Main Results
The aim of the current exploratory study was to examine characteristics of patients who damage their own household property and who were assessed by the EPS in Utrecht, The Netherlands. We compared the DPD patients to several other groups by reason of referral. Compared to patients referred because of suicidality, DPD patients were more often male, migrant, suffering from psychosis or mania and less frequently depressed. In comparison with patients referred because of aggression, the DPD patients were more frequently diagnosed with mania. With respect to age, substance use and personality disorder, no significant differences were observed. The DPD group had significantly lower scores on the GAF scale and had a higher chance of being hospitalised involuntarily and voluntarily (up to 64%) as compared to the other groups.
Comparison with Previous Studies
Many studies have illustrated the association between violence and various factors, such as substance use, personality disorder and environmental stressors (Freedman et al.
2007; Siever
2008; Elbogen and Johnson
2009; Fazal et al.
2009; Witt et al.
2013). The results of the current study did not identify substance use as a risk factor for DPD. However, the EPS patients in Utrecht were not tested for substance use, and patients who were scaled into the ‘no substance use’ category could still have used substances. In addition, DPD patients were possibly less capable of providing correct information about their substance use. Possibly, substance abuse remains a substantial risk factor for all types of violence, including DPD, irrespective of the presence of a psychotic disorder (Fazal et al.
2009).
The results illustrate that the DPD group had the largest percentage of patients with a migrant background. Since several decades, the Netherlands have received many migrants, labour migrants, as well as refugees, from a wide range of countries (Statistics Netherlands
2013). Patients with a migration background are likely to have a disadvantage with respect to the Dutch language. Research points out that only 3% of people with a language disadvantage in the Netherlands takes an interpreter to the doctor (Lamkaddem et al.
2013). A study on equal access of mental healthcare services in the Netherlands illustrates that for the non-Dutch-speaking migrants, utilisation of the mental healthcare only reached about half the level of the Dutch citizens (Koopmans et al.
2013). A language disadvantage and cultural habits can influence (and discourage) help-seeking behaviour of migrants born in the Netherlands as well. Due to socio-cultural and personal situations, a migrant can question the additional value of the available mental healthcare in the country of residence which can lead to a substantial patient-delay (Straβmayr et al.
2012). Another Dutch study on compulsory admissions and clinical presentation among immigrants at the EPS in Rotterdam found that first- and second-generation immigrants from non-Western countries to be at a higher risk of contact with EPS than members of the native Dutch population (Mulder et al.
2006). Mulder et al. explained the association between the non-Western ethnicity and compulsory admission by the greater severity of psychiatric symptoms, greater level of threat, lack of treatment motivation and lower level of functioning. Moreover, Selten et al. suggests in a study on social defeat as a hypothesis of schizophrenia that migration and childhood trauma are the strongest association for the increased risk on schizophrenia (Selten et al.
2013).
Nonetheless, Morgan et al. describe two American studies that found no association between ethnicity and compulsory admission but found an association between compulsory admission and living alone or living far away from family which Post van der et al. also concluded (Morgan et al.
2004). Furthermore, Morgan et al. suggests that because of the stigma attached to mental illness among some communities, immigrants do not follow the usual pathway to mental healthcare, have a patient delay or do not seek help at all. Less access to mental healthcare or inadequate utilisation of the mental healthcare can emerge from a culturally based lack of acceptance, prejudice and lack of knowledge about access and possibilities of mental healthcare. Therefore, it can be an obstacle to seek help or start the suggested therapy. Consequently, a high chance arises that these patients do not get the proper healthcare which ultimately may result in an escalation such as DPD.
Way et al. concluded that suicide potential, danger to others, and symptom severity were the best predictors of an admission in a healthcare center (Way et al.
2001). However, other studies show low rates of admittance of patients with suicidality which is more in line with findings of the current study (Mulder et al.
2005; George et al.
2002). Apparently, there is a different approach to the referral for suicidality between countries (Mulder et al.
2005). Another argument is that some families have the preference for the patient not to be hospitalized (Mulder et al.
2005). Making a distinction between personality disorder and suicidality can reflect on the suicidality referral rates. Breslow et al. suggest that suicidal patients are more likely to be discharged because of the strong association with personality disorder (Breslow et al.
1993). Patients with personality disorders are easily overwhelmed which can lead to suicidality. The current study made a distinction between suicidality and other referrals (including personality disorders). Nonetheless, personality disorders may have been underdiagnosed, as such diagnoses usually take a more lengthy and in-depth assessment than is usually available in psychiatric emergency conditions, where, more often than not, other clinical priorities may prevail. These arguments may to some extent explain the difference in admittance rates of patients with suicidality among these studies.
Several studies suggest that personality disorders, especially borderline and antisocial personality disorders, are associated with a higher chance of engaging in impulsive or violent behaviour (Yu et al.
2012; de Barros and de Pádua Serafim
2008; Freedman et al.
2007; Siever
2008). The current findings do not support this assumption with respect to DPD patients. The results do not reveal a significant association with personality disorder and DPD or other forms of violence. It seems not unlikely that personality disorders may have been underdiagnosed, as suggested before. Personality disorder may therefore remain unrecognised as a major underlying reason for acute psychiatric presentations such as psychosis or mania. This may explain the current findings.
The literature is inconclusive on the management of psychiatric patients after engaging in violent behaviour. An earlier study describes that 29%, of those who were referred to the EPS of Utrecht because of aggression, were admitted involuntarily (Hoek and Braam
2017). However, prevalence figures of involuntary admission show considerable variation between countries (van der Post et al.
2009; Gandré et al.
2017; Zhou et al.
2015). The current study has found a 43.2% involuntary admission within the DPD group, and within the overall comparison (B, C, D), a 15.5% involuntary admission. Altogether, the DPD patients have a significant higher chance of admission (OR = 4.03, CI 2.47–6.57) in comparison to the overall group. Some of the characteristics, described in literature, of patients who are admitted involuntarily are similar to the DPD group such as male gender and psychotic disorders (van der Post et al.
2009,
2012; Gandré et al.
2017; Zhou et al.
2015). Some additional analyses even showed that the rate of admission the patients in the ‘trashing everything’ and ‘throwing things outside’ groups even amounted to 85%. Admission could be considered as a plausible, temporary part of management, and preferred to example Intensive Home Treatment (Johnson and Thornicroft
2008), because the crisis apparently emerged in the domestic context.
Limitations
Several limitations of the current, exploratory study need consideration. First, the reason for referral was not always entirely obvious: there is a possibility that patients fitted in more than one group. Consequently, it frequently depended on the opinion of the investigators, staff members and the senior psychiatrist, which category was chosen. In addition, medical records occasionally contain too concise or inaccurate information leading to missing values in the study. Inaccurate and possibly unreliable information with respect to substance use and abuse has already been mentioned. In addition, the assessment of migrant status could be inaccurate as well where in cases, when parental place of birth was not registered, it was determined on the basis of a non-Dutch family name in combination with the description of cultural background in the mental status examination, which was generally derived from earlier information in the patient’s file. However, in The Netherlands, the majority of non-Western migrants originating from four well acknowledged regions: Morocco, Turkey, The Dutch Caribbean Islands and the previous colony of Surinam (Centraal Bureau voor de Statistiek
2018).
Furthermore, it is questionable whether the term ‘DPD’ would only be applicable to psychopathological states. People can also deliberately damage their belongings, or belongings of the owners of their accommodation, for purposes such as expecting a renovation or hurting someone’s feelings. The intention of the DPD is far from evident. Therefore, the term, as meant in the current study, should be ‘DPD during psychopathological states’.