Narcissism in patients admitted to psychiatric acute wards: its relation to violence, suicidality and other psychopathology

<p>Abstract</p> <p>Background</p> <p>The objective was to examine various aspects of narcissism in patients admitted to acute psychiatric wards and to compare their level of narcissism to that of an age- and gender-matched sample from the general population (NORM).</p> <p>Methods</p> <p>This cross-sectional study interviewed 186 eligible acute psychiatric patients with the Brief Psychiatric Rating Scale (BPRS) and the Global Assessment of Functioning (GAF). The patients filled in the Narcissistic Personality Inventory-21 item version (NPI-21), The Hospital Anxiety and Depression Scale (HADS) and the Rosenberg Self-Esteem Scale. High and low narcissism was defined by the median of the total NPI-21 score. An age- and gender-matched control sample from the general population also scored the NPI-21 (NORM).</p> <p>Results</p> <p>Being male, involuntary admitted, having diagnosis of schizophrenia, higher self-esteem, and severe violence were significantly associated with high narcissism, and so were also low levels of suicidality, depression, anxiety and GAF scores. Severe violence and high self-esteem were significantly associated with high narcissism in multivariable analyses. The NPI-21 and its subscales showed test-retest correlations ≥0.83, while the BPRS and the HADS showed lower correlations, confirming the trait character of the NPI-21. Depression and suicidality were negatively associated with the NPI-21 total score and all its subscales, while positive association was observed with grandiosity. No significant differences were observed between patients and NORM on the NPI-21 total score or any of the NPI subscales.</p> <p>Conclusion</p> <p>Narcissism in the psychiatric patients was significantly associated with violence, suicidality and other symptoms relevant for management and treatment planning. Due to its trait character, use of the NPI-21 in acute psychiatric patients can give important clinical information. The similar level of narcissism found in patients and NORM is in need of further examination.</p

Risk assessment of violent, suicidal and self-injurious behaviour in acute psychiatry– a bio-psycho-social approach

