817040

research-article2018
JIVXXX10.1177/0886260518817040Journal of Interpersonal ViolenceHuitema et al.

Original Research
Journal of Interpersonal Violence
1­–19
A Study Into the Severity © The Author(s) 2018
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DOI: 10.1177/0886260518817040
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Inpatient Aggression journals.sagepub.com/home/jiv

Anneloes Huitema,1 Nienke Verstegen,1

and Vivienne de Vogel1,2

Abstract
Aggressive incidents occur frequently in health care facilities, such as
psychiatric care and forensic psychiatric hospitals. Previous research
suggests that civil psychiatric inpatients may display more aggression than
forensic inpatients. However, there is a lack of research comparing these
groups on the incident severity, even though both frequency and severity
of aggression influence the impact on staff members. The purpose of this
study is to compare the frequency and severity of inpatient aggression
caused by forensic and civil psychiatric inpatients in the same Dutch
forensic psychiatric hospital. Data on aggressive incidents occurring
between January 1, 2014, and December 31, 2017, were gathered from
hospital files and analyzed using the Modified Overt Aggression Scale,
including sexual aggression (MOAS+). Multilevel random intercept models
were used to analyze differences between forensic and civil psychiatric
patients in severity of aggressive incidents. In all, 3,603 aggressive incidents
were recorded, caused by 344 different patients. Civil psychiatric patients
caused more aggressive incidents than forensic patients and female
patients caused more inpatient aggression compared with male patients.
Female forensic patients were found to cause the most severe incidents,
followed by female civil psychiatric patients. Male forensic patients caused

1De Forensische Zorgspecialisten, Utrecht, The Netherlands

2HU University of Applied Sciences Utrecht, The Netherlands

Corresponding Author:
Anneloes Huitema, De Waag Utrecht, De Forensische Zorgspecialisten, P.O. Box 1362, 3500
BJ Utrecht, The Netherlands.
Email: [email protected]
2 Journal of Interpersonal Violence 00(0)

the least severe incidents. The findings have important clinical implications,
such as corroborating the need for an intensive treatment program for
aggressive and disruptive civil psychiatric patients, as well as emphasizing
the importance of gender-responsive treatment.

Keywords
inpatient aggression, severity, forensic patients, civil commitment, gender

Aggressive incidents occur frequently in psychiatric hospitals, in general

psychiatric care as well as in forensic psychiatric hospitals. A review of 424
studies on inpatient aggression found that forensic patients have higher rates
of violence than general psychiatric patients, but these differences disap-
peared when controlling for the longer duration of forensic treatment (Bowers
et al., 2011). Taking the occupied bed days into account, the risk of experi-
encing aggression for staff members was found to be lower in forensic set-
tings than in general psychiatry. However, a meta-analysis on these studies
shows a very large variation in study outcomes (Bowers et al., 2011). This
heterogeneity is likely due to several factors, such as differences in settings
and countries, with different legislations and policies. For example, more
aggressive incidents occur on acute wards compared with other types of
wards (Bowers et al., 2011). As a result, it is difficult to compare different
studies across settings and countries on inpatient aggression.
It is important to compare forensic and civil psychiatric patients regarding
their aggressive behavior, as findings of previous research suggest that civil
psychiatric patients may resemble or even surpass forensic patients in the risk
these patients pose, both during and after their treatment. For example, rela-
tively high rates of inpatient aggression were found in both of these groups,
with a higher prevalence rate among the civil psychiatric patients (Verstegen,
De Vogel, De Vries Robbé, & Helmerhorst, 2017). A study following male
patients with schizophrenic disorders after discharge from a psychiatric hos-
pital found that civil psychiatric patients displayed more aggression toward
others in the community than forensic patients (Hodgins et al., 2007).
Information on the frequency and severity of aggressive incidents caused by
forensic and civil psychiatric patients is important for the implementation of
preventive measures and for acknowledgment of the staff members working
with these patients, as patient aggression places a considerable burden on the
psychiatric staff. The impact of aggression on staff members is dependent on
both the frequency and severity of aggression (Nijman, Bowers, Oud, &
Jansen, 2005). A systematic review of the impact of patient aggression found
Huitema et al. 3

that staff members commonly experience posttraumatic stress symptoms,

guilt, self-blame, and shame (Needham, Abderhalden, Halfens, Fischer, &
Dassen, 2005). Inpatient aggression has a negative impact on an organiza-
tional level as well. Absenteeism caused by aggressive incidents results in
greater costs for the organization. Furthermore, the risk of experiencing
aggression may lead to difficulties in the recruitment of new staff, as well as
in retaining current employees (Jackson, Clare, & Mannix, 2002).

Types of Aggression
Research on aggression has been impeded by a myriad of definitions of
aggression, which has resulted in considerable differences between studies
regarding what types of behavior are considered aggressive. In the past, many
studies focused exclusively on physical aggression. Self-harm is often stud-
ied separately from aggression directed to others or objects, but there are
good reasons to include self-harm in the definition of aggression. It involves
the intentional infliction of physical harm toward oneself and can cause psy-
chological harm to others who are confronted with these behaviors. Therefore,
following the definition proposed by Rippon (2000), the current study
includes verbal aggression, aggression toward objects, self-harm, physical
aggression, and sexual aggression, which was carried out with the intent to
harm or with indifference regarding whether harm would occur.

