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OP-13. BRAIN FUNCTION, PSYCHOPATHOLOGY AND HUMAN AGGRESSION  

OP-13.1.-NEUROIMAGING IN HUMAN AGGRESSION: CONCEPTUAL AND METHODOLOGICAL ISSUES

Wong, M.
Acute Adult Psychiatry Service, Outer East Mental Health Network; Academic and Clinical Research Unit (Maroondah Campus; Department of  Psychological Medicine, Monash University, Ringwood East; Mental Health Research Institute of Victoria, Parkville, Victoria, Australia

Various hypotheses of morbid neuroanatomy and pathophysiology have been proposed to account for human aggression in the presence or absence of mental illness or personality disorder. Conceptual issues that make neuroimaging in human aggression a controversial and difficult area to study include the use of different definitions and parameters, the diversity of aggressive behaviours, and the complex interplay of social factors, personality variables, cognitive and behavioural patterns and psychopathology, neuroanatomy, neurochemistry  and neurophysiology The problem of cooperation from violent subjects poses never-ending challenges in regard to how to minimize selection bias, optimize sample size and to ensure adequate control as well as performing repeated measures and activation studies. Major neuroimaging (MRI, PET) studies to date in this field (Volkow & Tancredi, 1987;  Tonkonogy, 1991; Seidenwurm et al, 1994; Goyer et al, 1994; Raine et al, 1994; Wong et al, 1997a, 1997b, 1997c) highlight the complexity of investigating the neural correlates of violent behaviour. Methodological issues include the validity and reliability of using rating scales in delineating different groups of violent subjects, correlating conventional brain investigation findings with violent ratings, applying new neuroimaging techniques to clarify the structural and metabolic nature of the changes noted in the conventional brain investigations, the use of new analytical techniques in quantifying these structural and metabolic changes and the interpretation of discordance in multi-modal neuroimaging findings.  A PET protocol for imaging transient cognitive events and a MRI protocol for volumetric measurement of amygdala are potential neuroimaging tools that address some of the conceptual and methodological issues in the study of human aggression.    

OP-13.2.-HALLMARKS OF ”VIOLENCE-PRONE” HALLUCINATIONS AND DELUSIONS: A LITERATURE REVIEW OF SOME PRELIMINARY FINDINGS.

Bjørkly, S.
Faculty of Health Sciences, Molde College, Molde, Norway

The main scope of this paper is to delineate some findings from a literature review focusing the role of hallucinations and delusions in violence by psychiatric patients.  According to this review a substantial number of studies have disclosed an association between hallucinations and delusions and increased risk of violence across a variety of contexts.  Since hallucinations and delusions also are common in non-violent psychiatric patients, there is an emerging evidence that our attention should be directed to specific hallmarks pertaining to hallucinations and delusions that indicate increased risk of violence.   This presentation will focus on some promising, though preliminary, findings concerning such hallmarks: a) the concept of  “threat and control override” (TCO); b) the content and theme of  hallucinations and delusions; c) three areas of phenomenology that make a difference to the likelihood of a persecutory delusion being acted upon; d) the extent to which hallucinations induce violent action; e) the role of  delusional distress, and f)  the combined effect of  fear-inducing persecutory delusions and violent command hallucinations. Despite the apparent effectiveness of neuroleptics up to 50% of psychotic patients are reported to continue to experience persistent delusions and hallucinations, and up to 30% to 40% of schizophrenic patients will relapse on medication. It is argued here that major therapeutic gains may be achieved by a more extensive clinical application of the growing knowledge of risk factors pertaining to specific hallmarks of delusions and hallucinations in violent patients.  This presentation is concluded by a brief review of major findings from the application of cognitive-behavioural techniques (CBT) in systematic attempts to modify patients’ delusions and hallucinations.  

OP-13.3.- REDUCING VIOLENCE ON PSYCHIATRIC INPATIENT UNITS: A CONTROLLED EVALUATION OF TWO INTERVENTIONS.

