Aggressives Verhalten psychisch Kranker im stationären Bereich: Häufigkeit, Risikofaktoren, Prävention

Zusammenfassung

Im Gegensatz zu angloamerikanischen und skandinavischen Ländern, in denen aggressives Verhalten psychisch Kranker während stationärer Behandlung seit längerem als Problem angesehen wird, findet im deutschsprachigen Raum erst seit einigen Jahren eine Auseinandersetzung mit diesem Thema statt, wobei die bisher vorliegenden Ergebnisse deutliche Parallelen zur internationalen Entwicklung zeigen. In der vorliegenden Arbeit wird nach der Erörterung methodologischer Probleme (unterschiedliche Definitionen, Informationsquellen und Registrierungsmöglichkeiten) anhand der vorhandenen Literatur der aktuelle Wissensstand dargestellt:

Generell wird die Häufigkeit, vor allem bei Frauen, unterschätzt; relativ wenige Patienten sind für die Mehrzahl der Übergriffe verantwortlich; Opfer werden eher Mitglieder des Betreuungspersonals als Mitpatienten; es besteht eine Diskrepanz zwischen den meist geringfügigen körperlichen und den erheblichen emotionalen Folgen für die Opfer, dementsprechend werden die negativen Auswirkungen auf das Stationsklima oft unterschätzt. Neben statischen/aktuarischen Risikofaktoren, wie soziale Schicht, aggressives Verhalten in der Vorgeschichte, dissoziale Persönlichkeitsmerkmale und (teilweise) Diagnosen haben vor allem dynamische Risikofaktoren, wie akute Intoxikation, Substanzmissbrauch, mangelnde Krankheitseinsicht bzw. Compliance sowie produktiv-psychotische Symptome Einfluss auf Frequenz und Schweregrad von einschlägigen Vorfällen, an externen Faktoren Personaldichte, Stationsgröße und -struktur, vor allem aber Haltung und Einstellung des Betreuungspersonals sowie dessen Fähigkeit, Risikosituationen und Frühwarnzeichen zu erkennen bzw. adäquat damit umzugehen. Für Behandlung und Prävention sind - abgesehen von medikamentösen Interventionen - vor allem die erwähnten personalbezogenen Maßnahmen von Bedeutung. Sie stellen die grundsätzliche Basis für die suffiziente Versorgung hospitalisierter Patienten auch jenseits des Phänomens Aggression dar.

Abstract

In contrast to Angloamerican and Scandinavian countries inpatient violence was not regarded as a problem in German-speaking countries for a long time. Only recently it has become a topic of increasing interest for clinical practice and research, whereby the present data exhibit significant parallels to the international development. After the discussion of methodological problems (e. g. varying definitions, sources of information, ways of registration) the paper presents the current state of knowledge about inpatient violence:

Underestimation in general, mainly with respect to female patients; only a few patients are responsible for the majority of assaults; victims are rather staff members than fellow patients; discrepancy between the mostly minor physical, though major emotional consequences for victims; considerably negative effects on patient-staff interactions and ward climate. Aside from patient-related actuarial and dynamic risk factors (social origin, previous history of aggressive behaviour, dissocial personality traits and - partly - diagnoses, acute intoxication, substance abuse, lack of insight and compliance, psychotic symptoms) external/contextual factors as patient-staff ratio, ward size, structure and climate, staff-attitudes, recognition of early warning signs and handling of risk situations are of major importance for the frequency and severity of incidents. Intervention and prevention strategies are focussing - aside from medication - on the aforementioned staff-related factors and patient-staff interactions. They are the principal basis for sufficient inpatient treatment beyond the problem of violence.

