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CRIMINAL JUSTICE AND BEHAVIOR

"The Scale for the Prediction of Aggression and Dangerousness in Psychotic Patients (PAD): A Prospective Pilot Study"

by StâI Bjorkly

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THE SCALE FOR THE PREDICTION OF AGGRESSION AND DANGEROUSNESS IN PSYCHOTIC PATIENTS (PAD): A Prospective Pilot Study STAL BJØRKLY Molde County Hospital, Hjelset, Norway

The Scale for the Prediction of Aggression and Dangerousness in Psychotic Patients (PAD) is a rating scale constructed for the assessment of psychotic patients in relation to 29 situations or interactions. The instrument is used to rate the potential of these situations/interactions for precipitating aggressive behavior in psychotic patients. These assessments result in a profile of situational vulnerability that describes a patient's potential for aggressive behavior in relation to the 29 situations or interactions. In this pilot study, 10 psychotic patients at a special secure unit were assessed by means of this scale. After the completion of the PAD ratings, systematic observations of episodes involving verbal, threatened, and physical aggression were made throughout a 2-year follow-up period. The results indicate that the PAD was able to predict the patients' potential for aggression and, to some extent, the situations that were the most potent precipitants of aggressive behavior.

T

he prediction of aggressive behavior in psychiatric patients has been a central issue for mental health professionals during the last several decades. Monahan (1988) concluded that the most striking AUTHOR'S NOTE: The present study was supported by a grantfrom the Norwegian Council for Research in the Medical Sciences (NAVF-RMF). The author thanks Tor Løberg, Odd E. Havik, and Gary VandenBos for their advice and support in completing this paper Jam also grateful to the patients and nursing staff of the special secure unit of the Psychiatry Department of Molde County Hospital for their participation. Address all correspondence to Stâl Bjørkly, Psykiatrisk storavdeling, FSH Molde, 6450 Hjelset, Norway. CRIMINAL JUSTICE AND BEHAVIOR, Vol. 21 No. 3, September 1994 341-356 © 1994 American Association for Correctional Psychology 341

342 CRIMINAL JUSTICE AND BEHAVIOR

characteristic of risk-assessment research is that it is so inconsistent. Promising findings in some of the more recent studies, however, have provided new hope for achieving acceptable levels of predictive accuracy (Kiassen & O'Connor, 1989; McNiel& Binder, 1987,199 1). To make further progress, it has been advocated that research addresses the following central issues: (a) the need for agreed-upon operational criteria for the definition of aggression as a criterion measure (James, Fineberg, Shah, & Priest, 1990; Kay, Wolkenfeld, & Murrill, 1988; Lindquist & Allebeck, 1990), (b) the importance of assessing situational variables (Cooper & Mendonca, 1989; Dunvage, 1989; Sheridan, Henrion, Robinson, & Baxter, 1990), (c) the desirability of changing predictor variables from measures based on all-or-none categories to measures based on graded estimates of the potential for showing aggressive behavior (Convit, Isay, Gadioma, & Volavka, 1988; Poythress, 1990), and (d) the need for predictive and follow-up assessments that are conducted while the patients are staying in the same setting (e.g., within a hospital ward) (Convit et al., 1988; McNiel & Binder, 1991). Retrospective studies are more numerous than prospective ones, particularly where demographic and psychometric variables are used (Craig, 1982; Monahan, 1988). Prospective studies on intra-institutional prediction of aggression are scarce. Most of these studies are short-term, with the follow-up period ranging from 3 to 7 days (Janofsky, Spears, & Neubauer, 1988; Kirk, 1989; McNiel & Binder, 1987, 1991; Werner, Rose, & Yesavage, 1983; Yesavage, Werner, Becker, & Mills, 1982). The studies of Convit et al. (1988) and Kiassen and O'Connor (1988b) are rare exceptions to this, covering 3- and 6-month follow-up periods, respectively. Research on the impact of situational variables on aggression in psychiatric patients is limited. Results from some studies, however, have suggested that situational variables must be integrated into the assessment of aggressive potential in psychiatric patients (Dietz & Rada, 1982; Durivage, 1989; Harris & Varney, 1986; Lee, Villar, Juthani, & Bluestone, 1989). Situational factors, such as limit setting and conflict with fellow patients (Sheridan et al., 1990), personal space (McGurk, Davis, & Grehan, 1981), inactivity (Cooper & Mendonca, 1989), and staff characteristics (Felthous, 1986), may provoke aggression in the inpatient setting.

Bjørkly / PREDICTION OF AGGRESSION 343

To integrate the analysis of situational factors into the prediction of aggression, the Scale for the Prediction of Aggression and Dangerousness in Psychotic Patients (PAD) was developed. The interactional model that forms the theoretical basis for the present study has been described elsewhere (Bjørkly, 1988). In addition to personality variables, this model emphasizes detailed analyses of each patient's situational and interactional vulnerability, defined as increased liability to act aggressively toward others in a given situation or interaction. The current pilot study was conducted to examine (a) the results of long-term predictions of aggression by means of PAD assessments in a small sample of psychotic patients, (b) the PAD's predictive accuracy concerning particular situational or interactional precipitants to aggressive behavior, and (c) the clinical relevance of PAD-assessed profiles of situational vulnerability on an individual level.

