Understanding interpersonal hostile-dominance and its role in aggression occurring in hospital psychiatry services

Staff and patients of hospital psychiatry services are commonly confronted by the aggressive behaviour of patients. Such behaviour can result in numerous, and varied, adverse outcomes that ultimately reduce the quality of care that can be offered. Psychiatric services and mental health legislation place great emphasis on providing services within the least-restrictive environment; this means that prompt identification and treatment of patients at risk of aggression and violence is critical. Thus, elucidation of the personal features of patients that influence aggression is an important focus for empirical research. Moreover, it is essential that in explicating such features, the contextual nature of aggression occurring in hospital psychiatry services be considered. In this thesis, a number of personal features relevant to aggression in hospital psychiatry services are discussed. The main focus is on understanding interpersonal hostile-dominance (HD) and its relationship with aggression in hospital psychiatry services through the integration of two complementary theoretical models: the General Aggression Model (GAM) and Interpersonal Theory. The GAM is a comprehensive aggression theory, while Interpersonal Theory highlights the importance of relational functioning in understanding personality and interpersonal behaviour. Underpinning this dissertation are four distinct, yet related research aims: (1) To assess the influence of interpersonal and personality factors, GAM-specified cognitions and related affective states, and clinical factors on psychiatric inpatient aggression; (2) To delineate interpersonal HD in psychiatric inpatients; (3) To examine the stability of HD and its relationship with psychiatric symptoms and aggression over time; and (4) To explore whether HD mediates the relationship between childhood abuse and neglect and aggressive behaviour in psychiatric inpatients. For the empirical component of this research, 200 adult psychiatry inpatients were assessed using the Positive and Negative Syndrome Scale (PANSS), the State-Trait Anger Expression Inventory-2: Trait Anger scale (STAXI-2:TA), the Measures of Criminal Attitudes and Associates: Attitudes Towards Violence scale (MCAA:ATV), the Schedule of Imagined Violence (SIV), the Childhood Trauma Questionnaire (CTQ), the Psychopathy Check List: Screening Version (PCL:SV), the Impact Message Inventory-Circumplex (IMI-C), and the Overt Aggression Scale (OAS). Assessments took place within five days of their admission to the low-dependence environment. Forty-one participants were available at six months post-hospital discharge for follow-up assessment using the PANSS, IMI-C, and the Life History of Aggression Questionnaire: Aggression subscale (LHA:A). In relation to the first aim, results showed that HD, psychopathy, the tendency to rehearse aggressive scripts, positive attitudes towards violence, trait anger, and disorganised and excited symptoms predicted psychiatric inpatient aggression. However, only HD remained as a significant unique predictor in the hierarchical regression analysis, confirming the importance of HD in the prediction of psychiatric inpatient aggressive behaviour. In relation to the second aim, interpersonal, affective, and behavioural features of psychopathy, the tendency to rehearse aggressive scripts, and positive, negative, disorganised, and excited psychiatric symptoms remained as significant unique predictors of HD in a hierarchical regression model. This suggests that HD reflects a characteristic tendency towards interpersonal, affective, and behavioural problems marked by hostility and dominance, combined with a tendency toward frequent aggressive script rehearsal, and more severe psychopathology. In relation to the third aim, results showed that HD was stable over time, despite an overall reduction in psychiatric symptoms, and that HD was associated with greater symptom severity over time. Furthermore, it was found that elevated HD and greater severity of excited psychiatric symptoms in the community, along with more severe positive psychiatric symptoms in the hospital and in the community, were associated with aggressive behaviour occurring post-discharge. These findings implicate HD as a risk factor for more severe psychopathology, and highlight HD as a risk factor for post-discharge aggression. In relation to the final aim, childhood abuse and neglect experiences were commonly reported, with between 41% and 50.5% of participants reporting having experienced at least moderate severity of the different forms of childhood maltreatment. More severe emotional, physical, and sexual abuse, and physical neglect in childhood were associated with higher HD in adulthood. Higher levels of HD and all forms of childhood abuse and neglect were associated with aggression; HD mediated the relationship between childhood abuse and neglect, and aggression. These results indicate that childhood maltreatment contributes to interpersonal HD, which then influences aggressive behaviour. Together, these findings highlight the importance of HD and Interpersonal Theory to the problem of aggression in hospital psychiatric services. These results are also important to the GAM and suggest interpersonal style and Interpersonal Theory should have an important role in models that seek to account for interpersonal aggression and violence. Additionally, this body of research enhances conceptualisations of HD and reinforces the importance of understanding the developmental impact of childhood abuse and neglect experiences from an interpersonal perspective. By assessing interpersonal style on admission, patients with elevated levels of HD can be identified. HD can then be considered in subsequent treatment plans and aggression prevention strategies. Post-discharge assessments of HD would also be useful. Reductions in HD, and therefore aggression, might be achieved through a broad intervention that covers interpersonal and affective characteristics, emotional and behavioural regulation, cognitions and psychiatric symptoms, in an interpersonally informed framework.