Severity
While many researchers have studied factors relating to the occurrence of
inpatient aggression, studies focusing on the severity of aggression are rather
scarce. The studies that do include severity often lack depth in their opera-
tionalization of the construct. For example, some studies consider different
types of aggression as a way to distinguish severe and less severe incidents.
These studies define severe aggressive incidents as incidents involving phys-
ical aggression to others (Daffern, Howells, Ogloff, & Lee, 2005) and/or
sexual aggression (Nicholls, Brink, Greaves, Lussier, & Verdun-Jones, 2009)
and consider all other forms of aggression to be less severe. However, this
approach underestimates the severity of other types of aggression. Verbal
aggression can seriously affect the staff member’s psychological well-being
and can even lead to the development of posttraumatic stress disorder (Inoue,
Tsukano, Muraoka, Kaneko, & Okamura, 2006). Other studies focus on staff
injuries to gauge the severity of the incident (Bader, Evans, & Welsh, 2014),
even though this limits the severity measure to a small minority of incidents
(Nicholls et al., 2009).
4 Journal of Interpersonal Violence 00(0)

There are several instruments available that include a numerical severity

measure, such as the Overt Aggression Scale (OAS; Silver & Yudofsky, 1987),
the Staff Observation Aggression Scale–Revised (SOAS-R; Nijman et al.,
1999), and the Modified Overt Aggression Scale (MOAS; Kay, Wolkenfeld, &
Murrill, 1988). All these scales include the same types of aggression, but differ
in the way the severity score is calculated. For example, Abderhalden and col-
leagues (2007) used the SOAS-R to distinguish severe (scores 9-22) and less
severe incidents (score ≤8) and included severity in a logistic regression
model. Over half of the incidents (52.1%) were coded as severe.

Gender Differences in Aggression

There are several patient characteristics that may influence the relationship
between legal status and inpatient aggression (Linhorst & Scott, 2004).
Patient sex is one of these characteristics. In the general population, it is a
robust finding that men display more aggressive behavior than women (e.g.,
Bettencourt & Miller, 1996). However, aggressive incidents in psychiatric
hospitals often involve female aggressors. In some studies, female and male
forensic and civil psychiatric inpatients are found to be equally likely to dis-
play physical aggression (Daffern et al., 2005; Nicholls et al., 2009). There is
also research suggesting that female inpatients exhibit more aggression com-
pared with their male counterparts (Broderick, Azizian, Kornbluh, &
Warburton, 2015; Verstegen et al., 2017). There may be an interaction effect
between gender and patient population, as a meta-analysis found that among
forensic patients, women are more likely to engage in aggression, whereas in
non-forensic wards, male patients are more likely to cause aggressive inci-
dents (Dack, Ross, Papadopoulos, Stewart, & Bowers, 2013).
In addition to differences in the frequency of aggressive behaviors, there
may also be gender differences in the severity of the aggression. No gender
differences were found in the likelihood of aggressive incidents resulting in
injury to others, neither among civil psychiatric inpatients (Lam, McNiel, &
Binder, 2000) nor among forensic inpatients (Nicholls et al., 2009). A study
among acute civil psychiatric patients found that aggressive incidents caused
by female patients had higher SOAS-R severity scores (Grassi, Peron,
Marangoni, Zanchi, & Vanni, 2001).

Psychopathology of the Aggressor

Psychopathology may influence the occurrence of aggressive behavior.
Psychotic disorders are associated with a higher prevalence of aggression in
psychiatric wards than other disorders (Cornaggia, Beghi, Pavone, & Barale,
2011). A higher prevalence of positive symptoms, such as hallucinations and
Huitema et al. 5

delusions, increases the rate of aggression among psychotic patients (Witt,

Van Dorn, & Fazel, 2013). Furthermore, patients with a diagnosis of schizo-
phrenia were found to cause aggressive incidents with higher severity scores
on the SOAS-R (Abderhalden et al., 2007; Grassi et al., 2001).

Research Questions
This study compares the aggressive behavior exhibited by forensic and civil
psychiatric inpatients who are treated in the same Dutch forensic hospital in
a 4-year time period. The main research question on the differences between
forensic and civil psychiatric patients is divided into two subquestions.

Frequency
The first subquestion is as follows: Do forensic and civil psychiatric patients
differ in the frequency of aggressive incidents in the hospital? Are these dif-
ferences moderated by the patient’s gender or primary diagnosis of a psy-
chotic disorder? Based on the literature described above, the following
hypotheses were formulated:

Hypothesis 1a: Civil psychiatric patients cause more incidents than foren-
sic patients.
Hypothesis 1b: Female patients cause more incidents than male patients.
Hypothesis 1c: Patients with a primary diagnosis of a psychotic disorder
cause more incidents than patients with other diagnoses.
Hypothesis 1d: Patient gender moderates the relationship between legal
status and number of incidents the patient causes.

Severity
The second subquestion is as follows: Do forensic and civil psychiatric
patients differ in the severity of the aggressive incidents they cause? Are
these differences moderated by the patient’s gender or primary diagnosis of a
psychotic disorder?

