Received: 15 April 2020 | Revised: 19 June 2020 | Accepted: 21 July 2020

DOI: 10.1111/ppc.12589

ORIGINAL ARTICLE

An exploration of the sleep quality and potential violence

among patients with schizophrenia in community

Zi‐Ting Chen MSN1,2 | Hsiao‐Tzu Wang RN, MSN3 | Ke‐Hsin Chueh RN, PhD4,5 |
6 7
I‐Chao Liu MD, DSc | Chien‐Ming Yang PhD

1
Department of Nursing, Fu Jen Catholic
University, Taipei, Taiwan Abstract
2
Department of Nursing, Taipei Tzu Chi
Purpose: Sleep quality in patients with schizophrenia is correlated with potential
Hospital Buddhist Tzu Chi Medical Foundation,
Taipei, Taiwan violence. However, few studies have conducted in‐depth discussions on community
3
Department of Nursing, Bali Psychiatric patients with schizophrenia. The purpose of this study was to explore the influences
Center, Ministry of Health and Welfare, Taipei,
Taiwan of demographic characteristics, psychiatric symptom severity, and sleep quality in
4
Department of Nursing, College of Medicine, community patients with schizophrenia on the risks of potential violence and its
Fu Jen Catholic University, Taipei, Taiwan
subdimensions (ie, physical aggression, verbal aggression, anger, and hostility).
5
Deputy Director of Department of Nursing,
Fu Jen Catholic University Hospital, Taipei,
Design and Methods: This study adopted a cross‐sectional research design. Using
Taiwan convenience sampling, 78 community patients with schizophrenia were recruited from
6
Director of Department of Psychiatry, Fu Jen psychiatric outpatient clinics, day wards, and those who received home‐care services.
Catholic University Hospital, Taipei, Taiwan
7 Findings: This study discovered that sleep quality is a crucial factor that influences
Department of Psychology, National Chengchi
University, Taipei, Taiwan the risks of potential violence. Analysis on the subdimensions revealed that having a
violence history during the preceding month and sleep quality are crucial factors
Correspondence
Ke‐Hsin Chueh, RN, PhD, No. 510 Zhongzheng that influence physical aggression. In addition, sleep quality is a crucial factor that
Rd, Xinzhuang District, New Taipei 24205,
influences the occurrence of anger. Age and sleep quality substantially influence
Taiwan.
Email: kchueh@gmail.com hostility. However, this study did not identify any crucial factors that influenced
verbal aggression.
Practice Implications: In the future, community nursing professionals should collect
data on the patients’ age, whether the patients exhibited violence behavior during
the preceding month, and their sleep quality to prevent risks of potential violence,
physical aggression, anger, or hostility.

KEYWORDS

community, potential violence, schizophrenia, sleep quality

1 | INTRODUCTION physical violence while 58.1% had experienced psychological violence in

The number of patients with schizophrenia in Taiwan increases annually.
By 2018, this number had increased to 151 844. Among these patients,
136 097 (89.63%) were outpatients, and the percentages of male and
female patients were 50.04% and 49.96%, respectively.1 In schizophrenia,
changes in emotion, perception, and thinking are considered psychotic
symptoms that can increase the risk of potential violence.2,3 The parents
of patients with schizophrenia had experienced 34.8% had experienced
the past year.4 Therefore, predicting patient violence is crucial for family
members who care for patients. This study examined the influences of
personal characteristics, severity of psychiatric symptoms, and sleep
quality on the risks of potential violence and its subdimensions (ie, phy-
sical aggression, verbal aggression, anger, and hostility) among commu-
nity patients with schizophrenia. The results of this study can serve as a
reference for community healthcare staff to predict and prevent patient
violence.

Perspect Psychiatr Care. 2020;1–7. wileyonlinelibrary.com/journal/ppc © 2020 Wiley Periodicals LLC | 1