METHOD SUBJECTS

The sample consisted of 10 patients at a special secure unit in Molde Psychiatric Hospital, Norway (see Table 1). This special secure unit receives dangerous patients for long-term treatment from a catchment area of about 240,000 people. On average, the patients had been admitted for psychiatric care 10.1 times, SD = 8.6, and spent 12.7 years, SD = 6.3, in psychiatric hospitals. Two of the patients were discharged 12 months after the study period started, leaving only eight patients for the entire 2-year follow-up period. ASSESSMENTS AND PROCEDURE

Prediction of Aggressive Behavior by the PAD The PAD was designed to assess/predict the degree and type of future aggressive behavior in relation to specific situations or interactions. The instrument is described in detail elsewhere (Bjørkly, 1993).

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CRIMINAL JUSTICE AND BEHAVIOR

TABLE 1: Characteristics of Ten Patients Assessed in 1987 Sex

Age

Characteristic DSM-III Diagnosis

Discharge Year

A

F

32

1988

B C D

F F M

31 32 39

E F

M F

42 27

G H

M M M M

38 21 42 59

Schizophrenia, disorganized type! schizoid personality disorder Schizophrenia, paranoid type Schizophrenia, paranoid type Schizophrenia, paranoid type! paranoid personality disorder Schizophrenia, disorganized type Schizophrenia, disorganized type! avoidant personality disorder Schizophrenia, paranoid type Schizophrenia, disorganized type Schizophrenia, disorganized type Schizophrenia, paranoid type

Patient

J

nda nd 1991 1988 1990 1990 nd 1992 1990

a. Not discharged by September, 1993.

It consists of 29 situations/interactions that are grouped into seven main categories: Physical contact (e.g., physical contact to patient from unfamiliar person), Limit-setting (e.g., refusal of wishes or requests), Problems of communication (e.g., the patient appears to be guided by inner voices, misidentifications), Changes/readjustments (e.g., ward unrest), Persons (e.g., being in a one-to-one situation with a female), High-risk contact (e.g., availability of dangerous tools, such as broken glass or knives), and Drugs/stimulants (e.g., drug intoxication). The patients were rated in relation to these 29 situations/ interactions on two 6-point scales (predicted occurrence and predicted severity). Predicted occurrence scores indicate increasing degrees of probability of aggressive behavior taking place, ranging from practically no probability (0) to extremely high probability (5). Predicted severity scores serve to quantify the intensity of aggressive expression expected to be manifested within each of the 29 PAD situations/interactions. For each of the situations/interactions, predicted severity scores can range from aggressive behavior not expected (0) to physical assaults with the use of any dangerous means at hand, including blunt and sharp instruments and firearms if they are accessible (5). Combined occurrence and severity score (O*S score) and dangerousness score (D-score) are the two aggregated scores of interest in the present study. The OS score is obtained by adding the predicted

Bjørkly / PREDICTION OF AGGRESSION

345

occurrence score to the predicted severity score for each of the 29 PAD situations. This score expresses a combination of probability of occurrence and expected intensity of that particular aggressive behavior. A predicted severity score of 5 qualifies for a dangerousness score of 1 for that particular PAD interaction. D-scores monitor a distinction between life-threatening and less serious aggression. Thus, any predicted severity score lower than 5 qualifies for a D-Score of 0. The patients' aggressive potentials are rated in relation to two social contexts. The outside-ward context covers ratings of future aggression provided that the patients are discharged into society. The within-ward context covers assessments of future aggression provided that the assessed patients continue to live in the same environmental context in the follow-up period. In the present study, this meant the special secure unit. Consequently, patients who were transferred to other wards or discharged into the community were not included in the current study. Interrater reliability, involving nine independent judges, was evaluated by intraclass correlations. Intraclass correlations (coefficient alpha) for ratings pertaining to the within-ward context was .85 on the 6-point scale. The PAD assessments used in the present pilot study were carried out by three different groups of ward staff members. One of these groups rated four patients, while the two other groups rated three patients each. The ward staff member with the most thorough knowledge of the patient to be rated completed a preliminary PAD form. The group then met to discuss and revise the PAD scores of this preliminary form. This revision led to the final PAD scores of predicted dangerousness. PAD ratings were done in November, 1987, for 10 patients and again in November, 1988, for 8 of the original 10 patients. Observations of Actual Aggressive Behavior Continuous records of the actual occurrence of aggressive behavior toward others were kept throughout the 2-year study period. Incidents of physical assaults, physical threats, and verbal threats were recorded separately. Punching, kicking, and strangleholds were the most frequent types of physical assaults. Scratching and pulling by the hair were the least severe physical assaults that qualified to be recorded. Physical and verbal threats were recorded only when the potential