De psykiatriske avdelingene i Norge har vært utsatt for tildels sterk kritikk etter voldsdhandlinger og selvmord begått av pasienter under innleggelse, etter utskriving eller ved manglende innleggelse. Med innleggelsespress og kort liggetid er akuttavdelinger særlig utsatt. Ofte legges alene klinisk skjønn til grunn for en risikovurdering. Det foreligger imidlertid instrumenter til formålet, men de er tidkrevende og forutsetter spesiell ekspertise. Et av siktemålene med dette ”risikoprosjektet” ved Ålesund sjukehus var å identifisere tidlig hvilke pasienter som trenger videre utredning og oppfølging. Forskjellige metoder ble prøvet i et prospektivt, naturalistisk design. Denne avhandlingen tar for seg resultater fra deler av ”risikoprosjektet” og omfatter ulike metoder brukt til vurdering av risiko for vold, selvmord og selvskading: (i) Biologisk basert: Serotonin og lipider målt i blod, (ii) Pasientbasert: Pasientenes egen risikovurdering (SRS), samt (iii) et personalbasert, strukturert screening instrument for volds-risiko (V-RISK-10, utviklet for bruk i akuttpsykiatrien) . ”risikoprosjektet” og omfatter ulike metoder brukt til vurdering av risiko for vold, selvmord og selvskading: (i) Biologisk basert: Serotonin og lipider målt i blod, (ii) Pasientbasert: Pasientenes egen risikovurdering (SRS), samt (iii) et personalbasert, strukturert screening instrument for volds-risiko (V-RISK-10, utviklet for bruk i akuttpsykiatrien) . SRS og V-RISK-10 ble skåret ved innleggelse og utskriving. Blodprøver ble tatt ved innleggelse. Risikovurderingene og blodprøvesvarene ble sammenliknet med suicidalitet, selvskading og vold registrert under oppholdet og i løpet av første året etter utskriving. Målgruppen var alle akutt innlagte pasienter gjennom ett år, fra 07.03.06 – 07.03.07.  Studien av biologiske variabler og SRS  ble utført på ett sykehus (n=489 pasienter).  V-RISK-10 studien ble gjennomført på to sykehus (n=1017). Antallet pasienter var henholdsvis 254 innlagte og 196 utskrevne for den biologiske studien, 429 og 266 for SRS, og 980 og 381 for V-RISK-10. Vold og sucidalatferd under innleggelse, dessuten vold de tre første månedene etter utskriving, ble predikert av lave verdier av total kolesterol. Noen få pasienter med flere innleggelser og gjentatte voldshandlinger var kjennetegnet ved lave verdier av HDL. Disse funn samsvarer med tidligere undersøkelser. Høye triglyceridverdier predikerte selvskade i løpet av oppholdet, og også suicidalitet og selvskade etter utskriving. Presisjonsnivået var størst for dem som ble registret med både suicidalatferd og selvskading. Resultatet støtter tre studier om virkningen av kortvarig og kronisk psykologisk stress, men er det motsatte av tidligere funn om lave triglyceridverdier ved sucidalitet. I vårt materiale ble det ikke funnet noen sammenheng mellom serotoninnivå og aggresjon. SRS predikerte vold, suicidalitet og selvskade. I løpet av innleggelsen var SRS mest presis for suicidalitet og selvskade. Etter utskriving var den mest nøyaktig for vold. Vi har ikke funnet andre rapporter om pasienters egne risikovurderinger. Valideringen av V-RISK-10 var like god eller bedre enn for andre etablerte risikoinstrumenter. Våre funn var gyldige både for kvinner og menn. Nøyaktigheten var størst ved alvorlige voldsepisoder. V-RISK-10 gav signifikante resultater for pasienter uten kjent voldshistorie.  Resultatene for lipider og SRS var ikke gode nok til at disse metodene kan anbefales å bli brukt alene som screening instrumenter. De kan imidlertid vise seg nyttige som tillegg til etablerte prosedyrer. V-RISK-10 viste gode egenskaper som screeninginstrument. Resultatene bør bekreftes av annen forskning før metodene kan bli brukt med ønsket sikkerhet.  Recently, psychiatric hospitals in Norway have been criticised for premature discharges and for poor assessments of patients’ risks of violence or self-harm. Due to the high turnover of patients and the obligation to admit all acutely ill patients who are in need of hospitalisation, the acute wards are particularly exposed to such criticism. Unstructured clinical judgements alone still appear to be the dominant approach to risk assessments. Currently used instruments for risk assessment are time consuming, and their use require special expertise. The goal of the “Risk Project” at Ålesund Hospital was early identification of patients in need of risk assessments. Various screening methods were tested in a prospective, naturalistic design. This dissertation is a part of the larger Risk Project.  In the dissertation, different approaches towards risk analyses of violence, suicide and self-injury were examined: (i) Biologically based, in which lipids and serotonin are measured in the blood; (ii) Patient based, in which patients’ self-reports of risk (SRS) are employed, and (iii) Structured professional, by applying a violence screening instrument developed for use in acute psychiatry (V-RISK-10). SRS and V-RISK-10 were scored both at the time of admittance and discharge. Blood was drawn at admission. These measures were then compared with the episodes of violent, suicidal and self-injurious behaviour recorded during the patient’s hospital stay and also, during the first year after discharge. The study sample for the biological markers and the SRSs included all of the acutely admitted patients during one year (n=489) in one acute psychiatric unit. The V-RISK-10 study included all admissions of two units (n=1017). The numbers of patients who completed the study were 254 during their hospital stay and 196 after discharge, all with regard to lipids/serotonin, 429 and 266 for SRS, and 980 and 381 for V-RISK-10, respectively. Similar to findings from other studies, low concentrations of total cholesterol were found to predict inpatient suicidal and violent behaviour and also, violent behaviour three months after discharge. Low HDL levels were predictive of violence repeaters. High triglyceride levels predicted self-injurious behaviour (SIB) during the hospital stay, and both suicidal behaviour and SIB during the first year after discharge. The best results were obtained among patients who had recorded episodes of both suicidal behaviour and SIB. This finding contradicts prior studies on self-harm but concurs with three recent studies that look at the effects of short-term and chronic psychological stress. No significant correlations between serotonin levels and violence, suicidal behaviour or SIB were found in our sample. SRS predicted violence, suicidal behaviour and SIB both during the hospital stay and at three months after discharge. In addition, SRS of violence was also significant at 12 months after discharge. The accuracy was higher for self-harm during the hospital stays and for violence after discharge. We found no other validation studies of patients’ self-reported risk of suicide or violence. The predictive validity of the V-RISK-10 was equal to or better than those of the comprehensive risk assessment instruments, and it was very high in relation to severe violence. The screening instrument was sensitive to the risk of violence independent of gender and even for patients without any known history of violence. Despite significant findings for the lipids and SRS, these methods are not recommended for regular clinical use as single predictor variables, but they may be used together in combination with established risk procedures or clinical judgements. V-RISK-10 demonstrated good psychometric properties as a violence screening tool for acute psychiatry. Further research should be undertaken to confirm the finding