Literatur

• 1 Ekblom B. Acts of violence by patients in mental hospitals.  Uppsala; Scandinavian University Books 1970
• 2 Myers K M, Dunner L D. Self and other directed violence on a closed acute ward.  Psychiatr Q. 1984;  56 178-188
• 3 Dorwart R A. A ten-year follow-up study of the effects of deinstitutionalisation.  Hosp Community Psychiatry. 1988;  39 287-291
• 4 Snyder W. Hospital downsizing and increased frequency of assaults on staff.  Hosp Community Psychiatry. 1994;  45 378-380
• 5 Beck J C. Forensic psychiatry in the USA and UK: a clinician’s review.  CBMH. 1996;  6 11-27
• 6 Monahan J. Mental disorder and violent behavior. Perceptions and evidence.  Am Psychologist. 1992;  47 511-521
• 7 Torrey E F. Out of the shadows. Confronting America’s mental illness crisis. New York: Wiley 1997
• 8 Reimer F. Gewalttaten in psychiatrischen Krankenhäusern. Eine Umfrage.  Spektrum. 1987;  1 29
• 9 Stierlin H. Der gewalttätige Patient. Eine Untersuchung über die von Geisteskranken an Ärzten und Pflegepersonal verübten Angriffe. Basel; Karger 1956
• 10 Böker W, Häfner H. Gewalttaten Geistesgestörter.  Berlin, Heidelberg, New York: Springer 1973
• 11 Schanda H. Die Versorgung psychisch Kranker zur Jahrtausendwende - ein Weg in die Zweiklassenpsychiatrie?.  Fortschr Neurol Psychiat. 2001;  69 195-202
• 12 Steinert T, Vogel W D, Beck M, Kehlmann S. Aggressionen psychiatrischer Patienten in der Klinik. Eine Ein-Jahres-Studie an vier psychiatrischen Landeskrankenhäusern.  Psychiat Prax. 1991;  18 155-161
• 13 Genz A, Krüger E, Dorst W. Aggressives Verhalten in der psychiatrischen Klinik.  Neurol Med Psychol. 1988;  40 542-551
• 14 Klimitz H, Uhlemann H, Fähndrich E. Fixieren wir zu häufig? Indikation, Häufigkeit und Randbedingungen von Fixierungen in einer allgemeinpsychiatrischen Abteilung.  Psychiat Prax. 1998;  25 235-239
• 15 Spießl H, Krischker S, Cording C. Aggressive Handlungen im psychiatrischen Krankenhaus. Eine auf die psychiatrische Basisdokumentation gestützte 6-Jahres-Studie bei 17.943 stationären Aufnahmen.  Psychiat Prax. 1998;  25 227-230
• 16 Steinert T, Gebhardt R P. Wer ist gefährlich? Probleme der Validität und Reliabilität bei der Erfassung und Dokumentation von fremdaggressivem Verhalten.  Psychiat Prax. 1998;  25 221-226
• 17 Steinert T, Beck M, Vogel W D, Wohlfahrt A. Gewalttätige Patienten.  Ein Problem für Therapeuten an psychiatrischen Kliniken? Nervenarzt. 1995;  66 207-211
• 18 Steinert T, Hermer U, Faust V. Die Motivation aggressiven Patientenverhaltens in der Einschätzung von Ärzten und Pflegepersonal.  Krankenhauspsychiatrie. 1995;  6 11-16
• 19 Steinert T, Hermer K, Faust V. Comparison of aggressive and non-aggressive schizophrenic inpatients matched for age and sex.  Eur J Psychiatry. 1996;  10 100-107
• 20 Steinert T, Voellner A, Hermer K. Violent behaviour in schizophrenics - caused by schizophrenia itself or by premorbid behaviour disorder?.  Eur Psychiatry Suppl 4. 1996;  11 297-298
• 21 Steinert T, Wiebe C, Gebhardt R P. Aggressive behavior against self and others among first-admission patients with schizophrenia.  Psychiatr Serv. 1999;  50 85-90
• 22 Zeiler J. Der aggressive Patient - Anmerkungen zur Sozialpsychologie der Gewalt.  Psychiat Prax. 1993;  20 130-135
• 23 Carmel H, Hunter M. Psychiatrists injured by patient attack.  Bull Am Acad Psychiatry Law. 1991;  19 309-316
• 24 Edwards J G, Jones D, Reid W H, Chu Ch-Ch. Physical assaults in a psychiatric unit of a general hospital.  Am J Psychiatry. 1988;  145 1568-1571
• 25 Noble P, Rodger S. Violence by psychiatric in-patients.  Br J Psychiatry. 1989;  155 384-390
• 26 Rabinowitz J, Mark M. Risk factors for violence among long-stay psychiatric patients: national study.  Acta Psychiatr Scand. 1999;  99 341-347
