Zusammenfassung
Anliegen: Die Beurteilung des Risikos gewalttätiger Verhaltensweisen bei psychiatrischen Patienten ist nicht nur in der forensischen Psychiatrie bedeutsam, sondern hat auch in der Allgemeinpsychiatrie wichtige Implikationen für klinische Entscheidungen. Im letzten Jahrzehnt wurden zahlreiche Studien zu dieser Problematik publiziert, deren Ergebnisse allerdings teilweise Fehlinterpretationen unterliegen. Methode: Es wird ein zusammenfassender Literaturüberblick zum Thema gegeben. Ergebnisse: Es zeigt sich, dass strikt zu trennen ist zwischen „Gewalt in der Gemeinde” und „Gewalt in Institutionen”. Während Prädiktoren für gewalttätiges Verhalten in der Gemeinde weitgehend identisch sind mit denjenigen für Gewalttaten bei nicht psychisch erkrankten Personen und psychopathologische und klinische Variablen von untergeordneter Bedeutung sind, ist in psychiatrischen Kliniken aggressives Verhalten eng mit psychopathologischen Variablen korreliert. Der Versuch einer genaueren Differenzierung klinischer Risikovariablen endet allerdings regelmäßig mit widersprüchlichen Befunden, was auf unvermeidbare Probleme der Stichprobenselektion zurückzuführen ist. Schlussfolgerungen: Gewalt in Institutionen und außerhalb derselben in der Gemeinde geschieht unter völlig unterschiedlichen Rahmenbedingungen und Risikokonstellationen. Entsprechende Befunde dürfen nicht übertragen werden. Personenbezogene Vorhersagemöglichkeiten sind grundsätzlich begrenzt, weil situativen Faktoren eine bedeutende Rolle zukommt.
Abstract
Objective: The assessment of violence risk has impact on psychiatrists' decisions not only in forensic psychiatry but concerns many aspects of civil psychiatric units, too. Within the last decade, many studies on violence have been published. The results are misinterpreted sometimes. Method: A review about studies on in-patient violence is given. Results: In-patient violence and violence in the community should strictly be separated concerning predictors and predictions. Predictors of community violence both for persons with major mental disorders and persons without mental illness are criminal history, male gender, younger age, and substance abuse. Psychopathological and clinical variables play a minor role. In contrast, in-patient violence is closely related to the severity of psychopathological symptoms. More detailed determinations of risk-related symptoms yield conflicting results due to inevitable problems of sample selection. Conclusions: The assessment of violence risk has to consider the different risk constellations for violence in institutions and in the community. Predictions of violence by individual risk variables are limited because situation-related factors are important, too.
Literatur
-
1
Steinert T, Vogel W D, Beck M, Kehlmann S.
Aggressionen psychiatrischer Patienten in der Klinik. Eine 1-Jahres-Studie an 4 psychiatrischen Landeskrankenhäusern.
Psychiat Prax.
1991;
18
155-161
-
2
Steinert T, Beck M, Vogel W D, Wohlfahrt A.
Gewalttätige Patienten - ein Problem für Therapeuten an psychiatrischen Kliniken?.
Nervenarzt.
1995;
66
207-211
-
3
Richter D, Berger K.
Patientenübergriffe auf Mitarbeiter. Eine prospektive Untersuchung der Häufigkeit, Situationen und Folgen.
Nervenarzt.
2001;
72
693-699
-
4 Böker W, Häfner H. Gewalttaten Geistesgestörter. Eine psychiatrisch-epidemiologische Untersuchung in der Bundesrepublik Deutschland. Berlin; Springer 1973
-
5
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
-
6
Linaker O M, Busch-Iversen H.
Predictors of imminent violence in psychiatric inpatients.
Acta Psychiatr Scand.
1995;
92
250-254
-
7
Apperson L J, Mulvey E P, Lidz C W.
Short-term clinical prediction of assaultive behavior: artifacts of research methods.
Am J Psychiatry.
1993;
150
1374-1379
-
8
Spießl H, Krischker S, Cording C.
Aggressive Handlungen im psychiatrischen Krankenhaus.
Psychiat Prax.
1998;
25
227-230
-
9
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
-
10
Schanda H, Gruber K, Habeler A.
Aggressives Verhalten zurechnungsunfähiger psychisch kranker Straftäter während stationärer Behandlung.
Psychiat Prax.
2000;
27
263-269
-
11
Steinert T, Woelfle M, Gebhardt R P.
Aggressive behaviour during in-patient treatment. Measurement of violence during in-patient treatment and association with psychopathology.
Acta Psychiatr Scand.
2000;
102
107-112
-
12
Angermeyer M, Schulze B.