Hypothesis 2a: There are no differences in the severity of incidents

caused by forensic and civil psychiatric patients.
Hypothesis 2b: There are no gender differences in the severity of aggres-
sive incidents.
Hypothesis 2c: Patients with a primary diagnosis of a psychotic disorder
cause more severe incidents than patients with a different disorder as their
primary diagnosis.
6 Journal of Interpersonal Violence 00(0)

Method
Setting
The study was conducted in the high-security forensic psychiatric hospital Van
der Hoeven Kliniek in Utrecht, The Netherlands. The hospital has a total num-
ber of 262 beds. Approximately 183 of these beds are occupied by forensic
patients receiving court-mandated treatment following a serious offense (in
Dutch: terbeschikkingstelling, TBS). The TBS-order is a judicial measure
which can be imposed on offenders suffering from mental illnesses who, as a
result of their disorder, are considered to have diminished responsibility for
their offense and have a high risk of recidivism. A regular TBS-order does not
have a fixed duration, as the offender remains hospitalized as long as the court
considers this to be necessary for the protection of others. The hospital provides
an evaluation and advice to prolong or end the TBS-order every 1 or 2 years.
The average treatment duration for the forensic patients is 8.7 years. The major-
ity of patients serve a prison sentence before the start of the treatment order.
The hospital also includes a 53-bed facility for the treatment of civilly
committed psychiatric patients whose treatments in less secured psychiatric
settings have failed due to the patient’s severely aggressive or disruptive
behavior (Van Rooijen & Neijmeijer, 2014). The average treatment duration
is 1 year, after which they are typically transferred to another psychiatric
hospital with a lower security status. Finally, a minority of patients are admit-
ted with a forensic judicial status other than TBS. For example, offenders can
receive a conditional sentence, under the condition that they are admitted for
treatment in a forensic hospital. Treatment under these judicial statuses is less
intrusive than treatment under a TBS-order.

Sample
Between January 1, 2014, and December 31, 2017, 542 patients have been
admitted to the hospital. This included 302 (55.7%) forensic TBS patients
and 212 (39.1%) civil psychiatric patients. Twenty-seven (5.0%) patients had
a forensic judicial status other than TBS, and one TBS patient got discharged,
but returned a year later as a civil psychiatric patient. These 28 patients were
excluded from the analyses including legal status. There were 98 female
patients (18.1%) and 444 (81.9%) male patients, with equal proportions of
female forensic patients (18.5%) and female civil psychiatric patients
(18.4%). Almost half of the patients (47.2%) were diagnosed with any kind
of psychotic disorder and 30.8% had a personality disorder as their primary
diagnosis, most commonly borderline or antisocial personality disorder. The
majority of civil psychiatric patients (63.2%) had a psychotic disorder as
Huitema et al. 7

their primary diagnosis, versus only 31.8% of forensic patients. Almost half
of the forensic patients (49.8%) had a personality disorder as their primary
diagnosis, compared with 23.7% of civil psychiatric patients. The average
age of patients who displayed aggression was 36.9 years (range = 19-68).
Forensic TBS patients who displayed aggressive behavior were on average
older (M = 41.4 years, range = 20-68) than civil psychiatric patients display-
ing aggression (M = 32.8, range = 19-63), t(3275.8) = −25.8, p < .001.
Regarding diversity concerns, this study includes all patients who have been
admitted to the forensic hospital Van der Hoeven Kliniek during the study
period, regardless of their gender, race, age, religion, or any other aspect.

Procedure
This research entails a quantitative study, where data on the aggressive inci-
dents occurring between January 1, 2014, and December 31, 2017 were gath-
ered from daily hospital reports. These reports inform staff members and
patients of current events in the hospital, including aggressive incidents. A
more comprehensive description of each incident was subsequently retrieved
from the daily notes in the patient’s file, which was used to score the severity
of the aggressive incident. The hospital does not yet have standard incident
registration. Therefore, the information on aggressive incidents was gathered
specifically for the purpose of this study. The incidents were scored by the
first author. Information regarding the patient’s gender and primary diagnosis
was also gathered from the patient’s file. For the two patients with gender
dysphoria, each patient’s gender was coded to conform to their gender iden-
tity. Ethical approval for this study was obtained from the Ethical Review
Committee Psychology and Neuroscience in Maastricht.

Measures
The aggressive incidents were scored on the category and severity of aggres-
sion using the MOAS. This is a validated instrument for rating aggressive
behavior (e.g., Margari et al., 2005; Oliver, Crawford, Rao, Reece, & Tyrer,
2007). The MOAS consists of four categories of aggression. Within these
categories, four different levels of severity are distinguished, ranging from
light (1) to extreme (4). Each severity level has a description of what types of
behaviors are classified as such. A total severity score is calculated by multi-
plying the severity level with Factor 1 for verbal aggression, Factor 2 for
aggression against objects, Factor 3 for autoaggression, and Factor 4 for
physical aggression (Kay et al., 1988). A revised version of this scale called
the MOAS+ was developed by Crocker and colleagues (2006). They added a
8 Journal of Interpersonal Violence 00(0)

fifth category, sexual aggression, again with four levels of severity ranging
from light to extreme. However, the category of sexual aggression was not
included in the severity scoring.
A random sample of 10% of incidents was coded independently by the
second author to calculate the interrater reliability. This was performed using
two-way random-effects consistency intraclass correlation coefficient (ICC),
in accordance with the procedure described by Landers (2015). The interrater
reliability was excellent, with ICCs ranging from .866 for sexual aggression
to .933 for aggression against objects.

Data Analysis
The statistical analyses were carried out using IBM SPSS version 25. For all
tests, assumptions were checked as described in Field (2013). First, a general
overview of the number of incidents and the number of patients involved in
aggressive incidents was provided using descriptive statistics. To test whether
forensic and civil psychiatric patients differed in the frequency of aggressive
incidents, Mann–Whitney U test was used. The Mann–Whitney U test was
chosen due to the positive skew in the distribution (many patients did not
display any aggression) and due to a rather large number of outliers. Mann–
Whitney U tests were also used to test for gender differences and differences
between patients with and without a diagnosis of psychotic disorders in the
frequency of aggressive incidents. Hierarchical multiple linear regression
analysis with bootstrap resampling of 1,000 samples was used to test for
interaction effects.
A multilevel linear regression analysis was carried out to test whether civil
and forensic patients differed in the severity of the aggressive incidents they
caused. Patient gender and having a primary diagnosis of a psychotic disor-
der were included in the model as potential moderator variables. A random
intercept + scaled identity covariance structure was used for all models
involving multilevel analysis.