• 27 Reid W H, Bollinger M F, Edwards G. Assaults in hospitals.  Bull Am Acad Psychiatry Law. 1985;  13 1-4
• 28 Cheung P, Schweitzer I, Tuckwell V, Crowley K C. A prospective study of assaults on staff by psychiatric in-patients.  Med Sci Law. 1997;  37 46-52
• 29 Binder R L, McNiel D. Effects of diagnosis and context on dangerousness.  Am J Psychiatry. 1988;  145 728-732
• 30 McNiel D E, Binder R L. Clinical assessment of the risk of violence among psychiatric inpatients.  Am J Psychiatry. 1991;  148 1317-1321
• 31 McNiel D E, Myers R S, Zeiner H K, Wolfe H L, Hatcher C. The role of violence in decisions about hospitalization from the psychiatric emergency room.  Am J Psychiatry. 1992;  149 207-212
• 32 Palmstierna T, Wistedt B. Risk factors for aggressive behaviour are of limited value in predicting the violent behaviour of acute involuntarily admitted patients.  Acta Psychiatr Scand. 1989;  81 152-155
• 33 Palmstierna T, Wistedt B. Changes in the pattern of aggressive behaviour among inpatients with changed ward organisation.  Acta Psychiatr Scand. 1995;  91 32-35
• 34 Raja M, Azzoni A, Lubich L. Aggressive and violent behavior in a population of psychiatric inpatients.  Soc Psychiatry Psychiatr Epidemiol. 1997;  32 428-434
• 35 Hammill K, McEvoy J P, Koral H, Schneider N. Hospitalized schizophrenic patients views about seclusion.  J Clin Psychiatry. 1989;  50 174-177
• 36 Way B B, Banks S M. Use of seclusion and restraint in public psychiatric hospitals - patient characteristics and facility effects.  Hosp Community Psychiatry. 1990;  41 75-80
• 37 Davis S. Violence by psychiatric inpatients: a review.  Hosp Community Psychiatry. 1991;  42 585-589
• 38 Dietz P E, Rada R T. Battery incidents and batterers in a maximum security hospital.  Arch Gen Psychiatry. 1982;  39 31-34
• 39 Schanda H, Gruber K, Habeler A. Aggressives Verhalten zurechnungsunfähiger psychisch kranker Straftäter während stationärer Behandlung.  Psychiat Prax. 2000;  27 1-7
• 40 Lion J R, Snyder W, Merrill G. Underreporting of assaults on staff in a state hospital.  Hosp Community Psychiatry. 1981;  32 497-498
• 41 Baxter E, Hafner R J, Holme G. Assaults by patients: the experience and attitudes of psychiatric hospital nurses.  Aust N Z J Psychiatry. 1992;  26 567-573
• 42 Yudofsky S C, Silver J M, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression.  Am J Psychiatry. 1986;  143 35-39
• 43 Palmstierna T, Wistedt B. Staff observation aggression scale - SOAS. Presentation and evaluation.  Acta Psychiatr Scand. 1987;  76 657-663
• 44 Taylor P, Schanda H. Violence against others by psychiatric hospital in-patients with psychosis: prevention strategies and challenges to their evaluation. In: Hodgins S (Hrsg). Violence among the mentally ill Dordrecht; Kluwer 2000: 251-275
• 45 Thackrey M, Bobitt R G. Patient aggression against clinical and non-clinical staff in a VA medical center.  Hosp Community Psychiatry. 1990;  41 195-197
• 46 Cheung P, Schweitzer I, Tuckwell V, Crowley K C. A prospective study of aggression among psychiatric inpatients in rehabilitation wards.  Aust N Z J Psychiatry. 1996;  30 257-262
• 47 James D V, Fineberg N A, Shah A K, Priest R G. An increase in violence on an acute psychiatric ward: a study of associated factors.  Br J Psychiatry. 1990;  156 846-852
• 48 Convit A, Isay D, Gadioma R, Volavka J. Underreporting of physical assaults in schizophrenic inpatients.  J Nerv Ment Dis. 1988;  176 507-509
• 49 Lanza M L. Nurses as patient assault victims: An update, synthesis and recommendations.  Arch Psychiat Nursing. 1992;  6 163-172
