Mental Health Care: Violence and Aggressive Behaviour - Contributing Factors, Personal/Intrinsic Factors (Part 2)

      As victims or perpetrators, mental health patients are vulnerable to the risks associated with violence and aggressive behaviour. In inpatient environments in particular, violence and aggressive behaviour create a significant safety risk for staff, other people, and the person exhibiting the behaviour. All interventions should first ensure the personal safety of staff and the person, followed by attempts to de-escalate the behaviour using calm talk-down approaches. In all instances, prevention includes environment-of-care considerations, proper training for all staff, and an empathetic and understanding care culture.
Factors related to the person 
      It is important to avoid equating risk of violence or aggressive behavior as a personal feature; rather it should be clear that it is a feature of the condition. Instead of referring to a person in care as a "violent or aggressive person" refer to the person as "someone whose condition may increase the risk of harm to him/herself or others". This change in language moves away from labeling the person and helps highlight the fact that it is the condition or conditions that are driving the risk. 
The following are factors related to the person that may increase the risk of violence or aggressive behaviour. 
      1. Prior violence or aggressive behaviour. In both mental health and the general populations, prior expressions of violence or aggressive behaviour are the strongest predictors of future violence or aggressive behaviour. This behaviour will most often occur where the person feels threatened and fearful, particularly when the person has poor coping skills and strategies for managing ongoing distress. This can be exacerbated by trait characteristics of the person that may not change over time.
      2. Demographic factors. Research on the relationship between age as well as gender and aggressive behavior or violence is somewhat inconclusive. To the extent that these factors are taken into account during a risk assessment, they are more likely to play a role in identifying the type of violence or aggressive behaviour that will occur as opposed to the likelihood that it that it will happen. Men often express physically abusive behaviour while women more commonly express verbally abusive behaviour. A similar issue exists for the relationship between age and violence. Overall, it is likely that any relationship between age and harm to others represents a proxy association for other factors such as impulsivity or unrecognized distress. 
     3. Mental illness. Some persons with mental illness may experience symptoms (for example, paranoia, command hallucinations, mania, anger, impulsivity) that affect his or her ability to assess and react rationally to changes in the environment (for example, hospitalization, interactions with new or unfamiliar people). 
  Here are some factors found to be associated with risk of violence or aggressive behaviour. 
      * Insight: A person who lacks insight into his or her mental health problem may react aggressively to the provision of treatment. 
      * Trauma: A person who has experienced a psychological trauma, often unrecognized or untreated, may have an induced agitated state due to triggers related to his or her trauma (for example, sounds, smells, physical environment, and conversations). 
      * Bipolar disorder: Persons with bipolar disorder who are in a manic state may have a pervasive fear of loss of control and may respond with aggressive behaviour in instances where control is perceived to be lost.
      * Psychotic symptoms or disorders: Persons with psychotic symptoms or disorders may be at risk of harming others due command hallucinations or delusions. Risk may increase with concurrent alcohol or substance abuse, antisocial personality, or neurological impairment. 
      * Antisocial personality disorder: Persons with antisocial personality disorder may express aggressive or violent behaviors as a result of negative emotional states as well as in reaction to interventions or care environments, particularly if expectations about treatment and rules of the care setting are unclear. Be aware that some persons may engage in "limit testing" and "splitting." In both of these events, the person may engage in verbal threats or physically violent or aggressive acts. These aggressive behaviours usually have an instrumental purpose, with the person having a goal or an objective served by the behaviour. 
      * Dementia or recent cognitive loss: Examples include Alzheimer's disease, a stroke, an intellectual disability, and a decline in cognitive function. A person with such conditions may have difficulty communicating needs or may lack inhibition, which can lead to aggression. General medical conditions Medical conditions such as delirium, brain lesions, and other neurological syndromes may increase the risk of violence or aggressive behaviour due to factors related to the condition such as agitation, stress or disorientation. As well, persons who have conditions that cause physical pain or discomfort such as oral health problems or arthritis may express aggressive behaviour especially if they are unable to express their distress, perhaps due to language barriers, poor communication skills, or cognitive impairments. 
      * Behaviour Substance abusePersons who are intoxicated or experiencing withdrawal symptoms may be at an increased risk of aggressive behaviours and violence due to anxiety, irritability, agitation, impaired impulse control, disinhibition, decreased pain sensitivity, and impaired reality testing. Specific substances that may contribute to increased risk include alcohol, cocaine, methamphetamine, PCP, anabolic steroids, hallucinogens, cannabis, or combinations such as alcohol and psychostimulants or benzodiazapines. 
      * Persons who use tobacco, particularly on a daily basis, may also be at heighted risk of violence or aggressive behaviour when they are not allowed to smoke in settings where smoking is prohibited. Nicotine replacement therapies may curb this risk in these settings. 
      * Perceived threat, fear, and loss of personal control may increase the risk of aggressive behaviour and violence. Feeling threatened or fearful may be the result of symptoms, such as command hallucinations. 
      * Environmental factors can also influence threat or fear responses. As an example, the institutionalization process can invoke fear or paranoia, particularly without a strong therapeutic rapport between the person and care providers. 
      * Social marginalization, as experienced through poverty, transient lifestyle, and substance use, may increase the risk of violence or aggressive behaviour. Any of these experiences may expose persons, and especially those with mental illness, to an increased likelihood of being the victim or perpetrator of violence or aggressive behaviour.
In our next issue, 'Part 3 - Contributing Factors of Violence and Aggressive Behaviour - Factors Related to Treatment and the Environment' 
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