Psychisch Kranke - eine Gefahr?.
Psychiat Prax.
1998;
25
211-220
-
13
Steinert T.
Psychische Erkrankung und Gewaltkriminalität: Mythen und Fakten.
Dtsch Med Wschr.
2001;
126
378-382
-
14
Hodgins S.
Mental disorder, intellectual deficiency and crime. Evidence from a birth cohort.
Arch Gen Psychiatry.
1992;
49
476-483
-
15
Wessely S C, Castle D, Douglas A J, Taylor P J.
The criminal carreers of incident cases of schizophrenia.
Psychol Med.
1994;
24
483-502
-
16
Hodgins S, Mednick S A, Brennan P A, Schulsinger F, Engberg M.
Mental disorder and crime. Evidence from a danish birth cohort.
Arch Gen Psychiatry.
1996;
53
489-496
-
17
Swanson J W, Holzer C E, Ganju V K, Iono R T.
Violence and psychiatric disorder in the community: evidence from the epidemiologic catchment area surveys.
Hosp Community Psychiatry.
1990;
41
761-770
-
18
Eronen M, Hakola P, Tiihonen J.
Mental disorders and homicidal behavior in Finland.
Arch Gen Psychiatry.
1996;
53
497-501
-
19
Räsänen P, Tiihonen J, Isohanni M, Rantakallio P, Lehtonen J, Moring J.
Schizophrenia, alcohol abuse, and violent behavior: a 26-year follow-up study of an unselected birth cohort.
Schizophr Bull.
1998;
42
437-441
-
20
Bonta J, Law M, Hanson K.
The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis.
Psychol Bull.
1998;
123
123-142
-
21
Harris G T, Rice M E.
Risk appraisal and management of violent behavior.
Hosp Community Psychiatry.
1997;
48
1168-1176
-
22 Webster C D. et al .Capturing change. In: Hodgins S (ed) Violence among the mentaly ill. Effective treatments and management strategies. Dordrecht; Kluwer Academic Publishers 2000
-
23
Eaton S, Ghannam M, Hunt N.
Prediction of violence on a psychiatric intensive care unit.
Med Sci Law.
2000;
40
143-146
-
24
Gebhardt R P, Steinert T.
Should severely disturbed psychiatric patients be distributed or concentrated in specialized wards? An empirical study on the effects of hospital organization on ward atmosphere, aggressive behavior, and sexual molestation.
Eur Psychiatry.
1999;
14
291-297
-
25
Owen C, Tarantello C, Jones M, Tenant C.
Violence and aggression in psychiatric units.
Psychiatr Serv.
1998;
49
1452-1457
-
26
Bjorkly S.
A ten-year prospective study of aggression in a special secure unit for dangerous patients.
Scand J Psychol.
1999;
40
57-65
-
27
Powell G, Caan W, Crowe M.
What events precede violent incidents in psychiatric hospitals?.
Br J Psychiatry.
1994;
165
107-112
-
28
Harris G T, Varney G W.
A ten-year study of assaults and assaulters on a maximum security psychiatric unit.
J Interpersonal Violence.
1986;
1
173-191
-
29
Shader R I, Jackson A H, Harmatz J S, Appelbaum P S.
Patterns of violent behavior among schizophrenic inpatients.
Dis Nerv Syst.
1977;
38
13-16
-
30
Kiejna A, Janska-Skomorowska M, Baranowski P.
Medical procedure with aggressive patients: experiences of the psychiatric clinic in Wroclaw.
Psychiatr Pol.
1993;
27
501-513
-
31
Myers K M, Dunner D L.
Self and other directed violence on a closed acute care ward.
Psychiatric Q.
1984;
56
178-188
-
32
Tardiff K.
Characteristics of assaultive patients in private hospitals.
Am J Psychiatry.
1984;
141
1232-1235
-
33
Hodgkinson P E, Mc Ivor L, Phillips M.
Patient assaults on staff in a psychiatric hospital. A two-year retrospective study.
Med Sci Law.
1985;
25
288-294
-
34
Noble P, Rodger S.
Violence by psychiatric in-patients.
Br J Psychiatry.
1989;
155
384-390
-
35
Watson M A, Segal S P, Newhill C E.
Police referral to psychiatric emergency services and its effect on disposition decisions.
Hosp Community Psychiatry.
1993;
44
1085-1090
-
36
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
-
37
Kennedy H G.
Relationship between psychiatric diagnosis and patient aggression.
Issues Ment Health Nurs.
1993;
14
263-273
-
38
Walker W D, Caplan R P.
Assault behaviour in acute psychiatric wards and its relationship to violence in the community. A comparison of two health districts.