• 50 Monahan J. Clinical and actuarial predictions of violence. In: Faigman D, Kaye D, Saks M, Sanders J (Hrsg). Modern scientific evidence: the law and science of expert testimony. Vol 1 St. Paul; West Publishing Company 1997: 300-318
• 51 Ball E M, Young D, Dotson L A, Brother L T, Robbins D. Factors associated with dangerous behavior in forensic inpatients: results from a pilot study.  Bull Am Acad Psychiatry Law. 1994;  22 605-620
• 52 Larkin E, Murtagh S, Jones S. A preliminary study of violent incidents in a general hospital (Rampton).  Br J Psychiatry. 1988;  153 226-231
• 53 Heilbrun K, Golloway G G, Shoukry V E, Gustafson D. Physical control of patients on an inpatient setting: forensic vs. civil populations.  Psychiatr Q. 1995;  66 133-145
• 54 Junginger J, Parks-Levy J, McGuire L. Delusions and symptom-consistent violence.  Psychiatr Serv. 1998;  49 218-220
• 55 Rofman E S, Askinazi C, Fant E. The prediction of dangerous behavior in emergency civil commitment.  Am J Psychiatry. 1980;  137 1061-1064
• 56 Tardiff K, Koenigsberg H W. Assaultive behavior among psychiatric outpatients.  Am J Psychiatry. 1985;  142 960-963
• 57 Tardiff K, Marzuk P M, Leon A C, Portera L, Weiner C. Violence by patients admitted to a private psychiatric hospital.  Am J Psychiatry. 1997;  154 88-93
• 58 Link B, Andrews H, Cullen F T. The violent and illegal behavior of mental patients reconsidered.  Am Sociol Rev. 1992;  57 275-292
• 59 Swanson J, Holzer C, Ganju V, Jono R. Violence and the psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area Surveys.  Hosp Community Psychiatry. 1990;  41 761-770
• 60 Binder R L, McNiel D E. The relationship of gender to violent behavior in acutely disturbed psychiatric inpatients.  J Clin Psychiatry. 1990;  51 110-114
• 61 Blomhoff S, Seim S, Friis S. Can prediction of violence among psychiatric inpatients be improved?.  Hosp Community Psychiatry. 1990;  41 771-775
• 62 Fottrell E. A study of violence behaviour among patients in psychiatric hospitals.  Br J Psychiatry. 1980;  136 216-221
• 63 Hodgkinson P E, McIvor L, Phillips M. Patient assaults on staff in a psychiatric hospital: a two-year retrospective study.  Med Sci Law. 1985;  25 288-294
• 64 Hoge S K, Lidz C W, Eisenberg M, Monahan J, Bennett N, Gardner W, Mulvey E, Roth L. Family, clinician and patient perceptions of coercion in mental hospital admission.  Int J Law Psychiatry. 1998;  21 131-146
• 65 Kay S R, Wolkenfeld F, Murrill L M. Profiles of aggression among psychiatric patients. I. nature and prevalence.  J Nerv Ment Dis. 1988;  176 539-546
• 66 Lidz C, Mulvey E P, Gardner W. The accuracy of predictions of violence to others.  JAMA. 1993;  269 1007-1011
• 67 Tardiff K, Sweillam A. Assaultive behavior among chronic inpatients.  Am J Psychiatry. 1982;  139 212-215
• 68 Tardiff K. A survey of drugs used in the management of assaultive inpatients.  Bull Am Acad Psychiatry Law. 1983;  11 215-222
• 69 Owen C, Tarantello C, Jones M, Tennant C. Violence and aggression in psychiatric units.  Psychiatr Serv. 1998;  49 1452-1457
• 70 Owen C, Tarantello C, Jones M, Tennant C. Repetitively violent patients in psychiatric units.  Psychiatr Serv. 1998 ;  49 1458-1461
• 71 McNiel D E, Binder R L, Greenfield T K. Predictors of violence in civilly committed acute psychiatric patients.  Am J Psychiatry. 1988;  145 965-970
• 72 Greenfield T K, McNiel D E, Binder R L. Violent behavior and length of psychiatric hospitalisation.  Hosp Community Psychiatry. 1989;  40 809-814
• 73 Miller R J, Zadolinnyj K, Hafner R J. Profiles and predictors of assaultiveness for different psychiatric ward populations.  Am J Psychiatry. 1993;  150 1368-1373