Results
Frequency
General overview. Of the 542 patients admitted to the forensic hospital during
the study period, 344 patients (63.5%) caused at least one aggressive incident.
Of these 344 patients, 270 (78.5%) caused more than one incident. Thirteen
patients caused more than 50 incidents each and one female civil psychiatric
patient caused 97 incidents, which included one incident involving aggression
Huitema et al. 9

Table 1. Number of Aggressive Incidents.

Forensic Patients Civil Patients

Male Female Male Female

(n = 246) (n = 56) Total (n = 173) (n = 39) Total
M 4.46 11.71 5.8 7.92 9.82 8.27
SD 8.81 17.51 11.28 12.82 17.31 13.73
Median 1 3 1 2 4 3

toward self and 96 incidents involving aggression toward others and/or

objects. Of the 3,603 aggressive incidents recorded, 1,766 (49.0%) were
caused by forensic TBS patients, 1,747 (48.5%) were caused by civil psychi-
atric patients, and 90 incidents (2.5%) were caused by patients with a forensic
status other than TBS. Patients differed greatly in the number of incidents they
caused, which results in large standard deviations (see Table 1). As a conse-
quence, the median is more appropriate in comparing the frequency of aggres-
sive incidents of forensic and civil psychiatric patients than the mean.

Legal status. Patients with a forensic status other than TBS were excluded from
the following analysis. The number of aggressive incidents caused by each
patient ranged from 0 to 97 among civil psychiatric patients and from 0 to 69
among forensic patients. Civil psychiatric patients caused significantly more
incidents than forensic TBS patients, U = 26,901, z = 3.16, p = .002, r = .14.

Patient gender. Female patients were found to cause significantly more aggres-
sive incidents than male patients, U = 17,029.5, z = −3.46, p = .001, r = .15.
Almost one third (30.3%) of the aggressive incidents were caused by female
patients, even though they only made up 18.1% of the patient population. The
median number of incidents was 1 for male patients and 4 for female patients.
When incidents involving autoaggression were not included in the analysis,
female patients were still found to cause more aggressive incidents than male
patients, U = 17,923, z = −2.81, p = .005, r = .12.

Primary diagnosis. No significant differences were found in the number of

incidents caused by patients with psychotic disorders or a different primary
diagnosis, U = 39,180.5, z = 1.68, p = .093. In addition, having a primary
diagnosis of a psychotic disorder did not moderate the relationship between
legal status (excluding forensic status other than TBS) and number of inci-
dents, b = −0.58, 95% confidence interval (CI) = [−5.11, 3.94], p = .801.
10 Journal of Interpersonal Violence 00(0)

Table 2. Prevalence of Different Types of Aggression.

Verbal Aggression Aggression Physical Sexual

Aggression Towards Towards Aggression Aggression
(%) Objects (%) Self (%) (%) (%)
Light (1) 809 (22.5) 259 (7.2) 28 (0.8) 634 (17.6) 99 (2.7)
Moderate (2) 705 (19.6) 632 (17.5) 77 (2.1) 350 (9.7) 42 (1.2)
Severe (3) 809 (22.5) 398 (11.0) 77 (2.1) 99 (2.7) 15 (0.4)
Extreme (4) 344 (9.5) 87 (2.4) 76 (2.1) 12 (0.3) 1 (0.03)

Note. N = 3,603 aggressive incidents. The percentages add up to more than 100%, as multiple
types of aggression can occur in one incident.

Interaction between legal status and patient gender. The following analyses
exclude patients with a forensic status other than TBS. The main effect of legal
status remained significant when controlled for patient gender, b = −2.56, p =
.025, 95% bias-corrected and accelerated (BCa) CI = [−4.74, −.039]. The
main effect of patient gender also remained significant, b = −5.10, p = .005,
95% BCa CI = [−9.03, −1.89]. Although small differences appeared between
men and women in the two patient groups (see Table 1), adding the interaction
term between patient gender and legal status did not result in a significant
improvement in the model, ΔR2 = .007, p = .057. Thus, patient gender does not
moderate the relationship between legal status and number of incidents.
Although legal status and gender were significant predictors, the effect size of
the total model was small, R2 = .042.
When incidents involving autoaggression were excluded from the analy-
sis, the model did not change. The main effect of legal status remained
significant, b = −2.60, p = .015, as well as the main effect of patient gender,
b= −4.32, p = .001. Adding the interaction term between patient gender and
legal status did not improve the model, ΔR2 = .006, p = .104.

Severity
Verbal aggression was the most frequent type of aggression, with 74% of all
incidents including verbal aggression. Sexual aggression was the least prevalent
type of aggression, present in only 4.4% of recorded incidents (see Table 2). As
sexual aggression is not included in the MOAS severity scoring, the 100 inci-
dents including only sexual aggression were excluded from the following analy-
ses, as were incidents caused by patients with a forensic status other than TBS.

Legal status and patient gender. The relationship between legal status and incident
severity showed significant variance in intercepts across patients, Var(u0j) = 2.41,
Huitema et al. 11

Figure 1. Interaction effect between legal status and patient gender on incident
severity.

