Revisiting Assaults by Psychiatric Patients with Both Schizophrenia and Substance Use
by Dr. Raymond B. Flannery Jr. on
Previous blogs in this series have documented the ongoing issue of psychiatric patient assaults on healthcare staff (January 16, 2015, and January 30, 2018). This is a worldwide occupational hazard. A recent 62-year analysis of this research (1) noted that patients with schizophrenia and substance use disorder are the more frequent assailants. This blog examines several of the possible causes of this ongoing violence. It is a complex issue with multiple psychological and biological/neurological components that interact. We begin this review by discussing different patterns of assaults by patients diagnosed with schizophrenia.
Patterns of Assaults
There are at least three different patterns of assaults by these patients (2). The first group is comprised of patients who were aggressive as juveniles before the onset of their schizophrenic illnesses. This youthful propensity for aggression continued after the onset of their psychotic illnesses. The second group of patients were never aggressive until the onset of their schizophrenia illnesses, and these patients have no histories of juvenile aggression. The third group are those with no juvenile histories of aggression and no violence during the first decade after the onset of their schizophrenic illnesses. However, in the second or third decade of their illnesses they do become assaultive.
To be sure, not all patients with schizophrenia become assaultive, but as noted earlier some do. This research suggests that there may be at least these three different patterns/causes of the same type of assaultive behavior.
Psychological Causes
There has been considerable research on the possible psychological causes of patient assaults (3). These are often grouped into static and dynamic factors. Common examples of static factors include age, gender, intellectual level, histories of head trauma, past aggression, and/or personal victimization. Dynamic factors include the negative emotions that anyone can experience such as fear, anxiety, anger, frustration, and depression. Dynamic factors may also include a variety of conflicts with others and could include disputes over limited resources, denial of services, objections to rules set by healthcare providers, various family issues, theft of personal property, court commitments, and substance use disorders. To this mix of static/dynamic factors we need to include the biological issues that manifest in psychological states: acute psychosis, perceptual disturbances such as auditory and visual hallucinations, paranoid and grandiose delusions, disorganized thinking, impaired memory, impulse-control issues, and suicidal/homicidal thoughts.
Biological Causes
Further adding to this complexity is a range of biological/neurological possible causes for these assaults (4,5). These include structural changes and circuit disorders in the brain as well as genetic influences. The information in this section is complex and highly technical. It is presented so that the reader is aware in a general way of the complex biological processes that may be occurring.
First, the basic structures in the brain of persons with schizophrenia do not appear to develop normally. The affected areas include the frontal cortex, wherein thinking and reasoning occur, and the temporal regions, wherein memory is kept. The brain is also covered with gray matter to ensure proper brain functioning. In persons with schizophrenia, this gray matter is diffusely distributed with density loss in the neocortex and subcortical gray-matter area.
The second issue is disrupted brain circuits. The various components of the brain communicate with each other by means of various chemicals, so that the person can think about a task, decide on a course of action, and address the issue. Chemicals transport the various message components to the other necessary brain structures. Research has demonstrated hypoconnectivity (slowed) in the frontal, postcentral and cerebral cortices, and additional dysregulation in the mesolimbic-dopamine system as well as the hypothalamic-pituitary-adrenal axis (5).
The third area of brain dysfunction is found in a large body of data that indicates a likely genetic basis for schizophrenic illness (5).
Psychological Trauma
As if these complexities were not enough, many persons with schizophrenia include those who become assaultive, having been victims of personal victimization (6,7). These traumatic incidents may introduce further neurobiological changes in the prefrontal cortex and in the limbic system, where feeling states begin. This is the safety-alarm system of the brain that seeks out ways to escape and, if this is not possible, how best to cope. These brain circuits may be permanently altered as well and result as components in assaultive outbursts or social withdrawal with the use of substances to manage associated stress. See (7) for detailed discussion.
Much of this victimization occurs before age 6, but the victims do not act on their anger over these events until between ages 12 and 14. Treating this youth victimization early on may prevent subsequent violence in the form of patient assaults before it begins (8).
Substance Use Disorder
The use of substances greatly compromises brain functioning in normal adults. This includes impaired executive functioning, impaired memory, impaired personal-control deficits, irritability, depression, and fetal alcohol syndrome (FAS). It may also result in states of anger and short-temperedness with resultant aggressive outbursts. Different drugs may also prove to impair the brain in different ways. Unfortunately, some persons with schizophrenia, as well as persons with schizophrenia and histories of victimization, complicate their ability to cope by using substances to manage their stress. These drugs may reduce stress in the short term, but their continued use further degrades brain functioning and personal control.
Fifty years ago, the assaultive patient was one diagnosed with both schizophrenia and substance use disorder. Fifty years later, the most-assaultive patient is one diagnosed with both schizophrenia and substance use disorder. Patients need to have both diagnoses as assault rates do not increase for either diagnosis alone. Given the possible complexities in patients diagnosed with both schizophrenia and substance use disorder, it is not surprising that these illnesses have proved resistant to treatment. Medications, differing forms of psychotherapy, and various psychosocial interventions have not proved effective as standard forms of care, and this review has delineated some of the most common possible causes for these patient assaults. Clinical researchers and practitioners are now focusing on the neurobiological interactions of both schizophrenia and substance use disorder to assess possible etiologies in the search for clinically efficacious, cost-effective solutions for these treatment issues. It may well be that some patient assaults are triggered by environmental cues that trip off flashbacks from patients’ past traumatic episodes.
References
7. Flannery, R. B. Jr. Posttraumatic Stress Disorder: The Victim’s Guide to Healing and Recovery. Second Edition. Riverdale, NY: American Mental Health Fdn., 2012.
8. Flannery, R. B. Jr. Preventing Youth Violence Before It Begins. Riverdale, NY: American Mental Health Fdn., 2022.
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Dr. Raymond B. Flannery Jr., Ph.D. FACLP, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops, all types of groups, and may be reached at The American Mental Health Foundation: elomke[at]americanmentalhealthfoundation.org.
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