• 74 Maden A, Curle C, Meux C, Burrow S, Gunn J. The treatment and security needs of patients in special hospitals.  CBMH. 1993;  3 290-306
• 75 Lehmann L S, McCormick R A, Kizer K W. A survey of assaultive behavior in Veterans Health Administration facilities.  Psychiatr Serv. 1999;  50 384-389
• 76 Sheridan M, Henrion R, Robinson L, Baxter V. Precipitants of violence in a psychiatric inpatient setting.  Hosp Community Psychiatry. 1990;  41 776-780
• 77 Volavka J, Mohammad Y, Vitrai J, Conolly M, Stefanovic M, Ford M. Characteristics of State Hospital patients arrested for offences committed during hospitalisation.  Psychiatr Serv. 1995;  46 796-800
• 78 Caldwell M. Incidence of PTSD among staff victims of patient violence.  Hosp Community Psychiatry. 1992;  26 838-839
• 79 Cooper A J, Mendonca J A. A prospective study of patient assaults on nurses in a provincial psychiatric hospital in Canada.  Acta Psychiatr Scand. 1991;  84 163-166
• 80 Hoptman M J, Yates K F, Patalinjug M B, Wack R C, Convit A. Clinical prediction of assaultive behavior among male psychiatric patients at a maximum-security forensic facility.  Psychiatr Serv. 1999;  50 1461-1466
• 81 McNiel D E, Binder R L. Correlates of accuracy in the assessment of psychiatric inpatients’ risk of violence.  Am J Psychiatry. 1995;  152 901-906
• 82 Swartz M S, Swanson J W, Hiday V A, Borum R, Wagner H R, Burns B J. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication.  Am J Psychiatry. 1998;  155 226-231
• 83 Convit A, Jaeger J, Lin S P, Meisner M, Volavka J. Predicting assaultiveness in psychiatric inpatients: a pilot study.  Hosp Community Psychiatry. 1988;  39 429-434
• 84 Janofsky I S, Spears S, Neubauer D N. Psychiatrists’ accuracy in predicting violent behavior on an inpatient unit.  Hosp Community Psychiatry. 1988;  39 1090-1094
• 85 Kay S R, Wolkenfeld F, Murrill L M. Profiles of aggression among psychiatric patients. II. covariates and predictors.  J Nerv Ment Dis. 1988;  176 547-557
• 86 Lowenstein M, Binder R L, McNiel D E. The relationship between admission symptoms and hospital assaults.  Hosp Community Psychiatry. 1990;  41 311-313
• 87 Morrison E F. A coercive interactional style as an antecedent to aggression in psychiatric patients.  Res Nurs Health. 1992;  15 421-431
• 88 Krakowski M, Czobor P. Violence in psychiatric patients: the role of psychosis, frontal lobe impairment and ward turmoil.  Compr Psychiatry. 1997;  38 230-236
• 89 Tidmarsh D. Schizophrenia. In: Bluglass R, Bowden P (Hrsg). Principles and practice of forensic psychiatry Edinburgh; Churchill Livingstone 1990: 321-343
• 90 Lapierre D, Braun CM J, Hodgins S, Toupin S, Leveillee S, Constantineau C. Neuropsychological correlates of violence in schizophrenia.  Schizophr Bull. 1995;  21 253-262
• 91 Nolan K A, Volavka J, Mohr P, Czobor P. Psychopathy and violent behavior among patients with schizophrenia or schizoaffective disorder.  Psychiatr Serv. 1999;  50 787-792
• 92 Buchanan A, Reed A, Wessely S, Garety P, Taylor D, Grubin D, Dunn G. Acting on delusions. II: the phenomenological correlates of acting on delusions.  Br J Psychiatry. 1993;  163 77-81
• 93 Björkly S. High-risk factors for violence. Emerging evidence and its relevance to effective treatment and prevention of violence on psychiatric wards. In: Hodgins S (Hrsg). Violence among the mentally ill Dordrecht; Kluwer 2000: 237-250
• 94 Taylor P J. When symptoms of psychosis drive serious violence.  Soc Psychiatry Psychiatr Epidemiol. 1998;  33 47-54
• 95 Taylor P J, Leese M, Williams D, Butwell M, Daly R, Larkin E. Mental disorder and violence. A special (high security) hospital study.  Br J Psychiatry. 1998;  172 218-226