victim was within physical reach of the patient at the time the threat was expressed. Threats were recorded if they conveyed a clear intention of inflicting serious physical injury or death upon the potential victim. Thus, shaking one's fist at somebody, or otherwise signaling bodily preparation for an assault, was recorded as a physical threat. The least severe verbal threats that qualified to be recorded were verbally expressed intentions of the weakest qualified physical assault described above. A revised form for the recording of aggressive behavior was developed and put into effect after 4 months of the study period. Consequently, prediction results concerning precipitants of aggressive behavior after PAD ratings in 1987 were confined to only 8 months of the first follow-up year. Whereas the first form recorded only types and frequencies of aggressive incidents, the revised form also contained seven main categories of precipitants to aggressive behavior. These situational/interactional precipitants were identical to the seven main categories of precipitants in the PAD. Incidents involving physical assaults, physical threats, or verbal threats were recorded as close in time to the episode as possible. This was done by the ward personnel who observed and/or were involved in the aggressive incidents. In response to threats and physical assaults, the patients were routinely brought to a "debriefing room." In this setting, the episodes were reconstructed. Staff attempted to correct the aggressive behavior by engaging the patients in finding alternatives to aggressive behavior if a similar precipitating situation should arise. Information obtained during this routine was of special value in obtaining a detailed understanding of the patient's subjective experience of the aggressive episode. Accordingly, recording of the precipitants of aggressive behavior was based on a broad range of information. The surveillance routines of the ward staff were so arranged that, with few exceptions, the aggressive incidents in the follow-up period were observed by more than one staff member. Consequently, recording of the aggressive incidents was carried out jointly by at least two of the ward staff members. A total of 35 ward staff members were actually involved in recording a total of 550 incidents. To prevent underreporting and erroneous use of the form, records of dangerous behavior were checked daily by the ward psychologist and the ward

Bjørkly / PREDICTION OF AGGRESSION

347

psychiatrist of the special secure ward. The ward staff members were instructed to consult the ward psychologist in case of doubt or controversy concerning how to fill in the form after an aggressive episode had occurred.

RESULTS PREDICTIONS AND ACTUAL OCCURRENCE OF AGGRESSIVE BEHAVIOR

Predictions were distributed across the seven PAD main categories of precipitants of aggressive behavior as follows. The percentage of total O*S scores for 1987 predictions, with 10 subjects observed, is above the slash, and for 1988 predictions, with 8 subjects observed, is below it. The O*S scores were Limit-setting (32%/29%), Changes! readjustments (18%/18%), Persons (17%/18%), Physical contact (11%/11%), Problems of communication (7%/10%), High-risk contact (8%/8%), and Drugs/stimulants (8%16%). A total of 282 verbal threats, 120 physical threats, and 148 physical assaults were recorded during the 2-year follow-up period. During the first year, 170 verbal threats, 77 physical threats, and 91 physical assaults were observed from the 10 subjects, while the corresponding figures for the second year were 112, 43, and 57, with 8 subjects under observation. Ward staff members were the targets for about 80% of the reported incidents. The remaining 20% were patient-to-patient interactions. Table 2 presents the distribution of the precipitants of aggressive episodes during the 2-year follow-up. As explained above, for only 20 months of the 2-year study period was there detailed recording of the precipitants of the aggressive episodes that occurred. Of the seven PAD main categories, limit-setting situations were the most frequent precipitants. The association (Spearman rank-order correlations) between (a) PAD ratings (O*S scores) of the patients and (b) the subsequent occurrence of aggressive behavior during the following 1- and 2-year periods proved to be strong (see Table 3). The correlations involving the 1988 PAD assessment were all above .80. To test whether the correlations for the 1987 and the 1988 samples were significantly different, a test of differences between correlations


TABLE 2: Precipitants of Observed Aggressive Behavior During the 2-Year Follow-up Period Aggressive Behavior Verbal Threats

Physical Threats

Physical Assaults

Threats + Assaults

Precipitant

%

( n)

%

(n)

%

(n)

%

(n)

Physical contact Limit-setting Problems of communication Changes! readjustments Persons High-risk contact Drugs/stimulants

2 56

(5) (133)

1 68

(1) (56)

11 58

(12) (64)

4 59

(18) (253)

23

(54)

8

(7)

9

(10)

17

(71)

2 17 0 0

(5) (40) (—) (—)

4 19 0 0

(3) (16) (—) (—)

6 13 1 2

(7) (14) (1) (2)

4 16 0 0

(15) (70) (1) (2)

from two dependent samples (Hinkle, Wiersma, & Jurs, 1979) was run. When comparing the eight patients who were assessed both in 1987 and in 1988, the correlations between the ranked PAD scores and the ranked observed occurrence of physical assaults were significantly greater for the 1988 predictions than for the 1987 ones, t(6) = 5.5 1, p