Bell, F.
Maudsley Hospital, London, UK

Ongoing research at the Maudsley Hospital in South London seeks to explore the issue of violence on acute psychiatric wards which has been accepted as being on the increase at local, national, and international levels. The focus of the study is the implementation and use of control and restraint techniques on four acute wards at the Maudsley Hospital. The main aims of the study are; to monitor the introduction of 'control and restraint' techniques within the four wards and to assess their effectiveness by measuring the pre- and post- intervention levels of violence in the clinical area using the modified overt aggression scale.and; to assess to what extent C&R techniques combined with advanced techniques in conflict resolution impact upon client care, from a staff and service-user perspective. Using calibrated Likert scales to measure the staff and service-users perception of both the safety and therapeutic aspects of the ward atmosphere on a weekly basis, and the modified overt aggression scale observations to compile an accurate picture of the levels of violent incidents on each ward, early findings from this study suggest that there is a dichotomy between staff and service-user perceptions of what constitutes a safe and therapeutic environment. This finding alone has implications for the delivery of quality clinical care in the sphere of control and restraint. The study will also employ organizational actuarial measures such as the levels of nursing agency staff, the level of emergency team call-outs and the daily nursing reports. The second phase of this research will implement a specialist teaching package building on the basic concepts of de-escalation and interpersonal conflict resolution that form the cornerstone of the control and restraint course. The tentative hypothesis is that staff who are trained in C&R techniques will become more confident in crisis situations and therefore become more effective. Similarly staff who undergo both the C&R course and the advanced course in psychosocial management strategies will become even more effective which will be reflected in a more pronounced decrease in violent incidents.

OP-13.4.-PERSISTENCE AND DESISTANCE OVER TIME: ECOLOGICAL CORRELATES OF CONDUCT DISORDER

Tyson, J.A., Roeser., R., Eccles*, J.S. and Samaroff*, A.J.
School of Education, Stanford University. * University of Michigan.

Each person's growth is directly affected by the immediate systems he or she has contact with and indirectly affected by more distal and/or broader systems. Such systems form a nested array. Systems directly affecting the individual rest nearest the organism, while those exercising more indirect effects are more distal. Dishion (1992) adapted the ecological model to organize a literature review examining antisocial behavior into "four spheres of causative influence:" (a) intrapersonal factors; (b) relationship processes; (c) behavior settings; and (d) community contexts. The use of an ecological framework provides a means of simultaneously mapping complex development processes and identifying targets for intervention. In the proposed paper the authors utilize Dishion's adaptation to examine the influence relationship processes and behavior settings exert on the development of conduct disorder as defined by The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). The data and participants for this paper come from the original Maryland Adolescent Development in Context Study, a large longitudinal study that was part of the MacArthur Network on Successful Adolescent Development in High Risk Settings. The original study included 1480 primarily African-American and White families with an adolescent who was beginning seventh grade in middle school during the first wave of the study in 1991. Data is examined over two time points: (a) 7th grade; and (b) 9th grade, to identify variables and ecological correlates associated with persistence and/or desistance of conduct disorder. Using variables describing qualitative attributes of behavior settings and relationship processes, analysis yielded classification rates of 83.2%. Nomethic data is supplemented by idiographic data from case reports compiled at the Stanford Counseling Institute. 

OP-13.5.-PSYCHIATRIC CHRONO-EPIDEMIOLOGY. ITS RELEVANCE FOR THE STUDY OF  AGGRESSION

Preti*+, A., Miotto* , P., De Coppi*, M., Caon*, F.,  Petretto+ D. and Masala+, C.
* Genneruxi Medical Center, Cagliari, Italy. +Department of Psychology, University of Cagliari, Cagliari, Italy.

Chrono-epidemiology is the study of the distribution of health events  according to the time. Time intervals which are taken into account  have cyclic patterns, and include circadian, weekly, seasonal and  circannual rhythms. In the behavioral fields chrono-epidemiology is applyed to studies  concerning causes of death (suicide and homicide) and clinical events  such as admissions and contacts with mental healthcare, and the  seasonal distribution of births in specific patient groups. Often reported findings include: clear circadian and seasonal rhythms  of suicides, more evident for violent suicides; the prevalence of the  births of psychotic patients in cooler months; a circannual recurrence of admissions for affective disorders, with spring peaks. The intrinsic circadian and seasonal rhythms of some neuronal systems, particularly those of serotonine, are thought to favour the emergence of the behavioral rhythms observed, though the contribution of socio-environmental (the fluctuation according to the time of supportive networks) and organic (obstetric complications and exposure to viruses, in the case of the uneven seasonal distribution of births among psychotics) factors also is ackonowledged. Mental disorders show important links with aggressive and violent behavior. Though the majority of mentally suffering patients seem not to be more aggressive than the general population, some psychopathologies bear a greater risk of violent acts. Patients with delusions of thought control or persecution may behave aggressively when out of treatment. In some types of murder (matricide, infanticide, murder-suicide, spree-killing) the prevalence of mental disorders among perpetrators is very high. Co-morbidity of psychosis and substance abuse often lead to a greater risk of legal infractions, both for violent and non-violent crimes. Also in non-psychotic disorders, such as bulimia, borderline personality disorder, and some types of alcoholism, impulsive inclinations may lead to aggressive outburst, both against self (self-harm) and others.Chrono-epidemiology, showing non-casual recurrence of behaviors and exploring socio-biological bases of the rhythms beneath these recurrences, may offer important ethiologic and preventive clues to the understanding of the biological and environmental correlates of aggressive behavior.