2 |
1.1 | Literature review
5,6
Schizophrenia is a type of severe mental disorder. Following the
onset of schizophrenia, patients may experience impairment of
mental reasoning and emotion recognition (eg, emotional tone re-
cognition) abilities. In addition, the severity of their positive and
negative symptoms may influence their social interactions and even
result in interpersonal conflicts.7 According to statistical analysis for
the year 2016,8 87.6% of patients with chronic mental disorders in
Taiwan lived in communities. Moreover, 68.8% of outpatients were
9
failed to adhere to their antipsychotic medications, thereby causing
symptom recurrence and also increasing the risks of potential
violence10 and the rehospitalization rate.11
Sleep is a basic physiological need and is a crucial factor for the
maintenance of excellent health status.12 Sleep disorders lead to a
continuous activation of the sympathetic nervous system13 and a
reduction in frontal‐lobe activity, which results in distraction and
cognitive impairment among patients and even causing behavioral
control problems.14 Insomnia is commonly observed in patients with
15,16
schizophrenia. Compared patients with schizophrenia without
insomnia, patients with both schizophrenia and insomnia exhibit
more notable psychiatric symptoms and have a higher risk of
aggravated symptoms after stopping antipsychotic medications. They
also demonstrate poorer treatment compliance and receive lower
levels of family support.17
Violent behavior has been defined as an attempt or action to
harm a target.18 Patients with mental disorders often exhibit violent
behavior due to physical disease, recurrence of psychotic symptoms
by irregular medication,19 urgency, and emotional regulation
impairment.20 Psychiatric symptoms such as hostility are closely
correlated with the frequency of severe violent behaviors. Coid et al2
revealed that general psychological distress and specific psychiatric
symptoms are correlated with the patients’ frequency of violent
episodes within each 6‐month period. The frontal lobe is a pivotal
brain area responsible for emotional adjustment.21 The schizophrenia
22
patients' frontal functions may abnormalities, and the white‐matter
deficits in the left inferior frontal gyrus23 atrophy and hypometa-
bolism of temporal, subcortical areas, and frontal.24 The frontal lobe
function deficits increase the risk of a patient exhibiting impulsive
and aggressive behavior.25 Changes in brain structure may influence
brain functions. Moreover, sleep disturbance, which is commonly
observed in patients with schizophrenia,16 reduces frontal cortex
function, impairs emotional control, and increases the frequency of
violent behaviors, anger, and aggressive impulses.26 An analysis of
psychological violence among patients with mental illnesses in the
Japanese communities revealed that 56.1% of these patients ex-
hibited physical aggression27 and that is related to family stigma, low
household income, and the patient's age.4 Studies in other countries
have identified parents as the main targets of aggression by patients
with schizophrenia. These violent behaviors include verbal aggres-
sion, physical aggression, self‐harm, and sexual violence; the most
common of which is physical aggression are like punching and kicking,
27
etc. A previous study has revealed that aggressive behaviors are
CHEN ET AL.
often observed among male patients with schizophrenia.28 Another
study indicated that the male‐to‐female ratio among Chinese homi-
cide offenders with schizophrenia was 4:1.29 In addition, studies have
found that younger patients exhibit stronger hostility than older
patients do.30 Patients with a history of violent behaviors have a
relatively high risk of exhibiting violent behavior.31 The violent be-
haviors of patients with schizophrenia include physical aggression,
verbal aggression, anger, and hostility, which correlate with physio-
logical changes in the brain. Sleep disorders may reduce emotional
control, thereby increasing the frequency of violent behaviors.
Moreover, sex, age, and history of violence are correlated with vio-
lent behavior among patients with schizophrenia.
In summary, physiological changes and unsatisfactory sleep
quality among patients with schizophrenia can influence their emo-
tional adjustment. Therefore, sleep quality is closely correlated with
changes in these patients’ emotions. In the present study, we ex-
amined the influences of personal characteristics, psychiatric symp-
tom severity, and sleep quality on the risks of potential violence and
its subdimensions (ie, physical aggression, verbal aggression, anger,
and hostility) among community patients with schizophrenia.
2 | M ETHO DO LO G Y
2.1 | Research design
This was a cross‐sectional study, and the convenience sampling
method was adopted. From 11 October 2018 to 16 August 2019,
patients from the psychiatric outpatient clinics and day wards at a
regional teaching hospital in New Taipei City and patients partici-
pating in home‐care services provided by this hospital were recruited
for the study. The researcher explained the research purpose and
process to the patients, including signing of the informed consent
form, collection of daily rest times and basic information, and
scheduled date and place of the investigation. The investigation time
was from 9:00 AM to 12:00 PM at least 2 hours after patients woke up
in the morning and at least 30 minutes after their last meal and ex-
ercise. To ensure patient privacy, data were collected at the patient's
residence or in a quiet interview room in the clinic ward. The patients
were surveyed using Chinese versions of self‐report Pittsburgh Sleep
Quality Index and The Aggression Questionnaire. In addition, the
Brief Psychiatric Rating Scale (BPRS) was administered and the
pharmaceutical equivalence of psychiatric medication was recorded.
This study was approved by the ethics committee of the hospital (No.
07‐XD‐073).
2.2 | Participants
A total of 78 participants were recruited for this study. The inclusion
criteria were as follows: (a) patients who were diagnosed with schi-
zophrenia by a psychiatrist according to Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition32; (b) patients who had not
CHEN ET AL.
