This is Part 1 of a three-part lecture series on managing aggression.

1. VIOLENCE,
AGGRESSION &
MENTAL ILLNESS
Dr Tuti Iryani Mohd Daud
Senior Lecturer &
Consultant Psychiatrist,
National University of
Malaysia Medical Centre.

2. Part 1:
Violence, aggression and mental illness
Part 2:
De-escalation technique
Part 3:
Seclusion and restraints
MANAGING AGGRESSION
(Video series)

3. BY THE END OF THIS LECTURE,
YOU WILL BE ABLE TO:
Discuss the relationship between aggression,
violence & mental illness
(problems with media reporting)
Identify risk factors contributing to aggression
Describe the neurobiology of aggression & violence
Describe cycle of assault

4. Aggression vs Violence

5. Aggression:
“as behavior directed toward
another individual carried out
with the proximate (immediate)
intent to cause harm.
Furthermore, the perpetrator
must believe that the behavior
will harm the target, and that the
target is motivated to avoid the
behavior. Actual harm is not
required. “ (Anderson and Huesmann, 2007)
Violence:
“The intentional use of physical
force or power, threatened or
actual, against oneself, another
person, or against a group or
community, that either results in
or has a high likelihood of
resulting in injury, death,
psychological harm,
maldevelopment or
deprivation.“ (WHO, 2002)
“extreme form
of aggression,
such as assault,
rape or murder.”
(American Psychological
Association)
Violence
Aggression
References:
Anderson, C. A. and L. R. Huesmann (2007). Human aggression: A social-cognitive view. The Sage Handbook of Social Psychology, Revised Edition. M. A. Hogg and J. Cooper.
London, Sage Publications: 296-323.
World Health Organization (2002). World report on violence and health: summary. Geneva, World Health Organization.

6. Are the mentally ill
violent?

7. Violence
General population
Violence and aggression in the community
(Rueve & Welton, 2008)
Reference:
Asnis GM, Kaplan ML, Hundorfean G, Saeed W. Violence and
homicidal behaviors in psychiatric disorders. Psych Clin N Am.
1997;20: 405–425.
Rueve, M. E. and R. S. Welton (2008). "Violence and Mental Illness."
Psychiatry (Edgmont) 5(5): 34-48.
Mentally ill
3.7% among
general US population
4% among
outpatient
(in an urban setting)
(Asnis et al, 1997)

8. Mentally ill
Violence and aggression in the community
individuals with major
mental disorder
who did not abuse
substances
individuals without
mental disorder
who did not abuse
substances
=
}
Substance abuse
(risk of violence increases by 2 fold)
References:
Monahan J, Steadman HJ, Silver E et al. Risk
assessment: the MacArthur Study of Mental
Disorder and Violence. Oxford: Oxford
University Press, 2001.
Steadman HJ, Mulvy EP, Monahan J et al. Violence
by people discharged from acute
psychiatric inpatient facilities and by others
in the same neighbourhoods. Arch Gen
Psychiatry 1998;55:393-404.
Prospective study (Steadman et al, 1998)
18% - major mental illness
31% - major mental illness + comorbid substance use
43% - major mental illness + comorbid substance use +
personality disorder

9. RISK FACTORS FOR
VIOLENCE
Static
(patient characteristics that cannot be changed with clinical intervention)
• Prior history of violence
• male sex
• younger adult age
• lower intelligence
• history of head trauma or
neurological impairment
• dissociative states
• history of military service
• weapons training
• diagnoses of major mental illnesses
• dysfunctional family of origin and a
history of abuse as a child.
Dynamic
(variables in a patient’s presentation that can potentially be improved with clinical
intervention)
• substance abuse
• persecutory delusions
• command hallucinations,
nonadherence with treatment,
impulsivity
• low Global Assessment of Functioning
(GAF) score
• homicidality,
• depression,
• hopelessness,
• suicidality,
• feasibility of homicidal plan,
• access to weapons,
• recent move of a weapon out of
storage.
Rueve, M. E. and R. S. Welton (2008). "Violence and Mental Illness." Psychiatry (Edgmont) 5(5): 34-48.

