PubMed Health⌕ Search

Biomedical subjects

D E McNiel

Publications and source records attributed to D E McNiel.

At least 19 recordsLinked to original sources
PubMed2000

The relationship between command hallucinations and violence.

OBJECTIVE: The purpose of this study was to describe the relationship between command hallucinations and violent behavior. METHODS: One hundred and three psychiatric inpatients completed measures of command hallucinations, other psychotic symptoms, violent behavior, and social desirability response biases. RESULTS: Thirty percent of the patients reported having had command hallucinations to harm others during the last year, and 22 percent of the patients reported they complied with such commands. Logistic regression analyses suggested that patients who experienced command hallucinations to harm others were more than twice as likely to be violent, even when the analysis controlled for demographic variables, history of substance abuse, and social desirability response biases. CONCLUSIONS: The results support the clinical utility of asking about command hallucinations when assessing the risk of violence in patients with major mental disorders.

Adolescent↗
PubMed2000

The relationship between patients' gender and violence leading to staff injuries.

OBJECTIVE: Although recent research has found similar rates of violence by female and male patients who have serious mental disorders, it is less clear whether violence by female patients is as likely to result in injury as violence by male patients. This study examined the relationship between violent patients' gender and injury to staff members on an inpatient unit. METHODS: All injuries to staff caused by violent behavior by patients on a locked university-based short-term inpatient unit were identified in a search of institutional records from October 1988 to June 1999. We reviewed the medical charts of the 76 patients who injured staff members to compare their demographic and clinical characteristics with those of 314 patients hospitalized during the same period who did not injure staff. RESULTS: Nearly half of the injuries (45 percent) were caused by female patients. Moreover, the proportion of injuries caused by female and male patients was similar to the proportion of females and males in the comparison group. Multivariate logistic regression analysis showed that patients' gender was not associated with injury to staff, even when the analyses controlled for other correlates of violence such as history of violence, violent thought content expressed in the admission mental status examination, and history of noncompliance with medication. CONCLUSIONS: The findings suggest that injuries to staff members on a unit treating both men and women are as likely to be caused by violence by female patients as by male patients. When a female patient exhibits signs of an elevated risk of violence, the significance of that risk should not be discounted on the basis of her gender.

Female↗
PubMed2000

Relevance of interrater agreement to violence risk assessment.

This study considered whether assessments of violence risk in which 2 clinicians reach similar conclusions are more accurate than the conclusions of either clinician alone when their assessments disagree. One hundred ten physicians and 44 nurses estimated the probability of physical assault of 478 patients admitted to a short-term locked psychiatric inpatient unit. The level of assessed risk showed a substantial correspondence with the likelihood of later violence when the physician and nurse ratings were highly concordant. As the extent of agreement between the physician and nurse ratings decreased, the strength of the association between the risk assessments and the occurrence of violence decreased accordingly.

Adolescent↗
PubMed1998

The relationship between confidence and accuracy in clinical assessment of psychiatric patients' potential for violence.

The authors studied the relationship between confidence and accuracy in clinical assessments of psychiatric patients' short-term risk of violence. At the time of entry to the hospital, physicians (N = 78) estimated the probability that each of 317 patients would physically attack other people during the first week of psychiatric hospitalization. The clinicians also indicated the degree of confidence they had in their estimates of violence potential. Nurses rated the occurrence of inpatient physical assaults with the Overt Aggression Scale. The results showed that when clinicians had a high degree of confidence, their evaluations of risk of violence were strongly associated with whether or not patients became violent. At moderate levels of confidence, clinicians' risk estimates had a lower, but still substantial relationship with the later occurrence of violence. However, when clinicians had low confidence, their assessments of potential for violence had little relationship to whether or not the patients became violent. The findings suggest that the level of confidence that clinicians have in their evaluations is an important moderator of the predictive validity of their assessments of patients' potential for violence.

Attitude of Health Personnel↗
PubMed1998

Management of threats of violence under California's duty-to-protect statute.