been hospitalized because of aggravated symptoms for 1 month or
those whose medicine had not been changed due to changes in their
psychiatric symptoms for 1 month; (c) patients who could understand
Mandarin or Taiwanese and could communicate using these lan-
guages; (d) patients who were fully conscious and able to complete
the questionnaires; (e) patients who were taking antipsychotic
medicine within the suggested dosage; patients aged of 20 to
65 years. Patients with comorbid personality disorders, mood dis-
orders, or substance use disorders were excluded.
2.3 | Research instruments
This study adopted the following questionnaires: a demographic in-
formation sheet; the BPRS, and the Chinese versions of the Pittsburgh
sleep quality index (PSQI) and the Aggression Questionnaire.
The demographic information sheet was self‐developed to
record participants’ ages, sex, education levels, and histories of vio-
lence during the preceding month and their regular medication
33
habits. The BPRS developed by Overall and Gorham is used to
rapidly assess the severity of a patient's psychiatric symptoms. In
1986, Chang, Hu, and Wei translated the 16 items of the BPRS into
Chinese.34 The intraclass correlation coefficient of this scale was
0.69, indicating satisfactory reliability. Psychiatric symptoms are
classified into affective, behavioral, cognitive, and drive symptoms.
This scale was used to assess patients’ psychiatric symptoms during
the preceding week. In the present study, the Cronbach's α (internal
consistency) for this scale was .84.
The Chinese version of the PSQI comprises seven dimensions of
sleep quality, namely subjective sleep quality, sleep duration, sleep
disturbances, sleep latency, habitual sleep efficiency, daytime dys-
function, and use of sleep medication. Each dimension is scored 0 to
3 points, with a higher overall score indicating poor sleep quality.35,36
The Cronbach's α (internal consistency) and test‐retest reliability
(retest conducted after 14‐21 days) were .82 to .83 and .85,
respectively. For a cut‐off point of 5, the sensitivity and specificity
levels were 98% and 55%, respectively.36 The original scale assesses
sleep quality during the preceding month. To assess patients’ short‐
term sleep quality, the present study assessed the patients’ sleep
quality during the preceding week. In this study, the Cronbach's α
(internal consistency) for this scale was .73.
The Chinese version of the Aggression Questionnaire was used
to assess risks of potential violence. This scale was developed from
the Hostility Inventory by Buss and Durkee37 and was translated into
Chinese by Liu.38 The scale comprises 29 items measuring physical
aggression, verbal aggression, anger, and hostility. A 5‐point Likert
scale from 1 (completely wrong) to 5 (completely correct) was adopted.
The full score was 145 points and the cut‐off point was 66 points.
Higher scores indicate higher risks of potential violence. Buss and
Perry39 conducted a retest of 372 participants after 9 weeks, and the
test‐retest reliabilities for physical aggression, verbal aggression,
anger, and hostility were 0.80, 0.76, 0.72, and 0.72, respectively. This
study conducted retest on Taiwanese university students after
| 3
3 weeks, which yielded a test‐retest reliability of 0.93, and the test‐
retest reliabilities for physical aggression, verbal aggression, anger,
and hostility were 0.90, 0.67, 0.77, and 0.79, respectively. In Liu,38
the Cronbach's α (internal consistency) for this scale was .77, The
Cronbach's α of the subdivisions of physical aggression, verbal ag-
gression, anger, and hostility were .67, .64, .78, .76, respectively, thus
demonstrating satisfactory consistency. In this study, the Cronbach's
α for the overall scale was .77; the Cronbach's α values for the
subdimensions of physical aggression, verbal aggression, anger, and
hostility were .70, .72, .73, and .81, respectively.
2.4 | Data analysis
The SPSS 22 (Windows) software package was employed for statis-
tical analysis. Descriptive statistics were used to explore correlations
of demographic data, severity of psychiatric symptoms, and sleep
quality with risks of potential violence and its subdimensions (ie,
physical aggression, verbal aggression, anger, and hostility). A mul-
tiple regression analysis was performed to examine the influential
factors for potential violence.
3 | RE SU LTS
This study recruited community patients with schizophrenia between
21 and 64 years old. The average age of the participants was 42.59
(±10.10) years old. Most patients were aged 30 to 39 years (35.90%)
and were women (N = 50; 64.10%). In addition, most of the patients
had a senior or vocational high school education level (N = 34;
43.59%). The majority of the patients had not exhibit violent beha-
viors (N = 74; 94.87%) and had taken their medicine regularly
(N = 68; 87.18%) during the preceding month.
Table 1 presents the correlations of demographic data, severity
of psychiatric symptoms, and sleep quality with risks of potential
violence and its subdimensions. The results revealed that the physical
aggression scores of patients who exhibited violent behavior during
the preceding month were significantly higher than that of those who
did not (t = −2.19, P = .032). The anger scores of patients who took
their medicine regularly were significantly higher than that of those
who did not (t = 2.02, P = .047). Patients with more severe psychiatric
symptoms had significantly higher scores in potential violence
(r = .37, P = .001), physical aggression (r = .34, P = .002), anger (r = .35,
P = .002), and hostility (r = .32, P = .004). Subsequently, patients with
less satisfactory sleep quality had significantly higher scores in po-
tential violence (r = .48, P ≤ .001), physical aggression (r = .41,
P ≤ .001), anger (r = .42, P ≤ .001), and hostility (r = .49, P ≤ .001).
Table 2 presents the multiple regression analysis for the influ-
ence of demographics, severity of psychiatric symptoms, and sleep
quality on risks of potential violence and its subdimensions. The
results revealed that unsatisfactory sleep quality was the only in-
fluential factor for risks of potential violence (β = .38, P = .003); sleep
quality explained 21% of the variance in the risk of potential violence.
 4
|