χ2(1) = 293.12, p < .01. Forensic and civil psychiatric patients did not differ
regarding the severity of the incidents they caused, F(1, 292.74) = 0.41, p = .521.
There was significant variance in intercepts across patients regarding the
relationship between patient gender and incident severity, Var(u0j) =1.90,
χ2(1) = 219.30, p < .01. Female patients caused significantly more severe
incidents than male patients, F(1, 230.53) = 39.01, p < .001. The average
severity score of incidents caused by female patients was 6.91 (SE = 0.23),
compared with an average severity of 5.24 (SE = 0.13) for incidents caused
by male patients.
A random intercept model including legal status, gender, and the interaction
between legal status and gender as fixed effects was found to be significantly
better than the model including only legal status as a fixed effect, χ2(2) = 41.46,
p < .01, and significantly better than the model including only patient gender as
a fixed effect χ2 (2) = 515.82, p < .01. In this model, patient gender remained a
significant predictor, F(1, 228.48) = 30.62, p < .001. However, there was also a
significant interaction effect between gender and legal status, F(1, 266.60) =
10.23, p = .002. Female forensic patients were found to cause the most severe
incidents, with an estimated marginal mean severity score of 7.23 (SE = 0.29),
followed by female civil patients (M = 6.23, SE = 0.36). Male civil patients had
a mean severity of 5.58 (SE = 0.19), and the least severe incidents were caused
by male forensic patients (M = 4.91, SE = 0.19; see Figure 1).
12 Journal of Interpersonal Violence 00(0)

When the analyses excluded autoaggression, similar results emerged. Patient

gender remained a significant predictor, F(1, 219.40) = 4.47, p = .036, as well as
the interaction term between patient gender and legal status, F(1, 253.57) = 6.58,
p = .011. The interaction effect followed the same pattern as shown in Figure 1,
where female forensic patients caused the most severe incidents and male foren-
sic patients the least severe. Adding patient age to the model significantly
improved the model fit, χ2(1) = 42.96, p < .01. There was significant variance in
intercepts across patients regarding the relationship between age and incident
severity, Var(u0j) = 2.31, χ2(1) = 289.27, p < .01. Younger patients caused more
severe incidents than older patients, F(1, 314.85) = 15.25, p < .001. Adding
patient age did not change the relationship between legal status and incident
severity, F(1, 316.73) = 0.43, p = .513.

Primary diagnosis. The relationship between primary diagnosis and incident

severity showed significant variance in intercepts across patients, Var(u0j) =
2.37, χ2(1) = 292.01, p < .01. Patients with a primary diagnosis of a psychotic
disorder caused less severe incidents than patients with other primary diagno-
ses, F(1, 228.48) = 6.34, p = .012. Primary diagnosis remained a significant
predictor when added to the model, including patient gender, legal status, and
the interaction between gender and legal status, F(1, 252.69) = 4.36, p = .038.
Adding the patient’s primary diagnosis as a predictor significantly improved
this model, χ2(1) = 30.36, p < .01. There was no interaction between the
patient’s primary diagnosis and legal status, F(1, 294.86) = 1.08, p = .299.

Discussion
This study compared the frequency and severity of aggressive incidents
caused by forensic and civil psychiatric patients in a 4-year time period in a
Dutch forensic psychiatric hospital. As expected in Hypothesis 1a, civil psy-
chiatric patients were found to cause more incidents than forensic patients.
The civil psychiatric patients admitted to the forensic hospital often have
acute psychiatric problems (Van Rooijen & Neijmeijer, 2014). In general
psychiatry, inpatient aggression is also found to occur more frequently in
acute wards compared with non-acute wards (Bowers et al., 2011). In con-
trast, forensic patients may have already been stabilized to a certain degree
before arriving to the forensic hospital, as most forensic patients serve a
prison sentence before the start of their treatment order. Furthermore, the
aggressive civil psychiatric patients in the sample were found to be on aver-
age younger than the aggressive forensic patients, which might also influ-
ence their involvement in aggression. A meta-analysis including 26 studies
that compared the age of aggressive and non-aggressive patients found that
Huitema et al. 13

inpatient aggression is associated with younger age, but also noted that half
of the included studies did not find a significant effect of age (Dack et al.,
2013).
Female patients were found to cause more incidents than male patients,
thus confirming Hypothesis 1b. Previous research has yielded mixed results,
with some studies finding no gender differences in inpatient aggression
(Daffern et al., 2005; Nicholls et al., 2009) and others finding that female
inpatients are more aggressive than their male counterparts (Broderick et al.,
2015). Differences between forensic and civil psychiatric patients regarding
the severity of incidents were also moderated by patient gender. Female
forensic patients caused the most severe incidents, followed by female civil
psychiatric patients. Male forensic patients caused the least severe incidents.
These findings reject Hypotheses 2a and 2b, which stated the expectation that
incident severity would not differ between patients of a different gender or
legal status. The differences in both frequency and severity of aggression
between male and female patients are not explained by a higher involvement
of female patients in autoaggression. One explanation for the finding that
female patients caused more incidents and especially female forensic patients
caused severe incidents may be that the judicial system tends to be more
lenient toward female offenders than to male offenders (Spohn & Beichner,
2000). The female offenders who do get a TBS-order appear to suffer from
relatively more complex psychopathology than their male counterparts (De
Vogel, Stam, Bouman, Ter Horst, & Lancel, 2016). It may also be that foren-
sic treatment is catered more toward the needs of male patients, which may
disadvantage female forensic patients in their treatment (Van Voorhis, Wright,
Salisbury, & Bauman, 2010). More research is necessary to understand these
differences between male and female patients and between forensic and civil
psychiatric patients.
This study found no significant interaction between patient gender and
legal status regarding the frequency of inpatient aggression, which rejects
Hypothesis 1d, whereas this was found in the meta-analysis by Dack and col-
leagues (2013). The current data do show a trend similar to the pattern of
differences found in severity of incidents, where male forensic patients
appear to cause the least number of incidents of all groups of patients.
However, the number of incidents varied greatly between individuals and the
groups differed in size, with 246 male forensic patients compared with only
39 female civil psychiatric patients.
Finally, patients with a primary diagnosis of a psychotic disorder were not
found to cause more aggressive incidents than patients with a different pri-
mary diagnosis, which rejects Hypothesis 1c. Hypothesis 2c stated the expec-
tation that patients with a primary diagnosis of a psychotic disorder would
14 Journal of Interpersonal Violence 00(0)

