts during the hospital stay. RESULTS: Results showed a base rate for aggression of 9%. The predictive validity of the V-RISK-10 was estimated by Receiver Operating Characteristics (ROC). It yielded an area under the curve (AUC) of 0.83, with sensitivity/specificity of 0.81/0.73 and corresponding positive and negative predictive values (PPV/NPV) of 0.24/0.97. The screen was easy-to-use and showed a short completion time. CONCLUSION: Despite promising results further validation studies are required before the V-RISK-10 is adopted into routine clinical practise.

V-RISK-10: validation of a screen for risk of violence after discharge from acute psychiatry.

BACKGROUND: Current violence risk assessment instruments are time-consuming and mainly developed for forensic psychiatry. A paucity of violence screens for acute psychiatry instigated the development and validation of the V-RISK-10. The aim of this prospective naturalistic study was to test the predictive validity of the V-RISK-10 as a screen of violence risk after discharge from two acute psychiatric wards. METHODS: Patients were screened with V-RISK-10 before discharge, and incidents of violence were recorded 3, 6, 9 and 12 months after discharge. A total of 381 of the 1017 patients that were screened completed the follow up. RESULTS: The ROC-AUC values for any violent behaviour were 0.80 and 0.75 (p<0.001) for the 3 and 12 months follow-up periods, respectively, and significant for both genders. The most accurate risk estimates were obtained for severe violence. For persons without a known history of violence prior to the screening, AUCs were 0.74 (p=0.004) and 0.68 (p=0.002). CONCLUSIONS: Results indicate that the V-RISK-10 is a valid and clinically useful screen for violence risk after discharge from acute psychiatry, and even significant for patients without a known previous history of violence.

Development of a brief screen for violence risk (V-RISK-10) in acute and general psychiatry: An introduction with emphasis on findings from a naturalistic test of interrater reliability.

Most violence risk assessment scales were originally developed for use in forensic settings at the time of discharge or release of patients into the community after long-term treatment. However, there is a considerable need for specialized, brief and structured risk assessment tools to inform risk decisions in short-term psychiatric treatment. The present study reports on research findings from the development and implementation of the violence risk screening-10 (V-RISK-10) in two acute psychiatric settings in Norway. The 10-item screen is easy to use, time-saving and may be used for screening of violence risk during hospital stay and after discharge into the community. Prospective validation studies of the screen concerning inpatient and post-release community violence have been conducted. Although data analyses are not yet complete, preliminary findings indicate that the screen has good predictive validity. This suggests that the screen is a promising tool in short-term acute psychiatric settings. However, the importance of reliability in mental health data and tests is well recognized, and a screen with good predictive validity is not worth much if clinicians are unable to agree on the scoring of one and the same patient. In this article we report results from a naturalistic interrater reliability investigation that involved 25 mental health professionals and 73 acute psychiatric patients. V-RISK-10 scoring was accomplished by two raters for each patient. The interrater reliability value for total scores was acceptable. Variations pertaining to the individual V-RISK-10 item, patient characteristics and rater characteristics are discussed.

Associations between outdoor air pollutants and hospitalization for respiratory diseases.

The concentration of particulate matter in outdoor air, as indicated by daily measures of particulate matter 10 microm in diameter (PM10) in many cities, has been found to be associated with the daily number of deaths and hospital admissions in these cities. To understand this association better, we studied the daily number of hospital admissions for respiratory diseases and the concentrations of eight pollutants in ambient air, during a period of 38 months, in an area with cold winters and air pollution that comes mainly from motor vehicles. We estimated the changes in risk of hospitalization by interquartile increases in pollutant concentrations by Poisson regression analyses. Controlling for periodic trends and weather, the relative risk of hospitalization associated with an interquartile increase of PM10 was 1.038 [95% confidence interval (CI) = 0.991-1.087]. In contrast, the relative risk associated with benzene was 1.105 (95% CI = 1.047-1.166). In a two-pollutant model, the relative risk estimates were 1.014 (95% CI = 0.966-1.063) for PM10 and 1.090 (95% CI = 1.031-1.153) for benzene. We evaluated other two- and three-pollutant models and concluded that pollutants other than PM10 are more strongly associated with hospital admissions for respiratory diseases.

