A survey of gun collection and use among three groups of veteran patients admitted to veterans affairs hospital treatment programs. (Original Article).Background: An important risk factor for suicide is psychiatric psy·chi·at·ric adj. Of or relating to psychiatry. psychiatric adjective Pertaining to psychiatry, mental disorders illness, but only a limited amount of work has been directed at assessing the use of firearms This is an extensive list of small arms — pistol, machine gun, grenade launcher, anti-tank rifle — that includes variants. : Top - 0–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A
Method: Patients with combat-related posttraumatic stress disorder Posttraumatic stress disorder An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life. (PTSD PTSD posttraumatic stress disorder. PTSD abbr. posttraumatic stress disorder Post-traumatic stress disorder (PTSD) ), patients with schizophrenia schizophrenia (skĭt'səfrē`nēə), group of severe mental disorders characterized by reality distortions resulting in unusual thought patterns and behaviors. , and patients undergoing rehabilitation rehabilitation: see physical therapy. for substance abuse were asked to complete a weapons-use survey and measures of psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je) 1. the branch of medicine dealing with the causes and processes of mental disorders. 2. abnormal, maladaptive behavior or mental activity. . Results: The PTSD patients surveyed related owning more than four times as many firearms as other subjects and reported significantly higher levels of potentially dangerous firearm-related behaviors than the other psychiatric subjects surveyed. Conclusion: High levels of aggression, impulsive im·pul·sive adj. 1. Inclined or tending to act on impulse rather than thought. 2. Motivated by or resulting from impulse. im·pul and dangerous weapon use, and ready weapon availability may be significant factors in gun-related violence in the PTSD patient population. Additional prospective research is needed to determine whether gun ownership or certain types of weapon use in this population is associated with future acts of violence. ********** Extensive research has examined the general public's use of handguns, with attention focused on the relationship among handgun ownership, suicide, and homicide homicide (hŏm`əsīd), in law, the taking of human life. Homicides that are neither justifiable nor excusable are considered crimes. A criminal homicide committed with malice is known as murder, otherwise it is called manslaughter. . (1,2) Research has revealed that firearms are used in approximately 60% of all suicides, and indicates that firearm-related deaths accounted for almost all of the increase in suicide rates during the 1980s. (3) Case-controlled research has shown that the risk of suicide is almost five times higher for persons who live in a household where at least one firearm firearm, device consisting essentially of a straight tube to propel shot, shell, or bullets by the explosion of gunpowder. Although the Chinese discovered gunpowder as early as the 9th cent., they did not develop firearms until the mid-14th cent. is kept when compared with households without firearms. (4) Other research reveals that alcohol intoxication intoxication, condition of body tissue affected by a poisonous substance. Poisonous materials, or toxins, are to be found in heavy metals such as lead and mercury, in drugs, in chemicals such as alcohol and carbon tetrachloride, in gases such as carbon monoxide, and is associated with at least 25 to 50% of all suicides and is especially common in suicides involving guns. (5) Given that an important risk factor for suicide is psychiatric illness, (6) however, only a limited amount of work has been directed at assessing the use of firearms and other weapons by select psychiatric populations at high risk for violent acts. We previously reported that posttraumatic stress disorder (PTSD) patients consistently reported owning large numbers of weapons. (7) More importantly, these PTSD patients consistently related a high incidence of potentially dangerous behaviors with these weapons (eg, considering suicide with a gun, aiming firearms at family members and friends, and loading guns while contemplating suicide). Given the potential relevance of these findings in a patient population reported to exhibit high levels of directed violence (8) and completed suicides, (9) we undertook a study to survey gun use in three groups of patients admitted to a Veterans Affairs Veterans Affairs is a term of the business that deals with the relation between a government and its veteran communities, usually administered by the designated government agency. (VA) hospital for various rehabilitation programs Noun 1. rehabilitation program - a program for restoring someone to good health program, programme - a system of projects or services intended to meet a public need; "he proposed an elaborate program of public works"; "working mothers rely on the day care . We chose three groups of patients commonly encountered in VA psychiatric populations and took our subjects from residential treatment groups. We did not survey patients from acute hospital settings. One sample consisted of patients with a chart diagnosis of schizophrenia, a group of psychiatric patients at risk for suicide , (10) substance abuse, (11) and aggressive behavior. (12) The other two samples were a group of patients presenting for a PTSD rehabilitation program and a patient group with primary alcoholism alcoholism, disease