社區精神分裂症病患攻擊行為的追蹤研究

社區精神分裂症病患攻擊行為的追蹤研究

中 華 民 國 93 年 2 月 3 日

Preparation of NSC Project Reports 計畫編號：NSC91－2314－B－002－328 執行期間：91 年 8 月至 92 年 10 月 主持人：陳杏佳講師/台灣大學醫學院護理系 共同主持人：胡海國教授/台灣大學醫學院醫學系 I.摘要 中文摘要 精神病患的潛在性攻擊問題，是精神醫療照護的重要課題，亦是社區復健的關 鍵議題。本研究以某教學醫院急性短期住過院的精神分裂症病患為對象，針對病患 攻擊行為的發生情形，進行個案系列的出院追蹤，採回溯性研究設計，由病患與病 患家屬的資料來源，以自填為主，訪談為輔的方式進行資料收集，以 SPSS 統計軟 體分析資料，瞭解出院達一年的精神分裂症病患最近這一個月和這一年攻擊行為發 生的頻率與類型，以及病患人口學背景、精神症狀、與家庭生活情境主觀限制感等 預測因子。 關鍵字：攻擊行為，預測因子，出院精神分裂症病患 English Abstract:

The aggressive behavior of psychiatric patients is an important issue in the area of psychiatric care and community rehabilitation. Schizophrenic discharged patients were followed up as the study targets from a psychiatric short-term acute ward of a teaching hospital. In the retrospective design of this study, data came from patients and their family. Self-reporting were used as primary method and interviewing was supported to collect data.

Using SPSS statistic program, data was analyzed to understand the frequency and type of patients’ recent one-month and one-year aggressive behaviors who were discharged from the hospital for at least one year, and the predictors of patients’ aggressive behavior. The predictors include patients’ demographic data, psychotic symptoms, and subjective feelings for situational limits of daily life in the patients’ family.

II. Background and Purposes

The aggressive acts have two elements: intention to harm and acting out. The types of aggressive acts could be verbal, nonverbal or physical, and the targets could be self, other persons or property (Freedman, Kaplan, & Sadock, 1972). The aggressive measurement issues usually include (1) the overuse of indirect measures of violence, such as incident reports and arrest rates, and (2) the lack of psychometric testing of direct violence measures (Morrison, 1988). The way of criterion measures was suggested (Barrat, 1998). Therefore, aggressive acts were better measured with an objective rating scale and a sensitive scale format, which allowed for increase reliability testing (Morrison, 1993).

In psychiatric population, psychiatric diagnosis was related to the styles and prevalence of aggressive behaviors (Krakowski et al. 1986; McNiel & Binder, 1994). There is a moderate but significant association between schizophrenia and violence (Angermeyer, 2000). To compare to other diagnostic categories, most violent patients had a diagnosis of Schizophrenia (Grassi et al., 2001; Saverimuttu, Lowe, 2000; Tam, Engelsmann, Fugere, 1996), though compared with the risk of violence associated with substance abuse and personality disorders the occurrence of violence is small. In addition, the proportion of violent crimes committed by people suffering from a severe mental disorder is small (Angermeyer, 2000).

Among the attribution factors, diseases or symptoms: severity of mental illness (Ruesch, Miserez, Hell, 2003), and/or delusional syndromes (55.1%) or with a personality disorder (Saverimuttu, Lowe, 2000) were important, which were related to aggressive psychological and pathological factors (Link & Stueve 1994; McNiel & Binder, 1994); interaction with outside environment: time of admission (Chen, 1997), environmental factors (ratio of patients and nurses & the density of ward), medical staff’s interactive characteristics (2001 ), and social context (Morrison, 1993).

Personal behavior interacts with his or her intrapersonal, interpersonal, and

environmental factors. The patients with psychosis need high support ward atmosphere or low level of staff control to intermediate anger and aggression level, as opposed to non-psychotic patients (Friis, 1986). Under the protection basis, staff kept routine interview, observation and dispensing medication. That may intrude patients’ personal space. And, the emphasis on psychiatric ward is to socialize and to participate in activities to appease patients’ frequent social withdrawal syndrome. But, this syndrome maybe used as a strategy to cope with crowed condition and patient may perceive as a limitation or force, and then stress increases and violence may ensure (Kumar & Ng, 2001). In the empirical study, Morrison (1992) reported this kind of coercive interaction was highly correlated to psychotic patients’ aggressive behaviors. When patients were discharged from hospital and back to home, their social interactive environment was changed with family.

difference from the predictors.

III. Result and Discussion

A total of the targets were 110 psychiatric inpatients with the psychiatric diagnoses of Schizophrenic spectrum (SCZs) based on DSMIV and confirmed by psychiatrists. 166 adult psychiatric inpatients (>16yrs) randomly admitted to the acute psychiatric ward during the period of ten months (April 1, 2002 to January 31, 2003) with the primarily psychiatric

diagnoses of SCZs were included as the initial participants. During their hospitalization, 24 of their psychiatric diagnoses were confirmed and changed to Non-SCZs. The exclusive rate was 14.5% (=24/166). There were other 18 patients whose primary psychiatric diagnoses of Non-SCZs were changed to SCZs during their hospitalization. 160 patients possibly could be our total participants. But, the number must be deducted for below empirical conditions. First, the refuse rate caused by patients and their family totally refused to participate was

3.8%(=6/160). Second, the natural loss rate caused by patients’ primary diagnoses was Non-SCZs but confirmed to SCZs and at that time their longitudinal data could not be

collected was 4.4% (=7/160). And, the personal loss rate caused by the data collector who did not continuously measure patients’ longitudinal data was 23.1% (=37/160).

The result of the following up showed that the characteristics of the patients and their family as below: Patients most were male, age range 25 to 60 years. Psychiatric diagnosis was most with schizophrenia and paranoid type. The further demographical data included: mean of total education was about 12 years and most of their highest education was senior high school, range of junior high school level to university level; marital condition most was single;

religion most was eastern (Folklore and Buddhism); and most of them were without occupation. Their family most was patient’s parent, especially the patient’s mother. Their highest education was elementary school, and the range was to senior high level. Their religion most was eastern (Folklore and Buddhism); and most of them were housekeepers.

To compare with patients’ psychiatric symptoms when they are admitted in the

psychiatric acute ward of the hospital, their conditions improved markedly when they were discharged, including positive, negative, and affective symptoms. The frequency of their aggressive behaviors was lower down much as well. During one-month period of time around the interviewing, few patients had made vague threats to harm property without having a plan of action, but the frequency is very low. During one-year period of time around the

interviewing, few patients damaged property or engaged in loud verbal arguments with others, which involved curses or insults, etc, but the frequency is also very low.

IV. Self evaluation

2. The result was a primary study to understand the characteristics of the aggressive behaviors and the predictors among discharged patients with schizophrenia. 3. The rate of case lost was high. This kind of the study needs to be supported by

multiple resources to proceed smoothly.

4. For constructing the model of discharged patients with schizophrenia, patients and their families need to be continuously followed up.

V. Reference 陳杏佳(1993)•護理人員對精神病患者的暴力風險評估與其常見護理問題的處 理自信•護理研究，1(4)，359-368。 陳杏佳(1995)•暴力行為的認知與展望•護理雜誌，42(1)，47-52。 陳杏佳(1997)•精神科急性病房病患的暴力行為研究•護理研究，5(2)，195-205。 黃瑞媛、陳杏佳*、林如玉、蕭淑貞(2000)•精神科暴力處置護理標準之設立• 護理雜誌，47(5)，47-54。 *表示為通訊作者

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