10. 1. Majority of people with mental illness are not violent.
• The major determinants: young, male, and of lower socio-economic status.
2. General public magnify the relationship between major mental
disorders and violence
• It is far more likely that people with a serious mental illness will be the victim of violence.
3. Substance abuse appears to be a major determinant of violence.
• a third of self-reported violent acts
• 7 out of every 10 crimes of violence among mentally disordered offenders.
4. Research in the past had focussed on the person with the mental
illness.
• need emphasis on the triggers
Stuart, H. (2003). "Violence and mental illness: an overview."
World Psychiatry 2(2): 121-124.
VIOLENCE & MENTAL
ILLNESS

11. Source:
https://www.time-to-change.org.uk/sites/
default/files/film-report-screening-
madness-time-to-change.pdf
DEPICTION
OF
MENTAL
ILLNESS
IN THE MEDIA

12. Source:
https://www.time-to-change.org.uk/sites/default/files/film-report-screening-madness-time-to-change.pdf

13. Negative media
coverage
Negative attitude
towards mental illness
Reference:
McKeown, M. and B. Clancy (1995). "Media influence on societal perceptions of mental illness." MENTAL HEALTH NURSING-LONDON-COMMUNITY
PSYCHIATRIC NURSES ASSOCIATION 15: 10-10.
Fules
Response to

14. https://youtu.be/buCU6eP9iVA

15. Neurobiology of
aggression and
violence

16. From: Neurobiology of Aggression and Violence
American Journal of Psychiatry
Figure 1. Susceptibility to Aggression and Psychiatric Diagnosis
Copyright © American Psychiatric Association.
All rights reserved.
Date of download:
09/19/2015
Reference: Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.

17. From: Neurobiology of Aggression and Violence
American Journal of Psychiatry
Figure 2. Initiation and Modulation of Aggression
a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third
Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure
appeared in Davidson et al., Science 2000; 289:591.
Copyright © American Psychiatric Association.
All rights reserved.
Date of download:
09/19/2015
Reference:
Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.

18. From: Neurobiology of Aggression and Violence
American Journal of Psychiatry
Figure 4. Pretreatment Abnormalities in the Pathophysiology of Aggression
a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third
Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure
appeared in Davidson et al., Science 2000; 289:591.
Copyright © American Psychiatric Association.
All rights reserved.
Date of download:
09/19/2015
Reference:
Siever, L. J. (2008). "Neurobiology of aggression and violence." Am J Psychiatry 165(4): 429-442.

19. Cycle of assault

20. Trigger
Escalation
phase
Crisis
phase
Recovery
phase
Post-crisis
depression
phase
CYCLE OF ASSAULT
(Kaplan & Wheeler,1983)
Perceived as
serious threat
body and mind
prepare for a fight.
Violent act
body and mind relaxes
fatigue,
depression, and
guilt.
Source: http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf

21. Trigger
Escalation
phase
Crisis
phase
Recovery
phase
Post-crisis
depression
phase
CYCLE OF ASSAULT
(Kaplan & Wheeler,1983)
Perceived as
serious threat
body and mind
prepare for a fight.
Violent
act
body and mind
relaxes
fatigue,
depression, and
guilt.
Source: http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf
De-escalation
technique
Seclusion & restraints
Breakaway technique
Observation
Communication
Counselling
Negotiation and
observation

22. SUMMARY
• Majority of people with mental illness are not
violent
• Among those with mental illness, only a small
proportion are at higher risk of violence:
• i.e. comorbid substance use, comorbid personality disorder, poor
illness control
• To understand the principles of managing
aggression, it is useful to understand the:
• Neurobiology
• cycle of assault

23. This work by Dr. Tuti Mohd Daud is licensed under a
Creative Commons Attribution-NonCommercial-
NoDerivatives 4.0 International License.

24. This work by Dr. Tuti Mohd Daud is licensed under a Creative
Commons Attribution-NonCommercial-NoDerivatives 4.0
International License.