• 96 Nijman H LI, Rector G. Crowding and aggression on inpatient psychiatric wards.  Psychiatr Serv. 1999;  50 830-831
• 97 Palmstierna T, Huitfeldt B, Wistedt B. Effects of crowding on aggressive behaviour on an acute psychiatric intensive care unit.  Hosp Community Psychiatry. 1991;  42 1237-1240
• 98 Drinkwater J, Gudjonsson G. The nature of violence in psychiatric hospitals. In: Hollin CR, Howells K (Hrsg). Clinical approaches to violence Chichester; Wiley 1989: 287-310
• 99 Crichton J HM. Psychodynamic perspectives on staff response to inpatient misdemeanour.  CBMH. 1998;  8 266-274
• 100 Carmel H, Hunter M. Compliance with training in managing assaultive behavior and injuries from in-patient violence.  Hosp Community Psychiatry. 1990;  41 558-560
• 101 Infantino J, Musingo S. Assaults and injuries among staff with and without training in aggression control techniques.  Hosp Community Psychiatry. 1985;  36 1312-1314
• 102 Smoot S L, Gonzales J L. Cost-effective communication skills training for state hospital employees.  Psychiatr Serv. 1995;  46 819-822
• 103 Flannery R B, Hanson M A, Penk W E, Flannery G J. Violence and the lax milieu?: preliminary data.  Psychiatr Q. 1996;  67 47-50
• 104 Friis S, Helldin L. The contribution made by the clinical setting to violence among psychiatric patients.  CBMH. 1994;  4 341-352
• 105 Haller R M, Deluty R H. Assaults on staff by psychiatric inpatients.  Br J Psychiatry. 1988;  152 174-179
• 106 Melle I, Friis S, Hauff E, Island T K, Lorentzen S, Vaglum P. The importance of ward atmosphere in inpatient treatment of schizophrenia on short-term units.  Psychiatr Serv. 1996;  47 721-726
• 107 Katz P, Kirkland F. Violence and social structure on mental hospital wards.  Psychiatry. 1990;  53 262-277
• 108 Ionno J A. A prospective study of assaultive behavior in female psychiatric inpatients. In: Lion JR, Reid WH (Hrsg). Assaults within psychiatric facilities. New York; Grune & Stratton 1983: 71-80
• 109 Smith J, Hucker S. Schizophrenia and substance abuse.  Br J Psychiatry. 1994;  165 13-21
• 110 Hellerstein D, Frosch W, Koenigsberg H W. The clinical significance of command hallucinations.  Am J Psychiatry. 1987;  144 219-221
• 111 McNiel D E. Hallucinations and violence. In: Monahan J, Steadman H (Hrsg). Violence and mental disorder. Chicago; University of Chicago Press 1994: 183-202
• 112 Link B, Stueve A. Psychotic symptoms and the violent/illegal behavior of mental patients compared to the community. In: Monahan J, Steadman H (Hrsg). Violence and mental disorder: developments in risk assessment Chicago; University of Chicago Press 1994: 137-158
• 113 Swanson J, Borum R, Swartz M S, Monahan J. Psychiatric symptoms and disorders and the risk of violent behaviour in the community.  CBMH. 1996;  6 309-329
• 114 Appelbaum P S, Clark Robbins P, Monahan J. Violence and delusion: data from the McArthur Violence Risk Assessment Study.  Am J Psychiatry. 2000;  157 566-572
• 115 Stompe T, Ortwein-Swoboda G, Schanda H. Schizophrenia, delusional symptoms and violence: the threat/control-override-concept re-examined. Unveröffentlichtes Manuskript
• 116 Cheung P, Schweitzer I, Crowley K, Tuckwell V. Violence in schizophrenia: role of hallucinations and delusions.  Schizophr Res. 1997;  26 181-190
• 117 Swanson J, Estroff S, Swartz M, Borum R, Lachicotte W, Zimmer C, Wagner R. Violence in severe mental disorder in clinical and community populations: the effects of psychotic symptoms, comorbidity and lack of treatment.  Psychiatry. 1997;  60 1-22
• 118 Swanson J, Swartz M, Estroff S, Borum R, Wagner R, Hiday V. Psychiatric impairment, social contact, and violent behavior: evidence from a study of outpatient-committed persons with severe mental disorder.  Soc Psychiatry Psychiatr Epidemiol. 1998;  33 86-94