A ten-year prospective study of aggression in a special secure unit for dangerous patients.

In a 10-year prospective study inpatient aggression was investigated in a Norwegian special secure unit covering a well-defined catchment area with a population of 240,000. The seven bed special secure unit receives dangerous, psychotic patients for long-term treatment. Only 19 patients were treated during the ten-year study lasting from 1 April 1987 to 1 April 1997. Incidents of aggressive behavior were recorded on the Report Form for Aggressive Episodes by the nursing staff. The study aimed to identify, classify and measure the occurrence of aggressive behavior, as well as the relative frequency of events preceding such behavior. A total of 2021 incidents of aggressive behavior were recorded. Seventy-five per cent of the aggressive acts were verbal or physical threats, while the remaining 25% were physical assaults directed at other persons. Four patients accounted for about 80% of the aggressive encounters. Nursing staff were victims in about 90% of the incidents. Serious physical injury was extremely rare. Situations pertaining to limit-setting and problems of communication accounted for approximately 90% of the precipitants of aggressive behavior. There were no sex differences regarding the occurrence of aggressive behavior.

Interrater reliability of the Report Form for Aggressive Episodes in group ratings.

This paper reports on the interrater reliability of the Report Form for Aggressive Episodes, a rating scale designed to measure displayed aggressive behaviour and its situational determinant(s) according to a list of 30 potential precipitants of aggression. 10 groups of nurses who assessed 10 clinical vignettes each by means of the rating scale showed high interrater agreement and interrater reliability.

Report form for aggressive episodes: preliminary report.

This paper gives a description of the development and initial empirical testing of the Report Form for Aggressive Episodes, a behavioural rating scale used to measure displayed aggressive behaviour and the situational determinant(s) according to a list of 30 potential precipitants to aggression. Findings from a one-year study in a special secure unit for the long-term treatment of dangerous patients show very high rates of underreporting of aggressive episodes in ward journals and patient files compared to this scale. Illustrations of the clinical use of the scale are provided by scoring examples and two case vignettes.

Open-area seclusion in the long-term treatment of aggressive and disruptive psychotic patients, an introduction to a ward procedure.

The clinical rationale and procedure of "open-area seclusion" as a treatment modality with psychotic patients is presented. This standard procedure was originally introduced as an alternative to arbitrary measures in response to aggressive and disruptive behavior. The seclusion area is locked, but the patient is never locked up alone in any single room. The method of open-area seclusion is composed of four overlapping phases: (1) assisting the patient to the seclusion area, (2) time for a "calming down" process, (3) debriefing, and (4) reintegration. Verbal confrontation is central in enhancing the secluded patient's reality-testing, for reinforcing responsibility for one's own behavior, and for encouraging alternative problem-solving. A step-by-step description of the procedure of open-area seclusion is presented and illustrated by a case history.

Trauma and violence: the role of early abuse in the aggressive behavior of two violent psychotic women.

The author explores the impact of early-life physical and sexual abuse on later-life violent behavior in two psychotic women. He proposes that their defending against the aftermath of early and severe abuse is a dynamic factor in the development and maintenance of violent behavior. He also focuses on the influence of maladaptive defensive operations and the impact of abuse on violence-triggering hallucinations and delusions. Finally, he contends that psychotherapy can contribute positively to enhanced control of violent behavior, even in severely violent and psychotic patients.

Scale for the Prediction of Aggression and Dangerousness in Psychotic Patients, an introduction.

The design and theoretical bases of the Scale for the Prediction of Aggression and Dangerousness in Psychotic Patients (PAD) are described. The scale is based on an interactional understanding of aggressive behaviour in psychotic patients. This model emphasizes detailed analyses of each patient's situational and interactional vulnerability, in addition to personality 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 patient's profile of interactional vulnerability. Empirical data from the clinical and research application of PAD at a special secure unit for dangerous patients are presented.