T A B L E 1 Influence of the demographic characteristics of community patients with schizophrenia on their risk of potential violence and its subdimensions (N = 78)

Potential violence Physical aggression Verbal aggression Anger Hostility

Variable n (%) M SD t/F/r P M SD t/F/r P M SD t/F/r P M SD t/F/r p M SD t/F/r P

Age F = 0.27 .898 F = 0.47 .755 F = 1.02 .404 F = 0.64 .636 F = 0.93 .450
20‐29 y 7 (8.97) 72.43 23.66 23.43 7.28 12.86 5.90 15.71 5.85 20.43 7.87
30‐39 y 28 (35.90) 70.39 17.97 20.89 6.17 12.82 4.72 18.04 5.99 18.64 7.25
40‐49 y 18 (23.08) 69.56 18.36 19.72 6.11 13.89 4.25 17.89 5.51 18.06 7.04
50‐59 y 21 (26.92) 71.00 19.65 21.48 6.10 14.33 5.18 19.38 6.58 15.81 7.04
60‐64 y 4 (5.13) 61.00 20.96 21.00 8.16 9.50 3.42 15.75 8.46 14.75 4.99

Sex t = −0.26 .796 t = 1.32 .192 t = −0.23 .823 t = −1.25 .217 t = −0.62 .537
Men 28 (35.90) 69.32 20.51 22.25 6.79 13.14 5.23 16.89 6.14 17.04 6.99
Women 50 (64.10) 70.48 17.99 20.32 5.87 13.40 4.62 18.68 6.05 18.08 7.22

Education level F = 1.49 .232 F = 1.42 .247 F = 0.46 .631 F = 2.24 .113 F = 0.88 .418
Low 12 (15.38) 67.50 19.52 21.83 5.67 13.50 4.87 16.67 6.31 15.50 5.28
Medium 34 (43.59) 74.21 17.74 22.06 6.36 13.82 4.79 19.68 5.87 18.65 7.46
High 32 (41.03) 66.63 19.37 19.59 6.23 12.69 4.90 16.81 6.03 17.53 7.31

Exhibited violent behavior t = −1.09 .281 t = −2.19 .032 t = −1.70 .093 t = −0.41 .686 t = 0.49 .625
within the preceding
month
Yes 4 (5.13) 80.00 6.40 27.50 6.19 17.25 2.06 19.25 3.59 16.00 5.66
No 74 (94.87) 69.53 19.10 20.66 6.09 13.09 4.83 17.97 6.22 17.80 7.20