Triglycerides as a biological marker of repeated re-hospitalization resulting from deliberate self-harm in acute psychiatry patients: a prospective observational study

Background: Biological factors have been associated with deliberate self-harm (DSH) but have not been integrated with clinical factors in routine risk assessments. This study aimed to examine the incremental validity of lipid levels and platelet serotonin when combined with psychosocial factors in risk assessments for repeated admissions due to DSH. Methods: In this prospective observational study of 196 acutely admitted patients, results of blood tests performed upon admission and the MINI Suicidal Scale and psychosocial DSH risk factor assessments performed at discharge were compared with the incidence of DSH recorded during the first 3 and 12 months after discharge. Results: High triglyceride levels were found to be a significant marker for patients admitted 3 or more times due to DSH (repeated DSH, DSH-R) when tested against other significant risk factors. When all (9) significant univariate factors associated with 12-month post-discharge DSH-R were analyzed in a multivariate logistic regression, the MINI Suicidal Scale (p = 0.043), a lack of insight (p = 0.040), and triglyceride level (p = 0.020) remained significant. The estimated 12-month area under the curve of the receiver operator characteristic (ROC-AUC) for DSH-R was 0.74 for triglycerides, 0.81 for the MINI, 0.89 for the MINI + psychosocial factors, and 0.91 for the MINI + psychosocial factors + triglycerides. The applied multifaceted approach also significantly discriminated between 12-month post-discharge DSH-R patients and other DSH patients, and a lack of insight (p = 0.047) and triglycerides (p = 0.046) remained significant for DSH-R patients in a multivariate analysis in which other DSH patients served as the reference group (rather than non-DSH patients). Conclusion: The triglyceride values provided incremental validity to the MINI Suicidal Scale and psychosocial risk factors in the assessment of the risk of repeated DSH. Therefore, a bio-psychosocial approach appears promising, but further research is necessary to refine and validate this method

The Safe pilot study : a prospective naturalistic study with repeated measures design to test the psychosis - violence link in and after discharge from forensic facilities

The research evidence is very strong for high recidivism rates of violence after discharge from forensic facilities. Big data research has found that a substantial proportion of the forensic population with relapse into violence has a psychosis diagnosis and a criminal record. However, more research on the association between psychotic symptoms and violence may inform and enhance risk assessment, prevention, and treatment. We conducted a prospective naturalistic study with a repeated measures design in a sample of 22 psychotic patients during follow-up after discharge from forensic mental health facilities. We had three aims: to test the predictive validity of three psychotic symptom scales for violence, to analyze main and interaction effects between psychotic symptoms and previous criminal conviction, and to explore the feasibility and potential benefit of the repeated measures design for prospective follow-up research. Interpreted within the limitation of the small sample size, the results were promising for all scales, particularly for adjusted effects without interaction. Two scales remained significant when their interaction with criminal conviction was adjusted. This indicates that risk judgment of psychotic patients with criminal conviction can be improved by adding measurement of fluctuations in psychotic symptoms. The repeated measures design was instrumental in this research. Keywords: forensic mental health, repeated measures, discharge, psychotic symptoms, criminality, violenc

The risk of not knowing – A predictive validity study of the “Don't know” scores on a violence screen in acute psychiatry