characterized by impaired control over the consumption of alcoholic beverages. Alcoholism is a serious problem worldwide; in the United States the wide availability of alcoholic beverages makes alcohol the most accessible drug, and alcoholism is and substance-abuse diagnoses. We chose this last group because the use of alcohol and substances is typically cited as the most significant confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor factor in studies of aggression in psychiatric populations. (8) This study surveyed these three groups of male veteran patients with similar histories of alcohol and substance use, and compared them on several psychologic measures, demographic information, and their self-reported use and collection of weapons. Methods Thirty-three consecutive admissions to the North Little Rock PTSD rehabilitation program, 23 patients admitted to a dual-diagnosis rehabilitation program with a chart diagnosis of schizophrenia, and 22 substance-abusing control subjects admitted to a domiciliary domiciliary pertaining to a household. domiciliary calls professional veterinary calls made to patients at their owners' residences. Called also house calls. program for substance-abuse recovery and work retraining re·train tr. & intr.v. re·trained, re·train·ing, re·trains To train or undergo training again. re·train were interviewed and completed a variety of psychologic measures. These included the Michigan Alcoholism Screening Test (MAST), a 24-item instrument often used for assessment of alcoholism (13); the Drug Abuse Screening Test (DAST DAST Department of Arts, Sport and Tourism (Ireland) DAST Drug Abuse Screening Test DAST Distributed Applications Support Team (NLANR) DAST Dyslexia Adult Screening Test DAST Draw-a-Scientist Test ), a similar 28-question instrument used to assess abuse of substances other than alcohol (14); the Hostility Scale, a 30-item true/false questionnaire used to assess hostility and (15); the Aggression Questionnaire, a 29-question instrument designed to assess anger and aggression (16); and our weapons survey. (7) The weapons survey asks only about weapons owned after or before any military experience, not during military experience. Written consent to complete the surveys and to have their charts reviewed for additional information was gathered from all subjects. All study subjects were screened for the presence or absence of PTSD with the Clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher. cli·ni·cian n. Administered PTSD Scale. (17) Also, all of the PTSD subjects provided proof of military service (form DD-214) as a part of the application process to the PTSD rehabilitation unit. Schizophrenics and substance-abusing subjects were excluded from the study if they met Clinician Administered PTSD Scale criteria for PTSD. Individuals in the schizophrenia group who were deemed by their attending physician to be too impaired to complete the evaluations because of cognitive impairment Impairment 1. A reduction in a company's stated capital. 2. The total capital that is less than the par value of the company's capital stock. Notes: 1. This is usually reduced because of poorly estimated losses or gains. 2. or severe psychosis psychosis (sīkō`sĭs), in psychiatry, a broad category of mental disorder encompassing the most serious emotional disturbances, often rendering the individual incapable of staying in contact with reality. were not approached to enter the study. Two subjects approached in the schizophrenic schiz·o·phren·ic adj. Of, relating to, or affected by schizophrenia. n. One who is affected with schizophrenia. group refused consent for the study, and one subject consented but did not complete all the survey items; all three were excluded from the study. Substance-abusing subjects were further evaluated using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective , Fourth Edition, and were excluded if they met diagnostic criteria for a psychotic disorder Psychotic disorder A mental disorder characterized by delusions, hallucinations, or other symptoms of lack of contact with reality. The schizophrenias are psychotic disorders. . Of the 22 members of the substance-abuse group, 15 met criteria for alcohol dependence, 7 met criteria for mixed substance dependence, 2 met criteria for comorbid major depression, and 1 met criteria for comorbid generalized gen·er·al·ized adj. 1. Involving an entire organ, as when an epileptic seizure involves all parts of the brain. 2. Not specifically adapted to a particular environment or function; not specialized. 3. anxi ety disorder. None of the substance-abusing subjects were excluded for diagnostic reasons. Results Average age was significantly different among the three samples, with PTSD subjects being the oldest (Table 1), although no veteran subjects in the current study were older than those of the Vietnam era Vietnam Era is a term used by the United States Department of Veterans Affairs to classify veterans of the Vietnam War. The Vietnam Era is considered to have begun in 1964 and ended in 1975. The U.S. Congress, U.S. . The PTSD group was primarily composed of Vietnam-era veterans, with 27 Vietnam combat veterans in the PTSD group (82% of the sample), 10 Vietnam-era veterans in the schizophrenic group (43% of the sample), and 10 Vietnam-era veterans in the substance-abuse group (45% of the sample). The three groups did not produce significantly different scores on self-reported measures of alcohol and substance abuse as measured by the MAST and DAST; however, the three groups did differ significantly in