Having taken medicine t = 1.50 .139 t = 0.37 .712 t = 0.84 .405 t = 2.02 .047 t = 1.34 .185
regularly for the preceding
month
Yes 68 (87.18) 68.85 19.12 20.91 6.48 13.13 4.94 17.51 6.13 17.29 7.00
No 10 (12.82) 78.30 14.79 21.70 4.52 14.50 3.81 21.60 4.72 20.50 7.58

BPRS r = .37 .001 r = .34 .002 r = .08 .484 r = .35 .002 r = .32 .004

CPSQI r = .48 <.001 r = .41 <.001 r = .07 .518 r = .42 <.001 r = .49 <.001

Note: Educational level is classified into the following categories: Low: illiteracy, elementary school, or junior high school; Medium: Senior or vocational high school; High: university or graduate school.
Abbreviations: BPRS, Brief Psychiatric Rating Scale; CPSQI, Chinese versions of self‐report Pittsburgh Sleep Quality Index; SD, standard deviation.
CHEN
ET AL.
CHEN ET AL. | 5

T A B L E 2 Multiple regression analysis of the influences of the severity of psychiatric symptoms and sleep quality on risks of potential violence
and its subdimensions (N = 78)

Potential violence Physical aggression Verbal aggression Anger Hostility

Variable β P β P β P β P β P

Demographic characteristics
Age −.10 .389 −.02 .864 .03 .837 .04 .739 −.29 .008
Sex .09 .421 −.11 .319 .01 .939 .15 .194 .20 .063
Education level −.06 .569 −.16 .117 −.03 .805 −.04 .730 .04 .709
Violent episodes within the preceding month .09 .393 .25 .017 .18 .144 −.01 .906 −.09 .357
Having taken medicine regularly for the preceding .03 .794 .13 .263 −.04 .780 −.07 .551 .05 .630
month

BPRS .21 .078 .15 .200 .06 .655 .24 .052 .18 .111

CPSQI .38 .003 .37 .003 .02 .877 .30 .019 .41 .001

Adj R 2
.21 .23 −.05 .17 .28

F 3.84 4.28 .48 3.32 5.30

Note: Multiple regression analysis was adopted to analyze demographic characteristics, severity of psychiatric symptoms (assessed using the BPRS), and
sleep quality (assessed using the Chinese version of the PSQI).
Abbreviations: Adj, adjusted; BPRS, Brief Psychiatric Rating Scale; CPSQI, Chinese versions of self‐report Pittsburgh Sleep Quality Index.

