Aggressive Behavior in Patients with Schizophrenia – What Causes It?
The definition of violence by World Health Organization (WHO, 2010) is actual or threatened violence done intentionally and unintentionally by using physical force, against any person leading to death, harm, injury and maladaptive behavior or deprivation.
As a student, I see and work with patients having a variety of mentally illnesses. Patients who have schizophrenia have a violent attitude toward other and also toward health care providers. I wish to create awareness about violence, its causes and role of health care provider to prevent from violence towards other.
Case scenario: I encountered a woman, 28 years of age, having schizophrenia; she was very agitated, irritated and displayed physical violence and aggressive behavior toward staff and others people in ward. The patient was having severe persecutory delusions, and suicidal and homicidal ideation. My patient’s mother was also experiencing some psychological problems. She showed violent behavior and kept repeating that “if you disturb me I will hit you because I want to go home, and don’t try to catch me.” With this, she went on to hit the staff with shoes.
Physical violence in mentally ill patients is a social problem and common in both eastern and western countries. Mentally ill patients behave aggressively and may try to harm staff, other patients, properties or themselves. Around 44% of clinical staff and 72% of nursing staff are assaulted by patients. (Royal college of psychiatrists, 2007)
Causes of physical violence: There are multiple factors which lead to physical violence including, social factors, psychological factors, cognitive factors, effective factors and biological factors.
Family history plays a major role in violent behavior. Violence is a polygenetic condition in which multiple number of genes reacting in a parallel direction produce an aggression. There is a risk of development of conductive disorder, aggression and antisocial behavior in children who have family history of antisocial personality disorder (Stanley B 2006).
Researchers have focused on neurotransmitter involvement in a pathological model of aggression, suggesting that tendency towards physical violence may be related to low levels of concentration of 5-hydroxyndoleacetic acid (5-HiAA) a metabolite of serotonin, in cerebrospinal fluid (CSF). Brown GL,)
Increasing dopamine in mesolimbic dopamine pathway enhances irritability which leads to violence (Depue and Spoout 2011). Increase in norepinephrine in central nervous system results in an increase in violent behavior. Substance abuse also plays an important role in violent behavior. Steadman et al, 2005, showed 73% more chances of violence in patients with mental illness and substance abuse as compared to non-substance use.
Untreated psychotic patients have increased risk factors including severe hallucinations, poor insight and delusions such as paranoia, jealousy etc. (Buckley PF, 2003). Patients with persecutory delusions believe that they are protecting themselves by violence and my patient also suffered from severe persecutory delusions and thought that everyone was harming her.
My client exhibited paranoia, irritation and aggression. The risk factors of command hallucination, hopelessness, impulsivity, homicidal thoughts, depression, hopelessness, suicidality, feasibility of homicidal plan, were all present in my patient (Norko MA,2005).
The consequences of physical violence can be severe and may result in injury to staff and other patients. Due to this many health care providers are unable to provide therapeutic and effective care. It also affects patient safety. Most of the staff members experience emotional problems including anger, shock, depression, fear and sleep disturbance.
Moreover, physical violence against staff leads to increased sickness and many are changing their jobs which could lead to less availability of staff (Garcia I,2005). The dependency acting staff increases cost of service and is associated with low standard of care, also the perception about threat of violence results in the taking of different safety action plans including restraints, seclusion and forceful medication administration. So instead of involvement and compliance, the client develops traumatic and aggressive behavior (Olofsson B, 2001). My patient was also noncompliant with medication and was not cooperative with the staff. She was sometimes restrained and forcefully giving the medicine. (Daffern M, june 2006).
The Aggression Theory of John Dollard and Neal Miller (1939) says that frustration can lead to aggression. Frustration occurs when an individual is unable to achieve her goal (Baron, & Richardson, 1994). This theory is also related to my patient’s behavior because she wanted to go home and was not taking medication or following the hospital rules so when the staff tried to force the patient she became violent because her goal was not being fulfilled so her frustration led to violence.
At the individual level, we must change our own perception that mentally ill patients are not as dangerous and violent. To enhance their self-esteem, we should talk to them in a calm manner and plan activities to lessen their violent action. These activities provide opportunities to expel their frustration, anger and fear. We could also provide information regarding meditation, games, yoga, exercises, mindfulness and holistic care to enhance their wellbeing. To reduce stressors, we could also provide occupational therapy, pharmacological therapy, behavioral therapy and cognitive therapy (Am J Psychiatry. 2010 Mar).
Through restraint, medication and seclusion at the cost of examining means of prevention we could control violent (Sheridan et1990)
At the community level, with the help of support groups we could reduce the violence in mentally ill clients (Swanson, 2008). We could formulate a law and policy for prevention of physical violence and allow for these people to ventilate their feeling. For improving their wellbeing (Br J Psychiatry. 2008 Jul).
In conclusion although physical violence is harmful for client and patient but we could reduce it by proper counselling, medication, follow-ups, awareness. This is our responsibility to treat them in proper way because they are not aware of how to behave.
Volvaka, J. (2012). violence in schizophrenia and bipolar disorder. psychiatric dambina, 25, 24-33. Retrieved from http://www.hdbp.org/psychiatria_danubina/pdf/dnb_vol25_no1/dnb_vol25_no1_24.pdf
Wehring, W. J., & Carpenter, W. T. (2011). Violence and Schizophrenia. Oxford journal, 37, 877-878. Retrieved from http://schizophreniabulletin.oxfordjournals.org/content/37/5/877.full.pdf+htm
Short, V., Lennox, C., Stevenson, C., Senior, J., & Shaw, J. (2012). Mental Illness, Personality and Violence: A Scoping Review. e Offender Health Research Network, 1-83. Retrieved from http://www.ohrn.nhs.uk/OHRNResearch/MIviolence.pdf
Hodgins, S. (2008). Violent behavior among people with schizophrenia: a framework for investigations of causes, and effective treatment, and prevention. Philosophical Transactions of the Royal Society B: Biological Sciences, 363(1503), 2505-2518. doi:10.1098/rstb.2008.0034
Rueve, M. E., & Welton, R. S. (2008). Violence and Mental Illness. Psychiatry (Edgmont) , 5(5), 34-48. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686644/#B34
Anderson, A., & West, S. G. (2011). Violence Against Mental Health Professionals: When the Treater Becomes the Victim. Innov Clin Neurosci, 8(3), 34-39. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074201/
Stewart, D., Bowers, L., & Ross, J. (2011). Managing risk and conflict behaviours in acute psychiatry: the dual role of constant special observation. Journal of Advanced Nursing, 68(6), 1340-1348. doi:10.1111/j.1365-2648.2011. 05844.x
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