terms of other psychologic measures, the Hostility Scale and Aggression Questionnaire, with the PTSD subjects scoring significantly higher on these instruments than the two other subject groups. Schizophrenic subjects scored significantly higher than the, substance-abuse sample on both the Aggression Questionnaire (t = 2.301; P = 0.026) and the Hostility Scale (t 2.768; P = 0.008). Patients with PTSD scored higher than schizophrenic subjects on the Aggression Questionnaire (t = 4.384; P < 0.001) and Hostility Scale (t = 3.219; P = 0.002). In their responses to various questions relating specifically to weapon collection and use, the three groups differed significantly on every query. Subjects with PTSD more frequently reported owning more firearms, both currently and in the past, than did the other patient groups (Table 2). The PTSD patients also reported a significantly increased frequency of various weapons-related activities, such as aiming and firing weapons at others, considering suicide with firearms, patrolling their property with loaded weapons, carrying a gun on their person, killing or mutilating animals while enraged en·rage tr.v. en·raged, en·rag·ing, en·rag·es To put into a rage; infuriate. [Middle English *enragen, from Old French enrager : en-, causative pref. , and hiding weapons in their homes, than did schizophrenic subjects or substance abusing subjects. In addition, PTSD subjects related that their families had asked them to get rid of their firearms more often than did other psychiatric subjects. Perhaps not surprisingly, PTSD patients also more frequently related feeling at risk from their own guns than the two other psychiatric groups (Table 3). Discussion The results of this study support and extend our findings from previous work with patients presenting for PTSD treatment. Overall, the current PTSD subject group was similar to our previous study group in both the number of weapons owned and the fashion in which the firearms were used. (7) In the current study, PTSD subjects collected more firearms and related more potentially dangerous activities with these firearms than did the other subject groups. This difference was significant even in the presence of similar levels of alcohol and substance abuse among the three groups (as measured by the MAST and DAST). Although these findings have very definite clinical relevance, several shortcomings A shortcoming is a character flaw. Shortcomings may also be:
v. gen·er·al·ized, gen·er·al·iz·ing, gen·er·al·iz·es v.tr. 1. a. To reduce to a general form, class, or law. b. To render indefinite or unspecific. 2. these findings may be to other PTSD patient populations. First, the current PTSD sample is not representative of the general PTSD patient population nationwide. Subjects surveyed for this study were exclusively male, usually unemployed, and most frequently had suffered from their symptoms for at least 30 years. In addition, all related their traumatic experiences as being combat-related. Therefore, one cannot extrapolate extrapolate - extrapolation these findings to other, non-combat-related PTSD patients. Finally, reports of gun ownership and use in all surveyed populations were derived from self-report alone, and may be biased in terms of either over- or underreporting. Despite the limitations of this study, a number of important points can be gleaned from these findings. First, our findings suggest that assessing a patient's gun usage is an important and very useful portion of the history of patients admitted to VA clinics, and particularly in combat veterans with PTSD. Second, because they own significant numbers of weapons and frequently use those weapons in potentially dangerous ways, patients presenting for PTSD rehabilitation offer a unique group in which to carefully study the interaction of psychopathology, alcohol and substance use, suicidal ideation suicidal ideation Suicidality Psychiatry Mental thoughts and images which hinge around committing suicide. See Suicide. , and firearm usage. Finally, whereas collecting large numbers of weapons may be commonplace among combat-related PTSD patients, one clear and potentially tragic result of this behavior is the close proximity of weapons to individuals with histories of suicidal ideation, substance abuse, depression, and impulsive aggression. Prospective studies of the relationships between levels of aggression, suicidal su·i·cid·al adj. 1. Of or relating to suicide. 2. Likely to attempt suicide. behaviors, weapo ns use, and violence are needed and are currently underway.
Table 1
Patient demographics and scores on psychological measures (a)
Schizophrenia
Measure PTSD (n = 33) (n = 23)
Mean age (yr) 48 [+ or -] 7.5 43.7 [+ or -] 10.4
Mean MAST score 21.3 [+ or -] 20.2 17.4 [+ or -] 15.2
Mean DAST score 6.0 [+ or -] 7.7 7.4 [+ or -] 7.3
Mean Hostility Scale score 21.2 [+ or -] 5.1 15.7 [+ or -] 7.7
Aggression Questionnaire score 105.4 [+ or -] 20.9 80.8 [+ or -] 20.3
Significance
(one-way
ANOVA)
Substance
Measure abuse (n = 22) F
Mean age (yr) 42 [+ or -] 5.2 4.22
Mean MAST score 21.5 [+ or -] 18.3 0.38
Mean DAST score 11.09 [+ or -] 8.8 2.78
Mean Hostility Scale score 10.02 [+ or -] 5.9 21.87
Aggression Questionnaire score 66.7 [+ or -] 20.8 24.65
Significan
ce
(one-way
ANOVA)
Measure P value
Mean age (yr) 0.018
Mean MAST score 0.683
Mean DAST score 0.068
Mean Hostility Scale score <0.001
Aggression Questionnaire score <0.001
(a)PTSD, posttraumatic stress disorder; ANOVA, analysis of variance;
MAST, Michigan Alcoholism Screening Test; DAST, Drug Abuse Screening
Test.