Analysis of the subdimensions revealed that unsatisfactory sleep
quality (β = .37, P = .003) and violent behaviors during the preceding
month (β = .25, P = .017) significantly influenced risks of physical ag-
gression and explained 23% of its variance. Unsatisfactory sleep
quality was the only influential factor for anger (β = .30, P = .019) and
explained 17% of its variance. Unsatisfactory sleep quality (β = .41,
P = .001) and young age (β = −.29, P = .008) significantly influenced
hostility and explained 28% of its variance. In this study, no variables
significantly influenced verbal aggression.
4 | D I S C U S SI O N
According to the 2018 annual report of National Health Insurance
Statistics, 114 891 outpatients aged 20 to 64 years were diagnosed
as having schizophrenia; among them, those aged 40 to 49 years
constituted the largest group (24.99%), followed by those aged 30 to
39 years (20.73%).1 The average age of the community patients with
schizophrenia in the present study was 42.59 (±10.10) years. Among
these patients, 23.08% were aged 40 to 49 years. This proportion
was slightly lower than that recorded by the Ministry of Health and
Welfare. In the current study, patients aged 30 to 39 years were the
largest group (35.90%), indicating that the proportion of younger
patients in this study is greater than that of those in the 2018 report.
According to the data provided by the Ministry of Health and
Welfare in 2018, among outpatients with schizophrenia aged 20 to
64 years, 52.10% were men and 47.90% were women. In the present
study, 35.90% and 64.10% of the patients were men and women,
respectively, indicating that the proportion of female patients was
higher in the present study than the 2018 report. In addition, in this
study, most of the patients (87.2%) had taken their medicine
regularly during the preceding month. In previous studies of patients
with schizophrenia in acute psychiatric wards, 84.85% of patients
took their medicine regularly before hospitalization.40 The propor-
tion of patients who had taken their medicine regularly during the
preceding month was slightly higher in the present study than that in
previous studies.
In this study, we analyzed factors that influenced risks of po-
tential violence, physical aggression, verbal aggression, anger, and
hostility among community patients with schizophrenia. The results
indicated that unsatisfactory sleep quality was a crucial influential
factor. A study of patients with mental disorders in criminal treat-
ment institutions in the Netherlands revealed that patients with
sleep disturbances were more irritable, less tolerant to frustration,
more impulsive, and more aggressive. The study also revealed that
unsatisfactory sleep quality was positively correlated with risks of
potential violence.41 Another study of junior and senior secondary
school students revealed that sleep duration was negatively corre-
lated with Sibling aggression (r = −.45, P < .001); thus, a shorter sleep
duration increased the occurrence of aggression.42 These studies
have indicated that unsatisfactory sleep quality significantly influ-
ences risks of potential violence, physical aggression, anger, and
hostility; the results of the present study are consistent with these
findings. In this study of community patients with schizophrenia, no
variables significantly influenced verbal violence. This result was not
consistent with the findings of a study on sleep in adults, which in-
dicated that short sleep duration was relatively high scores on anger,
verbal, and physical expression.43 According to the regression ana-
lysis in the present study, only a very small proportion of the variance
in verbal aggression could be explained; therefore, unknown vari-
ables remain to be investigated. In this study, the participants were
community patients with schizophrenia with senior or vocational high
6 |
school education levels. Whether the condition and education level
of patients influenced their risk of verbal aggression could be
explored in future studies.
Few studies have explored the relationship between the age of
community patients with schizophrenia and their risk of hostility.
However, Sloan et al30 assigned patients into groups of those aged
40 years or older and those aged younger than 40 years; this study
revealed that patients aged younger than 40 years exhibited higher
levels of hostility than those aged 40 years or older. This result is in
agreement with the findings of the present study, which indicated
that young age was a crucial influential factor for risk of hostility and
that younger patients exhibited stronger hostility.
The present study revealed that a history of violence among
community patients with schizophrenia during the preceding month
was a crucial influential factor for the risks of physical aggression. In
addition, the risk of physical aggression among patients who had
exhibited violent behavior during the preceding month was sig-
nificantly higher than that of those who had not. A previous study has
