A survey of assaultive behavior in Veterans Health Administration facilities.

OBJECTIVE: To more clearly define the scope and impact of violence in health care facilities, national data on assaults in VA medical centers and freestanding clinics were examined. METHODS: A survey was distributed to all VA medical centers and freestanding clinics asking for cumulative data for one fiscal year (October 1990 through September 1991). Data were obtained on number, types, and locations of physical assaults and other assaultive behavior; the types of staff assaulted and number of workdays lost due to injuries; diagnoses of perpetrators; recommendations made after the incidents were reviewed; training in prevention and management of assaultive behavior; and the impact of training on rates of assaultive behavior. RESULTS: During the survey year, 24,219 incidents of assaultive behavior were reported by 166 VA facilities; 8,552 incidents involved battery or physical assault. Weapon possession by perpetrators was common (8.5 percent of incidents), and weapons were used in 130 assaults (1.5 percent of assaults). Assaults occurred most frequently in psychiatric units (43.1 percent), followed by long-term-care units (18.5 percent) and admitting or triage areas (13.4 percent). Assault-related injuries were most common among nursing personnel. Perpetrators of assaults were most typically diagnosed as having psychoses, substance use disorders, or dementia. On inpatient psychiatry units, an inverse correlation was found between expenditures on staffing and the frequency of assaultive incidents. Staff training on management of assaultive behavior varied widely. CONCLUSIONS: Assaultive behavior is a significant problem for health care workers. Staff in all clinical areas need to be prepared to deal with assaultive patients. More research is needed on staff training and interventions for preventing and limiting assaults.

Repeated assaults by patients in VA hospital and clinic settings.

OBJECTIVE: The study aim was to determine the prevalence of repeated assaults on staff and other patients and characteristics of patients who commit repeated assaults in the Veterans Health Administration of the Department of Veterans Affairs. METHODS: Patients in VA medical centers and freestanding outpatient clinics who committed two or more assaults in fiscal years 1995 and 1996 were identified through a survey of facility quality or risk managers. For each repeatedly assaultive patient, structured information, including incident reports, was obtained for all assault occasions. RESULTS: A total of 153 VA facilities responded, for a response rate of 99 percent. The survey identified 8,968 incidents of repeated assault by 2,233 patients, for a mean of 4.02 assaults per patient in the two-year study period. In 92 percent of the incidents, the assaultive patient had a primary or secondary psychiatric diagnosis. The mean age of the repeat assaulters was 62 years. Ninety-eight percent of the repeat assaulters were male, and 76.6 percent were Caucasian. At least 16 percent of the assaulters, 22 percent of the patients assaulted, and 20 percent of the staff assaulted required medical attention for injuries, which, along with the number of lost work days, indicates that repeated assaults are costly. CONCLUSIONS: Repeatedly assaultive patients represent major challenges to their own safety as well as to that of other patients and staff. Identifying patients at risk for repeated assaults and developing intervention strategies is critically important for ensuring the provision of health care to the vulnerable population of assaultive patients.

The relationship of NEO-PI performance to coping styles, patterns of use, and triggers for use among substance abusers.

We investigated the construct validity of the NEO Personality Inventory (NEO-PI) with a clinical population of 2,676 substance abusers. Scores on the NEO-PI were correlated with self-reported measures of psychopathology as well as patterns of substance abuse, reported coping styles, relapse triggers, and relapse confidence. Substance abusers were more Neurotic and less Agreeable and Conscientious than were the NEO-PI nonclinical normative sample. Within subgroups of substance users, cocaine-only users were more Extroverted and Open than were alcohol-only users. Polysubstance users were the least Agreeable and Conscientious group. Alcohol-only users and polysubstance users scored higher on Neuroticism than did other groups. Personality dimensions related to reported coping styles in meaningful ways. For example, Neuroticism was highly related to escape avoidant coping (r = .53), Agreeableness was negatively related to confrontive coping (r = -.28), and Conscientiousness was related to problem solving (r = -.27) and negatively related to escape avoidance (r = -.29). Neuroticism, Conscientiousness, Agreeableness, and Extroversion were associated with reported triggers of use including negative emotional states, social rejection, and tension. Higher levels of Conscientiousness, Agreeableness, and Extroversion were associated with greater confidence in ability to refrain from use, whereas Neuroticism was associated with a corresponding lack of confidence in self-restraint.

Personality subtypes, coping styles, symptom correlates, and substances of choice among a cohort of substance abusers.

To explore the use of normal personality measures in clinical populations, we investigated the usefulness of the Five-Factor personality domains measured by the NEO Personality Inventory (NEO-PI) in identifying subtypes among a cohort of 3,256 substance abusers. Three groups were reliably identified across clustering methods and the groups differed in reported coping style, psychopathological symptoms, and pattern of substance choice. The largest differences between group members' personality dimensions were found for measures of neuroticism, agreeableness, and conscientiousness. Members of groups characterized by elevated levels of neuroticism demonstrated low levels of conscientiousness and agreeableness. The more extreme the group members' levels on these personality dimensions, the higher their reported levels of depressive symptoms, aggressive/hostile cognitions, impulsiveness, maladaptive coping styles, and likelihood of abusing more than one substance. Results support the use of measures of normal domains of personality in identifying meaningful subtypes of substance abusers.

Suicidal behavior among patients in the VA health care system.