Table 2
Weapon ownership (a)
Schizophrenia
Measure PTSD (n = 33) (n = 23)
Mean no. of firearms owned 4.9 [+ or -] 6.2 0.48 [+ or -] 0.85
currently
Mean greatest no. of firearms ever 9.3 [+ or -] 8.6 0.48 [+ or -] 0.85
owned
Mean no. of handguns owned 1.6 [+ or -] 2.6 0.13 [+ or -] 0.34
currently
Significance
(one-way
ANOVA)
Substance
Measure abuse (n = 22) F
Mean no. of firearms owned 0.72 [+ or -] 1.7 10.13
currently
Mean greatest no. of firearms ever 2.77 [+ or -] 2.5 17.72
owned
Mean no. of handguns owned 0.28 [+ or -] 0.61 6.19
currently
Significan
ce
(one-way
ANOVA)
Measure P value
Mean no. of firearms owned <0.001
currently
Mean greatest no. of firearms ever <0.001
owned
Mean no. of handguns owned 0.003
currently
(a)PTSD, posttraumatic stress disorder; ANOVA, analysis of variance.
Table 3
Weapon use
PTSD Schizophren
ia
(n =33) (n = 23)
Question Yes No Yes
Ever aimed gun at family, at least 13 20 2
once?
Ever fired gun at anyone 13 20 2
(not in combat), at least once?
Ever considered committing suicide 22 11 6
with gun, at least once?
Ever held and loaded gun with 21 12 3
suicide in mind, at least once?
Do you patrol your property with 23 10 1
loaded gun (now in past), at least
a few times per month?
Have friends or family asked you to 21 12 3
get a rid of firearms?
Have you ever felt at risk of 16 17 3
harm for your own gun(s)?
Do you carry a gun on your person 11 22 0
at least some of the time?
Have you ever killed or mutilated 11 22 0
an animal in a fit of rage
(not while hunting)?
Have you ever hidden weapons in 23 10 3
your home?
Substance
Schizophre abuse
nia
(n = 23) (n = 22)
Question No Yes No
Ever aimed gun at family, at least 21 0 22
once?
Ever fired gun at anyone 21 4 18
(not in combat), at least once?
Ever considered committing suicide 17 3 19
with gun, at least once?
Ever held and loaded gun with 20 3 19
suicide in mind, at least once?
Do you patrol your property with 22 0 22
loaded gun (now in past), at least
a few times per month?
Have friends or family asked you to 20 4 18
get a rid of firearms?
Have you ever felt at risk of 20 2 20
harm for your own gun(s)?
Do you carry a gun on your person 23 0 22
at least some of the time?
Have you ever killed or mutilated 23 0 22
an animal in a fit of rage
(not while hunting)?
Have you ever hidden weapons in 20 5 17
your home?
Significance
Question P value [chi square]
Ever aimed gun at family, at least <0.001 15.519
once?
Ever fired gun at anyone 0.023 7.567
(not in combat), at least once?
Ever considered committing suicide <0.001 18.041
with gun, at least once?
Ever held and loaded gun with <0.001 21.287
suicide in mind, at least once?
Do you patrol your property with <0.001 40.791
loaded gun (now in past), at least
a few times per month?
Have friends or family asked you to <0.001 19.256
get a rid of firearms?
Have you ever felt at risk of 0.001 13.606
harm for your own gun(s)?
Do you carry a gun on your person <0.001 17.463
at least some of the time?
Have you ever killed or mutilated <0.001 17.463
an animal in a fit of rage
(not while hunting)?
Have you ever hidden weapons in <0.001 21.870
your home?
(a)PTSD, posttraumatic stress disorder; ANOVA, analysis of variance.