Med Sci Law.
1993;
33
300-304
-
39
Cooper A J, Mendonca J D.
A prospective study of patient's assaults on nurses in a provincial psychiatric hospital in Canada.
Acta psychiatr Scand.
1991;
84
163-166
-
40
Grossman L S, Haywood T W, Canavaugh J L, Davis J M, Lewis D A.
State psychiatric hospital patients with past arrests for violent crimes.
Psychiatr Serv.
1995;
46
790-795
-
41
Tardiff K, Sweillam A.
Assaultive behavior among chronic inpatients.
Am J Psychiatry.
1982;
139
212-215
-
42
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
-
43
Pearson M, Wilmot E, Padi M.
A study of violent behaviour among in-patients in a psychiatric hospital.
Br J Psychiatry.
1986;
149
232-235
-
44
Beck J C, White K A, Gage B.
Emergency psychiatric assessment of violence.
Am J Psychiatry.
1991;
148
1562-1565
-
45
Fottrell E.
A study of violent behaviour among patients in psychiatric hospitals.
Br J Psychiatry.
1980;
136
216-221
-
46 Tardiff K. A survey of assault by chronic patients in a state hospital system. In: Lion JR, Reid WH (eds) Assaults within psychiatric facilities. New York; Grune & Stratton 1983: 3-19
-
47
Runyon N W, Wagner E E, Dambrot F H.
Sex differences in acting out chronic undifferentiated schizophrenics.
Percept Mot Skills.
1985;
61
631-635
-
48
Binder R L, Mc Niel D E.
The relationship of gender to violent behavior in acutely disturbed psychiatric patients.
J Clin Psychiatry.
1990;
51
110-114
-
49
Rasmussen K, Levander S.
Crime and violence among psychiatric patients in a maximum security psychiatric hospital.
Crim Just Behav.
1996;
23
455-471
-
50
Rossi M, Jacobs M, Monteleone M, Olsen R, Surber R W, Winkler E L, Wommack A.
Violent or fear-inducing behavior associated with hospital admission.
Hosp Community Psychiatry.
1985;
36
643-647
-
51
Convit A, Isay D, Otis D, Volavka J.
Characteristics of repeatedly assaultive psychiatric inpatients.
Hosp Community Psychiatry.
1990;
41
1112-1115
-
52
Aquilina C.
Violence by psychiatric in-patients.
Med Sci Law.
1991;
31
306-312
-
53
Hoptman M J, Yates K F, Patalinjug M B, Wack R C, Convit A.
Clinical prediction of assaultive behaviour among male psychiatric patients at a maximum-security forensic facility.
Psychiatr Serv.
1999;
50
1461-1466
-
54
Mc Niel D E, Binder R L, Greenfield T K.
Predictors of violence in civilly committed acute psychiatric patients.
Am J Psychiatry.
1988;
145
965-970
-
55
Blomhoff S, Seim S, Friis S.
Can prediction of violence among psychiatric inpatients be improved?.
Hosp Community Psychiatry.
1990;
41
771-775
-
56
Steinert T, Hermer K, Faust V.
Comparison of aggressive and non-aggressive schizophrenic inpatients matched for age and sex.
Eur J Psychiat.
1996;
10
100-107
-
57
Arango C, Barba A C, González-Salvador T, Ordónez A C.
Violence in inpatients with schizophrenia: a prospective study.
Schizophr Bull.
1999;
25
493-503
-
58
Krakowski M, Convit A, Jaeger J, Shang L, Volavka J.
Neurological impairment in violent schizophrenic inpatients.
Am J Psychiatry.
1989;
146
849-853
-
59
Yesavage J A.
Correlates of dangerous behavior by schizophrenics in hospital.
J Psychiatry Res.
1984;
18
225-231
-
60
Janofsky J S, Spears S, Neubauer D N.
Psychiatrists' accuracy in predicting violent behavior on an inpatient unit.
Hosp Community Psychiatry.
1988;
39
1090-1094
-
61
Greenfield T K, Mc Niel D E, Binder R L.
Violent behavior and length of psychiatric hospitalization.
Hosp Community Psychiatry.
1989;
40
809-814
-
62
Krakowski M I, Czobor P.
Clinical symptoms, neurological impairment, and prediction of violence in psychiatric inpatients.
Hosp Community Psychiatry.
1994;
45
700-705
-
63
Krakowski M, Czobor P.
Violence in psychiatric patients: the role of psychosis, frontal lobe impairment, and ward turmoil.
Compr Psychiatry.
1997;
38
230-236
-
64
Yesavage J A, Werner P D, Becker J, Holman C, Mills M.
