Acta Psychiatr Scand 2002: 106 (Suppl.

412): 142–143 Copyright ª Blackwell Munksgaard 2002

Printed in UK. All rights reserved ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0065-1591

A model of aggression in psychiatric

hospitals
Nijman HLI. A model of aggression in psychiatric hospitals H. L. I. Nijman
Acta Psychiatr Scand 2002: 106 (Suppl. 412): 142–143. Forensic Psychiatric Hospital De Kijvelanden,
ª Blackwell Munksgaard 2002. Poortugaal, the Netherlands

Objective: Research of the determinants of inpatient aggression

indicates that certain environmental hospital variables play a role in
triggering aggression in psychiatric hospitals. Yet, how patient, staff
and ward variables interact in eliciting aggression is not well
understood.
Method: On the basis of earlier findings, a model was proposed in
which psychopathology and distorted cognitions of the patient are
combined with environmental and communicational stressors that are
specific for psychiatric wards.
Results: The proposed model elucidates how certain patient, staff and Key words: aggression; violence; inpatients
ward characteristics may interact in causing aggression. The model H. L. I. Nijman, Forensic Psychiatric Hospital De
also emphasizes that repeated inpatient aggression may be the result of Kijvelanden, Kijvelandsekade 1, 3172 AB, Poortugaal,
a vicious circle, i.e. inpatient violence is often followed by an increase the Netherlands
in environmental and ⁄ or communication stress on the patient, thereby This paper, in its preliminary version, was read at the
heightening the risk of a repeated outburst of violence. 2nd European Congress on Violence in Clinical Psych-
Conclusion: Although tentative, the model may shed light on the iatry symposium 'Violence in public health and victims'
mechanisms that lead to (repeated) violence. perspective', Stockholm, Sweden, 28–30 June 2001

Introduction Patient variables: psychopathology

Compared with the relatively large number of
studies on the characteristics of violent patients,
little work has been done on the contribution of
situational variables to inpatient aggression (e.g. 1).
Yet, certain environmental hospital variables, such
as the ward program, rules and architecture, may
be linked to violence (e.g. 2, 3).
In the present paper, a model of inpatient aggres-
sion is described that tries to take into account both
patient characteristics as well as situational variables
that are specific for psychiatric wards.
An outline of the proposed model of inpatient aggression
In Figure 1, the proposed model of inpatient
aggression is outlined. The model and its implica-
tions have been addressed in detail in Psychiatric
Services (4). The left part specifies three categories
or levels of aggression-eliciting factors, namely
patient, ward and staff variables.
With regard to patient variables, severe psycho-
pathology (e.g. schizophrenia of the paranoid
type) is thought to be one of the major sources of
inpatient aggression. The psychopathology of the
patient leads to (involuntary) admission of the
patient to a psychiatric hospital, but this admis-
sion inevitably introduces a number of new
stressors.
Ward variables: environmental stress
With admission to a psychiatric ward, several
environmental stressors come into play. For
example, the patient may have to be locked up
for safety reasons and he or she will generally have
little privacy. On a crowded psychiatric ward, the
patient may be exposed to overstimulation (5, 6).
Furthermore, patients may be exposed to demand-
ing therapies, resulting in frustration, anger or
violence.

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 A model of aggression in psychiatric hospitals

Environmental stress Vicious circle

ward ward too crowded/
variables no privacy/no rest/
too demanding After the first outburst of aggression, a vicious
therapies/being
locked in circle may develop: as a reaction to violent
behaviour of the patient, environmental stressors
Psychopathology
Cognitive stress may have to be increased in order to guard the
misinterpretation of
patient
e.g.,
schizophrenia (involuntary)
ward activities: safety of all parties involved. The patient may have
“ they are locking Aggression
variables (with paranoid
delusions)
admission me up forever” to be secluded or may no longer be allowed to leave
“ they are poisoning
me with pills” the ward. These measures may affirm distorted
beliefs of the patient about being endangered on
Communication stress
treatment goals the ward, and may make him or her more afraid of
ward rules
inaccesibility of staff the ward team. The aggressive behaviour may also
interpersonal staff-
staff
variables patient problems elicit negative countertransference reactions in staff
members (e.g. anger, anxiety), creating additional
Fig. 1. A model of inpatient aggression (based on 4). communication problems. As a result of this
increase in environmental and communication
stressors, a repetitive pattern of violent behavior
Staff variables: communication stress (see Fig. 1), followed by the use of more restricting
Possibly, problematic communication between measures may emerge.
staff and patient contributes to aggression (7). To
prevent this, treatment goals and ward rules need References
to be explained carefully and repeatedly to psychi- 1. Friis S, Helldin L. The contribution made by the clinical
atric inpatients. Inaccessibility of the staff and the Fsetting to violence among psychiatric patients. Crim Behav
impossibility for patients to obtain information Ment Health 1994;4:341–352.
about their treatment may also elicit aggression (2). 2. Nijman HLI, Allertz WWF, Merckelbach HLGJ, à Campo
Inconsistency in limit setting may also act as a JMLG, Ravelli DP. Aggressive behaviour on an acute
psychiatric admissions ward. Eur J Psychiatry 1997;11:
communication stressor leading to aggression. 106–114.
3. Nijman HLI, à Campo JMLG. Situational determinants of
inpatient self-harm. Suicide Lifethreat Behav, in press.
Patient variables: cognitive distortions 4. Nijman HLI, à Campo JMLG, Ravelli DP, Merckelbach
In the centre of the model, at the patient variable HLGJ. A tentative model of aggression on inpatient
psychiatric wards. Psychiatr Serv 1999;50:832–834.
level, the perception of the situation plays a key 5. Krakowski M, Czobor P. Violence in psychiatric patients.
role in whether a patient will become aggressive or The role of psychosis, frontal lobe impairment, and ward
not. Under the influence of psychopathology, turmoil. Compr Psychiatry 1997;38:230–236.
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may fuel distorted cognitive interpretations of crowding and aggressive behavior on a psychiatric intensive
care unit. Hosp Commun Psychiatry 1991;42:1237–1240.
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tions are: ÔtheyÕre going to lock me up for ever’ or violence by psychiatric patients. Br J Clin Psychol 1996;35:
Ôthey are slowly poisoning me with pillsÕ. 11–20.

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