OBJECTIVE: This is the first study to assess clinical practices under one of the new duty-to-protect statutes, some version of which has been passed in many states. In 1985, California enacted a statute enabling psychotherapists to limit their liability when a patient makes a serious threat of violence by 1) making reasonable efforts to warn the victim of the threat and 2) notifying local police. METHOD: The authors examined all duty-to-protect notifications over a 5-year period in San Francisco by reviewing police and court records. RESULTS: Police received only 337 notifications, typically made by nondoctoral staff members at public facilities such as psychiatric hospitals and crisis clinics. Patients most commonly directed their threats toward family members. Of the patients who made threats resulting in notifications, 51% had prior arrest records, and 14% had subsequent arrests. Only 52% of the patients who made threats were civilly committed. CONCLUSIONS: The findings suggest that 1) clinicians rarely discharge the duty to protect in the manner specified by the law, 2) many patients whose threats result in notifications have extensive involvement with the criminal justice system, and 3) family intervention may have clinical relevance in many duty-to-protect situations.

Adolescent↗
PubMed1998

Characteristics of psychiatric inpatients who stalk, threaten, or harass hospital staff after discharge.

OBJECTIVE: The purpose of this study was to identify demographic and clinical characteristics of psychiatric inpatients who stalk, threaten, or harass hospital staff after discharge. METHOD: The authors retrospectively summarized the demographic and clinical characteristics of 17 inpatients who engaged in this type of behavior and a comparison group of 326 inpatients. RESULTS: The patients who stalked, threatened, or harassed staff after discharge were significantly more likely than the comparison patients to have a diagnosis of personality disorder and/or paranoid disorder, erotomanic subtype, and to have a history of physically assaultive or fear-inducing behavior. The data suggest that they were more likely to be male and never married and to have histories of multiple hospitalizations, suicidal or self-injurious behavior, and substance abuse or dependence. CONCLUSIONS: The findings reveal several risk factors that may be useful in identifying a subgroup of patients who pose a risk of directing aggressive behavior toward hospital staff after discharge.

Adult↗
PubMed1998

A naturalistic study of clinical use of risperidone.

Follow-up data on 97 of the 101 patients at a university-based psychiatric hospital for whom risperidone had been prescribed between February 1994, when the medication was introduced, and October 1996 were reviewed an average of 102 weeks after the start of the medication. Only 28.9 percent of the patients were still on risperidone at follow-up. Patients who were maintained on risperidone were able to tolerate a higher dose with fewer side effects. The most common reasons for discontinuation were failure to achieve a therapeutic effect, noncompliance, and adverse side effects. The findings of this naturalistic study represent a cautionary consideration for the remarkable enthusiasm that surrounded the introduction of risperidone.

Adult↗
PubMed1997

Utility of the initial therapeutic alliance in evaluating psychiatric patients' risk of violence.

OBJECTIVE: Evaluation of patients' potential for violence is an important component of care in psychiatric emergency and inpatient settings. Although situational variables are widely acknowledged to influence the risk of violence by psychiatric patients, most past research has been limited to patient attributes and has neglected the interpersonal context in which violence occurs. To the authors' knowledge, this is the first study to assess a new type of situational risk factor, the quality of the initial therapeutic alliance between the therapist and patient, as a predictor of the risk of violent behavior during short-term hospitalization. METHOD: The admitting physician's written initial evaluation for each of 328 patients hospitalized on a locked inpatient unit was reviewed by using a standardized alliance scale. The checklist measures the patient's level of active collaboration with the treatment process. Acute symptoms were rated at admission by physicians using the Brief Psychiatric Rating Scale. Nurses rated aggressive behavior in the hospital with the Overt Aggression Scale. RESULTS: Patients who had a poorer therapeutic alliance at the time of admission were significantly more likely to display violent behavior during hospitalization. Logistic regression analysis showed that the quality of the initial therapeutic alliance remained a strong predictor of violence even when other clinical and demographic correlates of violence were considered concurrently. CONCLUSIONS: The results suggest a new class of situational, interactional variable--reflected in the quality of the therapeutic relationship--that may be useful in evaluating patients' potential for violence. Implications for risk management are discussed.

Adolescent↗
PubMed1997

The impact of hospitalization on clinical assessments of suicide risk.

