Aggression in hospitalized criminal offenders with mental illness and personality disorders: A psychoanalytic retrospective longitudinal study

This study examined assaults by patients of a forensic psychiatric hospital against other patients and staff across an eight-year period. In this study, assault was defined as an attempt to cause physical injury to another person. Axis I diagnosis, comorbid personality disorder, and commitment status were shown to be related to inpatient aggression. However, the specific groups identified as more aggressive in this study differed from the groups suggested by previous studies. Axis I disorders did not show a strong and consistent relationship to aggression as Axis II disorders did. Axis I psychotic disorders were associated with fewer assaults, while any comorbid personality disorder was associated with more assaults. Some combinations of commitment status with specific diagnoses were noted to have a particularly high frequency of assaults. Patients with antisocial (APD) and borderline personality disorders (BPD) had the highest assault frequency. Commitment statuses with limited consequence for aggression and without the goal of hospital release were strongly associated with aggression. This suggested that assaults were generally volitional, motivated by needs of the personality and legal circumstance. The characteristics of these disorders are similar to those traits described in psychoanalytic theory that precipitate violence. The intrapsychic difficulties theorized to be present in aggressors (weak ego, sadistic relationship style and guilt) are present in APD and BPD. This study proposed an empirical approach to protecting the safety of the patients and staff at forensic inpatient facilities by integrating research findings to improve the quality of assessment of assault risk in patients.