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Salud Mental 2007; 30 (1)
Language: English
References: 35
Page: 25-30
PDF size: 111.15 Kb.
ABSTRACT
The potential for violence in a number of persons with mental illnesses stimulates public fear and prevents general acceptance of persons with psychiatric disabilities.
Schizophrenia has been the diagnosis most often associated with violence as it has been taken as a paradigm of insanity, incompetence and dangerousness.
Clinicians’ efforts to prevent violence through conventional external patient treatment are impede by several situational variables and patients become trapped in a costly cycle of repeated institutional admissions (revolving door phenomenon) in the most
restrictive settings, going through involuntary in-patient treatment.
The major hypothesis proposed in this review is that violence in schizophrenia can become a part of a self-perpetuating cycle, in which the combination of non-adherence to treatment and an inadequate management of illness from families and caregivers leads to violent behavior and deteriorated social relationships, finally resulting in institutional recidivism.
As some of the initial symptoms of the illness, such as irritability and agitation may not be detected by the patient and his/her family, these symptoms eventually can easily escalate into open hostility, and the accompanying behavior is frequently violent.
Disturbed moods secondary to psychotic symptoms, such as fear and anger apparently can also activate violent psychotic action.
Accordingly, the path from the characteristics of the illness to violence leads to them through psychotic symptoms and lack of insight, and results in symptom-consistent violence.
When psychotic symptoms and violent behavior cannot be managed by caregivers, patients are brought to the attention of psychiatric services and frequently admitted to patient service.
During admission for a psychotic episode, there are more violent incidents than later on in the disease. As patients respond to medication and hospital environment, violent incidents and psychotic symptoms decrease in frequency and severity.
After hospital discharge, patients may assume greater autonomy and control over several aspects of their daily lives. Nevertheless, this process may be hampered by familial reactions to the burden of living with a family member with schizophrenia. This burden can also be exacerbated because many patients have a history of violent behavior and families may experience negative attitudes towards them.
In line with this, there is evidence of significant differences between the professionals’ perception about symptoms and illness, and that of the patient and his/her family. Sometimes, these different conceptions may reflect a lack of awareness regarding illness and treatment that may lead to discontinue medication.
Medication suspension can lead to an eventual relapse which most obvious sign is the emergence of positive psychotic symptoms.
Nevertheless if a patient has a past history of violent behavior, it is very likely that these behaviors will appear during relapse and it may be necessary to consider hospitalization.
Although treatment with antipsychotics may be useful when violence is secondary to psychotic symptoms, violence might be indirectly reduced through clinical programs aimed at increasing insight into illness and treatment. A psychoeducational strategy may improve antipsychotic treatment compliance by helping the patients to work through their ambivalence regarding antipsychotic medication. For families, a psychoeducation strategy can lead to a change in attitudes toward the disorder, as well as to promote problem-solving skills for violence.
The model presented here suggests that violence in schizophrenia is conditioned by several factors such as psychotic symptoms, medication non-compliance and lack of social support. The prevention of violent behavior in schizophrenia should include attention to other areas, such as the quality of the social environment surrounding the patient. For the “revolving door” patients, violence may be a key factor that complicates treatment.
Health professionals have the responsibility to work in partnership with patients and their families for the prevention of violence.
REFERENCES
ARANGO C, CALCEDO BA, GONZALEZ S, CALCEDO OA: Violence in inpatients with schizophrenia: a prospective study. Schizophr Bull, 25:493-503, 1999.
BINDER R, MCNIEL D: Effects of diagnosis and context on dangerousness. Am J Psychiatry, 145:728-732, 1988.
BORUM R, SWARTZ M, SWANSON J: Assessing and managing violence risk in clinical practice. J Prac Psychiatr Behav Health, 2:205-215, 1996.
BUCHANAN A: Social support and schizophrenia: a review of the literature. Arch Psychiatr Nurs, 9:68-76, 1995.
CUFFEL B: Disruptive behaviour and the determinants of costs in the public mental health system. Psychiatr Serv, 48:1562-1566, 1997.
EVERT H, HARVEY C, TRAUER T, HERRMAN H: The relationship between social networks and occupational and self-care functioning in people with psychosis. Soc Psychiatry Psychiatr Epidemiol, 38:180-188, 2003.
FADDEN G: Family intervention. En: Brooker C, Repper J (eds), Serious Mental Health Problems in the Community. Policy, Practice and Research. Balliere-Tindall, 159-183, London, 1998.
FERRITER M, HUBAND N: Experiences of parents with a son or daughter suffering from schizophrenia. J Psychiatr Ment Health Nurs, 10:552-560, 2003.