cause more severe incidents than patients with a different primary diagnosis.
However, patients with a psychotic disorder were found to cause less severe
incidents compared with patients with a different primary diagnosis, whereas
previous studies found that patients with schizophrenia caused more severe
aggressive incidents (Abderhalden et al., 2007; Grassi et al., 2001). More
research is needed to find out in what way the incident severity differs
between patients with different primary diagnoses.

Limitations
While the current study has some interesting findings, there are also several
limitations. All data were retrieved in retrospect from the patient files, which
means that the quality of the information is dependent on how well the staff
member reported it. Only incidents mentioned in the daily reports were
included in this study, which is likely to be an underestimation of the actual
aggression rate, as aggression may go unnoticed or unreported. This method
of data collection also precluded the possibility of getting each patient’s per-
spective on the incidents.
Another serious limitation is the severity scoring based on the MOAS.
Even though the MOAS is validated in several studies (e.g., Margari et al.,
2005), this measure faces a number of shortcomings. Some aggressive behav-
iors are not mentioned in the instrument and are difficult to weigh according
to the current descriptions, such as threatening someone with a weapon. This
may result in an underestimation of the severity scores for incidents where
weapon use does not result in injuries, as the two most severe categories of
physical aggression require the aggressor to cause injuries to the victim. This
requirement confounds the severity of the aggression with its outcomes,
without taking the intention of the aggressor into account (Bowers, 1999).
This means that an incident where a patient throws down an object which
accidentally hits and injures someone would be rated as more severe than an
incident where a patient intends to kill a ward full of people by shooting a gun
at them, but by chance fails to wound anyone. Finally, the comparability of
different types of aggression can be called into question. The severity scoring
is based on a multiplication of the category of aggression and the level of
severity, which means that the same score can be achieved with multiple
types of aggression. It is questionable whether repeated and detailed death
threats about someone’s children can be considered equally severe as a
patient kicking the furniture once, even though both result in a severity score
of 4. However, there is no reason to assume the shortcomings of the instru-
ment would affect the scores of aggressive incidents among forensic patients
Huitema et al. 15

differently compared with civil psychiatric patients, as there appear to be no

systematic differences between these groups which would make one of the
groups more prone to underestimation of severity.
Finally, it should be noted that this study includes a specific patient popu-
lation. The civil psychiatric patients in this study have been placed in a foren-
sic hospital because they have already displayed disruptive or aggressive
behavior and are therefore considered to be unmanageable in regular psychi-
atric care. Therefore, these patients cannot be readily compared with civil
psychiatric patients in other settings. Similarly, the forensic patients in this
study include offenders who are considered to have a high recidivism risk and
were deemed to need treatment in a high-security forensic hospital. Thus,
both the forensic and civil psychiatric patients in this study have displayed
(severe) aggressive or transgressive behavior before their arrival at the hospi-
tal, which makes the comparison of their aggression in the forensic hospital
interesting, but limits generalization to psychiatric patients in other settings.

Future Research Directions

The current study raises several questions that could be addressed in future
research. As the retrospective nature of the present study posed limitations,
future research should aim to employ prospective methods of data collection.
Future research should expand the topic of severity of inpatient aggression by
employing qualitative methods to gain more in-depth insight into the severity
of aggression. This would also offer the possibility of including the patient’s
perspective. Aggression is likely to have impact on patients too, but this topic
has attracted very little research attention.
More research is also needed to improve the available aggression registra-
tion instruments. As described above, the MOAS has some serious limita-
tions. However, this is also the case for other instruments such as the OAS and
SOAS-R. The severity scoring of the OAS and SOAS-R includes the interven-
tions used to address the aggression, where higher severity scores are given
to incidents where restrictive interventions are used. This confounds the inci-
dent with its consequences. Furthermore, the SOAS-R gives higher severity
ratings to aggression targeted at staff members than to aggression targeted at
patients, which seems ethically questionable. New instruments or revisions
of the currently used instruments are necessary to address these concerns and
to take the intent of the aggressor into account, rather than focusing on out-
comes (Bowers, 1999). Bowers, Nijman, Palmstierna, and Crowhurst (2002)
developed a new scale for this purpose, called attempted and actual assault
scale (attacks), but research on this instrument is very limited.
16 Journal of Interpersonal Violence 00(0)

Clinical Implications
The present study found that female patients and civil psychiatric patients
committed more aggression than male and forensic patients, and female foren-
sic patients caused the most severe aggressive incidents. This has important
clinical implications. Previous research found that staff members have more
positive feelings, such as sympathy and receptiveness, toward the female
forensic patients and more negative feelings, such as anxiousness and feeling
threatened, toward male forensic patients (De Vogel & Louppen, 2016). It
might be helpful for staff members to learn that female patients rather than
male patients cause most incidents and female forensic patients cause the most
severe aggression. Underestimating the aggression potential of female patients
might contribute to higher rates of aggression, for example, when early warn-
ing signals are not interpreted correctly. These differences between male and
female patients emphasize the need for gender-responsive risk assessment and
treatment strategies (De Vogel et al., 2016). Furthermore, the finding that the
group of civil psychiatric patients cause more aggressive incidents than foren-
sic patients validates the need for a specialized intensive treatment program in
a forensic hospital for a group of civil psychiatric patients with severe aggres-
sion problems. This difficult population of civilly committed patients deserves
more attention among researchers, health care managers, and policy makers,
which is needed to implement successful aggression prevention strategies.
Furthermore, staff members deserve acknowledgment of the difficulties of
working with these aggressive patients. Health care managers should be cog-
nizant of the impact of aggression on staff members to reduce absenteeism and
to retain them as employees.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
Anneloes Huitema https://orcid.org/0000-0003-0297-256X