Access to information about risk factors of violence for patients admitted to acute psychiatric wards may be sparse. This prospective study from three acute wards explored associations between items scored “Don't know” and violence during hospital stays (N ​= ​1435) and the first three months after discharge (N ​= ​461) when using a violence risk screening tool (Violence risk screening - 10; V-RISK-10). When V-RISK-10 was scored at admission and “Don't know” was weighted 0 or 1, the area under the curve of the receiver operating characteristics (AUC) was 0.79 and 0.82 for inpatient violence and 0.79 and 0.80 for post-discharge violence. “Don't know” scored at admission was significantly associated with inpatient violence for eight risk items and with violence after discharge for seven items. Numbers of “Don't know” scores decreased substantially at discharge. A substantial proportion of those scores seemed to change into “Maybe/moderate” or “Yes”. There were some differences in single items in the associations of “Don't know” with violence and the distribution of scores. Findings indicate that items scored “Don't know” at the time of admission may be associated with violence during hospital stay and after discharge. More research is needed to elaborate these findings

Low cholesterol level as a risk marker of inpatient and post-dischargeviolence in acute psychiatry : a prospective study with a focus on genderdifferences

Several studies indicate an association between low levels of serum cholesterol and aggressive behaviour, but prospective studies are scarce. In this naturalistic prospective inpatient and post-discharge study from an acute psychiatric ward, we investigated total cholesterol (TC) and high-density lipoprotein (HDL) as risk markers of violence. From March 21, 2012, to March 20, 2013, 158 men and 204 women were included. TC and HDL were measured at admission. Violence was recorded during hospital stay and for the first 3 months post-discharge. Univariate and multivariate binary logistic regression were used to estimate associations between low TC and low HDL and violence. Results showed that HDL level was significantly inversely associated with violence during hospital stay for all patients. For men, but not for women, HDL level was significantly inversely associated with violence the first 3 months post-discharge. Results indicate that low HDL is a risk marker for inpatient and post-discharge violence in acute psychiatry and also suggest gender differences in HDL as a risk marker for violence

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and highdensity lipoprotein cholesterol (HDL) were examined in an inpatient (N=348) and a 3-months follow-up (N=101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist. Keywords: acute psychiatry, total cholesterol, HDL, self-report, V-RISK-10, biomarkers, screening tool

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL) were examined in an inpatient (N = 348) and a 3-months follow-up (N = 101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist

Nouvelles stratégies de recueil de données sur le terrain, exemples à travers le projet Atlas Multimédia Prosodique de l'Espace Roman (AMPER)

National audienc

Characteristics associated with later self-harm hospitalization and/or suicide: A follow-up study of the HUNT-2 cohort, Norway

Background To improve suicide and self-harm prevention in adults, better knowledge on preexisting characteristics and risk factors is of great importance. Methods This is a population-based case-control study; baseline measures were collected in the second wave of the North-Trøndelag Health Study (HUNT-2, 1995–1997) in Norway, and outcomes were observed for up to 19 years. Average follow up time was 4.9 years for self-harm and 6.8 years for suicides. Out of 93,898 eligible adult inhabitants aged 20 and above, a total of 65,229 (70%) participated in the study. The data were linked to the National Mortality Registry and hospital patient records in the three hospitals covering the HUNT-2 catchment area. Results Among the participants, 332 patients (68% women) were hospitalized because of self-harm (HSH), and 91 patients (32% women) were died by suicide (SU). A total of 10% of those who died by SU had previously been HSH. People in the HSH and SU groups were younger, reported more depression and anxiety symptoms, sleeping problems, higher use of alcohol and tobacco, poorer social network and more economic problems, compared to the rest of the HUNT-2 population. In addition, the HSH group reported more somatic health problems, higher use of health services, higher sick leave, and lower work participation than the SU group. Limitations Younger adults (20–40 years) were under-represented in HUNT-2. Younger adults (20–40 years) were constituted 31.7% in HUNT-2, 50% in HSH and 33% in SU. Further, we did not identify less severe self-harm, not requiring hospitalization. Life changes, adverse events, and other possible triggers to self-harming behavior were not recorded. Conclusion Psychological problems were long-term predictors of both HSH and SU. Somatic health problems and lower functional performance were more present in HSH-group compared to the SU-group