• 119 Walker Z, Seifert R. Violent incidents in a psychiatric intensive care unit.  Br J Psychiatry. 1994;  164 826-828
• 120 Björkly S. A ten-year prospective study of aggression in a special secure unit for dangerous patients.  Scand J Psychology. 1999;  40 57-65
• 121 Perregard R N, Bartels U. Violence against staff in mental hospital (abstract). First European Symposium on aggression in clinical psychiatric practice. The psychiatric institution. Stockholm; Karolinska Institute, Danderyd Hospital 1992: 22-23
• 122 Shah A K, Fineberg N A, James D V. Violence among psychiatric inpatients.  Acta Psychiatr Scand. 1991;  84 305-309
• 123 Blair T. Assaultive behaviour: does provocation begin in the front office?.  J Psychosocial Nursing. 1991;  29 21-26
• 124 Linaker O M, Busch-Iversen H. Predictors of imminent violence in psychiatric inpatients.  Acta Psychiatr Scand. 1995;  92 250-254
• 125 Kalogjera I J, Bedi A, Watson W N, Meyer A D. Impact of therapeutic management on use of seclusion and restraint with disruptive adolescent inpatients.  Hosp Community Psychiatry. 1989;  40 280-285
• 126 Tardiff K. Assessment and management of violent patients. Washington; American Psychiatric Press 1996
• 127 Citrome L, Volavka J. Pharmacological treatments for psychotic offenders. In: Hodgins S, Müller-Isberner R (Hrsg). Violence, crime and mentally disordered offenders. Chichester; Wiley 2000: 153-176
• 128 Coccaro E F, Kavoussi R J. Fluoxetine and impulsive aggressive behavior in personality-disordered subjects.  Arch Gen Psychiatry. 1997;  54 1081-1088
• 129 Vartiainen H, Tiihonen J, Putkonen A, Koponen H, Virkkunen M, Hakola P, Lehto H. Citalopram, a selective serotonin reuptake inhibitor in the treatment of aggression in schizophrenia.  Acta Psychiatr Scand. 1995;  91 348-351
• 130 Troisi A, Vicario E, Nuccetelli F, Ciani N, Pasini A. Effects of fluoxetine on aggressive behavior of adult inpatients with mental retardation and epilepsy.  Pharmacopsychiatry. 1995;  28 73-76
• 131 Hughes D H. Pharmacologic management of the chronically aggressive psychiatric patient.  Psychiatr Ann. 1998;  28 367-370
• 132 Wickham E A, Reed J U. Lithium for the control of aggressive and self-mutilating behavior.  Int Clin Psychopharmacol. 1987;  2 181-190
• 133 Wilson W H. Addition of lithium to haloperidol in non-affective, antipsychotic non-responsive schizophrenia: a double-blind placebo-controlled parallel design clinical trial.  Psychopharmacology. 1993;  111 359-366
• 134 Steinert T. Neuere Tendenzen in der Pharmakotherapie aggressiven Verhaltens bei psychisch Kranken.  Fortschr Neurol Psychiat. 1992;  60 393-400
• 135 Okuma T, Yamashita I, Takahashi R, Itoh A, Kurihara M, Otsuki S, Watanabe S, Hazamura H, Inanaga K. The double-blind study of adjunctive carbamazepine versus placebo on excited states of schizophrenia and schizoaffective disorders.  Acta Psychiatr Scand. 1989;  80 250-259
• 136 Young J, Hillbrand M. Carbamazepine lowers aggression: a review.  Bull Am Acad Psychiatry Law. 1994;  22 53-61
• 137 Tiihonen J. Pharmacological treatments for personality disordered offenders. In: Hodgins S, Müller-Isberner R (Hrsg). Violence, crime and mentally disordered offenders. Chichester; Wiley 2000: 177-192
• 138 Wilcox J. Divalproex sodium in the treatment of aggressive behaviour.  Ann Clin Psychiatry. 1994;  6 17-20
• 139 Citrome L. Valproate: Extent of use within the in-patient population of the New York State Office of Mental Health psychiatric hospital system.  Psychiatr Q. 1998;  69 283-300
• 140 Freeman M P, Stoll A L. Mood stabilizer combinations: a review of safety and efficacy.  Am J Psychiatry. 1998;  155 12-21