Accepted March 20, 2002. References (1.) Kellermann AL, Westphal L, Fischer L, Harvard B. Weapon involvement in home invasion home invasion n. Burglary of a dwelling while the residents are at home. Noun 1. home invasion - burglary of a dwelling while the residents are at home crimes. JAMA JAMA abbr. Journal of the American Medical Association 1995;273:1759-1762. (2.) Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries: Beyond the tip of the iceberg tip of the iceberg n. pl. tips of the iceberg A small evident part or aspect of something largely hidden: afraid that these few reported cases of the disease might only be the tip of the iceberg. . JAMA 1995;273:1749-1754. (3.) Monk M. Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause of suicide. Epidemiol Rev 1987;9:51-69. (4.) Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, et al. Suicide in the home in relation to gun ownership. N Engl J Med 1992;327:467-472. (5.) Baker SP, O'Neill B, Karpf RS. The Injury Fact Book. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , Oxford University Press, 1992, ed 2. (6.) Blumenthal SJ. Suicide: A guide to risk factors, assessment, and treatment of suicidal patients suicidal patient Psychiatry A Pt at ↑ risk of committing suicide in the near future Risk factors–♂: ≥ age 60, widowed, divorced, white, Native American, living alone, unemployed or having financial difficulties, substance abuse Risk . Med Clin North Am 1988;72:937-971. (7.) Freeman T, Clothier J, Thornton C, Keesee N. Firearm collection and use among combat veterans admitted to a posttraumatic stress disorder rehabilitation unit. J Nerv Ment Dis 1994;182:592-594. (8.) McFall M, Fontana A, Raskind M, Rosenheck R. Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder. J Trauma Stress 1999;12:501-517. (9.) Lehmann L, McCormick RA, McCracken L. Suicidal behavior among patients in the VA health care system. Psychiatry psychiatry (səkī`ətrē, sī–), branch of medicine that concerns the diagnosis and treatment of mental, emotional, and behavioral disorders, including major depression, schizophrenia, and anxiety. Serv 1995;46:1069-1071. (10.) King E. Suicide in the mentally ill: An epidemiological epidemiological emanating from or pertaining to epidemiology. epidemiological associations the associative relationships between the frequency of occurrence of a disease and its determinants, its predisposing and precipitating sample and implications for clinicians. Br J Psychiatry 1994;165:658-663. (11.) DeQuardo JR, Carpenter CF, Tandon R. Patterns of substance abuse in schizophrenia: Nature and significance. J Psychiatry Res 1994;28:267-275. (12.) Yesavage JA. Dangerous behavior by Viet Nam veterans with schizophrenia. Am J Psychiatry 1983;140:1180-1183. (13.) Selzer ML. The Michigan alcoholism screening test: The quest for Verb 1. quest for - go in search of or hunt for; "pursue a hobby" quest after, go after, pursue look for, search, seek - try to locate or discover, or try to establish the existence of; "The police are searching for clues"; "They are searching for the a new diagnostic instrument. Am J Psychiatry 1971;127:1653-1658. (14.) Staley D, el-Guebaly N. Psychometric psy·cho·met·rics n. (used with a sing. verb) The branch of psychology that deals with the design, administration, and interpretation of quantitative tests for the measurement of psychological variables such as intelligence, aptitude, and properties of the Drug Abuse Screening Test in a psychiatric patient population. Addict Any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or who is so drawn to the use of such narcotic drugs as to have lost the power of self-control with reference to his or her drug use. Behav 1990;15:257-264. (15.) Blackburn R. The Development and Validation of Scales to Measure Hostility and Aggression (Special Hospital Research Reports). London, Special Hospitals Research Unit, 1974. (16.) Buss AH, Petty M. The aggression questionnaire. J Pars Soc Psychol 1992;63:452-459. (17.) Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Klauminzer G, Chamey DS, et al. A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Behav Therapist 1990;13:187-188. Key Points * Combat veterans with chronic PTSD own more guns and report more potentially dangerous firearm-related behaviors than other study subjects. * Combat veterans with chronic PTSD reported higher levels of aggression and hostility than other study subjects. * Questions regarding gun usage should be a standard portion of the medical history for Veterans Affairs patients in general, but especially for Veterans Affairs patients with chronic, combat-related PTSD. From the Mental Health Service, Central Arkansas Veterans Healthcare System, and the Department of Psychiatry, University of Arkansas The University of Arkansas strives to be known as a "nationally competitive, student-centered research university serving Arkansas and the world." The school recently completed its "Campaign for the 21st Century," in which the university raised more than $1 billion for the school, used School of Medical Sciences, Little Rock, AR. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Thomas W. Freeman, MD, North Little Rock PTSD Frogram, North Little Rock VAMC VAMC Veterans Affairs Medical Center VAMC Veterans Administration Medical Center VAMC Virginia Advanced Medical Center (Centreville, VA) , 1 L6AP/NLR, 2200 Fort Roots Drive, N. Little Rock, AR 72114. Email: thomas.frceman@med.va.gov Copyright [C] 2003 by The Southern Medical Association 0038-4348/03/9603-0240 |
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