FRESAN A, APIQUIAN R, ULLOA R, LOYZAGA C et al.: Ambiente familiar y psicoeducación en el primer episodio de esquizofrenia. Resultados preliminares. Salud Mental, 24:36-40, 2001.
FRESAN A, DE LA FUENTE-SANDOVAL C, JUAREZ F, LOYZAGA C et al.: Sociodemographic features related to violent behavior in schizophrenia. Actas Esp Psiquiatr, 33:188-193, 2005.
GELLER J: A report on the «worst» state hospital recidivists in the US. Hosp Community Psychiatry, 43:904-908, 1992.
HAYWOOD T, KRAVITZ H, GROSSMAN L, CAVANAUGH JJ et al.: Predicting the «revolving door» phenomenon among patients with schizophrenic, schizoaffective and affective disorders. Am J Psychiatry, 152:856-861, 1995.
HOCKING B: Reducing mental illness stigma and discrimination- everybody’s business. Med J Aust, 178:547-548, 2003.
HOLDEN D, LEWINE R: How families evaluate mental health professionals, resources and effect of illness. Schizophr Bull, 4:626-633, 1982.
HUMPHREYS M, JOHNSTONE E, MACMILLAN J, TAYLOR P: Dangerous behaviour preceding first admissions for schizophrenia. Br J Psychiatry, 161:501-505, 1992.
JOHNS L, VAN OS J: The continuity of psychotic experiences in the general population. Clin Psychol Rev, 21:1125-1141, 2001.
JOHNSON S, ORRELL M: Insight and psychosis. A social perspective. Psychol Med, 25:515-520, 1995.
JOHNSTONE L: Do families cause schizophrenia? Revisting a taboo subject. En: Newnes C, Holmes G, Dunn C (eds). This is Madness. A Critical Look at Psychiatry and the Future of Mental Health Services. Llangarron, PCCS Books, 119-134, 1999.
JUNGINGER J: Psychosis and violence: the case for a content analysis of psychotic experience. Schizophr Bull, 22:91-103, 1996.
KRAKOWSKI M, CZOBOR P, CHOU J: Course of violence in patients with schizophrenia: relationship to clinical symptoms. Schizophr Bull, 25:505-517, 1999.
MACINNES D: Relatives and informal caregivers. En Chaloner CU (ed), Forensic Mental Health Nursing. Current Approaches. Blackwell Science Ltd, 208-231, Oxford, 2000.
MIKLOWITZ D: The role of family systems in severe and recurrent psychiatric disorders: a developmental psychopathology view. Dev Psychopathol, 16:667-688, 2004.
NEDOPIL N: Violence of psychotic patients: how much responsability can be attributed? Int J Law Psychiatry, 20:243-247, 1997.
NESTOR P, HAYCOCK J, DOIRON S, KELLY J, KELLY D: Lethal violence and psychosis: a clinical profile. Bull Am Acad Psychiatry Law, 23:331-41, 1995.
NORDSTRÖM A, KULLGREN A: Victim relations and victim gender in violent crimes committed by offenders with schizophrenia. Soc Psychiatry Psychiatr Epidemiol, 38:326-330, 2003.
OLFSON M, MECHANIC D, HANSELL S, BOYER C et al.: Predicting medication noncompliance after hospital discharge among patients with schizophrenia. Psychiatr Serv, 51:216-222, 2000.
SIMON R: Psychiatrists’ duties in discharging sicker and potentially violent inpatients in the managed care era. Psychiatr Serv, 49:62-67, 1998.
STEADMAN H: Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry, 55:1-9, 1998.
SWANSON J, BORUM R, SWARTZ M, HIDAY V: Violent behavior preceding hospitalization among persons with severe mental illness. Law Hum Behav, 23:185-204, 1999.
SWANSON J, SWARTS M, BORUM R, HIDAY V et al.: Involuntary out-patient commitment and reduction of violent behavior in persons with severe mental illness. Br J Psychiatry, 176:324-331, 2000.
TAYLOR M, CHAUDHRY I, CROSS M: Towards consensus in the long-term management of relapse prevention in schizophrenia. Hum Psychopharmacol Clin Exp, 20:175-181, 2005.
TAYLOR P: When symptoms of psychosis drive serious violence. Soc Psychiatry Psychiatr Epidemiol, 33:S47-s54, 1998.
WALLACE C, MULLEN P, BURGESS P, PALMER S et al.: Serious criminal offending and mental disorder. Case linkage study. Br J Psychiatry, 172:477-84, 1998.
WALSH E, BUCHANAN A, FAHY T: Violence and schizophrenia: examining the evidence. Br J Psychiatry, 180:490-495, 2002.
WESSELY S, TAYLOR P: Madness and crime: criminology or psychiatry? Crim Behav Ment Health, 1:193-228, 1991.
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