OBJECTIVE: Clinicians' assessments of patients' suicide risk at admission to and discharge from a psychiatric hospital were examined to learn how clinical estimates of risk changed over the course of hospitalization and to identify which demographic and clinical characteristics were associated with higher estimates of risk at admission and discharge. METHODS: Seventy-one treating physicians evaluated risk of self-harm of 241 patients at admission to and discharge from a short-term inpatient unit. Risk within the next week (short-term risk) and within the next year (long-term risk) was estimated. At discharge and admission, the physicians also rated patients' symptoms using the Brief Psychiatric Rating Scale. Nurses rated self-directed aggression during hospitalization with the Overt Aggression Scale. RESULTS: Ratings of short-term risk were lower at discharge than at admission, whereas ratings of long-term risk showed relatively little change. At both discharge and admission, the estimated risk of self-harm was associated with a history of suicidal behavior and with acute symptoms, such as depression, anxiety, and emotional withdrawal. At discharge, the estimated risk was also associated with substance abuse, severity of psychosocial stressors, and living alone. CONCLUSIONS: Clinicians appeared to view their hospital-based interventions as influencing variables relevant to short-term risk of suicide but as having little impact on long-term risk. Implications are discussed for management of suicide risk and for medicolegal assertions regarding prevailing community practices that are made in litigation alleging negligent release of patients from hospitals.

Adolescent↗
PubMed1996

Application of the Tarasoff ruling and its effect on the victim and the therapeutic relationship.

OBJECTIVE: The Tarasoff case and subsequent court decisions and legislation in many jurisdictions established a duty to protect the intended victims of patients who pose a serious threat of violence. An approach that has been legally sanctioned is to warn the intended victim. This study examined the effects of such warnings on the warned persons and on the therapeutic relationship. METHODS: All second-, third-, and fourth-year psychiatric residents (N = 46) in a university-based psychiatric residency program in San Francisco were interviewed about their experiences related to issuing Tarasoff warnings. RESULTS: Almost half of the residents (N = 22) reported having issued a Tarasoff warning. Most warnings were issued for patients seen in inpatient units and emergency rooms. In almost half of the cases, the resident was unable to contact the intended victim but did report the threat to a law enforcement agency. In almost three-fourths of the cases in which the intended victim was contacted, the individual already knew of the threat. The most common reaction among those warned was anxiety mixed with thankfulness; most expressed an intent to modify their behavior to increase safety. The second most common reaction was denial that the patient would ever hurt them. Clinicians reported that in most cases issuing the warning had a minimal or a positive effect on the psychotherapeutic relationship. CONCLUSIONS: Many of the anticipated negative effects of the Tarasoff decision have not materialized.

Adolescent↗
PubMed1996

Is adaptive coping possible for adult survivors of childhood sexual abuse?

Thirty adult women survivors of childhood sexual abuse who believed they were functioning well were selected through advertisements in local newspapers and presentations at an incest-survivor support group. Subjects were assessed by a battery of structured diagnostic interviews and standardized psychological measures, including the MMPI, the Trauma Symptom Checklist-40, and the Dissociative Experiences Scale. The results showed the existence of a subgroup of survivors of childhood sexual abuse who do not have devastating long-term psychological effects. Better adult psychological functioning was predicted by certain characteristics of the abuse, the family system, and the survivors.

Adaptation, Psychological↗
PubMed1996

Impact of a smoking ban on a locked psychiatric unit.

BACKGROUND: This study prospectively evaluated the impact of a complete smoking ban on a locked psychiatric unit. METHOD: The setting was a 16-bed inpatient unit with 83% (134/162) involuntary patients, no off-unit smoking area, no possibility of granting smoking passes, and a mean length of stay of 2 weeks. The effect of a complete smoking ban was measured by surveys of both staff and patients before and after the ban. In addition, objective indicators of ward disruption were measured, including rates of aggression, use of p.r.n. medications, need for seclusion and restraints, elopement, and discharges against medical advice. RESULTS: Although staff initially expressed concern about the ban's potential negative impact, after it began, t tests revealed that staff were significantly (p < .05) less concerned about patients' needing more medication, becoming restless, being too fragile to cope with withdrawal, leaving the unit against medical advice, or trying to elope. Staff were significantly (p < .02) more positive about the ban than were patients. Although patients, overall, had negative views toward the new policy, their opinions were somewhat less negative after its implementation. Rates of assaultive behavior, use of seclusion and restraints, use of p.r.n. medication, and against-medical-advice or elopement discharges did not change after the ban was in effect. When polled, 78% (40/51) of the staff voted to keep the ban. CONCLUSION: This study found that staff anticipated negative consequences to a total smoking ban; however, their attitudes changed after it began. The ban had no significant impact on the ward milieu, and although patients were not in favor of it, they felt less negative over time.

Adult↗
PubMed1995

Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence.