References
Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Fischer, J. E., & Haug, H. J.
(2007). Frequency and severity of aggressive incidents in acute psychiatric wards
Huitema et al. 17

in Switzerland. Clinical Practice and Epidemiology in Mental Health, 3, Article

30. doi:10.1186/1745-0179-3-30
Bader, S., Evans, S. E., & Welsh, E. (2014). Aggression among psychiatric inpa-
tients: The relationship between time, place, victims, and severity rat-
ings. Journal of the American Psychiatric Nurses Association, 20, 179-186.
doi:10.1177/1078390314537377
Bettencourt, B., & Miller, N. (1996). Gender differences in aggression as a func-
tion of provocation: A meta-analysis. Psychological Bulletin, 119, 422-447.
doi:10.1037//0033-2909.119.3.422
Bowers, L. (1999). A critical appraisal of violent incident measures. Journal of
Mental Health, 8, 339-349. doi:10.1080/09638239917265
Bowers, L., Nijman, H., Palmstierna, T., & Crowhurst, N. (2002). Issues in the
measurement of violent incidents and the introduction of a new scale: The
“attacks”(attempted and actual assault scale). Acta Psychiatrica Scandinavica,
106, 106-109. doi:10.1034/j.1600-0447.106.s412.23.x
Bowers, L., Stewart, D., Papadopoulos, C., Dack, C., Ross, J., Khanom, H., & Jeffery,
D. (2011). Inpatient violence and aggression: A literature review (Report from
the Conflict and Containment, Reduction Research Programme). London,
England: Section of Mental Health Nursing, Health Service and Population
Research, Institute of Psychiatry, Kings College London.
Broderick, C., Azizian, A., Kornbluh, R., & Warburton, K. (2015). Prevalence of
physical violence in a forensic psychiatric hospital system during 2011–2013:
Patient assaults, staff assaults, and repeatedly violent patients. CNS Spectrums,
20, 319-330. doi:10.1017/S1092852915000188
Cornaggia, C. M., Beghi, M., Pavone, F., & Barale, F. (2011). Aggression in psychia-
try wards: A systematic review. Psychiatry Research, 189, 10-20. doi:10.1016/j.
psychres.2010.12.024
Crocker, A. G., Mercier, C., Lachapelle, Y., Brunet, A., Morin, D., & Roy, M.-E.
(2006). Prevalence and types of aggressive behaviour among adults with intel-
lectual disabilities. Journal of Intellectual Disability Research, 50, 652-661.
doi:10.1111/j.1365-2788.2006.00815.x
Dack, C., Ross, J., Papadopoulos, C., Stewart, D., & Bowers, L. (2013). A review and
meta-analysis of the patient factors associated with psychiatric in-patient aggres-
sion. Acta Psychiatrica Scandinavica, 127, 255-268. doi:10.1111/acps.12053
Daffern, M., Howells, K., Ogloff, J., & Lee, J. (2005). Individual characteristics pre-
disposing patients to aggression in a forensic psychiatric hospital. Journal of
Forensic Psychiatry & Psychology, 16, 729-746.
De Vogel, V., & Louppen, M. (2016). Measuring feelings of staff members towards
their most complex female and male forensic psychiatric patients: A pilot study
into gender differences. International Journal of Forensic Mental Health, 15,
174-185. doi:10.1080/14999013.2016.1170741
De Vogel, V., Stam, J., Bouman, Y. H., Ter Horst, P., & Lancel, M. (2016). Violent
women: A multicentre study into gender differences in forensic psychiatric
patients. The Journal of Forensic Psychiatry & Psychology, 27, 145-168. doi:10
.1080/14789949.2015.1102312
18 Journal of Interpersonal Violence 00(0)