Inpatient evaluation of aggression in psychiatric patients.
J Nerv Ment Dis.
1981;
169
299-302
-
65
Mc Niel D E, Binder R L.
Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence.
Am J Psychiatry.
1995;
152
901-906
-
66
Cheung P, Schweitzer I, Crowley K, Tuckwell W.
Aggressive behavior in schizophrenia: the role of psychopathology.
Aust NZ J Psychiatry.
1997;
31
62-67
-
67
Krakowski M, Czobor P, Chou J C.
Course of violence in patients with schizophrenia: relationship to clinical symptoms.
Schizophr Bull.
1999;
25
505-517
-
68
Krakowski M, Jaeger J, Volavka J.
Violence and psychopathology: a longitudinal study.
Compr Psychiatry.
1988;
29
174-181
-
69
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
-
70
Goodwin D W, Alderson P, Rosenthal R.
Clinical significance of hallucinations in psychiatric disorders.
Arch Gen Psychiatry.
1971;
24
76-80
-
71
Hellerstein D, Frosch W, Koenigsberg H W.
The clinical significance of command hallucinations.
Am J Psychiatry.
1987;
144
219-221
-
72
Rogers R, Nussbaum D, Gillis R.
Command hallucinations and criminality: a clinical quandry.
Bull Am Acad Psychiatry Law.
1988;
16
251-258
-
73
Kasper M E, Rogers R, Adams P A.
Dangerousness and command hallucinations: an investigation in psychotic inpatients.
Bull Am Acad Psychiatry Law.
1996;
24
219-224
-
74
Werner P D, Rose T L, Yesavage J A.
Psychiatrists' judgments of dangerousness in patients on an acute care unit.
Am J Psychiatry.
1984;
141
263-266
-
75
Quinsey V L, Varney G W.
Characteristics of assaults and assaulters in a maximum security psychiatric unit.
Crime and Justice.
1977;
5
212-220
-
76
Addad M, Benezech M, Bourgeois M, Yesavage J.
Criminal acts among schizophrenics in French mental hospitals.
J Nerv Ment Dis.
1981;
169
289-293
-
77
Richardson M A, Craig T J, Haughland G.
Treatment patterns of young chronic schizophrenic patients in the era of deinstitutionalization.
Psychiatric Q.
1985;
57
243-249
-
78
Tardiff K, Sweillam A.
Assault, suicide and mental illness.
Arch Gen Psychiatry.
1980;
37
164-169
-
79
Hillbrand M.
Aggression against self and aggression against others in violent psychiatric patients.
J Consult Clin Psychol.
1995;
63
668-671
-
80
Apter A, Kotler M, Sevy S, Plutchik R, Brown S L, Foster H, Hillbrand M, Korn M L, van Praag H M.
Correlates of risk of suicide in violent and nonviolent psychiatric patients.
Am J Psychiatry.
1991;
148
883-887
-
81
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
-
82
Palmstierna T, Huitfeld B, Wistedt B.
The relationship of crowding and aggressive behavior on a psychiatric intensive care unit.
Hosp Community Psychiatry.
1991;
42
1237-1240
-
83
Palmstierna T, Wistedt B.
Changes in the pattern of aggressive behaviour among in-patients with changed ward organisation.
Acta Psychiatr Scand.
1995;
91
32-35
-
84
Lanza M L, Kayne H L, Hicks C, Milner J.
Environmental characteristics related to patient assault.
Issues Ment Health Nurs.
1994;
15
319-335
-
85
Crowner M L, Stepcic F, Peric G, Czobor P.
Typology of patient-patient assaults detected by videocameras.
Am J Psychiatry.
1994;
151
1669-1672
-
86
Hillbrand M, Spitz R T, Foster H G, Krystal J H, Young J L.
Creatine kinase elevations and aggressive behavior in hospitalized forensic patients.
Psychiatric Q.
1998;
69
69-82
-
87
Hillbrand M, Spitz R T, Foster H G.
Serum cholesterol and aggression in hospitalized male forensic patients.
J Behav Med.
1995;
18
33-43
-
88
Steinert T, Woelfle M, Gebhardt R P.
No correlation of serum cholesterol levels with measures of violence in patients with schizophrenia and non-psychotic disorders.
Eur Psychiatry.
1999;
14
346-348
-
89
Steinert T, Sippach T, Gebhardt R P.
How common is violence despite neuroleptic treatment?.
Pharmacopsychiatry.
2000;
33
98-102
Priv.-Doz. Dr. med. Tilman Steinert
Zentrum für Psychiatrie · Die Weissenau
Postfach 2044
88190 Ravensburg
eMail: tilman.steinert@zfp-weissenau.de