also indicated that patients with a history of violent behavior have a
high risk of exhibiting aggressive behavior again.31 This result is in
agreement with the findings of the present study.
4.1 | Research limitations and suggestions
This study conducted cross‐sectional research to explore the in-
fluences of demographic characteristics, severity of psychiatric
symptoms, and sleep quality on potential violence risks of com-
munity patients with schizophrenia. The results showed that sleep
quality was a crucial influential factor that explained 21% of the
variance in potential violence. However, a causal relationship be-
tween sleep quality and the risk of potential violence among
community patients with schizophrenia was not established.
Therefore, we suggest that future studies should adopt a long-
itudinal design to further explore this topic. In addition, the dis-
tributions of sex and age among community patients with
schizophrenia recruited in this study were slightly biased. This may
influence the external validity of the findings. Future studies that
cite the present study should consider the differences in popula-
tion and avoid overgeneralization.
4.2 | Implications for nursing practice
The present study revealed that the sleep quality of community
patients with schizophrenia significantly influenced their risks of
potential violence, physical aggression, anger, and hostility.
Therefore, the community nursing professionals should collect
data on the patients’ age, whether the patients exhibited violence
behavior during the preceding month, and managing their sleep
quality of such patients to reduce risks of potential violence,
physical aggression, anger, and hostility, thereby protecting the
safety of psychiatric personnel.
CHEN ET AL.
AC KNO WL EDG M EN TS
The authors thank the schizophrenia patients and the administrative
units in the Taipei Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation
and the Fu Jen Catholic University Hospital for their cooperation.
CON F LI CT OF IN TE RES T S
The authors declare that there are no conflict of interests.
ORCI D
Ke‐Hsin Chueh http://orcid.org/0000-0001-9214-4316
R E F E R E N CE S
1. Ministry of Health and Welfare (2019). 2018 annual report of
national health insurance medical statistics. Retrieved from https://
dep.mohw.gov.tw/DOS/lp-4648-113.html
2. Coid JW, Kallis C, Doyle M, Shaw J, Ullrich S. Shifts in positive and
negative psychotic symptoms and anger: effects on violence. Psychol
Med. 2018;48(14):2428‐2438.
3. O'Reilly K, Donohoe G, Coyle C, et al. Prospective cohort study of the
relationship between neuro‐cognition, social cognition and violence in
forensic patients with schizophrenia and schizoaffective disorder.
BMC Psychiatry. 2015;15(1):155.
4. Kageyama M, Solomon P, Yokoyama K. Distress psychological and
violence towards parents of patients with schizophrenia. Arch Psychiatr
Nurs. 2016;30(5):1‐6. https://doi.org/10.1016/j.apnu.2016.02.003
5. Wu CY, Lee MB, Yu CT, Lin JuY, Huang RP, Chen HC. The perspectives of
contemporary community psychiatric and mental health nursing. Formosan
J Med. 2016;20(1):96‐105. https://doi.org/10.6320/FJM.2016.20(1).13
6. Yildiz M. Recovery as a process in severe mental illnesses. Noropsikiyatr
Ars. 2015;52(1):1‐3. https://doi.org/10.5152/npa.2015.0120148
7. Wu CL, Liu IC, Gen WK, Yeh ZT. The relationship between positive
and negative symptoms, theory of mind, and emotion cognition in
patients with schizophrenia. Arch Clin Psychol. 2017;8(2):15‐25.
https://doi.org/10.6550/ACP.0802.002
8. Ministry of Health and Welfare (2018). 2016 survey on living
conditions and needs of people with disabilities. Retrieved from
https://dep.mohw.gov.tw/DOS/cp-1770-3599-113.html
9. Sultan MAR, El Sayad H, Mohsen NM, Barakat DH, Ryad RA, Khalil AH.
Studying medication adherence in patients with schizophrenia: focus on
antipsychotic‐related factors. MECPsych. 2016;23(1):27‐34.
10. Caqueo‐Urízar A, Fond G, Urzúa A, Boyer L, Williams DR. Violent
behavior and aggression in schizophrenia: prevalence and risk factors.
A multicentric study from three Latin‐America countries. Schizo-
phrenia Res. 2016;178(1‐3):23‐28.
11. Fond G, Boyer L, Favez M, et al. Violence in psychiatric units. Soc
Psych Psych Epid. 2006;41(9):698‐703.
12. Chang BW, Liu FC, Lin CH, Yang ML, Feng CK. An effect study of
mood status on sleep quality: to study the moderating effect of in-
ternet used behaviors. J Sport Recreation Res. 2017;12(1):79‐91.
13. Zhuang ZT. Relationship between sleep disorders and cardiovascular
disease. J Vasc Med Prevention and Treatment. 2016;25:24‐26. https://
doi.org/10.6527/PVM.2016.25.10
14. Naghan PA, Setareh J. Sleep and cognition in schizophrenia. J Sleep Sci.
2017;2(3‐4):89‐94.
15. Hou CL, Li Y, Cai MY, et al. Prevalence of insomnia and clinical and
quality of life correlates in Chinese patients with schizophrenia
treated in primary care. Perspect Psychiatr Care. 2017;53:80‐60.
16. Mulligan LD, Haddock G, Emsley R, Neil ST, Kyle S.D. High resolution
examination of the role of sleep disturbance in predicting functioning