Field, A. (2013). Discovering statistics using IBM SPSS statistics (4th ed.). London,
England: SAGE.
Grassi, L., Peron, L., Marangoni, C., Zanchi, P., & Vanni, A. (2001). Characteristics
of violent behaviour in acute psychiatric in-patients: A 5-year Italian study. Acta
Psychiatrica Scandinavica, 104, 273-279. doi:10.1111/j.1600-0447.2001.00292.x
Hodgins, S., Müller-Isberner, R., Freese, R., Tiihonen, J., Repo-Tiihonen, E., Eronen,
M., . . . Kronstrand, R. (2007). A comparison of general adult and forensic
patients with schizophrenia living in the community. International Journal of
Forensic Mental Health, 6, 63-75. doi:10.1080/14999013.2007.10471250
Inoue, M., Tsukano, K., Muraoka, M., Kaneko, F., & Okamura, H. (2006).
Psychological impact of verbal abuse and violence by patients on nurses working
in psychiatric departments. Psychiatry and Clinical Neurosciences, 60, 29-36.
doi:10.1111/j.1440-1819.2006.01457.x
Jackson, D., Clare, J., & Mannix, J. (2002). Who would want to be a nurse? Violence
in the workplace—A factor in recruitment and retention. Journal of Nursing
Management, 10, 13-20. doi:10.1046/j.0966-0429.2001.00262.x
Kay, S. R., Wolkenfeld, F., & Murrill, L. M. (1988). Profiles of aggression among
psychiatric patients: I. Nature and prevalence. Journal of Nervous and Mental
Disease, 176, 539-546. doi:10.1097/00005053-198809000-00007
Lam, J. N., McNiel, D. E., & Binder, R. L. (2000). The relationship between patients’
gender and violence leading to staff injuries. Psychiatric Services, 51, 1167-
1170. doi:10.1176/appi.ps.51.9.1167
Landers, R. N. (2015). Computing intraclass correlations (ICC) as estimates of
interrater reliability in SPSS. The Winnower, 2, e143518.81744. doi:10.15200/
winn.143518.81744
Linhorst, D., & Scott, L. P. (2004). Assaultive behavior in state psychiatric hospitals:
Differences between forensic and nonforensic patients. Journal of Interpersonal
Violence, 19, 857-874. doi:10.1177/0886260504266883
Margari, F., Matarazzo, R., Casacchia, M., Roncone, R., Dieci, M., Safran, S., . . . Epica
Study Group. (2005). Italian validation of MOAS and NOSIE: A useful package
for psychiatric assessment and monitoring of aggressive behaviours. International
Journal of Methods in Psychiatric Research, 14, 109-118. doi:10.1002/mpr.22
Needham, I., Abderhalden, C., Halfens, R. J. G., Fischer, J. E., & Dassen, T. (2005).
Non-somatic effects of patient aggression on nurses: A systematic review. Journal
of Advanced Nursing, 49, 283-296. doi:10.1111/j.1365-2648.2004.03286.x
Nicholls, T. L., Brink, J., Greaves, C., Lussier, P., & Verdun-Jones, S. (2009).
Forensic psychiatric inpatients and aggression: An exploration of incidence,
prevalence, severity, and interventions by gender. International Journal of Law
and Psychiatry, 32, 23-30. doi:10.1016/j.ijlp.2008.11.007
Nijman, H., Bowers, L., Oud, N., & Jansen, G. (2005). Psychiatric nurses’ experi-
ences with inpatient aggression. Aggressive Behavior, 31, 217-227. doi:10.1002/
ab.20038
Nijman, H. L. I., Muris, P., Merckelbach, H. L., Palmstierna, T., Wistedt, B., Vos,
A. M., . . . Allertz, W. (1999). The staff observation aggression scale-revised
Huitema et al. 19

(SOAS-R). Aggressive Behavior, 25, 197-209. doi:10.1002/(sici)1098-2337

(1999)25:3<197::aid-ab4>3.3.co;2-3
Oliver, P. C., Crawford, M. J., Rao, B., Reece, B., & Tyrer, P. (2007). Modified Overt
Aggression Scale (MOAS) for people with intellectual disability and aggres-
sive challenging behaviour: A reliability study. Journal of Applied Research in
Intellectual Disabilities, 20, 368-372. doi:10.1111/j.1468-3148.2006.00346.x
Rippon, T. J. (2000). Aggression and violence in health care professions. Journal of
Advanced Nursing, 31, 452-460. doi:10.1046/j.1365-2648.2000.01284.x
Silver, J. M., & Yudofsky, S. C. (1987). Documentation of aggression in the assess-
ment of the violent patient. Psychiatric Annals, 17, 375-384. doi:10.3928/0048-
5713-19870601-08
Spohn, C., & Beichner, D. (2000). Is preferential treatment of female offenders a
thing of the past? A multisite study of gender, race, and imprisonment. Criminal
Justice Policy Review, 11, 149-184. doi:10.1177/0887403400011002004
Van Rooijen, S., & Neijmeijer, L. (2014). Klinieken voor Intensieve Behandeling:
In profile [Centres of intensive treatment: A profile]. Utrecht, The Netherlands:
Trimbos Instituut.
Van Voorhis, P., Wright, E. M., Salisbury, E., & Bauman, A. (2010). Women’s risk
factors and their contributions to existing risk/needs assessment: The current sta-
tus of a gender-responsive supplement. Criminal Justice and Behavior, 37, 261-
288. doi:10.1177/0093854809357442
Verstegen, N., De Vogel, V., De Vries Robbé, M., & Helmerhorst, M. (2017).
Inpatient violence in a Dutch forensic psychiatric hospital. Journal of Forensic
Practice, 19, 102-114. doi:10.1108/JFP-04-2016-0020
Witt, K., Van Dorn, R., & Fazel, S. (2013). Risk factors for violence in psychosis:
Systematic review and meta-regression analysis of 110 studies. PLoS ONE, 8,
e55942. doi:10.1371/journal.pone.0055942

Author Biographies
Anneloes Huitema, MSc, is a psychologist and outpatient treatment provider at De
Waag, part of De Forensische Zorgspecialisten (a Dutch forensic center including the
Van der Hoeven Kliniek) in Utrecht, The Netherlands. She previously published on
attitudes toward male victims of sexual coercion by a female perpetrator.
Nienke Verstegen, MSc, is a medical anthropologist and a researcher at De
Forensische Zorgspecialisten (a Dutch forensic center including the Van der Hoeven
Kliniek) in Utrecht, The Netherlands. She is currently working on her PhD research
on inpatient violence in forensic psychiatry.
Vivienne de Vogel, PhD, is a psychologist and professor at the HU University of
Applied Sciences Utrecht, Research Centre for Social Innovation. She also works as
a researcher at De Forensische Zorgspecialisten (a Dutch forensic center including the
Van der Hoeven Kliniek) in Utrecht, The Netherlands.