OBJECTIVE: The authors evaluated characteristics of patients whom clinicians accurately assessed as being at high or low risk for violence and patients for whom clinicians overestimated or underestimated the risk. METHOD: At admission, physicians estimated the probability that each of 226 psychiatric inpatients would physically attack someone during the first week of hospitalization. Nurses rated assaultive behavior in the hospital with the Overt Aggression Scale. Acute symptoms were rated with the Brief Psychiatric Rating Scale. RESULTS: For the group as a whole, assessed levels of risk were substantially related to later physical aggression (sensitivity = 67%, specificity = 69%). Multinomial logit analysis showed that patients with psychotic disorders such as schizophrenia, organic psychotic conditions, and mania were more likely to be accurately assessed by clinicians as being at high risk (true positives) than to be true negatives or false positives. A recent history of violence was associated with higher estimated risk but did not distinguish true positives from false positives. An admission mental status characterized by low levels of hostility, uncooperativeness, and suspiciousness and high levels of depression, guilt, and anxiety differentiated true negative patients from others, but symptom profiles did not differ among true positives, false positives, and false negatives. Clinical judgments emphasizing gender and race/ethnicity were associated with predictive errors: nonwhite and male patients tended to be false positives. CONCLUSIONS: While clinicians can accurately classify the potential for violence in the majority of patients at admission, systematic errors characterize inaccurate assessments of the risk. Awareness of these patterns may help improve assessment of the risk of violence in clinical practice.

Adult↗
PubMed1994

The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence.

OBJECTIVE: Previous research on violence and mental disorder has typically focused on the relationship between diagnosis and risk of violence or between symptoms within a particular diagnostic category and risk of violence. The authors' goal was to evaluate whether the pattern of symptoms associated with short-term risk of violence varies depending on patients' diagnoses. METHODS: Subjects were 330 patients with a variety of diagnoses who were hospitalized on a university-based, locked psychiatric inpatient unit. At hospital admission, physicians rated patients' symptoms using the Brief Psychiatric Rating Scale. Nurses rated whether patients became violent during hospitalization by completing the Overt Aggression Scale at the end of each shift. RESULTS: Assaultive patients had different symptom patterns than nonassaultive patients. Symptoms patterns varied significantly across diagnostic groups, and the symptom patterns associated with violence also varied significantly across diagnostic groups. Higher levels of hostile-suspiciousness, agitation-excitement, and thinking disturbance were generally associated with violence, although these symptoms were less predictive of assaultiveness among schizophrenic patients than among patients in other diagnostic groups. CONCLUSIONS: Symptom profiles represent a useful level of analysis for understanding the relationship between violence and psychopathology. However, the value of particular symptom profiles as indicators of imminent violence varies with diagnosis.

Acute Disease↗
PubMed1994

Staff gender and risk of assault on doctors and nurses.

Clinical staff on acute psychiatric inpatient units often are asked to provide care for potentially violent patients. Documentation of which staff are at greatest risk of being assaulted is a necessary step in developing interventions to reduce that risk. The present study evaluated the relationship between staff gender and the risk of becoming a victim of assault while taking into account the professional discipline of the staff victims. The sample included all medical staff (n = 120) and nursing staff (n = 83) who worked on a short-term psychiatric unit between August 1988 and May 1991. Seventy-two percent of the medical and nursing staff were female and 28 percent were male. Five hundred ten assaults were directed toward medical and nursing staff during the study period. Staff gender was not significantly associated with the risk of being a victim of violence for the staff as a whole, the doctors, or the nurses. Staff discipline, however, was strongly associated with risk of assault. Nurses as a group were significantly more likely to be assaulted than were doctors. The findings suggest that violent behavior is a significant occupational hazard on acute inpatient units, and that the role relationship with the patient is more important than the gender of the clinician as a predictor of who is most likely to be assaulted. The authors discuss the implications of the findings for administrative decisions regarding staffing.

Analysis of Variance↗
PubMed1994

Patterns of recall of childhood sexual abuse as described by adult survivors.

Issues concerning the phenomenon of delayed recall of childhood trauma have arisen in forensic settings. For example, the courts have had to address the issue of delayed recall because of legislation extending the statute of limitations for bringing lawsuits related to childhood sexual abuse. Many states now allow victims to bring suit for up to three years after their memory returns. This paper describes patterns of recall of childhood sexual abuse as recounted by 30 adult women survivors in a nonforensic setting. Eleven of the women described remembering their childhood sexual abuse after a period of amnesia. Examples are given of the types of circumstances that were associated with the delayed recall of the abuse. Implications for assessment in clinical and forensic settings are discussed.

Adult↗