and psychotic symptoms in schizophrenia: A novel experience
sampling study. J Abnorm Psychol. 2016;125(6):788‐797. https://doi.
org/10.1037/abn0000180\
CHEN ET AL.
17. Afonso P, Brissos S, Cañas F, Bobes J, Bernardo FI. Treatment ad-
herence and quality of sleep in schizophrenia outpatients. Int
J Psychiatry Clin Pract. 2014;18(1):70‐76. https://doi.org/10.3109/
13651501.2013.845219
18. Zhu X, Wang K, Cao A, Zhang Y, Qiu J. Personality traits and negative
affect mediate the relationship between cortical thickness of superior
frontal cortex and aggressive behavior. Neurosci Lett. 2020;718:134728.
19. Wu Y, Kang R, Yan Y, et al. Epidemiology of schizophrenia and risk
factors of schizophrenia‐associated aggression from 2011 to 2015.
J Int Med Res. 2018;46(10):4039‐4049.
20. Hoptman MJ, Ahmed AO. Neural foundations of mood‐induced im-
pulsivity and impulsive aggression in schizophrenia. Curr Neurol Neu-
rosci Rep. 2016;3(3):248‐255.
21. Doré BP, Weber J, Ochsner KN. Neural predictors of decisions to
cognitively control emotion. J Neurosci. 2017;37(10):2580‐2588.
22. Leclerc MP, Regenbogen C, Hamilton RH, Habel U. Some neuroana-
tomical insights to impulsive aggression in schizophrenia. Schizo-
phrenia Res. 2018;201:27‐34.
23. Lyu H, Hu M, Eyler LT, et al. Regional white matter abnormalities in drug‐
naive, first‐episode schizophrenia patients and their healthy unaffected
siblings. Australian & New Zealand J Psychiatry. 2015;49(3):246‐254.
24. Van Assche L, Morrens M, Luyten P, Van de Ven L, Vandenbulcke M.
The neuropsychology and neurobiology of late‐onset schizophrenia
and very‐late‐onset schizophrenia‐like psychosis: a critical review.
Neuroscience & Biobehavioral Reviews. 2017;83:604‐621.
25. Reddy KJ, Menon KR, Hunjan UG. Neurobiological aspects of violent
and criminal behaviour: deficits in frontal lobe function and neuro-
transmitters 1. Int J Criminal Justice Sci. 2018;13(1):44.
26. Kamphuis J, Meerlo P, Koolhaas JM, Lancel M. Poor sleep as a po-
tential causal factor in aggression and violence. Sleep Med. 2012;13(4):
327‐334. https://doi.org/10.1016/j.sleep.2011.12.006
27. Kageyama M, Solomon P. Post‐traumatic stress disorder in parents of
patients with schizophrenia following familial violence. PLoS One.
2018;13:6.
28. Kageyama M, Solomon P. Physical violence experienced and wit-
nessed by siblings of persons with schizophrenia in Japan. Int J Ment
Health. 2019;48(1):2‐13.
29. Wang J, Zhang SM, Zhong SL, et al. Gender differences among
homicide offenders with schizophrenia in Hunan Province, China.
Psychiatry Res. 2019;271:124‐130.
30. Sloan PR, Shapiro AP, Bigger T, Bagiella E, Richard C, Gorman MJ.
Cardiac autonomic control and hostility in healthy subjects. Am
J Cardiol. 1994;74:298‐300.
31. Barlati S, Stefana A, Bartoli F, et al. Violence risk and mental disorders
(VIORMED‐2): a prospective multicenter study in Italy. PLoS One.
2019;14(4):e0214924.
| 7
32. American Psychiatric Association (2014). Desk reference to the
diagnostic criteria from DSM‐5 (translated by Taiwanese Society of
Psychiatry). New Taipei City Hochi Books. The original book was
published in 2013.
33. Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep.
1962;10:799‐812.
34. Chang DR, Hu H, G, Wei FW. Inter‐rater reliability for the brief
psychiatric rating scale. Chinese Soc Neurol Psychiatry Bulletin. 1986;
12(1):29‐35.
35. Lin JN. Gender differences in self‐perceptions about aging and sleep
among elderly Chinese residents in Taiwan. J Nurs Res. 2016;24(4):
347‐356.
36. Tsai PS, Wang SY, Wang MY, et al. Psychometric evaluation of the
Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in pri-
mary insomnia and control subjects. Qual Life Res. 2005;14:1943‐1952.
https://doi.org/10.1007/s11136-005-4346-x
37. Buss AH, Durkee A. An inventory for assessing different kinds of
hostility. J Consult Psychol. 1957;21(4):343‐349.
38. Liu SF. (2000). The influence of multi‐faceted self‐esteem on university
students’ depression and aggressive behavior (unpublished Master's
thesis). Taipei: National Chengchi University.
39. Buss AH, Perry M. The aggression questionnaire. Personality Soc Psy-
chol. 1992;63(3):452‐459.
40. Wang HT. (2017). Relationships between sleep quality and
aggressive behavior among Schizophrenia patients hospitalized
in acute wards within two weeks (Master's thesis, Fu Jen Catholic
University).
41. Kamphuis J. (2017). The relation between sleep and violent
aggression (Doctoral dissertation, Rijksuniversiteit Groningen).
42. Makinde O, Österman K, Björkqvist K. The association between
sleep deprivation, aggression, and antisocial behavior in adoles-
cents in Ejigbo, Lagos, Nigeria. Eur J Interdisciplinary Stud. 2018;
4(1):154‐158.
43. Arbinaga F. Subjective sleep quality and anger. Int J Psychol Behav Sci.
2017;7(1):41‐48.
How to cite this article: Chen Z‐T, Wang H‐T, Chueh K‐H,
Liu I‐C, Yang C‐M. An exploration of the sleep quality and
potential violence among patients with schizophrenia in
community. Perspect Psychiatr Care. 2020;1–7.
https://doi.org/10.1111/ppc.12589