A total of 167 Department of Veterans Affairs medical centers responded to a survey that sought information on suicidal behavior during a one-year period among patients in inpatient or outpatient treatment. Of 248 completed suicides during the period, about 60 percent occurred among patients in outpatient mental health treatment. The incidence of anxiety disorder diagnoses (17.7 percent), particularly posttraumatic stress disorder, among patients who completed suicide was much higher than that reported for persons who completed suicide in the general population. Many patients with psychiatric diagnoses who completed suicide had comorbid substance abuse diagnoses.

Aggression and hostility in substance abusers: the relationship to abuse patterns, coping style, and relapse triggers.

A cohort of 3,367 substance abusers seeking treatment were administered measures of aggression and hostility including the Buss-Durkee Hostility Inventory and the NEO Personality Inventory Hostility Scale. Polysubstance abusers scored significantly higher on all measures of hostility and aggression, regardless of whether they abused cocaine or not. Subjects scoring higher on aggression and hostility utilized escape-avoidance, distancing, and confrontational coping styles more regularly. Subjects scoring higher on measures of aggression and hostility reported more situations that triggered their use of substances and less confidence that they could resist using when faced with such situations in the future. This was especially true for situations involving unpleasant internal states, situations involving rejection, and situations involving conflict with family and friends. The implications of these findings for clinical assessment and treatment planning are discussed.

Testing a tripartite model: II. Exploring the symptom structure of anxiety and depression in student, adult, and patient samples.

L. A. Clark and D. Watson (1991) proposed a tripartite model of depression and anxiety that divides symptoms into 3 groups: symptoms of general distress that are largely nonspecific, manifestations of anhedonia and low positive affect that are specific to depression, and symptoms of somatic arousal that are relatively unique to anxiety. This model was tested by conducting separate factor analyses of the 90 items in the Mood and Anxiety Symptom Questionnaire (D. Watson & L. A. Clark, 1991) in 5 samples (3 student, 1 adult, 1 patient). The same 3 factors (General Distress, Anhedonia vs. Positive Affect, Somatic Anxiety) emerged in each data set, suggesting that the symptom structure in this domain is highly convergent across diverse samples. Moreover, these factors broadly corresponded to the symptom groups proposed by the tripartite model. Inspection of the individual item loadings suggested some refinements to the model.

Testing a tripartite model: I. Evaluating the convergent and discriminant validity of anxiety and depression symptom scales.

L.A. Clark and D. Watson (1991) proposed a tripartite model that groups symptoms of depression and anxiety into 3 subtypes: symptoms of general distress that are largely nonspecific, manifestations of somatic tension and arousal that are relatively unique to anxiety, and symptoms of anhedonia and low Positive Affect that are specific to depression. This model was tested in 5 samples (3 student, 1 adult, and 1 patient sample) using the Mood and Anxiety Symptom Questionnaire (MASQ; D. Watson & L. A. Clark, 1991), which was designed to assess the hypothesized symptom groups, together with other symptom and cognition measures. Consistent with the tripartite model, the MASQ Anxious Arousal and Anhedonic Depression scales both differentiated anxiety and depression well and also showed excellent convergent validity. Thus, differentiation of these constructs can be improved by focusing on symptoms that are relatively unique to each.

The importance of coping skill enhancement in the treatment of the pathological gambler.

The importance of coping skill enhancement in the treatment of pathological gamblers is discussed. It is particularly critical to assess and enhance the coping skills of relapse prone gamblers who are marked by unusual degrees of impulsivity, high levels of negative affect and feelings of helplessness and hopelessness. A study of 1129 substance abusers, including 140 with serious gambling problems is reported. All were assessed to determine their repertoire of coping skills. The patients with serious gambling problems utilized significantly more avoidant and impulsive coping styles.

Disinhibition and negative affectivity in substance abusers with and without a gambling problem.

A cohort of 2,171 substance abusers were assessed for their gambling behavior, and divided into three groups: those with no significant gambling problem (87%); those with a probable problem (7.2%); and those with a severe problem (5.8%). Substance abusers with a gambling problem scored significantly higher on measures of: impulsivity; disinhibition of aggressive/hostile responses; and negative affectivity. They also abused more substances than the nongamblers. The results underscore the importance of assessing a wide range of impulsive behaviors in substance abusers and the potential for subtyping substance abusers based on psychological traits.

Follow-up of male pathological gamblers after treatment: The relationship of intellectual variables to relapse.

Male pathological gamblers entering a comprehensive treatment program were followed-up for twelve months after treatment completion. Twelve month follow-up was obtained for 45 of the 66 patients entering treatment. Total abstinence was reported by 55% (n=25) of the patients located for twelve month follow-up. A relationship was found between abstinence at six month follow-up and selected subscales of the Wechsler Adult Intelligence Scale, performance scale. The implications of these findings for sub-typing gamblers are discussed.

Plasma cortisol and depression in pathological gamblers.

Basal serum cortisol and dexamethasone suppression test (DST) results were studied in 21 pathological gamblers who varied on the Beck Depression Inventory and selected scales of the Minnesota Multiphasic Personality Inventory, which had previously been shown to be related to depression in gamblers. All subjects were suppressors on the DST. There was a significant relationship between fluctuation in 08.00 h and 16.00 h basal cortisol levels and the psychological measures, suggesting a subtype of pathological gambler with potential clinical significance.