• 141 Lindenmayer J -P, Kotsaftis A. Use of sodium valproate in violent and aggressive behaviors: a critical review.  J Clin Psychiatry. 2000;  61 123-128
• 142 Kane J M, Marder S R. Psychopharmacologic treatment of schizophrenia.  Schizophr Bull. 1993;  19 287-302
• 143 McEvoy J P, Hogarty G E, Steingard S. Optimal dose of neuroleptic in acute schizophrenia.  Arch Gen Psychiatry. 1991;  48 739-745
• 144 Peralta V, Cuesta M J, Caro F, Martinez-Larrea A. Neuroleptic dose and schizophrenic symptoms - a survey of prescribing practices.  Acta Psychiatr Scand. 1994;  90 354-357
• 145 Dalal B, Larkin E, Leese M, Taylor P J. Clozapine treatment of long-standing schizophrenia and serious violence: a two-year follow-up study of the first 50 patients treated with clozapine in Rampton high security hospital.  CBMH. 1999;  9 168-178
• 146 Maier G J. The inpact of clozapine on 25 forensic patients.  Bull Am Acad Psychiatry Law. 1992;  20 297-307
• 147 Rabinowitz J, Avnon M, Rosenberg V. Effect of clozapine on physical and verbal aggression.  Schizophr Res. 1996;  22 249-255
• 148 Ratey J L, Leveroni C, Kilmer D, Gutheil C, Swartz B. The effects of clozapine on severely aggressive psychiatric inpatients in a state hospital.  J Clin Psychiatry. 1993;  54 219-223
• 149 Wilson W H, Claussen A M. 18-month outcome of clozapine treatment for 100 patients in a state psychiatric hospital.  Psychiatr Serv. 1995;  46 368-389
• 150 Swinton M, Ahmed A G. Reasons for non-prescription of clozapine in treatment-resistant schizophrenia.  CBMH. 1999;  9 207-214
• 151 Freeman D, Garety P A, Fowler D, Kuipers E, Dunn G, Bebbington P, Hadley C. The London-East Anglia randomized controlled trial of cognitive-behaviour therapy for psychosis. IV: self-esteem and persecutory delusions.  Br J Clin Psychology. 1998;  37 415-430
• 152 Garety P A, Kuipers E, Fowler D, Chamberlain F, Dunn G. Cognitive behavioural therapy for drug-resistant psychosis.  Br J Med Psychology. 1994;  67 259-271
• 153 Kuipers E, Fowler D, Garety P, Chisholm D, Freeman D, Dunn G, Bebbington P, Hadley C. London-East Anglia randomized controlled trial of cognitive-behavioural therapy for psychosis. III: follow-up and evaluation at 18 months.  Br J Psychiatry. 1998;  173 61-68
• 154 Beauford J E, McNiel D E, Binder R L. Utility of the Initial Therapeutic Alliance in evaluating psychiatric patients’ risk of violence.  Am J Psychiatry. 1997;  154 1272-1276
• 155 Nijman H LI, Merkelbach H LGJ, Allert W FF, aCampo J MLG. Prevention of aggressive incidents on a closed psychiatric ward.  Psychiatr Serv. 1997;  48 694-698
• 156 Scott P D. Punishment or treatment: prison or hospital?.  BMJ. 1970;  2 167-169
• 157 Hoge S K, Lidz C W, Eisenberg M, Gardner W, Monahan J, Mulvey E, Roth L, Bennett N. Perceptions of coercion in the admission of voluntary and involuntary psychiatric patients.  Int J Law Psychiatry. 1997;  20 167-181
• 158 Kjellin L, Westrin C -G. Involuntary admissions and coercive measures in psychiatric care.  Int J Law Psychiatry. 1998;  21 31-42
• 159 Lidz C W, Hoge S K, Gardner W, Bennett N S, Monahan J, Mulvey E P, Roth L H. Perceived coercion in mental hospital admission.  Arch Gen Psychiatry. 1995;  52 1034-1039
• 160 McKenna B G, Simpson A IF, Laidlaw T M. Patient perception of coercion on admission to a acute psychiatric services. The New Zealand experience.  Int J Law Psychiatry. 1999;  22 143-153
• 161 Vartiainen H, Vuorio O, Halonen P, Hakola P. The patients’ opinions about curative factors in involuntary treatment.  Acta Psychiatr Scand. 1995;  91 163-166
• 162 Schanda H. The Ashenputtel-principle in modern mental health care.  CBMH. 1999;  9 199-204